Whispering Pines Lodge

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to protect and promote the rights of the resident in an environment that promoted maintenance or enhancement of his or her quality of life for 4 of 18 residents (Resident #69, Resident # 52, Resident # 78 and Resident # 54) reviewed for resident rights. <BR/>The facility failed to protect and value Resident #69, Resident # 52 and Resident #78's quality of life and provide a peaceful atmosphere when facility staff engaged in unprofessional and obscene behavior with family members of residents. <BR/>The facility failed to ensure staff knocked prior to entering Resident #54's room.<BR/>This failure could place residents at risk for decreased quality of life, increased anxiety, and increased stress. <BR/>Findings included:<BR/>1. Record review of Resident #69's admission Record indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alcohol Induced Dementia (a type of alcohol-related brain damage), Tremors (causes involuntary and rhythmic shaking), Muscle Wasting and Atrophy (Muscular atrophy is the decrease in size and wasting of muscle tissue), Muscle Weakness (Muscle weakness happens when full effort doesn't produce a normal muscle contraction or movement), Communication Deficiency (an impairment in the ability to receive, send, process, and comprehend concepts or verbal, nonverbal and graphic symbol systems.)<BR/>Record review of Resident #69's MDS dated [DATE] revealed that Resident #69 was understood and understood others. The MDS indicated a BIMS of 9 indicating moderate cognitive impairment for Resident #69. The MDS also revealed, Resident #69, required a two person assist for transfers. The activity of walking in the room and on the unit did not occur.<BR/>During an interview on 9/12/23 at 9:45 a.m., Resident # 69 stated that she remembers the incident that occurred between the Family Member A and staff. She said she remembered an incident happening at the nurse's station. She stated she remembers them all being very loud and yelling at each other. She stated that it was the Family Member A and some aides. She stated that she did not hear any cusswords being yelled at anyone. She stated that it bothered her with all the yelling because how is she to have a normal life with all the drama these aides cause. <BR/>2. Record review of Resident #52's face sheet dated 1/10/23 indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses including heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides - in your blood), paresthesia of skin (tingling or prickling, pins-and-needles sensation; usually temporary, often occurs in the arms, hands, legs, or feet.)<BR/>Record review of Resident #52's MDS dated [DATE] indicated she was understood and understood others. The MDS indicated a BIMS score of 13 which indicated Resident #52 had intact cognitive. The MDS indicated Resident #52 did not have behavioral symptoms. The MDS indicated Resident #52 required supervision from staff for most activities of daily living and used a wheelchair device for mobility when out of the bed.<BR/>During an interview on 9/12/23 at 4:44 p.m., Resident# 52 stated that she remembers the incident that occurred last weekend. She stated that she heard lots of screaming and yelling at the nurse's station. She stated that she did not know who the people that were yelling were but some were staff. She said that she was waiting to go out to meet her son who was picking her up. She stated that it bothered her with all the yelling because she doesn't want to live with all that commotion and also the police showed up to an old folk's home. <BR/>3. Record review of Resident #78's admission Record indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), dysphagia (swallowing difficulties), general anxiety disorder (a condition of excessive worry about everyday issues and situations.)<BR/>Record review of Resident #78's MDS dated [DATE] revealed that Resident #78 had a BIMS score of 13 indicating he was cognitively intact. MDS revealed that Resident # 78 he was understood and understood others. <BR/>During an attempted interview on 9/11/23 at 2:02 p.m., Resident # 78 was unintelligible and not forming words when answering questions asked. Resident # 78 was mumbling and would not look at the surveyor when he spoke of Family Member A or the incident that occurred the previous Saturday. <BR/>4. Record review of Resident #54's admission Record dated 09/14/2023 indicated that resident was an 63-year- old female who admitted to the facility on [DATE] with diagnosis of non-pressure chronic ulcer of buttock with necrosis of the muscle (commonly occur in patients with arterial (ischemic) disease, venous disease, neuropathy, or a combination of these diseases), type 2 diabetes ( a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) fibromyalgia (a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), and urinary tract infection (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract).<BR/>Record review of Resident #54's MDS assessment, dated 07/03/2023, indicated that resident had a BIMS score of 15 which indicated resident had no cognition issues. Resident #54 is understood and understands others. The MDS also indicated that Resident #54 required extensive assistance of for bathing and personal hygiene.<BR/>During an interview and observation on 09/11/2023 at 9:15 a.m., Resident #54 said her only concerns about the facility were lack of privacy and that she did not feel the employees understood infection control. During the conversation with Resident #54, Housekeeper D walked into the room without knocking. Resident #54 became upset and said this is exactly what I am talking about! No one has respect for us. They treat this place like it is their house and not ours. Housekeeper D exited the room without addressing Resident #54. Resident #54 said, what did she want? Why bust in my door and not tell me the purpose of the rudeness?<BR/>During an interview on 09/11/2023 at 9:25 a.m., Housekeeper D said she was entering to empty trash, sweep and mop. Housekeeper D said she forgot to knock. She said she was not aware that Resident #54 would make such a big deal out of her walking in her room. Housekeeper D said she walked into her room everyday and she never freaked out like that before. Housekeeper D said knocking on the door before entering showed respect and she was supposed to knock on everyone's doors before entering.<BR/>During an interview and Record Review on 9/11/23 at 2:41 p.m., A video was observed with CNA C. Video shows the incident between CNA C and Family Member B. The video was taken from a cellphone. The video was grainy in appearance and not high definition. Faces of individuals were not clear. CNA C was identified due to her unique (artificial red) hair color. She stated that it was her with the red hair in the video. CNC C was observed in a verbal altercation with Family Member B. CNA C can be hear arguing and yelling, Lets be professional to Family Member B. An unidentified resident is observed in a wheelchair. Other staff are observed in the video watching CNA C and Family Member B's verbal altercation. The video is 25 seconds long and ends abruptly. <BR/>During an interview on 9/11/23 at 2:50 p.m., LVN B stated that she has worked for the facility almost 5 years. She stated that she worked this weekend Friday through Sunday. She stated that she worked the 6A to 6P shift. She stated that last Saturday she was near the dining room and she heard Family Member A speaking with another staff. She stated that the family member of Resident # 78 was looking for the CNA that she had a verbal altercation with over the phone. She stated that she did not know the CNAs name. She stated that she intervened because Family Member A was being aggressive. She stated that she asked her if she could help, and she told her about the altercation over the phone with the unknown CNA. She stated that Family Member A said that a CNA told her to, pull up. She stated that she told her that she could come back on Monday, and she could speak to the DON or ADM. She stated that she wanted her to go get the CNA that she had the altercation with, and she told Family Member A she would not do that. She stated that she then became verbally aggressive with her. She stated that Family Member A started waving her hands and pointing her fingers at her. She stated that Family Member A continued to insist that she got the CNA she had an altercation with. She stated that Family Member A was yelling at this point. She stated that she did not think that there were any residents around when this occurred. She stated that the residents were in the dining room, and she was outside of the dining room near a hallway entrance. She stated that the verbal aggression continued so she asked her to leave. She stated that she refused to leave the facility after two verbal requests. She stated that she told her since she would not leave, she would call the police. She stated that the police arrived, and Family Member A was now outside waiting for the cops. She stated that no one got physical with each other and the entire confrontation was verbal. She stated that she knew of the other separate incident that occurred over the weekend on Sunday with Resident # 235's family but was on her break getting lunch. <BR/>During an interview on 9/12/23 at 2:04 p.m. CNA C stated that on Sunday, 9/10/23, she was working and there was an incident. She stated that she was getting ready to eat her lunch when an aide came and got her. She stated that the aide from D hall was upset because of the way Family Member B was behaving. She stated that Family Member B was angry about Resident #235's clothes. She stated that she went to the nurse's station and Family Member B was there. She stated that she introduced herself to Family Member B and she yelled at her that she did not want to hear all that and she wanted Resident #235's fucking clothes. She stated that she asked the girlfriend to talk to her professionally. She stated that she told her that she would help her but she needed to stop yelling. She stated that she was calling her ignorant. She stated that she had raised her voice at Family Member B because she was yelling and she was trying to match her sound level so she could hear what she was saying. She stated that the police came and escorted Family Member B out. She stated that she was told that Resident # 52 may have been in the vicinity when this occurred. She stated that she never cussed at the girlfriend she just said lets be professional lets be professional but she was saying that to her with a raised voice.<BR/>During an interview on 9/12/23 at 2:21 p.m., CNA D stated that she has worked at the facility for two years. She stated that she was working last weekend. She stated that she worked on Saturday 9/9/2023. She stated that she was outside with Resident # 78 when he was smoking. She stated that resident # 78 had Family Member A on speaker phone and Family Member A said, I will get you some grease for your feet because them [NAME] is not doing their job. She stated that she then made the comment to Family Member A that there was no [NAME] here I am a bitch. She stated that this made Family Member A angry. She stated that Family Member A was still going off and yelling on the phone and she was laughing at Family Member A because it was funny. She stated that at one point Family Member A said, I will come up there and drag that bitch in the river. She stated that she told Family Member A I was at 2131 Alpine RD. She stated that she may have told Family Member A to, pull up. She stated that she went back to work because she hung up the phone with Resident # 78. She said that another staff came to get her because Family Member A that she was talking to had come to the building with three other women. She stated that she never went face to face with Family Member A, but she could hear and see Family Member A yelling from behind the door of the locked unit. She stated that she was watching all this happen as Family Member A talked to the other staff at the nurse's station. She stated that it was LVN B that was dealing with Family Member A She stated that she heard LVN B say you are upsetting my residents. She stated that she doesn't know which residents that were there. She stated that it was all funny to her and it still is funny to her. <BR/>An attempted contact on 9/12/23 at 4:55 p.m. with Resident # 235. Resident # 235 was unable to answer any questions by the surveyor. Resident # 235 resides on the locked memory care unit. Resident # 235 did not witness the incident as the family member of Resident # 235 did not enter the locked unit. <BR/>An attempted contact on 9/12/23 at 4:58 p.m., with Family Member B. A voicemail was left requesting an interview.<BR/>An attempted contact on 9/12/23 at 5:02 p.m., with Family Member A. A voicemail was left requesting an interview.<BR/>An attempted contact on 9/12/23 at 5:04 p.m., with the Wife of Resident # 78. A voicemail could not be left as the voicemail box was full.<BR/>During an interview on 9/12/23 at 5:13 p.m., the Administrator stated that she was aware of the incidents that took place over the weekend and her opinion of the staff's behavior was as follows: CNA D's behavior could be considered obscene as she instigated the confrontation. She stated that CNA C did not say anything that could be considered offensive but the way she carried her self could be considered offensive or obscene. She stated that CNA D made the situation with Family Member A worse with her behavior. She stated that she should not have engaged with the family member and instead walked away from the situation. She stated that she cannot say whether or not CNA C's behavior made the situation worse as she did not say anything offensive but did yell at Family Member A. She stated that the residents were at risk for a reduced quality of life due to the yelling and screaming. She stated that they try and keep a peaceful atmosphere in the facility. She stated that both CNA C and CNA D's behavior was inappropriate for the workplace. She stated that behavior of these two staff was unbecoming as an employee of the company.<BR/>During an interview on 9/13/23 at 2:10 p.m., the DON stated that she has seen the video with CNA C and she would agree that her behavior was unprofessional. She stated that she would not condone the behavior of CNA C as she aggravated the situation with her tone of voice. She stated that she did not see or hear the incident between CNA D and Family Member A, but she heard some of the language that was used over the phone as she was told by other staff what was said. She stated that CNA D instigated the incident and did not help calm the situation. She stated that CNA D's behavior was unprofessional.<BR/>During an interview on 09/13/2023 at 2:15 p.m., the DON stated she expected all employees regardless of department to treat the facility like the resident's home. The DON said it was best practice to knock on all resident's doors and wait for permission to enter. The DON said knocking showed respect for the resident's privacy.<BR/>During an interview on 09/13/2023 at 3:00 p.m., the Administrator stated all resident rooms should not be entered without permission, especially a closed door. Resident care could have been occurring and Resident #54 could have been exposed to staff or residents in the hallway. The Administrator stated even if the resident did not seem to understand what was going on, it was best to knock and make the resident aware you would like to enter. The Administrator said it was the right of the residents to have privacy.<BR/>Review of the facility 's policy titled Resident Rights with a revised date of November of 2016 indicated, . Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. Respect and dignity- The resident has a right to be treated with respect and dignity, including: The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. Self-determination - The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.<BR/>Record review of facility Employee Handbook section entitled Corporate Code of Conduct, revised 09/20/2023. Types of behavior and conduct that this facility considers inappropriate include, but are not limited to, the following: Fighting or using obscene, abusive, or threatening language or gestures; Violation of resident's rights; Horseplay, practical jokes and other kinds of behavior inappropriate in the workplace; Conduct unbecoming of an employee of the company.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 25 residents (Resident #6) reviewed for quality of care.The facility failed to notify the physician when Resident #6 experienced low blood pressure, low heart rate and/or low blood pressure with an increased heart rate on 7/16/25, 7/18/25, 7/20/25, 7/21/25, 7/23/25, 7/25/25, 7/26/25, 7/27/25, 7/28/25,7/29/25, 7/30/25, and 8/1/25. On 8/1/25, Resident #6 had low hemoglobin 5.8 and low hematocrit 21.6. Resident #6 was sent to the ER due to critical lab values. Resident #6 was admitted and diagnosed with gastrointestinal hemorrhage. Resident #6 received a blood transfusion at the hospital. An Immediate Jeopardy (IJ) was identified on 9/11/25. The IJ Template was provided to the facility on 9/11/25 at 2:01 p.m. While the IJ was removed on 9/12/25 at 4:40 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to complete training in-services with all staff and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of a decline in condition, delay in life-saving treatments, hospitalization, serious harm, and death. Findings included: Record review of Resident #6's face sheet dated 9/8/25 indicated Resident #6 was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #6 had diagnoses including Dementia (is a general term describing a group of conditions that cause a progressive decline in cognitive abilities, including memory, thinking, reasoning, and judgment, which interfere with daily life), gastrointestinal hemorrhage (is when there is blood loss from any of the several organs included in your digestive system), iron deficiency anemia (is a common blood disorder that affects your red blood cells) secondary to blood loss (chronic), hypertension (is when the pressure in your blood vessels is too high (140/90 mmHg or higher)), and acute embolism and thrombosis of deep veins of right lower extremity (is a condition where a blood clot forms in a deep vein, often in the leg). Resident #6's most recent hospital stay was 8/1/25-8/5/25. Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated Resident #6 was sometimes understood and sometimes had the ability to understand others. Resident #6 had a BIMS score of 2 which indicated severe cognitive impairment. Resident #6 required supervision for eating, substantial assistance for oral and personal hygiene, and dependent for toileting hygiene, shower/bathe self and dressing. Resident #6 was on an anticoagulant (is a medical treatment that prevents blood clots from forming). Record review of Resident #6's care plan dated 3/5/25 indicated: *Resident #6 was on an anticoagulant therapy. Intervention included monitor/document/report to MD signs/symptoms of anticoagulant complications such as lethargy, loss of appetite, sudden change in mental status, and significant or sudden changes in vital signs. *Resident #6 had a diagnosis of hypertension. Intervention included give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (is a condition where blood pressure drops significantly upon standing up from a sitting or lying position) and increased heart rate and effectiveness. Record review of Resident #6's order summary dated 8/1/25 indicated: *Eliquis (anticoagulant) Oral Tablet 5 MG, give 1 tablet by mouth two times a day related to acute embolism and thrombosis of deep veins of right lower extremity. Start date 3/4/25. *Lisinopril (antihypertensive; treats high blood pressure) Oral Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure (is the pressure when your heart beats to pump blood around your body) below 100, diastolic blood pressure (measures the pressure on blood vessel walls when your heart is relaxed between contractions) below 55 or heart rate less than 50. Start date 3/5/25. *Metoprolol Tartrate (antihypertensive; treats high blood pressure) Oral Tablet 50 MG, give 1 tablet by mouth two times a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Start date 3/5/25. Record review of Resident #6's medication administration record dated 7/1/25-7/31/25 indicated: *Eliquis (anticoagulant) Oral Tablet 5 MG, give 1 tablet by mouth two times a day related to acute embolism and thrombosis of deep veins of right lower extremity. Resident #6 received 61 out of 62 doses. *Lisinopril (antihypertensive; treats high blood pressure) Oral Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6's MAR indicated (AM) 7/16/25 (BP: 118/63, HR: 98) MA B, 7/18/25 (BP: 90/65, HR: 88) MA X; Vitals Outside of Parameters, 7/20/25 (BP: 96/56, HR: 56) MA Y, 7/21/25 (BP: 110/66, HR: 105) MA B, 7/23/25 (Hold see nurse notes) MA B, 7/25/25 (BP: 108/74, HR: 108) MA B, 7/26/25-7/28/25 (Hold see nurse notes) MA B, 7/29/25 (BP: 119/60, HR: 98) MA Z, and 7/30/25 (BP: 110/67, HR: 88) MA Z. *Metoprolol Tartrate (antihypertensive; treats high blood pressure) Oral Tablet 50 MG, give 1 tablet by mouth two times a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6's MAR indicated (AM) 7/16/25 (BP: 118/63, HR: 98) MA B, 7/18/25 (BP: 90/65, HR: 88) MA X; Vitals Outside of Parameters, 7/20/25 (BP: 96/56, HR: 56) MA Y, 7/21/25 (BP: 110/66, HR: 105) MA B, 7/23/25 (Hold see nurse notes) MA B, 7/25/25 (BP: 108/74, HR: 108) MA B, 7/26/25-7/28/25 (Hold see nurse notes) MA B, 7/29/25 (BP: 119/60, HR: 98) MA Z, and 7/30/25 (BP: 110/67, HR: 88) MA Z. Resident #6's MAR indicated PM 7/18/25 (BP: 110/62, HR: 84) MA AA, 7/20/25 (BP: 115/76, HR: 60) MA AA, 7/21/25 (BP: 98/63, HR 79) MA X, 7/25/25 (BP: 90/70, HR: 100) MA X, 7/27/25 (BP: 90/41, HR: 116); Vitals Outside of Parameters, 7/29/25 (BP: 100/55, HR: 95) MA BB, 7/30/25 (Vitals Outside of Parameters) *Amlodipine Besylate Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 110, diastolic blood pressure below 60 or heart rate less than 55. Discontinued on 7/30/25. Resident #6's MAR indicated 7/16/25 (BP: 118/63, HR: 98) MA B, 7/18/25 (BP: 90/65, HR: 88) MA X; Vitals Outside of Parameters, 7/20/25 (BP: 96/56, HR: 56) MA Y, 7/21/25 (BP: 110/66, HR: 105) MA B, 7/23/25 (Hold see nurse notes) MA B, 7/25/25 (BP: 108/74, HR: 108) MA B, 7/26/25-7/28/25 (Hold see nurse notes) MA B, 7/29/25 (BP: 119/60, HR: 98) MA Z, and 7/30/25 (BP: 110/67, HR: 88) MA Z. Record review of Resident #6's MAR dated 8/1/25-8/31/25 indicated: *Lisinopril Oral Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6's MAR indicated (AM) 8/1/25 (BP: 115/85, HR: 123) MA AA. *Metoprolol Tartrate Oral Tablet 50 MG, give 1 tablet by mouth two times a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6's MAR indicated (AM) 8/1/25 (BP: 115/85, HR: 123) MA AA. Record review of Resident #6's progress notes dated 7/1/25-9/8/25 indicated: *7/23/25 at 12:44 p.m. by MA B: Amlodipine Besylate Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 110, diastolic blood pressure below 60 or heart rate less than 55. Resident #6 BP low 127/51. *7/23/25 at 12:45 p.m. by MA B: Metoprolol Tartrate Oral Tablet 50 MG, give 1 tablet by mouth two times a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6 BP low. *7/26/25 at 1:15 p.m. by MA B: Lisinopril Oral Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6 BP low. *7/26/25 at 1:15 p.m. by MA B: Amlodipine Besylate Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 110, diastolic blood pressure below 60 or heart rate less than 55. Resident #6 BP low 96/53 HR 101. *7/26/25 at 1:16 p.m. by MA B: Metoprolol Tartrate Oral Tablet 50 MG, give 1 tablet by mouth two times a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6 BP low. *7/27/25 at 12:55 p.m. by MA B: Amlodipine Besylate Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 110, diastolic blood pressure below 60 or heart rate less than 55. Resident #6 BP low 95/72 HR 58. *7/27/25 at 12:55 p.m. by MA B: Lisinopril Oral Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6 BP low. *7/27/25 at 12:56 p.m. by MA B: Metoprolol Tartrate Oral Tablet 50 MG, give 1 tablet by mouth two times a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6 BP low. *7/28/25 at 12:48 p.m. by MA B: Amlodipine Besylate Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 110, diastolic blood pressure below 60 or heart rate less than 55. Resident #6 diastolic BP low 115/52 HR 101. *7/28/25 at 12:49 p.m. by MA B: Lisinopril Oral Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6 diastolic BP low 115/52 HR 101. *7/28/25 at 12:50 p.m. by MA B: Metoprolol Tartrate Oral Tablet 50 MG, give 1 tablet by mouth two times a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6 diastolic BP low. *7/30/25 at 6:00 a.m. by LVN O: Neuro assessment BP 98/48, Pulse 93. Resident #6 had an unwitnessed fall in his room. *7/30/25 at 6:30 a.m. by LVN O: [NAME] assessment BP 87/45, Pulse 80. *7/30/25 at 6:45 a.m. by LVN O: [NAME] assessment BP 110/67, Pulse 88. *7/30/25 at 7:15 a.m. by LVN O: [NAME] assessment BP 100/56, Pulse 60. *7/30/25 at 7:45 a.m. by LVN O: [NAME] assessment BP 98/52, Pulse 87. *7/30/25 at 8:45 a.m. by LVN O: [NAME] assessment BP 92/59, Pulse 95. *7/30/25 at 9:45 a.m. by LVN O: [NAME] assessment BP 114/62, Pulse 82. *7/30/25 at 10:24 a.m. by LVN O: Notified MD K of family's concerns about the resident [Resident #6] being drowsy so much of the time. *7/30/25 at 11:45 a.m. by LVN O: [NAME] assessment BP 98/58, Pulse 82. *7/30/25 at 1:11 p.m. by LVN O: New order received from MD K to stop Amlodipine, Mirtazapine and Marinol. To get CBC (is a blood test that measures the number and types of various cells in the blood, including red blood cells (RBCs), white blood cells (WBCs), and platelets), CMP (is a blood test that measures multiple substances in the body to assess overall health and identify potential medical conditions), and ammonia (measures the amount of ammonia in the blood) in AM. *7/30/25 at 1:45 p.m. by LVN O: Neuro assessment BP 94/54, Pulse 79. *7/30/25 at 9:45 p.m. by RN T: Neuro assessment BP 88/65, Pulse 71. *7/31/25 at 5:44 a.m. by RN T: Neuro assessment BP 108/64, Pulse 69. *7/31/25 at 1:08 p.m. by LVN L: When resident [Resident #6] was gotten up this morning his BP dropped to 75/62 and HR was 100. Resident #6 was laid back down and his BP and HR returned to normal. MD K notified and said to monitor. *7/31/25 at 7:20 p.m. by RN T: Neuro assessment BP 96/64, Pulse 76. *8/1/25 at 3:31 a.m. by RN T: Neuro assessment BP 93/56, Pulse 76. *8/1/25 at 11:18 a.m. by LVN L: Dr. lab called with critical labs. WBC 15.33 (The normal white blood cell count ranges between 4,000 and 11,000 cells per microliter), Hemoglobin (is the protein contained in red blood cells that is responsible for delivery of oxygen to the tissues; The normal Hb level for males is 14 to 18 g/dl (grams per deciliter)) 5.8, Hematocrit (is a blood test that measures the amount (percent) of your blood that is made up of red blood cells; The normal hematocrit for men is 40 to 54%) 21.6. *8/1/25 at 11:21 a.m. by LVN L: MD K notified about labs, no new orders. *8/1/25 at 5:08 p.m. by LVN L: Notified MD K of critical labs and he [MD K] recommended that we send him out to the hospital.Resident #6's progress note did not reflect any documented SBARs. Record review of Resident #6's hospital records dated 8/1/25 indicated, .brought in from nursing home after found to have some abnormal labs. he [Resident #6] does appear to be severely anemic with hemoglobin of 5.8.due to his anemia, a stool occult blood was checked in the ER which was positive though he [Resident #6] has not had an actual visible GI bleeding.impression.gastrointestinal hemorrhage. plan. transfuse PRBCs (packed red blood cells). Record review of Resident #6's hospital Discharge summary dated [DATE] indicated, .chief complaint.severe anemia. final diagnoses. iron deficiency anemia due to blood loss. gastrointestinal hemorrhage.hospital course.he [Resident #6] has been noted to be more fatigued recently, and blood work revealed severe anemia.he was found to be profoundly anemic initially with a hemoglobin of 5.8, and elevated creatinine 2.5.he received IV fluids and blood transfusion.he [Resident #6] was guaiac positive (a test result indicating the presence of occult (hidden) blood in the stool), and Gastroenterology (is the medical specialty that studies and treats diseases of the digestive system) was consulted.the plan was for the patient to undergo EGD (is a medical procedure used to examine the lining of the esophagus, stomach, and upper part of the small intestine (duodenum)) and colonoscopy (is an examination of the inside of your large intestine (colon)) yesterday, but he had episode of severe epistaxis (nosebleed), and it was felt the patient will not be able to tolerate an NG (nasogastric) tube.for the pre-op medication. On 9/9/25 at 9:40 a.m., attempted to contact MA Y by phone. Contact was unsuccessful. Unable to leave a message because the subscriber was not accepting calls. During an interview on 9/9/25 at 9:46 a.m., MA B said that she got the residents' vital signs for blood pressure medication. She said if the residents' vital signs were out of the parameters, she documented in the facility's charting system and held the medication. She said when she documented the medication was held due to the vital signs being out of range, it notified the charge nurse. She said the charge nurse received a notification in the facility's charting system. She said the held documentation, on the residents' MAR, flowed over to the progress notes. She said she also verbally notified the charge nurse when she held a blood pressure medication due to the vital signs being out of range. She said if she held a blood pressure medication on Resident #6, she probably reported to the charge nurse. She said if a resident had a low blood pressure (It is typically defined as a systolic pressure (the top number) below 90 mmHg and/or a diastolic pressure (the bottom number) below 60 mmHg) and high heart rate, it could mean the resident was in atrial fibrillation (is an irregular and often very rapid heart rhythm) or distress. She said it was important to notify the MDs if a blood pressure medication was held due to vital signs being out of range so they could make medication adjustments. On 9/9/25 at 10:27 a.m., attempted to contact LVN O by phone. Contact was unsuccessful and a message was left with callback phone number. During an interview on 9/9/25 at 11:37 a.m., the DON said the MAs were responsible for notifying the charge nurses when a blood pressure medication was held due to vital signs being outside of the parameters. She said the charges nurses were responsible for notifying the MD. She said the MD should be notified every time the blood pressure medication was held. She said the charges nurses documented in the residents' progress notes when they contacted the MD. She said if a resident had a low blood pressure and increased heart rate, it could indicate sepsis, dehydration, infection, and volume loss. She said the signs and symptoms of a GI bleed were low blood pressure, nosebleed, vomiting of blood, and tarry stools. She said when a resident's hemoglobin was low, they could experience low blood pressure, drowsiness, and fatigue. She said the ADON and DON should monitor this process by following up on vital sign alerts from the facility's charting system. She said she was not aware Resident #6 had several days of missed blood pressure medication and vital signs out of the parameters. During an interview on 9/9/25 at 2:52 p.m., RN P said the MAs were supposed to report to the charge nurses when a residents' vital signs were out of the parameters. She said the charge nurse should recheck the residents' vital signs. She said if the residents' vital signs were still out of range, then the charge nurse should notify the MD and family and do a SBAR. She said the facility's charting system did not notify the charge nurses when a medication was held due to vital signs being out of the parameters. She said if a resident had lower blood pressures it could indicate cardiac arrest and shock. She said the resident could need the emergency room. She said the charge nurses documented in a progress note when the physician was notified. She said it was important for the physician to be notified to receive orders. During an interview on 9/9/25 at 3:16 p.m., MD K said he could not recall what was reported to him on 7/31/25 in relation to Resident #6. He said he did not know if he would have changed his orders to only monitor Resident #6 if he knew about the other blood pressure and heart rate issues. He said he would have needed more information. He said he would have wanted to be notified of Resident #6's low blood pressures with lower (is a condition where the heart beats at a rate below 60 beats per minute (bpm) while resting) and higher heart rates (is a condition where the heart beats faster than normal, typically at a rate of over 100 beats per minute (bpm) at rest). He said he would have wanted to be notified when Resident #6's blood pressure medications were held due to vital signs being out of the parameters. He said a sign or symptom of a GI bleed was low blood pressure. During an interview on 9/9/25 at 3:38 p.m., LVN O said she did not remember being notified about Resident #6's low blood pressure readings and blood pressure medications being held. She said the MAs verbally notified the charge nurses about out-of-range vital signs and documented on the MAR. She said the charge nurses were responsible for notifying the physician. She said she did not recall doing a neuro assessment on Resident #6 after a fall in July 2025. She said if Resident #6's had a trend of low blood pressure readings then the MD should have been notified. She said signs or symptoms of a GI bleed were low blood pressure, tarry stool, and passing of blood. She said it was important to notify the physician because the resident could not need the prescribed blood pressure medication and so they could address the issue. During an interview on 9/10/25 at 9:45 a.m., LVN L said she was not aware Resident #6 had several days of low blood pressure readings with low and high heart rates prior to the incident on 7/31/25. She said when she called MD K about Resident #6 incident on 7/31/25, she did not report his previous low blood pressure readings with low and high heart rates. She said the MAs usually verbally told the charge nurses when the residents' vital signs were out of range and the medication was held. She said then the charge nurse could notify the MD. She said if the residents' blood pressure continued to be low, then the MD needed to be contacted for a medication adjustment. She said if the residents' blood pressure was low but the heart rate was high, then it could indicate anemia. She said if MD K had been given more information on 7/31/25, related to Resident #6's vital signs being out of normal range prior to the incident on 7/31/25, he may have done a different intervention. She said she wished she had known about Resident #6's previous vital signs so she could have reported it. She said the charge nurses documented on a progress note when the MD was notified and responded back. She said she did not know why there were two different notification entries on 8/1/25 to MD K about Resident #6 critical labs. During an interview on 9/11/25 at 1:03 p.m., the ADM said the charge nurses were responsible for notifying the physician when a resident had a change in condition. She said the charge nurses should also notify the ADON and DON. She said it was important to notify the physician in case the resident needed to be sent out to the ER or medication changed. She said the charge nurses documented the physician notification in a progress note. She said if the physician was not contacted, it could be detrimental to the resident. She said the nursing management should ensure the charge nurses responded to the residents' change of condition. She said the nursing management should ensure this process by doing in-services. Record review of an undated facility's Abuse/Neglect policy indicated, . Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of a facility's Notifying the Physician of Change in Status policy revised 3/11/2013 indicated, .The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes the INTERACT tool, Change in Condition - When to Notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. Before the physician is contacted, the nurse will gather and organize resident information. Applicable information will include current medications, vital signs, signs and symptoms initiating call, current laboratory information, and interventions that have currently been implemented. The nurse is responsible, however, for responding to a change of condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. Record review of a facility's Medication Administration and General Guidelines policy revised 3/2025 indicated, . Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time. The physician must be notified when a dose of medication has not been given. If an electronic medical record is being utilized then the caregiver administering the medication will enter the correct documentation that will then be electronically date/time stamped with their initials. The ADM and the Regional Compliance Nurse were notified of an IJ on 9/11/25 at 1:59 p.m. and a Plan of Removal (POR) was requested. The IJ template was emailed to the ADM on 9/11/25 at 2:01 p.m. The following plan of removal was submitted by the facility and accepted on 09/12/25 at 4:40 p.m. and included the following: Interventions: 1. Resident #6 no longer resides in the facility as of 9/11/25. 2. All residents in the facility had their blood pressures and heart rates reviewed for any abnormal readings. No additional changes in condition were noted that required notification to the MD. Completed 9/11/25. 3. The DON/ADON/Designee will review the 24hr report and PCC dashboard (is a customized, centralized view within the PointClickCare healthcare management platform that provides real-time, at-a-glance information relevant to a user's role, displaying clinical, financial, or administrative data to improve efficiency, decision-making, and patient care) daily for abnormal vital signs or changes in condition that need to be communicated to the MD. Completed 9/11/25 and will continue indefinitely. 4. The Administrator and DON were in-serviced 1:1 by the Regional Compliance Nurse and Area Director. Completed 9/11/25. a. Abuse and Neglect: Examples include failure to provide assistance with showers, changing clothes, meal trays, eating, positioning with enteral feeding, providing treatments, following MD orders, treating pain, administer medication, notifying MD of change in condition, provide adequate supervision to prevent falls or resident to resident altercations. b. Notification of Change in Condition: notify a MD and RP of all changes in conditions such as abnormal vital signs, new onset or worsening pain or injuries from incidents. Med aides will report all abnormal vital signs during medication administration to charge nurse immediately. c. PCC Dashboard/24hr Report: Charge nurses will monitor the PCC Dashboard/24hr report throughout their shift and at change of shift for any abnormal vital signs that need to be reported to the physician. 5. The medical director was notified of the immediate jeopardy citation by the administrator on 9/11/25. 6. An ADHOC QAPI meeting was held with interdisciplinary team including the medical director to discuss the immediate jeopardy and plan of removal. Completed on 9/11/25. In-services: 1. The following in-services were initiated by Administrator, Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced as of 9/11/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completion date 9/11/25. a. Abuse and Neglect: Examples include failure to provide assistance with showers, changing clothes, meal trays, eating, positioning with enteral feeding, providing treatments, following MD orders, treating pain, administer medication, notifying MD of change in condition, provide adequate supervision to prevent falls or resident to resident altercations. b. Notification of Change in Condition: notify a MD and RP of all changes in conditions such as abnormal vital signs, new onset or worsening pain or injuries from incidents. c. PCC Dashboard/24hr Report: Charge nurses will monitor the PCC Dashboard/24hr report throughout their shift and at change of shift for any abnormal vital signs that need to be reported to the physician The surveyor verification of the Plan of Removal from 9/12/25 was as follows: *Record review of a resident roster provided on 9/8/25 indicated Resident #6 was not in the facility. *Record review of Resident #6's progress note dated 8/27/25 at 1:45 a.m., reflected Resident #6 was pronounced at 12:25 a.m. *Record review of the facility's Weights and Vitals Summary dated 9/8/25-9/30/25 indicated all residents, unit, and floors had been reviewed. The vital signs of blood pressure and pulse were targeted. Twenty-six residents had blood pressure and/or pulse that triggered a warning. RCN DD reviewed and signed the report on 9/12/25. *Record review of an email sent by RCN EE to MD K dated 9/11/25 at 7:09 p.m., indicated an attached list of residents with low pulse (5 residents), high pulse (3 residents), low blood pressure readings (7 residents), and high blood pressure readings (20 residents). *Record review of an email sent back from MD K to RCN EE dated 9/12/25 at 1:39 a.m., indicated MD K made medication adjustments for 2 residents. MD K acknowledged other vital signs and no new orders. *Record review of the facility's Daily Quality Assurance Meeting dated 9/11/25 at 9:00 a.m., indicated the 24-hour report, medication administration, and the facility's charting system dashboard had been reviewed by the DON. The clinical alerts had been reviewed. *Record review of the facility's 24-hour Summary report dated 9/11/25-9/12/25 indicated residents' vital signs and progress notes. Five residents had reported changes of conditions or new findings. The report indicated notifications to the MD, family, and hospice. *Record review of a provided document from the ADO on 9/12/25 indicated the Medical Director, MD K, was notified by the ADM on 9/11/25 at 3:55 p.m. of the immediate jeopardy citations. *Record review of a facility's AD Hoc QAPI Meeting dated 9/11/25 indicated the following members were in attendance: ADM, DON, ADON, Medical Director (via phone), Social Service, Dietary, RNC EE, Administrator in Training, MDS Coordinator RR and MDS Coordinator QQ. *Record review of the in-service training report, dated 09/11/25, reflected the DON and Administrator signed and received in-service training on abuse and neglect which included the following: examples such as failure to provide assistance with shower, changing clothes, meal trays, eating, positioning with enteral feeding, providing treatments, following physician orders, treating pain, administering medications, notify the physician of changes in condition, and providing adequate supervision to prevent falls or resident to resident altercations. It also included the abuse/neglect policy and procedure. *Record review of the in-service training report, dated 09/11/25, reflected the DON and Administrator signed and received in-service education on notifying physician of change in status which included the following: notifying the physician and responsible party of all changes in conditions such as abnormal vital signs, pain or injuries from accidents. It also included the Notifying the Physician of Change in Status policy. *Record review of the in-service training report dated 9/12/25, reflected the DON and Administrator signed and received in-service training on PCC Dashboard/ 24 Hour Report which included the following: the Charge nurses will monitor the PCC Dashboard/24hr report throughout their shift and at change of shift for any abnormal vital signs that need to be reported to the physician. *During an interview on 09/12/25 at 3:08 PM, the Medical Director stated he was notified of the immediate jeopardy situations at the facility. He said he was notified by the Regional Compliance Nurse on 09/11/25 and it was discussed with plans being implemented. *During an interview on 09/12/25 at 4:05 PM, the DON stated she was provided 1:1 in-service education as follows: Abuse and neglect to include the types of abuse and examples of each. The DON stated that failure to provide care and services such as notifying the physician of change of condition, following physician orders,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 20 of 25 (Resident's #2, #4, #5, #6, #8, #9, #10, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #23, #24) reviewed for abuse and neglect. 1. The facility failed to ensure LVN D did not physically abuse Resident #4 when she picked her up from her wheelchair and threw her on to the mattress on the floor on 07/17/25. Resident #4 sustained a bruise to her right elbow and redness to the mid abdomen. 2. The facility failed to ensure LVN E did not verbally abuse Resident #9 when LVN E yelled and cursed at Resident #9 when she asked for pain medication on 08/17/25. 3. The facility failed to ensure Resident #12 did not physically abuse Resident #13 when he shoved her on 08/07/25 and on 08/23/25. On 08/23/25, Resident #13 sustained scratches to her face. 4. The facility failed to ensure Resident #5 was properly positioned during a tube feeding on 08/20/25. Resident #5's head and torso were leaning over the left armrest of his Geri-chair for approximately 1 hour and 30 minutes, which resulted in aspiration pneumonia. 5. The facility failed to ensure sufficient staff were available to provide wound care treatment and documentation for Resident's #2, #16, #17, #18, #19, #20, #23 and #24 during August 2025 and September 2025. 6. The facility failed to ensure Resident's #4, #6, and #19 were provided feeding assistance during mealtimes. 7. The facility failed to ensure the secured unit was adequately staffed to prevent accidents for Resident's #8, #10, #12, #13, #14, #19, and #21. 8. The facility failed to ensure Resident #7, Resident #8, Resident #14 Resident #21, and Resident #22 were provided supervision during the lunch meal on 09/08/25. An immediate jeopardy (IJ) was identified on 09/11/25 at 12:59 PM. The IJ template was provided to the facility on [DATE] at 2:01 PM. While the IJ was removed on 09/13/25 at 12:49 PM, the facility remained out of compliance at a scope of a pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been provided education on abuse and neglect, notification of changes in condition, documentation policy, pain management policy, fall prevention policy, pressure prevention policy, medication administration policy, enteral feeding policy, and the bathing and showers policy. These failures could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, decreased quality of life, serious harm, injury, impairment, and death.Findings included:1. Record review of a face sheet dated 09/17/25 indicated Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Huntington's disease (an inherited condition in which nerve cells in the brain break down over time), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder), anxiety disorder, abnormal weight loss, dysphagia (difficulty swallowing foods or liquids). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #4 understood others and was never/rarely understood by others. The MDS indicated Resident #4 had a BIMS score of 0 which indicated Resident #4 was severely impaired and unable to complete the interview. The MDS indicated Resident #4 required supervision and touching assistance with eating, and dependent for showering, toileting, hygiene and transfers. Record review of Resident #4's care plan with a revised date of 09/08/25 indicated Resident #4 had a history of falls due to Huntington's disease and required staff times two for transfers. Record review of Resident #4's Order Summary Report dated 09/17/25 indicated an order for mattresses on floor with walls and floor surrounding mattresses padded every shift dated 07/12/25. Record review of a Provider Investigation Report dated 07/17/25 at 07:09 PM, indicated Resident #4's family member come to the facility and reported that she saw on the camera that a staff member had brought Resident #4 to her room in her wheelchair and threw her down on the mattress. The facility completed skin and pain assessment and order x-rays. Documented facility follow-up action was to in-service staff members with 1:1 education and physical therapy in-service regarding transfer of residents, police department notified, safe surveys conducted, trauma assessments for all residents. Record review of skin assessment completed on 07/17/25 by LVN CC indicated Resident #4 had bruising on right elbow and redness to lower abdomen. Record review of written statement by LVN D dated 07/17/25, indicated after Resident #4 had finished eating, she was slipping out of her chair. LVN D returned Resident #4 to her room in the wheelchair. LVN D stated when she stood up Resident #4 and she pulled against her, and she let her go before she knew it and had tried to grab her. LVN D stated she did not want to fall on her. LVN D wrote she saw Resident #4 was ok and left to clean up the wheelchair. During an observation on 09/09/25 at 09:32 AM, Resident # 4 was laying on the mattress in room. Resident #4 was non- interviewable. During an interview on 09/09/25 at 10:05 AM, Resident #4's family member stated she was very upset upon viewing the camera video of how LVN D threw Resident #4 on to the mattress during the transfer. Resident's 4's family member stated she immediately contacted the Administrator regarding the unnecessary roughness and lack of care used when providing care to Resident #4 on 07/17/2025. Resident #4's family member said she provided the Administrator with the video of the transfer. Resident #4's family member stated to her knowledge LVN D had not been back into Resident #4's room and was terminated. Resident #4's family member was tearful. Resident #4 's family member stated Resident #4 had a bruise to her right elbow and redness on her abdomen. During an observation on 09/09/25 at 1:27 PM of a video, date stamped 07/17/25 at 01:08 PM, LVN D wheeled Resident #4 into her room. Resident #4's bed mattress was located directly on the floor. LVN D lifted Resident #4 from the wheelchair and threw her onto the mattress. Resident #4 could be heard moaning and was rolling from side to side. LVN D turned and walked out of the room. Attempted telephone call to LVN D on 09/09/25 at 02:15 PM; left a voice message and requested a call back. During an interview on 09/09/25 at 04:30 PM, the Administrator stated she was the abuse coordinator for the facility and responsible to investigate and report any and all abuse allegations. The Administrator stated the importance of reporting and investigation timely was to prevent any further harm or harm to residents. The Administrator stated she had seen the video provided by Resident #4's family member on 07/17/25. The Administrator said the police were notified immediately. The Administrator said she did not report LVN D to the board of nursing because the police stated they could not get a good view to decide if LVN D had pushed or just lost her balance when Resident #4 was transferred. The Administrator stated LVN D was terminated on 07/18/25 and had not provided care to any residence after 07/17/25. The Administrator become tearful during the interview and said the care provided by LVN D during the video was abuse. Attempted telephone call to LVN D on 09/09/25 at 09:01 PM; left a voice message and requested a call back. Record review of the personnel chart of LVN D reflected she was terminated on 07/18/25. Record review of the personnel chart of LVN D reflected completion of Abuse and Neglect training upon hire date of 10/03/18 and yearly thereafter. The following Employee Disciplinary Memorandums for LVN D: 10/18/24 regarding failure to properly perform skin assessments. 2. Record review of a face sheet dated 09/11/25 indicated Resident #9 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including acute kidney failure, metabolic encephalopathy (imbalance in body's chemical processes leading to abnormal brain function), chronic obstructive pulmonary disease (progressive lung disease causing shortness of breath, cough, and airflow limitations), type 2 diabetes mellitus (excessive sugar in the blood). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #9 understood others and was understood by others. The MDS indicated Resident #9 had a BIMS score of 11 and was moderately cognitively impaired. The MDS indicated Resident #9 was independent with eating, required moderate assistance with showering and dressing, and dependent with toileting hygiene. Record review of Resident #9's care plan dated 08/06/25 indicated Resident #9 had a history of trauma related to being choked that may have a negative impact. The interventions included monitor for escalating anxiety, depression and sleep disturbances, perform de-escalation techniques as needed. Record review of Resident #9's Order Summary Report dated 09/11/25 indicated Acetaminophen-Codeine Tablet 300-30mg, give one tablet by mouth every 6 hours as needed for pain related to kidney failure dated 007/29/25 Record review of a Provider Investigation Report dated 08/18/25 at 08:17 AM, indicated Resident #9 alleged, [LVN E] refused to give her pain medications and hit the side of her mattress with her fist and told her she didn't need the pain medication. [Resident #9] alleged LVN E stormed out of the room cussing and yelling up and down the hall. LVN E was suspended pending investigation and safe surveys conducted, staff in services and trauma assessment completed on Resident #9. Record review of trauma assessment completed on 08/18/25 by the SW indicated Resident #9 had no trauma. Record review of written statement by LVN E dated 08/20/25 stated, whenever, Resident #9, asks for her medicine (pain meds) I always check the time, assess her pain and let her know whether it's time or not. Sometimes she agrees and sometimes she doesn't. She often states that she doesn't know why she turns her light on (forgets) or she just shrugs her shoulders. Most times she is easily redirected. Sunday, August 17th, 2025, I had the opportunity to meet and greet Resident #9's . I kneeled down in front of Resident #9 because she was in her wheelchair, took her left hand held it and greeted her and introduced myself to her family and thanked them for allowing me to be a part of her care. I stated it was my pride and privilege to take care of their loved one. The smiled, nodded and said, that is enough. It startled me just a bit, I stood up and apologized for interrupting their visit. He smiled and that was it. I empathically deny any allegations of cussing up and down the hall. First, profanity is verbal abuse. Second, there were CNA's present most of the night. I was the only one there at 02:30 AM. Third, I respect these elders home period. Attempted telephone call to LVN E on 09/09/25 at 11:40 AM left a voice message and requested a call back. During an interview on 09/09/25 at 12:25 PM, Resident #9's family member stated, he had received a call at approximately 03:00 AM on 08/17/25 from Resident #9. Resident #9's family member stated that Resident #9 complained that LVN E would not give her pain medications and was cussing and yelling at her. Resident #9 stated LVN E snatched up the blanket and slammed it back down on to her feet. Resident #9 family member stated he contacted the facility by phone and spoke with a nurse but could not recall the name and requested Resident #9's was checked on and pain medication administered appropriately. Resident #9's family member stated he did not hear anything more from Resident #9 or the facility the remainder of the night. Resident #9's family member stated that on 08/17/25 while visiting Resident #9, he had encountered LVN E. Resident #9's family member stated LVN E was talking to Resident #9 like she was a child and in a condescending manner. Resident #9's family member stated he told LVN E that was enough. Resident #9's family member stated, LVN E acted very peculiar as if she was on drugs. Resident #9's family member stated he received a call from the Administrator on 08/18/25 regarding Resident #9's previous allegations regarding LVN E. Resident #9's family member confirmed he had received the call from Resident #9. Resident #9's family member stated he also reported the incident wherein he had told LVN E to stop talking to Resident #9 in the childlike, condescending manner on 07/17/25 during a visit. Resident #9's family member stated he had requested LVN E not take care of Resident #9 due to her behaviors. Resident #9's family member stated that later perhaps the next day or so, he had received a call from the Administrator wherein she stated the allegations had been confirmed and LVN E was terminated from the facility. During an interview on 09/09/25 at 12:45 PM, Resident #9 stated she had used the call light button and waited on LVN E for a long time the night the incident occurred. Resident #9 stated upon LVN E entering her room she asked for her pain medication. Resident #9 stated LVN E began cussing and hitting the side of her bed and said she was not getting her pain medication, and she could not have it. Resident #9 said LVN E picked up her covers and slammed it back down over her feet. Resident #9 said LVN E then left her room yelling and cussing that she was not going to get the pain medication for her. Resident #9 stated she called her family member. Resident #9 stated she did not see LVN E for the remainder of the shift. Resident #9 said it was not very long before the day shift arrived, and she received her medication. Resident #9 said LVN E was always talking and moving around fast and rushed. Resident #9 stated she reported the incident to the one of the night shifts nurses the following evening. Resident #9 stated that later that evening after she told the nurse about the incident with LVN E, the Administrator spoke with her regarding the incident. During an interview on 09/09/25 at 12:55 PM, the Administrator stated Resident #9 had reported to RN T on 08/18/25 at approximately 07:00 PM that LVN E had grabbed her and thrown her into a chair and cursed her. The Administrator stated upon interviewing Resident #9, she stated she had used her call light and requested pain medication after waiting a long time. Resident #9 stated when LVN E walked into the room, she told Resident #9 she was not getting pain medication and begin hitting the side of the bed and slung the covers off her. The Administrator stated Resident #9 said she was not physically touched by LVN E. The Administrator stated Resident #9 left the room and was cussing and yelling in the halls. The Administrator stated when she contacted Resident #9's family member, she was told that LVN E had talked to Resident E in a condescending manner. The Administrator stated Resident #9's family member expressed concern and requested LVN E be kept away from Resident #9. The Administrator stated she had interviewed staff and confirmed LVN E had erratic behaviors such has yelling and cussing in front of the residents. The Administrator stated LVN E had only worked at the facility for about 2 weeks. The Administrator stated LVN E was terminated on 08/20/25. Attempted telephone call to LVN E on 09/09/25 at 01:15 PM; left a voice message and requested a call back. Attempted telephone call to RN T on 09/09/25 at 04:17 PM; sent a text message requesting call back per the voice mail message instructions. Attempted telephone call to RN T on 09/09/25 at 07:30 PM; sent a text message requesting call back per the voice mail message instructions Attempted telephone call to LVN E on 09/09/25 at 07:49 PM; left a voice message and requested a call back. During an interview on 09/09/25 at 07:50 PM, CNA F stated she had worked at the facility for 14 years. CNA F stated she currently worked the B hall. CNA F stated she had heard LVN E hollering before in the hallways. CNA F stated she did not know the situation of why LVN E was cussing and hollering but she had heard it. CNA F stated she had been reassigned to work B hall over the last month and had been working in the locked unit before. Attempted telephone call to LVN E on 09/10/25 at 02:30 PM; left a voice message and requested a call back. During an interview on 09/12/25 at 10:57 AM, the DON stated she had witnessed, on the night shift, LVN E holler and using profanity in the hallway while residents were present. The DON stated it was around the time of the incident with Resident #9. The DON stated she immediately addressed the issue with LVN E and had written up LVN E for those actions. The DON stated she expected the staff to treat the residents with respect and dignity. The DON stated all staff were responsible to report any suspicion or allegations of abuse to the abuse coordinator immediately. The DON stated the facility was the resident's home and no one appreciated being talked to or listening to that type of language in their own homes. The DON said using profanity to the residents was considered verbal abuse and could result in the residents feeling frightened, scared, degraded, or even humiliated. During an interview on 09/12/25 at 12:30 PM, the Administrator said she was the abuse coordinator. The Administrator said she expected all staff to report any type of abuse to her immediately. The Administrator said it was her responsibility to report and investigate allegations of abuse. The Administrator said the purpose of reporting timely and investigating properly was to prevent further abuse from occurring. The Administrator said LVN E was terminated following the investigation that involved Resident #9. Record review of the personnel chart of LVN E reflected she was terminated on 08/21/25. Record review of the personnel chart of LVN E reflected completion of Abuse and Neglect training upon hire date of 08/06/25 and yearly thereafter. The following Employee Disciplinary Memorandums for LVN E: 08/15/25 regarding hollering and using profanity in the hallways with residents present. 3. Record review of the face sheet, dated 09/11/25, reflected Resident #12 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of dementia (memory loss) psychosis (state of impaired reality), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the admission MDS assessment, dated 08/11/25, reflected Resident #12 had clear speech, was usually understood, and was usually able to understand others. Resident #12 had a BIMS score of 9, which indicated moderately impaired cognition. The MDS reflected Resident #12 had physical behaviors directed toward others 1-3 days and wandering behaviors 4 to 6 days during the look-back period. Record review of Resident #12's comprehensive care plan, initiated on 08/06/25, reflected no care plan had been developed for behaviors. Record review of the order summary report, dated 09/11/25, reflected Resident #12 had an order, which started on 07/31/25, that indicated he may reside on the secured unit related to exit seeking behaviors. Record review of the behavior incident report, dated 08/07/25 at 7:25 AM, reflected CNA N reported that Resident #13 was in Resident #12's room looking at pictures on his nightstand when Resident #12 pushed Resident #13. There were no injuries. The report reflected Residents #12 and #13 were separated and the Administrator was notified. Record review of the behavior incident report, dated 08/23/25 at 6:20 AM, reflected Resident #12 pushed Resident #13 to the floor. Resident #12 reported Resident #13 tried to come into his room, so he stopped her. The incident was unwitnessed by staff. Record review of Resident #12's progress notes, reflected the following: On 09/06/25 at 12:41 PM, Resident #12 was transferred to another facility. Record review of the face sheet, dated 09/11/25, reflected Resident #13 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of dementia (memory loss) and anxiety disorder. Record review of the quarterly MDS assessment, dated 05/29/25, reflected Resident #13 had clear speech, was usually understood, and was sometimes able to understand others. Resident #13 had a BIMS score of 3, which indicated severe cognitive impairment. The MDS reflected Resident #13 had no behaviors or refusal of care. Record review of the comprehensive care plan, last reviewed 06/05/25, reflected Resident #13 had the potential to demonstrate verbally and physically abusive behaviors. The care plan further revealed Resident #13 was at risk for elopement and resided on the secured unit. The interventions included: supervise closely and make regular compliance rounds whenever resident is in room. Record review of the order summary report, dated 08/23/25, reflected Resident #13 had an order, which started on 02/26/25, that she may reside on the secured unit related to exit seeking behaviors. Record review of Resident #13's progress notes, reflected the following: On 08/07/25 at 4:25 PM a trauma assessment was completed and was negative. On 08/08/25 at 9:02 PM, it was documented Resident #13 had no injury or adverse reaction from being pushed. On 08/23/25 at 6:20 AM, an event note was completed that reflected Resident #13 had 2 scratches on the right side of face and redness to side of left arm below the elbow. She reported that Resident #12 pushed her. X-rays were ordered of hips and elbows. On 08/23/25 at 9:11 AM, the Social Worker documented that she was notified Resident #13 was pushed by another male resident, which resulted in a fall to the floor. Resident #13 did not appear to be in distress, she was smiling and in a pleasant mood. On 08/26/25 at 12:04, Resident #13 was discharged to another facility. 4. Record review of the face sheet, dated 09/11/25, reflected Resident #5 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills), severe protein-calorie malnutrition (not getting enough protein or calories to meet the bodies demands), gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), anorexia (loss of appetite), and dysphagia (difficulty swallowing). Record review of the quarterly MDS assessment, dated 07/30/25, reflected Resident #5 had unclear speech, was rarely/never understood, and was rarely/never able to understand others. Resident #5 had short-term and long-term memory problems. Resident #5 had no memory or recall ability and had severely impaired decision- making skills. The MDS reflected Resident #5 had upper and lower extremity impairments to both sides which interfered with daily functions. The MDS reflected Resident #5 was dependent on staff for all his ADLs. Resident #5 used a feeding tube while a resident and also received a mechanically altered diet. The MDS reflected Resident #5 received 51% of more of his total calories through tube feeding. Record review of the comprehensive care plan, last reviewed 06/17/25, reflected Resident #5 required tube feeing related to anorexia and Alzheimer's disease. The interventions included: .the resident needs the head of bed elevated 30 degrees during and thirty minutes after tube feeding. The care plan further reflected Resident #5 had an ADL self-care deficit and required staff assistance x 1 with eating. Record review of the order summary report, dated 09/11/25, reflected Resident #5 had an order for regular diet and pureed texture with pudding consistency fluids, [Family member] or nurse to assist with feeding. The order started on 08/26/25. Record review of the progress notes reflected the following: On 08/21/25 at 4:03 AM, the note reflected [Resident #5]'s family member requested a chest x-ray due to possible aspiration . due to positioning of resident in chair on previous shift.No signs or symptoms of aspiration noted . head of bed elevated to 30 degrees. On 08/21/25 at 7:47 AM, the note reflected a response was received from the physician for a chest x-ray. On 08/22/25 at 3:29 AM, the note reflected Resident #5 was transferred to the hospital related to chest x-ray results findings indicated aspiration. Record review of Resident #5's diagnostic chest x-ray report, dated 08/21/25, reflected .reported gastrostomy tube is not definitely visualized.air distended stomach.left basilar airspace disease (condition in which the lower lungs of the left lung collapse, preventing air exchange), likely atelectasis (collapse of lung or part of lung from lack of air in the air sacs) given elevation of the hemidiaphragm. Record review of the inpatient hospital record, dated 08/22/25, reflected Resident #5 arrived at the hospital at 4:04 AM via ambulance and was discharged back to the facility at 5:46 AM. The problems addressed was aspiration into airway, initial encounter. During an observation on 09/08/25 beginning at 1:25 PM of a video date and time stamped, 08/20/25 3:13 PM, revealed Resident #5 leaning over the left armrest of his Geri-chair. He was moaning and grunting, unable to lift his torso or head. At 3:16 PM, CNA G walked into the room, pulls his arm and ask him to sit up, and then walked out of the room. The interaction lasted approximately 45 seconds. Resident #5 returned to the same position within approximately 30 seconds after CNA G left the room. Resident #5 remained in the same position, where his head and torso were leaning over the left armrest for approximately 1 hour and 30 minutes. Resident #5 constantly moaned and grunted during the video until LVN L sets up him with pillows and positioned him comfortably at 4:26 PM. During an interview on 09/09/25 beginning at 2:38 PM, Resident #5's family member stated on 08/20/25 she had gone out to eat and did not watch the camera as she normally did. Resident #5's family member stated when she got home, she noticed a neck pillow was blocking the view of the camera, so she called the facility. Resident #5's family member stated she went back to review the video prior to the pillow blocking camera and noticed he had been leaning over his chair for about 2 hours. Resident #5's family member was concerned he may have aspirated so she requested a chest x-ray be performed. Resident #5's family member stated the chest x-ray showed aspiration pneumonia, and he was sent to the hospital. Resident #5's family member stated he was returned to the facility on antibiotics. Resident #5's family member stated the facility staff did not have enough help. Resident #5's family member stated she believed the incident would not have occurred if the facility had sufficient staffing because they would have been able to check on him more frequently. During an interview on 09/09/25 beginning at 10:55 AM, LVN M stated Resident #5's family member had requested that he go to the hospital because she was concerned about something that had occurred on the camera, and she believed he could have possibly aspirated. LVN M stated she notified the physician, and he was agreeable, so she sent Resident #5 to the hospital per the family member's request. LVN M stated Resident #5 had no signs or symptoms of aspiration, such as nasal drainage, shortness of breath, or wheezing. LVN M stated the facility had obtained the order for a chest x-ray, but it had not been completed before he was sent to the hospital, if she remembered correctly. LVN M stated Resident #5 did not return back from the hospital on her shift, so she was unaware of what he was treated for at the hospital. During an interview on 09/09/25 beginning at 11:50 AM, CNA G stated on 08/20/25 she was on the way to answer another resident's call light when she walked by Resident #5's room and noticed he was leaning over. CNA G stated she grabbed Resident #5 under the arm and elbow to sit him up. CNA G stated she sat Resident #5 up the best she could then proceeded to answer the call light. CNA G stated she was the only staff member assigned to her hallway and stated she never thought to check on him again because she had so much going through her mind. CNA G stated she was called later on to provide a statement of the incident. CNA G said she had just graduated CNA school about 4 months ago and was still learning things. CNA G stated grabbing someone by the arm was not the proper way to position them. CNA G stated the facility did provide her one-on-one education on proper positioning. CNA G stated looking back she should have checked on Resident #5 sooner, but it was hard to recognize in the moment because of the staffing concerns. CNA G stated Resident #5 should have been positioned in a Fowler's position (upright) during a tube feeding. CNA G stated improperly positioning a resident during a tube feeding could result in aspiration. CNA G stated she did help the nurse with wound care for Resident #2 because there was no one else to help. CNA G stated there were staffing concerns at the facility because no one wanted to work. CNA G stated the facility staff did not like the management staff. CNA G stated she had only worked at the facility since June 2025. CNA G stated at times she was the only CNA who was assigned to two halls, which was approximately 25 residents. CNA G stated she was unable to provide the care and services each resident required when she was scheduled alone. CNA G stated she felt rushed with the residents. CNA G stated management staff were aware of the staffing concerns, but felt like nothing was addressed. CNA G stated management did not consistently help out on the floor. CNA G stated the DON would provide assistance to one resident because of the camera in the room, but most of the time when she asked for help the DON would say Let me find someone to help you. CNA G stated she normally worked the C-Hall (the secured unit) and was the only staff member scheduled. Record review of Resident #2's face sheet dated 9/11/25 indicated Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnosis including acute posthemorrhagic anemia (is a condition that develops when you lose a large amount of blood quickly), heart failure (is a condition where the heart muscle cannot pump blood effectively enough to meet the body's needs), type 2 diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and pressure ulcer of left heel, stage 3 (injuries extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and usually had the ability to understand others. Resident #2's had a BIMS score of 7 which indicated moderate cognitive impairment. Resident #2 required setup assistance for eating, supervision for oral hygiene, partial assistance for upper body dressing and personal hygiene, and dependent for toileting hygiene, shower/bathe self, and lower body dressing. Resident #2 was always incontinent for urine and occasionally incontinent for bowel. Resident #2 had one, stage 3 unhealed pressure ulcers/injuries. Resident #2 had pressure reducing device for bed and pressure ulcer/injury care. Record review of Resident #2's care plan, revised on 9/11/25, indicated Resident #2 had a pressure ulcer due to decreased mobility. Resident #2 had stage 3 pressure injury to left heel. Interventions included follow facility policies/protocols for the prevention/treatment of skin breakdown and administer medications as ordered. Record review of Resident #2's order summary report dated 9/11/25 indicated: Stage 3 pressure injury, cleanse left heel with normal saline, apply collagen powder, and cover with gauze island with border every day and as needed, one time a day for wound healing. Start date 8/25/25. Record review of Resident #2's wound administration record dated 8/1/25-8/31/25 indicated: Cleanse left heel with normal saline, apply collagen powder, and cover with gauze island with border ev

