Every finding on record at Autumn Care of Cornelius

Based on observations and staff interviews, the facility failed to maintain hot food at or above 135 degrees ( ) Fahrenheit (F) during meal service on 1 of 4 steam tables (700/800 hall kitchenette), failed to remove dented canned goods stored for use in the dry goods storage room, failed to date and label leftover food items stored in 1 of 1 walk-in cooler and 1 of 1 walk-in freezer and failed to ensure frozen food items were sealed in the walk-in freezer. This practice had the potential to affect food served to residents. Findings included: 1. On 08/26/2026 at 11:45 AM, food items were prepared in the main kitchen and just prior to meal service, Dietary [NAME] #1 used a thermometer to check the temperature and all food items were above 165 degrees F. Steam table pans were then placed into separate, insulated meal carts for delivery to the four kitchenettes (100/200 hall, 300/400 hall, 500/600 hall, and 700/800 hall) for meal service. On 08/26/26 at 12:35 PM an observation was conducted of the 700/800 hall kitchenette meal service with Dietary [NAME] #2 and the Registered Dietitian (RD). The insulated meal cart arrived to the kitchenette, Dietary [NAME] #2 removed the pans from the insulated carts, placed them on the hot steam table, and then used a digital thermometer to take the temperature of the food items as follows: *Mashed potatoes: 83 degrees F *Green Beans: 87 degrees F *Ground Chicken: 80 degrees F *Pureed Salisbury steak: 120 degrees F The RD stepped in to assist Dietary [NAME] #2, she used the digital thermometer to check the mashed potatoes and the temperature was 87 degrees F. The RD removed the steam-table pan containing the mashed potatoes and took it back to the kitchen to be reheated. The green beans, ground chicken and pureed Salisbury steak remained on the steam table. On 08/26/26 at 12:45 PM, the RD returned to the 700/800 hall kitchenette with the pan of mashed potatoes and a second thermometer. With the RD present, Dietary [NAME] #2 used the second thermometer and retested the food temperatures as follows: *Mashed potatoes: 127 degrees F *Ground Chicken: 125 degrees F *Pureed Salisbury steak: 120 degrees F *Pureed green beans: 122 degrees F After the food temperatures were retaken, Dietary [NAME] #2 then proceeded to plate the meals to serve to the residents at the direction of the RD. During an interview on 08/27/26 at 1:57 PM, the RD stated it was her understanding that holding temperatures of food items on the steam table should be a tolerable or pleasurable temperature. She explained during the lunch meal service yesterday (08/26/26) on the 700/800 hall kitchenette, they discovered it was a thermometer issue when the food items initially temped at or below 87 degrees F. She expressed that when the food temperatures were retaken with a different thermometer and the temperatures of the food items were between 120 degrees F and 127 degrees F, she felt those temperatures were ok and food service could resume. The RD stated had she known the regulatory guidance recommended the holding temperatures of hot food items on the steam table should be 135 degrees F or above, she would have had dietary staff pull the food to take back to the kitchen for reheating. During an interview on 08/27/26 at 5:55 PM, the Administrator stated that during the lunch meal service on 08/26/26, he heard the RD made the comment that there was no real guidance for the holding temperatures of food items on the steam table and he felt that since she was a RD, she must know what she was talking about. The Administrator expressed that he would review the regulatory guidance with the RD so that she would be aware food temperatures on the steam table should be maintained above the recommended temperature of 135 degrees F. 2a. An observation conducted 8/24/2026 at 9:40 AM with the Administrator in dry storage revealed six dented cans of black beans stored on a shelf with other canned goods. The dents were located at the bottom of the cans and extended approximately two inches up the sides. Signage in the designated area directed staff not to use dented items and to place them on the bottom shelf for credit. b. An observation 0n 08/24/2026 at 9:45 AM conducted with the Regional Registered Dietitian (RD) in the walk in cooler revealed an uncovered quarter size metal steamer pan containing a clear resealable plastic bag containing raw chicken. The bag of raw chicken was unsealed and stored in a container that had a thin layer of thick pink liquid with pieces of raw chicken adhering to the sides and bottom of the pan. The bag was not labeled or dated. The RD confirmed the chicken was not sealed or labeled with a preparation or expiration date. c. An observation conducted in the walk-in freezer with the RD 8/24/2026 at 9:50 AM revealed multiple food items that were not sealed or labeled with an open date or expiration date. There were nineteen four ounce beef patties open, undated, and not sealed. Eight four ounce veggie burger patties were also observed unsealed, undated, and sitting inside an open box on the shelf. Additionally, half a bag of potato steak fries was open, undated, and not sealed. Eleven three ounce breaded chicken patties were found open, not sealed, and not dated. Twenty breaded fish filets were stored open, undated, and not sealed. One 9 by 11 inch pan of cooked chocolate chip cookie dough was observed uncovered and undated. The RD stated on 8/24/2026 at 9:55 AM that staff should have resealed open packages using a tie, wrapped items in plastic wrap, or placed them in a resealable bag. She explained that each opened item should have been labeled with the date opened and an expiration date to prevent spoilage and ensure safe storage. She stated that if staff found an unsealed, unlabeled open item, they should determine whether it was used during the last meal. If it had been used for the last meal, staff could safely label and reseal it for future use. Interview with the Breakfast [NAME] on 8/24/2026 at 10:00 AM explained that labels were available for dietary staff to use on food items and that any partially used package should have been labeled with the open date and expiration date. She stated all dietary staff received training upon hire on how to safely handle and store food. Interview with the Dietary Manager on 8/25/2026 at 4:00 PM stated it was the responsibility of all kitchen staff to ensure all items in all storage areas were sealed and dated correctly. Interview conducted with the Administrator on 8/25/2026 at 4:00 PM stated the facility had procedures for food storage and that staff needed to follow them. The facility submitted a plan of correction created on 06/12/2026 addressing systems to honor resident preferences and choices, ensure accurate meal tray tickets, maintain adequate food service staffing, ensure palatable meals, uphold a sanitary environment, and maintain proper food storage. However, the plan of correction was not accepted by the state agency due to concerns identified during the survey regarding unlabeled and undated opened food items and food with visible spoilage that remained available for use. Additionally, the plan did not address maintaining holding temperatures of food items on the steam table during meal service.

Based on observation, record review, and interviews with the resident and staff, the facility failed to maintain a safe environment free from accident hazards and failed to provide adequate supervision when staff provided a drinking straw to a resident with an active physician order prohibiting straws due to aspiration risk, then left the resident unsupervised while he ate lunch. The deficient practice occurred for 1 of 3 residents reviewed for accidents (Resident #8).Findings included:Resident #8 was admitted to the facility on [DATE] with diagnoses of severe dementia with agitation and dysphagia (difficulty swallowing) following a stroke. The comprehensive Minimum Data Set (MDS) dated [DATE] indicated Resident #8 had severe cognitive impairment. Resident #8 showed signs and symptoms of possible swallowing disorder that included the loss of liquids/solids from his mouth when eating or drinking. Resident #8 was on a mechanically altered diet (required a change in the texture of foods or liquids) and required assistance for meal set-up and clean-up. Review of the medical record revealed the speech therapy Discharge summary dated [DATE] indicated Resident #8 required a pureed diet with nectar thick liquids, upright positioning, small bites, slow pacing, close supervision during meals, and no straw use due to dysphagia.Review of the orders included physician's orders dated 6/14/26 for Resident #8's diet to include pureed food, nectar thick liquids, divided plate with meals, and no straws.Review of the Care Plan dated 8/21/26 documented Resident #8 required a pureed diet, nectar thick liquids, meal supervision, and no straws.On 8/24/26 at 9:30 AM, Resident #8 was observed seated in his wheelchair with a two handled cup of thickened water and an 8 ounce cup of thickened dark liquid containing a straw on the over the-bed tray next to him.On 8/25/26 at 12:00 PM, an 8 ounce plastic cup containing a straw was observed on the over the-bed tray table in Resident #8's room.On 8/25/26 at 12:39 PM, Resident #8 was observed in the 100/200-Hall dining room seated across from NA #1. NA #1 asked him if he wanted a bite. Resident #8 dropped his head forward with eyes closed and did not respond when NA #1 called his name. NA #1 continued feeding another resident (Resident #75) at the same table.During an observation on 8/25/26 at 12:44 PM in the 100/200-hall dining room, Resident #8 awakened, lifted his head, and began eating from his sectioned plate. He consumed his pureed lunch at a slow pace, cleared his throat after every few spoonfuls, and drank thickened liquid independently while NA #1 remained seated across the table feeding Resident #75.During an observation on 8/25/26 at 1:00 PM in the 100/200-hall dining room, NA #1 stood up, wheeled Resident #75 to the adjacent sitting area, turned on the television, spoke briefly to that resident, and then walked to the nurse station. Resident #8 remained at the table eating and drinking without staff supervision.During an observation on 8/25/26 at 1:02 PM in the 100/200-hall dining room, Resident #8 remained seated at the table eating and drinking while all staff left the dining room, adjacent nurses' station and sitting area, and moved down the 100 and 200 hallways into resident rooms.On 8/25/26 at 1:05 PM, the Director of Nursing (DON) was interviewed in the 100/200 hall dining room while Resident #8 was seated eating his lunch meal without staff present in the room. The DON was not aware that all staff had left the dining room and adjacent areas which included the nurses station and sitting room. The DON indicated that staff should have remained in the dining room to provide Resident #8 with observation while he continued to eat his lunch meal. She indicated that staff must be able to visualize him as he ate or drank. The DON stated the care plan and physician orders required supervision during meals and prohibited straw use. The DON reported staff should remove any straw found in his cup and stated it was unacceptable for staff to leave Resident #8 unsupervised while he ate or drank. The DON stated it was her expectation that staff follow the physician orders and Care Plan for Resident #8. The DON stated she would remain in the dining room and supervise Resident #8 while he finished his lunch meal, or until staff returned to the dining room and they could supervise him.During an interview on 8/25/26 at 3:41 PM, NA #3 was not aware that Resident #8 was left unsupervised during the lunch meal. NA #3 reported that NA #1 was seated across from Resident #8 and monitoring him while feeding another resident. NA #3 indicated the unit used an assignment book documenting which NA was responsible for meal monitoring and supervision. She reported Resident #8 often required cueing and that NAs worked together to supervise residents needing feeding assistance. During an interview with the Speech Therapist on 8/26/26 at 8:00 AM, she indicated her April 2026 evaluation resulted in recommendations for pureed foods, nectar thick liquids, supervision during meals, and no straw use due to dysphagia and aspiration risk. She explained that supervision required direct visual observation. The Speech Therapist stated it was her expectation that staff follow the physician orders and care plan for Resident #8 for the no straws and meal supervision.During an interview with NA #2 on 08/26/26 at 11:50 AM, NA #2 indicated she had been unaware that Resident #8 had a no straw restriction. She reported she did not place a straw in Resident #8's cup and explained that other staff also brought drinks to him. NA #2 stated Resident #8 required supervision with eating to prevent choking and confirmed his diet included nectar thick liquids and pureed foods. She reported the Kardex listed diet and restriction information and stated she reviewed Resident #8's care plan but did not see no straw documented. NA #2 explained she was trained to provide supervision during meals and stated supervision required direct visual observation. She reported she was assigned to Resident #8 on 8/25/26 and stated nursing assistants worked together during meals. NA #2 reported she observed hospice staff bring Resident #8 to the dining room and seat him across from another resident. She reported she observed NA #1 talking to Resident #8 and giving cues to eat and assumed NA #1 was supervising him so did not return to the dining room. NA #2 stated she was later informed that a straw had been found in Resident #8's cup.During an interview with NA #1 on 8/26/26 at 12:15 PM, NA #1 reported she was trained in feeding assistance, modified diets, and food and liquid restrictions as part of her education to become a Nursing Assistant. NA #1 stated she was unaware that Resident #8 had a no straw restriction and reported she did not provide a cup or straw to him. NA #1 explained she learned during her training to become an NA that residents on thickened liquids should not use straws due to aspiration risk. NA #1 indicated Resident #8 required supervision during meals to prevent choking and confirmed his diet included nectar thick liquids and pureed foods. She stated the Kardex listed resident diet restrictions. NA #1 reported she supervised Resident #8 during lunch while also providing feeding assistance to Resident #75 seated across the table from him. She stated she escorted Resident #75 to the common room and then forgot to return to supervise Resident #8. NA #1 reported that she should have returned to finish supervising Resident #8 as he finished his meal.On 8/27/26 at 4:15 PM, the Administrator reported he was unaware staff had left Resident #8 unsupervised in the dining room while he consumed the remainder of his lunch. He stated he was also unaware that the DON had entered the dining room and remained with Resident #8 to provide supervision until staff returned. He reported he did not know a cup containing a straw had been present in Resident #8's room on 8/24/26 and 8/25/26, despite his no straw restriction. The Administrator stated supervision required direct visual observation and that providing a straw violated physician orders and posed an aspiration risk. He stated it was his expectation that staff follow the physician orders and care plan for Resident #8.On 8/27/26 at 4:49 PM, the Medical Director reported he was not aware Resident #8 had consumed half of his lunch and an additional drink without supervision and demonstrated throat clearing. He reported no adverse symptoms had been documented. The medical Director indicated that physician orders for no straws and meal supervision must be followed to prevent aspiration and intervene if aspiration or choking occurred. It was his expectation that staff follow physician orders for Resident #8.

Based on observation, record review, staff and Pharmacy Manager interviews, the facility failed to refrigerate medication according to the manufacturer's recommendation and failed to remove expired medication for 1 of 3 medication carts observed for medication storage (300/400 Hall medication cart).The findings included:On 08/26/26 at 3:00 PM an observation was conducted of the 300/400 Hall medication cart accompanied by Nurse #9. The observation yielded the following findings:a. Two sealed boxes of Latanoprost ophthalmic 0.005% solution (an eye drop used for glaucoma or ocular hypertension). The medication boxes had delivery dates of 08/20/26 and 08/23/26 which was on the pharmacy prescription label. There was no sticker on the medication box from the pharmacy that indicated the medication needed to be refrigerated. Review of the manufacturer's package insert for Latanoprost ophthalmic solution indicated that an unopened Latanoprost ophthalmic solution should be stored in the refrigerator between 36 degrees Fahrenheit to 46 degrees Fahrenheit.b. One package that contained four individual syringes of ABH (Ativan/Benadryl/Haldol) compound mixture (a custom made topical medication primarily used for hospice care). The package was noted with an expiration date of 05/25/26. An interview was conducted with Nurse #9 on 08/26/26 at 3:10 PM. Nurse #9 stated she was aware that the Latanoprost eye drops should have been refrigerated until open and should have been put in the refrigerator when the medication was delivered to the facility. She stated the boxes of Latanoprost should have come from the pharmacy in a cold pack that would indicate the boxes needed to be refrigerated but she did not know that for sure since she was not on duty when they were delivered. Nurse #9 stated she did not have to administer the Latanoprost or the ABH compound mixture on her shift so she did not look at the medications. Nurse #9 reported the night shift nurses were responsible for checking the medication carts.On 08/28/2026 at 10:25 AM a telephone interview was conducted with the Unit Manager #1 who explained that she was not responsible for checking the 300/400 Hall medication cart and only checked the medication carts on her side of the facility. She stated she did not check the 300/400 Hall medication cart on 08/26/26.Unit Manager #2 who was previously responsible for the 300/400 Hall medication cart was not available for an interview.On 08/27/26 at 12:25 PM a telephone interview was conducted with the Pharmacy Manager who reported the unopen Latanoprost ophthalmic 0.005% solution should be refrigerated until open and the ABH compound mixture should have been discarded when expired on 05/25/26.Interviews were conducted with the Director of Nursing (DON) on 08/26/26 at 4:26 PM and 08/28/26 at 10:10 AM. The DON explained that the Unit Managers were responsible for checking the medication carts for cleanliness and expired medications twice a week. She stated Unit Manager #2, who was responsible for checking the 300/400 Hall medication cart, changed from a full time working schedule to working as needed last week but should have caught the expired medication during her audits before she left last week. The DON also stated the pharmacy should have delivered the Latanoprost ophthalmic solution in a bag labeled to refrigerate until open so the nurse who accepted the pharmacy delivery would have known to refrigerate the medication. The DON continued to explain that although the Unit Managers checked the medication carts twice a week, each nurse was responsible for checking the expiration dates on the medications before they administer the medication. She stated Unit Manager #1checked the medication carts earlier that day (08/26/26) and should have found the unopened Latanoprost and the expired medication.

