Every finding on record at Avir at Cowhorn Creek

Based on interview and record review, the facility failed to ensure medical records were maintained in accordance with accepted professional standards and practices on each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of medical records. The facility failed to ensure LVN A documented Resident #1's assessment and vital signs on 08/09/26 after throwing up. This failure could place residents at risk of not receiving care and services to meet their needs. The findings included: Record review of the face sheet, dated 08/13/26, reflected Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis) and hemiparesis (weakness) following a stroke, affecting the right dominant side, aphasia (brain disorder that impairs ability to process, speak, read, write, and understand language) following a stroke, and gastro-esophageal reflux disease (chronic digestive condition where stomach acid or fluid repeated flows back into the tube connecting your mouth and stomach). Record review of the discharge, return not anticipated MDS assessment, dated 08/10/26, reflected Resident #1 had an unplanned discharge to the acute care hospital. During an interview on 08/13/26 at 2:50 p.m., CNA B stated, on 08/09/26 around dinner time, LVN A notified her that Resident #1 had thrown up. She stated she got Resident #1 cleaned up and repositioned comfortably in the bed. She stated she checked on him throughout her shift, and he had no other concerns. During an interview on 08/13/26 at 5:09 p.m., LVN A stated on 08/09/26, when she arrived at work, she was walking to the nurses' station and noticed Resident #1 had vomit on the side of his bed. LVN A stated she reported to CNA B that Resident #1 had thrown up and she replied, Yeah, I know. LVN A stated she assumed CNA B had reported Resident #1's nausea and vomiting to LVN C and it had been addressed. LVN A stated after she received report LVN A stated she obtained Resident #1's vital signs, which were stable. She stated she assessed his abdomen and it was flat, non-distended, and non-tender. She stated she offered Resident #1 something for nausea, but he declined. She stated Resident #1 was checked on multiple times throughout the night and had no further issues or signs of distress. Record review of the progress note by LVN A on 08/09/26 at 11:04 p.m., reflected . respite [times] 5 days. [Awake, alert, and oriented to person, place, and time]. [Mechanical] arm to [right upper extremity] [twice a day]. Assist with ADL's and transfer. Medication whole. No sign of distress, discomfort, or [shortness of breath] noted. [Incontinent] to [bowel and bladder]. Resting in bed with eyes closed, chest rise and fall. Call light and [water] in reach and encouraged. During an interview on 08/14/26 at 10:15 a.m., the DON stated she expected the nurses' documentation to accurately reflect the residents' status and any interventions that were provided by the nursing staff. The DON stated LVN A explained she had performed vital signs and a focused assessment on Resident #1. The DON stated LVN A also reported she offered Resident #1 something for nausea and he declined it. The DON stated LVN A should have documented the vital signs, her assessment, and Resident #1's response to interventions. The DON stated it was important to ensure the clinical record accurately reflected the resident's status and interventions provided by the facility staff to ensure on-going monitoring of the resident's status or determine any changes of condition. During an interview on 08/14/26 at 12:57 p.m., the Administrator stated she expected the nurses to ensure procedures, assessments, or changes of conditions were documented in the clinical record. She stated the nurse management was responsible for monitoring to ensure documentation was completed accurately. The Administrator stated it was important to ensure clinical documentation was accurate so appropriate follow-up and monitoring could have been completed. Record review of the Charting and Documentation policy, dated July 2017, reflected, 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 following information is to be documented in the resident medical record: objective observations; medications administered; treatments or services performed; changes in the resident's conditions; event, incidents or accidents involving the resident. documentation in the medical record will be objective. Complete, and accurate.

Based on observation, interview and record review, the facility failed to ensure the resident's environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents and supervision. 1. The facility failed to ensure CNA A did not attempt a one-person resident transfer from the shower chair to Resident #1's wheelchair and then from her wheelchair to her bed on [DATE] by lifting her under her arms.2. The facility failed to ensure CNA A and CNA B performed a safe transfer from Resident #1's wheelchair to her bed on [DATE] by lifting her under her arms without the use of a gait belt or other assistive devices.3. The facility failed to ensure ADON E documented the staff's report of almost dropping Resident #1 or when Resident #1's family member showed her the video of the [DATE] transfer that showed CNA A almost drop Resident #1 trying to transfer her by himself and then the unsafe transfer performed by CNA A and CNA B.These failures could place residents at risk of injury.Findings included:Record review of Resident #1's face sheet dated [DATE] indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses including hemiplegia {unable to move one side of body}and hemiparesis {partial weakness of one side of body} following a cerebral infarction {stroke-death of brain tissue caused by blocked blood vessels that cuts off oxygen and blood} affecting the left non-dominant side, chronic obstructive pulmonary disease {long-term lung condition that limits airflow and makes it hard to breathe}, heart failure, peripheral vascular disease {slow blood circulation disorder caused by narrowing, blocking, or spasms of blood vessels outside the heart and brain}, fracture of upper end of left humerus {upper arm bone}, displaced simple supracondylar fracture of left humerus {lower end of upper arm bone}, history of fracture of lower end of left humerus in 2021, other specified disorders of bone density and structure, osteoarthritis {joint disease, characterized by the breakdown of the protective cartilage, pain during movement, and joint stiffness}, pain, lack of coordination, weakness and abnormality of gait and mobility.Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she was usually understood and usually understood others. The MDS indicated she had a BIMS of 13, which indicated she was cognitively intact. The MDS indicated Resident #1 had functional limitation of motion to upper and lower extremities on one side of her body. The MDS indicated Resident #1 used a wheelchair for mobility. The MDS indicated Resident #1 dependent on staff for most ADLs including tub/shower transfer, chair/bed to chair transfers, and rolling side to side.Record review of Resident #1's care plan dated initially [DATE] and revised on [DATE] indicated she had limited physical mobility related to left sided hemiplegia with left hand contracture, age related debility, and generalized weakness with interventions including she required total assist of two staff and mechanical lift for transfers and in the event of equipment unavailability, utilize 2-3 person total assist for transfers to ensure resident and staff safety. The care plan indicated Resident #1 was at risk for injury related to diagnosis of osteoporosis (medical condition that makes bones weak, thin, fragile, greatly increasing the risk of sudden breaks) and osteopenia (condition of lower-than-normal bone mineral density that serves as a warning sign for osteoporosis) with an initiated date of [DATE].Record review of progress notes dated [DATE] did not indicate ADON E had assessed Resident #1 after being notified by staff that they almost dropped her during a transfer.Record review of progress notes dated [DATE] indicated ADON E had done a skin assessment on Resident #1 and it did not reveal any new skin issues.Record review of video footage dated [DATE] beginning at 2:50 PM, started with Resident #1 sitting up in a wheelchair near her bed in her room. There were three staff members in the room. CNA C was standing on the opposite side of the bed. CNA B locked the wheelchair and then stood behind the wheel chair holding it. CNA A then walked in front of Resident #1 and put his arms under both of Resident #1's arms with his hands placed just behind her shoulders and lifted Resident #1 from her wheelchair and started to turn her toward her bed. Resident # 1's arms then went straight up, and she began to slip through CNA A's hands. CNA A then tried to turn Resident #1 back toward the wheelchair and her lower part of her back could be seen at the level of the wheelchair seat. CNA B then reached over the back of the wheelchair and grabbed Resident #1 under her arms and said Come on {CNA C's name}. CNA C came around the end of the bed, and CNA A, CNA B, and CNA C were able to pull Resident #1 back up into the wheelchair. Staff were heard saying We got you, unable to determine which staff said it. Resident #1 was wearing only a hospital type gown with the back of the gown open and there was no gait belt or any other assistive device being used. CNA C then stepped in front of Resident #1 and put both of her arms under both of Resident #1's arms and CNA A put his right arm under Resident #1's right arm. CNA C and CNA A then lifted Resident #1 and turning/dragging her to her left as CNA B pushed Resident #1's bottom toward the bed with one hand and they were able to get her top half of Resident #1's body onto the bed and then lifted her legs onto the bed. Resident #1 said put me on the bed and CNA B and CNA C both said you are on the bed. CNA B asked Resident #1 if she was okay. Resident #1 said I'm fine, sit me up. CNA B said they could not sit her up until they put her brief on. CNA B and CNA C then rolled Resident #1 from side to side and placed her brief on her and pulled her up in bed. CNA B then rubbed lotion on Resident #1's legs. Resident #1 said get me some pills and CNA C said, that's the nurse's job, do you want me to tell her? Resident #1 said yes, I'm hurting. CNA B and CNA C were discussing the shower chair and CNA B said, that shower chair did it, they need to get a better shower chair, and then it sounded like they were discussing the mechanical lift but was only able to make out all that was said, except someone going to get stuck midair. The three staff members covered Resident #1 with a sheet and blanket and continued their discussion but was unable to understand what was being said over the sound of the television. CNA B asked Resident #1 if she was good and Resident #1 said cover me up and CNA B said, I got you. The video ended at 2:55 PM.During an interview on [DATE] at 12:03 PM, Resident #1's family member said he had video footage of a male staff member (CNA A) trying to transfer Resident #1 by himself on [DATE] without a mechanical lift or gait belt and he almost dropped her when she slid down and additional staff came in and helped get her back up in the wheelchair.During an interview on [DATE] at 2:35 PM, LVN F said she had worked at the facility since 12/2025. LVN F said staff had reported that the mechanical lift was not working at times. LVN F said normally it was the battery and they had several batteries to change it out. LVN F said staff would just have to go get another battery and replace it. LVN F said she worked on [DATE] and staff did not report having to manually transfer Resident #1. LVN F said Resident #1 was a mechanical lift and it would depend if the three staff members were strong enough to lift her to safely transfer her safely manually. LVN F said there was no way to safely transfer Resident #1 other than using a mechanical lift. LVN F said staff could possibly use the mechanical lift pad with four people, 1 on each corner if they had to. LVN F said there was one mechanical lift, and she thought they used the one lift for both ends of the building. LVN F said they could drop Resident #1 and could cause injury to the resident if they performed an unsafe transfer.During an interview on [DATE] at 2:53 PM CNA C said she had worked at the facility for about four months. CNA C said she did assist transfer Resident #1 without a mechanical lift because the aide that had her that day said that the mechanical lift would not work and they had changed the battery and it still did not work. CNA C said they came and got her to assist to transfer Resident #1 from the wheelchair to her bed. CNA C said it was CNA B and CNA A who were in Resident #1's room to manually transfer her. CNA C said the transfer went good, because they had three people in there. CNA C said there was not a time that they almost dropped her. CNA C said the only thing Resident #1 said before the transfer was to get her out of the wheelchair because her bottom hurt. CNA C said they did tell the nurse about the lift not working and was told to change the battery and it still was not working, so she guessed that was when they came and got her to assist with the transfer. CNA C said they needed to use the mechanical lift or at least 3-4 people to lift Resident #1 safely. CNA C said they probably should have used a gait belt. CNA C said Resident #1 could have fell and been injured.During an interview on [DATE] at 3:13 PM, CNA B said she had worked at the facility since [DATE]. CNA B said CNA A and herself gave Resident #1 a shower on [DATE] and there was no issue in the shower itself. CNA B said there was an issue with the mechanical lift and the battery died. CNA B said she left the shower room and went to the nurses' station and told the nurse the battery was dead and the older white lady went into the room and brought her a battery. CNA B said she put the battery on the mechanical lift and it was dead, so she then went and told the older white lady that battery did not work either. CNA B said she tried a total of three batteries, the one on the mechanical lift and 2 others, and did not know they had six batteries. CNA B said there was a charger behind the nurses' station, but she did not know there were more batteries because she had just started [DATE]. CNA B said there were two batteries on chargers and one on the lift and they were all dead. CNA B said she put the battery on the charger so it would charge. CNA B said she went and told CNA A and asked him what they were supposed to do then if the lift was not charged. CNA B said she did not know if CNA A asked the nurse what to do, but she knew she did not tell anyone about manually lifting Resident #1. When CNA B was informed of viewing the video footage of the transfer from the wheelchair to the bed for Resident #1 on [DATE], she said CNA A and CNA C transferred Resident #1 from the wheelchair to the bed and she held the wheelchair from behind. CNA B said the first time CNA A tried to transfer Resident #1 by himself and he almost dropped her. CNA B said she was still learning at that time and was not comfortable doing the transfer. CNA B said they should not have lifted her from under her arms and they should have used a gait belt. CNA B said they did not wait for the mechanical lift battery to charge because Resident #1 was crying out in pain due to her bottom was hurting. CNA B said at that moment they did what they thought was right. CNA B said Resident #1 could have fell and could have been injured during the transfer. CNA B said after the transfer, she told ADON E that it was not a smooth transfer and told her CNA A almost dropped Resident #1 when he attempted to transfer her by himself and they eased her back to the wheelchair and then two people transferred her back to bed from the wheelchair. CNA B said after Resident #1's shower and they could not get a working battery for the mechanical lift; she did not feel comfortable transferring Resident #1 from the shower chair to the wheelchair and CNA A transferred Resident #1 by himself and thought he bear hugged her. CNA B said that transfer went much smoother than the one in her room.During an observation and interview on [DATE] at 3:40 PM, Resident #1's family member was at Resident #1's bedside. Resident #1 was lying in bed asleep and she appeared clean and well kept. Resident #1's family member said he was told the mechanical lift was not working on [DATE] and he did not know how staff transferred her from the shower chair to the wheelchair to take her back to her room. Resident #1's family member said he came to the facility on [DATE] and showed ADON E the [DATE] video footage of the male staff member (CNA A) almost dropping Resident #1 in her room when trying to transfer her by himself. Resident #1's family member said ADON E called him back that afternoon at 4:27 PM and said she had talked to the staff and said the lift was broken because the battery did not charge, and they denied they dropped Resident #1. Resident #1's family member said ADON E said the staff should have at least used a gait belt because they could have re-injured her arm by lifting her under her arms. During an interview on [DATE] at 4:57 PM, CNA A said he had worked at the facility for two to three months PRN. CNA A said he could not really remember much about Resident #1's transfer on [DATE]. CNA A said the best he could remember was the lift quit working, but he did not know what was wrong with it. CNA A said it would not work up and down. CNA A said he guessed it was the battery. CNA A said he did not remember exactly how they transferred Resident #1 in the shower room. CNA A said him and CNA C were on each side of Resident #1 and as far as he could remember, she had a gait belt on Resident #1. CNA A said he did not remember him and CNA C lifting Resident #1 under her arms to transfer her. CNA A said there were no issues with the transfer to his knowledge. CNA A said he did not remember trying to lift Resident #1 under her arms by himself without a gait belt or other equipment. CNA A said he thought there was a gait belt, as much as he could remember. CNA A said he did not know how to answer how it could have affected the resident by trying to lift her by himself or without the proper equipment. CNA A said he had been trained by the DON on the use of a gait belt. CNA A said they should use a gait belt during transfers to balance the weight, so not to have all the weight on the resident.During an interview on [DATE] at 9:19 AM, ADON E said she assessed Resident #1 after one of the CNAs told her, they almost dropped Resident #1 during the transfer on [DATE] after they transferred her. ADON E said there were not any issues, and she did not do an incident report because she did not have anything to document. ADON E said Resident #1's family member did show her the video later, but she did not remember what day he showed it to her. ADON E said the video showed one staff member was trying to transfer Resident #1 by himself and Resident #1 slid down. ADON E said they got her back into the wheelchair and then two staff members transferred Resident #1 to the bed. ADON E said she did not see anything in the transfer that she thought needed to be put in an incident report because Resident #1 did not fall. ADON E said she reported to the DON/ADM, but she did not remember what day that was, that she had seen the video but Resident #1 did not fall. ADON E said she assessed Resident #1 and did not see anything that needed to be documented. ADON E said she talked to the staff members and asked them why they did not use the mechanical lift and they said the battery went out. ADON E said she would not think all the batteries were dead. ADON E said after staff told her they had to manually transfer Resident # 1, she checked the mechanical lift and said all she did was put another battery on it and there was a charged battery available. ADON E said there were other ways to transfer a resident with 2-4 people if the mechanical lift was not working, so not sure what the risk to the resident would be. ADON E said staff should use a gait belt during manual transfers but using a gait belt on Resident #1 could cause her more harm because she could not stand. ADON E said if they had to manually transfer a resident that was a mechanical lift, then they should use a sheet or the mechanical lift pad for a safe transfer with one person on each corner. ADON E said she had trained them on that through demonstration after watching the video. ADON E said she did not document the in-service with demonstration and did not have the staff sign that they had received the in-service. ADON E said she felt they did a safe transfer. ADON E said they should not have lifted Resident #1 from under her arms.During an interview on [DATE] at 11:50 AM, LVN F said staff could not safely transfer Resident #1 by getting under her arms and without a gait belt or a lift pad. LVN F said she would have never approved or suggested it. LVN F said it could have caused a fall and risk of injury to Resident #1.During an interview on [DATE] at 1:14 PM, ADON D said she was the ADON for halls 100 and 200. ADON D said Resident #1 required a mechanical lift for transfers. ADON D said it would not be safe for one person to transfer Resident #1 by lifting under her arms. ADON D said Resident #1 would require 2-3 persons with a gait belt to transfer without a mechanical lift. ADON D said it would not be a proper transfer if two staff members lifted Resident #1 from under her arms. ADON D said it would be a risk of injury to the resident and staff. ADON D said they should use a gait belt for safety. ADON D said she was not aware of any issues with the mechanical lift not functioning, but they did have to change out the batteries when they were dead. ADON D said they had multiple batteries, so there should always be an extra charged battery. ADON D said if a staff member told her that they almost dropped the resident, she would report it to the DON. ADON D said she did not know if she would do an incident report but would assess the resident and investigate the incident and would document any findings in the resident's chart. ADON D said if a family member showed her a video that showed the staff almost dropped the resident and the improper transfer, she would notify DON and assess the resident, investigate, document any findings, notify the family and physician if needed.During an interview on [DATE] at 2:17 PM, the DON said the resident could be transferred manually if there was an issue with the mechanical lift, only as a backup. The DON said she would expect the manual lift to be done safely and with the proper equipment. The DON said she would expect to be notified of any issues if a staff member reported they almost dropped a resident or did an unsafe transfer, so she could in-service staff. The DON said her ADONs were pretty good about reporting stuff to her. The DON said she did not recall ADON E reporting any incident related to a staff member reporting almost dropping the resident or doing an unsafe transfer. The DON said ADON E did report that the battery died on the mechanical lift, but they had a lot batteries and the staff must have not gone and got another battery. The DON said ADON E said there was a charged battery, but she could not say that was on [DATE]. The DON said ADON E did not tell her about the video shown to her previously and she was not aware of the video until the [DATE]. The DON viewed the video from [DATE] and said it was not so much of a good transfer. The DON said all three of the staff should have done a body lift with sheet under the resident to lift Resident #1. The DON said they did not perform a safe transfer. The DON said Resident #1 was dead weight and she would not use a gait belt because she could not stand and pivot. The DON said there were several possible things that could possibly happen if transferred improperly, such as harming the resident. The DON said ADON E would not have done an incident report because the resident fall and there was no injury related to the [DATE] manual transfer.During an interview on [DATE] at 2:51 PM, the ADM said if there was a reason the mechanical lift was not feasible, then she would expect the staff to do a manual lift in the safest way possible. The ADM viewed the [DATE] transfer video and said obviously they should have used a mechanical lift. The ADM said she would expect the facility policies to be followed. She said the video showed they should have used a mechanical lift.During an interview on [DATE] at 3:10 PM, the Regional Nurse viewed the video footage of the [DATE] transfer. She said the staff should have used a sheet under Resident #1 to transfer her. She said it was not a good body lift. The Regional Nurse said Resident #1 was at risk of falling. She said ADON E should have done an incident report because there was a change in the plane which was the definition of a fall. She explained that to the DON and said she would be in-servicing staff. She said at the very least ADON E should have documented her assessment and no findings.Record review of the facility's Competency Assessment check-off titled Transferring the Resident dated [DATE], indicated CNA A had successfully demonstrated Transfer Performance (Bed to Chair/Wheelchair) which included Positioned wheelchair/chair correctly and locked wheels . used gait belt or mechanical lift as per care plan/Kardex . pivoted safely, avoiding twisting motions, uses small pivot steps . two-person assists: position on each side of the resident and grasps belt on front and back, used small pivot steps . gently lowed resident into chair, ensuring resident was comfortable, repositioned properly and checked for alignment .Record review of the facility's Competency Assessment check-off titled Transferring the Resident dated [DATE], indicated CNA B had successfully demonstrated Transfer Performance (Bed to Chair/Wheelchair) which included Positioned wheelchair/chair correctly and locked wheels . used gait belt or mechanical lift as per care plan/Kardex . pivoted safely, avoiding twisting motions, uses small pivot steps . two-person assists: position on each side of the resident and grasps belt on front and back, used small pivot steps . gently lowed resident into chair, ensuring resident was comfortable, repositioned properly and checked for alignment .Record review of the facility's Competency Assessment check-off titled Transferring the Resident dated [DATE], indicated CNA C had successfully demonstrated Transfer Performance (Bed to Chair/Wheelchair) which included Positioned wheelchair/chair correctly and locked wheels . used gait belt or mechanical lift as per care plan/Kardex . pivoted safely, avoiding twisting motions, uses small pivot steps . two-person assists: position on each side of the resident and grasps belt on front and back, used small pivot steps . gently lowed resident into chair, ensuring resident was comfortable, repositioned properly and checked for alignment .Record review of the facility's policy titled Safe Lifting and Movement of Residents dated revised [DATE], indicated . In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents . 1. Resident safety, dignity, comfort and medical condition would be incorporated into goals and decisions regarding the safe lifting and moving of residents . 2. Manual lifting shall be eliminated when feasible . 4. Staff responsible for direct resident care would be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices . 5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary . 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents . 8. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used twenty-four hours a day while batteries were being charged .Record review of the facility's policy titled Accidents and Incidents-Investigating and Reporting dated revised [DATE], indicated . All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator . 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . 2. The following data, as applicable, shall be included in the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The names of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; g. The time the injured person's attending physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom; i. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); k. Any corrective action taken; l. Follow-up information; . n. The signature and the title of the person completing the report .