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident had the right to be free from misappropriation of property for 1 of 2 residents reviewed for misappropriation of property. (Resident #15) The facility failed to prevent a drug diversion (misappropriation) of Resident #15's Oxycodone 10 MG on 8/15/25. This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity.Findings included:Record review of Resident #15's face sheet dated 9/8/25 indicated Resident #15 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #15 had diagnoses including fibromyalgia (is a long-term condition that involves widespread body pain), and low back pain.Record review of Resident #15's quarterly MDS assessment dated [DATE] indicated Resident #15 had clear speech, adequate hearing and vision. Resident #15 was understood and had the ability to understand others. Resident #15 had a BIMS score of 15 which indicated intact cognition. Resident #15 was independent for eating, oral hygiene, and toilet hygiene, partial assistance for shower/bathe self and personal hygiene. Resident #15 received scheduled pain medication regimen. Resident #15 received opioids. Record review of Resident #15's care plan dated 3/23/22 indicated Resident #15 was on pain medication therapy related to fibromyalgia and wound. Intervention included administer medications as ordered. Record review of Resident #15's order summary report dated 8/1/25 indicated: Oxycodone Oral Tablet 10 MG (is used to relieve pain severe enough to require opioid treatment and when other pain medicines did not work well enough or cannot be tolerated), give 1 tablet by mouth five times a day for pain. Start date 8/8/25. Record review of Resident #15's MAR dated 8/1/25-8/31/25 indicated Oxycodone Oral Tablet 10 MG, give 1 tablet by mouth five times a day for pain. Times: 6am, 11am, 4pm, 9pm, and 1am. The MAR indicated on 8/15/25, Resident #15 received doses at 1am, 6am, 11am, 4pm, and 9pm. Record review of Resident #15's Individual Control Drug Record for Oxycodone 10 MG dated 8/8/25 indicated:*8/15/25 at 1am or 9am (notation of time is unclear), 1 pill given, 55 pills left, LVN E.*8/15/25 at (notation of time is unclear), 1 pill given, 54 pills left, LVN E.*8/15/25 at 6am, 1 pill given, 53 pills left, LVN E.*8/15/25 at 11am, 1 pill given, 52 pills left, MA B.*8/15/25 at 4pm, 1 pill given, 51 pills left, LVN Q*Unknown date at 8:26 pm, 1 pill given, 50 pills left, LVN LResident #15's Individual Control Drug Record reflected 6 administrations of oxycodone on 8/15/25. Resident #15 is scheduled for 5 oxycodone doses each shift (1am, 6am, 11am, 4pm, and 9pm). Record review of Resident #15's e-MAR report dated 9/9/25 provided by RCN EE indicated:*8/15/25: Scheduled for 1am, 1 tablet, given at 12:25 am by LVN E.*8/15/25: Scheduled for 6am, 1 tablet, given at 5:58 am by LVN E.*8/15/25: Scheduled for 11am, 1 tablet, given at 11:04 am by MA B.*8/15/25: Scheduled for 4pm, 1 tablet, given at 4:25 pm by LVN Q.*8/15/25: Scheduled for 9pm, 1 tablet, given at 8:25 pm by DON.Resident #15's e-MAR report did not reflect 6 administration times on 8/15/25 to correlate with the Individual Control Drug Record. Record review of a witness statement by the DON dated 8/15/25 indicated, .issue related to: medication administration error. on Friday, August 15th this nurse was notified around 2 pm by the CMA [MA B] and Treatment Nurse [LVN L] that LVN E had signed out too many Oxycodone for Resident #15 on the morning of August 15th. This nurse [DON] assessed the resident and asked her about this. Resident #15 state that [LVN E] administers her medications but not always at the right time. No adverse side effects or harm was done to the resident. Signature of witness: DON. Signature of Management Employee Obtaining Statement: ADM. During an interview on 9/9/25 at 9:46 a.m., MA B said she had been working at the facility for 2 years. She said she worked Hall C and D. She said on 8/15/25, she started the shift and counted Resident #15's oxycodone pills. She said she noticed an extra entry on the narcotic count sheet for Resident #15. She said when she asked LVN E about the extra entry, LVN E said she must have given Resident #15 too many pills. MA B said that did not seem right because Resident #15 counted her pills before she took them. She said she asked Resident #15 if LVN E gave her an extra oxycodone pill. She said Resident #15 said, no. She said she reported the issue to the ADM and DON. She said 8/15/25 was the first time she had noticed a medication administration issue from LVN E. She said LVN E had strange behaviors. She said LVN E moved around really fast all time. She said LVN E continued to work Hall D with Resident #15. She said she eventually was fired for another incident. Attempted telephone call to LVN E on 9/9/25 at 01:15 PM left a voice message and requested a call back. Attempted telephone call to LVN E on 9/9/25 at 07:49 PM left a voice message and requested a call back. During an interview on 9/10/25 at 9:45 a.m., LVN L said on 8/15/25, MA B reported to her that she did a shift-to-shift narcotic count with LVN E. She said MA E said the count with LVN E was not right. She said MA B reported there were too many entries for LVN E's shift. She said she could not quite remember LVN E exact words on what caused the discrepancy. She said LVN E reported to the effect, that she thought she gave Resident #15 her oxycodone but could not remember. She said one of Resident #15's oxycodone pills was missing and could not be accounted for. She said LVN E did not say she wasted or discarded one of Resident #15's oxycodone pills. She said she reported the incident to the ADM and DON. She said the DON went to Resident #15 to see if she had received pain medication. She said she did not know what Resident #15 had reported to the DON. She said Resident #15 counted and inspected her pills during medication pass. She said the incident with LVN E could have been a drug diversion. She said that was why she reported the incident to the ADM and DON. She said LVN E was an abnormally strange person. She said LVN E was eventually let go, but not for the incident on 8/15/25. During an interview on 9/10/25 at 12:42 p.m., Resident #15 said she did not recall the incident on 8/15/25. She said sadly, she got asked about her pain medication all the time. She said she inspected and counted her pills before she took them. She said she would not have taken an extra oxycodone on 8/15/25. Attempted telephone call to LVN E on 09/10/2025 at 02:30 PM left a voice message and requested a call back. During an interview on 9/12/25 at 10:45 a.m., the DON said the incident on 8/15/25 with LVN E was reported by MA B. She said when she questioned LVN E about the documented extra oxycodone dose on Resident #15; LVN E said she administered it at the right time but wrote down the wrong time. She said the MA B did not report what LVN E said when asked about the extra entries on the narcotic count sheet. She said she did not get a written statement from LVN E about the incident on 8/15/25. She said the incident on 8/15/25 could have possibly been a drug diversion. She said she did not ask Resident #15 if LVN E gave her an extra oxycodone dose on 8/15/25. She said when a resident medication was misappropriated, they could miss a dose or get too many. She said when a resident medication was misappropriated, it was considered abuse and neglect. She said the MAs and CNs should initially ensure a resident did not experience misappropriation. She said then it was the responsibility of the ADON and DON. During an interview on 9/12/25 at 12:51 p.m., the ADM said she was aware of the incident on 8/15/25 regarding LVN E. She said if Resident #15's oxycodone was missing then it would be considered a drug diversion. She said the staff did not report LVN E had any suspicious behavior on 8/15/25. She said when a residents' medication was misappropriated, it could cause harm. She said the DON was responsible for ensuring the residents' medications were not appropriated. During an interview on 9/12/25 at 4:37 p.m., RCN EE said the DON asked her for help with a medication error. She said the DON texted her and reported that LVN E had administered Resident #15's oxycodone too close together. She said the DON reported when she looked at Resident #15's narcotic count sheet, it looked like LVN E signed the oxycodone out too close together. She said the DON may have not known how to run an eMAR report on Resident #15's oxycodone to see the actual times of administration. She said the DON was new to the facility and role as a DON. She said she asked the DON if Resident #15 had experienced any adverse effects from the medication error. She said the DON reported Resident #15 had not experienced adverse effects. She said the DON reported LVN E said she gave Resident #15's oxycodone too close together also. She said she instructed the DON to notify the MD of the incident and do a medication error report. She said if a drug diversion was suspected, then the facility suspended the MA or CN involved in the incident. She said the facility also drug tested the staff members if suspicious behavior was noted. She said it was important to prevent misappropriation because the resident needed their medications, and it affected their quality of life. She said the MAs and CNs were responsible for ensuring the residents' medications were not misappropriated. She said the shift-to-shift count should ensure misappropriation did not occur. Record review of LVN E's Employee Disciplinary Report dated 8/15/25 indicated, .LVN E. date of Infraction: 8/15/25. written counseling. LVN E failed to adhere to the Corporate Code of Conduct by failing to meet their job duty/responsibility expectations. On 8/15/25, LVN E failed to administer medication correctly, resulting in a medication error. Record review of an undated facility's Abuse/Neglect policy indicated, . The resident has the right to be free from abuse, neglect, misappropriation of resident property. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff. misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all allegations of abuse and neglect had evidence that all alleged violations were thoroughly investigated and prevent further potential for 2 of 20 residents (Resident #15 and Residents #9) reviewed abuse, neglect and misappropriation. 1. The ADM and DON, failed to thoroughly investigate allegation of misappropriation of property, when LVN E documented an extra administration of Resident #15's oxycodone on 8/15/25. Resident #15 denied receiving an extra dose on 8/15/25. The ADM and DON, failed to provide evidence that Resident #15's incident on 8/15/25, with allegation of misappropriation of property, Oxycodone 10 MG, was thoroughly investigated. The facility failed to protect Resident #15 from potential further misappropriation of property after the allegation. LVN E continued to work from the date of the incident until suspension on 8/18/25. 2. The facility failed to protect Resident #9, after not thoroughly investigating Resident #15 incident on 8/15/25, from experiencing allegation of neglect from LVN E. LVN E failed to administer Resident #9 her pain medication as requested on 08/17/2025. The facility failed to investigate Resident #9's allegation of neglect when LVN E failed to administer Resident #9 her pain medication as requested on 08/17/2025. These failures could place residents at risk increased pain, decreased quality of life, and further abuse and neglect.Findings include:<BR/>1. Record review of a witness statement by the DON dated 8/15/25 indicated, &ldquo;&hellip;issue related to: medication administration error&hellip; on Friday, August 15th this nurse was notified around 2 pm by the CMA [MA B] and Treatment Nurse [LVN L] that LVN E had signed out too many Oxycodone for Resident #15 on the morning of August 15th&hellip; This nurse [DON] assessed the resident and asked her about this&hellip; Resident #15 state that [LVN E] administers her medications but not always at the right time&hellip; No adverse side effects or harm was done to the resident&hellip; Signature of witness: DON&hellip; Signature of Management Employee Obtaining Statement: ADM&hellip;&rdquo; <BR/>Record review of LVN E's &ldquo;Employee Disciplinary Report&rdquo; dated 8/15/25 indicated, &ldquo;&hellip;LVN E&hellip; date of Infraction: 8/15/25&hellip; written counseling&hellip; LVN E failed to adhere to the Corporate Code of Conduct by failing to meet their job duty/responsibility expectations&hellip; On 8/15/25, LVN E failed to administer medication correctly, resulting in a medication error&hellip;&rdquo;<BR/>Record review of Resident #15's face sheet dated 9/8/25 indicated Resident #15 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #15 had diagnoses including fibromyalgia (is a long-term condition that involves widespread body pain), low back pain, major depressive disorder (a persistently low or depressed mood and a loss of interest in activities that you used to enjoy), and anxiety (intense, excessive, and persistent worry and fear about everyday situations).<BR/>Record review of Resident #15's quarterly MDS assessment dated [DATE] indicated Resident #15 had clear speech, adequate hearing and vision. Resident #15 was understood and had the ability to understand others. Resident #15 had a BIMS score of 15 which indicated intact cognition. Resident #15 was independent for eating, oral hygiene, and toilet hygiene, partial assistance for shower/bathe self and personal hygiene. Resident #15 received scheduled pain medication regimen. Resident #15 received opioids. <BR/>Record review of Resident #15's care plan dated 3/23/22 indicated Resident #15 was on pain medication therapy related to fibromyalgia and wound. Intervention included administer medications as ordered.<BR/>Record review of Resident #15's &ldquo;Individual Control Drug Record&rdquo; Oxycodone 10 MG dated 8/8/25 indicated LVN E signed out administrations on 8/15/25, 8/16/25, 8/17/25, and 8/18/25.<BR/>During an interview on 9/9/25 at 9:46 a.m., MA E said she had been working at the facility for 2 years. She said she worked Hall C and D. She said on 8/15/25, she started the shift and counted Resident #15's oxycodone pills. She said she noticed an extra entry on the narcotic count sheet for Resident #15. She said when she asked LVN E about the extra entry, LVN E said she must have given Resident #15 too many pills. MA E said that did not seem right because Resident #15 counted her pills before she took them. She said she asked Resident #15 if LVN E gave her an extra oxycodone pill. She said Resident #15 said, &ldquo;no&rdquo;. She said she reported the issue to the ADM and DON. She said 8/15/25 was the first time she had noticed a medication administration issue from LVN E. She said LVN E had strange behaviors. She said LVN E moved around really fast all time. She said LVN E continued to work Hall D with Resident #15. She said she eventually was fired for another incident. She said she did not recall receiving an in-service related to the incident on 8/15/25. <BR/>Attempted telephone call to LVN E on 9/9/25 at 01:15 PM left a voice message and requested a call back. <BR/>Attempted telephone call to LVN E on 9/9/25 at 07:49 PM left a voice message and requested a call back. <BR/>During an interview on 9/10/25 at 9:45 a.m., LVN L said on 8/15/25, MA B reported to her that she did a shift-to-shift narcotic count with LVN E. She said MA B said the count with LVN E was not right. She said MA B reported there were too many entries for LVN E's shift. She said she could not quite remember LVN E exact words on what caused the discrepancy. She said LVN E reported to the effect, that she thought she gave Resident #15 her oxycodone but could not remember. She said one of Resident #15's oxycodone pills was missing and could not be accounted for. She said LVN E did not say she wasted or discarded one of Resident #15's oxycodone pills. She said she reported the incident to the ADM and DON. She said the DON went to Resident #15 to see if she had received pain medication. She said she did not know what Resident #15 had reported to the DON. She said Resident #15 counted and inspected her pills during medication pass. She said the incident with LVN E could have been a drug diversion. She said that was why she reported the incident to the ADM and DON. She said LVN E was an &ldquo;abnormally strange&rdquo; person. She said LVN E was eventually let go, but not for the incident on 8/15/25. She said she may have received abuse and neglect training after the incident. She said she did not recall training about medication administration and narcotic counts sheets.<BR/>During an interview on 9/10/25 at 12:42 p.m., Resident #15 said she did not recall the incident on 8/15/25. She said sadly, she got asked about her pain medication all the time. She said she inspected and counted her pills before she took them. She said she would not have taken an extra oxycodone on 8/15/25. <BR/>Attempted telephone call to LVN E on 09/10/2025 at 02:30 PM left a voice message and requested a call back. <BR/>On 9/11/25 at 8:57 a.m., requested a copy of Resident #15's investigation by email. The email was sent to the ADM and RCN EE.<BR/>On 9/11/25 at 1:00 p.m., requested a copy of Resident #15's investigation from ADM. <BR/>During an interview on 9/12/25 at 10:45 a.m., the DON said the incident on 8/15/25 with LVN E was reported by MA B. She said she told the ADM about the incident. She said the ADM was the Abuse Coordinator. She said the ADM told her to investigate the incident. She said she got a statement from MA B, spoke to Resident #15 and called LVN E. She said she did not get a written statement from LVN E about the incident on 8/15/25. She said when she questioned LVN E about the documented extra oxycodone dose on Resident #15; LVN E said she administered it at the right time but wrote down the wrong time. She said the incident on 8/15/25 could have possibly been a drug diversion. She said the staff did not report LVN E having any suspicious behaviors. She said she did not ask Resident #15 if LVN E gave her an extra oxycodone dose on 8/15/25. She said LVN E continued to pass medication to Resident #15. She said it was important to do a thorough investigation to make sure the abuse did not go any further and stop it from happening. She said when it was not done the resident could experience continued abuse. She said after the incident on 8/15/25, LVN E yelled at the staff and a resident. She said similar allegation were reported on LVN E related to pain medication. Requested a copy of Resident #15's investigation. Did not receive a copy prior or after exit.<BR/>During an interview on 9/12/25 at 12:51 p.m., the ADM said she was aware of the incident on 8/15/25 regarding LVN E. She said if Resident #15's oxycodone pill was missing then it would be considered a drug diversion. She said the staff did not report LVN E had any suspicious behavior on 8/15/25. She said the DON investigated the incident because it was nursing related. She said the DON told her it was a medication error. She said she also thought RCN EE was a part of investigation and agreed it was a medication error. She said it important to do a thorough investigation because it affected the residents' quality of life. She said if the incident was thorough investigated, the drug diversion process would have been followed. She said whoever the investigation was assigned to, was responsible its thoroughness. She said she was the abuse coordinator for the facility. <BR/>During an interview on 9/12/25 at 4:37 p.m., RCN EE said the DON asked her for help with a medication error. She said the DON texted her and reported that LVN E had administered Resident #15's oxycodone too close together. She said the DON reported when she looked at Resident #15's narcotic count sheet, it looked like LVN E signed the oxycodone out too close together. She said the DON may have not known how to run an eMAR report on Resident #15's oxycodone to see the actual times of administration. She said the DON was new to the facility and role as a DON. She said the DON reported LVN E said she gave Resident #15's oxycodone too close together also. She said if the DON did not ask Resident #15 if she received two pills at an administration time, then it was not thorough investigated. She said when an investigation was not thoroughly investigated, it put the resident at risk for continued misappropriation of property. She said the ADM and DON were responsible for investigating allegation of abuse and neglect. She said if a drug diversion was suspected, then the facility suspended the MA or CN involved in the incident. She said the facility also drug tested the staff members if suspicious behavior was noted. <BR/>2. Record review of a face sheet dated 09/11/2025 indicated Resident #9 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including acute kidney failure (condition in which the kidneys cannot filter waste from blood), metabolic encephalopathy (imbalance in body's chemical processes leading to abnormal brain function), chronic obstructive pulmonary disease (progressive lung disease causing shortness of breath, cough, and airflow limitations), and type 2 diabetes mellitus (excessive sugar in the blood).<BR/> Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #9 understood others and was understood by others. The MDS indicated Resident #9 had a BIMS of 11 and was moderately cognitively impaired. The MDS indicated Resident #9 was independent with eating, required moderate assistance with showering and dressing, and was dependent with toileting hygiene. <BR/> Record review of Resident #9's care plan dated 08/06/2025 indicated Resident #9 had a history of trauma related to being choked that may have a negative impact. The interventions included to monitor for escalating anxiety, depression and sleep disturbances, perform de-escalation techniques as needed. <BR/> Record review of Resident #9's Order Summary Report dated 09/11/2025 indicated Resident #9 had an order for Hydrocodone/Acetaminophen (a narcotic pain reliever) 5-325 tablet, give one tablet by mouth every four hours as needed for pain with a start date of 08/10/2025.<BR/> Record review of a Provider Investigation Report dated 08/18/2025 at 08:17 AM, indicated Resident #9 alleged, &ldquo;LVN E refused to give her pain medications and hit the side of her mattress with her fist and told her she didn't need the pain medication. Resident #9 alleged LVN D stormed out of the room cussing and yelling up and down the hall. LVN E was suspended pending investigation and safe surveys conducted, staff in services and trauma assessment completed on Resident #9&rdquo;. Record review of A The Provider Investigation indicated there was no documentation to reflect a pain assessment was completed for Resident #9. Additionally, there was no documentation that reflected Resident #9's medication administration record had been reviewed to verify whether the medication was charted as given or omitted, and there were no documented attempts to determine the reason for the alleged omission. <BR/> Record review of trauma assessment completed on 08/18/2025 by the SW indicated Resident #9 had no trauma.<BR/> Record review of a written statement by LVN E dated 08/20/2025 stated, &ldquo;whenever, Resident #9, asks for her medicine (pain meds) I always check the time, assess her pain and let her know whether it's time or not. Sometimes she agrees and sometimes she doesn't. She often states that she doesn't know why she turns her light on (forgets) or she just shrugs her shoulders. Most times she is easily redirected. Sunday, August 17th, 2025, I had the opportunity to meet and greet Resident #9's son and his wife. I kneeled down in front of Resident #9 because she was in her wheelchair, took her left hand held it and greeted her and introduced myself to her family and thanked them for allowing me to be a part of her care. I stated it was my pride and privilege to take care of their loved one. The son smiled, nodded and said, &ldquo;that is enough&rdquo;. It startled me just a bit, I stood up and apologized for interrupting their visit. His wife smiled and that was it. I empathically deny any allegations of cussing up and down the hall. First, profanity is verbal abuse. Second, there were CNA's present most of the night. I was the only one there at 02:30 AM. Third, I respect these elders home period.&rdquo; <BR/> Record review of Resident #9's Individual Control Drug Record for Hydrocodone/Acetaminophen (a narcotic pain reliever) 5-325 tablet, give one tablet by mouth every four hours as needed for pain was not signed on for 08/17/2025. <BR/>During an interview on 09/09/2025 at 12:25 PM, Resident #9's family member stated, he had received a call at approximately 03:00 AM on 08/17/2025 from Resident #9. Resident #9's family member stated that Resident #9 complained she was in pain and that LVN E would not give her pain medications and was cussing and yelling at her. Resident #9 stated LVN E snatched up the blanket and slammed it back down on to her feet. Resident #9's family member stated he contacted the facility by phone and spoke with a nurse (unsure of name) and requested Resident #9 to be checked on and pain medication to be administered appropriately. Resident #9's family member stated he did not hear anything more from Resident #9 or the facility the remainder of the night. Resident #9's family member stated that on 08/17/2025 while visiting Resident #9, he had encountered LVN E. Resident #9's family member stated LVN E was talking to Resident #9 like she was a child and in a condescending manner. Resident #9's family member stated he told LVN E that was enough. Resident #9's family member stated, &ldquo;LVN E acted very peculiar as if she was on drugs.&rdquo; Resident #9's family member stated he received a call from the Administrator on 08/18/2025 regarding Resident #9's previous allegations regarding LVN E. Resident #9's family member confirmed he had received the call from Resident #9. Resident #9's family member stated he also reported the incident where he had told LVN E to stop talking to Resident #9 in the childlike, condescending manner on 08/17/2025 during a visit. Resident #9's family member stated he had requested LVN E not take care of Resident #9 due to her behaviors. Resident #9's family member stated that later perhaps the next day or so, he had received a call from the Administrator where she stated the allegations had been confirmed and LVN E was terminated from the facility. <BR/> During an interview on 09/09/2025 at 12:45 PM, Resident #9 stated on the day of the incident (08/17/25) she had used the call light button because she was in pain and needed pain medication. She said she waited on LVN E for a long time that night. Resident #9 stated upon LVN E entering her room she asked for her pain medication. Resident #9 stated LVN E &ldquo;began cussing and hitting the side of her bed and said she was not getting my pain medication, and I could not have it&rdquo;. Resident #9 said LVN E picked up her covers and slammed it back down over her feet. Resident #9 said LVN E &ldquo;then left her room yelling and cussing that she was not going to get the pain medication for me&rdquo;. Resident #9 stated she called her family member and reported the incident to them. Resident #9 stated she did not see LVN E for the remainder of the shift. Resident #9 stated she drifted off to sleep. Resident #9 said it was not very long before the day shift arrived, and she received her pain medication at that time. Resident #9 said LVN E was always talking and moving around fast and rushed. Resident #9 stated she reported the incident to one of the night shift nurses the following evening. Resident #9 stated that later that evening after she told the nurse about the incident with LVN E, the Administrator spoke with her regarding the incident. Resident #9 stated the Administrator did not ask her anything more about her pain medication. Resident #9 stated the day nurse assessed her pain around 7 the next AM. Resident #9 stated that was approximately 3 to 4 hours later after she had requested the pain medication from LVN E. <BR/> During an interview on 09/09/2025 at 12:55 PM, the Administrator stated upon interviewing Resident #9, she stated she had used her call light and requested pain medication after waiting a long time. Resident #9 stated when LVN E walked into the room, she told Resident #9 she was not getting pain medication and begin hitting the side of the bed and slung the covers off her. The Administrator stated Resident #9 said she was not physically touched by LVN E. The Administrator stated LVN E left the room and was cussing and yelling in the halls. The Administrator stated when she contacted Resident #9's family member, she was told that LVN E had talked to Resident #9 in a condescending manner. The Administrator stated Resident #9's family member expressed concern and requested LVN E be kept away from Resident #9. The Administrator stated she had interviewed staff and confirmed LVN E had erratic behaviors such has yelling and cussing in front of the residents. The Administrator stated LVN E had only worked at the facility for about 2 weeks. The Administrator stated LVN E was terminated on 08/21/2025. The administrator stated she had not inquired any further regarding the pain medication because she was not clinical and had told the DON. The Administrator stated she was not responsible to follow -up on clinical side. The Administrator said neglect and misappropriation was considered abuse. The Administrator said she was the abuse coordinator for the facility. The Administrator said the lack of appropriate investigations of alleged allegations could result in a resident experiencing an increase in pain as well as a decreased quality of life. <BR/> Attempted telephone call to LVN E on 09/09/2025 at 01:15 PM left a voice message and requested a call back. <BR/> Attempted telephone call to LVN E on 09/09/2025 at 07:49 PM left a voice message and requested a call back. <BR/> Attempted telephone call to LVN E on 09/10/2025 at 02:30 PM left a voice message and requested a call back. <BR/> During an interview on 09/12/2025 at 10:57 AM, the DON stated she had not investigated the allegations of Resident # 9 not receiving pain medications. The DON stated that was the responsibility of the Administrator because she was the Abuse Coordinator. The DON stated when she had heard of the allegations it was days later and the resident was no longer complaining of pain. The DON said misappropriation was considered abuse. The DON said when allegations not investigated could leave the resident at risk of decreased quality of life if they had experience untreated pain. <BR/> Record review of the facility's undated &ldquo;Abuse/Neglect Policy&rdquo;, indicated, &ldquo;The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart &hellip; Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist&hellip; All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated&hellip; The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC&hellip; The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incident(s)&hellip;&rdquo;<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents environment remained as free of accident hazards as possible for 1 of 7 residents (Resident #1) reviewed for accidents and hazards.<BR/>The facility failed to ensure staff checked straps for damage prior to transferring Resident #1 which resulted in a laceration to Resident #1's forehead. <BR/>This failure could place residents at risk for injury.<BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 02/10/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis (weakness on one side of your body) following cerebral infarction (Stroke) affecting the left dominant side.<BR/>Record review of Resident #1''s MDS, dated [DATE], revealed Resident #1 required two-person assistance for transfers and had a BIMS score of 15, which indicated Resident #1 was cognitively intact, alert to person, place, and time. Resident #1 used a wheelchair to ambulate. Resident #1 required extensive assistance with most activities of daily living.<BR/>Record review of Resident #1's care plan, dated 12/27/22, revealed Resident #1 required two-person assistance for transfers and required a mechanical lift due to a self-care performance deficit. <BR/>Record review of Resident #1's nurse's note, dated 02/05/23 at 9:23 PM, by LVN B, revealed Resident #1 was kicking and yelling at staff. LVN B asked LVN A to assist in transferring Resident #1 from his wheelchair to his bed using a Mechanical lift. When LVN A and LVN B arrived in the room three of four straps were already attached to the lift. LVN A attached the last strap and proceeded with the transfer. During the transfer LVN B reported hearing a snap, and Resident #1 fell from the lift to the floor hitting his head causing a laceration. LVN B called 911 and Resident #1 was transferred to the hospital for evaluation and treatment.<BR/>Record review of Resident #1's hospital records, dated 02/05/23, revealed Resident #1 arrived at the hospital with a facial laceration. The fall involved a lift chair assistance as the cause of accidental injury. The injury was repaired with stiches. CT scan (scans take a fast series of X-ray pictures, which are put together to create images of the area that was scanned.), showed no acute intercranial abnormalities, laceration to the soft tissue, swelling to the left frontal scalp and preorbital (around the eye) soft skin. There was mild soft tissue swelling to the left cheek. Resident #1 was released back to the facility after treatment. <BR/>Observation of a video surveillance tape, date stamped on 02/05/22 at 8:48 PM, showed Resident #1 was being transferred from a wheelchair to a bed by LVN A and LVN B using a mechanical lift. The front left strap on the lift appeared to be frayed or damaged. During the transfer, the front left strap holding Resident #1, snapped and Resident #1 fell from the lift and hit his head on the floor.<BR/>During an observation and interview on 02/10/23 at 1:20 PM revealed Resident #1 was in his bed. There was a bandage on his forehead, above his left eye with a date of 02/10/23. There was a Hoyer lift Sling under him. The sling appeared to be in good condition with no frayed edges. Resident #1 said he was doing okay. He said he fell while staff attempted to transfer him from his wheelchair to his bed. Resident #1 said he did not remember much about what happened. He said all he remembered was the strap broke and he hit the floor. He said the next thing he remembered was being at the hospital. He said he did not feel he had been abused or neglected and what happened was an accident. Resident #1 said he was not afraid to be transferred with the Hoyer Lift.<BR/>During an interview on 01/17/23 at 1:20 PM, LVN A said he assisted LVN B with transferring Resident #1 with a Hoyer Lift on 02/05/23 around 8:30 PM. LVN A said while transferring Resident #1, a strap on the front left side of the lift snapped and Resident #1 fell to the floor and hit his head. LVN A said LVN B left the room and called 911 for assistance. LVN A said when he looked at Resident #1, there was blood on the floor coming from Resident #1's head. LVN A said she went and got a towel and applied pressure to the wound until EMS arrived and transported Resident #1 to the hospital for evaluation and treatment. LVN A said he did not realize the strip was damaged. LVN A said the cause of the accident was due to the defective strap. LVN A said he should have inspected the straps before he attempted to transfer Resident #1. LVN A said he was notified on 02/10/23 that he was suspended pending an investigation due to the incident. LVN A said he was scheduled to complete Mechanical Lift skills training before returning to work, but he had not yet received the training.<BR/>During an interview on 01/17/23 at 1:45 PM, LVN B said she and LVN A was asked to assist in transferring Resident #1 from his wheelchair to his bed because staff reported Resident #1 was being verbally and physically aggressive toward staff who attempted to transfer him to his bed. LVN B said she asked LVN A to assist in the transfer. LVN B said when she arrived in the room, there were three straps already attached to the lift and LVN A attached the fourth strap to transfer Resident #1. LVN B said she was operating the lift and LVN A lowered the bed to the lowest position. LVN B said the bed caught on the edge of a trash can at the foot of the bed when the bed was lowered. LVN B said she raised Resident #1 out of the wheelchair and LVN A was moving the wheelchair out of the way when she heard a snap. LVN B said the strap on the front left side of the sling holding Resident #1 broke and Resident #1 fell to the floor hitting his head. LVN B said she went to the door and yelled for help. LVN B said she called 911 on her cell phone and LVN A went and got a towel to stop the bleeding. LVN B said she did not notice the strap was damaged and if so, she would have not used the defective sling to transfer Resident #1. LVN B said she was notified on 02/10/23 by the DON she was suspended pending an investigation into the incident. LVN B said she should have assessed the condition of the straps before she attempted to transfer Resident #1. LVN B said since the incident she had received skills training on transferring using a Mechanical lift on 02/15/23. <BR/>During an interview on 02/10/23 at 12:12 PM, the DON said the first time she viewed the video was with the surveyor. DON said she had not reviewed the video of the incident with Resident #1 before this time. The DON said LVN A and LVN B failed to use proper technique when transferring Resident #1 with the Mechanical lift. The DON said staff should always assess the condition of the lift sling to ensure it was safe prior to use. The DON said it was obvious by viewing the video that the strap on the front left side was damaged and the sling should not have been used. The DON said after the incident she completed an assessment of all other lift slings in the building and found there were some that needed to be retired and new slings were ordered to replace the damaged slings. The DON said all staff received training to inspect the slings prior to use and if a sling showed signs of being defective or damaged the sling should not be used to transfer residents. The damaged sling should be reported to the charge nurse and the DON. The DON said the sling should be taken out of service and replaced with a new sling. The DON said all nursing staff would receive skills training with a check-off for each one on how to transfer a resident using a Mechanical lift. The DON said the skills training would be conducted by the DON and the Director of Rehabilitation. <BR/>During an interview on 02/10/23 at 12:08 PM, the Administrator said she was notified Resident #1 had a fall from a Mechanical lift on 02/05/23 around 8:30 PM. The Administrator said the cause was a damaged strap that broke which caused injury to Resident #1. The Administrator said she reported the incident to the state on 02/05/23 at around 9:45 PM. The Administrator said all the slings and straps in the facility were assessed by the DON for possible damage and those found to be damaged were removed from service immediately. The Administrator said new slings were ordered to replace the damaged slings. The Administrator said on 02/06/23 an intervention plan was developed by QAPI regarding the Hoyer Lift issue. The Administrator said all staff were in-serviced on inspecting the straps and slings before use. The Administrator said the DON would monitor and inspect slings and straps weekly to ensure they were in good condition. The Administrator said any slings found to be damaged would be removed from service and replaced. The Administrator said all nursing staff would receive skills training on how to properly operate the Mechanical Lift. The Administrator said the skills training would be conducted by the DON and Director of Rehabilitation. <BR/>An observation and interview on 02/10/23 at 1:45 PM revealed NA-A, NA-B and NA-C using a Hoyer lift to transfer Resident #1 from his bed to his wheelchair. NA A and NA B used proper technique in transporting the resident. Transfer was successfully completed with no concerns for Resident #1's safety. The equipment and sling were in good working order with no concerns. NA-A, NA-B and NA-C said they had recently received in-service training on safely using the Hoyer lift. They said they were to assess the condition of the sling and straps before using to transfer a resident. They said if the sling or straps were damaged, they were not to use them and report to the charge nurse and/or the DON.<BR/>Interview on 02/10/23 at 1:30 PM, the Laundry Aide said she washed two to three Hoyer Lift slings daily. She said she followed the manufacturer's suggested care instructions. She said the slings were washed in cold to warm water, but never hot water. She said all slings were hung to air dry and slings were never dried in the dryer. She said heat could cause the material to stretch or become weak.<BR/>Record review of Sling Laundry Instructions revealed .While the materials comply with applicable standards for strength, shrinkage and flammability, slings are subject to wear and tear, which increases with usage. Before each use check for fraying or cuts/tears in the straps and body of the sling. Slings that show wear or damage should be taken out of service . LAUNDRY INSTRUCTIONS: . Machine wash normal setting and at 140F/60C. Depending on the washing machine, this usually means on a medium temperature setting.<BR/>Record review of in-service records from 02/06/23 through 02/17/23 revealed documentation that nursing staff received training on 10/17/22. Staff received in-service training on laundry instructions of Hoyer Lift Slings. The in-service was conducted by the Housekeeping Supervisor. After washing the Hoyer Lift sling, you cannot put heat on it. The sling needs to air dry or put in the dryer with no heat. The fabric when heated can stretch and snap! This will cause an injury. This will be an automatic [NAME]!<BR/>Record review of in-service records revealed on 02/06/23 nursing staff received in-service training on Hoyer Lift transfer. <BR/>o <BR/>Must have 2 nursing staff (CNA, Nurse, Medication Aide) to use a Hoyer lift on a resident. <BR/>o <BR/>Always check sling and sling straps to verify they do not appear compromised.<BR/>o <BR/>If there is any question, have nurse verify it is okay to use. <BR/>o <BR/>DO NOT USE A DAMAGED SLING Under any circumstances.<BR/>Record review of Mechanical lift Competency Evaluations dated 02/10/23 - 02/17/23, showed staff using a Hoyer life to transfer residents received a skills assessment on using a Mechanical Life to transfer residents safely. <BR/>Record review of the facility's, undated, policy on Hydraulic lift revealed: . The resident will achieve safe transfer to bed or chair via mechanical lift device . The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift .23. Immediately remove any malfunctioning equipment from direct care use. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that pain management was provided to that require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices of 2 of 11 residents reviewed for pain management. (Resident #6 and Resident #15) 1. The facility failed to ensure Resident #15 received her scheduled Oxycodone as ordered on [DATE], [DATE], and [DATE]. The facility failed to ensure Resident #15 received her scheduled Gabapentin as ordered on [DATE]. The facility failed to notify Resident #15's physician when doses of the Oxycodone and Gabapentin, scheduled for 3pm and 4pm, were not administered on [DATE]. The facility failed to offer Resident #15 alternative prn pain medication options on [DATE] per the facility's policy. The facility failed to offer Resident #15 non-pharmacological interventions on [DATE] per the facility's policy. The facility failed to follow the Pain Management policy. 2. The facility failed to ensure Resident #6, who received scheduled opioid medications, had pain assessments at least every shift. The facility failed to ensure Resident #6, who displayed nonverbal signs of pain such as grimacing, hollering out and pushing staff away during ADL care, was administered prn medication. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ Template was provided to the facility on [DATE] at 2:01 p.m. While the IJ was removed on [DATE] at 12:49 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to complete training in-services with all staff and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for unrealized pain, serious harm, decrease quality of life and decline in condition.Findings included: 1. Record review of Resident #15's face sheet dated [DATE] indicated Resident #15 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #15 had diagnoses including fibromyalgia (is a long-term condition that involves widespread body pain), low back pain, major depressive disorder (a persistently low or depressed mood and a loss of interest in activities that you used to enjoy), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #15's quarterly MDS assessment dated [DATE] indicated Resident #15 had clear speech, adequate hearing and vision. Resident #15 was understood and had the ability to understand others. Resident #15 had a BIMS score of 15 which indicated intact cognition. Resident #15 was independent for eating, oral hygiene, and toilet hygiene, partial assistance for shower/bathe self and personal hygiene. Resident #15 received scheduled pain medication regimen. Resident #15 received opioids. Record review of Resident #15's care plan dated [DATE] indicated Resident #15 was on pain medication therapy related to fibromyalgia and wound. Intervention included administer medications as ordered. Record review of Resident #15's order summary report dated [DATE] indicated: *Tylenol Capsule 325 MG, give 2 capsules by mouth every 6 hours as needed for mild pain. Start date [DATE]. *Instant hot pack apply to affected area every hour as needed for pain, every 1 hour as needed for pain. Start date [DATE]. *Assess for pain each shift, every shift. Start date [DATE]. *Oxycodone Oral Tablet 10 MG (is used to relieve pain severe enough to require opioid treatment and when other pain medicines did not work well enough or cannot be tolerated), give 1 tablet by mouth five times a day for pain. Start date [DATE]. *Gabapentin Oral Capsule 300 MG (is an anticonvulsant medication used to treat nerve pain), give 1 capsule by mouth three times a day for pain for 5 days. Start dated [DATE]. Record review of Resident #15's Medication Administration Record dated [DATE]-[DATE] indicated: *Tylenol Capsule 325 MG, give 2 capsules by mouth every 6 hours as needed for mild pain. The MAR did not reflect an administration on [DATE]. This alternate prn pain medication was not administered on [DATE]. *Instant hot pack apply to affected area every hour as needed for pain, every 1 hour as needed for pain. The MAR did not reflect an administration on [DATE]. This non-pharmacological option was not administered on [DATE]. *Assess for pain each shift, every shift. The MAR did not reflect assessments on [DATE] (Nights), [DATE] (Nights), and [DATE] (Nights). *Oxycodone Oral Tablet 10 MG, give 1 tablet by mouth five times a day for pain. Times: 1am, 6am, 11am, 4pm, and 9pm. The MAR indicated on [DATE] at 1am administration was not given due to sleeping. The MAR did not reflect administration on [DATE] at 4pm. The MAR indicated on [DATE] administration at 9pm. The MAR indicated on [DATE] administration at 6am. *Gabapentin Oral Capsule 300 MG, give 1 capsule by mouth three times a day for pain for 5 days. The MAR did not reflect administration on [DATE] at 3pm. Record review of Resident #15's Individual Control Drug Record for Oxycodone 10 MG dated [DATE] indicated: *[DATE] at 6am, 1 pill given by RN S. *[DATE] at 11am, 1 pill given by MA B. *[DATE] at 9pm, 1 pill given by LVN M. *[DATE] at 11:55 p.m., 1 pill given by RN T. *[DATE] at 8am, 1 pill given by the DON. The Individual Control Drug Record did not reflect entries for [DATE] at 1am and 4pm. The Individual Control Drug Record did not reflect entries for [DATE] at 9pm. The Individual Control Drug Record did not reflect entries for [DATE] at 6am. Resident #15 scheduled doses are 1am, 6am, 11am, 4pm, and 9pm. Record review of Resident #15's e-MAR report dated [DATE] provided by RCN EE indicated: *[DATE] at 1am, code: 7 (sleeping), RN S. *[DATE] at 6am, 1 tablet, RN S. *[DATE] at 11am, 1 tablet, MA B. *[DATE] at 9pm, 1 tablet, LVN M. *[DATE] at 11:55pm (9pm), 1 tablet, RN T. *[DATE] at 8am (6am), 1 tablet, DON. The e-MAR did not reflect an entry for [DATE] at 4pm. Record review of Resident #15's progress notes dated [DATE]-[DATE] indicated: *[DATE] at 9:37 a.m. by LVN M, . CNA to this nurse that resident [Resident #15] was upset because she didn't get her 3pm Oxycodone. I [LVN M] entered the resident room with PM medications in hand. Resident #15 stated, 'I want to know why I didn't get my 3 o'clock pain medication'. I [LVN M] was not the nurse on duty at that time, apologized to her for her not receiving her 3 pm pain medication. I [LVN M] assured resident [Resident #15] am of what's going however at this time my hands are tied and the only thing I could do was give the medications that are due now. *[DATE] at 1:39 p.m., by the ADON, . Oxycodone Oral 10 MG.first oxycodone given late, so resident [Resident #15] refused this dose. *[DATE] at 8:00 a.m., by the DON, . Oxycodone Oral 10 MG.Resident #15 stated that she did not receive her medication at 6am. Resident state that she is in pain.This nurse [DON] administered medication and contacted NP. Record review of a PIR, Witness Statement by LVN M dated [DATE] indicated, . upon start of shift report is received off going nurse voiced she [RN P] can count with me [LVN M] but she didn't know what was going on either hall because she been all over the place and the ADON kept getting pulled off the floor so its gone be some stuff red cause I couldn't get to it. we [RN P & LVN M] then proceeded to count the nursing cart for A and D and the med aide cart for D. after counting the nurse [RN P] asked well do you want me to go ahead and catch up. I [LVN M] responded letting her know to do what she feels like she needed to do. Then she [RN P] asked for the keys to the cart back. Approx 15 min or so later she brought back the keys saying she has to go.This nurse [LVN M] to continue with only the scheduled medications for my shift. Record review of undated Customer Service Assessment submitted by a family member of Resident #15 indicated, .she [Resident #15] states that she received her 9:00 p.m. medications at 10:00 p.m., which technically not late. she [Resident #15] states that I called the desk at 5:00 about her 4:00 p.m. medications that did not come. she [Resident #15] saw no one until her nurse [LVN M] arrived at 10:00 p.m. Resident #15 states that she went 11 hours without pain medications. Resident #15 states that her medications have been more than two hours late many times, and no one addressed this.Resident #15 understands the window time frame of distributing medications however this window time frame is very extensive from the prior dose. Record review of Resident #15's grievance dated [DATE] indicated Resident #15 reported to Social Service regarding a grievance related to medications. Resident #15 stated that she did not receive her 6am oxycodone. The DON and ADM were assigned to take action. Resident #15 was provided with her oxycodone at 8am. The grievance was confirmed. During an interview on [DATE] at 5:04 p.m., Resident #15 said she did not get her Gabapentin and Oxycodone at 4 p.m. on [DATE]. She said she woke up around 5:30 p.m. in pain. She said her pain level was a 6 on scale from 1-10. She said she had called the front desk at 6:15 p.m. and 6:40 p.m., asking for her 4 p.m. medications. She said LVN M did not show up until almost 10:00 p.m. She said when LVN M finally showed up, her pain level was 7-8. She said LVN M did not offer to give a prn medication or non-pharmacological option to help with the pain. She said she had not had pain medication since 11am. She said she was so upset. She said her pain medications were given late a lot and they also missed doses. During an interview on [DATE] at 10:42 a.m., LVN M said she had been employed at the facility for about 30 days. She said she worked 6pm-6am shift. LVN M said Resident #15 was upset about not receiving her 4 p.m. pain medications. She said she arrived around 10 p.m. to give Resident #15 the evening medications. She said Resident #15 said she was in pain but did not tell her a specific number. She said Resident #15 said she was always in pain. She said CNA TT reported to her around 9:30 p.m. that Resident #15 was looking for her pain medications. She said she thought Resident #15 was looking for her pm medications, not her missed afternoon pain meds. She said when a resident did not receive their scheduled pain medication, it could affect their mood, sleep, and participation in therapy. She said the MAs and CNs were responsible for administering the residents' pain medication on schedule. She said the MAs and CNs documented pain medication administration in the facility's charting system and narcotic count sheet. She said the residents' pain assessment should be documented in the facility's charting system. She said the residents' pain should be assessed before and after administering pain medication and with complaints of pain. She said she did not go back and check on Resident #15's pain level until 1am. She said Resident #15 did not want her in her room after their disagreement. She said she received report from RN P on [DATE]. She said RN P, said she did not know if she gotten to everything due for the shift. She said RN P, said there were residents' medications left in red. She said she did not remember, if RN P specified, that Resident #15 did not get her scheduled medications. During an interview on [DATE] at 2:52 p.m., RN P said she started back at the facility recently and started orientation around [DATE]. RN P said on [DATE], she and the ADON were working the same medication cart. She said she did not know which residents got their medications or not. She said Resident #15 may have been one of the residents who did not get their medications on [DATE]. She said Resident #15 was in her right mind. She said if Resident #15 said she did not get her pain medications, then she did not. She said the facility was short staffed that day ([DATE]). She said the residents' needed their pain medications because they could become agitated and be in pain. She said the residents should get their scheduled medications because it was ordered that way. She said the residents could not be able to sleep, eat, or be bothered when in pain. She said the MAs and CNs documented pain medication administration in the facility's charting system on the MAR. She said they also charted on the residents' narcotic count sheet. During an interview on [DATE] at 12:42 p.m., Resident #15 said she would have wanted to be woken up on [DATE] at 1am for her pain medication. She said after she called the front desk several time for her pain medication on [DATE] and no one came; she was mad. She said she got changed before she received her 9pm pain medication on [DATE]. She said she was in a lot of pain during the changing. She said her pain ramped up her agitation. She said which did not help the situation with LVN M. She said LVN M did not offer to call the doctor, give her Tylenol, or a heating pad. She said LVN M, said it was not her responsibility to fix what another shift did not do. She said she was just screwed. She said when she got her pain medications late or missed doses, she was chasing her pain. She said her pain level was not going to get back level for a few days. On [DATE] at 5:31 p.m., attempted to contact LVN M by phone and sent text message. During an interview on [DATE] at 6:08 p.m., LVN M said she did not call the MD or NP when Resident #15 had a missed oxycodone dose on [DATE]. She said when she was counseled by the ADM and DON, they said she should have. She said she just did not think the MD or NP would let her have two doses of oxycodone. She said she did not offer Resident #15 any prn pain medication. She said when she previously offered Resident #15 the prn Tylenol for a headache, she said it did not work. She said she did not know Resident #15 had non-pharmacological options ordered. She said it was important to offer other option for pain to help with breakthrough pain. She said it helped keep the residents' pain under control. During an interview on [DATE] at 9:05 a.m., MA U said that scheduled medications were supposed to be given one hour before or after the scheduled time. She said that was the facility's policy. She said Resident #15's 6am oxycodone was administered late because of shift change. She said Resident #15 complained about her medications being late. She said when Resident #15's scheduled pain medications were given late or missed, it messed up the administration times for the next doses. She said Resident #15 could be in pain because of late or missed pain medications. During an interview on [DATE] at 5:03 p.m., CNA TT said Resident #15 called twice about her missed pain medications on [DATE]. She said she reported to LVN M, Resident #15 wanted her pain medications. She said Resident #15 was grimacing and red faced after the incident with LVN M. During an interview on [DATE] at 8:38 a.m., RN T said Resident #15 was not on her assigned hall. She said she had to administer Resident #15's medications because LVN M could not do it anymore. She said she may have given Resident #15's oxycodone late one night. She said she may have forgotten to pass medications to Resident #15 because she was not on her assigned hall. She said Resident #15 should get her scheduled medication on time so she did not hurt. She said it was also important because that was what Resident #15's body was used to. She said the residents' pain assessment were done each shift. She said it was important to do a pain assessment to make sure the pain medication was adequate for relief. During an interview on [DATE] at 10:45 a.m., the DON said she expected the nursing staff to wake the residents up to give medications. She said on [DATE], Resident #15's 6am oxycodone dose was not given. She said she notified the NP and administered the missed dose at 8am. She said she expected the nursing staff to assess the residents' pain every shift. She said it was important to do a pain assessment to address the residents' pain. She said if the residents' pain was not assessed and addressed, they could not be able to do ADLs and be uncomfortable. She said nursing staff should document medication administration when administered, not later. She said it was important to document the medications when administered so it would tell the actual time. She said the nursing staff should be following the 5 rights of medication administration. She said the ADON and DON oversaw the nursing staff to ensure pain assessments were done and timely medication administration. She said they should monitor this process by doing chart audits, reviewing the residents' MARs and TARs. She said she had not had a lot of time to do chart audits. She said morning meetings had not been happening to discuss the residents due to working the floor. 2. Record review of Resident #6's face sheet dated [DATE] indicated Resident #6 was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #6 had diagnoses including Dementia (is a general term describing a group of conditions that cause a progressive decline in cognitive abilities, including memory, thinking, reasoning, and judgment, which interfere with daily life), gastrointestinal hemorrhage (is when there is blood loss from any of the several organs included in your digestive system), and chronic pain. Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated Resident #6 was sometimes understood and sometimes had the ability to understand others. Resident #6 had a BIMS score of 2 which indicated severe cognitive impairment. Resident #6 required supervision for eating, substantial assistance for oral and personal hygiene, and dependent for toileting hygiene, shower/bathe self and dressing. Resident #6 was always incontinent of urine and bowel continence was not rated. Resident #6 received scheduled pain medication. Resident #6 had not received prn pain medications or was offered and declined. Resident #6 had not received non-medication intervention for pain. Resident #6's occasionally experienced pain in last 5 days, made it hard to sleep at night, limited participation in rehabilitation therapy sessions, and limited day-to-day activities. Resident #6 rated his worst pain as a 3 over the last 5 days. Resident #6 received opioid medications. Record review of Resident #6's care plan dated [DATE] indicated: *Resident #6 had impaired cognitive function/dementia or impaired thought process related to diagnosis of dementia. Intervention included monitor/document/report to MD any change in cognitive function. *Resident #6 had ADL self-care performance deficit. Intervention included monitor/document/report to MD PRN any changes and declined in function. Record review of Resident #6's care plan dated [DATE] indicated Resident #6 was on routine pain medication therapy. Intervention included administer medication as ordered Record review of Resident #6's care plan dated [DATE] indicated: *Resident #6 had terminal prognosis and/or was receiving hospice services. Intervention included observe closely for signs of pain, administer pain medication as ordered, and notify physician immediately if there was breakthrough pain. Work with nursing staff to provide maximum comfort for the resident. *Resident #6 required hospice as evidence by terminal illness. Intervention included monitor for signs and symptoms of increased pain and discomfort. Give meds and treatments and monitor for relief. Assists with ADLs and provide comfort measures as needed. Record review of Resident #6's order summary dated [DATE]-[DATE] indicated: *Tramadol Oral Tablet 50 MG, give 2 tablets by mouth two times a day related to chronic pain. Start dated [DATE]. *Tylenol Oral Capsule 325 MG, give 2 capsules by mouth every 4 hours as needed for mild pain or fever. Start date [DATE]. *Tylenol with codeine #3 Tablet 300-30 MG (is a prescription combination pain medication containing acetaminophen and the opioid codeine), give 1 tablet by mouth every 8 hours as needed for pain. Start date [DATE]. *Lorazepam Tablet 0.5 MG (is used to treat anxiety disorders), give 1 tablet by mouth every 4 hours as needed for agitation. Start dated [DATE]. *Morphine Sulfate 10MG/5ML (is a powerful opioid analgesic used to treat moderate to severe pain), give 10 milligrams by mouth every 3 hours as needed for pain. Start date [DATE]. The order summary did not reflect a pain assessment every shift. Record review of Resident #6's MAR dated [DATE]-[DATE] indicated: *Tramadol Oral Tablet 50 MG, give 2 tablets by mouth two times a day related to chronic pain. Start dated [DATE]. The MAR indicated Resident #6 received 35 of 44 doses. *Tylenol Oral Capsule 325 MG, give 2 capsules by mouth every 4 hours as needed for mild pain or fever. The MAR indicated administration on [DATE] for pain level of 4. *Tylenol with codeine #3 Tablet 300-30 MG (is a prescription combination pain medication containing acetaminophen and the opioid codeine), give 1 tablet by mouth every 8 hours as needed for pain. The MAR did not reflect any administrations. *Lorazepam Tablet 0.5 MG (is used to treat anxiety disorders), give 1 tablet by mouth every 4 hours as needed for agitation. The MAR did not reflect any administrations. *Morphine Sulfate 10MG/5ML (is a powerful opioid analgesic used to treat moderate to severe pain), give 10 milligrams by mouth every 3 hours as needed for pain. The MAR did not reflect any administrations. Record review of Resident #6's Individual Control Drug Record for Morphine indicated the starting balance of 30 ML and destroyed quantity of 30 ML. The record did not reflect any administrations. Record review of Resident #6's progress notes dated [DATE]-[DATE] indicated: *[DATE] at 3:36 p.m. by LVN A, .Resident #6 has new order for Tylenol #3 for every 8 hours PRN for pain. Order to give before baths and wound care. *[DATE] at 9:08 p.m. by MD K, . Progress note.contractures, right knee.contracture, left knee. Stage 2 ulcers. administer Tylenol with codeine #3 as needed for pain.provide comfort care measures. he [Resident #6] exhibits signs of pain, particularly with movement. when attempting to place between his knees, even minimal movement of his left leg caused him to grimace and attempt to push the examiner's [MD K] hand away. *[DATE] at 11:48 a.m. by the DON, . family also informed that the resident [Resident #6] is being repositioned from side to side due to his knees being contracted upwards. Resident #6 moans and groans when turned and repositioned, and during incontinent care. Resident #6 continues to pull the pillow from between knees and pulls the wound care dressing off his knees and hip. Hospice Nurse spoke to the family about increasing routine pain medications. *[DATE] at 6:45 p.m. by the DON, . this nurse [DON] repositioned the resident [Resident #6] onto back, put pillow between his legs, and under his right side. Resident #6 moaning and groaning during repositioning. On [DATE] at 10:27 a.m., attempted to contact LVN O by phone. Contact was unsuccessful and a message was left with callback phone number. During an interview on [DATE] at 11:37 a.m., the DON said Resident #6 was in pain when he was admitted to hospice service. She said Resident #6 could not talk but vocalized pain by moaning. She said Resident #6 would moan when he was messed with. She said the residents' prn pain medications should be administered when the resident was in pain. She said if Resident #6 had prn pain medications ordered, she would have expected them to be used. She said it was important to administer prn pain medications to control pain, especially breakthrough pain. She said if a resident was in pain, it affected their ability to do ADLs or sleep more. She said a pain assessment should be documented in the facility's charting system. She said the nursing staff should document the pain assessment every shift and before prn pain medication was administered. During an interview on [DATE] at 1:20 p.m., the ADON said Resident #6 moaned when he was turned. She said Resident #6 screamed out in pain and grabbed at staff. She said Resident #6 was in pain and anxious when he pulled off his brief and clothes. She said she did not know if the CNs administered Resident #6 prn pain medication when he displayed signs of pain. She said she would have expected the CNs to administer Resident #6's ordered prn pain and anxiety medications when he was in pain. During an interview on [DATE] at 3:16 p.m., MD K said Resident #6 was severely contracted. He said Resident #6 was contracted into a fetal position. He said when he visited Resident #6, he moaned when moved. He said the staff would place a pillow between Resident #6's knees and he would start hollering out in pain. He said he would want the nursing staff to give prn pain medications if there were signs of distress. During an interview on [DATE] at 4:11 p.m., the hospice nurse said Resident #6 was admitted to the company on [DATE]. She said prn comfort medications were ordered for Resident #6. She said she saw Resident #6, two or three times before he expired on [DATE]. She said when the CNAs rolled Resident #6 for incontinence care or repositioning, he would say, stop or put his hand up. She said after Resident #6's care plan meeting on [DATE], she increased his scheduled pain medication. She said she increased Resident #6 scheduled pain medication because she knew he was guaranteed get it. She said Resident #6 was the most contracted man she had ever seen. She said she thought Resident #6 could not participant in therapy anymore because his contractures caused him so much pain. She said Resident #6 would have benefited from receiving prn pain medications. During an interview on [DATE] at 9:45 a.m., LVN L said she used to be the facility's treatment nurse. She said Resident #6 would wince when rolled over for wound care treatments. She said Resident #6 had 3 or 4 pressure ulcers. She said she wanted to say the nursing staff administered Resident #6 pain medication when he needed it. She said she could not remember though. She said if Resident #6 received prn pain medications, it would be documented on the MAR. She said the residents' pain level was assessed before and after administration. During an interview on [DATE] at 10:38 a.m., the Social Service said the facility had a care plan meeting with a family member of Resident #15. She said the family member of Resident #15 had reported, Resident #15 had been in pain on [DATE]. She said the family member of Resident #15 reported Resident #15 had waited an extended period for pain medication on [DATE]. She said the facility had a care plan meeting for Resident #6 on [DATE]. She said in the meeting, the DON and Hospice Nurse mentioned Resident #6 was in pain when touched or moved. She said they addressed the increased pain by scheduling Resident #6 pain medication. During an interview on [DATE] at 9:28 a.m., CNA AAA said Resident #6 pushed, grabbed, and held on to you when he was messed with. She said Resident #6 hollered out in pain when they would put a pillow between his knees, turned, and changed him. She said Resident #6 needed constant attention because he took off his gown and played in his feces. She said she reported it to the nurses and they gave Resident #6 pain medication. She said Resident #6 got pain medication before his bed baths, if it lined up with his scheduled dose times. She said when Resident #6 hollered out in pain, he was probably due for his scheduled pain medication. She said there may have been times she provided care to Resident #6 and he was in pain. She said the residents should receive pain medication to make them comfortable and easier to take care of. During an interview on [DATE] at 10:10 a.m., LVN O said Resident #6 moaned and groaned when he was turned and changed. She said Resident #6 stopped when they were done. She said she never gave prn pain medication before Resident #6's cares were done. She said she should have since it caused him so much pain. She said she did not premedicate him before wound care treatments. She said Resident #6 would holler out when his knees had to be separated for wound care. She said pain medications should be given to prevent or reduce pain. She said not providing pain medications when a resident displayed signs and symptoms could negatively affect them. During an interview on [DATE] at 1:03 p.m., the ADM said the CNs then the DON was responsible for the residents' pain management. She said the facility had a care plan meeting to address Resident #15's concerns. She said Resident #15 was given the ADON's phone number to contacted if she did not get her scheduled pain medications. She said LVN M should have notified Resident #15's physician when she found out she had missed doses of pain medications. She said LVN M was in-serviced on notifying the physician for missed doses of pain medications. She said LVN M should have offered Resident #15 prn pain medication and non-pharmacological options. She said she expected the nursing staff to follow the pain management policy. She said the staff were in-serviced on the pain management policy after the incident on [DATE] and probably before. She said it was important for the policy to be followed to take care of the residents and not to be in pain. She said Resident #6 was contracted. She said the few times she saw Resident #6; he was asleep. She said Resident #6 experienced pain when his contractures had to be pulled apart. She said she expected the nursing staff to give prn pain medication when needed. She said she expected the nursing staff to perform pain assessments. She said the CNs were responsible for administering prn pain medications. She said prn pain medication should be used when needed for comfort and pain management. She said when prn pain medication was not used, the residents could be uncomfortable, in pain, and decreased quality of life. She said the nursing management and hospice were responsible for Resident #6's pain management. She said they should review the residents' documentation to ensure prn medication were being used when needed. During an interview on [DATE] at 4:39 p.m., Resident #6's family member said Resident #6 moaned and groaned when he was touched. The family member of Resident #6 said they expressed this concern to the facility. During an interview on [DATE] at 12:18 p.m., CNA R said when she was assigned the hall Resident #6 was on, she was a Hospitality Aide. She said she could not provide ADL care on him. She said she never touched Resident #6 but noticed when other staff did, he would be in pain. She said Resident #6 would scream out in pain, push staff away, or say leave me alone. She said when he was in pain, she saw the CNAs tell the nurses. She said she never saw a nurse give Resident #6 pain medication before turning or changing him. She said Resident #6 would have benefited from prn pain medications if he got cares done before the next scheduled dose. Record review of an undated facility's Abuse/Neglect policy indicated, . Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of an undated facility's Pain Management, Assessment Scale policy indicated, . Pain is a subjective sensation of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological. or psychological stimuli. Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. PRN-if the resident comp