Based on observations, record review, and staff, resident, and physician assistant interviews, the facility failed to safely transfer a dependent, non-ambulatory resident from their wheelchair to their bed for 1 of 3 residents reviewed for provide supervision to prevent accidents. (Resident #1) The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included type II diabetes mellitus, major depressive disorder, age related osteoporosis, severe nonuse osteopenia, hypertension, anxiety disorder, muscle weakness, difficulty walking, and lack of coordination.A review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed resident to be cognitively intact with no delusions, behaviors, rejection of care, or instances of wandering. Resident #1 was coded as needing set up assistance with eating and oral hygiene, she required extensive assistance with personal hygiene and bed mobility, and was dependent on others for toileting hygiene, bathing, upper and lower body dressing, and putting on and taking off footwear. The following activities of daily living (ADLs) were coded as not attempted due to medical condition or safety concerns: transfers, walking, sit to lying, and lying to sitting on the side of the bed. Resident #1 was coded as having no pain indicators or falls since the previous assessment. Resident #1 was also coded as taking scheduled pain medications.Review of Resident #1's care plan which was initiated on 01/15/25 and last reviewed on 07/23/26 revealed the following care areas and interventions:[Resident #1] has ADL self-care and mobility deficits related to physical limitations, generalized weakness, noncompliance with getting out of bed, and refusal to wear protective foot coverings. Interventions included Resident #1 was non-ambulatory, required 2 people to assist with bed mobility, and required a mechanical lift with 2 people to assist for transfers. Review of Resident #1's electronic progress notes revealed a note written by Nurse #1 dated 07/19/26 at 6:34PM. The progress noted that Resident #1 had been out with her family for most of the day and was picked up by a family member from the facility at 9:00 AM. The note also indicated that Resident #1 was brought back to the facility by the same family member around 3:30 PM and had informed the hall staff that Resident #1 was hurting and needed to be placed back into bed. The note continued, stating she observed Nurse Aide #3 (NA #3) go into Resident #1's room to assist her back into bed. Nurse #1's note also stated she heard Resident #1 call out so she immediately went into Resident #1's room and noted Resident #1 sitting on the bed still strapped in a sit to stand lift. Nurse #1 assisted NA #3 to finish getting Resident #1 in her bed. Resident #1 reported to Nurse #1 that she was hurting, and pain medication was given.An interview with Nurse Aide #1 (NA #1) on 08/11/26 at 2:27 PM revealed she was working on 1st shift on 07/19/26. She reported Resident #1 needed to be gotten out of bed and transferred to her wheelchair for an outing she was going on with her family. NA #1 reported she and NA #2 went into Resident #1's room, got her dressed for the day and then used the mechanical lift to transfer Resident #1 from her bed to her wheelchair. NA #1 stated once they got Resident #1 transferred into her wheelchair, the lift sling was left under Resident #1 for use when she returned after her outing. NA #1 also reported she did not recall Resident #1 having any pain or discomfort during the transfer or before Resident #1 left the facility to go with her family.Attempts to reach NA #2 via telephone were unsuccessful.Review of a written statement by NA #2 dated 07/20/26 revealed she had assisted NA #1 with getting Resident #1 dressed and transferred into her wheelchair. The statement also indicated that NA #1 and NA #2 used the mechanical lift to transfer Resident #1 and that the lift sling was left under Resident #1 after getting Resident #1 into her wheelchair.An interview with Nurse Aide (NA) #3 on 08/11/26 at 2:55 PM revealed she was working on 07/19/26 on 2nd shift and that she was the staff member that assisted Resident #1 back into bed after she had returned from an outing with her family. NA #3 stated when Resident #1 returned to the facility, she was in a neighboring room when she heard the family state that Resident #1 wanted to get back into her bed. NA #3 reported she finished with the resident she was assisting and went into Resident #1's room and brought the sit to stand lift with her. NA #3 reported she brought the sit to stand lift with her because she did not see a mechanical lift sling under Resident #1. NA #3 then secured Resident #1 into the sit to stand lift and ensured she was comfortable. NA #3 then lifted Resident #1 from her wheelchair and rotated her to her bed. As she began to lower Resident #1 down towards her bed, Resident #1 began stating that her legs were hurting and Resident #1 began to lean forward with her bottom sticking out. NA #3 stated when this happened, her mattress slid away from her a little and NA #3 stopped what she was doing and grabbed Resident #3's waistband to steady her. She continued, stating Resident #3 began calling out and Nurse #1 came into the room and finished assisting her in getting Resident #1 back into bed. NA #3 stated once Resident #1 was back in bed, she had no complaints and the conversation shifted towards beauty standards of women. NA #3 stated she then assisted Resident #1 with incontinence care with no issues and no complaints from Resident #1 of any pain or discomfort. NA #3 stated it was the facility's process to leave mechanical lift slings under the residents after transferring them and when she did not see one under Resident #1 while she was in her wheelchair, she assumed Resident #1 was a sit to stand transfer. NA #3 stated that she had worked with Resident #1 regularly but had not had to transfer Resident #1 before as she always stayed in bed.An interview with Nurse #1 on 08/11/26 at 3:24 PM via telephone revealed she was working on 07/19/26 on the day shift and she verified that she was assigned to Resident #1's hall. Nurse # 1 reported she was familiar with Resident #1 and described her as alert and oriented and required a mechanical lift for transfers with two person assist. Nurse #1 stated she recalled that Resident #1 had gone out of the facility with her family earlier in the day and was out of the facility for a good portion of the day. Nurse #1 continued, stating she did not recall exactly when Resident #1 returned but stated she had spoken with a member of Resident #1's family that had returned her to the facility and she was asked if someone could hurry up and get Resident #1 back into bed because she was very tired and uncomfortable. Nurse #1 stated shortly after this conversation, she heard Resident #1 call out so she immediately went into the room and observed Resident #1 sitting on the side of her bed, down towards the footboard. Nurse #1 stated Resident #1 was strapped into a sit to stand lift and while she was on the side of the bed, she did not appear to be securely sitting on the side of the bed and appeared uncomfortable. Nurse #1 stated she assisted NA #3 in getting Resident #1 situated in bed and reported Resident #1 did not complain of pain or discomfort. Nurse #1 reported later in the shift a (now unknown) NA came to her and stated that Resident #1 was complaining of some pain all over so she went into Resident #1's room and provided her with some pain medication. Nurse #1 stated it was near the end of her shift, so she reported the pain medication dose to the oncoming nurse (Nurse #2). Nurse #1 stated when she returned the following day on 7/20/26 for her shift, Resident #1 was still complaining of pain, so she reported it and the Nurse Practitioner who saw Resident #1 and ordered x-rays. She stated the x-rays were taken but the results were not returned before the end of her shift.Review of a Nurse Practitioner note dated 07/20/26 revealed Resident #1 was seen for bilateral knee pain. Resident #1 was noted with previous diagnosis of chronic arthritis pain, but the pain was worse following a transfer over the weekend. The progress not continued stating that there was some swelling that was consistent with arthritis, but range of motion was unable to be performed due to complaints of pain. There was no erythema, discoloration, gross deformity, or localized swelling observed. The Nurse Practitioner's note also indicated that she ordered pain medication and x-rays of Resident #1's bilateral knees as soon as possible.Review of Resident #1's physician orders revealed two orders for x-rays, one for her right knee and one for her left knee.Review of the x-ray results from the x-rays ordered by the facility revealed no acute injury to Resident #1's right knee. The left knee x-ray showed no visible fracture but there was some lipohemarthosis (a medical condition where both fat and blood escape from the bone marrow and collect inside a joint space) which may indicate an acute injury.Review of a progress note written by the Assistant Director of Nursing (ADON) on 07/20/26 at 8:00 PM revealed that the facility had received the results of x-rays taken at the facility. The Nurse Practitioner was notified of the following findings: Right knee showed mild osteoarthritis, no acute fracture. The left knee results are no visible fracture, though lipohemarthrosis concerning for a radiographically occult injury. Recommendation for four view knee series or computed tomography (a specialized imaging test that combines a series of x-ray views taken from different angles to create cross-sectional slices of bones, blood vessels, and soft tissues inside the body. Also known as a CT or CAT scan) for further evaluation. The Nurse Practitioner ordered Resident #1 to be sent to the emergency department for CT scan of left knee.Additional review of Resident #1's physician orders revealed an order dated 07/20/26 for Resident #1 to be sent out to the hospital for a CT scan of her left knee.Review of Resident #1's hospital records revealed Resident #1 was seen on 07/20/26 in the hospital with two CT scans taken, one of her right knee and one of her left knee. The results of the right knee CT scan showed no acute injury but noted severe osteopenia and some soft tissue swelling or edema overlying the knee. Results of Resident #1's left knee CT scan revealed a fracture of the proximal tibia (top of the shin bone) that extended longitudinally (upwards) with severe osteopenia with the lipohemarthrosis likely coming from the fracture.An interview with the ADON on 08/11/26 at 2:55 PM revealed she was familiar with Resident #1 and verified that she had written a note regarding the x-rays to Resident #1's lower extremities that were completed in the facility. The ADON reported when the facility received the x-ray results, they were provided to the NP and after her review, she requested that Resident #1 be sent to the hospital for additional imaging due to the inconclusiveness of Resident #1's left knee x-ray. She stated that Resident #1 was transported to the hospital for further imaging and she called and left a voicemail requesting a return call to Resident #1's emergency contact.An interview with Resident #1 on 08/11/26 at 11:05 AM revealed she remembered 07/19/26 and that she had spent most of the day out with her family. Resident #1 reported she always used a mechanical lift when she was transferred from her bed to her wheelchair or from her wheelchair to her bed with 2 staff members assisting. Resident #1 reported when she returned to the facility after her day out with her family, she was tired and worn out from sitting in her wheelchair for an extended period. Resident #1 stated she did not recall having a lot of pain in her lower extremities at the time she returned. Resident #1 stated when she returned to the facility, she was sitting in her room when a nurse aide whom she had not worked with before came into her room and brought with her a contraption she had not seen before. Resident #1 stated she was strapped into the contraption and the nurse aide stood her up. She reported she had some weakness and atrophy in her lower extremities, and she ultimately fell and hit the floor on her side. Resident #1 also stated that while she was being transferred, there was only one staff member in the room. Resident #1 also reported she believed that her neighbor across the hall (Resident #2) had witnessed her fall and saw her on the floor. When questioned, Resident #1 stated that while she was out of the facility, her family members transferred her in and out of their personal car without a mechanical lift and they did not use a wheelchair accessible van.A review of Resident #2's annual Minimum Data Set assessment dated [DATE] revealed her to be cognitively intact with no delusions, behaviors, rejection of care, or instances of wandering.An interview with Resident #2 on 08/11/26 at 12:10 PM revealed she recalled the incident on 07/19/26. She stated Resident #1 had gone out of the facility that morning with her family to attend a church service and was returned later that afternoon by a family member. She stated while she was sitting in her room she could see across the hall and into Resident #1's room. She reported seeing a nurse aide enter Resident #1's room with a sit to stand lift and a short time later heard Resident #1 call out I'm not on the bed. Resident #2 reported at that time, her visual of Resident #1 was blocked by the nurse aide and the sit to stand lift and she could not see if Resident #1 had fallen or not. Resident #2 stated when Resident #1 began calling out, staff members on the hall responded to the room and closed the door.An interview with the Nurse Practitioner (NP) on 08/12/26 at 9:58 AM revealed she was familiar with Resident #1 and stated she was alert and oriented and rarely got out of bed. The NP stated she was asked to see Resident #1 on 07/20/26 after she was complaining of some pain in her lower extremities. The NP stated she had seen Resident #1 off and on for a while with complaints of pain in her lower extremities. The NP stated when she first went and saw Resident #1, she first had to figure out what had happened as there were multiple versions of what had occurred and various factors she needed to consider. The NP stated Resident #1 reported to her that staff had dropped her on the floor, the staff reported they had not dropped her but had used the wrong lift to transfer Resident #1from her wheelchair to her bed, and finally that Resident #1 had spent most of the day of 07/19/26 out with her family and she did not know how the family transferred Resident #1 while she was out of the facility. The NP stated she was informed that Resident #1 was transferred via a sit to stand lift from her wheelchair to her bed when she returned to the facility on [DATE] and that she could not determine if that was an appropriate transfer as that decision would typically be made by the therapy department. She also stated, based on what she knew, she did not believe that Resident #1 had fallen during the transfer at the facility because the way the sit to stand lift operated, it would have been very difficult for Resident #1 to have fallen without taking the whole sit to stand lift down with her. The NP stated when she saw Resident #1 on 07/20/26 she completed a skin assessment and stated that while there was some slight bruising to Resident #1's left knee, there did not appear to be any other skin issues or injuries. The NP stated with the complaints of pain from Resident #1 she ordered some pain medication and x-rays to be taken of Resident #1's left and right knees. The NP reported the x-rays were taken and the results came back later as inconclusive for an acute injury, so she decided to send Resident #1 to the emergency department for further imaging. The NP stated based on the imaging done at the hospital it was determined that Resident #1 had severe osteopenia (a condition of low bone mineral density with no symptoms until a fracture occurs) and had a fracture to the top of her tibia. The NP stated she did not believe she would be able to determine when the injury occurred as she did not know how Resident #1 was transferred while out of the facility with the family and also that residents who were as osteopenic as Resident #1 was, it would not take much for the bone to break. The NP stated she had seen residents who were severely osteopenic that broke bones while moving in bed. The NP also stated she believed the first set of x-rays were inconclusive due to the amount of bone density degradation (softening of the bones) in Resident #1's knee which prevented the fracture from being identified.An interview with the Director of Nursing (DON) on 08/12/26 at 11:18 AM revealed when she arrived to the facility on the morning of 07/20/26 she was informed that Resident #1 wanted to speak with her. She reported she went to Resident #1's room but observed her to be sleeping soundly. The DON stated she went about her morning and while she was in a morning meeting, she and the Administrator received an email from Resident #1's emergency contact that stated Resident #1 had been dropped on the floor, the facility staff had used the wrong lift to transfer Resident #1 from her wheelchair to her bed the day before and that Resident #1 was having excessive pain in her right knee. The DON stated as soon as she received the email, she left the meeting and began an investigation. She reported Nurse #1 and NA #3 were interviewed along with the two nurse aides that transferred Resident #1 from her bed into her wheelchair on the morning of 07/19/26 before Resident #1 left the facility for a day outing with her family and another resident who was identified as potentially being a witness to the fall. The DON stated when Resident #1 was interviewed and reported she was dropped during the transfer, however when she interviewed Nurse #1 and NA #3, they indicated that Resident #1 was never dropped. The DON did report during their investigation, the facility did determine that although they did not believe that Resident #1 had been dropped during the transfer, it was apparent that NA #3 had used the wrong lift while transferring Resident #1 from her wheelchair to her bed. The DON also reported that when Resident #1 was interviewed, she was complaining of some pain in her lower extremities, so she was scheduled to see the NP that same day. The DON reported that the NP did evaluate Resident #1 and ordered x-rays to Resident #1's bilateral lower extremities. The DON stated the results of those x-rays revealed no issues in the right lower extremity, but the x-ray of the left lower extremity was inconclusive for injury, so the NP decided to send Resident #1 out to the emergency department for additional imaging. The DON stated the hospital's imaging determined that Resident #1 had severe osteopenia in her bilateral lower extremities with no acute fracture on the right side, but the left side was determined to have an acute fracture of the tibia. The DON reported that Resident #1 was at the hospital less than 24 hours and returned to the facility with an immobilizer on her left leg. The DON stated there were no other recommendations made by the hospital other than to follow-up with an orthopedic physician. The DON stated Resident #1 was seen by the orthopedic physician on 06/28/26 with no recommendations made. The DON stated Resident #1 had been non-ambulatory during the course of her entire stay and required a mechanical lift with two people assisting. The DON stated she did not know why NA #3 did not verify Resident #1's transfer status prior to transferring her and was able to tell the DON that she knew where resident transfer statuses were located when NA #3 was interviewed. The DON stated she expected her staff to verify transfer statuses of residents prior to transferring them.An interview with the Administrator on 08/12/26 at 12:27 PM revealed he was first alerted to the incident when he received an email from Resident #1's emergency contact on 07/20/26. He stated the facility began an investigation immediately and included speaking to Resident #1, an alleged resident witness, and staff who worked with Resident #1 that day. The Administrator stated after speaking with everyone they were unable to determine that Resident #1 had fallen but did identify that a staff member (NA #3) had utilized the wrong lift when she transferred Resident #1 from her wheelchair to her bed after being out of the facility with her family. He stated he questioned NA #3 why she had used the sit-to-stand lift instead of the mechanical lift and reported that NA #3 stated it was due to Resident #1 not having a lift sling underneath her and since she had not transferred Resident #1 before, she assumed that the sit-to-stand transfer was appropriate. The Administrator stated he expected his staff to verify transfer statuses of residents prior to them transferring a resident. He stated as a result of the incident, the facility added transfers to their quality assurance program and were currently monitoring to ensure compliance.The facility provided the following plan of corrective action for past non-compliance:How corrective action was accomplished for the resident found to have been affected by the deficient practice:Resident #1 is a long-term care resident with a diagnosis of diabetes, age related osteoporosis, arthritis in the right knee, adult failure to thrive, and megaloblastic anemia. Resident #1 is non-ambulatory, a total mechanical lift for transfers and chose to stay in bed most days. On 7/19/2026, Nurse Aide (NA) # 1 and NA #2 transferred Resident #1 into her electric wheelchair via total lift to go on a leave of absence with her family. The lift sling was left underneath the resident. Resident # 1 left the facility around 9:00 AM and arrived back around 3:00 PM from on outing with her family. The family reported to Nurse #1 that Resident #1 was hurting and needed to get back to bed soon. On 7/19/26 NA #3 was unaware of any pain but did overhear Resident #1 requesting to be put back to bed at 3:30 PM. NA #3 honored the request of Resident #1, NA #3 noticed there wasn't a sling under Resident #1, had never transferred her before and assumed that Resident #1 was a sit-to-stand lift. NA #3 went to the lift storage room and retrieved a sit-to-stand lift and sling. The lift and sling were brought to the room and NA #3 locked the bed. Resident # 1 was hooked up via sit-to-stand sling and lift and lifted just over the bed. As Resident #1 was just to the bed, the resident vocalized pain. Nurse#1 overheard the resident yelling help me help me because she thought she was falling and the mattress was sliding. Nurse #1 came into the room to assist. Nurse #1 and NA #3 laid Resident #1 in bed. Resident #1 did not request the transfer to stop. After Resident #1 was put in bed she proceeded to discuss beauty products with Nurse #1 and NA #3. Resident #1 did not voice complaints of discomfort or pain once in bed. Resident #1 was determined to be a total lift, not a sit to stand, and had general pain before and after the transfer. Nurse #1 administered two 500 milligrams (MG) Tylenol Extra Strength at 6:41 PM on 7/19/26 due to hurting all over. A head-to-toe assessment was complete on 7/19/26 by Nurse #1 with no unusual findings from residents baseline status. On 7/20/26 at 6:45 AM the Director of Nursing was notified that Resident #1 wanted to speak with her. Director of Nursing went to Resident #1 room, but resident was sleeping. Family Member #2 emailed Administrator on 7/20/26 at 9:47 AM alleging resident fell from a lift. Unit Manager #1 interviewed Resident #1 on 7/20/26 at 10:00 AM. Resident #1 has a BIMS (Brief Interview of Mental Status) of 14. Initial part of the interview did not indicate a fall and Resident #1 struggled to remember the events. Later in the interview the Resident #1 stated NA #3 used the wrong lift, knees hit the floor and was picked up by the staff member. Immediately upon discovery of the incident on 7/20/2026, the following actions were taken:Resident #1's had a head-to-toe nursing assessment completed on 7/20/2026 by Nurse #1.On 7/20/26 Family Member #2 was notified of the incident and provided a summary of investigation by Administrator. Administrator attempted to interview the Family Member #1 about what happened while the resident was out of the facility, but Family Member #1 declined to answer questions.Nurse #1 contacted Nurse Practitioner #1 on 7/20/26 and obtained new orders for stat (now) bilateral two view AP lateral X-ray and pain medication. 7/20/26 mobile X-Ray indicated left knee no visible fracture, though lipohemarthrosis present, which is a medical condition where fat and blood [NAME] form the bone [NAME] into a joint space. Correlate for recent trauma, and recommend a 4 view knee series (AP, lateral and bilateral obliques) or CT for further evaluation (especially if new difficulty bearing weight). Right knee mild osteoarthritis and no acute fracture.7/20/26 at 8:30PM resident sent to hospital for CT scan. CT scan indicated closed fracture of medial portion of left tibial plateau. The Administrator and DON contacted the Medical Director on 7/20/2026.The Director of Rehabilitation Services completed a therapy screen on 7/20/26 before Resident #1 was sent to the Emergency Room. Resident #1's comprehensive care plan was reviewed by the Director of Nursing with no changes on 7/20/2026Residents #1's bed and mattress were reviewed by Environmental Services Director to ensure proper fit on 7/20/26, no abnormal findings.Mechanical Lift reenactment return demonstration was complete with NA #3, Administrator, Director of Nursing and Assistant Director of Nursing on 7/20/26. Resident #1 returned from the hospital on 7/21/26 at 12:35 PM with a diagnosis of a nondisplaced fracture of the proximal tibia extending into the lateral tibial plateau longitudinally in the setting of sever osteopenia with heterogeneous attenuation throughout the marrow and was recommended to follow up with an orthopedic surgeon within 1 week. Resident then returned to [NAME] Care of Cornelius with a knee immobilizer on at all times except during care. Orthopedic Consult complete on 7/28/26. 2. How the facility identified other residents who had the potential to be affected by the same deficient practiceProper transfer status is determined by the therapy team with input from the nursing team. Transfer status is determined based on physical functioning, mobility, endurance, and cognition. Immediately upon discovery of the event on 7/20/2026, the Unit Managers and ADON conducted an audit of recommended current transfer statuses. Therapy and nursing reviewed what is on the resident care profile to ensure proper transfer status and care plans for each individual resident.On 7/20/26 all residents with a BIMS greater than 12 utilizing total mechanical lifts were interviewed by Social Services Assistant to ensure they were receiving the proper mechanical lift transfers. Those not able to answer were assessed by the nurse. Assessments were complete with no abnormal findings.On 7/20/26, the Environmental Services Directors coordinator evaluated all lifts and slings to ensure lifts and slings were functioning per manufactures recommendations. No abnormal findings and all in proper operating condition. On 7/21/26, the Environmental Services Directors coordinator evaluated all bed frames and mattresses, including air mattresses, for proper fit/function, to ensure beds safety was adhered to. No abnormal findings and all in proper operation/condition. On 7/21/26 facility Director of Nursing reviewed the incident and accident log for the previous 30 days to determine if others had issues with lift transfers. There were no abnormal findings.3. Measures put into place and systemic changes to ensure the deficient practice does not recurBeginning 7/21/2026 the Director of Nursing (or designee) re-educated all nursing staff including Nurses, MDS Coordinators and NA on the facility's transfer status policy and procedures. Beginning 7/21/26 the Therapy Director educated all therapy staff on facility transfer status policy and procedures. The Director of Nursing or designee is responsible for tracking staff to ensure all required staff receive education. New hires will be educated upon hire by the Director of Nursing or designee. No staff member will be permitted to work until this education has been completed by Director of Nursing or designee.Education included the following:Educated regarding facility policies, procedures and protocols for transferring a resident. For all new admissions the admitting nurse will assess and determine resident transfer status. Admitting Nurse then communicates verbally to direct care staff the resident transfer status. Therapy then evaluates the residents and determine transfer status. Transfer statues are communicated to the IDT. MDS Coordinator updates the electronic care plan and care profile. A paper care profile is then placed on the inside of the resident wardrobe by the MDS Coordinator. All nursing staff will be educated annually and new staff will be educated upon hire by the Director of Nursing or designee. Expectations for nursing staff to review resident transfer status within resident electronic care plan or paper Kardex behind wardrobe door prior to transferring a resident.What to do in the event a resident indicates pain during a transfer.New admission transfer status is determined upon admission by the admitting nurse and verified by a therapist. Therapy will review transfer status quarterly, and after any significant change in condition. Updates to the care plan are complete as necessary by the MDS Coordinator. NA #1 completed a lift competency on 7/21/26 from the Assistant Director of Nursing. All other Nursing staff and therapy staff completed a quiz on 7/21/26 to ensure they understood the education. Lift and transfer status competencies are complete for all new staff upon hire by the DON or designee. The quiz results were reviewed by the DON and designee to ensure understanding. 4. How will the facility monitor its corrective actions to ensure the deficient practice will not recur?On 7/21/2026, the interdisciplinary team reviewed the incident and implemented monitoring through the facility's Quality Assurance and Performance Improvement (QAPI) program for 12 weeks to ensure sustained compliance.Beginning the week of 7/20/2026, for 12 weeks, the Director of Nursing (or designee) will:The Director of Nursing or designee will conduct 5 nursing staff interviews each week to ensure nursing staff are aware of how to properly find transfer status of each resident. This audit will cover all shifts, 7 days per week. The Director of Nursing or designee will conduct 5 resident interviews each week to ensure nursing staff are transferring them the proper way. This audit will cover all shifts, 7 days per week. The Director of Nursing or designee will conduct observations of 5 residents per week to ensure residents are utilizing a lift are receiving the proper transfer. This audit will cover all shifts, 7 days per week. Audit results will be reviewed weekly during the clinical meeting and monthly during the QAPI meeting.At the conclusion of the 12-week monitoring period, the QAPI committee will evaluate the results and determine whether additional monitoring is necessary to ensure sustained compliance.Alleged Date of Compliance: 7/22/2026The following plan of corrective action was verified via interviews with staff, record review, and observations.