Based on and record review, the facility failed to develop and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 1 of 7 residents (Resident #1) reviewed for care plans.1. The facility failed to implement Resident #1's care plan by not performing a mechanical lift.2. The facility failed to implement Resident #1's care plan when CNA A attempted to transfer Resident #1 by himself on [DATE] by lifting her under her arms.These failures could place residents in the facility at an increased risk of injury, a decline in physical or functional well-being, and not receiving necessary care or services to meet their needs. Findings included:Record review of Resident #1's face sheet dated [DATE] indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses including hemiplegia {unable to move one side of body}and hemiparesis {partial weakness of one side of body} following a cerebral infarction {stroke-death of brain tissue caused by blocked blood vessels that cuts off oxygen and blood} affecting the left non-dominant side, chronic obstructive pulmonary disease {long-term lung condition that limits airflow and makes it hard to breathe}, heart failure, peripheral vascular disease {slow blood circulation disorder caused by narrowing, blocking, or spasms of blood vessels outside the heart and brain}, fracture of upper end of left humerus {upper arm bone}, displaced simple supracondylar fracture of left humerus {lower end of upper arm bone}, history of fracture of lower end of left humerus in 2021, other specified disorders of bone density and structure, osteoarthritis {joint disease, characterized by the breakdown of the protective cartilage, pain during movement, and joint stiffness}, pain, lack of coordination, weakness and abnormality of gait and mobility.Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she was usually understood and usually understood others. The MDS indicated she had a BIMS score of 13, which indicated she was cognitively intact. The MDS indicated Resident #1 had functional limitation of motion to upper and lower extremities on one side of her body. The MDS indicated Resident #1 used a wheelchair for mobility. The MDS indicated Resident #1 dependent on staff for most ADLs including tub/shower transfer, chair/bed to chair transfers, and rolling side to side.Record review of Resident #1's care plan dated initially [DATE] and revised on [DATE] indicated she had limited physical mobility related to left sided hemiplegia with left hand contracture, age related debility, and generalized weakness with interventions including she required total assist of two staff and mechanical lift for transfers and in the event of equipment unavailability, utilize 2-3 person total assist for transfers to ensure resident and staff safety. The care plan indicated Resident #1 was at risk for injury related to diagnosis of osteoporosis (medical condition that makes bones weak, thin, fragile, greatly increasing the risk of sudden breaks) and osteopenia (condition of lower-than-normal bone mineral density that serves as a warning sign for osteoporosis) with an initiated date of [DATE].Record review of video footage dated [DATE] beginning at 2:50 PM, started with Resident #1 sitting up in a wheelchair near her bed in her room. There were three staff members in the room. CNA C was standing on the opposite side of the bed. CNA B locked the wheelchair and then stood behind the wheel chair holding it. CNA A then walked in front of Resident #1 and put his arms under both of Resident #1's arms with his hands placed just behind her shoulders and lifted Resident #1 from her wheelchair and started to turn her toward her bed. Resident # 1's arms then went straight up, and she began to slip through CNA A's hands. CNA A then tried to turn Resident #1 back toward the wheelchair and her lower part of her back could be seen at the level of the wheelchair seat. CNA B then reached over the back of the wheelchair and grabbed Resident #1 under her arms and said Come on {CNA C's name}. CNA C came around the end of the bed, and CNA A, CNA B, and CNA C were able to pull Resident #1 back up into the wheelchair. Staff were heard saying We got you, unable to determine which staff said it. Resident #1 was wearing only a hospital type gown with the back of the gown open and there was no gait belt or any other assistive device being used. CNA C then stepped in front of Resident #1 and put both of her arms under both of Resident #1's arms and CNA A put his right arm under Resident #1's right arm. CNA C and CNA A then lifted Resident #1 and turning/dragging her to her left as CNA B pushed Resident #1's bottom toward the bed with one hand and they were able to get her top half of Resident #1's body onto the bed and then lifted her legs onto the bed. Resident #1 said put me on the bed and CNA B and CNA C both said you are on the bed. CNA B asked Resident #1 if she was okay. Resident #1 said I'm fine, sit me up. CNA B said they could not sit her up until they put her brief on. CNA B and CNA C then rolled Resident #1 from side to side and placed her brief on her and pulled her up in bed. CNA B then rubbed lotion on Resident #1's legs. Resident #1 said get me some pills and CNA C said, that's the nurse's job, do you want me to tell her? Resident #1 said yes, I'm hurting. CNA B and CNA C were discussing the shower chair and CNA B said, that shower chair did it, they need to get a better shower chair, and then it sounded like they were discussing the mechanical lift but was only able to make out all that was said, except someone going to get stuck midair. The three staff members covered Resident #1 with a sheet and blanket and continued their discussion but was unable to understand what was being said over the sound of the television. CNA B asked Resident #1 if she was good and Resident #1 said cover me up and CNA B said, I got you. The video ended at 2:55 PM.During an interview on [DATE] at 12:03 PM, Resident #1's family member said he had video footage of a male staff member (CNA A) trying to transfer Resident #1 by himself on [DATE] without a mechanical lift or gait belt and he almost dropped her when she slid down and additional staff came in and helped get her back up in the wheelchair.During an interview on [DATE] at 2:35 PM, LVN F said she had worked at the facility since 12/2025. LVN F said staff had reported that the mechanical lift was not working at times. LVN F said normally it was the battery and they had several batteries to change it out. LVN F said staff would just have to go get another battery and replace it. LVN F said she worked on [DATE] and staff did not report having to manually transfer Resident #1. LVN F said Resident #1 was a mechanical lift and it would depend if the 3 staff members were strong enough to lift her to safely transfer her manually. LVN F said there was no way to safely transfer Resident #1 other than using a mechanical lift. LVN F said staff could possibly use the mechanical lift pad with four people, 1 on each corner if they had to. LVN F said there was one mechanical lift, and she thought they used the one lift for both ends of the building. LVN F said they could drop Resident #1 and could cause injury to the resident if they performed an unsafe transfer.During an interview on [DATE] at 2:53 PM, CNA C said she had worked at the facility for about four months. CNA C said she did assist transfer Resident #1 without a mechanical lift because the aide that had her that day said that the mechanical lift would not work and they had changed the battery and it still did not work. CNA C said they came and got her to assist to transfer Resident #1 from the wheelchair to her bed. CNA C said it was CNA B and CNA A who were in Resident #1's room to manually transfer her. CNA C said the transfer went good, because they had three people in there. CNA C said there was not a time that they almost dropped her. CNA C said the only thing Resident #1 said before the transfer was to get her out of the wheelchair because her bottom hurt. CNA C said they did tell the nurse about the lift not working and was told to change the battery and it still was not working, so she guessed that was when they came and got her to assist with the transfer. CNA C said the needed the lift or at least 3-4 people to lift Resident #1. CNA C said they probably should have used a gait belt. CNA C said Resident #1 could have fell and been injured.During an interview on [DATE] at 3:13 PM, CNA B said she had worked at the facility since [DATE]. CNA B said CNA A and herself gave Resident #1 a shower on [DATE] and there was no issue in the shower itself. CNA B said there was an issue with the mechanical lift and the battery died. CNA B said she left the shower room and went to the nurses' station and told the nurse the battery was dead and the older white lady went into the room and brought her a battery. CNA B said she put the battery on the mechanical lift and it was dead, so she then went and told the older white lady that battery did not work either. CNA B said she tried a total of three batteries, the one on the mechanical lift and 2 others, and did not know they had six batteries. CNA B said there was a charger behind the nurses' station, but she did not know there were more batteries because she had just started [DATE]. CNA B said there were two batteries on chargers and one on the lift and they were all dead. CNA B said she put the battery on the charger so it would charge. CNA B said she went and told CNA A and asked him what they were supposed to do then if the lift was not charged. CNA B said she did not know if CNA A asked the nurse what to do but she knew she did not tell anyone about manually lifting Resident #1. When CNA B was informed of viewing the video footage of the transfer from the wheelchair to the bed for Resident #1 on [DATE], she said CNA A and CNA C transferred Resident #1 from the wheelchair to the bed and she held the wheelchair from behind. CNA B said the first time CNA A tried to transfer Resident #1 by himself and he almost dropped her. CNA B said she was still learning at that time and was not comfortable doing the transfer. CNA B said they should not have lifted her from under her arms and they should have used a gait belt. CNA B said they did not wait for the mechanical lift battery to charge because Resident #1 was crying out in pain due to her bottom was hurting. CNA B said at that moment they did what they thought was right. CNA B said Resident #1 could have fell and could have been injured during the transfer. CNA B said after the transfer, she told ADON E that it was not a smooth transfer and told her CNA A almost dropped Resident #1 when he attempted to transfer her by himself and they eased her back to the wheelchair and then two people transferred her back to bed from the wheelchair. CNA B said after Resident #1's shower and they could not get a working battery for the mechanical lift; she did not feel comfortable transferring Resident #1 from the shower chair to the wheelchair and CNA A transferred Resident #1 by himself and thought he bear hugged her. CNA B said that transfer went much smoother than the one in her room. CNA B said they have the resident's transfer status on their computer system on the Kardex (care plan for aides) and it did say Resident #1 was a mechanical lift. CNA B said the Kardex should be followed to provide safe care to the residents.During an interview on [DATE] at 3:40 PM, Resident #1's family member was at Resident #1's bedside. Resident #1's family member said he was told the mechanical lift was not working on [DATE] and he did not know how staff transferred her from the shower chair to the wheelchair to take her back to her room. Resident #1's family member said he came to the facility on [DATE] and showed ADON E the [DATE] video footage of the male staff member (CNA A) almost dropping Resident #1 in her room when trying to transfer her by himself. Resident #1's family member said ADON E called him back that afternoon at 4:27 PM and said she had talked to the staff and said the lift was broken due to the battery did not charge, and they denied they dropped Resident #1. Resident #1's family member said ADON E said the staff should have at least used a gait belt because they could have re-injured her arm by lifting her under her arms. During an interview on [DATE] at 4:57 PM, CNA A said he had worked at the facility for two to three months PRN. CNA A said he could not really remember much about Resident #1's transfer on [DATE]. CNA A said the best he could remember was the lift quit working, but he did not know what was wrong with it. CNA A said it would not work up and down. CNA A said he guessed it was the battery. CNA A said he did not remember exactly how they transferred Resident #1 in the shower room. CNA A said him and CNA C were on each side of Resident #1 and as far as he could remember, she had a gait belt on Resident #1. CNA A said he did not remember him and CNA C lifting Resident #1 under her arms to transfer her. CNA A said there were no issues with the transfer to his knowledge. CNA A said he did not remember trying to lift Resident #1 under her arms by himself without a gait belt or other equipment. CNA A said he thought there was a gait belt, as much as he could remember. CNA A said he did not know how to answer how it could have affected the resident by trying to lift her by himself or without the proper equipment. CNA A said he had been trained by the DON on the use of a gait belt. CNA A said they should use a gait belt during transfers to balance the weight, so not to have all the weight on the resident. CNA A said the Kardex told them what assistance a resident needed for transferring. CNA A said he did not know how to answer what the risk would be if they did not follow the Kardex/care plan for transferring a resident.During an interview on [DATE] at 9:19 AM, ADON E said one of the CNAs told her about they almost dropped Resident #1 during the transfer on [DATE] after they transferred her. ADON E said she talked to the staff members and asked them why they did not use the mechanical lift and they said the battery went out. ADON E said she would not think all the batteries were dead. ADON E said after staff told her they had to manually transfer Resident # 1, she checked the mechanical lift and said all she did was put another battery on it and there was a charged battery available. ADON E said the purpose of the care plan was to tell staff what the care plan was for that resident and told them how to care for that resident. ADON E said they should follow the care plan to ensure the best care for that resident. ADON E said it depended on what the situation was, so she could not say what the risks to the resident would be from staff not following the care plan. ADON E said the Kardex let staff know what transfer assistance the resident needed. ADON E said staff could transfer a resident, who was care planned for a mechanical lift, manually depending on what could have occurred.During an interview on [DATE] at 11:50 AM, LVN F said staff could not safely transfer Resident #1 by getting under her arms and without a gait belt or a lift pad. LVN F said she would have never approved or suggested it. LVN F said it could have caused a fall and risk of injury to Resident #1. LVN F said the care plan was to show what staff needed to do to take care of the resident. LVN F said not following the care could cause injury to the resident. LVN F said the nurses, ADON, and the DON would be responsible for ensuring the care plans were followed. LVN F said the aides were trained with a tenured aide when they came to the floor and then the nurses could educate staff as needed on the care needs of the residents.During an interview on [DATE] at 1:14 PM, ADON D said the staff knew what the resident's transfer status was by looking in the Kardex. ADON D said the care plan was to let everyone know what care that individual resident needed to care for the resident. ADON D said the only time the resident would be transferred differently from what was on the care plan would be if the mechanical lift malfunctioned for some reason, but then it should be done safely with 2-3 people with a gait belt. ADON D said the staff could injure themselves or the resident.During an interview on [DATE] at 2:17 PM, the DON said the purpose of the care plan was to let staff know how to take care of the patient and tell staff about the patient. The DON said it would be important to follow the care plan because that was how you take care of the patient. The DON said there were a lot of risks to the resident if the care plan was not being followed, depending on what was not followed. The DON said all the nursing staff, ADONs, and MDS nurses were responsible for ensuring the care plan was followed. The DON said the Kardex (the care plan for the CNAs) and the ADL flowsheet was like a roadmap of how to care for the resident. The DON said the resident could be transferred manually if there was an issue with the mechanical lift, only as a backup. The DON said she would expect the manual lift to be done safely and with the proper equipment.During an interview on [DATE] at 2:51 PM, the ADM said the purpose of the care plan was to be person centered for staff to know how to care for the resident in the best way possible. The ADM said she would expect the care plan to be followed. The ADM said if there was a reason the mechanical lift was not feasible, then she would expect the staff to do a manual lift in the safest way possible. The ADM said she would expect the facility's policies to be followed.Record review of the facility's policy dated revised [DATE] and titled Care Plans, Comprehensive Person-Centered, indicated . A comprehensive, person-centered care plan that includes measurable objectives and timetables to the meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident . the care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment . each resident's comprehensive person-centered care plan was consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to . g. receive the services and/or items included in the plan of care . the comprehensive person-centered care plan . described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . care plan interventions were 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 .

