Every finding on record at Ascension Oaks Nursing & Rehab Center

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's room was maintained in a clean and homelike manner for 1 (Resident #81) of 4 sampled residents investigated for environment. Findings:Review of the facility's admission Packet, dated 02/2023, revealed, in part, the facility must provide a safe, clean, comfortable, and homelike environment. Further review revealed the facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Review of Resident #81's medical record revealed, in part, Resident #81 was admitted to the facility on [DATE] with diagnoses which included chronic cough, shortness of breath, seasonal allergies, and communication deficit. Review of Resident #81's Minimum Data Set (MDS) with an Assessment Reference Date of 05/05/2026 revealed, in part, Resident #81 had a Brief Interview for Mental Status summary score of 15, which indicated Resident #81 was cognitively intact. Observation of Resident #81's room on 06/09/2026 at 3:10PM revealed Resident #81's upper window area was covered in spider webs and dead insects. Observation of Resident #81's room on 06/10/2026 at 1:00PM revealed Resident #81's upper window area was covered in spider webs and dead insects. In an interview on 06/10/2026 at 1:15PM, Resident #81 indicated the spider webs and dead insects in his room bothered him and he would like them removed. Observation of Resident #81's room on 06/11/2026 at 9:30AM revealed Resident #81's upper window area was covered in spider webs and dead insects. In an interview on 06/11/2026 at 9:53AM, S3Housekeeping Supervisor (HS) confirmed Resident #81's room should not have spider webs and dead insects on the windows and/or curtains. S3HS further confirmed housekeepers should have kept Resident #81's room clean and sanitary.

Based on observations, interviews, and record reviews, the facility failed to ensure staff knocked before entering a resident's room for 2 (S4Housekeeper, S5Housekeeper) of 2 staff identified not respecting residents' dignity. Findings:Review of the facility's admission Packet, dated 02/2023, revealed, in part, the facility must promote care for residents in a manner that maintains or enhances each resident's dignity and respect. Resident #24Review of Resident #24's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/03/2026 revealed, in part, Resident #24 had a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #24 was cognitively intact. Further review revealed Resident #24's hearing was adequate. Observation on 06/08/2026 at 10:30AM revealed Resident #24's room door was partially open with the room lights off, and Resident #24 was lying in bed. Further observation revealed S4Housekeeper entered Resident #24's room without knocking and turned the light switch on without saying anything to Resident #24. Further observation revealed Resident #24 appeared startled as the lights came on and S4Housekeeper entered the room. In an interview on 06/08/2026 at 10:45AM, Resident #24 indicated he was startled when the lights suddenly came on. Resident #24 further indicated he preferred if staff knocked and greeted him prior to entering his room and turning on his lights. Resident #54Review of Resident #54's MDS with an ARD of 03/22/2026 revealed, in part, Resident #54 had a BIMS summary score of 15, which indicated Resident #54 was cognitively intact. In an interview during the Resident Council facility task on 06/09/2026 at 10:45AM, Resident #54 indicated approximately 3 days prior, an unknown housekeeper walked into his room without knocking or identifying themselves, and turned on the light. Resident #54 further indicated he was not dressed at the time and did not want the housekeeper to enter his room without requesting permission to enter his room. Resident #71Review of Resident #71's MDS with an ARD of 06/09/2026 revealed, in part, Resident #71 had a BIMS summary score of 13, which indicated Resident #71 was cognitively intact. Observation on 06/09/2026 at 11:55AM revealed Resident #71's room door was partially open, and Resident #71 was sitting on her bed with a cell phone to her ear. Further observation revealed S5Housekeeper entered Resident #71's room without knocking and/or, identifying herself and/or greeting Resident #71 to remove trash from her room. Resident #95Review of Resident #95's MDS with an ARD of 04/10/2026 revealed, in part, Resident #95 had a BIMS summary score of 15, which indicated Resident #95 was cognitively intact. In an interview during the Resident Council facility task on 06/09/2026 at 10:50AM, Resident #95 indicated approximately 3 days prior, the door to her room was closed while she was changing her clothes, and an unknown housekeeper entered her room without knocking and/or requesting permission to enter. Resident #95 further indicated she did not want the housekeeper to enter her room without knocking. In an interview on 06/11/2026 at 9:53AM, S3Housekeeping Supervisor (HS) confirmed housekeeping staff should always knock and identify themselves before entering an occupied room. S3HS further indicated housekeeping staff should ask the resident for permission to enter their room prior to turning the lights on. In an interview on 06/11/2026 at 11:00AM, S1Administrator confirmed housekeepers should have knocked before entering a resident's room and should receive permission from residents to enter their rooms.

Based on interview and record reviews, the Quality Assurance and Performance Improvement (QAPI) committee failed to provide sufficient evidence that ongoing monitoring and evaluations were implemented to ensure corrective actions were put in place after identifying that coffee temperatures needed to be monitored. Findings: Review of the facility's undated Quality Assessment and Performance Improvement (QAPI) Guidelines policy revealed, in part, the policy was to establish procedures within the facility for QAPI by incorporating monitoring. Further review revealed the facility should put in place systems to monitor care and services. Further review revealed the facility would use performance indicators to monitor care process and outcomes, and review findings. Review of the facility's In-Service Training Report dated 05/28/2025 revealed, in part, staff were to allow coffee to cool to a temperature of 120 to 140 degrees Fahrenheit before serving to residents. Review of the facility's QAPI plan related to coffee temperatures dated May 2025 revealed, in part, coffee temperatures were obtained daily from 05/28/2025 through 06/12/2025 from 3 coffee pots labeled A, B, and C and documented on an audit form titled, Coffee Temperature served from Kitchen. Further review revealed on 06/10/2025 at 6:30AM the temperature of coffee obtained from coffee pot C was documented as 149.1 degrees Fahrenheit. Further review revealed S14Dietary Manager documented that a coffee temperature of 149.1 degrees Fahrenheit was in normal range and did not indicate a corrective action was taken. In an interview on 06/12/2025 at 10:00AM, S14Dietary Manager indicated she was in-serviced to ensure coffee was served to residents at a temperature that ranged between 120 to 140 degrees Fahrenheit. In an interview on 06/12/2025 at 10:30AM, S14Dietary Manager indicated she was responsible for monitoring the temperature of coffee before it was served to the residents and documenting the temperature obtained. S14Dietary Manager confirmed on 06/10/2025 she documented on the audit form the temperature of the coffee in coffee pot C was 149.1 degrees Fahrenheit. Record review revealed no documented evidence, and the facility did not present any documented evidence, the coffee temperatures obtained during audits were monitored and/or evaluated by the QAPI committee to ensure the coffee was served to residents at the appropriate temperature. Further review revealed no documented evidence, and the facility did not present any documented evidence showing how the QAPI committee monitored the effectiveness of the coffee temperature in-service training. In an interview on 06/12/2025 at 11:05AM, S2Director of Nursing (DON) indicated after S14Dietary Manager completed the coffee temperature audit forms, S2DON placed the forms into the QAPI binder. S2DON further indicated there was no staff member assigned to monitor and/or evaluate the coffee temperatures obtained or evaluate effectiveness of in-service trainings to ensure coffee was served to residents at the appropriate temperature.