Based on observations, record review, and dietary staff, Registered Dietitian (RD), and Regional Registered Dietitian interviews, the facility failed to provide food items as specified by the approved menu. This practice had the potential to affect 11 residents receiving a regular diet and 2 residents receiving a puree diet (consisting of foods with a pudding-like texture) on 1 of 4 units (700/800 hall). Findings included:A review of the approved menu for residents receiving a regular diet on 07/23/25 revealed the following foods were on the menu: chili and beans, garden salad with dressing, cornbread, and carrot cake. Alternate food items for the lunch meal included mixed vegetables and noodles. A review of the approved menu for residents receiving a puree diet revealed the following foods were on the menu: chili and beans, steamed squash, puree bread, and carrot cake. a. An observation of Dietary Aide #1 on the 700/800 hall on 07/23/25 from 12:10 PM through 12:19 PM revealed he checked the temperature of the garden salad, and the temperature was 43 degrees Fahrenheit. Dietary Aide #1 placed the pan of salad on ice and re-checked the temperature, which was 46.8 degrees Fahrenheit. Dietary Aide #1 was instructed by the Regional Registered Dietitian to serve mixed vegetables instead of garden salad to residents receiving a regular diet since the garden salad did not reach the correct temperature.An observation of Dietary Aide #1 revealed he began plating food on 07/23/25 at 12:20 PM. Residents receiving a regular diet received chili and beans, mixed vegetables, cornbread, and carrot cake. On 07/23/25 at 12:50 PM Dietary Aide #1 ran out of mixed vegetables and began serving chili and beans, noodles, cornbread, and carrot cake to residents receiving a regular diet. Dietary Aide #1 did not ask the Registered Dietitian (RD) or the Regional Registered Dietitian before substituting noodles for mixed vegetables.An interview with Dietary Aide #1 on 07/23/25 at 1:05 PM revealed he frequently ran out of food on the tray line, and he would plate whatever food he had left on the serving line. He stated he did not notify his supervisor when he ran out of food and did not ask for guidance to provide a nutritionally equivalent substitute. An interview with the Regional Registered Dietitian on 07/24/25 at 1:21 PM revealed Dietary Aide #1 should have stopped the meal tray line for the lunch meal on 07/23/25 when he ran out of mixed vegetables, notified his supervisor, and waited until a nutritionally equivalent substitute was available before sending regular trays to residents. She stated noodles were not an appropriate substitution for mixed vegetables. An interview with the Administrator on 07/24/25 at 3:22 PM revealed Dietary Aide #1 should have waited until an appropriate substitute was available for the lunch meal on 07/23/25 instead of substituting noodles for mixed vegetables. b. An observation of the meal tray line on 07/23/25 at 12:20 PM revealed Dietary Aide #1 began plating the food. Residents on a puree diet did not receive puree bread or a substitute for bread. In an interview with the RD on 07/23/25 at 12:30 PM she confirmed no puree bread was available for the lunch meal on 07/23/25. She stated residents receiving a puree diet should receive the same food or an appropriate substitution as residents receiving any other diet texture. An interview with Dietary Aide #1 on 07/23/25 at 1:05 PM revealed he did not have puree bread or a substitute to serve residents receiving a puree diet on 07/23/25 and he did not notify his supervisor that the puree bread was unavailable. An interview with [NAME] #1 on 07/24/25 at 1:21 PM revealed she did make puree bread for the lunch meal on 07/23/25, but it did not get sent to the 700/800 hall. An interview with the Administrator on 07/24/25 at 3:22 PM revealed puree bread did not get sent to the 700/800 hall for the lunch meal on 07/23/25. He stated residents receiving a puree diet on 07/23/25 did not receive bread and they should have received bread per the menu.

Based on record review, and Responsible Party and staff interviews, the facility failed to refund the balance of an expired resident's personal fund account within thirty days to the individual or probate jurisdiction administering the resident's estate (Resident #107) and failed to refund Social Security checks received after a resident transferred to another nursing facility (Resident #104) for 2 of 2 residents reviewed for personal funds.Findings included:1. Resident #107 was admitted to the facility on [DATE].A discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #107 passed away at the facility.The Resident Statement for Resident #107 with a billing date of [DATE] revealed a payment in the amount of $10,304.00 received on [DATE] was applied to room charges for the period [DATE] to [DATE] totaling $2,944.00 resulting in an overpayment in the amount of $7,360.00.Review of the refund requests for Resident #107 provided by the Business Office Manager on [DATE] at 1:00 PM revealed an initial request for a refund was submitted to the corporate office on [DATE] and a second refund request was submitted to the corporate office on [DATE].During a phone interview on [DATE] at 2:00 PM, Resident #107's Responsible Party (RP) revealed prior to Resident #107's passing, a payment was made to pay Resident #107's account in full. The RP explained after Resident #107 passed away, he had been corresponding frequently with the Business Office Manager to get a refund issued so that he would be able to close Resident #107's estate. The RP stated he wasn't sure why it took the facility 5 months to issue the refund but it was finally received approximately two weeks ago ([DATE]).During interviews on [DATE] at 2:30 PM and [DATE] at 1:00 PM, the Business Office Manager revealed Resident #107 passed away at the facility mid-month February 2025, however, resident accounts were not closed out until the following month to ensure there was no balance owed. If there was a refund due once the account was closed, she submitted a request to the corporate office to issue a refund that included the amount of the refund, name of the person to make the check payable to and the address to mail the refund. The Business Office Manger stated she was aware of the 30 day regulatory requirement for issuing refunds and explained it was hard to meet that requirement due to the facility's process of closing accounts the following month. The Business Office Manager stated one reason for the delay in issuing the refund was due to waiting on Resident #107's RP to send documentation that he was named as the executor of the estate which she received via email on [DATE]. She stated a refund check was then issued to Resident #107's RP. The Business Office Manager explained after receiving a call from Resident #107's RP on [DATE] stating he had not received the refund, she submitted a inquiry to the corporate office for a status. She discovered when the check was initially mailed to Resident #107's RP by the corporate office, it was sent to the incorrect address. She stated the refund was reissued and mailed to Resident #107's RP at the correct address on [DATE]. During interviews on [DATE] at 12:48 PM and 3:40 PM, the Administrator stated a refund should have been issued to Resident #107's RP within the 30 day regulatory timeframe following Resident #107's death. He explained with the facility's process on closing out resident accounts, it was difficult to get refunds processed timely. The Administrator stated a refund check was issued to Resident #107's RP and when it was discovered the refund was mailed to the wrong address, another refund check was reissued. 2. Resident #104 was admitted to the facility on [DATE].A discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 discharged to the community.The Resident Statement detail report for Resident #104 revealed checks were received from the Social Security Administration (SSA) on [DATE] in the amount of $2,094.00 and on [DATE] in the amount of $2,518.00. During a phone interview on [DATE] at 7:14 PM, Resident #104's Responsible Party (RP) revealed at her request, Resident #104 discharged from the facility on [DATE] to move out of state to an assisted living facility closer to her. The RP stated following Resident #107's discharge on [DATE], the facility received Resident #107's social security checks for [DATE] and [DATE]. The RP stated she contacted the SSA in both states and was told the money had not been returned. The RP explained Resident #104 owed a balance for [DATE] and [DATE] to the assisted living facility where she now resided and was fearful Resident #104 would be discharged due to non-payment since the facility had not refunded the money to SSA nor sent the refund to the assisted living facility.During an interview on [DATE] at 2:30 PM, the Business Office Manager revealed when Resident #104 first admitted to the facility (2021) she received a pension check in addition to her social security check. She explained Resident #104's social security check was sent directly to the facility but the pension check was not which resulted in her accumulating a balance owed at the facility. The Business Office Manager stated at one point she noticed that Resident #104's social security payments were short and when she called the SSA to inquire, she found out Resident #104's checks were being garnished due to back taxes. She stated she filled out a form to have the garnishment refunded which was applied to the balance Resident #104 owed at the facility. The Business Office Manager explained when Resident #104 discharged from the facility ([DATE]) the remaining amount of her [DATE] social security check was also applied to her balance owed. She explained on [DATE] a refund check was issued to Resident #104 in the amount of $2,254.62 for the remainder of the [DATE] social security check the facility received but still showed as outstanding (not cashed). The Business Office Manager explained she wasn't aware the facility had also received Resident #104's [DATE] social security check in the amount of $2,448.00 because a credit did not generate on her account due to the system automatically applying the payment to her balance owed. The Business Office Manager stated she submitted a request for an expedited refund in the amount of $2,448.00 that was being sent to Resident #104 at the assisted living facility she now resided and she would be contacting the corporate office to inquire about having the refund in the amount of $2,254.62 reissued and sent to Resident #104. During an interview on [DATE] at 1:00 PM, the Administrator stated they had overlooked the refund owed to Resident #104 and a refund should have been issued within the regulatory timeframe.

Based on observations, record reviews, staff and resident interview, the facility failed to reassess for the ability to self-administer medications for a resident who was self-administering a medication for 1 of 1 resident reviewed for self-administering medications (Resident #10).The findings included:Resident #10 was admitted to the facility on [DATE] with diagnoses that included gastroesophageal reflux disease (GERD).Review of Resident #10's physician orders dated 08/06/24 for calcium carbonate chewable tablets 500 milligrams, take two tablets every eight hours as needed for GERD.Review of Resident #10's Self-Administration assessment dated [DATE] indicated the Resident did not want to self-administer medications.Review of Resident #10's annual Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was cognitively intact.On 07/22/25 at 1:05 PM during an interview and observation of Resident #10 it was noted that there was a bottle of antiacid tablets approximately 1/4 full of tablets of various colors sitting on her over bed table in her room. When Resident #10 was asked about the medication the Resident explained that a family member brought the medication to her because she had gastric reflux and heart burn mostly at night and she took the medication when she needed them. The Resident stated she did not have heartburn every night, but she wanted them close by when she needed them. Subsequent observations were made on 07/23/25 at 2:23 PM, 07/24/25 at 8:42 AM and 07/25/25 at 8:51 AM and the bottle of antiacid tablets remained at Resident #10's bedside.An interview was conducted with Nurse #4 on 07/25/25 from 11:25 AM. The Nurse explained that Resident #10 did not have an order to self-medicate and she did not think she would be able to administer her own medications. The Nurse was notified of the bottle of antiacids on the Resident's over bed table and the Nurse retrieved the medication and stated she would address it with the Director of Nursing. The Nurse stated she had not noticed the medication in the Resident's room.During an interview with the Director of Nursing (DON) on 07/25/25 at 11:54 AM, the DON explained that residents had to be assessed to be able to keep their medications at bedside and had to be assessed to be able to medicate themselves according to the physician orders. She indicated that Resident #10 could possibly self-administer her antiacid medication but first she would have to be assessed in order to do so.

Based on record review and Law Enforcement Detective and staff interviews, the facility failed to assure residents' property was safeguarded and staff did not misappropriate the residents' property for personal gain. Nurse Aide #1 used Resident #118‘s credit card to make unauthorized purchases totaling $757.73 without Resident #118's permission or knowledge and Housekeeper #1 used Resident #119‘s credit card to make an unauthorized purchase totaling $152.13 without Resident #119's permission or knowledge for 2 of 3 residents reviewed for misappropriation of resident property (Resident #118 and Resident #119).Findings included:The facility's Resident Abuse policy, last revised on 08/30/23, revealed in part, the facility would ensure all residents were free from misappropriation of property.1. Resident #118 was admitted to the facility on [DATE].The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #118 with intact cognition.Review of the facility's investigation revealed on 12/12/24 at 3:30 PM the facility became aware of an allegation of misappropriation of property when Resident #118 reported her credit card was missing and an investigation was initiated. Resident #118 was notified by a family member that there were charges made using her credit card and when Resident #118 looked, she was unable to locate the credit card. Resident #118's credit card was frozen by the bank, the charges were disputed and law enforcement was notified. Continued review of the facility's investigation included an undated statement signed by the Administrator that revealed in part, the Law Enforcement Detective contacted the Administrator on 12/23/24 at 1:00 PM stating they had identified Nurse Aide (NA) #1 through video surveillance as the person who made the unauthorized purchases using Resident #118's credit card. NA #1 was working at the facility on 12/23/24 and was on break until 2:00 PM. Immediately upon returning from break, NA #1 was escorted to the Director of Nursing's (DON) office by the Administrator and interviewed. At first, NA #1 denied the accusation but when NA #1 was informed that law enforcement had video evidence of her making the purchases using Resident #118's credit card, NA #1 admitted to the Administrator and DON that she had taken Resident #118's credit card without authorization. NA #1 was terminated from employment and escorted out of the facility.A review of Resident #118's bank account records from 12/07/24 to 12/12/24 revealed four separate purchases were made to restaurants on 12/07/24 totaling $92.92; five separate purchases were made to restaurants and department stores on 12/10/24 totaling $489.38; and three separate purchases were made to restaurants and a grocery store on 12/12/24 totaling $175.43. Resident #118 discharged from the facility on 12/20/24 and was unable to be interviewed during this investigation.During a phone interview on 07/23/25 at 2:55 PM, NA #1 stated she did not take Resident #118's credit card and did not make the unauthorized credit card purchases. NA #1 expressed she never provided care to Resident #118 and was not working the day the credit card was allegedly lost. When asked if she was informed that law enforcement was able to positively identify her through video surveillance as the person making the unauthorized purchases, she replied no. NA #1 restated she did not do what she was being accused of and voiced she felt the facility administration singled her out for one reason or another. Review of the time clock report and corresponding staff schedule for 12/06/24 revealed NA #1 worked 7:00 PM to 7:00 AM and was assigned to Resident #118's hall.During a phone interview on 07/25/25 at 9:40 AM, the Law Enforcement Detective revealed he went to the grocery store and one of the department stores where purchases were made, told store employees what he was looking for and they were able to provide him with video security footage. He explained he was able to get still shots (photographs) from the video security footage, ran the images through facial recognition software and NA #1 was positively identified when a match was made to her driver's license photo. In addition, the loss prevention employee at the department store was able to confirm NA #1 used her membership number when making the purchase. The Law Enforcement Detective stated he never interviewed NA #1 as he had all the information needed and charges were filed.During an interview on 07/24/25 at 1:55 PM, the DON confirmed she was present on 12/23/24 when the Administrator interviewed NA #1 about Resident #118's credit card. The DON stated once the Administrator informed NA #1 that law enforcement had video evidence, NA #1 admitted that she took Resident #118's credit card without her knowledge and made the purchases. The DON stated NA #1 never provided any explanation as to why she took Resident #118's credit card.During interviews on 07/23/25 at 10:21 AM and 07/25/25 at 7:50 AM, the Administrator revealed at the time of Resident #118's admission to the facility (12/06/24), her family was managing her finances, noticed the charges made on her credit card and when they called Resident #118 about the charges, she denied spending any money. He stated he was informed by Resident #118's family they had notified her bank to freeze her account and they provided him with copies of the detailed transactions from her account. The Administrator stated when he spoke with Resident #118 she displayed no emotional distress, just appeared annoyed over the situation, and had no idea who would have taken her credit card. The Administrator stated at the time the allegation was made, he initially suspected another staff member who was involved in a similar situation a few weeks prior; however, she had resigned her position on 12/02/24 which was prior to this incident. He explained at the conclusion of the facility's investigation they were unable to determine what had happened to Resident #118's credit card or if it had been taken by an employee at the facility. The Administrator stated NA #1 was never a suspect until he was notified by law enforcement on 12/23/24 that they had video evidence of NA #1 making the unauthorized purchases and were able to make a positive identification by comparing pictures from the video to NA #1's driver's license photo. The Administrator stated after speaking to law enforcement, he brought NA #1 to the DON's office for an interview. He stated at first, NA #1 denied taking Resident #118's credit card and making unauthorized purchases but when she was told law enforcement stated they had video footage of her using the credit card, she told him well you got me, there is no way around it and finally admitted to taking and using Resident #118's credit card without her knowledge. The Administrator stated NA #1 never provided an explanation as to why she took Resident #118's credit card and basically stopped talking. The Administrator stated NA #1's employment was terminated and she was escorted out of the building. The Administrator stated he was informed by Resident #118 that her bank had refunded the money from the unauthorized purchases.2. Resident #119 was admitted to the facility on [DATE].The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #119 with intact cognition.Review of the facility's investigation revealed on 12/06/24 at 2:15 PM the facility became aware of an allegation of misappropriation of property for Resident #119 and an investigation was initiated. Resident #119 reported an unauthorized purchase was made to a department store in the amount of $152.13 and her credit card was missing from her wallet. Resident #119 also alleged she thought Housekeeper #1 was the person who had taken her credit card. Resident #119 contacted her bank to freeze the card, reissue a new card and disputed the charges. The accused employee resigned employment around the same time the purchase was made using Resident #119's credit card. Resident #119 reported the bank refunded the money from the unauthorized purchase and issued her a new credit card. Law enforcement, Health Care Personnel Registry and Adult Protective Services were all notified of the incident.Resident #119 discharged from the facility on 12/23/24 and was unable to be interviewed during this investigation.Unsuccessful telephone attempts for an interview with Housekeeper #1 were made on 07/23/25 at 9:09 AM and 07/24/25 at 12:06 PM with no return phone call.During interviews on 07/23/25 at 10:21 AM and 07/25/25 at 7:50 AM, the Administrator revealed when Resident #119 reported her credit card was missing on 12/06/24, she alleged it was a housekeeper who took the credit card without her permission and he knew by the process of elimination that Housekeeper #1 was assigned to Resident #119's hall. The Administrator stated when he spoke with Resident #119 she displayed no emotional distress, just appeared annoyed over the situation. He explained an investigation was initiated, including reporting the incident to law enforcement, Adult Protective Services and the State Agency, and Housekeeper #1 had already resigned her position on 12/02/24 prior to the incident being reported. He stated he tried calling Housekeeper #1 but she never returned any of his phone calls. The Administrator stated Resident #119 reported that her bank had refunded the money from the unauthorized purchase.

