Every finding on record at Aventura at the Bay

Based on observation, record review, interviews, and photographic evidence, the facility failed to ensure sufficient nursing staff with appropriate competencies and skill sets to provide nursing services needed to meet Activity of Daily Living (ADL) needs for six (#4, 5, 7, 9, 16, 17, 18) of twenty one sampled residents. Applying a reasonable person's concept, the lack of sufficient nursing staff with appropriate competencies and skill sets to provide nursing services necessary to meet ADL needs, in order to attain or maintain physical, mental, and psychosocial well being, of Residents #4, 7, 9, 16, 17, and 18 experienced harm. Cross reference: F584, F585, F686, F689, Findings included: On 06/22/2026 at 9:35 a.m., an observation was conducted of the posted staff assignment for the secure memory unit. The posting listed one nurse, Staff F, Registered Nurse (RN), and four aides. The census for the unit was posted as 40 residents. On 06/22/2026 at 9:46 a.m., Resident #9 was observed independently ambulating out of her room. Resident #9's hair was matted and oily in appearance. She was wearing mismatched shoes of different colors, and one pink shoe was on the wrong foot. On 06/22/2026 at 9:49 a.m., Resident #16, a male, was observed independently ambulating down the high 200 hall. Resident #16 entered and exited multiple resident rooms on the hall. No staff were observed monitoring or redirecting the resident during this time. On 06/22/2026 at 10:06 a.m., an interview was conducted with Staff F, RN. She stated she worked Monday through Friday, 7 a.m. to 3 p.m. She stated that usually two nurses worked on the unit during this shift, but she was the only nurse that day. Staff F, RN said it is difficult to get all our duties completed. On 06/22/2026 at 4:30 p.m., Resident #16 was observed exiting Resident #17's room, a female resident's room. Resident #16 closed the door behind him, walked down the hall, and entered another resident's room. Surveyors knocked on the closed door of Resident #17's room. A female voice was heard. Upon entering the room, Resident #17 was observed in the window bed. An odor of feces was strong. The bed was at regular height, and the head of the bed was elevated approximately 30 degrees. A hospital gown was draped over her torso, and her breast was exposed at the side of the gown. Resident #17's eyes were open and she was alert but did not respond in sentences. A soiled brief was observed on the floor at her bedside. Her right foot was draped over her left foot. The soles of both feet had visible dried, caked brown matter throughout the bottoms of the feet and toes. A dime sized dark maroon scab was present on the right lower shin, with multiple smaller discolored scabs on both legs. Resident #17 did not respond when asked what was on her feet or whether she felt safe. The mattress on the door bed had no linens and had dried brown matter smeared across the surface with an odor of feces. The room had no television; a radio was present but not playing. (Photographic evidence obtained.) On 06/22/2026 at 4:44 p.m., Resident #7 was observed in the door bed of his room, verbalizing nonsensical words, pulling at his sheet, and moving around in the bed. The room had a strong odor of feces. The sheet at mid torso had smeared feces present. The resident was not able to answer questions. On 06/22/2026 at 4:46 p.m., Staff O, Certified Nursing Assistant (CNA), was observed standing at a point of care electronic board near the middle of the high 200 hall, reviewing the electronic board. Staff O was not documenting only reviewing. On 06/22/2026 at approximately 5:00 p.m., an interview was conducted with Staff J, RN. She stated she was working the 3 p.m. to 11 p.m. shift and confirmed she had Residents #17 and #7 on her assignment. She stated she arrived at 2:30 p.m. When asked if she had checked her residents upon starting her shift, she stated, for the most part. Staff J could not state when she last visualized all the residents being responsible for. Staff J stated she had no concerns reported for Resident #17 and that Resident #7 was generally in bed and she had no concerns reported. On 06/22/2026 at approximately 5:11 p.m., Resident #18 was observed independently walking back and forth in the high 200 hall. He was dressed in seasonally appropriate clothing, wearing a shirt and shorts, and no shoes, but non slip socks. A visible trail of wetness was present on the floor where the resident had ambulated. His socks were visibly wet and stained. No staff were observed assisting the resident to change his clothing or socks. Staff J, RN, was in the hall during the observation. On 06/23/2026 at 9:45 a.m., Staff G, RN, was observed at her medication cart near the nurses' station. A resident was yelling from a nearby room, I need a towel, I need a towel, continuously. The yelling came from the closed door of Resident #4's room. Staff G, RN, entered the room, looked in the bathroom, spoke to the resident, and the resident stopped yelling. Staff G confirmed Resident #4 was in the shower by himself. On 06/23/2026 at 9:47 a.m., Staff F, RN, was interviewed and stated Resident #4 should receive assistance with showers and that sometimes he did not ask for help. On 06/23/2026 at 10:13 a.m., Resident #9 was observed independently ambulating in the high 200 hall. An uncovered open wound was visible in the middle of her chest. The wound was oozing, with a raised darker pink area surrounding it. The resident was observed rubbing her hands over the wound and then wiping her hands on her clothing and the handrail. Resident #9 could not answer questions posed. On 06/23/2026 at 10:29 a.m., Resident #18 was observed sitting on the porch area of the secure unit, dressed in seasonally appropriate clothing. Staff F, RN, stated Resident #18 was incontinent all the time and staff were supposed to clean him if he had an accident. On 06/23/2026 at 10:30 a.m., an observation of Resident #16, sitting in a chair on the porch area of the secure unit. Resident #16 was dressed in seasonally appropriate clothing. During the observation, Staff F, RN, was interviewed, and she stated Resident #16 was new. I do not know him well. I have not heard of him wandering into other residents' rooms. On 06/23/2026 at 10:30 a.m., an interview was conducted with Staff F, RN. She stated her shift was 7 a.m. to 3 p.m. When asked if observing her assigned residents at the start of her shift was part of her responsibilities, she stated, not really. She stated nurses received report at the desk and that new nurses (new to the unit) were given information about the patients. She confirmed certified nurse aides (CNAs) worked 8 hour shifts (7a-3p, 3p-11p, 11p-7a) and were expected to conduct walking rounds within the first 15-20 minutes of the shift. On 06/23/2026 at 10:51 a.m., Staff F, Registered Nurse, (RN) was interviewed. When asked if Resident #9 had any wounds, she stated, I have to look. Staff F was observed to review Resident #9's clinical record and stated, the resident is getting triple antibiotic to her arms. Her last skin check was yesterday, 06/22/2026, she had no issues. During the review, Staff F, also reviewed Resident #9's progress notes and stated, no report of any new skin issues. Staff F stated Resident #9 needed assistance getting dressed. She stated Resident #9 does not always use the toilet and will drop her pants and poop. Yes, she goes into other residents' rooms, when this happens, we clean up the area and take her to the bathroom and clean her up. When asked if staff documented when she had the defecation behavior in other resident's rooms, she stated, Don't think they do. On 06/23/2026 at 10:55 a.m., interview with Staff F, RN was continued. She stated Resident #17 does not speak a lot. Staff have to change her in bed. Staff F stated Resident #17 had the behavior of refusing care at times, but she was unaware of the resident having any behavior with fecal smearing. She said, if the resident had fecal smearing behavior, it should be documented. On 06/23/2026 at 11:13 a.m., an observation of Resident #17 was conducted with Staff F, RN. Resident #17 was observed in her room, alert, eyes open. The bed was low, a sheet covered her torso. Staff F, RN stated (Resident #17) likes to be naked. Staff F, RN was observed to review the bottom of Resident #17 feet, and she stated, it looks like dirt. I know the aid came in this morning and she refused to put on a gown. Her big toes nails could be cut. She has fragile skin. During the observation of the soles of the feet, the brown dried caked-on material on the bottom of the feet that had been observed on 06/22 had been reduced to a dark color layer on the bottom of the feet. Resident #17's toenails on the big toes were observed to be approximately 0.5 centimeters beyond the toe and cracked in appearance. Staff F, RN, stated, her toenails could be cut. She stated toenails would have to be cut by a podiatrist. During the review of Resident #17, Staff F, RN, stated she would want to know about an unclean mattress with feces on it. No one had told her. She stated it was important due to infection control; it is gross and would need to get someone to clean it. On 6/22/26 at 11:06 a.m., a telephone interview was conducted with Resident #5. Resident #5 said he communicated grievances several times to the facility staff. He said he felt the facility was short staffed. Resident #5 provided an example that he was turned and laying on his side for four hours. He said when the certified nursing assistant (CNA) came to assist him, he was told she was busy with other residents. He said he talked to the nursing supervisor about his concerns but was not sure if the concerns were written down. Resident #5 stated, There should be documentation and some kind of follow up. On 6/24/26 at 3:22 p.m., an interview was conducted with Staff D, Licensed Practical Nurse (LPN). He said Resident #5 always expressed his concerns. Staff D, LPN said the resident was on top of his care and wanted to be turned and repositioned every two hours. He said he communicated Resident #5's concerns to the nursing supervisor and the UM. Staff D, LPN said there were about three to four occurrences where the resident expressed the same concerns. On 06/22/2026 at 3:59 p.m., a phone interview was conducted with Resident #11's family representative. She stated she was aware Resident #11 had multiple falls, she stated for the first fall, she was notified by the facility, and the resident was not sent to the hospital. On the second fall, Resident #11 was sent to the hospital and returned the same day. On the third fall, she was sent to a different hospital and they kept her. The first fall, she (Resident #11) was complaining about seeing floaters in her eyes. I was there for one of the falls, I found (Resident #11) yelling from the bathroom. Two staff came, one said she had a bad back and couldn't assist, they need better training. On the third fall, she was face down. Resident #11 had eleven falls for the one month residency, 5/15/26 to 6/13/26 when discharged to the hospital due to a fall. On 06/23/2026 at 12:13 p.m., the Director of Nursing (DON) was interviewed. She stated she expected CNAs to conduct walking rounds every two hours. She stated CNAs were encouraged to go room to room during report and that they used a walking round sheet. She stated rounding required seeing the resident every two hours at minimum. A review of Resident #7's clinical chart, the Face sheet documented and admission of 12/2022. Resident #7's diagnosis list included: Alzheimer's disease with early onset, need for assistance with personal care and cognitive communication deficit. A review of a Brief interview For Mental Status, dated 04/23/2026, documented a score of 1, which indicated severe cognitive impairment. A review of Resident #7's Care Plan revealed a focus area: The resident has a risk for complications r/t (due to) incontinence of bowel and bladder, initiated 06/11/2023. Interventions included: Monitor for incontinence frequently and provide prompt care, initiated 06/11/2023; provide good hygiene practices, clean peri area will after BM in order to help prevent bacteria in urinary tract, initiated 06/11/2023. On 06/22/2026 at 9:54 a.m. and 4:26 p.m., and on 06/23/2026 at 9:45 a.m., observations were made of a sitting chair located in the small common area at the end of the high end 200 hall - secured unit. The chairs had visible stains and uneven discoloration. Both the chairs and the floor were unclean, with brown streaks and an odor of feces present. In the corner of the common area, a clear trash bag containing soiled incontinent products, an open milk carton, and other trash was observed. In the middle of the high end 200 hall - secured unit, a recessed area contained two sitting chairs with brown stains and varying discoloration to the fabric. The floor beneath this area had a dark brown smear and appeared soiled. On 06/22/2026 at 4:30 p.m. and again on 06/23/2026 at 10:15 a.m., an observation of room [ROOM NUMBER] was conducted. An open closet was observed. On the floor of the closet were dried clumps of feces and smeared fecal matter surrounding them. A noticeable feces odor was present. Additionally, on the floor next to the window-side bed, a semi dried liquid substance was observed that appeared sticky. On 06/22/2026 at 4:30 p.m., an observation of room [ROOM NUMBER] was conducted. A soiled brief was observed on the floor at the bedside. The door-side bed did not have linens present and had dried brown matter smeared across the top and sides of the mattress, accompanied by a noticeable bowel movement odor. A padded cloth sitting chair positioned in front of the closet was observed with smears and discoloration. A review of the facility's guideline for Nursing Rounds, undated, documented:Guidelines: rounds should be conducted by a nursing staff at least every two (2) hours. This task will be completed to identify residents' needs proactively.Steps:The nursing staff will conduct walking rounds during shift changes.Additionally, the nursing rounds will conduct nursing rounds at least every two (2) hours to identify residents' needs proactively and promote customer satisfaction.If there is a need for more frequency of rounds, the IDT will determine if an enhance supervision, such as hourly, Q-30 minute, or Q-15-minute checks/rounds is necessary for a specific resident.The IDT (Interdisciplinary Team) will obtain an order from the nurse practitioner/ attending physician if enhance supervision is needed.The resident care plan will be also be reviewed and updated to address the need for enhanced supervision.Any identified concern identified during nursing rounds will be addressed accordingly.Any identified patterns/trends will be discussed during QAPI meetings. A review of the facility's job description for Charge Nurse, undated, documented the position description: Provides direct nursing care to the residents and supervises the day-to-day nursing activities performed by the certified nursing assistants in accordance with current federal, state, and local regulations and guidelines and established facility policies and procedures.Essential Functions included:Observes for changes in residents' status, notifying the physician and resident family or representative and documenting accordingly.Performs rounds to ensure resident needs are being met and personnel are performing their assigned duties.Knowledge/Skills/Abilities included:Treats all residents with dignity and respect. Promotes and protects all residents' rights.Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct, and state/federal regulations and guidelines. A review of facility's job description for Certified Nursing Assistant (CNA), undated, documented the position description: Provides CNA nursing services to assigned residents in accordance with care plans, facility policies and procedures and at the direction of supervisor(s).Essential Functions included:Assists resident with or performs activity of daily living for residents in accordance with care plans and established policies and procedures.Assists with tracking the condition of the resident's skin. Reports any presence of pressure areas, skin breakdown or skin tears to nurse and supervisor.Assists nursing staff in carrying out toileting program activities.Knowledge/Skills/Abilities included:Treats all residents with dignity and respect. Promotes and protects all residents' rights.Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct, and state/federal regulations and guidelines. A review of the facility's assessment, last updated on 06/18/2026, Part 2: Services and care we offer based on our residents' needs:General Care included:Activities of daily living: Bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairment; supporting resident independence in doing as much of these activities by himself/herself.Bowel / Bladder: Bowel/bladder toileting programs, incontinence prevention and care, intermittent or indwelling or other urinary catheter, ostomy, responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity.Skin integrity: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds).Mental health and behavior: Mange the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD (Post Traumatic Stress Disorder), or other psychiatric diagnoses, intellectual or developmental disabilities.

Based on observation, record review, and interviews, the facility failed to 1) follow wound care orders for one resident (#5), and 2) conduct accurate skin assessments to identify skin integrity concerns for one resident (#11), out of three residents reviewed for wounds. These failures resulted in discomfort for Resident #5 and worsening of the wound and a failure to identify a sacral pressure injury in Resident #11.Findings include: 1. A review of Resident #5's admission record documented admission on [DATE] and discharge on [DATE]. Diagnoses included a stage 3 pressure ulcer to the sacral region, unspecified protein calorie malnutrition, and quadriplegia. A review of Resident #5's care plan, dated 03/28/2026, documented impaired skin integrity related to a sacral pressure injury, paralysis, malnutrition, colostomy, and incontinence. The goal included healing the pressure injury and remaining free from infection. Interventions included evaluation and treatment by a wound care specialist per order. A review of Resident #5's Brief Interview for Mental Status (BIMS), dated 04/02/2026 and 06/05/2026, documented a score of 15, indicating intact cognition. A review of Resident #5's physician orders documented: On 04/15/2026, orders to cleanse the sacral wound and lightly pack with collagen daily until wound vac initiation. The order was discontinued on 04/25/2026. On 04/27/2026, orders for negative pressure wound therapy (wound vac) using black and white foam, with pressure set at 125 mmHg (millimeters of mercury), to be changed three times weekly and as needed. On 04/01/2026, orders for weekly wound clinic appointments on Tuesdays discontinued on 04/14/2026. A review of Resident #5's Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented that beginning 04/27/2026, the wound vac order required dressing changes three times weekly. In May 2026, the order was coded 16 (hold/see nurses notes) on 05/04/2026 and 05/11/2026. There was no documentation the wound vac was changed on 05/18/2026. A review of Resident #5's progress notes showed: 5/4/26, Wound Vac - black foam/ white foam to undermining (be sure black foam touches white foam) Pressure settings @ 125mm Hg, change 3 times per week. every evening shift every Mon, Wed, Fri for wound care Resident went to wound care center. 5/5/26, Went to see patient. He says that no one has put the wound vac on him since he returned. I requested that nurse please put back on asap [as soon as possible]. 5/6/26, Patient seen in his room. The wound vac is still not in place and he says they don't have a cannister for it. I spoke with DON [director of nursing] and it was very dirty so they ordered a new one and it should be here today. It was originally supposed to be here yesterday but was delayed. She says as soon as it arrives then they will put the wound vac back on. 5/7/26, Patient seen in his room. Wound vac is now in place. 5/11/26, Wound Vac - black foam/ white foam to undermining (be sure black foam touches white foam) Pressure settings @ 125mm Hg, change 3 times per week. every evening shift every Mon, Wed, Fri for wound care Resident went to wound care today, wet to dry dressing in place. canister not available to place wound vac. Further review of the progress notes showed no documentation on 5/18/26 regarding the wound vac order that was not completed. A review of Resident #5's wound clinic notes documented: 4/15/26, . Wound Clinic Results Review All results: -Sacral Pressure ulcer stage 3: Decreased in length/width, increased in Depth . SNF [skilled nursing facility] has not ordered wound vac as per SNF representative they thought the wound clinic would order the vac. Discontinue santyl treatment, calcium alginate, bordered foam dressing daily. Start Primsa [type of wound dressing], draw tex [hydro conductive wound dressing], and bordered foam dressing 3 times weekly until wound vac initiated. Order to start NPWT [negative pressure wound therapy] @SNF, 125 mmHG, continuous, white sponge to undermining, black sponge to wound bed, change 3 times weekly and prn [as needed] dislodgement. Script for wound vac provided to SNF staff member accompanying patient. Counseling also provided for SNF to call wound clinic with any issues or questions regarding the wound vac. 5/4/26, . Wound Clinic Results Review . Decreased in size, depth decreased 1.1 from 2. SNF did not send wound vac container today. Start calcium alginate Ag [silver] and sacral border foam dressing in clinic; NPWT to be applied on arrival to SNF. 5/11/26, .Subjective . Today---patient came to wound clinic with wound vac dressing and not connected to wound vac. Per patient the vac was off all weekend because the facility had to order a wound vac cannister. No cannister send to the wound clinic today. Wound Clinic Results Review: . Sacral Pressure ulcer stage 3: Increased in size. SNF did not send wound vac cannister today. NPWT to be reapplied on arrival from SNF from wound clinic. On 6/22/26 at 1:39 p.m., a telephone interview was conducted with the wound clinic Nurse Practitioner (NP). She said on 4/15/26, the facility had not ordered the wound vac as the facility's representative thought the clinic would order and provide it. She stated, It was miscommunication and it never works like that. She said the wound clinic ordered a specific type to be used. The wound clinic NP said Resident #5 had scheduled, weekly clinic appointments. She said they were important especially with a wound vac and debridement. She said on the 5/11/26 appointment, the facility did not send the wound vac with the resident. The wound clinic NP confirmed with Resident #5 the facility had it and it was being used. She said the wound clinic physician saw the resident on 5/18/26 and he was due back on 5/25/26 and 6/1/26, but he did not attend those appointments. She said Resident #5 went to the appointment on 6/8/26, the wound had a lot of undermining, and he did not have the wound vac again. She said she had requested the facility put the wound vac on when he had returned from that appointment. The wound clinic NP said the facility would not send the wound vac or cannisters at times. She said the wound orders at the clinic was to complete the debridement then put the wound vac back on, which is why they needed it at his appointments. The wound clinic NP said after his appointments the clinic would send detailed orders to include changes and additional directions. On 06/22/2026 at 5:10 p.m., an interview was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The DON said she had to request Resident #5's records from the wound clinic as the facility did not have them. The ADON said they only had the initial wound vac orders. On 06/22/2026 at 5:12 p.m., a telephone interview was conducted with Resident #5. Resident #5 stated he provided clinic paperwork to whichever nurse was available on return from appointments and confirmed a non-nurse staff member accompanied him to the appointments. On 06/23/2026 at 12:51 p.m., ., an interview was conducted with Staff B, Certified Nursing Assistant (CNA). Staff B stated Resident #5 would ask her to check whether the wound vac was plugged in and stated she did not observe it functioning. Staff B also stated Resident #5 preferred to be on his side as lying on his back was uncomfortable. On 06/23/2026 at 2:10 p.m., an interview was conducted with the ADON. The ADON stated the facility believed the wound clinic would order the wound vac, and later learned the facility was responsible. She stated there were delays in obtaining cannisters and dressing (foams). The ADON confirmed due to confusion on who was providing the wound vac, Resident #5 did not have the wound vac from admission to 4/27/2026. The ADON stated after receiving the wound vac, Resident #5 was not able to have the wound vac place on different occasions due to not having adequate supplies on hand. On 06/24/2026 at 1:25 p.m., an interview was conducted with the DON. The DON stated a facility nurse discarded a wound vac cannister, leaving no remaining supplies available until additional cannisters were ordered. On 06/24/2026 at 1:59 p.m., an interview was conducted with the ADON. The ADON confirmed there was no documentation explaining why wound vac supplies were not available on certain dates and no documentation concerning unmet wound care orders on 05/18/2026. The ADON stated the facility was responsible for providing the wound vac and obtaining the supplies. 2. On 06/22/2026 at 3:59 p.m., an interview occurred with Resident #11's representative (RR). The RR stated Resident #11 was sent to the hospital after a fall and was identified at the emergency room as having an unstageable sacral wound, which had not been previously identified by the facility. A review of Resident #11's face sheet documented an admission on [DATE]. Diagnoses included hemiplegia, chronic obstructive pulmonary disease, bipolar disorder, vascular dementia, cognitive communication deficit, and muscle weakness. A review of Resident #11's BIMS assessment dated [DATE] documented a score of 12, indicating moderate cognitive impairment. A review of Resident #11's care plan documented risk for impaired skin integrity beginning 05/15/2026 with interventions including weekly skin sweeps, use of a pressure relief mattress, prompt incontinent care, application of barrier ointment, and assistance with turning and positioning. A review of Resident #11's Weekly Skin Observation, dated 05/31/2026, at 7:30 a.m., was reviewed and confirmed with the Minimum Data Set (MDS) coordinator, to document three areas on Resident #11, a right knee abrasion, a left knee abrasion, and left elbow skin tear. The document revealed no documentation of redness on Resident #11's Sacrum. A review of Resident 11's progress note dated 06/01/2026 at 1:28 p.m. documented the resident returned from the emergency room without new orders. A review of Resident #11's Weekly Skin Observation dated 06/01/2026 at 8:00 p.m. documented sacral redness with an open area, described without measurements, and dressing intact. A review of Resident #11's progress notes, dated 06/01/2026 at 8:00 p.m. documented a skin progress note: Weekly skin evaluation completed. Findings are as follows: Resident's color is normal. Skin is warm/dry. Edema is not present on assessment. Resident has red/excoriated areas. The resident does not have any skin issues on bony prominences. The resident does not have any skin issues on the right buttocks. The resident does not have any skin issues on the left buttocks. The resident does not have any skin issues on the right heel. The resident does not have any skin issues on the left heel. During an interview with the MDS Coordinator on 06/23/2026 at 1:34 p.m. she stated, Staff M, LPN (licensed practical nurse) put in the progress notes, on 06/01/2026, the resident had no skin issues. Staff M, LPN was also the one that put in the notes the resident had a stage III (full-thickness skin loss where subcutaneous fat is visible) on 06/01/2026. The MDS coordinator stated it was her expectation that accurate notes were documented. A review Resident #11's wound provider's note dated 06/01/2026 documented a stage 3 pressure ulcer to the sacrum/coccyx measuring 1.3 cm × 1.2 cm × 0.1 cm. A review of Resident #11's clinical record documented she was out of the facility for approximately five and a half hours on 06/01/2026. On 06/23/2026 at 3:55 p.m., an interview was conducted with the DON. The DON confirmed the skin assessment dated [DATE] should have included sacral documentation. On 06/24/2026 at 3:46 p.m., the DON stated the facility had no written policy for weekly skin assessments On 06/24/2026 at 3:46 p.m., interview with the DON, she stated for weekly skin assessments, there was no policy and procedure, we go by best practices. A review of the facility's policy titled Charting and Documentation, revealed the following, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Further review of the policy, under policy interpretation and implementation, revealed the following, .2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives.

Based on record review and interviews, the facility failed to provide adequate supervision and implement effective interventions to prevent falls for one (#11) out of three sampled residents. This resulted in Resident #11 experiencing eight unwitnessed falls and one witnessed fall over a 30 day period, and transfer to a higher level of care on two separate occasions. Findings included: A review of Resident #11's face sheet documented an admission on [DATE] and discharge date of 06/13/2026. Diagnoses included hemiplegia affecting the left side, chronic obstructive pulmonary disease, bipolar disorder, need for assistance with personal care, cognitive communication deficit, generalized muscle weakness, and vascular dementia. A family member was listed as the emergency contact. A review of Resident #11's Brief Interview for Mental Status, dated 06/05/2026, documented a score of 12, which indicated moderate cognitive impairment. A review of Resident #11's care plan, initiated 05/25/2026, documented the resident was at risk for falls due to dementia, gait and balance problems, impaired cognition, impaired communication, incontinence, history of falls, and inability to recognize safety needs.Interventions included:Created:05/25/2026Encourage and assist resident to be out of bed and to common areas when restlessEncourage and assist resident to bed after dinner05/26/2026I am unable to communicate my need to use the bathroom so check frequently for incontinence and provide prompt careStaff to monitor medications for adverse side effects and therapeutic effectiveness. Staff to ensure call bell is within reachAnticipate resident's needs05/29/2026If I appear restless with frequent attempts to get up, check for pain, hunger, thirst, fatigue, incontinence, boredomKeep my call light within reach so I can call for assistance [repeated]06/03/2026Maintain bed in lowest locked positionMonitor my positioning when OOB (out of bed) in chair and help me to reposition into a safer or more comfortable position06/08/2026Encourage and assist resident with rest periods after lunch 06/15/2026ER (Emergency Room) transferNeuro consult: Falls programEncourage and assist resident back to bed for rest periods after lunch [repeated]Encourage and assist resident with toileting upon risingHonor residents early rising preferencesHonor residents late night preferencesPsych consult: med review A review of the facility's fall log documented three fall events for Resident #11 on 05/25/2026 at 1:45 a.m., 05/31/2026 at 4:15 a.m., and 06/01/2026 at 7:00 a.m. On 06/22/2026 at 3:59 p.m., a phone interview was conducted with Resident #11's family representative. She stated she was aware Resident #11 had multiple falls, she stated for the first fall, she was notified by the facility, and the resident was not sent to the hospital. On the second fall, Resident #11 was sent to the hospital and returned the same day. On the third fall, she was sent to a different hospital and they kept her. The first fall, she (Resident #11) was complaining about seeing floaters in her eyes. I was there for one of the falls, I found (Resident #11) yelling from the bathroom. Two staff came, one said she had a bad back and couldn't assist, they need better training. On the third fall, she was face down. On 06/24/2026 at 11:27 a.m. an interview was conducted with the Risk Manager (RM) to review Resident #11's fall events, the RM stated each fall should be thoroughly documented and interventions put into place to assist in attaining the resident's goal. The RM stated the following reviewing the documentation: 05/15/2026, 8:00 p.m., unwitnessedthe location was stated to be the hallway across from the nurses' station. They said they could not see her clearly, there was no one at the nurses' station. The resident was in a manual wheelchair (w/c), fell out of the w/c, they found her sitting next to the chair. The resident was not able to state what she was doing. RM stated the resident had no injury. When asked the last time someone saw the resident prior to the fall, the RM stated she would have to look at the clinical record, she stated we double check the clinical record at the time, but I do not put it in the investigation. She stated she would have to look for the Neuro-check documentation for this fall; she did not have it available for review at the time of the interview. She stated the physician and family were notified at 8:00 p.m. No Neuro-check documentation was provided for this fall during the survey. No interventions were found in the fall care plan for this time frame 05/16/2026, 9:15 p.m., unwitnessedthe location was stated to be the resident's room. The resident was found in her room, sitting on her butt, in front of her bed, the foot of the bed. Resident was not able to say what happened, she was not soiled at the time of the fall. I do not have where the w/c was. They said the last time they had seen her, she was in her w/c. The RM was not able to state when the resident was last observed by staff prior to the fall. The RM stated there was no injury, and for Neuro-checks, she provided the sheet, starting 05/16, time start at 2115 until 05/18, 1700. She stated the physician was notified at 10:03 p.m. and family at 10:05 p.m. No interventions were found in the fall care plan for this time frame 05/25/2026, 12:45 p.m., unwitnessedthe resident was found lying on her back in the hallway with her wheelchair next to her. The resident was unable to report how she fell. A bruise to the right forehead near the eyebrow was documented. Neuro checks were documented from 1:45 p.m. on 05/25/2026 through 06/27/2026 at 6:00 a.m. 05/29/2026 at 4:15 a.m., unwitnessed,the location was stated to be the resident's room at the bedside. The resident was on her floor mat lying down. Resident stated she was awake and getting up. The bed was in low position. The RM could not state whether the resident was found in a prone or supine position. She stated it did not specify. She stated, they are supposed to paint a picture. The RM was not able to state when the resident was last observed by staff prior to the fall. The RM stated the resident had no injury and Neuro checks were provided for 05/29, 0430 through 05/31/2026, 0400. The RM stated the new intervention was honor resident's early rising preference. Physician and family were notified on 05/29/2026 at 4:30 a.m. During a review of Resident #11's progress notes, the fall documented to have occurred on 05/29/2026 at 04:30, the resident was documented to have a skin tear to left knee, re-opened, with bleeding observed. The documentation in the progress note did not match the investigation conducted by the RM, as she reported the resident had no injury during the fall. No interventions were found in the fall care plan for this time frame 05/31/2026 at 4:15 a.m., unwitnessed,the location was the resident's room, observed lying on the floor, next to the bed on the floor mat. She said she was trying to get out of the gate. The RM was not able to state whether the resident was found in a prone or supine position or when the last time the resident had been observed by the staff prior to the fall. The RM stated the resident had no new injury. When asked what no new injury meant, the RM read the note, not anything new. The RM stated she found the injury, on 05/29/2026, there was a skin tear, abrasion to the left knee; the resident received treatment. The RM stated, the resident re-opened the skin tear on her left knee. During the review, the Neuro check for the 05/29 fall was reviewed, and it was noted that a staff member, DT had signed as having completed the Neuro check on 05/31/2026 at 0400, fifteen minutes prior to the fall event. When the RM was asked who the staff member was and if a witness statement had been obtained, she stated she would have to follow up. No further information was provided during the survey. Neuro checks were provided for 05/31, 04:15 a.m. through 06/01/2026, 0400. The physician and family were stated to be notified on 05/31/2026 at 4:30 a.m. The RM stated the new intervention was a neurological consult and the resident was assisted to the chair since she was up. No neurological consult was provided by the facility during the survey. No interventions were found in the fall care plan for this time frame 06/01/2026 at 7:00 a.m., witnessed,the location was the small dining room on A wing. Resident was observed by CNAs (certified nursing assistants) throwing self onto floor, she was in her w/c. Injury, a bruise to the forehead, left side; hematoma; it does not say the size. The RM stated the immediate intervention was to transfer the resident to the emergency room. A psych consult was requested. Resident #11 was seen on 06/02/2026, they changed her medication. The physician was notified at 7:20 a.m. and the family at 7:25 a.m. Neuro checks were reviewed, which documented the resident was out to the hospital from 10:15 a.m. and return documentation at 18:15. 06/03/2026 at 4:30 a.m., unwitnessed,the location was the resident's room at bedside. The resident was lying on the floor. The resident said she was going to the bathroom. The RM was not able to state whether the resident was found in a prone or supine position or when the last time the resident had been observed by the staff or the last time the resident had been assisted to toilet prior to the fall. When asked if the position of the resident at the time of the fall was relevant, the RM stated, yes, depending on the circumstances, it is important to help determine the injury and possible cause. The RM confirmed Resident #11 needed assistance to use the bathroom, I would say she is one person assist. The new intervention was encourage and assist resident with toileting at rising. The physician was notified 06/03 at 4:33 a.m. and family at 6:30 a.m. 06/13/2026 at 5:14 p.m., unwitnessed,the location was the resident's room. A family member found the resident lying face down on the floor in her room in front of her wheelchair. Swelling to the left eye was documented, and the resident was transferred to the hospital. The facility documented no further interventions as the resident was not returning. During a review of Resident #11's progress notes, a fall was documented on 05/29/2026 at 0009; the fall was documented to have occurred at approximately 2000 on 05/28/2026, the RM did not provide information on this fall; no physician or family was documented to have been notified. The progress note revealed: 05/29/2026, 0009: Resident was placed in bed by staff. At approximately 2000, resident was found on the floor next to the bed. Upon assessment, resident was alert and responsive. Resident denied pain/discomfort and denied hitting head. No visible injuries noted at the time of assessment. Vitals wnl (within normal limits) Resident denies pain/discomfort. Bed in lowest position. Call light within reach. Observation continues. No interventions were found in the fall care plan for this time frame During a review of Resident #11's progress notes, a fall was documented 05/29/2026, 0430: Resident found on floor mat next to bed after self transferring from bed. Resident alert upon assessment. Skin tear to left knee noted to have reopened with small amount of bleeding observed. Area cleansed and dressing applied per treatment order. No additional injuries or new bruising noted during head to toe assessment. Resident denied pain or discomfort. Previous bruising remain (sic) on resident right side of face. Safety precautions reinforced with resident. Bed in low position with floor mat in place and call light within reach. MD and responsible party notified of resident. Resident to continue to be monitored for changes in condition. The RM did not provide information on this fall. No new interventions were found in the fall care plan after this incident. A review of the facility Post Fall Management Guidelines, undated, documented the policy: This facility is committed to safety and amplifying each resident's physical, mental, and psychosocial well-being.The objectives of the facility's Fall Prevention and Management Program are to:Deliver our residents with an interdisciplinary approach to assess risk of falls.Provide applicable interventions to prevent falls.Make sure that in the event a fall occurs:The incident will be investigated.Appropriate emergency interventions will be provided.Other interventions will be executed to prevent another fall from occurring as much as possible.The Fall Prevention and Management Program uses clinically accepted guidelines to guide the prevention and management of falls.The program includes abut is not limited to:Identification risk for fallsImplementation of person-centered interventions to decrease the incidence of falls.Implement interventions to decrease the incidence of fall with injuries.Guidelines:Post fall physical assessment .C. Skin observation for bruises, lacerations, hematoma, discoloration, swelling.F. Neurologic. 5. Neuro checks are completed for falls where the resident hit his/her head or if fall was unwitnessed and head injury is demonstrated. May be documented on the Neuro Check Flowsheet.III. Accident/ Incident Report and Investigation:Complete risk Management after each fall.LocationDescriptionImmediate action takenInjuries observedLevel of painMental statusInjury report post fallPredisposing environmental factorsPredisposing psychological factorsPredisposing situational factorsWitnessesNotificationsNotesInvestigation of the fallInterviews of resident, staff, and others as appropriateWhere was the resident?What was the resident doing before the fall?What was the resident trying to do?Ho did the resident feel when he/she fell?Did the resident hit any part of the body during or after the fall?What may have put the resident at risk?Activity at time of the fallMedications taken within the 24 hours before the fall; medications placing resident at risk.Functional and mental status at the time of the fall.Fall risk and history of fallsMedical conditions that increase risk of fallsEnvironmental factors that may have contributed to the fallAnalysis of the findings.IV. Implement additional interventions to reduce risk.The Fall Prevention Strategies/Interventions may be used as a guide to develop appropriate interventions.AlarmsAdditional use of appliances, positioning aidsAdditional assessments (therapy screen, restorative programs, vision, audiology, psychosocial, etc.)Environmental adaptionsMonitoringIncreased use of activities.VI. DocumentationFall is documented in the medical record.Date and timeLocation and any facts necessary to describe the fallAssessment post fallAny injuries and care provided.Notification of physician and family.Suggested documentation up to seventy-two (72) hours after the fall.Fall risk and care plan are reviewed and updated.Completed fall risk assessmentComplete pain assessment.Review interventions to prevent falls.Revise or implement additional individualized interventions as appropriate . A review of the facility's Fall Prevention & Management Program guidelines, undated, documented the Guidelines: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.Steps:Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk.The nurse will document the resident's fall risk in the resident's records and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk.For high fall risk identified, the facility will develop a plan to address the risk.Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care.Interventions will be monitored for effectiveness.The plan of care will be revised as needed.When any resident experiences a fall, the facility will:Assess the resident.Complete a post fall assessment.Complete an incident reportNotify physician and family.Review the resident's care plan and update as indicate.Document all assessments and actions.Complete an investigation.

Based on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment on one (200 hall - secured unit) of four units.Findings included:On 06/22/2026 at 9:54 a.m. and 4:26 p.m., and on 06/23/2026 at 9:45 a.m., observations were made of a sitting chair located in the small common area at the end of the high end 200 hall - secured unit. The chairs had visible stains and uneven discoloration. Both the chairs and the floor were unclean, with brown streaks and an odor of feces present. In the corner of the common area, a clear trash bag containing soiled incontinent products, an open milk carton, and other trash was observed. In the middle of the high end 200 hall - secured unit, a recessed area contained two sitting chairs with brown stains and varying discoloration to the fabric. The floor beneath this area had a dark brown smear and appeared soiled. On 6/22/2026 at 10:03 a.m., an interview was conducted with Resident #19 who stated seeing bugs all the time in his room. On 06/22/2026 at 4:30 p.m. and again on 06/23/2026 at 10:15 a.m., an observation of room [ROOM NUMBER] was conducted. An open closet was observed. On the floor of the closet were dried clumps of feces and smeared fecal matter surrounding them. A noticeable feces odor was present. Additionally, on the floor next to the window-side bed, a semi dried liquid substance was observed that appeared sticky. On 06/22/2026 at 4:30 p.m., an observation of room [ROOM NUMBER] was conducted. A soiled brief was observed on the floor at the bedside. The door-side bed did not have linens present and had dried brown matter smeared across the top and sides of the mattress, accompanied by a noticeable bowel movement odor. A padded cloth sitting chair positioned in front of the closet was observed with smears and discoloration.An observation of the bathroom in room [ROOM NUMBER] revealed a toilet containing an adult washcloth package, a used washcloth, and an unflushed bowel movement. The shower floor contained fragments of a large bug carcass. On 06/22/2026 at 10:15 a.m., an observation was made of rooms [ROOM NUMBERS]. In room [ROOM NUMBER], a dead roach was observed by the window-side bed. The floors were dirty and had sticky appearing stains on the right side of the bed. The nightstand at the window-side bed had an old meal ticket with another resident's name on it. In front of room [ROOM NUMBER], a dark brown stain was observed on the door. On 06/22/2026 at 10:19 a.m., an observation was made of room [ROOM NUMBER]. The nightstand contained resident belongings in the top drawers and the bottom drawers had insect droppings. The light switch near the room entrance had a brown substance smeared on it. The trash can by the sliding glass door contained trash. On 6/23/2026 at 9:45 a.m., a follow up observation was made of the trash can in room [ROOM NUMBER] still containing trash. On 06/22/2026 at 10:40 a.m. and again on 06/23/2026 at 9:45 a.m., an observation was made of room [ROOM NUMBER]. Stains were observed on the floor, and a collection of debris was present under the door-side bed. On 6/24/2026 at 11:44 a.m. an observation was made of the bed in room [ROOM NUMBER]. The stains on the floor were gone, however the debris was still present underneath the bed. On 06/23/2026 at 9:45 a.m., a follow up tour of the 200 hall - secured unit was conducted and the following observations.room [ROOM NUMBER] revealed two pills on the floor behind the residents' beds.room [ROOM NUMBER] revealed roach droppings and a liquid stain on the closet floor, as well as two brown stains on the closet door.room [ROOM NUMBER] revealed urine on the bathroom trash can, on the floor surrounding the trash can, and around the door frame outside of the bathroom.room [ROOM NUMBER] showed a resident's lotion bottle smeared with brown stains on the front. The resident's beige colored sandals, located between the bed and the table, had a dark brown, caked substance on them.room [ROOM NUMBER] revealed dark brown substance, smudging, and staining of the shower room floor. A dark red substance and red smudge were observed on the bathroom shower wall. The closet floor contained insect droppings and dust underneath the resident's bed.room [ROOM NUMBER] revealed a brown stain on the doorframe inside the bathroom. The floor between the bed and the sliding glass door showed stains in various shades of green, dark brown, and red. On 06/23/2026 at 9:59 a.m., an observation was made of the bathroom in room [ROOM NUMBER]. Dark brown fecal stains were observed on the grout of the shower room seating area. Additional stains were present in front of the seating area, and a red stain was observed on the floor. The toilet seat had brown stains on the inner rim. On 06/23/2026 at 10:12 a.m., an observation was made of a shared shower room in the hallway of a resident's room. A dirty, reddish brown-stained brief was observed discarded on the bottom ledge of the shower. On 6/22/2026 at 9:21 a.m., an interview was conducted with Staff C, Housekeeper. Staff C stated the routine for normal cleaning included cleaning other parts of the facility along with the 200 hall - secured unit. Staff C stated she had seen bugs in some of the residents' rooms in the 200 hall - secured unit and will just kill it. No further process was stated. An interview was conducted with Staff E, Certified Nursing Assistant (CNA) on 6/22/2026 at 12:35 p.m. Staff E stated that there were a couple of times she had seen roaches in the facility, but staff sprayed chemicals that eliminated them. She reported that if she observed a pest, she would report it to the supervisor. She further stated that the pest control company would come to treat the facility after a day or two. On 06/22/2026 at 2:40 p.m., an interview was conducted with the Housekeeping Manager (HM). The HM stated informs the housekeeping staff of their duties when they arrive for their shift. The housekeepers' responsibilities early in their shifts include; cleaning common areas, nurses' stations, pantries, and staff bathrooms. After the housekeeping staff take their break, they begin cleaning resident rooms. The HM stated the housekeepers are expected to spray the bathrooms with a bleach solution, provided and allow the solution to sit for the required amount of time. During this time, the housekeepers are responsible for cleaning and sanitizing the resident room from high to low. Housekeeping staff are also responsible for removing trash, cleaning residents' beds, bedside tables, call lights, and light switches. The Housekeeping Manager stated the expectation is for the housekeepers to mop all floors daily. Once the residents' rooms are completed, staff will finish cleaning the residents' bathrooms. The HM stated the facility did not have a specific checklist for cleaning individual rooms. The HM stated she completes facility rounds to ensure the facility is thoroughly cleaned, this would include the 200 hall - secured unit. The HM stated she believed the strong odors in the facility were coming from the floors; therefore, she ordered a floor stripping machine on 06/19/2026. The observations of room [ROOM NUMBER]'s findings were discussed with HM. The HM stated she would have it cleaned immediately. The HM stated the expectations for daily cleaning included the 200 hall - secured unit, and had not received reports of residents urinating or defecating on the floors An interview was conducted with Staff C, Housekeeper, on 06/23/2026 at 10:30 a.m. Staff C described her daily routine for cleaning residents' rooms, stating she sprayed all areas with two disinfectants and allowed them to sit for two minutes before wiping everything down with a rag. She reported that she swept and mopped daily and was the only staff member working in the 200 hall - secured unit lately. She believed the facility was short-staffed.Staff C stated that if she encountered a dirty brief or feces, she would clean it herself rather than informing the CNAs, as she felt that was a faster process. She stated that walls were sprayed and wiped daily and that she took extra time on high contact areas she frequently observed residents touching or leaning against. Staff C also stated she cleaned showers daily by disinfecting them and wiping them down with a mop head. She cleaned closets and non occupied rooms daily because residents often walked in and out of them. Showers in non occupied rooms were not cleaned daily. On 6/23/2026 at 10:41 a.m. an interview was conducted with the Staff G, Registered Nurse (RN) who stated she had never seen feces in any closets or beds. She had never seen residents perform a bowel movement in main areas such as the lobby or hallways. On 6/23/2026 at approximately 12:00 p.m. an interview was conducted with Staff H Unit Clerk. Staff H stated CNAs were responsible for checking rooms after breakfast and lunch to ensure everything was clean. Angel rounds occur daily. During these rounds, department heads were to examine each room and report the findings to the Unit Clerk or a nurse. Staff H, Unit Clerk said whenever urine or feces was observed on the floor or other surfaces, the CNAs are responsible for picking it up. The housekeeping staff would then wash and sanitize the area. Staff H said she had never seen feces in closets but would see them in the hallway. Staff H believed there are a lot of housekeeping staff, but not enough in the 200 hall - secured unit. On 6/23/2026 at 1:45 p.m. an interview was conducted with the Risk Quality Manager (RQM). The RQM stated the checklist utilized during morning rounds included a different topic to examine each day. However, the environmental components remained the same every day. She stated that no items had been checked in the environmental section for any rooms located on the 200 hall - secured unit for June 2026. On 6/23/2026 at 4:09 p.m. an observation was made of an unflushed toilet containing brown fecal matter in the toilet bowl with soiled toilet paper on top. There was a brown smudge or streak on the wall underneath the silver handrail. On 06/24/2026 at 10:05 a.m., an observation of the 200 hall - secured unit was conducted with the Director of Nursing (DON). room [ROOM NUMBER] was reviewed; the brown matter was present on the floor of the closet. The DON stated, I do not know what that is. She stated she would notify housekeeping. On 6/24/2026 at 11:22 a.m. an interview was conducted with the Housekeeping Manager. The HM stated cleaning schedules are kept. Upon reviewing these schedules several rooms did not have check marks next to them. When asked about this, the housekeeping manager stated it was done, her staff member just forgot to check it. When observing this cleaning schedule sheet, there were some rooms marked with Xs' and some checkmarks. When asked what the X meant, she stated obviously it means it was done. I don't know. The HM was unable to explain the difference. An interview was conducted with the Nursing Home Administrator (NHA) on 06/24/2026 at 3:09 p.m. The NHA stated her expectations for housekeeping was to ensure the environment was clean and free of odors, bugs, and any other items that did not belong. She explained that housekeeping staff were expected to clean all residents' rooms daily, including those in the 200 hall - secured unit, working from top to bottom. This included cleaning showers, bathrooms, and items such as curtains, which she stated were part of the daily checklist.The NHA stated the Housekeeping Manager's role is to serve as her eyes and ears and ensure the housekeeping staff is completing their assigned duties. The NHA reported the Housekeeping Manager is aware of these expectations, which are listed in the housekeeping form used by staff when cleaning resident rooms. When informed that the Housekeeping Manager did not utilize a separate checklist with specific items to clean for resident rooms, the NHA appeared alarmed. The NHA stated she expected the Housekeeping Manager to ensure proper cleaning by conducting routine rounds and using the detailed cleaning checklist. The NHA stated she also conducts rounds to verify appropriate cleaning is completed. The NHA stated feces and urine or any hazard to other residents should be cleaned immediately. The NHA said that if feces was observed, CNAs are expected to clean them as soon as possible, and housekeeping staff are expected to sanitize. The NHA emphasized that feces, urine, or blood should not be present on any surfaces and stained chairs should be removed immediately and reported, as some stains are not removable. The NHA stated that consistent morning rounds should have identified the environmental concerns observed. The NHA reported not receiving any notifications regarding feces stained chairs remaining in the hallway of the 200 hall - secured unit for two days. Upon review of the photos regarding the above findings, she stated this should have been cleaned immediately by nursing staff and then sanitized by housekeeping. The NHA further stated housekeeping may not have been done consistently, noting that urine should have been cleaned by the end of the shift, the dust like collection in room [ROOM NUMBER] should have been addressed immediately after informing the housekeeping manager, and roach droppings should have been cleaned by housekeeping. Review of the facility policy titled Housekeeping & Maintenance Guidelines, not dated, revealed: The staff will ensure that the facility is equipped and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public.5. Preventative maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment. Review of the facility policy titled, Pest Control Program, with no revision date, revealed: The facility will maintain an effective pest control program that eradicates and contains common household pests and rodents. Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice and rats).Review of the facility policy titled, Resident Environmental Quality (Home-like Environment) policy and procedures, with no revision date, revealed a guideline: The facility will be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public .5. Maintain an effective pest control program so the facility is free of pests and rodents. Housekeeping and maintenance guidelines: 1. preventative maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment.7. All facility personnel are responsible for reporting broken comma defective or malfunctioning Equipment or furnishings immediately upon identification of the issue. (photographic evidence obtained).