Based on interview and record reviews the facility failed to ensure a resident's electronic Medication Administration Record (eMAR) were maintained and accurately documented for 2 (Resident #38, Resident #60) of 22 (Resident #2, Resident #3, Resident #8, Resident #13, Resident #19, Resident #21, Resident #22, Resident #26, Resident #27, Resident #37, Resident #38,Resident #40, Resident #41, Resident #53, Resident #60, Resident #71, Resident #77, Resident #79, Resident #81, Resident #83, Resident #85, and Resident #302) sample residents reviewed for accurate records. Findings: Review of the facility's undated General Medical Records policy/procedure revealed, in part, staff were to record all care given, including medication and treatments. Further review revealed staff were to record any adverse reactions, anything abnormal, or anything out of the ordinary. Review of Resident #38's June 2025 physician's orders revealed, in part, the following orders: -Mirtazapine (a medication used to treat insomnia) 15 milligrams (mg) by mouth (po) at bedtime for insomnia; -Sennosides-Docusate Sodium (a medication used to treat constipation) 2 tablets 8.6-50 mg by mouth (po) at bedtime; -Lactulose solution (a medication used to treat constipation) 15 milliliters (ml) by mouth (po) two times a day; -Tramadol (a medication used to treat pain) 50 mg by mouth (po) two times a day; -TwoCal house supplement (a nutritional supplement) 6 ounces (oz) by mouth (po) three times a day; -Depakote DR (a medication used to treat a mood disorder) 500 mg by mouth (po) three times a day; -Seroquel (a medication used to treat a mood disorder) 100 mg by mouth (po) three times a day; -Seroquel (a medication used to treat a mood disorder) 50 mg by mouth (po) three times a day; and, -Xanax (a medication used to treat anxiety) 0.5 mg by mouth (po) three times a day. Review of Resident #38's eMAR revealed, in part, there was no documented evidence, and the provider did not present any documented evidence Resident #38's medications/supplements were administered and/or not given for the following medications: - Mirtazapine 15 mg po on 05/13/2025, 05/15/2025, and 05/16/2025 at 9:00 PM; - Sennosides-Docusate Sodium 8.6-50 mg po on 05/13/2025, 05/15/2025, and 05/16/2025 at 9:00 PM; - Lactulose solution 15 ml po on 05/13/2025, 05/15/2025, and 05/16/2025 at 5:00 PM; - Tramadol 50 mg po on 05/13/2025, 05/15/2025, and 05/16/2025 at 9:00 PM; - TwoCal house supplement 6 ounces po on 05/13/2025, 05/15/2025, and 05/16/2025 at 5:00 PM; - Depakote DR 500 mg po on 05/13/2025, 05/15/2025, and 05/16/2025 at 5:00 PM; - Seroquel 100 mg po on 05/13/2025, 05/15/2025, and 05/16/2025 at 9:00 PM; - Seroquel 50 mg po on 05/13/2025, 05/15/2025, and 05/16/2025 at 9:00 PM; and, - Xanax 0.5 mg po three times a day on 05/13/2025, 05/15/2025, and 05/16/2025 at 5:00 PM. Review of Resident #60's June 2025 physician's orders revealed, in part, the following orders: -Trazodone HCI (a medication used to treat insomnia) 100 mg by mouth (po) at bedtime; and, -Eliquis (a medication used to thin blood) 5 mg by mouth (po) two times a day. Review of Resident #60's eMAR revealed, in part, there was not documented evidence, and the provider did not present any documented evidence Resident #60's medications/supplements were administered and/or not given for the following medications: - Trazodone HCI 100 mg po on 05/05/2025 and 05/16/2025 at 9:00 PM; and, - Eliquis 5 mg po on 05/05/2025 and 05/16/2025 at 9:00 PM. In an interview on 06/12/2025 at 12:09 PM, S2Director of Nursing (DON) indicated staff should have documented on Resident #38 and Resident #60's eMAR if medication/supplements were administered or not administered. S2DON further indicated there should not be any missing documentation of signatures for any Resident's eMAR.

Based on observations and interviews, the facility failed to serve residents' food at an acceptable temperature as required. Findings: In an interview on 06/09/25 at 10:20 AM, Resident #71 (who resided on Hall a) indicated the facility's food is terrible and cold. Observation on 06/11/2025 at 11:51AM revealed a facility staff member transported the lunch trays down Hall a on a tray cart. Further observation revealed the door to the tray cart was left opened and Resident #72's lunch tray could be visualized. On 06/11/2025 at 11:51AM the surveyor collected Resident #72's lunch tray to be used as a test tray. Upon sampling the food on Resident #72's tray, surveyors found the black eyed peas, fried pork fritter, and cooked turnip greens to be lukewarm (not at a temperature consistent with a palatable food temperatures). Observation on 06/11/2025 at 11:55AM, revealed S14DM checked the temperatures of the food on Resident #72's above mentioned lunch tray. Further observation revealed the black eyed peas were 103 degrees Fahrenheit, the cooked turnip greens were 107 degrees Fahrenheit, and the fried pork fritter was 99 degrees Fahrenheit. In an interview on 06/11/2025 at 11:57AM, S14Dietary Manager indicated she expected the food to be around 120 degrees Fahrenheit when it was served to the residents. S14DM further indicated the lunch trays for Hall a exited the kitchen at 11:35AM on 06/11/2025. S14DM acknowledged that it was an issue that the lunch trays for Hall a had exited the kitchen at 11:35AM and had not yet been served to all the residents on Hall a at 11:51AM on 06/11/2025. In an interview on 06/11/2025 at 12:00PM, Resident #13 (who resided on Hall a) indicated that her food for lunch today was not hot/lukewarm. In an interview on 06/11/2025 at 12:01PM, Resident #40 (who resided on Hall a) indicated that her lunch today was served cold.

Based on interview and record reviews, the facility failed to ensure a resident with a serious mental illness was referred to the Louisiana Office of Behavioral Health for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #85) of 2 (Resident #2, Resident #85) sampled residents reviewed for PASARR. Findings: Review of Resident #85'a clinical record, reveled, in part, Resident #85 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder (a serious mental illness that causes mood swings). Review of Resident #85's Minimum Data Set with an Assessment Reference Date of 4/15/2025 revealed, in part, Resident #85 had an active diagnosis of bipolar disorder. There was no documented evidence, and the facility did not present any documented evidence, a referral was made to the Louisiana Office of Behavioral Health's PASARR program regarding Resident #85's diagnosis of bipolar disorder since admission on [DATE] as required. In an interview on 06/11/2025 at 12:38PM, S16Social Worker indicated she was responsible to initiate a Level II PASARR referral for residents. S16Social Worker confirmed Resident #85 had a diagnosis of bipolar disorder since admission on [DATE] and had not been referred to the Louisiana Office of Behavioral Health for a Level II PASARR review, as required.

Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure food stored in the facility's freezer was properly contained and labeled with an opened date; and, 2. Ensure staff followed the manufacturer's instructions for the 3 compartment sink to correctly sanitize dishware. Findings: 1. Review of the facility's Storage of Frozen Food policy and procedure revised on 12/2012 revealed, in part, the facility ensured the quality and safety of frozen food through accepted storage practices. Further review revealed the facility staff were to ensure no food was left uncovered and opened boxes of frozen foods should be closed and sealed tightly, and dated when opened. Observation of the facility's freezer with S14Dietary Manager on 06/09/2025 at 9:31AM, revealed an opened box of okra. Further observation revealed the bag of okra was not closed and was unlabeled with an opened date. In an interview on 06/09/2025 at 9:31AM, S14Dietary Manager indicated the bag of frozen okra was not sealed and was not labeled with an opened date, and should have been. 2. Review of the facility's undated manufacturer's instructions for the proper steps to clean dishes using the 3 compartment sink revealed, in part, the water and sanitizer should be kept at proper temperatures and concentrations. Further review revealed staff should keep the water in the rinse compartment of the 3 compartment sink to be at least 110 degrees Fahrenheit and keep the water in the sanitization compartment of the 3 compartment sink at 75 degrees Fahrenheit. Further review revealed dishes should be left in the sanitization compartment of the 3 compartment sink for 45 seconds. In an interview on 06/11/2025 at 2:32PM, S15Cook indicated she routinely washed dishes in the 3 compartment sink. S15Cook further indicated the temperature of the wash compartment of the 3 compartment sink should be kept at 75 degrees Fahrenheit. S15Cook further indicated she did not soak dishes in the sanitization compartment of the 3 compartment sink for any specific amount of time. Observation on 06/11/2025 at 2:32PM, with S14Dietary Manager indicated S15Cook only tested the temperature of the wash compartment of the 3 compartment sink and did not test the temperature of the rinse and sanitization compartments of the three compartment sink. In an interview on 06/12/2025 at 2:45PM, S14Dietary Manager indicated the dishes should have been submerged in the sanitization compartment of the 3 compartment sink for at least 30 seconds. In an interview on 06/12/2025 at 2:25PM, S17Regional Director of Operations, indicated dishes should be soaked in the sanitization compartment of the 3 compartment sink for at least 45 seconds.

Based on observation, interviews and record reviews, the facility failed to ensure staff performed hand hygiene between glove changes when performing wound care for 1 (Resident #2) of 2 (Resident #2, Resident #40) residents observed for wound care. Findings: Review of the facility's undated Universal Precautions policy and procedure, revealed, in part, handwashing was to be performed before and after each contact with a resident whether gloves are worn or not, and handwashing was to be performed following exposure of hands to body fluids, blood, excretions, or other contaminates (see Handwashing Technique policy and procedure). Review of the facility's undated Handwashing Technique policy and procedure revealed, in part, hands must be washed during performance of duties such as handling dressings. Observation on 06/11/2025 at 9:14AM revealed S12Wound Care Nurse sanitized her hands and applied a gown and gloves before she performed Resident #2's right foot dressing change. Further observation revealed S12Wound Care Nurse removed Resident #2's right foot dressing and placed the dressing into a biohazard bag. Further observation revealed S12Wound Care Nurse removed her gloves and put on a new pair of gloves without performing hand hygiene after handling Resident #2's right foot dressing. Observation then revealed S12Wound Care Nurse cleaned Resident #2's wound with normal saline, removed her gloves, and put on a new pair of gloves without performing hand hygiene. In an interview on 06/11/2025 at 11:55AM, S12Wound Care Registered Nurse confirmed she did not perform hand hygiene in between glove changes during Resident #2's right foot dressing change, and she should have. In an interview on 06/11/2025 at 12:02PM, S13Licensed Practical Nurse/Infection Preventionist confirmed hand hygiene should have been performed in between glove changes during Resident #2's right foot dressing change. In an interview on 06/11/2025 at 12:28PM, S2Director of Nursing confirmed hand hygiene should have been performed between glove changes during Resident #2's right foot dressing change.

Based on observations and interviews, the facility failed to ensure a resident in a semiprivate room had a ceiling suspended curtain around the bed for 1 (Resident #79) of 14 (Resident #2, Resident #8, Resident #13, Resident #26, Resident #27, Resident #37, Resident #38, Resident #60, Resident #71, Resident #77, Resident #79, Resident #81, Resident #83, Resident #302) sampled residents observed for privacy. Findings: Observation on 06/09/2025 at 10:28AM revealed Resident #79 did not have a ceiling suspended privacy curtain suspended around Resident #79's bed as required, to ensure privacy. Observation on 06/10/2025 at 10:40AM revealed Resident #79 did not have a ceiling suspended privacy curtain suspended around Resident #79's bed as required, to ensure privacy. In an interview on 06/10/2025 at 11:08AM, S11Certified Nursing Assistant (CNA) indicated Resident #79 was in a semi-private room and currently had a roommate. S11CNA further indicated Resident #79's ceiling suspended privacy curtain was missing and should not have been. In an interview on 06/11/2025 at 2:22PM, S1Administrator confirmed a resident in a semiprivate room should have a ceiling suspended privacy curtain suspended around their bed to ensure privacy, and acknowledged Resident #79's privacy curtain was missing.