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment for 19 of 25 resident's (Resident's #2, #4, #5, #6, #7, #8, #10, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #23, #24) reviewed for sufficient staffing. 1. The facility failed to ensure sufficient facility staff were available to assist Resident #5 with positioning during a tube feeding on 08/20/25. Resident #5's head and torso were leaning over the left armrest of his Geri-chair for approximately 1 hour and 30 minutes, which resulted in aspiration pneumonia. 2. The facility failed to ensure sufficient staff were available to provide wound care treatment and documentation for Resident's #2, #16, #17, #18, #19, #20, #23 and #24 during August 2025 and September 2025. 3. The facility failed to ensure the secured unit was adequately staffed to prevent accidents for Resident's #8, #10, #12, #13, #14, #19, and #21. 4. The facility failed to ensure the secured unit was adequately staffed to provide supervision during mealtime for Resident's #7, #8, #14, #21, and #22 on 09/08/25. 5. The facility failed to follow the facility assessment for sufficient nurse staffing. An immediate jeopardy (IJ) was identified on 09/11/25 at 12:59 PM. The IJ template was provided to the facility on [DATE] at 2:01 PM. While the IJ was removed on 09/13/25 at 12:49 PM, the facility remained out of compliance at a scope of patterned and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been provided education on abuse and neglect, notification of changes in condition, documentation policy, pain management policy, fall prevention policy, pressure prevention policy, medication administration policy, enteral feeding policy, and the bathing and showers policy. These failures placed residents at risk of inadequate supervision, an unsafe environment, decreased quality of care, increased risk of pressure ulcers, unwitnessed falls, risk for impaired nutrition, serious harm, injury, abuse, and death.The finding included: 1. Record review of the face sheet, dated 09/11/25, reflected Resident #5 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills), severe protein-calorie malnutrition (not getting enough protein or calories to meet the bodies demands), gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), anorexia (loss of appetite), and dysphagia (difficulty swallowing). Record review of the quarterly MDS assessment, dated 07/30/25, reflected Resident #5 had unclear speech, was rarely/never understood, and was rarely/never able to understand others. Resident #5 had short-term and long-term memory problems. Resident #5 had no memory or recall ability and had severely impaired decision making skills. The MDS reflected Resident #5 had upper and lower extremity impairments to both sides which interfered with daily functions. The MDS reflected Resident #5 was dependent on staff for all his ADLs. Resident #5 used a feeding tube while a resident and also received a mechanically altered diet. The MDS reflected Resident #5 received 51% of more of his total calories through tube feeding. Record review of the comprehensive care plan, last reviewed 06/17/25, reflected Resident #5 required tube feeing related to anorexia and Alzheimer's disease. The interventions included: .the resident needs the head of bed elevated 30 degrees during and thirty minutes after tube feeding. The care plan further reflected Resident #5 had an ADL self-care deficit and required staff assistance x 1 with eating. Record review of the order summary report, dated 09/11/25, reflected Resident #5 had an order for regular diet and pureed texture with pudding consistency fluids, [family member] or nurse to assist with feeding. The order started on 08/26/25. Record review of the progress notes reflected the following: On 08/21/25 at 4:03 AM, the note reflected Resident #5's family member requested a chest x-ray due to possible aspiration . due to positioning of resident in chair on previous shift.No signs or symptoms of aspiration noted . head of bed elevated to 30 degrees. On 08/21/25 at 7:47 AM, the note reflected a response was received from the physician for a chest x-ray. On 08/22/25 at 3:29 AM, the note reflected Resident #5 was transferred to the hospital related to chest x-ray results findings indicated aspiration. Record review of Resident #5's diagnostic chest x-ray report, dated 08/21/25, reflected .reported gastrostomy tube [opening from the abdomen directly into the stomach] is not definitely visualized.air distended stomach.left basilar airspace disease [condition in which the lower lungs of the left lung collapse, preventing air exchange], likely atelectasis [collapse of lung or part of lung from lack of air in the air sacs] given elevation of the hemidiaphragm. Record review of the inpatient hospital record, dated 08/22/25, reflected Resident #5 arrived at the hospital at 4:04 AM via ambulance and was discharged back to the facility at 5:46 AM. The problems addressed was aspiration into airway, initial encounter. 2. Record review of Resident #2's face sheet dated 9/11/25 indicated Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnosis including acute posthemorrhagic anemia (is a condition that develops when you lose a large amount of blood quickly), heart failure (is a condition where the heart muscle cannot pump blood effectively enough to meet the body's needs), type 2 diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and pressure ulcer of left heel, stage 3 (injuries extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and usually had the ability to understand others. Resident #2's had a BIMS score of 7 which indicated moderate cognitive impairment. Resident #2 required setup assistance for eating, supervision for oral hygiene, partial assistance for upper body dressing and personal hygiene, and dependent for toileting hygiene, shower/bathe self, and lower body dressing. Resident #2 was always incontinent for urine and occasionally incontinent for bowel. Resident #2 had one, stage 3 unhealed pressure ulcers/injuries. Resident #2 had pressure reducing device for bed and pressure ulcer/injury care. Record review of Resident #2's care plan, revised on 9/11/25, indicated Resident #2 had a pressure ulcer due to decreased mobility. Resident #2 had stage 3 pressure injury to left heel. Interventions included follow facility policies/protocols for the prevention/treatment of skin breakdown and administer medications as ordered. Record review of Resident #2's order summary report dated 9/11/25 indicated: Stage 3 pressure injury, cleanse left heel with normal saline, apply collagen powder, and cover with gauze island with border every day and as needed, one time a day for wound healing. Start date 8/25/25. Record review of Resident #2's wound administration record dated 8/1/25-8/31/25 indicated: Cleanse left heel with normal saline, apply collagen powder, and cover with gauze island with border every day and as needed, one time a day for wound healing. Discontinued 8/24/25. Resident #2 did not have documentation for administration on 8/20/25, 8/21/25, 8/23/25, and 8/24/25. Resident #2 was in the hospital 8/3/25-8/13/25. Record review of Resident #2's wound administration record dated 9/1/25-9/30/25 indicated: Stage 3 pressure injury: Cleanse left heel with normal saline, apply collagen powder, and cover with gauze island with border every day and as needed, one time a day for wound healing. Resident #2 did not have documentation for administration on 9/2/25, 9/5/25, 9/6/25, and 9/8/25. 3. Record review of the face sheet, dated 09/11/25, reflected Resident #16 was a [AGE] year-old female who initially admitted to the facility on [DATE] had diagnoses of Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills), pressure ulcer of sacral region, stage 4 (wound created from pressure that is characterized by full-thickness skin loss that extends to muscle, tendon, and/or bone), and chronic osteomyelitis (bone infection). Record review of the significant change MDS assessment, dated 08/04/25, reflected Resident #16 had unclear speech, was rarely/never understood, and was rarely/never able to understand others. Resident #16 had short-term and long-term memory problems, no memory recall ability, and severely impaired decision making skills. The MDS reflected Resident #16 had upper and lower extremity impairment to both sides that interfered with daily functions. Resident #16 was normally dependent on staff for all ADLs. Resident #16 had two stage 3 pressure ulcers and eight arterial wounds. The MDS reflected Resident #16 had a pressure reducing device for bed, nutrition or hydration interventions, pressure ulcer/injury care, application of non-surgical dressing, and application of dressings to feet. Record review of the comprehensive care plan, last reviewed 09/03/25, reflected the following: Resident #16 had an arterial wound to the right lateral ankle. The interventions included: position and treat the wound per facility protocol. Resident #16 had an arterial wound to the right heel. The interventions included: position and treat the wound per facility protocol. Resident #16 had an arterial wound of the left dorsal foot. The interventions included: position and treat the wound per facility protocol. Resident #16 had an arterial wound of the left heel. The interventions included: position and treat the wound per facility protocol. Resident #16 had an arterial wound of the right first toe. The interventions included: position and treat the wound per facility protocol. Resident #16 had a stage 3 pressure injury to her right upper back. The interventions included: follow facility protocol for treatment of injury, assist with turning and repositioning every 2 hours and as needed; low air loss mattress. Resident #16 had a stage 3 pressure ulcer to right upper back. The interventions included: Administer treatment and monitor for effectiveness, avoid positioning on injury, float heels, follow facility policies/protocols for prevention and treatment of skin issues, turn and reposition every 2 hours, cushion to wheelchair, bed as flat as possible, and use lifting devices, draw sheet, etc. to reduce friction. Resident #16 had a stage 3 pressure injury to sacrum. The interventions included: follow facility protocol for treatment of injury, assist with turning and repositioning every 2 hours and as needed; low air loss mattress. Resident #16 had an arterial wound to left shin. The interventions included: position and treat the wound per facility protocol. Resident #16 had an arterial wound to right shin. The interventions included: position and treat the wound per facility protocol. Resident #16 had a non-pressure wound to right chest. The interventions included: treat the wound per facility protocol. Record review of Resident #16's order summary report, dated 09/11/25, reflected the following: Arterial wound left heel. Apply skin prep three times a week and as needed until healed, every Monday, Wednesday, and Friday. Start date 08/11/25. Arterial wound of the left calf. Cleanse with normal saline, pat dry, apply xeroform to wound bed, wrap with kerlix every day and as needed if saturated, soiled, or dislodged. Start date 09/05/25. Arterial wound of the left dorsal foot. Cleanse with normal saline, pat dry, apply xeroform to wound bed, wrap with kerlix, every day and as needed if saturated, soiled, or dislodged. Start date 09/05/25. Arterial wound of the left shin. Cleanse with normal saline, pat dry, apply xeroform to wound bed, wrap with kerlix, every day and as needed if saturated, soiled, or dislodged. Start date 09/05/25. Arterial wound of the right first toe. Apply skin prep 3 times a week on Monday, Wednesday, and Friday. Start date 09/08/25. Arterial wound of the right foot. Cleanse with normal saline, pat dry, apply skin prep, wrap with kerlix every day and as needed if saturated, soiled, or dislodged. Start date 09/06/25. Arterial wound of the right heel. Cleanse with normal saline, pat dry, apply skin prep, wrap with kerlix 3 times a week and as needed if saturated, soiled, or dislodged. Start date 08/06/25. Arterial wound of the right lateral ankle. Cleanse with normal saline, pat dry, apply Medi honey to wound bed, apply alginate calcium, wrap with kerlix every day and as needed if saturated, soiled, or dislodged. Start date 09/05/25. Arterial wound of the right shin. Cleanse with normal saline, pat dry, apply xeroform gauze, cover with dry border dressing three times per week and as needed if saturated, soiled, or dislodged every Monday, Wednesday, and Friday. Start date 08/06/25. Non-pressure injury of the right chest. Cleanse with normal saline, pat dry, apply alginate calcium, cover with dry dressing every day and as needed if saturated, soiled, or dislodged. Start date 08/05/25. Stage 3 pressure injury to upper back. Cleanse with normal saline, pat dry, apply calcium alginate, and cover with bordered dressing one time a day. Start date 08/25/25. Record review of Resident #16's wound administration record dated 8/1/25-8/31/25 indicated: Arterial wound left heel. Apply skin prep three times a week and as needed until healed, every Monday, Wednesday, and Friday. Resident #16 did not have documentation of administration on 08/11/25, 08/18/25, 08/20/25, and 08/29/25. Arterial wound of the left dorsal foot. Cleanse with normal saline, pat dry, apply alginate calcium, wrap with kerlix every day and as needed if saturated, soiled, or dislodged one time a day for wound healing. The order was stopped on 08/04/25 and was missing documentation of administration for 08/02/25. Arterial wound of the left dorsal foot. Cleanse with normal saline, pat dry, apply skin prep, wrap with kerlix every day and as needed if saturated, soiled, or dislodged one time a day for wound healing. The order was stopped on 09/05/25. Resident #16 was missing documentation of administration on 08/05/25, 08/06/25, 08/09/25, 08/10/25, 08/11/25, 08/14/25, 08/16/25, 08/17/25, 08/18/25, 08/19/25, 08/20/25, 08/21/25, and 08/29/25. Arterial wound of the left shin. Cleanse with normal saline, pat dry, apply Medi honey to wound bed, apply alginate calcium, wrap with kerlix every day and as needed if saturated, soiled, or dislodged one time a day for wound healing. The order was stopped on 08/04/25 and was missing documentation of administration for 08/02/25. Arterial wound of the left shin. Cleanse with normal saline, pat dry, apply Medi honey to wound bed, apply alginate calcium, wrap with kerlix every day and as needed if saturated, soiled, or dislodged one time a day for wound healing. The order was stopped on 09/05/25. Resident #16 was missing documentation of administration on 08/05/25, 08/06/25, 08/09/25, 08/10/25, 08/11/25, 08/14/25, 08/16/25, 08/17/25, 08/18/25, 08/19/25, 08/20/25, 08/21/25, and 08/29/25. Arterial wound of the right foot. Cleanse with normal saline, pat dry, apply skin prep, wrap with kerlix once daily and as needed if saturated, soiled, or dislodged one time a day for wound healing. The order was stopped on 08/04/25 and was missing documentation of administration for 08/02/25. Arterial wound of the right foot. Cleanse with normal saline, pat dry, apply skin prep, wrap with kerlix once daily and as needed if saturated, soiled, or dislodged one time a day for wound healing. The order was stopped on 08/06/25 and was missing documentation of administration for 08/05/25 and 08/06/25. Arterial wound of the right lateral ankle. Cleanse wound with normal saline, pat dry, apply alginate calcium, wrap with kerlix every day and as needed if saturated, soiled, or dislodged one time a day for wound healing. The order was stopped on 09/05/25. Resident #16 was missing documentation of administration on 08/09/25, 08/10/25, 08/11/25, 08/14/25, 08/16/25, 08/17/25, 08/18/25, 08/19/25, 08/20/25, 08/21/25, and 08/29/25. Arterial wound of the right lateral ankle. Cleanse wound with normal saline, pat dry, apply Medi honey to wound bed, apply alginate calcium, wrap with kerlix every day and as needed if saturated, soiled, or dislodged one time a day for wound healing. The order was stopped on 08/04/25 and was missing documentation of administration for 08/02/25. Arterial wound of the right lateral ankle. Cleanse wound with normal saline, pat dry, apply Medi honey to wound bed, apply calcium alginate, wrap with kerlix every day and as needed if soiled or dislodged one time a day for wound healing. The order was stopped on 08/06/25 and was missing documentation of administration for 08/06/25. Arterial wound of the right shin. Cleanse with normal saline, pat dry, apply xeroform gauze, cover with dry border dressing tree times per week and as needed if saturated, soiled, or dislodged one time a day every Monday, Wednesday, and Friday for wound healing. Resident #16 was missing documentation for 08/06/25, 08/11/25, 08/18/25, 08/20/25, and 08/29/25. Non-pressure injury of the right chest. Cleanse with normal saline, pat dry, apply alginate calcium, cover with dry dressing every day and as needed if dressing is saturated, soiled, or dislodged one time a day for wound healing. Resident #16 was missing documentation of administration for 08/02/25, 08/05/25, 08/06/25, 08/09/25, 08/10/25, 08/11/25, 08/14/25, 08/16/25, 08/17/25, 08/18/25, 08/19/25, 08/20/25, 08/21/25, and 08/29/25. Pressure wound to upper back. Apply calcium alginate to wound bed and dry dressing one time a day for promote wound healing. The order was stopped on 08/24/25 and was missing documentation of administration for 08/09/25, 08/10/25, 08/11/25, 08/14/15, 8/16/25, 08/17/25, 08/18/25, 08/19/25, 08/20/25, 08/21/25, 08/24/25, and 08/29/25. Stage 3 pressure injury to right upper back. Cleanse with normal saline, pat dry, apply Medi honey, cover with dry dressing every day and as needed if dressing is saturated, soiled, or dislodged, one time a day for wound healing. The order was stopped on 08/12/25 and was missing documentation of administration for 08/02/25, 08/05/25, 08/06/25, 08/09/25, 08/10/25, and 08/11/25. Stage 3 pressure injury to sacrum. Cleanse with normal saline, pat dry, apply xeroform gauze, cover with dry dressing every day and as needed if dressing is saturated, soiled or dislodged, one time a day for wound healing. The order was stopped on 08/28/25. Resident #16 was missing documentation of administration for 08/02/25, 08/05/25, 08/06/25, 08/09/25, 08/10/25, 08/11/25, 8/14/15, 8/16/25, 08/17/25, 08/18/25, 08/19/25, 08/20/25, and 08/21/25. Record review of Resident #16's wound administration record dated 9/1/25-9/30/25 indicated: Arterial wound of the left heel. Apply skin prep 3 times a week and as needed until healed one time a day every Monday, Wednesday, and Friday for promote wound healing. Resident #16 had missing documentation of administration for 09/03/25, 09/05/25, and 09/08/25. Arterial wound of the left calf. Cleanse with normal saline, pat dry, apply xeroform to wound bed, wrap with kerlix every day and as needed if saturated, soiled, or dislodged. Resident #16 had missing documentation of administration for 09/08/25 and 09/09/25. Arterial wound of the left dorsal foot. Cleanse with normal saline, pat dry, apply skin prep, wrap with kerlix every day and as needed if saturated, soiled, or dislodged for wound healing. The order was stopped on 09/05/25 and was missing documentation of administration for 09/02/25, 09/03/25, and 09/05/25. Arterial wound of the left dorsal foot. Cleanse with normal saline, pat dry, apply xeroform to wound bed, wrap with kerlix every day and as needed if saturated, soiled or dislodged for wound healing. Resident #16 was missing documentation of administration for 09/08/25 and 09/09/25. Arterial wound of the left shin. Cleanse with normal saline, pat dry, apply Medi honey to wound bed, apply alginate calcium, wrap with kerlix every day and as needed if saturated, soiled, or dislodged. The order was stopped on 09/05/25 and was missing documentation of administration for 09/02/25, 09/03/25, and 09/05/25. Arterial wound of the left shin. Cleanse with normal saline, pat dry, apply xeroform to wound bed, wrap with kerlix every day and as needed if saturated, soiled, or dislodged. Resident #16 was missing documentation of administration for 09/08/25 and 09/09/25. Arterial wound of the right first toe. Apply skin prep three times a week on day shift on Monday, Wednesday, and Friday. Resident #16 was missing documentation of administration for 09/08/25. Arterial wound of the right foot. Cleanse with normal saline, pat dry, apply skin prep, wrap with kerlix every day and as needed if saturated, soiled, or dislodged. There was missing documentation of administration on 09/08/25 and 09/09/25. Arterial wound of the right heel. Cleanse with normal saline, pat dry, apply skin prep, wrap with kerlix three times a week and as needed is saturated, soiled, or dislodged one time a day every Monday, Wednesday, and Friday for wound healing. There was missing documentation of administration for 09/03/25 and 09/08/25. Arterial wound of the right lateral ankle. Cleanse wound with normal saline, pat dry, apply alginate calcium, wrap with kerlix every day and as needed if saturated, soiled, or dislodged. The order was stopped on 09/05/25 and there was missing documentation of administration for 09/02/25, 09/03/25, and 09/05/25. Arterial wound of the right lateral ankle. Cleanse wound with normal saline, pat dry, apply Medi honey to wound bed, apply alginate calcium, wrap with kerlix every day and as needed if saturated, soiled, or dislodged. There was missing documentation for 09/08/25 and 09/09/25. Arterial wound of the right shin. Cleanse with normal saline, pat dry, apply xeroform gauze, cover with dry border dressing three times per week and as needed if saturated, soiled, or dislodged. There was missing documentation of administration for 09/03/25 and 09/08/25. Non-pressure injury of the right chest. Cleanse with normal saline, pat dry, apply alginate calcium, cover with dry dressing every day and as needed if dressing is saturated, soiled, or dislodged for wound healing. There was missing documentation of administration for 09/02/25, 09/03/25, 09/08/25, and 09/09/25. Stage 3 pressure injury to upper back. Cleanse with normal saline, pat dry, apply alginate calcium, cover with bordered dressing one time a day for promote wound healing. There was missing documentation of administration for 09/02/25, 09/03/25, 09/08/25, and 09/09/25. 4. Record review of the face sheet, dated 09/11/25, reflected Resident #17 was an [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills) and pressure ulcer of the sacral region, stage 4 (wound created from pressure that is characterized by full-thickness skin loss that extends to muscle, tendon, and/or bone). Record review of the significant change MDS assessment, dated 08/22/25, reflected Resident #17 had clear speech, was usually understood, and was usually able to understand others. Resident #17 had short-term and long-term memory problems, no recall ability, and severely impaired decision making skills. The MDS reflected Resident #17 had upper and lower extremity impairment to both sides that interfered with daily function. Resident #17 required total dependence with most ADLs. The MDS reflected Resident #17 had a stage 4 pressure ulcer. Resident #17 had a pressure reducing device for the bed and applications of nonsurgical dressings. Record review of the comprehensive care plan, last reviewed on 09/04/25, reflected Resident #17 had a stage 4 pressure injury to her sacrum. The interventions included: treatment as ordered and monitor effectiveness, turn and reposition every 2 hours, and air mattress. Record review of Resident #17's order summary report, dated 09/11/25, reflected the following: Stage 4 pressure injury to sacrum. Cleanse with normal saline, pat dry, apply collagen powder, apply calcium alginate, cover with dry border dressing daily and as needed if soiled or dislodged. Start date of 07/25/25. Record review of Resident #17's wound administration record dated 8/1/25-8/31/25 indicated: Stage 4 pressure injury to sacrum. Cleanse with normal saline, pat dry, apply collagen powder, apply calcium alginate, cover with dry border dressing daily and as needed if soiled or dislodged. There was missing documentation of administration for 08/06/25, 08/07/25, 08/12/25, 08/15/25, 08/16,25, 08/17/25, 08/20/25, 08/21/25, and 08/24/25. Record review of Resident #17's wound administration record dated 9/1/25-9/30/25 indicated: Stage 4 pressure injury to sacrum. Cleanse with normal saline, pat dry, apply collagen powder, apply calcium alginate, cover with dry border dressing daily and as needed if soiled or dislodged. There was missing documentation of administration for 09/02/25, 09/05/25, 09/06/25, and 09/08/25. 5. Record review of the face sheet, dated 09/12/25, reflected Resident #18 was an [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of brain bleed, peripheral vascular disease (refers to any disease or disorder of the circulatory system outside of the brain and heart), stroke, and a history of colon, lung, and testicular cancer. Record review of the significant change MDS assessment, dated 07/16/25, reflected Resident #18 had clear speech, was understood, and was able to understand others. Resident #18 had a BIMS score of 15, which indicated no cognitive impairment. The MDS reflected Resident #18 had an upper extremity impairment to one side and a lower extremity impairment to both sides that interfered with daily function. The MDS reflected Resident #18 required total dependence with showers, toileting, and personal hygiene. Resident #18 required set-up help with eating and oral hygiene. Resident #18 required substantial/maximum assistance with dressing, bed mobility, and transfers. The MDS assessment reflected Resident #18 had a stage 4 pressure ulcer. Resident #18 had a pressure reducing device for bed and received pressure ulcer/injury care. Record review of the comprehensive care plan, last reviewed 07/14/25, reflected Resident #18 had a stage 4 pressure injury to right heel. The interventions included: treatment per orders and monitor for effectiveness, turn and reposition every 2 hours, and encourage the use of podus boot. Record review of Resident #18's order summary report, dated 09/12/25, reflected the following: Stage 4 pressure ulcer to right heel. Cleanse with normal saline, pat dry, apply collagen to wound bed, apply calcium alginate, and cover with dry dressing and wrap with kerlix daily and as needed related to soiling/dislodgement to promote wound healing. Start date of 06/18/25. Record review of Resident #18's wound administration record dated 8/1/25-8/31/25 indicated: Apply collagen powder to wound bed, cover with calcium alginate and dry dressing one time a day for promote wound healing. The order was stopped on 09/07/25. There was missing documentation of administration for 08/12/25, 08/14/25, 08/16/25, 08/20/25, 08/21/25, 08/23/25, and 08/25/25. Dakin's (1/4 strength) external solution 0.125% (sodium hypochlorite) - apply to right heel topically once time a day for apply Dakin's soaked gauze to wound bed. The order was stopped on 09/07/25. There was missing documentation of administration for 08/06/25, 08/07/25, 08/12/25, 08/16/25, 08/20/25, 08/21/25, and 08/24/25. Lymphedemic wound to left heel. Apply skin prep daily one time a day for promote wound healing. There was missing documentation of administration for 08/06/25, 08/07/25, 08/12/25, 08/16/25, 08/20/25, 08/21/25, and 08/24/25. Stage 4 pressure ulcer to right heel. Cleanse with normal saline, pat dry, apply collagen to wound bed, apply calcium alginate, and cover with dry dressing and wrap with kerlix daily and as needed related to soiling/dislodgment. There was missing documentation of administration for 08/06/25, 08/07/25, 08/12/25, 08/16/25, 08/20/25, 08/21/25, and 08/24/25. Record review of Resident #18's wound administration record dated 9/1/25-9/30/25 indicated: Apply collagen powder to wound bed, cover with calcium alginate and dry dressing one time a day for promote wound healing. The order was stopped on 09/07/25. There was missing documentation of administration for 09/02/25, 09/05/25, and 09/06/25. Dakin's (1/4 strength) external solution 0.125% (sodium hypochlorite) - apply to right heel topically one time a day for apply Daikin's soaked gauze to wound bed. The order was stopped on 09/07/25. There was missing documentation of administration for 09/02/25, 09/05/25, and 09/06/25. Lymphedemic wound to left heel. Apply skin prep daily one time a day for promote wound healing. There was missing documentation of administration for 09/02/25, 09/05/25, and 09/06/25. Stage 4 pressure ulcer to right heel. Cleanse with normal saline, pat dry, apply collagen to wound bed, apply calcium alginate, and cover with dry dressing and wrap with kerlix daily and as needed related to soiling/dislodgement. There was missing documentation of administration for 09/02/25, 09/05/25, and 09/06/25. 6. Record review of the face sheet, dated 09/12/25, reflected Resident #19 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of senile degeneration of brain (encompasses a range of neurological disorders characterized by a progressive decline in cognitive function, impacting memory, reasoning, and the ability to perform everyday activities). Record review of the significant change MDS assessment, dated 08/06/25, reflected Resident #19 had unclear speech, was sometimes understood, and was sometimes able to understand others. Resident #19 had a BIMS score of 4, which indicated severe cognitive impairment. The MDS reflected Resident #19 had a lower extremity impairment to both sides which interfered with daily function. Resident #19 was totally dependent on staff for ADLs, which included eating. The MDS reflected Resident #19 had a fall within the last month prior to admission. Resident #19 was checked for signs and symptoms of a swallowing disorder: holding food in mouth/cheeks or residual food in mouth after meals. Resident #19 required a mechanically altered diet while a resident of the facility. The MDS reflected Resident #19 was at risk for developing pressure ulcers/injuries. Resident #19 had a pressure reducing device for the bed. Record review of Resident #19's comprehensive care plan, last reviewed 09/09/25, reflected the following: Resident #19 had an ADL self-care performance deficit and required staff assistance x 1 with eating and was resistive to eating at times. Resident #19 had a history of falls and the interventions included: fall mat beside bed, appropriate footwear, call light in reach, anticipate needs, and staff assistance x 2 with transfers. Resident #19 had a stage 2 pressure ulcer to her right buttocks. The interventions included: treatments as ordered and monitor for effectiveness and follow facility policies/protocols for the prevention/treatment of pressure injuries. Record review of Resident #19's order summary report, dated 09/12/25, reflected the following: Regular diet with pureed texture, and regular c

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Residents #65) of 5 residents observed for infection control. <BR/>Housekeeper DD failed to doff (take off) PPE while exiting isolation room and entered Resident #65's room wearing contaminated PPE. Housekeeper DD wore soiled gloves in the hallway.<BR/>These failures could place residents at risk of cross-contamination and infections leading to illness.<BR/>Findings included:<BR/>Record review of Resident #65's admission Record dated 09/14/2023 indicated that resident was an 63-year- old female who admitted to the facility on [DATE] with diagnosis of non-pressure chronic ulcer of buttock with necrosis of the muscle (commonly occur in patients with arterial (ischemic) disease, venous disease, neuropathy, or a combination of these diseases), type 2 diabetes ( a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) fibromyalgia (a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), and urinary tract infection (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract).<BR/>Record review of Resident #65's MDS assessment, dated 07/03/2023, indicated that resident had a BIMS score of 15 which indicated resident had no cognition issues. The MDS also indicated that Resident #65 required extensive assistance of for bathing and personal hygiene.<BR/>Record review of Resident #65's Care Plan created on 09/07/2023 indicated that resident had a urinary tract infection with the goal of having the urinary tract infection resolved by 10/09/2023.<BR/>Record review of an in-service titled Prevention of Infection: Donning and Doffing PPE was signed by Housekeeper DD on 07/24/2023. Review revealed doffing (taking off) PPE was to be done within the isolation room and disposed of in a labeled biohazard container. PPE included gloves, mask, gown, hair covers, and shoe covers.<BR/>During an interview and observation on 09/11/2023 at 9:15 a.m., Resident #65 said she had concerns about the man that was placed in the room across the hall from her room. Resident #65 said she knew he was on isolation for something that was air borne and the staff kept his door open all the time and kept her door open despite Resident #65 having asked for it to be closed every time they left for privacy. During this conversation Resident #65's door was pushed open without a knock and Housekeeper DD entered the room with a mask, gloves, and isolation gown on. When Housekeeper DD saw the surveyor, she said, oh no and exited the room. Resident #65 became upset and said see what I mean, she spread his infection to my room! Now we (roommate and Resident #65) are going to get his disease! The room across the hall was noted to have an isolation set up outside of it and an air borne isolation poster on the door.<BR/>During an interview on 09/11/2023 at 9:25 p.m., Housekeeper DD said it was an accident that she walked into Resident #65's room. Housekeeper DD said she was taking out the biohazard material from the isolation room across the hall and forgot to take off her PPE before exiting the room. She opened Resident #65's door to clean her room but then saw the surveyor and realized her mistake of not taking her PPE off. Housekeeper DD was not aware of any potential adverse effects of not taking PPE off in the isolation room and washing her hands.<BR/>During an observation on 09/12/2023 at 8:50 a.m., Housekeeper DD exited a room on D hall with gloves on, walked down hallway pushing housekeeping cart and entered the next room with the same gloves on.<BR/>During an observation on 09/12/2023 at 10:20 a.m., Housekeeper D walked from D hall to the kitchen to return dirty dishes wearing gloves, then walked back to the housekeeping cart on D hall, pushed it to next room on the hall, and entered the room still wearing the same gloves.<BR/>During an interview on 09/12/2023 at 10:25 a.m., Housekeeper DD said she forgot to change gloves before entering the next room and was not aware she was not allowed to wear the gloves in the hallway. <BR/>During an interview on 09/13/2023 at 2:15 p.m., the DON said she had multiple in services on isolation, infection control prevention, and donning and doffing PPE and presented them to all staff including nursing, kitchen staff, housekeeping staff, and department heads. The DON said she would continue to educate the staff on infection prevention and control. The DON said not following isolation precautions could result in the spread of infections and she expected the staff to follow all isolation precautions and standard precautions to aid in the prevention of spreading infections.<BR/>During an interview on 09/13/2023 at 3:00 p.m., the Administrator said she expected the staff to follow the facilities policy for infection control. The Administrator said that the policies were in place to prevent the spread of infection throughout the building and protect the vulnerable residents that lived in the facility. <BR/>Record review of an infection control policy dated 07/2021 titled 'Infection Control' revealed: Begin removing PPE at patient's doorway or in anteroom. Eye protection and mask/respirator to be removed outside the room. Outside surfaces of PPE are considered to be contaminated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents environment remained as free of accident hazards as possible for 1 of 7 residents (Resident #1) reviewed for accidents and hazards.<BR/>The facility failed to ensure staff checked straps for damage prior to transferring Resident #1 which resulted in a laceration to Resident #1's forehead. <BR/>This failure could place residents at risk for injury.<BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 02/10/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis (weakness on one side of your body) following cerebral infarction (Stroke) affecting the left dominant side.<BR/>Record review of Resident #1''s MDS, dated [DATE], revealed Resident #1 required two-person assistance for transfers and had a BIMS score of 15, which indicated Resident #1 was cognitively intact, alert to person, place, and time. Resident #1 used a wheelchair to ambulate. Resident #1 required extensive assistance with most activities of daily living.<BR/>Record review of Resident #1's care plan, dated 12/27/22, revealed Resident #1 required two-person assistance for transfers and required a mechanical lift due to a self-care performance deficit. <BR/>Record review of Resident #1's nurse's note, dated 02/05/23 at 9:23 PM, by LVN B, revealed Resident #1 was kicking and yelling at staff. LVN B asked LVN A to assist in transferring Resident #1 from his wheelchair to his bed using a Mechanical lift. When LVN A and LVN B arrived in the room three of four straps were already attached to the lift. LVN A attached the last strap and proceeded with the transfer. During the transfer LVN B reported hearing a snap, and Resident #1 fell from the lift to the floor hitting his head causing a laceration. LVN B called 911 and Resident #1 was transferred to the hospital for evaluation and treatment.<BR/>Record review of Resident #1's hospital records, dated 02/05/23, revealed Resident #1 arrived at the hospital with a facial laceration. The fall involved a lift chair assistance as the cause of accidental injury. The injury was repaired with stiches. CT scan (scans take a fast series of X-ray pictures, which are put together to create images of the area that was scanned.), showed no acute intercranial abnormalities, laceration to the soft tissue, swelling to the left frontal scalp and preorbital (around the eye) soft skin. There was mild soft tissue swelling to the left cheek. Resident #1 was released back to the facility after treatment. <BR/>Observation of a video surveillance tape, date stamped on 02/05/22 at 8:48 PM, showed Resident #1 was being transferred from a wheelchair to a bed by LVN A and LVN B using a mechanical lift. The front left strap on the lift appeared to be frayed or damaged. During the transfer, the front left strap holding Resident #1, snapped and Resident #1 fell from the lift and hit his head on the floor.<BR/>During an observation and interview on 02/10/23 at 1:20 PM revealed Resident #1 was in his bed. There was a bandage on his forehead, above his left eye with a date of 02/10/23. There was a Hoyer lift Sling under him. The sling appeared to be in good condition with no frayed edges. Resident #1 said he was doing okay. He said he fell while staff attempted to transfer him from his wheelchair to his bed. Resident #1 said he did not remember much about what happened. He said all he remembered was the strap broke and he hit the floor. He said the next thing he remembered was being at the hospital. He said he did not feel he had been abused or neglected and what happened was an accident. Resident #1 said he was not afraid to be transferred with the Hoyer Lift.<BR/>During an interview on 01/17/23 at 1:20 PM, LVN A said he assisted LVN B with transferring Resident #1 with a Hoyer Lift on 02/05/23 around 8:30 PM. LVN A said while transferring Resident #1, a strap on the front left side of the lift snapped and Resident #1 fell to the floor and hit his head. LVN A said LVN B left the room and called 911 for assistance. LVN A said when he looked at Resident #1, there was blood on the floor coming from Resident #1's head. LVN A said she went and got a towel and applied pressure to the wound until EMS arrived and transported Resident #1 to the hospital for evaluation and treatment. LVN A said he did not realize the strip was damaged. LVN A said the cause of the accident was due to the defective strap. LVN A said he should have inspected the straps before he attempted to transfer Resident #1. LVN A said he was notified on 02/10/23 that he was suspended pending an investigation due to the incident. LVN A said he was scheduled to complete Mechanical Lift skills training before returning to work, but he had not yet received the training.<BR/>During an interview on 01/17/23 at 1:45 PM, LVN B said she and LVN A was asked to assist in transferring Resident #1 from his wheelchair to his bed because staff reported Resident #1 was being verbally and physically aggressive toward staff who attempted to transfer him to his bed. LVN B said she asked LVN A to assist in the transfer. LVN B said when she arrived in the room, there were three straps already attached to the lift and LVN A attached the fourth strap to transfer Resident #1. LVN B said she was operating the lift and LVN A lowered the bed to the lowest position. LVN B said the bed caught on the edge of a trash can at the foot of the bed when the bed was lowered. LVN B said she raised Resident #1 out of the wheelchair and LVN A was moving the wheelchair out of the way when she heard a snap. LVN B said the strap on the front left side of the sling holding Resident #1 broke and Resident #1 fell to the floor hitting his head. LVN B said she went to the door and yelled for help. LVN B said she called 911 on her cell phone and LVN A went and got a towel to stop the bleeding. LVN B said she did not notice the strap was damaged and if so, she would have not used the defective sling to transfer Resident #1. LVN B said she was notified on 02/10/23 by the DON she was suspended pending an investigation into the incident. LVN B said she should have assessed the condition of the straps before she attempted to transfer Resident #1. LVN B said since the incident she had received skills training on transferring using a Mechanical lift on 02/15/23. <BR/>During an interview on 02/10/23 at 12:12 PM, the DON said the first time she viewed the video was with the surveyor. DON said she had not reviewed the video of the incident with Resident #1 before this time. The DON said LVN A and LVN B failed to use proper technique when transferring Resident #1 with the Mechanical lift. The DON said staff should always assess the condition of the lift sling to ensure it was safe prior to use. The DON said it was obvious by viewing the video that the strap on the front left side was damaged and the sling should not have been used. The DON said after the incident she completed an assessment of all other lift slings in the building and found there were some that needed to be retired and new slings were ordered to replace the damaged slings. The DON said all staff received training to inspect the slings prior to use and if a sling showed signs of being defective or damaged the sling should not be used to transfer residents. The damaged sling should be reported to the charge nurse and the DON. The DON said the sling should be taken out of service and replaced with a new sling. The DON said all nursing staff would receive skills training with a check-off for each one on how to transfer a resident using a Mechanical lift. The DON said the skills training would be conducted by the DON and the Director of Rehabilitation. <BR/>During an interview on 02/10/23 at 12:08 PM, the Administrator said she was notified Resident #1 had a fall from a Mechanical lift on 02/05/23 around 8:30 PM. The Administrator said the cause was a damaged strap that broke which caused injury to Resident #1. The Administrator said she reported the incident to the state on 02/05/23 at around 9:45 PM. The Administrator said all the slings and straps in the facility were assessed by the DON for possible damage and those found to be damaged were removed from service immediately. The Administrator said new slings were ordered to replace the damaged slings. The Administrator said on 02/06/23 an intervention plan was developed by QAPI regarding the Hoyer Lift issue. The Administrator said all staff were in-serviced on inspecting the straps and slings before use. The Administrator said the DON would monitor and inspect slings and straps weekly to ensure they were in good condition. The Administrator said any slings found to be damaged would be removed from service and replaced. The Administrator said all nursing staff would receive skills training on how to properly operate the Mechanical Lift. The Administrator said the skills training would be conducted by the DON and Director of Rehabilitation. <BR/>An observation and interview on 02/10/23 at 1:45 PM revealed NA-A, NA-B and NA-C using a Hoyer lift to transfer Resident #1 from his bed to his wheelchair. NA A and NA B used proper technique in transporting the resident. Transfer was successfully completed with no concerns for Resident #1's safety. The equipment and sling were in good working order with no concerns. NA-A, NA-B and NA-C said they had recently received in-service training on safely using the Hoyer lift. They said they were to assess the condition of the sling and straps before using to transfer a resident. They said if the sling or straps were damaged, they were not to use them and report to the charge nurse and/or the DON.<BR/>Interview on 02/10/23 at 1:30 PM, the Laundry Aide said she washed two to three Hoyer Lift slings daily. She said she followed the manufacturer's suggested care instructions. She said the slings were washed in cold to warm water, but never hot water. She said all slings were hung to air dry and slings were never dried in the dryer. She said heat could cause the material to stretch or become weak.<BR/>Record review of Sling Laundry Instructions revealed .While the materials comply with applicable standards for strength, shrinkage and flammability, slings are subject to wear and tear, which increases with usage. Before each use check for fraying or cuts/tears in the straps and body of the sling. Slings that show wear or damage should be taken out of service . LAUNDRY INSTRUCTIONS: . Machine wash normal setting and at 140F/60C. Depending on the washing machine, this usually means on a medium temperature setting.<BR/>Record review of in-service records from 02/06/23 through 02/17/23 revealed documentation that nursing staff received training on 10/17/22. Staff received in-service training on laundry instructions of Hoyer Lift Slings. The in-service was conducted by the Housekeeping Supervisor. After washing the Hoyer Lift sling, you cannot put heat on it. The sling needs to air dry or put in the dryer with no heat. The fabric when heated can stretch and snap! This will cause an injury. This will be an automatic [NAME]!<BR/>Record review of in-service records revealed on 02/06/23 nursing staff received in-service training on Hoyer Lift transfer. <BR/>o <BR/>Must have 2 nursing staff (CNA, Nurse, Medication Aide) to use a Hoyer lift on a resident. <BR/>o <BR/>Always check sling and sling straps to verify they do not appear compromised.<BR/>o <BR/>If there is any question, have nurse verify it is okay to use. <BR/>o <BR/>DO NOT USE A DAMAGED SLING Under any circumstances.<BR/>Record review of Mechanical lift Competency Evaluations dated 02/10/23 - 02/17/23, showed staff using a Hoyer life to transfer residents received a skills assessment on using a Mechanical Life to transfer residents safely. <BR/>Record review of the facility's, undated, policy on Hydraulic lift revealed: . The resident will achieve safe transfer to bed or chair via mechanical lift device . The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift .23. Immediately remove any malfunctioning equipment from direct care use. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 10 residents (Resident #1) reviewed for reasonable accommodations. <BR/>The facility failed to ensure Resident #1 was allowed to use his personal motorized wheelchair during his stay at the facility. <BR/>This failure could place residents at risk for a loss of independence, decreased quality of life, self-worth, and dignity. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 04/15/25, indicated he was a [AGE] year-old male, admitted to the facility on [DATE], and discharged on 02/24/25. His diagnoses included spastic quadriplegic cerebral palsy (a severe form of cerebral palsy that affects all four limbs, leading to paralysis and muscle stiffness), and chronic kidney disease (a long-term condition where the kidneys are damaged and can't filter blood as effectively, leading to a buildup of waste and fluids in the body). <BR/>Record review of Resident #1's MDS assessment, dated 02/21/25, indicated he had a BIMS score of 15, which indicated intact cognition. The assessment indicated he used a motorized wheelchair prior to his admission. He had impairment of one of his upper extremities, and both of his lower extremities. <BR/>During an interview on 04/15/25 at 1:05 PM, the ADON said the facility did not allow the residents to use motorized wheelchairs in the facility. She said this had been in effect since before the current corporate entity took over. She said it has always been this way.<BR/>During an interview on 04/15/25 at 1:18 PM, the <BR/>ADON said Resident #1 had Cerebral Palsy. She said when he admitted to the facility, he used a wheelchair for mobility. She said he had poor trunk control. She said she did not think he was able to move the wheelchair on his own and had to be propelled when he wanted to be moved. She said he required substantial to maximal assistance with mobility. She said a previous administrator disallowed the motorized wheelchairs because of a previous resident that was unsafe with the motorized wheelchair. She said from then on they would allow the residents to use a motorized wheelchair, provided that they were assessed to be safe to use the motorized wheelchair.<BR/>During an interview on 04/15/25 at 2:00 PM, Resident #1 said the facility did not let him use his motorized wheelchair. He said when he arrived, he told the facility that his motorized wheelchair was on the way, and the facility staff did not allow him to use his motorized wheelchair. He said he did not have the strength to move his facility provided wheelchair. He said he did not like having to wait on staff to help him. He said he was used to being independent. He said it felt like they were taking away his independence. He said he was in the facility for about a week. He said he was frustrated about it while he was in the facility. He did not recall who specifically did not allow him to use his motorized wheelchair. <BR/>During an interview on 04/16/25 at 9:43 AM, the ADON said the risk to not allowing residents to use motorized wheelchairs was that residents would have to depend on staff for care and could lose their sense of independence<BR/>During an interview on 04/16/25 at 9:56 AM, RNC A said she expected the facility to allow the resident to use his motorized wheelchair. She said they required a safety assessment with therapy, and the motorized wheelchair should be in working condition. She said the facility was under the impression they did not allow wheelchairs from an administrator about 4 administrators ago. She said not allowing a resident to use their motorized wheelchair could affect their dignity and diminish their sense of independence.<BR/>During an interview on 04/16/25 at 10:14 AM, the Administrator said she was not working in the facility during Resident #1's stay. She said she expected the staff to allow the motorized wheelchair as long as they are assessed by the therapy department, and were found to be safe. She said the risk was that it was possible the resident could feel isolated from the building, socialization, and activities if they were not allowed to use their motorized wheelchair.<BR/>Record review of the facility's undated policy, Resident Rights, stated:<BR/>The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy.<BR/>A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident .<BR/> .Respect and dignity - The resident has a right to be treated with respect and dignity, including: .<BR/> .2. The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.<BR/>3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents .<BR/>Record review of the facility's policy, Electric or Motorized Wheelchair, last revised 02/27/15, stated:<BR/> .A Medicaid and Medicare certified [Nursing Facility] must not discriminate on the basis of disability. A nursing facility that denies access and service to a potential resident may be found in noncompliance with state rules and federal regulations. <BR/>It is out policy to ensure, to the best of our ability, the safety of residents who own and use an electric wheelchair, as well as the safety of all other resident's, staff and visitors in the facility. Therefore, resident's owning/using an electric wheelchair will be assessed on admission, quarterly and upon a significant change of condition for their ability to guide/drive the wheelchair .<BR/> .The facility should allow a resident to store the power mobility device in the resident's room if there are no Life Safety Codes concerns, such as blocking or limiting egress .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents environment remained as free of accident hazards as possible for 1 of 7 residents (Resident #1) reviewed for accidents and hazards.<BR/>The facility failed to ensure staff checked straps for damage prior to transferring Resident #1 which resulted in a laceration to Resident #1's forehead. <BR/>This failure could place residents at risk for injury.<BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 02/10/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis (weakness on one side of your body) following cerebral infarction (Stroke) affecting the left dominant side.<BR/>Record review of Resident #1''s MDS, dated [DATE], revealed Resident #1 required two-person assistance for transfers and had a BIMS score of 15, which indicated Resident #1 was cognitively intact, alert to person, place, and time. Resident #1 used a wheelchair to ambulate. Resident #1 required extensive assistance with most activities of daily living.<BR/>Record review of Resident #1's care plan, dated 12/27/22, revealed Resident #1 required two-person assistance for transfers and required a mechanical lift due to a self-care performance deficit. <BR/>Record review of Resident #1's nurse's note, dated 02/05/23 at 9:23 PM, by LVN B, revealed Resident #1 was kicking and yelling at staff. LVN B asked LVN A to assist in transferring Resident #1 from his wheelchair to his bed using a Mechanical lift. When LVN A and LVN B arrived in the room three of four straps were already attached to the lift. LVN A attached the last strap and proceeded with the transfer. During the transfer LVN B reported hearing a snap, and Resident #1 fell from the lift to the floor hitting his head causing a laceration. LVN B called 911 and Resident #1 was transferred to the hospital for evaluation and treatment.<BR/>Record review of Resident #1's hospital records, dated 02/05/23, revealed Resident #1 arrived at the hospital with a facial laceration. The fall involved a lift chair assistance as the cause of accidental injury. The injury was repaired with stiches. CT scan (scans take a fast series of X-ray pictures, which are put together to create images of the area that was scanned.), showed no acute intercranial abnormalities, laceration to the soft tissue, swelling to the left frontal scalp and preorbital (around the eye) soft skin. There was mild soft tissue swelling to the left cheek. Resident #1 was released back to the facility after treatment. <BR/>Observation of a video surveillance tape, date stamped on 02/05/22 at 8:48 PM, showed Resident #1 was being transferred from a wheelchair to a bed by LVN A and LVN B using a mechanical lift. The front left strap on the lift appeared to be frayed or damaged. During the transfer, the front left strap holding Resident #1, snapped and Resident #1 fell from the lift and hit his head on the floor.<BR/>During an observation and interview on 02/10/23 at 1:20 PM revealed Resident #1 was in his bed. There was a bandage on his forehead, above his left eye with a date of 02/10/23. There was a Hoyer lift Sling under him. The sling appeared to be in good condition with no frayed edges. Resident #1 said he was doing okay. He said he fell while staff attempted to transfer him from his wheelchair to his bed. Resident #1 said he did not remember much about what happened. He said all he remembered was the strap broke and he hit the floor. He said the next thing he remembered was being at the hospital. He said he did not feel he had been abused or neglected and what happened was an accident. Resident #1 said he was not afraid to be transferred with the Hoyer Lift.<BR/>During an interview on 01/17/23 at 1:20 PM, LVN A said he assisted LVN B with transferring Resident #1 with a Hoyer Lift on 02/05/23 around 8:30 PM. LVN A said while transferring Resident #1, a strap on the front left side of the lift snapped and Resident #1 fell to the floor and hit his head. LVN A said LVN B left the room and called 911 for assistance. LVN A said when he looked at Resident #1, there was blood on the floor coming from Resident #1's head. LVN A said she went and got a towel and applied pressure to the wound until EMS arrived and transported Resident #1 to the hospital for evaluation and treatment. LVN A said he did not realize the strip was damaged. LVN A said the cause of the accident was due to the defective strap. LVN A said he should have inspected the straps before he attempted to transfer Resident #1. LVN A said he was notified on 02/10/23 that he was suspended pending an investigation due to the incident. LVN A said he was scheduled to complete Mechanical Lift skills training before returning to work, but he had not yet received the training.<BR/>During an interview on 01/17/23 at 1:45 PM, LVN B said she and LVN A was asked to assist in transferring Resident #1 from his wheelchair to his bed because staff reported Resident #1 was being verbally and physically aggressive toward staff who attempted to transfer him to his bed. LVN B said she asked LVN A to assist in the transfer. LVN B said when she arrived in the room, there were three straps already attached to the lift and LVN A attached the fourth strap to transfer Resident #1. LVN B said she was operating the lift and LVN A lowered the bed to the lowest position. LVN B said the bed caught on the edge of a trash can at the foot of the bed when the bed was lowered. LVN B said she raised Resident #1 out of the wheelchair and LVN A was moving the wheelchair out of the way when she heard a snap. LVN B said the strap on the front left side of the sling holding Resident #1 broke and Resident #1 fell to the floor hitting his head. LVN B said she went to the door and yelled for help. LVN B said she called 911 on her cell phone and LVN A went and got a towel to stop the bleeding. LVN B said she did not notice the strap was damaged and if so, she would have not used the defective sling to transfer Resident #1. LVN B said she was notified on 02/10/23 by the DON she was suspended pending an investigation into the incident. LVN B said she should have assessed the condition of the straps before she attempted to transfer Resident #1. LVN B said since the incident she had received skills training on transferring using a Mechanical lift on 02/15/23. <BR/>During an interview on 02/10/23 at 12:12 PM, the DON said the first time she viewed the video was with the surveyor. DON said she had not reviewed the video of the incident with Resident #1 before this time. The DON said LVN A and LVN B failed to use proper technique when transferring Resident #1 with the Mechanical lift. The DON said staff should always assess the condition of the lift sling to ensure it was safe prior to use. The DON said it was obvious by viewing the video that the strap on the front left side was damaged and the sling should not have been used. The DON said after the incident she completed an assessment of all other lift slings in the building and found there were some that needed to be retired and new slings were ordered to replace the damaged slings. The DON said all staff received training to inspect the slings prior to use and if a sling showed signs of being defective or damaged the sling should not be used to transfer residents. The damaged sling should be reported to the charge nurse and the DON. The DON said the sling should be taken out of service and replaced with a new sling. The DON said all nursing staff would receive skills training with a check-off for each one on how to transfer a resident using a Mechanical lift. The DON said the skills training would be conducted by the DON and the Director of Rehabilitation. <BR/>During an interview on 02/10/23 at 12:08 PM, the Administrator said she was notified Resident #1 had a fall from a Mechanical lift on 02/05/23 around 8:30 PM. The Administrator said the cause was a damaged strap that broke which caused injury to Resident #1. The Administrator said she reported the incident to the state on 02/05/23 at around 9:45 PM. The Administrator said all the slings and straps in the facility were assessed by the DON for possible damage and those found to be damaged were removed from service immediately. The Administrator said new slings were ordered to replace the damaged slings. The Administrator said on 02/06/23 an intervention plan was developed by QAPI regarding the Hoyer Lift issue. The Administrator said all staff were in-serviced on inspecting the straps and slings before use. The Administrator said the DON would monitor and inspect slings and straps weekly to ensure they were in good condition. The Administrator said any slings found to be damaged would be removed from service and replaced. The Administrator said all nursing staff would receive skills training on how to properly operate the Mechanical Lift. The Administrator said the skills training would be conducted by the DON and Director of Rehabilitation. <BR/>An observation and interview on 02/10/23 at 1:45 PM revealed NA-A, NA-B and NA-C using a Hoyer lift to transfer Resident #1 from his bed to his wheelchair. NA A and NA B used proper technique in transporting the resident. Transfer was successfully completed with no concerns for Resident #1's safety. The equipment and sling were in good working order with no concerns. NA-A, NA-B and NA-C said they had recently received in-service training on safely using the Hoyer lift. They said they were to assess the condition of the sling and straps before using to transfer a resident. They said if the sling or straps were damaged, they were not to use them and report to the charge nurse and/or the DON.<BR/>Interview on 02/10/23 at 1:30 PM, the Laundry Aide said she washed two to three Hoyer Lift slings daily. She said she followed the manufacturer's suggested care instructions. She said the slings were washed in cold to warm water, but never hot water. She said all slings were hung to air dry and slings were never dried in the dryer. She said heat could cause the material to stretch or become weak.<BR/>Record review of Sling Laundry Instructions revealed .While the materials comply with applicable standards for strength, shrinkage and flammability, slings are subject to wear and tear, which increases with usage. Before each use check for fraying or cuts/tears in the straps and body of the sling. Slings that show wear or damage should be taken out of service . LAUNDRY INSTRUCTIONS: . Machine wash normal setting and at 140F/60C. Depending on the washing machine, this usually means on a medium temperature setting.<BR/>Record review of in-service records from 02/06/23 through 02/17/23 revealed documentation that nursing staff received training on 10/17/22. Staff received in-service training on laundry instructions of Hoyer Lift Slings. The in-service was conducted by the Housekeeping Supervisor. After washing the Hoyer Lift sling, you cannot put heat on it. The sling needs to air dry or put in the dryer with no heat. The fabric when heated can stretch and snap! This will cause an injury. This will be an automatic [NAME]!<BR/>Record review of in-service records revealed on 02/06/23 nursing staff received in-service training on Hoyer Lift transfer. <BR/>o <BR/>Must have 2 nursing staff (CNA, Nurse, Medication Aide) to use a Hoyer lift on a resident. <BR/>o <BR/>Always check sling and sling straps to verify they do not appear compromised.<BR/>o <BR/>If there is any question, have nurse verify it is okay to use. <BR/>o <BR/>DO NOT USE A DAMAGED SLING Under any circumstances.<BR/>Record review of Mechanical lift Competency Evaluations dated 02/10/23 - 02/17/23, showed staff using a Hoyer life to transfer residents received a skills assessment on using a Mechanical Life to transfer residents safely. <BR/>Record review of the facility's, undated, policy on Hydraulic lift revealed: . The resident will achieve safe transfer to bed or chair via mechanical lift device . The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift .23. Immediately remove any malfunctioning equipment from direct care use. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 10 residents (Resident #4) reviewed for the ability to call for staff assistance. <BR/>The facility failed to ensure Resident #4 had a call light that was functional. Resident #4's call light did not turn on when the button was pressed. <BR/>This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. <BR/>Findings included:<BR/>Record review of Resident #3's face sheet, dated 04/15/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lung). <BR/>Record review of Resident #3's admission MDS assessment, dated 04/11/25, indicated she had a BIMS score of 15, which indicated intact cognition. <BR/>Record review of Resident #4's face sheet, dated 04/15/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia (loss of brain function, including memory, thinking, language, judgment, or behavior, that interferes with daily life), heart failure (occurs when the heart can't pump enough blood to meet the body's needs), and major depressive disorder (a serious mental illness that involves persistent feelings of sadness and loss of interest in activities).<BR/>Record review of Resident #4's quarterly MDS assessment, dated 03/05/25, indicated she had a BIMS score of 7, which indicated severe cognitive impairment. She had impairment of all four extremities. She was completely dependent on staff for toileting, bathing, lower body dressing, personal hygiene, and bed-to-chair transfers. She required maximal assistance with upper body dressing, roll left and right, sit to lying, and lying to sitting on side of bed. She was always incontinent of both bowel and bladder. <BR/>Record review of Resident #4's care plan, dated 04/01/25, indicated a focus of the resident was dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits, disease process, and physical limitations. Interventions included ensure that adaptive equipment that the resident needs is provided and is present and functional. <BR/>During an interview 04/15/25 at 10:17AM, Resident #3 was sitting up in bed watching TV. She said her roommate Resident #4's call light had not been working for around 2 weeks. She said while she was in the room, if Resident #4 needed anything, then she would press her own call light for Resident #4.<BR/>During an observation and interview on 04/15/25 at 10:22AM, Resident #4 was lying in bed resting. She asked this surveyor if she could be changed. This surveyor pressed her call light to call for a staff member. The light did not turn on. This surveyor asked her roommate Resident #3 to press her light and it then came on. <BR/>During an observation and interview on 04/15/25 at 10:27AM, CNA C came into Resident #3 and Resident #4's room and answered the call light. She attempted to press the call light on Resident #4's side and it did not come on. She said she would notify the maintenance department. She said the risk to the resident was that she would be unable to call for help if she needed something or if she fell and needed help.<BR/>During an interview on 04/16/25 at 8:37AM, the Maintenance Supervisor said he checked the call lights in at least 5 rooms each week. He said he checks the call light panel at the nurse's station daily. He said if he notices an issue, then he checks on the lights right away. He said he was not aware of the light not working in Resident #4's room before this surveyor noticed it was not working. He said he replaced the call light cord in Resident #4's room and it was functional at that time. He said the risk to the resident was they could fall and get hurt and be unable to call for help. He said someone could have a nursing related issue and be unable to call for help. He said he had worked in the facility since the end of February. He said he was unaware of the last time the call light was checked because it would have been before he started working there. He said they use a maintenance request program to request the maintenance director to check things. He said he had not received a request for the call light in Resident #4's room. <BR/>During an interview on 04/16/25 at 9:43AM, the ADON said she was not aware of the call light in Resident #4's room not working before this surveyor pointed it out. She said it was replaced and was working. She said the cable was bad and not working. She said the risk was that the resident could miss care she wanted due to not being able to turn on the light. She said it was possible the resident could fall and not be able to call for help. <BR/>During an interview on 04/16/25 at 9:56AM, RNC A said she expected the call light to be functional. She said she expected the call light, if it was not working, to be communicated to the maintenance director to be addressed immediately. She said the risk was that the resident's needs could not be met timely. She said it was possible the resident could fall and not be able to call for help.<BR/>During an interview on 04/16/25 at 10:14AM, the Administrator said she expected the call lights to be functional at all times. She said if it was not working, then staff should notify maintenance immediately. She said the risk was that the resident could need assistance and the staff would not know to come help her. She said it was possible the resident could fall and be unable to get help.<BR/>Record review of the facility's undated Life Safety Binder stated:<BR/> .Call Lights - Check 2 rooms a hall weekly and 100% before full book .<BR/>Record review of a sheet titled Call Lights Check, dated 03/03/25 through 04/15/25, indicated Resident #3 and Resident #4's room call lights were checked on 04/15/25. There were no other dates for Resident #3 and Resident #4's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents environment remained as free of accident hazards as possible for 1 of 7 residents (Resident #1) reviewed for accidents and hazards.<BR/>The facility failed to ensure staff checked straps for damage prior to transferring Resident #1 which resulted in a laceration to Resident #1's forehead. <BR/>This failure could place residents at risk for injury.<BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 02/10/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis (weakness on one side of your body) following cerebral infarction (Stroke) affecting the left dominant side.<BR/>Record review of Resident #1''s MDS, dated [DATE], revealed Resident #1 required two-person assistance for transfers and had a BIMS score of 15, which indicated Resident #1 was cognitively intact, alert to person, place, and time. Resident #1 used a wheelchair to ambulate. Resident #1 required extensive assistance with most activities of daily living.<BR/>Record review of Resident #1's care plan, dated 12/27/22, revealed Resident #1 required two-person assistance for transfers and required a mechanical lift due to a self-care performance deficit. <BR/>Record review of Resident #1's nurse's note, dated 02/05/23 at 9:23 PM, by LVN B, revealed Resident #1 was kicking and yelling at staff. LVN B asked LVN A to assist in transferring Resident #1 from his wheelchair to his bed using a Mechanical lift. When LVN A and LVN B arrived in the room three of four straps were already attached to the lift. LVN A attached the last strap and proceeded with the transfer. During the transfer LVN B reported hearing a snap, and Resident #1 fell from the lift to the floor hitting his head causing a laceration. LVN B called 911 and Resident #1 was transferred to the hospital for evaluation and treatment.<BR/>Record review of Resident #1's hospital records, dated 02/05/23, revealed Resident #1 arrived at the hospital with a facial laceration. The fall involved a lift chair assistance as the cause of accidental injury. The injury was repaired with stiches. CT scan (scans take a fast series of X-ray pictures, which are put together to create images of the area that was scanned.), showed no acute intercranial abnormalities, laceration to the soft tissue, swelling to the left frontal scalp and preorbital (around the eye) soft skin. There was mild soft tissue swelling to the left cheek. Resident #1 was released back to the facility after treatment. <BR/>Observation of a video surveillance tape, date stamped on 02/05/22 at 8:48 PM, showed Resident #1 was being transferred from a wheelchair to a bed by LVN A and LVN B using a mechanical lift. The front left strap on the lift appeared to be frayed or damaged. During the transfer, the front left strap holding Resident #1, snapped and Resident #1 fell from the lift and hit his head on the floor.<BR/>During an observation and interview on 02/10/23 at 1:20 PM revealed Resident #1 was in his bed. There was a bandage on his forehead, above his left eye with a date of 02/10/23. There was a Hoyer lift Sling under him. The sling appeared to be in good condition with no frayed edges. Resident #1 said he was doing okay. He said he fell while staff attempted to transfer him from his wheelchair to his bed. Resident #1 said he did not remember much about what happened. He said all he remembered was the strap broke and he hit the floor. He said the next thing he remembered was being at the hospital. He said he did not feel he had been abused or neglected and what happened was an accident. Resident #1 said he was not afraid to be transferred with the Hoyer Lift.