Based on observation, interview, and record review, the facility failed to protect one (Resident #17) of three sampled residents from neglect and failed to ensure a safe, clean, and supervised environment. The facility failed to provide adequate supervision to prevent Resident #16, a male resident with severe cognitive impairment, from entering Resident #17's room; failed to maintain Resident #17's room in a sanitary condition as evidenced by a mattress with dried fecal material; failed to ensure Resident #17 received necessary bathing and hygiene services as evidenced by caked, dried fecal material on both feet; and failed to ensure Resident #17 received meaningful activities or room based engagement. These failures resulted in Resident #17 being exposed to an unsafe, unsanitary environment and placed her at risk for psychosocial harm and neglect. Findings included: On 06/22/2026 at 9:49 a.m., during the initial tour of the secure memory unit, Resident #16, a male resident with severe dementia, was observed independently ambulating down the high 200 hallway. He entered and exited multiple resident rooms without staff monitoring or redirection. No staff were present in the hallway during this observation. On 06/22/2026 at 4:30 p.m., Resident #16 was observed exiting Resident #17's room and closing the door behind him. He then proceeded down the hallway and entered another resident's room. No staff were present monitoring him. Surveyors knocked on Resident #17's closed door, and a female voice responded. Resident #17 was observed lying in her window side bed with the head of the bed elevated approximately 30 degrees. A hospital gown was draped loosely over her torso, and her breast was visible at the side of the gown. She was alert with eyes open but unable to answer questions in complete sentences. A soiled brief was on the floor at the bedside. Resident #17's right foot was crossed over her left foot. Both feet had visibly caked, dried, cracked brown material on the soles and toes, with an odor of bowel movement present. Resident #17 was unable to answer when asked what was on her feet and did not respond when asked whether she felt safe. The room had no television. A radio was present but not turned on. The bed on the door side of the room had no linens. The mattress surface had dried brown smears consistent with fecal material and emitted an odor of bowel movement. On 6/22/2026 at approximately 5:00 p.m., an interview was conducted with Staff J, Registered Nurse (RN). She stated she was working the 3:00 p.m. to 11:00 p.m. shift. She confirmed she had Resident #17 on her assignment. She stated she had come onto her shift at 2:30 p.m. When asked if she had checked her residents when she came on her shift, she said, for the most part. Resident #17, no concerns. On 06/23/2026 at 10:09 a.m., Resident #17 was observed in a low bed with eyes open. The caked fecal material on both feet had been removed; however, dark discoloration remained on the soles and toes. The previously soiled mattress on the door side of the room had been cleaned. On 06/23/2026 at 10:30 a.m., Staff F, RN, stated Resident #16 was new, and she was not aware of him wandering into resident rooms. She also stated that nurses were not expected to visually check all assigned residents at the start of the shift, while confirming Certified Nursing Assistants (CNAs) were expected to conduct walking rounds within 15-20 minutes of shift start. On 06/23/2026 at 10:55 a.m., interview with Staff F, RN was continued. Staff F stated Resident #17 did not speak much and required total care in bed. She was unaware of any fecal smearing behaviors and stated such behaviors should be documented if present. On 06/23/2026 at 11:13 a.m., Staff F again reviewed Resident #17 and stated the discoloration now present on the soles of her feet looked like dirt. She confirmed that no one had informed her of the fecal soiled mattress and stated she would have wanted to know due to infection control concerns. She also stated she had been the only nurse on the 40-bed secure unit on 06/22/2026. On 06/24/2026 at 12:20 p.m., Staff L, Activities Aide, stated she did not go back to the secure unit, assists only with the other three units, A, C, D. She stated Staff K; Activities Aide is the activity aide for the secure memory unit. Staff L stated room bound residents, are asked if they would like an activity; sometimes they want nothing; if they like music, we provide them with a player. She stated the facility does not provide a television. She stated most of the residents on the A, C, D wings had televisions, even if they did not want them. On 06/24/2026 at 1:25 p.m., Staff K, Activity Aide stated she only conducted group activities in common areas and did not perform room visits in the secure unit. Staff K reported Resident #17 sometimes attended activities but often returned to her room. On 06/24/2026 at 1:40 p.m., an interview was conducted with the Social Service Director (SSD). The SSD stated being unaware Resident #17 did not have a television and that room-based activities were completed by activities staff. On 06/24/2026 at 1:50 p.m., an interview was conducted with the Business Office Manager. The BOM stated Resident #17 had a guardian and stated no one had asked him to contact the guardian about obtaining a television. He stated he could assist with such requests. On 06/24/2026 at 2:05 p.m., an interview was conducted with the Activity Director. The Activity Director stated activities staff were expected to perform daily room visits for room-bound residents. For the secure unit, she was unsure whether these visits occurred. At 2:31 p.m., she reported she had no documentation of room visits for Resident #17. Resident #17 was admitted in 12/2025 and had diagnoses including dementia, COPD, coronary artery disease, and depression. Her care plans indicated she required assistance with all activities of daily living, including bathing, grooming, and toileting, and that she should appear neat, tidy, and free from body odor. Her activity care plan indicated a need for stimulation, encouragement, and daily interaction. Resident #17's Brief Interview for Mental Status (BIMS), dated 06/15/2026, documented a score of 99, which indicated the resident refused to participate or 4 (four) or more items were coded 0 because the individual chose not to answer or gave a nonsensical response. Resident #16 was admitted [DATE] with diagnoses including Alzheimer's disease and severe dementia with agitation. His care plan documented the need for redirection for wandering behaviors but had no interventions specific to entering other residents' rooms. Resident #16's BIMs, dated 06/18/2026, documented at score of 6, which indicated severe cognitive impairment On 06/23/2026 at 1:08 p.m., an interview was conducted with the Minimum Data Set (MDS) Coordinator/RN. The MDS Coordinator confirmed Resident #16's care plan did not address Resident #16's room to room wandering and stated such behaviors should be documented and added through the 24 hour report system. When asked why it would be important for a male resident to be care planned for room to room wandering, she stated, Wandering in and out of a female room can cause anguish; especially if the male shows off parts of his body. When asked how staff provide a safe environment for a female resident that likes to stay undressed, she stated, Make sure the male wanderer has it on his Kardex to keep an eye on him. Keep him in common areas to keep him busy. On 06/23/2026 at 1:19 p.m., an interview was conducted with the MDS Coordinator/RN. The MDS Coordinator/RN stated Resident #17's preference for being unclothed was not documented and that she would want this information to ensure safety and honor preferences. The MDS Coordinator/RN stated Resident #17 does not have a care plan for behaviors related to fecal smearing. On 06/24/2026 at 10:10 a.m., the DON observed Resident #17 with clean feet and a clean room. The DON stated Resident #17 preferred staying in her room.A review of the facility Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, Injury of Unknown Source (ANEMMI) and Grievances policy and procedure documented:Each resident has the right to be free from abuse, including verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, and any physical or chemical restraint not required to treat the resident's medical symptom. Abuse includes deprivation of goods and services necessary to attain or maintain physical, mental, and psychosocial well-being.The Elder Justice ActIt requires that a nursing home must immediately report crimes that occur inside of facility. Reporting: Report any reasonable suspicion of a crime to State Agency AND Local Law Enforcement and Reasonable suspicion a crime has occurred.If serious bodily injury within 2 hours .Within 24 hours:Financial abuse/ exploitationConfinementPassive neglect.Definitions:Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.Signs of psychological abuse:Caregiver isolates the elderly person.Caregiver is aggressive, controlling, or uncaring toward the elder person.Signs of Neglect:Elder person lacks basic hygiene.Elder person lacks medical aids (e.g. glasses, walker, hearing aid, medications).Bed-bound person left without carePeople with dementia left without care.Types of Abuse:Identify facility characteristics that could increase the risk for abuse include, but are not limited to:Unsympathetic or negative attitude towards residents.Chronic staffing problems.Lack of administrative oversight, staff burnout, and stressful working conditions.Poor or inadequate preparation or training for care giving responsibilities.Deficiency of the physical environment.Facility policies operate in the interests of the institution rather than the residents.In addition, the risk of abuse may increase when a resident exhibits any behavior(s) that may provoke a reaction by staff, residents, or others such as:Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting race or ethnic group, intimidating.Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects.Sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing.Taking, touching, or rummaging through other's property.Wandering into other's rooms/space.Resistive to care and services. Prevention of ANEMMIObserve resident behavior and their reaction to other residents and staff. Observe for signs of post-traumatic stress disorder, any signs of substance use disorder, and intervene as appropriate.Maintain an environment that is calm.Inform residents and family members to whom they may report concerns, incidents, and grievances without the fear of reprisal.Identify areas of the environment that may make abuse or neglect more likely to occur, such as secluded areas.Always provide instructions to staff regarding the care plan of the residents, care needs, and follow-through with implementation.Adequate supervision of staff related to caregiving activities and interactions with residents.Recognize burnout, frustration and stress in employees that may lead to abuse.Take immediate action when complaints, concerns and grievances are brought up by residents/ resident families.Evaluate residents and ensure necessary medical care or treatment is provided and notify treating physicians as appropriate. A review of a second policy and procedure provided by the facility, Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and procedure, dated 2025 compliance consulting group, documented the purpose: To ensure that all of (the facility) residents are free from abuse, neglect misappropriation of their property, and exploitation.Procedure:Associates must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion against any resident.The Facility will ensure that residents are free from physical or chemical restraints.The facility shall review altercations from resident to resident as a potential situation of abuse.Staff shall monitor for any behaviors that may provoke a reaction by residents or others, which include, but are not limited to:Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group intimidating;Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/ shoving, biting, spitting, threatening gestures, throwing objects;Sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing;Taking, touching, or rummaging through other's property; andWandering into other's room/space . When the Facility has identified abuse, the Facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The Facility will increase enforcement action, including, but not limited to:Taking steps to prevent further potential abuse.Reporting the alleged violation and investigation within required timeframes pursuant to Federal and State statutes and regulations.Conducting a thorough investigation of the alleged violation.Taking appropriate corrective action.The facility will revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.The facility will develop written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation with the QAPI program to allow the QAA Committee to determine:If a thorough investigation is conducted;Whether the resident is protected;Whether an analysis was conducted as to why the situation occurred;Risk factors that contributed to the abuse (e.g., history of aggressive behaviors, environmental factors); andWhether there is further need for systemic action such as: Insight on needed revisions to the policies and procedures that prohibit and prevent abuse/neglect/ misappropriation/exploitation (ANME).Increased training on specific components of identifying and reporting that staff may not be aware of or are confused about.Efforts to educate residents and their families about how to report any alleged violations without fear of repercussions.Measures to verify the implementation of corrective actions and timeframes, andTracking patterns of similar occurrences.The facility will not employ or otherwise engage individuals who: .The Facility will report to the State nurse aide registry or licensing authorities .The Facility explicitly and expressly prohibits, and will take steps to prevent any Associates from engaging in any behavior or actions that may result in the abuse, neglect, and exploitation of residents and misappropriation of resident property.The Facility will investigate any allegations made alleging abuse, neglect, and exploitation of residents and misappropriation of resident property.The Facility will ensure that all Associates are properly trained.The Facility will ensure that any suspicion of resident ANME is coordinated with the Facility's QAPI program.The Facility will ensure compliance with the Elder Justice Act .Response:In response to allegations of ANME, the Facility shall:Ensure that all alleged violations involving ANMEI of resident property are reported in the proper time frame pursuant to this policy.Have evidence that all alleged violations are thoroughly investigated.Prevent further potential ANME while the investigation is in progress.Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey agency within 5 working days of the incident, and if alleged violation is verified appropriate corrective action must be taken.

Based on record review, observation, and interviews, the facility failed to develop and implement person centered care plan interventions for three of three sampled residents (Residents #9, #16, and #17). Specifically: For Residents #9 and #16, the facility failed to develop care plan interventions for identified wandering behaviors, including entering other residents' rooms. For Resident #9, the facility failed to develop care plan interventions for defecation behaviors in other residents' rooms, failed to complete and document accurate skin assessments, failed to notify the physician of a new wound and obtain treatment orders, and failed to implement activities of daily living (ADL) care related to dressing, including ensuring shoes were worn correctly. For Resident #17, the facility failed to implement care and services related to bathing, hygiene, and skin assessments; failed to identify and address unclean, dried fecal matter on the feet and a fecal soiled mattress; and failed to complete timely weekly skin checks. In addition, the facility failed to develop person centered care plan interventions for room based activities, resident preference for staying in the room, and podiatry services.These failures resulted in residents not receiving services necessary to maintain physical, mental, and psychosocial well being. Applying a reasonable person concept, these failures placed Residents #9, #16, and #17 at risk for compromised dignity, infection, unsafe wandering, unmet ADL needs, and unaddressed changes in condition. Findings included: 1.A review of Resident #9's clinical chart, the Face Sheet, documented an admission in 09/2024.Resident #9's diagnosis information included but not limited to: Unspecified dementia with mood disturbance, heart failure, chronic obstructive pulmonary disease (COPD), muscle weakness, unsteadiness on feet, need for assistance with personal care and cognitive communication deficit. A review of a Brief Interview for Mental Status (BIMs), dated 06/11/2026, revealed a score of 99, which documented the individual refused to participate or 4 (four) or more items were coded 0 because the individual chose not to answer or gave a nonsensical response. A review of Resident #9's Care Plan revealed the following:Focus: I am at risk for impaired skin integrity r/t (related to) decrease in mobility, incontinence, initiated 09/12/2024. Goal: Risk for skin impairment will be decreased by review date, initiated 09/12/2024.Interventions included: Weekly skin checks. Report abnormalities to Dr. (doctor), initiated 09/12/2024. Focus: The staff have identified that I am at moderate risk for falls because of these risk factors: Unaware of safety needs, dementia, muscle weakness, unsteady on feet, initiated 09/12/2024. Goal: My risks for falls and fall related injuries will be minimized with interventions daily through the next review date, last revised on 01/28/2026.Interventions included: Anticipate resident's needs, initiated 09/12/2024; I should have sneakers, shoes, slippers with rubber soles or non-slip socks when I am out of bed, initiated 09/12/2024. Focus: The resident is on Antiplatelet therapy r/t: disease process, initiated 09/12/2024.Goal: The resident will have minimized discomfort or adverse reactions related to anticoagulant use through the review date, initiated 09/12/2024.Interventions included: Weekly skin inspection. Report abnormalities to the nurse, initiated 09/12/2024. Focus: I need assistance with activities of daily living because of weakness, dementia, COPD (chronic obstructive pulmonary disease), HF (heart failure), anxiety, HTN (hypertension), HLD (hypersensitivity lung disease), initiated 09/12/2024. Goal: Staff will help me with all my ADL needs so that I appear neat and tidy with absence of foul body odor through next review, initiated 09/12/2024.Interventions included: Anticipate resident's needs, initiated 09/12/2024; Assist me with toileting promptly when requested, initiated 09/12/2024; Dressing-Assist of 1, Toileting-Assist of 1, Transfers-Assist of 1, initiated 10/25/2024. Review of the care plan revealed no care plan interventions addressing the resident's wandering into other residents' rooms or defecation behaviors. The care plan documented needs for assistance with ADLs and weekly skin checks with reporting of abnormalities but did not include interventions to address observed behaviors. On 06/22/2026 at 9:46 a.m., Resident #9 was observed ambulating independently in the hallway with visibly oily and matted hair, wearing mismatched shoes with one shoe on the wrong foot. On 06/22/2026 at 5:10 p.m., she was observed seated in the dining area with the same mismatched shoes and an uncovered nickel sized open wound on her chest with surrounding dark pink tissue. On 06/23/2026 at 10:13 a.m., Resident #9 was again observed ambulating independently with the open chest wound visible and oozing. She was observed touching the wound with her hands and wiping her fingers on her clothing and the hallway handrail. Resident #9 was not able to answer questions. On 06/23/2026 at 10:51 a.m., Staff F, Registered Nurse, (RN) was interviewed. When asked if Resident #9 had any wounds, she stated, I have to look. Staff F was observed to review Resident #9's clinical record and stated, the resident is getting triple antibiotic to her arms. Her last skin check was yesterday, 06/22/2026, she had no issues. During the review, Staff F, also reviewed Resident #9's progress notes and stated, no report of any new skin issues. Staff F stated Resident #9 needed assistance getting dressed. She stated Resident #9 does not always use the toilet and will drop her pants and poop. Yes, she goes into other residents' rooms, when this happens, we clean up the area and take her to the bathroom and clean her up. When asked if staff documented when she had the defecation behavior in other resident's rooms, she stated, Don't think they do. On 06/23/2026 at 11:10 a.m., an observation and interview of Resident #9 was conducted with Staff F, RN and she confirmed the open area on the resident's chest. She stated no one had brought the skin issue to her attention. On 06/23/2026 at 12:57 p.m. an interview was conducted with the MDS (Minimum Data Set) Coordinator regarding Resident #9. The MDS coordinator stated Resident #9 had a care plan for wandering, but she did not see a care plan for the behavior of the resident entering and exiting other resident's bedrooms and having the behavior of pulling her pants down and defecating. The MDS Coordinator stated the behaviors of entering rooms and defecation were not care planned but should have been. She stated the shoes of a resident should be on the correct foot. On 06/24/2026 at 9:43 a.m., the Director of Nursing (DON) was interviewed. The DON stated the expectation for new skin area concerns a new skin issue form be completed. This form is different from the skin assessment form completed weekly. When a resident is observed with a new skin issue, the nurse should put a progress note in the clinical record along with the skin issue form. Then new skin issue form would go to the wound care provider. On 06/24/2026 at 9:50 a.m., review of skin assessments with the Director of Nursing (DON) revealed skin assessments dated 06/16/2026, 06/22/2026, and 06/23/2026 with no documentation of the observed chest wound. The DON stated the assessments should have reflected the wound. The DON stated her expectation was for the nurses to document accurate skin assessments. 2.Record review showed Resident #16 was admitted on [DATE] with diagnoses including COPD, Alzheimer's disease, and dementia with agitation. A BIMS dated 06/18/2026 reflected a score of 6, indicating severe cognitive impairment. A review of Resident #16's Care Plan revealed the following:Focus: Due to Resident #16's memory impairments and limited ability to understand he needs more supervision and assistance to maintain his safety, the benefit of the secured unit is to provide more direction and supervision appropriate for his abilities, initiated 06/08/2026. Goal: Resident #16 will have care which is focused on the level of his mental and physical abilities to participate and understand through next review, initiated 06/08/2026.Interventions: Provide redirection during wandering behaviors or exit seeking attempts, initiated 06/08/2026.The care plan included redirection during wandering but did not identify or address wandering into other residents' rooms. On 06/22/2026 at 9:49 a.m., Resident #16 was observed independently entering and leaving multiple resident rooms without staff redirection. At 4:30 p.m., he was observed exiting Resident #17's room a female resident room, closing the door behind him, and entering another room. On 06/23/2026 at 1:08 p.m., the MDS Coordinator confirmed there was no care plan addressing room to room wandering. She stated that such behaviors would be added only if documented on the 24-hour report or communicated in clinical meetings. When asked why it would be important for a male resident to be care planned for room to room wandering, she stated, Wandering in and out of a female room can cause anguish; especially if the male shows off parts of his body. When asked how staff provide a safe environment for a female resident that likes to stay undressed, she stated, Make sure the male wanderer has it on his Kardex to keep an eye on him. Keep him in common areas to keep him busy. 3.Record review showed Resident #17 was admitted in 12/2025 with diagnoses including COPD, unspecified dementia, coronary artery disease, and depression. A BIMS dated 06/15/2026 scored 99. A review of Resident #17's Care Plan documented the following:Focus: I need assistance with activities of daily living because of a diagnosis of dementia with memory impairment, tremors, initiated 12/11/2025; Goal: Staff will help me with all my ADL needs so that I appear neat and tidy with absence of foul body odor through next review, initiated 12/11/2025. Focus: When planning activities for me I need staff to consider: I have a great desire to practice my religious beliefs. I have memory impairments and stimulation will help me to maintain or slow further decline, initiated 03/18/2026. Goal: I will be satisfied with present activity program through review; I will continue to interact with staff and other residents every day through next review; I will engage in self-directed activities both in and out of room on a daily basis through next review; I will practice my religious beliefs as I desire through next review, last revised 03/18/2026. Interventions included: Assure that the activities I attend are compatible with my physical and mental capabilities, initiated 03/18/2026; I am very restless and can't pay attention very long so provide short non demanding activities for me to do, initiated 03/18/2026; Sometimes I need encouragement to attend activities. Engage me in conversation by letting me know about upcoming events and the positive effects it has on mood and overall well-being, initiated 03/18/2026. Focus: I have alteration in skin integrity or risk for impairment skin integrity r/t advanced age with fragile skin, incontinence, initiated 12/11/2025. Goal: My skin will remain free from pressure ulcers through next review, initiated 12/22/2025. Interventions included: Inform resident/family/Dr (doctor) of any new areas of skin breakdown, initiated 12/22/2025; Monitor for incontinence frequently and provide prompt care, initiated 03/25/2026; Skin checks on resident's shower days. Report any abnormalities to nurse, initiated 12/22/2025; Weekly skin checks. Report any abnormalities to Dr., initiated 12/22/2025. The care plan included assistance with ADLs and skin monitoring but did not include room based activities, preferences for room stay, or podiatry needs. On 06/22/2026 at 4:30 p.m., Resident #17 was observed lying in bed with a hospital gown draped loosely across her torso exposing the side of her breast. A soiled brief was on the floor. Both feet had caked, dried brown material covering the soles and toes. A strong fecal odor was present. The mattress on the door side bed had dried brown fecal matter smeared across the surface with no linens present. Resident #17 was observed to have a dime sized dark maroon colored scab on her right lower shin with multiple smaller discolored scabs on both legs. The resident did not respond to questions. The room had no television. A radio was observed on a nightstand not turned on. On 06/23/2026 at 10:09 a.m., an observation of Resident #17. The residents' feet remained darkly discolored after partial cleaning, and the mattress had been cleaned. At 10:55 a.m., Staff F, RN, stated that CNAs should perform walking rounds at shift start but did not identify when Resident #17 had last been assessed. She stated fecal smearing should be documented, though no documentation existed. On 06/23/2026 at 11:13 a.m., an observation of Resident #17 was conducted with Staff F, RN. Staff F, RN was observed to review the bottom of Resident #17 feet, and she stated, it looks like dirt. Staff F, RN confirmed Resident #17's feet were dirty. Resident #17's toenails on the big toes were observed to be approximately 0.5 centimeters beyond the toe and cracked in appearance. Staff F, RN, stated, her toenails could be cut. She stated toenails would have to be cut by a podiatrist. During the review of Resident #17, Staff F, RN, stated she would want to know about an unclean mattress with BM on it. Staff F stated it was important to clean up bodily fluids, etc. due to infection control; it is gross and would need to get someone to clean it. On 06/23/2026 at 4:40 p.m., the DON confirmed no weekly skin assessment had been completed on 06/22/2026 and no documentation explained the omission. Review of the last 30 days of bathing documentation showed only one shower on 06/11/2026, despite scheduled Monday and Thursday bathing. The DON confirmed there were no refusal notes. The MDS Coordinator confirmed on 06/23/2026 at 1:19 p.m. that Resident #17 was not care planned for her preference to stay unclothed or stay in her room, and podiatry services had not been arranged until the date of interview. On 06/24/2026 at 10:10 a.m., an observation of Resident #17 conducted with the DON. The bottoms of her feet were observed to be clean with no residue present. The DON reviewed the scabs on the lower legs; she did not comment on the source of the scabs. The DON stated her toenails, the big toes, she would contact social services for podiatry services. The DON stated the Resident #17 prefers to be in her room. 06/24/2026 at 12:20 p.m., an interview occurred with Staff L, Activities Aide. Staff L stated that she did not provide any assistance to the secure unit. On 06/24/2026 at 1:25 p.m. an interview was conducted with Staff K, Activities Aide. Staff K stated she was assigned to conduct activities in the secure unit area. Staff K stated she did not conduct room visits. The Activities Director later confirmed no documentation of room visits was available for Resident #17. A review of the facility's policy and procedure for Care Plans, Comprehensive Person-Centered, dated 2001 med-Pass, Inc, documented the policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The Policy interpretation and implantation:The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.The comprehensive, .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.Each resident's comprehensive person-centered care plan is consistent with the resident's right to participate in the development and implementation of his or her plan of care, including the right to:Participate in the planning process;Identify individuals or roles to be included;Request meetings;Request revisions to the plan of care;Participate in establishing the expected goals and outcomes of care;Participate in determining the type, amount, frequency and duration of care;Receive the services and/or items included in the plan of care;See the care plan and sign it after significant changes are made.The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences.If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process.The comprehensive, person-centered care plan:Includes measurable objectives and timeframes;Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:Services that would otherwise be provided for the above, but ar not provided due to the resident exercising his or her rights, including the right to refuse treatment;Any specialized services to be provided as a result of PASARR recommendations; andWhich professional services are responsible for each element of care;Includes the resident's stated goals upon admission and desired outcomes;Builds on the residents' strengths; andReflects currently recognized standards of practice for problem areas and conditions.Services provided for or arranged by the facility and outlined in the comprehensive care plan are:Provided by qualified persons;Culturally competent; andTrauma-informedCare plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition change.The interdisciplinary team reviews and updates the care plan:When there has been a significant change in the resident's condition;When the desired outcome is not met;When the resident has been readmitted to the facility from a hospital stay; andAt least quarterly, in conjunction with the required quarterly MDS (Minimum Data Set) assessment. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.

Based on record review and interviews, the facility failed to ensure an allegation of resident to resident physical abuse was reported within 24 hours for two (#8 and #9) out of three sampled residents. This failure resulted in delayed notification to facility leadership and created the potential for unidentified injury and inadequate protection of the residents involved.Findings include: A review of Resident #9's clinical record, including the face sheet, documented an admission in September 2024. Resident #9's diagnoses included, but were not limited to, unspecified dementia with mood disturbance; unspecified heart failure; chronic obstructive pulmonary disease; muscle weakness; unsteadiness on feet; need for assistance with personal care; and a cognitive communication deficit. A Brief Interview for Mental Status (BIMS), dated June 11, 2026, documented a score of 99, indicating the resident refused to participate or four or more items were coded 0 due to refusal or nonsensical responses. A review of Resident #8's face sheet documented an admission in December 2023. Diagnoses included dementia with anxiety; unspecified acute kidney failure; and the need for assistance with personal care. A BIMS dated May 26, 2026, documented a score of 8, indicating moderate cognitive impairment. A review of Resident #8's care plan, initiated November 25, 2024, documented the following: Focus: Resident #8 has the potential to demonstrate verbally abusive behaviors and may hit staff or other residents due to ineffective coping skills. Goal: Resident #8 will demonstrate effective coping skills through the review date. Interventions: Analyze triggers and de escalation strategies; intervene early when agitation occurs; guide resident away from distress; speak calmly; if aggressive, staff should walk away and re approach later. A review of Resident #8's progress note, dated June 22, 2026, at 4:17 a.m., documented: upon leaving nursing station observed resident sitting on the floor in hallway[sic]. approached resident to assess what happened. resident states i was walking in the hallway and she [Resident #9] and she [sic] called me a [expletive] which made me upset and ihit [sic] her , [sic] she grabbed my arm ,[sic] I [sic] lost my balance and fell onto the floor.' resident [sic] states she did not hit her head and c/o [complained of] some pain to L [left] knee. no injuries noted [sic] at this time. On June 23, 2026, at 11:05 a.m., an interview was conducted with Staff F, Registered Nurse (RN), regarding the June 22 progress note. Staff F stated the incident occurred at approximately 3:30 a.m. When asked if the incident should have been reported to leadership, Staff F stated yes, because it involved resident to resident contact and was a potential abuse situation. On June 23, 2026, at 3:35 p.m., an interview was conducted with the Director of Nursing (DON) regarding the incident. The DON stated she was not notified until 7:00 a.m. on June 22, 2026. She stated the Risk Manager (RM) began an investigation after seeing the note entered in Resident #8's chart. The DON confirmed that Resident #9's record did not contain documentation of the incident and stated that a skin sweep was completed that morning. The DON stated it is a resident-to-resident potential abuse and unsure if the RM reported. On June 24, 2026, at 9:44 a.m., an interview was conducted with the Licensed Practical Nurse (LPN) serving as Risk Manager. The Risk Manager stated the incident was not reported to her, the Nursing Home Administrator, or the DON when it occurred. She stated the incident was discovered upon reviewing the progress note and had to determine whether it met criteria for an abuse allegation. She reported she was still gathering information and attempting to obtain a statement from the nurse involved. The Risk Manager stated she was uncertain whether the incident was abusive in nature and noted that staff are required to report incidents to the DON and Administrator. The RM stated she was investigating the incident but had to figure out what happened first to see if it meets the abuse definitions. The RM confirmed the nurse progress notes states one resident admitted to striking another resident. A review of a policy and procedure provided by the facility, Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and procedure, dated 2025 compliance consulting group, documented the purpose: To ensure that all of (the facility) residents are free from abuse, neglect misappropriation of their property, and exploitation.Procedure:Associates must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion against any resident.The Facility will ensure that residents are free from physical or chemical restraints.The facility shall review altercations from resident to resident as a potential situation of abuse.Staff shall monitor for any behaviors that may provoke a reaction by residents or others, which include, but are not limited to:Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group intimidating;Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/ shoving, biting, spitting, threatening gestures, throwing objects;Sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing;Taking, touching, or rummaging through other's property; andWandering into other's room/space . When the Facility has identified abuse, the Facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The Facility will increase enforcement action, including, but not limited to: Taking steps to prevent further potential abuse.Reporting the alleged violation and investigation within required timeframes pursuant to Federal and State statutes and regulations.Conducting a thorough investigation of the alleged violation.Taking appropriate corrective action.The facility will revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.The facility will develop written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation with the QAPI program to allow the QAA Committee to determine:If a thorough investigation is conducted;Whether the resident is protected;Whether an analysis was conducted as to why the situation occurred;Risk factors that contributed to the abuse (e.g., history of aggressive behaviors, environmental factors); andWhether there is further need for systemic action such as: Insight on needed revisions to the policies and procedures that prohibit and prevent abuse/neglect/ misappropriation/exploitation (ANME).Increased training on specific components of identifying and reporting that staff may not be aware of or are confused about.Efforts to educate residents and their families about how to report any alleged violations without fear of repercussions.Measures to verify the implementation of corrective actions and timeframes, andTracking patterns of similar occurrences.The facility will not employ or otherwise engage individuals who: .The Facility will report to the State nurse aide registry or licensing authorities .The Facility explicitly and expressly prohibits, and will take steps to prevent any Associates from engaging in any behavior or actions that may result in the abuse, neglect, and exploitation of residents and misappropriation of resident property.The Facility will investigate any allegations made alleging abuse, neglect, and exploitation of residents and misappropriation of resident property.The Facility will ensure that all Associates are properly trained.The Facility will ensure that any suspicion of resident ANME is coordinated with the Facility's QAPI program.The Facility will ensure compliance with the Elder Justice Act .Response:In response to allegations of ANME, the Facility shall:Ensure that all alleged violations involving ANMEI of resident property are reported in the proper time frame pursuant to this policy.Have evidence that all alleged violations are thoroughly investigated.Prevent further potential ANME while the investigation is in progress.Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey agency within 5 working days of the incident, and if alleged violation is verified appropriate corrective action must be taken.

Based on interviews and record review, the facility failed to ensure the grievance process was followed for one (#5) out of 11 residents reviewed.Findings included: On 6/22/26 at 11:06 a.m., a telephone interview was conducted with Resident #5. Resident #5 said he communicated grievances several times to the facility staff. He said he felt the facility was short staffed. Resident #5 provided an example that he was turned and laying on his side for four hours. He said when the certified nursing assistant (CNA) came to assist him, he was told she was busy with other residents. He said he talked to the nursing supervisor about his concerns but was not sure if the concerns were written down. Resident #5 stated, There should be documentation and some kind of follow up. A review of Resident #5's admission record revealed an admission date of 3/27/26 and discharge date of 6/6/26. Further review of the admission record revealed diagnoses to include pressure ulcer of sacral region, stage 3, quadriplegia, disorder of kidney and ureter, and neuromuscular dysfunction of bladder. A review of Resident #5's physician orders revealed the following:- Supra-pubic catheter due to neurogenic bladder, with an order date of 3/29/26.- Suprapubic Catheter Care every shift for Urinary Elimination, with an order date of 3/29/26.- Please flush suprapubic catheter with 30 ml [milliliters] NS [normal saline] daily. every night shift for maintenance, with an order date on 3/31/26- Supra-Pubic catheter site: Cleanse with normal saline, pat dry and apply split Gauze every night shift. every night shift, with an order date on 3/31/26.- Change 18 Fr [French] Suprapubic catheter with 10 cc [milliliters] balloon every 4 weeks AND as needed for leakage/blockage or dislodgement every day shift every 1 month(s) starting on the 21st for 28 day(s) ., with an order date on 4/21/26 and discontinued on 5/14/26. Further review of the order revealed the following note, NP [nurse practitioner] gave orders for suprapubic to be changed tomorrow per resident visit today.- Change suprapubic foley catheter 18 Fr 10 cc, every 28 days routinely every night shift every 28 day(s) AND as needed for blockage or dislodging, with an order date on 5/16/26.- cleanse sacral wound with. lightly pack depth and undermining with moistened collagen, cover with silicone super absorbent dressing everyday shift . d/c once wound VAC applied AND as [sic] needed ., with an order date on 4/15/26 and discontinued on 4/25/26.- Wound Vac - black foam/ white foam to undermining (be sure black foam touches white foam) Pressure settings @ [at] 125 mm Hg [millimeters of mercury], change 3 times per week. every evening shift every Mon [Monday], Wed [Wednesday], Fri [Friday] for wound care AND as needed for soiled/ dislodged, with an order date on 4/27/26. - Appointment every Tuesday [hospital name] wound clinic @1245, [clinic phone number] every day shift every Tue [Tuesday] for wound care., with an order date on 4/1/26 and discontinued on 4/14/26. A review of Resident #5's progress notes revealed the following:-3/31/26, . Subjective: Patient seen in his room. Aidejust [sic] finished feeding him lunch. He says that he still has not received the wound vac [vacuum assisted closure] yet. Nurse is not sure about this. I sent message to wound care nurse to check on this. Patient says they haven't flushed his suprapubic catheter as well, so I requested nurse to do this and placed order in [electronic health record vendor]. has not come to check his bed yet so I asked aide to please check into this as well.-4/16/26, .Subjective: to have wound vac placed today. Unhappy w [with] care at Aventura and want to transfer to [facility name]. Its also close to his house. Staff aware.-4/24/26, Patient seen in his room. He is upset and saws it has been 4 1/2 hours since he was turned. He says he is having pain over the sacrum from lying on the area for that long. I notified DON [Director of Nursing] of patient concerns and she will investigate.-4/28/26, . Subjective: Patient seen in his room. He is upset for several reasons today. He missed his appointment with the wound care clinic yesterday because they were late getting him downstairs and the ride left. They are still not flushing the catheter in the mornings as ordered. Yesterday it was clogged and had to be changed. He doesn't feel he is getting enough to drink. Labs showed hyponatremia so will give him IVF [intravenous fluids]. He says they also haven't changed anything on the wound vac since it was placed last week. He says there are also still issues with him being turned often enough. Nurse manager and DON are aware of concerns. Patient has filed grievance.-5/7/26, Patient seen in his room. Wound vac is now in place. He didn't receive the IV [intravenous] fluids yesterday as ordered. I notified nurse and DON and they will administer these. Patient has no other complaints. A review of the grievance log revealed two documented grievances for Resident #5 on 4/1/26 and 4/10/26. A review of the grievance on 4/1/26 was related to a CNA sitting outside the resident's room on the phone, he had to call reception to get assistance, and the turning and repositioning sign was removed from the wall. A review of the grievance on 4/10/26 was related to a staff member not completing rounds/assisting the resident before the end of their shift. On 6/22/26 at 1:39 p.m., an interview was conducted by telephone with the wound clinic Nurse Practitioner (NP). She said he verbalized concerns about the facility to her. She said the resident was alert and oriented to person, place, time, and situation. The wound clinic NP said she would communicate with the assigned nurse at the facility to discuss wound orders, as well as his concerns. On 6/22/26 at 5:46 p.m., a telephone interview was conducted with Staff A, Unit Clerk. She stated the concerns Resident #5 expressed to her were related to, Changing the wound and the wound vac. She said whenever he communicated concerns with the wound vac, such as it being off, she would let the nurse know and they would put the wound vac on. When asked if there written grievances for Resident #5, she stated, I'm sure there is grievances, but she never documented them. Staff A, Unit Clerk said she would let the assigned nurse or Unit Manager (UM) know and they told her they would write the grievance. On 6/23/26 at 11:23 a.m., an interview was conducted with the Social Services Director (SSD). She said any resident who had a grievance can voice their concerns to any staff member. She said there were forms that would be filled out and filed with social services. She stated, Everyone has access to grievance forms. The SSD said grievances are followed up immediately. She said the social services team would speak with staff or residents who may be involved and resolve the issue immediately. The SSD said the grievance would be resolved the same day depending on the situation. She said they tried to resolve grievances within 3 to 5 days. The SSD said they are also made aware of grievances in the stand up and stand down meetings, which occurred at the beginning and the end of the day. She said if a provider was aware of a resident's concerns, they typically speak with the DON or nursing staff. The SSD said the DON would then fill out a grievance form and advise the social services team. On 6/23/26 at 12:51 p.m., an interview was conducted with Staff B, CNA. She stated, [Resident #5] expresses everything. She said he was unhappy about his care and confirmed he expressed his complaints. Staff B, CNA said she informed the unit clerk about his complaints for her to file a grievance, but she is not sure if a grievance form completed. Staff B, CNA recalled telling the unit clerk about Resident #5's concerns at the end of May 2026. On 6/23/26 at 2:10 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). She said any staff member could complete the grievance form with the resident or assist them with completion of the form. The ADON said staff should let the grievance coordinator or UM know so they could follow up with the resident's grievance. She said grievances were discussed in the morning and clinical meetings. She said sometimes residents communicated concerns but did not want a grievance written up. She said they are still documented to bring awareness to the issue. The ADON confirmed providers' notes are reviewed every morning at the clinical meeting, to include all notes written in the last 24 hours. She said if a provider is communicating a concern from a resident, they usually discuss that with the UM, DON, or herself. The ADON confirmed the expectation that every grievance should be documented. Regarding Resident #5, she stated, On occasion he would express concerns, but he would say 'I don't want to get someone in trouble' and he did not want to write a grievance. He just did not want certain staff to care for him. On 6/24/26 at 12:48 p.m., an interview was conducted with the DON. She said grievance forms are located at the front of the facility and at the nurse's stations. She said staff could help a resident fill out the form, then it was provided to the SSD. She said grievances were discussed as a team, an investigation was completed, then the resolved grievance was returned to the SSD. The DON said the SSD would follow up with the resident's resolved grievance, then file it for documentation. She said even if a concern was resolved right away, it should be documented as a grievance. The DON said if a provider documented their notes about a resident's concerns, she would expect them to communicate with her, the UM, the ADON, or the grievance official. She said if a provider's progress note was uploaded immediately, they would see the notes in the clinical meeting the next day. Regarding Resident #5, she said a care plan meeting was held with him and his family members, in May 2026, to discuss his multiple concerns. She said she gave him her personal number as he would have more complaints over the weekend when the UM or herself was not there. She said he would call her anytime he had concerns. The DON said there was an issue with repositioning him, but they took care of it on the spot and did not have a grievance for it. A review of the provider's progress note on 3/31/26 was conducted with the DON; the grievance form on 4/1/26 did not show the same concerns as documented in the progress note. She said the concerns expressed in the provider's progress note on 4/16/26 were not new complaints and it was about care in general; she said the grievance on 3/31/26 addressed those concerns. She said the resident did not want to be at the facility and a transfer was being worked on, therefore that did not require a grievance to be completed. The DON said the provider's progress note on 4/28/26, that had multiple concerns documented, was addressed in a nursing huddle meeting on 4/28/26. A review of the nursing huddle meeting minutes, dated 4/28/26, showed catheter flushing and repositioning concerns, but did not include concerns about Resident #5's missed appointment or that he may not be receiving enough fluids. On 6/24/26 at 3:22 p.m., an interview was conducted with Staff D, Licensed Practical Nurse (LPN). He said Resident #5 always expressed his concerns. Staff D, LPN said the resident was on top of his care and wanted to be turned and repositioned every two hours. He said he communicated Resident #5's concerns to the nursing supervisor and the UM. Staff D, LPN said there were about three to four occurrences where the resident expressed the same concerns. A review of the facility's policy titled Resident and Family Concerns and Grievances Policy and Procedure, revealed the following, Purpose To provide for the prompt resolution of medical and non-medical grievances while maintaining confidentiality, in accordance with applicable federal and state statutes and regulations. Further review of the policy, under procedure, revealed the following, .II. Documentation of Grievances A. The Facility's Compliance and Ethics Officer or a designated Associate will document and keep a log of all grievances expressed either orally and/or in writing on the day that it is received or as soon as possible after the event or events that precipitated the grievance. IV. Responses to and Resolution of Grievances . D. The Facility will provide the resident with a written Grievance Decision, which shall include: a. the date the grievance was received; b. a summary statement of the resident's grievance; c. the steps taken to investigate the grievance; d. a summary of the pertinent findings or conclusions regarding the resident's concern(s); e. a statement as to whether the grievance was confirmed or not confirmed; f. any corrective action taken or to be taken by the Facility as a result of the grievance; and g. the date the written decision was issued.

Based on observation, interview and record review, the facility failed to provide proper catheter care for two (Resident #4 and Resident #20) out of three residents reviewed.Findings include: A review of the medical record for Resident #4 showed the resident to be admitted to the facility in January of 2023 with diagnoses of breakdown (mechanical) of cystostomy catheter, urinary tract infection, parkinsonism, unspecified dementia with psychotic disturbance, major depressive disorder, neuromuscular dysfunction of bladder, Asperger's syndrome, chronic kidney disease stage 3a, benign prostatic hyperplasia with lower urinary tract symptoms, and retention of urine. A review of the resident's Minimum Data Set (MDS), section C, showed the resident to have a Brief interview for mental cognition (BIMS) score of 08, indicating moderate impaired cognitive ability. Resident 4's functional abilities showed resident to be independent for eating, toileting, dressing and minimal assistance needed for personal hygiene, oral hygiene, and sit-to-stand mobility. Resident #4 to have an indwelling urinary catheter. A review of the medical record, Progress Notes, for Resident #4 showed the following progress notes:05/29/2026 Progress Note: Positive for Urinary Tract Infection (UTI), provider notified new orders received responsible party notified06/03/2026 11:27 Progress Note: This writer is reporting patient (pt) is on Intramuscular (IM) antibiotic therapy (ABT) Ertapenem for UTI pt tolerated well no adverse reactions reported or observed vital signs (v/s) stable afebrile no signs & symptoms (s/s) of respiratory distress call bell within reach for safety,.6/07/2026 17:09 electronic Medication Administration Record (eMAR) communication: Change indwelling urinary catheter 16_Fr with 10cc balloon and drainage bag for clinical indications such as infection, obstruction, leaking or dislodgement.as needed.Progress Notes from 06/17/2026-06/19/2026 stating resident refused catheter site cleaning. 6/22/2026 08:56 Provider follow up Note: male long term resident admitted to the facility in January of 2023 post hospitalization for toxic encephalopathy. re-admitted on [DATE] diagnosis (dx) chest pain. His past medical history (PMH) of urine retention, hypertension (HTN) ,anemia and Parkinson .Patient has had multiple re-admission for foley catheter re-insertion and chronic UTI infection and falls. A review of the orders for Resident #4 showed the resident to have the following order : Cleanse suprapubic catheter (sp cath) site daily with mild soap and water, pat dry, and apply CDD [clean dry dressing]. A review of the Treatment Administration Record (TAR) for Resident #4 showed no catheter care, or documentation of the resident refusing, was recorded for dates 05/05/2026 and 05/28/2026 and June dates 06/17/2026-06/19/2026. An interview was conducted with the family and representative of Resident #4 on 06/22/2026 at 9:42AM. Resident representative (RR) stated Resident #4 had been in the facility for years and had many hospitalizations due to recurring UTIs'. The RR stated discussed many times with staff at the facility her concerns regarding his catheter care and his frequent UTIs. The RR stated she had many discussions with the facility, including care plan meetings, for staff to call her when/if Resident #4 refused any care, as she can talk to him and get him to comply within a few minutes. The RR stated expressing her concerns to the facility many times and did not understand why they were not calling her. An interview with Staff F, Registered Nurse (RN), was conducted on 06/22/2026. Staff F, RN stated Resident #4 had a suprapubic catheter and confirmed the order for catheter care. Staff F, RN stated the site cleaning was not done on day shift, it was scheduled to be done daily on the overnight shift. Staff F, RN pulled up resident's progress notes on catheter site cleaning noting the times were between 2:50AM and 6:15AM. Staff F stated no one had ever tried moving the timing of catheter site cleaning to see if the resident would be more cooperative to their knowledge. An interview was conducted on 06/22/2026 with the Assistant Director of Nursing (ADON) at 11:50AM. The ADON confirmed Resident #4 does refuse care frequently and confirmed staff knowing to call their family member which usually got the resident to then comply with their care. The ADON stated they did not know of a reason why the catheter site cleaning needed to be scheduled for the overnight shift so early in the morning, stating that was just how it was ordered. The ADON confirmed no one had ever thought to move the scheduling to later in the morning or day to see if it could keep the resident from refusing care as often, also allowing them to call the family member for assistance. The ADON confirmed frequent refusals of catheter site cleaning could possibly be contributing to frequent UTIs. Resident #20 is an [AGE] year old female, admitted to the facility in June 2026 with diagnoses Urinary Tract Infection (UTI), Unspecified dementia, neuromuscular dysfunction of bladder, personal history of transient ischemic attack (TIA), nonrheumatic aortic valve stenosis, muscle weakness, and need for assistance with personal care. A review of the MDS dated [DATE], Resident #20 has a BIMS score of 00 indicating highly impaired cognitive function. Functional abilities showed resident to require minimal assistance for eating, oral hygiene, and some bed mobility. Resident required moderate assistance for shower/bathing, putting on/off footwear, and personal hygiene. Resident #20 to have an indwelling urinary catheter. A review of the resident's medical record, Progress Notes, showed the following progress note:06/16/2026 Admit Visit: [AGE] year old female seen for initial stabilization after hospital stay for increased confusion and possible UTI. Started on Macrobid (antibiotic) in hospital. Currently still very confused, unable to coordinate or make needs known. 06/12/2026 Health Status Note: Per 3-11 Nurse resident had previously pulled out her foley catheter and had not voided on 3-11 shift. physician informed, new orders received for 3-11 nurse that foley catheter is to be reinserted. An 18fr/5cc catheter reinserted without difficulty at this time, resident tolerating (tol) well, plan of care (poc) ongoing. A review of the progress notes after the 06/12/2026 note regarding a foley catheter no other progress notes to be found regarding the catheter care for Resident #20 or a removal of the urinary catheter. A review of the medical records, Orders, for Resident #20 showed no orders, active or discontinued, for catheter care or the removal of a catheter, for the resident. A review of the TAR for Resident #20 showed no catheter care documentation. An observation of Resident #20 on 06/22/2026 at 4:56PM found the resident to be in her bed, dressed appropriately and pleasantly confused. The resident did not have visible catheter tubing or a a catheter drainage bag. An interview with the Director of Nursing (DON) was conducted on 06/22/2026 at 5:15PM. DON stated Resident #20 did not currently have an indwelling urinary catheter. DON stated she did not know why there were no orders regarding the catheter and confirmed without any orders or anything documented in the TAR or Progress Notes there is no way to see that the catheter care was completed for Resident #20 nor how long the catheter was in before it was removed. Regarding missing documentation in the TAR for Resident #4, the DON confirmed it would be her expectation for each day to have documentation with no blank days even if the resident had refused. The facility failed to follow their policy & procedure for the following policies: Documentation in the Residents' Records guidelinesGuidelines:The facility will ensure that each resident's medical record shall contain an accurate representation of the actual experiences of the resident during his/her stay in the facility and will ensure that the documentation the resident's progress are complete, accurate, and timely.Important:False information shall not be documented. Documentation shall be accurate, relevant, and complete, which contains sufficient details about the resident's care and/or responses to care. The facility staff will also document timely and in chronological order.Steps:The IDT (interdisciplinary Team) members shall document all observations, assessments, and services provided in the resident's medical record.The documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.Documentation may be performed either manually or by using the facility's approved electronic medical record software program.Documentation shall be factual, objective, and resident centered.If there are contradicting information, the information may be clarified by a new entry in the medical record. The documentation will include date and time of the entry, and include details to support that the current information is accurate.Late documentation will be labeled as late entry. Care of Indwelling Catheter guidelinesGuidelines:The facility will follow these guidelines when providing care to a resident with indwelling urinary catheter.Steps:The facility will conduct assessments for residents at risk for urinary catheterization or on residents with indwelling catheters to determine if the catheter needs to be continued or removed if the catheter is no longer necessary.If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to:a.Timely and appropriate assessments related to the indication for use of an indwelling catheter;b. Identification and documentation of clinical indications for the use of the catheter; as well as criteria for discontinuation of the catheter when the indication for use is no longer present;c.Response of the resident during the use of the catheter; andd.Observation for changes in condition related to potential catheter-associated urinary tract infections, recognizing, reporting and addressing such changes.3. Appropriate indications for indwelling catheter use include:Acute urinary retention or bladder outlet obstruction;Need for accurate measurements of urinary output;Assistance in healing of open sacral or perineal wounds in incontinent residents (typically stage 3 or 4);d.Residents that require prolong immobilization (e.g. potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures); ande. To improve comfort for end of life care, if needed.Inappropriate use for indwelling catheters include:As a substitute for nursing care of an incontinent resident; andAs a means of obtaining urine for culture or other diagnostic tests when the resident can voluntarily void.Additional care practices include:Recognition and assessment for complications and their causes, and maintaining a record of any catheter-related problems;Attempts to remove the catheter as soon as possible when continued catheter use is not indicated;Monitoring for excessive post void residual, after removing a catheter that was inserted for obstruction or overflow incontinence;Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodgement of the catheter; andSecurement of the catheter to facilitate flow of urine, prevention of kinks in the tubing and positioning below the level of the bladder.Catheters and drainage bags should be changed based on clinical indications such as infection, obstruction, or when the closed system is compromised. Routine, fixed intervals is not recommended. Guideline: Orders and administration of medications and treatments will be consistent with principles of safe and effective order writing.Procedure:Medications shall be administered upon the written order of a person duly licensed and authorized to prescribe such medications in this state as soon as practicable.Authorized, licensed practitioners, or individuals authorized to practitioners, shall be allowed to write orders in the medical record.take verbal orders fromDrug and biological orders must be recorded on the Physician's Order Sheet in the resident's electronic chart.The staff and practitioner shall use Approved abbreviations and symbols when ordering and/or charting medications.Verbal orders should be recorded in the resident's chart by the authorized person receiving the order and should include the prescriber's name, credentials, the date and the time of the order.Verbal telephone orders may be received by licensed personnel (e.g., RN, LPN/LVN, pharmacist, physician, etc.). Orders should be transcribed by the authorized person receiving the order, and recorded in the resident's medical record.The entry should contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information.Orders for medications should include:a.Name and strength of the drug;b.Number of doses, start and stop date, and/or specific duration of therapy;Dosage and frequency of administration;d.Route of administration;e.Clinical condition or symptoms for which the medication is prescribed andPhysician orders should be followed as prescribed, and if not followed, this should be recorded in the resident's medical record during that shift. The physician should be notified and the responsible party if indicated.The resident will be informed of medication changes as they occur. If the resident is deemed incapable of making health care decisions, the resident's responsible party will be informed of medication changes as they occur.