Based on observation, interview and record review, the facility failed to provide supervision to the facility's staff to keep a resident's environment free of accidents/hazards by failing to ensure: 1. The facility's staff transferred a resident with a [NAME]- Lift (a mechanical lift used to transfer residents) per the facility's policy (Resident #69); and, 2. The facility's staff properly laundered [NAME]-Lift slings (slings used to transfer residents with the mechanical lift). This deficient practice resulted in an Immediate Jeopardy situation on 04/14/2024 at 6:05 p.m. for Resident #69, when staff failed to inspect Resident #69's entire [NAME]-Lift sling prior to using and failed to ensure to unlock the [NAME]-Lift's [NAME] brakes when Resident #69 was raised and transferred with the [NAME]-Lift. During Resident #69's transfer, the straps of the [NAME]-Lift sling broke, which caused Resident #69 to fall to the floor. This resulted in Resident #69 being sent to a hospital emergency room where it was determined Resident #69 sustained a left temporoparietal subarachnoid hemorrhage (bleeding in the area between the brain and the protective tissues that cover and protect it). S1Administrator was notified of the Immediate Jeopardy on 06/25/2024 at 7:50 p.m. The Immediate Jeopardy was removed on 06/26/2024 at 2:18 p.m., after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. This deficient practice had the likelihood to cause more than minimum harm to the 14 residents who resided in the facility and required the use of a [NAME]-Lift for transfers. Findings: 1. Review of the provider's undated policy titled, Hydraulic Lift, revealed, in part, staff were to consult the manufacturer's recommendations for the specific procedure for each lift. Review of the [NAME]-Lift's Operating Manual dated November 2017, revealed, in part, before each patient transfer, the [NAME]-Lift sling must be inspected for signs of damage, for loose and missing stitching, and for tears and excessive wear that might cause the [NAME]-Lift sling to fail. Further review revealed, the [NAME]-Lift transfer procedure indicated the [NAME] brakes of the [NAME]-Lift should be left unlocked when a resident was transferred. Further review revealed, leaving the [NAME]-Lift [NAME] brakes unlocked would allow the [NAME]-Lift to walk forward to center itself over the resident's center of gravity as it was raised. Further review revealed, this procedure increased the stability of the [NAME]-Lift. Review of Resident #69's Electronic Medical Record revealed, in part, Resident #69 was admitted to the facility on [DATE]. Further review revealed Resident #69 had diagnoses of Down syndrome and Alzheimer's disease. Review of Resident #69's nurse's note dated 04/15/2024 at 12:14 a.m. revealed, in part, on 04/14/2024 at 6:05 p.m., S3Licensed Practical Nurse (LPN) was called to Resident #69's room by S8Certified Nursing Assistant (CNA). Further review revealed, S8CNA, indicated Resident #69 had fallen from the [NAME]- Lift due to the straps on the [NAME]-Lift sling breaking. Further review revealed, Resident #69 was found lying flat on the floor on her back. Further review revealed, S8CNA indicated, when the strap to the [NAME]-Lift sling broke, Resident #69 flipped out the [NAME]-Lift, hit the back of her head on the floor, and hit her back on the leg of the lift. Further review revealed, Resident #69 had a superficial wound on the right side of her head. Review of Resident #69's hospital note dated 04/16/2024 revealed, in part, Resident #69 was seen in the emergency roiagnom on [DATE], due to a fall during transfer from a mechanical lift. Review of Resident #69's medical record indicated Resident #69 fell when she was transferred with a mechanical lift, and the mechanical lift sling's strap broke. Further review revealed a Computed Tomography (CT) scan (a medical imaging technique used to obtained detailed internal images of the body) was completed on Resident #69. Further review revealed the CT scan results revealed Resident #69 had a left temporoparietal subarachnoid hemorrhage. In an interview on 06/25/2024 at 12:42 p.m., S8CNA indicated the straps of the [NAME]-Lift sling broke when she and S9CNA were transferring Resident #69 from her chair to her bed. S8CNA further indicated the [NAME] brakes to the [NAME]-Lift were locked when Resident #69 was raised from her chair with the [NAME]-Lift. S8CNA further indicated the [NAME]-Lift sling was already positioned under Resident #69 prior to the transfer on 04/14/2024. S8CNA further indicated that she did not inspect the parts of the [NAME]-Lift sling that were under Resident #69 prior to beginning Resident #69's transfer with the [NAME]-Lift. In an interview on 06/25/2024 at 2:20 p.m., S9CNA indicated she was in the room when she and S8CNA were transferring Resident #69, and the [NAME] brakes to the [NAME]-Lift were locked when Resident #69 was raised from her chair with the [NAME]-Lift on 04/14/2024. Observation on 06/24/2024 at 2:54 p.m., revealed S5CNA and S6CNA were preparing to transfer Resident #69 from her Geri-chair to her bed with a [NAME]-Lift. Further observation revealed S5CNA locked the [NAME] brakes of the [NAME]-Lift, positioned Resident #69 in the [NAME]-Lift sling, and raised Resident #69 up with the [NAME]-Lift with the [NAME] breaks of the [NAME]-Lift locked. In an interview on 06/25/2024 at 11:50 a.m., S5CNA confirmed she had the [NAME] brakes to the [NAME]-Lift locked when she was raising/transferring Resident #69 on 06/24/2024. In an interview on 06/25/2024 at 2:00 p.m., S13CNA Supervisor, indicated staff were to visually check the entire [NAME]-Lift sling for any rips, holes, and/or loose threads prior to the [NAME]-Lift slings being used to transfer residents. S13CNA Supervisor further indicated, if a [NAME]-Lift sling was already under a resident prior to transfer, the staff should move the resident, and do a full visual inspection of the [NAME]-Lift sling. In an interview on 06/25/2024 at 2:58 p.m., S1Administrator indicated the facility's staff should transfer the facility's residents according to the manufacturer's instructions. S1Administrator further indicated he was aware the [NAME]-Lift's [NAME] brakes should not be locked when a resident was raised with the lift. S1Administrator offered no explanation or comment related to the above mentioned deficient practice. 2. Review of the [NAME]-Lift's Operating Manual dated November 2017, revealed, in part, [NAME]-Lift slings must be tumble-dried on the delicate temperature cycle in the dryer. Further review revealed, if the facility's dryer does not have a delicate cycle, [NAME]- Lift slings should be hung to air dry. Further review revealed a warning that bleach may not be used as it can weaken the stitching and fabric, and that it was important that the laundry department was told how to care for slings correctly. Observation on 06/25/2024 at 8:54 a.m., revealed no signage indicating the facilities dryers had delicate cycle. In an interview on 06/25/2024 at 8:55 a.m., S7Housekeeping/Laundry Supervisor indicated after the [NAME]-Lift slings were washed, they were placed in the facility dryer. S7Housekeeping/Laundry Supervisor further indicated the facility's dryer did not have a delicate cycle. S7Housekeeping/Laundry Supervisor further indicated she was unaware of the manufacture's guidelines for drying [NAME]-Lift slings. In an interview on 06/25/2024 at 10:45 a.m., S14Regional Director of Operations indicated the facility's staff should be following the manufacturer's guidelines for laundering the [NAME]- Lift slings. In an interview on 06/25/2024 at 10:52 a.m., S1Administrator indicated the facility's staff should be following the manufacturer's guidelines for [NAME]-Lift sling care. S1Administrator offered no explanation or comment related to the above mentioned deficient practice.