Based on interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and supervision, in that: Resident #1 was transferred without a gait belt and staff failed to utilize safe body mechanics during the transfer on 6/22/26. This failure placed the residents at risk for loss of balance, fall, and injury. The findings included: Record review of Resident #1's face sheet, dated 07/06/2026, revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebral vascular accident (a type of stroke that occurs when a blocked or narrowed blood vessel disrupts blood flow to the brain), hemiplegia (one-sided paralysis or weakness of the face, arm or leg), and dementia (pattern of mental decline caused by different diseases or conditions. Most commonly, dementia occurs when brain nerve cells (neurons) die, and connections between neurons are interrupted). Record review of Resident #1's quarterly MDS assessment dated [DATE], indicated Resident #1 required maximal/substantial (helper does more than 1/2 the work) for transfer to and from chair to bed. Record review of Resident #1's physical therapy treatment encounter notes dated 06/19/2026 revealed Resident #1 required maximal assist with verbal and tactile cueing for safety from bed to wheelchair. Record review of Resident #1's care plan, dated 06/25/2026, revealed a care plan for : ADL performance deficit: Resident #1 required substantial/maximal assistance for ADLs such as transfer and bed mobility. Record review of a video dated 06/22/2026 at 9:54 a.m., showed Resident #1 being transferred from her wheelchair to her bed by CNA A. Resident #1 was in her wheelchair sitting perpendicular to her bed. CNA A pulled Resident #1 up by looping her forearms under Resident #1's armpits and spun her around 180 degrees. No gait belt was used. Resident #1 did not participate in the transfer and 100% of the work was done by CNA A. During an interview on 07/06/2026 at 1:15 p.m., the Director of Rehab viewed the video and stated the transfer of Resident #1 by CNA A on 06/22/2026 at 9:54 a.m., was very unsafe. She stated all transfers were to be done with a gait belt. She stated Resident #1 should have been aligned parallel to her bed for a 90-degree pivot transfer. She stated swinging Resident #1 from 180 degrees could have injured Resident #1 and CNA A or Resident #1 could have fallen related to the improper transfer. The Director of Rehab stated Resident #1 had been a maximum assist pivot transfer for several months. She stated Resident #1 had been on therapy services for over 60 days working on transfer training. During an interview on 07/06/2026 at 1:44 p.m., CNA A stated she remembered the transfer with Resident #1 on 06/22/2026 because she almost dropped Resident #1. She stated Resident #1 would generally assist the smallest amount, but she felt Resident#1's knees buckle during the transfer causing her to almost drop Resident #1. She stated she should have used a gait belt and chicken winging (putting your arms under the residents' arms and lifting the resident) the resident during transfer was not a proper transfer technique. She stated a few days after the transfer an in-service was done about proper transfer techniques and using a gait belt during transfer. During an interview on 07/06/2026 at 3:00 p.m., the DON stated it was the facility's policy to use gait belts with transfers. She stated the CNAs had access to the residents' profile that showed how much assistance each resident needed for safe care. She stated Resident #1 was maximum assistance and required only 1 staff member for safe transfer with a gait belt. She stated she did transfer training in-servicing on 06/23/2025-06/25/2026 for CNAs. She stated she estimated she in-serviced about 1/2 the staff so far and was continuing with the training until she had everyone trained. She stated all staff were educated about safe transfer on hire and annually unless circumstances arose when an in-service or training needed to be done in-between. During an interview on 07/06/2026 at 3:30 p.m., the Administrator stated it was the facility's policy to follow the safest technique for transfers for all residents. The Administrator stated Resident #1's care plan stated 1 person for transfers, but CNA A should have used proper technique and a gait belt. The Administrator stated training had been done with most of the staff on proper transferring. She stated improper transfers could lead to falls or injuries for both the residents and staff. Review of an undated facility policy titled 'Safe Lifting and Movement of Residents' revealed .Manual lifting of residents shall be eliminated when feasible .Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belt, lateral boards) and mechanical lifting techniques. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 1 residents reviewed for pharmacy services. (Resident #1)The facility failed to accurately administer medications for Resident #1 when LVN A administered 15 medications late.This failure could place residents at risk for inaccurate drug administration and worsening of condition. Findings included:Record review of a face sheet dated 04/13/26 indicated Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (common, often debilitating, one-sided motor impairments following cerebral infarction (stroke)), atrial fibrillation (a common heart rhythm disorder characterized by rapid, erratic electrical signals causing the upper chambers of the heart to quiver instead of beating effectively), seizures, and high blood pressure.Record review of an Order Summary Report for Resident #1 dated 04/13/26 indicated the following physician's orders:Amlodipine Beslylate (a medication for high blood pressure) 10 mg 1 tablet by mouth 1 time a day for hypertension (high blood pressure) with a start date of 04/07/25.Artificial Tears Ophthalmic (concerning the eyes) Solution, instill 1 drop in both eye two times a day for dry eyes with a start date of 05/13/25.Aspirin 81 mg oral tablet, 1 tablet by mouth one time a day related to hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side with a start date of 04/07/25.Carvedilol 6.25 mg, 1 tablet two times a day related to hypertension with a start date of 08/31/25.Eliquis 5 mg, give 1 tablet by mouth two times a day related to hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side with a start date of 08/31/25.Keppra (Lefetiraceta) 500 mg, give 1 tablet by mouth two times a day related to seizures with a start date of 08/31/25.Losartan 100 mg, give 1 tablet orally one time a day for heart failure with a start date of 04/07/25.Mucinex Oral Tablet Extended Release12 Hour, 600 mg, give 1 tablet by mouth two times a day related to acute respiratory failure with a start date of 09/02/25.Multivitamin with minerals, give 1 tablet by mouth once a day for vitamin deficiency with a start date of 04/07/25.Myrbetriq 40 mg, give 1 tablet orally once time a day related to urinary incontinence with a start date of 04/07/25.Pantoprazole 40 mg, give 1 tablet orally two times a day related to gastro-esophageal reflux disease (heartburn) with a start date of 08/31/25.Potassium Chloride 10 milliequivalent, give 1 tablet orally two times a day related to hypokalemia (low potassium) with a start date of 08/31/25.Senna Oral Tablet 8.6 mg, give 1 tablet by mouth two times a day related to constipation with a start date of 08/31/25.Vitamin D3 Oral table 25 micrograms, give 1 tablet by mouth one time per day related to a vitamin deficiency with a start date of 04/07/25.Zyrtec Allergy Oral tablet 10 mg, give 1 tablet orally one time a day related to allergies with a start day of 10/11/25.Record review of an annual MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 12 which indicated moderately impaired cognition. The MDS indicated Resident #1 was dependent on staff for most ADLs.Record review of a care plan last revised on 01/27/26 indicated Resident #1 was at risk for an impaired breathing pattern. There was an intervention to administer medications as ordered. The care plan indicated Resident #1 had a diagnosis of hypertension and was at risk for decrease cardiac output. There was an intervention to administer medications as ordered. The care plan indicated Resident #1 was at risk for seizures related to a history of seizures. There was an intervention to administer medications as ordered. The care plan indicated Resident #1 was incontinent of bowel and bladder. There was an intervention to administer medications as ordered. The care plan indicated Resident #1 was at risk for bruising and bleeding related to the anti-coagulant Eliquis. There was an intervention to administer the medication as ordered. The care plan indicated Resident #1 had high blood pressure. There was an intervention to give anti-hypertensive medications as ordered.Record review of a MAR dated 04/01/26 - 04/13/26 for Resident #1 indicated LVN A administered medications that were due at 7:00 a.m. on 04/13/26. The MAR did not indicate an administration time. The following medications were administered:Amlodipine Beslylate (a medication for high blood pressure) 10 mg 1 tablet by mouth.Artificial Tears Ophthalmic (concerning the eyes) Solution, 1 drop in both eyes.Aspirin 81 mg oral tablet, 1 tablet by mouth.Carvedilol 6.25 mg, 1 tablet by mouth.Eliquis 5 mg, give 1 tablet by mouth.Keppra (Lefetiraceta) 500 mg, 1 tablet by mouth.Losartan 100 mg,1 tablet orally.Mucinex Oral Tablet Extended Release12 Hour, 600 mg, 1 tablet by mouth.Multivitamin with minerals, 1 tablet by mouth.Myrbetriq 40 mg, 1 tablet by mouth.Pantoprazole 40 mg, 1 tablet orally.Potassium Chloride 10 milliequivalent, 1 tablet orally.Senna Oral Tablet 8.6 mg, 1 tablet by mouth.Vitamin D3 Oral table 25 micrograms,1 tablet by mouth.Zyrtec Allergy Oral tablet 10 mg,1 tablet orally.During an observation and interview on 04/13/26 at 8:54 a.m., LVN A said she worked on an as needed basis for the facility. She said she did the best she could when passing medications to residents. She said the only time she was late passing medications was because she worked on an as needed basis and it took her awhile to find things. LVN A prepared and administered the following medications:Amlodipine Beslylate (a medication for high blood pressure) 10 mg 1 tablet by mouth.Artificial Tears Ophthalmic (concerning the eyes) Solution, 1 drop in both eyes.Aspirin 81 mg oral tablet, 1 tablet by mouth.Carvedilol 6.25 mg, 1 tablet by mouth.Eliquis 5 mg, give 1 tablet by mouth.Keppra (Lefetiraceta) 500 mg, 1 tablet by mouth.Losartan 100 mg,1 tablet orally.Mucinex Oral Tablet Extended Release12 Hour, 600 mg, 1 tablet by mouth.Multivitamin with minerals, 1 tablet by mouth.Myrbetriq 40 mg, 1 tablet by mouth.Pantoprazole 40 mg, 1 tablet orally.Potassium Chloride 10 milliequivalent, 1 tablet orally.Senna Oral Tablet 8.6 mg, 1 tablet by mouth.Vitamin D3 Oral table 25 micrograms,1 tablet by mouth.Zyrtec Allergy Oral tablet 10 mg,1 tablet orally.During an interview on 04/13/26 at 1:42 p.m., LVN A said the morning medications for Resident #1 were late the morning of 04/13/26. She said even with the hour window they are given for medication administration, the medication were still late. She said the medications were due at 7:00 a.m. She said they were late because she was not familiar with the medication cart and she was slower.During an interview on 04/13/26 at 2:19 p.m., RN B said she had not known medications to be passed late. She said it was important for medications to be passed on time, so the residents get the medications they need. She said some residents get the same medications several times a day and you did not want to give them too early or too late. She said you had an hour before the ordered time and an hour after the ordered time to pass the medication.During an interview on 04/13/26 at 2:36 p.m., the DON said she expected for residents to have received their medications on time. She said they normally had a medication aide and LVN A did not normally pass medications. She said it was important for staff to follow the doctor's orders. She said she did not know medications were being passed late.During an interview on 04/13/26 at 3:07 p.m., the Administrator said she expected for medications to be passed timely and as ordered. She said it was important for residents to get their medications on time, it was important to follow the physician's order and how it affected the resident depended on the medication.During an interview on 04/13/26 at 3:38 p.m., the ADON said she expected medications to have been given on time. She said they did have an hour before and an hour after the ordered time. She said it was important to be given on time because that was how the doctor ordered the medication and they had to follow doctor's orders.Record review of an Administering Medications facility policy last revised on 04/2019 indicated, .Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any required time frames.Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include.enhancing optimal therapeutic effect of the medication.preventing potential medication or food interactions.Medications are administered within one (1) hour of their prescribed time.As required or indicated for a medication, the individual administering the medication records in the resident's medical record.the date and time the medication was administered.