Based on observation, record review and interview, the facility failed to ensure: 1) resident food and beverage items were labeled and dated in two (100 and 300 wings) out of four nourishment rooms, 2) refrigerator and freezer temperatures were documented on two (100 and 400 wings) out of four nourishment rooms, 3) equipment in the kitchen and one (100 wing) out of four nourishment rooms were functioning appropriately, and 4) hand hygiene/infection control practices were followed in the kitchen.Findings included:On 3/2/2026 at 7:35 a.m., an initial observation of the 100 wing nourishment room was conducted. An observation of the thermometer located in the refrigerator showed a temperature between 58 and 59 degrees Fahrenheit ( F). Further observation of the refrigerator revealed two small cups of cottage cheese and fruit with no resident name or room number written on the items. An observation of the thermometer located in the freezer showed a temperature of 40 degrees F. Further observations of the freezer showed the following items were not labeled with a resident's name/room number: popsicles, a 20-ounce bottle of lemon lime soda, and a bag of individual pieces of pound cake dated 1/31.On 3/2/2026 at 8:14 a.m., an initial observation of the 300 wing nourishment room was conducted. An observation of the refrigerator revealed two small, round Tupperware with unidentifiable food and an unidentifiable food item in a large brown paper bag had no resident name or room number. Further observations revealed a large clear Tupperware with lettuce mix did not have a resident name/room number or a date on it. An observation of the freezer revealed a 16-ounce water bottle with no resident name or room number written on it.On 3/2/2026 at 8:59 a.m., an observation of Staff I, cook revealed he had a Smartwatch on his left wrist. He was observed in front of the stove preparing food on the preparation table. On 3/2/2026 at 9:00 a.m., an initial tour of the kitchen was conducted with the Kitchen Manager (KM) and Staff J, Registered Dietitian (RD). At 9:18 a.m., an observation of the dish machine revealed it was in use by Staff K, dietary aide. He walked to the dish machine area with gloves on and put on an apron. He said he assumed it was a low temperature machine and pointed to the information posted on the dish machine with sanitization information. Staff K, dietary aide said he pushed the primer located to the right of the machine, sanitizer came out, and he puts the food items and kitchenware through the machine four to five times. Staff K, dietary aide was observed putting items from the clean side to the dirty side with gloved hands and put the items through the dish machine approximately five times. After multiple attempts of pressing the primer and putting items through the dish machine, Staff K, dietary aide showed the sanitizer strip was white, after putting it on a bead water of water from a clean dome lid. He said the test strip is supposed to be a purple color, indicating the proper sanitizer concentration. At 9:24 a.m., the KM said he checked the sanitizer solution this morning for the dish machine, and it was giving him issues. He said the final rinse was reaching up to 115 degrees F and not any higher, when it was supposed to be 120 degrees F. The KM said he called the maintenance staff who fixed it. A review of the dish machine log was conducted with the KM and showed he logged the final rinse temperature at 120 degrees F that morning and initialed next to the documentation.On 3/2/2026 at 9:26 a.m., an observation of the Director of Maintenance (DOM) and Staff L, Assistant DOM was conducted in the dish machine area, then in the walk-in freezer. The DOM had a beard guard that did not fully cover his beard which exposed part of the facial hair around his chin and mouth area. An observation of Staff L, Assistant DOM revealed he had noticeable facial hair that would require a beard covering, but he was not wearing one. On 3/2/2026 at 9:31 a.m., an observation of the walk-freezer revealed ice build-up on top of and under the fan to the back of the freezer. Further observation of the back of the freezer received ice buildup on top of a large cardboard box that contained seafood patties of imitation snow crab and other fish products. Further observation of the walk-in freezer revealed ice buildup on the bottom of the fan by the door. The KM said he had not noticed the ice build up and would communicate with maintenance.On 3/2/2026 at 9:42 a.m., an observation of the dumpster area was conducted. There was debris and garbage, such used gloves, around the sides and back of the dumpster. The KM said the cleanliness of the dumpster area falls on the kitchen/dietary staff.On 3/2/2026 at 9:48 a.m., a follow-up observation of the 100 hall nourishment room was conducted with the KM. He said the temperature logs for the refrigerator and freezer are found at the nurse's station of each unit. A review of the 100 hall temperature log revealed the temperature on 3/1/26 was not documented. A review of the 3/2/26 temperature documentation showed the refrigerator temperature was at 34 F and the freezer at 6 F. Staff M, Registered Nurse (RN)/Unit Manager (UM) said the 11:00 a.m. to 7:00 p.m. nursing staff are expected to document the temperatures. The KM said it was the nursing staff's responsibility to label and date the residents' personal items in the refrigerator and freezer. He said approximately three months ago the nursing staff received education on labeling and dating items. The KM said he was not sure when the refrigerator/freezer stopped working in the 100 hall and he was not aware of the temperatures not being appropriate. Resident food and beverage items observed earlier in the refrigerator and freezer were seen on top of the counter in the nourishment room.On 3/2/2026 at 9:54 a.m., an observation of the 400 hall nourishment room revealed the temperature log for the refrigerator and freezer was filled out for February until 2/27/26. There was no temperature log observed for March 2026.On 3/2/2026 at 10:04 a.m., follow up observation of the 300 hall nourishment room was conducted with the KM. He observed the large Tupperware with lettuce mix and confirmed it did not have a resident name or date. He proceeded to remove the Tupperware and said it needed to be discarded. Further observation of the refrigerator revealed he removed a large brown paper bag with an unidentifiable food item in red sauce. He confirmed the food item in the brown paper bag did not have a resident name or room number written on it.On 3/3/2026 at 10:54 a.m., a follow-up tour of the kitchen was conducted. An observation of Staff I, cook revealed he had the same Smartwatch on his left wrist that was observed on 3/2/2026. Staff I, cook was observed completing a task by the area where dry kitchenware is stored and was asked by the KM to come to the tray line to take the lunch meal temperatures. He was observed walking to the steam table with gloves on, he did not remove his gloves and perform hand hygiene prior to taking the lunch meal temperatures. At 10:59 a.m., while observing the lunch meal tray line, the long string of the thermometer touched the Salisbury steak when Staff I, cook was taking the temperature of the zucchini. The thermometer string was not cleaned or sanitized after it touched the Salisbury steak.On 3/3/2026 at 11:19 a.m., a follow-up interview was conducted with the KM about the dish machine. He confirmed there was an issue today with the temperature and sanitizing concentration. He said maintenance fixed the issue today. The KM said the dish machine had the same issue approximately three to four weeks ago. He said it was an issue with the valve that needed to be adjusted to get the sanitizer out. The KM stated it, Keeps happening. He said he called maintenance every time the issue occurred and they fixed it. He said the parts for the dish machine were ordered and received but had not been put in yet.On 3/3/2026 at 1:48 p.m., Staff J, RD provided an order and delivery summary from an online purchasing vendor. The documentation showed the dish machine parts were ordered on 2/24/2026 and delivered on 2/26/2026. He said the parts for the dish machine arrived on 2/26/2026 and were installed, but he did not know the date of installment. On 3/5/2026 at 11:01 a.m., an interview was conducted with the DOM. A review of a work order dated 2/20/2026 for the 100 wing nourishment room refrigerator was conducted. He said the temperature of the refrigerator that day was 39 F and 18 F in the freezer. The DOM stated they were, On higher end of where they need to be. He said they cleaned the coil, checked the fan that was keeping the refrigerator/freezer cool, and moved it six inches away from the wall. He said the temperatures were checked again the next day, then the following day, and continued to increase; therefore, the refrigerator was removed. The DOM said from 2/20/2026 to current, the staff are using a miniature refrigerator, that was typically used for staff's personal items, for resident items. He said he thought around 2/22 or 2/23 the refrigerator/freezer was removed from the 100 hall nourishment pantry. He said there should not be a refrigerator in the nourishment room, was surprised to hear there was one there, and was not sure who put it there. Regarding the dish machine, he said there are issues with the final rinse not being high enough and the sanitizer not being produced due to the spare heads not functioning the way they should. He said they went to different stores in order to look for the spare head parts they needed and eventually found some online which arrived to the facility last week. He said the parts were installed on 3/2/2026. He said there had not been any issues since Monday as there was a better flow on all of them. The DOM said what he was previously doing was taking off the heads and tried to flush out the sanitizer supply line to to force the chemicals through. He said it was corroded/rusted which did not let the sanitizer through. He said cleaning out the lines and spare heads worked occasionally and he would loosen/tighten them for a temporary fix. He said this issue had been occurring for approximately three to four months. He said they thought they were in the clear as the dish machine would work for three to four weeks at a time.On 3/5/2026 at 11:25 a.m., an interview was conducted with Staff L, Assistant DOM. He said on 2/27/2026 he put a new refrigerator in the 100 hall nourishment room and confirmed it was not the one that was out of service. He stated it was working when he put the refrigerator in the nourishment room and the, Temperatures were where they need to be. Staff L, Assistant DOM said on Monday or Tuesday of this week he removed the refrigerator as the nursing staff told him it had not been working.On 3/5/2026 at 12:08 p.m., a follow-up interview was conducted with the KM. He said the nursing staff, to include certified nursing assistants (CNAs), should be writing the resident's name with the date received on the resident's items. The KM said juices are supposed to be dated when the nursing staff opened them. He confirmed the nursing staff and CNAs have had training. He said the nursing supervisor took over training to include the completion of the temperature log and labeling of resident items. The KM said approximately three months ago, the nursing supervisor took over the responsibility of educating the nursing staff. Regarding staff wearing jewelry, he said the expectations are no dangling from the wrists such as a bracelet that hangs. He said if staff were wearing a watch, they should have a glove over it. For hand hygiene, the KM said for every new task the dietary staff needed to take their gloves off, wash their hands with soap and water, dry them and put on new gloves. He confirmed that Staff I, cook came to the steam table, during the lunch meal service observed, without washing his hands and he should have since it was a new task. The KM said he did not think the thermometer string had ever been cleaned or sanitized. He said the staff used the thermometer three times day, before every meal, and hung it up between uses. Regarding the ice buildup in the walk-in freezer, the KM said the cause was the defrost cycle was occurring during the day and it should be at night. He said the defrost cycle is supposed to heat up the compressor to make sure it did not build up ice. The KM said the maintenance staff changed the cycle and timing of it.A review of the employee handbook, with an effective date of 7/26/23, revealed the following under dress code: . For All Employees in All Departments: . Jewelry may not interfere with job performance and personal or patient safety.A review of a facility policy titled Handwashing, dated 6/2025, revealed the following, Hands shall be washed in accordance with established procedures; before working, after eating, after smoking, after touching any part of the body, after using the restroom, after working with any dirty equipment, and between working with foods.A review of a facility policy titled Food Handling, dated 6/2025, revealed the following, Food shall be handled in a proper method to ensure retention of flavor, appearance, quality, nutrients, and to safeguard against contamination. Further review of the policy under, Policy Interpretation and Implementation, revealed the following, . 3. When it is necessary for staff to touch food during preparation, they must wash their hands immediately before beginning the process. Disposable gloves are used. A review of a facility policy titled Food Receiving and Storage, dated 6/2025, revealed the following, 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated.8. Refrigerated foods must be stored at 41 F or below.10. Freezer temperature maintained to keep frozen food solid. Frozen food wrapping must stay intact until thawing.11. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the Food Service Manager or designee and documented on an approved log.13. Food items and snacks kept on the nursing units must be maintained as indicated below: Perishable food items will be covered/labeled and dated under refrigeration at 41 F or below. Frozen food items will be covered/labeled and dated at a temperature maintained to keep frozen food solid. All foods belonging to residents must be labeled with the resident's name, item and date. Refrigerators and freezers must have working thermometers and be monitored for temperature.A review of a facility policy titled Storage of Foods Brought to Residents by Family/Visitors, dated 6/2025, revealed the following, Policy Interpretation and Implementation .7. The nursing staff is responsible for discarding perishable foods within 3 days or before the use by/ expiration date, whichever comes first.8. The nursing and/or food service staff must discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates).Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than 2 hours will be discarded.

Based on observations, interviews, and record review, the facility did not ensure the medication error rate was below 5% for one resident (#31) out of six residents sampled for medication administration. This resulted in 8 errors out of 25 medication administration opportunities for a medication error rate of 32%.Findings included:An observation of medication administration on 3/3/2026 at 11:02 a.m. with Staff V, Licensed Practical Nurse (LPN), at the C Wing, middle, medication cart was conducted. Observation of the medication administration record (MAR) revealed medications that were being prepared, were marked green on the MAR; green indicated medications were previously completed.An observation was conducted on 3/3/3036 at 11:02 a.m. of medication administration with Staff V, LPN. Staff V, LPN was observed preparing and administering the following medications for Resident #31:Methocarbamol oral tablet Give 250 mg - 1/2 tablet (equaling 250mg)Lisinopril oral tablet 10 MG - 1 tabletKeppra tablet 250 MG - 2 tabletsClopidogrel Bisulfate oral tablet 75 MG - 1 tabletCitalopram Hydrobromide tablet 10 MG - 1 tabletCarbidopa-Levodopa oral tablet 25-100 MG - 1 tabletAspirin oral tablet delayed release (enteric coated) - 1 tabletStaff V, LPN proceeded to crush 8 pills and administered the crushed medications to Resident #31 on 3/3/2026 at 11:34 a.m.Review of the medications not to be crushed list on the nursing cart listed Keppra, Carbidopa-Levodopa, and Aspirin enteric coated.A review of the medication audit report for Resident #31 revealed there was documentation 5 of the medications were administered at 9:26 a.m. and 9:27 a.m.An interview on 3/3/2026 at 2:45 p.m. with Staff V, LPN was conducted. She said she documented at 9:27 a.m. that she had administered 5 medications to Resident #31, but she said the medications were not given at that time. She said another resident needed their medications first. She said she administered the medications during the medication observation ending at 11:34 a.m. She said she did not document at that time and instead documented later in her shift at 12:48 p.m. She said she did not give Levetiracetam oral tablet 500 MG and she should not have documented that she administered that medication because she administered Keppra Tablet 250 MG x 2 tablets. She said the methocarbamol had only been administered one time during her shift at 11:34 a.m.An interview on 3/3/2026 at 10:35 a.m. with the Pharmacist was conducted. He said education was being completed with the nurses using the do not crush list located on the medication carts.An interview on 3/5/2026 at 3:04 p.m. with the DON was conducted. She said the medications should not have been crushed. She said the nurse that documented the wrong medications is an agency nurse. She does not know why she documented early or late.A review of an undated policy titled, Medication Administration Guidelines indicates the steps are: 10: Ensure that the six rights of medication administration are followed: b: Right drug, e: right time, f: right documentation. 12: Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time. b: Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by a physician. 20: Sign MAR after administered. - Do not crush medications: Slow release and enteric coated.

Based on observations, interviews and record review, the facility failed to protect residents from the risk of accidents and hazards related to:1. Ensuring resident rooms were free from accident hazards, to include sharp objects and chemicals in one unit (memory/dementia) of four units toured, 2. Addressing smoking hazards for two residents (#138, and #68) of two residents sampled for smoking, and 3. Failed to eliminate potential hot liquid hazards related to coffee temperatures in four nourishment rooms (100, 200, 300 and 400) of four units observed. Findings included: 1. During observational tours conducted on 3/2/2026 at 8:00 a.m., on 3/3/2026 at 8:45 a.m., on 3/4/2026 at 10:00 a.m. and on 3/5/2026 at 9:30 a.m. the facility's memory care/dementia unit revealed accessible and sharp thumbtacks stuck on walls and activities corkboards in resident rooms; 221 (A) and (B) side, 222 (A) side, 227 (A) and (B) side, 228 (B) side, 230 (A) and (B) side, 232 (B) side, 205 (B) side, 204 (A) and (B) side, 207 (A) and (B) side, 210 (A) side, 211 (A) and (B) side, 212 (A) and (B) side and 215 (A) and (B) side. Some of the cork boards were observed with ten to fifteen colorful thumbtacks that were easily accessible to the residents who have confusion, dementia, Alzthiemer's, and were walking in and out each other's rooms, putting them at risk for hazards. On 3/5/2026 at 1:30 p.m. an interview was conducted with the 200-unit nurse, Staff B, Registered Nurse (RN). Staff B confirmed the presence of thumbtacks in resident rooms that used to hold papers up on corkboards. She stated she had never thought about thumb tacks being accident/injury hazards. Staff B confirmed the residents who reside in the 200 memory/secured unit wander in and out of other resident rooms and present with confusion, dementia and other cognitive deficits. Staff B confirmed after making a tour, there were several resident rooms that had numerous unused thumbtacks stuck in the corkboards. Staff B confirmed the thumbtacks could be easily removed by residents and presented potential injury hazards. On 3/5/2026 at 2:00 p.m. an interview with the Activities Director (AD) revealed she and her staff post information on the cork boards in each individual resident rooms for both the (A) bed and the (B) bed area. The AD confirmed they had not posted information in the 200 memory/secured unit individual rooms for a while as most of the residents cannot read or understand the activity calendar. The AD and her two staff stated they did not think the thumbtacks were injury hazards. The AD said after thinking about it, they are injury hazards and should not be accessible to the residents who reside in that unit. On 3/5/2026 at 2:40 p.m. an interview with the Nursing Home Administrator, (NHA) revealed the 200 unit was the memory/secured unit which houses residents who require supervision due to cognitive deficits and various behaviors. The NHA confirmed many residents in this unit ambulate on their own and wander in and out from other resident rooms and spaces. The NHA stated not being aware of sharps hazards in the resident rooms, to include the activities cork boards. She stated she did not think the thumbtacks that were easily accessible to these residents were presenting as injury hazards. The NHA said, however, the thumbtacks are a hazard risk, and the activities staff should have been using other ways to secure paper to the corkboard. The NHA confirmed the facility did not have a specific policy with regards to sharps or injury hazards in the memory/secured unit but confirmed the thumbtacks should not be used in the memory/secured unit. During multiple tours on 03/02/2026 and 03/05/2026 tours were conducted of the facility's secured/memory care unit. The following was observed: On 03/02/2026 at 8:41 a.m. an observation of room [ROOM NUMBER] – B showed a large bottle of [Brand name] mouthwash which was a quarter full. This mouthwash was easily accessible on the shelf above the television. Additionally, there was a hole on the lower right side on the outside of the footboard. It was about four inches in diameter. On 03/05/2026 at 10:00 a.m. an observation and interview was conducted of room [ROOM NUMBER] with Staff A, Certified Nursing Assistant (CNA). A nail clipper was found inside the resident's nightstand. Staff A said the nail clipper should not have been in the nightstand. On 03/05/2026 at 9:22 a.m. an observation was made of room [ROOM NUMBER] revealing a nail [NAME] out of the cork board. On 03/05/2026 at 9:24 a.m. an observation was made of room [ROOM NUMBER] revealing a staple observed hanging from the cork board. One side of the sharp staple was slightly inserted inside the cork board while the other side was hanging off. On 03/05/2026 at 9:25 a.m. an observation was made of room [ROOM NUMBER] revealing a bottle of [Brand Name] wipes on the side table. The bottle label revealed the wipes contained dimethyl benzyl ammonium chloride and dimethyl ethylbenzyl ammonium chloride, alcohol, cleaning agents, and fragrances. On 03/05/2026 at 9:51 a.m. an observation of room [ROOM NUMBER] revealed a pinned badge on the table which was against the wall to the right of the bed. The pin contained sharp points. On 03/05/2026 at 10:00 a.m. and at 10.24 a.m. an interview ws conducted with Staff A, CNA, about the potentially hazardous items found in resident rooms in the secured /memory unit. Staff A revealed mouthwash, toothpaste and toothbrushes were to be put in a zipped bag if they were in a resident's room. Staff A stated if nail clippers were given to residents from staff, then they must give them back. Staff A said he did not know or did not think residents should have pinned badges. He stated he thought the family had brought it in as it was not given to the resident by the facility. Staff A said he did not know what the guests were told in terms of allowed items. He said he knew they were not allowedto bring glass vases and certain flowers are they are toxic if ingested. Staff A said if these items were seen, the staff would tell the guest they could not bring them into the unit. Staff A stated if he saw a resident with an item they could not have, he would give it to the nurses. On 03/05/2026 at 10:28 a.m. an interview was conducted with Staff B, Registered Nurse (RN) about what belongings residents in the secured/memory unit were allowed to have. She stated residents were allowed to keep their belongings such as badges with pins, nail clippers and mouthwash. Staff B did not identify these items as hazards. 2. A review of Resident #138's admission record showed she was readmitted to the facility on [DATE] with diagnoses including but not limited to nicotine dependence, cigarettes, dependence on supplemental oxygen, and need for assistance with personal care. A review of Resident #138's minimum data set (MDS), section C, dated 2/17/2026 revealed a brief interview for mental status (BIMS) score of 15 indicating cognitively intact. A review of Resident #68's admission record showed she was readmitted to the facility on [DATE] with diagnoses including but not limited to nicotine dependence, cigarettes and need for assistance with personal care. A review of Resident #68's minimum data set (MDS), section C, 1/4/2026 revealed a brief interview for mental status (BIMS) score of 15 indicating cognitively intact. An interview on 3/2/2026 at 7:35 a.m. with Resident #138 was conducted. She said she was caught smoking in a non-smoking area of the facility last week. Resident #138 said she leaves her cigarettes with the receptionist and gets them when she goes outside to the covered area by the pond. An interview on 3/4/2026 at 2:25 p.m. with Staff N, Administrative Assistant was conducted. She said residents that are competent can sign themselves out and walk around outside. She said the facility does have residents that smoke. An observation and interview on 3/4/2026 at 3:00 p.m. with Resident #138 and #68 was conducted. Resident #138 and #68 said they were headed outside to smoke. Resident #138 said she retrieves her cigarettes from Staff O, Receptionist before she goes outside. Resident #138 retrieved her cigarettes from Staff O, Receptionist and looked in her rolling walker chair for a lighter and stated, I can't find my lighter, Resident #68 stated, I have mine; it's under my [breasts]. An interview on 3/4/2026 at 3:03 p.m. was conducted with Staff O, Receptionist. He said Resident #138 is the only resident that keeps their cigarettes at the front desk. He said the facility does have residents sign out at the reception desk and go outside to smoke. On 3/4/2026 at 3:08 p.m. Resident #138 and #68 were observed smoking a cigarette under the covered patio area on the facility property. Resident #138 had a portable oxygen tank with her and was wearing a nasal cannula. The NHA was made aware of the observation of the resident's smoking under the covered patio area on the facility property and Resident #138 wearing oxygen on 3/4/2026 at 3:09 P.M. An observation on 3/4/2026 at 3:10 p.m. was made of the NHA and the DON exiting the building. The DON said she was going to the non-smoking area [using hand gesture air quotes]. The DON said that is where the residents are caught smoking a lot. An interview was conducted on 3/4/2026 at 3:15 p.m. with the NHA, Regional Nurse Consultant (RNC), and Staff P, Activity Consultant. The NHA confirmed Resident #138 was smoking on the facility property. Staff P, Activity Consultant said it was not acceptable for Resident #138 to be smoking because she was wearing oxygen. Staff P, Activity Consultant said smoking with oxygen was a safety risk. A review of Resident #138's medical record revealed the following progress notes:On 3/3/2026, history details: . Current smoker of cigarettes.On 2/27/2026 social services note, explained smoking policy to the resident. Resident is aware that this is a non-smoking facility and agreed to not smoke on the facility grounds.On 3/4/2026 a social services note read, Resident was observed smoking on facility premises. A review of the facility's policy titled, Campus Wide Non-Smoking Policy and Procedure, dated 2024, revealed, Facility prohibits smoking in any part of its facility or anywhere on its premises. This policy applies to all tobacco products. The procedure of the policy is II: C: Residents are not permitted to have any smoking paraphernalia in their room or on their person. 3. On 3/2/2026 at 9:43 a.m., a tour was conducted with the Kitchen Manager (KM) of the four nourishment room pantries on the 100, 200, 300 and 400 units. Single service coffee and hot water machines were observed in all four pantries. The KM said he did not know if staff were checking the temperatures of the coffee and hot water before providing them to residents. He said staff do not record the temperature. The KM said the coffee was brewed at 180 and came out of the machine at 160 . A review of an article from the American Burn Association titled, Scald Burns, accessed on 3/10/2026, revealed the following, Scald burns happen when hot liquids or steam come into contact with the skin. They're among the most common burns, especially in children and older adults, and can range from mild to severe. Further review of the article revealed common causes of scald burns came from hot water and hot drinks spilled on the skin, especially for older adults. Further review of information on the American Burn Association and from John Hopkins School of Public Health revealed times and temperatures for water to cause a serious burn:- 140 within 3 seconds.- 120 within 10 minutes. Referenced from: https://www.ameriburn.org/, https://publichealth.jhu.edu/. On 3/5/2026 at 9:32 a.m., an interview was conducted with Staff Q, Licensed Practical Nurse (LPN). She said she assisted in the dining room in the secured unit and in the main dining room. Staff Q, LPN confirmed there was a coffee machine in the nourishment room. She said when a resident asked for coffee she would pour from the machine and ask how the resident liked it. She said there was also a button for hot water on the machine. Staff Q, LPN stated the coffee was, Usually hot when it comes out, the creamer cools it down. She said for residents with dementia staff needed to monitor to make sure it was not too hot. She said for residents with dementia she normally puts creamer in the coffee to cool and looks for the smoke that rises from the beverage. Staff Q, LPN said she also felt the mug with coffee or tea, with her hands to determine if it was too hot. She said for residents in the main dining, not the secured unit, they can monitor on their own if the coffee or water is too hot for them. On 3/5/2026 at 9:39 a.m., an interview was conducted with Staff T, CNA. She said when she worked in the secured unit, she gets coffee and tea from the machine in the nourishment room. She said residents who are alert and oriented usually asked for coffee. Staff T, CNA said coffee is typically provided with breakfast and lunch. She said during dining, the staff get a pot and fill it with coffee. She said she added whatever the resident wanted such as sugar or creamer. Staff T, CNA said she lets the alert and oriented residents decide if the temperature is okay and if they wanted to drink it or not. She said the residents who are not alert or oriented do not typically ask for coffee but may get it during activities. On 3/5/2026 9:48 a.m., an interview was conducted with Staff M, Registered Nurse (RN)/Unit Manager (UM). She said any staff member can provide a resident with coffee or tea. She said she asked the resident how they prefer their beverage such as black coffee/plain or with sugar. Staff M, RN/UM said the temperature for the coffee is already set. She said she was not sure what the temperature of the coffee or tea was when it comes out because the KM controlled that. Staff M, RN/UM said by the time staff prepared the beverage with sugar and creamer, the coffee is not very hot because there is no steam coming out. She said when it comes out of the machine the coffee is not extremely hot because there was no steam. She said by the time the coffee or tea is provided to the resident the temperature is warm. On 3/5/2026 at 12:08 p.m., a follow-up interview was conducted with the KM. He stated 180 is the temperature of the coffee recommended by the vendor because it is, The best flavor for coffee. He said the vendor told him the coffee temperature comes out at 160 . He said when the vendor comes to the facility, he will ask them to adjust the temperature to 150 . He said when the coffee came from the kitchen, they do not take the temperature. He said they put coffee in a pot, and it goes on the meal cart to the 100 wing as the machine in the nourishment room was not functioning at this time. He said all the other units get the coffee from the machine in the nourishment rooms. On 3/5/2026 at 1:06 p.m., an interview with the Director of Nursing (DON) was conducted. She said the nursing and CNA staff were provided an education/in-service in October 2025 about not putting hot liquids in Styrofoam cups. The DON said staff were educated to make sure there was no steam and letting the hot liquid cool before providing to the resident. She said staff were instructed to put the coffee from the coffee maker into carafes. She said when the beverage came directly from the machine it was hot, therefore staff are encouraged to use the carafes. She said the carafe gave the coffee time to cool when they are passing it out during mealtimes. The DON said non-clinical staff should ask the nursing staff before providing coffee or tea as the resident may have a restriction. She stated non-clinical staff, Do not get resident items such as food or beverages, they should tell the CNA or nurse. The facility did not have a policy for accident hazards related to hot liquids. A review of the facility's policy titled Reporting Accidents and Incidents, revealed the following, PROCEDURE:1. The facility will ensure that:a. The resident environment remains as free from accident hazards as is possible; andb. Each resident receives adequate supervision and assistance devices to prevent accidents.2. The facility will provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes:a. Identifying hazard(s) and risk(s);b. Evaluating and analyzing hazard(s) and risk(s);c. Implementing interventions to reduce hazard(s) and risk(s); andd. Monitoring for effectiveness and modifying interventions when necessary. (Photographic Evidence Obtained)

Based on observation and interviews facility did not ensure medications were stored properly related to 1) an unlocked treatment cart; 2) expired medications on one unit (C-Wing) out of two units observed for medication storage. Findings included:An observation on 3/2/2026 at 7:38 a.m. of a treatment cart on the C-Wing was unlocked (photographic evidence obtained).An observation on 3/2/2026 at 7:40 a.m. of the medication room on the C-Wing revealed 4 immunizations in the refrigerator were expired (photographic evidence obtained).An interview on 3/2/2026 at 7:45 a.m. with the Assistant Director of Nursing (ADON) was conducted. The ADON said those immunizations should not be in the refrigerator. The ADON stated, the resident's must not have received them. The ADON said the medication storage rooms are messy.An observation of C- Wing HIGH medication cart revealed 3 bottles of expired medications.Sodium Chloride Tablets 1 gram Expired: 11/2025Vitamin D Tablets 400 Expired: 12/2025Zinc Oxide Expired: 1/2026An interview on 3/5/2026 at 11:40 a.m. with Staff S, Registered Nurse (RN) was conducted. Staff S, RN said the expired medications should not be in the cart.An interview on 3/5/2026 at 3:04 P.M. with the DON was conducted. The DON said the expired medications should not have been in the cart. The DON said all nurses are responsible for removing expired medications from the medication carts and refrigerators.A review of an undated policy titled, Labeling & Storage had the following steps: 4). Labels for individual drug containers must include h. the expiration date. 6). Labels for over-the-counter medications must include c: The expiration date. 9) Expired medications will be discarded.

Based on interviews and record review, the facility failed to ensure voiced concerns from resident council meetings were documented as a grievance and acted upon during three meetings held on (12/10/2025, 1/16/2026, and 2/6/2026) out of seven resident council meeting minutes reviewed.Findings included:On 3/5/2026 at 2:15 p.m., a resident council meeting was conducted with Resident #134, Resident #186, Resident #73, and Resident #29 who regularly attended meetings The residents stated the following:- Resident #29 and #134 expressed they were missing clothing items, their items cannot be found, and they felt the items were, disappearing, despite them being labeled. They said they told social services and the administrator, Weeks ago, and the concerns were not addressed. They both confirmed their laundry is completed by the facility. Resident #73 expressed she also had missing clothing. She said she started washing her clothes in the bathroom sink as she was hesitant to give her clothes to laundry at the facility as they would not be returned.- Resident #134 and #73 stated concerns with having written grievances on their own, which is why they voiced them at resident council meetings. Resident #134, #73, and #186 discussed concerns with lack of supplies such as toilet paper, towels, sheets, blankets and the absorbent pads that go on the bed or chair. They all said there was a shortage of these items.- Resident #134 stated the resident council president (RCP), and/or Staff W, Activities Assistant (AA) completed the resident council meeting minutes.- All residents present expressed concerns with staff walking into their rooms without knocking and call light responses not being timely, especially on the weekend shifts. - -Resident #134 stated having waited an hour and a half sometimes for the call light to be answered.- Resident #73 and Resident #186 expressed concerns with cold food and stated it had been discussed in resident council. They said the kitchen manager was aware and his response was to send the food back if it was cold because the staff cannot reheat the items in the microwave. They both said when they had returned the food, and the food they received back was still cold.- All the residents present said they did know their rights and rules of the facility. They said they had asked for it in writing and asked for it to be discussed at the resident council meeting, but they had not received the requested information. A review of the resident council meeting minutes revealed the following:- On 12/10/2025 the resident council meeting conducted at 2:00 p.m., showed the following concerns were documented as discussed to include: timeliness of call light response/needs not being met, staff using personal items such as cell phones, medications being left at the bedside without explanation, and supply shortage such as towels.- On 1/16/2026 the resident council meeting conducted at 2:00 p.m., showed the following concerns were documented as having been discussed to include: call light response/needs not being met and staff use of personal items was a continued issue; new concerns related to staffing boards on the units did not include staff names, dietary concerns related to meal ticket accuracy/not receiving preferences, and the RCP asked on behalf of the group about resident rights.- On 2/6/2026 the resident council meeting conducted at 2:00 p.m., showed the following concerns were documented to include: continued issues with little to no improvement such as call light response, poor staff customer service, brief quality causing urine or bowel movement to leak, medications being left at bedside and being provided late, and a resident sitting in the dining room for prolonged periods of time with behaviors. Other concerns included environmental issue related to cleanliness of bathrooms, and the request for the ombudsman to discuss resident rights had not been addressed.A review of the grievance logs for 12/2025, 1/2026 and 2/2026 revealed the following:- 12/21/2025 documented grievances for Resident #73 related to care concern and customer service/interaction with reported resolutions on 1/6/26 and 1/9/26.- 12/30/2025 documented grievance for Resident #134 related to care concern with a reported resolution on 1/2/26.- 12/29/2025 documented grievances for Resident #134 related to care concern, dining, customer service/interaction with reported resolutions on 1/2/26 and 1/5/26.- 1/12/2026 documented grievances for Resident #134 related to care concern and dining with a reported resolution on 1/12/26.- 2/24/2026 documented grievance for Resident #134 related to customer service with no resolution date.A review of the grievance logs did not show any documented concerns from the resident council group. The individual concerns from Resident #73 and Resident #134 were not documented on the dates of resident council meetings.The review confirmed there were undocumented and unresolved grievances from resident council meetings.On 3/5/2206 at 3:28 p.m., an interview was conducted with Staff W, AA. She said she had been invited to the resident council meetings, On and off, since August 2025. She stated, It varies sometimes, who documented the resident council minutes. She said the resident council president (RCP) asked her to take the minutes this time. Staff W, AA said during meetings they reviewed old notes and concerns that were resolved or not. She said for concerns not resolved, they discussed if there was any progress or not. She stated the, Residents among themselves talk about problems. Staff W, AA said she recorded generalized complaints on the resident council minutes because she did not know if she was supposed to name the individuals. She said the RCP addressed the concerns and explained to the residents what they needed to do and who to address the complaint with. Staff W, AA confirmed she had not written a grievance on behalf of resident council. She said the nursing home administrator (NHA) received the resident council meeting minutes, reviewed them during morning meeting and delegated the concerns to those who needed to address them. She said the concerns from resident council are addressed by the RCP/ Resident #134. Staff W, AA said if a resident had a concern, she would address it with the department such as nursing or laundry. She said if a resident said they did not receive medications she would go straight to the nurse or if they did not receive care she would go straight to the certified nursing assistant (CNA). She said when she was first hired in 2016, she was trained by their director at the time on what to do during resident council meetings. She said since her training, what was changed about the process are the forms for the meeting minutes but nothing else had changed.On 3/5/2026 at 3:53 p.m., an interview was conducted with the Social Service Director (SSD) and Staff X, Social Service Assistant (SSA). The SSD said grievances are communicated to her in different ways such as verbally from residents and staff, a form given directly to her, or a phone call from a family member which she documented on the grievance log. The SSD said residents will typically tell her/another staff member or they would fill out the grievance form. She said when she received a grievance in written form, she read them for potential allegations that needed to be reported. The SSD said she made a copy of the grievances, then gives it to the corresponding department for them to investigate and resolve. She said during morning meetings she reminded staff about returning the resolved grievances. She said they tried to resolve grievances right away. The SSD said she speaks to the resident to let them know about the resolution and asked them to sign the grievance form if they were satisfied with the outcome. The SSD and Staff X, SSA both said even if the concern can be resolved immediately, the expectation is to document the grievance. The SSD said grievances from resident council would be written on the log individually if a resident is identified or it could be written as a group labeled, resident council. The SSD and Staff X, SSA said resident council concerns/complaints have not been communicated to them. The SSD stated, Not sure if they are given to someone else. She said she had never seen the resident council meeting minutes and expected concerns to be communicated to her. She said the NHA has access to the resident council minutes. A review of the resident council meeting minutes with the SSD and Staff X, SSA was conducted. They both confirmed concerns related to call lights, customer service, and staff cell phone use was being addressed. They both said they were not aware of concerns from resident council such as resident food items being discarded without their knowledge or dietary concerns. The SSD confirmed they did not have documented grievances for Resident #186, Resident #29, and Resident #73.On 3/5/2026 at 5:01 p.m., an interview was conducted with the NHA. She said she met with the residents who attended resident council the following day after the meeting. She said she frequently followed up with the RCP and was always invited to resident council meetings. The NHA said she also ate breakfast and lunch with them three times a week, which helped get information about concerns. She stated, I already know information from resident council. The NHA said she talked about resident council concerns, from her interactions with them and the meeting minutes, in stand up and stand down meetings. The NHA said she documented grievances for resident council if it came from an individual resident and/or the group. She stated she was, On top of communication when it comes to concerns.A review of the facility's policy titled Resident and Family Concerns and Grievances Policy and Procedure, revealed the following, Purpose To provide for the prompt resolution of medical and non-medical grievances while maintaining confidentiality, in accordance with applicable federal and state statutes and regulations.Further review of the policy revealed the following under procedure:I. Filing of Grievances.A. Residents or their family members, guardian, or representative may voice a grievance to the Facility staff in person, by telephone, or via written communication.B. Should a resident require assistance in voicing a grievance, the Facility Associates shall provide any needed assistance to the resident.C. The Facility shall provide the attached Grievance Report Form to facilitate the voicing of a grievance if requested by a resident or family member.Il. Documentation of GrievancesA. The Facility's Compliance and Ethics Officer or a designated Associate will document and keep a log of all grievances expressed either orally and/or in writing on the day that it is received or as soon as possible after the event or events that precipitated the grievance.IV. Responses to and Resolution of GrievancesA. The Facility will follow up with resident or their family members, guardian, or representative within 72 hours of the filing of the grievance.B. The Facility will make reasonable efforts to ensure that all grievances are adequately resolved within thirty (30) calendar days from the day the grievance is received.C. The Facility will advise the resident of the outcome of the grievance investigation and shall make reasonable efforts to contact the resident's family members to advise them of the outcome of the grievance investigation.

Based on interviews and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate related to diagnosis for three residents (#134, #211 and #226) of three residents reviewed for MDS assessments. Findings Included: 1. A review of Resident #134's admission record showed an original admission date of 3/1/2024 with a readmission date of 4/19/2024 with diagnoses to include but not limited to bipolar disorder, major depressive disorder, and anxiety disorder. A review of Resident #134's behavioral health progress note dated 11/6/2025 showed a diagnosis of Post Traumatic Stress Disorder (PTSD). A review of Resident #134's annual Minimum Data Set (MDS), dated [DATE], Section I, revealed PTSD was not marked. Review of Resident #134's care plan initiated, 3/20/2024 showed the following focus: [Resident #134's] anxiety level associated with her trauma will be minimized through next review. Interventions include ensure Resident #134's privacy before starting care, Resident #134 prefers female care staff when available and staff will approach anxiety or behaviors as a trauma survivor with empathy and caring. During an interview and record review on 3/5/2026 at 10:41 a.m., Staff C, Registered Nurse (RN) and MDS Coordinator, stated the PTSD diagnosis for Resident #134 had been missed. She indicated the diagnosis should have been updated during the Gradual Dose Reduction (GDR) meeting. She further stated that an audit will need to be conducted. 2. A review of Resident #211's admission record revealed an admission date of 09/14/2025 with diagnoses to include urinary tract infection, site not specified, acute cystitis without hematuria, Parkinson's disease without dyskinesia, without mention of fluctuations, unspecified dementia, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, and chronic kidney disease, stage 3 unspecified. A review of Resident #211's quarterly minimum data set (MDS), dated [DATE], revealed under section I – active diagnoses to the following diagnoses were not marked:- Neurological: non-Alzheimer's dementia and Parkinson's disease.- Psychiatric/Mood Disorder: no diagnoses were marked. A review of Resident #211's physician orders revealed the following:- Nuplazid oral capsule 34 milligrams (MG) for Parkinson's psychosis.- Sinemet tablet 25-100 MG for Parkinson's.- Duloxetine hydrochloride (hcl) oral capsule delayed release sprinkle 30 mg for depression. 3. A review of Resident #226's admission record revealed an admission date of 01/29/2026 with diagnoses to include alcohol dependence with withdrawal, unspecified, difficulty in walking, not elsewhere classified, muscle weakness (generalized), and need for assistance with personal care. A review of Resident #226's comprehensive MDS, dated [DATE], revealed under section I – active diagnoses, the diagnosis of dementia was not marked. A review of Resident #226's physician orders revealed the following:- Donepezil hydrochloride (HCI) oral tablet 5 milligrams (mg), give one tablet via percutaneous endoscopic gastrostomy (PEG) tube, one time a day for dementia. On 3/5/2026 at 12:47 PM an interview with Staff C, MDS Coordinator was conducted. She reviewed Resident #211's medical record and confirmed a progress note, dated 1/27/2026, showed the diagnosis of psychotic disorder with delusions due to known physiological condition. Staff C confirmed the diagnoses were missed. During an interview and record review on 3/5/26 at 1:21 p.m., Staff C, (RN) and MDS Coordinator said the facility follows the RAI manual and does not have an MDS specific policy. Staff C said the facility follows the Resident Assessment Instrument (RAI) manual and does not have an MDS policy.