Based on observation, interview and record review, the facility failed to ensure: 1. The facility's staff (S8Certified Nursing Assistant [CNA]) was trained and deemed competent to transfer a resident using a [NAME]-Lift (a mechanical lift used to transfer residents) as per the manufacturer's guidelines (Resident #69); and, 2. A qualified individual, who was trained and competent, was assigned the task of evaluating if the facility's staff were competent with transferring residents using a [NAME]-Lift per the manufacturer's guidelines (S13CNA Supervisor). This deficient practice resulted in an Immediate Jeopardy situation on 04/14/2024 at 6:05 p.m. for Resident #69, when staff failed to inspect Resident #69's entire [NAME]-Lift sling prior to using and failed to ensure to unlock the [NAME]-Lift's [NAME] brakes when Resident #69 was raised and transferred with the [NAME]-Lift. During Resident #69's transfer, the straps of the [NAME]-Lift sling broke, which caused Resident #69 to fall to the floor. This resulted in Resident #69 being sent to a hospital emergency room where it was determined Resident #69 sustained a left temporoparietal subarachnoid hemorrhage (bleeding in the area between the brain and the protective tissues that cover and protect it). S1Administrator was notified of the Immediate Jeopardy on 06/25/2024 at 7:50 p.m. The Immediate Jeopardy was removed on 06/26/2024 at 2:18 p.m., after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. This deficient practice had the likelihood to cause more than minimum harm to the 14 residents who resided in the facility and required the use of a [NAME]-Lift for transfers. Findings: Review of the provider's undated policy titled, Hydraulic Lift, revealed, in part, staff were to consult the manufacturer's recommendations for the specific procedure for each lift. Review of the [NAME]-Lift's Operating Manual, dated November 2017, revealed, in part, before using the [NAME]-Lift to transfer residents, all staff must be trained and authorized to use the [NAME]-Lift. Further review revealed a video demonstrating transfer techniques was sent to the facility with the lift and this video, along with hands on training led by a nurse or professional rehabilitation staff member. Further review revealed only staff members who have been trained according to the procedures in this manual, by a manufacturer's representative, by a nurse, or by a professional rehabilitation staff member designated as your facility's mechanical lift trainer, should be allowed to use the [NAME]-Lift. Further review revealed a warning of staff members who have not had hands on training may not use the [NAME]-Lift. The above mentioned manual also revealed only staff members who have been trained according to the procedures in this manual, by a manufacturer's representative, by a nurse, or by a professional rehabilitation staff member designated as your facility's mechanical lift trainer, should be allowed to use the [NAME]-Lift. Further review revealed, the [NAME]-Lift transfer procedure indicated the [NAME] brakes of the [NAME]-Lift should be left unlocked when a resident was transferred. Further review revealed, leaving the [NAME]-Lift [NAME] brakes unlocked would allow the [NAME]-Lift to walk forward to center itself over the resident's center of gravity as it was raised. Further review revealed, this procedure increased the stability of the [NAME]-Lift. Further review revealed [NAME]-Lift slings must be tumble-dried on the delicate temperature cycle in the dryer, and if the facility's dryer does not have a delicate cycle, [NAME]-Lift slings should be hung to air dry. Further review revealed a warning that bleach may not be used as it can weaken the stitching and fabric, and that it was important that the laundry department was told how to care for slings correctly. Observation on 06/24/2024 at 2:54 p.m., revealed S5CNA and S6CNA were preparing to transfer Resident #69 from her Geri-chair to her bed with a [NAME]-Lift. Further observation revealed S5CNA locked the [NAME] brakes of the [NAME]-Lift, positioned Resident #69 in the [NAME]-Lift sling, and raised Resident #69 up with the [NAME]-Lift with the [NAME] breaks of the [NAME]-Lift locked. Review of Resident #69's nurse's note dated 04/15/2024 at 12:14 a.m. revealed, in part, on 04/14/2024 at 6:05 p.m., S3Licensed Practical Nurse (LPN) was called to Resident #69's room by S8Certified Nursing Assistant (CNA). Further review revealed, S8CNA, indicated Resident #69 had fallen from the [NAME]-Lift due to the straps on the [NAME]-Lift sling breaking. Further review revealed, Resident #69 was found lying flat on the floor on her back. Further review revealed, S8CNA indicated, when the strap to the [NAME]-Lift sling broke, Resident #69 flipped out the [NAME]-Lift, hit the back of her head on the floor, and hit her back on the leg of the lift. Further review revealed, Resident #69 had a superficial wound on the right side of her head. Review of Resident #69's hospital note dated 04/16/2024 revealed, in part, Resident #69 was seen in the emergency roiagnom on [DATE] due to a fall during transfer from a mechanical lift. Review of Resident #69's medical record indicated Resident #69 fell when she was transferred with a mechanical lift, and the mechanical lift sling's strap broke. Further review revealed a Computed Tomography (CT) scan (a medical imaging technique used to obtained detailed internal images of the body) was completed on Resident #69. Further review revealed the CT scan results revealed Resident #69 had a left temporoparietal subarachnoid hemorrhage. In an interview on 06/25/2024 at 11:50 a.m., S5CNA confirmed she had the [NAME] brakes to the [NAME]-Lift locked when she was raising/transferring Resident #69 on 06/24/2024. In an interview on 06/25/2024 at 12:42 p.m., S8CNA indicated the straps of the [NAME]-Lift sling broke when she and S9CNA were transferring Resident #69 from her chair to her bed. S8CNA further indicated the [NAME] brakes to the [NAME]-Lift were locked when Resident #69 was raised from her chair with the [NAME]-Lift. S8CNA further indicated the [NAME]-Lift sling was already positioned under Resident #69 prior to the transfer on 04/14/2024. S8CNA further indicated that she did not inspect the parts of the [NAME]-Lift sling that were under Resident #69 prior to beginning Resident #69's transfer with the [NAME]-Lift. In an interview on 06/25/2024 at 2:00 p.m., S13CNA Supervisor indicated she, the Director of Nursing, and the Assistant Director of Nursing were responsible for training the nursing staff on resident transfers using a [NAME]-Lift and on evaluating the CNA's competency for the use of the [NAME]-Lift when transferring residents. S13CNA Supervisor further indicated the [NAME]-Lift [NAME] breaks must be locked when a resident was being lifted up in the [NAME]-Lift. S13CNA Supervisor further indicated she used the CNA Skill Check Off for [NAME]-Lifts when evaluating CNAs for competency and reiterated the [NAME]-Lift was to be locked when a resident was being lifted up. S13CNA Supervisor further indicated she did not train the facility's staff per the [NAME]-Lift's Operating Manual and was unaware the [NAME]-Lift's [NAME] brakes needed to be unlocked when a resident was being raised up. In an interview on 06/25/2024 at 2:20 p.m., S9CNA indicated that the [NAME] brakes to the [NAME]-Lift were locked when Resident #69 was raised from her chair with the [NAME]-Lift on 04/14/2024. Review of S8CNA's personnel record revealed, in part, no documented evidence, and the facility did not present any documented evidence, S8CNA was evaluated for competency of transferring residents with a [NAME]-Lift. In an interview on 06/25/2024 at 2:58 p.m., S1Administrator indicated he was aware the [NAME]-Lift's [NAME] brakes should not be locked when a resident was raised with the [NAME]-Lift. S1Administrator offered no other explanation or comment related to the above mentioned deficient practice. In an interview on 06/25/2024 at 3:40 p.m., S13CNA Supervisor indicated the facility was unable to produce any documented evidence S8CNA was evaluated and deemed competent to transfer a resident with a [NAME]-Lift.

Based on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure: 1. The facility's staff transferred a resident with a [NAME]-Lift (a mechanical lift used to transfer residents) per the facility's policy (Resident #69); 2. The facility's staff properly laundered [NAME]-Lift slings (slings used to transfer residents with the mechanical lift); and 3. Facility administration ensured competency of assigned trainers and staff on the use and care of the [NAME]-Lift and slings prior to allowing staff to transfer residents. This lack of administrative oversight resulted in Immediate Jeopardy situation on 04/14/2024 at 6:05 p.m. for Resident #69, when staff failed to inspect Resident #69's entire [NAME]-Lift sling prior to using and failed to ensure to unlock the [NAME]-Lift's [NAME] brakes when Resident #69 was raised and transferred with the [NAME]-Lift. During Resident #69's transfer, the straps of the [NAME]-Lift sling broke, which caused Resident #69 to fall to the floor. This resulted in Resident #69 being sent to a hospital emergency room where it was determined Resident #69 sustained a left temporoparietal subarachnoid hemorrhage (bleeding in the area between the brain and the protective tissues that cover and protect it). S1Administrator was notified of the Immediate Jeopardy on 06/25/2024 at 7:50 p.m. The Immediate Jeopardy was removed on 06/26/2024 at 2:18 p.m., after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. This deficient practice had the likelihood to cause more than minimum harm to the 14 residents who resided in the facility and required the use of a [NAME]-Lift for transfers. Findings: Cross reference F689 and F726. In an interview on 06/25/2024 at 8:55 a.m., S7Housekeeping/Laundry Supervisor indicated after the [NAME]-Lift slings were washed, they were placed in the facility dryer. S7Housekeeping/Laundry Supervisor further indicated the facility's dryer did not have a delicate cycle. S7Housekeeping/Laundry Supervisor further indicated she was unaware of the manufacture's guidelines for drying [NAME]-Lift slings. In an interview on 06/25/2024 at 10:45 a.m., S14Regional Director of Operations indicated the facility's staff should be following the manufacturer's guidelines for laundering the [NAME]- Lift slings. In an interview on 06/25/2024 at 10:52 a.m., S1Administrator indicated the facility's staff should be following the manufacturer's guidelines for [NAME]-Lift sling care. S1Administrator offered no explanation or comment related to the above mentioned deficient practice. In an interview on 06/25/2024 at 2:00 p.m., S13CNA Supervisor, indicated staff were to visually check the entire [NAME]-Lift sling for any rips, holes, and/or loose threads prior to the [NAME]-Lift slings being used to transfer residents. S13CNA Supervisor further indicated, if a [NAME]-Lift sling was already under a resident prior to transfer, the staff should move the resident, and do a full visual inspection of the [NAME]-Lift sling. In an interview on 06/25/2024 at 2:58 p.m., S1Administrator indicated the facility's staff should transfer the facility's residents according to the manufacturer's instructions. S1Administrator further indicated he was aware the [NAME]-Lift's [NAME] breaks should not be locked when a resident was raised with the lift. In an interview on 06/25/2024 at 3:40 p.m., S13CNA Supervisor indicated the facility was unable to produce any documented evidence S8CNA was evaluated and deemed competent to transfer a resident with a [NAME]-Lift.