<BR/>During an interview on 01/17/23 at 1:20 PM, LVN A said he assisted LVN B with transferring Resident #1 with a Hoyer Lift on 02/05/23 around 8:30 PM. LVN A said while transferring Resident #1, a strap on the front left side of the lift snapped and Resident #1 fell to the floor and hit his head. LVN A said LVN B left the room and called 911 for assistance. LVN A said when he looked at Resident #1, there was blood on the floor coming from Resident #1's head. LVN A said she went and got a towel and applied pressure to the wound until EMS arrived and transported Resident #1 to the hospital for evaluation and treatment. LVN A said he did not realize the strip was damaged. LVN A said the cause of the accident was due to the defective strap. LVN A said he should have inspected the straps before he attempted to transfer Resident #1. LVN A said he was notified on 02/10/23 that he was suspended pending an investigation due to the incident. LVN A said he was scheduled to complete Mechanical Lift skills training before returning to work, but he had not yet received the training.<BR/>During an interview on 01/17/23 at 1:45 PM, LVN B said she and LVN A was asked to assist in transferring Resident #1 from his wheelchair to his bed because staff reported Resident #1 was being verbally and physically aggressive toward staff who attempted to transfer him to his bed. LVN B said she asked LVN A to assist in the transfer. LVN B said when she arrived in the room, there were three straps already attached to the lift and LVN A attached the fourth strap to transfer Resident #1. LVN B said she was operating the lift and LVN A lowered the bed to the lowest position. LVN B said the bed caught on the edge of a trash can at the foot of the bed when the bed was lowered. LVN B said she raised Resident #1 out of the wheelchair and LVN A was moving the wheelchair out of the way when she heard a snap. LVN B said the strap on the front left side of the sling holding Resident #1 broke and Resident #1 fell to the floor hitting his head. LVN B said she went to the door and yelled for help. LVN B said she called 911 on her cell phone and LVN A went and got a towel to stop the bleeding. LVN B said she did not notice the strap was damaged and if so, she would have not used the defective sling to transfer Resident #1. LVN B said she was notified on 02/10/23 by the DON she was suspended pending an investigation into the incident. LVN B said she should have assessed the condition of the straps before she attempted to transfer Resident #1. LVN B said since the incident she had received skills training on transferring using a Mechanical lift on 02/15/23. <BR/>During an interview on 02/10/23 at 12:12 PM, the DON said the first time she viewed the video was with the surveyor. DON said she had not reviewed the video of the incident with Resident #1 before this time. The DON said LVN A and LVN B failed to use proper technique when transferring Resident #1 with the Mechanical lift. The DON said staff should always assess the condition of the lift sling to ensure it was safe prior to use. The DON said it was obvious by viewing the video that the strap on the front left side was damaged and the sling should not have been used. The DON said after the incident she completed an assessment of all other lift slings in the building and found there were some that needed to be retired and new slings were ordered to replace the damaged slings. The DON said all staff received training to inspect the slings prior to use and if a sling showed signs of being defective or damaged the sling should not be used to transfer residents. The damaged sling should be reported to the charge nurse and the DON. The DON said the sling should be taken out of service and replaced with a new sling. The DON said all nursing staff would receive skills training with a check-off for each one on how to transfer a resident using a Mechanical lift. The DON said the skills training would be conducted by the DON and the Director of Rehabilitation. <BR/>During an interview on 02/10/23 at 12:08 PM, the Administrator said she was notified Resident #1 had a fall from a Mechanical lift on 02/05/23 around 8:30 PM. The Administrator said the cause was a damaged strap that broke which caused injury to Resident #1. The Administrator said she reported the incident to the state on 02/05/23 at around 9:45 PM. The Administrator said all the slings and straps in the facility were assessed by the DON for possible damage and those found to be damaged were removed from service immediately. The Administrator said new slings were ordered to replace the damaged slings. The Administrator said on 02/06/23 an intervention plan was developed by QAPI regarding the Hoyer Lift issue. The Administrator said all staff were in-serviced on inspecting the straps and slings before use. The Administrator said the DON would monitor and inspect slings and straps weekly to ensure they were in good condition. The Administrator said any slings found to be damaged would be removed from service and replaced. The Administrator said all nursing staff would receive skills training on how to properly operate the Mechanical Lift. The Administrator said the skills training would be conducted by the DON and Director of Rehabilitation. <BR/>An observation and interview on 02/10/23 at 1:45 PM revealed NA-A, NA-B and NA-C using a Hoyer lift to transfer Resident #1 from his bed to his wheelchair. NA A and NA B used proper technique in transporting the resident. Transfer was successfully completed with no concerns for Resident #1's safety. The equipment and sling were in good working order with no concerns. NA-A, NA-B and NA-C said they had recently received in-service training on safely using the Hoyer lift. They said they were to assess the condition of the sling and straps before using to transfer a resident. They said if the sling or straps were damaged, they were not to use them and report to the charge nurse and/or the DON.<BR/>Interview on 02/10/23 at 1:30 PM, the Laundry Aide said she washed two to three Hoyer Lift slings daily. She said she followed the manufacturer's suggested care instructions. She said the slings were washed in cold to warm water, but never hot water. She said all slings were hung to air dry and slings were never dried in the dryer. She said heat could cause the material to stretch or become weak.<BR/>Record review of Sling Laundry Instructions revealed .While the materials comply with applicable standards for strength, shrinkage and flammability, slings are subject to wear and tear, which increases with usage. Before each use check for fraying or cuts/tears in the straps and body of the sling. Slings that show wear or damage should be taken out of service . LAUNDRY INSTRUCTIONS: . Machine wash normal setting and at 140F/60C. Depending on the washing machine, this usually means on a medium temperature setting.<BR/>Record review of in-service records from 02/06/23 through 02/17/23 revealed documentation that nursing staff received training on 10/17/22. Staff received in-service training on laundry instructions of Hoyer Lift Slings. The in-service was conducted by the Housekeeping Supervisor. After washing the Hoyer Lift sling, you cannot put heat on it. The sling needs to air dry or put in the dryer with no heat. The fabric when heated can stretch and snap! This will cause an injury. This will be an automatic [NAME]!<BR/>Record review of in-service records revealed on 02/06/23 nursing staff received in-service training on Hoyer Lift transfer. <BR/>o <BR/>Must have 2 nursing staff (CNA, Nurse, Medication Aide) to use a Hoyer lift on a resident. <BR/>o <BR/>Always check sling and sling straps to verify they do not appear compromised.<BR/>o <BR/>If there is any question, have nurse verify it is okay to use. <BR/>o <BR/>DO NOT USE A DAMAGED SLING Under any circumstances.<BR/>Record review of Mechanical lift Competency Evaluations dated 02/10/23 - 02/17/23, showed staff using a Hoyer life to transfer residents received a skills assessment on using a Mechanical Life to transfer residents safely. <BR/>Record review of the facility's, undated, policy on Hydraulic lift revealed: . The resident will achieve safe transfer to bed or chair via mechanical lift device . The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift .23. Immediately remove any malfunctioning equipment from direct care use. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident had the right to be treated with dignity and respect and free from physical restraints for 1 of 3 residents (Resident #1) reviewed for resident rights.<BR/>CNA D said she restrained Resident #1 on three occasions during the last month or so. She said about a month ago she had swaddled Resident #1 with a blanket by folding a blanket around Resident #1 to restrict her movements. CNA D said she had swaddled Resident #1 on the night of [DATE] to calm her down. On the morning of [DATE] CNA D said around 3:15 a.m. she had used a pair of leggings and tied Resident #1's legs to the bed to keep her from getting out of bed. <BR/>Resident #1 was tied to the bed from 3:15 a.m. until around 8:00 a.m. on the morning of [DATE]. <BR/>An IJ was identified on [DATE]. The IJ began on [DATE] and was removed on [DATE]. The facility took action to remove the IJ before the survey began. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm because all staff had not been trained on physical restraints, behaviors, fall prevention, and resident rights. <BR/>This failure placed residents at risk of entrapment with serious injury or death. <BR/>Findings included: <BR/>The surveyor entered the facility on [DATE] at 1:15p.m. <BR/>Record review of Resident #1's face sheet dated [DATE] indicated a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were Huntington's Disease (disease that caused nerve cells in the brain to gradually break down-causing cognitive, psychiatric, thinking, and movement disorders), schizoaffective disorder ( mental health condition with mixed symptoms of hallucinations, delusions, mood disorders such as depression, or mania), anxiety disorder, and history of falling. <BR/>Record review of Resident #1's significant change MDS dated [DATE] indicated she had long and short-term memory loss. She was not coded for any behaviors. She required supervision for eating and was dependent on staff for all other ADLs. <BR/>Record review of Resident #1's care plan last revised on [DATE] indicated a Focused area of at risk for falls due to Huntington's Disease secondary to movement disorder. Some of the interventions were the resident was to be on a low bed with mattress on the floor beside her bed. The resident was able to and did crawl out of bed onto the mattress by herself. The resident needed activities that minimize the potential for falls while providing diversion and distraction. A Focused area of communication barrier secondary to Huntington's Disease. A Focused area of potential to demonstrate physical behaviors due to her poor impulse control such as crawling on the floor. Throwing her legs over the side of the bed, spastic movements caused her to come out of her bed or hit herself unintentionally. Some of the interventions were when the resident became agitated to intervene before the agitation escalated. <BR/>Record review of Resident #1's active orders as of [DATE] indicated an order for a fall mat to floor at bedside dated [DATE]. An order that indicated she may have a scoop mattress to help establish bed boundaries dated [DATE]. An order dated [DATE] that indicated to admit to hospice. <BR/>Record review of Resident #1's nursing notes dated [DATE] at 8:15 a.m. indicated Resident #1 was noted with legs tied together with a pair of leggings and tied to the bed. There was no signs and symptoms of distress noted. Investigation in progress. Signed by the ADON.<BR/>Record review of Resident #1's Weekly skin check dated [DATE] indicated the resident had discoloration on her left and right arms. She had multiple scabs on her legs. Signed by treatment nurse.<BR/>Record review Resident #1's Trauma Informed assessment dated [DATE] indicated the resident had a mental disorder and the questions were asked of the resident or responsible party. The assessment indicated they recently felt angry. <BR/>Record review of CNA D's Proficiency Audit dated [DATE] indicated she had knowledge of the Abuse and Neglect Protocol.<BR/>Record review of CNA D's personnel file indicated she began working at the facility on [DATE]. Her transcript details indicated she had a training on [DATE] regarding Creating a Restraint Free Environment, Fall Prevention, Preventing, Recognizing, and Reporting Abuse, and Essentials of Resident Rights. <BR/>Record review of an in-service dated [DATE] regarding abuse and neglect indicated CNA D signed the training roster indicating she had received abuse training. <BR/>Record review of a statement written and signed by CNA D indicated she said on the night of [DATE] she was taking care of Resident #1 and she took her leggings she was wearing off. She then tied one leg to the strap of the bed and put the other one through her legs. She stated she tied it to her gown to keep her from jumping out of the bed and hurting herself at about 3:15 a.m. She dated the statement [DATE]. She wrote another statement dated [DATE] that indicated in the past Resident #1 had two beds placed together and she kicked the mattress of the second bed and jumped on the metal frame. She put her back in the bed and she did it again. The aide wrote, So I swaddled her with blankets and she calmed down and went to sleep. <BR/>During an interview on [DATE] at 2:06 p.m. RN A said she was on the unit working with a resident on the morning of [DATE]. She said CNA C came to her and said Resident #1 was tied up with a blanket or something to the bed frame. She said she told CNA C to get the ADON, because she was busy at that time. RN A said she did not actually see Resident #1 tied to the bed. She said Resident #1 had Huntington's with involuntary jerking movements of the arms and legs, and limited communication. RN A said Resident #1 communicated with gestures, was easily frustrated, and she could not walk. She said she did not know a lot about the incident as she was not really involved. <BR/>During an interview on [DATE] at 2:10 a.m. CNA B said she heard Resident #1 was tied to the bed, but she did not see anything. She said she had written a statement saying she had not seen Resident #1 or any other resident restrained.<BR/>During an observation and interview on [DATE] at 2:18 p.m. the ADON/LVN said CNA C called her to Resident #1's room. The ADON said when she arrived in the room Resident #1 had a pair of leggings (stretch pants) wrapped around her legs. She said Resident #1 had abnormal movements and it was hard to tell what was going on. The ADON said she first thought the pants were just pulled down until she looked closer. She said the leg part was wrapped around her leg and other leg was tied to the bed. She said the bed had straps that were used to keep the low air loss mattress in place. The pants were tied to the one of the bed straps at the foot of the bed. She said she had spoken with CNA D later and she said she did not want Resident #1 coming out of the bed. The ADON said the facility Administrator called the police, reported the incident, and suspended the aide. The ADON had a picture of Resident #1's legs tied to the bed. Review of the picture showed a black pair of pants wrapped around and through Resident #1's legs. The left leg looked like it may have still been in the appropriate pant leg. The other pant leg looked to be wrapped around the right leg and then tied to a strap on the side of the bed. The left side of the pants were below the knee, and the right side was at the knee joint. <BR/>During an interview on [DATE] at 2:32 p.m. CNA C said on the morning of [DATE], she clocked in at 7:00 a.m. She said she had just finished passing trays, and she made Resident #1 her last resident because she required assistance with eating. CNA C said she was trying to assist Resident #1 to get up for her breakfast about 8:00 a.m. to 8:15 a.m. When she tried to get Resident #1 out of bed she could not. CNA C said Resident #1 ate her meals in her chair. She said Resident #1 could feed herself but must have staff to watch her. She said she could not get the resident out of bed and looked to see what was going on. CNA C said it looked like some pants wrapped around Resident #1's leg, connected to her leg somehow and tied to the bed. CNA C said she tried to untie the pants and she started to panic because she could not untie them. She said she had gotten the Housekeeper to come in and witness what was going on. She said she had gone and reported to RN A. She said RN A told her to report it immediately to the ADON. CNA C said the ADON came in and it took her a while to get Resident #1 untied. She said she did not know if Resident #1 was agitated or just having involuntary movements but she would not be still so she could be untied. CNA C said she came on shift and worked behind CNA D who was on the hall the night before. She said that was the first time she had seen any resident tied or restrained. She said Resident #1 would get agitated, she would crawl out of the bed, and she would jerk and move about. She said Resident #1 was mad and panicking because she could not get her up that morning. <BR/>During an interview on [DATE] at 2:40 p.m. the Administrator, said she was notified by the ADON about 8:15 a.m. today, [DATE] of the incident. The Administrator said when she was notified Resident #1 was already untied. She said she was told CNA C found Resident #1's legs wrapped in a pair of pants or leggings and tied to the mattress. She said they had investigated and determined CNA D was the perpetrator. She said she called CNA D back to the facility and she had written statements. The Administrator said CNA D's justification for tying Resident #1 to the bed was, she had worked with a Huntington patent before, and they had fallen and died. The Administrator said CNA D said she was only trying to protect Resident #1 from hurting herself. The Administrator said they did a skin assessment, a pain assessment, the SW did a trauma informed assessment on Resident #1. She said they called the police and the family member. The Administrator said she had called the incident into the State this morning and they had started to conduct skin assessments on all the residents in the building and were in the process of interviewing all staff to determine if they had ever seen any type of restraint. She said they were doing safe surveys with all interview able residents to determine if any abuse was identified. She said they had also started in services. <BR/>During an interview on [DATE] at 3:08 p.m. the DON said she was informed Resident #1 had been tied to the bed. She said she did not see the restraint, it had been removed when she arrived at the facility on today, [DATE]. She said she was present for the interview with CNA D who said she had tied Resident #1 to the bed because she was scared for Resident #1's safety. The DON said the aide told them Resident #1 was getting out bed, and her behaviors appeared worse on the night of [DATE] going into the morning of [DATE]. <BR/>During a telephone interview on [DATE] at 3:14 p.m. CNA D said when she arrived at work on of [DATE] at 6:00 p.m. Resident #1 was agitated, she was hollering out, and could be heard at the nursing station. She said she had asked the nurse to give her something because she was so agitated. She said LVN E refused and said it would be a chemical restraint. CNA D said about a month ago she had swaddled Resident #1. She said swaddling was like when you swaddle a baby. She said she took her blanket tucked it under Resident #1 on one side, and then wrapped her in the blanket and tucked it under her on the other side. She said she did that about a month ago when there was an issue with her being in a bed that was too high. She said at that time Resident #1 calmed down and went to sleep. CNA D said Resident #1 was fighting with her demons last night. She said on the night of [DATE] Resident #1 would not calm down. CNA D said at first, she had swaddle Resident #1. She said Resident #1 kept fighting and squirming around trying to get out of the bed. She said around 3:15 a.m. she had tied Resident #1 to the bed. She said she had gotten busy with another resident and had left the facility without checking on her. CNA D said she tied Resident #1 to the bed because she did not want her to hurt herself. She said she tied her loosely she could still move but not jump out of the bed. CNA D said she thought Resident #1's disease had gotten worse, she felt she had a bond with Resident #1 and could calm her down. She said on that day Resident #1 would not calm down and kept trying to jump out of bed. <BR/>During an interview on [DATE] at 3:25 p.m. with the ADON she said that she had difficult time getting the pants untied from around Resident #1's legs. She said she would not cooperate. She had spastic movements, or she may have been struggling it was hard to tell. She said once she got one leg straightened out the other one was bent. She said it did not take her too long, but it was not easy. She said when she had gone in the room the bed was in the lowest position and there was a mattress on the floor. <BR/>During an observation on [DATE] at 3:50 p.m. showed Resident #1's room had a bed in the lowest position. There were two mattresses on the floor lying next to the bed and at the foot of the bed was a fall matt. Observation of the bed showed all corners, and any surface of the bed was wrapped with tape and a pool noodle. Resident #1 was laying on two mattresses. Her head was on the bed, and she was stretched parallel across the mattress. She was drinking from a cup and was making gestures with the cup. She made noises but she did not communicate except for gestures. <BR/>During an interview on [DATE] at 9:00 a.m. the Administrator said she had not gotten a statement from the LVN E, but LVN E said Resident #1 was not agitated on the evening on [DATE] going into the night of [DATE]. The Administrator said when she talked to the Responsible Party on the phone, they were upset about the situation.<BR/>During an interview and observation on [DATE] at 9:30 a.m. CNA B (who was more familiar with Resident #1) tried to ask her questions. Resident #1 was observed on a mattress on the floor. Observation showed there was a mattress on both sides of the low bed. When CNA B asked Resident #1 if anyone had hurt her, she shook her head no. Observation showed Resident #1's left eye was dark and discolored. CNA B asked Resident #1 about being tied up but Resident #1's responses were grunts and noises. Resident #1 would hide her face in the mattress and not respond. <BR/>During an interview on [DATE] at 10:07 a.m. the SW said Resident #1's Responsible Party was mad in the beginning at the individual. She said the Responsible Party was given the option of pressing charges if he wanted to. The SW said Resident #1 liked to interact, but not too much social stimulation. She said she went to talk to Resident #1 but was unable to have a conversation about the incident. <BR/>During an interview on [DATE] at 10:23 a.m. the Housekeeper said on the morning of [DATE] around 8:00 a.m. she was asked by CNA C to look at Resident #1. She said she observed Resident #1 with legging tied around her legs and to the bed. She said the pants were tied to a rail strap on the side of the bed. She said Resident #1 was making noises, grunting, and struggling to get united, it appeared. The Housekeeper said CNA C could not get Resident #1 untied and had gotten the ADON to assist. She said she had been in serviced on restraints, abuse, neglect, and if residents have behaviors, report immediately. She said she had not seen any residents restrained prior to this incident. <BR/>During an interview on [DATE] at 11:25 a.m. RN A said Resident #1 could not stand up unassisted. She said she had a hip fracture that did not heal properly prior admission. There were several falls documented and RN A said Resident #1 would throw herself on the floor. She said she was very impatient if no one was there when she wanted something she would crawl to get across the room to what she wanted. RN A said it appeared sometimes Resident #1 just preferred to be on the floor. She said they would put her in the bed, and she would immediately roll back out on purpose. She said Resident #1 should not have been tied up. She said Resident #1 had jerking movements and could have hurt herself with spastic movements and getting tangled up more. She said Resident #1 would throw her body and, got easily frustrated when she could not have her way. She said, she picture Resident #1 behaving like an animal stuck in a fence struggling to get free. She said she could have hurt herself in the struggle to get free. RN A said Resident #1 crawled out of her broad chair this morning, she was found with her feet on the chair and her body on the floor. <BR/>During an interview on [DATE] at 11:39 a.m. CNA B said Resident #1 would try to stand on her own, and could do so by pulling up on something, but she was not steady. She said Resident #1 could stand while in her chair but not from the bed. CNA B said she would get out of her chair, by leaning forward and rolling out of the chair. She said if Resident #1 wanted to get across the room she would figure out a way to get to her drawer to get a snack. CNA B said Resident #1 was easily frustrated when things did not go her way. She said if she were tied to the bed and could not move like she wanted Resident #1 could become frustrated quickly. CNA B said they could not leave Resident #1 in chair unattended, but she often wanted to sit in the chair. She said she was in serviced on abuse, restraints, Huntington's, and resident rights. CNA B said she was not aware of any staff tying residents to the bed and she knew not to do such a thing. <BR/>During a telephone interview on [DATE] at 1:05 p.m. a family member said they had known Resident #1 all their life and if she was in her right mind or able to voice her frustrations, she would have been very upset to be treated like an animal. The family member said Resident #1 would have been cursing and likely trying to fight. The family member said there was no way Resident #1 would have stood for that kind of treatment, she would have been very upset. The family member said they were upset when they heard about the incident. They were trying to give the perpetrator the benefit of the doubt but had concerns about how many other residents had she done that to. They also had concerns that may not have been the first time she had tied Resident #1 to the bed because the staff was too busy. The family member said Resident #1 could not say how she felt but if she could not be happy. <BR/>During a telephone interview on [DATE] at 3:36 a.m. LVN E said at the beginning of the shift on [DATE] at 6:00 p.m. Resident #1 was in her bed. She said when she passed the room her face was toward the door, and she appeared to be fine. LVN E said there was one mattress on the floor and the bed was in the lowest position. She said Resident #1 was not hollering or screaming. LVN E said CNA D did not come to her at any time during the night. She said Resident #1 was on hospice and she had as needed medications for anxiety. LVN E said if the resident had exhibited anxiety symptoms she would have given her medications as ordered. LVN E said she never saw Resident #1 swaddled, and she had no idea Resident #1 was tied to the bed. LVN E said the idea of her being tied up broke her heart. She said Resident #1 hurt herself all the time, by swinging her arms and legs around. She said sometimes she would hit herself in the face. LVN E said Resident #1, or anyone could hurt themselves worse by being tied up. She said she worked from 6p to 6 am and had a whole stack of in services on abuse and reporting, Huntington's disease, resident rights. She said she knew no one was to be tied to the bed. <BR/>During an interview on [DATE] at 10:10 a.m. Resident #1's Responsible Party said the Administrator told him staff responsible for tying Resident #1 up was going to be fired. The Responsible Party said it was saddening and upsetting that someone would do that to a disabled person. The Responsible Party said Resident #1 had a cracked hip from 4-years ago, and it was not fixed, and she could not stand. The Responsible Party said if the staff did not want to be bothered, they did not have to tie Resident #1 up. He said the staff should consider their self-lucky that Resident #1 could not get up and untie herself. He said several years ago before her disease progressed, she would have wanted to fight that person for tying her up. The Responsible Party said it was hard to tell if Resident #1 had any reaction to the incident. They said they felt Resident #1 kind of clung to them more on that day. The Responsible Party said Resident #1 still had her mind but was unable to communicate. They said the most Resident #1 could do was roll out of bed and crawl all over the floor. The Responsible Party said she could pull herself up with the assistance of the chair. The Responsible Party said they tried to be sympathetic towards the person that treated Resident #1 that way, but that person did not take into consideration how his felt being tied down like she was not a human. The Responsible Party said for someone to tie Resident #1 up it took time, they would have had to tie the good leg first if not she would have kicked them. The Responsible Party said they were having a hard time dealing with the issue because they could only think that was not the first time the alleged perpetrator had tied Resident #1 up. The Responsible Party said that person should never be allowed to work in the healthcare field again because they may treat other residents the same way. The Responsible Party said staff should not tie someone up because they did not want to be bothered.<BR/>Record review of the facility policy on Restraints revised [DATE] indicated it was the policy to ensure that residents are free from physical or chemical restraints imposed for purposes of discipline or convenience and are not required to treat the residents' medical symptoms. Physical restrains are defined as any manual method or physical/mechanical device, material, or equipment attached or adjacent to the resident's body that the resident cannot remove easily, which restrict freedom of movement or normal access to one's body. Physical restrains include, but are not limited to leg restraints, arm restraints, that the resident cannot remove. Physical restraints for behavior control shall only be used in an emergency which threatens to bring immediate injury to the resident or others. Practices that are not to be used bed rails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed. Tucking sheets so tightly that a bed bound resident cannot move.<BR/>The facility had suspended CNA D and started putting corrective actions in place on [DATE] when the surveyor entered the building. They conducted skin assessments on Resident #1 and all residents in the facility. They conducted safe surveys on all interview able residents. They interviewed all staff to determine if any had noted any abuse or restraints in the facility. The facility in-serviced staff on Resident Rights, Restraints, Trauma Informed Care, Behaviors, Fall Prevention, and Abuse and Neglect <BR/>During an interview on [DATE] 4:15 p.m. the Administrator said they had put corrective measures in place to ensure this type of thing does not occur again. She said they were a restraint free facility and had no idea why the staff member would tie Resident #1 to the bed. The Administrator said that she was infomed of the incident at 8:15 a.m. and immediately began to investigate. She called CNA D back to the facility and called the police. She said she suspended CNA D before she called the incident into the state agency into the State Agency around 10:00 a.m. on [DATE]. She said they had initiated skin assessments on all residents, safe surveys on interview able residents, initiated interviews with staff on restraints. She said they had in serviced on falls, behaviors, restraints, trauma informed care, abuse, and resident rights. The Administrator said they had suspended CNA D, and they were going to terminate her because the investigation was almost complete. She said the police had talked to CNA D, and said it was up to the family if they wanted to press charges. She said the family had not decided on what they wanted to do at the current time, but they did request a police report.<BR/>Record review of CNA D's Employee Disciplinary Report dated [DATE] indicated she was placed on investigator suspension due to allegations of resident mistreatment. <BR/>Record review of the facility Provider Self Reporting of Incidents indicated the Administrator was informed of the incident on [DATE] at 8:15 a.m. The State reporting system indicated they were notified at 10:04 a.m. on [DATE]. <BR/>Record review of a payroll input /personnel action form for CNA D indicated she was terminated effective [DATE]. <BR/>Record review of an in-service training dated [DATE] indicated training was provided to facility staff on the facility restraint policy. <BR/>Record review of an in-service training dated [DATE] indicated staff were trained on Huntington's Disease with an attachment from the Mayo Clinic which indicated Huntington's Disease usually caused movement disorders. Movement disorders that cannot be controlled called Chorea. Chorea are involuntary movements affecting all muscles of the body, specifically the arms, legs, face, and tongue. Symptoms include involuntary jerking or writhing movements, muscle rigidity or contracture, slow eye movement, trouble walking or keeping posture and balance and trouble with speech or swallowing. <BR/>Record review indicated an in-service conducted on [DATE] indicated staff were educated on Behavior management. Review of the attached Behavior Management Policy dated [DATE] indicated Behavior management included the management of anger, confusion and other behaviors that be attributed to dementia disorders or psychological conflicts resulting from a loss of control over body, environment, or unmet needs. The utilization of physical restraints by a physician order only. <BR/>Record review indicated facility staff were in-service was conducted on [DATE] on Fall Prevention Strategies, Trauma Informed Care and Abuse and neglect. <BR/>Record review indicated facility staff were in-service dated [DATE] on Resident Rights dated [DATE] indicated the resident has the right to exercise their rights in the facility. the resident has a right to be treated with respect and dignity including: the right to be free from any physical or chemical restraints imposed for purpose of discipline or convenience and not required to treat the residents' medical symptoms. <BR/>Record review witness statements indicated 41 staff had not seen any residents restrained all dated [DATE].<BR/>Record review of 22 resident safe surveys dated [DATE] revealed there were no concerns regarding restraints. <BR/>Record review of Weekly Nursing Skin Checks dated [DATE] indicated all residents had skin assessments completed with no suspicious areas noted. <BR/>Interviews were conducted with 4 CNAs and 3 LVNs, from [DATE] at 10:45 a.m. to [DATE] at 3:36 p.m., who were knowledgeable about the facility abuse policy and the restraints policy. They said they were in serviced on resident rights and when a resident said no that means do not force the resident to do something they did not want to do. They were in-service on the facility policy on restraints, behaviors, Huntington's, fall prevention, and resident rights. Those interviews are as follows. <BR/>During an interview on [DATE] at 10:45 a.m. LVN F said he had received in services on Huntington's, restrains, abuse, trauma, behaviors, and resident rights. He said they were informed how residents may react, what are appropriate things to do, do not tie up a resident, give medications or speak with the doctors. <BR/>During an interview on [DATE] at 2:20 p.m. CNA G said she worked from 7:30 a.m. to 3:30 p.m. as a restorative aide. She said she had in- services on abuse and neglect, restraints, Huntington's, behaviors, falls, and resident rights. She said she had not seen anyone tied up and that she knew better than to tie someone up.<BR/>During an interview on [DATE] at 2:23 p.m. CNA K said she worked 6a to 2p. She said she had in- services on abuse and neglect, restraints, Huntington's, behaviors, falls, and resident rights. She said she had not seen anyone tied up and she knew better than to tie someone up. <BR/>During an interview on [DATE] at 2:24 p.m. LVN H said she was she had in services on [DATE] but it was not over anything she did not already know. They had in-services on behaviors, falls, do not tie anyone up, and abuse. <BR/>During an interview on [DATE] at 2:27 p.m. MA/CNA I said she worked from 6 a to 2p and on occasion would work 2p to 10 p. She said she had not seen anyone restrained and she would report it if she did. She said they had been in serviced on [DATE] about abuse, neglect, falls, behaviors, restraints, and Huntington's.<BR/>During an interview on [DATE] at 2:30 p.m. CNA J said she worked from 6a to 6p. She said she was in-service on resident rights, and abuse. She said she knew you could not hit residents or tie them up. She said she had never seen anyone restrained. She was also in served on falls, restraints, Huntington's disease, and behaviors. <BR/>During a telephone interview on [DATE] at 3:36 p.m. LVN E she worked from 6p to 6a and had a whole stack of in services on abuse and reporting, Huntington's disease, resident rights. She said she knew no one was to be tied to the bed.<BR/>During an interview on [DATE] at 3:53 p.m. the facility Corporate Nurse said they were not going to allow CNA D to return to work, she had been terminated. She did not know how long it took the corporate HR to have the information in the system, but CNA D no longer worked for the facility. <BR/>The immediate Jeopardy was determined after exit on [DATE] at 4:14 p.m. The facility Corporate Nurse was informed via phone.<BR/>An IJ was identified on [DATE]. The IJ began on [DATE] and was removed on [DATE]. The facility took action to remove the IJ before the survey began. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm because all staff had not been trained on physical restraints, behaviors, fall prevention, and resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents environment remained as free of accident hazards as possible for 1 of 7 residents (Resident #1) reviewed for accidents and hazards.<BR/>The facility failed to ensure staff checked straps for damage prior to transferring Resident #1 which resulted in a laceration to Resident #1's forehead. <BR/>This failure could place residents at risk for injury.<BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 02/10/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis (weakness on one side of your body) following cerebral infarction (Stroke) affecting the left dominant side.<BR/>Record review of Resident #1''s MDS, dated [DATE], revealed Resident #1 required two-person assistance for transfers and had a BIMS score of 15, which indicated Resident #1 was cognitively intact, alert to person, place, and time. Resident #1 used a wheelchair to ambulate. Resident #1 required extensive assistance with most activities of daily living.<BR/>Record review of Resident #1's care plan, dated 12/27/22, revealed Resident #1 required two-person assistance for transfers and required a mechanical lift due to a self-care performance deficit. <BR/>Record review of Resident #1's nurse's note, dated 02/05/23 at 9:23 PM, by LVN B, revealed Resident #1 was kicking and yelling at staff. LVN B asked LVN A to assist in transferring Resident #1 from his wheelchair to his bed using a Mechanical lift. When LVN A and LVN B arrived in the room three of four straps were already attached to the lift. LVN A attached the last strap and proceeded with the transfer. During the transfer LVN B reported hearing a snap, and Resident #1 fell from the lift to the floor hitting his head causing a laceration. LVN B called 911 and Resident #1 was transferred to the hospital for evaluation and treatment.<BR/>Record review of Resident #1's hospital records, dated 02/05/23, revealed Resident #1 arrived at the hospital with a facial laceration. The fall involved a lift chair assistance as the cause of accidental injury. The injury was repaired with stiches. CT scan (scans take a fast series of X-ray pictures, which are put together to create images of the area that was scanned.), showed no acute intercranial abnormalities, laceration to the soft tissue, swelling to the left frontal scalp and preorbital (around the eye) soft skin. There was mild soft tissue swelling to the left cheek. Resident #1 was released back to the facility after treatment. <BR/>Observation of a video surveillance tape, date stamped on 02/05/22 at 8:48 PM, showed Resident #1 was being transferred from a wheelchair to a bed by LVN A and LVN B using a mechanical lift. The front left strap on the lift appeared to be frayed or damaged. During the transfer, the front left strap holding Resident #1, snapped and Resident #1 fell from the lift and hit his head on the floor.<BR/>During an observation and interview on 02/10/23 at 1:20 PM revealed Resident #1 was in his bed. There was a bandage on his forehead, above his left eye with a date of 02/10/23. There was a Hoyer lift Sling under him. The sling appeared to be in good condition with no frayed edges. Resident #1 said he was doing okay. He said he fell while staff attempted to transfer him from his wheelchair to his bed. Resident #1 said he did not remember much about what happened. He said all he remembered was the strap broke and he hit the floor. He said the next thing he remembered was being at the hospital. He said he did not feel he had been abused or neglected and what happened was an accident. Resident #1 said he was not afraid to be transferred with the Hoyer Lift.<BR/>During an interview on 01/17/23 at 1:20 PM, LVN A said he assisted LVN B with transferring Resident #1 with a Hoyer Lift on 02/05/23 around 8:30 PM. LVN A said while transferring Resident #1, a strap on the front left side of the lift snapped and Resident #1 fell to the floor and hit his head. LVN A said LVN B left the room and called 911 for assistance. LVN A said when he looked at Resident #1, there was blood on the floor coming from Resident #1's head. LVN A said she went and got a towel and applied pressure to the wound until EMS arrived and transported Resident #1 to the hospital for evaluation and treatment. LVN A said he did not realize the strip was damaged. LVN A said the cause of the accident was due to the defective strap. LVN A said he should have inspected the straps before he attempted to transfer Resident #1. LVN A said he was notified on 02/10/23 that he was suspended pending an investigation due to the incident. LVN A said he was scheduled to complete Mechanical Lift skills training before returning to work, but he had not yet received the training.<BR/>During an interview on 01/17/23 at 1:45 PM, LVN B said she and LVN A was asked to assist in transferring Resident #1 from his wheelchair to his bed because staff reported Resident #1 was being verbally and physically aggressive toward staff who attempted to transfer him to his bed. LVN B said she asked LVN A to assist in the transfer. LVN B said when she arrived in the room, there were three straps already attached to the lift and LVN A attached the fourth strap to transfer Resident #1. LVN B said she was operating the lift and LVN A lowered the bed to the lowest position. LVN B said the bed caught on the edge of a trash can at the foot of the bed when the bed was lowered. LVN B said she raised Resident #1 out of the wheelchair and LVN A was moving the wheelchair out of the way when she heard a snap. LVN B said the strap on the front left side of the sling holding Resident #1 broke and Resident #1 fell to the floor hitting his head. LVN B said she went to the door and yelled for help. LVN B said she called 911 on her cell phone and LVN A went and got a towel to stop the bleeding. LVN B said she did not notice the strap was damaged and if so, she would have not used the defective sling to transfer Resident #1. LVN B said she was notified on 02/10/23 by the DON she was suspended pending an investigation into the incident. LVN B said she should have assessed the condition of the straps before she attempted to transfer Resident #1. LVN B said since the incident she had received skills training on transferring using a Mechanical lift on 02/15/23. <BR/>During an interview on 02/10/23 at 12:12 PM, the DON said the first time she viewed the video was with the surveyor. DON said she had not reviewed the video of the incident with Resident #1 before this time. The DON said LVN A and LVN B failed to use proper technique when transferring Resident #1 with the Mechanical lift. The DON said staff should always assess the condition of the lift sling to ensure it was safe prior to use. The DON said it was obvious by viewing the video that the strap on the front left side was damaged and the sling should not have been used. The DON said after the incident she completed an assessment of all other lift slings in the building and found there were some that needed to be retired and new slings were ordered to replace the damaged slings. The DON said all staff received training to inspect the slings prior to use and if a sling showed signs of being defective or damaged the sling should not be used to transfer residents. The damaged sling should be reported to the charge nurse and the DON. The DON said the sling should be taken out of service and replaced with a new sling. The DON said all nursing staff would receive skills training with a check-off for each one on how to transfer a resident using a Mechanical lift. The DON said the skills training would be conducted by the DON and the Director of Rehabilitation. <BR/>During an interview on 02/10/23 at 12:08 PM, the Administrator said she was notified Resident #1 had a fall from a Mechanical lift on 02/05/23 around 8:30 PM. The Administrator said the cause was a damaged strap that broke which caused injury to Resident #1. The Administrator said she reported the incident to the state on 02/05/23 at around 9:45 PM. The Administrator said all the slings and straps in the facility were assessed by the DON for possible damage and those found to be damaged were removed from service immediately. The Administrator said new slings were ordered to replace the damaged slings. The Administrator said on 02/06/23 an intervention plan was developed by QAPI regarding the Hoyer Lift issue. The Administrator said all staff were in-serviced on inspecting the straps and slings before use. The Administrator said the DON would monitor and inspect slings and straps weekly to ensure they were in good condition. The Administrator said any slings found to be damaged would be removed from service and replaced. The Administrator said all nursing staff would receive skills training on how to properly operate the Mechanical Lift. The Administrator said the skills training would be conducted by the DON and Director of Rehabilitation. <BR/>An observation and interview on 02/10/23 at 1:45 PM revealed NA-A, NA-B and NA-C using a Hoyer lift to transfer Resident #1 from his bed to his wheelchair. NA A and NA B used proper technique in transporting the resident. Transfer was successfully completed with no concerns for Resident #1's safety. The equipment and sling were in good working order with no concerns. NA-A, NA-B and NA-C said they had recently received in-service training on safely using the Hoyer lift. They said they were to assess the condition of the sling and straps before using to transfer a resident. They said if the sling or straps were damaged, they were not to use them and report to the charge nurse and/or the DON.<BR/>Interview on 02/10/23 at 1:30 PM, the Laundry Aide said she washed two to three Hoyer Lift slings daily. She said she followed the manufacturer's suggested care instructions. She said the slings were washed in cold to warm water, but never hot water. She said all slings were hung to air dry and slings were never dried in the dryer. She said heat could cause the material to stretch or become weak.<BR/>Record review of Sling Laundry Instructions revealed .While the materials comply with applicable standards for strength, shrinkage and flammability, slings are subject to wear and tear, which increases with usage. Before each use check for fraying or cuts/tears in the straps and body of the sling. Slings that show wear or damage should be taken out of service . LAUNDRY INSTRUCTIONS: . Machine wash normal setting and at 140F/60C. Depending on the washing machine, this usually means on a medium temperature setting.<BR/>Record review of in-service records from 02/06/23 through 02/17/23 revealed documentation that nursing staff received training on 10/17/22. Staff received in-service training on laundry instructions of Hoyer Lift Slings. The in-service was conducted by the Housekeeping Supervisor. After washing the Hoyer Lift sling, you cannot put heat on it. The sling needs to air dry or put in the dryer with no heat. The fabric when heated can stretch and snap! This will cause an injury. This will be an automatic [NAME]!<BR/>Record review of in-service records revealed on 02/06/23 nursing staff received in-service training on Hoyer Lift transfer. <BR/>o <BR/>Must have 2 nursing staff (CNA, Nurse, Medication Aide) to use a Hoyer lift on a resident. <BR/>o <BR/>Always check sling and sling straps to verify they do not appear compromised.<BR/>o <BR/>If there is any question, have nurse verify it is okay to use. <BR/>o <BR/>DO NOT USE A DAMAGED SLING Under any circumstances.<BR/>Record review of Mechanical lift Competency Evaluations dated 02/10/23 - 02/17/23, showed staff using a Hoyer life to transfer residents received a skills assessment on using a Mechanical Life to transfer residents safely. <BR/>Record review of the facility's, undated, policy on Hydraulic lift revealed: . The resident will achieve safe transfer to bed or chair via mechanical lift device . The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift .23. Immediately remove any malfunctioning equipment from direct care use. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 4 of 8 residents (Resident #15 #16, #49, and #52) reviewed for PASRR Level I screenings.<BR/>1. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #49. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Post Traumatic Stress Disorder, a mental health condition that can develop after a person experiences or witnesses a traumatic event with an onset date of 08/01/21) was present upon Resident #49's re-admission date on 11/16/23.<BR/>2. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #15. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Major depressive disorder with an onset date of 06/28/22) was present upon Resident #15's admission date on 06/28/22.<BR/>3. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #52. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Major depressive disorder with an onset date of 04/07/22) was present upon Resident #52's re-admission date on 09/12/24.<BR/>4. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #16. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Major depressive disorder with an onset date of 12/15/2020 was present upon Resident #16's re-admission date on 2/11/2021.<BR/>This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.<BR/>Findings included:<BR/>1. Record review of Resident #49's face sheet, dated 08/01/21 reflected a [AGE] year-old female admitted on [DATE]. She was most recently re-admitted on [DATE]. The reflected diagnoses that included PTSD (a m ental health condition that can develop after a person experiences or witnesses a traumatic event) with an onset date of 08/01/2021, Chronic Systolic Heart Failure (a condition where the left ventricle of the heart is unable to contract properly, resulting in less blood circulating throughout the body), Hyperlipidemia (a condition where there are abnormally high levels of lipids or fats in the blood.)<BR/>Record review of Resident #49's quarterly MDS assessment, dated 07/31/24, reflected Resident #49 had a BIMS of 10, which indicated moderate cognitive impairment. Shows that Resident #49 received an antianxiety medication during the assessment period.<BR/>Record review of Resident #49's PASRR Level 1 Screening, dated 08/01/21, reflected in Section C Mental Illness was marked as no, which indicated Resident #49 did not have a mental illness.<BR/>During an interview on 10/02/24 at 11:21 a.m., MDS Nurse J said she had worked at the facility for two years. She said that when a new resident comes into the facility their PASRR level one needs to be completed or if a level one was completed it needs to be checked for accuracy. She said that PTSD, Schizophrenia, and Major Depressive Disorder all qualify for a mental illness. She said that if one of these diagnoses were present then the resident's PASRR would be marked, Yes to indicate the presence of mental illness. She said that residents #15 and #49 both had mental illnesses that should have been marked as, Yes.<BR/>2. Record review of Resident #15's face sheet, dated 06/28/22 reflected a [AGE] year-old female admitted on [DATE]. She was most recently re-admitted on [DATE]. Revealed diagnoses that included schizoaffective disorder (a chronic mental illness that combines symptoms of schizophrenia and a mood disorder, such as bipolar disorder or depression) onset date of 6/28/2022, Major Depressive Disorder (a serious mental disorder that can affect how someone feels, thinks, and acts) onset date of 6/28/2022, and Hyperthyroidism (occurs when the thyroid gland produces too much thyroid hormone). <BR/>Record review of Resident #15's significant change MDS assessment, dated 07/14/24, reflected Resident #15 had a BIMS of 10, which indicated moderate cognitive impairment. Resident #15's MDS reflected there was no serious mental illness. <BR/>Record review of Resident #15's PASRR Level 1 Screening, dated 06/28/22, reflected that in Section C Mental Illness was marked as no, which indicated Resident #15 did not have a mental illness.<BR/>During an interview on 10/02/24 at 11:21 a.m., MDS Nurse J said she had worked at the facility for two years. She said that when a new resident comes into the facility their PASRR level one needs to be completed or if a level one was completed it needs to be checked for accuracy. She said that PTSD, Schizophrenia, and Major Depressive Disorder all qualify for a mental illness. She said that if one of these diagnoses was present with a resident then their PASRR would be marked, Yes to indicate the presence of mental illness. She said that residents #15 and #49 both had mental illnesses that should have been marked as, Yes.<BR/>3. Record review of Resident #52's face sheet, dated 09/30/24, reflected she was a [AGE] year-old female, admitted to the facility initially on 02/15/22, and readmitted to the facility on [DATE]. Her diagnoses included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) with an onset date of 04/07/22. <BR/>Record review of Resident #52's quarterly MDS assessment, dated 09/16/24, reflected she had a BIMS score of 15, which indicated intact cognition. She also took an antidepressant medication during the assessment window. <BR/>Record review of Resident #52's PASRR Level 1 Screening, dated 02/15/22, reflected that in Section C, Mental Illness was marked as no, which indicated Resident #52 did not have a mental illness.<BR/>During an interview on 10/02/24 at 11:37 AM, the SW A said she had started working in the facility in January 2022. She said Resident #52 should have had a positive PASRR Level 1 screening for mental illness. She said there was a possibility that Resident #52 could have received PASRR services if her PASRR Level 1 had been marked positive for mental illness.<BR/>4. Review of Resident #16's face sheet dated 10/1/2024 reflected [AGE] year-old female re-admitted to the facility on [DATE] diagnosis included Heart Failure (occurs when the heart muscle doesn't pump blood as well as it should causing blood often backs up and fluid can build up in the lungs, causing shortness of breath), Atrial Fibrillation (an irregular and often very rapid heart rhythm and can lead to blood clots in the heart), Major Depressive disorder (a common but serious mood disorder that causes severe symptoms that affect how a person feels, thinks, and handles daily activities, such as sleeping, eating, or working), Pseudobulbar Affect (a condition that's characterized by episodes of sudden uncontrollable and inappropriate laughing or crying), and Anxiety disorder (usually involves a persistent feeling of anxiety or dread, which can interfere with daily life. usually involves a persistent feeling of anxiety or dread, which can interfere with daily life). <BR/>Review of Resident # 16's MDS Assessment, dated 2/17/2021, reflected a [AGE] year-old female re-admitted to the facility on [DATE] diagnoses included anxiety disorder (usually involves a persistent feeling of anxiety or dread, which can interfere with daily life, depression (a common but serious mood disorder that causes severe symptoms that affect how a person feels, thinks, and handles daily activities, such as sleeping, eating, or working) and psychotic disorder (psychosis refers to a collection of symptoms that affect the mind, where there has been some loss of contact with reality). <BR/>Review of Resident # 16's PASRR Level 1 Screening, dated 12/11/2020, reflected a negative screening for mental illness.<BR/>During an interview on 10/2/2024 at 11:24 AM, Social Worker A said admissions ensured the PASARR was completed before a resident was admitted to the facility. Social Worker A said she would refer the resident's if they qualified for services and refer them to the local mental health authority if the PASARR was positive. <BR/>During an interview on 10/2/2024 at 11:30 AM, Social Worker L said Resident # 16 went to the hospital and then returned. He said there was a diagnosis on the readmit from the hospital for depression. Social Worker L said he was not sure if another PASARR should had been completed in February. He said Resident #16 was readmitted with an antidepressant which required the facility to give her a diagnosis of depression. Social Worker L said he did not realize the facility would need to obtain a new PASARR. He said Resident #16 could have been available to receive services. Social Worker L said Resident #16 already had services in place upon return to the facility. <BR/>During an interview on 10/2/2024 at 2:15 PM, MDS nurse J said all residents should have a PASARR. She said she is currently working on fixing issues from a previous employee. The MDS nurse J said the facility should have completed a form 1012 to send to the physician following the updated diagnosis of major depression on 1/18/2021. She said it was not completed. The MDS nurse said the PASARR update would not have changed Resident #16's care because Resident #16 was already receiving psychiatric services by a visiting psychiatric service that comes to the facility. She said the services started on 3/30/2024 which she admitted was a delay in care of a couple of months. <BR/>During an interview on 10/2/2024 at 2:20 PM, MDS nurse M said she was currently working on resolving issues identified from a previous employee. She said if a resident were positive for mental illness, the local mental health authority would call the resident on 30/60/90 days and check on them and would offer psychiatric services.<BR/>During an interview on 10/2/24 at 11:09 a.m. with the DON she said that the MDS nurse was responsible to ensure the accuracy of PASRR level one screenings. She said that PTSD, Major Depressive Disorder, and Schizophrenia would trigger a Yes response on the PASRR level one. Residents could be placed at risk for not receiving the services they require if they are not accurately assessed on their PASRR level one. <BR/>During an interview on 10/2/24 at 11:09 a.m. the ADM said that the MDS nurse was responsible for completing PASRR for newly admitted residents as well as ensuring that already completed PASRR's from the community are accurate. She said that residents would be placed at risk for not receiving services if they did not have an accurate PASRR. <BR/>Record review of the facility's policy, PASRR Evaluation PE Policy and Procedure, dated 10/30/2017, reflected: 1. Policy: It is the policy of Creative Solutions in Healthcare facilities to ensure the LIDDA and/or LMHA complete a PE within the appropriate time periods (14 days). Note: this may vary depending on the type of admission and length of stay . The PE is to be printed and closely reviewed to determine if the resident was PASRR POSITIVE and notification to IDT Team is completed if indeed PASRR POSITIVE. The PE is placed in the medical record under the PASRR Tab . Positive PL1 will alert the LA to complete the Pasrr Evaluation. The PE (Pasrr Evaluation) is an evaluation to confirm or deny the suspicion of ID, DD, or MI recorded on the PL1. The evaluation also determines the need for specialized services that may be beneficial to the individual if they are confirmed positive for ID, DD, or MI. The PE is critical because it is the first identification of services an individual's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 5 residents reviewed for new admissions (Resident #34). <BR/>The facility failed to provide Resident #34's RP a copy of the summary of the baseline care plan. <BR/>This failure could place residents at risk of not receiving care and services to meet their needs.<BR/>Findings included:<BR/>Record review of Resident #34's face sheet dated 09/30/24 indicated Resident #34 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including dementia (a group of thinking and social symptoms that interferes with daily functioning) with psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), paranoid schizophrenia (is a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), and acute embolism (is an obstruction or blockage in a blood vessel) and thrombosis (is a blood clot within blood vessels that limits the flow of blood). The face sheet indicated a family member was Resident #34's responsible party. <BR/>Record review of Resident #34's quarterly MDS assessment dated [DATE] indicated Resident #34 was usually understood and understood others. Resident #34 had a BIMS score of 03 which indicated severe cognition impairment. Resident #34 required setup for dressing, eating, and putting on footwear, supervision assistance for oral hygiene, partial assistance for shower/bath self and personal hygiene, and dependent for toilet hygiene. <BR/>Record review of Resident #34 baseline care plan acknowledgement sheet indicated a copy of the baseline care plan was provided to the resident on 05/12/24. <BR/>During an interview on 09/30/24 at 4:15 p.m., the responsible party of Resident #34 said he did not get a copy of Resident #34's baseline care plan. He said it would have been nice to have a copy of it. <BR/>During an interview on 10/02/24 at 2:20 p.m., LVN E said LVNs completed certain parts on the baseline care plan and the MDS Coordinator finished it. She said the ADON printed a copy of the resident's baseline care plan then gave it to the nurses to give to the family. She said Resident #34 had a responsible party. She said Resident #34's RP should have also gotten a copy if Resident #34 received a copy. She said it was important for the RP to receive a copy of the baseline care plan, so they knew how the facility was going to care for their family member. She said if family members or RPs did not receive a copy of the baseline care plan, they would not know what was going on with the resident.<BR/>During an interview on 10/02/24 at 3:21 p.m., MDS Nurse M said the charge nurse and ADON were responsible for baseline care plans. She said the charge nurse gave the baseline care plan acknowledgement form to the resident and/or RPs. She said she did not feel like Resident #34 would have understood her baseline care plan. She said Resident #34's RP should have received a copy. She said it was important for RPs to receive a copy of the resident's baseline care plan, so they understood the treatment and care being provided. She said not giving the resident's RP a copy, could make the family member feel out of the loop. <BR/>During an interview on 10/03/24 at 10:21 a.m., the DON said the admission nurse was responsible for completing the baseline care plan and giving a copy to the resident and/or RP. She said the RP should get a copy of the baseline care plan and the resident if they wanted a copy. She said the facility provided a copy of the baseline care plan to the resident and/or RP 48 hours after admission. She said it was important to provide the RP with a copy, so they were informed on the resident's care being provided and how the facility was going to deliver the care. She said when a copy of the baseline care plan was not provided, RPs would not know what care was being provided. She said when a copy was not provided to the RPs, the facility could miss getting information like preferences and things that worked better for the resident. She said she did not know why Resident #34 only received a copy of the baseline care plan and not her RP. <BR/>During an interview on 10/03/24 at 11:00 a.m., the ADM said the charge nurses were responsible for giving a copy of the baseline care plan to the RP and/or resident. She said the nursing administrative staff should ensure a copy of the resident's baseline care plan was given to the RP and/or resident if they were cognitive enough. She said a copy of the baseline care should be provided to the RP and/or resident within 72 hours of admission. She said it was important to provide a copy to the RP to ensure the information was correct, to add any missed information, and get information that could help better care for the resident. <BR/>Record review of an undated facility's Base Line Care Plans policy indicated .the facility will provide the resident and their representative with a summary of the baseline care plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 1 memory care unit reviewed for activities.<BR/>The facility failed to provide meaningful activities for dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) residents on the memory care unit on 9/30/24-10/1/ 24. <BR/>This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being.<BR/>Findings included:<BR/>During an observation on 09/30/24 at 9:32 a.m., the dining area had a large television playing a television show in the dining area of the memory care unit. Approximately 20 residents were in the dining area. <BR/>During an observation on 09/30/24 at 10:50 a.m.-11:55 a.m., the dining and sitting area nor hallways had any memory care/dementia focused activities. Television on in dining area, but residents did not show interest. <BR/>During observation on 10/01/24 at 2:22 p.m. residents on memory care unit sitting in Dining area with Television on, but residents did not show interest.<BR/>Record review of the October 2024 Activity schedule reflected:<BR/>*10/01/24: 9am- Coffee and Friends, 10am- Daily Chronicle, 10:30am- Appetizer 2pm- Bingo with, 3pm- Music Hour.<BR/>*10/02/24: 9am- Coffee and News, 10am- Daily Chronicle, 10:30am- Appetizer, 2pm- Arts and Crafts, 3pm- [NAME] & River.<BR/> *10/03/24: 9am- Coffee and Friends, 10am- Daily Chronicle, 10:30am- Appetizer, 2pm- Bingo, 3pm- Movie & Snack.<BR/>*10/04/24: 9am- Coffee and News, 10am- Daily Chronicle, 10:30am- Appetizer, 2pm- Bingo, 3pm- Snack Pass With A Smile.<BR/>During an interview on 10/02/24 at 9:37 a.m., CNA C said the activity director was responsible for doing activities with the residents on the memory care unit. CNA C said some residents loved to play BINGO. She said she was not sure what Resident #67 liked to do. CNA C said she was not sure if the incident and falls were due to the lack in activities for the residents. She said easy activities would be good for dementia residents.<BR/>During an interview on 10/02/24 at 9:49 a.m., CNA D said the activity director was supposed to do activities with the residents on the memory care unit, but the aides normally do them. CNA D said the activity director came to the memory care unit once or twice a day to deliver snacks, then she leaves right back out. CNA D said some residents did not have a specific activity she liked to do, but they tried to keep them occupied all day. CNA D said the lack of activities on the memory care unit could be a reason why the residents had falls and incidents. She said she felt like if the residents had things to do it would not be as much aggression back here. She said dementia residents should be do different activities. She said some of the residents could do flower arrangements, puzzles and memory card games for activities. <BR/>During an interview on 10/02/24 at 9:59 a.m., with LVN E she said activity director was the one that tried to put the activity calendars in the resident's rooms on the memory care unit. She said she was not sure if the October activity calendar were up yet, because she had just returned to work. She said the facility had an activity director in the building that was responsible for the activities on the memory care unit, but her and the CNA's tried to do things with the residents: like give snacks, let them watch television and the CNA's paint the resident finger nails. She said some residents loved to watch western shows. She said she thought the falls and incidents occurred due to the resident's disease process. She said she thought activities are good when the activity director stayed with the resident while they worked on activities, because they were easily distracted. She said one of residents on the unit loved to play the piano. <BR/>During an interview on 10/02/24 at 10:15 a.m., CNA D said the activity director had not brought an updated activity calendar to the memory care unit since July 2024.<BR/>During an interview on 10/02/24 at 11:22 a.m., DON said the activity director was responsible for the activities on the memory care unit. She said was sure the more activities back there would be better, because the more activities back there would help with the falls and incidents. The DON said coloring, activity boards, music, dancing and crafts were good for dementia residents to do. She said she felt anything was safe that would be good for the residents on the memory care unit to do.<BR/>During an interview on 10/03/24 at 10:18 a.m., the Administrator stated they had an activity plan for the resident to do more. She said when the activity director was there, and she did activities with the residents. The Administered said the activity director mother had a fall and she had not been there the last 3 days. She said there was an activity closet with games and crafts for the resident to have activities if the activity director was not here, so the aides should be utilizing it. She said the resident's need to have activities. The Administrator said the negative effects of no activities on the memory care unit, the residents do get bored, and the staff should make more of an effort to keep the residents occupied. The Administrator said here was only one main calendar and there was not a specific calendar for the memory care unit. <BR/>During an observation on 09/30/24 at 4:04 p.m., 15-20 residents in sitting area and dining area on the secured unit with no meaningful activities offered to residents.<BR/>During an observation on 10/01/24 at 11:04 a.m., 15-18 residents in sitting area and dining area on the secured unit with television on, but residents did not show interest.<BR/>During an observation on 10/01/24 at 3:34 p.m., 11-15 residents in sitting area and dining area on the secured unit with no meaningful activities offered to residents.<BR/>Record review of a facility's Activity Policy & Procedure Manual policy dated 2011 reflected . the Activity Director and staff will provide individual programming to meet individual needs and interests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 4 residents (Resident #54) reviewed for nutrition/weight loss.<BR/>The facility failed to obtain a readmission weight after Resident #54 readmitted from the hospital on [DATE] per the facility policy.<BR/>The facility failed to consistently document Resident #54's meal intakes.<BR/>These failures could place residents at risk for decreased nutritional and weight status and decline in health.<BR/>Findings included:<BR/>Record review of a face sheet dated 09/12/23 indicated Resident #54 was a [AGE] year-old male and admitted on [DATE], with a readmission on [DATE], with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose).<BR/>Record review of a significant change MDS assessment, dated 08/31/23, indicated Resident #54 was understood and understood others. The MDS indicated Resident #54 had a BIMS score of 02 which indicated severe cognitive impairment and required extensive assistance for bed mobility, dressing, eating, toilet use, personal hygiene, and total dependence for transfer and bathing. The MDS assessment indicated Resident #54 had loss of liquids/solids from mouth when eating or drinking, no significant weight loss, and mechanically altered, therapeutic diet.<BR/>Record review of a care plan dated 04/11/23, with revision date on 09/01/23, indicated Resident #54 had potential risk for malnutrition due to impaired cognition and poor eating habits. Intervention: monitor and document meal intake. <BR/>Record review of Resident #54's discharge summary from a local hospital dated 08/26/23 indicated Resident #54 weighed 186lbs on 08/22/23. <BR/>Record review of Resident #54 's admission notes, completed by RN K, dated 08/26/23 indicated Resident #54 recent admission was 08/26/23 at 8:10 p.m. from the hospital.<BR/>Record review of Resident #54's weight summary dated 09/13/23, indicated on 08/10/2023, the resident weighed 180.5 lbs. On 09/12/2023, the resident weighed 167.5 pounds which is a -7.20 % Loss.<BR/>Record review of Resident #54's progress note dated 09/05/23 at 8:17 p.m., completed by the Dietitian indicated .weights (#): [DATE].5, July 185.2, June 185.5 .staff report usual by mouth intake: 75-100% .nursing stated Resident #54 with good by mouth intake and accepts what is offered .recommendation: continue current plan of care at this time . The Dietitian had Resident #54's pre-hospital weight and did not have a readmission weight or weekly weight x 4 after readmission. <BR/>Record review of Resident #54's amount eaten task report ran on 09/13/23 for the last 20 days indicated no meal percentage documented for:<BR/>*08/29/23: dinner<BR/>*08/30/23: dinner<BR/>*09/04/23: dinner<BR/>*09/05/23: breakfast, lunch, dinner<BR/>*09/06/23: breakfast, lunch, dinner<BR/>*09/07/23: dinner<BR/>*09/08/23: dinner<BR/>*09/09/23: dinner<BR/>*09/10/23: dinner<BR/>*09/11/23: breakfast, lunch, dinner<BR/>During an attempted to contact RN J on 09/13/23 at 3:45 p.m., unable to leave voicemail due to mailbox being full.