Based on record review and interviews, the facility failed to ensure an accurate Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability review (PASARR) was completed for five residents (#2, #112, #9, #211, and #226) of six residents reviewed for PASARR.Findings included:1. A review of Resident #2's admission record revealed an admission date of 12/9/2025 with diagnoses to include psychotic disorder with hallucinations due to known physiological condition, unspecified dementia, unspecified severity, with mood disturbance, depression, unspecified, epilepsy, unspecified, not intractable, without status epilepticus and other seizures.A review of Resident #2's physician orders revealed the following:- Sertraline hydrochloride (HCl) oral tablet 50 milligrams (mg), give one tablet by mouth one time a day for mood.- Donepezil HCl oral tablet 10 mg, give one tablet by mouth one time a day for memory.- Quetiapine fumarate oral tablet 100 mg, give one tablet by mouth three times a day related to psychotic disorder with hallucinations due to known physiological condition.- Lorazepam oral tablet 0.5 mg, give one tablet by mouth every eight hours as needed for anxiety for 30 days. A review of Resident #2's care plan revealed the following:- At times I can have verbal outbursts by yelling out randomly and squirm myself in the bed to be sideways in the bed with legs hanging. Date Initiated: 12/11/2025.- I take a psychotropic medication: antianxiety, antidepressant, antipsychotic Date Initiated: Date initiated 12/22/25.- [Resident #2] is at risk for alteration in mood state r/t [related to] dx [diagnosis] of dementia with mood disorder, anxiety, depression. Date Initiated: 12/10/2025- The resident uses anti-anxiety medications r/t psychotic disorder Date Initiated: 12/10/2025.- The resident uses antidepressant medication r/t depression Date Initiated: 12/10/2025.- The resident uses antipsychotic medication r/t dx of dementia with mood disturbance Date Initiated: 12/17/2025.- Resident has a potential for seizure activity, Date Initiated: 12/20/2025.A review of Resident #2's level I PASSAR screen, dated 11/25/2025, showed depressive disorder was marked under section A - MI or suspected MI. Further review of section A showed no other diagnoses were marked. A review of section II - other indications for PASSAR screen decision-making, showed the question was marked yes for the following, Does the individual have a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis is an Serious Mental Illness or Intellectual Disability? A level II PASSAR evaluation and determination was not found in Resident #2's medical record and was not provided by the facility.2. A review of Resident #112's admission record revealed an admission date of 10/14/2021 with diagnoses to include epilepsy, unspecified, not intractable, without status epilepticus (primary), generalized anxiety disorder, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, mood disorder due to known physiological condition, unspecified, major depressive disorder, recurrent, mild, and unspecified psychosis not due to a substance or known physiological condition.A review of Resident #112's physician orders revealed the following:- Lorazepam intensol oral concentrate 2 mg/mL (milligrams/milliliters), give 0.25 mL by mouth every six hours for anxiety/restlessness.- Valproic acid syrup 250 mg/5mL, give 5 ml by mouth three times a day for seizures.A review of Resident #112's care plan revealed the following:- [Resident #112] has mood symptoms of: feeling sad at times, decreased energy, difficulty sleeping, due to my diagnosis and history of depression. I may become tearful at times. [Resident #112] prefers to remain in bed most of the time. Date Initiated: 10/22/2021.- [Resident #112 ] can be accusatory and critical of staff. Resident presents with a negative disposition mostly. [Resident #112] requires moderate assistance with ADL's [activities of daily living]. Resident #112 will frequently refuse such and may become physically and verbally aggressive towards staff. Refuses to have nails cut. Frequently refuses medication, supplements and treatments. Often refuses care and unable to redirect makes derogatory and defamatory statements toward and about staff refuse to be turn/repositioned, refuse showers, meals refuse weights and showers refuses to have labs drawn. Resident at times makes inflammatory and confabulatory statements. Date Initiated: 04/20/2022.The care plan revealed:- I take a psychotropic medication: antianxiety. Date Initiated: 09/21/2022.- [Resident #112] impaired cognition with decreased ability to comprehend and/or express myself due to: Dementia, impaired short-term memory. Mental state may flux [fluctuate]. Date Initiated: 09/19/2022.- [Resident #112] has noted noncompliance with medications. She is not always easily redirected r/t [related to]. Patient education and 1:1 [one to one supervision] with [Resident #112] in regard to prescribed medications, risks of noncompliance. [Resident #112] does have dementia, impaired cognition. Staff will continue to encourage compliance, redirect as able. Physician/responsible party aware. Date Initiated: 03/17/2025.- [Resident #112] receives anticonvulsant medication secondary to seizure disorder. Date Initiated: 03/17/2025.A review of Resident #112's level I PASSAR screen, dated 7/15/2024, showed depressive disorder, anxiety disorder, and mood disorder was marked under section A - MI or suspected MI. Further review of section A showed no other diagnoses were marked. A level II PASSAR evaluation and determination was not found in Resident #112's medical record and was not provided by the facility.3. A review of Resident #9's admission record revealed an original admission date of 1/24/2024 and a re-admission date of 8/22/2025 with diagnoses to include bipolar disorder, unspecified and major depressive disorder, single episode, moderate.A review of Resident #9's physician orders revealed the following:- Trazodone hcl (hydrochloride) tablet 150 mg, give one tablet by mouth at bedtime related to major depressive disorder.- Oxcarbazepine tablet 300 mg, give one tablet by mouth in the morning and give one tablet by mouth in the evening related to bipolar disorder. A review of Resident #9's care plan revealed the following:- [Resident #9] takes a psychotropic medication: antidepressant, DX [diagnosis] of insomnia, potential for adverse drug effects such as falls, decline in mood, behavior, cognition and ADL's [activities of daily living] Date Initiated: 08/26/2025.A review of Resident #9's level I PASSAR screen, dated 8/20/2025, showed anxiety and depressive disorder was marked under section A - MI or suspected MI. On 3/5/2026 at 4:21 p.m., an interview was conducted with the Social Service Director (SSD). She said upon admission to the facility, she reviewed the residents Level I PASSAR to see what diagnoses were listed. The SSD said she also reviewed the residents' history and physical documents from the hospital. She said she did not have access to the PASSAR system. The SSD said she kept a log and provided the information to the Assistant Director of Nursing (ADON) who had access to the PASSAR system. She said about two to three weeks ago the Director of Nursing (DON) gained access to the PASSAR system and is now updating them. The SSD said through gradual dose reduction (GDR) meetings or if a diagnosis changed, she wrote it down to update the resident's Level I PASSAR. The SSD said since November 2025, she had been overseeing ensuring the PASSARs were accurate and communicating with the ADON to update them as needed. She said she reviewed the resident's PASSARs to see if the diagnoses matched and also reviewed the history and physical to catch a diagnoses that was not carried over. The SSD said for level II PASSAR evaluations she looked at the provisional information, then reviewed the observational page on the PASSAR and if one of the questions was marked Yes, she would submit for a level II PASSAR. She said if she thought a resident required a level II PASSAR evaluation and the system did not trigger it; the DON can override that and open a new case. She stated, A mental illness, sometimes if there's a developmental disability or TBI [traumatic brain injury], that might need a level II. A review of Resident #112's level I PASSAR was conducted with the SSD. She said a new Level I PASSAR would need to be completed to see if Resident #112 needed a Level II evaluation. She said the previous ADON identified PASSARs that needed to be updated but was not sure where they left off. The SSD said she was not aware Resident #112's Level I PASSAR needed to be updated. A review of Resident #2's PASSAR was conducted with the SSD. She confirmed the resident was admitted on [DATE]. The SSD confirmed the diagnoses of epilepsy and dementia would need to be added to the Level I PASSAR and may need a Level II evaluation. A review of Resident #9's Level I PASSAR was conducted with the SSD. She confirmed Resident #9 was admitted to the facility on [DATE]. She said the diagnosis of bipolar disorder should be on the Level I PASSAR and it would most likely be flagged for a Level II evaluation.4. A review of Resident #211's admission record revealed an original admission date of 09/14/2025. Further review of the admission record revealed diagnoses to include psychotic disorder with delusions due to known physiological condition, unspecified dementia, unspecified severity, with other behavioral disturbance, and adjustment disorder with anxiety.A review of resident #211's physician orders revealed the following:- Nuplazid oral capsule 34 milligrams (MG) for Parkinson's psychosis.- Sinemet tablet 25-100 MG for Parkinson's.- Duloxetine hydrochloride (hcl) oral capsule delayed release sprinkle 30 mg for depression.A review of Resident #211's Level I PASSAR screen, dated 9/13/2025, showed parkinsons disease and dementia. No diagnosis of psychotic disorder was found on the PASSAR. A level II PASSAR evaluation and determination was not found in Resident #211's medical record or provided by the facility.5. A review of Resident #226's admission record revealed an original admission date of 1/29/2026 and a readmission date of 2/19/2026. Further review of the admission record revealed diagnoses to include alcohol dependence with withdrawal, unspecified.A review of resident #226's physician orders revealed the following:- Quetiapine fumarate oral tablet 25 mg for mood.- Anti psychotic behavior monitoringA review of Resident #226's PASSAR Level I screen, dated 1/29/2026, showed no diagnoses were marked under section A- MI or suspected MI. A level II evaluation/determination was marked for dementia.An interview and review of Resident #226's level 1 PASSAR was conducted on 03/05/2026 at 4:37 PM with Social Service Director. She stated the alcohol dependence diagnosis for this resident would be marked under other on the PASARR. The SSD said she would not put in the dementia diagnosis as the minimum data set (MDS) coordinator would update the medical record to include that diagnosis code. She questioned, Why is his diagnosis not on there. She reviewed Resident #226's H&P (history and physical) which showed the diagnosis of dementia. She confirmed dementia is not on the list of current diagnoses. A review of the facility's policy titled Coordination with PASARR, revealed the following, This facility coordinates assessments with the preadmission screening and residents review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Further review of the policy revealed the following under Policy Explanation and Compliance Guidelines, : 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I - initial pre-screening that is completed prior to admission i. Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission. b. PASARR Level II - a comprehensive evaluation by the appropriate state- designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs.

Based on observations, record review and interviews, the facility failed to ensure the resident had assistive devices to maintain hearing abilities for one resident (#3) of two residents reviewed for communication and sensory problems.Findings included:During an interview and observation on 3/2/2026 at 11:06 a.m. Resident #3 said to stand on the right side because there is no hearing in the left ear and stated difficulty hearing in the right ear. While speaking in a loud voice approximately six inches from Resident #3's ear, the same information had to be repeated multiple times before the resident was able to hear and understand it.A review of Resident #3's face sheet showed an original admission date of 3/21/2023 with a readmission date of 11/17/2025 and a primary diagnosis of acute gastroenteropathy due to Norwalk agent.A review of Resident #3's care plans showed the following focus: [Resident #3] has difficulty with communication due to hearing deficit, initiated on 3/23/2023. The interventions included:-Face when speaking and make eye contact. Turn off TV/radio as needed to reduce environmental noise.-Refer to audiology for hearing consult as needed.-Use strategies such as touch, facial expression, eye contact, gestures, tone of voice, non-threatening posture, short direct phrases, speak slowly, speak in a calm distant manner, speak with increased voice volume. Repeat statement or question as needed. Stand in close proximity.A review of Resident #3's social services (SS) progress note, dated 5/17/2023 revealed, Met with resident yesterday and encouraged the resident to lower volume on television .Resident agreeable, but stated it's hard for me to hear it when I don't have the volume high enough .she is hoping to receive hearing aids in the near future. Informed resident she may be able to receive headphones that would allow [the resident] to hear the television better [Resident #3] was agreeable to wear headphones if they were provided.A review of Resident #3's SS progress note dated 8/5/2024 revealed, SS sent out audiology referral per resident's request.A review of Resident #3's SS progress note dated 4/9/2025, Audiologist referral sent to [Vendor].A review of Resident #3's Minimum Data Set (MDS) dated [DATE] showed a Brief Interview Mental Status (BIMS) score of 13, which indicates moderate cognitive impairment.During an interview on 3/2/2026 at 11:14 a.m. Staff G, certified nursing assistant (CNA) said she must, Talk loud for Resident #3 to hear. The CNA demonstrated this by cupping one hand around her mouth while speaking to project her voice so the resident could hear her more clearly.During an interview on 3/4/2026 at 9:56 a.m. Staff H, Social Services Assistant (SSA) said, Sure there was an audiology consult for Resident #3. He said he communicated with the facility's audiology services vendor by email, and he will check email for additional communication. Staff H, SSA read Resident #3's audiology note, dated August 2024 for Debrox (medication used to soften and loosen excess earwax) 2 drops in each ear twice daily for 5 days repeat after two weeks. He said Resident #3's second audiology referral was April 9, 2025, and he will review the resident's records for additional information. During an interview on 3/4/2026 at 10:02 a.m. the Social Services Director (SSD) reviewed a list of residents with hearing aids or hearing aids pending from the facility's audiology vendor and said Resident #3's name was not listed.During an interview on 3/4/2026 at 10:57 a.m. the Nursing Home Administer (NHA) said the facility's expectation was to make sure all resident needs are met, the cost does not limit the resident's access to services or supplies.During an interview on 3/5/2026 at 9:55 a.m. the Director of Nursing (DON) said, once it is brought to my attention a resident is hard of hearing (HOH), SS is notified immediately.On 3/4/2026 at 3:45 p.m. the NHA said the facility does not have a policy regarding audiology services.

Based on observation, interviews, and record review, the facility failed to obtain physician orders for the percent of humidity to provide supplemental oxygen by tracheostomy according to professional standards of practice for one (#5) of two residents reviewed for respiratory care.Findings Included:On 03/02/2026 at 7:48 a.m. observed Resident #5's oxygen set to 3 L (Liters).Review of Resident #5's face sheet showed admission on [DATE] and readmission [DATE] with diagnoses to include acidosis, disorders of diaphragm, acute and chronic respiratory failure with hypoxia, pneumonitis and chronic respiratory failure.Review of Resident #5's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008 form) dated 12/12/25, Section V, Treatment Devices show order for oxygen at 6 liters (L) per [minute] means how much gas is moving and 28% how rich in oxygen the air is.Review of Resident #5's order recap report, dated 3/4/26 showed an order for Trach-continuous humidified oxygen 2.5 L via trach mask .Review of Resident #5's care plan include show care plan focus: resident has tracheostomy related to chronic respiratory failure. The interventions include give humidified oxygen as prescribed via trach mask.During an interview on 3/3/2026 at 5:26 p.m. when asked about Resident #5's oxygen settings Staff D, Licensed Practical Nurse(LPN) said she knows the setting is 2.5 liter and Respiratory Therapy (RT) takes care of the humidifier. During an interview on 3/4/2026 at 10:18 a.m. Staff E, LPN said Resident #5's humidifier setting is 28%.During an interview on 3/4/2026 at 10:27a.m.with Staff F, Registered Nurse, RN said there should be order for a mist setting. After reviewing Resident #5's 3008 form dated 12/12/25 said there should be an order for 28% humidity, I am going to fix the order right now.Review of the facility's Physician Orders policy, undated, showed the policy did not include guidance or relevant information regarding the requirement for physician orders for tracheostomy humidification or respiratory care interventions according to professional standards of practice.

Based on observations, interviews and record review, the facility failed to take a trauma-informed approach to deliver care that involves understanding, recognizing and responding to the effects of a specific trauma Post Traumatic Stress Disorder (PTSD) for one resident (#6) of five residents reviewed with PTSD. Findings included:On 3/2/2026 at 7:35 a.m. the facility's memory/dementia unit was toured and the dining room was observed with residents either being served their breakfast meal, or were waiting for their breakfast meal to be served. Resident #6 was observed seated in her wheelchair positioned at a table and awaiting her breakfast meal. Resident #6 appeared to be dressed for the day, well groomed and appeared generally in good spirits. She was observed interacting with other staff members and was laughing. Resident #6, who resides in the 200 memory/dementia unit, was observed with cognitive deficits and when attempted interview, she could not speak with relation to her medical care and services. She was able to answer simple questions about her day and revealed she had no immediate complaints. She was served her breakfast meal and was observed to take bites and eat without any staff assistance.At 9:50 a.m. while touring the facility's memory/dementia unit, Resident #6's room was approached and the door was closed. Upon knocking and announcing Resident #6 called out with permission to come in. Once the door was opened, Resident #6 was observed seated in her wheelchair, dressed for the day and positioned towards the glass window and was just looking out from it. Resident appeared to be isolated and with nothing to do. When attempting to interview her, she did not appear to be in the same pleasant mood as she was when she was eating breakfast. Resident was attempted interview and she did not want to offer any information about her day. She continued to look out the window. At 10:45 a.m. Resident #6 was visited while in her room again and she appeared to be in a very pleasant mood. She was still observed seated in her wheelchair but was laughing and offering information about her day. She had no complaints and stated she was just sitting in her room. When she was asked if she likes sitting in her room by herself and with the door closed, she stated, I don't know.On 3/2/2026 at 11:00 a.m. an interview with the 200 Unit Nurse staff B, and review of the facility's Resident Matrix, revealed Resident #6 had either Post Traumatic Stress Disorder (PTSD) or some form of it. Staff B was not sure of the reason why Resident #6 had PTSD, but she did present at times with behaviors, agitation, and yelling out.Review of the electronic medical record revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives revealed Resident #6 had a Power of Attorney (POA) medical decision maker to make her decisions. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Psychotic disorder, Dementia, Psychosis, Paranoid disorder, Adult failure to thrive, Anxiety, PTSD, and Depression. Review of the current Annual Minimum Data Set (MDS) assessment dated [DATE] revealed;(Cognition/Brief Interview, Mental Status or BIMS score - 5 of 15, which indicated Resident #6 had cognitive deficits preventing her from speaking to her medical care and services.); (Mood - Presents 7-11 days Feeling down with no other mood indicators during timeframe); (Behaviors - None documented as exhibited during timeframe); (Active Diagnosis - Anxiety, Depression, Psychotic disorder, PTSD).Further review of the medical record revealed evidence of psychiatric physician visits/assessments to include dates 12/10/2025, 12/18/2025, 1/15/2026, 1/29/2026, 2/19/2026, and 2/23/2026. Each of the assessment/visit documents revealed Resident #6 had PTSD, but did not mention what her PTSD history was, nor revealed any type of documentation to support specific triggers and trauma based behaviors.Review of the Certified Nursing Assistant Care Plan Kardex documents for the last three months reviewed to include months 3/2026, 2/2026, and 1/2026 all did not support any documentation to reflect Resident #6 with specific behaviors and triggers related to PTSD. There was no documentation to let the aides know what to look out for that may trigger Resident #6 to have trauma based behaviors. Review of the current care plans with a next review date 5/31/2026 revealed focus areas to include but not limited to:Resident #6 has a history of PTSD related to witnessing a traumatic event with her son, trigger includes talking about the event with interventions to include (Avoid the topic of [NAME]'s trauma unless she begins the conversation, If becomes agitated during a conversation, redirect the topic of conversation, [NAME] will be able to discuss my cultural, privacy gender issues, Will be afforded the opportunity for peer support of her choice, whether that be from peer support as desired.On 3/3/2026 at 10:00 a.m. a telephone interview with Resident #6's Power of Attorney (POA), revealed he was aware there was something that happened with Resident #6 in the past but did not know what. He revealed the facility staff does not bring it up during the care plan meetings he attends and he would also not know what types of behaviors may trigger her related to her past trauma/PTSD. Resident #6's POA was also not sure if psych services was addressing this diagnosis as nobody has ever told him. Review of the 3/2026, 2/2026, and 1/2026 Physician's Order Sheet revealed orders for Behavior monitoring and to perform each shift with documentation and to note codes for what behavior was observed. The order was for staff to document behaviors attributed to psychotropic medication use, and other behaviors not specific to PTSD.Further, review of the same noted month's Medication Administration Record revealed daily behavior monitoring for each shift, but also did not identify any types of specific behaviors that may be attributed to trauma/PTSD. On 3/4/2026 at 1:00 p.m. an interview with a Minimum Data Set (MDS) coordinator Staff C revealed she normally completes MDS assessments and care planning for the long term care residents and does not know everyone that well in the 200 memory/dementia unit. She stated the MDS coordinator for that unit is not available today (3/4/2026) for interview. However, Staff C revealed she can go over the record and answer questions about the resident. Staff C confirmed she did know Resident #6 very little and just knew she has Post Traumatic Stress Disorder (PTSD). Staff C confirmed she was not aware of why Resident #6 had PTSD, nor knew of types of behaviors that staff should be looking out for related to her trauma PTSD diagnosis. Staff C reviewed Resident #6's current care plans and identified and confirmed there was a focus area to include history of PTSD. Further review of the care plan and interview with Staff C confirmed the problem area of PTSD was related to witnessing a traumatic event with her son. Staff C confirmed the focus area did not detail in specific of what experience Resident #6 had, nor were there any specific interventions to capture the types of behaviors Resident #6 may present with related to PTSD.Further interview with Staff C stated she now understands there is nothing in the chart, MDS, care plans that identify what behaviors the resident may have, and therefore staff would not be able to quantify/monitor for specific behaviors. She said we (staff) do not know what to look out for to reduce trauma based PTSD behaviors.Staff C further confirmed psych. services assessments also only revealed diagnosis of PTSD but with no further detail and did not believe the doctor was evaluating for that diagnosis. On 3/5/2026 at 8:50 a.m. an interview with Staff B, Registered Nurse (RN) confirmed she knows Resident #6 well and knows her family is involved with her medical care. Staff B stated Resident #6 has confusion and a lower level of decision making skills. Also, Staff Q, Licensed Practical Nurse (LPN) was present during the interview and she too explained she knew Resident #6 and that she had cognitive impairment but could make her daily decisions. Staff B and Q both confirmed Resident #6 usually stays in her room for parts of the day, but she does come out for meals, group activities and out in the screened in porch with other residents and staff. Staff B and Q confirmed Resident #6 resides in the 200 memory/dementia unit because of her diagnosis of dementia with the need for more supervision. Staff B and Q both confirmed they were aware Resident #6 had Post Traumatic Stress Disorder (PTSD), but they vaguely knew what it was about. Staff B stated she only knew there was something related to her (Resident #6) and with one of her son's, which happened a long time ago. Both Staff B and Q were not aware of anything specific and did not know of what specific triggers and behaviors to look out for related to PTSD. Staff B revealed Resident #6 was care planned with a focus area of PTSD, but it did not reflect what specific behaviors/triggers to look out for. On 3/5/2026 at 9:30 a.m. an interview with Staff A, Certified Nursing Assistant (CNA) confirmed he knows Resident #6 well and speaks with her family when they visit. Staff A Confirmed Resident #6 resides on the memory/dementia unit due to her dementia and behaviors. He stated Resident #6 will at time get sideways with her behaviors and will yell at staff and other residents. Staff A was aware Resident #6 has PTSD but did not really know the specifics of what happened to cause her PTSD. Staff A was unable to say what specific behaviors to look out for that would trigger her PTSD, but would report any type of behaviors to his nurse. On 3/5/2026 at 9:40 a.m. an interview with Staff R, CNA revealed she has Resident #6 on her assignment routinely and she is in the memory/dementia unit due to her dementia. Staff R further confirmed Resident #6 does have behaviors at times but did not know she had PTSD. Staff R could not say how she would determine what types of triggers/behaviors to look out for related to trauma/ PTSD.On 3/5/2026 at 5:00 p.m. an interview with the Nursing Home Administrator confirmed Resident #6's medical record and care planning did identify her as having past Trauma/PTSD, but she was not aware of the specific problem/focus area and also did not know what types of behaviors/triggers to look out for so the care planning team could further evaluate it. The Nursing Home Administrator provided the facility's Trauma Informed Care policy and procedure (no date) for review.The policy revealed;Guidelines:It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimalizing triggers and/or re-traumatization.Definitions: Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. Common sources of trauma include, but not limited to: Natural and human caused diseases; Accidents; Rape; [NAME] crime; Physical, sexual, mental, emotional abuse; War; History of imprisonment; History of homelessness; Traumatic life events. Trauma informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. StepsThe facility will work to facilitate the principles of trauma informed care which include but not limited to:a . Safety - Ensuring residents have a sense of emotional and physical safety.b . Trustworthiness and transparency - Efforts to establish a relationship based on trust, and clear and open communication between the staff and the resident.The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, and others. 4 . The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions. 6 . The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the resident's care plan. While most triggers are highly individualized, some common triggers may include, but are not limited to:Experiencing a lack of privacy or confinement in a crowded or small space.Exposure to loud noises, or bright/flashing lights.Certain sights, such as objects that are associated with their abuser.Sounds, smells, and physical touch. 7 . Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as the substance abuse, eating disorders, depression, and anxiety. These interventions will also recognize the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery. 8 . The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization. The resident and/or his or her family or representative will be included in this evaluation to ensure clear and open discussion and better understand if interventions must be modified. 10 . In situations where trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident, and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. The Nursing Home Administrator also provided a Comprehensive Care Plan policy and procedure (not dated), for review.The policy revealed;Guidelines:The facility will develop and implement a comprehensive person-centered care plan for each resident. The care plan will be consistent with resident rights, with measurable objectives and timeframes to meet a resident's needs as identified through comprehensive assessment.Steps:4. vii - Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated.7. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.

Based on observations, interviews and record review, the facility did not ensure the physician was notified of missed doses of pain medications for one resident (#3) out of three residents sampled. Findings included: On 11/17/25 at 10:37 AM, Resident #3 reported waking up in the middle of the night in pain. The resident reported she calls the night nurse to ask if her scheduled pain medications could be administered. The resident stated there were concerns with the nurse being unresponsive to her request.On 11/17/25 at 2:03 PM Resident #3 stated that on the nights of 11/14/25 and 11/15/25 they woke up in pain in the right arm around 2:00-3:00 AM and called their night nurse to inquire if the scheduled pain medications could be received. Resident #3 stated being on a strict regime of every 4 hours to receive their pain medications to prevent oncoming pain per doctor's orders. Resident #3 said being on a consistent schedule with their pain medications helps to prevent them from feeling any additional pain. Resident #3 stated to strongly preferring for nurses to wake them up to take the scheduled pain medications in order to have prevented the pain. The resident said she was always talking about wanting to be woken up and doesn't mind being woken up to take their pain medications.A review of Resident #3's admission record revealed an admission date of 7/30/25 with a medical diagnosis of seizures, muscle weakness, anxiety disorder, major depressive disorder, and post concessional syndrome. A review of Resident #3's orders revealed that starting on 10/27/25, the resident is to start Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen) with one tablet scheduled for every 4 hours to prevent pain. A review of Resident #3's care plan revealed no documentation related to refusing medications or to not be woken up in order to receive scheduled medications. A review of Resident #3's progress notes from 11/7/25 to 11/17/25 revealed no documentation of advising the resident's representative or physician of the missed pain medications. A review of Resident #3's quarterly Minimum Data Set (MDS) assessment, dated 10/30/25, in section C - cognitive patterns revealed a Brief Interview Mental Score (BIMS) of 15. A review of Resident #3's Medication Administration Record (MAR) for dates of 11/1/25 to 11/30/25 revealed that the resident did not receive their hydrocodone 2:00AM dose on the nights of 11/14/25 and 11/15/25. The reasons for the medication not being administered is because the nurse documented Resident #3 as sleeping for both attempts. On 11/17/25 at 2:12 PM an interview was conducted with Staff A, Licensed Practical Nurse (LPN). Staff A, LPN said if a resident is sleeping at the time of medication administration, the process is to gently wake up the resident to either give them their medications, or to at least give the resident the opportunity to refuse the medication. Staff A, LPN mentioned that Resident #3 is followed by pain management and uttered the importance of keeping the resident's routine of pain medications in order to prevent pain from coming. On 11/17/25 at 2:40 PM an interview was conducted with Staff B, Unit Manager (UM). Staff B stated there is a high priority to attempt to wake up a resident when they have a scheduled medication to be provided, and to give the resident the opportunity to refuse if they would prefer. Staff B said it is not up to the nurse's discretion to refuse or not provide a resident without their scheduled pain medications. Staff B, UM said that medication was not administered as scheduled for Hydrocodone on 11/14/25 and 11/15/25.On 11/17/25 at 3:25 PM an interview with the Interim Director of Nursing (DON) and the Assistant Director of Nursing (ADON) in training was conducted. The DON stated staff should re-attempt to wake up the resident to administer scheduled pain medications with no specific time frame and also make a note in the resident's progress notes of the attempts. The DON confirmed there was no medication administered to the resident both dates of 11/14/25 and 11/15/25. The DON stated for both missed doses should have been administered to Resident #3 since they were scheduled. The DON said the expectation was for nurses to attempt to wake up the resident. The DON said it was not up to the nurses' discretion on when to and when not to administer medications. A review of the facility's Pain Management Guidelines revealed the following: The facility staff will identify key characteristics of the pain which includes: . iv. Timing. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the residents representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission.

Based on observations, interviews, and record review the facility failed to ensure adequate supervision and interventions were provided 1) to prevent major injuries for two residents (#213 and #81); and 2) to maintain a hazard free environment for one resident (#55) out of six residents sampled for falls and hazards. Findings included: 1) During an interview on 8/25/25 at 9:05 a.m. Resident #213’s Resident Representative (RR) stated being upset with the facility at the lack of treatment and identification of concerns regarding Resident #213’s falls and answering of call lights. The RR noted on a visit to the facility Resident #213 had a swollen hand and upon notifying the staff, the staff stated, “we did not notice.” The RR stated not being made aware of any recent falls. A review of Resident #213’s admission Record showed an admission date of 11/3/23 and readmissions on 3/16/25 and 7/9/25 with the following diagnosis: Parkinson’s disease, unspecified dementia, adjustment disorder anxiety, unsteadiness on feet, muscle weakness, hypotension, psychotic disorder with delusions due to known physiological condition, age related osteoporosis without pathological fractures, and other co-morbidities. A review of Resident #213’s care plan record revealed: · Care plan focus: The staff have identified that I am at risk for falls because of these risk factors: muscle wasting, impaired cognition, unaware of safety needs, dementia, history of falls, hypotension. I place myself on the floor, states “prefers to be on the floor”. Date initiated 11/6/23. Goal: My risk for falls and fall related injuries will be minimized with nursing interventions daily through the next review dated. Date Initiated: 11/6/23. · Interventions revealed: o 11/6/23 initiated the following: § Anticipate residents’ needs. § Encourage and assist resident to toilet before and after meals and at bedtime. Offer urinal as indicated. § I should have sneakers, shoes, slippers with rubber soles or nonslip socks when I am out of bed. § Keep frequently used items within reach: TV remote, tissues, water glass over bed stand and my water glass (unless I need thickened liquids or can’t have anything by mouth). § Keep my call light within reach so I can call for assistance. § Offer/assist with nonskid socks as resident allows. o 11/14/23 initiated the following: Floor mats to right and left side while in bed in lowest position as resident allows. o 12/12/23 initiated the following: maintain bed in lowest position except during care. o 1/15/24 initiated the following: Remind and encourage resident to use call light. o 3/20/24 initiated the following: medication review, psychological evaluation – resolved: 6/30/25. o 5/14/24 initiated the following: encourage resident to be in common areas while OOB [out of bed] o 5/16/24 initiated the following: family education r/t [related to] not leaving resident unsupervised in the room. o 6/3/24 initiated the following: § encourage use of footrest while in wheelchair § floor mat(s) to side of bed on floor. (repeat intervention) o 6/5/24 initiated the following: wheelchair modifications as per orders. o 12/9/24 initiated the following: § bolsters on while in bed, scoop mattress § encourage rest period after breakfast o 12/10/24 initiated the following: non-slip surface to wheelchair cushion o 12/18/24 initiated the following: PT [physical therapy] evaluation and treatment prn (as needed). o 12/24/24 initiated the following: encourage resident to be OOB while restless o 1/1/25 initiated the following: assist resident with ambulating short distance during periods of restless. o 3/4/25 initiated the following: will discuss with wife the use of antiroll backs to wheelchair. resolved: 6/30/25 o 3/10/25 initiated the following: toileting before getting in bed (repeat intervention) o 3/21/25 initiated the following: Offer toileting after dinner (repeat intervention) o 4/3/25 initiated the following: Environmental review of wheelchair r/t brake function o 5/26/25 initiated the following: § encourage and assist resident to common areas when out of bed. (repeat intervention) § Therapy eval (evaluation) for balance testing r/t Parkinson’s diagnosis. Resolved: 6/30/25 o 6/30/25 initiated the following: offer and assist to bed after visits from family. (repeat intervention) Review of the progress notes revealed: · 3/03/25 at 8:53 p.m. Summary for Providers note revealed: Fall, no major injury and provider recommendations: continue to monitor neurological checks; post fall assessment with score of 95 indicated: High Risk (Score 45 and higher) no further notes were found. · 3/20/25 at 6:30 p.m. Summary for Providers note revealed: Fall no major injury; Resident was sitting in wheelchair in front of room, then suddenly stood up while holding onto wheelchair and sat back down, when prompted. Resident attempted to stand up again and slid to the floor onto the buttocks. Resident’s head did not hit the floor or met any hard surface. Resident does have a history of falling. No injuries assessed. Vital signs within normal limits. post fall assessment completed with score of 75 indicated high risk. No other documentation was found. Intervention added to care plan was a repeated intervention of offer toileting. · 3/29/25 at 9:30 a.m. Summary for Providers note revealed: Observed resident lying on back on floor near wheelchair. Resident assessed and assisted back to wheelchair. Resident is alert and awake. Laceration noted above left eye. Notifications made. Physician requested for resident be sent to the hospital for evaluation. Returned at 12:28 p.m. No change to the care plan, no notes regarding review of the care plan or note from IDT. · 4/02/25 at 6:38 p.m. Summary for Providers note revealed: resident was found on floor in room, assessed resident and obtained vitals. No complaints of pain and no injuries. fall scale completed score 75 – High Risk, neuro checks started. Care plan updated 4/3/25 to review the wheelchair for function. · 5/1/25 at 6:20 p.m. Progress note revealed: writer was called into room; resident was lying on right side in front of his wheelchair. Resident was fully dressed including shoes. RR said resident leaned forward and just rolled out of wheelchair and did not hit head. Range of motion in all extremities as before. No injuries noted. At 6:32 p.m. progress note: vitals were taken and were within normal range. Physician contacted, RR was present in room with resident during fall. Plan of care on going. 5/2/25 Progress note: Interdisciplinary Team (IDT) met and reviewed r/t fall interventions to include therapy to eval for balance testing. (resident was on therapy case load since 3/5/25). · 5/25/25 at 10:40 a.m. Summary for Providers note revealed: Fall: Provider/RR notified. 10:47 a.m. Progress note: Nurse was notified by the aid immediately that the resident fell on the floor after they were done toileting them. When nurse arrived, the resident was found on floor on the right side between the dresser and bed. Resident did not hit head per nurse aid. Resident was on right side and right wrist has a skin tear, forearm, and elbow has an abrasion. Resident complained immediately about pain on right side. Bruise on upper back on the left noted. Family came in within 30 minutes and was given report on what happened, physician notified and new orders/diagnostics ordered. · 5/27/25 at 7:54 a.m. Summary for Providers note revealed: Fall Provider/RR notified and order to monitor changes. 12:56 p.m. Progress Note revealed: IDT met 5/26/25 and reviewed fall and interventions to encourage/assist resident to common areas when out of bed. (repeated intervention) · 6/8/25 at 8:45 p.m. Summary for Providers note revealed: skin condition. Provider notified/RR present. 8:35 p.m. progress note revealed: RR informed writer resident had a wound on left heel. Writer went to resident’s room and noted left heel with blister like wound. Wound was cleansed with normal saline and topical antibiotic ointment applied and left open to air. No other skin issues were noted. · 6/28/25 at 8:10 p.m. progress note revealed: writer noted resident was on floor in dining room lying on left side, with face on floor. Resident was assessed and no injuries noted. No open wound noted. Vitals were taken. Physician notified and ordered resident to hospital for evaluation due to unwitnessed fall. RR notified. 8:30 p.m. Summary for Providers note revealed: writer found resident lying on floor in dining room. No open wound noted on resident. Vitals were taken. No complaint of pain. Resident was sent to hospital for evaluation. RR notified. Resident returned 6/29/25. · 7/1/25 at 8:19 p.m. Progress note revealed: resident seen sitting on floor in front of chair, no injuries noted, vitals within normal limits, neuro checks initiated, physician notified. 8:54 p.m. Summary for Providers note revealed: Physician notified with no new orders. · 7/2/25 at 1:29 p.m. progress note revealed: patient is status post fall, as needed pain medication administrated, patient took all meds as ordered and is performing at baseline. Area to knee cleansed and dressed as ordered, vitals are within range. Patients assisted with meals, transfers and peri-care. · 7/5/25 at 12:10 p.m. Progress note revealed: RR notified nurse of hand swelling. Writer noted left hand swelling and discoloration. Physician notified of injury by an unknown etiology and ordered x-ray series. Ice pack was given to resident. Discomfort noted on touch. Will continue to monitor. · 7/6/25 at 3:55 p.m. progress note revealed: Resident left via ambulance to hospital. · 7/9/25 at 7:07 p.m. progress note revealed: Resident returned to facility from hospital via stretcher. Review of hospital records revealed: -x-ray report dated 7/6/25 at 5:47 p.m. revealed: acute mildly displaced intra-articular fracture at the base of the thumb proximal phalanx extending into the MCP (metacarpophalangeal) joint. Resident had a left thumb fracture status post closed reduction and pinning on 7/7/25. -x-ray report dated 7/6/25 at 7:13 p.m.: subacute nondisplaced right sixth through eighth lateral rib fractures. These are single site rib fractures. During an interview on 8/28/25 at 2:22 p.m. the Minimum Data Set Coordinator (MDS-C) stated the care plan is updated the following morning during an IDT meeting. The MDS-C stated not being familiar with Resident #213 and therefore does not want to comment on the resident’s care plan. The MDS-C stated the care plan should be reviewed and updated after each fall. A note should be entered into the residents’ chart indicating this has been completed, especially if the care plan does not have any changes needed. During an interview on 8/28/25 at 2:30 p.m. the Assistant Director of Nursing (ADON) stated not being familiar with Resident #213 as being new to the facility. The ADON stated the process the nurses complete when a fall occurs is as follows: nurse is notified of the fall and ensures the safety of the resident. Complete an assessment of the resident documents and ensures proper notifications are completed. The nurse should speak with staff/resident/witnesses regarding what happened and document. Complete incident documentation and any other assessments needed, i.e Neuro checks. Then update the care plan. The following day the IDT reviews the information and discusses to ensure interventions are appropriate and document the information. During an interview on 8/28/25 at 2:46 p.m. the facility Risk Manager (RM) stated the expectations for when a resident has an incident is as follows: nurse completes the incident report to include as much information as possible. The care plan is updated at this time. The following day the IDT reviews the information and ensures the care plan is appropriate and documents this review. Sometimes, the nurse does not update the plan of care, and the IDT will need to do this. The care plan is also reviewed during a standard of care (SOC) meeting on a weekly basis. Any resident who has fallen is added to this meeting for follow up for 4 weeks. The SOC would review of the care plan, document discussion and update as needed. The RM stated being familiar with Resident #213. The RM reviewed Resident #213’s care plan and confirmed several of the interventions were repeated on different occasions and the absence of a care plan update on 7/1/25. The RM stated the root cause for Resident #213’s falls was the resident’s Parkinson’s and impulsivity. During the interview the RM stated interventions should be added after each fall to reduce the risk of further falls and reduction of potential for injury with the fall. 2) On 8/25/25 at 11:56 a.m. Resident #81 was observed lying in bed at approximately knee height. Resident #81 was groomed and clean, non verbal with interaction at this time, no movement was occurring. During an interview on 8/25/25 at 12:00 p.m. Resident #81’s alert and oriented roommate stated resident is bed bound and has not been out of bed since the fall. The facility had Resident #81’s RR take the resident’s wheelchair home. A review of Resident #81’s admission Record showed an admission date of 1/1/22 and readmissions on 3/14/25 with the following diagnosis: unspecified intracranial injury with loss of consciousness of unspecified duration, traumatic brain injury, moderate protein calorie malnutrition, spastic hemiplegia affecting right dominant side, functional quadriplegia, post traumatic seizures, vitamin d deficiency, and other co-morbidities. A review of Resident #81’s medical record from 1/1/25 to 2/16/25 did not reveal any incidents. A review of Resident #81’s nurse progress note dated 2/17/25 revealed: Writer was notified by CNA that resident had a skin issue to the left lateral leg. Writer observed yellow bruising around the resident’s knee and a blue/purple bruise to the lateral left thigh. Resident did not show any signs of pain when assessing the area. UM (Unit Manager) notified. Writer notified the physician no new orders. Writer called POA no answer. Writer left VM (Voice Mail) to callback. A review of Resident #81’s nurse progress note dated 2/18/25 revealed: resident seen for follow up related to bruising left lateral knee/thigh. yellow discoloration noted to left medial thigh/ knee and purple bruising 17.0x4.5cm to left lateral thigh. resident moves extremities without difficulty. no s/s of pain or discomfort expressed at this time. A review of Resident #81’s nurse progress note dated 2/21/25 revealed: Edema noted to resident's left lower extremity accompanied by redness, area is warm to touch. Norco administered this shift for pain. In house ARNP notified and order received for left lower extremity venous doppler. Requested for doppler. notification with no answer, message left. Will continue to monitor. A review of Resident #81’s Physician/Provider progress note dated 2/21/25 revealed: chief complaint/History Present Illness (HPI) relating to this visit: Patient is a poor historian due to cognitive/psychiatric impairment: Chief complaint/Reason for this visit: Follow up visit r/t edema and erythema to left leg. HPI Relating to this Visit: Long-term resident admitted to the facility in January of 2000 dx intracranial injury w/ (loss of consciousness) LOC. Resident seen today at the request of staff. Resident's left leg is warm to the touch and slightly edematous. Resident is largely non-verbal and unable to provide any history as to if an injury occurred. Skin intact without bruising. … Assessment and Plan: Peripheral edema: Ultrasound of left leg to rule out DVT (deep vein thrombosis)… Orders for this Visit: Ultrasound of left leg A review of Resident #81’s Physician/Provider progress note dated 2/23/25 the provider note revealed: chief complaint/HPI relating to this visit: Patient is a poor historian due to cognitive/psychiatric impairment: Chief complaint/Reason for this visit: Follow up visit r/t edema and erythema to left leg. HPI Relating to this Visit: Long-term resident admitted to the facility in January of 2000 dx intracranial injury w/LOC. Resident seen today at the request of staff. Resident's left leg is warm to the touch and slightly edematous. Resident is largely non-verbal and unable to provide any history as to if an injury occurred. Skin intact without bruising. Ordered ultrasound of left leg. Results were unremarkable. Contacted resident's POA who is aware. No acute issues at this time. … Assessment and Plan: Peripheral edema: US (ultra sound) results unremarkable Will monitor … A review of Resident #81’s nurse progress note dated 2/27/25 revealed: Weekly skin evaluation completed. Findings are as follows: Resident's color is normal. Skin is Warm / Dry. Skin Turgor is good. Edema is not present on assessment. It is noted that the resident has skin integrity concerns. The resident does not have any skin issues on bony prominences. The resident does not have any skin issues on the right buttocks. The resident does not have any skin issues on the left buttocks. The resident does not have any skin issues on the right heel. The resident does not have any skin issues on the left heel. A review of Resident #81’s progress notes dated 3/6/25 at 20:43 revealed: Skin progress note: Weekly skin evaluation completed. Findings are as follows: Resident's color is normal. Skin is Warm / Dry. Skin Turgor is good. Edema is noted as present. It is noted that the resident has skin integrity concerns. Resident has noted bruise(s). A review of Resident #81’s provider note dated 3/7/25 revealed: … chief complaint/Reason for this visit: Follow up visit r/t edema and erythema to left leg. History Present Illness (HPI) relating to this visit: Long-term resident admitted to the facility in January of 2000 dx intracranial injury w/LOC. Resident seen today at the request of staff. Resident seen previously for assessment of erythema and swelling to left leg. Ultrasound performed, result unremarkable. Resident seen again today at the request of staff. Her left knee is still edematous and tender to touch. Resident is largely non-verbal and cannot provide an accurate history of the injury. … Assessment and Plan: Peripheral edema: Ok per POA to have x-ray of left knee. Review of the hospital x-ray report dated 3/8/25 at 5:30 p.m. revealed: indication: knee swelling, outside x-ray knee partially viewed femur fracture. Findings: displaced distal third diaphyseal femur fracture. The fracture extent seems to extend into the medial femoral condyle, not well characterized. Recommend dedicated plain film views of the knee as well. The tibia and fibula appear intact. Review of the hospital emergency room physician report dated 3/8/25 revealed: eyes open and grimaces in pain only, … Left upper extremity: … limited range of motion (ROM) left shoulder, elbow, wrist, and hand; with no crepitation or deformity noted some contractures …, Right Upper Extremity: … limited ROM right shoulder, elbow, wrist and hand; with no crepitation or deformity noted some contractures, … Left Lower Extremity: … contracture of the knee bruising about the left thigh I; … right lower extremity: … limited ROM right hip, knee, ankle and foot; … Assessment/Plan: Resident #81 is a [AGE] year old female that is bed ridden with a history of traumatic brain injury nursing home resident that was noted to have a deformity about her left thigh. The left lower extremity is contracted a flexion position. X-rays are completed showed a left distal femur fracture. The family wish operative treatment stabilization of the left femur fracture. Review of the pre-operative report dated 3/10/25 revealed: Operative Indications: Patient is a [AGE] year-old female with a 30-year history of traumatic brain injury. The patient is non-ambulatory and requires maximum assistance for mobilization. Patient currently resides in a skilled nursing facility. Approximately 4 weeks ago the patient potentially fell onto her left lower extremity. The patient exhibited pain and underwent evaluation. … Attempted closed management was performed however the patient had persistent complaints of pain and the patient ultimately presented to the emergency department on March 8th, 2025. … treatment option given the patient's current state of pain and difficulty with motion of the left lower extremity, patient is indicated for surgical fixation of the left femur. … During an interview on 8/27/25 at 3:49 p.m. Staff MM, Certified Occupational Therapy Assistant (COTA) and Staff NN, Physical Therapy Assistant (PTA) both stated not being familiar with Resident #81. Staff MM, COTA stated resident was last on case load for therapy in 12/24. During an interview on 8/27/25 at 4:22 p.m. Staff OO, Certified Nursing Assistant (CNA) stated being familiar with Resident #81. Stated recalling hearing resident #81 fell out of the wheelchair but does not recall anything else regarding the incident. Staff OO, stated not actually seeing Resident #81 fall. Staff O stated not knowing Resident #81 to be restless or move around a lot. Staff OO, CNA worked on 3/6/25. During an interview on 8/28/25 at 8:10 a.m. Staff W, CNA stated not being aware of how Resident #81 was hurt, although hearing the fracture occurred during a transfer. It is very hard with all the new staff; they are unfamiliar with the residents. Staff W, CNA worked on 3/6/25. During an interview on 8/28/25 at 8:15 a.m. Staff PP, CNA stated “oh goodness, I know about the incident, I was almost blamed for it.” Staff PP continued to state, having just been reassigned to the unit Resident #81 resides and a CNA who no longer works here reported a bruise on Resident #81. The Director of Nursing (DON) at the time asked me if Resident #81 had fallen, nothing else was inquired. Staff PP stated only hearing about a fall Resident #81 had prior to arrival to the unit. Resident #81’s RR told me the orthopedic physician at the hospital told Resident #81’s RR the fracture had to occur with a fall. Staff PP stated Resident #81 does not move around in the bed. Resident #81 has not gotten out of the bed since return from the hospital. Was not on the schedule of 3/6/25. During an interview on 8/28/25 at 8:22 a.m. Staff QQ, CNA stated not recalling anything, although it is odd as Resident #81 is total care. During an interview on 8/28/25 at 8:35 a.m. Staff S, Registered Nurse (RN) stated being quite familiar with Resident #81 as being the resident’s primary nurse. Staff S, RN states not recalling anything, I don’t even recall Resident #81 hurting the leg. Staff S, RN stated Resident #81 does not move much. During an interview on 8/28/25 at 8:24 a.m. Staff U, Licensed Practical Nurse (LPN) stated Resident #81 is dependent for all care. Staff U, LPN stated not being employed at the facility for long, and Resident #81 had the fracture before Staff U, LPN started. During an interview on 8/28/25 at 8:38 a.m. Staff T, LPN stated Resident #81 is dependent for all care needs and is bed bound now and does not move much. Staff T, LPN stated not being aware of any prior incidents. During an interview on 8/28/25 at 8:40 a.m. Staff RR, CNA stated not caring for Resident #81 primarily although is familiar. States Resident #81 is totally dependent for care and had heard about the fracture and no one had spoken with Staff RR, CNA about anything, no questions at all. During an interview on 8/26/25 at 5:37 p.m. Staff SS, CNA stated being familiar with Resident #81. Staff S, CNA stated, not knowing directly what happened although did hear Resident #81 fell. On 8/27/25 at 1:26 p.m. Resident #81’s RR was left a voice mail message to return call regarding Resident #81. During an interview on 8/27/25 at 4:28 p.m. Staff TT, CNA stated being familiar with Resident #81 and has provided care for resident. Resident #81 is dependent for all care and does not move much as is contracted. Staff TT, CNA stated Resident #81 used to get up in a wheelchair but does not any longer, “odd if you were to ask me”. Staff TT, CNA states not knowing anything about what happened. During an interview on 8/28/25 at 9:29 a.m. the RM stated as the RM role April 25 and therefore is not directly familiar with Resident #81’s incident. The RM did review the facility’s file regarding Resident’s 81’s fracture. The facility had completed an investigation regarding the bruise to resident #81’s leg 2/17/25, the bruise was reported on the left lateral side of the back of the knee. The facility determined the bruise was from spastic left sided hemiplegia. No statements or other documents were available for review. The facility closed the investigation on 2/24/25. The RM stated another investigation was completed in 3/25. The RM stated Resident #81 started taking pain medication around the time the bruise was noted, then stopped them a few days later. The RM stated Resident #81 started to take pain medications again and x-rays were ordered with results the resident had a fracture. Resident #81 was sent to the hospital. The RM stated the investigation started in 3/7/25 when the fracture was reported to the facility and was a major injury. The RM stated the staff interview questions were in regards to a fall. One staff interview revealed: DON notified and stated not reportable. During an interview on 8/28/25 at 2:30 p.m. the DON stated just starting and has no knowledge of Resident #213 or #81. During an interview on 8/28/25 at 6:30 p.m. the Nursing Home Administrator (NHA) stated just starting and has no knowledge of Resident #213 or #81. A review of the facility’s policy and procedure titled Reporting Accidents and Incidents dated 8/1/2024 showed: INTENT: It is the policy of the facility to report Accidents and Incidents in accordance with State and Federal regulations. PROCEDURE: 1. The Accident and Incident Reporting System will include a comprehensive process which will allow for: a. Collection of the accident and incident occurrence b. Investigation of accidents and incidents c. Evaluation of injuries of unknown source (IUS) d. Tracking and trending of accidents and incidents 2. The Incident Report will be completed by the Nurse assigned to the resident at the time of the event. 3. The Investigation will be completed by the Nurse Manager, or designee, within 72 hours from the event. 4. The IUS Tool will be completed by the Nurse Manager, or designee, within 72 hours from the event. 5. The Director of Nursing Services, or designee, will add the investigation results into the Risk Management system. 6. The Director of Nursing Services, or designee, will track accidents and incidents on the facility surveillance log to determine patterns and trends. 7. Monthly during the facility Risk Management Quality Assurance Meeting, the results of the Accident and Incident Tracking System will be evaluated. 8. The facility will ensure that: a. The resident environment remains as free from accident hazards as is possible. b. Each resident receives adequate supervision and assistance devices to prevent accidents. … 9. The facility will provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes: a. Identifying hazard(s) and risk(s); b. Evaluating and analyzing hazard(s) and risk(s); c. Implementing interventions to reduce hazard(s) and risk(s); and d. Monitoring for effectiveness and modifying interventions when necessary. 10. The facility will identify each resident at risk for accidents and/or falls, and adequately plan care and implement procedures to prevent accidents. 11. The facility will ensure each resident receives adequate supervision and assistive devices to prevent accidents. … 13. The facility will develop and implement an accident and incident reporting system that will report adverse incidents to the Administrator, or to his or her designee. 14. The reporting system will consist of: a. Report all alleged violations and all substantiated incidents to the state agency, and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation; b. Report to the State nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service; and c. Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. d. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. … 16. The facility will conduct an internal risk management and quality assurance program to include the use of incident reports to be filed with the risk manager and facility administrator. The risk manager shall have free access to all resident records of the licensed facility. The incident reports are part of the work papers of the attorney defending the licensed facility in litigation relating to the licensed facility and are subject to discovery but are not admissible as evidence in court. 17. A person filing an incident report is not subject to civil suit by virtue of such incident report. As part of the internal risk management and quality assurance program, the incident reports shall be used to develop categories of incidents which identify problem areas. Once identified, procedures shall be adjusted to correct the problem areas. 18. The facility will, for purposes of reporting to the agency, use the t