Based on observations, record review, and staff interviews the facility failed to ensure Nurse #7 suctioned a resident's tracheostomy (a surgical opening in the neck to allow breathing) using sterile technique (a way of providing care that attempts to eliminate germs to prevent infection) for 1 of 1 resident reviewed for tracheostomy care (Resident #1).Findings included:Resident #1 was admitted to the facility 07/07/25 with diagnoses including pneumonia and respiratory failure (when the lungs can't properly exchange oxygen and carbon dioxide). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and received tracheostomy care and suctioning. Review of a respiratory care plan initiated 07/07/25 revealed Resident #1 had a tracheostomy and interventions included providing oxygen as ordered and suctioning her tracheostomy as needed. A continuous observation of Nurse #7 on 07/25/25 from 10:50 AM to 11:20 AM revealed she was providing tracheostomy care for Resident #1. During tracheostomy care, Resident #1 indicated she needed to be suctioned. Nurse #7 immediately discontinued tracheostomy care, removed her gloves, washed her hands, applied clean gloves, opened the package containing the sterile suction catheter (tube), connected the suction catheter to the suction machine, turned on the suction machine, and inserted the suction catheter into Resident #1's tracheostomy, applied suction for approximately 15 seconds, removed the suction catheter from the tracheostomy, waited approximately 30 seconds, reinserted the suction catheter, applied suction for approximately 15 seconds, removed the suction catheter from Resident #1's tracheostomy, removed the suction catheter from the suction machine, discarded the suction catheter in the trash, removed her clean gloves, discarded the gloves in the trash, and washed her hands. Nurse #7 did not don sterile gloves or use sterile technique while suctioning Resident #1.In an interview with Nurse #7 on 07/25/25 at 11:24 AM she confirmed she did not use sterile gloves or sterile technique to suction Resident #1's tracheostomy. She stated she was aware there were tracheostomy suction kits which contained sterile gloves and sterile water that she was supposed to use, but she was nervous and forgot. An interview with the Director of Nursing (DON) on 07/25/25 at 11:48 AM revealed she expected sterile technique to be used when suctioning a tracheostomy tube. An interview with the Administrator on 07/25/25 at 12:55 PM revealed he expected nursing staff to follow facility policy for suctioning a tracheostomy.

Based on record review and interviews, the facility failed to ensure accurate accounting for the receipt of nine (9) tablets of controlled medications. This was for 1 of 1 facility emergency-controlled medication storage areas.The findings included:Review of a pharmacy order sheet for scheduled I and II controlled medications revealed one (1) oxycodone immediate release (IR) 5 milligrams (mg) was ordered on 08/07/24.Review of a pharmacy order sheet for scheduled IV controlled medications revealed four (4) lorazepam 0.5 mg tablets and four (4) tramadol 50 mg tablets were ordered on 08/07/24.Review of a pharmacy delivery sheet for controlled medications revealed the following controlled medications were delivered to the facility on [DATE]: (1) oxycodone IR 5 mg tablet, (4) tramadol 50 mg tablets and (4) lorazepam 0.5 mg tablets. The delivery sheet was signed by the delivery driver and Nurse #5.On 07/22/2025 at 3:03 PM an interview was conducted with the Director of Nursing (DON) who explained that on 08/09/24 she reviewed the pharmacy delivery sheet for the controlled medications and found that the controlled medications were signed for by Nurse #5. The DON went to the medication cart that Nurse #5 worked on 08/08/24 to obtain the controlled medications but the medications were not on the medication cart. Nurse #6 who was assigned to the medication cart on 08/09/24, reported that she did not count controlled medications from the pharmacy with Nurse #5 during shift change that morning on 08/09/24. The DON continued to explain that she and Nurse #6 completed a review of all medication carts and could not find the controlled medications. The DON called Nurse #5 to inquire about the controlled medications and Nurse #5 reported that she received controlled medications for a resident but not for the facility's emergency controlled medication storage. Nurse #5 explained to the DON that she signed the delivery sheet but admitted ly she did not count the controlled medications in the package with the delivery driver before she signed the delivery sheet. The DON explained that she notified the Administrator who called the pharmacy to report the missing controlled medications and inquire about the delivery driver.An interview was conducted with Nurse #5 on 07/22/25 at 7:46 PM who confirmed that she worked on the night of 08/08/24. The Nurse explained that she received the pharmacy delivery of controlled medications for a resident but did not receive the controlled medications for the emergency controlled storage. Nurse #5 reported she did not count the controlled medications with the delivery driver but did sign the delivery sheet. The Nurse was insistent that there were no other medications in the package except for the resident's controlled medications. The Nurse continued to explain that she was asked to come to the facility on [DATE] to provide a statement and adhere to a drug test for reasonable suspicion which she complied, and the result was negative on 08/09/24. Nurse #5 reported that she was suspended on 08/09/24 pending investigation of the missing controlled medications which lasted ten (10) days. The Nurse stated she was reported to the Board of Nursing (BON) and the BON informed the Nurse that there would be no formal disciplinary action. The Nurse explained that she was called to the facility on [DATE] and was given a written warning on not following the proper procedure of obtaining controlled medications and was educated on the proper procedure of obtaining controlled medications. The Nurse reported that now the new procedure was for two (2) nurses to verify the controlled medication count when delivered from the pharmacy.During an interview with Nurse #6 on 07/22/25 at 8:00 PM the Nurse explained that she was approached by the DON on 08/09/24 and asked if she counted the emergency controlled medications during shift change with Nurse #5 and the Nurse reported that she had not counted any emergency storage medications with Nurse #5. Nurse #6 continued to explain that she helped the DON search for missing controlled medications and could not find them and she helped count all the controlled medications on all the medication carts in the facility and the counts were all reconciled.On 07/22/25 at 4:50 PM an interview was conducted with the Administrator who reported that he was notified on 08/09/24 of the missing emergency controlled medications ordered by the DON on 08/07/24. The Administrator explained that all the medication carts and medication rooms were searched but the missing controlled medications were not found. The Administrator stated that they brought Nurse #5 in on 08/09/24 for a written statement and a drug test which was negative and suspended her pending the completion of the investigation. He continued to explain that he reported the missing controlled medications to the local law enforcement who investigated the situation and there were no charges related to the investigation. He stated he reported the missing controlled medications to Adult Protective Services (APS) and there was no report taken by APS citing there was no resident involved in the missing controlled medications therefore, there was no abuse, neglect or exploitation. The Administrator explained that he called the pharmacy manager to inform them of the situation and asked that the delivery driver provide a written statement and adhere to a drug test, but the driver refused, and the pharmacy manager stated it was not a part of their policy to provide it. The facility provided the following correction action plan:Address how corrective actions will be accomplished for those residents to have been affected by the deficient practices. On 08/08/24 Nurse #5 signed a narcotics delivery sheet which states that 4 house stock Ativan 0.5 mg tablets, 1 house stock oxycodone 5 mg tablet, 4 house stock tramadol 50 mg tablets and 2 bottles of lorazepam 60 milliliters for a resident were delivered. Nurse #5 states that she did not verify and count the narcotics with the delivery driver but did sign the delivery sheet. Nurse #5 stated she acknowledges receiving 2 bottles of liquid lorazepam for the resident which she secured in the refrigerator. Nurse #5 does not recall seeing the house stock narcotics in the delivery. On 08/09/24 the Director of Nursing became aware that the house stock narcotics were missing. Nurse #5 was suspended on 08/09/24. The Director of Nursing or designee searched Nurse #5's medication cart and medication room and was unable to locate the missing house stock narcotics on 08/09/24. The Administrator submitted a 24-hour report to the Division of Health Services Regulation to report the missing narcotics on 08/09/24. The Administrator reported the missing medications to Adult Protective Services and the police department on 08/14/24. Nurse #5 was drug tested on [DATE]. Results of the drug test were negative. Human resources completed a review of Nurse #5's employee file on 08/16/24 and verified she had a valid nurse license, had no disciplinary action against her license, had no exclusions from government programs, and had nothing on her background check that would preclude her from employment in a nursing home. Nurse #5 was drug tested on hire 01/06/21, and the results were negative. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 08/09/24 the Director of Nursing or designee completed a search of all other medication carts and medication rooms in the building. An audit was completed of the narcotics in the Omnicell, and an audit was completed of all resident narcotics on the medication carts. All other narcotics were accounted for. Human resources reviewed the employee files of five other employees on 08/14/24 and verified they had a valid license, and had no disciplinary action against their license, had no exclusions from government programs, and had nothing in their background checks that would preclude them from employment in a nursing home. All five employees were drug tested on hire and were negative. The 4-house stock Ativan, 1 house stock oxycodone, and 4 house stock tramadol were unable to be located. No other residents were affected by the missing house stock narcotics. The facility never ran out of any of the house stock narcotics. Narcotics were continually available to all residents. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 08/09/24 the Director of Nursing or Designee educated all licensed nurses and medication aides on the facility policy for narcotics handling to include reviewing the delivery manifest with the driver and completing a count of each narcotic listed on the manifest with the driver ensuring the accuracy of what medication was delivered and the quantity of each medication was delivered prior to two nurses signing the delivery form. Immediately after receiving the medication the nurse will secure the narcotics into the medication cart or the narcotics refrigerator. If the medication delivered is not correct the nurse is to decline the delivery and immediately inform the Director of Nursing. The Director of nursing or designee will ensure that all licensed nurses receive this education prior to working their next shift. The Director of Nursing will ensure all newly hired licensed nurses will receive this education during their orientation. No nurse will work prior to receiving this education. Indicate how the facility plans to monitor its performance to make sure that solutions are sustainedOn 08/09/24 the Administrator and Director of Nursing discussed the plan of correction and determined to have an ADHOC Quality Assurance Process Improvement (QAPI) meeting. A verbal ADHOC QAPI was held on 08/09/24 with the Interdisciplinary team and educated the team on the interventions that were put into place to prevent narcotic medication discrepancies. The Medical Director was notified by the Director of Nursing via phone on 08/09/25 regarding narcotics discrepancy and what interventions that were put in place. The Director of Nursing implemented the plan of correction 08/09/24. During the QAPI meeting on 08/09/24 the decision was made to audit the plan of correction, and the Administrator informed the Director of Nursing or designee beginning the week of 08/19/24 she will audit the delivery slips with for house stock narcotics to ensure the delivery was reviewed by two nurses. Audits will continue for 8 weeks. The Interdisciplinary team will review and provide recommendations on the audit results provided by the Director of Nursing and or Designee during the QAPI meeting for the next 3 months to ensure sustained compliance. Changes to the plan of correction will be made as needed. The Administrator and Director of Nursing will ensure the corrective action plan is implemented. Date of Compliance: 08/19/24The Plan of Correction was validated on 07/25/25 which included reviewing the facility's weekly audits of the pharmacy emergency controlled delivery sheets that ensured two (2) nurses signed the delivery sheets. The education provided to the nurses was evident by the signatures on the education sign in sheets and through verbal affirmation by the nurses that they received the education. The audits were presented to QA for three (3) consecutive months. The facility's compliance date of 08/19/24 was validated.

Based on observations, record reviews and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 25 opportunities, resulting in a medication error rate of 12% for 3 of 5 residents observed during the medication administration (Resident #79, Resident #84 and Resident #26).The findings included:The manufacturer's instructions for a prefilled insulin pen indicated that priming the insulin pen each time was an important step to ensure there were no air bubbles in the insulin and the full dose of insulin was given. Priming the insulin pen: 1. Dial up 2 units: turn the dose selector dial to 2 units, 2. Prime the pen: Press the injection button to let out any air bubbles and ensure the insulin is flowing correctly, 3. Check for a drop of insulin: you should see a drop of insulin on the tip of the needle, 4. Repeat if necessary.1. Resident #79 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus.Review of Resident #79's physician orders dated 04/29/25 for Lantus insulin give 10 units subcutaneously every day.On 07/23/25 at 8:55 AM an observation was made of Nurse #3 preparing to administer insulin to Resident #79 via an insulin pen. The Nurse removed the Lantus insulin pen from the medication cart and set the counter to 10 units. Nurse #3 administered the 10 units of insulin without priming the insulin pen as advised by the manufacturer's instructions.An interview was conducted with Nurse #3 on 07/23/25 at 2:51 PM. The Nurse was asked to review the steps of giving insulin via an insulin pen. Nurse #3 repeated the steps she had taken when administering insulin to Resident #79 but did not include priming the insulin pen. The Nurse was asked if she knew about priming the insulin and she indicated she knew but thought it was only for the first time the insulin pen was used.During an interview with the Pharmacist on 07/24/25 at 2:30 PM the Pharmacist explained it was important to prime the insulin every time it was used in order to remove any air bubbles that may be present in order to inject the full amount of insulin prescribed for the Resident. During an interview with the Director of Nursing (DON) on 07/24/25/25 at 2:30 PM the DON indicated that she expected Nurse #3 to follow the manufacture's recommendations when given insulin using an insulin pen.2. Resident #84 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus.Review of Resident #84's physician orders revealed an order dated 01/18/25 for Lispro insulin 2 units subcutaneously before meals.On 07/22/25 at 4:10 PM an observation was made of Nurse #2 preparing to administer insulin to Resident #84 via an insulin pen. The Nurse removed the Lispro insulin pen from the medication cart and set the counter to 2 units. Nurse #2 administered the 2 units of insulin without priming the insulin pen as advised by the manufacturer's instructions.An interview was conducted with Nurse #2 on 07/23/25 at 2:35 PM. The Nurse was asked to review the steps when giving insulin using an insulin pen and Nurse #2 repeated how he administered the insulin the day before. When the Nurse was asked about priming the insulin pen the Nurse reported that he was not aware that the insulin pen needed to be primed before giving the insulin and stated he would remember to do that going forward.During an interview with the Pharmacist on 07/24/25 at 2:30 PM the Pharmacist explained it was important to prime the insulin every time it was used in order to remove any air bubbles that may be present in order to inject the full amount of insulin prescribed for the Resident. During an interview with the Director of Nursing (DON) on 07/24/25/25 at 2:30 PM the DON indicated that she expected Nurse #2 to follow the manufacture's recommendations when given insulin using an insulin pen.3. Resident #26 was admitted to the facility on [DATE] with diagnoses that included neuralgia (nerve pain caused by damage or irritation).Review of Resident #26's physician orders dated 03/22/25 revealed Vitamin B-12, 2,500 micrograms (mcg) by mouth once a day for neuralgia.An observation was made of Nurse #3 on 07/23/25 at 9:00 AM during a medication administration of Resident #26. The Nurse prepared Resident #26's medications which included Vitamin B-12. The Vitamin B-12 was supplied in a bottle of 1,000 mcg per tablet. The Nurse picked up the bottle of B-12 and stated she would have to cut one of the tablets in half in order to give the correct dose then proceeded to cut one tablet in half and put the half tablet in the medicine cup along with a whole tablet and administered 1,500 mcgs to Resident #26 instead of 2.5 tablets which would equal 2,500 micrograms.An interview was conducted with Nurse #3 at 2:51 PM on 07/23/25. The Nurse was asked to review the calculation of Resident #26's Vitamin B-12 tablets. The Nurse stated the total dose to be given was 2,500 and she cut one tablet in half and thought she gave the Resident 2.5 tablets. The Nurse was informed that she only gave 1.5 pills which was not enough to equal the 2,500 dose of Vitamin B-12 and the Nurse stated she should have gotten the 500-microgram stock bottle from the medication room and used it instead of cutting one of the pills in half. Nurse #3 stated she was nervous during the medication pass.On 07/24/25 at 2:30 PM an interview was conducted with the Pharmacist who explained that the correct dose of Vitamin B-12 should have been administered to Resident #26.An interview was conducted with the Director of Nursing (DON) on 07/24/25 at 2:30 PM. The DON stated Nurse #3 should have retrieved the bottle of Vitamin B-12 from the medication room to help prevent making the medication error.

Based on observations, record review, and staff interviews, the facility failed to secure 3 bottles of medicated powder observed in a resident's room for 1 of 1 resident reviewed for medication storage (Resident #19).Findings included:Resident #19 was admitted to the facility 08/13/24 with diagnoses including obstructive uropathy (a condition that occurs when urine cannot drain out of the body) and macular degeneration (an eye disease that causes vision loss). The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was severely cognitively impaired and required partial/moderate assistance with bed to chair transfers. An observation of Resident #19's dresser on 07/21/25 at 3:10 PM revealed two 15 gram (gm) and one 60 gm bottles of Nystatin powder (antifungal medication) 100,000 units/gm sitting on top. Additional observations Of Resident #19's dresser on 07/22/25 at 1:55 PM, on 07/23/25 at 8:22 AM, on 07/24/25 at 8:42 AM, and on 07/25/25 at 10:32 AM revealed two 15 gm and one 60 gm bottles of Nystatin powder 100,000 units/gm sitting on top. An observation of Resident #19's dresser with Nurse #4 on 07/25/25 at 11:35 AM revealed two 15 gm and one 60 gm bottles of Nystatin powder 100,000 units/gm sitting on top. An interview with Nurse #7 on 07/25/25 at 11:35 AM revealed medicated powders should be stored in the treatment cart unless there was a physician's order to leave the medication in the resident's room. She stated she had not been all the way in Resident #19's room since beginning her shift at 7:00 AM on 07/25/25 and had not seen the bottles of medicated powder or she would have removed them. An interview with the Director of Nursing (DON) on 07/25/25 at 11:40 AM revealed Resident #19's medicated powder should have been stored in the treatment cart unless there was a physician's order to store the medication in the resident's room. The DON confirmed there was no physician order to leave Nystatin powder in Resident #19's room. An interview with the Administrator on 07/25/25 at 12:55 PM revealed he expected staff to follow the facility's policy for medication stored at the bedside.