<BR/>During an interview on 09/13/23 at 3:53 p.m., LVN F said residents had to be weighed on readmission. She said she did not know who was responsible for admission or readmission weights. LVN F went into the DON's office and came back to finish the interview. She said she was informed by the DON the admission nurse had 24-hours after admission to obtain a weight. LVN F said she did not know if the admission nurse had 24-hours to weigh the residents or 24-hours to weigh and document the weight in the chart. LVN F left the interview to verify with DON. LVN F said the admission nurse had 24-hours to weigh and document the weight in the chart per the DON. She said the readmission weight was important to know if the resident lost weight in the hospital. LVN F said Resident #54 did not have a readmission weight. She said without a readmission weight you do not know if there has been a significant change and the dietary recommendations could not be correct and dietary needs could not be addressed. She said the CNAs were responsible for documenting the amount the residents consumed. LVN F said all nursing staff had access to a resident's care plan. She said LVNs should ensure the CNAs documented the intake amounts. LVN F said LVNs should check the resident intake record before the end of the shift to ensure CNAs documented. She said CNAs should document 3 meals a day in the electronic charting system. LVN F said it was important to document meal intake amounts to monitor residents with poor intake or appetite as indicated by the care plan intervention. She said it could negatively affect the resident due to unknown significant weight loss or not presenting an adequate information for the nutritionist or doctor.<BR/>During an interview on 09/13/23 at 4:35 p.m., SCNA G said she had worked at the facility in different departments but had been a SCNA for a couple of months. She said she occasionally worked the hall Resident #54 was on. SCNA G said she charted resident's amount eaten in the electronic charting system. She said CNAs were supposed to chart after every meal the percentage the resident ate. SCNA G said the LVNs were supposed to make sure CNAs documented intake amounts on residents. She said it was important to chart the resident's intake amounts to know if they were not eating, tell if something was wrong, and know why the resident lost weight. SCNA G said not documenting meal intakes did not let the dietician know the resident's real intake amounts.<BR/>During an interview on 09/13/23 at 4:40 p.m., the DON said she had been at the facility for 2 years. The DON said residents were supposed to have readmission weights done. She said Resident #54 had been gone for 8 days so he should have had one done. The DON said the admission nurse had 24-hours to weigh and document the weight in the resident's chart. She said nursing administration was responsible for ensuring the facility's weight policy was followed. The DON said readmission weights were important to monitor for weight loss. She said not obtaining readmission weights risked residents not being put on the right dietary supplements, or not being put on a dietary supplement at all, and continued weight loss. The DON said weights were monitored weekly or monthly dependent on the resident orders and condition. She said the CNAs were responsible for documenting the amount the residents consumed. The DON said LVNs should ensure the CNAs documented the intake amounts after every meal which was three times a day. She said following the care plan intervention to document meal intake amounts was important to know how much a resident ate, could indicate a change of condition, and it help monitor for weight loss. The DON said missed meal intake amounts would not paint a complete picture of the resident and the dietician would not have correct information to make accurate dietary recommendations. She said nursing administration should be doing random chart audits to ensure CNAs and LVNs were doing their responsibilities. The DON said the facility did not have a policy related to nutrition.<BR/>During an interview on 09/13/23 at 5:01 p.m., the ADM said CNAs or LVNs, whoever fed the resident was responsible for documenting meal intakes. She said the charge nurse at the end of the shift should review the chart to ensure charting was completed. The ADM said documentation of meal consumption should happen after every meal. She said if the intervention of documenting meal consumption was important because you would not know why the resident was lost weight, needed to obtain, or update resident's dislikes, likes, or preferences. The ADM said corporate ran reports on the percentage of electronic charting system entry. She said ADON L oversaw the process. The ADM said she expected the nursing staff to follow the weight policy. She said not getting readmission weights placed resident at risk for the dietitian not to know about the weight loss and not order correct dietary interventions.<BR/>Record review of a facility Resident Weight policy revised on 02/13/07, indicated .all residents will be weighed by the 10th of the month and their weights documented correctly .weights shall be obtained and documented at admission, readmission, and monthly unless ordered by the physician, or unless dictated more frequently by the resident's condition .all new admission and readmission will have a height and weight obtained within 24 hours of admission then weighed at least weekly x4 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services that assure acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of 4 residents (#36, #59, #85, #238) of 11 residents whose medications were reviewed for administration.<BR/>The facility failed to administer Residents #36, #59, #85, and #238's morning medication within the recommended time frames. <BR/>These failures could place residents at risk of adverse medical outcomes as a result of not receiving physician ordered medications in a timely manner, and at risk of not receiving the intended therapeutic benefit of their medications.<BR/>The findings included:<BR/>1. <BR/>Record review of Resident #36's Order Summary Report dated 07/27/22 indicated that resident was an [AGE] year-old male who admitted to the facility, in the secure unit, on 05/02/2022 with the diagnosis of Alzheimer's, Dementia, Muscle wasting and atrophy, hypertension (high blood pressure), cerebral infarction (disruption in blood flow causing a stroke), Congestive heart failure, and restless and agitation. The Order Summary report also indicated that Resident #36 was prescribed, Aspirin 325mg tablet 1 tablet one time a day related to Cerebral infarction on 05/02/2022, Carvedilol 3.125mg tablet 1 tablet two times a day for hypertension on 05/02/2022, Divalproex Sodium Capsule delayed release sprinkle 125mgcapsule 2 capsules two times a day 07/08/2022, Finasteride 5mg tablet 1 tablet one time a day for benign prostatic hyperplasia on 05/02/2022, Furosemide 80mg tablet 1 tablet one time a day for edema (swelling) on 05/02/2022, and Namenda 10mg tab two times a day for Alzheimer's on 05/02/2022. <BR/>Record review of Resident #36's Quarterly MDS dated [DATE] indicated that resident had a BIMS score of 00, which indicated resident had severe cognitive impairment. <BR/>Record review of Resident #36's undated current Care Plan indicated The resident has a diagnosis of hypertension with interventions to educate resident/family/caregiver .give anti-hypertensive medications as ordered . The resident has potential to demonstrate verbally abusive behaviors with interventions assess and anticipates resident's needs .The resident is on diuretic therapy r/t CHF (congestive heart failure) with interventions to give medication as ordered .<BR/>Record review of the Medication Admin Audit Report dated 07/26/2022 indicated that Divalproex Sodium capsule delayed release sprinkle 125mg 2 caps were scheduled on 07/26/2022 at 0630 and administered on 07/26/2022 at 11:28 AM by LVN K, Aspirin tablet 325mg 1 tablet was scheduled on 07/26/2022 at 0630 and administered on 07/26/2022 at 11:28 AM by LVN K, Furosemide tablet 80mg 1 tablet was scheduled on 07/26/2022 at 0630 and administered on 07/26/2022 at 11:28 AM by LVN K, Finasteride tablet 5mg 1 tablet was scheduled on 07/26/2022 at 0630 and administered on 07/26/2022 at 11:28 AM by LVN K, Carvedilol tablet 3.125mg tablet 1 tablet was scheduled on 07/26/2022 at 0800 and administered on 07/26/2022 at 11:28 AM by LVN K, and Namenda tablet 10mg tablet 1 was scheduled on 07/26/2022 at 0800 and administered on 07/26/2022 at 11:28 AM by LVN K. <BR/>2. <BR/>Record review of Resident #59's Order Summary Report dated 07/27/2022 indicated that resident was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnosis of persistent mood disorder, pain, hypertension (high blood pressure), anxiety disorder, and pseudobulbar affect (nervous system disorder). The Order Summary Report also indicated that Resident #59 was prescribed Aspirin 81mg tablet 1 tablet one time a day for preventative on 12/20/2021, Cholecalciferol 1000 unit tablet 2 tablets one time a day for preventative on 12/20/2021, Depakote Sprinkles capsule 125mg 2 capsules four times a day for persistent mood disorder on 04/29/2022, Escitalopram Oxalate 20mg tablet 1 tablet one time a day for persistent mood disorder on 03/24/2022, Fluticasone propionate suspension 50mcg/act 1 spray each nostril two times a day for allergies on 12/30/2021, Gabapentin 300mg capsule 1 capsule one time a day for nerve pain on 12/30/2021, GNP Vitamin C 500mg tablet 2 tablets one time a day for supplement on 12/30/2021, Lisinopril 5mg tablet 1 tablet one time a day for hypertension on 12/30/2021, Lorazepam 0.5mg tablet 1 tablet two times a day for anxiety on 07/16/2022, Metoprolol Tartrate 12.5mg tablet 1 tablet two times a day for hypertension on 12/30/2021, Nuedexta 20-10mg capsule 1 capsule two times a day for pseudobulbar affect on 02/23/2022, and Tylenol Extra strength 500mg tablet 1 tablet two times a day for pain on 07/12/2022.<BR/>Record review of Resident #59's Annual MDS dated [DATE] indicated that resident sometimes made herself understood and sometimes understood others. Resident #59 could not complete a BIMS assessment related to moderately impaired cognition. <BR/>Record review of Resident #59's Care Plan last reviewed 07/25/2022 indicated The resident requires psychotropic medication: Receives antipsychotic, antidepressant, and antianxiety .Interventions include administer medications as ordered. Monitor for side effects and effectiveness .The resident has potential for demonstrate physical behaviors r/t dementia .The resident has a psychosocial well-being problem r/t anxiety . The resident is on pain medication r/t nerve pain with interventions to administer medications as ordered . The resident has impaired cognitive function/dementia with interventions to administer meds as ordered .The resident has hypertension with interventions to give anti-hypertensive medications as ordered .The resident has edema with a goal that the resident's fluid balance will improve or not worsen through the next review date. Interventions included administer medications as ordered .<BR/>Record review of Resident #59's Medication Admin Audit Report indicated that Aspirin 81mg tab 1 tablet was scheduled for 0630 and administered at 11:16AM by LVN K, Gabapentin 300mg tab 1 capsule was scheduled for 0630 and administered at 11:15AM by LVN K, Cholecalciferol 1000 unit tablet 2 tablets were scheduled for 0630 and administered at 11:15AM by LVN K, Fluticasone Propionate suspension 50mcg/act 1 spray to each nostril was scheduled for 0630 and administered at 11:15AM by LVN K, Lisinopril 5mg tab 1 was scheduled for 0630 and administered at 11:16AM by LVN K, Metoprolol tartate 12.5mg tablet 1 tablet was scheduled for 0630 and administered at 11:15AM by LVN K, Escitalopram oxalate 20mg tablet 1 tablet was scheduled for 0630 and administered at 11:15AM by LVN K, Nuedexta 20-10mg capsule was scheduled for 0630 and administered at 11:16AM by LVN K, Tylenol extra strength 500mg tablet 1 tablet was scheduled for 0800 and administered at 11:16AM by LVN K, Lorazepam 0.5mg tablet 1 tablet was scheduled for 0800 and administered at 11:16AM by LVN K, Depakote sprinkles 125mg capsule 2 capsules were scheduled for 0800 and administered at 11:16AM by LVN K, Depakote sprinkles 125mg capsule 2 capsules were scheduled for 12:00PM and administered at 11:16AM by LVN K.<BR/>3. <BR/>Record review of #85's Order Summary Report dated 07/27/2022 indicated that resident was an [AGE] year-old female who admitted to the facility on [DATE] and on to the secure unit on 04/10/2019 with the diagnosis of Hypertension (high blood pressure), dementia with behavior disturbances, myocardial infarction (heat attack), diabetes, depression, and pain. The Order Summary Report also indicated that Resident # 85 was prescribed Amlodipine 5mg tablet 1 tablet one time a day for hypertension on 05/07/2021, Aspirin EC 81mg delayed release 1 tablet one time a day for myocardial infarction on 01/11/2019, Cranberry 450mg tablet 2 tablets two times a day for a supplement on 01/11/2019, Cyanocobalabine 100mcg tablet 1 tablet one time a day for a supplement on 01/11/2019, Depakote ER 250mg tablet 1 tablet two times a day for dementia on 01/24/2022, Docusate Sodium 100mg tablet 1 tablet one time a day for constipation on 01/11/2019, Fenofibrate 145mg tablet 1 tablet one time a day for myocardial infarction on 01/11/2019, Lorazepam 0.5mg tablet 1 tablet one time a day for anxiety on 01/24/2022, Losartan 50mg tablet 1 tablet two times a day for hypertension on 01/14/2020, Meloxicam 15mg tablet 1 tablet one time a day for pain on 04/04/2022, Metformin 500mg tablet 1 tablet one time a day for diabetes on 04/04/2022, Metoprolol tartate 25mg tablet 1/2 tablet two times a day for hypertension on 05/07/2021, Miralax powder 17GM in water one time a day for constipation on 01/11/2019, Vesicare 5mg tablet 1 tablet one time a day for overactive bladder on 01/11/2019. <BR/>Record review of Resident #85's annual MDS dated [DATE] indicated that Resident #85 Had a BIMS score of 3 that indicated the resident had severely impaired cognition. <BR/>Record review of Resident #85's Care Plan last reviewed on 07/25/2022 indicated that The resident is on anticoagulant therapy for the disease process of myocardial infarction .The resident has a psychosocial well-being problem r/t anxiety .The resident has constipation at risk for complications with interventions to administer medications as ordered .The resident has diagnosis of depression with interventions to administer medications as ordered .The resident has diabetes mellitus with interventions to give diabetes medications as ordered by doctor .The resident requires psychotropic medications for depression and anxiety with interventions to administer medications as ordered .The resident has hypertension/hyperlipidemia at risk for complications with interventions to give anti-hypertensive medications as ordered .<BR/>Record review of Resident #85's Medication Admin Audit Report indicated that Lorazepam 0.5mg tablet 1 tablet was scheduled for 06:30 AM and administered at 11:42 AM by LVN K, Metformin 500mg tablet 1 tablet was scheduled for 0630 and administered at 11:43AM by LVN K, Meloxicam 15mg tablet 1 tablet was scheduled for 0630 and administered at 11:43AM by LVN K, Omeprazole 20mg tablet 1 tablet scheduled for 0630 and administered at 11:43AM by LVN K, Losartan 25mg tablet 1 tablet was scheduled for 0630 and administered at 11:42AM by LVN K, Metoprolol tartate 25mg tablet &frac12; tablet was scheduled for 0630 and administered at 11:43AM by LVN K, Cyanocobalamine 100mcg tablet 1 tablet was scheduled for 0800 and administered at 11:30AM by LVN K, Aspirin 81mg EC tablet 1 tablet was scheduled for 0800 and administered at 11:30AM by LVN K, Cranberry 450mg tablet 1 tablet was scheduled for 0800 and administered at 11:30AM by LVN K, Docusate sodium 100mg tablet 1 tablet scheduled for 0800 and administered at 11:30AM by LVN K, Fenofibrate 145mg tablet 1 tablet was scheduled for 0800 and administered at 11:42AM by LVN K, Vesicare 5mg tablet 1 tablet was scheduled for 0800 and administered at 11:43AM by LVN K, Miralax powder 17GM in water was scheduled for 0800 and administered at 11:43AM by LVN K, Depakote ER 250mg tablet 1 tablet was scheduled for 0800 and administered at 11:42AM by LVN K. <BR/>4. <BR/>Record review of Resident #238's Order Summary Report dated 07/27/2022 indicated that resident was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnosis of Parkinson's, Alzheimer's, Heart disease, high blood pressure readings, and pain. The Order Summary Report also indicated that Resident #238 was prescribed Amlodipine 10mg tablet 1 tablet one time a day for Hypertension on 05/19/2022, Aspirin EC 81mg delayed release tablet 1 tablet one time every other day for heart disease on 05/19/2022, Docusate sodium tablet 1 tablet one time a day for constipation on 05/19/2022, Hydralazine HCl 50mg tablet 1 tablet two times a day for elevated blood pressure readings on 05/19/2022, Losartan Potassium HCTZ 100-25mg tablet 1 tablet one time a day for elevated blood pressure readings on 05/19/2022, and Potassium Chloride ER 20MEQ tablet 2 tablets one time a day for hypokalemia (low potassium labs) on 05/19/2022. <BR/>Resident #238 was admitted for respite care and did not have a care plan nor an MDS. <BR/>Record review of Resident #238's Medication Admin Audit Report dated 07/27/2022 indicated that Amlodipine 10mg tablet 1 tablet was scheduled for 0630 and administered at 11:35AM by LVN K, Docusate sodium tablet 1 tablet was scheduled for 0630 and administered at 11:35AM by LVN K, Potassium Chloride 20 MEQ tablet 2 tablets were scheduled for 0630 and administered at 11:35AM by LVN K, Losartan Potassium 100-25mg tablet 1 tablet was scheduled for 0630 and administered at 11:35AM by LVN K, and Hydralazine HCL 50mg tablet 1 tablet was scheduled for 0630 and administered at 11:35AM by LVN K. <BR/>During observation and interview on 07/25/2022 10:10AM with the ADON, she said the facility had a liberalized medication pass for all medications. The ADON provided a form that read the morning medication pass was from 6:30 A-10:30 A, the evening medication pass was from 6:30 P-10:30 P, BID (twice a day medications) are 09:00A, 09:00P, TID (three times a day medications) are 09:00A, 03:00P, 09:00P, and QID (four times a day medications) are 09:00A, 01:00P, 05:00P, 09:00P. <BR/>During an interview on 07/26/2022 at 10:13 AM, LVN K said the medication aide was late that morning of 07/26/2022 and she did not find out until 9AM that she had to pass her own pills. She said she knew this could cause problems with the residents getting medications late, but she had to pass them correctly as she was going down the hall. LVN K said if she had known the medication aide was not going to be at work, she would have started passing her medications earlier on the morning of 07/26/2022. LVN K said the facility used a Liberalized medication administration. Medication should be given Mornings between 0630AM-1030AM and Nights between 0630PM-1030PM. <BR/>During an interview on 07/27/2022 at 02:45 PM, the Administrator said that no one had been notified of the medication aide being late for work or not being in the facility. She said LVN K should have notified management that there was no medication aide in the secure unit. She said she expected the medications to be passed in a timely manner to prevent complications. The Administrator said she usually would have checked the schedules to see who was in the building for that day, but she was too busy and never got around to it on that day. The Administrator said the nurse was responsible for making sure all staff working under her was there. <BR/>Record review of the Policy for Medication Administration Procedures revised 10/25/2017 indicated 1. All medications are administered by licensed medical or nursing personnel .9. Defining schedules for administering medications to: Maximize effectiveness (optimal therapeutic effect) of medication, Prevent potential significant medication interactions .20. The five rights of medication should be adhered to 1. Right drug 2. Right dose 3. Right resident 4. Right time 5. Right route

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #54) reviewed for unnecessary psychotropic medications.<BR/>The facility failed to ensure Resident #54's Lorazepam (anti-anxiety) had an appropriate diagnosis for use.<BR/>The facility failed to limit Resident #54's Lorazepam prn medications to 14 days and the prescribing practitioner did not provide a rationale for extended use.<BR/>These failures could put residents at risk of receiving unnecessary psychotropic medications. <BR/>Findings included:<BR/>Record review of a face sheet dated 09/12/23 indicated Resident #54 was an [AGE] year-old male and admitted on [DATE], with a readmission on [DATE], with diagnoses including Alzheimer's disease with late onset (a progressive disease that destroys memory and other important mental functions), insomnia (persistent problems falling and staying asleep), and depression. <BR/>Record review of a significant change MDS assessment, dated 08/31/23, indicated Resident #54 was understood and understood others. The MDS indicated Resident #54 had a BIMS score of 02 which indicated severe cognitive impairment and required extensive assistance for bed mobility, dressing, eating, toilet use, personal hygiene, and total dependence for transfer and bathing. The MDS indicated Resident #54 had not received an antianxiety during the last 7 days of the MDS assessment period. <BR/>Record review of the care plan dated 06/14/23 indicated Resident #54 used anti-anxiety medications for anxiety disorder. Intervention included give anti-anxiety medications ordered by physician.<BR/>Record review of Resident #54's consolidated physician order dated 05/04/03 indicated Lorazepam 1MG, give 1MG by mouth every 4 hours as needed for agitation. No end date noted on orders.<BR/>Record review of Resident #54's MAR dated 08/1/23-08/31/23 indicated Resident #54 had not received Lorazepam 1MG since 08/18/23. <BR/>Record review of Resident #54's MAR dated 09/1/23-09/30/23 indicated Resident #54 had not received Lorazepam 1MG.<BR/>During an interview on 09/13/23 at 3:53 p.m., LVN F said Resident #54 had an order for a psychotropic medication. She said Resident #54 had an order for Lorazepam as needed. LVN F said the Lorazepam order did not have an end date. She said psychotropic medication could only be prescribed for 14 days. LVN F said Resident #54 used to be on hospice services but when he readmitted on [DATE], he was not placed back on hospice. She prn psychotropic medication needed to be ordered for 14 days at a time to see if the resident needed the medication scheduled instead or prn and to be reviewed for correct dose, frequency, and usage. LVN F said the DON reviewed medication orders to ensure they were accurate. She said anti-anxiety medication should be order for anxiety not only agitation. LVN F said Resident #54's Lorazepam was ordered for agitation not anxiety/agitation. She said Resident #54 did not have a diagnosis listed for anxiety or depression. <BR/>During an interview on 09/13/23 at 4:40 p.m. the DON said Resident #54's Lorazepam prn order should be for 14 days only. She said the nurse who received the prn order should make sure it is only for 14 days. The DON said the Lorazepam should have had at least a stop date of 180 days since it was ordered when he was on hospice. She said prn medication ordered for only 14-day periods was important to ensure psychotropic medications were not abused and see if it needed to be scheduled. The DON said ADON J, who was currently on vacation, was responsible for medication order reviews. She said the Lorazepam indication for use should be anxiety not agitation. <BR/>During an interview on 09/13/23 at 5:01 p.m., the ADM said prn psychotropic medication should only be ordered for 14 days. She said prn psychotropic medication should not have an indefinite end date and not intended for long term use. The ADM said anti-anxiety medication should be prescribed to treat anxiety not agitation. <BR/>Record review of a facility Psychotropic Drugs policy, revised on 10/25/17 indicated .an prn orders for psychotropic medications are only used when the medication is necessary and prn use is limited .a psychotropic drug is .anti-anxiety .residents do not receive psychotropic drugs pursuant to a prn order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical records .prn orders for psychotropic drugs are limited to 14 days .he or she should document their rationale in the resident's medical record and indicate the duration for the prn order .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 61.76%, based on 21 errors out of 34 opportunities, which involved 4 of 4 residents (Resident #15, Resident #20, Resident #53, and Resident #73) reviewed for medication administration. <BR/>1. MA O administered Buspirone 10mg (is commonly used to treat anxiety disorders), Lorazepam 1mg (treats anxiety), and Tramadol 50mg (a pain relief medication, specifically indicated for moderate-to-severe pain) at 10:49 a.m.-11:21 a.m. instead of 8:00 a.m. as ordered on 09/30/24 for Resident #53.<BR/>2. MA O administered Divalproex 250mg (is used to treat certain types of seizures (epilepsy)), Senna-Plus (is used to treat constipation), Levetiracetam 500mg (is a medicine used to treat epilepsy), and Sertraline 100mg (used to treat depression, obsessive-compulsive disorder, panic disorder, anxiety and more) at 10:49 a.m.-11:21 a.m. instead of liberalized policy time of 6:30 a.m.-10:30 a.m. on 09/30/24 for Resident #53. <BR/>3. MA O administered Acetaminophen 500 mg (is used to treat many conditions such as headache, muscle aches, arthritis, backache, toothaches, colds and fevers) at 11:24 a.m. instead of 8:00 a.m. as ordered on 09/30/24 for Resident #20. <BR/>4. MA O administered Arginaid 4.5g (is an arginine-based powder designed to support the unique nutritional needs of people with chronic wounds (e.g pressure injury)), Vitamin C 500mg, Chewable Aspirin 81mg (is a type of nonsteroidal anti-inflammatory drug (NSAID) that can treat mild to moderate pain, inflammation or arthritis), Benztropine 1mg (is used with other medicines to treat Parkinson's disease), Haloperidol 5mg (is used to treat nervous, emotional, and mental conditions (eg, schizophrenia)), Levetiracetam 500mg (is a medicine used to treat epilepsy), Lithium Carbonate 150mg (is used to treat manic-depressive disorder (bipolar disorder)), Multi Vitamin with minerals, Pro-Mod 15g 30ml (ready-to-drink medical food providing 15 grams of enzyme-hydrolyzed complete protein and 100 calories), and Vitamin D3 1000mg at 11:24 a.m. instead of liberalized policy time of 6:30 a.m.-10:30 a.m. on 09/30/24 for Resident# 20. <BR/>5. LVN N administered Resident #73's Cefazolin (is used to treat bacterial infections in many different parts of the body (eg, lungs, bladder, skin, bone and joints, and more)) 2gm/100ml IV over 30 minutes (200ml/hr) instead of 1 hour (100ml/hr) as directed by the physician's order on 10/01/24 at 7:57 a.m.<BR/>6. GVN Q administered Ferrous Sulfate 325mg (is a type of iron that's used as a medicine to treat and prevent iron deficiency anemia) at 08:27 a.m. instead of 6:30 as ordered on 10/01/24 for Resident #15.<BR/>7. GVN Q did not administer Resident #15's Lidocaine Patch (is a topical anesthetic that numbs pain by blocking the nerve signals in your skin) due at 8:00 a.m. on 10/01/24. <BR/>These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. <BR/>Findings included:<BR/>1. Record review of Resident #53 face sheet dated 09/30/24 indicated Resident #53 was a [AGE] year-old female admitted on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), cerebral infarction (stroke), major depressive disorder (a persistently low or depressed mood and a loss of interest in activities that you used to enjoy), anxiety (is a feeling of fear, dread, and uneasiness.), and aphasia following cerebral infarction (loss of ability to understand or express speech, caused by brain damage).<BR/>Record review of Resident #53's quarterly MDS assessment dated [DATE] indicated Resident #53 had unclear speech, was rarely/never understood, and rarely/never understood others. Resident #53 was unable to complete the BIMS assessment. Resident #53 had short-and-long term memory loss and severely impaired cognitive skills for daily decision making. Resident #53 had upper and lower extremities functional limitation in range of motion. Resident #53 was dependent for eating, oral, toilet, and personal hygiene, dressing and shower/bathe self. Resident #53 received scheduled pain medication regimen. Resident #53 received an antianxiety, antidepressant, and opioid during the last 7 days of the assessment period. <BR/>Record review of Resident #53's care plan last review completed on 07/11/24 indicated:<BR/>*Resident #53 required antidepressant medication. Intervention included give antidepressant medications ordered by physician. <BR/>*Resident #53 used anti-anxiety medications. Intervention included give anti-anxiety medications ordered by physician. <BR/>*Resident #53 required psychotropic medications. Intervention included administer medications as ordered. <BR/>*Resident #53 had chronic condition of multiple sclerosis (a chronic disease of the central nervous system). Intervention included give medications as ordered. <BR/>*Resident #53 had a chronic condition of seizure disorder (is abnormal electrical activity in your brain that temporarily affects your consciousness, muscle control and behavior). Intervention included give seizure medication as ordered by doctor. <BR/>Record review of Resident #53's order summary dated 09/30/24 indicated:<BR/>*Buspirone HCL Oral Tablet 10mg, give 1 tablet by mouth three times a day related to anxiety. Start date 04/03/23.<BR/>*Depakote Sprinkles Oral Capsule Delayed Release 125 mg (Divalproex Sodium), give 2 capsules by mouth two times a day related to dementia with agitation. Start date 05/16/23.<BR/>*Keppra Tablet 500mg (Levetiracetam), give 1 tablet by mouth two times a day related to convulsions (is a medical condition where the body muscles contract and relax rapidly and repeatedly, resulting in uncontrolled shaking). Start date 11/20/23. <BR/>*Lorazepam Oral Tablet 1mg, give 1 tablet by mouth three times a day related to anxiety disorder. Start date 05/16/23. <BR/>*Senna-Plus Oral Tablet 8.6-50mg, give 1 tablet by mouth one time a day related to constipation. Start date 06/19/24. <BR/>*Sertraline HCL Oral tablet 100mg, give 1 tablet by mouth one time a day related to major depressive disorder. Start date 04/01/23.<BR/>*Tramadol HCL Oral Tablet 50mg, give 1 tablet by mouth three times a day related to multiple sclerosis. Start date 08/08/24. <BR/>Record review of Resident #53's MAR dated 09/01/24-09/30/24 indicated:<BR/>*Buspirone HCL Oral Tablet 10mg, give 1 tablet by mouth three times a day related to anxiety. Due at 8:00 a.m. The medication was administered on 09/30/24. <BR/>*Depakote Sprinkles Oral Capsule Delayed Release 125 mg (Divalproex Sodium), give 2 capsules by mouth two times a day related to dementia with agitation. Due in the AM and PM. The medication was administered on 09/30/24. <BR/>*Keppra Tablet 500mg (Levetiracetam), give 1 tablet by mouth two times a day related to convulsions (is a medical condition where the body muscles contract and relax rapidly and repeatedly, resulting in uncontrolled shaking). Due in the AM and PM. The medication was administered on 09/30/24. <BR/>*Lorazepam Oral Tablet 1mg, give 1 tablet by mouth three times a day related to anxiety disorder. Due at 8:00 a.m. The medication was administered on 09/30/24. <BR/>*Senna-Plus Oral Tablet 8.6-50mg, give 1 tablet by mouth one time a day related to constipation. Due in the AM. The medication was administered on 09/30/24. <BR/>*Sertraline HCL Oral tablet 100mg, give 1 tablet by mouth one time a day related to major depressive disorder. Due in the AM. The medication was administered on 09/30/24. <BR/>*Tramadol HCL Oral Tablet 50mg, give 1 tablet by mouth three times a day related to multiple sclerosis. Due at 8:00 a.m. The medication was administered on 09/30/24. <BR/>During an observation on 09/30/24 from 10:49 a.m.-11:21 a.m., MA O prepared and administered Resident #53's, 6 tablets (Tramadol, Sertraline, Senna-Plus, Lorazepam, Buspirone, and Keppra and 2 capsules. MA O crushed 6 tablets and added the medications in individual medicine cups with a yellow custard substance. MA O separated 2 capsules (Depakote Sprinkles) and placed the sprinkles in a medicine cup with a yellow custard substance. <BR/>2. Record review of Resident #20's face sheet dated 10/08/2024 indicated Resident #20 was a 68-years-old male admitted to the facility on [DATE] with diagnoses including cerebral ischemia (is a common mechanism of acute brain injury that results from impaired blood flow to the brain), low back pain, extrapyramidal and movement disorders (also called drug-induced movement disorders, describe the side effects caused by certain antipsychotic and other drugs), convulsions (a condition in which muscles contract and relax quickly and cause uncontrolled shaking of the body), Vitamin D deficiency (means you don't have enough of this vitamin in your body), mood disorder (is a mental health condition that primarily affects your emotional state), schizophrenia (is a serious mental health condition that affects how people think, feel and behave), bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). <BR/>Record review of Resident #20's quarterly MDS assessment dated [DATE] indicated Resident #20 was usually understood and usually understood others. Resident #20 had a BIMS score of 02 which indicated severe cognitive impairment. Resident #20 received an antipsychotic and antiplatelet during the last 7 days of the assessment period. <BR/>Record review of Resident #20's care plan last review completed on 07/15/24 indicated:<BR/>*Resident #20 required psychotropic medications: antipsychotic/antimanic at risk for complications. Intervention included administer medications as ordered. <BR/>*Resident #20 had seizure disorder. Intervention included give medication as ordered. <BR/>*Resident #20 had history of transient ischemic attack (is a brief period of stroke-like symptoms caused by a temporary lack of blood flow to the brain). Intervention included give medications as ordered by physician. <BR/>Record review of Resident #20's order summary dated 10/01/24 indicated:<BR/>*Arginaid packet, two times a day for wound care. Start date 02/07/24. <BR/>*Ascorbic Acid (Vitamin C) Tablet 500mg, give 1 tablet by mouth two times a day for wound care. Start date 02/07/24. <BR/>*Aspirin Tablet Chewable 81mg, give 1 tablet by mouth one time a day related to transient cerebral ischemic attack. Start date 01/22/19. <BR/>*Benztropine Mesylate Tablet 1mg, give 1 tablet by mouth two times a day related to extrapyramidal and movement disorders. Start date 01/10/19. <BR/>*Haloperidol Tablet 5mg, give 1 tablet by mouth two times a day related to schizophrenia. Start date 08/02/22. <BR/>*Levetiracetam Tablet 500mg, give 1 tablet by mouth two times a day related to convulsions. Start date 01/10/19. <BR/>*Lithium Carbonate Capsule 150mg, give 1 capsule by mouth two times a day related to schizophrenia, bipolar disorder. Start date 08/02/22. <BR/>*Multivitamin Adult (Minerals) Oral Tablet (Multi Vitamins with Minerals), give 1 tablet by mouth one time a day for wound healing. Start date 02/07/24. <BR/>*ProMod Oral Liquid (Nutritional Supplements), give 30ml by mouth one time a day for wound care. Start date 02/07/24. <BR/>*Tylenol Extra Strength Tablet 500mg (Acetaminophen), give 1 tablet by mouth three times a day for back pain. Start date 07/12/22. <BR/>*Vitamin D3 Capsule 1000 Unit (Cholecalciferol), give 2 capsules by mouth one time a day for supplement (2 capsule=2000 Units). Start date 01/11/19. <BR/>Record review of Resident #20's MAR dated 09/01/24-09/30/24 indicated: <BR/>*Arginaid packet, two times a day for wound care. Due in the AM and PM. The medication was administered on 09/30/24. <BR/>*Ascorbic Acid Tablet (Vitamin C) 500mg, give 1 tablet by mouth two times a day for wound care. Due in the AM and PM. The medication was administered on 09/30/24. <BR/>*Aspirin Tablet Chewable 81mg, give 1 tablet by mouth one time a day related to transient cerebral ischemic attack. Due in the AM. The medication was administered on 09/30/24. <BR/>*Benztropine Mesylate Tablet 1mg, give 1 tablet by mouth two times a day related to extrapyramidal and movement disorders. Due in the AM and PM. The medication was administered on 09/30/24. <BR/>*Haloperidol Tablet 5mg, give 1 tablet by mouth two times a day related to schizophrenia. Due in the AM and PM. The medication was administered on 09/30/24. <BR/>*Levetiracetam Tablet 500mg, give 1 tablet by mouth two times a day related to convulsions. Due in the AM and PM. The medication was administered on 09/30/24. <BR/>*Lithium Carbonate Capsule 150mg, give 1 capsule by mouth two times a day related to schizophrenia, bipolar disorder. Due in the AM and PM. The medication was administered on 09/30/24. <BR/>*Multivitamin Adult (Minerals) Oral Tablet (Multi Vitamins with Minerals), give 1 tablet by mouth one time a day for wound healing. Due in the AM. The medication was administered on 09/30/24. <BR/>*ProMod Oral Liquid (Nutritional Supplements), give 30ml by mouth one time a day for wound care. Due in the AM. The medication was administered on 09/30/24. <BR/>*Tylenol Extra Strength Tablet 500mg (Acetaminophen), give 1 tablet by mouth three times a day for back pain. Due at 8:00 a.m., 2:00 p.m., and 8:00 p.m. The medication was administered on 09/30/24. <BR/>*Vitamin D3 Capsule 1000 Unit (Cholecalciferol), give 2 capsules by mouth one time a day for supplement (2 capsule=2000 Units). Due in the AM. The medication was administered on 09/30/24. <BR/>During an observation on 09/30/24 at 11:24 a.m., MA O prepared and administered Resident #20's 7 tablets (Aspirin, Benztropine, Haloperidol, Levetiracetam, Multivitamin, Tylenol, and Vitamin C) 2 capsule (Lithium and Vitamin D (2)), and 2 liquid medications (Arginaid in water and Pro-Mod). <BR/>3. Record review of Resident #73's face sheet dated 10/03/24 indicated Resident #73 was a 50-years-old male admitted to the facility on [DATE] with diagnoses including bacteremia (is the presence of viable bacteria in the circulating blood), sepsis (is your body's extreme reaction to an infection), and acute hematogenous osteomyelitis, right ankle, and foot (is an infection caused by bacterial seeding from the blood). <BR/>Record review of Resident #73's admission MDS assessment dated [DATE] indicated Resident #73 was understood and understood others. Resident #73 had a BIMS score of 14 which indicated intact cognition. Resident #73 received an antibiotic in the last 7 days during the assessment period. Resident #73 received IV medication and had IV access while a resident in the facility, within the last 14 days. <BR/>Record review of Resident #73's care plan dated 09/11/24 indicated:<BR/>*Resident #73 had osteomyelitis. Intervention included give antibiotics as ordered.<BR/>*Resident #73 had intravenous (IV) access. Intervention included administer IV medications as ordered. <BR/>Record review of Resident #73's order summary dated 10/01/24 indicated Cefazolin Sodium Injection Solution Reconstituted 2gm, use 2 grams intravenously every 8 hours related to acute hematogenous osteomyelitis, right ankle, and foot until 10/16/24 11:59 p.m., Administer 100ml/hr. Start date 09/20/24. <BR/>Record review of Resident #73's MAR dated 10/01/24-10/31/24 indicated Cefazolin Sodium Injection Solution Reconstituted 2gm, use 2 grams intravenously every 8 hours related to acute hematogenous osteomyelitis, right ankle, and foot until 10/16/24 11:59 p.m., Administer 100ml/hr. Due at 12:00 a.m., 8:00 a.m., and 4:00 p.m. The medication was administered on 10/01/24. <BR/>During an observation and interview on 10/01/24 at 7:57 a.m., LVN N reconstituted and administered Resident #73's IV medication. LVN N placed the dial on the tubing on 200ml/hr. LVN N said the medication would run for 30 mins. <BR/>4. Record review of Resident #15's face sheet dated 10/03/24 indicated Resident #15 was a 64-years-old female admitted to the facility on [DATE] and 07/01/24 with diagnoses including Huntington's disease (is an inherited disorder that causes nerve cells (neurons) in parts of the brain to gradually break down and die) and iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells). <BR/>Record review of Resident #15's significant change MDS assessment dated [DATE] indicated Resident #15 was understood and understood others. Resident #15 had a BIMS score of 10 which indicated moderate cognitive impairment. Resident #15 received scheduled pain medication regimen. <BR/>Record review of Resident #15's care plan dated 10/08/2024 indicated Resident #15 had a nutritional problem or potential nutritional problem. Intervention included administer medications as ordered. <BR/>Record review of Resident #15's order summary dated 10/01/24 indicated:<BR/>*Ferrous Sulfate oral Tablet 325 (65 Fe), give 1 tablet enterally one time a day related to anemia. Start date 07/17/24. <BR/>*Lidocaine Pain Relief Patch 4%, apply to lower back topically one time a day for pain, remove after 12 hours and remove per schedule. Start date 03/13/24. <BR/>Record review of Resident #15's MAR dated 10/01/24-10/31/24 indicated:<BR/>*Ferrous Sulfate oral Tablet 325 (65 Fe), give 1 tablet enterally one time a day related to anemia. Due at 6:30 a.m. The medication was administered on 10/01/24.<BR/>*Lidocaine Pain Relief Patch 4%, apply to lower back topically one time a day for pain, remove after 12 hours and remove per schedule. Due remove 7:59 a.m. and apply 8:00 a.m. The MAR did not indicate administration on 10/01/24. <BR/>During an observation on 10/01/24 at 8:27 a.m., GVN Q administered one tablet of Ferrous Sulfate 325 mg to Resident #15. GVN Q did not apply Resident #15's Lidocaine Pain Relief Patch 4%. <BR/>During an interview on 10/02/24 at 1:55 p.m., MA O said if a medication was due at 8am, it had to be administered by 9am. He said if it was administered after 9am, it was considered late. He said if a medication was scheduled for AM, if was due by 11:30 a.m. He said after 11:30 a.m., the medication was considered late. He said on 09/30/24, he had gotten behind which caused him to administer several medications late. He said when he got behind, LVNs did not assist him to catch up. He said it was important to administer medications as ordered so the effects worked better. <BR/>During an interview on 10/02/24 at 3:44 p.m., LVN N said Resident #73 was admitted on antibiotics. She said the medication order from the hospital did not specify the rate of administration. She said the medication order was sent to the pharmacy and they sent the appropriate fluid to reconstitute the antibiotic with. She said the nurse was supposed to call the MD to confirm the correct medication was ordered and what rate to run it over. She said the pharmacy returned Resident #73's medication with an administration rate of 30 minutes. She said the nurse who ordered the medication received an order for 30 minutes. She said a nurse put special direction on the order for 100ml/hr. She said before administering a medication, she was responsible to verify the medication label matched the physician's order. She said she did not notice the physician order rate was 100ml/hr. She said when a medication was administered too fast, the resident could experience fluid overload and adverse reaction to the medication. <BR/>On 10/02/24 at 4:15 p.m., call GVN Q but was unable to leave a message. <BR/>During an interview on 10/03/24 at 10:21 a.m., the DON said if a medication was due at 8am, staff had an hour before and after to administer it. She said if a medication was scheduled for AM, it was due between 6:30 a.m.-10:30 a.m. She said after those time ranges, those medications were considered late. She said MAs were responsible for administering medications on schedule. She said LVNs and the nursing administration should be ensuring MAs were giving medication on schedule. She said when medications were given late, it placed residents at risk for getting doses too close together. She said staff had to document when a medication was administered. She said if a medication administration was not documented, it could imply it was not given. She said if IV medications were administered too long, the medication could become ineffective. She said if an IV medication was run too fast, it could cause unwanted effects. <BR/>During an interview on 10/03/24 at 11:00 a.m., the ADM said MAs and charge nurse were responsible for administering medication on time. She said charge nurse should use the 5 rights and ensure the medication label and physician order match. She said it depended on the type of medication how it would affect the resident if administered late. She said when medications were administered late, it affected the next scheduled doses. She said the resident could experience a negative outcome if a medication was administered too fast. She said the nurse managers should be ensuring nursing staff administered medications as ordered. <BR/>Record review of an undated facility's Liberalized Medication policy indicated .AM time code=maybe given from 5:30 am until 10:30 am .medications that require a certain amount of time, i.e. 12 hours in between doses will continue to have scheduled times .if a physician's order specifically states the time of day a medication is to be given, then the facility must administer it at the times specified .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 7 residents reviewed for medication errors. (Resident #58)<BR/>The facility failed to ensure Resident #58 received her IV antibiotic therapy as ordered by the physician. <BR/>This failure could place the resident at risk of medical complications including an abnormal level of the medication in the blood stream.<BR/>Findings included:<BR/>Record review of a face sheet dated 7/26/2022 indicated Resident #58 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the diagnoses of leukemia, heart failure, and high blood pressure. <BR/>Record review of a Significant Change MDS dated [DATE] indicated Resident #58 understands and was understood. The MDS indicated Resident #58 BIMS score was 14 indicating her memory cognition was intact. The MDS did not reflect at the time of completion Resident #58 was receiving IV antibiotics.<BR/>Record review of the consolidated physician orders dated 7/26/2022 indicated Resident #58 had an order for Vancomycin solution reconstituted give 500 milligrams one time every other day for an osteomyelitis (bone infection).<BR/>Record review of the comprehensive care plan dated 7/25/2022 indicated Resident #58 had a bone infection with a goal of the infection resolved without any complications. The care plan intervention indicated to give antibiotics as ordered, and monitor laboratory work as ordered.<BR/>Record review on 7/26/2022 of the Vancomycin medication label indicated Vancomycin 500 milligrams/100 milliliters via IV over 60 minutes every other day. <BR/>During an observation and interview on 7/26/2022 at 8:44 a.m., Resident #58's Vancomycin IV was infusing at 200 milliliters an hour. LVN A was asked to come and review the Vancomycin administration with the surveyor. LVN A indicated the label indicated to administer 100 milliliters over 1 hour. LVN A indicated she had initiated the IV medication. LVN A said administering the medication at 200 milliliters would make the IV administer over more than 1 hour. LVN A indicated she had been trained on IV medication administration, but a training record was not provided.<BR/>Record review of a Vancomycin Trough drawn on 7/26/2022 at 12:12 p.m., indicated the level was high at 24.8 with the normal range of 10.0 to 20.0. The result was noted to be faxed to her physician without any new orders.<BR/>During an interview on 7/27/2022 at 3:39 p.m., the Corporate DON indicated LVN A understood the medication error. The Corporate DON stated the nurses should be IV certified prior to administering IV medications. The Corporate DON indicated LVN A did not have an IV certification, and the DON was responsible for ensuring the LVNs had an IV certification course. The Corporate DON indicated the medication errors could affect a resident's health.<BR/>During an interview on 7/27/2022 at 4:03 p.m., the Administrator indicated a resident's health could be affected by not receiving the correct medication, correct route, and correct rate. The Administrator was unaware whose responsibility it was to monitor whether the DON or Human Resource manager.<BR/>Record review of a medication Administration Procedure policy dated 2003 indicated 20. The five rights of medication should always be adhered to 1. Right drug 2. Right dose 3. Right resident 4. Right time and 5. Right route.<BR/>Record review of the website accessed on 8/1/22: http://www.accessdata.fda.gov/drugsatfda-doc/label2017/050671s024lbl.pdf accessed on 8/01/2022 Warnings . Infusion Reactions Rapid bolus administration (e.g., over several minutes) may be associated with exaggerated hypotension, including shock and rarely, cardiac arrest. Vancomycin should be administered over a period of not less than 60 minutes to avoid rapid-infusion-related reactions. Stopping the infusion usually results in prompt cessation of these reactions Precautions Vancomycin is irritating to tissue and must be given by a secure intravenous route of administration. Pain, tenderness, and necrosis occur with inadvertent extravasation. Thrombophlebitis may occur, the frequency and severity of which can be minimized by slow infusion of the drug and by rotation of venous access sites.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary storage of residents' food items for 2 of 12 resident personal refrigerators reviewed for food safety (Resident #37 and Resident #38).<BR/>1. The facility failed to ensure the refrigerator for Resident #37 did not have expired protein drinks. <BR/>2. The facility failed to ensure the refrigerator for Resident #38 was cleaned and free from a brown and black substance with black dead gnats. <BR/>This failure could place resident at risk for food borne illnesses.<BR/>Findings include:<BR/>1. Record review of Resident #37's face sheet, dated 3/2/21 revealed an [AGE] year old male admitted on [DATE]. He was most recently re-admitted on [DATE]. The face sheet revealed diagnoses that included Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Essential Hypertension (abnormally high blood pressure that's not the result of a medical condition), Insomnia (a sleep disorder that makes it hard to fall asleep, stay asleep, or get quality sleep). <BR/>Record review of Resident #37's Quarterly MDS assessment, dated 09/5/24, revealed Resident #37 had a BIMS of 02, which indicated severe cognitive impairment. The MDS showed that Resident #37 required substantial assistance with their ADLs.<BR/>Record review of a care plan for Resident #37 dated 10/2/2024 revealed a problem initiated on 3/3/21: The resident has an ADL Self Care Performance Deficit . Resident may require more or less assistance throughout the day/shift due to generalized weakness or disease processes.<BR/>During an interview and observation on 10/01/2024 at 8:19 a.m., Resident #37 was sitting in a wheelchair looking outside his window. Resident #37 had a personal refrigerator on his side of the room. Upon surveyor looking inside the refrigerator two bottles of protein drink with an expiration date of 2023 were discovered. Resident #37 said he both ate and drank from his refrigerator. Resident #37 said he did not know if anyone cleaned out his refrigerator. Resident #37 said he did not look at expiration dates on the items in his refrigerator. <BR/>During an interview on 10/2/24 at 11:09 a.m., the DON said that housekeeping and CNAs are responsible to ensure that resident's personal refrigerators were clean and did not have expired food in them. She said Resident #37 could have been placed at risk of harm from drinking a protein drink that expired in 2023. She said that staff are responsible for the safety of residents. <BR/>During an interview on 10/2/24 at 11:36 a.m. with the ADM she said that housekeeping was responsible for removing expired food from a resident's personal refrigerator. She said that housekeeping is also responsible to ensure that residents' refrigerators are clean if their family or responsible party was not cleaning it out. She said that resident's family or responsible party may not be at the facility enough to ensure their personal refrigerators were clean.<BR/>2. Record review of a face sheet dated 10/3/2024 indicated Resident #38 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar type (a rare mental health condition that involves both schizophrenia and a mood disorder, with manic episodes), abnormal weight loss (when you lose weight without trying and it's not due to normal circumstances like dieting or exercising) and unspecified protein-calorie malnutrition (a condition that occurs when a person doesn't get enough calories or the right amount of nutrients, such as proteins carbohydrates, fats, vitamins, and minerals). <BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #38 usually understood others and usually made himself understood. The MDS indicated Resident #38 had intact cognition with a BIMS score of 13. The MDS indicated Resident #38 needed supervision with ADL's. <BR/>Record review of a care plan for Resident #38 dated 08/19/2024 revealed Resident #38 had impaired cognitive function or impaired thought processes bi-polar disorder: use the residents preferred name, identify yourself at each interaction. Face the resident when speaking, make eye contact. Reduce any distractions turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. Monitor/document/report to MD any changes in cognitive function, specifically. <BR/>During an observation on 9/30/24 at 10:45 a.m., in Resident #38's personal refrigerator it was observed not clean and had a brown and black substance with dead gnats in bottom of it with 2 glass containers of chip dips .<BR/>During an observation on 10/01/24 at 8:22 a.m., Resident #38's personal refrigerator had a brown and black substance with dead gnats. <BR/>During an observation on 10/01/24 at 9:22 a.m., Resident #38's personal refrigerator had a brown and black substance with dead gnats. <BR/>During an observation on 10/01/24 at 3:04 p.m., Resident #38's personal refrigerator had a brown and black substance with dead gnats. <BR/>During an interview on 10/02/24 at 9:31 a.m., with CNA B she said housekeeping was responsible for keeping the resident's refrigerators clean. She said Resident #38's refrigerator looked nasty. She said the refrigerator could be a hazard to Resident #38's health if he were to eat out of it and she would not want to eat out of it.<BR/>During an interview on 10/02/24 at 10:19 a.m., with Housekeeper F she said no one told her she needed to clean out the refrigerators in resident's rooms. She said she did know housekeeping was responsible to ensure the resident's refrigerators were cleaned. Housekeeper F said she cleaned Resident #38's refrigerator on 10/02/2024.<BR/>During an interview on 10/2/2024 at 10:22 a.m., with Resident #38 he said he did not know staff was supposed to clean out his refrigerator. He said he ate his chip dip in the refrigerator when he got hungry. He said he knew the refrigerator was nasty.<BR/>During an interview on 10/02/24 at 10:27 a.m., CNA G said housekeeping should ensure the residents' refrigerators are clean. CNA G thought the refrigerator would be a hazard to the resident, because if he were to accidently rub the bottom of the refrigerator before he ate, he could get sick.<BR/>During an interview on 10/02/24 at 11:12 a.m., RN H said she was not sure who was responsible for cleaning the resident's refrigerators. She said she thought his Resident #38's refrigerator could be a hazard to him, because if he ate something out of the refrigerator it could make him sick. RN H said Resident #38's refrigerator looked like it had not been cleaned in more than a couple of days.<BR/>During an interview on 10/02/24 at 11:22 a.m., with the DON, she said their policy said family members were responsible to ensure the residents' refrigerators were clean, but if they did not have family the facility staff was responsible. DON said housekeeping staff and CNAs were responsible to clean out the resident's refrigerators. She said Resident #38 could get sick if he ate from the refrigerator.<BR/>During an interview on 10/03/24 at 10:18 a.m., with the Administrator she said it is the responsibility of all staff to clean out the resident's refrigerators. She said there was no excuse for the resident's refrigerator to look like that. She said the staff on that hall should do a better job and she would work on that.<BR/>Record review of facility policy titled Personal Refrigerator's Policy dated 2012 revealed that, Residents of the facility may place a personal or dormitory size refrigerator in their room if space permits and under Life Safety Code regulations, that the resident room has an adequate electrical system, such as proper outlets, to allow the connection of a refrigerator without overloading the electrical system The care and maintenance of any refrigerator is the responsibility of the resident and/or responsible party. It is also the responsibility of the resident and/or resident representative to properly store non-facility supplied foods that require refrigeration in their personal refrigerator. If food is expired or appears spoiled or moldy, the facility reserves the right to discard it. Housekeeping can assist the resident and/or family member by inspecting the refrigerators at least weekly and assist with removal of outdated food items and cleanliness. Food should be stored in the refrigerator/freezer as determined by the food item. Commonly Used Dates Sell by date - indicates that a product should not be sold after that date if the buyer is to have it at its best quality Best by or Use by date -the maker's estimate of how long a product will keep at its best quality. They are quality dates only, not safety dates. If stored properly, a food product should be safe, wholesome and of good quality after its Use by or Best by date. Expired date - the food items should not be consumed and should be discarded if not eaten by the expiration date

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Residents #65) of 5 residents observed for infection control. <BR/>Housekeeper DD failed to doff (take off) PPE while exiting isolation room and entered Resident #65's room wearing contaminated PPE. Housekeeper DD wore soiled gloves in the hallway.<BR/>These failures could place residents at risk of cross-contamination and infections leading to illness.<BR/>Findings included:<BR/>Record review of Resident #65's admission Record dated 09/14/2023 indicated that resident was an 63-year- old female who admitted to the facility on [DATE] with diagnosis of non-pressure chronic ulcer of buttock with necrosis of the muscle (commonly occur in patients with arterial (ischemic) disease, venous disease, neuropathy, or a combination of these diseases), type 2 diabetes ( a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) fibromyalgia (a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), and urinary tract infection (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract).<BR/>Record review of Resident #65's MDS assessment, dated 07/03/2023, indicated that resident had a BIMS score of 15 which indicated resident had no cognition issues. The MDS also indicated that Resident #65 required extensive assistance of for bathing and personal hygiene.<BR/>Record review of Resident #65's Care Plan created on 09/07/2023 indicated that resident had a urinary tract infection with the goal of having the urinary tract infection resolved by 10/09/2023.<BR/>Record review of an in-service titled Prevention of Infection: Donning and Doffing PPE was signed by Housekeeper DD on 07/24/2023. Review revealed doffing (taking off) PPE was to be done within the isolation room and disposed of in a labeled biohazard container. PPE included gloves, mask, gown, hair covers, and shoe covers.<BR/>During an interview and observation on 09/11/2023 at 9:15 a.m., Resident #65 said she had concerns about the man that was placed in the room across the hall from her room. Resident #65 said she knew he was on isolation for something that was air borne and the staff kept his door open all the time and kept her door open despite Resident #65 having asked for it to be closed every time they left for privacy. During this conversation Resident #65's door was pushed open without a knock and Housekeeper DD entered the room with a mask, gloves, and isolation gown on. When Housekeeper DD saw the surveyor, she said, oh no and exited the room. Resident #65 became upset and said see what I mean, she spread his infection to my room! Now we (roommate and Resident #65) are going to get his disease! The room across the hall was noted to have an isolation set up outside of it and an air borne isolation poster on the door.<BR/>During an interview on 09/11/2023 at 9:25 p.m., Housekeeper DD said it was an accident that she walked into Resident #65's room. Housekeeper DD said she was taking out the biohazard material from the isolation room across the hall and forgot to take off her PPE before exiting the room. She opened Resident #65's door to clean her room but then saw the surveyor and realized her mistake of not taking her PPE off. Housekeeper DD was not aware of any potential adverse effects of not taking PPE off in the isolation room and washing her hands.<BR/>During an observation on 09/12/2023 at 8:50 a.m., Housekeeper DD exited a room on D hall with gloves on, walked down hallway pushing housekeeping cart and entered the next room with the same gloves on.<BR/>During an observation on 09/12/2023 at 10:20 a.m., Housekeeper D walked from D hall to the kitchen to return dirty dishes wearing gloves, then walked back to the housekeeping cart on D hall, pushed it to next room on the hall, and entered the room still wearing the same gloves.<BR/>During an interview on 09/12/2023 at 10:25 a.m., Housekeeper DD said she forgot to change gloves before entering the next room and was not aware she was not allowed to wear the gloves in the hallway. <BR/>During an interview on 09/13/2023 at 2:15 p.m., the DON said she had multiple in services on isolation, infection control prevention, and donning and doffing PPE and presented them to all staff including nursing, kitchen staff, housekeeping staff, and department heads. The DON said she would continue to educate the staff on infection prevention and control. The DON said not following isolation precautions could result in the spread of infections and she expected the staff to follow all isolation precautions and standard precautions to aid in the prevention of spreading infections.<BR/>During an interview on 09/13/2023 at 3:00 p.m., the Administrator said she expected the staff to follow the facilities policy for infection control. The Administrator said that the policies were in place to prevent the spread of infection throughout the building and protect the vulnerable residents that lived in the facility. <BR/>Record review of an infection control policy dated 07/2021 titled 'Infection Control' revealed: Begin removing PPE at patient's doorway or in anteroom. Eye protection and mask/respirator to be removed outside the room. Outside surfaces of PPE are considered to be contaminated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 2 of 11 residents (Resident #1 and Resident #2) reviewed for abuse and neglect. <BR/>The facility failed to ensure the provider investigation report was turned into the state survey agency (HHSC) within 5 working days of the reported incident between Resident #1 and Resident #2. <BR/>This failure could place residents at risk for abuse and neglect. <BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet, dated 09/04/24, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia (a decline in cognitive abilities that can affect a person's ability to perform everyday activities), generalized anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about various aspects of daily life), and chronic obstructive pulmonary disease (a group of progressive lung diseases that cause obstructed airflow from the lungs and make breathing difficult).<BR/>Record review of Resident #1's quarterly MDS assessment, dated 06/07/24, indicated she was able to make herself understood and understand others. She had a BIMS score of 10, indicating moderate cognitive impairment.<BR/>2. Record review of Resident #2's face sheet, dated 09/04/24, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a progressive neurological disorder that leads to the degeneration and death of brain cells), generalized anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about various aspects of daily life), and paranoid personality disorder (a mental health condition characterized by pervasive and irrational distrust and suspicion of others).<BR/>Record review of Resident #2's quarterly MDS assessment, dated 06/17/24, indicated she was usually able to make herself understood and usually understood others. She had a BIMS score of 5, indicating severe cognitive impairment.<BR/>Record review of the facility's provider investigation report for the reported incident between Resident #1 and Resident #2, dated 07/11/24, indicated that Resident #1 had reported being slapped by Resident #2. The residents were separated and placed on 15-minute checks. There were no witnesses to the incident, and assessments of both residents showed no marks or injuries. Ultimately, the facility's investigation concluded that the allegation of abuse was unfounded. In-services were conducted with facility staff on the prevention of abuse, neglect, and exploitation. The allegation was reported to the state survey agency on 07/05/24. <BR/>During an interview on 09/03/24 at 10:32 AM, the Administrator said she did not send the provider investigation report for the incident between Resident #1 and Resident #2 to the state. She explained that she was unable to find the email and must have forgotten to send it.<BR/>During an interview on 09/04/24 at 12:20 PM, the Administrator said that she did not send the provider investigation report for the incident between Resident #1 and Resident #2 to HHSC within 5 days of the investigation. She said she was solely responsible for submitting the report and mentioned that she was going to send it on that day. Additionally, she noted that the abuse policy would address this deficiency.<BR/>Record review of the facility's undated policy, Abuse/Neglect, stated:<BR/> .F. Investigation .<BR/> .3. A report to the appropriate agency will include the following: .<BR/> .The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting form .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to protect and promote the rights of the resident in an environment that promoted maintenance or enhancement of his or her quality of life for 4 of 18 residents (Resident #69, Resident # 52, Resident # 78 and Resident # 54) reviewed for resident rights. <BR/>The facility failed to protect and value Resident #69, Resident # 52 and Resident #78's quality of life and provide a peaceful atmosphere when facility staff engaged in unprofessional and obscene behavior with family members of residents. <BR/>The facility failed to ensure staff knocked prior to entering Resident #54's room.<BR/>This failure could place residents at risk for decreased quality of life, increased anxiety, and increased stress. <BR/>Findings included:<BR/>1. Record review of Resident #69's admission Record indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alcohol Induced Dementia (a type of alcohol-related brain damage), Tremors (causes involuntary and rhythmic shaking), Muscle Wasting and Atrophy (Muscular atrophy is the decrease in size and wasting of muscle tissue), Muscle Weakness (Muscle weakness happens when full effort doesn't produce a normal muscle contraction or movement), Communication Deficiency (an impairment in the ability to receive, send, process, and comprehend concepts or verbal, nonverbal and graphic symbol systems.)<BR/>Record review of Resident #69's MDS dated [DATE] revealed that Resident #69 was understood and understood others. The MDS indicated a BIMS of 9 indicating moderate cognitive impairment for Resident #69. The MDS also revealed, Resident #69, required a two person assist for transfers. The activity of walking in the room and on the unit did not occur.<BR/>During an interview on 9/12/23 at 9:45 a.m., Resident # 69 stated that she remembers the incident that occurred between the Family Member A and staff. She said she remembered an incident happening at the nurse's station. She stated she remembers them all being very loud and yelling at each other. She stated that it was the Family Member A and some aides. She stated that she did not hear any cusswords being yelled at anyone. She stated that it bothered her with all the yelling because how is she to have a normal life with all the drama these aides cause. <BR/>2. Record review of Resident #52's face sheet dated 1/10/23 indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses including heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides - in your blood), paresthesia of skin (tingling or prickling, pins-and-needles sensation; usually temporary, often occurs in the arms, hands, legs, or feet.)<BR/>Record review of Resident #52's MDS dated [DATE] indicated she was understood and understood others. The MDS indicated a BIMS score of 13 which indicated Resident #52 had intact cognitive. The MDS indicated Resident #52 did not have behavioral symptoms. The MDS indicated Resident #52 required supervision from staff for most activities of daily living and used a wheelchair device for mobility when out of the bed.<BR/>During an interview on 9/12/23 at 4:44 p.m., Resident# 52 stated that she remembers the incident that occurred last weekend. She stated that she heard lots of screaming and yelling at the nurse's station. She stated that she did not know who the people that were yelling were but some were staff. She said that she was waiting to go out to meet her son who was picking her up. She stated that it bothered her with all the yelling because she doesn't want to live with all that commotion and also the police showed up to an old folk's home. <BR/>3. Record review of Resident #78's admission Record indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), dysphagia (swallowing difficulties), general anxiety disorder (a condition of excessive worry about everyday issues and situations.)<BR/>Record review of Resident #78's MDS dated [DATE] revealed that Resident #78 had a BIMS score of 13 indicating he was cognitively intact. MDS revealed that Resident # 78 he was understood and understood others. <BR/>During an attempted interview on 9/11/23 at 2:02 p.m., Resident # 78 was unintelligible and not forming words when answering questions asked. Resident # 78 was mumbling and would not look at the surveyor when he spoke of Family Member A or the incident that occurred the previous Saturday. <BR/>4. Record review of Resident #54's admission Record dated 09/14/2023 indicated that resident was an 63-year- old female who admitted to the facility on [DATE] with diagnosis of non-pressure chronic ulcer of buttock with necrosis of the muscle (commonly occur in patients with arterial (ischemic) disease, venous disease, neuropathy, or a combination of these diseases), type 2 diabetes ( a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) fibromyalgia (a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), and urinary tract infection (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract).<BR/>Record review of Resident #54's MDS assessment, dated 07/03/2023, indicated that resident had a BIMS score of 15 which indicated resident had no cognition issues. Resident #54 is understood and understands others. The MDS also indicated that Resident #54 required extensive assistance of for bathing and personal hygiene.<BR/>During an interview and observation on 09/11/2023 at 9:15 a.m., Resident #54 said her only concerns about the facility were lack of privacy and that she did not feel the employees understood infection control. During the conversation with Resident #54, Housekeeper D walked into the room without knocking. Resident #54 became upset and said this is exactly what I am talking about! No one has respect for us. They treat this place like it is their house and not ours. Housekeeper D exited the room without addressing Resident #54. Resident #54 said, what did she want? Why bust in my door and not tell me the purpose of the rudeness?<BR/>During an interview on 09/11/2023 at 9:25 a.m., Housekeeper D said she was entering to empty trash, sweep and mop. Housekeeper D said she forgot to knock. She said she was not aware that Resident #54 would make such a big deal out of her walking in her room. Housekeeper D said she walked into her room everyday and she never freaked out like that before. Housekeeper D said knocking on the door before entering showed respect and she was supposed to knock on everyone's doors before entering.