Based on observations, interviews, and record review the facility failed to ensure food allergies and preferences were honored for four residents (#169, #71, #171, #172) out of six sampled for dietary concerns. Findings included: 1) An interview was conducted on 8/25/25 at 11:02 a.m. with Resident #169. Resident #169 stated he/she was allergic to fish and about a week ago he/she was served a fish sandwich. The resident said the tray card did not say what the meal was, and it did not look like fish. Resident #169 stated he/she took two bites of the sandwich before feeling his/her throat start to close. The resident said the nurse had to come and administer the epinephrine (epi) pen that is ordered for life threatening allergies. Resident #169 said a nurse practitioner (NP) also came in and provided care. The resident states he/she also was not supposed to have tomatoes because of a significant history of ulcers. Review of admission Records showed Resident #169 was admitted on [DATE] with diagnoses including heart failure, myasthenia gravis, presence of a cardiac pacemaker, and dependence on supplemental oxygen. Review of the facility’s Allergy Report, Resident #169’s food allergies were listed as crab, fish and seafood, peanuts, and shrimp. Review of Resident #169 admission Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, showed a brief Interview for mental (BIMS) score of 15, indicating she was cognitively intact. Review of Resident #169’s progress notes showed: 8/15/25 4:16 p.m. Nursing note by Staff EE, Registered Nurse (RN). “SN [Skilled Nurse] was informed by the CNA [Certified Nursing Assistant] that the patient was c/o [complaining of] having SOB [shortness of breath] due to eating some fish from lunch; informed the CNA that she hadn't ate fish in 20 years and that she had a allergy to fish & c/o having SOB. SN immediately went to assess to the patient. Once entering the pt room she was sitting in her chair at the bedside still alert and talking. She c/o having SOB. SN checked pt [patient] orders for Epi-Pen and gave injection - Epinephrine 0.3mg for anaphylaxis to left thigh; and applied 2L/min via NC [nasal cannula] PCP [primary care provider] & Family were notified. New order received by [NAME], APRN [Advanced Practice Registered Nurse] who also was present during the incident; to apply 02 @ 2L/min. Allergy list has been updated; SN also informed the patient to not eat anything in the future that she has a allergy to; per the son the pt stated that it didn't look like fish. Pt has been doing fine s/p [status post] bEpi injection. Staff will continue to monitor the pt.” Review of Resident #169’s physician orders showed: -Epinephrine Solution Auto-injector 0.3 mg/0.2 ml. Inject 1 application intramuscularly as needed for anaphylaxis until 9/9/25. Administration: press firmly against the outer thigh until you hear it click. Hold in the thigh for 10 seconds. Can be given through clothing. Dated 8/9/25. Review of Resident #169’s August 2025 Medication Administration Record (MAR) showed epinephrine was administered 8/15/25 at 11:28 a.m. and it was documented as effective at 12:43 p.m. An interview was conducted on 8/26/25 at 3:36 p.m. with the Director of Nursing (DON). The DON said Resident #169 had not told the facility she was allergic to fish, and they did not know. She said the resident ate the entire fish sandwich and did not have a reaction. The DON said Resident #169 only complained of itching on her arms. She said the doctor was called and the epi pen was administered “to make her feel better.” The DON said Resident #169 did not have an anaphylactic reaction and did not have to go to the hospital. Review of Resident #169’s hospital records from 8/4-8/9/25, provided by the facility, listed allergies including crab, fish, lactose, peanuts, shrimp, and tomatoes. Review of Resident #169’s Primary Care Provide note, dated 8/11/25, listed allergies included crab, fish flavor, lactose, peanut, shrimp, and tomatoes. The Primary Care Provider note, dated 8/18/25 noted Resident #169’s “only concern is that of [his/her] meal preference and allergies not being addressed by Dietary.” An observation was conducted on 8/25/25 at 12:21 p.m. of Resident #169’s lunch. The resident was observed to have stewed tomatoes on her lunch tray. An interview was conducted on 8/28/25 at 10:16 a.m. with Staff EE, RN. Staff EE said he/she was assigned Resident #169 on 8/15/25 when she had an allergic reaction. Staff EE said a CNA came down and said it appeared Resident #169 was short of breath. The nurse said the resident was having a hard time taking a good deep breath but did not have any other symptoms. Staff EE said she went to the resident’s room and the NP that was on the unit went with as well. Staff EE said the epi pen was administered to the resident quickly and the resident had relief. Staff EE said allergies are listed on the resident’s tray cards and the assumption was that the kitchen checked to make sure the residents were not served food they were allergic to. Staff EE said he/she was not aware of a process in place to check the tray for allergies on the unit. An interview was conducted on 8/28/25 at 1:57 p.m. with Staff FF, NP. Staff FF confirmed he/she was on the unit when a CNA said Resident #169 was having an allergic reaction. Staff FF said the nurse told her there was an emergency. The CNA said Resident #169 had eaten fish and was allergic to it. Staff FF said he/she entered the room with the nurse. Staff FF said the resident was having a difficult time breathing and said he/she felt like their throat was closing. Staff FF said the nurse administered the epi pen and had a second epi pen available if the resident needed it. Staff FF said the nurse was told to administer the second epi pen if the resident had any further breathing issues. 2) An observation was conducted on 8/25/25 at 4:47 p.m. of Resident #71’s dinner. The resident was observed sitting on the side of the bed. The dinner tray had been delivered to his/her room. Resident #71 was observed opening the container and inside was a whole beef steak with rice and round carrots. The tray card on the resident’s tray had “Alerts: CUT MEAT IN BITE SIZE PIECES” The resident complained the food was cold, a nurse came to the room and took the tray to heat it up, then returned the tray to the resident with the beef steak still whole. Review of admission Records showed Resident #71 was admitted on [DATE] with diagnoses including intraarticular fracture of lower end of left radius, nondisplaced fracture of left ulna styloid process, dysphagia, gastro-esophageal reflux disease (GERD) without esophagitis, mild cognitive impairment, and cognitive communication deficit. Review of Resident #71’s 7/3/25 admission MDS, Section C, Cognitive Patterns, showed a BIMS score of 15 indicating he/she was cognitively intact. Section GG, Functional Abilities, showed the resident needed partial/moderate assistance for eating. Review of Resident #71’s care plan showed a focus area of risk for alteration in nutritional status related to left radius fracture, diabetes mellitus type 2, hypertension, GERD, dysphagia, weakness, chronic kidney disease, atherosclerosis, major depression, head injury, hyperlipidemia, epilepsy, anemia, cognitive impairment, osteoporosis, elevated body mass index, obesity status. Gradual weight loss therapeutic/desired, dated 6/23/25. Interventions included serve diet as ordered, monitor intake and record every meal, and provide assistance with all meals as needed. Review of Resident #71’s Nutrition Risk Assessment, dated 6/23/25 noted chewing difficulties due to missing teeth. Interventions were “recommend mechanical altered diet.” A follow-up interview was conducted on 8/28/25 at 12:15 p.m. with Resident #71. The resident stated he/she often received food that was not cut up in small pieces. Resident #71 said he/she needs assistance due to a broken left wrist as well as difficulty swallowing. The resident said he/she occasionally had a hard time swallowing the food that was delivered from the kitchen. Resident #71 said when he/she struggles with the food she will ask staff for something else, “if they will listen.” The resident said he/she had asked multiple staff members to have the dietician come discuss his/her diet and making sure they are getting something they can eat. Resident #71 said it would be very helpful if the diet was fixed and food came up that he/she could eat. An interview was conducted on 8/28/25 at 1:32 p.m. with the Registered Dietician (RD). He said he did Resident #71’s Nutrition Risk Assessment on 6/23/25. He said he remembered the resident talking about having difficulty swallowing. He said he recommended a mechanically altered diet. The RD said he would expect the kitchen to be cutting the resident’s food into small bites if that is the instructions on her tray card. He said if a resident had swallowing issues, he would often request a speech therapy evaluation, but he does not recall if he did for Resident #71. The RD followed up on 8/28/25 at 3:34 p.m. and said he reviewed the resident’s record and said his/her meat was to be cut up in small pieces due to her missing some teeth and having difficulties cutting with a broken wrist. An interview was conducted on 8/28/25 at 1:53 p.m. with Staff HH, Physical Therapy Assistant (PTA). Staff HH reviewed Resident #71’s therapy records and said he did not see any record of the resident being seen for speech therapy. A follow-up interview was conducted on 8/28/25 at 2:35 p.m. with the DON. The DON said no education was completed or processes changed related to meal service and allergies after the incident on 8/15/25 with Resident #169 because the facility didn’t know she had a fish allergy. The DON said, “We don’t know not to give them something if they don’t tell us they have an allergy.” When the DON was told Resident’s hospital records and provider notes both showed the resident’s fish allergy she stated “I don’t read his notes. There are 200 residents here.” The DON reviewed Resident #169’s medication record and confirmed both the hospital record and provider note was in Resident #169’s medical record at the facility prior to the incident on 8/15/25. The DON said she would expect the facility to know the resident had a fish allergy if it was in the medical record. The DON also said she would expect the kitchen staff to know what is in the food that is served. Regarding Resident # 71 the DON reviewed the photo of the meal when the resident was served a full piece of meat and said she would expect the food to be served right. 3) On 8/25/25 at 10:12 a.m., an observation of Resident #171 revealed she was laying down in bed. She said she wanted choices with meals. She said she received chicken on most days of the week. She said she does not get the option of choosing a substitute for the main meal. Resident #171 stated she has told staff and, “Nothing happens.” She said she’d like a hot dog or hamburger. She confirmed that staff have talked to her about her food preferences and dislikes. On 8/25/25 at 12:05 p.m., an observation of Resident #171’s lunch meal was conducted. The resident said she received gravy when her meal ticket indicated a dislike of gravy. She opened the Styrofoam to-go-box which had mashed potato and gravy on top. Further observations of the tray revealed a meal ticket which had gravy under dislikes. Resident #171 gave permission to take photo evidence of her meal and meal ticket. On 8/27/25 at 12:09 p.m., an observation of Resident #171 revealed she was sitting up in bed with the bedside table in front of her. Resident #171 said she was supposed to get a chef salad today and it’s on her meal ticket. She said she told the CNA about ten minutes ago but had not received the salad yet. An observation of Resident #171’s meal ticket revealed the following, “Standing Orders: … 3oz[ounce]/2c[cup] Chef Salad (Mo, We, Fr) [Monday, Wednesday, Friday] …” Resident #171 opened the Styrofoam to-go-box to reveal it was not a salad. She gave permission to take photo evidence of her meal and meal ticket. A review of Resident #171’s admission record revealed an admission date of 3/5/24. Further review of the admission record revealed diagnoses to include type 2 diabetes mellitus with unspecified complications, morbid (severe) obesity due to excess calories, and atherosclerotic heart disease of native coronary artery without angina pectoris. A review of Resident #171’s quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, cognitively intact. A review of Resident #171 orders revealed, dietary consult to discuss food preferences as needed for pt [patient] request dietary consult,” with an order date of 5/21/25. A review of Resident #171’s progress notes and forms/assessments, after 5/21/25, revealed no documentation of a nutrition or dietary consultation regarding the resident’s food preferences. 4) On 8/27/25 at 12:11 p.m., an observation of Resident #172 revealed he was laying down in bed with a meal tray on the bedside table next to him. He said he received gravy today and it was on his dislikes. He said this has happened before and he had told staff about it. Resident #172 said he does not eat gravy because it bothered his stomach. Resident #172 gave permission to take photo evidence of his meal and meal ticket. A review of Resident #172’s admission record revealed an original admission date of 6/7/24 and re-admission date of 5/23/25. Further review of the admission record revealed diagnoses to include atherosclerotic heart disease of native coronary artery without angina pectoris, morbid (severe) obesity due to excess calories, diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding, and hyperlipidemia. A review of Resident #172’s comprehensive MDS, dated [DATE], revealed a BIMS score of 15, cognitively intact. A review of Resident #172’s meal ticket revealed the following under dislikes, “Gravy, Sausage, Beans (Pinto Beans), Greens (Turnip).” On 8/26/25 at 5:17 p.m., an interview was conducted with the Certified Dietary Manager (CDM). He said the residents’ likes and dislikes are on their meal ticket. The CDM said there is no other form used such as a preference sheet. He confirmed the food committee meets once a month. He said he had three months of food committee minutes. The CDM said he gave them to the previous administrator and doesn’t know if the facility has record of them. A review of food committee minutes revealed the following: - 3/4/25, “… 7) We are still getting tickets wrong. Need to make sure that we check them better …” - 4/1/25, “… 7) We are still getting tickets wrong. Need to make sure that we check them better …” - 6/10/25, “ … 1) Reviewed the minutes from April 1th [first] Meeting. The residents talked about the issues that still are happening … 7) We are still getting tickets wrong. Need to make sure that we check them better. Did inservice with tickets again … “ - 7/1/25, “… 1) Reviewed the minutes from June 10th Meeting. The residents talked about the issues that still are happening. … 7) We are still getting tickets wrong. Need to make sure that we check them better. Did inservice with tickets again …” - 8/5/25, “… 7) We are still getting tickets wrong. Need to make sure that we check them better. Did inservice with tickets again. … ” A review of an in-service, provided by the CDM, that was conducted on 7/1/25 revealed it was regarding ticket and tray accuracy with notes to include the following: “Allergies: … Always double check trays for potential allergy foods! … Dislikes: … Be sure preferences are always followed! … Before sending the tray: 1. Right Diet? 2. Right Liquids? 3. Allergies reviewed and compared? 4. Food preferences reviewed and compared? Remember: if a resident receives a wrong diet, or something that’s an allergy, it could be their last meal. Do you want to be responsible for that mistake?” On 8/28/25 at 1:30 p.m., a follow-up interview was conducted with the CDM. He confirmed there are specific concerns that are repetitive every month in the food committee meetings. He said he tried to honor the residents’ requests of food choices. The CDM said if a resident doesn’t want the main entrée, there is an always available menu, and the resident has to tell the CNA. He stated if a resident has a certain preference and/or dislikes, he will resolve it, “If he gets the message.” He confirmed he is aware of meal ticket accuracy concerns and has conducted audits. The CDM said the last meal ticket and tray accuracy audit was conducted about four months ago. He discussed the recent incident with Resident #169. He said her meal ticket previously had shellfish and crab as an allergen. The CDM said Resident #169’s meal ticket now has fish listed as an allergen, but it previously did not. The CDM said he looked at the ingredients after the incident and found out the fish sandwich that was provided had [NAME], salmon, [NAME], [NAME], squid, and New Jersey bluefish. He said he did not know squid was considered shellfish, and thought the meal had no shellfish. The CDM said he was the one serving during that meal and recalled the dietary aid calling out the food and allergen. He said he found out the next day Resident #169 had an allergic reaction that required the use of an EpiPen. The CDM confirmed he has spoken to the resident before and after the incident. He said Resident #169 has a long list of dislikes, but he is waiting on her family member to provide that information. He confirmed the resident should not have been provided that meal because of the shellfish allergy. The CDM said he has provided in-services and re-education to staff. He said he has the staff on the tray line read the meal ticket back to him and tries to position staff in a way that the end person catches any discrepancies. He said the main issues with meal tray accuracy are residents not receiving condiments or salad dressing but no salad. The CDM said he brings up those issues to the staff member who checks the meal tickets and tray items. He said he thinks the dietary staff are making mistakes or not paying attention when on the tray line. He said he needed to do another ticket audit to make sure the residents are getting items they want and are not getting their disliked food items. A review of the facility’s policy titled, “Tray Identification,” dated 6/2025, revealed the following under policy interpretation and implementation, “…2. The Food Services Manager or designee will check trays for correct diets before the food carts or meal trays are transported to their designated areas. 3. Nursing staff shall check each food tray for the correct diet before serving the residents. 4. If there is an error, Nursing will notify the Dietary Department immediately so that the appropriate food tray can be served.” A review of the facility’s policy titled, “Food and Nutrition Services,” dated 10/2017, revealed the following, “Each resident Is provided with a nourishing, palatable, well- balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.” Further review of the policy, under policy interpretation and implementation, revealed the following, “…4. Reasonable efforts will be made to accommodate resident choices and preferences. … 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the Food Service Manager so that a new food tray can be issued. …” A review of the facility’s policy titled, “Food Allergies and Intolerances,” dated 8/2017, revealed the following, “Residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen(s).” Further review of the policy, under assessments and interventions, revealed the following, “1. Residents are assessed for a history of food allergies and intolerances upon admission and as part of the comprehensive assessment. 2. All resident reported food allergies and intolerances are documented in the assessment notes and incorporated into the resident’s care plan. … 5. Residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat. …” A review of the facility’s policy titled, “Resident Food Preferences,” dated 7/2017, revealed the following, “Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident’s or representative’s consent.” Further review of the policy, under policy interpretation and implementation, revealed the following, “1. Upon the resident’s admission (or within twenty-four (24) hours after his/her admission) the Dietitian or nursing staff will identify a resident’s food preferences. 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3. Nursing staff will document the resident’s food and eating preferences in the care plan. …”

Based on interview and record review the facility failed to maintain a Governing Body that was aware of the facility emergency plans. The Governing body was not aware the facility did not update their emergency plan as changes occurred. The facility failed to address the needs of their patient population during an emergency and failed to provide for continuity of operations during a natural disaster, a hurricane. The facility maintained an evacuation agreement with a local church that began in 2018. In February 2024 the church informed the facility that the agreement was to be terminated effective May 31, 2024. No alternative evacuation location was arranged. In September of 2024 when evacuation was ordered for hurricane [NAME] the facility staff moved 226 residents to a local church. Family members of the residents called the police and emergency medical services to report conditions. Local Police, Fire and Emergency officials assessed the location and deemed it unsafe. The residents were on small cots placed right next to each, staff did not have enough room to care for the residents, the resident care was not organized, supplies were not available, there was not enough room for every resident to be indoors, important supplies were housed outside with rain predicted and the residents were not safe in terms of fire exits and supervision. The local authorities moved all the residents to a county shelter the night before hurricane [NAME]. The conditions during hurricane [NAME] led to the injury of 2 residents (#12, #22) known to have suffered harm, including a fracture for one resident as a result of lack of supplies and lack of supervision during that evacuation that lasted from 9/25/2024 to 9/28/2024. Before hurricane [NAME] the facility Nursing Home Administrator (NHA) began calling Local County Emergency Operation Center (CEOC), and State officials asking for an evacuation location or to be allowed to not evacuate. Again, the facility did not have a plan for the safety and care of its residents. A volunteer at the CEOC working with the Emergency Operations leadership assisted the NHA by determining that the most acutely ill residents could be moved to a local Nursing Home. The NHA moved all the remaining 217 residents to a church in a nearby county. The CEOC acknowledged awareness of his plan and said they were unable to approve evacuation plans at the last minute. Upon review after the storm, the County Emergency Management did not approve of this location due to it being in an evacuation zone and unsuitable if evacuations were ordered for a hurricane. The facility remains without a safe evacuation location. These failures created a situation that resulted in a worsened condition for two residents (#12, #22) and the likelihood for serious injury and or death to all facility Residents and resulted in the determination of Immediate Jeopardy on 09/24/2024. The findings of Immediate Jeopardy are ongoing and have not been removed, the severity and scope remains an L as there has been no verification of removal of immediacy of harm. Findings included: Review of the Facility assessment dated [DATE] and signed by the NHA, DON, Governing Body Representative, Medical Director and Infection Control Prevention Officer revealed, on page 24, Section IV Facility and Community-Based Risk Assessment, B. Emergency Management, Please note: In lieu of completing this section, your facility can include a copy of its required Emergency Preparedness Plan. 1. See CEMP book for further information. CEMP Binder is located in Administrator's Office. Review of the approved facility disaster plan dated February 2024, provided by the local Emergency Management office showed multiple sections such as Facility Basic information, Incident Command Structure. It included Policies and Procedures on a Food Plan, Water Plan, Emergency Power Plan, Medical Supplies, Medical Records, Sewage, Transportation and Rationale for disaster plan. It contained a Hazard Analysis, Elevation certificate, Evacuation Plan and Essential Business Functions, Disaster Chain of Command, a Floor Plan of the facility, Emergency meal plan, menus, a food a water list needed, Evacuation Time Table, Information, Training and Exercises, Emergency Preparedness Communication Plan, management and staff contact numbers. It contained the Sheltering License Agreement with (Evacuation Location #1) and Mutual Aid Agreements with two local nursing homes. It contained agreements with a Food distributor, commercial buses, wheelchair transport, a rental truck company, Review of the approved facility disaster plan dated February 2024, provided by the local Emergency Management office included a Sheltering License Agreement effective June 1, 2018, with the [NAME] of a local church (Evacuation Location #1). The church agreed to make certain areas available to the Nursing Home in the event of a hurricane evacuation order. A Shelter Agreement Clarification page was included that showed the Church (Evacuation Location #1) would be able to accommodate 379 Residents from the facility for the year 2023, signed by the NHA at the time and the [NAME] of the church on 5/3/2023. Mutual Aid Agreements were included with two nearby nursing homes. Both Mutual Aid Agreements specified that the receiving facility could only take 60 residents from an outside source and the number would depend on current in-house census and both facilities understand that a local in-house emergency, and or emergency that affected all facilities in the [NAME] Bay Area, would render a variance in available space. The Mutual Aide Agreements were signed by each facility and the current NHA in February of 2024. Review of a letter dated 2/16/2024, written to the administrator of the facility and signed by the [NAME] of a local church (Evacuation Location #1) showed the church was terminating the agreement to be the evacuation location for the facility effective May 31,2024. The termination was due to the facility not following agreed upon safety and cleanliness procedures during the past evacuations, and other problems described in the letter. An interview was conducted with a member of the Governing Body on 11/6/2024 at 1:55 p.m. She said she has been working for Aventura for 2 years and on the Governing Body of Aventura for a year and 1/2. She said that the Administrator reports regularly to the Governing Body through regularly scheduled meetings, emails, and impromptu meetings. She said there is a constant flow of information. She said that problems are communicated with the Governing Body, resource needs, system breakdowns. She said that the Governing Body responds to the Administrator with phone calls, Zoom calls, in person visits and sometimes QAPI programs are started. She said that the Administrator is held accountable by reports that are sent, Risk management meetings weekly, and the Administration is supervised through the Electronic medical record. She said she was not aware until recently that the facility did not have an approved Evacuation Location. An Emergency Management Planning document was provided to the surveyors on 10/24/2024 by the NHA and described by him as the plan followed for hurricane [NAME]. The document showed the facility was licensed to house 274 residents including a secure dementia unit of up to 70 residents. The facility is in hurricane evacuation Zone A (most vulnerable zone and is usually the first to be evacuated), the elevation was 9 feet 4 inches above sea level and will be evacuated to an offsite location as directed by the Local County Emergency Management. Review of the document showed Evacuation Location #1 crossed out and replaced by a different church located in a nearby city (Evacuation Location #2). Evacuation location #2 was dated to be effective 7/1/2024. On multiple pages of the Emergency Management Planning Document Evacuation Location #1 was still listed. No documentation was provided for the approval of Evacuation Location #2 by the local Emergency Management Office. Review of an email communication from the Emergency Management Health Care Plan Compliance Specialist showed the last review and approval of an Emergency Plan for the facility on 10/3/2023. Review of a letter from the local County Emergency Management office dated 10/3/2023 signed by the Healthcare Plan Compliance Specialist showed, To the current Administrator, We are pleased to inform you that your electronic Comprehensive Emergency Management Plan (CEMP) was reviewed. You will receive the CEMP Approval Certificate upon payment. The facility was instructed to submit their plan for the March 2024 to February 2025 time frame by January 2, 2024. Review of the local County Emergency Operations Center evacuation orders for hurricane [NAME] showed, September 24, 2024, Attn: Facility Administration: Level An Evacuation order for Residential Health Care Facilities, [local] County has issued an evacuation order for all Level A facilities. The anticipated impacts of the storm include: -Storm Surge of 5 to 8 ft is possible along areas of [local] County; however, this is highly dependent on where the storm makes landfall. -Strong tropical storm force winds are forecast for [local] County starting 10 am on Thursday. -Heavy rainfall of up to 6 inches is forecast for [local] County. -Isolated to scattered tornadoes will be possible, especially in the outer rainbands of the storm. -Hazardous surf and rip currents are expected to continue until the storm passes If you are included in the evacuation level A you should complete your evacuation and be in your safe location by Thursday at 7am. The [local] County Emergency Operations Center (EOC) will be calling to ensure that you are evacuating as planned and as called for in the Comprehensive Emergency Management Plan (CEMP) for your facility. If you are not included in the evacuation level, but choose to evacuate anyway, please ensure that you inform the Emergency Operations Center of your plans and sheltering location. We will continue to monitor the system. Please monitor your emails for any further protective measures. The contact information for the [local] County Emergency Operations Center is: The Health and Human Services EOC Desk [PHONE NUMBER] or [PHONE NUMBER] Sincerely, [local]County Emergency Operations Center. The facility evacuated to Evacuation Location #2, a church in a nearby city on 9/25/2024, an unapproved location. Review of a [local] Police Department Incident report dated 9/25/2024 showed they were called at 7:40 pm, and arrived at 7:42 pm at the Evacuation Location #2. This report is to document the conditions at [evacuation location #2], during the preparation for tropical storm [NAME]. On 9/25/2024 two officers did an area check . there were 4 different rooms that people were placed in. Each room was over-packed with cots half the size of a person pushed together leaving no space for a person to move around or get up in most areas. Each room was hotter than outside inside the building, leaving many people uncomfortable. The majority of the people were barely dressed due to the conditions of the room. A lot of people were placed in adult diapers. There was only 1 fan observed running which was a small ceiling fan in the primary chapel. The primary chapel had more than 80 people in it, the memory care had more than 50 people in it, and the two other rooms had more than 30 people in each room. Multiple wheelchairs were left outside with no cover for the storm to come. Multiple medical and survival supplies were also left outside with no cover for the storm to come. While these rooms were already packed full there were more than 20 people outside standing and in wheelchairs waiting to be placed in a room. This information was forwarded up the chain of command. Review of an e-mail communication from the Deputy Director of Safety and Emergency Services for local County Government written on 9/26/2024 at 3:00 am to 5 [local] County staff members regarding the facility's residents at Evacuation Location #2 revealed: Good morning, [facility name], is a skilled nursing facility located in zone A and were required to evacuate 250 residents. They evacuated to [Evacuation Location #2] in [city name]. We were advised that the SNF [skilled nursing facility] had all of the medical support needed for its patients, but the facility lacked a few resources. We received a request to assist them with a generator at the church and a safety concern was raised because the church did not have fire suppression, so [local] FD [fire department] responded and put them on fire watch. More calls came in concerned about the safety of the patients due to a lack of generator for refrigerated medicine, heating ventilation and air conditioning (HVAC) so County Officials, [the local County EMS Medical Director and the EMS and FIRE Administrator for local County] responded to the church. Upon arrival and conversations between [Local city] FD, [local county] PD [police department], [the local County EMS Medical Director] and [the EMS and FIRE Administrator for local County], it was decided that the facility was not safe for the residents. Initially, it was decided that the patients would be moved to an Academy due to the nearby location. After multiple conversations with the school district and due to a lack of a generator at [the academy] was decided that the patients should be moved to [a local middle school] which is further away but is a special needs shelter and has a generator back up for those patients dependent on electricity. [County Busses] helped move the 50 patients that could walk and provided transport for wheelchairs. Multiple trucks with liftgates from [commercial ambulance service] helped transport equipment and the [commercial ambulance service] and the Fire Departments transported the rest of the patients to the shelter. An interview was conducted with the local County EMS Medical Director, 10/31/23024 at 1:30 p.m. He said concerns about the facility (Evacuation Location #2) came about as follows: 1) Concerns were raised to the Emergency Operations Center (EOC) by a Fire Department officer that had run a 911 call to the facility and reported concerns about conditions. 2) A request for assistance was made for power for the refrigerator. [The local County EMS Medical Director], went with a group to evaluate the situation, and he said that on 09/25/2024 ahead of [NAME]: 1)Medications and computers were being stored outside in a courtyard area. 2) Residents were on cots, shoulder to shoulder and head to foot, there was no access to residents, the square footage available was woefully short. 3) Security concerns were identified for the memory care residents in a hall room with little to no safeguards. 4) Means of egress was not clear of all obstructions. 5) They had a handful of portable generators that looked like they were picked up at (a home improvement store) that day. 6) Several residents were on Oxygen concentrators and would have posed a significant problem in the event of power loss. [The local County EMS Medical Director] stated that a consensus meeting was held between himself, [local city] Police, and [local city] Fire and they were all on the same page that the facility was inadequate to care for so many residents. Together the group decided that the most appropriate course of action was to relocate the residents to a more suitable location. An interview was conducted with Staff Member Q, Certified Nursing Assistant (CNA) on 10/28/2024 at 11:38 a.m. She said she has worked for the facility since 2022. She said the hurricane staffing and patient care were a big mess. The administration has no idea what they are doing. For hurricane [NAME] it was an absolute nightmare, She was scheduled to work 11-7 a.m. and they were told to meet at the church at 11 pm, not even come in early, crazy. She said, The residents were packed into this church with no linen, you could not walk between cots. It was so hot even with the portable units, there was no air flow. We were short staffed, there were no fluid passes, you could not get to the residents, they were covered with towels, there were not enough linens. There were no assignments, everyone was everywhere, except with residents. Residents were not provided supplies; you could not get to the supplies. Then we evacuated to the school, even though we were at the school still there was confusion, no direction given on who to take care of, we were left to guess, which means no one accepts responsibility. I stayed in the cafeteria from 7am to 7 pm. I did hear that someone fell in the gym, but I did not see it. An interview was conducted on 10/21/24 at 3:11 p.m. with Resident #15. She said during the hurricane [NAME] evacuation the residents were taken to a church big enough for 100 people but there were 250 people there. Resident #15 said she didn't do well in tight spaces and was a little claustrophobic. She said, It was so bad. I called my grandson and told him to get me the [explicative] out of here. Resident #15 said she was not happy because she was put on a cot and her wheelchair was taken away. She said she was independent and used the bathroom herself. She said she was left on her cot for hours without being able to get up. Resident #15 said staff told her to just go in her pants and they wound just change me. Resident #15 said the evacuations were horrible. An interview was conducted on 10/24/24 at 2:15 p.m. with the Staff Member II, Occupational Therapist (OT) who stated there were safety concerns. I tried to give my opinion, but no one wanted to hear me. The evacuations were Very disorganized. Therapy knew their responsibility of transferring residents on to the buses and off only. The facility had Charter buses for the evacuations for the first (storm). If residents were able to sit upright in a wheelchair, we were able to sit them in the bus seat. We had to physically lift the residents into the bus. To my knowledge the wheelchairs did not go to the evacuation site unless the resident had to travel in the chair. Those residents were evacuated by wheelchair transporters. An interview was conducted on 10/24/24 at 2:35 p.m. with Staff Member JJ, Physical Therapist (PT) who stated the evacuations were confusing regarding transport. He found out no transport had been set up for return after hurricane [NAME]. The facility was only utilizing the buses they owned for transport, this took forever. Resident #23 received a skin tear during one of the transfers. A nurse came to evaluate the wound right away, but they were not able to find a first aid kit for supplies to cover the skin tear. Thirty minutes went by, and someone finally drove over with supplies, to cover the skin tear. An interview was conducted on 10/24/24 at 2:47 p.m. with Staff Member KK, CNA who stated regarding the evacuations, No one knew what was up with any of the evacuations, chaos. I'm sure that is why I don't remember anything specific except chaos. An interview was conducted on 10/24/2024 at 4:37 p.m. with former Staff Member M, CNA. She said, The evacuation for [NAME] to the church was unorganized, the Therapy department completed the transferring charter. At the church everyone was being put on a cot, no elevated head, just a sheet, maybe a pillow I don't think enough for everyone. There was not enough room for everyone, you could hardly squeeze between cots, residents were outside in the rain as there was no room in the church. Families started to come there complaining, I don't remember who. The bathroom hallway had cots as there was no room. No one was told anything, we did not know who we were to care for, except follow normal schedules, be at work at 7 a.m. at the nursing home, then we went to the church at 3:30 p.m. It started to get dark; it started raining. I'm not sure if everyone got to eat, there was no organization, everyone received the same diet, we were not sure who was who, it was a total mess. We could not pass fluids because we couldn't get to residents, we had to walk sideways between cots. They stuck some residents in a closet, at least they left the doors open for them, but it was hot, even with the spot cooler. There were residents who had been bed bound for years and now they were on these cots with only a sheet. I was instructed to go assist alert residents. All the officials came, and we had to move again, at least that evacuation had organization somewhat. You could tell the officials were frustrated. When we got to the school (Evacuation Location #3) the meals were the same, no one had their diets indicated but it was better than the church as the school was giving out meals. Then they told us not to give the school meals, we were only supposed to use our supply. Well, who knew where that was? The only fluids were given with a meal, if you received meal. I don't think they had a way to know who got what or if everyone got to eat. I didn't see anyone helping anyone eat. I was assigned the alert residents, so they only needed to be served. There were no assignments [NAME] except B wing (the memory care wing) was in gym, but I am not sure who was in the gym with them. I saw a Resident outside on the sidewalk exiting to the street. I brought her back in, I am not sure who it was, but she got out. Review of CEOC evacuation orders for hurricane [NAME] showed, October 6, 2024, Attn: Facility Administration: Level A-C Evacuation order for Residential Health Care Facilities, (local) County has issued an evacuation order for all Level A, B and C facilities. The anticipated impacts of the storm include: Storm Surge over 10 ft. is possible along areas of (local) County, however this is highly dependent on where the storm makes landfall. Life-threatening storm surge flooding will be possible across coastal areas of (local) County on Wednesday (10/09).Heavy rain of 5 to 8 inches, with isolated higher amounts of up to 12 inches is forecast through Thursday (10/10).Tropical storm force winds are forecast to start in the early morning hours of Wednesday (10/09)and continue through late Wednesday night (10/09). The wind field is expected to expand. There is the potential for some tornadoes and /or waterspouts on Thursday (10/10). If you are included in the evacuation level A, B or C you should complete your evacuation and be in your safe location by Tuesday 8pm. The (local) County Emergency Operations Center (EOC) will be calling to ensure that you are evacuating as planned and as called for in the Comprehensive Emergency Management Plan (CEMP) for your facility. If you are not included in the evacuation level, but choose to evacuate anyway, please ensure that you inform the Emergency Operations Center of your plans and sheltering location. We will continue to monitor the system. Please monitor your emails for any further protective measures. The contact information for the (local) County Emergency Operations Center is: The Health and Human Services EOC Desk [PHONE NUMBER] or [PHONE NUMBER] An interview was conducted by phone with the Director of the Department of Health in (local) County on 10/31/23024 at 4:00 p.m. He stated that requests for assistance in finding a place to evacuate to were being made by the facility as [NAME] was approaching. The facility ultimately evacuated to the church in (local city), Evacuation Location #2. He said the EOC received a Fire Officers concerns about conditions following a 911 call they responded to (at Evacuation Location #2). He said an additional request for assistance with powering refrigeration equipment at the location was received. He said the EOC dispatched the Medical Director for the (local) County EMS, (local) Police, and (local) Fire Departments to assess and evaluate conditions at (Evacuation location #2). He said the EOC received a report that available square footage was inadequate for the number of residents present, creating security concerns for the police, and egress concerns due to crowding for the fire representative. The (local) County allowed them to relocate to a Middle School, (Evacuation Location #3) where they were operating a special needs shelter. The Director of the Department of Health in (local) County noted that while actions were taken because of need, (local) County evacuee numbers were expected to be in the thousands (for Hurricane [NAME]) and their system is not designed to support long term care facility residents. The Director of the Department of Health in (local) County acknowledged that it was a short turnaround between [NAME] and when the evacuation for [NAME] was ordered. The facility did request the use of the special needs shelter again. The (local county) was expecting large numbers of evacuees, has multiple long term care facilities, and planning for evacuations is the responsibility of the facility. The Director of the Department of Health in (local) County said that, while unfortunate, it does not change the responsibility of the facility to develop arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. Review of an e-mail communication from the County Emergency Operations Center written on 10/06/2024 at 7:54 pm to 5 (local) County staff members regarding the facility revealed: As The Director of [the] Department of Health in (local) County knows, [name] the NHA of this building had a [Emergency Plan] approved with receiving facility that unfortunately failed meaning the receiving facilities backed out thus they did not have placement for this larger facility. The plan in motion is 23 residents with higher acuity to [Local Nursing Home] and the rest to go with the Administrator, Director of Nurses (DON) and staff to (Evacuation Location #4) that is 10 K SQT, high and not in an evac zone, has a kitchen, etc. The facility would bring a generator, 12 portable AC units and 4 wet vacs in case needed in addition to food, fluids, medications, treatments, mattresses, etc. We did have a conversation with [name] the Administrator explaining that the CEOC [(local) County Emergency Operations Center] cannot review or approve a new or temporary plan at this point other than verbally as done. In doing so we explained that it is his decision what is best for the residents and staff of his facility and that the CEOC acknowledges this new plan, but it is not approved. [NHA] did verbalize his understanding. Signed by a volunteer at the (CEOC). An interview was conducted with the Emergency Management Healthcare Plan Compliance Specialist with the (local) County Emergency Management office on 10/31/2024 at 10:30 a.m. She stated that the facility did not submit an alternative location for approval prior to the hurricanes. The facility did not ask for approval for either Evacuation Location #2 or Evacuation Location #4. She reviewed the location information for Evacuation Location #4 and said that it would not be approved as an evacuation site because it is in Flood Zone D. She said only facilities in no flood zone areas can be used as evacuation locations. Resident #12 Review of Resident #12's progress notes, dated 9/26/2024 at 3:44 p.m., authored by Staff AA, Registered Nurse (RN) showed: Pt [patient] found on the floor at evacuation site. VSS [Vital Signs Stable]. EMS [Emergency Medical Services] on site. Pt sent to hospital. Family called. Message left. Review of Resident #12's hospital records, dated 9/26/24, showed admission to the Emergency Department [AGE] year-old female presenting with left lateral superior orbital rim fracture (a break in the thick bone on the outer edge of the eye socket, on the left side, and in the upper part) minimally displaced and left humerus (long bone of the arm) fracture with need of surgical intervention status post ground level fall. Review of Resident #12's hospital records, from her admission on 9/26/24, showed She suffered a fall after her skilled nursing facility was forced to evacuate. The patient reportedly struck her head on the wall and also complained of pain in her arm. The assessment showed the resident had a left humerus fracture with surgical intervention and orbital wall fracture. Review of Admission Records showed Resident #12 was admitted on [DATE] with diagnoses including hypertension, weakness, dementia, Huntington's disease, and other co-morbidities. Review of Resident #12's Admission Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 8, indicated the resident had moderate cognitive impairment, Section J, Health Conditions showed no pain and no falls. Review of Resident #12's Physical Therapy Discharge Summary, dated 9/5/24, showed: Resident #12 was able to perform sitting to standing with the use of an assistive device; was able to transfer with supervision only, and was able to walk 150 feet with a front wheeled walker with contact guard assistance. Review of Resident #12 Comprehensive Care Plan, dated 7/19/24, showed: Focus: The staff have identified that I am at risk for falls because of these risk factors: Dementia, use of anti-psychotic medication, use of antidepressant medication. The care plan interventions showed: Anticipate resident's needs; I should have sneakers, shoes, slippers with rubber soles or non-slip socks when I am out of bed; Keep frequently used items within reach: TV remote, tissues, water glass over bed stand and my water glass (unless I need thickened liquids or can't have anything by mouth); Keep my call light within reach so I can call for assistance; Maintain bed in lowest locked position. An interview was conducted on 10/24/24 at 11:50 a.m. with Staff V, CNA. Staff V stated, During the evacuation things happened. Yes, there was a fall. I was in the gym where [Resident #12] was assigned. The management did not leave out assignments for CNAs, so I am not sure who was responsible for [Resident #12]. Staff V said, I was in a doorway and heard a loud thud. I turned and noted [Resident #12] on the floor, it looked bad, no one was near. Staff V stated there was no walker and most of the residents came without their walkers or wheelchairs, etc. She said those items were not brought with them for the evacuation. Staff V, said the DON did finally come over to Resident #12, after another nurse had already been providing care. Staff V stated, The DON was not in the gym when Resident #12 fell . Staff V stated she did not remember who else was in the gym. An interview was conducted on 10/24/24 at 2:08 p.m. with Staff AA, Registered Nurse (RN). Staff AA stated, I did not see [Resident #12] fall, no one did. I heard a noise, and she was on the floor when I looked. I believe [Resident #12] was heading toward a door. A follow-up interview was conducted on 10/24/24 at 1:17 p.m. with the DON and AIT. The DON stated, Oh, I forgot to mention that fall earlier. I saw her fall in the gym. I was standing and talking to [Resident #12], who had rubber/foam slip on shoe with holes on the top and [Resident #12] turned around fell and hit the door frame before I could reach my hand out to catch [Resident #12]. The nurse [Staff AA] assisted her. Resident #22 Review of Resident #22's Admission Records showed he was admitted on [DATE] with diagnoses including sepsis, unspecified protein-calorie malnutrition, chronic pain, other specified local infections of the skin and subcutaneous tissue and acquired absence of the right and left leg above the knee. He was readmitted on [DATE] with the additional diagnoses of osteomyelitis, arthritis due to other bacteria unspecified joint, and unspecified open wound, left hip, subsequent encounter. Review of Resident #22's Treatment Administration Record (TAR), from 9/1/24 to 9/20/24, revealed the resident did not receive his wound care treatment on 9/27/24, while at the hurricane evacuation site. Wound care was also missed on 9/4/24 and 9/11/24 with no documentation as to why. Review of Resident #22's progress note, dated 9/27/2 [TRUNCATED]