Based on observations, record review, resident and staff interviews, the facility failed to honor a resident's food preferences for 1 of 1 resident reviewed for food preferences (Resident #88).Findings included:Resident #88 was admitted to the facility 03/08/23.Review of Resident #88's physician orders revealed an order dated 05/31/24 for a low concentrated sugar diet (a diet that reduces or eliminates foods with high amounts of sugar).Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was cognitively intact, was able to make herself understood, and was able to understand others. Resident #88's nutrition care plan, last edited 06/23/25, revealed she had increased nutrition/hydration risks related in part to diabetes and interventions included monitoring her dietary intake and respecting/honoring resident dietary choices.The Dietary Manager (DM) was observed to interview Resident #88 on 07/21/25 at 1:04 PM. During the interview Resident #88 informed the DM that she was taught not to waste food and it was upsetting to her when she received food like oatmeal or grits that she knew she would not eat. The DM stated she understood that Resident #88 did not want to receive oatmeal or grits on her meal trays. An observation of Resident #88's meal tray ticket on 07/22/25 at 8:30 AM revealed she was documented to receive scrambled eggs, sausage patties, toast, cereal of choice, and a banana. Resident #88's meal tray ticket documented she was to receive double portions. There was no documentation on her meal tray ticket reflecting her dislikes. An observation of Resident #88's breakfast meal tray at the same date and time revealed she received a bowl of grits, a scoop of eggs, 2 pieces of sausage patties, 2 pieces of toast, and no banana. An interview with Resident #88 on 07/22/25 at 8:32 AM revealed she would like to have her banana as requested. She stated having fresh fruit for breakfast was important to her and receiving the grits on her tray was frustrating to her because she had informed the dietary department numerous times she did not like grits.An interview with the Dietary Manager (DM) on 07/24/25 at 10:41 AM revealed residents should receive all items listed on their tray ticket, and she expected resident preferences to be honored. She stated residents should not receive items they had asked not to receive. An interview with the Administrator on 07/24/25 at 3:30 PM revealed he expected residents to receive the food preferences they communicated to staff.

Based on observations, record review, and staff interviews, the facility failed to ensure staff implemented their infection control policy for hand hygiene when a nurse aide failed to remove dirty gloves and perform hand hygiene during incontinence care for Resident #1. This deficient practice was identified for 1 of 7 staff members observed for infection control practices (Nurse Aide #4). Findings included:Review of the facility's policy titled Hand Hygiene/Handwashing Policy last revised 02/28/25 read in part as follows: Hand hygiene is the most important component for preventing the spread of infection. Use of gloves does not replace the need for hand cleaning by handwashing. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: before moving from work on a soiled body site to a clean body site on the same patient, after contact with bodily fluids, and immediately after glove removal.A continuous observation of Nurse Aide (NA) #3 on 07/23/25 from 8:41 AM through 9:05 AM revealed NA #3 provided incontinence care to Resident #1. With gloved hands NA #3 cleaned urine with resident care wipes, placed the wipe in the trash can, assisted Resident #1 with rolling onto her left side, cleaned urine with resident care wipes, placed the wipe in the trash can, applied skin barrier ointment to Resident #1's right buttock, rolled a clean brief and bed pad under Resident #1, assisted Resident #1 with rolling onto her right side, cleaned urine with resident care wipe, placed the wipe in the trash can, pulled the clean brief and bed pad under resident, applied skin barrier ointment to Resident #1's left buttock, assisted Resident #1 with rolling onto her back, pulled up the brief and fastened it, pulled Resident #1's gown down, removed the pillow under Resident #1's head and pulled her up in the bed using the bed pad, assisted Resident #1 with rolling on her left side, placed a pillow under her left side, assisted Resident #1 with rolling onto her right side, placed a pillow under her right side, placed a pillow under Resident #1's head, pulled up her bed sheet and cover, used the bed control to raise Resident #1's head, placed the call light on Resident #1's bed and within her reach, pulled her overbed table across her bed and lowered the table, removed his gloves and placed them in a trash bag, picked up the trash bag, and exited the room. NA #3 did not remove his gloves and perform hand hygiene after removing urine, after applying ointment to Resident #1's buttocks, and before touching other items in Resident #1's environment. NA #3 did not perform hand hygiene after removing his gloves at the completion of care and before exiting Resident #1's room. An interview with NA #3 on 07/23/25 at 9:08 AM revealed he usually changed his gloves during incontinence care only if they were visibly soiled and he performed hand hygiene when he was ready to exit the resident's room. He stated he was nervous and that was why he did not perform hand hygiene after removing his gloves when he finished providing care and before exiting Resident #1's room. An interview with the Director of Nursing (DON) on 07/23/25 at 10:40 AM revealed she expected staff to remove gloves and perform hand hygiene when moving from dirty to clean tasks. An interview with the Administrator on 07/24/25 at 4:20 PM revealed he expected staff to remove their gloves and perform hand hygiene after performing incontinence care and before performing the next task. An interview with the Infection Preventionist on 07/25/25 at 10:11 AM revealed when staff performed incontinence care they should remove their gloves after cleaning the resident, perform hand hygiene, and then continue care.

Based on observations, record reviews and interviews, the facility failed to prevent urinary catheter bags from touching the floor for 2 of 3 residents (Resident #11 and Resident #17) reviewed for urinary catheters. The findings included: 1. Resident #17 with a cumulative diagnosis that included urinary retention. A review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident's cognition was moderately impaired and she was always incontinent of urine. The MDS was also coded as not having an indwelling urinary catheter. A review of Resident #17's care plan revealed there was no care plan for a urinary catheter. A review of a Urology consult dated 04/12/24 revealed a #16 urinary catheter with 10 cubic centimeters (cc) was inserted into the bladder for significant history of Parkinson Disease, urinary infections, incontinence of bladder and bowel and immobility. Change the urinary catheter monthly at nursing facility. A review of Resident #17's physician orders dated 04/17/24 revealed orders for a) urinary catheter, b) change catheter as needed (prn), c) stabilizing device, d) privacy bag, e) catheter care and f) keep catheter below bladder. Multiple observations were made during the survey of Resident #17's urinary catheter bag positioned on the floor. The observations were as noted: -04/30/24 at 12:00 PM Resident #17 was sitting in the dining room in her wheelchair with the catheter bag mounted under the wheelchair and the catheter bag was positioned on the floor. Multiple staff were observed walking around in the dining room. -04/30/24 at 12:27 PM Resident #17 was sitting in the dining room in her wheelchair with the catheter bag positioned on the floor. Multiple staff were observed walking around in the dining room. -04/30/24 at 12:57 PM Resident #17 remained in the dining room sitting in her wheelchair. Multiple staff walked by the Resident while the catheter bag was positioned on the floor. -04/30/24 at 3:32 PM Resident #17 was observed sitting in her wheelchair in the activity room with staff present. The catheter bag was mounted under the wheelchair and the catheter bag was positioned on the floor. 05/01/24 10:55 AM Resident #17 was observed in her room sitting in her wheelchair with the catheter bag mounted under the wheelchair and positioned on the floor. 05/01/24 at 11:09 AM accompanied staff into the Resident #17's room for interview and observation of the transfer of Resident #17 being put into bed by Nurse Aide (NA) #1 and NA #2. Both NAs noted the Resident's catheter bag positioned on the floor under the wheelchair. NA #1 explained that she mounted the catheter bag under the wheelchair because she did not have anywhere else to attach it. The NA continued to explain that it was not touching the floor when she hung it there and stated it should not be on the floor because it could cause infection. 05/01/24 at 11:13 AM An interview was conducted with Nurse #5 who was assigned to care for Resident #17 on 05/01/24. The Nurse explained that she did not know the specific reason for Resident #17's catheter but she did know that Resident #17 went for a urology consult last week (04/12/24) and came back with the catheter. She stated the Resident had numerous complaints of burning on urination and was tested monthly for urinary tract infections. Nurse #5 also explained that the catheter bag should not be on the floor due to the potential for infection. She stated that she did not notice the catheter bag was on the floor when she worked with her, but she stated she did not specifically look for it either. On 05/02/24 at 2:37 PM during an interview with the Director of Nursing (DON) she stated Resident #17 went for a urology consult and came back with a urinary catheter. She stated the catheter bag should not be positioned on the floor for infection control reasons. 38515 2. Resident #11 was admitted to the facility on [DATE] with diagnoses that included presence of urogenital implants, history of urinary tract infections, history of falling and urinary retention. Review of Resident #11's quarterly Minimum Data Set assessment dated [DATE] revealed her to be cognitively intact without delirium, behaviors, or rejection of care. Resident #11 was coded as not having a catheter at the time and was occasionally incontinent of bladder and always continent of bowel. An observation of Resident #11 on 04/29/24 at 12:19 PM revealed her to be in her room, in bed resting. Resident #11's catheter bag was observed to be 3/4 full and resting on the floor causing the bag to fold in on itself. Another observation of Resident #11 was completed on 04/30/24 at 11:51 AM. Resident #11 was observed to be in her room, in bed asleep. Resident #11's catheter bag was observed to be laying flat on the floor due to her bed being placed in the lowest possible position. An interview with NA #4 on 04/30/24 at 12:31 PM revealed she had been assigned to Resident #11 on 04/29/24 and 04/30/24. She reported Resident #11 required to be kept with her bed in the lowest position due to her being a fall risk. She reported she was aware Resident #11 had a catheter and indicated resident's catheter bag being on the floor was due to her having to be in the lowest position. NA #4 reported she was aware that the catheter bag would be resting on the floor when Resident #11's bed was placed in the lowest position. An interview with Nurse #3 on 04/30/24 at 12:40 PM revealed Resident #11 was a fall risk and was required to keep her bed in the lowest position. Nurse #3 also reported that she was aware Resident #11 had a catheter and that Resident #11's bed should be kept in the lowest possible position that prevented the catheter bag from resting on the floor. An observation of Resident #11 with Nurse #3 completed on 04/30/24 at 12:43 PM revealed Resident #11's catheter bag resting on the floor. Nurse #3 reported the catheter bag would occasionally come into contact with the floor due to Resident #11 having to be in a low bed but there had been no issues with Resident #11's catheter and the output was still good. Nurse #3 ultimately raised Resident #11's bed to ensure the catheter bag was not in contact with the floor. During an interview with the Director of Nursing on 05/02/24 at 1:36 PM she reported she was familiar with Resident #11 and was aware she had a catheter. The Director of Nursing reported that catheter bags should never come into contact with the floor and if a resident was required to be kept in a low bed, then the bed should be kept in the lowest possible position that prevented the catheter bag from touching the floor. An interview with the Administrator on 05/02/24 at 2:21 PM revealed he expected catheter bags to not touch the floor. He reported if a resident was required to be in a low bed, then the bed should be low enough to ensure that catheter bags were kept off the floor.

Based on observations, record review, and staff interviews, the facility failed to ensure a controlled substance medication ordered for a resident was safely stored and secured using a double lock feature for 1 of 4 medication storage refrigerators observed (Resident #65). A controlled substance has an accepted medical use, a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. The facility also failed to date an open vial of insulin on 1 of 2 medication carts reviewed (300/400 hall medication cart) and failed to date a vial of Tuberculin Serum (used to conduct tuberculosis screening) and failed discard the Tuberculin serum after 30 days in 2 of 4 medication rooms reviewed 300/400 hall medication cart and 500/600 hall medication cart). The findings included: Review of a facility policy titled Storage and Expiration Dating of Medications, Biologicals revised last on 08/07/23 read in part, facility should store Schedule II-V controlled substances in a separate compartment within the locked medication carts and should have a different key or access device. Store all drugs and biologicals in locked compartments, including the storage of scheduled II-V medications in separately locked, permanently affixed compartments permitting only authorized personnel to have access. 1. Resident #65 was admitted to the facility on [DATE]. Review of a physician order dated 04/03/24, Lorazepam (schedule IV antianxiety) 2 milligrams (mg)/1 milliliter (ml), give 0.5 mg by mouth at bedtime for anxiety. An observation of the 700/800 hall medication room refrigerator was made on 04/30/24 at 3:29 PM along with Nurse #1 revealed the small medication room refrigerator did not have a lock device on it. Once opened the refrigerator had a small permanently affixed container but the lock was not present and only contained a small hole where the lock used to be. The permanently affixed container was opened by inserting a finger into the lock hole and opening the container. Inside the container was a box labelled with Resident #65's name and directions. The medication was Lorazepam 2mg/1ml that contained approximately 12 ml of medication in it. The Director of Nursing (DON) was interviewed on 04/30/24 at 3:57 PM. The DON was asked to observe the 700/800 hall medication room refrigerator. She stated that she was unaware that the lock was broken on the refrigerator and on the small permanently affixed container. She stated she was aware that the Lorazepam needed to be secured and she would get a lock installed immediately. Nurse #1 was interviewed on 04/30/24 at 4:10 PM who stated the lock on the medication room refrigerator in the medication room had been broken for months and she had reported it several people but could not recall who all she had reported to. Nurse #1 explained that the lock on the refrigerator had been broken since last week and she had not report that to anyone. She added that the lock that was on the refrigerator was so flimsy and was hanging on by a thread and then eventually just fell off sometime last week. 2. Review of a facility policy titles Storage and Expiration Dating of Medications, Biologicals revised last on 08/07/23 read in part, facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. An observation of the 300/400 hall medication cart was made on 05/01/24 at 10:00 AM along with Nurse #2. The observation revealed an opened via of Humalog insulin that contained no date of when it was opened. Nurse #2 was interviewed on 05/01/24 at 10:10 AM, she stated she was not sure when the vial had been opened as she only worked one day a week. She indicated that she would discard the vial of insulin. The Director of Nursing (DON) was interviewed on 04/30/24 at 3:49 PM, who stated that the third shift staff were expected to go through the medication room and carts at least weekly and then of course the nurses should be going through the medication carts on a daily basis as they were medicating residents to ensure that everything was dated and labelled correctly. The DON stated insulin vials were good usually for 28 days after being opened and coming out of the refrigerator and the nurses should be keeping track of the 28 days by dating the insulin vial or pen when it was opened. The Administrator was interviewed on 05/02/24 at 3:29 who stated that all insulin vials should be dated when they were opened. 3. Review of a facility policy titles Storage and Expiration Dating of Medications, Biologicals revised last on 08/07/23 read in part, facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. A. An observation of the 500/600 hall medication room refrigerator was made on 04/30/24 at 3:34 PM along with Nurse #3. The observation revealed a vial of Tuberculin serum that was dated as being opened on 03/12/24. B. An observation of the 300/400 hall medication room refrigerator was made on 04/30/24 at 3:46 PM along with Nurse #4. The observation revealed an opened vial of Tuberculin serum that had no date of when it was opened. Nurse #4 was interviewed on 04/30/24 at 4:00 PM, she stated she was fairly new to the facility, and she was not sure about the vial of serum and would have to ask the Director of Nursing (DON). The DON was asked to observe the 500/600 hall medication room refrigerator and the 300/400 hall medication room refrigerator on 04/30/24 at 3:57. The DON stated she was not aware that the vials of Tuberculin serum were undated and were kept past the 30-day shelf life after opening. The DON again confirmed that the tuberculin serum was good for 30 days after opening and then should be discarded. The Administrator was interviewed on 05/02/24 at 3:29 PM who stated he expected the staff to follow the facility policy and procedures for dating vials of medication and removing them by their use by or expiration date.

Based on test tray observations, resident, and staff interviews the facility failed to serve food that was palatable in taste for 7 of 7 residents reviewed for food (Resident #25, Resident #26, Resident #30, Resident #47, Resident #77, Resident #124, and Resident #126). This practice had the potential to affect other residents. The findings included: 1a. Resident #25 was admitted to the facility 10/14/21. A review of Resident #25's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and required set up assistance with eating activity. An interview was conducted with Resident #25 on 05/01/24 at 2:50 PM. The Resident was sitting in her wheelchair at her bedside and when asked about her lunch she remarked that they served her beef stir fry, rice and a roll with mango mousse for dessert. The Resident explained that she could not eat the beef stir fry because it was too salty, so she ate the rice, roll and the mousse. The Resident stated she would have to wait until supper to eat again. b. Resident #26 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #26 was cognitively intact and required set up assistance with eating. An interview was conducted with Resident #26 on 05/01/24 at 1:10 PM. Resident #26 was sitting in his wheelchair on the front porch of the facility. When asked how his lunch was, Resident #26 shook his head and stated, I could not eat it, it was too salty. When asked if he had eaten anything Resident #26 stated he had not and stated he would be ok until dinner time. c. Resident #30 was admitted [DATE]. A review of Resident #30's quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact, and she required set up assistance with eating activity. During an interview with Resident #30 on 05/01/24 at 4:10 PM the Resident explained that she was served beef stir fry and rice for lunch, but she could not eat the beef because it was too salty. The Resident stated luckily, they brought her baked chicken, or she would not have eaten any meat until supper. d. Resident #47 was admitted to the facility on [DATE]. A review of Resident #47's quarterly Minimum Data Set assessment dated [DATE] revealed her cognition was moderately impaired and she was independent with her eating activity. During an interview with Resident #47 on 05/01/24 at 4:15 PM the Resident explained that she was given beef stir fry and rice for lunch, but she could not eat the beef stir fry because it was too salty and spicy for her taste. She stated she would have to wait for supper before she would eat again. e. Resident #77 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #77 was cognitively intact and required set up assistance with eating. The MDS also indicated that Resident #77 received a therapeutic diet during the assessment reference period. An interview was conducted with Resident #47 on 05/01/24 at 3:01 PM. Resident #47 was up in her wheelchair in her room. She stated, lunch was terrible, I took a couple of bites, and it was too salty, and I could not take it. Resident #47 stated she had not asked the staff for anything else, she just snacked on some things that that she had in her room to tide her over until dinner. f. Resident #124 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #124 was cognitively intact and required set up assistance with eating. The MDS further revealed that Resident #124 received a therapeutic diet during the assessment reference period. An observation and interview were conducted with Resident #124 on 05/01/24 at 3:00 PM. Resident #124 was resting in bed in a gown. She was observed to have a package of pecan wheels on her bedside table and 2 had been eaten. Resident #124 stated she could not eat the beef stir fry because it was full of salt and then there was clump of rice with no gravy or anything on it. It was terrible. Resident #124 stated she had eaten 2 pecan wheels because she had to have something to eat all I had for breakfast was a small box of cereal. g. Resident #126 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] indicated that Resident #126 was cognitively intact and required no assistance with eating. An observation and interview were conducted with Resident #126 on 05/01/24 at 5:30 PM. Resident #126 was sitting in her wheelchair in room visiting with her family member. There was a cup that had a milkshake in it on her bedside table. Resident #126 stated she could not eat the beef stir fry that was served for lunch because it was too salty. She stated someone from the facility had brought her some chicken nuggets and her family member had brought her a milkshake so she was full but again stated that lunch was just too salty, and she could not eat it. Cook #1 was interviewed on 05/02/24 at 12:24 PM. Cook #1 confirmed that she had prepared lunch on 05/01/24 and confirmed that it was beef vegetable stir fry. She stated that she had prepared the meat on the flat top grill and chopped the meat and vegetables (broccoli, green beans, peas, cauliflower, and red peppers) together. Once the meat was cooked and vegetables chopped, she added the soy sauce. Cook #1 stated that the recipe called for 2 cups of soy sauce for 50 people, and she was preparing for 100 people so added 4.5 to 5 cups of soy sauce. She stated that before she added the soy sauce, she tasted the stir fry and it tasted perfect, but she had not tasted it after she added the soy sauce. Cook #1 confirmed that the soy sauce was not low sodium and that she thought it was a lot of soy sauce but stated I thought it would balance out since I was cooking a big portion. 2. An observation of the test tray was conducted on 05/01/24 at 12:46 PM along with the Administrator and Dietary Manager (DM). The tray was served on a plate that was enclosed on an insulated plate bottom and covered with an insulated lid. When the lid was lifted off the plate there was visible steam noted. The plate contained a portion of rice and beef stir fry. There was no egg roll or dessert (mango mousse) served with the test tray. The test tray was sampled and noted to be hot, the rice was a bit mushy, and the stir fry was very salty. The DM indicated that the beef stir fry was too salty for her as well but stated that they had followed the recipe that called for 2 cups of soy sauce for 50 people, and they doubled it since they were preparing for 100 people. The Administrator was interviewed on 05/02/24 at 3:36 PM. He stated that the DM had been at the facility since it opened but recently just moved into the manager role. He stated that he had worked with her closely for about a month then that allowed her to take over and run the show. He stated that they were getting some feedback from the residents that required them to take a step back and look at the whole operation of the kitchen. He stated for palatability the kitchen staff were required to send him a picture of the meals and he had accumulated over 200 pictures of the meals that were served to the residents. The Administrator did state that he did not conduct test trays and had not eaten the food at the facility.