<BR/>During an interview and Record Review on 9/11/23 at 2:41 p.m., A video was observed with CNA C. Video shows the incident between CNA C and Family Member B. The video was taken from a cellphone. The video was grainy in appearance and not high definition. Faces of individuals were not clear. CNA C was identified due to her unique (artificial red) hair color. She stated that it was her with the red hair in the video. CNC C was observed in a verbal altercation with Family Member B. CNA C can be hear arguing and yelling, Lets be professional to Family Member B. An unidentified resident is observed in a wheelchair. Other staff are observed in the video watching CNA C and Family Member B's verbal altercation. The video is 25 seconds long and ends abruptly. <BR/>During an interview on 9/11/23 at 2:50 p.m., LVN B stated that she has worked for the facility almost 5 years. She stated that she worked this weekend Friday through Sunday. She stated that she worked the 6A to 6P shift. She stated that last Saturday she was near the dining room and she heard Family Member A speaking with another staff. She stated that the family member of Resident # 78 was looking for the CNA that she had a verbal altercation with over the phone. She stated that she did not know the CNAs name. She stated that she intervened because Family Member A was being aggressive. She stated that she asked her if she could help, and she told her about the altercation over the phone with the unknown CNA. She stated that Family Member A said that a CNA told her to, pull up. She stated that she told her that she could come back on Monday, and she could speak to the DON or ADM. She stated that she wanted her to go get the CNA that she had the altercation with, and she told Family Member A she would not do that. She stated that she then became verbally aggressive with her. She stated that Family Member A started waving her hands and pointing her fingers at her. She stated that Family Member A continued to insist that she got the CNA she had an altercation with. She stated that Family Member A was yelling at this point. She stated that she did not think that there were any residents around when this occurred. She stated that the residents were in the dining room, and she was outside of the dining room near a hallway entrance. She stated that the verbal aggression continued so she asked her to leave. She stated that she refused to leave the facility after two verbal requests. She stated that she told her since she would not leave, she would call the police. She stated that the police arrived, and Family Member A was now outside waiting for the cops. She stated that no one got physical with each other and the entire confrontation was verbal. She stated that she knew of the other separate incident that occurred over the weekend on Sunday with Resident # 235's family but was on her break getting lunch. <BR/>During an interview on 9/12/23 at 2:04 p.m. CNA C stated that on Sunday, 9/10/23, she was working and there was an incident. She stated that she was getting ready to eat her lunch when an aide came and got her. She stated that the aide from D hall was upset because of the way Family Member B was behaving. She stated that Family Member B was angry about Resident #235's clothes. She stated that she went to the nurse's station and Family Member B was there. She stated that she introduced herself to Family Member B and she yelled at her that she did not want to hear all that and she wanted Resident #235's fucking clothes. She stated that she asked the girlfriend to talk to her professionally. She stated that she told her that she would help her but she needed to stop yelling. She stated that she was calling her ignorant. She stated that she had raised her voice at Family Member B because she was yelling and she was trying to match her sound level so she could hear what she was saying. She stated that the police came and escorted Family Member B out. She stated that she was told that Resident # 52 may have been in the vicinity when this occurred. She stated that she never cussed at the girlfriend she just said lets be professional lets be professional but she was saying that to her with a raised voice.<BR/>During an interview on 9/12/23 at 2:21 p.m., CNA D stated that she has worked at the facility for two years. She stated that she was working last weekend. She stated that she worked on Saturday 9/9/2023. She stated that she was outside with Resident # 78 when he was smoking. She stated that resident # 78 had Family Member A on speaker phone and Family Member A said, I will get you some grease for your feet because them [NAME] is not doing their job. She stated that she then made the comment to Family Member A that there was no [NAME] here I am a bitch. She stated that this made Family Member A angry. She stated that Family Member A was still going off and yelling on the phone and she was laughing at Family Member A because it was funny. She stated that at one point Family Member A said, I will come up there and drag that bitch in the river. She stated that she told Family Member A I was at 2131 Alpine RD. She stated that she may have told Family Member A to, pull up. She stated that she went back to work because she hung up the phone with Resident # 78. She said that another staff came to get her because Family Member A that she was talking to had come to the building with three other women. She stated that she never went face to face with Family Member A, but she could hear and see Family Member A yelling from behind the door of the locked unit. She stated that she was watching all this happen as Family Member A talked to the other staff at the nurse's station. She stated that it was LVN B that was dealing with Family Member A She stated that she heard LVN B say you are upsetting my residents. She stated that she doesn't know which residents that were there. She stated that it was all funny to her and it still is funny to her. <BR/>An attempted contact on 9/12/23 at 4:55 p.m. with Resident # 235. Resident # 235 was unable to answer any questions by the surveyor. Resident # 235 resides on the locked memory care unit. Resident # 235 did not witness the incident as the family member of Resident # 235 did not enter the locked unit. <BR/>An attempted contact on 9/12/23 at 4:58 p.m., with Family Member B. A voicemail was left requesting an interview.<BR/>An attempted contact on 9/12/23 at 5:02 p.m., with Family Member A. A voicemail was left requesting an interview.<BR/>An attempted contact on 9/12/23 at 5:04 p.m., with the Wife of Resident # 78. A voicemail could not be left as the voicemail box was full.<BR/>During an interview on 9/12/23 at 5:13 p.m., the Administrator stated that she was aware of the incidents that took place over the weekend and her opinion of the staff's behavior was as follows: CNA D's behavior could be considered obscene as she instigated the confrontation. She stated that CNA C did not say anything that could be considered offensive but the way she carried her self could be considered offensive or obscene. She stated that CNA D made the situation with Family Member A worse with her behavior. She stated that she should not have engaged with the family member and instead walked away from the situation. She stated that she cannot say whether or not CNA C's behavior made the situation worse as she did not say anything offensive but did yell at Family Member A. She stated that the residents were at risk for a reduced quality of life due to the yelling and screaming. She stated that they try and keep a peaceful atmosphere in the facility. She stated that both CNA C and CNA D's behavior was inappropriate for the workplace. She stated that behavior of these two staff was unbecoming as an employee of the company.<BR/>During an interview on 9/13/23 at 2:10 p.m., the DON stated that she has seen the video with CNA C and she would agree that her behavior was unprofessional. She stated that she would not condone the behavior of CNA C as she aggravated the situation with her tone of voice. She stated that she did not see or hear the incident between CNA D and Family Member A, but she heard some of the language that was used over the phone as she was told by other staff what was said. She stated that CNA D instigated the incident and did not help calm the situation. She stated that CNA D's behavior was unprofessional.<BR/>During an interview on 09/13/2023 at 2:15 p.m., the DON stated she expected all employees regardless of department to treat the facility like the resident's home. The DON said it was best practice to knock on all resident's doors and wait for permission to enter. The DON said knocking showed respect for the resident's privacy.<BR/>During an interview on 09/13/2023 at 3:00 p.m., the Administrator stated all resident rooms should not be entered without permission, especially a closed door. Resident care could have been occurring and Resident #54 could have been exposed to staff or residents in the hallway. The Administrator stated even if the resident did not seem to understand what was going on, it was best to knock and make the resident aware you would like to enter. The Administrator said it was the right of the residents to have privacy.<BR/>Review of the facility 's policy titled Resident Rights with a revised date of November of 2016 indicated, . Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. Respect and dignity- The resident has a right to be treated with respect and dignity, including: The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. Self-determination - The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.<BR/>Record review of facility Employee Handbook section entitled Corporate Code of Conduct, revised 09/20/2023. Types of behavior and conduct that this facility considers inappropriate include, but are not limited to, the following: Fighting or using obscene, abusive, or threatening language or gestures; Violation of resident's rights; Horseplay, practical jokes and other kinds of behavior inappropriate in the workplace; Conduct unbecoming of an employee of the company.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 10 residents (Resident #1) reviewed for reasonable accommodations. <BR/>The facility failed to ensure Resident #1 was allowed to use his personal motorized wheelchair during his stay at the facility. <BR/>This failure could place residents at risk for a loss of independence, decreased quality of life, self-worth, and dignity. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 04/15/25, indicated he was a [AGE] year-old male, admitted to the facility on [DATE], and discharged on 02/24/25. His diagnoses included spastic quadriplegic cerebral palsy (a severe form of cerebral palsy that affects all four limbs, leading to paralysis and muscle stiffness), and chronic kidney disease (a long-term condition where the kidneys are damaged and can't filter blood as effectively, leading to a buildup of waste and fluids in the body). <BR/>Record review of Resident #1's MDS assessment, dated 02/21/25, indicated he had a BIMS score of 15, which indicated intact cognition. The assessment indicated he used a motorized wheelchair prior to his admission. He had impairment of one of his upper extremities, and both of his lower extremities. <BR/>During an interview on 04/15/25 at 1:05 PM, the ADON said the facility did not allow the residents to use motorized wheelchairs in the facility. She said this had been in effect since before the current corporate entity took over. She said it has always been this way.<BR/>During an interview on 04/15/25 at 1:18 PM, the <BR/>ADON said Resident #1 had Cerebral Palsy. She said when he admitted to the facility, he used a wheelchair for mobility. She said he had poor trunk control. She said she did not think he was able to move the wheelchair on his own and had to be propelled when he wanted to be moved. She said he required substantial to maximal assistance with mobility. She said a previous administrator disallowed the motorized wheelchairs because of a previous resident that was unsafe with the motorized wheelchair. She said from then on they would allow the residents to use a motorized wheelchair, provided that they were assessed to be safe to use the motorized wheelchair.<BR/>During an interview on 04/15/25 at 2:00 PM, Resident #1 said the facility did not let him use his motorized wheelchair. He said when he arrived, he told the facility that his motorized wheelchair was on the way, and the facility staff did not allow him to use his motorized wheelchair. He said he did not have the strength to move his facility provided wheelchair. He said he did not like having to wait on staff to help him. He said he was used to being independent. He said it felt like they were taking away his independence. He said he was in the facility for about a week. He said he was frustrated about it while he was in the facility. He did not recall who specifically did not allow him to use his motorized wheelchair. <BR/>During an interview on 04/16/25 at 9:43 AM, the ADON said the risk to not allowing residents to use motorized wheelchairs was that residents would have to depend on staff for care and could lose their sense of independence<BR/>During an interview on 04/16/25 at 9:56 AM, RNC A said she expected the facility to allow the resident to use his motorized wheelchair. She said they required a safety assessment with therapy, and the motorized wheelchair should be in working condition. She said the facility was under the impression they did not allow wheelchairs from an administrator about 4 administrators ago. She said not allowing a resident to use their motorized wheelchair could affect their dignity and diminish their sense of independence.<BR/>During an interview on 04/16/25 at 10:14 AM, the Administrator said she was not working in the facility during Resident #1's stay. She said she expected the staff to allow the motorized wheelchair as long as they are assessed by the therapy department, and were found to be safe. She said the risk was that it was possible the resident could feel isolated from the building, socialization, and activities if they were not allowed to use their motorized wheelchair.<BR/>Record review of the facility's undated policy, Resident Rights, stated:<BR/>The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy.<BR/>A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident .<BR/> .Respect and dignity - The resident has a right to be treated with respect and dignity, including: .<BR/> .2. The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.<BR/>3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents .<BR/>Record review of the facility's policy, Electric or Motorized Wheelchair, last revised 02/27/15, stated:<BR/> .A Medicaid and Medicare certified [Nursing Facility] must not discriminate on the basis of disability. A nursing facility that denies access and service to a potential resident may be found in noncompliance with state rules and federal regulations. <BR/>It is out policy to ensure, to the best of our ability, the safety of residents who own and use an electric wheelchair, as well as the safety of all other resident's, staff and visitors in the facility. Therefore, resident's owning/using an electric wheelchair will be assessed on admission, quarterly and upon a significant change of condition for their ability to guide/drive the wheelchair .<BR/> .The facility should allow a resident to store the power mobility device in the resident's room if there are no Life Safety Codes concerns, such as blocking or limiting egress .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Residents #23 and #33) reviewed for Medicare/Medicaid coverage. <BR/>The facility failed to ensure Resident #23 and #33 was given a SNF ABN (is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case) when discharged from skilled services at the facility at least 2 days prior covered days being exhausted.<BR/>The facility failed to ensure Resident #23 and #33 was given a NOMNC (is a notice that indicates when your care is set to end from a home health agency (HHA), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF), or hospice) when discharged from skilled services at the facility at least 2 days prior covered days being exhausted.<BR/>These failures could place residents at risk for not being aware of changes to provided services.<BR/>Findings included: <BR/>1. Record review of a face sheet, dated 09/13/23, indicated Resident #23 was a [AGE] year-old female and admitted on [DATE], with a readmission on [DATE], with diagnoses including heart failure (is a condition that develops when your heart doesn't pump enough blood for your body's needs), type 2 diabetes (is a disease in which your blood glucose, or blood sugar, levels are too high), anemia (a condition in which the blood doesn't have enough healthy red blood cells), and acute respiratory failure (occurs when the lungs can't release enough oxygen into your blood) with hypoxia (is low levels of oxygen in your body tissues). <BR/>Record review of a quarterly MDS assessment, dated 08/24/23, indicated Resident #23 was understood and understood others. The MDS indicated Resident #23 had a BIMS score of 12, which indicated moderately impaired cognition and required limited assistance for bed mobility, transfer, and dressing, extensive assistance for toilet use, personal hygiene, and total dependence for bathing. <BR/>Record review of the SNF Beneficiary Protection Notification Review indicated Resident #23 received Medicare Part A Skilled Services on 06/10/23 and last covered day of Part A service was 08/11/23. The SNF Beneficiary Protection Notification Review indicated the facility/provider initiated the discharge from Medicare Part A Services when days were not exhausted on 08/10/23. <BR/>Record review of Resident #23's NOMNC, indicated the effective date coverage of the current skilled nursing services ended on 08/11/23. The NOMNC indicated Resident #23 signed the form on 08/10/23 and verbal notification was provided to a family member. The NOMNC was not delivered at least two calendar days before Medicare covered services ended.<BR/>Record review of Resident #23's SNF ABN, indicated beginning of 08/12/23, Resident #23 may have to pay out of pocket for care if she did not have other insurance that may cover these costs. The SNF ABN indicated the care, reason Medicare may not pay, and estimated cost was not applicable. The SNF ABN did not indicated which option Resident #23 chose. The SNF ABN indicated Resident #23 signed the form on 08/10/23. <BR/>Record review of the resident roster provided on 09/13/23 indicated Resident #23 was discharged and unable to be interviewed regarding the ABN and NOMNC forms. <BR/>2. Record review of a face sheet, dated 09/13/23, indicated Resident #33 was a [AGE] year-old female and admitted [DATE], with a readmission on [DATE], with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), hydronephrosis (is swelling of one or both kidneys), and acute kidney failure (A condition in which the kidneys suddenly can't filter waste from the blood).<BR/>Record review of a Medicare Part A 5 day MDS assessment, dated 08/17/23, indicated Resident #33 was sometimes understood and sometimes understood others. The MDS indicated Resident #33 had a BIMS score of 02, which indicated severe cognitive impairment and required limited assistance for dressing, extensive assistance for bed mobility, transfer, toilet use, personal hygiene, and bathing. <BR/>Record review of the SNF Beneficiary Protection Notification Review indicated Resident #33 received Medicare Part A Skilled Services on 07/21/23 and last covered day of Part A service was 08/30/23. The SNF Beneficiary Protection Notification Review indicated the facility/provider initiated the discharge from Medicare Part A Services when days were not exhausted on 08/30/23.<BR/>Record review of Resident #33's NOMNC, indicated the effective date coverage of the current skilled nursing services ended on 08/30/23. The NOMNC indicated Resident #33's family member was verbal notified on 08/30/23. The NOMNC was not delivered at least two calendar days before Medicare covered services ended.<BR/>Record review of Resident #33's SNF ABN, indicated beginning of 08/31/23, Resident #33 may have to pay out of pocket for care if she did not have other insurance that may cover these costs. The SNF ABN indicated the care, reason Medicare may not pay, and estimated cost was not applicable. The SNF ABN did not indicated which option Resident #33 or resident representative chose. The SNF ABN indicated Resident #33's family member was verbally notified on 08/30/23.<BR/>During an interview on 09/13/23 at 3:15 p.m., the MDS Coordinator H said she had worked at the facility for almost 2 years. She said she had been doing MDS assessments for about 6 years. The MDS Coordinator H said NOMNC's, and ABNs are issued because if they had remaining benefit days, then they notify, because the patient was no longer medically necessary to remain on Medicare benefits. She said she was supposed to give 72 hours' notice and said Resident #33 was not given 72 hours' notice. She said it was her fault as to why it was not issued within the 72 hours timeframe. She said on Resident #23, she just did not call them when she initially planned to call them. She said the process was typically discussed with the Interdisciplinary Team and then she called the family and issued the NOMNC but said on those 2 residents she should have called sooner. She said the ADM, BOM and DON oversaw the process to ensure timely notification. She said she had a corporate consultant that in serviced her often. She said ABNs and NOMNCs should be issued 72 hours before benefits ended, to give the resident time to apply for an appeal. She said the residents could have a change in condition that they would need those skilled days for. The MDS Coordinator H said it could also cost the resident financially if the ABN notice was not given timely.<BR/>During an interview on 09/13/23 at 5:00 p.m., the ADM said MDS coordinator H was responsible for issuing NOMNC's and ABNs to Resident #23 and Resident #33. She said the residents should be issued NOMNC's and ABNs within 72 hours of skilled services ending. The ADM said the forms should have been issued if the resident had skilled benefit days remaining and was being discharged from Part A services and would continue living in the facility. The ADM said it was important for the residents to receive the completed forms so they could make an informed decision, in case they wanted to appeal, and they would know if they had days remaining on their benefit. The ADM said she was responsible to oversee the process, but MDS Coordinator H was normally good about completing the process correctly. She said not following the process correctly could cost the resident and facility financially. <BR/>Record review a facility Healthcare Policy and Procedure SNF ABN dated 04/30/18, indicated facilities will follow the instructions per CMS .a SNF ABN is evidence of beneficiary knowledge about the likelihood of a Medicare denial, for the purpose of determining financial liability for expenses incurred for extended care items or services furnished to a beneficiary and for which Medicare does not pay .a SNF ABN must be given to the beneficiary in order to transfer financial liability for the item or services .<BR/>Record review of CMS guidelines Beneficiary Notice Guidelines, approved by CMS-10124-DENC December 31, 2011, indicated Scenario Part A stay will end because: SNF (Skilled Nursing Facility) determines the beneficiary no longer requires daily skilled services. Resident has days remaining in the benefit period. Resident will remain in the facility (custodial care) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) CMS-10055 (2018) and Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (12/31/11)) to be completed .delivered to the resident with at least 2 days' notice even if he/she agrees with the notice/decision. <BR/> <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 12 residents (Resident # 64, Resident #6, and Resident #54) reviewed for comprehensive person-centered care plans.<BR/>1.The facility failed to develop a care plan for Resident # 64's diagnosis of post-traumatic stress disorder (PTSD).<BR/>2.The facility failed to implement the care plan intervention to document Resident #6 meal intake.<BR/>3.The facility failed to update Resident #54's from at risk for falls to actual fall on his care plan.<BR/>4.The facility failed to update Resident #54's fall care plan interventions.<BR/>Findings included:<BR/>1.Record review of a face sheet dated 09/12/2023, indicated Resident #64 was a [AGE] year-old female admitted on [DATE] with the diagnoses of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), PTSD (a real disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), and congestive heart failure ( a long-term condition in which your heart can't pump blood well enough to meet your body's needs).<BR/>Record review of the quarterly MDS dated [DATE] indicated, Resident #64 had a BIMS of 14, which indicated little to no memory impairment. Resident #64 was coded as being understood and understanding others, Resident #64 was coded for feeling down, depressed/hopeless daily, trouble falling or staying asleep for 7 to 11 days, and feeling tired for 7-11 days. Resident #64 had a diagnosis of PTSD.<BR/>Record review of the care plan dated 08/20/2023 revealed no care plan for PTSD.<BR/>During an interview on 09/13/2023 at 1:15 p.m., the social service director (SSD) stated she was aware Resident #64 had a diagnosis of PTSD. The SSD stated Resident #64 was seen by the counseling services that visited the facility for her PTSD. The SSD stated Resident #64 should have a care plan for PTSD with the services provided by the facility as interventions. The SSD stated it was the responsibility of the MDS Coordinators to develop and implement the care plans related to diagnosis and MDS triggers.<BR/>During an interview on 09/13/2023 at 2:00 p.m., MDS Coordinator BB stated there was no care plan created for PTSD for Resident #64. MDS Coordinator BB stated all Care Area Assessments, diagnoses, and medications were care planned by the MDS Coordinators assigned to them. MDS Coordinator BB stated she was unsure how Resident #64's PTSD diagnosis was missed. MDS Coordinator BB was assigned to Resident #64.<BR/>During an interview on 09/13/2023 at 2:30 p.m., the DON stated she expected the MDS Coordinator's to address all diagnosis in the care plan. The DON stated Resident #64 had the diagnosis of PTSD since she was admitted in 2021 and it should not have been missed for that long. The DON stated the care plan was used to guide the care for each resident and not care planning a diagnosis can affect the type of care the resident received.<BR/>During an interview on 09/13/2023 at 3:00 p.m., the Administrator stated that the MDS Coordinator or the SSD should have care planned Resident #64's diagnosis of PTSD to show the facility was aware and was treating the resident for her PTSD.<BR/>2. Record review of a face sheet, dated 09/12/23, indicated Resident #6 was [AGE] year-old female and admitted on [DATE] with diagnoses including Type 2 diabetes (is a disease in which your blood glucose, or blood sugar, levels are too high), chronic kidney disease, stage 4 (the kidneys are moderately or severely damaged and are not working as well as they should to filter waste from your blood), cerebrovascular disease (refers to a group of disorders that affect the blood vessels and blood supply to the brain), and hypothyroidism (the thyroid gland can't make enough thyroid hormone to keep the body running normally). <BR/>Record review of an admission MDS assessment, dated 08/25/23, indicated Resident #6 was understood and understood others. The MDS indicated Resident #6 had a BIMS score of 11 which indicated moderately cognitive impairment and was independent for eating. The MDS assessment did not indicated Resident #6 had weight loss.<BR/>Record review of the care plan dated 08/23/23, with revision on 09/01/23, indicated Resident #6 had a diet order other than regular and is at risk for unplanned weight loss or gain. Intervention included encourage meal completion and document amount consumed, offer sub, if resident eats less than 50% or dislikes meal and offer supplement if residents continue to eat less than 50%. <BR/>Record review of Resident #6's Amount Eaten report ran on 09/13/23 for the last 20 days indicated no meal intake amount for:<BR/>*08/25/23: 9:00 am, 1:00 pm<BR/>*08/26/23: 9:00 am, 1:00 pm <BR/>*08/27/23: 9:00 am, 1:00 pm<BR/>*08/28/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>*08/29/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>*08/30/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>*08/31/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>*09/01/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>*09/02/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>*09/03/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>*09/04/23: 9:00 am, 1:00 pm<BR/>*09/05/23: 9:00 am, 1:00 pm<BR/>*09/06/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>*09/07/23: 6:00 pm<BR/>*09/08/23: 9:00 am, 1:00 pm<BR/>*09/09/23: 9:00 am, 1:00 pm<BR/>*09/10/23: 9:00 am, 1:00 pm<BR/>*09/11/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>*09/12/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>Record review of Resident #6's weight record indicated:<BR/>*09/13/23 134 lbs. <BR/>*08/22/23 143.5 lbs.<BR/>During an interview and observation on 09/11/23 at 1:59 p.m., Resident #6 said she was admitted into the nursing home due to heart valve issues. She said she was trying to gain her strength so she could have heart surgery. Resident #6 said she did not care for the food, but she was a picky eater. She said occasionally a family brought her breakfast. On Resident #6's bedside table was an uneaten peanut butter and honey sandwich. Resident #6 said she did not eat much of lunch and gets sandwiches as a substitute. <BR/>During an interview and observation on 09/12/23 at 5:15 p.m., Resident #6 said she did not eat a lot today. She said her family had not brought her breakfast today. Resident #6 had 2 peanut butter and honey sandwiches on her bedside table. <BR/>During an interview and observation on 09/13/23 at 8:00 a.m., Resident #6 breakfast tray had 0-25% eaten. On Resident #6's breakfast tray was an unopen house supplement. She said she the house supplement tasted too sweet but if it had protein, she would start drinking them. She said she did not care for what was served for breakfast, but a family member was bringing her some food. <BR/>During an interview on 09/13/21 at 3:53 p.m., LVN F said she was assigned to Resident #6. She said the CNAs were responsible for documenting the amount the residents consumed. LVN F said all nursing staff had access to a resident's care plan. She said LVNs should ensure the CNAs documented the intake amounts. LVN F said LVNs should check the resident intake record before the end of the shift to ensure CNAs documented. She said CNAs should document 3 meals a day in the electronic charting system. LVN F said it was important to document meal intake amounts to monitor residents with poor intake or appetite as indicated by the care plan intervention. She said it could negatively affect the resident due to unknown significant weight loss or not presenting an adequate information for the nutritionist or doctor. LVN F said Resident #6 had a care plan problem for being at risk for weight loss and following the interventions were important. <BR/>During an interview on 09/13/23 at 4:35 p.m., SCNA G said she had worked at the facility in different departments but had been a SCNA for a couple of months. She said she worked the hall Resident #6 was on. SCNA G said she charted resident's amount eaten in the electronic charting system. She said CNAs were supposed to chart after every meal the percentage the resident ate. SCNA G said the LVNs were supposed to make sure CNAs documented intake amounts on residents. She said CNAs had access to the care plan problem and interventions. SCNA G said she could not recall Resident #6's intervention for her being at risk for unplanned weight loss. She said reviewing the interventions was important to know what the resident was supposed to have. She said it was important to chart the resident's intake amounts to know if they were not eating, tell if something was wrong, and know why the resident lost weight. SCNA G said not documenting meal intakes did not let the dietician know the resident's real intake amounts. She said if you did not know or follow the care plan interventions then residents could not get want, they needed. <BR/>During an interview on 09/13/23 at 4:40 p.m., the DON said she had been at the facility for 2 years. She said all nursing staff had access to view a resident's care plan. She said the CNAs were responsible for documenting the amount the residents consumed. The DON said LVNs should ensure the CNAs documented the intake amounts after every meal which was three times a day. She said following the care plan intervention to document meal intake amounts was important to know how much a resident ate, could indicate a change of condition, and it help monitor for weight loss. The DON said missed meal intake amounts would not paint a complete picture of the resident and the dietician would not have correct information to make accurate dietary recommendations. She said nursing administration should be doing random chart audits to ensure CNAs and LVNs were doing their responsibilities. The DON said the facility did not have a policy related to nutrition. the DON said she was responsible for the fall care plans. She said the fall care plans were normally updated 24-48 hours after an event or with assessments. The DON said it was important to have an updated or revised care plan because it was the resident's plan of care and to know what needed to be done to keep the resident safe. She said not updating a fall care plan placed residents at risk for falls and possible injury.<BR/>During an interview on 09/13/23 at 5:01 p.m., the ADM said CNAs or LVNs, whoever fed the resident was responsible for documenting meal intakes. She said the charge nurse at the end of the shift should review the chart to ensure charting was completed. The ADM said documentation of meal consumption should happen after every meal. She said the care plan interventions should be followed by all staff. The ADM said nursing staff had access to the care plan, but only certain staff members could update and revise it. She said if the intervention of documenting meal consumption was important because you would not know why the resident was lost weight, needed to obtain, or update resident's dislikes, likes, or preferences. The ADM said corporate ran reports on the percentage of electronic charting system entry. She said ADON L oversaw the process.<BR/>3. Record review of a face sheet dated 09/12/23 indicated Resident #54 was an [AGE] year-old male and admitted on [DATE], with a readmission on [DATE], with diagnoses including Alzheimer's disease with late onset (a progressive disease that destroys memory and other important mental functions), Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), insomnia (persistent problems falling and staying asleep), and pain. <BR/>Record review of a significant change MDS assessment, dated 08/31/23, indicated Resident #54 was understood and understood others. The MDS indicated Resident #54 had a BIMS score of 02 which indicated severe cognitive impairment and required extensive assistance for bed mobility, dressing, eating, toilet use, personal hygiene, and total dependence for transfer and bathing. The MDS indicated Resident #54 was not steady, only able to stabilize with staff assistance for surface-to-surface transfer (transfer between bed and chair or wheelchair). The MDS indicated Resident #54 used a wheelchair for a mobility device. The MDS indicated Resident #54 had a one fall since admission/entry or reentry or prior assessment with no injury. <BR/>Record review of Resident #54's fall event note, completed by RN K, dated 08/31/23 indicated an unwitnessed fall in the resident's room. Resident #54 was found lying on the floor at bedside. No injuries observed, Resident #54 denied pain. The fall event note indicated low bed was an intervention placed prior to this fall. The fall event note indicated additional interventions initiated in response to fall were floor mat and low bed.<BR/>Record review of a care plan dated 04/11/23, with revision date 06/11/23, indicated Resident #54 was at risk for falls due to confusion with gait and balance problems, and poor safety awareness. Intervention included anticipate and meet needs, be sure call light within reach and encourage to use it for assistance as needed, ensure resident wearing appropriate footwear when ambulating or mobilizing in wheelchair, and staff x2 assist with transfers (09/09/23). The care plan did not indicate added intervention of low bed and floor mat. The care plan did not indicate actual fall instead of at risk of falls. <BR/>During an observation on 09/11/23 at 2:06 p.m., Resident #54 was lying in bed with a hospital gown and 2 liters nasal cannula around his ears but not in his nose. Resident #54 had a fall mat beside his bed. <BR/>During an observation on 09/12/23 at 3:10 p.m., Resident #54 was lying in bed dressed in personal clothing and 2 liters nasal cannula in place. Resident #54 had a fall mat and low bed. <BR/>During an interview on 09/13/23 at 3:53 p.m., LVN F said Resident #54 had a fall on 08/31/23. She said she did not know for sure what Resident #54's fall interventions were without looking at the care plan. LVN F said Resident #54 did have fall mat and low bed. She said those intervention should be added to the care plan. LVN F said the DON updated care plans. She said care plan should be updated to reflect the current care the resident required. LVN F said a fall care plan that was not updated placed residents at risk for falls or not knowing when an intervention started to know if it worked. <BR/>During an interview on 09/13/23 at 4:35 p.m., SCNA G said CNAs had access to the care plan problem and interventions. She said Resident #54 had a fall mat and low bed. SCNA G said she did not know if those interventions were on the care plan. She said reviewing the interventions was important to know what the resident was supposed to have. SCNA G said if staff did not know the new interventions, residents could not get what they needed. She said not knowing the new intervention placed the resident at risk for falls and injuries. <BR/>During an interview on 09/13/23 at 4:40 p.m., the DON said she was responsible for the fall care plans. She said the fall care plans were normally updated 24-48 hours after an event or with assessments. The DON said it was important to have an updated or revised care plan because it was the resident's plan of care and to know what needed to be done to keep the resident safe. She said not updating a fall care plan placed residents at risk for falls and possible injury. <BR/>During an interview on 09/13/23 at 5:01 p.m. the ADM said she and the DON updated and revised care plans. She said updated or revised care plan interventions were important to ensure all current interventions were in place, determine if current interventions were working, and know if interventions needed to be added. The ADM said it could affect a resident's quality of care and new staff would not know how to care for the resident. She said the residents were at risk for getting hurt. <BR/>Record review of an undated facility's Comprehensive Care Planning policy indicated .they will develop and implement a comprehensive person-centered care plan for each resident .the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain grooming and personal hygiene for 3 of 19 residents reviewed for ADLs. (Resident #'s 7, 17, and 34)<BR/>The facility failed to provide assistance with facial hair removal for Resident #'s 7 and 34.<BR/>The facility failed to ensure Resident #17 was routinely showered.<BR/>The facility failed to ensure Resident #7's fingernails were cleaned and trimmed. <BR/>The facility failed to ensure Resident #7's teeth were brushed.<BR/>The facilty did not provide Resident #34 timely incontinent care. Resident #34 was found heavily saturated in urine with three brown colored rings on the linen. <BR/>These failures could place residents who were dependent of staff to perform personal hygiene at risk for embarrassment, decreased self-esteem, or decreased quality of life.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 7/26/2022 indicated Resident #7 was a [AGE] year-old female admitted on [DATE] with the diagnoses of Parkinson's disease (disease causing tremors), muscle weakness, and chronic pain.<BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #7 was understood and understands others. The MDS indicated Resident #7's BIMS score was 15 indicating no cognitive deficit. The MDS indicated Resident #7 required extensive assistance of one staff for her personal hygiene (Personal hygiene according to the MDS was combing hair, brushing teeth, shaving, apply makeup, washing/drying face and hands).<BR/>. <BR/>Record review of a comprehensive care plan with review date of 5/12/2022 indicated Resident #7 had an ADL self-care performance deficit. The goal was Resident #7 would maintain or improve her current level of function in personal hygiene. The approach included assisting with personal hygiene as required: hair, shaving, and oral care as needed. During bathing, to check nail length and clean on bath day and as necessary. If the resident was a diabetic, the nurse will provide toenail care. <BR/>Record review of a bath sheet indicated Resident #7 received a bed bath on 7/1/2022, 7/4/2022, 7/6/2022, 7//8/2022, 7/11/2022, 7/15/2022, 7/18/2022, 7/20/2022, and 7/25/2022. Resident #7 did not receive her bath on 7/13/2022 and 7/22/2022. Resident #7's shower days were Monday, Wednesday and Friday on 2:00 p.m. to 10:00 p.m. shift.<BR/>During an observation on 7/25/2022 at 10:16 a.m., Resident #7 had white facial hair to the left side of her chin &frac12; inch in length. Resident #7's fingernails were a half inch long with a brown colored material underneath them.<BR/>During an observation and interview on 7/26/2022 at 8:31 a.m., Resident #7 continued to have white facial hair to the left side to her chin measuring &frac12; inch in length. Resident #7's fingernails continued to be long with a brown colored material underneath them. Resident #7 said her teeth have not been brushed and she did not have a bath yesterday. Resident #7 said she felt dirty. Resident #7 said she had not had a shower in a month.<BR/>During an interview on 7/26/2022 at 10:17 a.m., CNA B indicated the nurse aides were responsible for ADLs. CNA B indicated ADLs included bathing, brushing teeth, shaving, and cleaning fingernails. <BR/>2. Record review of a face sheet dated 7/26/2022 indicated Resident #17 was an [AGE] year-old female admitted on [DATE] with the diagnoses of Alzheimer's dementia (a memory disease), depression and Bipolar disorder (a mood mental illness).<BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #17's BIMS Score was a 14 indicating intact cognition. The MDS indicated Resident #17 required physical of one staff member to assist with the transfer only for bathing.<BR/>Record review of a comprehensive care plan last reviewed/revised on 7/26/2022 indicated Resident #17 had an ADL self-care performance deficit. The care plan indicated the goal was to maintain or improve Resident #17's current function with the assistance of one staff with bathing. <BR/>Record review of the undated shower schedule indicated the right side of a hall was Monday-Wednesday-Friday and the left side of the hall was Tuesday-Thursday-Saturday. The shower schedule also indicated (A) bed received their shower on 6:00 a.m.- 2:00 p.m. shift and (B) bed received their showers on 2:00 p.m. to 6:00 a.m. Resident #17's room was on the right side of the hall in the A bed.<BR/>Record review of the computerized bathing tasks sheet dated 7/26/2022 indicated from July 1, 2022 through July 25, 2022 Resident #17 had 11 opportunities for bathing and it was documented she received 6 showers. Resident #17's shower days were Monday, Wednesday and Friday on 6:00 a.m. to 2:00 p.m. The coded reason for no shower was the activity did not occur.<BR/>During an interview on 7/25/2022 at 10:29 a.m., Resident #17 voiced it had been almost a week since she had a shower. She indicated today was her shower day.<BR/>During an interview on 7/26/2022 at 8:20 a.m., Resident #17 said she did not receive a bath yesterday. Resident #17 said no one even offered. Resident #17 indicated not receiving her bathes hurts her self-esteem and she feels neglected. Resident #17 said she did not have an issue with African American females providing care for her.<BR/>During an interview on 7/26/2022 at 8:25 a.m., CNA B indicated Resident #17 does not prefer African American CNAs to provide care this is why she does not provide Resident #17 a shower. CNA B said CNA D bathes Resident #17. <BR/>During an interview on 7/26/2022 at 11:17 a.m., CNA D indicated the last time she bathed Resident #17 was the previous Wednesday July 20, 2022.<BR/>During an interview on 7/26/2022 at 3:00 p.m., Resident #17 said she did not have a preference on African American CNAs bathing her.<BR/>During an interview on 7/27/2022 at 8:14 a.m., Resident #17 indicated she had not had a shower.<BR/>During an interview on 7/27/2022 at 12:50 p.m., Resident #17 indicated she had not had a bath yet today.<BR/>During an interview on 7/27/2022 at 1:35 p.m., the Corporate nurse indicated she would ensure Resident #17 was showered. <BR/>3Record review of a face sheet dated 7/27/2022 indicated Resident #34 was a [AGE] year-old female admitted on [DATE] and readmitted [DATE] with the diagnoses of heart failure, depressive disorder, and anxiety.<BR/>Record review of an admission MDS dated [DATE] indicated Resident #34 understands and was understood. The MDS indicated she required no cueing with recall and her BIMS score was 13 indicating intact cognition. The MDS indicated nearly every day she felt down, depressed, and hopeless. The MDS indicated Resident #34 was always incontinent of urine and required limited assistance of one staff with toileting.<BR/>Record review of a comprehensive care plan dated 7/25/2022 indicated Resident #34 had an ADL self-care deficit with a goal of maintaining or improvement in the current level of function. The interventions were to assist with toileting use. The interventions were to assist with personal hygiene as required including hair, shaving, and oral care.<BR/>Record review of a computerized bath task sheet dated July,2022, Resident #34 received 9 out of the 11 baths scheduled. Resident #34 was marked as activity did not occur on 7/13/2022 and 7/22/2022. Resident #34's shower days were Monday, Wednesday, and Friday on the 2:00 p.m. to 10:00 p.m. shift.<BR/>During an observation and interview on 7/25/2022 at 10:03 a.m., Resident #34 had short white facial hairs &frac14; inches long covering her entire chin. Resident #34 said she did not like having facial hair.<BR/>During an observation on 7/26/2022 at 8:13 a.m., Resident #34 pulled back her top linen and exposed she was lying on urine that had started drying and left behind a brown colored ring.<BR/>During an interview on 7/26/2022 at 11:29 a.m., CNA C indicated she provided Resident #'s 7 and #34 a bed bath the night before. CNA C indicated she did not clean Resident #7's fingernails nor did she remove her facial hair. CNA C indicated she did not remove Resident #34's facial hair. CNA C indicated she should have provided this care. CNA C indicated dirty fingernails and facial hair on a woman could affect their self-esteem. CNA C indicated she should have provided the nail care and provide shaving.<BR/>During an observation and interview on 7/26/2022 at 11:40 a.m., Resident #34 pulled back the linen on the left side of her bed. She revealed she was lying on a draw sheet with a visible brown ring. As Resident #34 turned over in her bed, the bottom sheet had two distinct brown rings of various stages of dried urine. Resident #34 indicated she had not been changed since early this morning. <BR/>During an observation and interview on 7/26/2022 at 11:50 a.m., Resident #34 revealed to LVN A the saturation of urine she was lying in. LVN A said she expected the CNAs to change the residents at frequent intervals. LVN A indicated she was in charge of Resident #34's care. LVN A said Resident #34 could have skin problems and dignity issues from being left in urine. LVN A indicated the CNAs were responsible for ADLs. LVN A indicated the nurse was responsible for ensuring ADLs were completed. LVN A said she expected the CNAs to complete the ADLs as scheduled. LVN A indicated not being bathed, shaved, and nail clean could lead to skin issues and dignity issues.<BR/>During an interview on 7/26/2022 at 2:15 p.m., CNAs B and E indicated they have been working short staffed today. CNAs B and E indicated they had been assigned to assist on other halls today including B-Hall. CNAs B and E indicated they had not had the time to change everyone on B-Hall including Resident #34. CNA B and E indicated Resident #34 should be assisted with incontinent care every two hours. CNA E indicated the residents should be shaved, nails cleaned, and teeth brushed every day. CNA E indicated she tried every day she works to complete the tasks but due to staff shortages the workload was too much to complete all the tasks.<BR/>During an interview on 7/27/2022 at 3:39 p.m., the Corporate DON indicated ideally the brown rings of urine should not happen. The Corporate DON indicated Resident #34 should have been changed timelier to prevent the brown rings. The Corporate DON indicated all nursing was responsible for ensuring a resident had timely incontinent care even she could change a resident. The Corporate DON indicated incontinent care was monitored with random rounds and failure to complete incontinent care timely could lead to dignity, health, and skin issues. The Corporate nurse indicated she expected the showers to be completed as scheduled. The Corporate nurse indicated she expected shaving to occur during bath days or as needed. She indicated she expected the resident's teeth to be brushed at least morning and night. The Corporate nurse indicated the lack of ADLs affects the resident's quality of life and dignity. The Corporate nurse indicated the nursing management was responsible for ensuring ADL compliance. The Corporate nurse indicated anyone could provide ADLs to these residents including herself.<BR/>During an interview on 7/27/2022 at 4:03 p.m., the Administrator indicated her expectation was that incontinent care was provided every 2 hours or as needed. The Administrator indicated the charge nurses were responsible to ensure incontinent care was provided timely. The Administrator indicated provision of incontinent care was monitored with every two-hour round, Champion rounds (rounds made by assigned management), and ADL documentation. The Administrator indicated the resident could have issues with dignity, skin break down and infections related to untimely incontinent care. An incontinent care policy was requested but not provided. The Administrator indicated she expected the residents to be bathed and shaved at least three times weekly. She indicated she expected oral care at least two times daily. The Administrator indicated due to the staffing challenges with numerous positions open she asked the residents to be flexible with bathing on the day shift when the facility was better staffed. The Administrator indicated the second shift after 5:00 p.m. were limited on staffing. <BR/>Record review of a Bath, Tub/Shower policy dated 2003 indicated bathing by tub bath or shower was done to remove soil, dead epithelial cells, microorganisms from the skin and body odor to promote comfort cleanliness, circulation, and relation. The goals were the resident would experience improved comfort and cleanliness by bathing.<BR/>Record review of a Shaving Policy dated 2003 indicated shaving of the male resident could be performed with an electric or safety razor. It is usually done as a part of daily personal hygiene, although every other day is sufficient for some based on the beard growth. Shaving is done to promote cleanliness and positive body image. <BR/>Record review of Teeth care/Oral hygiene policy dated 2003 oral and teeth care was the removal of soft plaque and food particles, bacteria, and odors to promote physical and psychological comfort. The resident will receive mouth care at least daily.<BR/>Record review of a Nail Care policy dated 2003 indicated nail management was the regular care of the toenails and fingernails to promote cleanliness and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 2 (Resident #54) residents reviewed for non-pressure wounds.<BR/>The facility failed to treat Resident #54's non-pressure wound (is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection) of the left buttock after readmission for 2 days.<BR/>This failure could place residents of risk for not receiving appropriate care and treatment.<BR/>Findings included:<BR/>Record review of a face sheet dated 09/12/23 indicated Resident #54 was a [AGE] year-old male and admitted on [DATE], with a readmission on [DATE], with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose). <BR/>Record review of a significant change MDS assessment, dated 08/31/23, indicated Resident #54 was understood and understood others. The MDS indicated Resident #54 had a BIMS score of 02 which indicated severe cognitive impairment and required extensive assistance for bed mobility, dressing, eating, toilet use, personal hygiene, and total dependence for transfer and bathing. The MDS indicated Resident #54 had two, stage 2 unhealed pressure ulcers/injuries (there is partial-thickness skin loss involving the epidermis (is the thin, outer layer of the skin that is visible to the eye and works to provide protection for the body) and dermis (is the layer of skin that lies beneath the epidermis and above the subcutaneous layer)), 1 unstageable, and Moisture Associated Skin Damage (is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection). The MDS indicated Resident #54 received pressure reducing device in bed, pressure ulcer/injury care, and applications of ointments/medications for skin and ulcer/injury treatments.<BR/>Record review of a care plan dated 04/11/23, with revision date on 08/29/23, indicated Resident #54 had a non-pressure wound of the left buttock and unstageable wound of the right buttock. Interventions included administer treatments as ordered and monitor effectiveness, follow facility policies/protocols for the prevention/treatment of skin breakdown, monitor nutritional status, serve diet as ordered, monitor intake and record.<BR/>Record review of Resident #54 's admission notes, completed by RN K, dated 08/26/23 indicated Resident #54 recent admission was 08/26/23 at 8:10 p.m. from the hospital.<BR/>Record review of the initial skin assessment dated [DATE], signed by RN K on 08/28/23, indicated Resident #54 had scattered bruising to right arm related to lab draws, no MASD, and wound to bottom. The initial skin assessment did not reveal wound measurement or staging. <BR/>Record review of Resident #54's progress note, dated 08/28/23 at 6:29 p.m., completed by ADON J indicated .this nurse summoned to room, incontinent care provided, upon assessment . MASD to left buttock: cleanse with normal saline, pat to dry and apply zinc every day and night shift to promote wound healing .<BR/>Record review of Resident #54's progress note, dated 08/28/23 at 6:38 p.m., completed by ADON J indicated .MASD to the left buttock measuring 3cm x 2.5cm area is blanchable (is a term used to describe skin that remains white or pale for longer than normal when pressed. This indicates that normal blood flow to a given area does not return promptly) . <BR/>Record review of Resident #54's consolidated physician order dated 08/29/23 indicated non-pressure wound of the left buttock: cleanse with normal saline, pat to dry and apply zinc every day and night shift to promote wound healing. <BR/>Record review of Resident #54's WAR dated 08/1/23-08/31/23 indicated MASD to left buttock: cleanse with normal saline, pat to dry and apply zinc every day and night shift to promote wound healing was started 08/28/23 by ADON J. <BR/>During an attempted to contact RN J on 09/13/23 at 3:45 p.m., unable to leave voicemail due to mailbox being full. <BR/>During an interview on 09/13/23 at 3:53 p.m., LVN F said the admission nurse was responsible for doing the first dressing change and getting measurements. She said residents in A bed with wounds were changed on day shift and B bed were night shift. LVN F said the facility had standing wound care orders to initiate. She said the wound care orders had to be placed in the facility's electronic charting system. LVN F said dressing changes and wound care should be documented in the electronic charting system to show it has been done and how the resident tolerated the procedure. She said not immediately providing wound care could cause the pressure ulcer to get worse. LVN F said it could cause the resident to get an infection, decrease their appetite, or death. <BR/>During an interview on 09/13/23 at 4:40 p.m., the DON said she had been at the facility for 2 years. The DON said the admission nurse should provide the wound care to the resident on admission or readmission. She said the admission nurse should follow the hospital wound care orders, if they had any or call the resident's doctor to get new orders. The DON said weekend admission followed the same process for wound care. She said the facility did not have designated Treatment nurse and LVNs were responsible for their resident's wounds and dressing changes. She said not doing wound care placed resident at risk for infection or deterioration of the pressure ulcer or wound. The DON said this could lead to rehospitalization or decline in health. <BR/>During an interview on 09/13/23 at 5:01 p.m., The ADM said the charge nurses were responsible for wound care dressings changes. She said ADON J was responsible for ensuring the wound care orders were accurate. The ADM said ADON J was unable to be interviewed due to being on vacation. She said not doing timely wound care could cause the wound to deteriorate or get infected. <BR/>Record review of a facility Pressure Injury: Prevention, Assessment and Treatment policy, revised 08/12/16, indicated .early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission .the nurse will determine if prevention and/or treatment of pressure sore(s) is indicated and notify the treatment nursing/ designee of any potential problems .upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee .the treatment nurse/designee will .notify the physician of pressure sore and obtain and follow any orders as directed by the physician .pressure sore identification: Director of nursing or treatment nurse/designee will classify the pressure injury .assessment of the pressure injury should also include the site, size, and W x L x D, of the injury .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents (Resident #54) reviewed for pressure injury.<BR/>The facility failed to treat Resident #54's unstageable sacrum pressure ulcer (is a term that refers to an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar) after readmission for 2 days.<BR/>This failure could place residents at risk for deterioration of wound. <BR/>Findings included:<BR/>Record review of a face sheet dated 09/12/23 indicated Resident #54 was a [AGE] year-old male and admitted on [DATE], with a readmission on [DATE], with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose).<BR/>Record review of a significant change MDS assessment, dated 08/31/23, indicated Resident #54 was understood and understood others. The MDS indicated Resident #54 had a BIMS score of 02 which indicated severe cognitive impairment and required extensive assistance for bed mobility, dressing, eating, toilet use, personal hygiene, and total dependence for transfer and bathing. The MDS indicated Resident #54 had two, stage 2 unhealed pressure ulcers/injuries (there is partial-thickness skin loss involving the epidermis (is the thin, outer layer of the skin that is visible to the eye and works to provide protection for the body) and dermis (is the layer of skin that lies beneath the epidermis and above the subcutaneous layer)), 1 unstageable, and Moisture Associated Skin Damage (is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection). The MDS indicated Resident #54 received pressure reducing device in bed, pressure ulcer/injury care, and applications of ointments/medications for skin and ulcer/injury treatments.<BR/>Record review of a care plan dated 04/11/23, with revision date on 08/29/23, indicated Resident #54 had a non-pressure wound of the left buttock and unstageable wound of the right buttock. Interventions included administer treatments as ordered and monitor effectiveness, follow facility policies/protocols for the prevention/treatment of skin breakdown, monitor nutritional status, serve diet as ordered, monitor intake and record.<BR/>Record review of Resident #54 's admission notes, completed by RN K, dated 08/26/23 indicated Resident #54 recent admission was 08/26/23 at 8:10 p.m. from the hospital.<BR/>Record review of the initial skin assessment dated [DATE], signed by RN K on 08/28/23, indicated Resident #54 had scattered bruising to right arm related to lab draws, no MASD, and wound to bottom. The initial skin assessment did not reveal wound measurement or staging.<BR/>Record review of Resident #54's progress note, dated 08/28/23 at 6:29 p.m., completed by ADON J indicated .this nurse summoned to room, incontinent care provided, upon assessment, black eschar (is a type of necrotic tissue that can develop on severe wounds), necrotic (death of cells or tissue through disease or injury) tissue noted . measuring 2.5 cm (Length) x 2.4 cm (Width) .Dr notified .new orders obtained: unstageable wound of the right buttock: cleanse with normal saline, pat to dry, apply Leptospermum honey, cover with dry dressing every shift to promote wound healing . MASD to left buttock: cleanse with normal saline, pat to dry and apply zinc every day and night shift to promote wound healing .<BR/>Record review of Resident #54's consolidated physician order dated 08/29/23, start date 08/30/23 indicated unstageable wound of the right buttock: cleanse with normal saline, pat to dry, apply Leptospermum honey, cover with dry dressing every shift to promote wound healing. No order to indicate treatment was started on admission date 08/26/23.<BR/>Record review of Resident #54's WAR dated 08/1/23-08/31/23 indicated Unstageable wound of the right buttock: cleanse with normal saline, pat to dry, apply Leptospermum honey, cover with dry dressing every shift to promote wound healing was performed on 08/28/23 by ADON J and 08/29/23 by ADON J.<BR/>Record review of Resident #54's weekly ulcer assessment dated [DATE], completed by ADON J indicated .right buttock .pressure .unstageable .3cm x 1cmx 0.1cm .76-100% necrotic tissue .pressure injury was present on admission .<BR/>During an attempted to contact RN J on 09/13/23 at 3:45 p.m., unable to leave voicemail due to mailbox being full.<BR/>During an interview on 09/13/23 at 3:53 p.m., LVN F said the admission nurse was responsible for doing the first dressing change and getting measurements. She said residents in A bed with wounds were changed on day shift and B bed were night shift. LVN F said the facility had standing wound care orders to initiate. She said the wound care orders had to be placed in the facility's electronic charting system. LVN F said dressing changes and wound care should be documented in the electronic charting system to show it has been done and how the resident tolerated the procedure. She said not immediately providing wound care could cause the pressure ulcer to get worse. LVN F said it could cause the resident to get an infection, decrease their appetite, or death.<BR/>During an interview on 09/13/23 at 4:40 p.m., the DON said the admission nurse should provide the wound care to the resident on admission or readmission. She said the admission nurse should follow the hospital wound care orders, if they had any or call the resident's doctor to get new orders. The DON said weekend admission followed the same process for wound care. She said the facility did not have designated Treatment nurse and LVNs were responsible for their resident's wounds and dressing changes. She said not doing wound care placed resident at risk for infection or deterioration of the pressure ulcer or wound. The DON said this could lead to rehospitalization or decline in health.<BR/>During an interview on 09/13/23 at 5:01 p.m., the ADM said the charge nurses were responsible for wound care dressings changes. She said ADON J was responsible for ensuring the wound care orders were accurate. The ADM said ADON J was unable to be interviewed due to being on vacation. She said not doing timely wound care could cause the wound to deteriorate or get infected.<BR/>Record review of a facility Pressure Injury: Prevention, Assessment and Treatment policy, revised 08/12/16, indicated .early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission .the nurse will determine if prevention and/or treatment of pressure sore(s) is indicated and notify the treatment nursing/ designee of any potential problems .upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee .the treatment nurse/designee will .notify the physician of pressure sore and obtain and follow any orders as directed by the physician .pressure sore identification: Director of nursing or treatment nurse/designee will classify the pressure injury .assessment of the pressure injury should also include the site, size, and W x L x D, of the injury .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 4 residents (Resident #54) reviewed for nutrition/weight loss.<BR/>The facility failed to obtain a readmission weight after Resident #54 readmitted from the hospital on [DATE] per the facility policy.<BR/>The facility failed to consistently document Resident #54's meal intakes.<BR/>These failures could place residents at risk for decreased nutritional and weight status and decline in health.<BR/>Findings included:<BR/>Record review of a face sheet dated 09/12/23 indicated Resident #54 was a [AGE] year-old male and admitted on [DATE], with a readmission on [DATE], with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose).<BR/>Record review of a significant change MDS assessment, dated 08/31/23, indicated Resident #54 was understood and understood others. The MDS indicated Resident #54 had a BIMS score of 02 which indicated severe cognitive impairment and required extensive assistance for bed mobility, dressing, eating, toilet use, personal hygiene, and total dependence for transfer and bathing. The MDS assessment indicated Resident #54 had loss of liquids/solids from mouth when eating or drinking, no significant weight loss, and mechanically altered, therapeutic diet.<BR/>Record review of a care plan dated 04/11/23, with revision date on 09/01/23, indicated Resident #54 had potential risk for malnutrition due to impaired cognition and poor eating habits. Intervention: monitor and document meal intake. <BR/>Record review of Resident #54's discharge summary from a local hospital dated 08/26/23 indicated Resident #54 weighed 186lbs on 08/22/23. <BR/>Record review of Resident #54 's admission notes, completed by RN K, dated 08/26/23 indicated Resident #54 recent admission was 08/26/23 at 8:10 p.m. from the hospital.<BR/>Record review of Resident #54's weight summary dated 09/13/23, indicated on 08/10/2023, the resident weighed 180.5 lbs. On 09/12/2023, the resident weighed 167.5 pounds which is a -7.20 % Loss.<BR/>Record review of Resident #54's progress note dated 09/05/23 at 8:17 p.m., completed by the Dietitian indicated .weights (#): [DATE].5, July 185.2, June 185.5 .staff report usual by mouth intake: 75-100% .nursing stated Resident #54 with good by mouth intake and accepts what is offered .recommendation: continue current plan of care at this time . The Dietitian had Resident #54's pre-hospital weight and did not have a readmission weight or weekly weight x 4 after readmission. <BR/>Record review of Resident #54's amount eaten task report ran on 09/13/23 for the last 20 days indicated no meal percentage documented for:<BR/>*08/29/23: dinner<BR/>*08/30/23: dinner<BR/>*09/04/23: dinner<BR/>*09/05/23: breakfast, lunch, dinner<BR/>*09/06/23: breakfast, lunch, dinner<BR/>*09/07/23: dinner<BR/>*09/08/23: dinner<BR/>*09/09/23: dinner<BR/>*09/10/23: dinner<BR/>*09/11/23: breakfast, lunch, dinner<BR/>During an attempted to contact RN J on 09/13/23 at 3:45 p.m., unable to leave voicemail due to mailbox being full.<BR/>During an interview on 09/13/23 at 3:53 p.m., LVN F said residents had to be weighed on readmission. She said she did not know who was responsible for admission or readmission weights. LVN F went into the DON's office and came back to finish the interview. She said she was informed by the DON the admission nurse had 24-hours after admission to obtain a weight. LVN F said she did not know if the admission nurse had 24-hours to weigh the residents or 24-hours to weigh and document the weight in the chart. LVN F left the interview to verify with DON. LVN F said the admission nurse had 24-hours to weigh and document the weight in the chart per the DON. She said the readmission weight was important to know if the resident lost weight in the hospital. LVN F said Resident #54 did not have a readmission weight. She said without a readmission weight you do not know if there has been a significant change and the dietary recommendations could not be correct and dietary needs could not be addressed. She said the CNAs were responsible for documenting the amount the residents consumed. LVN F said all nursing staff had access to a resident's care plan. She said LVNs should ensure the CNAs documented the intake amounts. LVN F said LVNs should check the resident intake record before the end of the shift to ensure CNAs documented. She said CNAs should document 3 meals a day in the electronic charting system. LVN F said it was important to document meal intake amounts to monitor residents with poor intake or appetite as indicated by the care plan intervention. She said it could negatively affect the resident due to unknown significant weight loss or not presenting an adequate information for the nutritionist or doctor.<BR/>During an interview on 09/13/23 at 4:35 p.m., SCNA G said she had worked at the facility in different departments but had been a SCNA for a couple of months. She said she occasionally worked the hall Resident #54 was on. SCNA G said she charted resident's amount eaten in the electronic charting system. She said CNAs were supposed to chart after every meal the percentage the resident ate. SCNA G said the LVNs were supposed to make sure CNAs documented intake amounts on residents. She said it was important to chart the resident's intake amounts to know if they were not eating, tell if something was wrong, and know why the resident lost weight. SCNA G said not documenting meal intakes did not let the dietician know the resident's real intake amounts.<BR/>During an interview on 09/13/23 at 4:40 p.m., the DON said she had been at the facility for 2 years. The DON said residents were supposed to have readmission weights done. She said Resident #54 had been gone for 8 days so he should have had one done. The DON said the admission nurse had 24-hours to weigh and document the weight in the resident's chart. She said nursing administration was responsible for ensuring the facility's weight policy was followed. The DON said readmission weights were important to monitor for weight loss. She said not obtaining readmission weights risked residents not being put on the right dietary supplements, or not being put on a dietary supplement at all, and continued weight loss. The DON said weights were monitored weekly or monthly dependent on the resident orders and condition. She said the CNAs were responsible for documenting the amount the residents consumed. The DON said LVNs should ensure the CNAs documented the intake amounts after every meal which was three times a day. She said following the care plan intervention to document meal intake amounts was important to know how much a resident ate, could indicate a change of condition, and it help monitor for weight loss. The DON said missed meal intake amounts would not paint a complete picture of the resident and the dietician would not have correct information to make accurate dietary recommendations. She said nursing administration should be doing random chart audits to ensure CNAs and LVNs were doing their responsibilities. The DON said the facility did not have a policy related to nutrition.<BR/>During an interview on 09/13/23 at 5:01 p.m., the ADM said CNAs or LVNs, whoever fed the resident was responsible for documenting meal intakes. She said the charge nurse at the end of the shift should review the chart to ensure charting was completed. The ADM said documentation of meal consumption should happen after every meal. She said if the intervention of documenting meal consumption was important because you would not know why the resident was lost weight, needed to obtain, or update resident's dislikes, likes, or preferences. The ADM said corporate ran reports on the percentage of electronic charting system entry. She said ADON L oversaw the process. The ADM said she expected the nursing staff to follow the weight policy. She said not getting readmission weights placed resident at risk for the dietitian not to know about the weight loss and not order correct dietary interventions.<BR/>Record review of a facility Resident Weight policy revised on 02/13/07, indicated .all residents will be weighed by the 10th of the month and their weights documented correctly .weights shall be obtained and documented at admission, readmission, and monthly unless ordered by the physician, or unless dictated more frequently by the resident's condition .all new admission and readmission will have a height and weight obtained within 24 hours of admission then weighed at least weekly x4 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #54) reviewed for unnecessary psychotropic medications.<BR/>The facility failed to ensure Resident #54's Lorazepam (anti-anxiety) had an appropriate diagnosis for use.<BR/>The facility failed to limit Resident #54's Lorazepam prn medications to 14 days and the prescribing practitioner did not provide a rationale for extended use.<BR/>These failures could put residents at risk of receiving unnecessary psychotropic medications. <BR/>Findings included:<BR/>Record review of a face sheet dated 09/12/23 indicated Resident #54 was an [AGE] year-old male and admitted on [DATE], with a readmission on [DATE], with diagnoses including Alzheimer's disease with late onset (a progressive disease that destroys memory and other important mental functions), insomnia (persistent problems falling and staying asleep), and depression. <BR/>Record review of a significant change MDS assessment, dated 08/31/23, indicated Resident #54 was understood and understood others. The MDS indicated Resident #54 had a BIMS score of 02 which indicated severe cognitive impairment and required extensive assistance for bed mobility, dressing, eating, toilet use, personal hygiene, and total dependence for transfer and bathing. The MDS indicated Resident #54 had not received an antianxiety during the last 7 days of the MDS assessment period. <BR/>Record review of the care plan dated 06/14/23 indicated Resident #54 used anti-anxiety medications for anxiety disorder. Intervention included give anti-anxiety medications ordered by physician.