Based on observations, interviews, and record review, the facility failed to ensure sufficient nursing staff, with the appropriate competencies and skill sets, provided nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident on four out of four resident units in the facility. This failure resulted in a fracture of unknown origin, falls with major injury, lack of wound care according to physician orders, lack of medication administration according to physician orders, missed laboratory orders, lack of follow-up for critical diagnostic results, and Activities of Daily Living (ADL) care not being provided to residents per care plans. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Residents #3, #8, #12, #9, #19, #21, #22, #20, #1, #13, #15, #16, #18, #7, #17, #24, #25 #14, and #10 and resulted in the determination of Immediate Jeopardy on 6/22/24. The findings of Immediate Jeopardy were determined to be removed on 10/28/04 and the severity and scope was reduced to a F. Findings included: Cross reference F600 An observation was conducted on 10/21/24 at 10:11 a.m. of Resident #19 in bed with the head of the bed elevated. He had a bandage on his right anterior forearm. The bandage was approximately 6 by 4 and clearly visible. The bandage had a faded date of 10/8/24 written on it. The same bandage remained in place on 10/22/24 and 10/23/24. An observation and interview was conducted on 10/21/24 at 10:47 a.m. with Resident #21. The resident was observed to have two bandages on his left leg, one on his knee and one on his foot. The bandage on the left knee had slid down his leg leaving the open wound exposed. The resident was also observed to have a bandage on his right knee and no bandage on his right foot. The bandage on the right knee was observed to have blood soaked through the underside. The right foot had an open wound on his 2nd toe and on his heel. None of the bandages in place had a date notated. Resident #21 said, I'm very upset. This is why I have come here. He said he was really worried because he didn't want any further infections. He said he had not had a dressing change for the 10 days he had been at the facility. He said he kept asking the nurses about changing the bandages with no follow-up on their part. He said no one responded to his call bell for two days and he felt very isolated. A follow-up observation and interview was conducted on 10/22/24 at 1:50 p.m. with Resident #21. The resident's bandages remained in the same condition as they were the previous day. The resident confirmed the bandages had not been changed. He said he was not sure why he was there and if the facility did not do something soon, he would leave against medical advice (AMA). On 10/23/24 9:30 a.m. Resident #21 was observed rolling through the front corridor with the same loose, undated dressing in place. An observation and interview was conducted on 10/23/24 at 12:38 p.m. with Resident #20. The resident was lying in bed uncovered. A large bandage was observed on her anterior lower right leg. The bandage was not dated. The resident said she had fallen and hit her leg about a month ago and the dressing had not been changed since she was admitted to the facility. The resident said she had a skin tear on her left leg, but it was almost healed. Resident #20 said the wound on her right leg is not being taking care of to my liking. On 10/21/2024 at 10:15 a.m. during an observation and interview, Resident #16 was observed in bed, dressed in a facility gown watching television. Resident #16 was observed partially covered by a bed sheet and his face had food from breakfast on it. Resident #16 said the care in facility was not great. He said he had not had a shower or a bed bath in a long time. He stated it had been about two weeks. Resident #16 said he had asked several times for a shower or bed bath, but was told by staff they were too busy, and he would have to wait. He said he does not like to feel dirty. On 10/21/2024 at 11:03 a.m. during an observation and interview, Resident #18 was observed in bed watching television. The resident stated he had not had any daily care for the day. Resident #18 said it sometimes takes staff hours to answer call lights, and he does not get showers or bed baths on the days he is supposed to. On 10/21/2024 at 12:50 p.m. during an observation and interview, Resident #7 was observed dressed and seated in his wheelchair eating lunch. His family member (FM) was in a chair at the resident's side assisting him with lunch. Resident #7's FM stated the facility is always short staffed with nurses and CNAs. She said Resident #7 does not always get showers on his shower days and will not get one until she speaks with the staff. On 10/21/2024 at 10:15 a.m. during an observation and interview, Resident #17 was observed dressed and sitting in his wheelchair watching a movie on his personal electronic device. Resident #17 said staffing in the facility is really bad and he doesn't always get a shower on his scheduled day because of short staffing. Resident #17 said he has even asked for a shower appointment on days when he does not get a shower on his scheduled day. He said he would at least like to have a shower on the two shower days he is scheduled for. An observation was conducted on 10/21/24 at 11:15 a.m. of Resident #24 lying in bed asleep. Her breakfast tray was sitting on her bedside table pushed approximately five feet aware from her bed, out of her reach. The call bell was also observed to be hanging on the wall out of reach for the resident. On 10/22/24 during the lunch meal the following was observed: - 12:03 p.m. the lunch meal carts arrived to A wing, four residents were observed in their wheelchairs, sitting around the table in the common area/dining room. No staff were seen in the area. - 12:13 p.m. a staff member served the four residents their lunch meal, set the meal up and walked away. - 12:19 p.m. no staff member in the dining room, one resident (Resident #25) calling for assistance and appeared to be having a difficult time eating, another resident was observed just looking at the tray. - 12:20 p.m. notified the A wing Unit Manager (UM) of Resident #25 needing assistance. The UM approached and spoke with resident, then proceeded back to the nurses' station. - 12:25 p.m. Resident #25 still requesting assistance. - 12:35 p.m. notified a passing CNA of Resident #25 request, CNA said OK and kept walking. - 12:54 p.m. All four residents still at dining table, two (one being Resident #25) residents had not touched their meals and one resident is calling out loudly. Two CNAs were at the far corner of the dining room talking. Three staff members (unit clerk, UM, and nurse) were observed at the nurse's station. No staff member attempted to assist the residents. - 12:55 p.m. Surveyors requested staff assist residents in the dining room. An interview was conducted on 10/21/24 at 11:30 a.m. with family members of a resident. The family said staff did not assist the residents with eating. They observed the staff offering one bite of food and if the resident did not take it immediately, the staff member took the tray away and no one attempted again to get the resident to eat. The family said staff asked them about feeding the resident themselves, but they do not feel comfortable doing that because they do not want the resident to choke. An observation and interview was conducted on 10/28/24 at 9:41 a.m. of a call light on in room [ROOM NUMBER]A and 109B. The call light system at the nurses' station showed the lights had been on for 26 minutes and 35 minutes respectively. Staff E, LPN, was observed standing a couple of rooms down in the hall but was not responding to the call lights. Upon entering room [ROOM NUMBER]A, the resident said her call light had been on for a long time. The resident was observed to have on a gown that was wet on the front. The resident said she spilled her drink from breakfast on her gown. She said a staff member came in and said they would get someone, but no one had come. The resident said it is normal to wait an hour and a half for your call light to be answered. She said You could be dying in here and no one would come. They never have enough staff. Upon entering room [ROOM NUMBER]B the resident was observed sitting in her wheelchair crying. She said she really needed to go to the bathroom and her light had been on for 30 mins. She said a CNA came in and told her she would be back after she had finished feeding other residents, but she had not returned. At 9:45 a.m. Staff E, LPN was observed going into room [ROOM NUMBER]B. The resident was overheard telling the nurse she had to go to the bathroom really bad. The nurse told her she would go find her CNA, then she exited the room. At 9:49 a.m. Staff FF, CNA was observed entering the room to assist the resident. The nurse then checked on the resident in 109A and assisted with getting a new gown. An interview was conducted on 10/28/24 at 9:56 a.m. with Staff FF, CNA. She said staffing was not good, especially on weekends. She confirmed the resident in 109B had her call light on for a while and she told her she would come back. She said the problem is that some residents get their breakfast early, including room [ROOM NUMBER]B. She said those residents then need to go to the bathroom and she is still feeding other residents. Staff FF said just on her assignment she had six residents to assist with breakfast. She said there is no additional help to feed residents or answer call bells during mealtimes. An interview was conducted on 10/25/24 at 3:23 p.m. with the ADON. She said residents were scheduled for two showers a week and additional if requested. She said if a resident missed a shower staff should document. She confirmed CNAs document showers in the Task section of the medical record. The ADON said if a resident asked for a shower they should have gotten one. Regarding call lights, she said they should have been responded to as soon as staff can. She said everyone should answer a call light, not just CNAs. The ADON said call light response times had been an issue and she had heard about it. The ADON agreed residents not getting assisted with eating is not acceptable. The ADON said she felt like a lot of things weren't getting done because agency just don't care. An interview was conducted on 10/21/24 at 10:22 a.m. with Resident #13. Resident #13 stated, They [the facility] are understaffed, as they have a significant amount of residents to care for. They don't have time to care for me a lot of the times, I have to sit in my soiled brief. I feel demoralized when this happens. I have expressed my concerns to the NHA, he useless and never gets back to me and makes comments like, we are doing the best we can. You can leave in you don't like it. So, I just deal with it. Resident #13 continued to state not receiving medications in a timely manner either. An observation and interview was conducted on 10/21/24 at 10:47 a.m. with Resident #21. He said, No one responded to me [my call bell] for two days, I felt very isolated. Resident #21 stated being thirsty and the facility only passes water one time per day, I have gotten smart and now ask for two cups. I don't think they [facility] have time for me. An interview was conducted on 10/21/24 at 10:57 a.m. with a family member while visiting. The family member stated I ensure myself or another family member is here to care for [resident] as the facility does not have enough staff. The CNAs are very compassionate and try their best but just not enough of them. An interview was conducted on 10/22/24 at 1:00 p.m. with Staff U, CNA. Staff U stated, Staffing is terrible, I can't get my job done. For example, today I was told at 9:30 a.m. that someone [another CNA] did not show up, so our assignments changed. Which means, no one was assigned to those residents from 7:00 to 9:30 a.m. they [the residents] had not been touched. It's too much, one and a half hours to figure out someone did not show up and rearrange assignment. Breakfast was done, hopefully those residents did not need assistance. There are a lot of heavy care residents (meaning total care) that need assistance with everything. We just don't have time to do everything. There is not enough staff. Agency won't come here for one reason or another. It's even worse on the weekends. On a couple of weekends there isn't even staff in the main dining room. Family members are passing trays to residents as no one [staff] shows up in the dining room. An interview was conducted on 10/22/24 at 1:10 p.m. with Staff CC, CNA. Staff CC stated, Hard working here, staffing is crazy, we are always short. You just have to work around, harder get up total care [residents] they have to stay in bed. We have difficulty assisting in dining, especially if the resident takes longer [to eat] and then food [gets] cold. Really hard to accomplish our job. Sometimes we are not even told if someone did not show up [for their shift] then that assignment doesn't even have anyone over [the residents] until it's noticed. An interview was conducted on 10/22/24 at 1:15 p.m. with Staff DD, CNA. Staff DD stated, Staffing is not good, call offs, workload is crazy. I can't get them [residents] 100%. I can do basics only, no showers, hardly any assistance with meals especially if they need a lot of encouragement. Just not enough to assist with everyone who needs. An interview was conducted on 10/22/24 at 2:09 p.m. with Staff W, CNA. Staff W stated, Work a lot, doubles, multiple days in a row. I don't have time for any extras with the residents, no time for breaks. Staff W continued to state it's easier to leave the residents in their beds due to time restraints. An interview was conducted on 10/22/24 at 2:18 p.m. with Staff X, CNA. Staff X stated, having to work a lot due to not enough staff, call offs, works many doubles and multiple days in a row. We want to do what we can for the residents, as the care is too much for the number we have. We don't have time for things like showers, or just getting them out of bed. An interview was conducted on 10/22/24 at 4:13 p.m. with Staff EE, LPN. Staff E stated the evening shift [3:00 p.m. to 11:00 p.m.) is especially challenging on staff. Many times, the staff scheduled don't show up and are not replaced, we don't start with the number needed, many reasons not enough. The facility receives a number of new admissions on the evening shift, not sure how those residents feel. Very sad, we do what we can. During an interview on 10/24/24 at 11:50 a.m. with Staff V, CNA. Staff V stated, Staffing is awful. It's crazy, no one knows what is up, people [staff] come and go as they please. No one pays attention to what anyone does. Staff V stated not having time to get resident up out of bed regularly, shower. Only, the basics. During an interview on 10/25/24 at 12:00 p.m. with Staff O, CNA stated, staffing was difficult, as have over 20 residents a piece to care for. Staff O said accomplishing anything outside of basic care is hard. Staff O stated, Showers don't happen, and you hope you have all good eaters as not much time to assist. During an interview on 10/28/24 at 11:38 a.m. with Staff Q, CNA stated working for the facility for many years and the past few months have just been terrible. She stated, Staffing and patient care is a big mess. The facility has no idea if staff are here or not. Nursing doesn't pay attention to residents, unless their families are here. Administration has no idea what they are doing. An interview was conducted on 10/22/24 at 12:17 p.m. with a family member. The family member stated having to come to ensure family member receives care. Someone from the family is here most of the time, especially for meals as the staff don't have time to assist. The family member stated, In fact, we have had to pass trays in the dining room to residents on weekends as no staff members show up. An interview was conducted on 10/28/24 at 9:45 a.m. with room [ROOM NUMBER]. Resident in room [ROOM NUMBER] stated, There is no staff on weekends. I have to help my roommate sometimes, he is a veteran so I don't mind, but they should be helping him. I will put the call light on for him, because he needs to be changed. The staff will comes in and turn the light off and says they will be back. It will be an hour and a half to two hours before they come back to change him. Numerous staff don't show up when they are supposed to, weekends are especially short. It is impossible to get any help around here. An interview was conducted on 10/22/24 at 11:58 a.m. with Resident #15. Resident #15 stated last Friday she Did not get shower and could not get help. This happens from time to time because they don't have enough staff. Resident #15 stated speaking with the administration many times and filed grievances but nothing happens. On 10/28/24 at 9:39 a.m. and 11:15 a.m. a strong smell of urine occurred on the 300 unit near the right side of the nurse's station. On 10/21/24 at 10:24 a.m. an observation on the A-wing revealed 6 call lights going off, two LPN's present in hallway took several minutes and surveyor walking by staff to enter one of the rooms with the light on. During an interview and observation on 10/21/24 at 12:50 p.m. the family member of Resident #7 was in the resident's room at the bedside assisting the with lunch meal. Resident #7 family member stated, The facility never knows what their staffing should be and is always short staffed from the nurses to the CNAs. She said the staffing numbers are never posted on the weekends even after she has told the facility they need to be posted. Resident #7 family member stated Resident #7 doesn't always get showers and they will skip the shower until I say something to the staff. Not sure why I need to keep asking for something they should be providing. During an interview on 10/21/24 at 10:07 a.m. Resident #16 stated the care here is not great, it takes a long time for his call light to be answered, if at all. Resident #16 states having to ask to have his sheets changed. Resident #16 said not having had a shower or bed bath for over two weeks, if requests the staff say they are busy and has to wait, which means I don't get one. During an interview on 10/21/24 at 11:03 a.m. Resident #18 stated, There is definitely a staff shortage here. It takes a long time for call lights to be answered, don't get showers or baths when supposed to. Resident #18 stated, I feel like management doesn't care. An interview was conducted on 10/23/2024 at 3:20 p.m. with Staff GG, CNA. Staff GG stated usually working the 3pm-11pm shift. Staff GG said there is supposed to be 7 CNAs, but sometimes there are only 5 working. Staff GG said it is very busy when this happens. Staff GG stated she does not get overwhelmed as she has been a CNA for many years and has a lot of experience. Staff GG stated, the CNAs with less experience have a harder time keeping up when there is not enough staffing, and they struggle. She stated, sometimes upon arrival to the shift residents have not had all of their needs met from the day shift and sometimes they have to change residents and do complete care that should have been done on the previous shift. An observation was conducted on 10/23/24 at 11:05 a.m. of Resident #17, who is cognitively intact, approaching Staff C, RN at the A Unit nurses' station. The resident expressed concerns related to staffing the previous shift. He stated there was only one nurse on the A Unit for part of the 10/22/24 11:00 p.m. to 10/23/24 7:00 a.m. shift. An interview was conducted on 10/23/24 at 1:03 p.m. with Staff C, RN. She confirmed she was scheduled to work on the A Unit until 11:00 p.m. on 10/22/24. She said she stayed over because a nurse did not come to relieve her. She said she left the facility before another nurse arrived, thus leaving Staff G, LPN as the only nurse for 64 residents. She said she left because the other nurse Was almost here. Staff C said she did not do a narcotic count or give report to Staff G, LPN. Staff C said she did not remember what time she left the facility. An interview was conducted on 10/25/24 at 11:18 a.m. with Staff G, LPN. Staff G confirmed he worked on 10/22/24 11:00 p.m. to 10/23/24 7:00 a.m. shift on the A Unit. Staff G said he does not know what time Staff C, LPN left. He confirmed he was the only nurse for 64 residents but does not remember how long it was between Staff C leaving and the Unit Manager arriving. Staff G remembered getting a new admission resident while being the only nurse on the unit. He said as transport was leaving the facility the Unit Manager arrived. Staff G said there were staffing issues in the facility. He said over the weekend the police were called by an agency nurse because she did not want to leave her assignment or it would be abandonment, but there was no staff in the facility. He said staff had called the staffing phone and no one answered and the ADON said she would not come in. He said he called the NHA and the NHA made some calls getting the D Wing Unit Manager to come in. Staff G said he counted narcotics with the agency nurse so she could leave, and he waited until the Unit Manager arrived. Staff G said, Staffing [explicative]. He said there were a lot of disgruntled employees, and they never had the staff they needed. Staff G said it was like that often and There is rarely a time we have adequate staff, so we have time to give the patients the adequate care they deserve. He said they do not know where people are working, and people had to switch units mid shift. Staff G said a week or so ago some of the resident's family members stepped in and helped in the dining room. He said the family were passing residents their meal trays and pouring juice and coffee for residents. He said staffing had been like that for a while and staff Feel like pawns in this big game. He said he often gets complaints from residents and family members about not getting showers and ADL care. He said, We don't have the capacity because of the workload. He said, If we don't have the eyes on the floor to see a resident on the edge of the bed because CNAs are in other rooms . A lot of the stuff can be prevented but we can't catch it in time. Staff G said they had a lot of residents that tried to stand up and needed to be watched because they tried to get up by themselves. He said if you have 4 CNAs taking care of 60 + patients, someone is going to get neglected. Staff G said there have been Many incidences of neglect that could have been prevented. An interview was conducted on 10/29/24 at 11:07 a.m. with the DON regarding staffing concerns. She agreed during mealtimes there are not enough hands on deck. She said the management team (i.e. DON, ADON, etc.) do not go to the units to help with meals. The DON said the facility had a lot of call outs and use agency staff. She said if all else fails they offered bonuses to their staff to come in. As for the night shift going from 10/22/24 into the morning or 10/23/24, she said she was told a nurse stayed over until the unit manager arrived and got report. She said she was not aware there was a period of time with only one nurse for 64 residents. She said having one nurse is not acceptable, unless there are under 40 residents. She said the nurse should have stayed on the unit until a relieving nurse arrived, report was given, and a narcotic count was completed. She said she heard the facility was short on CNAs over the weekend, but was told the NHA came in to work because he is a CNA. The DON said staff had been good about picking up shifts, but they are angry with management about several issues. She said they are down to very few agencies they work with. The DON said there is a problem with call outs, no shows, or some staff quitting. She agreed staffing concerns and shortages lead to a [NAME] effect with care not being provided. The DON agreed that all the concerns combined including staffing, wound care, ADL care, labs, and medications all together can lead to neglect of the residents. An interview was conducted on 10/24/24 at 2:35 PM with the Staffing Coordinator (SC). The SC stated overseeing the staffing for the building. The SC explained when a call off is received, we try to fill the position immediately. The SC stated staff know they have to report off a minimum of 2 hours prior to start of shift, if less than 2 hours it is considered a no call no show. The SC stated having had 4 call offs for 10/24/24 and was able to fill through calling staff and using agency staff which would be the process. The SC stated being instructed by the NHA and DON to staff the building based on census and state calculations of a minimum of 2.0 for CNA and 1.0 for Nursing. The SC stated the biggest obstacle for staffing is finding good staff. The SC stated they can only utilize one agency as the facility has not paid two other agencies monies owed. During an interview on 10/25/24 at 3:23 p.m. the ADON stated, I think there is enough staff here. We try to staff so nurses have no more than 40 residents and CNAs 20. We base the staffing on census. The ADON stated a nurse should not leave the facility until the next nurse arrives to take over the cart. The ADON stated being vaguely aware, that two nurses had to stay over as another nurse did not show up the other night, but I thought a nurse came in to relieve one. The ADON stated not being aware that the nurse did not stay until the other nurse arrived which left, one nurse to care for 64 residents. The ADON stated being unaware the police department was contacted regarding not having enough staff in the facility. During an interview on 10/25/2024 at 4:24 p.m. with the NHA staffing was discussed. The NHA stated staffing the facility is based on the census for day. The NHA stated the Staffing Coordinator (SC) is responsible for totaling the number of hours staff worked the day before. The NHA stated they did increase the number of staff on the rehab unit based on acuity but really it [staffing] is on census. The NHA stated if there is a call off, the supervisor is responsible for finding a replacement for the position. The supervisor works with the SC to accomplish this. If the position is a nurse, then the agency can be called and if the position remains open then the supervisor/UM will fill this position. The NHA stated the UM hours are in the system as direct care staff. The facility has a staffing phone for the staff to call with any need. The phone is carried by the Nurse Manager on call for the day. The NHA stated being aware of staffing concerns from staff and families. The NHA stated, Yes, I have heard of staffing concerns. I'll come over at 3:30 in the morning, as staff are complaining. I will say to them, why do we need more [staff] if you are not going to do the job, as you are just sitting at the station, talking when I come in. We are doing the best we can, we are focusing on the evening shift [3-11p]. Review of facility's policy and procedure titled Staffing, dated revised 8/2022 showed: Policy Statement: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. 2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. 3. Other support services (e.g., dietary, activities/recreational, social, therapy, environmental, etc.) are also staffed to ensure that resident needs are met. 4. Direct care staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter. 5. Inquiries or concerns relative to our facility's staffing should be directed to the administrator or his/her designee. Facility immediate actions to remove the Immediate Jeopardy included: 1. Staffing a. Current staffing model reviewed and updated to reflect resident needs and acuity. b. Facility assessment reviewed and updated on 10/25/2024 to reflect current resident population needs. c. Reassessed the acuity level of each unit. Reviewed assistance the level of care needs for ADLs including transfer status, mechanical lift usage, and residents requiring a higher level of care due to comorbidities. Education 1. Education provided to the staffing team to include administration, Director of Nursing, and staffing coordinator by RDO on 10/28/2024 regarding staffing standards and staffing for acuity on each unit to ensure quality resident care. Audit: 1. Initial audit was completed for 30 days to compare the AHCA report to the PPD report and compare with schedules to ensure that PPD was met, and ratios were appropriate for the resident acuity. In the initial audit, the administrator, staffing coordinator and payroll coordinator reviewed staffing from the previous day to ensure that hours and ratios were achieved according to the staffing plan based on acuity. Payroll also ran the PPD report from the payroll software, after editing missed punches, to compare and enter into the AHCA staffing sheets to encompass hours from the previous day. Staffing coordinator reviewed the schedule for the current day and next day to review attendance and staffing needs to ensure that resident needs are met, and staff are within the ratio of the staffing model. It is the administrator's responsibility to ensure that the staffing model is updated, and the facility assessment is completed to reflect resident acuity needs on each unit. Verification of the facility's removal plan was conducted by the survey team on 10/28/2024. A review of facility education was conducted to verify the staff on the staffing team were understand and implement staffing guideline changes. Interviews were conducted with the NHA, the DON, and two Nurse Managers to validate staffing needs education had been given and understanding of staffing guidelines. Based on verification of the facility's Immediate Jeopardy removal plan, the immediate jeopardy was determined to be removed on 10/28/2024 and the non-compliance was reduced to a scope and severity of F.

Based on interview and record review the administration of the facility failed to update their emergency plan as changes occurred and failed to plan and carry out a safe evacuation. There was a complete disregard for patient safety and quality of care to be maintained during a natural disaster that required an evacuation. Additionally, after one failed evacuation the facility did not secure a location for a second natural disaster that occurred shortly after the first one. The facility maintained an evacuation agreement with a local church that began in 2018. In February 2024 the church informed the facility that the agreement was to be terminated effective [DATE]. No alternative evacuation location was arranged. In September of 2024 when evacuation was ordered for hurricane [NAME] the facility staff moved 226 residents to a local church. Family members of the residents called the police and emergency medical services to report conditions. Local Police, Fire and Emergency officials assessed the location and deemed it unsafe. The residents were on small cots placed right next to each, staff did not have enough room to care for the residents, the resident care was not organized, supplies were not available, there was not enough room for every resident to be indoors, important supplies were housed outside with rain predicted and the residents were not safe in terms of fire exits and supervision. The local authorities moved all the residents to a county shelter the night before hurricane [NAME]. Before hurricane [NAME] the facility Nursing Home Administrator (NHA) began calling Local County Emergency Operation Center (CEOC), and State officials asking for an evacuation location or to be allowed to not evacuate. Again, the facility did not have a plan for the safety and care of its residents. A volunteer at the CEOC working with the Emergency Operations leadership assisted the NHA by determining that the most acutely ill residents could be moved to a local Nursing Home. The NHA moved all the remaining 217 residents to a church in a nearby county. The CEOC acknowledged awareness of his plan and said they were unable to approve evacuation plans at the last minute. Upon review after the storm, the County Emergency Management did not approve of this location due to it being in an evacuation zone and unsuitable if evacuations were ordered for a hurricane. The facility remains without a safe evacuation location. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to all facility Residents and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy are ongoing and have not been removed, the severity and scope remains an L as there has been no verification of removal of immediacy of harm. Findings included: During an interview on [DATE] at 3:15 p.m. with the Nursing Home Administrator (NHA) and the Administrator in Training (AIT), the NHA said he knew the agreement with Evacuation Location #1 was terminated sometime in [DATE] when he began as the NHA with the facility. The facility received the termination of contract letter in [DATE]. He said he started calling other vendors at this time to find a suitable location and admitted to only looking for options to keep the entire facility in one location (approximately 280 residents). The NHA stated he was unsuccessful and called (local) County Emergency Management (CEM) for assistance, who instructed him they could not assist him. The NHA did not have a location as of [DATE] when a hurricane was projected to impact St. Petersburg. The NHA stated he was not able to find a location and continued to contact CEM for assistance, and said they needed to help us. The NHA stated he was finally able to find a location. The NHA stated that no communication occurred to families during the evacuation for [NAME]. The AIT stated if families had her number they were contacting her, although only if they had her number. The NHA stated he thought this was successful event as no one eloped, died or (had a) major injury. The NHA admitted to not looking for a location for evacuation prior to the imminent need of the next major hurricane, [NAME]. The NHA stated, I kept contacting CEM and they did not help me. Review of the approved facility disaster plan dated February 2024, provided by the local Emergency Management office showed multiple sections such as Facility Basic information, Incident Command Structure. It included Policies and Procedures on a Food Plan, Water Plan, Emergency Power Plan, Medical Supplies, Medical Records, Sewage, Transportation and Rationale for disaster plan. It contained a Hazard Analysis, Elevation certificate, Evacuation Plan and Essential Business Functions, Disaster Chain of Command, a Floor Plan of the facility, Emergency meal plan, menus, a food a water list needed, Evacuation Time Table, Information, Training and Exercises, Emergency Preparedness Communication Plan, management and staff contact numbers. It contained the Sheltering License Agreement with (Evacuation Location #1) and Mutual Aid Agreements with two local nursing homes. It contained agreements with a Food distributor, commercial buses, wheelchair transport, a rental truck company, Review of the approved facility disaster plan dated February 2024, provided by the local Emergency Management office included a Sheltering License Agreement effective [DATE], with the [NAME] of a local church (Evacuation Location #1). The church agreed to make certain areas available to the Nursing Home in the event of a hurricane evacuation order. A Shelter Agreement Clarification page was included that showed the Church (Evacuation Location #1) would be able to accommodate 379 Residents from the facility for the year 2023, signed by the NHA at the time and the [NAME] of the church on [DATE]. Mutual Aid Agreements were included with two nearby nursing homes. Both Mutual Aid Agreements specified that the receiving facility could only take 60 residents from an outside source and the number would depend on current in-house census and both facilities understand that a local in-house emergency, and or emergency that affected all facilities in the [NAME] Bay Area, would render a variance in available space. The Mutual Aide Agreements were signed by each facility and the current NHA in February of 2024. Review of a letter dated [DATE], written to the administrator of the facility and signed by the [NAME] of a local church (Evacuation Location #1) showed the church was terminating the agreement to be the evacuation location for the facility effective [DATE]. The termination was due to the facility not following agreed upon safety and cleanliness procedures during the past evacuations, and other problems described in the letter. An Emergency Management Planning document was provided to the surveyors on [DATE] by the NHA and described by him as the plan followed for hurricane [NAME]. The document showed the facility was licensed to house 274 residents including a secure dementia unit of up to 70 residents. The facility is in hurricane evacuation Zone A (most vulnerable zone and is usually the first to be evacuated), the elevation was 9 feet 4 inches above sea level and will be evacuated to an offsite location as directed by the Local County Emergency Management. Review of the document showed Evacuation Location #1 crossed out and replaced by a different church located in a nearby city (Evacuation Location #2). Evacuation location #2 was dated to be effective [DATE]. On multiple pages of the Emergency Management Planning Document Evacuation Location #1 was still listed. No documentation was provided for the approval of Evacuation Location #2 by the local Emergency Management Office. Review of an email communication from the Emergency Management Health Care Plan Compliance Specialist showed the last review and approval of an Emergency Plan for the facility on [DATE]. Review of a letter from the local County Emergency Management office, dated [DATE] signed by the Healthcare Plan Compliance Specialist showed, To the current Administrator, We are pleased to inform you that your electronic Comprehensive Emergency Management Plan (CEMP) was reviewed. You will receive the CEMP Approval Certificate upon payment. The facility was instructed to submit their plan for the [DATE] to February 2025 time frame by [DATE]. Review of the local County Emergency Operations Center evacuation orders for hurricane [NAME] showed, [DATE], Attn: Facility Administration: An Evacuation order for Residential Health Care Facilities, [local] County has issued an evacuation order for all Level A facilities. The anticipated impacts of the storm include: -Storm Surge of 5 to 8 ft is possible along areas of [local] County; however, this is highly dependent on where the storm makes landfall. -Strong tropical storm force winds are forecast for [local] County starting 10 am on Thursday. -Heavy rainfall of up to 6 inches is forecast for [local] County. -Isolated to scattered tornadoes will be possible, especially in the outer rainbands of the storm. -Hazardous surf and rip currents are expected to continue until the storm passes If you are included in the evacuation level A you should complete your evacuation and be in your safe location by Thursday at 7am. The [local] County Emergency Operations Center (EOC) will be calling to ensure that you are evacuating as planned and as called for in the Comprehensive Emergency Management Plan (CEMP) for your facility. If you are not included in the evacuation level, but choose to evacuate anyway, please ensure that you inform the Emergency Operations Center of your plans and sheltering location. We will continue to monitor the system. Please monitor your emails for any further protective measures. The contact information for the [local] County Emergency Operations Center is: The Health and Human Services EOC Desk [DATE] or [DATE] Sincerely, [local]County Emergency Operations Center. The facility evacuated to Evacuation Location #2, a church in a nearby city on [DATE], an unapproved location. Review of a [local] Police Department Incident report dated [DATE] showed they were called at 7:40 pm, and arrived at 7:42 pm at the Evacuation Location #2. This report is to document the conditions at [evacuation location #2], during the preparation for tropical storm [NAME]. On [DATE] two officers did an area check . there were 4 different rooms that people were placed in. Each room was over-packed with cots half the size of a person pushed together leaving no space for a person to move around or get up in most areas. Each room was hotter than outside inside the building, leaving many people uncomfortable. The majority of the people were barely dressed due to the conditions of the room. A lot of people were placed in adult diapers. There was only 1 fan observed running which was a small ceiling fan in the primary chapel. The primary chapel had more than 80 people in it, the memory care had more than 50 people in it, and the two other rooms had more than 30 people in each room. Multiple wheelchairs were left outside with no cover for the storm to come. Multiple medical and survival supplies were also left outside with no cover for the storm to come. While these rooms were already packed full there were more than 20 people outside standing and in wheelchairs waiting to be placed in a room. This information was forwarded up the chain of command. Review of an e-mail communication from the Deputy Director of Safety and Emergency Services for local County Government written on [DATE] at 3:00 am to 5 [local] County staff members regarding the facility's residents at Evacuation Location #2 revealed: Good morning, [facility name], is a skilled nursing facility located in zone A and were required to evacuate 250 residents. They evacuated to [Evacuation Location #2] in [city name]. We were advised that the SNF [skilled nursing facility] had all of the medical support needed for its patients, but the facility lacked a few resources. We received a request to assist them with a generator at the church and a safety concern was raised because the church did not have fire suppression, so [local] FD [fire department] responded and put them on fire watch. More calls came in concerned about the safety of the patients due to a lack of generator for refrigerated medicine, heating ventilation and air conditioning (HVAC) so County Officials, [the local County EMS Medical Director and the EMS and FIRE Administrator for local County] responded to the church. Upon arrival and conversations between [Local city] FD, [local county] PD [police department], [the local County EMS Medical Director] and [the EMS and FIRE Administrator for local County], it was decided that the facility was not safe for the residents. Initially, it was decided that the patients would be moved to an Academy due to the nearby location. After multiple conversations with the school district and due to a lack of a generator at [the academy] was decided that the patients should be moved to [a local middle school] which is further away but is a special needs shelter and has a generator back up for those patients dependent on electricity. [County Busses] helped move the 50 patients that could walk and provided transport for wheelchairs. Multiple trucks with liftgates from [commercial ambulance service] helped transport equipment and the [commercial ambulance service] and the Fire Departments transported the rest of the patients to the shelter. An interview was conducted with the local County EMS Medical Director, [DATE] at 1:30 p.m. He said concerns about the facility (Evacuation Location #2) came about as follows: 1) Concerns were raised to the Emergency Operations Center (EOC) by a Fire Department officer that had run a 911 call to the facility and reported concerns about conditions. 2) A request for assistance was made for power for the refrigerator. [The local County EMS Medical Director], went with a group to evaluate the situation, and he said that on [DATE] ahead of [NAME]: 1)Medications and computers were being stored outside in a courtyard area. 2) Residents were on cots, shoulder to shoulder and head to foot, there was no access to residents, the square footage available was woefully short. 3) Security concerns were identified for the memory care residents in a hall room with little to no safeguards. 4) Means of egress was not clear of all obstructions. 5) They had a handful of portable generators that looked like they were picked up at (a home improvement store) that day. 6) Several residents were on Oxygen concentrators and would have posed a significant problem in the event of power loss. [The local County EMS Medical Director] stated that a consensus meeting was held between himself, [local city] Police, and [local city] Fire and they were all on the same page that the facility was inadequate to care for so many residents. Together the group decided that the most appropriate course of action was to relocate the residents to a more suitable location. An interview was conducted with Staff Member Q, Certified Nursing Assistant (CNA) on [DATE] at 11:38 a.m. She said she has worked for the facility since 2022. She said the hurricane staffing and patient care were a big mess. The administration has no idea what they are doing. For hurricane [NAME] it was an absolute nightmare, She was scheduled to work ,d+[DATE] a.m. and they were told to meet at the church at 11 pm, not even come in early, crazy. She said, The residents were packed into this church with no linen, you could not walk between cots. It was so hot even with the portable units, there was no air flow. We were short staffed, there were no fluid passes, you could not get to the residents, they were covered with towels, there were not enough linens. There were no assignments, everyone was everywhere, except with residents. Residents were not provided supplies; you could not get to the supplies. Then we evacuated to the school, even though we were at the school still there was confusion, no direction given on who to take care of, we were left to guess, which means no one accepts responsibility. I stayed in the cafeteria from 7am to 7 pm. I did hear that someone fell in the gym, but I did not see it. An interview was conducted on [DATE] at 3:11 p.m. with Resident #15. She said during the hurricane [NAME] evacuation the residents were taken to a church big enough for 100 people but there were 250 people there. Resident #15 said she didn't do well in tight spaces and was a little claustrophobic. She said, It was so bad. I called my grandson and told him to get me the [explicative] out of here. Resident #15 said she was not happy because she was put on a cot and her wheelchair was taken away. She said she was independent and used the bathroom herself. She said she was left on her cot for hours without being able to get up. Resident #15 said staff told her to just go in her pants and they wound just change me. Resident #15 said the evacuations were horrible. An interview was conducted on [DATE] at 2:15 p.m. with the Staff Member II, Occupational Therapist (OT) who stated there were safety concerns. I tried to give my opinion, but no one wanted to hear me. The evacuations were Very disorganized. Therapy knew their responsibility of transferring residents on to the buses and off only. The facility had Charter buses for the evacuations for the first (storm). If residents were able to sit upright in a wheelchair, we were able to sit them in the bus seat. We had to physically lift the residents into the bus. To my knowledge the wheelchairs did not go to the evacuation site unless the resident had to travel in the chair. Those residents were evacuated by wheelchair transporters. An interview was conducted on [DATE] at 2:35 p.m. with Staff Member JJ, Physical Therapist (PT) who stated the evacuations were confusing regarding transport. He found out no transport had been set up for return after hurricane [NAME]. The facility was only utilizing the buses they owned for transport, this took forever. Resident #23 received a skin tear during one of the transfers. A nurse came to evaluate the wound right away, but they were not able to find a first aid kit for supplies to cover the skin tear. Thirty minutes went by, and someone finally drove over with supplies, to cover the skin tear. An interview was conducted on [DATE] at 2:47 p.m. with Staff Member KK, CNA who stated regarding the evacuations, No one knew what was up with any of the evacuations, chaos. I'm sure that is why I don't remember anything specific except chaos. An interview was conducted on [DATE] at 4:37 p.m. with former Staff Member M, CNA. She said, The evacuation for [NAME] to the church was unorganized, the Therapy department completed the transferring charter. At the church everyone was being put on a cot, no elevated head, just a sheet, maybe a pillow I don't think enough for everyone. There was not enough room for everyone, you could hardly squeeze between cots, residents were outside in the rain as there was no room in the church. Families started to come there complaining, I don't remember who. The bathroom hallway had cots as there was no room. No one was told anything, we did not know who we were to care for, except follow normal schedules, be at work at 7 a.m. at the nursing home, then we went to the church at 3:30 p.m. It started to get dark; it started raining. I'm not sure if everyone got to eat, there was no organization, everyone received the same diet, we were not sure who was who, it was a total mess. We could not pass fluids because we couldn't get to residents, we had to walk sideways between cots. They stuck some residents in a closet, at least they left the doors open for them, but it was hot, even with the spot cooler. There were residents who had been bed bound for years and now they were on these cots with only a sheet. I was instructed to go assist alert residents. All the officials came, and we had to move again, at least that evacuation had organization somewhat. You could tell the officials were frustrated. When we got to the school (Evacuation Location #3) the meals were the same, no one had their diets indicated but it was better than the church as the school was giving out meals. Then they told us not to give the school meals, we were only supposed to use our supply. Well, who knew where that was? The only fluids were given with a meal, if you received meal. I don't think they had a way to know who got what or if everyone got to eat. I didn't see anyone helping anyone eat. I was assigned the alert residents, so they only needed to be served. There were no assignments [NAME] except B wing (the memory care wing) was in gym, but I am not sure who was in the gym with them. I saw a Resident outside on the sidewalk exiting to the street. I brought her back in, I am not sure who it was, but she got out. Review of EOC evacuation orders for hurricane [NAME] showed, [DATE], Attn: Facility Administration: Level A-C Evacuation order for Residential Health Care Facilities, (local) County has issued an evacuation order for all Level A, B and C facilities. The anticipated impacts of the storm include: Storm Surge over 10 ft. is possible along areas of (local) County, however this is highly dependent on where the storm makes landfall. Life-threatening storm surge flooding will be possible across coastal areas of (local) County on Wednesday (,d+[DATE]).Heavy rain of 5 to 8 inches, with isolated higher amounts of up to 12 inches is forecast through Thursday (,d+[DATE]).Tropical storm force winds are forecast to start in the early morning hours of Wednesday (,d+[DATE])and continue through late Wednesday night (,d+[DATE]). The wind field is expected to expand. There is the potential for some tornadoes and /or waterspouts on Thursday (,d+[DATE]). If you are included in the evacuation level A, B or C you should complete your evacuation and be in your safe location by Tuesday 8pm. The (local) County Emergency Operations Center (EOC) will be calling to ensure that you are evacuating as planned and as called for in the Comprehensive Emergency Management Plan (CEMP) for your facility. If you are not included in the evacuation level, but choose to evacuate anyway, please ensure that you inform the Emergency Operations Center of your plans and sheltering location. We will continue to monitor the system. Please monitor your emails for any further protective measures. The contact information for the (local) County Emergency Operations Center is: The Health and Human Services EOC Desk [DATE] or [DATE] An interview was conducted by phone with the Director of the Department of Health in (local) County on [DATE] at 4:00 p.m. He stated that requests for assistance in finding a place to evacuate to were being made by the facility as [NAME] was approaching. The facility ultimately evacuated to the church in (local city), Evacuation Location #2. He said the EOC received a Fire Officers concerns about conditions following a 911 call they responded to (at Evacuation Location #2). He said an additional request for assistance with powering refrigeration equipment at the location was received. He said the EOC dispatched the Medical Director for the (local) County EMS, (local) Police, and (local) Fire Departments to assess and evaluate conditions at (Evacuation location #2). He said the EOC received a report that available square footage was inadequate for the number of residents present, creating security concerns for the police, and egress concerns due to crowding for the fire representative. The (local) County allowed them to relocate to a Middle School, (Evacuation Location #3) where they were operating a special needs shelter. The Director of the Department of Health in (local) County noted that while actions were taken because of need, (local) County evacuee numbers were expected to be in the thousands (for Hurricane [NAME]) and their system is not designed to support long term care facility residents. The Director of the Department of Health in (local) County acknowledged that it was a short turnaround between [NAME] and when the evacuation for [NAME] was ordered. The facility did request the use of the special needs shelter again. The (local county) was expecting large numbers of evacuees, has multiple long term care facilities, and planning for evacuations is the responsibility of the facility. The Director of the Department of Health in (local) County said that, while unfortunate, it does not change the responsibility of the facility to develop arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. Review of an e-mail communication from the County Emergency Operations Center written on [DATE] at 7:54 pm to 5 (local) County staff members regarding the facility revealed: As The Director of [the] Department of Health in (local) County knows, [name] the NHA of this building had a [Emergency Plan] approved with receiving facility that unfortunately failed meaning the receiving facilities backed out thus they did not have placement for this larger facility. The plan in motion is 23 residents with higher acuity to [Local Nursing Home] and the rest to go with the Administrator, Director of Nurses (DON) and staff to (Evacuation Location #4) that is 10 K SQT, high and not in an evac zone, has a kitchen, etc. The facility would bring a generator, 12 portable AC units and 4 wet vacs in case needed in addition to food, fluids, medications, treatments, mattresses, etc. We did have a conversation with [name] the Administrator explaining that the CEOC [(local) County Emergency Operations Center] cannot review or approve a new or temporary plan at this point other than verbally as done. In doing so we explained that it is his decision what is best for the residents and staff of his facility and that the CEOC acknowledges this new plan, but it is not approved. [NHA] did verbalize his understanding. Signed by a volunteer at the (CEOC). An interview was conducted with the Emergency Management Healthcare Plan Compliance Specialist with the (local) County Emergency Management office on [DATE] at 10:30 a.m. She stated that the facility did not submit an alternative location for approval prior to the hurricanes. The facility did not ask for approval for either Evacuation Location #2 or Evacuation Location #4. She reviewed the location information for Evacuation Location #4 and said that it would not be approved as an evacuation site because it is in Flood Zone D. She said only facilities in no flood zone areas can be used as evacuation locations. Review of the Quality Assurance and Performance Improvement (QAPI) Policy and Procedure, dated 2024 revealed the following: PURPOSE, To ensure that (the Facility) implements a comprehensive QAPI program which addresses all the care and unique services that the facility provides. To ensure continuous evaluation of the Facility's systems with the objectives of: ensuring that care delivery systems function consistently, accurately, and incorporate current and evidence-based practice standards where available; preventing deviation from care processes, to the extent possible; identifying issues and concerns with the Facility's systems, as well as identifying opportunities for improvement; and developing and implementing plans to correct and/or improve identified areas. To ensure that the Facility implements a quality management program which takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality. An interdisciplinary approach encompasses all managerial, and clinical, services, which includes care and services provided by outside (contracted or arranged) providers and suppliers. [ .] VII. Governance and Leadership, A. The Facility Administrator is essentially responsible for the internal risk management and QAPI program. B. The governing body and/or executive leadership (or organized group or an individual who assumes full legal authority and responsibility for operation of the Facility), must ensure the QAPI Program: a. Is defined, implemented, and ongoing; b. Addresses identified priorities; c. Is sustained through transitions in leadership and staffing; d. Has adequate resources, including staff time, equipment, and technical training as needed; e. Uses performance indicator data, resident and staff input, and other information to identify and prioritize problems and opportunities; f. Implements corrective actions to address gaps in systems and evaluates actions for effectiveness; and g. Establishes clear expectations around safety, quality, rights, choice, and respect. [ .] IX. Responsibilities of QAA Committee. Functioning under the Facility's governing body, the QAA Committee is responsible for: A. Reporting to the Facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program; B. Regularly reviewing and analyzing data, including data collected under the QAPI program and data resulting from drug regimen reviews; C. determining what performance data will be monitored and the schedule or frequency for monitoring this data; D. Acting on available data to make improvements; E. Identifying and responding to quality deficiencies throughout the facility; F. Oversight of the QAPI program when fully implemented. G. Developing and implementing corrective action, and monitoring to ensure performance goals or targets are achieved; H. Revising corrective action when necessary. I. Meeting at least quarterly, and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