Based on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on 06/04/21. This failure was for two deficiencies that were originally cited in the areas of Resident Assessment (F636) and Pharmacy Services (F761) that were subsequently recited on the current recertification and complaint investigation survey of 05/02/24. The repeat deficiencies during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F636: Based on record review and staff interviews, the facility failed to complete Care Area Assessments (CAAs) comprehensively to address the underlying causes and contributing factors of the triggered areas for 2 of 5 sampled residents (Residents #67 and #52). During the recertification and complaint survey of 06/04/21 the facility failed to complete the Minimum Data Set (MDS) within 14 days of a resident's admission for 1 of 5 sampled residents. F761: Based on observations, record review, and staff interviews, the facility failed to ensure a controlled substance medication ordered for a resident was safely stored and secured using a double lock feature for 1 of 4 medication storage refrigerators observed (Resident #65). A controlled substance has an accepted medical use, a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. The facility also failed to date an open vial of insulin on 1 of 2 medication carts reviewed (300/400 hall medication cart) and failed to date a vial of Tuberculin Serum (used to conduct tuberculosis screening) and failed discard the Tuberculin serum after 30 days in 2 of 4 medication rooms reviewed 300/400 hall medication cart and 500/600 hall medication cart). During the recertification and complaint survey of 06/04/21 the facility failed to ensure a controlled substance medication ordered for a resident was safely stored and secured using a double locked feature for 1 of 2 medication storage refrigerators observed. A controlled substance has an accepted medical use, a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. The facility also failed to remove medications placed at bedside for 1 of 1 resident were reviewed for medications left at bedside. The Administrator was interviewed on 05/02/24 at 4:50 PM. He stated that the Quality Assurance (QA) committee met on a monthly basis and included the administrator, Director of Nursing, Social Worker, Business office Manager, Unit Managers, MDS Coordinator's, Maintenance Director, and Medical Director. Each member of the QA committee had a role, and they were required to bring last month's data to review which included infections, falls, weights, wound, quality measures, risk tools, abuse investigations, medication errors, elopements, and any other issues that needed to be reviewed and discussed. The Administrator stated that the committee also reviewed all policy updates and conducted mock surveys to help achieve and maintain ongoing compliance. The Administrator stated that at least quarterly the QA committee reviewed previous survey data to ensure nothing had changed and through that review they identify areas of opportunity to put a plan of correction in place, do a grievance or any other action that the facility may need to improve upon.

Based on observations, record review, staff and Resident interviews the facility failed to assess the resident for the ability to self-administer medications for 1 of 1 resident (Resident #25) reviewed for self-administration of medication. The findings included: Resident #25 was admitted to the facility on [DATE]. A review of Resident #25's physician orders revealed an order dated 04/01/23 for Fluticasone Propionate Nasal Suspension 50 micrograms per activation (mcg/act) 2 sprays, in both nostrils one time a day for allergies. The order did not include the Resident could self-administer the medication. A further review of Resident #25's physician orders revealed there were no orders for over the counter pain patches or an albuterol sulfate inhaler. There was no Self Administration assessment for an inhaler or pain patch. A review of Resident #25's quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact. A review of Resident #25's medical record revealed a Self-Administration assessment dated [DATE] that indicated the Resident was mentally and physically able to self-administer the Fluticasone Nasal Spray. The assessment was completed by Nurse #1. On 04/29/24 at 4:06 PM an observation and interview were conducted with Resident #25 in her room. On the Resident's over bed table was a bottle of Fluticasone Nasal Spray that the Resident explained she used every day for her allergies. Resident #25 also had a pain patch on her right knee, and she explained that she kept them in her cabinet and only used it when she had pain in her knee. The Resident removed a box of over the counter pain patches to show there were two remaining in the box. Resident #25 explained that she also had an inhaler in her purse that she used when she needed to and produced an Albuterol Sulfate inhaler. During an interview with Resident #25 on 04/30/24 at 8:56 AM the Resident explained again the use of the nasal spray which was sitting on her over bed table, the pain patch and the inhaler and stated they were still in her room. An interview was conducted with Nurse #1 on 04/30/24 at 3:02 PM. The Nurse explained that she remembered assessing Resident #25's ability to administer her nasal spray but stated she took the nasal spray to the Resident in the morning when she gave her morning medications to her and allowed the Resident to administer the nasal spray. Nurse #1 stated she was not aware that the Resident kept pain patches and an inhaler in her room and stated she did not have an order for them. She indicated she would need to obtain an order for the inhaler and pain patches and assess her ability to administer them. During an interview with the Director of Nursing (DON) on 04/30/24 at 3:12 PM she explained that the Resident should have been assessed for the ability to self-administer every medication that she kept in her room and there needed to be an order for that medication as well. The DON also stated the staff needed to be educated to monitor medications at the Residents' bedside.

Based on record review and staff interviews, the facility failed to complete Care Area Assessments (CAAs) comprehensively to address the underlying causes and contributing factors of the triggered areas for 2 of 5 sampled residents (Residents #67 and #32). The findings included: Resident #67 was admitted to the facility on [DATE] with diagnosis that included depression. Review of a physician order dated 01/11/24 read; Fluoxetine HCL (antidepressant) 10 mg by mouth every day for depression. Review of the comprehensive admission Minimum Data Set (MDS) dated [DATE] revealed Resident #67 was cognitively intact and had no behaviors, rejection of care, or wandering and no signs of delirium were noted during the assessment reference period. The MDS indicated that Resident #67's diagnosis included depression and that he had taken an antidepressant during the assessment reference period. Review of the triggered Care Area Assessment (CAA) worksheet for Psychosocial wellbeing dated 01/23/24 had the following boxes checked: resident says or indicated they feel lonely and indicted that Resident #67 had diagnosis of depression. Health status factors that may inhibit social involvement had the following boxes checked: decline in functional abilities, mood or behavior problem, health problems such as fall, and change in communication. The nature of the problem contained no information describing Resident #67's psychosocial needs, behaviors, medications, or how the facility would address and meet Resident #67's psychosocial needs. The care plan decision was made to proceed. The CAA was completed by MDS Nurse #1. MDS Nurse #1 was interviewed via phone on 05/02/24 at 9:47 AM. MDS Nurse #1 explained that when completing the CAA, she gathered the information from what she used to complete the MDS assessment, which included chart review, therapy notes, and doctor notes. Once the information was gathered, she would go into the CAA and check any applicable boxes and then make the care plan decision and develop the care plan. MDS Nurse #1 was asked if she had had ever been told that she needed to thoroughly assess each resident and their condition that was applicable to each CAA that triggered, she replied, I honestly felt like stating to proceed and then addressing it in the care plan was sufficient enough and that was why she did not further elaborate in the CAA. The Director of Nursing (DON) was interviewed on 05/02/24 at 3:16 PM. She stated that she would expect the CAA to be comprehensive and thorough and give the appropriate information to paint a picture of the resident, their condition, and their identified needs. 37280 2. Resident #32 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, amnesia, mood disturbance and psychotic disorder. A review of Resident #32's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident's cognition was coded as moderately impaired. A review of section V of the MDS (care areas triggered for assessment to indicate need for care plan) revealed the care area of psychotropic drug use was triggered but the facility did not include information in the analysis of findings that described the Resident's problems, possible causes and contributing factors, risk factors related to the care area and reasons to proceed to care planning. A review of Resident #32's medical record revealed the last gradual dose reduction of antipsychotic medication was 08/23/23 for Risperdal 1 milligram (mg) by mouth once a day to 0.5 mg by mouth once a day for psychotic disorder. A review of Resident #32's quarterly MDS dated [DATE] revealed her cognition was moderately impaired and she had no behaviors or rejection of care. The MDS also indicated Resident #32 received an antipsychotic medication. A review of Resident #32's April Medication Administration Record for 04/2024 revealed the Resident received a daily antipsychotic medication. On 05/01/24 at 4:57 PM during an interview with the Psychiatric Nurse Practitioner (NP) the NP explained that she routinely visited with Resident #32 for auditory hallucinations and paranoia in that someone was trying to get to her. She continued to explain that the Resident required an antipsychotic medication that in the past the gradual dose reductions had failed and recently (08/23/23) the medication was reduced again. She indicated she would continue to consult with the Resident. MDS Nurse #1 was interviewed via phone on 05/02/24 at 9:47 AM. MDS Nurse #1 explained that when completing the CAA, she gathered the information from what she used to complete the MDS assessment, which included chart review, therapy notes, and doctor notes. Once the information was gathered, she would go into the CAA and check any applicable boxes and then make the care plan decision and develop the care plan. MDS Nurse #1 was asked if she had had ever been told that she needed to thoroughly assess each resident and their condition that was applicable to each CAA that triggered, she replied, I honestly felt like stating to proceed and then addressing it in the care plan was sufficient enough and that was why she did not further elaborate in the CAA. An interview was conducted with the Director of Nursing (DON) on 05/02/24 at 3:16 PM. The DON explained that she expected the care area assessments to be comprehensive and thorough and give the appropriate information to paint a picture of the residents, their condition and their identified needs. During an interview with the Social Worker (SW) on 05/02/24 at 3:22 PM the SW explained that Resident #32 was seen by psychiatric services because she was refusing to take her medications and started to be fixated on her roommate and would not let the staff in her room. She indicated the Resident was stable at present and psychiatric services would continue.

Based on record review, staff, Nurse Practitioner, and Medical Director interview the facility failed to complete a thorough assessment after Resident #1 had an unwitnessed fall on 02/23/23 and landed on her right side before being transferred off the floor for 1 of 3 residents reviewed for falls. Resident #1 displayed or voiced no complaints of pain but was unable to bear weight on 02/24/23. An x-ray was ordered which showed an acute right intertrochanteric (type of hip fracture) fracture and Resident #1 was transported to the emergency room for evaluation and treatment on 02/25/23. The Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included fracture of left femur (thigh bone) and dementia. Review of a fall risk assessment dated [DATE] indicated Resident #1 was high risk for falls. Review of a care plan initiated on 02/23/23 indicated Resident #1 was at risk for falls related to decreased mobility, history of falls, recent hip fracture, and impaired cognition. The interventions included: bed in low position, call bell in reach, and nonskid socks. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 was severely cognitively impaired for daily decision making and was sometimes understood by others and sometimes understood what others were saying. The MDS further indicated that Resident #1 required limited assistance with transfers, pain reported rarely, and had one fall with major injury since admission. No fall history prior to admission was assessed during the assessment reference period. An incident report dated 02/23/23 completed by Nurse #1 read in part, at 5:50 PM this Nurse was made aware by a Nurse Aide (NA) that Resident #1 was on the floor in her room. This Nurse went into Resident #1's room and observed her laying on the floor beside of the recliner chair on her right side, family member standing over her. Resident #1 was unable to explain why she was on the floor, she showed no signs of distress or pain at this time. Immediate action taken: resident was assessed for injuries, vital signs were obtained, and she was assisted back into her wheelchair. Injury type: no injuries observed at this time. A Nurse's note dated 02/23/23 written by Nurse #1 read in part, on 02/23/23 at 5:50 PM this Nurse was made aware by a NA that Resident #1 was on was on the floor in her room. This Nurse went into Resident #1's room and observed her laying on the floor beside of the recliner chair on her right side. Resident was wearing yellow nonskid socks. There was a family member standing over her and her bed was in the lowest position. The call light was on the bed and was not activated. Resident #1 was unable to explain why she was on the floor or what she was attempting to do. She was assessed for injuries and obtained a small abrasion to her right elbow. She showed no signs of distress or pain at this time. Immediate action taken resident was assessed for injuries, vital signs were obtained, and she was assisted back into her wheelchair. Communication was left for Medical Doctor (MD) via communication book, Director of Nursing (DON) was notified, and Resident's family was present. An interview with Nurse #1 was conducted on 03/09/23 at 4:05 PM who confirmed she was on duty on 02/23/23 from 7:00 AM to 7:00 PM. Nurse #1 stated around 5:30 PM, Medication Aide (MA #1) approached her to notify her that she had obtained the blood sugars for the residents who resided on the unit where she was working and needed Nurse #1 to administer their insulin. Nurse #1 indicated within a few minutes, she and MA #1 headed to the unit where MA #1 was working and a NA (she could not recall her name) motioned for her and MA #1 to hurry and hollered that a resident was on the floor. Nurse #1 stated she and MA #1 quickly approached Resident #1's room where Resident #1 was laying on the floor next to her recliner on her right side. Nurse #1 stated Resident #1's husband was standing in the room next to her. Nurse #1 described Resident #1 to be lying on the floor on her right side with her arm in front of her and her legs were towards the door of the room. Nurse #1 stated she had MA #1 obtain Resident #1's blood pressure and pulse. Nurse #1 then stated she rolled Resident #1 onto her bottom, noticed she had a cut on her right elbow and then patted her right hip to see if she was hurt. Nurse #1 confirmed she did not check for leg shortening, internal/external rotation, or determine if Resident #1 could bear weight. Nurse #1 revealed since Resident #1 was cognitively impaired and unable to identify any pain, she, MA #1 and a third person (she could not recall who) picked Resident #1 up and carried her to her bed which was located across the room from where she was found in the floor and placed back to bed. Nurse #1 stated she left the room, wrote a note in the provider notebook, and returned to her hall to care for the residents she was assigned. Nurse #1 indicated she did not return to Resident #1's room the remainder of her shift. MA #1 was interviewed on 03/09/23 at 4:50 PM and revealed she was assigned to Resident #1 on 02/23/23 from 7:00 AM - 7:00 PM. Around 5:30-5:40 PM, she had finished her first evening medication pass and obtained blood sugars for residents on her unit. MA #1 stated since she was not able to administer insulin so she left the unit to get Nurse #1 who was assigned to work another unit to administer the insulin. MA #1 stated as she and Nurse #1 returned to the unit a NA who she was unable to identify hollered for them and stated a resident was on the floor. MA #1 stated she and Nurse #1 quickly approached Resident #1's room. She stated when they entered the room Resident #1 was laying on her right side with her head near the recliner chair and her feet near the door of the room. MA #1 explained Resident #1 was unable to explain what had happened to her or how she ended up on the floor. MA #1 indicated Resident #1's family member was standing next to her when Nurse #1 placed Resident #1 on her back. MA #1 said Nurse #1 ask her to obtain vital signs and she did so. MA #1 further explained Resident #1 was not able to vocalize pain or injury and therefore Nurse #1, MA #1, and Resident #1's family member lifted her and carried Resident #1 back to her bed. MA #1 stated Resident #1 seemed ok and therefore she and Nurse #1 left the room. NA #3 was interviewed on 03/10/23 at 4:24 PM and confirmed that she worked on 02/23/23 from 7:00 AM to 7:00 PM and was caring for Resident #1. NA #3 stated she was gathering supper trays on the unit and a resident had asked her to go to the restroom. NA #3 indicated she had placed the resident on the toilet when she heard Resident #1's family member hollering very loudly for help. NA #3 said she stepped out of the room and asked Resident #1's family member what he needed, and he stated Resident #1 was on the floor. NA #3 explained she left the resident on the toilet and quickly proceeded to Resident #1's room. When she entered the room, she noticed Resident #1's legs extended out passed the doorway. NA #3 stated Resident #1's family member was saying that she needed to be picked up and began trying to lift her to a seated position with his hands behind her back and under her left leg. NA #3 said she told Resident #1's family not to touch her and she would get the nurse. NA #3 left the room and proceeded down the hall where she saw MA #1 and Nurse #1 walking down the hall and she summoned them to come to help. When MA #1 and Nurse #1 approached she told them Resident #1 was on the floor. NA #3 said once MA #1 and Nurse #1 were in the room she left the room to go back to the resident who was on the toilet. NA #3 stated sometime after Resident #1 fell she saw Resident #1 in her wheelchair with her family member pushing her in the hallway. Nurse #2 was interviewed via phone on 03/09/23 at 11:32 PM and revealed she was the nurse assigned to care for Resident #1 on the night shift (7PM-7AM) on 02/23/23. Nurse #2 stated she was told in report that Resident #1 had fallen but had sustained no injuries and therefore did not further assess Resident #1 for injuries on her shift. Nurse #2 stated Resident #1 was in the bed all night with her family at her bedside. Attempts to speak to NA #4 on 03/13/23 were unsuccessful. NA #4 cared for Resident #1 on 02/23/23 from 7:00 PM to 7:00 AM. Nurse #3 was interviewed via phone on 03/09/23 at 5:44 PM who confirmed that she cared for Resident #1 on 02/24/23 from 7:00 AM to 7:00 PM. She stated that in report she was made aware that Resident #1 had fallen on 02/23/23 and had no injuries. Nurse #3 stated that at some point during her shift the Physical Therapist (PT) went into work with Resident #1 and noticed that she was resistive to exercises on her right leg. Nurse #3 stated that she and the PT went in to check on Resident #1, Nurse #3 stated Resident #1 could not tell us or point to any area that would indicate she was in pain. When attempting to do exercises on the right lower extremity she would draw back and knowing that she had fallen the PT stopped her treatment and Resident #1 went back to sleep and rested well for about an hour. After about an hour Occupation Therapy (OT) went into work with Resident #1 and when the OT attempted to stand Resident #1, she would not bear any weight on her right leg. Nurse #3 stated the Nurse Practitioner (NP) was contacted and an order for Xray was obtained. Nurse #3 confirmed that both times that she and the therapist were in her room, Resident #1 had no signs of pain, no moaning or grimacing or guarding. She stated that when we would lift her right leg, she would pull it back towards the bed. Nurse #3 also confirmed that there was no external/internal rotation or leg shortening noted to Resident #1's right lower extremity. Review of a physician order dated 02/24/23 read, Xray to right femur, right knee, right tibia/fibula (bones in lower leg), and right hip and pelvis. MA #2 was interviewed via phone on 3/10/23 at 4:15 PM and revealed she was assigned to work with Resident #1 on 02/24/22 from 7:00 PM to 7:00 AM. MA #2 stated when she arrived on shift Nurse #3 notified her Resident #1 had fallen on 02/23/22 and there was an order to obtain x rays that evening. MA #2 recalled around 8:00 PM the X-ray company arrived to obtain the X-rays to Resident #1's hip and right lower extremity. MA #2 stated following the X-ray Resident #1 appeared to be restless she was moaning and grimacing from the movement required to obtain the X-ray and MA #2 administered Tylenol for discomfort. MA #2 stated the Tylenol helped her simmer down and she seemed OK the remainder of the shift. MA #2 stated when the technician arrived to obtain the X-ray, she gave them the correct fax number to fax the results to. MA #2 stated during her shift she did not see the results arrive via fax and therefore reported to Nurse #4 when she arrived on shift on 02/25/23 at 7:00 AM. Nurse #4 was interviewed via phone on 03/09/23 at 5:07 PM who confirmed that she cared for Resident #1 on 02/25/23 from 7:00 AM until she discharged to the emergency room (ER). Nurse #4 stated that she had assisted in the admission process for Resident #1 on 02/22/23 and was aware that she had a surgical repair of a left hip fracture. During report on 02/25/23 she was told that Resident #1 had fallen at the same time the phone at the nurse's station rang and it was the Assistant Director of Nursing (ADON) asking if I had seen the Xray report for Resident #1. Nurse #4 stated she turned to the fax machine and pulled the report off the machine that had been faxed over at 5:31 AM and showed an acute right hip fracture. Nurse #4 stated she hung up with the ADON and immediately called the on-call provider and got an order sent to Resident #1 to the ER for evaluation and treatment. Nurse #4 stated that Resident #1 did not return to the facility. The Xray Alert from the mobile Xray company dated 02/24/23 and reported via fax confirmation on 02/25/23 at 5:31 AM read in part, acute right hip intertrochanteric fracture. A physician order dated 02/25/23 read, send Resident #1 to the ER post fall with right hip fracture. The Nurse Practitioner (NP) was interviewed via phone on 03/09/23 at 5:41 PM who confirmed that when she arrived at the facility on 02/24/23 she learned of Resident #1's fall on 02/23/23 with no injury noted. The NP stated that due to Resident #1's advance dementia her examination was very limited. She stated Resident #1 was sitting up in her wheelchair in her room with her family at bedside and was pleasantly confused. She stated at the time she had no verbal or nonverbal signs of any pain or discomfort, she allowed me to listen to her heart and examine her lower extremities. After the examination the NP stated she had no concerns of any hip injury or fracture as the patient appeared at her baseline, she was anxious but the family at bedside indicated that was normal. The NP further stated she had discontinued her narcotic pain medication because she was not able to ask for it and scheduled Tylenol to cover any discomfort Resident #1 might have had from her left hip fracture that she was admitted with. The DON was interviewed via phone on 03/13/23 at 11:22 AM. The DON stated that at the time of Resident #1's fall on 02/23/23 she had only been the DON for three days. She stated that at the time of the fall she was not aware of the facility's policy and procedures regarding falls. The DON stated that she had since learned that following a fall of a resident the nurses would conduct a physical assessment to assess for any pain or visible injuries, the nurse should check all extremities and if the resident was not complaining of any pain, then range of motion should be conducted as well. The DON stated that ideally a resident should not be moved off the floor until they are assessed by a nurse she added that Resident #1's husband was attempting to move Resident #1 and had to be redirected to wait for the nurse. The Administrator was interviewed via phone on 03/13/23 at 12:32 PM who stated that when Nurse #1 went to assess Resident #1 he though that she did what she felt was best for resident at the time. He stated that he believed an assessment was done but the thoroughness of the assessment was probably cut short due to the family member's involvement. The Medical Director (MD) was interviewed via phone on 03/13/23 at 11:39 AM who stated that after a fall in the facility the staff should render first aid, return the resident to comfortable position, and then notify the provider of the fall. At the time a fall, the resident should be assessed by a nurse or medical provider ideally before they are moved off the floor, to including checking for bleeding, moving extremities to check for pain or discomfort or any other visible injuries. The MD stated if there was obvious injury like deformity to a hip then that would be addressed on the floor or at the site of the fall before attempting to move the resident. He further stated that Resident #1 was severely demented and the staff would rely on grimacing, moaning, or guarding as indicators of pain as Resident #1 was not able to verbalize her pain or discomfort.