<BR/>Record review of Resident #54's consolidated physician order dated 05/04/03 indicated Lorazepam 1MG, give 1MG by mouth every 4 hours as needed for agitation. No end date noted on orders.<BR/>Record review of Resident #54's MAR dated 08/1/23-08/31/23 indicated Resident #54 had not received Lorazepam 1MG since 08/18/23. <BR/>Record review of Resident #54's MAR dated 09/1/23-09/30/23 indicated Resident #54 had not received Lorazepam 1MG.<BR/>During an interview on 09/13/23 at 3:53 p.m., LVN F said Resident #54 had an order for a psychotropic medication. She said Resident #54 had an order for Lorazepam as needed. LVN F said the Lorazepam order did not have an end date. She said psychotropic medication could only be prescribed for 14 days. LVN F said Resident #54 used to be on hospice services but when he readmitted on [DATE], he was not placed back on hospice. She prn psychotropic medication needed to be ordered for 14 days at a time to see if the resident needed the medication scheduled instead or prn and to be reviewed for correct dose, frequency, and usage. LVN F said the DON reviewed medication orders to ensure they were accurate. She said anti-anxiety medication should be order for anxiety not only agitation. LVN F said Resident #54's Lorazepam was ordered for agitation not anxiety/agitation. She said Resident #54 did not have a diagnosis listed for anxiety or depression. <BR/>During an interview on 09/13/23 at 4:40 p.m. the DON said Resident #54's Lorazepam prn order should be for 14 days only. She said the nurse who received the prn order should make sure it is only for 14 days. The DON said the Lorazepam should have had at least a stop date of 180 days since it was ordered when he was on hospice. She said prn medication ordered for only 14-day periods was important to ensure psychotropic medications were not abused and see if it needed to be scheduled. The DON said ADON J, who was currently on vacation, was responsible for medication order reviews. She said the Lorazepam indication for use should be anxiety not agitation. <BR/>During an interview on 09/13/23 at 5:01 p.m., the ADM said prn psychotropic medication should only be ordered for 14 days. She said prn psychotropic medication should not have an indefinite end date and not intended for long term use. The ADM said anti-anxiety medication should be prescribed to treat anxiety not agitation. <BR/>Record review of a facility Psychotropic Drugs policy, revised on 10/25/17 indicated .an prn orders for psychotropic medications are only used when the medication is necessary and prn use is limited .a psychotropic drug is .anti-anxiety .residents do not receive psychotropic drugs pursuant to a prn order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical records .prn orders for psychotropic drugs are limited to 14 days .he or she should document their rationale in the resident's medical record and indicate the duration for the prn order .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Residents #65) of 5 residents observed for infection control. <BR/>Housekeeper DD failed to doff (take off) PPE while exiting isolation room and entered Resident #65's room wearing contaminated PPE. Housekeeper DD wore soiled gloves in the hallway.<BR/>These failures could place residents at risk of cross-contamination and infections leading to illness.<BR/>Findings included:<BR/>Record review of Resident #65's admission Record dated 09/14/2023 indicated that resident was an 63-year- old female who admitted to the facility on [DATE] with diagnosis of non-pressure chronic ulcer of buttock with necrosis of the muscle (commonly occur in patients with arterial (ischemic) disease, venous disease, neuropathy, or a combination of these diseases), type 2 diabetes ( a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) fibromyalgia (a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), and urinary tract infection (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract).<BR/>Record review of Resident #65's MDS assessment, dated 07/03/2023, indicated that resident had a BIMS score of 15 which indicated resident had no cognition issues. The MDS also indicated that Resident #65 required extensive assistance of for bathing and personal hygiene.<BR/>Record review of Resident #65's Care Plan created on 09/07/2023 indicated that resident had a urinary tract infection with the goal of having the urinary tract infection resolved by 10/09/2023.<BR/>Record review of an in-service titled Prevention of Infection: Donning and Doffing PPE was signed by Housekeeper DD on 07/24/2023. Review revealed doffing (taking off) PPE was to be done within the isolation room and disposed of in a labeled biohazard container. PPE included gloves, mask, gown, hair covers, and shoe covers.<BR/>During an interview and observation on 09/11/2023 at 9:15 a.m., Resident #65 said she had concerns about the man that was placed in the room across the hall from her room. Resident #65 said she knew he was on isolation for something that was air borne and the staff kept his door open all the time and kept her door open despite Resident #65 having asked for it to be closed every time they left for privacy. During this conversation Resident #65's door was pushed open without a knock and Housekeeper DD entered the room with a mask, gloves, and isolation gown on. When Housekeeper DD saw the surveyor, she said, oh no and exited the room. Resident #65 became upset and said see what I mean, she spread his infection to my room! Now we (roommate and Resident #65) are going to get his disease! The room across the hall was noted to have an isolation set up outside of it and an air borne isolation poster on the door.<BR/>During an interview on 09/11/2023 at 9:25 p.m., Housekeeper DD said it was an accident that she walked into Resident #65's room. Housekeeper DD said she was taking out the biohazard material from the isolation room across the hall and forgot to take off her PPE before exiting the room. She opened Resident #65's door to clean her room but then saw the surveyor and realized her mistake of not taking her PPE off. Housekeeper DD was not aware of any potential adverse effects of not taking PPE off in the isolation room and washing her hands.<BR/>During an observation on 09/12/2023 at 8:50 a.m., Housekeeper DD exited a room on D hall with gloves on, walked down hallway pushing housekeeping cart and entered the next room with the same gloves on.<BR/>During an observation on 09/12/2023 at 10:20 a.m., Housekeeper D walked from D hall to the kitchen to return dirty dishes wearing gloves, then walked back to the housekeeping cart on D hall, pushed it to next room on the hall, and entered the room still wearing the same gloves.<BR/>During an interview on 09/12/2023 at 10:25 a.m., Housekeeper DD said she forgot to change gloves before entering the next room and was not aware she was not allowed to wear the gloves in the hallway. <BR/>During an interview on 09/13/2023 at 2:15 p.m., the DON said she had multiple in services on isolation, infection control prevention, and donning and doffing PPE and presented them to all staff including nursing, kitchen staff, housekeeping staff, and department heads. The DON said she would continue to educate the staff on infection prevention and control. The DON said not following isolation precautions could result in the spread of infections and she expected the staff to follow all isolation precautions and standard precautions to aid in the prevention of spreading infections.<BR/>During an interview on 09/13/2023 at 3:00 p.m., the Administrator said she expected the staff to follow the facilities policy for infection control. The Administrator said that the policies were in place to prevent the spread of infection throughout the building and protect the vulnerable residents that lived in the facility. <BR/>Record review of an infection control policy dated 07/2021 titled 'Infection Control' revealed: Begin removing PPE at patient's doorway or in anteroom. Eye protection and mask/respirator to be removed outside the room. Outside surfaces of PPE are considered to be contaminated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Residents #65) of 5 residents observed for infection control. <BR/>Housekeeper DD failed to doff (take off) PPE while exiting isolation room and entered Resident #65's room wearing contaminated PPE. Housekeeper DD wore soiled gloves in the hallway.<BR/>These failures could place residents at risk of cross-contamination and infections leading to illness.<BR/>Findings included:<BR/>Record review of Resident #65's admission Record dated 09/14/2023 indicated that resident was an 63-year- old female who admitted to the facility on [DATE] with diagnosis of non-pressure chronic ulcer of buttock with necrosis of the muscle (commonly occur in patients with arterial (ischemic) disease, venous disease, neuropathy, or a combination of these diseases), type 2 diabetes ( a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) fibromyalgia (a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), and urinary tract infection (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract).<BR/>Record review of Resident #65's MDS assessment, dated 07/03/2023, indicated that resident had a BIMS score of 15 which indicated resident had no cognition issues. The MDS also indicated that Resident #65 required extensive assistance of for bathing and personal hygiene.<BR/>Record review of Resident #65's Care Plan created on 09/07/2023 indicated that resident had a urinary tract infection with the goal of having the urinary tract infection resolved by 10/09/2023.<BR/>Record review of an in-service titled Prevention of Infection: Donning and Doffing PPE was signed by Housekeeper DD on 07/24/2023. Review revealed doffing (taking off) PPE was to be done within the isolation room and disposed of in a labeled biohazard container. PPE included gloves, mask, gown, hair covers, and shoe covers.<BR/>During an interview and observation on 09/11/2023 at 9:15 a.m., Resident #65 said she had concerns about the man that was placed in the room across the hall from her room. Resident #65 said she knew he was on isolation for something that was air borne and the staff kept his door open all the time and kept her door open despite Resident #65 having asked for it to be closed every time they left for privacy. During this conversation Resident #65's door was pushed open without a knock and Housekeeper DD entered the room with a mask, gloves, and isolation gown on. When Housekeeper DD saw the surveyor, she said, oh no and exited the room. Resident #65 became upset and said see what I mean, she spread his infection to my room! Now we (roommate and Resident #65) are going to get his disease! The room across the hall was noted to have an isolation set up outside of it and an air borne isolation poster on the door.<BR/>During an interview on 09/11/2023 at 9:25 p.m., Housekeeper DD said it was an accident that she walked into Resident #65's room. Housekeeper DD said she was taking out the biohazard material from the isolation room across the hall and forgot to take off her PPE before exiting the room. She opened Resident #65's door to clean her room but then saw the surveyor and realized her mistake of not taking her PPE off. Housekeeper DD was not aware of any potential adverse effects of not taking PPE off in the isolation room and washing her hands.<BR/>During an observation on 09/12/2023 at 8:50 a.m., Housekeeper DD exited a room on D hall with gloves on, walked down hallway pushing housekeeping cart and entered the next room with the same gloves on.<BR/>During an observation on 09/12/2023 at 10:20 a.m., Housekeeper D walked from D hall to the kitchen to return dirty dishes wearing gloves, then walked back to the housekeeping cart on D hall, pushed it to next room on the hall, and entered the room still wearing the same gloves.<BR/>During an interview on 09/12/2023 at 10:25 a.m., Housekeeper DD said she forgot to change gloves before entering the next room and was not aware she was not allowed to wear the gloves in the hallway. <BR/>During an interview on 09/13/2023 at 2:15 p.m., the DON said she had multiple in services on isolation, infection control prevention, and donning and doffing PPE and presented them to all staff including nursing, kitchen staff, housekeeping staff, and department heads. The DON said she would continue to educate the staff on infection prevention and control. The DON said not following isolation precautions could result in the spread of infections and she expected the staff to follow all isolation precautions and standard precautions to aid in the prevention of spreading infections.<BR/>During an interview on 09/13/2023 at 3:00 p.m., the Administrator said she expected the staff to follow the facilities policy for infection control. The Administrator said that the policies were in place to prevent the spread of infection throughout the building and protect the vulnerable residents that lived in the facility. <BR/>Record review of an infection control policy dated 07/2021 titled 'Infection Control' revealed: Begin removing PPE at patient's doorway or in anteroom. Eye protection and mask/respirator to be removed outside the room. Outside surfaces of PPE are considered to be contaminated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents environment remained as free of accident hazards as possible for 1 of 7 residents (Resident #1) reviewed for accidents and hazards.<BR/>The facility failed to ensure staff checked straps for damage prior to transferring Resident #1 which resulted in a laceration to Resident #1's forehead. <BR/>This failure could place residents at risk for injury.<BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 02/10/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis (weakness on one side of your body) following cerebral infarction (Stroke) affecting the left dominant side.<BR/>Record review of Resident #1''s MDS, dated [DATE], revealed Resident #1 required two-person assistance for transfers and had a BIMS score of 15, which indicated Resident #1 was cognitively intact, alert to person, place, and time. Resident #1 used a wheelchair to ambulate. Resident #1 required extensive assistance with most activities of daily living.<BR/>Record review of Resident #1's care plan, dated 12/27/22, revealed Resident #1 required two-person assistance for transfers and required a mechanical lift due to a self-care performance deficit. <BR/>Record review of Resident #1's nurse's note, dated 02/05/23 at 9:23 PM, by LVN B, revealed Resident #1 was kicking and yelling at staff. LVN B asked LVN A to assist in transferring Resident #1 from his wheelchair to his bed using a Mechanical lift. When LVN A and LVN B arrived in the room three of four straps were already attached to the lift. LVN A attached the last strap and proceeded with the transfer. During the transfer LVN B reported hearing a snap, and Resident #1 fell from the lift to the floor hitting his head causing a laceration. LVN B called 911 and Resident #1 was transferred to the hospital for evaluation and treatment.<BR/>Record review of Resident #1's hospital records, dated 02/05/23, revealed Resident #1 arrived at the hospital with a facial laceration. The fall involved a lift chair assistance as the cause of accidental injury. The injury was repaired with stiches. CT scan (scans take a fast series of X-ray pictures, which are put together to create images of the area that was scanned.), showed no acute intercranial abnormalities, laceration to the soft tissue, swelling to the left frontal scalp and preorbital (around the eye) soft skin. There was mild soft tissue swelling to the left cheek. Resident #1 was released back to the facility after treatment. <BR/>Observation of a video surveillance tape, date stamped on 02/05/22 at 8:48 PM, showed Resident #1 was being transferred from a wheelchair to a bed by LVN A and LVN B using a mechanical lift. The front left strap on the lift appeared to be frayed or damaged. During the transfer, the front left strap holding Resident #1, snapped and Resident #1 fell from the lift and hit his head on the floor.<BR/>During an observation and interview on 02/10/23 at 1:20 PM revealed Resident #1 was in his bed. There was a bandage on his forehead, above his left eye with a date of 02/10/23. There was a Hoyer lift Sling under him. The sling appeared to be in good condition with no frayed edges. Resident #1 said he was doing okay. He said he fell while staff attempted to transfer him from his wheelchair to his bed. Resident #1 said he did not remember much about what happened. He said all he remembered was the strap broke and he hit the floor. He said the next thing he remembered was being at the hospital. He said he did not feel he had been abused or neglected and what happened was an accident. Resident #1 said he was not afraid to be transferred with the Hoyer Lift.<BR/>During an interview on 01/17/23 at 1:20 PM, LVN A said he assisted LVN B with transferring Resident #1 with a Hoyer Lift on 02/05/23 around 8:30 PM. LVN A said while transferring Resident #1, a strap on the front left side of the lift snapped and Resident #1 fell to the floor and hit his head. LVN A said LVN B left the room and called 911 for assistance. LVN A said when he looked at Resident #1, there was blood on the floor coming from Resident #1's head. LVN A said she went and got a towel and applied pressure to the wound until EMS arrived and transported Resident #1 to the hospital for evaluation and treatment. LVN A said he did not realize the strip was damaged. LVN A said the cause of the accident was due to the defective strap. LVN A said he should have inspected the straps before he attempted to transfer Resident #1. LVN A said he was notified on 02/10/23 that he was suspended pending an investigation due to the incident. LVN A said he was scheduled to complete Mechanical Lift skills training before returning to work, but he had not yet received the training.<BR/>During an interview on 01/17/23 at 1:45 PM, LVN B said she and LVN A was asked to assist in transferring Resident #1 from his wheelchair to his bed because staff reported Resident #1 was being verbally and physically aggressive toward staff who attempted to transfer him to his bed. LVN B said she asked LVN A to assist in the transfer. LVN B said when she arrived in the room, there were three straps already attached to the lift and LVN A attached the fourth strap to transfer Resident #1. LVN B said she was operating the lift and LVN A lowered the bed to the lowest position. LVN B said the bed caught on the edge of a trash can at the foot of the bed when the bed was lowered. LVN B said she raised Resident #1 out of the wheelchair and LVN A was moving the wheelchair out of the way when she heard a snap. LVN B said the strap on the front left side of the sling holding Resident #1 broke and Resident #1 fell to the floor hitting his head. LVN B said she went to the door and yelled for help. LVN B said she called 911 on her cell phone and LVN A went and got a towel to stop the bleeding. LVN B said she did not notice the strap was damaged and if so, she would have not used the defective sling to transfer Resident #1. LVN B said she was notified on 02/10/23 by the DON she was suspended pending an investigation into the incident. LVN B said she should have assessed the condition of the straps before she attempted to transfer Resident #1. LVN B said since the incident she had received skills training on transferring using a Mechanical lift on 02/15/23. <BR/>During an interview on 02/10/23 at 12:12 PM, the DON said the first time she viewed the video was with the surveyor. DON said she had not reviewed the video of the incident with Resident #1 before this time. The DON said LVN A and LVN B failed to use proper technique when transferring Resident #1 with the Mechanical lift. The DON said staff should always assess the condition of the lift sling to ensure it was safe prior to use. The DON said it was obvious by viewing the video that the strap on the front left side was damaged and the sling should not have been used. The DON said after the incident she completed an assessment of all other lift slings in the building and found there were some that needed to be retired and new slings were ordered to replace the damaged slings. The DON said all staff received training to inspect the slings prior to use and if a sling showed signs of being defective or damaged the sling should not be used to transfer residents. The damaged sling should be reported to the charge nurse and the DON. The DON said the sling should be taken out of service and replaced with a new sling. The DON said all nursing staff would receive skills training with a check-off for each one on how to transfer a resident using a Mechanical lift. The DON said the skills training would be conducted by the DON and the Director of Rehabilitation. <BR/>During an interview on 02/10/23 at 12:08 PM, the Administrator said she was notified Resident #1 had a fall from a Mechanical lift on 02/05/23 around 8:30 PM. The Administrator said the cause was a damaged strap that broke which caused injury to Resident #1. The Administrator said she reported the incident to the state on 02/05/23 at around 9:45 PM. The Administrator said all the slings and straps in the facility were assessed by the DON for possible damage and those found to be damaged were removed from service immediately. The Administrator said new slings were ordered to replace the damaged slings. The Administrator said on 02/06/23 an intervention plan was developed by QAPI regarding the Hoyer Lift issue. The Administrator said all staff were in-serviced on inspecting the straps and slings before use. The Administrator said the DON would monitor and inspect slings and straps weekly to ensure they were in good condition. The Administrator said any slings found to be damaged would be removed from service and replaced. The Administrator said all nursing staff would receive skills training on how to properly operate the Mechanical Lift. The Administrator said the skills training would be conducted by the DON and Director of Rehabilitation. <BR/>An observation and interview on 02/10/23 at 1:45 PM revealed NA-A, NA-B and NA-C using a Hoyer lift to transfer Resident #1 from his bed to his wheelchair. NA A and NA B used proper technique in transporting the resident. Transfer was successfully completed with no concerns for Resident #1's safety. The equipment and sling were in good working order with no concerns. NA-A, NA-B and NA-C said they had recently received in-service training on safely using the Hoyer lift. They said they were to assess the condition of the sling and straps before using to transfer a resident. They said if the sling or straps were damaged, they were not to use them and report to the charge nurse and/or the DON.<BR/>Interview on 02/10/23 at 1:30 PM, the Laundry Aide said she washed two to three Hoyer Lift slings daily. She said she followed the manufacturer's suggested care instructions. She said the slings were washed in cold to warm water, but never hot water. She said all slings were hung to air dry and slings were never dried in the dryer. She said heat could cause the material to stretch or become weak.<BR/>Record review of Sling Laundry Instructions revealed .While the materials comply with applicable standards for strength, shrinkage and flammability, slings are subject to wear and tear, which increases with usage. Before each use check for fraying or cuts/tears in the straps and body of the sling. Slings that show wear or damage should be taken out of service . LAUNDRY INSTRUCTIONS: . Machine wash normal setting and at 140F/60C. Depending on the washing machine, this usually means on a medium temperature setting.<BR/>Record review of in-service records from 02/06/23 through 02/17/23 revealed documentation that nursing staff received training on 10/17/22. Staff received in-service training on laundry instructions of Hoyer Lift Slings. The in-service was conducted by the Housekeeping Supervisor. After washing the Hoyer Lift sling, you cannot put heat on it. The sling needs to air dry or put in the dryer with no heat. The fabric when heated can stretch and snap! This will cause an injury. This will be an automatic [NAME]!<BR/>Record review of in-service records revealed on 02/06/23 nursing staff received in-service training on Hoyer Lift transfer. <BR/>o <BR/>Must have 2 nursing staff (CNA, Nurse, Medication Aide) to use a Hoyer lift on a resident. <BR/>o <BR/>Always check sling and sling straps to verify they do not appear compromised.<BR/>o <BR/>If there is any question, have nurse verify it is okay to use. <BR/>o <BR/>DO NOT USE A DAMAGED SLING Under any circumstances.<BR/>Record review of Mechanical lift Competency Evaluations dated 02/10/23 - 02/17/23, showed staff using a Hoyer life to transfer residents received a skills assessment on using a Mechanical Life to transfer residents safely. <BR/>Record review of the facility's, undated, policy on Hydraulic lift revealed: . The resident will achieve safe transfer to bed or chair via mechanical lift device . The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift .23. Immediately remove any malfunctioning equipment from direct care use. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain grooming and personal hygiene for 3 of 19 residents reviewed for ADLs. (Resident #'s 7, 17, and 34)<BR/>The facility failed to provide assistance with facial hair removal for Resident #'s 7 and 34.<BR/>The facility failed to ensure Resident #17 was routinely showered.<BR/>The facility failed to ensure Resident #7's fingernails were cleaned and trimmed. <BR/>The facility failed to ensure Resident #7's teeth were brushed.<BR/>The facilty did not provide Resident #34 timely incontinent care. Resident #34 was found heavily saturated in urine with three brown colored rings on the linen. <BR/>These failures could place residents who were dependent of staff to perform personal hygiene at risk for embarrassment, decreased self-esteem, or decreased quality of life.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 7/26/2022 indicated Resident #7 was a [AGE] year-old female admitted on [DATE] with the diagnoses of Parkinson's disease (disease causing tremors), muscle weakness, and chronic pain.<BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #7 was understood and understands others. The MDS indicated Resident #7's BIMS score was 15 indicating no cognitive deficit. The MDS indicated Resident #7 required extensive assistance of one staff for her personal hygiene (Personal hygiene according to the MDS was combing hair, brushing teeth, shaving, apply makeup, washing/drying face and hands).<BR/>. <BR/>Record review of a comprehensive care plan with review date of 5/12/2022 indicated Resident #7 had an ADL self-care performance deficit. The goal was Resident #7 would maintain or improve her current level of function in personal hygiene. The approach included assisting with personal hygiene as required: hair, shaving, and oral care as needed. During bathing, to check nail length and clean on bath day and as necessary. If the resident was a diabetic, the nurse will provide toenail care. <BR/>Record review of a bath sheet indicated Resident #7 received a bed bath on 7/1/2022, 7/4/2022, 7/6/2022, 7//8/2022, 7/11/2022, 7/15/2022, 7/18/2022, 7/20/2022, and 7/25/2022. Resident #7 did not receive her bath on 7/13/2022 and 7/22/2022. Resident #7's shower days were Monday, Wednesday and Friday on 2:00 p.m. to 10:00 p.m. shift.<BR/>During an observation on 7/25/2022 at 10:16 a.m., Resident #7 had white facial hair to the left side of her chin &frac12; inch in length. Resident #7's fingernails were a half inch long with a brown colored material underneath them.<BR/>During an observation and interview on 7/26/2022 at 8:31 a.m., Resident #7 continued to have white facial hair to the left side to her chin measuring &frac12; inch in length. Resident #7's fingernails continued to be long with a brown colored material underneath them. Resident #7 said her teeth have not been brushed and she did not have a bath yesterday. Resident #7 said she felt dirty. Resident #7 said she had not had a shower in a month.<BR/>During an interview on 7/26/2022 at 10:17 a.m., CNA B indicated the nurse aides were responsible for ADLs. CNA B indicated ADLs included bathing, brushing teeth, shaving, and cleaning fingernails. <BR/>2. Record review of a face sheet dated 7/26/2022 indicated Resident #17 was an [AGE] year-old female admitted on [DATE] with the diagnoses of Alzheimer's dementia (a memory disease), depression and Bipolar disorder (a mood mental illness).<BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #17's BIMS Score was a 14 indicating intact cognition. The MDS indicated Resident #17 required physical of one staff member to assist with the transfer only for bathing.<BR/>Record review of a comprehensive care plan last reviewed/revised on 7/26/2022 indicated Resident #17 had an ADL self-care performance deficit. The care plan indicated the goal was to maintain or improve Resident #17's current function with the assistance of one staff with bathing. <BR/>Record review of the undated shower schedule indicated the right side of a hall was Monday-Wednesday-Friday and the left side of the hall was Tuesday-Thursday-Saturday. The shower schedule also indicated (A) bed received their shower on 6:00 a.m.- 2:00 p.m. shift and (B) bed received their showers on 2:00 p.m. to 6:00 a.m. Resident #17's room was on the right side of the hall in the A bed.<BR/>Record review of the computerized bathing tasks sheet dated 7/26/2022 indicated from July 1, 2022 through July 25, 2022 Resident #17 had 11 opportunities for bathing and it was documented she received 6 showers. Resident #17's shower days were Monday, Wednesday and Friday on 6:00 a.m. to 2:00 p.m. The coded reason for no shower was the activity did not occur.<BR/>During an interview on 7/25/2022 at 10:29 a.m., Resident #17 voiced it had been almost a week since she had a shower. She indicated today was her shower day.<BR/>During an interview on 7/26/2022 at 8:20 a.m., Resident #17 said she did not receive a bath yesterday. Resident #17 said no one even offered. Resident #17 indicated not receiving her bathes hurts her self-esteem and she feels neglected. Resident #17 said she did not have an issue with African American females providing care for her.<BR/>During an interview on 7/26/2022 at 8:25 a.m., CNA B indicated Resident #17 does not prefer African American CNAs to provide care this is why she does not provide Resident #17 a shower. CNA B said CNA D bathes Resident #17. <BR/>During an interview on 7/26/2022 at 11:17 a.m., CNA D indicated the last time she bathed Resident #17 was the previous Wednesday July 20, 2022.<BR/>During an interview on 7/26/2022 at 3:00 p.m., Resident #17 said she did not have a preference on African American CNAs bathing her.<BR/>During an interview on 7/27/2022 at 8:14 a.m., Resident #17 indicated she had not had a shower.<BR/>During an interview on 7/27/2022 at 12:50 p.m., Resident #17 indicated she had not had a bath yet today.<BR/>During an interview on 7/27/2022 at 1:35 p.m., the Corporate nurse indicated she would ensure Resident #17 was showered. <BR/>3Record review of a face sheet dated 7/27/2022 indicated Resident #34 was a [AGE] year-old female admitted on [DATE] and readmitted [DATE] with the diagnoses of heart failure, depressive disorder, and anxiety.<BR/>Record review of an admission MDS dated [DATE] indicated Resident #34 understands and was understood. The MDS indicated she required no cueing with recall and her BIMS score was 13 indicating intact cognition. The MDS indicated nearly every day she felt down, depressed, and hopeless. The MDS indicated Resident #34 was always incontinent of urine and required limited assistance of one staff with toileting.<BR/>Record review of a comprehensive care plan dated 7/25/2022 indicated Resident #34 had an ADL self-care deficit with a goal of maintaining or improvement in the current level of function. The interventions were to assist with toileting use. The interventions were to assist with personal hygiene as required including hair, shaving, and oral care.<BR/>Record review of a computerized bath task sheet dated July,2022, Resident #34 received 9 out of the 11 baths scheduled. Resident #34 was marked as activity did not occur on 7/13/2022 and 7/22/2022. Resident #34's shower days were Monday, Wednesday, and Friday on the 2:00 p.m. to 10:00 p.m. shift.<BR/>During an observation and interview on 7/25/2022 at 10:03 a.m., Resident #34 had short white facial hairs &frac14; inches long covering her entire chin. Resident #34 said she did not like having facial hair.<BR/>During an observation on 7/26/2022 at 8:13 a.m., Resident #34 pulled back her top linen and exposed she was lying on urine that had started drying and left behind a brown colored ring.<BR/>During an interview on 7/26/2022 at 11:29 a.m., CNA C indicated she provided Resident #'s 7 and #34 a bed bath the night before. CNA C indicated she did not clean Resident #7's fingernails nor did she remove her facial hair. CNA C indicated she did not remove Resident #34's facial hair. CNA C indicated she should have provided this care. CNA C indicated dirty fingernails and facial hair on a woman could affect their self-esteem. CNA C indicated she should have provided the nail care and provide shaving.<BR/>During an observation and interview on 7/26/2022 at 11:40 a.m., Resident #34 pulled back the linen on the left side of her bed. She revealed she was lying on a draw sheet with a visible brown ring. As Resident #34 turned over in her bed, the bottom sheet had two distinct brown rings of various stages of dried urine. Resident #34 indicated she had not been changed since early this morning. <BR/>During an observation and interview on 7/26/2022 at 11:50 a.m., Resident #34 revealed to LVN A the saturation of urine she was lying in. LVN A said she expected the CNAs to change the residents at frequent intervals. LVN A indicated she was in charge of Resident #34's care. LVN A said Resident #34 could have skin problems and dignity issues from being left in urine. LVN A indicated the CNAs were responsible for ADLs. LVN A indicated the nurse was responsible for ensuring ADLs were completed. LVN A said she expected the CNAs to complete the ADLs as scheduled. LVN A indicated not being bathed, shaved, and nail clean could lead to skin issues and dignity issues.<BR/>During an interview on 7/26/2022 at 2:15 p.m., CNAs B and E indicated they have been working short staffed today. CNAs B and E indicated they had been assigned to assist on other halls today including B-Hall. CNAs B and E indicated they had not had the time to change everyone on B-Hall including Resident #34. CNA B and E indicated Resident #34 should be assisted with incontinent care every two hours. CNA E indicated the residents should be shaved, nails cleaned, and teeth brushed every day. CNA E indicated she tried every day she works to complete the tasks but due to staff shortages the workload was too much to complete all the tasks.<BR/>During an interview on 7/27/2022 at 3:39 p.m., the Corporate DON indicated ideally the brown rings of urine should not happen. The Corporate DON indicated Resident #34 should have been changed timelier to prevent the brown rings. The Corporate DON indicated all nursing was responsible for ensuring a resident had timely incontinent care even she could change a resident. The Corporate DON indicated incontinent care was monitored with random rounds and failure to complete incontinent care timely could lead to dignity, health, and skin issues. The Corporate nurse indicated she expected the showers to be completed as scheduled. The Corporate nurse indicated she expected shaving to occur during bath days or as needed. She indicated she expected the resident's teeth to be brushed at least morning and night. The Corporate nurse indicated the lack of ADLs affects the resident's quality of life and dignity. The Corporate nurse indicated the nursing management was responsible for ensuring ADL compliance. The Corporate nurse indicated anyone could provide ADLs to these residents including herself.<BR/>During an interview on 7/27/2022 at 4:03 p.m., the Administrator indicated her expectation was that incontinent care was provided every 2 hours or as needed. The Administrator indicated the charge nurses were responsible to ensure incontinent care was provided timely. The Administrator indicated provision of incontinent care was monitored with every two-hour round, Champion rounds (rounds made by assigned management), and ADL documentation. The Administrator indicated the resident could have issues with dignity, skin break down and infections related to untimely incontinent care. An incontinent care policy was requested but not provided. The Administrator indicated she expected the residents to be bathed and shaved at least three times weekly. She indicated she expected oral care at least two times daily. The Administrator indicated due to the staffing challenges with numerous positions open she asked the residents to be flexible with bathing on the day shift when the facility was better staffed. The Administrator indicated the second shift after 5:00 p.m. were limited on staffing. <BR/>Record review of a Bath, Tub/Shower policy dated 2003 indicated bathing by tub bath or shower was done to remove soil, dead epithelial cells, microorganisms from the skin and body odor to promote comfort cleanliness, circulation, and relation. The goals were the resident would experience improved comfort and cleanliness by bathing.<BR/>Record review of a Shaving Policy dated 2003 indicated shaving of the male resident could be performed with an electric or safety razor. It is usually done as a part of daily personal hygiene, although every other day is sufficient for some based on the beard growth. Shaving is done to promote cleanliness and positive body image. <BR/>Record review of Teeth care/Oral hygiene policy dated 2003 oral and teeth care was the removal of soft plaque and food particles, bacteria, and odors to promote physical and psychological comfort. The resident will receive mouth care at least daily.<BR/>Record review of a Nail Care policy dated 2003 indicated nail management was the regular care of the toenails and fingernails to promote cleanliness and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 2 residents reviewed (resident #58) for care and maintenance of a central line.<BR/>The facility failed to ensure nursing staff was competent in providing care and maintenance of IV's, central lines, or PICC lines.<BR/>This failure could place residents with IVs, central lines, or PICC lines at risk of complications and further decline in health and could result in the resident developing CLABSI (central line associated blood stream infection) or CRBS I (catheter related blood stream infection), which could lead to serious illness of the resident.<BR/>Findings included:<BR/>Record review of a face sheet dated 7/26/2022 indicated Resident #58 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the diagnoses of leukemia, heart failure, and high blood pressure. <BR/>Record review of a Significant Change MDS dated [DATE] indicated Resident #58 understands and was understood. The MDS indicated Resident #58's BIMS score was 14 indicating her memory cognition was intact. The MDS did not reflect at the time of completion Resident #58 was receiving IV antibiotics.<BR/>Record review of the consolidated physician orders dated 7/26/2022 indicated Resident #58 had an order for Vancomycin solution reconstituted give 500 milligrams one time every other day for an osteomyelitis (bone infection).<BR/>Record review of the comprehensive care plan dated 7/25/2022 indicated Resident #58 had a bone infection with a goal of the infection resolved without any complications. The care plan intervention indicated to give antibiotics as ordered, and monitor laboratory work as ordered.<BR/>Record review on 7/26/2022 of the Vancomycin medication label indicated Vancomycin 500 milligrams/100 milliliters via IV over 60 minutes every other day. <BR/>During an observation and interview on 7/26/2022 at 8:44 a.m., Resident #58's Vancomycin IV was infusing at 200 milliliters an hour. LVN A was asked to come and review the Vancomycin administration. LVN A indicated the label indicated to administer 100 milliliters over 1 hour. LVN A said administering the medication at 200 milliliters would make the IV administer over more than 1 hour. LVN A indicated she initiated the IV at the 200 milliliter over 1 hour rate. LVN A indicated she was responsible for the care and medication administration of Resident #58.<BR/>During an interview on 7/27/2022 at 3:39 p.m., the Corporate DON indicated LVN A understood the medication error. The Corporate DON said the nurses should be IV certified prior to administering IV medications. The Corporate DON indicated LVN A did not have an IV certification, and the DON was responsible for ensuring the LVNs had an IV certification course. The Corporate DON indicated she could not find any IV certifications for the nurses. The Corporate DON indicated the medication errors could affect a resident's health.<BR/>During an interview on 7/27/2022 at 4:03 p.m., the Administrator indicated a resident's health could be affected by not receiving the correct medication, correct route, and correct rate. The Administrator was unaware whose responsibility it was to monitor whether the DON or Human Resource manager. The Administrator said she thought Human resources had the certifications but after checking no certifications were located on any nurses.<BR/>Review of the facility policy titled Central Venous Catheters in the Pharmacy Policy & Procedure Manual dated 2003, under procedures, indicated 1. See policies .3. The facility will require that the nurse(s) accessing or utilizing the CVC site to be qualified to do so .4. LVN may access/use the site when documented IV certification and competency specific to the CVC have been demonstrated. The RN may verify competency for the CVC procedures. 5. When a nurse is not qualified to perform routine procedures to the CVC, it is his/her responsibility to notify the DON and/or appropriate supervisor in order to receive appropriate training to perform the procedure .Nurses should never perform a procedure that they are not qualified to perform regardless of instruction to do so by physician or employer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 7 residents reviewed for medication errors. (Resident #58)<BR/>The facility failed to ensure Resident #58 received her IV antibiotic therapy as ordered by the physician. <BR/>This failure could place the resident at risk of medical complications including an abnormal level of the medication in the blood stream.<BR/>Findings included:<BR/>Record review of a face sheet dated 7/26/2022 indicated Resident #58 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the diagnoses of leukemia, heart failure, and high blood pressure. <BR/>Record review of a Significant Change MDS dated [DATE] indicated Resident #58 understands and was understood. The MDS indicated Resident #58 BIMS score was 14 indicating her memory cognition was intact. The MDS did not reflect at the time of completion Resident #58 was receiving IV antibiotics.<BR/>Record review of the consolidated physician orders dated 7/26/2022 indicated Resident #58 had an order for Vancomycin solution reconstituted give 500 milligrams one time every other day for an osteomyelitis (bone infection).<BR/>Record review of the comprehensive care plan dated 7/25/2022 indicated Resident #58 had a bone infection with a goal of the infection resolved without any complications. The care plan intervention indicated to give antibiotics as ordered, and monitor laboratory work as ordered.<BR/>Record review on 7/26/2022 of the Vancomycin medication label indicated Vancomycin 500 milligrams/100 milliliters via IV over 60 minutes every other day. <BR/>During an observation and interview on 7/26/2022 at 8:44 a.m., Resident #58's Vancomycin IV was infusing at 200 milliliters an hour. LVN A was asked to come and review the Vancomycin administration with the surveyor. LVN A indicated the label indicated to administer 100 milliliters over 1 hour. LVN A indicated she had initiated the IV medication. LVN A said administering the medication at 200 milliliters would make the IV administer over more than 1 hour. LVN A indicated she had been trained on IV medication administration, but a training record was not provided.<BR/>Record review of a Vancomycin Trough drawn on 7/26/2022 at 12:12 p.m., indicated the level was high at 24.8 with the normal range of 10.0 to 20.0. The result was noted to be faxed to her physician without any new orders.<BR/>During an interview on 7/27/2022 at 3:39 p.m., the Corporate DON indicated LVN A understood the medication error. The Corporate DON stated the nurses should be IV certified prior to administering IV medications. The Corporate DON indicated LVN A did not have an IV certification, and the DON was responsible for ensuring the LVNs had an IV certification course. The Corporate DON indicated the medication errors could affect a resident's health.<BR/>During an interview on 7/27/2022 at 4:03 p.m., the Administrator indicated a resident's health could be affected by not receiving the correct medication, correct route, and correct rate. The Administrator was unaware whose responsibility it was to monitor whether the DON or Human Resource manager.<BR/>Record review of a medication Administration Procedure policy dated 2003 indicated 20. The five rights of medication should always be adhered to 1. Right drug 2. Right dose 3. Right resident 4. Right time and 5. Right route.<BR/>Record review of the website accessed on 8/1/22: http://www.accessdata.fda.gov/drugsatfda-doc/label2017/050671s024lbl.pdf accessed on 8/01/2022 Warnings . Infusion Reactions Rapid bolus administration (e.g., over several minutes) may be associated with exaggerated hypotension, including shock and rarely, cardiac arrest. Vancomycin should be administered over a period of not less than 60 minutes to avoid rapid-infusion-related reactions. Stopping the infusion usually results in prompt cessation of these reactions Precautions Vancomycin is irritating to tissue and must be given by a secure intravenous route of administration. Pain, tenderness, and necrosis occur with inadvertent extravasation. Thrombophlebitis may occur, the frequency and severity of which can be minimized by slow infusion of the drug and by rotation of venous access sites.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents environment remained as free of accident hazards as possible for 1 of 7 residents (Resident #1) reviewed for accidents and hazards.<BR/>The facility failed to ensure staff checked straps for damage prior to transferring Resident #1 which resulted in a laceration to Resident #1's forehead. <BR/>This failure could place residents at risk for injury.<BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 02/10/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis (weakness on one side of your body) following cerebral infarction (Stroke) affecting the left dominant side.<BR/>Record review of Resident #1''s MDS, dated [DATE], revealed Resident #1 required two-person assistance for transfers and had a BIMS score of 15, which indicated Resident #1 was cognitively intact, alert to person, place, and time. Resident #1 used a wheelchair to ambulate. Resident #1 required extensive assistance with most activities of daily living.<BR/>Record review of Resident #1's care plan, dated 12/27/22, revealed Resident #1 required two-person assistance for transfers and required a mechanical lift due to a self-care performance deficit. <BR/>Record review of Resident #1's nurse's note, dated 02/05/23 at 9:23 PM, by LVN B, revealed Resident #1 was kicking and yelling at staff. LVN B asked LVN A to assist in transferring Resident #1 from his wheelchair to his bed using a Mechanical lift. When LVN A and LVN B arrived in the room three of four straps were already attached to the lift. LVN A attached the last strap and proceeded with the transfer. During the transfer LVN B reported hearing a snap, and Resident #1 fell from the lift to the floor hitting his head causing a laceration. LVN B called 911 and Resident #1 was transferred to the hospital for evaluation and treatment.<BR/>Record review of Resident #1's hospital records, dated 02/05/23, revealed Resident #1 arrived at the hospital with a facial laceration. The fall involved a lift chair assistance as the cause of accidental injury. The injury was repaired with stiches. CT scan (scans take a fast series of X-ray pictures, which are put together to create images of the area that was scanned.), showed no acute intercranial abnormalities, laceration to the soft tissue, swelling to the left frontal scalp and preorbital (around the eye) soft skin. There was mild soft tissue swelling to the left cheek. Resident #1 was released back to the facility after treatment. <BR/>Observation of a video surveillance tape, date stamped on 02/05/22 at 8:48 PM, showed Resident #1 was being transferred from a wheelchair to a bed by LVN A and LVN B using a mechanical lift. The front left strap on the lift appeared to be frayed or damaged. During the transfer, the front left strap holding Resident #1, snapped and Resident #1 fell from the lift and hit his head on the floor.<BR/>During an observation and interview on 02/10/23 at 1:20 PM revealed Resident #1 was in his bed. There was a bandage on his forehead, above his left eye with a date of 02/10/23. There was a Hoyer lift Sling under him. The sling appeared to be in good condition with no frayed edges. Resident #1 said he was doing okay. He said he fell while staff attempted to transfer him from his wheelchair to his bed. Resident #1 said he did not remember much about what happened. He said all he remembered was the strap broke and he hit the floor. He said the next thing he remembered was being at the hospital. He said he did not feel he had been abused or neglected and what happened was an accident. Resident #1 said he was not afraid to be transferred with the Hoyer Lift.<BR/>During an interview on 01/17/23 at 1:20 PM, LVN A said he assisted LVN B with transferring Resident #1 with a Hoyer Lift on 02/05/23 around 8:30 PM. LVN A said while transferring Resident #1, a strap on the front left side of the lift snapped and Resident #1 fell to the floor and hit his head. LVN A said LVN B left the room and called 911 for assistance. LVN A said when he looked at Resident #1, there was blood on the floor coming from Resident #1's head. LVN A said she went and got a towel and applied pressure to the wound until EMS arrived and transported Resident #1 to the hospital for evaluation and treatment. LVN A said he did not realize the strip was damaged. LVN A said the cause of the accident was due to the defective strap. LVN A said he should have inspected the straps before he attempted to transfer Resident #1. LVN A said he was notified on 02/10/23 that he was suspended pending an investigation due to the incident. LVN A said he was scheduled to complete Mechanical Lift skills training before returning to work, but he had not yet received the training.<BR/>During an interview on 01/17/23 at 1:45 PM, LVN B said she and LVN A was asked to assist in transferring Resident #1 from his wheelchair to his bed because staff reported Resident #1 was being verbally and physically aggressive toward staff who attempted to transfer him to his bed. LVN B said she asked LVN A to assist in the transfer. LVN B said when she arrived in the room, there were three straps already attached to the lift and LVN A attached the fourth strap to transfer Resident #1. LVN B said she was operating the lift and LVN A lowered the bed to the lowest position. LVN B said the bed caught on the edge of a trash can at the foot of the bed when the bed was lowered. LVN B said she raised Resident #1 out of the wheelchair and LVN A was moving the wheelchair out of the way when she heard a snap. LVN B said the strap on the front left side of the sling holding Resident #1 broke and Resident #1 fell to the floor hitting his head. LVN B said she went to the door and yelled for help. LVN B said she called 911 on her cell phone and LVN A went and got a towel to stop the bleeding. LVN B said she did not notice the strap was damaged and if so, she would have not used the defective sling to transfer Resident #1. LVN B said she was notified on 02/10/23 by the DON she was suspended pending an investigation into the incident. LVN B said she should have assessed the condition of the straps before she attempted to transfer Resident #1. LVN B said since the incident she had received skills training on transferring using a Mechanical lift on 02/15/23. <BR/>During an interview on 02/10/23 at 12:12 PM, the DON said the first time she viewed the video was with the surveyor. DON said she had not reviewed the video of the incident with Resident #1 before this time. The DON said LVN A and LVN B failed to use proper technique when transferring Resident #1 with the Mechanical lift. The DON said staff should always assess the condition of the lift sling to ensure it was safe prior to use. The DON said it was obvious by viewing the video that the strap on the front left side was damaged and the sling should not have been used. The DON said after the incident she completed an assessment of all other lift slings in the building and found there were some that needed to be retired and new slings were ordered to replace the damaged slings. The DON said all staff received training to inspect the slings prior to use and if a sling showed signs of being defective or damaged the sling should not be used to transfer residents. The damaged sling should be reported to the charge nurse and the DON. The DON said the sling should be taken out of service and replaced with a new sling. The DON said all nursing staff would receive skills training with a check-off for each one on how to transfer a resident using a Mechanical lift. The DON said the skills training would be conducted by the DON and the Director of Rehabilitation. <BR/>During an interview on 02/10/23 at 12:08 PM, the Administrator said she was notified Resident #1 had a fall from a Mechanical lift on 02/05/23 around 8:30 PM. The Administrator said the cause was a damaged strap that broke which caused injury to Resident #1. The Administrator said she reported the incident to the state on 02/05/23 at around 9:45 PM. The Administrator said all the slings and straps in the facility were assessed by the DON for possible damage and those found to be damaged were removed from service immediately. The Administrator said new slings were ordered to replace the damaged slings. The Administrator said on 02/06/23 an intervention plan was developed by QAPI regarding the Hoyer Lift issue. The Administrator said all staff were in-serviced on inspecting the straps and slings before use. The Administrator said the DON would monitor and inspect slings and straps weekly to ensure they were in good condition. The Administrator said any slings found to be damaged would be removed from service and replaced. The Administrator said all nursing staff would receive skills training on how to properly operate the Mechanical Lift. The Administrator said the skills training would be conducted by the DON and Director of Rehabilitation. <BR/>An observation and interview on 02/10/23 at 1:45 PM revealed NA-A, NA-B and NA-C using a Hoyer lift to transfer Resident #1 from his bed to his wheelchair. NA A and NA B used proper technique in transporting the resident. Transfer was successfully completed with no concerns for Resident #1's safety. The equipment and sling were in good working order with no concerns. NA-A, NA-B and NA-C said they had recently received in-service training on safely using the Hoyer lift. They said they were to assess the condition of the sling and straps before using to transfer a resident. They said if the sling or straps were damaged, they were not to use them and report to the charge nurse and/or the DON.<BR/>Interview on 02/10/23 at 1:30 PM, the Laundry Aide said she washed two to three Hoyer Lift slings daily. She said she followed the manufacturer's suggested care instructions. She said the slings were washed in cold to warm water, but never hot water. She said all slings were hung to air dry and slings were never dried in the dryer. She said heat could cause the material to stretch or become weak.<BR/>Record review of Sling Laundry Instructions revealed .While the materials comply with applicable standards for strength, shrinkage and flammability, slings are subject to wear and tear, which increases with usage. Before each use check for fraying or cuts/tears in the straps and body of the sling. Slings that show wear or damage should be taken out of service . LAUNDRY INSTRUCTIONS: . Machine wash normal setting and at 140F/60C. Depending on the washing machine, this usually means on a medium temperature setting.<BR/>Record review of in-service records from 02/06/23 through 02/17/23 revealed documentation that nursing staff received training on 10/17/22. Staff received in-service training on laundry instructions of Hoyer Lift Slings. The in-service was conducted by the Housekeeping Supervisor. After washing the Hoyer Lift sling, you cannot put heat on it. The sling needs to air dry or put in the dryer with no heat. The fabric when heated can stretch and snap! This will cause an injury. This will be an automatic [NAME]!<BR/>Record review of in-service records revealed on 02/06/23 nursing staff received in-service training on Hoyer Lift transfer. <BR/>o <BR/>Must have 2 nursing staff (CNA, Nurse, Medication Aide) to use a Hoyer lift on a resident. <BR/>o <BR/>Always check sling and sling straps to verify they do not appear compromised.<BR/>o <BR/>If there is any question, have nurse verify it is okay to use. <BR/>o <BR/>DO NOT USE A DAMAGED SLING Under any circumstances.<BR/>Record review of Mechanical lift Competency Evaluations dated 02/10/23 - 02/17/23, showed staff using a Hoyer life to transfer residents received a skills assessment on using a Mechanical Life to transfer residents safely. <BR/>Record review of the facility's, undated, policy on Hydraulic lift revealed: . The resident will achieve safe transfer to bed or chair via mechanical lift device . The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift .23. Immediately remove any malfunctioning equipment from direct care use. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services that assure acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of 4 residents (#36, #59, #85, #238) of 11 residents whose medications were reviewed for administration.<BR/>The facility failed to administer Residents #36, #59, #85, and #238's morning medication within the recommended time frames. <BR/>These failures could place residents at risk of adverse medical outcomes as a result of not receiving physician ordered medications in a timely manner, and at risk of not receiving the intended therapeutic benefit of their medications.<BR/>The findings included:<BR/>1. <BR/>Record review of Resident #36's Order Summary Report dated 07/27/22 indicated that resident was an [AGE] year-old male who admitted to the facility, in the secure unit, on 05/02/2022 with the diagnosis of Alzheimer's, Dementia, Muscle wasting and atrophy, hypertension (high blood pressure), cerebral infarction (disruption in blood flow causing a stroke), Congestive heart failure, and restless and agitation. The Order Summary report also indicated that Resident #36 was prescribed, Aspirin 325mg tablet 1 tablet one time a day related to Cerebral infarction on 05/02/2022, Carvedilol 3.125mg tablet 1 tablet two times a day for hypertension on 05/02/2022, Divalproex Sodium Capsule delayed release sprinkle 125mgcapsule 2 capsules two times a day 07/08/2022, Finasteride 5mg tablet 1 tablet one time a day for benign prostatic hyperplasia on 05/02/2022, Furosemide 80mg tablet 1 tablet one time a day for edema (swelling) on 05/02/2022, and Namenda 10mg tab two times a day for Alzheimer's on 05/02/2022. <BR/>Record review of Resident #36's Quarterly MDS dated [DATE] indicated that resident had a BIMS score of 00, which indicated resident had severe cognitive impairment. <BR/>Record review of Resident #36's undated current Care Plan indicated The resident has a diagnosis of hypertension with interventions to educate resident/family/caregiver .give anti-hypertensive medications as ordered . The resident has potential to demonstrate verbally abusive behaviors with interventions assess and anticipates resident's needs .The resident is on diuretic therapy r/t CHF (congestive heart failure) with interventions to give medication as ordered .<BR/>Record review of the Medication Admin Audit Report dated 07/26/2022 indicated that Divalproex Sodium capsule delayed release sprinkle 125mg 2 caps were scheduled on 07/26/2022 at 0630 and administered on 07/26/2022 at 11:28 AM by LVN K, Aspirin tablet 325mg 1 tablet was scheduled on 07/26/2022 at 0630 and administered on 07/26/2022 at 11:28 AM by LVN K, Furosemide tablet 80mg 1 tablet was scheduled on 07/26/2022 at 0630 and administered on 07/26/2022 at 11:28 AM by LVN K, Finasteride tablet 5mg 1 tablet was scheduled on 07/26/2022 at 0630 and administered on 07/26/2022 at 11:28 AM by LVN K, Carvedilol tablet 3.125mg tablet 1 tablet was scheduled on 07/26/2022 at 0800 and administered on 07/26/2022 at 11:28 AM by LVN K, and Namenda tablet 10mg tablet 1 was scheduled on 07/26/2022 at 0800 and administered on 07/26/2022 at 11:28 AM by LVN K. <BR/>2. <BR/>Record review of Resident #59's Order Summary Report dated 07/27/2022 indicated that resident was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnosis of persistent mood disorder, pain, hypertension (high blood pressure), anxiety disorder, and pseudobulbar affect (nervous system disorder). The Order Summary Report also indicated that Resident #59 was prescribed Aspirin 81mg tablet 1 tablet one time a day for preventative on 12/20/2021, Cholecalciferol 1000 unit tablet 2 tablets one time a day for preventative on 12/20/2021, Depakote Sprinkles capsule 125mg 2 capsules four times a day for persistent mood disorder on 04/29/2022, Escitalopram Oxalate 20mg tablet 1 tablet one time a day for persistent mood disorder on 03/24/2022, Fluticasone propionate suspension 50mcg/act 1 spray each nostril two times a day for allergies on 12/30/2021, Gabapentin 300mg capsule 1 capsule one time a day for nerve pain on 12/30/2021, GNP Vitamin C 500mg tablet 2 tablets one time a day for supplement on 12/30/2021, Lisinopril 5mg tablet 1 tablet one time a day for hypertension on 12/30/2021, Lorazepam 0.5mg tablet 1 tablet two times a day for anxiety on 07/16/2022, Metoprolol Tartrate 12.5mg tablet 1 tablet two times a day for hypertension on 12/30/2021, Nuedexta 20-10mg capsule 1 capsule two times a day for pseudobulbar affect on 02/23/2022, and Tylenol Extra strength 500mg tablet 1 tablet two times a day for pain on 07/12/2022.<BR/>Record review of Resident #59's Annual MDS dated [DATE] indicated that resident sometimes made herself understood and sometimes understood others. Resident #59 could not complete a BIMS assessment related to moderately impaired cognition. <BR/>Record review of Resident #59's Care Plan last reviewed 07/25/2022 indicated The resident requires psychotropic medication: Receives antipsychotic, antidepressant, and antianxiety .Interventions include administer medications as ordered. Monitor for side effects and effectiveness .The resident has potential for demonstrate physical behaviors r/t dementia .The resident has a psychosocial well-being problem r/t anxiety . The resident is on pain medication r/t nerve pain with interventions to administer medications as ordered . The resident has impaired cognitive function/dementia with interventions to administer meds as ordered .The resident has hypertension with interventions to give anti-hypertensive medications as ordered .The resident has edema with a goal that the resident's fluid balance will improve or not worsen through the next review date. Interventions included administer medications as ordered .<BR/>Record review of Resident #59's Medication Admin Audit Report indicated that Aspirin 81mg tab 1 tablet was scheduled for 0630 and administered at 11:16AM by LVN K, Gabapentin 300mg tab 1 capsule was scheduled for 0630 and administered at 11:15AM by LVN K, Cholecalciferol 1000 unit tablet 2 tablets were scheduled for 0630 and administered at 11:15AM by LVN K, Fluticasone Propionate suspension 50mcg/act 1 spray to each nostril was scheduled for 0630 and administered at 11:15AM by LVN K, Lisinopril 5mg tab 1 was scheduled for 0630 and administered at 11:16AM by LVN K, Metoprolol tartate 12.5mg tablet 1 tablet was scheduled for 0630 and administered at 11:15AM by LVN K, Escitalopram oxalate 20mg tablet 1 tablet was scheduled for 0630 and administered at 11:15AM by LVN K, Nuedexta 20-10mg capsule was scheduled for 0630 and administered at 11:16AM by LVN K, Tylenol extra strength 500mg tablet 1 tablet was scheduled for 0800 and administered at 11:16AM by LVN K, Lorazepam 0.5mg tablet 1 tablet was scheduled for 0800 and administered at 11:16AM by LVN K, Depakote sprinkles 125mg capsule 2 capsules were scheduled for 0800 and administered at 11:16AM by LVN K, Depakote sprinkles 125mg capsule 2 capsules were scheduled for 12:00PM and administered at 11:16AM by LVN K.<BR/>3. <BR/>Record review of #85's Order Summary Report dated 07/27/2022 indicated that resident was an [AGE] year-old female who admitted to the facility on [DATE] and on to the secure unit on 04/10/2019 with the diagnosis of Hypertension (high blood pressure), dementia with behavior disturbances, myocardial infarction (heat attack), diabetes, depression, and pain. The Order Summary Report also indicated that Resident # 85 was prescribed Amlodipine 5mg tablet 1 tablet one time a day for hypertension on 05/07/2021, Aspirin EC 81mg delayed release 1 tablet one time a day for myocardial infarction on 01/11/2019, Cranberry 450mg tablet 2 tablets two times a day for a supplement on 01/11/2019, Cyanocobalabine 100mcg tablet 1 tablet one time a day for a supplement on 01/11/2019, Depakote ER 250mg tablet 1 tablet two times a day for dementia on 01/24/2022, Docusate Sodium 100mg tablet 1 tablet one time a day for constipation on 01/11/2019, Fenofibrate 145mg tablet 1 tablet one time a day for myocardial infarction on 01/11/2019, Lorazepam 0.5mg tablet 1 tablet one time a day for anxiety on 01/24/2022, Losartan 50mg tablet 1 tablet two times a day for hypertension on 01/14/2020, Meloxicam 15mg tablet 1 tablet one time a day for pain on 04/04/2022, Metformin 500mg tablet 1 tablet one time a day for diabetes on 04/04/2022, Metoprolol tartate 25mg tablet 1/2 tablet two times a day for hypertension on 05/07/2021, Miralax powder 17GM in water one time a day for constipation on 01/11/2019, Vesicare 5mg tablet 1 tablet one time a day for overactive bladder on 01/11/2019. <BR/>Record review of Resident #85's annual MDS dated [DATE] indicated that Resident #85 Had a BIMS score of 3 that indicated the resident had severely impaired cognition. <BR/>Record review of Resident #85's Care Plan last reviewed on 07/25/2022 indicated that The resident is on anticoagulant therapy for the disease process of myocardial infarction .The resident has a psychosocial well-being problem r/t anxiety .The resident has constipation at risk for complications with interventions to administer medications as ordered .The resident has diagnosis of depression with interventions to administer medications as ordered .The resident has diabetes mellitus with interventions to give diabetes medications as ordered by doctor .The resident requires psychotropic medications for depression and anxiety with interventions to administer medications as ordered .The resident has hypertension/hyperlipidemia at risk for complications with interventions to give anti-hypertensive medications as ordered .<BR/>Record review of Resident #85's Medication Admin Audit Report indicated that Lorazepam 0.5mg tablet 1 tablet was scheduled for 06:30 AM and administered at 11:42 AM by LVN K, Metformin 500mg tablet 1 tablet was scheduled for 0630 and administered at 11:43AM by LVN K, Meloxicam 15mg tablet 1 tablet was scheduled for 0630 and administered at 11:43AM by LVN K, Omeprazole 20mg tablet 1 tablet scheduled for 0630 and administered at 11:43AM by LVN K, Losartan 25mg tablet 1 tablet was scheduled for 0630 and administered at 11:42AM by LVN K, Metoprolol tartate 25mg tablet &frac12; tablet was scheduled for 0630 and administered at 11:43AM by LVN K, Cyanocobalamine 100mcg tablet 1 tablet was scheduled for 0800 and administered at 11:30AM by LVN K, Aspirin 81mg EC tablet 1 tablet was scheduled for 0800 and administered at 11:30AM by LVN K, Cranberry 450mg tablet 1 tablet was scheduled for 0800 and administered at 11:30AM by LVN K, Docusate sodium 100mg tablet 1 tablet scheduled for 0800 and administered at 11:30AM by LVN K, Fenofibrate 145mg tablet 1 tablet was scheduled for 0800 and administered at 11:42AM by LVN K, Vesicare 5mg tablet 1 tablet was scheduled for 0800 and administered at 11:43AM by LVN K, Miralax powder 17GM in water was scheduled for 0800 and administered at 11:43AM by LVN K, Depakote ER 250mg tablet 1 tablet was scheduled for 0800 and administered at 11:42AM by LVN K. <BR/>4. <BR/>Record review of Resident #238's Order Summary Report dated 07/27/2022 indicated that resident was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnosis of Parkinson's, Alzheimer's, Heart disease, high blood pressure readings, and pain. The Order Summary Report also indicated that Resident #238 was prescribed Amlodipine 10mg tablet 1 tablet one time a day for Hypertension on 05/19/2022, Aspirin EC 81mg delayed release tablet 1 tablet one time every other day for heart disease on 05/19/2022, Docusate sodium tablet 1 tablet one time a day for constipation on 05/19/2022, Hydralazine HCl 50mg tablet 1 tablet two times a day for elevated blood pressure readings on 05/19/2022, Losartan Potassium HCTZ 100-25mg tablet 1 tablet one time a day for elevated blood pressure readings on 05/19/2022, and Potassium Chloride ER 20MEQ tablet 2 tablets one time a day for hypokalemia (low potassium labs) on 05/19/2022. <BR/>Resident #238 was admitted for respite care and did not have a care plan nor an MDS. <BR/>Record review of Resident #238's Medication Admin Audit Report dated 07/27/2022 indicated that Amlodipine 10mg tablet 1 tablet was scheduled for 0630 and administered at 11:35AM by LVN K, Docusate sodium tablet 1 tablet was scheduled for 0630 and administered at 11:35AM by LVN K, Potassium Chloride 20 MEQ tablet 2 tablets were scheduled for 0630 and administered at 11:35AM by LVN K, Losartan Potassium 100-25mg tablet 1 tablet was scheduled for 0630 and administered at 11:35AM by LVN K, and Hydralazine HCL 50mg tablet 1 tablet was scheduled for 0630 and administered at 11:35AM by LVN K. <BR/>During observation and interview on 07/25/2022 10:10AM with the ADON, she said the facility had a liberalized medication pass for all medications. The ADON provided a form that read the morning medication pass was from 6:30 A-10:30 A, the evening medication pass was from 6:30 P-10:30 P, BID (twice a day medications) are 09:00A, 09:00P, TID (three times a day medications) are 09:00A, 03:00P, 09:00P, and QID (four times a day medications) are 09:00A, 01:00P, 05:00P, 09:00P. <BR/>During an interview on 07/26/2022 at 10:13 AM, LVN K said the medication aide was late that morning of 07/26/2022 and she did not find out until 9AM that she had to pass her own pills. She said she knew this could cause problems with the residents getting medications late, but she had to pass them correctly as she was going down the hall. LVN K said if she had known the medication aide was not going to be at work, she would have started passing her medications earlier on the morning of 07/26/2022. LVN K said the facility used a Liberalized medication administration. Medication should be given Mornings between 0630AM-1030AM and Nights between 0630PM-1030PM. <BR/>During an interview on 07/27/2022 at 02:45 PM, the Administrator said that no one had been notified of the medication aide being late for work or not being in the facility. She said LVN K should have notified management that there was no medication aide in the secure unit. She said she expected the medications to be passed in a timely manner to prevent complications. The Administrator said she usually would have checked the schedules to see who was in the building for that day, but she was too busy and never got around to it on that day. The Administrator said the nurse was responsible for making sure all staff working under her was there. <BR/>Record review of the Policy for Medication Administration Procedures revised 10/25/2017 indicated 1. All medications are administered by licensed medical or nursing personnel .9. Defining schedules for administering medications to: Maximize effectiveness (optimal therapeutic effect) of medication, Prevent potential significant medication interactions .20. The five rights of medication should be adhered to 1. Right drug 2. Right dose 3. Right resident 4. Right time 5. Right route