48223 Based on observations, interviews and record reviews, the facility failed to protect the resident(s') right to be free from neglect when it failed: 1) to provide a hazard free environment and supervision for three residents (#3, #8, and #12) of three reviewed for falls with injuries; 2) to provide follow-up notification for critical radiology results for one resident (#9) of one reviewed for imaging; 3) to provide proper wound care to prevent the development of complications for four residents (#19, #21, #22, and #20) of four reviewed for wound care; 4) to provide medication administration per physician orders for three residents (#1, #13, #15) of three reviewed for medications; 5) to provide assistance with Activities of Daily Living (ADL's) related to showers, incontinence care, and assistance with meals for six resident (#16, #18, #7, #17, #24, and #25) out of six reviewed for Activities of Daily Living; 6) to provide laboratory services as ordered for three residents (#14, #13, and #10) out of three reviewed for laboratory orders. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #3, #8, #12, #9, #19, #21, #22, #20, #1, #13, #15, #16, #18, #7, #17, #24, #25 #14, and #10 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E. Findings included: 1. Review of Resident #3's progress note, dated [DATE] at 9:48 a.m., authored by Staff M, Licensed Practical Nurse (LPN) showed the following: Upon arriving on the unit and doing rounds the resident was observed sitting in wheelchair by resident's room door chanting but not outside of her normal behavior. Another nurse came and informed the nurse that the resident posture was not looking normal and if I would assess her. Upon walking up to the resident, the posture was abnormal, and her leg was twisted. When approaching the resident to touch her she begin screaming. Wheelchair was in locked position. The resident admitted to pain and responded to yes or no type questions. The nurse asked if she was in pain she stated 'yes'. The nurse asked was her leg bothering her and she stated 'yes'. The nurse asked did she fall, and she stated, 'yes'. When asked can the nurse look at her leg she stated, 'no don't'. PRN [as needed] offered to resident for pain but resident was not eating or drinking breakfast tray in front of her. EMS [Emergency Management Services] arrived and took resident to [Hospital Name]. Supervisor notified [family member] of resident's transfer. [Physician] office notified. Review of Resident #3's progress note, dated [DATE] at 2:45 p.m., authored by Staff M, LPN showed the following: The nurse spoke with ER [emergency room ] at [Hospital Name] and was notified that the resident was admitted for UTI [Urinary Tract Infection] and hip fracture. Review of Admission Records showed Resident #3 was admitted on [DATE] with diagnoses including pacemaker placement, weakness, low back pain, Alzheimer's disease, and other co-morbidities. Review of Resident #3's Quarterly Minimum Data Set (MDS), dated [DATE], showed the resident required maximum assistance with all Activities of Daily Living (ADL) care, the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months, and the resident had not had any falls since admission/entry or reentry prior to the assessment. Review of Resident #3's Comprehensive Care Plan, [DATE], showed the following: Focus: Resident needed assistance with activities of daily living because of a diagnosis of dementia with memory impairment, pain, and weakness. Goals included: -Caregivers will be able to perform a safe transfer using proper body mechanics with 100% carryover by the next review date. -Resident will perform self-feeding tasks with supervision or touching assistance by next review date. -Staff will help me with all my ADL needs so that I appear neat and tidy with absence of foul body odor through next review. Interventions included: -Anticipate resident's needs. -Assist me with hygiene, bathing, dressing, toileting and transfers. -Assist me with toileting promptly when requested. -Assist with all ADL care to ensure daily needs are met. Check nails, trim and clean on bath day and as necessary. -Encourage/allow me to do as much for self as possible with feeding self, provide assistance with ADLs that I am unable to do for myself as indicated. -Keep call bell within reach and remind/encourage me to use it to call for assistance. -Skin inspections twice a week on shower days and with ADL care: Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Review of the facility's Incident Log, from [DATE] to [DATE], did not reveal any incidents related to Resident #3 suffering an injury of unknown origin. Review of the facility's Abuse and Neglect Log, from [DATE] to [DATE], did not reveal any allegations/incidents of abuse or neglect for Resident #3 had occurred or been reported. Review of Resident #3's progress note, dated [DATE] at 3:20 p.m., authored by the Nursing Home Administrator (NHA) showed: Writer spoke to [family member] who stated that she was with [Resident #3] at the hospital and [Resident #3] was admitted with a hip fracture and UTI. I notified [family member] that we were working on the root cause investigation, and she was satisfied and understood. Review of Emergency Department (ED) records for Resident #3, dated [DATE], showed per EMS she had a possible trip and fall it was unwitnessed, but she does slip out of her wheelchair multiple times per the facility has a history of hip fracture falls . It showed prior to arrival in the ED the resident had 70 mcg (micrograms) of Fentanyl for pain, and she endorsed pain when pressing on her right hip. The extremities physical assessment showed, no deformity, moderate trauma. Difficult to examine the patient's right leg patient is curled up in bed she usually is in a wheelchair moderately confused and not following direction with palpitation of the patient's right thigh/right hip she does scream in excruciating pain . Review of the hospital History and Physical for Resident #3, dated [DATE], showed the resident was brought to the emergency department after she was found on the floor .patient found to have right periprosthetic proximal fracture with significant angulation . Review of the hospital Operative Reports for Resident #3, dated [DATE], showed the resident underwent an open reduction and internal fixation of right periprosthetic proximal femur fracture. The surgeon noted, The rationale for surgery would be for palliative measures. I do not anticipate this fracture will heal to the point where she will be more functional than she was before the injury, which was bedbound, wheelchair dependent, non-weight bearing. My hope is that the incision heals, and she does not develop any perioperative complications arising, such as blood clots, infections, wound healing problems, fractures, dislocations, or risks of the medications and anesthesia. Review of Resident #3's progress note, dated [DATE] at 3:36 p.m., authored by the Director of Nursing (DON) showed: Investigation and statements stated that fx [fracture] happened during transfer of resident from bed to chair. Resident at no time had a fall. Daughter made aware of findings of investigation. An interview was conducted on [DATE] at 4:43 p.m. with the DON and Risk Manager (RM). The DON stated during an investigation it was determined Resident #3's fracture occurred during a transfer. The DON said she had been notified the resident was transferred out with a potential fracture on [DATE]. She stated an investigation was started to see how the possible fracture happened. She said a report was not filed for abuse or neglect as the fracture occurred during transfer. An interview was conducted on [DATE] at 5:08 p.m. with the Nursing Home Administrator (NHA) and the Administrator in Training (AIT). The NHA said he became aware of Resident #3's fracture during a morning meeting on [DATE] when a nurse's note was read that stated Resident #3 had a fall. He said the management team reviewed the statements from the staff who worked, and everyone stated there was no fall. He said the management team did not complete interviews, they just read the written statements received. The NHA explained the Department of Children and Families (DCF) came in later that same morning ([DATE]) as the hospital had contacted them regarding the fracture. The NHA said the management team investigated and determined Resident #3 did not have a fall, therefore they did not file a reportable event. The NHA said the investigation they did, did not indicate how the resident was transferred to the wheelchair. During a follow-up interview on [DATE] at 9:38 a.m. with the NHA. The NHA stated he did not know how the fracture occurred, he stated, I went off the DCF investigation. An interview was conducted on [DATE] at 5:35 p.m. with Staff M, LPN. Staff M stated being familiar with Resident #3 and recalled the event on [DATE]. She said upon arrival to the unit on [DATE], Resident #3 was up in the wheelchair. Staff M said Resident #3 was usually self-propelling around the unit and talked nonsensically. She said on the morning on [DATE] Resident #3 was not self-propelling nor speaking as usual. Staff M said she did not think much of it, she thought maybe Resident #3 was just tired from the night before. She said another nurse came to her and asked if she thought Resident #3 looked funny. She stated, I then noted the angle of Resident #3's leg was not right. Staff M said she went to assess the resident's leg and as soon as she reached for her leg, Resident #3 started screaming. Staff M said the resident answered yes to being in pain when asked. She said Resident #3 was not able to be touched therefore they contacted 911. Staff M said when she was on the phone with 911, the DON told her to cancel the call, because the x-rays could be conducted in the facility. Staff M said she did not cancel the call and when 911 arrived, they had to sedate Resident #3 so she could be moved from the wheelchair to stretcher. An interview was conducted on [DATE] at 12:00 p.m. with Staff O, Certified Nursing Assistant (CNA). Staff O said she recalled Resident #3 and the shift when the fracture occurred. She said she worked [DATE] for the 3 p.m. to 11 p.m. shift and the 11 p.m. to 7 a.m. shift ending [DATE]. Staff O said she was not assigned to Resident #3. She said Staff P, CNA asked her to help transfer Resident #3. Staff O explained she overheard Resident #3 scream multiple times during the night, which is normal for her, so she did not think much about it. Staff O said when she entered the room to assist Staff P, Resident #3 screams were different, painful almost. She said she helped Staff P place Resident #3 in the wheelchair. Staff O explained for the transfer of Resident #3, she placed her arm under the resident's, to assist with standing. She said the two CNAs had the resident pivot and they assisted the resident to sit in the wheelchair. Staff O said she does not recall if the resident scream out or just took a deep breath during the transfer, but it was very quick. Staff O said Staff P was rushing and wanted to get off shift. Staff O said typically when Resident #3 was in the wheelchair, she self-propelled throughout the unit but she did not go anywhere. She said she thought Resident #3 was just tired from being up most of the night. Staff O said later that same morning she observed blood on the arm of Resident #3 and informed the nurse. Staff O stated no skin tears occurred during the transfer. Staff O stated no one ever spoke with her regarding the fracture until the next day when the supervisor asked her to write a statement as Resident #3 had a fracture. She stated she did not hear anything else regarding the subject. An interview was conducted on [DATE] at 11:38 a.m. with Staff Q, CNA. Staff Q recalled working [DATE] on the 11 p.m. to 7 a.m. shift into [DATE] and stated Resident #3 was on the morning list to get up early. She said Staff P, CNA was assigned to Resident #3 and would have been the one to transfer the resident. She said she did not recall anyone mentioning anything throughout the shift, it was a normal night until she noticed Resident #3 had blood on her hand and was gripping her hip. Staff Q said she brought this to the attention of Staff M, LPN and Staff G, LPN. She said the nurses commented about the resident's leg looking odd. She said she didn't notice the resident's leg at the time as she was looking at the blood on her hand. She said Staff M, LPN called 911 and while Staff M was on the phone, the DON told her to hang up because we could take care of the resident here. She said the nurse didn't hang up the phone. Staff Q said she was surprised that no one asked her about the incident. An interview was conducted on [DATE] at 11:18 a.m. with Staff G, LPN. Staff G confirmed he worked the evening of [DATE] into the morning of [DATE] and said he was the one that saw Resident #3 sitting in her wheelchair and her leg bent awkwardly. Staff G said he informed Staff M, LPN and told her to look at Resident #3 and Staff M immediately said, Oh her leg is broken. Staff G said they were not able to touch the leg because the resident would scream. Staff G said no one looked into how the fracture occurred. Staff G said they didn't know if Resident #3 fell and just got put back in the wheelchair. He said Resident #3 didn't ever try to walk or get out of bed and to his knowledge had never fallen before. Staff G said management did not know what happened, they got statements from a couple of CNAs then moved Staff P, CNA, who was assigned Resident #3, to a different floor. An interview was conducted on [DATE] at 2:35 p.m. with Staff P, CNA. Staff P stated she recalled Resident #3 and worked with on the 11p ([DATE]) to 7a ([DATE]) shift. Staff P said, I don't know anything about a fracture. Staff P said she arrived at the unit and Resident #3 was in the bed sleeping. Staff P said around 2:00 a.m. she completed incontinence care for Resident #3 while the resident slept. Staff P added Resident #3 was a squealing person, Resident #3 squeals all the time. She said Resident #3 was on the get up list so she got Resident #3 dressed and requested assistance from another CNA with the transfer to the wheelchair. Staff P could not recall how the transfer of Resident #3 occurred and denied any knowledge of a fracture or skin tear. Staff P said, If something happened maybe on her [Staff O, CNA]. Staff P, CNA stated, I didn't do anything wrong, DCF and the NHA said so. Staff P then disconnected the phone call. Review of Resident #3's primary care provider (PCP) note, dated [DATE], showed Patient was readmitted to [facility] on [DATE]. Patient was sent to ER for right hip pain that she sustain during a fall per hospital records. Review of Resident #3's Social Service note, dated [DATE] showed Resident will be hospice resident as of tomorrow, [DATE] . A progress note, dated [DATE], showed Resident without vital signs. Family made aware. Hospice was also notified. An interview was conducted on [DATE] at 4:37 p.m. with Staff N, (CNA). Staff N said she had taken care of Resident #3 several times and did hear about the fracture. She said she was not working at the time of the incident but heard the CNA tried to transfer Resident #3 and dropped her. Staff N said, Sad, resident was perfectly fine before the fall, when she came back, she just went downhill medically, never the same. An interview was conducted on [DATE] at 2:37 p.m. with Resident #3's primary care provider (PCP). He said he remembered the incident with Resident #3 and recalled that Staff H, Nurse Practitioner (NP) was upset neither of them were notified. The PCP reviewed Resident #3's medical records. He said the hospital records showed the resident had a fall and another note said there were no falls. He said, I would assume the facility has protocols in place if a resident had a fracture and they don't know where it came from. He said there should be a protocol and procedure for falls/injuries. An interview was conducted on [DATE] at 2:47 p.m. with Staff H, Nurse Practitioner (NP). She said she was a provider for Resident #3. She said she had not been notified when Resident #3 had a fall. She said facility staff should have called when something happened to a resident. She said she did not know until the resident returned from the hospital and she saw the fall in the hospital record. Staff H said the resident was having pain but was stable after she returned. She said, For sure, they should look into that if it is not known where the fracture came. Staff H said the resident's fracture was fixed for comfort, not really to be able to walk on it. 2. Review of the facility's Admission/Discharge To/From Report, dated [DATE] to [DATE], revealed Resident #8 was discharged to an acute care hospital on [DATE]. Review of the facility's Incident Log, dated ,d+[DATE] to ,d+[DATE], revealed Resident #8 had a fall on [DATE]. Review of a progress note for Resident #8, dated [DATE] at 11:35 p.m., by Staff S, LPN showed, This writer noticed other nurses and cna's running down the hall, I went to see what was going on and witnessed other nurses assisting the resident and speaking to keep to keep [sic] him awake. A focus assessment was performed on the resident. Resident Vital signs, kept residents on his Rt [right] side to prevent aspiration, held gauze and applied pressure to eyebrow area. 911 was called and stayed with the patient until EMS [Emergency Management Service] arrived. A message was left with the PCP [Primary Care Provider] answering service. Family was called and voicemail was left, shift supervisor was notified. Review of Admission Records showed Resident #8 was admitted on [DATE] with diagnoses including Cerebrovascular Accident (stroke) with right hemiparesis, sepsis, dysphagia, wounds, and other co-morbidities. Review of Resident #8's Admission MDS, dated [DATE], showed the resident was dependent with all activities of daily living care (ADL), had impairments in both upper and lower extremities preventing movement, and the resident had not had any falls since admission/entry or reentry prior to assessment. An interview was conducted on [DATE] at 3:31 p.m. with Staff S, LPN. Staff S, LPN confirmed working with Resident #8 on [DATE] and recalled the incident. Staff S recalled coming out of another resident's room seeing all these employees going to Resident #8's room. Staff S said she immediately followed, as she was the assigned nurse. She said upon arrival, she noted Resident #8 on the floor with blood on his head. Staff S said the CNA responsible for the resident (Staff T, CNA) stated she turned the resident, and he rolled out of the bed. She stated Resident #8 had an air mattress with collapsable sides. Staff S stated she was not sure how this happened as Resident #8 was tall, thin, and did not move. An interview was conducted on [DATE] at 5:13 p.m. with Staff T, CNA. Staff T confirmed she cared for Resident #8 on the night of [DATE]. She said he often had behaviors and yelled. She said she went in and talked to him, and he was calm. She said since the resident was calm, she thought she could clean him up on her own. She said she cleaned up his front and rolled him away from her to clean up his back side. She said the resident was on an air mattress and they are slippery. She said he was not really on a sheet. She said when she rolled him away from her, he slipped off the other side. She said she tried to catch him by his shirt, but he fell off and hit the floor. She said as that happened, she had to let go of his shirt and go search for someone to help. She said she went outside and got the nurse assigned to him. She said she didn't really know his injuries, but he was bleeding, and the nurse started working on him. The CNA said she had previously assisted with Resident #8 being cleaned and changed because he was sometimes combative. She said she was only worried about his behavior and thought since he was calm, she could change him herself. She said the CNAs do not know if a resident is a one-person or a two-person assist because it is not in the computer or on their Kardex. She said they have to go off of personal judgement and it is sometimes passed down from the previous shift's CNA. Staff T explained if shift to shift report was not completed, then you just go off your experience. She said the facility had not done any training on turning/positioning residents before or after the incident with Resident #8. Review of Resident #8's Comprehensive Care Plan, [DATE], showed the following: -Focus: Resident needed assistance with activities of daily living because of weakness. The goal showed: I will improve my ability to transfer, dress, toilet, ambulate by next review. The interventions included: Anticipate resident's needs; Assist me with all oral intake of food and fluids; Assist me with hygiene, bathing, dressing, toileting and transfers; Assist me with toileting promptly when requested; Assist with all ADL care to ensure daily needs are met. -Focus: The staff have identified that I am at risk for falls because of these risk factors: Unaware of safety needs. The goal showed: I will have minimized injury due to a fall through next review. The interventions included: Anticipate resident's needs; I should have sneakers, shoes, slippers with rubber soles or non-slip socks when I am out of bed; Keep frequently used items within reach: TV remote, tissues, water glass over bed stand and my water glass (unless I need thickened liquids or can't have anything by mouth); Keep my call light within reach so I can call for assistance; Maintain bed in lowest locked position. -Focus: At times I can agitated, combative, continuous outburst. The goal showed: I will show a decrease in my episodes of being resistant thru next review. The interventions included: Allow choices when able to give resident feeling of control; Converse with during care about topic of interest to redirect; Monitor for effectiveness of medication prescribed to limit behavior; Report to Dr if not effective or behavior continues to decline; Psych eval and follow up per order. An interview was conducted on [DATE] at 1:10 p.m. with Staff Z, LPN UM (Unit Manager). Staff Z said residents were evaluated by therapy and those results were sent to the MDS team. She said MDS then enters the information about the functional level of the resident and that populates to the Kardex. She said it usually says dependent or max assist, something like that. She said dependent means two-person assist and maximum assist means ,d+[DATE]. When asked how the CNAs would know which to use since they cannot assess residents she said, That is all I know about the process. An interview was conducted on [DATE] at 12:48 p.m. with Staff Y, CNA. She said the facility had not done any training on turning, positioning, or transferring residents. She said the CNAs do not know if a resident is a one or two-person assist or if they need a lift. She said the CNAs have To figure it out. Interviews were conducted from [DATE] to [DATE] at various times with the following staff: Staff U, D, W, X, V, N, O, Q, CNA's. During these interviews staff stated the computer system does not indicate specific directions for what level of care (i.e Assist of one, mechanical lift) is needed for residents' ADL needs. The staff stated usually they just know how to care for residents based on our experience. The CNAs said they try to complete shift to shift report to inform other CNAs of care needs, but it does not always happen with staffing patterns and time constraints. An interview was conducted on [DATE] at 2:23 p.m. with the MDS Coordinator. She said approximately a year ago, when the Minimum Data Set (MDS) changed from section G to section GG, it quit having an assist of 1 or two option. She stated related to the care plan not indicating a level of assistance needed, That is not a directive I have been given here. She said the CNAs would just know the level of care from passing it down in report. She doesn't know how else they would know. The MDS Coordinator confirmed CNAs cannot assess residents. Review of hospital records for Resident #8, dated [DATE], showed the resident presented to the emergency department and underwent a head and maxillofacial CT (computed tomography) scan which revealed an 8 millimeter (mm) subdural hemorrhage layering along the right frontotemporal convexity, with no significant midline shift, interval development of large right frontotemporal infarct is noted compared to February 2022, and possible acute/subacute. The resident was noted to have a right front scalp hematoma which was a laceration, and sutures were applied. Upon arrival the resident was noted to have a forehead laceration with a dressing in place that was blood soaked. The resident was unable to answer questions correctly although he was attempting to. The CT scan results, dated [DATE], showed the following: Calvarium/Scalp: large right frontal scalp hematoma calvaria fracture evaluation limited by motion artifact. CT Maxillofacial: comminuted right greater than left nasal bone fractures moderate overlying soft tissue swelling. Review Resident #8's ER record showed the resident received 12 sutures to right eyebrow laceration. Resident #8 was admitted to the ICU (intensive care unit). No other documentation is available at this time. An interview was conducted on [DATE] at 4:10 p.m. with the NHA and DON. The NHA stated the facility was following Resident #8's plan of care with one-person assist. The NHA confirmed the care plan did not have assist requirements as an intervention. The NHA stated, I thought it was there. The NHA stated no investigation was needed. The NHA stated after comparing statements from staff he decided to eventually find the CNA neglected to utilize proper positioning techniques and the facility had no control over this. The NHA stated this was based on the DCF investigation. After the NHA spoke with the investigator, the NHA decided to start a neglect report. The NHA stated the report was filed and the nursing assistant was reported to the board. The NHA and DON stated no other actions needed to be taken. They stated they did not do any in-services, review their policies, or interview other residents. They stated no education was provided to staff post-incident. An interview was conducted on [DATE] at 4:38 p.m. with the Director of Rehabilitation (DOR). He said Resident #8 had severe safety awareness concerns and had decreased coordination. He said Resident #8 was totally dependent and in therapy that means they would use two people to assist. He said nursing decides if two people should be used for transfers and care on the unit. He said the Resident #8 had rigid tone so Everything is total dependent, and he needs a lot of help. He said the resident having rigid tone means staff would have to hold him because he cannot hold himself while turning. He said if the resident was being turned, he would need a person on each side of him. The DOR stated, To roll him he still needs a lot of help. He said if the resident didn't have control, it is dangerous for a CNA to roll the resident away from them because they can roll off the bed if no one is on the other side. The DOR said for therapy, Total dependent means max assist; two people and lifts. Review of the facility's Abuse and Neglect Log, dated ,d+[DATE] to ,d+[DATE], did not reveal any reports after [DATE] of any incidents of abuse or neglect. An interview was conducted on [DATE] at 10:33 a.m. with the DON. The DON stated she had validated with the NHA, no other reports or allegations of abuse or neglect had been made since [DATE]. 3. Review of the facility's Admission/Discharge To/From Report, for dates [DATE] to [DATE], revealed Resident #12 was discharged to an acute care hospital on [DATE]. Review of Resident #12's progress notes, dated [DATE] at 3:31 p.m., authored by the DON showed: Resident had a fall blood pressure is ,d+[DATE] pulses 85. We're sending her to the hospital. Review of Resident #12's progress notes, dated [DATE] at 3:44 p.m., authored by Staff AA, Registered Nurse (RN) showed: Pt [patient] found on the floor at evacuation site. VSS [Vital Signs Stable]. EMS [Emergency Medical Services] on site. Pt sent to hospital. Family called. Message left. Review of Admission Records showed Resident #12 was admitted on [DATE] with diagnoses including hypertension, weakness, dementia, Huntington's disease, and other co-morbidities. Review of Resident #12's Admission MDS, dated [DATE], Section C, Cognitive Patterns, revealed a BIMS score of 8, indicated the resident had moderate cognitive impairment, Section J, Health Conditions showed no pain and no falls. Review of Resident #12's Physical Therapy Discharge Summary, dated [DATE], showed: Resident #12 was able to perform sitting to standing with the use of an assistive device; was able to transfer with supervision only, and was able to walk 150 feet with a front wheeled walker with contact guard assistance. Review of Resident #12 Comprehensive Care Plan, [DATE], shows: -Focus: The staff have identified that I am at risk for falls because of these risk factors: Dementia, use of anti-psychotic medication, use of antidepressant medication. The care plan interventions showed: Anticipate resident's needs; I should have sneakers, shoes, slippers with rubber soles or non-slip socks when I am out of bed; Keep frequently used items within reach: TV remote, tissues, water glass over bed stand and my water glass (unless I need thickened liquids or can't have anything by mouth); Keep my call light within reach so I can call for assistance; Maintain bed in lowest locked position. -Focus: I need assistance with activities of daily living because of weakness. The care plan intervention showed: Anticipate resident's needs; Assist me with all oral intake of food and fluids; Assist me with hygiene, bathing, dressing, toileting and transfers; Assist me with toileting promptly when requested; Assist with all ADL care to ensure daily needs are met. -Focus: The resident has an ADL Self Care Performance Deficit r/t Activity Intolerance, r/t cognitive deficits. The interventions showed: Encourage the resident to participate to the fullest extent possible with each interaction; Encourage the resident to use bell to call for assistance; Anticipate needs not verbalized as resident does not always clearly make needs Nursing known. Keep call bell within reach, encourage use, answer promptly. An interview was conducted on [DATE] at 3:15 p.m. with the NHA and AIT. They stated the facility needed to prepare for evacuation to a church on [DATE]. The NHA said at the church the County Emergency Management showed up and stated the facility should move their residents to a county shelter. The NHA and AIT stated no one was seriously injured, no one died , and no one eloped. They said there may have been a skin tear. The NHA stated, We did the best we could. The NHA confirmed they did not comple a post-storm assessment, as they did not have time; they needed to get ready for the next storm. An interview was conducted on [DATE] at 11:50 a.m. with Staff V, CNA. Staff V stated, During the evacuation things happened. Staff V stated, Yes there was a fall. I was in the gym where [Resident #12] was assigned. The management did not leave out assignments for CNAs, so I am not sure who was responsible for [Resident #12]. Staff V said, I was in a doorway and heard a loud thud. I turned and noted [Resident #12[ o [TRUNCATED]

Based on interviews and record review, the facility failed to provide a hazard free environment and adequate supervision for three residents (#3, #8, and #12) of three reviewed for falls with injuries, resulting in the need for transfer to a higher level of care for evaluation and treatment. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Residents #3, #8, and #12 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a E. Findings included: 1. Review of Resident #3's progress note, dated [DATE] at 9:48 a.m., authored by Staff M, Licensed Practical Nurse (LPN) showed the following: Upon arriving on the unit and doing rounds the resident was observed sitting in wheelchair by resident's room door chanting but not outside of her normal behavior. Another nurse came and informed the nurse that the resident posture was not looking normal and if I would assess her. Upon walking up to the resident, the posture was abnormal, and her leg was twisted. When approaching the resident to touch her she begin screaming. Wheelchair was in locked position. The resident admitted to pain and responded to yes or no type questions. The nurse asked if she was in pain she stated 'yes'. The nurse asked was her leg bothering her and she stated 'yes'. The nurse asked did she fall, and she stated, 'yes'. When asked can the nurse look at her leg she stated, 'no don't'. PRN [as needed] offered to resident for pain but resident was not eating or drinking breakfast tray in front of her. EMS [Emergency Management Services] arrived and took resident to [Hospital Name]. Supervisor notified [family member] of resident's transfer. [Physician] office notified. Review of Resident #3's progress note, dated [DATE] at 2:45 p.m., authored by Staff M, LPN showed the following: The nurse spoke with ER [emergency room ] at [Hospital Name] and was notified that the resident was admitted for UTI [Urinary Tract Infection] and hip fracture. Review of Admission Records showed Resident #3 was admitted on [DATE] with diagnoses including pacemaker placement, weakness, low back pain, Alzheimer's disease, and other co-morbidities. Review of Resident #3's Quarterly Minimum Data Set (MDS), dated [DATE], showed the resident required maximum assistance with all ADL care, the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months, and the resident had not had any falls since admission/entry or reentry prior to the assessment. Review of Resident #3's Comprehensive Care Plan, [DATE], showed the following: Focus: Resident needed assistance with activities of daily living because of a diagnosis of dementia with memory impairment, pain, and weakness. Goals included: -Caregivers will be able to perform a safe transfer using proper body mechanics with 100% carryover by the next review date. -Resident will perform self-feeding tasks with supervision or touching assistance by next review date. -Staff will help me with all my ADL needs so that I appear neat and tidy with absence of foul body odor through next review. Interventions included: -Anticipate resident's needs. -Assist me with hygiene, bathing, dressing, toileting and transfers. -Assist me with toileting promptly when requested. -Assist with all ADL care to ensure daily needs are met. Check nails, trim and clean on bath day and as necessary. -Encourage/allow me to do as much for self as possible with feeding self, provide assistance with ADLs that I am unable to do for myself as indicated. -Keep call bell within reach and remind/encourage me to use it to call for assistance. -Skin inspections twice a week on shower days and with ADL care: Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Review of the facility's Incident Log, from [DATE] to [DATE], did not reveal any incidents related to Resident #3 suffering an injury of unknown origin. Review of the facility's Abuse and Neglect Log, from [DATE] to [DATE], did not reveal any allegations/incidents of abuse or neglect for Resident #3 had occurred or been reported. Review of Resident #3's progress note, dated [DATE] at 3:20 p.m., authored by the Nursing Home Administrator (NHA) showed: Writer spoke to [family member] who stated that she was with [Resident #3] at the hospital and [Resident #3] was admitted with a hip fracture and UTI. I notified [family member] that we were working on the root cause investigation, and she was satisfied and understood. Review of Emergency Department (ED) records for Resident #3, dated [DATE], showed per EMS she had a possible trip and fall it was unwitnessed, but she does slip out of her wheelchair multiple times per the facility has a history of hip fracture falls . It showed prior to arrival in the ED the resident had 70 mcg (micrograms) of Fentanyl for pain, and she endorsed pain when pressing on her right hip. The extremities physical assessment showed, no deformity, moderate trauma. Difficult to examine the patient's right leg patient is curled up in bed she usually is in a wheelchair moderately confused and not following direction with palpitation of the patient's right thigh/right hip she does scream in excruciating pain . Review of the hospital History and Physical for Resident #3, dated [DATE], showed the resident was brought to the emergency department after she was found on the floor .patient found to have right periprosthetic proximal fracture with significant angulation . Review of the hospital Operative Reports for Resident #3, dated [DATE], showed the resident underwent an open reduction and internal fixation of right periprosthetic proximal femur fracture. The surgeon noted, The rationale for surgery would be for palliative measures. I do not anticipate this fracture will heal to the point where she will be more functional than she was before the injury, which was bedbound, wheelchair dependent, non-weight bearing. My hope is that the incision heals, and she does not develop any perioperative complications arising, such as blood clots, infections, wound healing problems, fractures, dislocations, or risks of the medications and anesthesia. Review of Resident #3's progress note, dated [DATE] at 3:36 p.m., authored by the Director of Nursing (DON) showed: Investigation and statements stated that fx [fracture] happened during transfer of resident from bed to chair. Resident at no time had a fall. Daughter made aware of findings of investigation. An interview was conducted on [DATE] at 4:43 p.m. with the DON and Risk Manager (RM). The DON stated during an investigation it was determined Resident #3's fracture occurred during a transfer. The DON said she had been notified the resident was transferred out with a potential fracture on [DATE]. She stated an investigation was started to see how the possible fracture happened. She said a report was not filed for abuse or neglect as the fracture occurred during transfer. An interview was conducted on [DATE] at 5:08 p.m. with the Nursing Home Administrator (NHA) and the Administrator in Training (AIT). The NHA said he became aware of Resident #3's fracture during a morning meeting on [DATE] when a nurse's note was read that stated Resident #3 had a fall. He said the management team reviewed the statements from the staff who worked, and everyone stated there was no fall. He said the management team did not complete interviews, they just read the written statements received. The NHA explained the Department of Children and Families (DCF) came in later that same morning ([DATE]) as the hospital had contacted them regarding the fracture. The NHA said the management team investigated and determined Resident #3 did not have a fall, therefore they did not file a reportable event. The NHA said the investigation they did, did not indicate how the resident was transferred to the wheelchair. During a follow-up interview on [DATE] at 9:38 a.m. with the NHA. The NHA stated he did not know how the fracture occurred, he stated, I went off the DCF investigation. An interview was conducted on [DATE] at 5:35 p.m. with Staff M, LPN. Staff M stated being familiar with Resident #3 and recalled the event on [DATE]. She said upon arrival to the unit on [DATE], Resident #3 was up in the wheelchair. Staff M said Resident #3 was usually self-propelling around the unit and talked nonsensically. She said on the morning on [DATE] Resident #3 was not self-propelling nor speaking as usual. Staff M said she did not think much of it, she thought maybe Resident #3 was just tired from the night before. She said another nurse came to her and asked if she thought Resident #3 looked funny. She stated, I then noted the angle of Resident #3's leg was not right. Staff M said she went to assess the resident's leg and as soon as she reached for her leg, Resident #3 started screaming. Staff M said the resident answered yes to being in pain when asked. She said Resident #3 was not able to be touched therefore they contacted 911. Staff M said when she was on the phone with 911, the DON told her to cancel the call, because the x-rays could be conducted in the facility. Staff M said she did not cancel the call and when 911 arrived, they had to sedate Resident #3 so she could be moved from the wheelchair to stretcher. An interview was conducted on [DATE] at 12:00 p.m. with Staff O, Certified Nursing Assistant (CNA). Staff O said she recalled Resident #3 and the shift when the fracture occurred. She said she worked [DATE] for the 3 p.m. to 11 p.m. shift and the 11 p.m. to 7 a.m. shift ending [DATE]. Staff O said she was not assigned to Resident #3. She said Staff P, CNA asked her to help transfer Resident #3. Staff O explained she overheard Resident #3 scream multiple times during the night, which is normal for her, so she did not think much about it. Staff O said when she entered the room to assist Staff P, Resident #3 screams were different, painful almost. She said she helped Staff P place Resident #3 in the wheelchair. Staff O explained for the transfer of Resident #3, she placed her arm under the resident's, to assist with standing. She said the two CNAs had the resident pivot and they assisted the resident to sit in the wheelchair. Staff O said she does not recall if the resident scream out or just took a deep breath during the transfer, but it was very quick. Staff O said Staff P was rushing and wanted to get off shift. Staff O said typically when Resident #3 was in the wheelchair, she self-propelled throughout the unit but she did not go anywhere. She said she thought Resident #3 was just tired from being up most of the night. Staff O said later that same morning she observed blood on the arm of Resident #3 and informed the nurse. Staff O stated no skin tears occurred during the transfer. Staff O stated no one ever spoke with her regarding the fracture until the next day when the supervisor asked her to write a statement as Resident #3 had a fracture. She stated she did not hear anything else regarding the subject. An interview was conducted on [DATE] at 11:38 a.m. with Staff Q, CNA. Staff Q recalled working [DATE] on the 11 p.m. to 7 a.m. shift into [DATE] and stated Resident #3 was on the morning list to get up early. She said Staff P, CNA was assigned to Resident #3 and would have been the one to transfer the resident. She said she did not recall anyone mentioning anything throughout the shift, it was a normal night until she noticed Resident #3 had blood on her hand and was gripping her hip. Staff Q said she brought this to the attention of Staff M, LPN and Staff G, LPN. She said the nurses commented about the resident's leg looking odd. She said she didn't notice the resident's leg at the time as she was looking at the blood on her hand. She said Staff M, LPN called 911 and while Staff M was on the phone, the DON told her to hang up because we could take care of the resident here. She said the nurse didn't hang up the phone. Staff Q said she was surprised that no one asked her about the incident. An interview was conducted on [DATE] at 11:18 a.m. with Staff G, LPN. Staff G confirmed he worked the evening of [DATE] into the morning of [DATE] and said he was the one that saw Resident #3 sitting in her wheelchair and her leg bent awkwardly. Staff G said he informed Staff M, LPN and told her to look at Resident #3 and Staff M immediately said, Oh her leg is broken. Staff G said they were not able to touch the leg because the resident would scream. Staff G said no one looked into how the fracture occurred. Staff G said they didn't know if Resident #3 fell and just got put back in the wheelchair. He said Resident #3 didn't ever try to walk or get out of bed and to his knowledge had never fallen before. Staff G said management did not know what happened, they got statements from a couple of CNAs then moved Staff P, CNA, who was assigned Resident #3, to a different floor. Staff G said, there were Many incidences of neglect that could have been prevented. He said, It is my belief she died from it, speaking of Resident #3's hip fracture. Review of the facility's staff roster did not list Staff R, LPN. The AIT stated Staff R, LPN is no longer employed at the facility but gave the last known phone number. On [DATE] at 4:00 p.m. the number was called, and a message was heard stating the number had been disconnected. An interview was conducted on [DATE] at 2:35 p.m. with Staff P, CNA. Staff P stated she recalled Resident #3 and worked with on the 11p ([DATE]) to 7a ([DATE]) shift. Staff P said, I don't know anything about a fracture. Staff P said she arrived at the unit and Resident #3 was in the bed sleeping. Staff P said around 2:00 a.m. she completed incontinence care for Resident #3 while the resident slept. Staff P added Resident #3 was a squealing person, Resident #3 squeals all the time. She said Resident #3 was on the get up list so she got Resident #3 dressed and requested assistance from another CNA with the transfer to the wheelchair. Staff P could not recall how the transfer of Resident #3 occurred and denied any knowledge of a fracture or skin tear. Staff P said, If something happened maybe on her [Staff O, CNA]. Staff P, CNA stated, I didn't do anything wrong, DCF and the NHA said so. Staff P then disconnected the phone call. Review of Resident #3's primary care provider (PCP) note, dated [DATE], showed Patient was readmitted to [facility] on [DATE]. Patient was sent to ER for right hip pain that she sustain during a fall per hospital records. Review of Resident #3's Social Service note, dated [DATE] showed Resident will be hospice resident as of tomorrow, [DATE] . A progress note, dated [DATE], showed Resident without vital signs. Family made aware. Hospice was also notified. An interview was conducted on [DATE] at 4:37 p.m. with Staff N, (CNA). Staff N said she had taken care of Resident #3 several times and did hear about the fracture. She said she was not working at the time of the incident but heard the CNA tried to transfer Resident #3 and dropped her. Staff N said, Sad, resident was perfectly fine before the fall, when she came back, she just went downhill medically, never the same. An interview was conducted on [DATE] at 2:37 p.m. with Resident #3's primary care provider (PCP). He said he remembered the incident with Resident #3 and recalled that Staff H, Nurse Practitioner (NP) was upset neither of them were notified. The PCP reviewed Resident #3's medical records. He said the hospital records showed the resident had a fall and another note said there were no falls. He said, I would assume the facility has protocols in place if a resident had a fracture and they don't know where it came from. He said there should be a protocol and procedure for falls/injuries. An interview was conducted on [DATE] at 2:47 p.m. with Staff H, Nurse Practitioner (NP). She said she was a provider for Resident #3. She said she had not been notified when Resident #3 had a fall. She said facility staff should have called when something happened to a resident. She said she did not know until the resident returned from the hospital and she saw the fall in the hospital record. Staff H said the resident was having pain but was stable after she returned. She said, For sure, they should look into that if it is not known where the fracture came. Staff H said the resident's fracture was fixed for comfort, not really to be able to walk on it. 2. Review of the facility's Admission/Discharge To/From Report, dated [DATE] to [DATE], revealed Resident #8 was discharged to an acute care hospital on [DATE]. Review of the facility's Incident Log, dated ,d+[DATE] to ,d+[DATE], revealed Resident #8 had a fall on [DATE]. Review of a progress note for Resident #8, dated [DATE] at 11:35 p.m., by Staff S, LPN showed, This writer noticed other nurses and cna's running down the hall, I went to see what was going on and witnessed other nurses assisting the resident and speaking to keep to keep [sic] him awake. A focus assessment was performed on the resident. Resident Vital signs, kept residents on his Rt [right] side to prevent aspiration, held gauze and applied pressure to eyebrow area. 911 was called and stayed with the patient until EMS [Emergency Management Service] arrived. A message was left with the PCP [Primary Care Provider] answering service. Family was called and voicemail was left, shift supervisor was notified. Review of Admission Records showed Resident #8 was admitted on [DATE] with diagnoses including Cerebrovascular Accident (stroke) with right hemiparesis, sepsis, dysphagia, wounds, and other co-morbidities. Review of Resident #8's Admission MDS, dated [DATE], showed the resident was dependent with all activities of daily living care (ADL), had impairments in both upper and lower extremities preventing movement, and the resident had not had any falls since admission/entry or reentry prior to assessment. An interview was conducted on [DATE] at 3:31 p.m. with Staff S, LPN. Staff S, LPN confirmed working with Resident #8 on [DATE] and recalled the incident. Staff S recalled coming out of another resident's room seeing all these employees going to Resident #8's room. Staff S said she immediately followed, as she was the assigned nurse. She said upon arrival, she noted Resident #8 on the floor with blood on his head. Staff S said the CNA responsible for the resident (Staff T, CNA) stated she turned the resident, and he rolled out of the bed. She stated Resident #8 had an air mattress with collapsable sides. Staff S stated she was not sure how this happened as Resident #8 was tall, thin, and did not move. An interview was conducted on [DATE] at 5:13 p.m. with Staff T, CNA. Staff T confirmed she cared for Resident #8 on the night of [DATE]. She said he often had behaviors and yelled. She said she went in and talked to him, and he was calm. She said since the resident was calm, she thought she could clean him up on her own. She said she cleaned up his front and rolled him away from her to clean up his back side. She said the resident was on an air mattress and they are slippery. She said he was not really on a sheet. She said when she rolled him away from her, he slipped off the other side. She said she tried to catch him by his shirt, but he fell off and hit the floor. She said as that happened, she had to let go of his shirt and go search for someone to help. She said she went outside and got the nurse assigned to him. She said she didn't really know his injuries, but he was bleeding, and the nurse started working on him. The CNA said she had previously assisted with Resident #8 being cleaned and changed because he was sometimes combative. She said she was only worried about his behavior and thought since he was calm, she could change him herself. She said the CNAs do not know if a resident is a one-person or a two-person assist because it is not in the computer or on their Kardex. She said they have to go off of personal judgement and it is sometimes passed down from the previous shift's CNA. Staff T explained if shift to shift report was not completed, then you just go off your experience. She said the facility had not done any training on turning/positioning residents before or after the incident with Resident #8. Review of Resident #8's Comprehensive Care Plan, [DATE], showed the following: -Focus: Resident needed assistance with activities of daily living because of weakness. The goal showed: I will improve my ability to transfer, dress, toilet, ambulate by next review. The interventions included: Anticipate resident's needs; Assist me with all oral intake of food and fluids; Assist me with hygiene, bathing, dressing, toileting and transfers; Assist me with toileting promptly when requested; Assist with all ADL care to ensure daily needs are met. -Focus: The staff have identified that I am at risk for falls because of these risk factors: Unaware of safety needs. The goal showed: I will have minimized injury due to a fall through next review. The interventions included: Anticipate resident's needs; I should have sneakers, shoes, slippers with rubber soles or non-slip socks when I am out of bed; Keep frequently used items within reach: TV remote, tissues, water glass over bed stand and my water glass (unless I need thickened liquids or can't have anything by mouth); Keep my call light within reach so I can call for assistance; Maintain bed in lowest locked position. -Focus: At times I can agitated, combative, continuous outburst. The goal showed: I will show a decrease in my episodes of being resistant thru next review. The interventions included: Allow choices when able to give resident feeling of control; Converse with during care about topic of interest to redirect; Monitor for effectiveness of medication prescribed to limit behavior; Report to Dr if not effective or behavior continues to decline; Psych eval and follow up per order. An interview was conducted on [DATE] at 1:10 p.m. with Staff Z, LPN UM (Unit Manager). Staff Z said residents were evaluated by therapy and those results were sent to the MDS team. She said MDS then enters the information about the functional level of the resident and that populates to the Kardex. She said it usually says dependent or max assist, something like that. She said dependent means two-person assist and maximum assist means ,d+[DATE]. When asked how the CNAs would know which to use since they cannot assess residents she said, That is all I know about the process. An interview was conducted on [DATE] at 12:48 p.m. with Staff Y, CNA. She said the facility had not done any training on turning, positioning, or transferring residents. She said the CNAs do not know if a resident is a one or two-person assist or if they need a lift. She said the CNAs have To figure it out. Interviews were conducted from [DATE] to [DATE] at various times with the following staff: Staff U, D, W, X, V, N, O, Q, CNA's. During these interviews staff stated the computer system does not indicate specific directions for what level of care (i.e Assist of one, mechanical lift) is needed for residents' ADL needs. The staff stated usually they just know how to care for residents based on our experience. The CNAs said they try to complete shift to shift report to inform other CNAs of care needs, but it does not always happen with staffing patterns and time constraints. An interview was conducted on [DATE] at 2:23 p.m. with the MDS Coordinator. She said approximately a year ago, when the MDS changed from section G to section GG, it quit having an assist of 1 or two option. She stated related to the care plan not indicating a level of assistance needed, That is not a directive I have been given here. She said the CNAs would just know the level of care from passing it down in report. She doesn't know how else they would know. The MDS Coordinator confirmed CNAs cannot assess residents. Review of hospital records for Resident #8, dated [DATE], showed the resident presented to the emergency department and underwent a head and maxillofacial CT (computed tomography) scan which revealed an 8 millimeter (mm) subdural hemorrhage layering along the right frontotemporal convexity, with no significant midline shift, interval development of large right frontotemporal infarct is noted compared to February 2022, and possible acute/subacute. The resident was also noted to have a right front scalp hematoma which was a laceration, and sutures were applied. Upon arrival the resident was noted to have a forehead laceration with a dressing in place that was blood soaked. The resident was unable to answer questions correctly although he was attempting to. The CT scan results, dated [DATE], showed the following: Calvarium/Scalp: large right frontal scalp hematoma calvaria fracture evaluation limited by motion artifact. CT Maxillofacial: comminuted right greater than left nasal bone fractures moderate overlying soft tissue swelling. Review Resident #8's ER record showed the resident received 12 sutures to right eyebrow laceration. Resident #8 was admitted to the ICU (intensive care unit). No other documentation is available at this time. An interview was conducted on [DATE] at 4:10 p.m. with the NHA and DON. The NHA stated the facility was following Resident #8's plan of care with one-person assist. The NHA confirmed the care plan did not have assist requirements as an intervention. The NHA stated, I thought it was there. The NHA stated no investigation was needed. The NHA stated after comparing statements from staff he decided to eventually find the CNA neglected to utilize proper positioning techniques and the facility had no control over this. The NHA stated this was based on the DCF investigation. After the NHA spoke with the investigator, the NHA decided to start a neglect report. The NHA stated the report was filed and the nursing assistant was reported to the board. The NHA and DON stated no other actions needed to be taken. They stated they did not do any in-services, review their policies, or interview other residents. They stated no education was provided to staff post-incident. An interview was conducted on [DATE] at 4:38 p.m. with the Director of Rehabilitation (DOR). He said Resident #8 had severe safety awareness concerns and had decreased coordination. He said Resident #8 was totally dependent and in therapy that means they would use two people to assist. He said nursing decides if two people should be used for transfers and care on the unit. He said the Resident #8 had rigid tone so Everything is total dependent, and he needs a lot of help. He said the resident having rigid tone means staff would have to hold him because he cannot hold himself while turning. He said if the resident was being turned, he would need a person on each side of him. The DOR stated, To roll him he still needs a lot of help. He said if the resident didn't have control, it is dangerous for a CNA to roll the resident away from them because they can roll off the bed if no one is on the other side. The DOR said for therapy, Total dependent means max assist; two people and lifts. Review of the facility's Abuse and Neglect Log, dated ,d+[DATE] to ,d+[DATE], did not reveal any reports after [DATE] of any incidents of abuse or neglect. An interview was conducted on [DATE] at 10:33 a.m. with the DON. The DON stated she had validated with the NHA, no other reports or allegations of abuse or neglect had been made since [DATE]. 3. Review of the facility's Admission/Discharge To/From Report, for dates [DATE] to [DATE], revealed Resident #12 was discharged to an acute care hospital on [DATE]. Review of Resident #12's progress notes, dated [DATE] at 3:31 p.m., authored by the DON showed: Resident had a fall blood pressure is ,d+[DATE] pulses 85. We're sending her to the hospital. Review of Resident #12's progress notes, dated [DATE] at 3:44 p.m., authored by Staff AA, Registered Nurse (RN) showed: Pt [patient] found on the floor at evacuation site. VSS [Vital Signs Stable]. EMS [Emergency Medical Services] on site. Pt sent to hospital. Family called. Message left. Review of Admission Records showed Resident #12 was admitted on [DATE] with diagnoses including hypertension, weakness, dementia, Huntington's disease, and other co-morbidities. Review of Resident #12's Admission MDS, dated [DATE], Section C, Cognitive Patterns, revealed a BIMS score of 8, indicated the resident had moderate cognitive impairment, Section J, Health Conditions showed no pain and no falls. Review of Resident #12's Physical Therapy Discharge Summary, dated [DATE], showed: Resident #12 was able to perform sitting to standing with the use of an assistive device; was able to transfer with supervision only, and was able to walk 150 feet with a front wheeled walker with contact guard assistance. Review of Resident #12 Comprehensive Care Plan, [DATE], shows: -Focus: The staff have identified that I am at risk for falls because of these risk factors: Dementia, use of anti-psychotic medication, use of antidepressant medication. The care plan interventions showed: Anticipate resident's needs; I should have sneakers, shoes, slippers with rubber soles or non-slip socks when I am out of bed; Keep frequently used items within reach: TV remote, tissues, water glass over bed stand and my water glass (unless I need thickened liquids or can't have anything by mouth); Keep my call light within reach so I can call for assistance; Maintain bed in lowest locked position. -Focus: I need assistance with activities of daily living because of weakness. The care plan intervention showed: Anticipate resident's needs; Assist me with all oral intake of food and fluids; Assist me with hygiene, bathing, dressing, toileting and transfers; Assist me with toileting promptly when requested; Assist with all ADL care to ensure daily needs are met. -Focus: The resident has an ADL Self Care Performance Deficit r/t Activity Intolerance, r/t cognitive deficits. The interventions showed: Encourage the resident to participate to the fullest extent possible with each interaction; Encourage the resident to use bell to call for assistance; Anticipate needs not verbalized as resident does not always clearly make needs Nursing known. Keep call bell within reach, encourage use, answer promptly. An interview was conducted on [DATE] at 3:15 p.m. with the NHA and AIT. They stated the facility needed to prepare for evacuation to a church on [DATE]. The NHA said at the church the County Emergency Management showed up and stated the facility should move their residents to a county shelter. The NHA and AIT stated no one was seriously injured, no one died , and no one eloped. They said there may have been a skin tear. The NHA stated, We did the best we could. The NHA confirmed they did not compile a post-storm assessment, as they did not have time; they needed to get ready for the next storm. An interview was conducted on [DATE] at 11:50 a.m. with Staff V, CNA. Staff V stated, During the evacuation things happened. Staff V stated, Yes there was a fall. I was in the gym where [Resident #12] was assigned. The management did not leave out assignments for CNAs, so I am not sure who was responsible for [Resident #12]. Staff V said, I was in a doorway and heard a loud thud. I turned and noted [Resident #12[ on the floor, it looked bad, no one was near. Staff V stated there was no walker and most of the residents came without their walkers/wheelchairs, etc. She said those items were not brought with them for the evacuation. Staff V, said the DON did finally come over to Resident #12, after another nurse had already been providing care. Staff V stated, The DON was not in the gym when Resident #12 fell . Staff V stated she did not remember who else was in the g [TRUNCATED]