Based on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to ensure RN coverage for 5 days during FY Quarter 4 2025 (July 1 to September 30). This failure could place residents at risk of harm due to being left without supervisory coverage for coordination of events such as emergency care and disasters.The findings included: Record review of the facility payroll-based journal for the fourth quarter of fiscal year 2025 reflected the facility did not have RN coverage on the following days: 08/28/2025, 08/29/2025, 09/01/2025, 09/02/2025, and 09/03/2025. Record review of the employee time sheets from August 2025 and September 2025, reflected no RN clock-in hours on 08/28/2025, 08/29/2025, 09/01/2025, 09/02/2025, and 09/03/2025. During an interview on 02/12/2026 beginning at 1:50 p.m., the Administrator stated the DON was on leave during the dates 08/28/2026, 08/29/2026, 09/01/2026, 09/02/2026, and 09/03/2026. She stated the facility partnered with a company of nurse practitioners. She stated that the nurse practitioner covered the 8 hours during those dates. The Administrator stated the company was unable to provide timesheets for the nurse practitioner because they were salary. The Administrator stated the company provided the nurse practitioner's check stub to show the hours worked within the timeframe and a picture of an excel spreadsheet with the number of visits listed on the dates in question. She stated that was the only evidence she had, and she was unable to verify the nurse practitioner covered the required 8-hour timeframe. She said it was important to ensure an RN worked 8 consecutive hours, 7 days a week because it was the regulatory requirement. She stated not having an RN working on staff would not have affected the residents. Record review of the Staffing, Sufficient and Competent Nursing policy, dated August 2022, reflected . A registered nurse provides services at least (8) hours every 24 hours, seven (7), days a week .

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety.1. The facility failed to ensure equipment surfaces were kept clean.2. The facility failed to ensure that all food items in Refrigerator #1, Refrigerator #2, and Freezer #1 were dated and labeled.3. The facility failed to ensure that the outside of the fryer and the side of the range facing the fryer were kept free of grease build up.These failures could place residents at risk of foodborne illness and food contamination.Record review of a blank Daily Cleaning Schedule indicated the cooks were to clean the stove and cook area after each meal.Record review of a blank Weekly Cleaning Schedule indicated the deep fryer was to be cleaned by the cook on Wednesday. The Weekly Cleaning Schedule indicated refrigerators were to be cleaned on Tuesdays by an aide.Record review of Dietary Orientation Competency Checklists dated 01/19/26 - 01/20/26 indicated 7 staff members were educated on storing foods and length of time and how to clean kitchen equipment.Record review of a Customer Service Report from a commercial dishwashing and laundry service company dated 02/12/26 at 9:15 indicated, There was a soil and water build up on top of the dishwasher from the tops of the doors. There was to much gap between the top face opening and the door. I adjusted this. There was also a piece of eggshell in one of the end spray nozzles. This caused water to spray up at an angle on the door instead of up on the dishes.During an observation on 02/09/26 at 9:49 a.m., there was a brown dry crusty looking substance all over the top of the dishwasher.During an observation on 02/09/26 at 9:50 a.m., on the outside of Refrigerator #1 there were white smudges of an unknown substance on the outside doors near the door handles. The smudges were dry to the touch. Inside Refrigerator #1 there was two bags of a yellow substance in a clear plastic bin on a lower shelf with no date or label, one bag of sausage patties with no date and one bag of brown food patties with no label. On the bottom shelf there was one bag of an unknown red meat food item with no date or label.During an observation on 02/09/26 at 9:53 a.m., on the outside of Refrigerator #2, beside the ice machine, there were multiple white drip marks down the outside door. The drips were dry to the touch. Inside Refrigerator #2 there was one bag of a purple jelly substance with no date or label.During an observation on 02/09/26 at 9:55 a.m., on the outside of Freezer #1 there were light colored smudges of an unknown substance on the doors near the handles. Inside Freezer #1 was a plastic bag containing green, yellow, and orange food items with no label, one bag of an unknown light brown breaded food item with no label, one bag of an unknown pink meats with no label, one plastic bag with beige food items with no label, one bag of light beige unknown meats with no date or label, and a plastic bag of many round red food items with no label.During an observation on 02/10/26 at 11:28 a.m., the fryer in the kitchen had an excessive amount of grease buildup down the front of the fryer and down the sides of the fryer. There was an excessive amount of grease buildup on the range next to the fryer. There were food crumbs on the floor between the fryer and range.During an observation on 02/10/26 at 11:52 a.m., there was a light brown gritty looking substance on top of the dishwasher. The substance felt dry and [NAME] to the touch.During an observation 02/10/26 at 11:55 a.m., on the outside of Refrigerator #1 there were white smudges of an unknown substance on the outside doors near the door handles. The smudges were dry to the touch. During an observation on 02/10/26 at 11:26 a.m., on the outside of Freezer #1 there were light colored smudges of an unknown substance on the doors near the handles.During an observation and interview on 02/11/26 at 3:14 p.m., the Dietary Manager said he had told staff to clean the top of the dishwasher. He said water was washing up on the top of the dishwasher. He said the [NAME] substance was food particles. The Dietary Manager ran the dishwasher, and water was washing up out of the top side of the dishwasher. After this, there was water and food particles on the top of the dishwasher. He said the company had previously been out and made adjustments to the machine.The Dietary Manager said years ago the deep fryer was painted. He said he did not know how long it had been since the deep fryer had been cleaned. He said it had been awhile. He said the deep fryer needed to be carried out of the kitchen and power washed. He said there was a weekly cleaning schedule that he expected staff to follow. He said he was responsible for making sure staff were cleaning equipment in the kitchen. He said dirty equipment could cause bacteria to grow and someone could get sick.He said that staff knew if food items came out of the box it had to be dated and labeled. He said he had recently in-serviced staff on dating and labeling foods. He said all staff should be dating and labeling foods. He said servicing undated food items could cause a resident to get sick. He said staff might not know what a food item was with no label.During an interview on 02/12/26 at 11:01 a.m., the Administrator said she expected for equipment surfaces to be kept clean. She said all kitchen staff were responsible for keeping equipment surfaces clean. She said she expected the deep fryer to be kept clean, along with the range sitting next to it. She said she expected for food in the freezers and refrigerators to be dated and labeled. She said you do not want dirty equipment to ensure sanitary conditions. She said food not being dated could not negatively affect a resident, but it helps ensure that the food was not spoiled. She said she felt food items not having labels could not negatively affect the residents.Record review of a Food Storage facility policy dated 2023 indicated, .Food should be dated as it is placed on the shelves if required by state regulation.Date marking should be visible on all high risk food.All refrigerator units should be kept clean.All foods should be covered, labeled and dated and routinely monitored to assure that foods.will be consumed by their use dates.All freezer units should be kept clean.Record review of a Cleaning and Sanitation of Dining and Food Service Areas facility policy dated 2023 indicated, .The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule.staff will be held accountable for cleaning assignments.Sample Cleaning Schedule.Daily.Exterior of dishwashers and other appliances.Weekly.Refrigerators.Twice per month.Ovens.Monthly.Freezers.Clean behind and under major appliances.

Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS admission assessment was transmitted to the CMS System within 7 days after completion for 1 of 18 residents (Resident #7) reviewed for admission MDS assessments. The facility failed to ensure Resident#7's admission MDS assessments were transmitted within 14 days of completion of admission assessment. This failure could place residents at risk of not having records completed and submitted in a timely manner as required.Findings included: 1. Record review of a face sheet dated 02/11/26 indicated Resident #7 was [AGE] years old and had an admission date of 12/24/25 with diagnoses including dementia, heart failure, and seizures. Record review of an admission MDS assessment dated [DATE] for Resident #7 indicated the MDS was a new record. The MDS revealed Resident #7 had a BIMS of 15, which indicated intact cognition. The MDS indicated Resident #7 required moderate to maximal assistance with most ADLs. The completion signature date was 01/02/26 and was signed by the MDS Coordinator. The MDS was to be transmitted by 01/16/26. Record review of a CMS Submission/Transmission Report dated 01/23/26 at 9:36 a.m. indicated Resident #7's admission assessment had an assessment reference date of 12/29/25. The report indicated a warning that the submission was transmitted on 01/23/26, more than 14 days after the completion signature date. During an interview on 02/11/26 at 2:29 p.m., the MDS Coordinator said she was responsible for completing and submitting MDS assessments. She said the admission assessments should be signed when the assessment was completed. She said the transmission date was within 14 days of the signature date. She said she knew she had some late assessments. She said she had found out they were late when she went to sign them and realized they should have been done. She said the MDS did not directly affect resident care. During an interview on 02/12/26 at 9:21 a.m., the DON said the MDS Coordinator was responsible for completing and transmitting the admission MDSs in a timely manner. She said she expected the MDS assessments to be completed and transmitted in the appropriate timeframe. She said MDSs not being completed and transmitted in the appropriate timeframe would not negatively affect resident's care. During an interview on 02/12/26 at 11:01 a.m., the Administrator said the MDS Coordinator was responsible for completing MDS assessments and transmitting them in a timely manner. She said she did not feel like there could be a negative outcome for the assessments not being completed timely or being transmitted timely. Record review of an email from the Administrator on 02/13/26 at 1:17 p.m. indicated, .we follow the RAI manual as it pertains to MDS timing. Record review of a Comprehensive Assessments facility policy last updated 02/2025 indicated, .Comprehensive assessments are conducted to assist in developing person-centered care plans.Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual.The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1. Record Review of the CMS RAI Version 3.0 Manual, dated October 2025, indicated, in Chapter 2.8, page 2-22 - Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days).