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain grooming and personal hygiene for 3 of 19 residents reviewed for ADLs. (Resident #'s 7, 17, and 34)<BR/>The facility failed to provide assistance with facial hair removal for Resident #'s 7 and 34.<BR/>The facility failed to ensure Resident #17 was routinely showered.<BR/>The facility failed to ensure Resident #7's fingernails were cleaned and trimmed. <BR/>The facility failed to ensure Resident #7's teeth were brushed.<BR/>The facilty did not provide Resident #34 timely incontinent care. Resident #34 was found heavily saturated in urine with three brown colored rings on the linen. <BR/>These failures could place residents who were dependent of staff to perform personal hygiene at risk for embarrassment, decreased self-esteem, or decreased quality of life.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 7/26/2022 indicated Resident #7 was a [AGE] year-old female admitted on [DATE] with the diagnoses of Parkinson's disease (disease causing tremors), muscle weakness, and chronic pain.<BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #7 was understood and understands others. The MDS indicated Resident #7's BIMS score was 15 indicating no cognitive deficit. The MDS indicated Resident #7 required extensive assistance of one staff for her personal hygiene (Personal hygiene according to the MDS was combing hair, brushing teeth, shaving, apply makeup, washing/drying face and hands).<BR/>. <BR/>Record review of a comprehensive care plan with review date of 5/12/2022 indicated Resident #7 had an ADL self-care performance deficit. The goal was Resident #7 would maintain or improve her current level of function in personal hygiene. The approach included assisting with personal hygiene as required: hair, shaving, and oral care as needed. During bathing, to check nail length and clean on bath day and as necessary. If the resident was a diabetic, the nurse will provide toenail care. <BR/>Record review of a bath sheet indicated Resident #7 received a bed bath on 7/1/2022, 7/4/2022, 7/6/2022, 7//8/2022, 7/11/2022, 7/15/2022, 7/18/2022, 7/20/2022, and 7/25/2022. Resident #7 did not receive her bath on 7/13/2022 and 7/22/2022. Resident #7's shower days were Monday, Wednesday and Friday on 2:00 p.m. to 10:00 p.m. shift.<BR/>During an observation on 7/25/2022 at 10:16 a.m., Resident #7 had white facial hair to the left side of her chin &frac12; inch in length. Resident #7's fingernails were a half inch long with a brown colored material underneath them.<BR/>During an observation and interview on 7/26/2022 at 8:31 a.m., Resident #7 continued to have white facial hair to the left side to her chin measuring &frac12; inch in length. Resident #7's fingernails continued to be long with a brown colored material underneath them. Resident #7 said her teeth have not been brushed and she did not have a bath yesterday. Resident #7 said she felt dirty. Resident #7 said she had not had a shower in a month.<BR/>During an interview on 7/26/2022 at 10:17 a.m., CNA B indicated the nurse aides were responsible for ADLs. CNA B indicated ADLs included bathing, brushing teeth, shaving, and cleaning fingernails. <BR/>2. Record review of a face sheet dated 7/26/2022 indicated Resident #17 was an [AGE] year-old female admitted on [DATE] with the diagnoses of Alzheimer's dementia (a memory disease), depression and Bipolar disorder (a mood mental illness).<BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #17's BIMS Score was a 14 indicating intact cognition. The MDS indicated Resident #17 required physical of one staff member to assist with the transfer only for bathing.<BR/>Record review of a comprehensive care plan last reviewed/revised on 7/26/2022 indicated Resident #17 had an ADL self-care performance deficit. The care plan indicated the goal was to maintain or improve Resident #17's current function with the assistance of one staff with bathing. <BR/>Record review of the undated shower schedule indicated the right side of a hall was Monday-Wednesday-Friday and the left side of the hall was Tuesday-Thursday-Saturday. The shower schedule also indicated (A) bed received their shower on 6:00 a.m.- 2:00 p.m. shift and (B) bed received their showers on 2:00 p.m. to 6:00 a.m. Resident #17's room was on the right side of the hall in the A bed.<BR/>Record review of the computerized bathing tasks sheet dated 7/26/2022 indicated from July 1, 2022 through July 25, 2022 Resident #17 had 11 opportunities for bathing and it was documented she received 6 showers. Resident #17's shower days were Monday, Wednesday and Friday on 6:00 a.m. to 2:00 p.m. The coded reason for no shower was the activity did not occur.<BR/>During an interview on 7/25/2022 at 10:29 a.m., Resident #17 voiced it had been almost a week since she had a shower. She indicated today was her shower day.<BR/>During an interview on 7/26/2022 at 8:20 a.m., Resident #17 said she did not receive a bath yesterday. Resident #17 said no one even offered. Resident #17 indicated not receiving her bathes hurts her self-esteem and she feels neglected. Resident #17 said she did not have an issue with African American females providing care for her.<BR/>During an interview on 7/26/2022 at 8:25 a.m., CNA B indicated Resident #17 does not prefer African American CNAs to provide care this is why she does not provide Resident #17 a shower. CNA B said CNA D bathes Resident #17. <BR/>During an interview on 7/26/2022 at 11:17 a.m., CNA D indicated the last time she bathed Resident #17 was the previous Wednesday July 20, 2022.<BR/>During an interview on 7/26/2022 at 3:00 p.m., Resident #17 said she did not have a preference on African American CNAs bathing her.<BR/>During an interview on 7/27/2022 at 8:14 a.m., Resident #17 indicated she had not had a shower.<BR/>During an interview on 7/27/2022 at 12:50 p.m., Resident #17 indicated she had not had a bath yet today.<BR/>During an interview on 7/27/2022 at 1:35 p.m., the Corporate nurse indicated she would ensure Resident #17 was showered. <BR/>3Record review of a face sheet dated 7/27/2022 indicated Resident #34 was a [AGE] year-old female admitted on [DATE] and readmitted [DATE] with the diagnoses of heart failure, depressive disorder, and anxiety.<BR/>Record review of an admission MDS dated [DATE] indicated Resident #34 understands and was understood. The MDS indicated she required no cueing with recall and her BIMS score was 13 indicating intact cognition. The MDS indicated nearly every day she felt down, depressed, and hopeless. The MDS indicated Resident #34 was always incontinent of urine and required limited assistance of one staff with toileting.<BR/>Record review of a comprehensive care plan dated 7/25/2022 indicated Resident #34 had an ADL self-care deficit with a goal of maintaining or improvement in the current level of function. The interventions were to assist with toileting use. The interventions were to assist with personal hygiene as required including hair, shaving, and oral care.<BR/>Record review of a computerized bath task sheet dated July,2022, Resident #34 received 9 out of the 11 baths scheduled. Resident #34 was marked as activity did not occur on 7/13/2022 and 7/22/2022. Resident #34's shower days were Monday, Wednesday, and Friday on the 2:00 p.m. to 10:00 p.m. shift.<BR/>During an observation and interview on 7/25/2022 at 10:03 a.m., Resident #34 had short white facial hairs &frac14; inches long covering her entire chin. Resident #34 said she did not like having facial hair.<BR/>During an observation on 7/26/2022 at 8:13 a.m., Resident #34 pulled back her top linen and exposed she was lying on urine that had started drying and left behind a brown colored ring.<BR/>During an interview on 7/26/2022 at 11:29 a.m., CNA C indicated she provided Resident #'s 7 and #34 a bed bath the night before. CNA C indicated she did not clean Resident #7's fingernails nor did she remove her facial hair. CNA C indicated she did not remove Resident #34's facial hair. CNA C indicated she should have provided this care. CNA C indicated dirty fingernails and facial hair on a woman could affect their self-esteem. CNA C indicated she should have provided the nail care and provide shaving.<BR/>During an observation and interview on 7/26/2022 at 11:40 a.m., Resident #34 pulled back the linen on the left side of her bed. She revealed she was lying on a draw sheet with a visible brown ring. As Resident #34 turned over in her bed, the bottom sheet had two distinct brown rings of various stages of dried urine. Resident #34 indicated she had not been changed since early this morning. <BR/>During an observation and interview on 7/26/2022 at 11:50 a.m., Resident #34 revealed to LVN A the saturation of urine she was lying in. LVN A said she expected the CNAs to change the residents at frequent intervals. LVN A indicated she was in charge of Resident #34's care. LVN A said Resident #34 could have skin problems and dignity issues from being left in urine. LVN A indicated the CNAs were responsible for ADLs. LVN A indicated the nurse was responsible for ensuring ADLs were completed. LVN A said she expected the CNAs to complete the ADLs as scheduled. LVN A indicated not being bathed, shaved, and nail clean could lead to skin issues and dignity issues.<BR/>During an interview on 7/26/2022 at 2:15 p.m., CNAs B and E indicated they have been working short staffed today. CNAs B and E indicated they had been assigned to assist on other halls today including B-Hall. CNAs B and E indicated they had not had the time to change everyone on B-Hall including Resident #34. CNA B and E indicated Resident #34 should be assisted with incontinent care every two hours. CNA E indicated the residents should be shaved, nails cleaned, and teeth brushed every day. CNA E indicated she tried every day she works to complete the tasks but due to staff shortages the workload was too much to complete all the tasks.<BR/>During an interview on 7/27/2022 at 3:39 p.m., the Corporate DON indicated ideally the brown rings of urine should not happen. The Corporate DON indicated Resident #34 should have been changed timelier to prevent the brown rings. The Corporate DON indicated all nursing was responsible for ensuring a resident had timely incontinent care even she could change a resident. The Corporate DON indicated incontinent care was monitored with random rounds and failure to complete incontinent care timely could lead to dignity, health, and skin issues. The Corporate nurse indicated she expected the showers to be completed as scheduled. The Corporate nurse indicated she expected shaving to occur during bath days or as needed. She indicated she expected the resident's teeth to be brushed at least morning and night. The Corporate nurse indicated the lack of ADLs affects the resident's quality of life and dignity. The Corporate nurse indicated the nursing management was responsible for ensuring ADL compliance. The Corporate nurse indicated anyone could provide ADLs to these residents including herself.<BR/>During an interview on 7/27/2022 at 4:03 p.m., the Administrator indicated her expectation was that incontinent care was provided every 2 hours or as needed. The Administrator indicated the charge nurses were responsible to ensure incontinent care was provided timely. The Administrator indicated provision of incontinent care was monitored with every two-hour round, Champion rounds (rounds made by assigned management), and ADL documentation. The Administrator indicated the resident could have issues with dignity, skin break down and infections related to untimely incontinent care. An incontinent care policy was requested but not provided. The Administrator indicated she expected the residents to be bathed and shaved at least three times weekly. She indicated she expected oral care at least two times daily. The Administrator indicated due to the staffing challenges with numerous positions open she asked the residents to be flexible with bathing on the day shift when the facility was better staffed. The Administrator indicated the second shift after 5:00 p.m. were limited on staffing. <BR/>Record review of a Bath, Tub/Shower policy dated 2003 indicated bathing by tub bath or shower was done to remove soil, dead epithelial cells, microorganisms from the skin and body odor to promote comfort cleanliness, circulation, and relation. The goals were the resident would experience improved comfort and cleanliness by bathing.<BR/>Record review of a Shaving Policy dated 2003 indicated shaving of the male resident could be performed with an electric or safety razor. It is usually done as a part of daily personal hygiene, although every other day is sufficient for some based on the beard growth. Shaving is done to promote cleanliness and positive body image. <BR/>Record review of Teeth care/Oral hygiene policy dated 2003 oral and teeth care was the removal of soft plaque and food particles, bacteria, and odors to promote physical and psychological comfort. The resident will receive mouth care at least daily.<BR/>Record review of a Nail Care policy dated 2003 indicated nail management was the regular care of the toenails and fingernails to promote cleanliness and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received and consumed foods with the appropriate form as prescribed by the physician for 1 of 13 residents (Resident #35) reviewed for 1 of 1 lunch meal observed in that: <BR/>Resident #35 was served regular apple pie on 7/25/2022 when her physician's order indicated she was to be on puree diet.<BR/>This failure could place residents who consume pureed foods at risk for choking. <BR/>Findings included:<BR/>Record review of a face sheet dated 7/26/2022 indicated Resident #35 was a [AGE] year-old female admitted on [DATE] with the diagnoses dementia without behaviors, oropharyngeal phase dysphagia (swallowing problems occurring in the mouth or throat).<BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #35 was usually understood and usually understands. Resident #35's BIMS score was an 11 indicating moderately impaired cognitive impairment. The MDS indicated Resident #35 required extensive assistance of 1 staff for eating. The MDS under the section of Nutritional Approaches revealed Resident #35 was marked for having a mechanically altered diet.<BR/>Record review of the comprehensive care plan dated 6/09/2022 indicated Resident #35 had a diet order for a Pureed diet with a goal of having appropriate nutrition with the intervention of to serve the diet as ordered.<BR/>Record review of the consolidated physician orders dated 7/26/2022 indicated Resident #35 was to receive a pureed diet with regular liquids.<BR/>During an observation on 7/25/2022 at 12:40 p.m., Resident #35's lunch tray was served by CNA B. Resident #35 was served pureed bar-b-q pork, pureed tater tots, pureed carrots and regular textured apple pie. Resident #35's meal card indicated she should have a pureed diet. After surveyor intervention the Treatment Nurse removed Resident #35's lunch tray and returned with a tray of all pureed items including the dessert. The Treatment Nurse indicated Resident #35 should have not been served a regular pie on a pureed diet.<BR/>During an interview on 7/25/2022 at 1:50 p.m., LVN A indicated Resident #35 was ordered a pureed diet. She indicated the nurses were responsible for checking the tray cards for accurate diets. <BR/>During an interview on 7/27/2022 at 3:39 p.m., the Corporate DON indicated the nurses were responsible for checking the tray for the accurate diets. The Corporate DON indicated an audit of resident diet orders and the dining tray card data was completed in June. The Corporate DON indicated a resident could choke receiving the wrong diet consistency.<BR/>During an interview on 7/27/2022 at 4:03 p.m., the Administrator indicated the nurse should check the trays prior to a resident receiving the tray. She indicated a resident could choke receiving the wrong diet texture.<BR/>Record review of the Diet Manual dated 2014 indicated the pureed diet was a texture modification of regular or therapeutic diets, designed to provide adequate nutrition for those persons with choking tendencies or difficulty with swallowing due to facial paralysis or other illness. Pureed foods should be the consistency of applesauce or mashed potato consistency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 12 residents (Resident # 64, Resident #6, and Resident #54) reviewed for comprehensive person-centered care plans.<BR/>1.The facility failed to develop a care plan for Resident # 64's diagnosis of post-traumatic stress disorder (PTSD).<BR/>2.The facility failed to implement the care plan intervention to document Resident #6 meal intake.<BR/>3.The facility failed to update Resident #54's from at risk for falls to actual fall on his care plan.<BR/>4.The facility failed to update Resident #54's fall care plan interventions.<BR/>Findings included:<BR/>1.Record review of a face sheet dated 09/12/2023, indicated Resident #64 was a [AGE] year-old female admitted on [DATE] with the diagnoses of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), PTSD (a real disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), and congestive heart failure ( a long-term condition in which your heart can't pump blood well enough to meet your body's needs).<BR/>Record review of the quarterly MDS dated [DATE] indicated, Resident #64 had a BIMS of 14, which indicated little to no memory impairment. Resident #64 was coded as being understood and understanding others, Resident #64 was coded for feeling down, depressed/hopeless daily, trouble falling or staying asleep for 7 to 11 days, and feeling tired for 7-11 days. Resident #64 had a diagnosis of PTSD.<BR/>Record review of the care plan dated 08/20/2023 revealed no care plan for PTSD.<BR/>During an interview on 09/13/2023 at 1:15 p.m., the social service director (SSD) stated she was aware Resident #64 had a diagnosis of PTSD. The SSD stated Resident #64 was seen by the counseling services that visited the facility for her PTSD. The SSD stated Resident #64 should have a care plan for PTSD with the services provided by the facility as interventions. The SSD stated it was the responsibility of the MDS Coordinators to develop and implement the care plans related to diagnosis and MDS triggers.<BR/>During an interview on 09/13/2023 at 2:00 p.m., MDS Coordinator BB stated there was no care plan created for PTSD for Resident #64. MDS Coordinator BB stated all Care Area Assessments, diagnoses, and medications were care planned by the MDS Coordinators assigned to them. MDS Coordinator BB stated she was unsure how Resident #64's PTSD diagnosis was missed. MDS Coordinator BB was assigned to Resident #64.<BR/>During an interview on 09/13/2023 at 2:30 p.m., the DON stated she expected the MDS Coordinator's to address all diagnosis in the care plan. The DON stated Resident #64 had the diagnosis of PTSD since she was admitted in 2021 and it should not have been missed for that long. The DON stated the care plan was used to guide the care for each resident and not care planning a diagnosis can affect the type of care the resident received.<BR/>During an interview on 09/13/2023 at 3:00 p.m., the Administrator stated that the MDS Coordinator or the SSD should have care planned Resident #64's diagnosis of PTSD to show the facility was aware and was treating the resident for her PTSD.<BR/>2. Record review of a face sheet, dated 09/12/23, indicated Resident #6 was [AGE] year-old female and admitted on [DATE] with diagnoses including Type 2 diabetes (is a disease in which your blood glucose, or blood sugar, levels are too high), chronic kidney disease, stage 4 (the kidneys are moderately or severely damaged and are not working as well as they should to filter waste from your blood), cerebrovascular disease (refers to a group of disorders that affect the blood vessels and blood supply to the brain), and hypothyroidism (the thyroid gland can't make enough thyroid hormone to keep the body running normally). <BR/>Record review of an admission MDS assessment, dated 08/25/23, indicated Resident #6 was understood and understood others. The MDS indicated Resident #6 had a BIMS score of 11 which indicated moderately cognitive impairment and was independent for eating. The MDS assessment did not indicated Resident #6 had weight loss.<BR/>Record review of the care plan dated 08/23/23, with revision on 09/01/23, indicated Resident #6 had a diet order other than regular and is at risk for unplanned weight loss or gain. Intervention included encourage meal completion and document amount consumed, offer sub, if resident eats less than 50% or dislikes meal and offer supplement if residents continue to eat less than 50%. <BR/>Record review of Resident #6's Amount Eaten report ran on 09/13/23 for the last 20 days indicated no meal intake amount for:<BR/>*08/25/23: 9:00 am, 1:00 pm<BR/>*08/26/23: 9:00 am, 1:00 pm <BR/>*08/27/23: 9:00 am, 1:00 pm<BR/>*08/28/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>*08/29/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>*08/30/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>*08/31/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>*09/01/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>*09/02/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>*09/03/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>*09/04/23: 9:00 am, 1:00 pm<BR/>*09/05/23: 9:00 am, 1:00 pm<BR/>*09/06/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>*09/07/23: 6:00 pm<BR/>*09/08/23: 9:00 am, 1:00 pm<BR/>*09/09/23: 9:00 am, 1:00 pm<BR/>*09/10/23: 9:00 am, 1:00 pm<BR/>*09/11/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>*09/12/23: 9:00 am, 1:00 pm, 6:00 pm<BR/>Record review of Resident #6's weight record indicated:<BR/>*09/13/23 134 lbs. <BR/>*08/22/23 143.5 lbs.<BR/>During an interview and observation on 09/11/23 at 1:59 p.m., Resident #6 said she was admitted into the nursing home due to heart valve issues. She said she was trying to gain her strength so she could have heart surgery. Resident #6 said she did not care for the food, but she was a picky eater. She said occasionally a family brought her breakfast. On Resident #6's bedside table was an uneaten peanut butter and honey sandwich. Resident #6 said she did not eat much of lunch and gets sandwiches as a substitute. <BR/>During an interview and observation on 09/12/23 at 5:15 p.m., Resident #6 said she did not eat a lot today. She said her family had not brought her breakfast today. Resident #6 had 2 peanut butter and honey sandwiches on her bedside table. <BR/>During an interview and observation on 09/13/23 at 8:00 a.m., Resident #6 breakfast tray had 0-25% eaten. On Resident #6's breakfast tray was an unopen house supplement. She said she the house supplement tasted too sweet but if it had protein, she would start drinking them. She said she did not care for what was served for breakfast, but a family member was bringing her some food. <BR/>During an interview on 09/13/21 at 3:53 p.m., LVN F said she was assigned to Resident #6. She said the CNAs were responsible for documenting the amount the residents consumed. LVN F said all nursing staff had access to a resident's care plan. She said LVNs should ensure the CNAs documented the intake amounts. LVN F said LVNs should check the resident intake record before the end of the shift to ensure CNAs documented. She said CNAs should document 3 meals a day in the electronic charting system. LVN F said it was important to document meal intake amounts to monitor residents with poor intake or appetite as indicated by the care plan intervention. She said it could negatively affect the resident due to unknown significant weight loss or not presenting an adequate information for the nutritionist or doctor. LVN F said Resident #6 had a care plan problem for being at risk for weight loss and following the interventions were important. <BR/>During an interview on 09/13/23 at 4:35 p.m., SCNA G said she had worked at the facility in different departments but had been a SCNA for a couple of months. She said she worked the hall Resident #6 was on. SCNA G said she charted resident's amount eaten in the electronic charting system. She said CNAs were supposed to chart after every meal the percentage the resident ate. SCNA G said the LVNs were supposed to make sure CNAs documented intake amounts on residents. She said CNAs had access to the care plan problem and interventions. SCNA G said she could not recall Resident #6's intervention for her being at risk for unplanned weight loss. She said reviewing the interventions was important to know what the resident was supposed to have. She said it was important to chart the resident's intake amounts to know if they were not eating, tell if something was wrong, and know why the resident lost weight. SCNA G said not documenting meal intakes did not let the dietician know the resident's real intake amounts. She said if you did not know or follow the care plan interventions then residents could not get want, they needed. <BR/>During an interview on 09/13/23 at 4:40 p.m., the DON said she had been at the facility for 2 years. She said all nursing staff had access to view a resident's care plan. She said the CNAs were responsible for documenting the amount the residents consumed. The DON said LVNs should ensure the CNAs documented the intake amounts after every meal which was three times a day. She said following the care plan intervention to document meal intake amounts was important to know how much a resident ate, could indicate a change of condition, and it help monitor for weight loss. The DON said missed meal intake amounts would not paint a complete picture of the resident and the dietician would not have correct information to make accurate dietary recommendations. She said nursing administration should be doing random chart audits to ensure CNAs and LVNs were doing their responsibilities. The DON said the facility did not have a policy related to nutrition. the DON said she was responsible for the fall care plans. She said the fall care plans were normally updated 24-48 hours after an event or with assessments. The DON said it was important to have an updated or revised care plan because it was the resident's plan of care and to know what needed to be done to keep the resident safe. She said not updating a fall care plan placed residents at risk for falls and possible injury.<BR/>During an interview on 09/13/23 at 5:01 p.m., the ADM said CNAs or LVNs, whoever fed the resident was responsible for documenting meal intakes. She said the charge nurse at the end of the shift should review the chart to ensure charting was completed. The ADM said documentation of meal consumption should happen after every meal. She said the care plan interventions should be followed by all staff. The ADM said nursing staff had access to the care plan, but only certain staff members could update and revise it. She said if the intervention of documenting meal consumption was important because you would not know why the resident was lost weight, needed to obtain, or update resident's dislikes, likes, or preferences. The ADM said corporate ran reports on the percentage of electronic charting system entry. She said ADON L oversaw the process.<BR/>3. Record review of a face sheet dated 09/12/23 indicated Resident #54 was an [AGE] year-old male and admitted on [DATE], with a readmission on [DATE], with diagnoses including Alzheimer's disease with late onset (a progressive disease that destroys memory and other important mental functions), Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), insomnia (persistent problems falling and staying asleep), and pain. <BR/>Record review of a significant change MDS assessment, dated 08/31/23, indicated Resident #54 was understood and understood others. The MDS indicated Resident #54 had a BIMS score of 02 which indicated severe cognitive impairment and required extensive assistance for bed mobility, dressing, eating, toilet use, personal hygiene, and total dependence for transfer and bathing. The MDS indicated Resident #54 was not steady, only able to stabilize with staff assistance for surface-to-surface transfer (transfer between bed and chair or wheelchair). The MDS indicated Resident #54 used a wheelchair for a mobility device. The MDS indicated Resident #54 had a one fall since admission/entry or reentry or prior assessment with no injury. <BR/>Record review of Resident #54's fall event note, completed by RN K, dated 08/31/23 indicated an unwitnessed fall in the resident's room. Resident #54 was found lying on the floor at bedside. No injuries observed, Resident #54 denied pain. The fall event note indicated low bed was an intervention placed prior to this fall. The fall event note indicated additional interventions initiated in response to fall were floor mat and low bed.<BR/>Record review of a care plan dated 04/11/23, with revision date 06/11/23, indicated Resident #54 was at risk for falls due to confusion with gait and balance problems, and poor safety awareness. Intervention included anticipate and meet needs, be sure call light within reach and encourage to use it for assistance as needed, ensure resident wearing appropriate footwear when ambulating or mobilizing in wheelchair, and staff x2 assist with transfers (09/09/23). The care plan did not indicate added intervention of low bed and floor mat. The care plan did not indicate actual fall instead of at risk of falls. <BR/>During an observation on 09/11/23 at 2:06 p.m., Resident #54 was lying in bed with a hospital gown and 2 liters nasal cannula around his ears but not in his nose. Resident #54 had a fall mat beside his bed. <BR/>During an observation on 09/12/23 at 3:10 p.m., Resident #54 was lying in bed dressed in personal clothing and 2 liters nasal cannula in place. Resident #54 had a fall mat and low bed. <BR/>During an interview on 09/13/23 at 3:53 p.m., LVN F said Resident #54 had a fall on 08/31/23. She said she did not know for sure what Resident #54's fall interventions were without looking at the care plan. LVN F said Resident #54 did have fall mat and low bed. She said those intervention should be added to the care plan. LVN F said the DON updated care plans. She said care plan should be updated to reflect the current care the resident required. LVN F said a fall care plan that was not updated placed residents at risk for falls or not knowing when an intervention started to know if it worked. <BR/>During an interview on 09/13/23 at 4:35 p.m., SCNA G said CNAs had access to the care plan problem and interventions. She said Resident #54 had a fall mat and low bed. SCNA G said she did not know if those interventions were on the care plan. She said reviewing the interventions was important to know what the resident was supposed to have. SCNA G said if staff did not know the new interventions, residents could not get what they needed. She said not knowing the new intervention placed the resident at risk for falls and injuries. <BR/>During an interview on 09/13/23 at 4:40 p.m., the DON said she was responsible for the fall care plans. She said the fall care plans were normally updated 24-48 hours after an event or with assessments. The DON said it was important to have an updated or revised care plan because it was the resident's plan of care and to know what needed to be done to keep the resident safe. She said not updating a fall care plan placed residents at risk for falls and possible injury. <BR/>During an interview on 09/13/23 at 5:01 p.m. the ADM said she and the DON updated and revised care plans. She said updated or revised care plan interventions were important to ensure all current interventions were in place, determine if current interventions were working, and know if interventions needed to be added. The ADM said it could affect a resident's quality of care and new staff would not know how to care for the resident. She said the residents were at risk for getting hurt. <BR/>Record review of an undated facility's Comprehensive Care Planning policy indicated .they will develop and implement a comprehensive person-centered care plan for each resident .the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 1 of 22 residents (Resident #49) reviewed for respiratory care.<BR/>The facility failed to replace the oxygen filter that was damaged for Resident #49. <BR/>This failure could place residents at risk for of respiratory infections.<BR/>Findings included:<BR/>Record review of Resident #49's face sheet, dated 11/16/23 revealed a [AGE] year old female admitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a common lung disease that causes breathing problems and restricted airflow), Chronic Systolic Heart Failure (a condition where the left ventricle of the heart is unable to contract properly, resulting in less blood circulating throughout the body), Hyperlipidemia (a condition where there are abnormally high levels of lipids or fats in the blood.)<BR/>Record review of Resident #49's quarterly MDS assessment, dated 07/31/24, revealed Resident #49 had a BIMS of 10, which indicated moderate cognitive impairment. The MDS showed that Resident #49 received oxygen therapy during the assessment period. <BR/>Record review of Resident #49's care plan revealed a problem initiated on 8/3/21, The resident has Emphysema/COPD Give oxygen therapy as ordered by the physician.<BR/>During an observation and interview on 9/30/24 at 9:52 a.m. Resident #49's oxygen concentrator had an oxygen filter that was 90% missing. An oxygen filter was present but appeared to have been torn off. Approximately 90% of the oxygen concentrator intake did not have a filter in place.<BR/>During an interview on 10/2/24 at 11:09 a.m., the DON said that residents' oxygen concentrators require a filter on the machine per policy. She said that it was the responsibility of nurses to ensure that residents who use an oxygen concentrator have a clean and functioning filter. She said that not having a filter on the oxygen concentrator puts the residents at risk for the machine to stop functioning properly. <BR/>During an interview on 10/2/24 at 11:33 a.m., the ADM said they have a system in place to prevent residents from having dirty or missing filters for the oxygen concentrators. She said the maintenance supervisor is supposed to check these daily. She said that residents could be placed at risk of breathing in dust and bacteria if their oxygen concentrator was missing its filter. <BR/>Record review of facility policy titled Oxygen Administration revised in March of 2023 revealed that, The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen The resident will maintain an effective breathing pattern with administration of oxygen The resident will be free from infection 16. <BR/>Change or clean oxygen concentrator filters according to manufactures' recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 3 residents (Resident #5) reviewed for enteral nutrition. During a tube feeding on 08/20/25, Resident #5's head and torso were leaning over the left armrest of his Geri-chair for approximately 1 hour and 30 minutes, which resulted in aspiration pneumonia. An immediate jeopardy (IJ) was identified on 09/11/25 at 12:59 PM. The IJ template was provided to the facility on [DATE] at 2:01 PM. While the IJ was removed on 09/12/25 at 4:40 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm that is not immediate jeopardy with the potential for more than minimal harm because all staff had not been provided education on abuse and neglect, notification of changes in condition, and enteral feeding tube management. This failure could place residents with gastrostomy tube at risk for complications from feeding tube administration such as aspiration and pneumonia, serious injury, harm, impairment, and death. The findings included: Record review of the face sheet, dated 09/11/25, reflected Resident #5 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills), severe protein-calorie malnutrition (not getting enough protein or calories to meet the body's demands), gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), anorexia (loss of appetite), and dysphagia (difficulty swallowing). Record review of the quarterly MDS assessment, dated 07/30/25, reflected Resident #5 had unclear speech, was rarely/never understood, and was rarely/never able to understand others. Resident #5 had short-term and long-term memory problems. Resident #5 had no memory or recall ability and had severely impaired decision making skills. The MDS reflected Resident #5 had upper and lower extremity impairments to both sides which interfered with daily functions. The MDS reflected Resident #5 was dependent on staff for all his ADLs. Resident #5 used a feeding tube while a resident and also received a mechanically altered diet. The MDS reflected Resident #5 received 51% of more of his total calories through tube feeding. Record review of the comprehensive care plan, last reviewed 06/17/25, reflected Resident #5 required tube feeding related to anorexia and Alzheimer's disease. The interventions included: .the resident needs the head of bed elevated 30 degrees during and thirty minutes after tube feeding. The care plan further reflected Resident #5 had an ADL self-care deficit and required staff assistance x 1 with eating. Record review of the order summary report, dated 09/11/25, reflected Resident #5 had an order for regular diet and pureed texture with pudding consistency fluids, family member or nurse to assist with feeding. The order started on 08/26/25. During an observation of a video date and time stamped, 08/20/25 3:13 PM, revealed Resident #5 leaning over the left armrest of his Geri-chair. He was moaning and grunting, unable to lift his torso or head. At 3:16 PM, CNA G walks into the room, pulls his arm and ask him to sit up, and then walked out of the room. The interaction last approximately 45 seconds. Resident #5 returned to the same position within approximately 30 seconds after CNA G left the room. Resident #5 remained in the same position, where his head and torso were leaning over the left armrest for approximately 1 hour and 30 minutes. Resident #5 constantly moans and grunts during the video until LVN L sets up him with pillows and positioned him comfortably at 4:26 PM Record review of the progress notes reflected the following: On 08/21/25 at 4:03 AM, the note reflected Resident #5's family member requested a chest x-ray due to possible aspiration . due to positioning of resident in chair on previous shift.No signs or symptoms of aspiration [entry of solid or liquid material such as secretions, food, drink, or stomach contents from the mouth or stomach into the lungs] noted . head of bed elevated to 30 degrees. On 08/21/25 at 7:47 AM, the note reflected a response was received from the physician for a chest x-ray. On 08/22/25 at 3:29 AM, the note reflected Resident #5 was transferred to the hospital related to chest x-ray results findings indicated aspiration. Record review of Resident #5's diagnostic chest x-ray report, dated 08/21/25, reflected .reported gastrostomy tube [opening from the abdomen directly into the stomach] is not definitely visualized.air distended stomach.left basilar airspace disease [condition in which the lower lungs of the left lung collapse, preventing air exchange], likely atelectasis [collapse of lung or part of lung from lack of air in the air sacs] given elevation of the hemidiaphragm. Record review of the inpatient hospital record, dated 08/22/25, reflected Resident #5 arrived at the hospital at 4:04 AM via ambulance and was discharged back to the facility at 5:46 AM. The problems addressed was aspiration into airway, initial encounter. During an interview on 09/09/25 beginning at 2:38 PM, Resident #5's family member stated on 08/20/25 she had gone out to eat and did not watch the camera as she normally did. Resident #5's family member stated when she got home, she noticed a neck pillow was blocking the view of the camera, so she called the facility. Resident #5's family member stated she went back to review the video prior to the pillow blocking camera and noticed he had been leaning over his chair for about 2 hours. Resident #5's family member was concerned he may have aspirated so she requested a chest x-ray be performed. Resident #5's family member stated the chest x-ray showed aspiration pneumonia, and he was sent to the hospital. Resident #5's family member stated he was returned to the facility on antibiotics. Resident #5's family member stated the facility staff did not have enough help. Resident #5's family member stated she believed the incident would not have occurred if the facility had sufficient staffing because they would have been able to check on him more frequently. During an interview on 09/09/25 beginning at 10:55 AM, LVN M stated Resident #5's family member had requested that he go to the hospital because she was concerned about something that had occurred on the camera, and she believed he could have possibly aspirated. LVN M stated she notified the physician, and he was agreeable, so she sent Resident #5 to the hospital per the family member's request. LVN M stated Resident #5 had no signs or symptoms of aspiration, such as nasal drainage, shortness of breath, or wheezing. LVN M stated the facility had obtained the order for a chest x-ray, but it had not been completed before he was sent to the hospital, if she remembered correctly. LVN M stated Resident #5 did not return back from the hospital on her shift, so she was unaware of what he was treated for at the hospital. During an interview on 09/09/25 beginning at 11:50 AM, CNA G stated on 08/20/25 she was on the way to answer another resident's call light when she walked by Resident #5's room and noticed he was leaning over. CNA G stated she grabbed Resident #5 under the arm and elbow to sit him up. CNA G stated she sat Resident #5 up the best she could then proceeded to answer the call light. CNA G stated she was the only staff member assigned to her hallway and stated she never thought to check on him again because she had so much going through her mind. CNA G stated she was called later on to provide a statement of the incident. CNA G said she had just graduated CNA school about 4 months ago and was still learning things. CNA G stated grabbing someone by the arm was not the proper way to position them. CNA G stated the facility did provide her one-on-one education on proper positioning. CNA G stated looking back now she should have checked on Resident #5 sooner, but it was hard to recognize in the moment because of the staffing concerns. CNA G stated Resident #5 should have been positioned in a Fowler's position (upright) during a tube feeding. CNA G stated improperly positioning a resident during a tube feeding could result in aspiration. CNA G stated there were staffing concerns at the facility because no one wanted to work. CNA G stated the facility staff did not like the management staff. CNA G stated she had only worked at the facility since June 2025. CNA G stated at times she was the only CNA who was assigned to two halls, which was approximately 25 residents. CNA G stated she was unable to provide the care and services each resident required when she was scheduled alone. CNA G stated she felt rushed with the residents. CNA G stated management staff were aware of the staffing concerns but felt like nothing was addressed. CNA G stated management did not consistently help out on the floor. CNA G stated the DON would provide assistance to one resident because of the camera in the room, but most of the time when she asked for help the DON would say Let me find someone to help you. CNA G stated she normally works C-Hall (the secured unit) and is the only staff member scheduled. During an interview on 09/10/25 beginning at 9:22 AM, LVN L stated on 08/20/25 she was acting as charge nurse. LVN L stated she was on the secured unit completing the medication pass and providing care as there was no CNA assigned to the secured unit. LVN L stated a little while later, she had someone relieve her on the secured unit and she was walking down B Hall when she noticed Resident #5 was slumped over. LVN L stated Resident #5 was repositioned and placed in the bed. LVN L stated CNA G had not reported he had been improperly positioned or slumped over. LVN L stated Resident #5 had a runny nose and snot was coming out of his nose. LVN L stated Resident #5's shirt was changed because the snot had made his shirt wet. LVN L stated Resident #5 had a slight runny nose after the incident but was not acting abnormal. LVN L stated Resident #5 had no signs or symptoms of respiratory distress. LVN L stated being improperly positioned during a tube feeding could have caused aspiration pneumonia. LVN L stated she expected the CNAs to notify her if they needed help. LVN L stated she believed if the facility was adequately staffed, this incident would not have occurred. During an interview on 09/11/25 beginning at 1:02 PM, The Administrator stated the charge nurse was responsible for monitoring to ensure residents who required a tube feeding were positioned properly. The Administrator stated the ADON was responsible for educating and overseeing the nurses and CNAs. The Administrator stated she was at a training on 08/20/25 when Resident #5 was left improperly positioned during a tube feeding. The Administrator stated the DON called her and explained what happened. The Administrator stated she was able to review the incident and the video that was obtained the next day. The Administrator stated in the video Resident #5 laid slumped over in his chair for approximately an hour and half. The Administrator stated she completed the self-report to HHSC and started 30 minute monitoring for Resident #5. The Administrator stated if any issues with positioning were observed, he was repositioned. The Administrator stated the DON provided 1:1 education with CNA G regarding proper positioning. The Administrator stated it was important to ensure residents were properly positioned during tube feedings to prevent aspiration. Record review of the Enteral Nutrition policy, undated, reflected .problems with the administration of the tube feeding are monitored and corrected by nursing. The policy did not address positioning. The Administrator was notified on 09/11/25 at 1:59 PM that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 09/11/25 at 2:01 PM. The following plan of removal was submitted by the facility and accepted on 09/12/25 at 12:05 PM and included the following: Interventions:1. Resident #5 was assessed for proper positioning and signs of aspiration. No signs of a change in condition noted to any residents. Completed 9/11/25. 2. All residents on enteral feeds in the facility were assessed for proper positioning and signs of aspiration. All enteral feedings are in place according to orders. No additional changes in condition were noted that required notification to the MD. Charge Nurses, CNAs, and Med Aides will be responsible for monitoring the positioning of residents on enteral feedings throughout the shift at a minimum of every two hours. Clinical leadership will verify proper positioning of residents on enteral feedings during clinical rounds daily throughout the day. Clinical rounds will be documented on a monitoring tool. Completed 9/11/25. 3. The Administrator and DON were in-serviced 1:1 by the Regional Compliance Nurse and Area Director. Completed 9/11/25. a. Abuse and Neglect: Examples include failure to provide assistance with showers, changing clothes, meal trays, eating, positioning with enteral feeding, providing treatments, following MD orders, treating pain, administer medication, notifying MD of change in condition, provide adequate supervision to prevent falls or resident to resident altercations.b. Notification of Change in Condition: notify a MD and RP of all changes in conditions such as abnormal vital signs, new onset or worsening pain or injuries from incidents.c. Enteral Feeding Policy to include adequate positioning- HOB elevated to prevent the risk of aspiration. If a resident is not positioned with the HOB elevated during enteral feedings, the charge nurse will be notified immediately. This in-service includes the signs and symptoms of aspiration such as coughing, drooling, choking, fever, noisy breathing, shortness of breath or wheezing. 4. The medical director was notified of the immediate jeopardy citation by the administrator on 9/11/25. 5. An ADHOC QAPI meeting was held with interdisciplinary team including the medical director to discuss the immediate jeopardy and plan of removal. Completed on 9/11/25. In-services:1. The following in-services were initiated by Administrator, Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced as of 9/11/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completion date 9/11/25.a. Abuse and Neglect: Examples include failure to provide assistance with showers, changing clothes, meal trays, eating, positioning with enteral feeding, providing treatments, following MD orders, treating pain, administer medication, notifying MD of change in condition, provide adequate supervision to prevent falls or resident to resident altercations.b. Notification of Change in Condition: notify a MD and RP of all changes in conditions such as abnormal vital signs, new onset or worsening pain or injuries from incidents.c. Enteral Feeding Policy to include adequate positioning- HOB elevated to prevent the risk of aspiration. If a resident is not positioned with the HOB elevated during enteral feedings, the charge nurse will be notified immediately. This in-service includes the signs and symptoms of aspiration such as coughing, drooling, choking, fever, noisy breathing, shortness of breath or wheezing. On 09/12/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the immediate jeopardy (IJ) by: 1. Record review of the inpatient hospital record, dated 08/22/25, reflected Resident #5 arrived at the hospital at 4:04 AM via ambulance and was discharged back to the facility at 5:46 AM. The problems addressed was aspiration into airway, initial encounter. 2. Record review of Resident #5 Resident #16, Resident #20's progress notes, reflected an assessment was completed on 09/11/25 of the feeding tubes and no issues or concerns were identified. 3. During an observation on 09/12/25 at 12:33 PM, Resident #5 was positioned in semi-Fowlers (30 - 45-degree angle) position. No issues or concerns with feeding. No signs or symptoms of aspiration were observed. 4. During an observation on 09/12/25 at 12:34 PM, Resident #16 was positioned in semi-Fowlers position with sitter at bedside. No issues or concerns with feeding. No signs or symptoms of aspiration were observed. 5. During an observation on 09/12/25 at 12:35 PM, Resident #20 was positioned in semi-Fowlers position. No issues or concerns with feeding. No signs or symptoms of aspiration was observed. 6. Record review of the in-service training report, dated 09/11/25, reflected the DON and Administrator signed and received in-service training on abuse and neglect which included the following: examples such as failure to provide assistance with shower, changing clothes, meal trays, eating, positioning with enteral feeding, providing treatments, following physician orders, treating pain, administering medications, notify the physician of changes in condition, and providing adequate supervision to prevent falls or resident to resident altercations. It also included the abuse policy and procedure. 7. Record review of the in-service training report, dated 09/11/25, reflected the DON and Administrator signed and received in-service education on notifying physician of change in status which included the following: notifying the physician and responsible party of all changes in conditions such as pain or injuries from accidents. It also included the Notifying the Physician of Change in Status policy. 8. Record review of the in-service training report, dated 09/11/25, reflected the DON and Administrator signed and received in-service education on the enteral nutrition policy and procedure, which included: adequate positioning with the head of the bed elevated to prevent the risk of aspiration, notification of the charge nurse if a resident was improperly positioned, and signs or symptoms of aspiration such as coughing, drooling, choking, fever, noisy breathing, shortness of breath or wheezing. 9. During an interview on 09/12/25 at 3:08 PM, the Medical Director stated he was notified of the immediate jeopardy situations at the facility. He said he was notified by the Regional Compliance Nurse on 09/11/25 and it was discussed with plans being implemented. 10. During an interview on 09/12/25 at 4:05 PM, the DON stated she was provided 1:1 in-service education as follows: Abuse and neglect to include the types of abuse and examples of each. The DON stated that failure to provide care and services such as showers, wound treatments, adequate supervision, changing clothing, providing assistance with eating, and improper positioning with enteral feeding was considered neglect. Notification of changes in condition to include examples of resident change in condition such as new skin issues or increased or new pain. The DON stated a change in condition should be reported immediately. The DON stated the physician should be notified and an assessment completed. Enteral feeding policy to include adequate positioning. The DON stated residents would be checked for positioning at least every 2 hours by the CNAs, MAs, and nurses. The DON stated residents who received enteral nutrition should have the head of the bed elevated at least 30 degrees. The DON stated signs or symptoms of aspiration included: coughing, drooling, or wheezing. 11. During an interview on 09/12/25 at 4:14 PM, the Administrator stated she was provided 1:1 in-service education as follows: Abuse and neglect to include the types of abuse and examples of each. The Administrator stated that failure to provide care and services such as showers, wound treatments, adequate supervision, changing clothing, providing assistance with eating, and improper positioning with enteral feeding was considered neglect. Notification of changes in condition to include examples of resident change in condition such as new skin issues or increased or new pain. The Administrator stated a change in condition should be reported immediately. The Administrator stated the physician should be notified and an assessment completed. Enteral feeding policy to include adequate positioning. The Administrator stated residents would be checked for positioning at least every 2 hours by the CNAs, MAs, and nurses. The Administrator stated residents who received enteral nutrition should have the head of the bed elevated at least 30 degrees. The Administrator stated signs or symptoms of aspiration included: coughing, drooling, or wheezing. 12. During an interview on 09/12/25 at 4:26 PM, the Regional Compliance Nurse stated she provided all the 1:1 in-service education for the DON and Administrator. 13. Record review of the AD HOC QAPI meeting dated 09/11/25, reflected 12 members were in attendance. 14. Record review of the in-service training report, dated 09/11/25, reflected in-service education was provided to all staff on the abuse and neglect policy and procedure to include the following: examples such as failure to provide assistance with shower, changing clothes, meal trays, eating, positioning with enteral feeding, providing treatments, following physician orders, treating pain, administering medications, notify the physician of changes in condition, and providing adequate supervision to prevent falls or resident to resident altercations. There were 36 staff signatures. 15. Record review of the in-service training report, dated 09/11/25, reflected in-service education was provided to all staff on notifying physician of change in status which included the following: notifying the physician and responsible party of all changes in conditions such as pain or injuries from accidents. It also included the Notifying the Physician of Change in Status policy. There were 36 staff signatures. 16. Record review of the in-service training report, dated 09/11/25, reflected in-service education was provided to direct care staff on the enteral nutrition policy and procedure, which included: adequate positioning with the head of the bed elevated to prevent the risk of aspiration, notification of the charge nurse if a resident was improperly positioned, and signs or symptoms of aspiration such as coughing, drooling, choking, fever, noisy breathing, shortness of breath or wheezing. There were 22 staff signatures. 17. During interviews between 09/12/25 and 09/13/25, staff from all departments and all shifts to include: the AD, Medical Records, MDS Coordinator QQ, MDS Coordinator RR, [NAME] HH, [NAME] KK, [NAME] MM, Dietary LL, Dietary NN, DM, Housekeeper OO, Housekeeping Supervisor PP, RN P, RN T, LVN A, LVN M, LVN Q, MA B, MA Z, MA UU, CNA C, CNA G, CNA V, CNA SS, CNA TT, Speech Therapist VV, Director of Rehabilitation WW, COTA XX, COTA ZZ, and PTA YY were provided in-service education and were able to verbalize the following: Abuse and Neglect to include the types of abuse and examples of each. The staff were able to give examples of neglect which included: failure to provide assistance with shower, changing clothes, meal trays, eating, positioning with enteral feeding, providing treatments, following physician orders, treating pain, administering medications, notify the physician of changes in condition, and providing adequate supervision to prevent falls or resident to resident altercations. The staff reported the Administrator was the abuse coordinator and any type of abuse should be reported immediately. Notification of changes in condition to include examples of resident change in condition such as new skin issues or increased or new pain. The staff were able to verbalize a change of condition should be reported to the charge nurse immediately. The charge nurses were able to verbalize the appropriate assessments and notifications of the physician and family during a change of condition. Enteral feeding policy to include adequate positioning. The facility staff reported residents would be checked for positioning at least every 2 hours by the CNAs, MAs, and nurses. The staff were able to verbalize residents who received enteral nutrition should have the head of the bed elevated at least 30 degrees. Staff reported if they noticed any residents were positioned improperly the charge nurse would be notified. The staff were able to verbalize the signs or symptoms of aspiration, which included: coughing, drooling, or wheezing. The Administrator was informed the IJ was removed on 09/12/25 at 4:40 PM. The facility remained out of compliance at a scope of isolated and a severity level of no actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents environment remained as free of accident hazards as possible for 1 of 7 residents (Resident #1) reviewed for accidents and hazards.<BR/>The facility failed to ensure staff checked straps for damage prior to transferring Resident #1 which resulted in a laceration to Resident #1's forehead. <BR/>This failure could place residents at risk for injury.<BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 02/10/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis (weakness on one side of your body) following cerebral infarction (Stroke) affecting the left dominant side.<BR/>Record review of Resident #1''s MDS, dated [DATE], revealed Resident #1 required two-person assistance for transfers and had a BIMS score of 15, which indicated Resident #1 was cognitively intact, alert to person, place, and time. Resident #1 used a wheelchair to ambulate. Resident #1 required extensive assistance with most activities of daily living.<BR/>Record review of Resident #1's care plan, dated 12/27/22, revealed Resident #1 required two-person assistance for transfers and required a mechanical lift due to a self-care performance deficit. <BR/>Record review of Resident #1's nurse's note, dated 02/05/23 at 9:23 PM, by LVN B, revealed Resident #1 was kicking and yelling at staff. LVN B asked LVN A to assist in transferring Resident #1 from his wheelchair to his bed using a Mechanical lift. When LVN A and LVN B arrived in the room three of four straps were already attached to the lift. LVN A attached the last strap and proceeded with the transfer. During the transfer LVN B reported hearing a snap, and Resident #1 fell from the lift to the floor hitting his head causing a laceration. LVN B called 911 and Resident #1 was transferred to the hospital for evaluation and treatment.<BR/>Record review of Resident #1's hospital records, dated 02/05/23, revealed Resident #1 arrived at the hospital with a facial laceration. The fall involved a lift chair assistance as the cause of accidental injury. The injury was repaired with stiches. CT scan (scans take a fast series of X-ray pictures, which are put together to create images of the area that was scanned.), showed no acute intercranial abnormalities, laceration to the soft tissue, swelling to the left frontal scalp and preorbital (around the eye) soft skin. There was mild soft tissue swelling to the left cheek. Resident #1 was released back to the facility after treatment. <BR/>Observation of a video surveillance tape, date stamped on 02/05/22 at 8:48 PM, showed Resident #1 was being transferred from a wheelchair to a bed by LVN A and LVN B using a mechanical lift. The front left strap on the lift appeared to be frayed or damaged. During the transfer, the front left strap holding Resident #1, snapped and Resident #1 fell from the lift and hit his head on the floor.<BR/>During an observation and interview on 02/10/23 at 1:20 PM revealed Resident #1 was in his bed. There was a bandage on his forehead, above his left eye with a date of 02/10/23. There was a Hoyer lift Sling under him. The sling appeared to be in good condition with no frayed edges. Resident #1 said he was doing okay. He said he fell while staff attempted to transfer him from his wheelchair to his bed. Resident #1 said he did not remember much about what happened. He said all he remembered was the strap broke and he hit the floor. He said the next thing he remembered was being at the hospital. He said he did not feel he had been abused or neglected and what happened was an accident. Resident #1 said he was not afraid to be transferred with the Hoyer Lift.<BR/>During an interview on 01/17/23 at 1:20 PM, LVN A said he assisted LVN B with transferring Resident #1 with a Hoyer Lift on 02/05/23 around 8:30 PM. LVN A said while transferring Resident #1, a strap on the front left side of the lift snapped and Resident #1 fell to the floor and hit his head. LVN A said LVN B left the room and called 911 for assistance. LVN A said when he looked at Resident #1, there was blood on the floor coming from Resident #1's head. LVN A said she went and got a towel and applied pressure to the wound until EMS arrived and transported Resident #1 to the hospital for evaluation and treatment. LVN A said he did not realize the strip was damaged. LVN A said the cause of the accident was due to the defective strap. LVN A said he should have inspected the straps before he attempted to transfer Resident #1. LVN A said he was notified on 02/10/23 that he was suspended pending an investigation due to the incident. LVN A said he was scheduled to complete Mechanical Lift skills training before returning to work, but he had not yet received the training.<BR/>During an interview on 01/17/23 at 1:45 PM, LVN B said she and LVN A was asked to assist in transferring Resident #1 from his wheelchair to his bed because staff reported Resident #1 was being verbally and physically aggressive toward staff who attempted to transfer him to his bed. LVN B said she asked LVN A to assist in the transfer. LVN B said when she arrived in the room, there were three straps already attached to the lift and LVN A attached the fourth strap to transfer Resident #1. LVN B said she was operating the lift and LVN A lowered the bed to the lowest position. LVN B said the bed caught on the edge of a trash can at the foot of the bed when the bed was lowered. LVN B said she raised Resident #1 out of the wheelchair and LVN A was moving the wheelchair out of the way when she heard a snap. LVN B said the strap on the front left side of the sling holding Resident #1 broke and Resident #1 fell to the floor hitting his head. LVN B said she went to the door and yelled for help. LVN B said she called 911 on her cell phone and LVN A went and got a towel to stop the bleeding. LVN B said she did not notice the strap was damaged and if so, she would have not used the defective sling to transfer Resident #1. LVN B said she was notified on 02/10/23 by the DON she was suspended pending an investigation into the incident. LVN B said she should have assessed the condition of the straps before she attempted to transfer Resident #1. LVN B said since the incident she had received skills training on transferring using a Mechanical lift on 02/15/23. <BR/>During an interview on 02/10/23 at 12:12 PM, the DON said the first time she viewed the video was with the surveyor. DON said she had not reviewed the video of the incident with Resident #1 before this time. The DON said LVN A and LVN B failed to use proper technique when transferring Resident #1 with the Mechanical lift. The DON said staff should always assess the condition of the lift sling to ensure it was safe prior to use. The DON said it was obvious by viewing the video that the strap on the front left side was damaged and the sling should not have been used. The DON said after the incident she completed an assessment of all other lift slings in the building and found there were some that needed to be retired and new slings were ordered to replace the damaged slings. The DON said all staff received training to inspect the slings prior to use and if a sling showed signs of being defective or damaged the sling should not be used to transfer residents. The damaged sling should be reported to the charge nurse and the DON. The DON said the sling should be taken out of service and replaced with a new sling. The DON said all nursing staff would receive skills training with a check-off for each one on how to transfer a resident using a Mechanical lift. The DON said the skills training would be conducted by the DON and the Director of Rehabilitation. <BR/>During an interview on 02/10/23 at 12:08 PM, the Administrator said she was notified Resident #1 had a fall from a Mechanical lift on 02/05/23 around 8:30 PM. The Administrator said the cause was a damaged strap that broke which caused injury to Resident #1. The Administrator said she reported the incident to the state on 02/05/23 at around 9:45 PM. The Administrator said all the slings and straps in the facility were assessed by the DON for possible damage and those found to be damaged were removed from service immediately. The Administrator said new slings were ordered to replace the damaged slings. The Administrator said on 02/06/23 an intervention plan was developed by QAPI regarding the Hoyer Lift issue. The Administrator said all staff were in-serviced on inspecting the straps and slings before use. The Administrator said the DON would monitor and inspect slings and straps weekly to ensure they were in good condition. The Administrator said any slings found to be damaged would be removed from service and replaced. The Administrator said all nursing staff would receive skills training on how to properly operate the Mechanical Lift. The Administrator said the skills training would be conducted by the DON and Director of Rehabilitation. <BR/>An observation and interview on 02/10/23 at 1:45 PM revealed NA-A, NA-B and NA-C using a Hoyer lift to transfer Resident #1 from his bed to his wheelchair. NA A and NA B used proper technique in transporting the resident. Transfer was successfully completed with no concerns for Resident #1's safety. The equipment and sling were in good working order with no concerns. NA-A, NA-B and NA-C said they had recently received in-service training on safely using the Hoyer lift. They said they were to assess the condition of the sling and straps before using to transfer a resident. They said if the sling or straps were damaged, they were not to use them and report to the charge nurse and/or the DON.<BR/>Interview on 02/10/23 at 1:30 PM, the Laundry Aide said she washed two to three Hoyer Lift slings daily. She said she followed the manufacturer's suggested care instructions. She said the slings were washed in cold to warm water, but never hot water. She said all slings were hung to air dry and slings were never dried in the dryer. She said heat could cause the material to stretch or become weak.<BR/>Record review of Sling Laundry Instructions revealed .While the materials comply with applicable standards for strength, shrinkage and flammability, slings are subject to wear and tear, which increases with usage. Before each use check for fraying or cuts/tears in the straps and body of the sling. Slings that show wear or damage should be taken out of service . LAUNDRY INSTRUCTIONS: . Machine wash normal setting and at 140F/60C. Depending on the washing machine, this usually means on a medium temperature setting.<BR/>Record review of in-service records from 02/06/23 through 02/17/23 revealed documentation that nursing staff received training on 10/17/22. Staff received in-service training on laundry instructions of Hoyer Lift Slings. The in-service was conducted by the Housekeeping Supervisor. After washing the Hoyer Lift sling, you cannot put heat on it. The sling needs to air dry or put in the dryer with no heat. The fabric when heated can stretch and snap! This will cause an injury. This will be an automatic [NAME]!<BR/>Record review of in-service records revealed on 02/06/23 nursing staff received in-service training on Hoyer Lift transfer. <BR/>o <BR/>Must have 2 nursing staff (CNA, Nurse, Medication Aide) to use a Hoyer lift on a resident. <BR/>o <BR/>Always check sling and sling straps to verify they do not appear compromised.<BR/>o <BR/>If there is any question, have nurse verify it is okay to use. <BR/>o <BR/>DO NOT USE A DAMAGED SLING Under any circumstances.<BR/>Record review of Mechanical lift Competency Evaluations dated 02/10/23 - 02/17/23, showed staff using a Hoyer life to transfer residents received a skills assessment on using a Mechanical Life to transfer residents safely. <BR/>Record review of the facility's, undated, policy on Hydraulic lift revealed: . The resident will achieve safe transfer to bed or chair via mechanical lift device . The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift .23. Immediately remove any malfunctioning equipment from direct care use. <BR/>

Based on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who completed a training course approved by the State for 1 of 1 facility reviewed for Activity Director qualifications. <BR/>The facility failed to ensure a certified Activity Directory was employed for the facility.<BR/>This failure could place residents at risk of not receiving a program of activities that met their assessed activity needs. <BR/>Findings included:<BR/>Record review of the undated Personnel File Review of Staff Members indicated no information for the Activity Director.<BR/>Record review of a hiring website, reviewed on 09/13/23, did not reveal a job posting for certified AD for this facility.<BR/>During an interview on 09/12/23 at 09:30 a.m., the ADM said the facility had an assistant activity director and she was about to start her training. The ADM said she was in nursing school in the mornings and then came to the facility for afternoon activities. She said she did not know how long the facility had been without a certified AD. The ADM said she would have to get with the BOM to get definite dates. She said she held the resident council meetings and did the activity assessments for the Assistant AD. <BR/>During an interview on 09/12/23 at 11:00 a.m., the BOM said she could only verify it had been more than 90 days since the facility had a certified AD. <BR/>During an interview on 09/13/23 at 5:01 p.m., the ADM said the facility had gone through several ADs and spent money training them, then they did not last long. She said corporate had decided to implement a 90-day probation period for potential ADs before they paid for training and certification. The ADM said the assistant AD was in nursing school and did a good job but was not sure paying for her to start AD training was good idea with her eventually becoming a nurse. She said she still could not confirm when the facility last had a certified AD. The ADM said ADs had to be certified because they needed to meet certain requirement and training. She said the training was important so the AD could learn different activities to provide for different types of population. The ADM said not having a certified AD could cause residents to be bored and lead to depression. She it was important to provide appropriate activities to meet the needs of the residents. <BR/>Record review of an undated Job Description Activity Director sheet, indicated will be responsible for the planning, developing, organizing, implementing, evaluating, and directing of Activity Programs in accordance with current existing federal, state, and local standards, as well as our established policies and procedures, to ensure that the spiritual development, emotional, recreational and social needs of the patient/resident are maintained on an individual basis . Certificates, Licenses, Registrations: Activity Professional Certification required .<BR/>Record of an undated facility Activity Programming policy indicated .the Activity Director and staff will provide for ongoing Activity programs .

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 medication cart of 4 (Medication Aide Cart #1) reviewed for medication storage:<BR/>The facility failed to ensure Medication Aide Cart #1 was locked when unattended. <BR/>This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. <BR/>Findings included:<BR/>An observation on 09/11/23 beginning at 3:40 p.m. revealed, Medication Aide Cart #1 was unlocked and unattended with no staff within eyesight of the nurse cart for 17 minutes. The keys were in the cart and the narcotic drawer was open. All other drawers could be opened, and medication and supplies could be easily accessed. The cart was observed to have prescribed medication blister packs, over counter medications, as well as a narcotic lock box.<BR/>During an interview with Medication Aide AA on 9/11/2023 at 4:20 p.m., Medication Aide A stated, Oops, I left it unlocked while I went to help a CNA pull someone up in bed. Medication Aide AA stated she had been trained to keep the cart locked and knew the importance of keeping it secured so residents did not access the medications. She stated she knew she should have kept it locked because she had been reminded in the past to lock the cart. <BR/>During an interview with the Administrator on 09/13/2023 at 2:45 p.m., the Administrator said medication carts should be always locked when not in use or unattended. The Administrator stated that Medication Aide AA had been previously in-serviced about keeping the medication cart locked at all times. <BR/>During an interview with the DON on 09/13/2023 at 3:19 p.m. the DON stated that medication carts should be locked so no one was able to get into it, including residents, family, nurses, or anyone else in the building. The DON stated that by leaving the medication cart unlocked there was a risk of medication errors, overdoses, residents taking something that was not prescribed to them and drug diversions. The DON stated that Medication Aide AA had been trained to keep the medication cart locked and it was the facility policy to keep it locked. The DON stated Medication Aides were trained in school to keep the carts always locked and keys with them. The DON stated no recent in-services were done about keeping medications locked up or medication storage.<BR/>Review of the facility's policy titled Security of Medication Cart last revised 04/2017 reflected the following: . Policy statement <BR/>The medication cart shall be secured during medication passes<BR/>Policy interpretation and Implementation<BR/>1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry.<BR/>2. The medication cart should be parked in the doorway of the resident's room during the medication pass<BR/>3. When medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.