Based on observations, record reviews, and staff interviews, the facility failed to identify the root causes, monitor, and implement effective interventions to a keep a wandering resident free from injury when a wandering resident sustained multiple skin tears, bruises, and had multiple falls of which one resulted in a right [CONDITION(S)] for 1 of 2 residents reviewed for accidents (Resident #43). The facility also failed to keep Resident #43 from wandering into 2 other resident's rooms and going through their personal belongings and touching them for 2 of 2 residents reviewed for privacy (Resident #21 and Resident #79). Findings included: 1.Resident # 43 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbances and a history of falling. A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #43 had severe cognitive impairment and required supervision assistance with locomotion both on and off the unit and had a fall with minor injury. The MDS further indicated Resident #43 wandered daily, exhibited symptoms of verbal behaviors directed at others and other behavioral symptoms not directed at others which included physical symptoms such as rummaging, or verbal/vocal symptoms like screaming, disruptive sounds. A review of the comprehensive plan of care revealed there was not a care plan for Resident #43's wandering behaviors included. The comprehensive care plan for falls revised 3/22/21 with interventions for multiple falls to include application of a stop sign on the bathroom door to encourage Resident #43 to call for assistance before attempting to toilet herself and non-skid footwear at all times. a. Resident #43's nursing progress note dated 3/19/21 at 10:12 revealed she had been found sitting in the floor in an unidentified resident's bathroom on the 700/800 hall unit (which was not the unit she resided). Resident #43 was noted to have obtained a skin tear to the right knee at the time. A nursing progress note dated 4/21/21 at 4:35 PM indicated Resident #43 had sustained a skin tear to her right forearm measuring 18cm x 0.4 x 0.1 of an unidentified origin. The skin tear required a wrap treatment and indicated staff notified maintenance to repair a door frame of an unspecified location. Resident #43's nursing progress note dated 4/29/21 at 9:54 AM revealed on 4/25/21 Resident #43 had been found wandering into another unidentified residents room and had told staff she had hit her head, pointing to her left eyebrow region on the door when she had tried opening it; however at the time, there was no visible injury. An icepack was provided, but two days later Resident #43 developed bruising in the same locations on the face she had previously identified. An observation on 5/23/21 at 12:38 PM revealed Resident #43 self-propelling her wheelchair in the hallway near the conference room which included the front lobby entrance. Resident #43 was observed to be near the front lobby looking for her mother and opening office doors. During the observation, there were no staff attempting to assist or redirect Resident #43 back to her unit. An observation on 05/24/21 at 2:00 PM revealed Resident #43 self-propelling herself in her wheelchair in the hallway and into other resident's room. Staff attempted to redirect Resident #43 to her room, but she quickly returned to her wandering behavior after only minutes. A nursing progress note dated 5/24/21 at 2:21 PM revealed Resident #43 was in the bathroom of room 506 and had fallen. Resident #43 sustained a skin tear to her right elbow which required a skin treatment and bruising to her left upper back from the fall. An interview on 5/25/21 at 12:00 PM with NA #3 revealed she was aware Resident #43 was a known wanderer and a high fall risk. NA #3 verified Resident #43 wanders off her unit almost daily and staff from other areas of the building must bring her back to the unit because Resident #43 gets out of the staff sight when they are busy. An interview on 5/25/21 at 12:05 PM with Nurse #10 revealed she was a nurse who was assigned to work the 500/600 hall unit. Nurse #10 verified Resident #43 was a known wanderer and wandered off the unit daily and was often located on the other side of the facility by staff who worked those units before hall staff were aware, she had exited the unit. Nurse #10 said, it is her right to wander so I don't try to redirect her even though I am aware she had sustained injuries when she had wandered off the unit in the past. An interview on 5/25/21 at 12:20 PM with the Social Worker (SW) revealed she had started as the social worker one month ago and was still acclimating to the position and was not familiar with Resident #43; however, after review of Resident #43's MDS dated [DATE] and her comprehensive care plan stated Resident #43 should be care planned for wandering to include interventions for all staff to monitor Resident #43's location on all shifts. An interview on 05/25/21 at 1:00 PM with Nurse #5 revealed she frequently worked the 500/600 hall and 700/800 hall on night shift and was familiar with Resident #43. Nurse #5 elaborated to explain Resident #43 was a known wanderer and wandered off the unit during her shift before staff were aware. Nurse #5 explained Resident #43 was started on a medication for anxiety recently which has improved her frequency of wandering at night. Nurse #5 verbalized Resident #43 exits her room looking for her mother or to use the bathroom and was known to wander into Resident #21 and Resident #79's room which frightened and startled them. Nurse #5 stated if an incident occurs, the nurse on the unit would complete an incident report in the electronic medical record and obtain orders from the provider for treatment if an injury occurs. A nurse progress note labeled fall follow-up dated 5/27/21 at 2:21 AM revealed Resident #43 with a new onset of back pain. A nurse progress note dated 5/27/21 at 12:00 PM revealed Resident #43 with new complaints of right hip pain which was swollen and was unable to be moved without screaming out. Resident #43 is unable to verbalize how she may have hurt her hip or when the pain originated. An order was obtained for a STAT x-ray of the right hip. An x-ray report of the right hip dated 5/27/21 indicated Resident #43 had sustained a moderately displaced acute fracture of the right femoral neck with clinical follow-up recommended. An interview on 5/27/21 at 2:48 PM with the Director of Nursing (DON) revealed she was familiar with Resident #43 and her known history of wandering and injury while unmonitored. She did not believe Resident #43 had ever eloped and therefore she did not have a wander guard in place; however, believed her comprehensive care plan should include wandering and interventions to keep Resident #43 from harm. In the event an incident occurs involving a resident, a nurse will complete an incident report and obtain orders for immediate aid if the resident sustains an injury. Following the incident, the incident reports are reviewed by the interdisciplinary team and an intervention will be put into place if needed and the care plan is updated to reflect the new interventions. An interview on 5/27/21 at 2:48 PM with the Administrator revealed he was familiar with Resident #43's wandering expected all residents with known behaviors to include wandering to have a care plan that reflects interventions for wandering to keep Resident #43 from injury. An interview on 06/04/21 at 3:45 PM with Nurse Practitioner (NP) revealed she is familiar with Resident #43 and her history of wandering and high fall risk. The NP indicated Resident #43 currently had a right [CONDITION(S)] that she believed to be sustained after an impact from a fall or trauma. She is aware Resident #43 had a fall on 5/24/21, but recalled visualizing Resident #43 up self-propelling her wheelchair in the hallway while she had been making resident rounds on either Tuesday 5/25/21 or Wednesday 5/26/21 and was unable to determine if the fractured right hip was a late onset symptom of the fall on 5/24/21 or if there was a possibility there could have been another unidentified fall between 5/24/21 and 5/27/21. The NP felt that three days was a long time for Resident #43 to appear at her baseline to having acute excruciating pain in the right hip three days post a fall for someone who is diagnosed with an acute displaced right [CONDITION(S)]. The NP also explained that according to the x-ray report the injury was not linked to an age-related condition or a spontaneous fracture. The NP elaborated she had not been to the building to evaluate Resident #43 since her return; however, she was aware the fracture required a surgical intervention and Resident #43 had an acute change of condition as a result of the fracture requiring surgical intervention. b. Resident #21 was admitted to the facility on [DATE] with diagnoses that included a history of falling. A quarterly MDS dated [DATE] revealed Resident #21 was cognitively intact and required supervision assistance with most activities of daily living (ADL's). Under a section labeled mood, the MDS revealed Resident #21 had trouble falling asleep and staying asleep and exhibited to behavioral concerns to include delusions or hallucinations. An interview on 5/23/21 at 10:28 AM with Resident #21 revealed she had been startled and frightened on several occasions when a wandering resident, identified to be Resident #43, had entered her room. Resident #21 stated she had trouble sleeping already and had recently been woke up by Resident #43 touching her and rummaging through her personal belongings. A follow-up interview on 5/26/21 at 10:45AM with Resident #21 revealed Resident #43 had entered her room again this week and she called for staff assistance to get Resident #43 out of her room, but Resident #43 fell in the bathroom before staff arrived. Resident #21 explained she needed to use the toilet but was delayed secondary to Resident #43's fall when she wandered into her bathroom. Resident #21 elaborated even if she (Resident #43) doesn't know what she is doing, staff should do a better job keeping her out of places she doesn't belong. Resident #21 further indicated she doesn't own much anymore but expected her belongings not to be accessed without her permission and it upset her to be woken up with Resident #43 touching her and her personal property. c. Resident #79 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbances [CONDITION(S)], and dependance on supplemental oxygen. A physician's order dated 9/28/20 indicated Resident #79 was to receive Oxygen via nasal cannula at 2 liters (L/NC) to keep oxygen saturations above 90%. A significant Change MDS dated [DATE] had moderate cognitive impairment, was able to make her needs known, and had no hallucinations or delusions. An interview on 05/23/21 at 10:10 AM with Resident #79 revealed she was happy with the facility other than facility staff not preventing a wandering resident (Resident #43) from entering her room. Resident #79 stated she had been awakened by Resident #43 recently when Resident #43 had been rummaging through her belongings. She stated she opened her eyes to see Resident #43 standing next to her bed and holding Resident #79's oxygen tubing in her hand after she had removed the oxygen tubing from the concentrator that was delivering supplemental oxygen to Resident #79. d. An observation on 05/25/21 at 11:55 PM revealed Resident #43 lying in her bed without non-skid socks. Her bare feet were exposed from the end of the sheet. There was no stop sign observed on the bathroom door as indicated as interventions on the fall care plan. An interview on 5/25/21 at 12:00 PM with NA #3 revealed she was not aware Resident #43 had an intervention to wear non-skid socks at all times, so she always removes all resident's socks before placing them to bed for a nap. An interview on 5/25/21 at 12:05 PM with Nurse #10 revealed she was a nurse who was assigned to work the 500/600 hall unit. Nurse #10 further revealed Resident #43 should wear non-skid footwear at all times due to her frequent falls. An interview on 05/25/21 at 1:00 PM with Nurse #5 revealed Resident #43 should wear non-skid footwear on her feet at all times. Nurse #5 stated there was occasional staff may remove her non-skid socks for short periods of time if Resident #43 had any swelling, but she had not had any recently that she was aware. An interview on 5/27/21 at 2:48 PM with the Director of Nursing (DON) revealed she expected all interventions on a resident's care plan to be followed to include non-kid socks and a stop sign on the bathroom door to deter Resident #43 from going to the bathroom unassisted. An interview on 5/27/21 at 2:48 PM with the Administrator revealed he expects staff to follow all care plan interventions to include non-skid socks and a stop sign in Resident #43's bathroom.

Based on observations, record review, resident, staff, and Nurse Practitioner interview the facility failed to administer pain medication when requested by the resident (Resident #1) for 1 of 4 residents reviewed for pain. Resident #1 experienced a right clavicle fracture and requested pain medication and subsequently waited over 2 hours for her pain medication for pain she rated on a pain scale of 7 out of 10 and described as miserable. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission assessment dated [DATE] stated that Resident #1 was alert and oriented times 3 (person, place, and time). Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) dated [DATE] was not yet completed. Review of pain interview and evaluation dated 05/11/21 indicated that Resident #1 reported pain frequently of a 7 on a pain scale. Review of a care plan dated 05/12/21 read, Resident has pain/potential for pain. The goal read; Resident will express pain level within satisfactory time. The interventions included: administer pharmacological interventions as indicated per physician and monitor effectiveness, assess for verbal and nonverbal signs and symptoms of pain, implement non-pharmacological interventions to release the pain, and provide education to resident and family. Review of an X-ray report dated 05/21/21 read in part, right clavicle: mildly displaced fracture of the medial aspect of the right clavicle. An observation and interview were conducted with Resident #1 on 05/23/21 at 10:21 AM. Resident #1 was resting in her bed and was noted to be guarding her right arm. Resident #1 stated that she had broken her collar bone on 05/21/21 and she had requested her medication which included her scheduled [MEDICATION(S)] at 8:30 AM and had not yet received it. Resident #1 stated that she was miserable, and her pain was a 7 on the pain scale. Resident #1 stated that she had requested her medication from Nurse #4 and looked at her phone and stated it has been almost 2 hours and she still had not gotten her medication. Resident #1 stated her pain had not gotten any worse, but it surely had not gotten any better either. An interview was conducted with Medication Aide (MA) #1 on 05/23/21 at 10:45 AM. MA #1 confirmed she was working the unit where Resident #1 resided because Nurse #4 had been pulled off the medication cart to assist with other duties. MA #1 stated that no one including Resident #1 had asked her for her medications. She stated, I will take her something now. A follow up interview was conducted with Resident #1 on 05/23/21 at 11:15 AM. Resident #1 confirmed that MA #1 had brought her medication including her [MEDICATION(S)] at 11:00 AM. Resident #1 stated that she was still hurting and her pain was still close to a 7 but she was beginning to relax a bit. An interview was conducted with Nurse #4 on 05/23/21 at 12:28 PM. Nurse #4 stated that she was supposed to be working the medication cart on the unit where Resident #1 resided but had been pulled from the medication cart to tend to other duties. Nurse #4 confirmed that earlier in the day approximately around 8:30 AM Resident #1 had requested her medications and she had explained to her that MA #1 would be bringing her medications soon. Nurse #4 stated that she did not report to MA #1 that Resident #1 had requested her medications because MA #1's medication cart was just a few door down from Resident #1's room and she assumed that Resident #1 would be next on the medication pass. An interview was conducted with the Director of Nursing (DON) on 05/27/21 at 2:48 PM. The DON stated that the staff conducted a pain assessment every shift and when administering pain medication they were to document where the pain was located and then go back and document the effectiveness of it. The DON stated that when Resident #1 requested her medications including her pain medication that the staff should have assessed her pain immediately and then administered the medications as ordered and requested by the resident.