Based on interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #5, Resident #14, Resident #41 and Resident #59) of 18 residents reviewed for care plans. 1. The facility failed to ensure Resident #5 had a complete comprehensive care plan.2. The facility failed to ensure Resident #14 had a care plan for hospice services.3. The facility failed to ensure Resident #41 had care plans for falls and psychotropic medication usage as coded on the MDS.4. The facility failed to ensure Resident #59 had care plans for anticonvulsant usage and seizure disorder as coded on the MDS. These failures could place residents at risk of not having their individualized needs met, falls, decreased range of motion and a decline in their quality of care and life. Findings included: 1.Record review of the face sheet, dated 02/11/2026, reflected Resident #5 was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #5 had a principal diagnosis of unspecified dementia, unspecified severity, with anxiety (memory loss). Record review of the quarterly MDS assessment, dated 11/17/2025, reflected Resident #5 had clear speech, was understood, and was able to understand others. Resident #5 had a BIMS score of 13, which indicated she was cognitively intact. Resident #5 had a functional limitation in range of motion that interfered with daily functions or placed her at risk for injury to both lower extremities. Resident #5 required set-up assistance with eating, oral hygiene, and personal hygiene. She was dependent on staff for assistance with toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, bed mobility, and transfers. The MDS reflected Resident #5 was always incontinent of bowel and bladder. She had active diagnoses that included: hypertension (high blood pressure), malnutrition (problems with nutrient absorption), anxiety disorder (mental health conditions characterized by persistent, excessive, and irrational fear or worry that is out of proportion to actual, everyday situation), depression (mental illness characterized by persistent sadness, loss of interest in activities, and low energy lasting at least 2 weeks), and chronic embolism and thrombosis of deep vein right lower extremity (blood clot hardens causing scarring and permanently narrows or blocks blood flow). Resident #5 had a scheduled pain medication regime and received as needed pain medications. Resident #5's pain assessment reflected that she had occasional pain during the 5 day look-back period that occasionally made it hard to sleep. The MDS reflected Resident #5 was at risk for developing pressure ulcers/injuries and utilized a pressure reducing device for her bed. Resident #5 was taking an anticoagulant (blood thinner) and opioid (pain) medications. Record review of Resident #5's comprehensive care plan, dated 03/17/2025, reflected only one focus problem. She was dependent on staff to anticipate and meet personal activity needs related to physical limitations. The comprehensive care plan did not address range of motion limitations, ADL assistance, bowel/bladder incontinence, active diagnosis, pain, risk for pressure injury, or high-risk medication usage. 2. Record review of an undated face sheet revealed Resident #14 was a [AGE] year-old female admitted on [DATE] with diagnoses of malignant neoplasm of parotid (a cancerous tumor arising in the parotid gland), end stage heart disease (the most advanced, chronic phase where the heart pumps inefficiently, causing severe, persistent symptoms even at rest), and hemiplegia (a severe, often permanent, form of unilateral paralysis affecting one side of the body, caused by brain or spinal cord damage). Record review of a significant change MDS assessment dated [DATE] revealed Resident #14 had a BIMS of 05, which indicated severe cognitive impairment. Resident #14 required substantial (helper did more than half of the work) for ADLs such as bed mobility, dressing, and bathing. The MDS also revealed Resident #14 was taking antiplatelet medication, opioids, diuretics, and antibiotics. Record review of the consolidated physician orders dated February 2026, revealed Resident #14 had an order dated 01/08/2026 for hospice services. Record review of the comprehensive care plan dated 1/11/2026 revealed no care plan for hospice services. 3. Record review of an undated face sheet revealed Resident #41 was a [AGE] year-old male admitted on [DATE] with the diagnoses CVA ( Cerebrovascular Accident (CVA), commonly known as a stroke, occurs when blood flow to the brain is interrupted, causing brain cells to die), hemiplegia (paralysis of one side of the body), and bipolar disorder (a chronic mental health condition characterized by extreme, often disabling, shifts in mood, energy, and activity levels, alternating between high (mania/hypomania) and low (depression) episodes). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #41 had a BIMS of 07 which indicated moderate cognitive impairment. Resident #41 required substantial assistance (helper does more than half of work) for ADLs such as toileting, transfer, and bathing. Resident #41 received high-risk drugs (antidepressants and antianxiety) during the look back. Record review of Resident #41's incident and accident reports revealed the following: 1. 12/08/2025- Resident #41 had a fall attempting to transfer from wheelchair to bed. 2. 01/05/2026- Resident #41 had a fall reaching to pick something up off the floor. Record review of the care plan dated 01/20/2026 revealed no care plan for Resident #41's high risk mediation usage of antidepressants and anti-anxiety medications or for his falls on 12/08/2025 or 01/05/2026. 4.Record review of an undated face sheet revealed Resident #59 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of sepsis (a life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection, leading to widespread inflammation, organ damage, and potential failure), MRSA infection of sacral pressure ulcer (Methicillin-resistant Staphylococcus aureus) infection in a sacral pressure ulcer is a serious, potentially fatal complication, causing rapid tissue destruction, abscesses, and systemic infection), and gastrostomy status (refers to the presence of an artificial, surgically created opening (stoma) into the stomach for a feeding tube). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #59 had a BIMS of 08, which indicated moderate cognitive impairment. Resident #59 required dependent assistance with ADLs. He received antidepressant, diuretic, and anticonvulsant mediations during the look back. Resident #59 had a seizure disorder. Record review of the comprehensive care plan dated 01/20/2026 revealed no care plan for anticonvulsant usage or seizure activity. During an interview on 02/11/2026 at 3:40 p.m., the MDS Coordinator stated care plans were to include all things that were coded on the MDS. She stated the care plan should be reviewed by the nursing staff to know the individual care instructions for each resident. The MDS Coordinator stated items such as falls, high risk medication usage, hospice services, and diagnoses should be care planned for resident safety. She stated not care planning an important item with the interventions could result in the staff not knowing what is needed for the management of the individual resident condition. During an interview on 02/12/2026 at 11:00 a.m., the DON stated it was the floor nurse and the administrative nurses' responsibility to ensure that staff were educated about interventions for all aspects of the resident's care. She stated all major diagnoses, conditions, medications, and falls should be care planned with interventions to alert the staff of the potential of these situations recurring and to give instructions on what to do in those cases. The DON stated not care planning important information could lead to the residents not receiving personalized care. During an interview on 02/12/2026 at 2:00 p.m., the ADM stated she expected the staff to follow the interventions decided on by the MDS coordinator and interdisciplinary team. She stated the interventions were in place to keep everyone safe and prevent accidents. She stated not having the items care planned would not necessarily cause any ill effect to the residents. Record review of the Care Plans, Comprehensive Person-Centered policy, dated March 2022, reflected 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 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 care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.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 wound otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;.and which professional services are responsible for each element of care; includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions.the interdisciplinary team reviews and updates the care plan. at least quarterly.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and attractive for 3 of 8 residents (Resident's #5, #32, and #39) reviewed for palatable food. The facility failed to provide food that was palatable and attractive to Resident #5, #32, and #39 who complained the food was served cool and bland. These failures could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: 1. Record review of the face sheet, dated 02/11/2026, reflected Resident #5 was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #5 had a principal diagnosis of unspecified dementia, unspecified severity, with anxiety (memory loss). She had further diagnoses that included: protein-calorie malnutrition (a severe, life-threatening condition caused by insufficient intake of protein, calories, or both, leading to significant changes in body composition and function) and dysphagia, oropharyngeal phase (difficulty initiating a swallow and moving food from the mouth to the throat, often causing choking, coughing, or nasal regurgitation). Record review of the quarterly MDS assessment, dated 11/17/2025, reflected Resident #5 had clear speech, was understood, and was able to understand others. Resident #5 had a BIMS score of 13, which indicated she was cognitively intact. Resident #5 required set-up assistance with eating. Resident #5 had no signs or symptoms of a swallowing disorder or significant weight loss during the look-back period. Record review of Resident #5's order summary report, dated 02/09/2026, reflected an order, which started on 03/26/2025 for a regular diet texture and thin liquid consistency. During an interview on 02/09/2026 beginning at 3:51 p.m., Resident #5 stated the food was terrible. She stated the food was often cold and had no flavor. 2. Record review of the face sheet, dated 02/11/2026, reflected Resident #32 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of acute embolism (blockage) and thrombosis (blood clot) of deep veins of right upper extremity, ovarian and anal cancer, and obesity. Record review of the quarterly MDS assessment, dated 01/15/2026, reflected Resident #32 had clear speech, was understood, and was able to understand others. Resident #32 had a BIMS score of 15, which indicated she was cognitively intact. She was independent with eating. Record review of the order summary report, dated 02/09/2026, reflected Resident #32 had an order which started on 07/15/2025 for a regular diet texture and regular consistency. During an interview on 02/09/2026 beginning at 11:40 a.m., Resident #32 stated the food was awful. She said that the food was served cold and bland. She said that the lettuce was often served wilted and the sandwich meat tasted bad, like it had been left sitting out. 3. Record review of the face sheet, dated 02/11/2026, reflected Resident #39 was a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of stroke. Resident #39 had further diagnoses that included: end stage renal disease (final, permanent stage of kidney failure, were the kidney's no longer filter waste and balance fluids) and dependance on renal dialysis (life-sustaining medical treatment that filters blood to remove excess waste, toxins, and fluids when kidney's no longer work). Record review of the quarterly MDS assessment, dated 12/04/2025, reflected Resident #39 had clear speech, was understood, and was able to understand others. Resident #39 had a BIMS score of 15, which indicated she was cognitively intact. Resident #39 usually required setup or clean-up assistance with eating. Record review of the order summary report, dated 02/09/2026, reflected Resident #39 had an order which started on 06/10/2025, for a no added salt diet with regular diet texture and consistency, limit bananas, potatoes, tomatoes, and oranges at meals. During an interview on 02/09/2026 beginning at 11:40 a.m., Resident #39 stated the food had no seasoning and was cold by the time they got it. During an interview and observation on 02/10/2026 beginning at 9:02 a.m., Resident #32 and Resident #39 were eating breakfast. Resident #32 stated she was served pork sausage that appeared undercooked and was pale in the center, she held it up for surveyor to see. Resident #32 stated her toast was rubbery and cold. Resident #32 stated for lunch on 02/09/2026 she received chili con carne or whatever it was. She said it looked like someone threw up on her tray and it tasted like it too. Resident #32 stated she had talked to the guy in the kitchen multiple times about the food, but nothing was done. She said sometimes they would ask her if she wanted something else, but she only had 3 choices to choose from, and they were all terrible. Resident #39 agreed with Resident #32 and stated her breakfast was cold and bland. During an observation and interview on 02/10/2026 at 1:06 p.m., Lunch tray was sampled with four surveyors and Dietary Manager. The hamburger steak was lukewarm. Some of the broccoli was bright and crunchy. The rest of the broccoli was dull-colored green and was soft. The broccoli was lukewarm. The mashed potatoes were lukewarm and bland. The peach cobbler was cold. The dietary manager said he agreed the potatoes were bland. He said the food could have been warmer. The Dietary Manager said he was not sure if the cobbler was supposed to have been served warm or cold, but the cook made the cobbler earlier in the morning. During an interview on 02/12/2026 beginning at 11:15 a.m., MA G stated she was aware of the complaints about the food. She stated some of the residents believed the food was nasty. She said when the residents did not like what was served, the staff was supposed to offer them a sandwich, or substitute. She said it was important to ensure the residents were served food that looked and tasted good to encourage them to eat and prevent weight loss. During an interview on 02/12/2026 beginning at 11:48 a.m., LVN H stated she had received complaints about the food. She said when she received complaints about the food, she took the tray back to the kitchen and offered them a substitute. She stated it was important to ensure the food looked and tasted good because this was their home and they did not have any other options for food; they should be able to get what they want. She said it could have caused nutrition issues. During an interview on 02/12/2026 beginning at 2:23 p.m., the Dietary Manager stated he had not received any food complaints recently. He stated he had not received complaints about the food being cold or bland. He stated when he did receive food complaints, he talked with the resident who made the complaint and tried to resolve the problem. He stated the person plating the food was responsible for monitoring to ensure the food looked good, tasted good, and was the appropriate temperature. He stated it was important to ensure the food looked good, tasted good, and was the appropriate temperature so the residents wanted to eat. During an interview on 02/12/2026 beginning at 3:30 p.m., the Administrator stated she was unaware of any food complaints recently. She stated they had previously made a lot of changes in the dietary department. She stated she expected the Dietary Manager to ensure the menu and recipe was followed and that food was served at the appropriate temperature. She said the Dietary Manager was responsible for monitoring to ensure the food looked good, tasted good, and was served at the appropriate temperatures. She said it was important to ensure the food looked good, tasted good, and was the appropriate temperature for resident satisfaction. Record review of the Food and Nutrition Services policy, dated October 2017, reflected 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 is served at a safe and appetizing temperature.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.

Based on observation, interview and record review, the facility failed to remove expired medications from active storage for 1 of 2 medication rooms (Medication room [ROOM NUMBER]). 1.The facility failed to ensure expired insulin and expired OTCs were removed from active storage in medication room [ROOM NUMBER]. 2.This failure could place residents at risk of expired medication being administered.3.Resident #15's Basaglar (long-acting insulin) 20 Units each morning was held for 19 of 41 days reviewed with no MD order to hold or notification of MD from 01/01/2026 through 02/10/2026. These failures could affect residents that are insulin dependent by placing them at risk for elevated blood glucose and poor glucose control.Findings included:1.Record review of Resident #15' s undated face sheet indicated she was an [AGE] year-old female admitted on [DATE], with the diagnoses which included, type II diabetes (refers to a group of diseases that affect how the body uses blood sugar (glucose) , retinopathy (disease of the retina which results in impairment or loss of vision), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #15 had a BIMS of 05, which indicated severe cognitive impairment. Resident #15 was dependent for ADLs, received oral hypoglycemic medication, and insulin daily. Record review of the comprehensive care plan dated 01/12/2026 revealed Resident #15 had unstable glucose levels and medications were to be administered as prescribed. Record review of the consolidated physician orders revealed an order dated 09/25/2025 for Basaglar 20 Units every morning with a start date of 09/25/2025. Record review of the MAR dated January 2026 revealed Resident #15's Basaglar insulin was held on the following days: 01/01/2026 01/06/2026 01/07/2026 01/08/2026 01/10/2026 01/14/2026 01/16/2026 01/17/2026 01/18/2026 01/22/2026 01/23/2026 01/24/2026 01/27/2026 01/29/2026 Record review of the MAR dated February 2026 revealed Resident #15's Basaglar insulin was held the following days: 02/01/2026 02/02/2026 02/06/2026 02/07/2026 02/10/2026 Record review of the MAR dated January 2026 revealed Resident 15's morning blood glucose levels (in mg/dL) were as follows: 01/01/2026-77 01/06/2026-109 01/07/2026-124 01/08/2026-115 01/10/2026-98 01/14/2026- 94 01/16/2026- 82 01/17/2026-135 01/18/2026-138 01/22/2026-128 01/23/2026-123 01/24/2026-143 01/27/2026-140 01/29/2026-122 Record review of the MAR dated February 2026 revealed Resident #15's morning blood glucose levels (in mg/dL) were as follows: 02/01/2026-97 02/02/2026-98 02/06/2026-119 02/07/2026-123 02/10/2026-149 During an interview on 02/10/2026 at 10:00 a.m., LVN A stated she held the Basaglar insulin when she worked if Resident #15's blood sugar was not over 200mg/dL because she had an order not to administer Novolog insulin when her blood glucose was less than 200mg/dL. LVN A stated Basaglar was a long-acting insulin that affected the blood sugar several hours from administration. She stated Novolog insulin was short acting and affected the blood glucose levels immediately. LVN A stated that if a medication was held it was best practice to notify the MD of the held medication. She stated she had not notified the MD on the occasions she held the Basaglar insulin for Resident #15 because there was no change in the resident's level of consciousness or vital signs. During a telephone interview on 02/12/2026 at 9:00 a.m., MD E stated he had received no notification from the facility that Resident #15's Basaglar insulin was being held. He stated the only reason it should be held was if the resident's blood glucose was below 50 mg/dL or they were showing signs of hypoglycemia (sweating, change in level of consciousness, blurred vision, shaking). MD E explained that Basaglar insulin was long acting and it would keep the resident from getting spikes in her blood glucose later in the day when she had consumed her lunch and supper meals. MD E stated he expected the nurses to administer all insulins as ordered and notify him if there was a need for the insulin to be held. He stated Resident #15 had not suffered any ill effects from not receiving the Basaglar because she had no wounds, infections, visual changes, and she received limited amounts of sliding scale insulin throughout the day. MD E stated elevated blood glucose levels could impair wound healing, make healing from infections difficult, and cause damage to the eyes and other organs. During an interview on 02/12/2026 at 10:00 a.m., the DON stated she was unaware that LVN A had held Resident #15's Basaglar insulin without contacting the MD and without an order to hold the long-acting insulin. She stated she would have to speak with the nurse about using nursing judgement and calling the MD when she felt the need to hold a mediation. The DON stated her expectation was for the nurse to contact her and the MD when any medication was held. The DON stated Resident #15 had no adverse effect from missing the doses of Basaglar because her blood glucose levels were not seriously out of control like some diabetics. During an interview on 02/12/2026 at 11:00 a.m., the Administrator stated she expected the nurses to follow MD orders at all times and contact the administrative nurses with any held medications. The Administrator stated the ADON and DON were very familiar with the facility policies and procedures and would ensure they were followed.2. During an observation on 02/10/2026 at 8:15 a.m., in medication room [ROOM NUMBER] for the 300 and 400 halls, a Basaglar (long-acting insulin) pen was noted in the refrigerator with the expiration date of November 2025.3. During an observation on 02/10/2026 at 8:30 a.m., in mediation room [ROOM NUMBER] for 300 and 400 halls, a box of OTC gas-relief medication was noted in the OTC active storage with the expiration date of August 2024.During an interview on 02/10/2026 at 8:35 a.m., ADON C stated she and the pharmacy consultant checked the mediation room for expired medications. She stated she checked weekly and the pharmacy consultant checked monthly. ADON C stated the insulin and the OTC gas-relief medication were an oversight. She stated she did not feel like expired gas-relief medication would harm the resident. She stated expired insulin would be less effective and it was important to keep an eye on insulin expiration dates, so the resident received insulin that was in date and effective for the control of blood glucose. During an interview on 02/11/2026 at 10:00 a.m., the DON said the medication storage room should only have expired medication in the discontinued medication bins. She stated it was not acceptable to have expired medication in the active OTC cabinet or the refrigerator. The DON stated expired medication could be less effective and not remedy or control the symptoms it was meant to control. During an interview on 02/11/2026 at 11:00 a.m., the Administrator said the medication rooms to be free of expired medications. The Administrator stated it was nursing' s job to ensure expired medications were disposed of properly. Review of the facility's policy titled Storage of Medications last revised 08-2024 reflected the following: . Policy statement. Medications and biologicals are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications.Procedures. 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aids) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access. III. Expiration Dating (Beyond-use dating) indicated .8. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 halls (hall 300) and 1 of 6 (Resident #59) residents reviewed for infection control practices. 1.The facility failed to ensure staff (CNA B) maintained infection control prevention while carrying soiled linen through the facility on 02/09/2026. 2. The facility failed to ensure staff (LVN A) wore PPE when providing direct care to a resident on EBP. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.Findings included: 1.During an observation on 02/09/2026 at 9:35 a.m., CNA B walked down the 300 hall with soiled bedding held next to her body, not covered in a bag. ADON C ran behind her and stated you cannot carry dirty linen outside of the room if it is not in a bag and definitely not next to your body. During an interview on 02/09/2026 at 10:12 a.m., CNA B stated she was aware that it was an infection control issue if she held dirty linen next to her body and carried it out in the hallway. She stated germs could be transferred to another resident from her clothes during care. She stated she just walked out with the linen without thinking. During an interview on 02/09/2026 at 10:22 a.m., ADON C stated she saw CNA B coming out of the room and tried to stop her from carrying the soiled linen through the building and holding it next to her body. ADON C stated it was a big no, no to leave a resident room with soiled linen or clothing without it being contained in a bag or barrel. ADON C stated CNA B could potentially spread infection to the other 11 residents she worked with by having germs on her clothes. 2. Record review of an undated face sheet revealed Resident #59 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of sepsis (a life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection, leading to widespread inflammation, organ damage, and potential failure), MRSA infection of sacral pressure ulcer (Methicillin-resistant Staphylococcus aureus) infection in a sacral pressure ulcer is a serious, potentially fatal complication, causing rapid tissue destruction, abscesses, and systemic infection), and gastrostomy status (refers to the presence of an artificial, surgically created opening (stoma) into the stomach for a feeding tube). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #59 had a BIMS score of 08, which indicated moderate cognitive impairment. Resident #59 required dependent assistance with ADLs. He received antidepressant, diuretic, and anticonvulsant mediations during the look back. Resident #59 had a seizure disorder. Record review of a care plan dated 02/06/2026 revealed Resident #59 had EBP related to PEG tube and sacral wound. The intervention was that staff must use gowns and gloves during high contact resident care activities that could possibly result in the transfer of MDROs from hand and clothing of staff. Record review of consolidated physician orders dated February 2026 revealed on order for EBP related to gastrostomy tube. During an observation on 02/10/2026 at 8:00 a.m., a sign for EBP precautions and PPE was noted outside of Resident #59's room. During an observation on 02/10/2026 at 8:30 a.m., LVN A entered Resident #59's room and adjusted him in the bed and untucked his PEG tube with no gown or gloves on. During an observation on 02/10/2026 at 9:01 a.m., LVN A reentered Resident #59's room and adjusted his sheets and covers, repositioned his PEG tube with no gown on. During an observation on 02/10/2026 at 9:31 a.m., LVN A completed administration of PEG meds, removed her gloves and reconnected Resident #59's tube feeding with no gloves on and without washing her hands. During an interview on 02/10/2026 at 9:33 a.m., LVN A stated she was under the impression dressing in the gown and gloves were only for incontinent care, wound care, or bathing was occurring. She stated she realized she went into the room without PPE to adjust him in the bed and make sure his PEG tube was not under his body before PEG medication administration. She stated she did not realize she took her gloves off before reconnecting his PEG feeding. LVN A stated she was aware that gloves had to be worn to prevent the spread of disease and infection and protect the resident. During an interview on 02/12/2026 at 10:00 a.m., the DON stated it was her expectation that the staff would wear a gown and gloves for EBP when their task required touching the resident. She stated EBP was to protect the residents from any germs that the staff brought in on their clothing and hands. The DON stated Resident #59 was compromised because he has a history of MRSA infections. She stated it was best practice to wear gloves when touching the residents in any manner to prevent transfer of disease-causing bacteria. During an interview on 02/12/2026 at 11:00 a.m., the Administrator stated she expected the nurses and CNAs to follow the facility policy on infection control and EBP. Review of a policy dated 2001 titled Enhanced Barrier Precaution, revealed Enhanced barrier precautions (EPBs) are utilized to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents.EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Record review of the facility Infection Prevention and Control Program Policy, date 2001, revealed.an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The infection prevention and control program developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary.