Based on record review and interview, the facility failed to have a facility-wide assessment which addressed all components. Findings: Review of the Facility assessment dated [DATE] and reviewed 06/14/2024 revealed the following sections were not addressed in the facility-wide assessment: 1. Staff competencies; 2. The physical environment and equipment; 3. Any ethnic, cultural, or religious factors; and, 4. The facility's resources. In an interview on 06/26/2024 at 12:47p.m., S14Regional Director of Operations indicated as of today (06/26/2024), the facility had not completed Section 3 of the facility-wide assessment. In an interview on 06/26/2024 at 1:27 p.m., S14Regional Director of Operations indicated there was a part 3 which covered the remaining sections of competencies, staff needs, equipment, and contracts that the facility missed; therefore, the facility-wide assessment did not contain the following required components: staff competencies, the physical environment and equipment, any ethnic, cultural, or religious factors, and the facility's resources.

Based on interview and record reviews, the provider failed to ensure Certified Nursing Assistant (CNA) staff received the required training on resident rights and facility responsibility for 7 (S4CNA, S5CNA, S8CNA, S10CNA, S11CNA, S12CNA, S13CNA Supervisor of 7 (S4CNA, S5CNA, S8CNA, S10CNA, S11CNA, S12CNA, S13CNA Supervisor) personnel records reviewed. Findings: Review of S4CNA's personnel record revealed, in part, S4CNA was hired on 06/06/2022. There was no documented evidence and the facility did not present any documented evidence that S4CNA received the required training on resident rights and facility responsibility for caring of residents. Review of S5CNA's personnel record revealed, in part, S5CNA was hired on 02/20/2016. There was no documented evidence and the facility did not present any documented evidence that S5CNA received the required training on resident rights and facility responsibility for caring of residents. Review of S8CNA's personnel record revealed, in part, S8CNA was hired on 07/26/2023. There was no documented evidence and the facility did not present any documented evidence that S8CNA received the required training on resident rights and facility responsibility for caring of residents. Review of S10CNA's personnel record revealed, in part, S10CNA was hired on 07/16/2019. There was no documented evidence and the facility did not present any documented evidence that S10CNA received the required training on resident rights and facility responsibility for caring of residents. Review of S11CNA's personnel record revealed, in part, S11CNA was hired on 06/21/2023. There was no documented evidence and the facility did not present any documented evidence that S11CNA received the required training on resident rights and facility responsibility for caring of residents. Review of S12CNA's personnel record revealed, in part, S12CNA was hired on 05/04/2021. There was no documented evidence and the facility did not present any documented evidence that S12CNA received the required training on resident rights and facility responsibility for caring of residents. Review of S13CNA Supervisor's personnel record revealed, in part, S13CNA was hired on 07/15/2014. There was no documented evidence and the facility did not present any documented evidence that S13CNA Supervisor received the required training on resident rights and facility responsibility for caring of residents. In an interview on 06/26/2024 at 2:45 p.m., S1Administrator indicated he could not produce documented evidence of the above mentioned required training for the above mentioned facility staff was completed as required.

Based on record reviews and interview, the facility failed to ensure a resident had an accurate blood glucose record for 1 (Resident #32) of 21 (Resident #1, Resident #8, Resident #13, Resident #15, Resident #16, Resident #22, Resident #27, Resident #28, Resident #32, Resident #38, Resident #46, Resident #47, Resident #49, Resident #52, Resident #55, Resident #61, Resident #69, Resident #76, Resident #86, Resident #94 and Resident #96) sampled residents reviewed for accurate record documentation. Findings: Review of Resident #32's June 2024 physician's orders revealed, in part, an order dated 08/19/2024 to administer Resident #32's Novolog (a medication used to treat diabetes) 100 Units (u)/Milliliter (ml) injection per sliding scale. Review of Resident #32's June 2024 electronic Medication Administration Record (eMAR) revealed, in part, Resident #32 was administered 3 units of Novolog 100 u/ml on 06/17/2024 for a blood glucose level of 173, 0 units of Novolog 100 u/ml administered with blood glucose documented as high, and no documentation of the blood glucose levels were documented on 06/09/2024. In an interview on 06/26/2025 at 12:27 p.m., S2Assistant Director of Nursing indicated Resident #32's above mentioned eMAR documentation on 06/17/2024 was inaccurate. S2Assistant Director of Nursing further indicated the facility's nurses should be documenting the actual blood glucose levels instead of documenting high to ensure an accurate record of Resident #32's blood glucose levels was being conducted.

Based on record reviews and interviews, the facility failed to ensure a resident was able to participate in care plan meetings for 2 (Resident #32 and Resident #46) of 2 (Resident #32 and Resident #46) sampled residents reviewed for care plan attendance in a total sample of 20 residents reviewed for Care Plans. Findings: Resident #32 Review of Resident #32's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/17/2024 revealed, in part, Resident #32 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #32 was cognitively intact. Review of the facility's list of care plan meetings for Resident #32 for 09/14/2023, 12/14/2023, and 03/14/2024, revealed no time noted next to Resident #32's name. In an interview on 06/23/2024 at 11:31 a.m., Resident #32 indicated she had never been invited to a care plan meeting and would go to one if the facility invited her. Resident #46 Review of Resident #46's MDS with an ARD of 05/17/2024 revealed, in part, Resident #46 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #46 was cognitively intact. Review of the list of care plan meetings for Resident #46 for 09/21/2023, 12/21/2023, and 03/21/2024, revealed no time noted next to Resident #46's name. In an interview on 06/23/2024 at 11:11 a.m., Resident #46 indicated that she was not invited to care plan meetings. In an interview on 06/26/2024 at 8:30 a.m., S17Social Services indicated a time would be noted next to a resident's name on the facility's list of residents scheduled for care plan meetings, if the resident or their representative went to the care plan meeting. In an interview on 06/26/2024 at 8:40 a.m., S17Social Services indicated the Interdisciplinary team (IDT) members met with the residents individually before the care plan meeting to assess the residents, and the IDT team met afterwards without the residents to review the resident's care plans. S17Social Services further indicated she had no documented evidence Resident #32 and Residents #46 were invited to care plan meetings. There was no documented evidence and the facility did not present any documented evidence of Resident #32 and Resident #46 were invited to the above mentioned care plan meetings.