Based on observations, record review, facility policies, interviews with facility staff, the resident's physician, Medical Director and family members, the facility failed to provide supervision, education and corrective action in response to incidents in order to prevent falls with injury for 1 resident (#3 ) out of 12 residents sampled for falls. Resident #3 was a long-term nursing care resident who was at risk for falls admitted to the facility on [DATE] and discharged on [DATE] to an acute care hospital for a fall with injury. On 2/14/23 at 1:45 pm a Certified Nursing Assistant (CNA) did not follow facility policy and independently used the sit to stand lift for Resident #3. The CNA did not use the appropriate size waist belt during the transfer even after Resident #3, who was assessed to have no cognitive deficits, told the CNA she was using the incorrect sling [waist belt] and that the blue sling was the right one for her not the red one. The CNA continued to use the wrong supportive waist belt and continued to use the sit to stand lift independently which resulted in Resident #3 sustaining a fracture of both bones of the lower leg which required surgical repairment. Resident #3 suffered multiple complications after the surgery, required intensive care and remained hospitalized on [DATE]. The facility was unable to provide documentation of the CNA's training on the lift during orientation. The facility's response to the incident did not address communicating individual resident sling size with staff. Additionally, based on observation, interview and record review the facility failed to provide supervision to prevent multiple falls in the facility's secured unit. A review of the facility's incident list revealed on 2/25/23, 2/26/23 and 2/27/23, 16 falls occurred in the facility. Ten of the 16 falls were unwitnessed and occurred on the secured unit to Residents #8, #9, #19, #11, #12, #13, #14, #15, #16 and #17. The residents who resided on the secured unit due to severe cognitive impairment, were observed unattended in the common area or with limited supervision on 4 of 4 days of the survey, (2/27/23, 2/28/23, 3/01/23 and 3/02/23). This placed them at risk for falls, accidents, and potentially injurious interactions between residents. The actual serious physical harm to Resident #3, likelihood of death to Resident #3, likelihood of serious harm to residents who require mechanical lifts, and very likely risk of serious harm, injury or death from a fall to the facility's residents who are at risk for falls resulted in the finding of on-going immediate jeopardy starting on 2/14/23. Findings included: An interview was conducted on 2/27/23 at 5:31 p.m. with Staff Q, Registered Nurse (RN) who said . [Resident #3] room was in a quad room [four person room, with 2 residents on the left side of an entrance hallway and 2 residents on the right side of an entrance hallway], and I was in one of the rooms taking care of another resident when I heard the resident yelling my leg! my leg! my leg! The CNA [Staff P, CNA] was also screaming [Staff Q, RN]! [Staff Q, RN]! Come help! The resident was in the hallway of the quad, I think [Staff P, CNA] was trying to transfer her to the bathroom, the bathroom is also in the hallway of the quad, I heard her screaming and I came out saw the resident and yelled for help because she was about to hit the floor, she was suspended on the lift. Her left leg was out past the foot plate towards the shift bar of the mechanical lift. The resident was in the strap that goes on like a belt around her waist and the straps were still hooked onto the sit to stand machine. Her two arms were still holding on to the handles of the machine. Both sides of the belt straps were still attached to the sit to stand. Her right leg was on the foot plate. She was slipping off of the belt I don't know if it was tight enough or what but she never touched the ground at this point. I think when [Staff P, CNA] noticed [Resident #3] was going to hit the ground that's when she started to call out. The hallway door was closed, I opened it and called out for help. The CNA was not touching the resident, the CNA was holding onto the remote of the machine with one hand and reaching for the wheelchair with the other and telling me to get the wheelchair to put the resident back into the wheelchair but I told her the resident was too low to put her back into her chair we need to lower her to the ground so I got behind the resident and supported her head and guided her to the floor and the CNA pressed the remote to lower the sit to stand which lowers the resident. We lowered the resident completely to the ground, the CNA removed the lift from the area and that's when I noticed her leg is facing an asymmetrical position and now, she was yelling, and the pain is too much and at that point 911 was called. Because of the pain, we couldn't touch her, and other people came to help, and we put pillows under her head and stayed with her until the paramedics came. I did not see the sit to stand on the resident. I don't think it fell on her, It is a very heavy machine and I don't think if it fell on the resident the CNA would not have been able to pick it up and get the resident back into the position I found her in. It's just my opinion but what I think might have happened was her leg got caught under the foot plate and when she was lifted up it could have broke but like I said that is just my opinion because her break was just above her ankle. But that is why we are supposed to have 2 people when they use the mechanical lifts, one to operate it and one to guide the resident. The CNA did not do that, that day. I don't know why she didn't use two people. She floats around all the units but she has worked with this resident before so she cannot say she doesn't know how she was supposed to be transferred. The CNA told me she was taking the resident to the bathroom. The resident did have a brief on, but she told me she was taking her to the toilet. And usually that's what they do when they take someone to the toilet they transfer them from the wheelchair onto the sit to stand with two people, wheel them into the bathroom, one person pulls down their clothes and the other lowers them onto the toilet while the other person guides them onto the toilet, the resident uses the bathroom, the staff member cleans them up, puts their clothes back up and then they wheel the resident back to the wheelchair and lowers them back onto the wheelchair. The resident never comes off of the lift they are strapped to it the entire time. The resident did not have a strap around her legs to stabilize her legs against the padded cushion of the sit to stand, no A phone interview was conducted on 2/28/23 at 2:11 p.m. with Staff P, CNA, who operated the mechanical lift at the time of Resident #3's fall. She stated I know when I wrote my initial letter about [Resident #3] I was emotional and all over the place. But, when I put her in the machine and we went up she kind of slipped, she did not hit the floor and once the nurse came, she told me to put her on the floor. My first instinct was to not let her touch the floor. I just didn't want her to touch the floor at all. I was holding the resident on her side she was still attached to the machine and then [Staff Q, RN] said let's put her on the floor [Staff Q, RN] said we aren't getting her back onto the wheelchair so I took the controller and lowered her down with the machine as low as it possibly could, unhooked her and we lowered her to the floor. The belt was Velcro'd on pretty decently .I was never told there was different sizes or different colored slings and belts .That day I was just getting off my 30-minute break and [Staff Q, RN] was saying my lights were on and people were waiting for me to take them to the restroom . so I was trying to prioritize who I saw first. I had one person in bed with a call light on, I had one person who was continent and then [Resident #3]. I went and saw the resident who was in their bed, they told me that they had already been helped so I turned off their light and then I heard the two women arguing about who has been waiting longer to go to the bathroom. [Resident #3] had her wipes and her brief in her lap and the other resident had her towels and I knew she was continent and she said she had been holding it for 30 minutes, so I put her on the sit-to-stand lift and took her to the bathroom, I came back out and put her back in her chair. Then I was going to take [Resident #3] to the bathroom and she had already soiled herself and as I was strapping her waist belt on and hooking her onto the machine, just as I did earlier that morning when I got her out of bed, I was talking to her apologizing to her for her wait and telling her I understand her frustration I didn't mean to frustrate her because when I was taking the other lady to the bathroom I could hear her arguing, well not arguing she was just expressing how she felt. But I don't want to use me talking to her as an excuse that I was distracted. As I was strapping the belt on her she was trying to strap it on herself, and she was trying to tell me how other people do it and I told her that I'm not the other CNA's I feel more comfortable doing it my way and then I told her I am going to lift you up and as I was lifting her up I was explaining to her you're wet let me take you to your room to change you and she said she said no I want to get changed right here and then everything happened so fast the resident was slipping, I grabbed her because I didn't want her to hit the floor, I called out for [Staff Q, RN] and [Staff Q, RN] came and that's when we lowered her to the floor. When I got back from break there was no one on the floor, everyone was doing their own thing except [Staff Q, RN] because she was the one who told me about my lights. I did not have another staff member right there with me because everyone was doing their own thing and when I got off break there was no one in the hallways and I just felt this sense of urgency because people needed to use the toilet and people are yelling at each other and I just wanted to help the residents. I did not have two people with me either time I used the sit to stand for both of them. So, the way the room worked is there is a door off the hallway and then there is a bathroom in the corridor of the hallway and 4 rooms that branch off that corridor; I was in the corridor with [Resident #3] and the other lady that is in one of the other rooms in [Resident #3's] hallway. [Staff Q, RN] was in one of the other residents' rooms in that hallway, but she was not right next to me when I used the lift. I had worked there for about 2 months before this happened . Review of Resident #3's admission record revealed she was an [AGE] year-old female resident admitted to the facility on [DATE] from an acute care hospital and discharged on [DATE] back to an acute care hospital. Resident #3 had diagnoses that included congestive heart failure, muscle weakness, dysphagia, type 2 diabetes with chronic kidney disease, type 2 diabetes with diabetic peripheral angiopathy without gangrene, diabetic neuropathy, dementia, pulmonary hypertension, anemia, hyperlipidemia, atherosclerosis, bipolar disorder current episode hypomanic, disorder of bone density and structure of right lower leg, primary osteoarthritis left hip and right knee, sciatica left side, localized edema, chronic kidney disease stage 3A, age related osteoporosis without current pathological fracture, generalized anxiety disorder, nonrheumatic mitral valve insufficiency, atrial fibrillation, other specified disorders of bone density and structure of the left forearm, pharyngoesophageal phase and vitreous degeneration, bilaterally. Review of Resident #3's progress note dated 2/14/23 at 13:45 p.m. revealed Resident had a fall incident. 2/14/23 1:45 PM resident is alert and oriented. Resident was Transferring at time of incident. Pain is noted. Resident sent to emergency room for evaluation. Neuro Checks immediate after. Physician notified Responsible party notified. Guardian Notified. Supervisor notified. Review of Resident #3's quarterly minimal data set (MDS) dated [DATE] section C, cognitive patterns, revealed she had a brief interview for mental status (BIMS) score of 15 out of 15 indicating no cognitive deficits. Section G, functional status, revealed Resident #3 had impairment on both sides of her lower extremities. For transfers Resident #3 required extensive assistance with two plus person's physical assist. Toilet use revealed Resident #3 required extensive assistance with two plus person's physical assist. Section H, bowel and bladder, revealed Resident #3 was frequently incontinent of bowel and bladder. Review of Resident #3's Task List Report revealed a task with an initiated date of 4/21/2022 and a resolved/cancelled date of 2/14/2023. The position(s) indicated the task was for Certified Nursing Aide. to Transfers: Sit to stand lift, Assist x2 [times 2] Everyday. Qshift [every shift]: Day (7-3), Night (11-7), Evening (3-11). Everyday, Qshift Night (7-7). Further review of February's task documentation revealed Staff P, CNA signed off Transfers: Sit to Stand lift, assist X2 on 2/14/23 at 8:59 a.m. Review of Resident #3's care plan initiated on 2/14/2019 revealed a focus of The staff have identified that I am at risk for falls because of these risk factors: weakness, impaired mobility, dementia, History of falls, Incontinence, use of opioid medication, dizziness, DM [diabetes mellitus] with neuropathy; Dx [diagnosis] of Osteoporosis with increased risk for pathological fractures. The goal revealed I will be free of major injury due to a fall through next review. Interventions included but are not limited to, .I will notify staff my need for assistance when I have a bowel or bladder accident. Toilet me upon rising before and after meals at hs [hours of sleep] and when needed . Assist of 2 staff with transfers using sit-to-stand lift. Further care plan review revealed a care plan with an initiated date of 2/14/2019 revealed a focus of I need assistance with activities of daily living because of muscle weakness, pain, dizziness, impaired mobility. The goal revealed I like to maintain a neat and tidy appearance. Staff will assist as needed to help maintain that goal through next review. Interventions included but are not limited to, 2 female staff to be present when caring for resident Assist of 2 staff using sit-to-stand for transfers . Review of Resident #3's Clinical Physician Orders revealed a physician's order with a start date of 2/14/2023 TRANSFER TO ER [emergency room ] HOSPITAL FOE [sic] EVALUATION AND TREATMENT FOR POSSIBLE TIBIA FRACTURE OF THE LEFT LEG. Review of Resident #3's Change in Condition Evaluation with an effective date of 2/14/23 at 1:45 p.m. revealed 1. The change in condition, symptoms or signs I am calling about is/are: Falls 2. This started on: 2/14/23 3. What time of day did this start: Afternoon 1. The resident is in the nursing home for: Long Term Care .4. Is the resident on warfarin/coumadin? No 4c. is the resident on another anticoagulant drug? (e.g. Aspirin, Plavix, Dabigatran, Rivaroxaban, Apixaban) Yes .Skin Evaluation 16. describe skin changes: No changes observed 16n. document location and details: Site: Left lower leg (front) Description: possible tibia fracture . Pain Evaluation 17. Is the resident cognitively able to rate their pain scale? Yes 17a. Rate pain on a scale of 0 to 10 (0=no pain, 4-5=moderate pain, 10=excruciating pain): 10 17b. Is the pain: acute 17c. Pain location: Musculoskeletal pain 17h. Describe musculoskeletal pain: Marked localized bruising, swelling, or pain over joint or bone, with or without recent fall. 17k. Specify exact location of pain: Site: Left lower leg (front) Description: possible tibia fracture .20. Since the change in condition occurred have the symptoms or sign gotten: Worse 21. Things that make the condition or symptoms worse are: activity 22. Things that make the condition of symptoms better are: pain medication .25. Summarize your observations and evaluation: Transfer to ER Hospital for treatment .2. Reported to primary care clinician: [Resident #3's physician] 3. Date and time of clinician notification: 2/14/23 2:08 p.m. 4. Orders obtained from the clinician: Other 4a. Specify other: Transfer to ER Hospital. 5. Name of Family/healthcare agent notified: [Resident #3's family member] 6. Date and time of family notification: 2/14/23 2:06 p.m. A phone interview was conducted on 2/27/23 at 3:13 p.m. with Resident #3's family member, she said It wasn't a fall it was a drop; my mother was in her room she needed a diaper change so she could go to activities this is a routine for her, she required a sit to stand, the CNA wheeled her out of the room into the hallway to change her diaper. I spoke to some of the nurses and that is supposably their new way of doing diaper changes is out in the hall. The CNA gets my mother, wheels her into the hallway, my mother tells her that's the wrong strap to the machine, the CNA said don't worry about it it'll be fine. My mother said no I am worried about it, that's the wrong strap. The CNA said it'll be fine and proceeded to use the strap and lift my mother up using the machine, The strap breaks, my mother falls to the floor, the machine flipped in the air and hit my mother's leg breaking her leg in two places. The ambulance was called this all happened on 2/14/23. She is still in the hospital. She is not doing good because of her other problems which they warned us about an [AGE] year-old women needing surgery is a risk. And every problem they warned us about she had. Her heart stopped twice, they had her on a respirator then they took her off the respirator and now she's on oxygen. Her Blood pressure tanked to 58/30, Her kidney's stops working no urine output at all. Her A-fib [Atrial Fibrillation] starts acting up. I'm in the ICU [intensive care unit] with her on 2/16/23 and she starts bleeding internally. They could not get her into surgery, they had to come to her. A tube went down her throat and into her stomach. Then she's back on the respirator and then taken off the respirator for the second time and back on oxygen. Then she got a tube through her nose down into her stomach for 5 days. Then that came out on Saturday. They did surgery on her leg, there was 2 breaks, she now has rods, screws all inserted in her leg permanently. My mother told me this whole story when I came to the hospital in between all her screaming because of the pain she was in. She told the same story to all the doctors and paramedics. The paramedics found her with the machine on her in the hallway, they even came back to the hospital to see my mom because they said it was such a horrific accident. When the administrator called me about what happened she said I feel so bad your mom was like my mom and I said to her well my mom did not give birth to you so yeah. A CNA is a Certified Nurse assistance that is someone who is trained on how to use these machines. The Sunday prior to the accident my brother was visiting my mom and the CNA said she does not know how to use the machine my brother asked her how is it you don't know how to work the machine and she said I don't know how to work it. My mother said here I will show you. [The NHA] said she was currently in the process training the staff on how to use the machine. I said what do you mean you are training them now. They are supposed to have training on this before they even get hired and she's telling me they are using real life people as practice dummies. The Director told me I understand you are very upset, and I want to assure you that the staff are being trained but they should already be trained she shouldn't just now be training them. Since then, the director called me back saying they have suspended her [Staff P, CNA] pending investigation and then they called me again and have since fired her and reported her licenses. A phone interview was conducted on 3/1/23 at 3:31 p.m. with Resident #3's physician. She stated I am very familiar with [Resident #3] I have worked with her for the last 3 years. I was immediately notified about the fall from someone, I'm not sure who called me, but I was notified that she had fallen, and it was suspected that her leg was broken. She was in a lot of pain, and I believe we had her sent out versus us getting X-rays. The hospitalist [hospital physician] will call me once the resident is done with their hospital stay to give an update, but I have not talked to anyone from the hospital. But middle to end of last week my Nurse Practitioner talked to someone and let me know that she {Resident #3] was not doing well, she had a really bad fracture and was having complications. The resident has severe lumbosacral disease which leaves her unable to use her legs which could lead to brittle bones, but I don't think we have any sort of osteoporosis on her. My understanding is that the resident had a fall from the lift, and the lift fell on the resident. I also heard another story regarding the lift so it's hard to say exactly what happen but the more reliable source I heard was the aid used a lift inappropriately, she used the wrong sling, the resident told her it was the wrong sling and the resident fell from the machine and the machine tipped and fell on the resident. I will say other than this event she was well taken care of . A phone interview was conducted on 3/1/23 at 3:34 P.M. with Staff P, CNA she stated, oh no the machine did not fall on the resident that would have meant we would've had to pick it back up off the resident and we did not have to do that. Review of Resident #3's hospital records revealed she sustained an acute displaced (bone breaks into two or more pieces and moves out of alignment) markedly comminuted (bone broken into three or more pieces) fracture involving the mid to proximal (near the knee) tibia (larger bone of the lower leg, also called the shin bone) . as well as an acute comminuted mildly displaced proximal fibular (outer smaller bone of the lower leg) fracture. Review of the hospital physician's notes dated 2/23/23 revealed [Resident #3] is an [AGE] year-old female with severe tricuspid regurgitation [heart valve does not close properly], moderate mitral regurgitation [heart valve does not close properly], suspected underlying heart failure with preserved ejection fraction [the heart pumps normally but too stiff to fill properly] on diuretics chronically, A-fib [atrial fibrillation, an irregular heart rhythm] on Eliquis, history of CVA[cerebral vascular accident], hypertension, DM 2 [diabetes mellitus 2] with peripheral neuropathy, hyperlipidemia [high levels of fat in the blood] who was admitted to [Hospital] following fall with tibia and fibula fracture. She is status post intramedullary nailing [permanent rod placed in the cavity of a bone to treat a fracture] 2/15. She developed gaseous distention concerning for ileus [when the intestines stop moving correctly and cannot push food through] versus obstruction/pseudoobstruction, CT [computerized tomography scan] abdomen pelvis showed marked gastric distention, possible transition and duodenum. NG [nasal gastric] tube was placed for decompression. She had acute anemia requiring transfer to the ICU [intensive care unit] with hypotension/shock. Echocardiogram showed EF [ejection fraction] 60 to 65%, severely dilated left and right atria [heart valve], severe pulmonary hypertension, severe tricuspid regurgitation. She received transfusions, EGD [esophagogastroduodenoscopy] revealed erosive esophagitis, adherent blood and edema with erosions and erythema, PPI [proton pump inhibitor] started, last transfusion 2/21. Additional issues have included but are not limited to hypernatremia [high concentration of sodium in the blood. Further hospital physician note review dated 2/23/23 revealed Plan - I reviewed the different disease trajectories for patients with multiple medical comorbidities, advanced age, acute event and introduced the idea of refocusing hopes and life goals as the timeline progresses and modifying what the expectations are for levels of functional ability and daily quality of life targets. Reviewed high possibility of development of cycle of frailty including more frequent hospitalization s and decline in overall performance status if she is not well able to participate with physical therapy and regain mobility. Daughter voiced agreement and stated she had discussed this previously with another physician prior to the surgery. --In light of possibility of further progressive decline offered outpatient palliative medicine referral for ongoing goals of care conversations following this hospitalization and trial of SNF [Skilled Nursing Facility]/rehab. Family declines at this time. --Reviewed what-ifs and family had questions about prognosis and including DIL[dangerous illness list] inquiring about possibility of hospice down the line. Reviewed mod-high [moderate to high] of 6mo-1yr mortality [6 month to 1 year mortality], particularly if mobility is not regained in light of multiple medical comorbidities. Review of Resident #3's Post Fall Review by IDT [interdisciplinary team] Team dated 2/15/23 revealed 1. In Attendance, Unit Manager, Risk Manager, DON [Director of Nursing], Social Services, Therapy, PT [Physical Therapy], OT [Occupational Therapy], ST [Speech Therapy], Reviewed details of resident's recent fall, .4. Comments, IDT meeting. Sent to ED [Emergency Department] for Eval and treatment, Staff educated re: staffing for mechanical lift, determining proper sling size for mechanical lift. Inventory all mechanical lift slings; invite [Medical Equipment Company]. Review of Resident #3's Incident Report dated Tuesday February 14, 2023, at 1:45 p.m. revealed, General Information, Type: Fall, Incident Location: Hallway/Corridor, Activity: Transfer, Reported by: [Staff Q, RN], Witness(es): [Staff P, CNA], .Cognition Prior to Incident: Oriented X3, Cognition after Incident: Oriented x3, Injuries, Type: R/O [rule out] Fracture, Location: Left Lower Leg, Date/Time: 2/14/23 1:45 p.m., Details: Left lower leg-external curvature and rotated, Actions, Skin assessment completed, Pain Assessment, Investigative Statements, Resident: [Resident #3] stated that she told the CNA she was using the incorrect sling and that the blue sling was the right one for her not the red one. And the CNA continued to use the red sling for the transfer., Staff interviews, No Staff Interviews. Review of facility's Sit-to-Stand Lift (Brand Name) Usage Procedure undated, revealed a sizing chart which indicated the red sling was a size medium and the blue sling was a size large. An interview was conducted on 3/1/23 at 1:15 p.m. with Staff T, Educator, she stated, on orientation I do lift education and lift competency check off. We also have a mentor check off sheet which also indicates the staff are competent in the use of lifts. The week [Staff P, CNA] was in orientation I was not here so the competencies did not get done and her mentor check offs, she didn't turn that in. Review of the facility's Transfer Equipment 2 people education dated 2/7/23 revealed 13 employes were present for the education but [Staff P, CNA] was not located on the sign in education sheet indicating she did not receive the training. Review of Staff P, CNA's employee file revealed she was hired on 12/12/2022 and was terminated on 2/24/23 for transferring a resident in a sit to stand lift, with her last day of work being 2/14/23. The resident started slipping from the sling and was lowered to the floor. She sustained a fracture of the left tibia and fibula during the procedure. [Staff P, CNA] disregarded the following facility protocols for mechanical lift transfers. 1. 2 staff members must be present when transferring a resident with a mechanical lift. 2. The proper size sling must be used. An interview was conducted on 2/28/23 at 12:04 p.m. with the Director of Therapy he said, No we don't have anything to do with lifts. In rehab we want them off the lifts and gaining more function. Usually nursing makes the decision if the residents need a lift or not. Once we do our assessment on the resident then we tell them why this person is one person assist or two person assist, but that's later on in the admission. Once the resident comes into the building that's when nursing decides if they need a lift or not. We are not the ones who make the decision on the lifts. Unless they have specific stuff like the resident has a broken hip then we will tell nursing that they cannot use a lift. [Resident #3] was on case load from 1/20/23-2/14/23 there is nothing in our notes regarding lifts for her. They [Therapists] did mention and recommend a sit to stand lift on her evaluation. Transfer to wheelchair via sit-to-stand lift, that's all they mentioned, which indicates that is how she transfers. She is a long-term resident who utilized a sit to stand for transfers since before January 20th, 2023. That was not something that changed she has always been using that. I cannot see any lift assessment for her. An interview was conducted with the DON on 2/28/23 at 12:21 p.m. she said So, after [Resident #3's] fall we actually assessed all the residents who are using lifts maybe ten days ago, after [Resident #3's] to make sure that we have the appropriate lift for everyone. [Staff S, Informatics Specialist] and [Staff R, RN] did the assessment. [Staff S, Informatics Specialist] is an LPN [Licensed Practical Nurse] and [Staff R. RN] is an RN. They determined what type of lift and slings or belts they needed for all the residents who are needing a lift. The criteria to use a sit to stand lift if they can bear partial weight and can't be an amputee. For the [complete body lift] the criteria is they are not able to bear weight at all they can use the Complete body lift. There are sizes for the sling for the Complete body lift and there is a Velcro belt for the sit to stand lift that comes in small, medium, large, and extra-large and [Staff R. RN] and [Staff S, Informatics Specialist] determined what size sling and belt those residents needed. They based their measurements on the manufacture's recommendations they measured the residents from mid shoulder to gluteal fold and based on that measurement they were able to ascertain what size sling they needed. The waist belt we had an in-service from the vendor they said the waist belt has to have at least a 2-inch overlap on the belt. This information is in the Kardex that the CNA's have access to in the [Electronic Medical Record]. The new residents who are admitted if they can't bear weight or partial weight bearing the nurses have been educated on how to determine the sling and belt sizes and have been checked off on their competency. To be honest with you the residents that were transferred with lifts before we put everything in place, I'm not sure what the process was the staff just knew what lift and what color band around the sling the residents needed and that band around the sling determines what size it is. For the waist belts the staff just knew what color each resident needed. I'm new I just started in October. There was no formal process before this, this is what we discovered they would just ask a nurse or another CNA or the CNA that was on shift before them would tell them what they used. An interview was conducted with [Staff R. RN] on 2/28/23 at 12:41 p.m. she said I worked with therapy and staff we identified who used a mechanical lift then I entered that information on the Kardex so all staff could see how a resident could transfer. I participated in the training on how to do the measuring of slings and belts, but I did not measure anyone. All I did was identify what type of lift the resident needs and if they had any other transfer needs like 2 persons assists. I just asked if therapy had any input on changes for the people they were working with. For example, they were able to tell me residents who were able to stand and pivot t [TRUNCATED]

Based on observations, record review, facility policies, interviews with facility staff, the resident's physician, Medical Director and family members, the facility failed to provide supervision, education and corrective action in response to incidents in order to prevent falls with injury for 1 resident (#3 ) out of 12 residents sampled for falls. Resident #3 was a long-term nursing care resident who was at risk for falls admitted to the facility on [DATE] and discharged on [DATE] to an acute care hospital for a fall with injury. On 2/14/23 at 1:45 pm a Certified Nursing Assistant (CNA) did not follow facility policy and independently used the sit to stand lift for Resident #3. The CNA did not use the appropriate size waist belt during the transfer even after Resident #3, who was assessed to have no cognitive deficits, told the CNA she was using the incorrect sling [waist belt] and that the blue sling was the right one for her not the red one. The CNA continued to use the wrong supportive waist belt and continued to use the sit to stand lift independently which resulted in Resident #3 sustaining a fracture of both bones of the lower leg which required surgical repairment. Resident #3 suffered multiple complications after the surgery, required intensive care and remained hospitalized on [DATE]. The facility was unable to provide documentation of the CNA's training on the lift during orientation. The facility's response to the incident did not address communicating individual resident sling size with staff. Additionally, based on observation, interview and record review the facility failed to provide supervision to prevent multiple falls in the facility's secured unit. A review of the facility's incident list revealed on 2/25/23, 2/26/23 and 2/27/23, 16 falls occurred in the facility. Ten of the 16 falls were unwitnessed and occurred on the secured unit to Residents #8, #9, #19, #11, #12, #13, #14, #15, #16 and #17. The residents who resided on the secured unit due to severe cognitive impairment, were observed unattended in the common area or with limited supervision on 4 of 4 days of the survey, (2/27/23, 2/28/23, 3/01/23 and 3/02/23). This placed them at risk for falls, accidents, and potentially injurious interactions between residents. The actual serious physical harm to Resident #3, likelihood of death to Resident #3, likelihood of serious harm to residents who require mechanical lifts, and very likely risk of serious harm, injury or death from a fall to the facility's residents who are at risk for falls resulted in the finding of on-going immediate jeopardy starting on 2/14/23. Findings included: An interview was conducted on 2/27/23 at 5:31 p.m. with Staff Q, Registered Nurse (RN) who said . [Resident #3] room was in a quad room [four person room, with 2 residents on the left side of an entrance hallway and 2 residents on the right side of an entrance hallway], and I was in one of the rooms taking care of another resident when I heard the resident yelling my leg! my leg! my leg! The CNA [Staff P, CNA] was also screaming [Staff Q, RN]! [Staff Q, RN]! Come help! The resident was in the hallway of the quad, I think [Staff P, CNA] was trying to transfer her to the bathroom, the bathroom is also in the hallway of the quad, I heard her screaming and I came out saw the resident and yelled for help because she was about to hit the floor, she was suspended on the lift. Her left leg was out past the foot plate towards the shift bar of the mechanical lift. The resident was in the strap that goes on like a belt around her waist and the straps were still hooked onto the sit to stand machine. Her two arms were still holding on to the handles of the machine. Both sides of the belt straps were still attached to the sit to stand. Her right leg was on the foot plate. She was slipping off of the belt I don't know if it was tight enough or what but she never touched the ground at this point. I think when [Staff P, CNA] noticed [Resident #3] was going to hit the ground that's when she started to call out. The hallway door was closed, I opened it and called out for help. The CNA was not touching the resident, the CNA was holding onto the remote of the machine with one hand and reaching for the wheelchair with the other and telling me to get the wheelchair to put the resident back into the wheelchair but I told her the resident was too low to put her back into her chair we need to lower her to the ground so I got behind the resident and supported her head and guided her to the floor and the CNA pressed the remote to lower the sit to stand which lowers the resident. We lowered the resident completely to the ground, the CNA removed the lift from the area and that's when I noticed her leg is facing an asymmetrical position and now, she was yelling, and the pain is too much and at that point 911 was called. Because of the pain, we couldn't touch her, and other people came to help, and we put pillows under her head and stayed with her until the paramedics came. I did not see the sit to stand on the resident. I don't think it fell on her, It is a very heavy machine and I don't think if it fell on the resident the CNA would not have been able to pick it up and get the resident back into the position I found her in. It's just my opinion but what I think might have happened was her leg got caught under the foot plate and when she was lifted up it could have broke but like I said that is just my opinion because her break was just above her ankle. But that is why we are supposed to have 2 people when they use the mechanical lifts, one to operate it and one to guide the resident. The CNA did not do that, that day. I don't know why she didn't use two people. She floats around all the units but she has worked with this resident before so she cannot say she doesn't know how she was supposed to be transferred. The CNA told me she was taking the resident to the bathroom. The resident did have a brief on, but she told me she was taking her to the toilet. And usually that's what they do when they take someone to the toilet they transfer them from the wheelchair onto the sit to stand with two people, wheel them into the bathroom, one person pulls down their clothes and the other lowers them onto the toilet while the other person guides them onto the toilet, the resident uses the bathroom, the staff member cleans them up, puts their clothes back up and then they wheel the resident back to the wheelchair and lowers them back onto the wheelchair. The resident never comes off of the lift they are strapped to it the entire time. The resident did not have a strap around her legs to stabilize her legs against the padded cushion of the sit to stand, no A phone interview was conducted on 2/28/23 at 2:11 p.m. with Staff P, CNA, who operated the mechanical lift at the time of Resident #3's fall. She stated I know when I wrote my initial letter about [Resident #3] I was emotional and all over the place. But, when I put her in the machine and we went up she kind of slipped, she did not hit the floor and once the nurse came, she told me to put her on the floor. My first instinct was to not let her touch the floor. I just didn't want her to touch the floor at all. I was holding the resident on her side she was still attached to the machine and then [Staff Q, RN] said let's put her on the floor [Staff Q, RN] said we aren't getting her back onto the wheelchair so I took the controller and lowered her down with the machine as low as it possibly could, unhooked her and we lowered her to the floor. The belt was Velcro'd on pretty decently .I was never told there was different sizes or different colored slings and belts .That day I was just getting off my 30-minute break and [Staff Q, RN] was saying my lights were on and people were waiting for me to take them to the restroom . so I was trying to prioritize who I saw first. I had one person in bed with a call light on, I had one person who was continent and then [Resident #3]. I went and saw the resident who was in their bed, they told me that they had already been helped so I turned off their light and then I heard the two women arguing about who has been waiting longer to go to the bathroom. [Resident #3] had her wipes and her brief in her lap and the other resident had her towels and I knew she was continent and she said she had been holding it for 30 minutes, so I put her on the sit-to-stand lift and took her to the bathroom, I came back out and put her back in her chair. Then I was going to take [Resident #3] to the bathroom and she had already soiled herself and as I was strapping her waist belt on and hooking her onto the machine, just as I did earlier that morning when I got her out of bed, I was talking to her apologizing to her for her wait and telling her I understand her frustration I didn't mean to frustrate her because when I was taking the other lady to the bathroom I could hear her arguing, well not arguing she was just expressing how she felt. But I don't want to use me talking to her as an excuse that I was distracted. As I was strapping the belt on her she was trying to strap it on herself, and she was trying to tell me how other people do it and I told her that I'm not the other CNA's I feel more comfortable doing it my way and then I told her I am going to lift you up and as I was lifting her up I was explaining to her you're wet let me take you to your room to change you and she said she said no I want to get changed right here and then everything happened so fast the resident was slipping, I grabbed her because I didn't want her to hit the floor, I called out for [Staff Q, RN] and [Staff Q, RN] came and that's when we lowered her to the floor. When I got back from break there was no one on the floor, everyone was doing their own thing except [Staff Q, RN] because she was the one who told me about my lights. I did not have another staff member right there with me because everyone was doing their own thing and when I got off break there was no one in the hallways and I just felt this sense of urgency because people needed to use the toilet and people are yelling at each other and I just wanted to help the residents. I did not have two people with me either time I used the sit to stand for both of them. So, the way the room worked is there is a door off the hallway and then there is a bathroom in the corridor of the hallway and 4 rooms that branch off that corridor; I was in the corridor with [Resident #3] and the other lady that is in one of the other rooms in [Resident #3's] hallway. [Staff Q, RN] was in one of the other residents' rooms in that hallway, but she was not right next to me when I used the lift. I had worked there for about 2 months before this happened . Review of Resident #3's admission record revealed she was an [AGE] year-old female resident admitted to the facility on [DATE] from an acute care hospital and discharged on [DATE] back to an acute care hospital. Resident #3 had diagnoses that included congestive heart failure, muscle weakness, dysphagia, type 2 diabetes with chronic kidney disease, type 2 diabetes with diabetic peripheral angiopathy without gangrene, diabetic neuropathy, dementia, pulmonary hypertension, anemia, hyperlipidemia, atherosclerosis, bipolar disorder current episode hypomanic, disorder of bone density and structure of right lower leg, primary osteoarthritis left hip and right knee, sciatica left side, localized edema, chronic kidney disease stage 3A, age related osteoporosis without current pathological fracture, generalized anxiety disorder, nonrheumatic mitral valve insufficiency, atrial fibrillation, other specified disorders of bone density and structure of the left forearm, pharyngoesophageal phase and vitreous degeneration, bilaterally. Review of Resident #3's progress note dated 2/14/23 at 13:45 p.m. revealed Resident had a fall incident. 2/14/23 1:45 PM resident is alert and oriented. Resident was Transferring at time of incident. Pain is noted. Resident sent to emergency room for evaluation. Neuro Checks immediate after. Physician notified Responsible party notified. Guardian Notified. Supervisor notified. Review of Resident #3's quarterly minimal data set (MDS) dated [DATE] section C, cognitive patterns, revealed she had a brief interview for mental status (BIMS) score of 15 out of 15 indicating no cognitive deficits. Section G, functional status, revealed Resident #3 had impairment on both sides of her lower extremities. For transfers Resident #3 required extensive assistance with two plus person's physical assist. Toilet use revealed Resident #3 required extensive assistance with two plus person's physical assist. Section H, bowel and bladder, revealed Resident #3 was frequently incontinent of bowel and bladder. Review of Resident #3's Task List Report revealed a task with an initiated date of 4/21/2022 and a resolved/cancelled date of 2/14/2023. The position(s) indicated the task was for Certified Nursing Aide. to Transfers: Sit to stand lift, Assist x2 [times 2] Everyday. Qshift [every shift]: Day (7-3), Night (11-7), Evening (3-11). Everyday, Qshift Night (7-7). Further review of February's task documentation revealed Staff P, CNA signed off Transfers: Sit to Stand lift, assist X2 on 2/14/23 at 8:59 a.m. Review of Resident #3's care plan initiated on 2/14/2019 revealed a focus of The staff have identified that I am at risk for falls because of these risk factors: weakness, impaired mobility, dementia, History of falls, Incontinence, use of opioid medication, dizziness, DM [diabetes mellitus] with neuropathy; Dx [diagnosis] of Osteoporosis with increased risk for pathological fractures. The goal revealed I will be free of major injury due to a fall through next review. Interventions included but are not limited to, .I will notify staff my need for assistance when I have a bowel or bladder accident. Toilet me upon rising before and after meals at hs [hours of sleep] and when needed . Assist of 2 staff with transfers using sit-to-stand lift. Further care plan review revealed a care plan with an initiated date of 2/14/2019 revealed a focus of I need assistance with activities of daily living because of muscle weakness, pain, dizziness, impaired mobility. The goal revealed I like to maintain a neat and tidy appearance. Staff will assist as needed to help maintain that goal through next review. Interventions included but are not limited to, 2 female staff to be present when caring for resident Assist of 2 staff using sit-to-stand for transfers . Review of Resident #3's Clinical Physician Orders revealed a physician's order with a start date of 2/14/2023 TRANSFER TO ER [emergency room ] HOSPITAL FOE [sic] EVALUATION AND TREATMENT FOR POSSIBLE TIBIA FRACTURE OF THE LEFT LEG. Review of Resident #3's Change in Condition Evaluation with an effective date of 2/14/23 at 1:45 p.m. revealed 1. The change in condition, symptoms or signs I am calling about is/are: Falls 2. This started on: 2/14/23 3. What time of day did this start: Afternoon 1. The resident is in the nursing home for: Long Term Care .4. Is the resident on warfarin/coumadin? No 4c. is the resident on another anticoagulant drug? (e.g. Aspirin, Plavix, Dabigatran, Rivaroxaban, Apixaban) Yes .Skin Evaluation 16. describe skin changes: No changes observed 16n. document location and details: Site: Left lower leg (front) Description: possible tibia fracture . Pain Evaluation 17. Is the resident cognitively able to rate their pain scale? Yes 17a. Rate pain on a scale of 0 to 10 (0=no pain, 4-5=moderate pain, 10=excruciating pain): 10 17b. Is the pain: acute 17c. Pain location: Musculoskeletal pain 17h. Describe musculoskeletal pain: Marked localized bruising, swelling, or pain over joint or bone, with or without recent fall. 17k. Specify exact location of pain: Site: Left lower leg (front) Description: possible tibia fracture .20. Since the change in condition occurred have the symptoms or sign gotten: Worse 21. Things that make the condition or symptoms worse are: activity 22. Things that make the condition of symptoms better are: pain medication .25. Summarize your observations and evaluation: Transfer to ER Hospital for treatment .2. Reported to primary care clinician: [Resident #3's physician] 3. Date and time of clinician notification: 2/14/23 2:08 p.m. 4. Orders obtained from the clinician: Other 4a. Specify other: Transfer to ER Hospital. 5. Name of Family/healthcare agent notified: [Resident #3's family member] 6. Date and time of family notification: 2/14/23 2:06 p.m. A phone interview was conducted on 2/27/23 at 3:13 p.m. with Resident #3's family member, she said It wasn't a fall it was a drop; my mother was in her room she needed a diaper change so she could go to activities this is a routine for her, she required a sit to stand, the CNA wheeled her out of the room into the hallway to change her diaper. I spoke to some of the nurses and that is supposably their new way of doing diaper changes is out in the hall. The CNA gets my mother, wheels her into the hallway, my mother tells her that's the wrong strap to the machine, the CNA said don't worry about it it'll be fine. My mother said no I am worried about it, that's the wrong strap. The CNA said it'll be fine and proceeded to use the strap and lift my mother up using the machine, The strap breaks, my mother falls to the floor, the machine flipped in the air and hit my mother's leg breaking her leg in two places. The ambulance was called this all happened on 2/14/23. She is still in the hospital. She is not doing good because of her other problems which they warned us about an [AGE] year-old women needing surgery is a risk. And every problem they warned us about she had. Her heart stopped twice, they had her on a respirator then they took her off the respirator and now she's on oxygen. Her Blood pressure tanked to 58/30, Her kidney's stops working no urine output at all. Her A-fib [Atrial Fibrillation] starts acting up. I'm in the ICU [intensive care unit] with her on 2/16/23 and she starts bleeding internally. They could not get her into surgery, they had to come to her. A tube went down her throat and into her stomach. Then she's back on the respirator and then taken off the respirator for the second time and back on oxygen. Then she got a tube through her nose down into her stomach for 5 days. Then that came out on Saturday. They did surgery on her leg, there was 2 breaks, she now has rods, screws all inserted in her leg permanently. My mother told me this whole story when I came to the hospital in between all her screaming because of the pain she was in. She told the same story to all the doctors and paramedics. The paramedics found her with the machine on her in the hallway, they even came back to the hospital to see my mom because they said it was such a horrific accident. When the administrator called me about what happened she said I feel so bad your mom was like my mom and I said to her well my mom did not give birth to you so yeah. A CNA is a Certified Nurse assistance that is someone who is trained on how to use these machines. The Sunday prior to the accident my brother was visiting my mom and the CNA said she does not know how to use the machine my brother asked her how is it you don't know how to work the machine and she said I don't know how to work it. My mother said here I will show you. [The NHA] said she was currently in the process training the staff on how to use the machine. I said what do you mean you are training them now. They are supposed to have training on this before they even get hired and she's telling me they are using real life people as practice dummies. The Director told me I understand you are very upset, and I want to assure you that the staff are being trained but they should already be trained she shouldn't just now be training them. Since then, the director called me back saying they have suspended her [Staff P, CNA] pending investigation and then they called me again and have since fired her and reported her licenses. A phone interview was conducted on 3/1/23 at 3:31 p.m. with Resident #3's physician. She stated I am very familiar with [Resident #3] I have worked with her for the last 3 years. I was immediately notified about the fall from someone, I'm not sure who called me, but I was notified that she had fallen, and it was suspected that her leg was broken. She was in a lot of pain, and I believe we had her sent out versus us getting X-rays. The hospitalist [hospital physician] will call me once the resident is done with their hospital stay to give an update, but I have not talked to anyone from the hospital. But middle to end of last week my Nurse Practitioner talked to someone and let me know that she {Resident #3] was not doing well, she had a really bad fracture and was having complications. The resident has severe lumbosacral disease which leaves her unable to use her legs which could lead to brittle bones, but I don't think we have any sort of osteoporosis on her. My understanding is that the resident had a fall from the lift, and the lift fell on the resident. I also heard another story regarding the lift so it's hard to say exactly what happen but the more reliable source I heard was the aid used a lift inappropriately, she used the wrong sling, the resident told her it was the wrong sling and the resident fell from the machine and the machine tipped and fell on the resident. I will say other than this event she was well taken care of . A phone interview was conducted on 3/1/23 at 3:34 P.M. with Staff P, CNA she stated, oh no the machine did not fall on the resident that would have meant we would've had to pick it back up off the resident and we did not have to do that. Review of Resident #3's hospital records revealed she sustained an acute displaced (bone breaks into two or more pieces and moves out of alignment) markedly comminuted (bone broken into three or more pieces) fracture involving the mid to proximal (near the knee) tibia (larger bone of the lower leg, also called the shin bone) . as well as an acute comminuted mildly displaced proximal fibular (outer smaller bone of the lower leg) fracture. Review of the hospital physician's notes dated 2/23/23 revealed [Resident #3] is an [AGE] year-old female with severe tricuspid regurgitation [heart valve does not close properly], moderate mitral regurgitation [heart valve does not close properly], suspected underlying heart failure with preserved ejection fraction [the heart pumps normally but too stiff to fill properly] on diuretics chronically, A-fib [atrial fibrillation, an irregular heart rhythm] on Eliquis, history of CVA[cerebral vascular accident], hypertension, DM 2 [diabetes mellitus 2] with peripheral neuropathy, hyperlipidemia [high levels of fat in the blood] who was admitted to [Hospital] following fall with tibia and fibula fracture. She is status post intramedullary nailing [permanent rod placed in the cavity of a bone to treat a fracture] 2/15. She developed gaseous distention concerning for ileus [when the intestines stop moving correctly and cannot push food through] versus obstruction/pseudoobstruction, CT [computerized tomography scan] abdomen pelvis showed marked gastric distention, possible transition and duodenum. NG [nasal gastric] tube was placed for decompression. She had acute anemia requiring transfer to the ICU [intensive care unit] with hypotension/shock. Echocardiogram showed EF [ejection fraction] 60 to 65%, severely dilated left and right atria [heart valve], severe pulmonary hypertension, severe tricuspid regurgitation. She received transfusions, EGD [esophagogastroduodenoscopy] revealed erosive esophagitis, adherent blood and edema with erosions and erythema, PPI [proton pump inhibitor] started, last transfusion 2/21. Additional issues have included but are not limited to hypernatremia [high concentration of sodium in the blood. Further hospital physician note review dated 2/23/23 revealed Plan - I reviewed the different disease trajectories for patients with multiple medical comorbidities, advanced age, acute event and introduced the idea of refocusing hopes and life goals as the timeline progresses and modifying what the expectations are for levels of functional ability and daily quality of life targets. Reviewed high possibility of development of cycle of frailty including more frequent hospitalization s and decline in overall performance status if she is not well able to participate with physical therapy and regain mobility. Daughter voiced agreement and stated she had discussed this previously with another physician prior to the surgery. --In light of possibility of further progressive decline offered outpatient palliative medicine referral for ongoing goals of care conversations following this hospitalization and trial of SNF [Skilled Nursing Facility]/rehab. Family declines at this time. --Reviewed what-ifs and family had questions about prognosis and including DIL[dangerous illness list] inquiring about possibility of hospice down the line. Reviewed mod-high [moderate to high] of 6mo-1yr mortality [6 month to 1 year mortality], particularly if mobility is not regained in light of multiple medical comorbidities. Review of Resident #3's Post Fall Review by IDT [interdisciplinary team] Team dated 2/15/23 revealed 1. In Attendance, Unit Manager, Risk Manager, DON [Director of Nursing], Social Services, Therapy, PT [Physical Therapy], OT [Occupational Therapy], ST [Speech Therapy], Reviewed details of resident's recent fall, .4. Comments, IDT meeting. Sent to ED [Emergency Department] for Eval and treatment, Staff educated re: staffing for mechanical lift, determining proper sling size for mechanical lift. Inventory all mechanical lift slings; invite [Medical Equipment Company]. Review of Resident #3's Incident Report dated Tuesday February 14, 2023, at 1:45 p.m. revealed, General Information, Type: Fall, Incident Location: Hallway/Corridor, Activity: Transfer, Reported by: [Staff Q, RN], Witness(es): [Staff P, CNA], .Cognition Prior to Incident: Oriented X3, Cognition after Incident: Oriented x3, Injuries, Type: R/O [rule out] Fracture, Location: Left Lower Leg, Date/Time: 2/14/23 1:45 p.m., Details: Left lower leg-external curvature and rotated, Actions, Skin assessment completed, Pain Assessment, Investigative Statements, Resident: [Resident #3] stated that she told the CNA she was using the incorrect sling and that the blue sling was the right one for her not the red one. And the CNA continued to use the red sling for the transfer., Staff interviews, No Staff Interviews. Review of facility's Sit-to-Stand Lift (Brand Name) Usage Procedure undated, revealed a sizing chart which indicated the red sling was a size medium and the blue sling was a size large. An interview was conducted on 3/1/23 at 1:15 p.m. with Staff T, Educator, she stated, on orientation I do lift education and lift competency check off. We also have a mentor check off sheet which also indicates the staff are competent in the use of lifts. The week [Staff P, CNA] was in orientation I was not here so the competencies did not get done and her mentor check offs, she didn't turn that in. Review of the facility's Transfer Equipment 2 people education dated 2/7/23 revealed 13 employes were present for the education but [Staff P, CNA] was not located on the sign in education sheet indicating she did not receive the training. Review of Staff P, CNA's employee file revealed she was hired on 12/12/2022 and was terminated on 2/24/23 for transferring a resident in a sit to stand lift, with her last day of work being 2/14/23. The resident started slipping from the sling and was lowered to the floor. She sustained a fracture of the left tibia and fibula during the procedure. [Staff P, CNA] disregarded the following facility protocols for mechanical lift transfers. 1. 2 staff members must be present when transferring a resident with a mechanical lift. 2. The proper size sling must be used. An interview was conducted on 2/28/23 at 12:04 p.m. with the Director of Therapy he said, No we don't have anything to do with lifts. In rehab we want them off the lifts and gaining more function. Usually nursing makes the decision if the residents need a lift or not. Once we do our assessment on the resident then we tell them why this person is one person assist or two person assist, but that's later on in the admission. Once the resident comes into the building that's when nursing decides if they need a lift or not. We are not the ones who make the decision on the lifts. Unless they have specific stuff like the resident has a broken hip then we will tell nursing that they cannot use a lift. [Resident #3] was on case load from 1/20/23-2/14/23 there is nothing in our notes regarding lifts for her. They [Therapists] did mention and recommend a sit to stand lift on her evaluation. Transfer to wheelchair via sit-to-stand lift, that's all they mentioned, which indicates that is how she transfers. She is a long-term resident who utilized a sit to stand for transfers since before January 20th, 2023. That was not something that changed she has always been using that. I cannot see any lift assessment for her. An interview was conducted with the DON on 2/28/23 at 12:21 p.m. she said So, after [Resident #3's] fall we actually assessed all the residents who are using lifts maybe ten days ago, after [Resident #3's] to make sure that we have the appropriate lift for everyone. [Staff S, Informatics Specialist] and [Staff R, RN] did the assessment. [Staff S, Informatics Specialist] is an LPN [Licensed Practical Nurse] and [Staff R. RN] is an RN. They determined what type of lift and slings or belts they needed for all the residents who are needing a lift. The criteria to use a sit to stand lift if they can bear partial weight and can't be an amputee. For the [complete body lift] the criteria is they are not able to bear weight at all they can use the Complete body lift. There are sizes for the sling for the Complete body lift and there is a Velcro belt for the sit to stand lift that comes in small, medium, large, and extra-large and [Staff R. RN] and [Staff S, Informatics Specialist] determined what size sling and belt those residents needed. They based their measurements on the manufacture's recommendations they measured the residents from mid shoulder to gluteal fold and based on that measurement they were able to ascertain what size sling they needed. The waist belt we had an in-service from the vendor they said the waist belt has to have at least a 2-inch overlap on the belt. This information is in the Kardex that the CNA's have access to in the [Electronic Medical Record]. The new residents who are admitted if they can't bear weight or partial weight bearing the nurses have been educated on how to determine the sling and belt sizes and have been checked off on their competency. To be honest with you the residents that were transferred with lifts before we put everything in place, I'm not sure what the process was the staff just knew what lift and what color band around the sling the residents needed and that band around the sling determines what size it is. For the waist belts the staff just knew what color each resident needed. I'm new I just started in October. There was no formal process before this, this is what we discovered they would just ask a nurse or another CNA or the CNA that was on shift before them would tell them what they used. An interview was conducted with [Staff R. RN] on 2/28/23 at 12:41 p.m. she said I worked with therapy and staff we identified who used a mechanical lift then I entered that information on the Kardex so all staff could see how a resident could transfer. I participated in the training on how to do the measuring of slings and belts, but I did not measure anyone. All I did was identify what type of lift the resident needs and if they had any other transfer needs like 2 persons assists. I just asked if therapy had any input on changes for the people they were working with. For example, they were able to tell me residents who were able to stand and pivot t [TRUNCATED]