Based on interview and record review the facility failed to complete the admission assessment for 5 of 18 (Resident #28, Resident #44, Resident #53, Resident #55, and Resident #72) residents reviewed for MDS completion.The facility failed to complete the admission MDS assessment for Resident #28, Resident #44, Resident #53, Resident #55, and Resident #72 within 14 calendar days.These failures could place residents at risk of not having records completed and submitted in a timely manner as required The findings included: 1. Record review of a face sheet dated 02/11/26 indicated Resident #44 was [AGE] years old and had an admission date of 01/08/26 with diagnoses including chronic obstructive pulmonary disease (chronic lung disease), muscle weakness, and anxiety disorder. Record review of an MDS dated [DATE] for Resident #44 indicated the MDS was a new record. The MDS revealed Resident #44 had a BIMS of 13, which indicated intact cognition. The MDS indicated Resident #7 required moderate assistance with most ADLs. The completion date was 01/26/26 and was signed by the MDS Coordinator. Record review of a CMS Submission/Transmission Report dated 01/26/26 at 6:14 p.m. indicated Resident #44's admission assessment had an assessment reference date of 01/12/26. The report indicated the admission assessment was completed late. The assessment was completed more than 13 days after the entry date. 2. Record review of a face sheet dated 02/11/26 indicated Resident #53 was [AGE] years old and had an admission date of 01/13/26 with diagnoses including Alzheimer's Disease (a progressive, incurable neurological disorder and the most common form of dementia, primarily affecting memory, thinking, and behavior in older adults), diabetes, and anxiety disorder. Record review of an MDS dated [DATE] for Resident #53 indicated the MDS was a new record. The MDS revealed Resident #53 had a BIMS of 03, which indicated her cognition was severely impaired. The MDS indicated Resident #53 required maximal assistance with most ADLs. The completion date was 02/06/26 and was signed by the MDS Coordinator. Record review of a CMS Submission/Transmission Report dated 02/06/26 at 5:25 p.m. indicated Resident #53's admission assessment had a target date of 01/23/26. The report indicated a warning that the assessment was completed late. The admission assessment was completed more than 13 days after the entry date. 3. Record review of a face sheet dated 02/11/26 indicated Resident #55 was [AGE] years old and had an admission date of 01/21/26 with diagnoses including muscle weakness, generalized anxiety disorder, and breast cancer. Record review of an MDS dated [DATE] for Resident #55 indicated the MDS was a new record. The MDS revealed a BIMS was not conducted due to Resident #55 being rarely to never understood. The MDS indicated Resident #55 required maximal assistance with most ADLs. The completion signature date was 02/05/26 and was signed by the MDS Coordinator. Record review of a CMS Submission Report dated 02/05/26 at 2:11 p.m. indicated Resident #55's admission assessment had a target date of 01/27/26. The report indicated a warning that the assessment was completed late. The admission assessment was completed more than 13 days after the entry date. 4. Record review of a face sheet dated 02/11/26 indicated Resident #72 was [AGE] years old and had an admission date of 01/07/26 with diagnoses including pain, kidney failure, and muscle weakness. Record review of an MDS dated [DATE] for Resident #72 indicated the MDS was a new record. The MDS revealed Resident #72 had a BIMS of 15, which indicated her cognition was intact. The MDS indicated Resident #72 required maximal assistance with most ADLs. The completion signature date was 01/26/26 and was signed by the MDS Coordinator. Record review of a CMS Submission Report dated 01/26/26 at 6:14 p.m. indicated Resident #72's admission assessment had a target date of 01/12/26. The report indicated a warning that the assessment was completed late. The admission assessment was completed more than 13 days after the entry date. 5. Record review of a face sheet dated 02/11/26 indicated Resident #28 was [AGE] years old and had an admission date of 01/07/26 with diagnoses including repeated falls, urinary tract infection, and chronic kidney disease. Record review of an admission MDS assessment dated [DATE] for Resident #28 indicated the MDS was a new record. The MDS revealed Resident #28 had a BIMS of 10, which indicated moderate impaired cognition. The MDS indicated Resident #10 required maximal assistance with most ADLs. The completion date was 01/23/26 and was signed by the MDS Coordinator. Record review of a CMS Submission/Transmission Report dated 01/23/26 at 6:25 p.m. indicated Resident #28's admission assessment had an assessment reference date of 01/12/26. The report indicated a warning that the admission assessment for Resident #28 was completed late. The admission assessment was completed more than 13 days after the entry date. During an interview on 02/11/26 at 2:29 p.m., the MDS Coordinator said she was responsible for completing and submitting MDS assessments. She said the admission assessments should be signed when the assessment was completed. She said the transmission date was within 14 days of the signature date. She said she knew she had some late assessments. She said she had found out they were late when she went to sign them and realized they should have been done. She said the MDS did not directly affect resident care. During an interview on 02/12/26 at 9:21 a.m., the DON said the MDS Coordinator was responsible for completing and transmitting the admission MDSs in a timely manner. She said she expected the MDS assessments to be completed and transmitted in the appropriate timeframe. She said MDSs not being completed and transmitted in the appropriate timeframe would not negatively affect resident's care. During an interview on 02/12/26 at 11:01 a.m., the Administrator said the MDS Coordinator was responsible for completing MDS assessments and transmitting them in a timely manner. She said she did not feel like there could be a negative outcome for the assessments not being completed timely or being transmitted timely. Record review of an email from the Administrator on 02/13/26 at 1:17 p.m. indicated, .we follow the RAI manual as it pertains to MDS timing. Record review of a Comprehensive Assessments facility policy last updated 02/2025 indicated, .Comprehensive assessments are conducted to assist in developing person-centered care plans.Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual.The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1. Record Review of the CMS RAI Version 3.0 Manual, dated October 2025, indicated, in Chapter 2.8, page 2-22 01. The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1.The MDS completion date (item Z0500B) must be no later than day 14. This date may be earlier than or the same as the CAA(s) completion date, but not later than.Chapter 5.2, page 5-2.For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600) .

Based on interview and record review the facility failed to ensure an accurate MDS assessment was completed for 1 of 18 residents reviewed for MDS accuracy. (Resident #1) The facility failed to accurately code Resident #1's significant weight loss of 12.8% in 180 days. This failure could place residents at risk of not receiving needed care and services.Findings included: Record review of an undated face sheet revealed Resident #01 was a [AGE] year-old male, admitted on [DATE] with the diagnoses of cerebral infarction (a type of ischemic stroke where a blockage in a blood vessel disrupts blood flow, causing brain or retinal cell death (necrosis) due to lack of oxygen), pulmonary embolus (a sudden, often life-threatening blockage in one or more of the pulmonary arteries in the lungs, usually caused by a blood clot that travels from the legs or other parts of the body), gout (a disease in which defective metabolism of uric acid causes arthritis, especially in the smaller bones of the feet, deposition of chalkstones, and episodes of acute pain). Record review of an annual MDS assessment dated [DATE] for Resident #01 revealed a BIMS of 09, which indicated moderate cognitive impairment. The MDS also revealed Resident #01 required a substantial (helper did more than half the work) level assistance with bed mobility, transfer, and toileting. The MDS revealed Resident #01 weighed 176 pounds and had no weight loss of 5% or more in the last month and no weight loss of 10% or more in the last 6 months. Record review of the EHR vital signs revealed the following weights for Resident #1: 06/07/2025-198 lbs. 11/07/2025-178 lbs.12/07/2025-175.5lbs. down 2.5 lbs./1% in 30 days; down 22.5 lbs./12.8 % in 180 days Record review of a nutrition care plan dated 10/03/2025 revealed Resident #01 had a nutritional problem or potential for nutritional problem related to requiring mechanically altered diet related to a CVA (stroke). During an interview on 02/11/2026 at 4:15 p.m., the MDS Coordinator revealed she was unaware until recently about how to calculate weight loss in the EHR. She stated she now understood where to look and how to calculate the weight loss for section K coding. The MDS Coordinator stated Resident #01 should have been coded for non-physician ordered weight loss on his annual MDS from 12/28/2025. She stated it was important to code accurate assessments, but she did not feel there would be any impact on the residents from an inaccurate assessment. During an interview on 02/12/2026 at 1:00p.m., the Administrator stated it was the responsibility of the MDS Nurse to produce accurate MDSs and care plans. The Administrator stated accuracy was important for revenue as well as to ensure the facility was reporting the correct information to CMS on the quality measures. She stated there would be no negative impact from miscoded information on the residents. During a record review of the facility's undated Minimum Data Set Policy for MDS assessment Data Accuracy, revealed the purpose of the MDS policy was to ensure each resident received an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being. The assessment should accurately reflect the resident's status.

Based on observation, interview, and record review the facility failed to ensure the residents received services in the facility with reasonable accommodation of resident needs 2 of 18 residents reviewed for accommodation of needs (Resident #14 and #26). The facility failed to ensure the call light was in reach on multiple occasions on 02/09/2026-02/10/2026 to call for assistance for Resident #14 and Resident #26. This failure could place residents at risk of decreased physical and psychosocial wellbeing and decreased quality of life. Findings included: 1.Record review of an undated face sheet revealed Resident #14 was a [AGE] year-old female admitted on [DATE] with diagnoses of malignant neoplasm of parotid (a cancerous tumor arising in the parotid gland), end stage heart disease (the most advanced, chronic phase where the heart pumps inefficiently, causing severe, persistent symptoms even at rest), and hemiplegia (a severe, often permanent, form of unilateral paralysis affecting one side of the body, caused by brain or spinal cord damage). Record review of a significant change MDS assessment dated [DATE] revealed Resident #14 had a BIMS of 05, which indicated severe cognitive impairment. Resident #14 required substantial (helper did more than half of the work) for ADLs such as bed mobility, dressing, and bathing. The MDS also revealed Resident #14 was taking antiplatelet, opioids, diuretics, and antibiotic medications. During an observation and interview on 02/09/2026 at 9:50 a.m., Resident #14 stated she could not find her call light. She stated she needed her call light to call her nurse to be cleaned up. The call light was in a closed drawer of her bedside dresser, approximately 3 feet behind the head of the bed and out of reach and sight of Resident #14. There was no sitter, family, or roommate present at that time. During an observation and interview on 02/09/2026 at 12:20 p.m., Resident #14 stated she was awaiting her lunch tray and still could not find her call light. The call light remained closed in the top drawer of her bedside dresser, approximately 3 feet behind the head of the bed and out of reach and sight of Resident #14. There remained no sitter, family, or roommate present at that time. During an interview on 02/09/2026 at 12:30 p.m., CNA D stated she was unsure how the call light was placed out of reach of the resident. She stated the facility staff tried very hard to keep a watchful eye on call light placement for all the residents. She stated the call light being in place for Resident #14 was important to ensure she did not fall out of bed reaching for it and her needs were met. 2. Record review of the face sheet, dated 02/11/2026, reflected Resident #26 was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #26 had a principal diagnosis of hemiplegia (paralysis) and hemiparesis (weakness) following a stroke that affected the left non-dominant side. Record review of the quarterly MDS assessment, dated 12/20/2025, reflected Resident #26 had clear speech, was usually understood, and was able to understand others. Resident #26 had a BIMS score of 3, which indicated severe cognitive impairment. The MDS reflected Resident #26 had a functional limitation in range of motion that interfered with daily functions, to one side of both the upper and lower extremities. Resident #26 was dependent upon staff for assistance with ADLs. Record review of Resident #26's comprehensive care plan, dated 04/01/2025, did not address keeping the call light in reach. During an observation on 02/09/2026 at 3:48 p.m., revealed Resident #26 was lying in the bed on her right side facing the door. Her call light was on the left side of her bed inside the bedside table with the drawer shut. Resident #26 was unable to reach the call light. During an observation on 02/10/2026 at 9:02 a.m., revealed Resident #26 was lying in her bed with the head of the bed elevated. The call light cord was behind the head of her bed, and the call light button was on the ground out of Resident #26's reach. During an interview on 02/12/2026 beginning at 11:15 a.m., MA G said she normally worked with Resident #26. She stated everyone was responsible for making sure call lights were in reach. She said it was important to ensure call lights were in reach so staff would know when residents needed assistance. She said the residents could have an emergency and no one would have known. During an interview on 02/12/2026 beginning at 11:31 a.m., CNA B stated she normally worked with Resident #26. CNA B stated she worked on 02/09/2026 and 02/10/2026. CNA B stated everyone was responsible for making sure the call lights were in reach. She stated Resident #26's call light might have fallen or been moved during care. CNA B stated it was important to ensure the call lights were in reach so the residents could have called for assistance. She said the residents might not have gotten care or assistance fast enough without their call lights. During an interview on 02/12/2026 beginning at 11:48 a.m., LVN H stated the CNAs were responsible for making sure the call lights were in reach. She stated all staff should have been making sure the call lights remain in place. LVN H stated it was important to ensure call lights were in reach so the residents' needs could have been addressed timely and to ensure nothing was wrong. During an interview on 02/12/2026 beginning at 2:34 p.m., ADON C stated everyone was responsible for making sure call lights were in reach. ADON C said she expected the CNAs to make sure the call lights were in reach when they left the resident's room. She said she performed spot checks at random to ensure call lights were in reach. ADON C stated she would ensure Resident #26's call light had a clamp to attach to her bed. She said it was important to ensure the call light was in reach so the residents could have called for help and assistance as needed. During an interview on 02/12/2026 at 10:00 a.m., the DON stated all staff, even housekeeping and maintenance, were responsible for looking to see if the call light was in place when they were in the resident's room. She stated all residents needed their call lights in place, but especially the residents that were dependent on staff for their care needs. The DON stated the residents could feel scared and neglected if they could not contact the staff to request assistance. During an interview on 02/12/2026 at 1:30 p.m., the Administrator stated she was shocked that Resident #14's family was not in the room and that the call light would have been in a drawer. She stated it was the responsibility of all staff to ensure all residents had their call light in reach. She stated several rounds were made each day to ensure the call lights were in place. The Administrator stated not having the call light in place could result in a delay in care for the residents. Record review of the Accommodation of Needs policy, dated March 2021, reflected .In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. The policy did not address call light placement.