Based on interviews and record reviews, the facility failed to ensure Certified Nursing Assistant (CNA) staff were trained on an infection control system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for 7 (S4CNA, S5CNA, S8CNA, S10CNA, S11CNA, S12CNA, S13CNA Supervisor) of 7 (S4CNA, S5CNA, S8CNA, S10CNA, S11CNA, S12CNA, S13CNA Supervisor) personnel records reviewed. Findings: Review of S4CNA's personnel record revealed, in part, S4CNA was hired on 06/06/2022. There was no documented evidence and the facility did not present any documented evidence that S4CNA received training on the requirements for an infection control system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. Review of S5CNA's personnel record revealed, in part, S5CNA was hired on 02/20/2016. There was no documented evidence and the facility did not present any documented evidence that S5CNA received training on the requirements for an infection control system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. Review of S8CNA's personnel record revealed, in part, S8CNA was hired on 07/26/2023. There was no documented evidence and the facility did not present any documented evidence that S8CNA received training on the requirements for an infection control system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. Review of S10CNA's personnel record revealed, in part, S10CNA was hired on 07/16/2019. There was no documented evidence and the facility did not present any documented evidence that S10CNA received training on the requirements for an infection control system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. Review of S11CNA's personnel record revealed, in part, S11CNA was hired on 06/21/2023. There was no documented evidence and the facility did not present any documented evidence that S11CNA received training on the requirements for an infection control system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. Review of S12CNA's personnel record revealed, in part, S12CNA was hired on 05/04/2021. There was no documented evidence and the facility did not present any documented evidence that S12CNA received training on the requirements for an infection control system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. Review of S13CNA Supervisor, personnel record revealed, in part, S13CNA Supervisor was hired on 07/15/2014. There was no documented evidence and the facility did not present any documented evidence that S13CNA Supervisor received training on the requirements for an infection control system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. In an interview on 06/26/2024 at 2:45 p.m., S1Administrator indicated he could not produce documented evidence of the above mentioned required training for an infection control system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases being completed for the above mentioned facility staff.

Based on interview and record reviews, the facility failed to ensure Certified Nursing Assistant (CNA) staff were trained on the requirements for Compliance and Ethics for 7 (S4CNA, S5CNA, S8CNA, S10CNA, S11CNA, S12CNA, S13CNA Supervisor) of 7 (S4CNA, S5CNA, S8CNA, S10CNA, S11CNA, S12CNA, S13CNA Supervisor) personnel records reviewed. Findings: Review of S4CNA's personnel record revealed, in part, S4CNA was hired on 06/06/2022. There was no documented evidence and the facility did not present any documented evidence S4CNA was trained on the requirements for compliance and ethics program as required. Review of S5CNA's personnel record revealed, in part, S5CNA was hired on 02/20/2016. There was no documented evidence and the facility did not present any documented evidence S5CNA was trained on the requirements for compliance and ethics program as required. Review of S8CNA's personnel record revealed, in part, S8CNA was hired on 07/26/2023. There was no documented evidence and the facility did not present any documented evidence S8CNA was trained on the requirements for compliance and ethics program as required. Review of S10CNA's personnel record revealed, in part, S10CNA was hired on 07/16/2019. There was no documented evidence and the facility did not present any documented evidence S10CNA was trained on the requirements for compliance and ethics program as required. Review of S11CNA's personnel record revealed, in part, S11CNA was hired on 06/21/2023. There was no documented evidence and the facility did not present any documented evidence S11CNA was trained on the requirements for compliance and ethics program as required. Review of S12CNA's personnel record revealed, in part, S12CNA was hired on 05/04/2021. There was no documented evidence and the facility did not present any documented evidence S12CNA was trained on the requirements for compliance and ethics program as required. Review of S13CNA Supervisor's, personnel record revealed, in part, S13CNA Supervisor was hired on 07/15/2014. There was no documented evidence and the facility did not present any documented evidence S13CNA Supervisor was trained on the requirements for compliance and ethics program as required. In an interview on 06/26/2024 at 2:45 p.m., S1Administrator indicated he could not produce documented evidence of training for compliance and ethics was completed for the above mentioned facility staff as required.

Based on interview and record reviews, the provider failed to ensure Certified Nursing Assistant (CNA) staff were trained on the requirements for Quality Assurance Performance Improvement (QAPI) for 7 (S4CNA, S5CNA, S8CNA, S10CNA, S11CNA, S12CNA, S13CNA Supervisor of 7 (S4CNA, S5CNA, S8CNA, S10CNA, S11CNA, S12CNA, S13CNA Supervisor) personnel records reviewed. Findings: Review of S4CNA's personnel record revealed, in part, S4CNA was hired on 06/06/2022. There was no documented evidence and the facility did not present any documented evidence that S4CNA received the required training on the elements and goals of the facility's QAPI program. Review of S5CNA's personnel record revealed, in part, S5CNA was hired on 02/20/2016. There was no documented evidence and the facility did not present any documented evidence that S5CNA received the required training on the elements and goals of the facility's QAPI program. Review of S8CNA's personnel record revealed, in part, S8CNA was hired on 07/26/2023. There was no documented evidence and the facility did not present any documented evidence that S8CNA received the required training on the elements and goals of the facility's QAPI program. Review of S10CNA's personnel record revealed, in part, S10CNA was hired on 07/16/2019. There was no documented evidence and the facility did not present any documented evidence that S10CNA received the required training on the elements and goals of the facility's QAPI program. Review of S11CNA's personnel record revealed, in part, S11CNA was hired on 06/21/2023. There was no documented evidence and the facility did not present any documented evidence that S11CNA received the required training on the elements and goals of the facility's QAPI program. Review of S12CNA's personnel record revealed, in part, S12CNA was hired on 05/04/2021. There was no documented evidence and the facility did not present any documented evidence that S12CNA received the required training on the elements and goals of the facility's QAPI program. Review of S13CNA Supervisor's, personnel record revealed, in part, S13CNA Supervisor was hired on 07/15/2014. There was no documented evidence and the facility did not present any documented evidence that S13CNA Supervisor received the required training on the elements and goals of the facility's QAPI program. In an interview on 06/26/2024 at 2:45 p.m., S1Administrator indicated he could not produce documented evidence of the above mentioned required training for QAPI for the above mentioned facility staff.