Based on record review, and interviews with staff, family, physician and nurse practitioner (NP), the facility failed to protect 1 of 3 sampled residents, Resident #1 from a significant injury of unknown origin. Resident #1 was evaluated in the emergency room (ER) after complaints of a fall in the facility. In the ER, Resident #1 was identified with acute fractures sustained of the distal end of her right femoral metaphyseal (thigh) and an impaction [MEDICAL CONDITION] end of her left tibia (knee). Resident #1 required intravenous (IV) opioid [MEDICATION NAME] for pain management. The findings included: Resident #1 was admitted to the facility [DATE]. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated [DATE] assessed Resident #1 with moderate cognitive impairment. A Functional Abilities assessment dated [DATE], assessed Resident #1 was dependent on staff for chair or bed to chair transfers. An annual MDS assessment dated [DATE], did not assess her cognitive status, but indicated she had clear speech, understood/understands, required extensive assistance of 2 staff for mobility, transfers only occurred once/twice and required extensive assistance of 2 staff when transfers did occur. Additionally, she was unsteady for surface to surface transfers, only able to stabilize with staff assistance. A care plan, revised on [DATE], documented Resident #1 required extensive staff assistance for bed mobility and transfers of 1 to 2 staff. A care guide, revised [DATE], documented that 2 staff used a total body lift to transfer Resident #1. A progress note, documented as a late entry note, by Nurse #1 on [DATE] for [DATE] recorded Nurse #1 entered the room of Resident #1 and conducted a head to toe assessment. Nurse #1 recorded I pulled covers down and observed nothing unusual. Resident BLE (bilateral lower extremity) extended straight out and B (bilateral) knees arthritic. Palpated from B hips to toes and Resident had no complaints. No bruising or discoloration observed. Brief opened and no unusual findings observed. RUE (right upper extremity) no unusual findings observed. RUE flaccid from [MEDICAL CONDITION](stroke) and old surgical scar observed. Did not complete assessment to posterior due to Resident lunch being served. Resident did complain of pain to RUE with movement. Resident would grab her R (right) wrist with her L (left) hand and move extremity and moan. One to one provided for comfort and Resident calm and appears comfortable. A second progress note for Resident #1 documented by Nurse #1, dated [DATE] at 4:45 PM recorded that Nurse #1 entered the room of Resident #1 and the Resident stated she wished I was in there when she was just talking to (Family member #3). Resident stated (Family member #3) was calling the hospital. I asked Resident if she needed to go to the hospital and Resident stated, I don't think I need to go. I grabbed the cordless phone spoke with (Family member #3). In room with Resident regarding Resident claim of falling out of the mechanical lift today. Family member #3, expressed his wishes for having Resident sent to the ER for a 3rd party assessment. Informed him I would initiate but Resident had stated she didn't think she needed to go. Resident then said she would go. At 4:53 PM - medic initiated (Emergency Medical Services). At 5:20 PM - Resident left via stretcher per 2 medic. An interview occurred on [DATE] at 2:22 PM with personal care assistant (PCA) #1 and physical therapy assistant as an interpreter. During the interview, PCA #1 stated she worked as a PCA at the facility for the prior 4 months, typically on the 7 AM - 3 PM shift. PCA #1 stated that in the past she assisted Resident #1 with incontinence care and with transfers. PCA #1 described Resident #1 as alert/oriented with periods of confusion/forgetfulness, difficult to reposition because she required total staff assistance with transfers and that Resident #1 preferred to stay in bed. PCA #1 also stated that when she assisted with nursing care for Resident #1, there were always 2 staff, the Resident was transferred with a total body lift and the lift pad was left under the Resident to assist staff with her transfers. PCA #1 stated that on [DATE] she and PCA #2 assisted Resident #1 with a transfer from her bed to her recliner to get ready for therapy. PCA #1 stated that a total body lift was used for the transfer and the transfer was uneventful. She stated that there were no concerns during the transfer. Then less than 30 minutes later, Nurse #1 advised PCA #1 that Resident #1 wanted to go back to bed. PCA #1 stated that when she entered the Resident's room, Resident #1 was seated on her recliner, leaning forward and to the left, her knees were bent and her feet were on the floor. PCA #1 stated that Resident #1 had only been out of bed less than 30 minutes, she complained of pain to her shoulder, she was uncomfortable in her recliner and wanted to be put back to bed. PCA #1 stated that she and PCA #2 used the lift pad that was underneath Resident #1 to lift her up and slid her back in her recliner. Then PCA #1 stated she and PCA #2 got the total body lift and used it to transfer Resident #1 back to bed. PCA #1 also stated that Nurse #1 was on the hall and was informed that Resident #1 was having shoulder pain and was back in bed. PCA #1 further stated that Resident #1 did not fall or hit anything during either transfer that morning and that a total body lift was used with both transfers. PCA #1 stated that shoulder pain was a common complaint for Resident #1, that was not new, and when Resident #1 got back to bed she said her legs hurt, and this was reported to Nurse #1. A phone interview occurred on [DATE] at 08:30 AM with PCA #2. During the interview, PCA #2 stated she worked at the facility on the 7 AM - 3 PM shift. PCA #2 stated she worked with Resident #1 occasionally. PCA #2 described Resident #1 as alert/oriented, at times forgetful/confused, bed bound, required a total body lift and 2 staff for transfers, bed mobility and nursing care. PCA #2 stated on [DATE] she assisted PCA #1 with nursing care and transfers for Resident #1. PCA #2 stated when she first entered the Resident's room that morning, Resident #1 was in bed and requested to get up to her recliner for therapy. PCA #2 and PCA #1 worked on either side of the Resident to position the lift pad underneath her and used a total body lift to transfer Resident #1 to her recliner. While in the total body lift, PCA #2 stated Resident #1 was positioned on her side, she was not completely seated upright in the lift because it was difficult to position her upright due to her size. PCA #2 described that her feet were exposed outside of the lift pad during the transfer and stated Resident #1 was placed in her recliner. PCA #2 then stated PCA #1 and #2 left Resident #1 in her room in her recliner and went to care for another resident. After about 5 minutes, Nurse #1 advised PCA #2 and #1 that Resident #1 wanted to be repositioned in her recliner. PCA #2 stated that within about 10 minutes, she and PCA #1 went back to the Resident's room and found her in her recliner leaning on her right side, her feet were on the floor and her knees were bent. Resident #1 complained of pain but was not specific as to the location of her pain. PCA #2 stated the Resident appeared to be in distress. PCA #2 stated she advised Resident #1 that she would let Nurse #1 know that she was in pain. PCA #2 then stated she and PCA #1 used the lift pad that was underneath Resident #1 to lift her up and positioned her by sliding her back in her recliner. Resident #1 continued to complain of pain and then asked to be placed back in bed. PCA #2 stated, we then got the total body lift and used it to transfer Resident #1 back to bed. PCA #2 described both transfers as uneventful with no incidents of Resident #1 falling or hitting anything and denied that Resident #1 was lifted by her arms. PCA #2 stated that since she did not work with Resident #1 that often, PCA #2 was not sure if Resident #1 commonly complained of pain. PCA #2 stated she could not remember the specific time that the transfers occurred, but stated they occurred after breakfast but before lunch. A telephone interview on [DATE] at 1:57 PM with occupational therapist (OT) revealed the OT entered the room of Resident #1 before lunch on [DATE] and observed Resident #1 in her bed. Resident #1 stated to OT that she had been dropped by staff that morning and fell to her knees because staff did not use a total body lift to move her. Resident #1 further stated to OT that when she was transferred that morning by staff from her recliner to her bed, she was picked up by her arms, was dropped to her knees and then picked up again by her arms and put in her bed. Resident #1 stated to OT that she could not tell if her knees were hurting at that time. OT stated she then left the room to obtain a grievance form, immediately returned to Resident #1's room to record her statement which remained consistent with her original complaint. After recording a written grievance for Resident #1, OT then advised Nurse #1. A telephone interview with Nurse #1 occurred on [DATE] at 12:11 PM. During the interview, Nurse #1 stated that on [DATE] she was in the room of Resident #1 about 15 minutes before OT went into the Resident's room. Nurse #1 stated, the Resident was at baseline, described as alert/oriented with periods of confusion/forgetfulness, pleasant, verbal, and smiling with no complaints. Nurse #1 medicated the Resident with scheduled [MEDICATION NAME] for chronic pain. Resident #1 did not communicate a concern to Nurse #1 regarding a fall or being dropped to her knees. Nurse #1 stated she was on the hall completing her medication pass before she medicated Resident #1 that morning and remained on the hall after she medicated Resident #1 to continue her medication pass and that no one else went into the Resident's room before OT entered. Nurse #1 stated that she saw PCA #1 and #2 obtain the total body lift and take it into the room of Resident #1 earlier that morning because Resident #1 required total staff assistance with transfers due to limited mobility in her upper body. Nurse #1 also stated that if staff had dropped Resident #1 during a transfer, because she was on the hall administering medications, Nurse #1 stated that she believed she would have heard the commotion. After being advised of Resident #1's complaint communicated by OT, Nurse #1 stated she went back into Resident #1's room, completed a head to toe assessment with no acute changes noted but during the assessment, Resident complained she had been dropped to her knees by staff, complained of pain to her shoulder and general pain to her legs. Nurse #1 medicated Resident #1 with Tylenol. Nurse #1 further stated that complaints of pain were common for Resident #1 due to her [DIAGNOSES REDACTED]. Nurse #1 also stated that once she was advised by OT of Resident #1's complaint of being dropped by staff, she spoke to PCA #1 and #2 who assisted Resident #1 that morning and both denied that Resident #1 was dropped. They both expressed to Nurse #1 that Resident #1 was always transferred with a total body lift. A phone interview occurred on [DATE] at 1:11 PM with family member (FM) #1. FM #1 stated that on [DATE] around 2:00 PM, she had a window visit with Resident #1. At the time of the window visit, FM #1 described Resident #1 was upset and crying and stated Resident #1 kept repeating, I'm hurting, they dropped me. FM #1 continued during the interview and stated that she asked Resident #1, when did this happen? Resident #1 responded, At 11 o'clock when they transferred me to my bed. FM #1 stated she asked Resident #1 to describe what was hurting and stated Resident #1 responded my knees. FM #1 then stated that she asked Resident #1 what were staff doing about her pain and that Resident #1 said someone came and looked at me but did not find anything wrong, they gave me pain medicine, but I'm hurting now. FM #1 stated that she told Resident #1 that she would get her some help. FM #1 then said she immediately contacted FM #2 to advise. A phone interview occurred on [DATE] at 11:24 AM with FM #2. During the interview, FM #2 stated that she received a phone call on [DATE] around 2:30 PM from FM #1. During the phone call, FM #2 stated she was told by FM #1 that when FM #1 went to see Resident #1 on [DATE] around 2:00 PM at the facility for a window visit, Resident #1 complained she had been dropped by facility staff and that her knees hurt. FM #2 stated that she immediately contacted FM #3. FM #2 stated Resident #1 expired in the hospital with Hospice Services because of the fractures she sustained from her fall. A phone interview occurred on [DATE] at 09:19 AM with FM #3. During the interview, FM #3 stated that he received a phone call from FM #2 on [DATE] around 2:30 PM advising that Resident #1 had a fall. FM #3 then stated that when he got the phone call from FM #2, he immediately called Resident #1 who advised him that around 11:00 AM that morning 2 staff came into her room to transfer her out of bed to her recliner. Resident #1 stated she asked the staff where the total body lift was because staff always used it to transfer her. The staff said, We will be the muscle. FM #3 went on to say that Resident #1 informed him that she was lifted up under her arms and transferred to her recliner, but at some point during the transfer, she was dropped to her knees. The staff picked her up off the floor using her arms and put her in her recliner, but she was in pain and was not comfortable in the recliner, so she asked to be put back in her bed. The staff went and got the total body lift and used it to transfer Resident #1 back to bed. FM #3 stated he asked Resident #1 when did this happen and she said around 11 o'clock that morning. FM #3 said since it was almost 3 PM at that point, I asked her what had staff done about it. Resident #1 replied that staff gave her pain medicine, but that she was in a lot of pain now. FM #3 stated he immediately got off the phone with Resident #1 and called the Administrator, he left a message and the Administrator called him back. FM #3 stated when he spoke to the Administrator, he told the Administrator what Resident #1 told him and the Administrator said that the facility was conducting an investigation, but that so far they had not found that the staff did anything wrong. FM #3 said he then asked the Administrator to have Resident #1 transferred by ambulance to the ER for evaluation by a physician. FM #3 then stated he called Resident #1 back, and Nurse #1 was in her room, so he spoke to Nurse #1 and told her to send Resident #1 to the ER for evaluation. FM #3 stated Resident #1 was sent to the ER. FM #3 also stated that Resident #1 was [DIAGNOSES REDACTED]. FM #3 then stated that Resident #1 later expired in the hospital. Review of a hospital history and physical (H&P) dated [DATE], recorded that Resident #1 was transferred to the hospital on [DATE] and reported that today instead of staff using a mechanical lift they attempted to manually lift her out of bed and dropped her to her knees. Then facility nursing staff attempted to pick her up under the arms to lift her up and were unable to do so. At that time facility nursing staff used a mechanical lift to get her back in bed. Patient reports that when she fell she only hit her knees; did not hit her head or lose consciousness. Patient reports that several hours after her fall that she began having extreme pain. The hospital H&P noted Resident #1 was alert and oriented times 2 with intermittent confusion. Review of a hospital discharge summary dated [DATE] reported Resident #1 was diagnosed with [REDACTED]. While in the hospital, she required IV opioid [MEDICATION NAME] for pain management. An orthopedics consult was completed with recommendation for non-surgical repair. Hospice services was consulted. Multiple attempts by the surveyor to interview radiology were unsuccessful. Review of the death certificate for Resident #1 revealed she expired on [DATE] in the hospital from aspiration pneumonia, acute [MEDICAL CONDITION], stroke and fractures. An Initial Allegation Report regarding an injury of unknown origin, which occurred on [DATE], was submitted by the facility to Health Care Personnel Investigations (HCPI) on [DATE] after being contacted by the family of Resident #1 on [DATE] to notify the facility that Resident #1 had been diagnosed with [REDACTED]. A 5 Day Investigation Report was submitted by the facility to HCPI on [DATE] which unsubstantiated the allegation for an injury of unknown origin sustained by Resident #1. The Administrator was interviewed on [DATE] at 01:32 PM and stated that on [DATE] he received a grievance from Resident #1 regarding timely assistance to get up for therapy. The grievance indicated that on [DATE] at 10:30 AM, Resident #1 was not up for therapy which started at 11:00 AM. The Administrator stated that Resident #1 was usually a pretty decent historian, but lately she was more confused. The Administrator further stated that when he arrived to the facility on [DATE] around 1:00 PM, he spoke to Resident #1 and she complained of pain to her shoulder, stated that staff did not get her up timely for therapy and that when staff transferred her that morning, they did not use a total body lift and dropped her. The Administrator described Resident #1 with a history of left sided weakness due to a prior stroke which left her without mobility or strength on her left side and stated she weighed about 180 pounds. The Administrator stated after he spoke to Resident #1, he then went to talk to Nurse #1 to advise of the Resident's complaints of pain, her grievance that staff transferred her without a lift, dropped her and to find out from Nurse #1 what happened. The Administrator stated that Nurse #1 responded that she had already addressed the Resident's complaints of pain, completed a head to toe skin assessment with no abnormal findings and that Resident #1 must be confused about the transfer because Nurse #1 had already confirmed with PCA #1 and #2 that Resident #1 was transferred with a total body lift and did not fall. The Administrator then stated he spoke to PCA #1 and #2 on [DATE] and both staff denied that Resident #1 fell during a transfer and both staff stated that Resident #1 was transferred each time that morning with a total body lift. The Administrator also stated that he addressed Resident #1's grievance about her timely assistance for therapy and spoke to FM #3 of Resident #1 to advise him that Resident #1 did not fall, but was transferred with a total body lift, both in and out of bed. The Administrator stated FM #3 requested to have Resident #1 evaluated in the ER so the NP was contacted on [DATE] and gave an order to send Resident #1 to the ER for evaluation. The Administrator then stated Resident #1 was transferred to theER on [DATE] for further evaluation at the request of FM #3. The Administrator stated that on [DATE], FM #3 contacted him by phone to advise that Resident #1 was diagnosed with [REDACTED]. The Administrator then stated he re-opened the investigation regarding Resident #1, obtained a copy of the Resident's hospital report and conducted an investigation regarding an injury of unknown origin. The Administrator stated staff were re-interviewed still without identification of a specific incident that caused the fractures. The Administrator further stated he was currently awaiting the Physician's review of her fractures in lieu of Resident #1 [DIAGNOSES REDACTED]. The NP was interviewed via phone on [DATE] at 12:08 PM. The NP stated during the interview that she assessed Resident #1 early in [DATE] due to complaints of right hip pain and obtained an X-ray that was negative for a fracture. The NP stated her pain was treated with [MEDICATION NAME]. The NP described Resident #1 as having a history of [MEDICAL CONDITION] and chronic pain. The NP stated that Resident #1 had frequent complaints of pain which varied. The NP further stated that in [DATE], Resident #1 complained of arthritic pain to her posterior neck, bilateral shoulders, and upper back, which was treated with [MEDICATION NAME] cream. The NP stated pain was a common complaint from Resident #1 due to her [MEDICAL CONDITION]. The NP went on to say that when she assessed Resident #1 in early [DATE] it was for a cough and complaints of upper back, neck and shoulder pain. The NP stated that an X-ray was not ordered because Resident #1 denied trauma and stated that she would prefer to have something for the pain due to her history of arthritis. The NP stated when she assessed Resident #1 in [DATE], there was no swelling, redness, warmth or anything to indicate trauma. The NP stated that due to her cough we ordered a chest X-ray which was positive for pneumonia which was treated with antibiotic therapy. Resident #1 stated that she thought her hip pain was because her mattress was deflated so staff changed out her mattress. The NP also stated that she thought that the Resident's [DIAGNOSES REDACTED]. The NP further stated that in the case of Resident #1 it was possible for her to sustain a fracture from being repositioned by staff and not from a traumatic event. A phone interview occurred on [DATE] at 3:00 PM with the Physician. The Physician stated that he was notified by the Administrator that Resident #1 reported a fall in the facility, she was transferred to the ER and diagnosed with [REDACTED]. The Physician stated that in his evaluation he felt that the fractures she sustained could be consistent with staff lifting her and putting her back on her bottom. The Physician stated Resident #1 had an underlying [DIAGNOSES REDACTED]. As a result, the Physician stated that in the case of Resident #1, a fracture could occur during staff repositioning because Resident #1 did not have the upper body strength to assist staff during her transfers, so all of her weight would be on the staff. The Physician also stated that although an impaction fracture usually speaks to a forceful event, in the case of Resident #1, the mechanics of her injury could have resulted from being repositioned by staff. The facility provided a plan of correction with a correction date of [DATE]. The facility's plan of correction included the following information: 1. On [DATE], the facility assessed and interviewed Resident #1, interviewed Nurse #1 and PCA #1 and #2 and conducted an investigation as a result of a report from Resident #1 that she had been dropped by staff and that she was in pain. Resident #1 was assessed by Nurse #1 with no acute findings. Resident #1 was medicated by Nurse #1 for complaints of pain. Resident #1 was transferred to the ER at the request of family due to complaints of pain. Resident #1 was diagnosed with [REDACTED]. The facility conducted and submitted an initial investigation on [DATE] to the HCPI and submitted 5-day investigation to HCPI on [DATE] for an injury of unknown origin. 2. The facility took the incident of unknown origin to QAPI (Quality Assurance and Performance Improvement) to develop a plan of correction with audit tools, monitoring tools and in-services. The facility identified the following: 1. We did not investigate abuse timely. An Initial investigation report was not submitted until [DATE] when the facility was notified by family that Resident #1 sustained fractures. Facility provided re-education to all staff regarding the facility policy on Abuse, Neglect and Exploitation, and on reporting abuse and conducting a thorough investigation after a reported event/concern to identify, report and investigate all allegations of abuse. This re-education began on [DATE] and was completed on [DATE]. The facility began auditing any concerns related to abuse. The facility conducted a daily review of any allegations of abuse for any concerns with prevention, reporting or investigation. No further concerns were noted. Concerns will be discussed in QAPI meetings for further follow up. 2. We did not follow the care plan for transfers. Resident #1 alleged she was transferred by her arms and not with a total body lift. We conducted a 100% audit on all care plans regarding transfers to ensure the care plan documents correctly. All staff were re-educated on completing transfers per the care plan. If a resident is found in an awkward position, we have trained staff to consult the nurse for an assessment and direction on how to reposition. Re-education to all staff for transfers began on [DATE] and was completed on [DATE]. All staff provided verbal and return demonstrations. The facility began audits and conducts audits on 10 transfer per week. Any concerns are taken to QAPI for further follow up. All residents have the potential to be affected by the deficient practice. The facility has monitored transfers weekly, reviewed progress notes for any documentation of changes in condition to ensure these changes are addressed timely and that the MD/NP, Administrator and DON are notified. The facility has met with nurses to review audits, review progress notes, complete rounding sheets and to ensure head to toe assessments are completed and documented in the medical record when a change in condition occurs. The facility completed a 100% chart audit for all residents regarding a change in condition. No additional concerns found. QAPI - The facility's QAPI team met after this incident occurred to discuss root cause, in-servicing, audit tools and monitoring. The facility identified the root cause to be Resident #1 slid down in her recliner, staff lifted her using her arms to get her upright then used the lift pad to slide her back in the recliner. Next meeting will be [DATE] for review of audit tools, monitoring and discussion of any changes in monitoring needed. The facility alleges correction date on [DATE]. On [DATE], the facility's corrective action plan with correction date of [DATE] was validated by the following: review of staff in-services (nursing, managers, nurse aides, PCAs and therapy staff), audit tools and monitoring tools regarding identifying, reporting and investigating abuse and neglect, transfers conducted per the care plan, documenting changes in condition, and completing/documenting head to toe assessments in the medical record when a change in condition occurs. Interviews with staff revealed they were re-educated per the documentation of in-services provided. Interviews with management staff revealed they completed audits and monitoring per the audit tools and monitoring documentation provided. Observations of transfers for sampled residents were conducted while the survey team was onsite on [DATE] with no concerns noted.