Based on observation, interview, and record review the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 1 of 4 residents reviewed for ADLs. (Resident #39) The facility did not ensure Resident #39 was assisted with brushing her hair. These failures could place residents at risk of not receiving care or services, decreased quality of life, embarrassment, and decreased self-esteem.The findings included: Record review of the face sheet, dated 02/11/2026, reflected Resident #39 was a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of stroke. Resident #39 had further diagnoses that included: end stage renal disease (final, permanent stage of kidney failure, were the kidney's no longer filter waste and balance fluids) and dependance on renal dialysis (life-sustaining medical treatment that filters blood to remove excess waste, toxins, and fluids when kidney's no longer work). Record review of the quarterly MDS assessment, dated 12/04/2025, reflected Resident #39 had clear speech, was understood, and was able to understand others. Resident #39 had a BIMS score of 15, which indicated she was cognitively intact. Resident #39 usually required setup or clean-up assistance with personal hygiene. Record review of the comprehensive care plan, dated 02/10/2026, reflected Resident #39 had a self-care deficit with bathing, dressing, and feeding. The interventions included: encourage resident to participate in planning day to day care, maintain consistent schedule with daily routine, and provide assistance with ADLs as needed. During an observation and interview on 02/11/2026 beginning at 12:50 p.m., Resident #39 stated she felt the facility staff believed she could do more for herself than she actually could. She was sitting up on the side of her bed and during the interview she was having trouble holding her head up. She stated she had problems with her neck and was going to be getting surgery on it soon. Resident #39 used her right hand to lift up her left arm and let her arm drop at her side. She said since her stroke the left side did not function properly. She said because of the deficits on her left side she was unable to brush her hair properly and she said the staff did not help her with brushing her hair. Resident #39's hair was sticking up in the air and had tangles in some areas. She became tearful during the interview and stated if she did not need assistance she would be at home. During an interview on 02/12/2026 beginning at 11:31 a.m., CNA B stated she normally worked with Resident #39. She said she normally helped Resident #39 get dressed and wiped down on dialysis days. She stated she helped Resident #39 comb her hair, if she asked. She stated she was unsure if she assisted Resident #39 with her hair during this week. CNA B stated it was important to ensure residents received assistance with ADLs for personal hygiene and dignity. During an interview on 02/12/2026 beginning at 11:48 a.m., LVN H stated she expected the CNAs to provide ADL assistance for residents who needed it. LVN H stated Resident #39 normally did things independently. LVN H stated she was unaware Resident #39 required assistance for ADLs. She said it was important to ensure ADL care was provided for residents who needed it, so they could feel good about themselves. During an interview on 02/12/2026 beginning at 2:34 p.m., ADON C stated she expected the CNAs to provide ADL assistance with grooming. ADON C stated Resident #39 did not usually require assistance with ADLs. ADON C stated she was unaware Resident #39 was having problems brushing her hair because of her neck and deficits from her stroke. She said it was important to ensure assistance with ADLs were provided to residents who needed help to maintain good hygiene, prevent infections, and prevent a decrease in mood. During an interview on 02/12/2026 beginning at 3:02 p.m., the DON stated she expected the staff to provide assistance with grooming as it was needed. She stated Resident #39 normally did not require assistance with ADLs. She stated she was independent. She said she was unaware Resident #39 was having trouble completing her ADLs because of her neck and stroke deficits. She said the ADONs were responsible for monitoring to ensure ADL assistance was provided. She said it was important to ensure ADL assistance was provided because it was what the residents were at the facility for. During an interview on 02/12/2026 beginning at 3:30 p.m., the Administrator stated she expected the nursing staff to assist the residents with grooming when it was needed. She stated the clinical staff were responsible for monitoring to ensure ADL assistance was provided. She stated it was important to ensure ADLs assistance was provided to boost confidence. Record review of the Activities of Daily Living (ADL), supporting policy, dated February 2025, reflected Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.appropriate care and services will be provided for residents who are unable to carry out ADLs independently.including appropriate support and assistance with. hygiene (bathing, dressing, grooming, and oral care).

Based on interview, and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to include all residents with newly evident or possible serious mental disorder for 1 of 5 residents (Resident #9) reviewed for the PASRR program.The facility failed to ensure Resident #9 was referred for a PASRR (Level II) evaluation when she received a new mental illness diagnosis.This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.Record review of the face sheet, dated 02/10/26, indicated Resident #9 was [AGE] years old. The face sheet indicated an admission date of 01/19/22 with an original admission date of 09/01/20. The face sheet indicated Resident #9 had diagnoses including dementia, paranoid schizophrenia with an onset date of 09/24/24, and pain.Record review of a hospital history and physical dated 01/16/22 indicated a problem of paranoid schizophrenia.Record review of quarterly MDS assessment, dated 10/24/25, indicated Resident #9 had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS indicated Resident #9 had an active diagnosis of Schizophrenia.Record review of the comprehensive care plan last revised on 11/07/25 indicated Resident #9 was prescribed an antipsychotic medication related to a diagnosis of paranoid schizophrenia.Record review of the PASRR Level 1 Screening form, dated 09/01/20, reflected Resident #9 had no evidence or indicator of a mental illness. Record review of the PASRR Level 1 Screening form, dated 02/10/26, reflected Resident #9 had no evidence or indicator of a mental illness.Record review of Resident #9's electronic medical record accessed on 02/10/26 did not indicate a PASRR Evaluation. A PASRR Evaluation was not provided by the facility.During an interview on 02/11/26 at 9:32 a.m., the MDS Coordinator said Resident #9 received the diagnosis of paranoid schizophrenia on 9/24/24. She said normally when an MDS assessment was completed for a resident, if there was a new diagnosis then a PASRR Level 1 Screening would need to be updated. The MDS Coordinator said she was new to this position and did not know why this had been done for the resident. She said she had only been the MDS Coordinator since November 2025. She said she had just completed the MDS Assessment on 2/10/26 for Resident #9. She said a resident not receiving an appropriate PASRR screening could potentially cause them to not receive PASRR services.During an interview on 02/12/26 at 9:21 a.m., the DON said she would have expected Resident #9's paranoid schizophrenia diagnosis to have been on her chart several years ago. The DON said she would have expected for her to have a positive PASRR Level 1 for mental illness. She said the MDS Coordinator was responsible for catching new diagnosis and making sure there was a revised PASRR Level 1 to reflect the diagnosis. She said Resident #9 had been at the facility since 2020. She said she had always had a diagnosis of paranoid schizophrenia and would have expected for the original PASRR Level 1 to have reflected that. She said by the PASRR Level 1 not being corrected meant her mental needs were not being addressed.During an interview on 02/12/26 at 11:01 a.m., the Administrator said when a someone received a new mental illness diagnosis the PASRR Level 1 Screening should be updated to reflect the new diagnosis. She said the MDS Coordinator was responsible for identifying a new diagnosis and updating the PASRR Level 1 Screening so that a PASRR Level II screening could be conducted. She said she would have expected for the PASRR Level 1 to have been updated when the diagnosis was first identified. She said she did not feel like not having a correct PASRR Level I Screening or a PASRR Level II Screening could negatively affect a resident.Record review of a PASRR facility policy dated 07/29/25 indicated, .The PASRR program aims to ensure that individuals with mental illness or intellectual disabilities receive appropriate care and services. It assesses whether the nursing home is the most suitable setting for the individual's needs.Nursing homes must comply with all federal and state regulations regarding PASRR. Failure to do so can result in penalties or loss of funding. The facility follows HHS (Health and Human Services) PASRR for Nursing Facility guidelines.

Based on observation, interview, and record review, the facility failed to ensure the resident had a right to organize and participate in resident groups in the facility for 1 of 8 residents reviewed for resident council. (Resident #39) The facility did not ensure Resident #39 was able to attend resident council meetings, as they were scheduled on her dialysis days. This failure could place residents at risk for decreased quality of life and resident rights not being honored.The finding included: Record review of the face sheet, dated 02/11/2026, reflected Resident #39 was a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of stroke. Resident #39 had further diagnoses that included: end stage renal disease (final, permanent stage of kidney failure, were the kidney's no longer filter waste and balance fluids) and dependance on renal dialysis (life-sustaining medical treatment that filters blood to remove excess waste, toxins, and fluids when kidney's no longer work). Record review of the quarterly MDS assessment, dated 12/04/2025, reflected Resident #39 had clear speech, was understood, and was able to understand others. Resident #39 had a BIMS score of 15, which indicated she was cognitively intact. Resident #39 received dialysis. Record review of the comprehensive care plan, dated 06/21/2025, reflected Resident #39 was diagnosed with renal failure and required dialysis. Resident #39 received dialysis on Tuesdays, Thursdays, and Saturdays. Record review of the resident council minutes reflected the resident council meetings were conducted on 08/12/2025 (Tuesday), 09/09/2025 (Tuesday), 10/07/2025 (Tuesday), 11/11/2025 (Tuesday), 12/09/2025 (Tuesday), and 01/06/2026 (Tuesday). Resident #39 was not listed in attendance at any of the meeting minutes. During an observation and interview on 02/10/2026 beginning at 9:13 a.m., Resident #39 was sitting up on the side of her bed, eating breakfast. She said that she had been asking to be part of resident council since being admitted to the facility. Resident #39 said she had been a part of resident council at every facility she had been at, and this facility continued to schedule resident council meetings on the days she attended dialysis. She said she had told the AD and the resident council president she wished to attend. Resident #39 stated she wanted her voice to be heard. During an interview on 02/12/2026 beginning at 2:03 p.m., the AD stated resident council was scheduled for the first Tuesday of every month. She said Resident #39 had expressed interest in attending the resident council meetings but declined because she was at dialysis. The AD stated she had not thought about changing the resident council meeting days so Resident #39 could have attended. She said it was important to ensure accommodations were made for residents who wished to attend resident council meeting because it made them feel positive about their community. She said it was important to have their suggestions heard. During an interview on 02/12/2026 beginning at 3:30 p.m., the Administrator said she expected the staff to ensure accommodations were made for residents who wished to attend resident council. She said she was unaware Resident #39 wished to attend resident council meetings. She said it would be difficult to accommodate every person because there were some residents who attended dialysis on Monday, Wednesday, and Friday. She said that it was important to ensure accommodations were made as appropriate, so the residents were satisfied with participating. Record review of the Resident Council policy, dated February 2021, reflected The facility supports residents' rights to organize and participate in the resident council.all residents are eligible to participate in the resident council.the facility staff encourages residents who are willing to participate.council meetings are scheduled monthly or more frequently if requested by residents.

Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #74) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #74 was given a SNF ABN (is document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services.The findings included: Record review of the face sheet, dated 02/11/2026, reflected Resident #74 was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #74 had a primary diagnosis of sepsis (blood infection). Resident #74 had a responsible party representative. Record review of the annual MDS assessment, dated 01/16/2026, reflected Resident #74 had a recent Medicare stay which started on 11/09/2025 and ended on 01/16/2026. Resident #74 had clear speech, was understood, and was able to understand others. Resident #74 had a BIMS score of 7, which indicated severe cognitive impairment. Record review of Resident #74's NOMNC, dated 01/14/2026, reflected it had been completed with signature confirmation of understanding from Resident #74's representative on 01/14/2026 with services ending on 01/16/2026. However, the SNF ABN CMS form 10055 was not completed, which would have informed Resident #74 and his representative of the option to continue services at a private pay rate. During an interview on 02/12/2026 beginning at 1:40 p.m., the Social Worker stated she was responsible for issuing the beneficiary notices, which included the NOMNC, to residents or their families when they were coming off skilled services. The Social Worker stated she was unsure who was responsible for completing the SNF ABNs, but she only completed the NOMNC. During an interview on 02/12/2026 beginning at 1:50 p.m., the Administrator stated the Social Worker was responsible for completing the beneficiary notices, which included NOMNC, and the SNF ABN form. She was unfamiliar with the SNF ABN form but stated she was aware it needed to be completed. The Administrator was unsure why Resident #74 was not given a SNF ABN form. The Administrator stated it was important to ensure the SNF ABN forms were given when required so the resident or family understood their benefits. Record review of the Medicare Advance Beneficiary and Medicare Non-Coverage Notices policy, dated September 2022, reflected Residents are informed in advance when changes will occur to their bills.The facility issues the Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) for the following triggering events: .termination - in the situation in which the facility proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF ABN is issued to the beneficiary before such extended are items or services are terminated. The resident (or representative) is informed that they may choose to continue receiving the skilled services that may not be paid for by Medicare, and assume financial responsibility.

Based on interview and record review, the facility failed to ensure that each resident who experienced a significant change in status is comprehensively assessed using the CMS-specified Resident Assessment Instrument (RAI) process for 1 of 8 residents reviewed for significant changes in status (Resident #14). The facility failed to comprehensively assess Resident #14 when she elected hospice services using the CMS-specified RAI process. This failure could place residents at risk of not receiving needed care and services.Findings included: Record review of an undated face sheet revealed Resident #14 was a [AGE] year-old female admitted on [DATE] with diagnoses of malignant neoplasm of parotid (a cancerous tumor arising in the parotid gland), end stage heart disease (the most advanced, chronic phase where the heart pumps inefficiently, causing severe, persistent symptoms even at rest), and hemiplegia (a severe, often permanent, form of unilateral paralysis affecting one side of the body, caused by brain or spinal cord damage). Record review of a significant change MDS assessment dated [DATE] revealed Resident #14 had a BIMS of 05, which indicated severe cognitive impairment. Resident #14 required substantial (helper did more than half of the work) for ADLs such as bed mobility, dressing, and bathing. The MDS also revealed Resident #14 was taking antiplatelet, opioids, diuretics, and antibiotic medications. Record review of the consolidated physician's orders dated February 2026, revealed Resident #14 had an order dated 01/08/2026 for hospice services. During an interview on 02/11/2026 at 4:00 p.m., the MDS Coordinator stated Resident #14 went back on hospice on 01/08/2026. She stated she came off hospice in November of 2025 to receive radiation for cancer and elected hospice again after radiation treatment was completed. The MDS Coordinator stated a significant change assessment was to be done anytime someone elected hospice services or was put on hospice services. She stated she overlooked the need for a significant change assessment to be completed on Resident #14. She stated the assessment was due by 01/22/2026, 14 days after the hospice services were elected for Resident #14. She stated the facility had weekly standard of care meetings and she should have caught on to the fact that Resident #14 needed a significant change, but she did not. The MDS Coordinator stated the resident could not be negatively affected by not completing the MDS assessment. The MDS Coordinator stated the MDS was what was used to create the care plan, and the care plan was a map for individualized care for each resident, but she did not feel the resident would be negatively affected by missed paperwork. During an interview on 02/12/2026 at 10:00 a.m., the DON stated she relied on the MDS Coordinator to complete the MDSs and comprehensive care plans timely. The DON stated the administrative nurses met daily to go over orders and weekly for standard of care meetings and that was the time that items were care planned and discussed for significant changes. She stated she was unaware of the regulation to complete significant change assessments on residents that elected hospice. She stated she knew they discussed Resident #14 going hospice on more than one occasion. The DON stated not completing the significant change MDS could potentially cause the care plan to not be completed and services to be overlooked and interventions to be overlooked. She stated Resident #14 not having hospice coded on the MDS could affect quality measures and affect billing, as well. During an interview on 02/12/2026 at 1:00 p.m., the Administrator stated she was unaware of the missing significant change MDS for Resident #14. She stated the administrative nursing staff meet weekly to discuss all orders and changes in resident status, such as falls and weight loss. She stated the MDS Coordinator was present for the meetings. The Administrator stated she did not feel the missed significant change assessment could negatively impact the residents. During a record review of the facility's undated Minimum Data Set Policy for MDS assessment Data Accuracy, revealed the purpose of the MDS policy was to ensure each resident received an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being. The assessment should accurately reflect the resident's status.