Based on record reviews and interviews, the facility failed to complete an annual performance review of Certified Nursing Assistant (CNA) staff and/or provide training education on performance review outcomes for 7 (S4CNA, S5CNA, S8CNA, S10CNA, S11CNA, S12CNA, S13CNA Supervisor of 7 S4CNA, S5CNA, S8CNA, S10CNA, S11CNA, S12CNA, S13CNASupervisor personnel records reviewed. Findings: Review of S4CNA's facility personnel record revealed, in part, S4CNA was hired on 06/06/2022. There was no documented evidence and the facility did not present any documented evidence that S4CNA had a yearly performance evaluation and/or received training based on performance evaluation outcomes. Review of S5CNA's facility personnel record revealed, in part, S5CNA was hired on 02/20/2016. There was no documented evidence and the facility did not present any documented evidence that S5CNA had a yearly performance evaluation and/or received training based on performance evaluation outcomes. Review of S8CNA's facility personnel record revealed, in part, S8CNA was hired on 07/26/2023. There was no documented evidence and the facility did not present any documented evidence that S8CNA had a yearly performance evaluation and/or received training based on performance evaluation outcomes. Review of S10CNA's facility personnel record revealed, in part, S10CNA was hired on 07/16/2019. There was no documented evidence and the facility did not present any documented evidence that S10CNA had a yearly performance evaluation and/or received training based on performance evaluation outcomes. Review of S11CNA's facility personnel record revealed, in part, S11CNA was hired on 06/21/2023. There was no documented evidence and the facility did not present any documented evidence that S11CNA had a yearly performance evaluation and/or received training based on performance evaluation outcomes. Review of S12CNA's facility personnel record revealed, in part, S12CNA was hired on 05/04/2021. There was no documented evidence and the facility did not present any documented evidence that S12CNA had a yearly performance evaluation and/or received training based on performance evaluation outcomes. Review of S13CNASupervisor, personnel record revealed, in part, S13CNASupervisor was hired on 07/15/2014. There was no documented evidence and the facility did not present any documented evidence that S13CNA Supervisor had a yearly performance evaluation and/or received training based on performance evaluation outcomes. In an interview on 06/25/2024 at 1:16 p.m., S13CNASupervisor indicated she did not complete performance evaluations on the above mentioned Certified Nursing Assistant (CNA) staff. In an interview on 06/26/2024 at 2:45 p.m., S1Administrator indicated he conducted performance evaluations on certain staff within the facility, but did not conduct performance evaluations on CNA staff.

Based on interviews and record reviews, the facility failed to ensure a resident's assistive device was available for use to decrease the risk of falls for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for accident hazards. This deficient practice resulted in actual harm on 02/21/2024 at 6:26 p.m. when S2Certified Nursing Assistant (CNA) removed Resident #1's wheelchair from her room and placed it in the hallway. Resident #1 was unable to access her wheelchair to assist with mobility. On 02/21/2024 at 7:48 p.m. Resident #1 was found sitting on a fall matt next to her bed. On 02/22/2024 Resident #1 complained of pain in the left upper leg and was diagnosed with a left femur fracture which required hospitalization and surgical repair. Resident #1 had a decline in functional mobility and continence due to the fall and resulting fracture. Findings: Review of the facility's undated Fall Prevention Program policy on 03/05/2024 at 1:05 p.m. revealed, in part, the facility's goal was to prevent falls by enabling staff to recognize those residents identified as high risk for potential falls to ensure appropriate interventions were implemented. Further review revealed assistive devices would be kept within residents reach for easy access. Review of Resident #1's Quarterly Minimum Data Set with an Assessment Reference Date of 01/03/2024 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 3 indicating severe cognitive impairment. Further review revealed Resident #1 used a wheelchair for mobility, required partial to moderate assistance with transfers, supervision or touch assistance with walking, and had one fall without injury since the previous assessment. Review of Resident #1's Fall Risk assessment dated [DATE] revealed Resident #1 required the use of an assistive device and had problems with balance when standing and/or walking. Further review revealed Resident #1 had a risk assessment score of 16 indicating resident was assessed as being high risk for falls. Review of Resident #1's fall care plan with a start date of 11/01/2019 revealed, in part, Resident #1 was high risk for falls with a goal to have no falls with injuries. Further review revealed the following active interventions: On 11/01/2019 Staff to keep Resident #1's assistive devices in reach; On 11/01/2019 Resident #1 had the falling star program in place; On 04/06/2023 Wheelchair provided to Resident #1 for safety; and, On 02/22/2024 Gerichair to assist Resident #1 with positioning when out of bed. Review of Resident #1's nurse note dated 02/23/2024 at 11:04 a.m. revealed, in part, a late entry nurse note for 02/21/2024 at 7:52 p.m. which revealed the nurse was called into Resident #1's room by the CNA, and Resident #1 was found next to her bed on the fall mat. Review or Resident #1's nurse note dated 02/22/2024 at 8:57 a.m. revealed, in part, Resident #1 complained of left upper leg pain and had decreased range of motion. Further review revealed an order was obtained for an x-ray of the left upper leg and hip. Review of hospital record dated 02/22/2024 revealed, in part, Resident #1 had a left femur fracture which required surgical intervention. Review of the facility's investigation documentation entered on 02/27/2024 at 11:16 a.m. revealed in part, Resident #1 sustained a fall on 02/21/2024 and was found to have a left femur fracture on 02/22/2024. Further review revealed prior to the above mentioned fall Resident #1 was ambulating with assistance. Due to the fall and fracture Resident #1 was now unable to bear weight on the left leg and had a decline functional in activities of daily living (ADL's). Review of Resident #1's Voiding Status Summary from February 2024 through March 5, 2024 revealed, in part, Resident #1 was generally continent with occasional episodes of incontinence from 02/01/2024 through 02/21/2014. Further review revealed from 02/27/2023 through 03/05/2023 at 12:33 p.m. Resident #1 was incontinent with no episodes of continence documented. Review of the facility's record titled Timeline of camera footage reviewed and documented by S1DON and S6Assistant Administrator on 02/22/2024 revealed, in part, the following: 6:18 p.m. through 6:21 p.m. - Resident #1 ambulated from the dining room down the hallway holding onto the wheelchair; 6:22 p.m. - CNA propelled Resident #1 to her room; and, 6:26 p.m. - CNA took the wheelchair out of Resident #1's room for an intervention to prevent Resident #1 from getting up without assistance. In an interview on 03/05/2024 at 1:22 p.m., S4Licensed Practical Nurse (LPN) indicated prior to Resident #1's left femur fracture she observed Resident #1 using her wheelchair as a walker to ambulate to her restroom. S4LPN indicated if Resident #1 had to go to the restroom and the wheelchair was not available it would have made it more difficult and, Resident #1 would have attempted to ambulate without the wheelchair. In an interview on 03/05/2024 at 1:50 p.m., S3CNA stated prior to Resident #1's left femur fracture Resident #1 would ambulate down the hallway using her wheelchair for balance and support. S3CNA stated Resident #1 needed some type of device to help her walk. S3CNA stated if Resident #1 did not have her wheelchair, Resident #1 would still have tried to ambulate to the restroom without it. In an interview on 03/05/2024 at 4:30 p.m., S5CNA indicated she would often find Resident #1 pushing her wheelchair into the restroom unassisted by staff. S5CNA indicated she never removed the wheelchair from Resident #1's room because that would have made the situation worse. S5CNA stated Resident #1 could not walk without something to hold onto. S5CNA indicated since Resident #1's left leg fracture, Resident #1 was now in a Gerichair for mobility, was always incontinent, and relied on staff for all personal care. In an interview on 03/05/2024 at 4:48 p.m., S1Director of Nursing (DON) indicated prior to Resident #1's fall on 02/21/2024 Resident #1 used the wheelchair as a walker to ambulate. S1DON confirmed Resident #1's was care planned to keep the assistive devices within reach. S1DON confirmed S2CNA should not have removed Resident #1's wheelchair from her room. S1DON confirmed Resident #1 had a decline in functional ADL's and required a Gerichair for mobility.