Based on interview and record review the facility failed to ensure residents were free from abuse for 1 of 13 residents (Resident #1) reviewed for resident abuse. The facility failed to ensure Resident #1 was free from abuse, as evidenced by video footage of multiple incidents where direct care staff had inappropriate interactions towards Resident #1, such as staff making inappropriate and disrespectful comments towards the Resident and failing to maintain the Resident's dignity by leaving the Resident exposed and in view of individuals who could have walked by, not allowing the Resident time to communicate her needs, not feeding resident timely, and not identifying when Resident #1's head was not in the appropriate position for using her communication device, ease of breathing and eating. An immediate jeopardy (IJ) was identified on 8/14/25 at 3:25 PM. The IJ template was provided to the facility on 8/14/25 at 3:43 PM. While the IJ was removed on 8/15/25 at 3:34 PM, the facility remained out of compliance at a scope of patterned and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to complete in-service trainings with all staff and evaluate the effectiveness of the corrective systems.These failures could place residents at risk of physical harm, mental anguish, and/or emotional distress.Findings included:Record review of Resident #1's face sheet dated 8/12/25 indicated she was [AGE] years old and was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Amyotrophic Lateral Sclerosis (ALS) (a nervous system disease that causes muscle weakness and paralysis (unable to move) and impacts physical function, ability to talk and breathe), muscle weakness, lack of coordination, anxiety (feeling of worry, dread, and uneasiness), speech disturbances, dyspnea (difficulty breathing), pain and hypertension (high blood pressure).Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was sometimes understood but was able understand others. The MDS indicated Resident #1 did not complete the BIMS because she was rarely/never understood). The MDS indicated Resident #1 had verbal behavioral symptoms directed toward others 1-3 days and rejected care daily. Resident #1 had impairment to upper and lower extremities. Resident #1 was dependent on staff for all ADLs. Resident #1 was occasionally incontinent of urine and frequently incontinent of bowel. The MDS indicated ALS was Resident #1's primary diagnosis. Resident #1 had shortness of breath or trouble breathing when lying flat. Resident #1 had loss of liquids/solids from mouth when eating or drinking and had coughing or choking during meals or when swallowing medications.Record review of Resident #1's Care Plan revised on 8/14/25 indicated she had a diagnosis of ALS and used a communication device to communicate her needs and would also make gestures with her head and able to say some words with interventions including: allowing resident time to use the communication device to communicate needs; if unable to understand resident when she was speaking then ask her to use her communication device; make sure communication device was in place before and after care needs; make sure resident was positioned properly in bed, with the use of pillows if needed to ensure that she can eat, use her device, breathe easily, and be comfortable; make sure the dot that helps her operate her communication device was in place; offer emotional support as needed; and staff to speak calm, clearly, and slowly. The care plan revised on 4/09/25 indicated Resident #1 had the potential for a nutritional problem and was resistive to care with intervention to provide consistency in care to promote comfort with ADLs, maintain consistency in timing of ADLs, caregivers and routine, as much as possible. 1. Record review of video footage dated 2/26/25 beginning at 4:40 PM, started with Resident #1 sitting up in bed looking at her communication device. CNA A and CNA D enter Resident #1's room. CNA A said, Is she typing something. CNA D looks at the communication device and said Girl, I don't know. CNA A then moves the communication device to the end of the bed, out of the reach of Resident #1. Then CNA A and CNA D without telling or asking, began to pull Resident #1's panties down and Resident #1 began to move her legs and make verbal noises. CNA D said we gonna get you on the bed pan. CNA A said, Don't act up, this gonna be the 2nd time and you on your period. Resident #1 was making vocal noises and grimacing and CNA A and CNA D were carrying on a conversation between themselves. CNA A and CNA D placed the bed pan under Resident #1 and left her lower half of her body fully exposed and the mini blinds open. Resident #1's room was directly in front of the entrance where vehicles entered the parking lot. CNA D kept turning and looking out the window. Both CNA A and D were standing over Resident #1's bed and began to laugh and CNA A said I got to get out of here and both aides left out of the camera view with Resident #1 still fully exposed on a bed pan. CNA D returns and goes and looks out the window. CNA A can be heard talking to the roommate. Then CNA D performs peri care, they both redressed her, and then left the room. 2. Record review of video footage dated 2/26/25 beginning at 4:50 PM, started with Resident #1 in bed, her head was leaning onto her left shoulder, she can be heard moaning loudly and then began screaming. CNA E had entered the room and can be seen sitting down in a chair barely in site of the camera and said {Resident #1's name}, I literally just walked in the room and I don't know why your screaming, then gets up, walks toward her and said I'm listening, but I cannot hear you or do what you need me to do with all that screaming. Resident #1 then began making verbal noises and not screaming. CNA E then walked to the opposite side of the bed and asked Resident #1 What do you want, what do you want, then adjusted her leg, covers, as resident was making verbal noises. CNA E said, I can't understand you with all that screaming you're doing. Resident was not screaming. Then CNA E walked back to other side of bed and adjusted Resident #1's head on pillows and sits her more upright. CNA E then asks Resident #1 What else can I do for you, what else, move what as Resident #1 continued to make verbal noises and then CNA E said I can't do that by myself and you'll have to wait, I can only move you left and right, then asks resident move what, move it out, then she moved Resident #1's communication device out some and then said to Resident #1, Please and Thank you, Please and Thank you.3. Record review of video footage dated 3/01/25 beginning at 4:50 PM, started with Resident #1 sitting up in bed. CNA A told Resident #1, Tell the truth, cause I'm not doing this with you today and I'm your aide while standing at the end side of the bed with her arms folded I moved you up then and you started screaming, this is why it's hard for us to take care of you. Resident #1 was saying something using her device, but CNA A was speaking over her and unable to hear what Resident #1 was saying. CNA A then said, I'm sick of you, I don't care about that camera, kick me out of here, I wish and walked out of the camera view. CNA A then returned and moved Resident #1's communication device to the end of the bed and placed Resident #1 on a bed pan and left lower half of her body exposed and then stood over resident while she used the bed pan. CNA A then removed the bed pan and cleaned Resident #1's peri area. CNA A pulled the resident toward her and allowed Resident #1's head to hang over the edge of bed against her body and Resident #1 began to scream. Then CNA A repositioned Resident #1 and resident was making verbal noises, and CNA A said {Resident #1's name} you gonna quit hollering at me, or I'm going to leave. Resident #1 continued to make verbal noises and appeared to use her foot to point at her communication device at the end of the bed. CNA A adjusted the pillows. CNA A then No, we not going to keep going back forward, I've already moved your head 3 times. CNA A then moved the communication device back in front of the Resident #1 and told her to type what she needed.4. Record review of video footage dated 3/13/25 beginning at 8:33 PM, started with Resident #1 sitting up in bed making moaning/crying sounds and her communication device was at the end of the bed out of her reach. CNA E was standing at the end of the bed and told Resident #1 to focus on her breathing and Resident #1 begun to scream. ADON F entered the room at 8:34 PM and said {Resident #1's name} they cannot lift you by your arms, it was unsafe for you and unsafe for them, the staff could not pull her up without a transfer sheet and Resident #1 was making verbal crying noises and ADON F said {Resident #1's name} if you don't listen they would walk out until she calmed down enough. ADON F told CNA E to walk out. The communication device was still at the end of the bed and ADON F moved the device back in front of the resident and told her to use her communication board. The Resident #1's head had fallen down on her left shoulder and chin on her chest, and she began to scream, and her left leg began to shake. ADON F said {Resident #1's name}, use your communication board. Then ADON F walked up and pulled Resident #1's pillow down and around by one corner, which caused her head to go further down and pulled the top part of her head further over and she began to scream. ADON F told Resident #1 multiple times to use her communication board and said, I'm going to walk away until you can use your communication board. Resident #1 began to scream louder. There was no way for her to use the communication device with her head in the position it was in. Then ADON F repositioned her head, but her head kept falling back over. ADON F then placed the touch pad call light over Resident #1's lap and told her to call her when she can use her communication board. Resident #1 is only able to use a touch pad if the pad was placed under her hand, because she cannot raise her arm to place her hand. Resident #1's head was laying over toward her left shoulder with the corner of the pillow between her head and shoulder. Resident #1 began to scream louder when ADON F left the room. ADON F did return and repositioned her head again and said, I keep putting your head up and you keep pushing it down and told resident again multiple times to use her communication board. ADON F told Resident #1 we aren't going to keep going over the same things, I've already discussed it with you, we aren't going to keep going over the same things over, over, and over again.5. Record review of video footage dated 5/22/25 beginning at 7:05 AM, started with CNA B was at Resident #1's bedside and Resident #1's communication device was at the end of the bed. CNA B used her left hand to push resident's right shoulder away from her as CNA B pushed a blue pad under the resident, Resident #1 began to holler. CNA B then let resident turn back onto her back and then reached over Resident #1 and grabbed the draw sheet and pulled Resident #1 toward her. Resident #1's left leg began to vigorously shake, and her voice was shaky, and CNA B continued to pull the blue pad out of the other side. Resident #1 was hollering and kicking her legs. CNA B did not speak a word to Resident #1 during the interaction.6. Record review of video footage dated 5/22/25 beginning at 7:06 AM, started with Resident #1 lying in bed with head of the bed elevated. Resident #1's communication device and touch pad call light were at the end of her bed and not in reach. Resident #1's doorbell rang, and CNA B entered the room. CNA B moved the communication device to in front of resident and placed her hand on the touch pad call light. CNA B did not speak to Resident #1 during the interaction. 7. Record review of video footage dated 8/03/25 beginning at 6:42 AM, started with Resident #1 sitting up in bed and said with the communication device, I need you to stop what you are doing to CNA G who was at the end of the bed. CNA G interrupted and said {Resident #1's name} if you're done, let me know so I can go, I have a lot to do today and I can't sit in here and go up and down, up and down, side to side while making hand gestures. Resident #1 said Oh, Oh with her communication device. CNA G then adjusted Resident #1's pillow and said I will let the nurse do your pillow, can't keep doing your pillow every thirty minutes as she was walking out of the room. 8. Record review of video footage dated 8/03/25 beginning at 8:10 AM, started with Resident #1 sitting up in bed. CNA G brought breakfast tray into Resident #1's room and said I'm here to feed you. Resident #1 said with her communication device need top corners pushed down around my head and CNA G said {Resident #1's name} I'm here to feed you, OK and started asking what she wanted to eat, and Resident #1 said get the nurse and as CNA G walked away, she said O, Okay, that's a refusal. Then LVN C was at Resident #1's bedside 8:15 AM and asked, what's wrong {Resident #1's name}. Resident #1 said with her communication device, I need pillow supporting head, before I can eat and LVN C said, it is supporting your head, got it fixed just right and Resident #1 shakes her head. LVN C asked, how is it not right and then pushed the pillow down behind her back and said, alright, it's tucked as good as it's going to tuck and asked Resident #1 you ready to eat now? LVN C and another staff member started to grab the draw sheet to reposition Resident #1 and Resident #1 started making noises and shaking her head no. LVN C said if you want me to move you over, I have to use your sheet, I'm not going to pull on you and Resident #1 continued to shake her head no. LVN C said alright {Resident #1's name} then we are not moving over, cause I'm not going to pull on you. LVN C then repositioned Resident #1 and said alright, your shoulders are over, you're ready to start eating. Resident #1 said need pillow tucked and LVN C tucked her pillow behind her back. Resident #1 was asking them to move her arm over and LVN C said, I don't know what that means. Resident #1 was looking at her device and appeared to be trying to communicate something and at 8:22 AM, LVN C said OK, let's leave and told Resident #1 when you are ready to eat, we will come back and left the room. Resident #1 sounded the alarm on her communication device at 8:22 AM and someone out of the view of the camera told her to shut the alarm off. At 8:35 AM, the housekeeper came into the room to clean. Resident #1's meal tray continued to sit on the bedside table. At 8:51 AM, CNA G was at the bedside and said, I'll go tell them, OK and left the room. At 9:04 AM, RN H entered the room and said yes, ma'am, how can I help you. Resident #1 told RN H using her communication device, they need to come feed me, they need to come feed me and RN H said, yes ma'am, they are getting all the other . CNA G returned to the room at 9:53 AM and asked {Resident #1's name} are you ready to eat now. Resident #1 asked CNA G to see if she had some yogurt. Then at 9:55 AM, a police officer entered Resident #1's room with LVN C and asked what he could do for her. Resident #1 told the officer that they put my breakfast in here two hours ago, but they won't feed it to me and I'm not able to feed myself. LVN C said {Resident #1's name} you know we have been in here multiple times trying to feed you. Resident #1 said it was two hours . it needed to be warmed and LVN C said okay, we'll warm it, it's not a problem, we have a microwave, are you going to eat it if we warm it. At 9:58 AM, LVN C and CNA G then begin taking items off the breakfast tray that had been sitting on the bedside table since 8:10 AM asking which items she wanted warmed. The police officer said, they are going to warm it up and they were going to feed you. At 10:00 CNA G said I have to go get a cup to mix it (holding a plastic bag with a white substance in it, later identified as thickener) and then she returned and said it was not in her scope to mix it and would have to take it to dietary to have them mix it and that was the way it had to be, so her food or whatever you want your thickener in, I'll have to take it to them, so they can do it. CNA G asked Resident #1 how do you want your coffee and Resident #1 said I'll take as it is and CNA G said OK, I'll be back and left the room at 10:04 AM. Then at 10:04 AM, LVN C entered the room and placed items on the bedside table and left without speaking to Resident #1. At 10:17 AM, CNA G returned and said OK, they mixed it and Resident #1 said head up and CNA G raised the head of the bed. At 10:19 AM, CNA G sat down in a chair at bedside and at 10:21 AM, Resident #1 said using her communication device will you move me over, move me forward away from the bed first, then over and then back. CNA G then asked resident #1, you want to be moved over, you want moved over here. At 10:22 AM, LVN C entered the room and said, what's wrong now {Resident #1's name} and CNA G said, it's everything but eating, I don't know. LVN C said {Resident #1's name} what's wrong. CNA G then pulls resident over toward her as she was telling LVN C that Resident #1 wanted to be pulled over and LVN C said, I already pulled her over and CNA G said, I know. LVN C said, are you ready to eat now {Resident #1's name}. CNA G tells LVN C in front of Resident #1, it takes two hours, it takes a while to feed her, so it doesn't really matter how long it takes to feed anyone else, then asked Resident #1 so you ready now, you ready. At 10:54 AM, Resident #1 started making crying noises while CNA G was feeding her and CNA G went and got LVN C. As LVN C entered the room, Resident #1 said with her communication device, I just want a drink, I just want a drink, I just want a drink LVN C said, she's been trying to give you a drink since 7:30 this morning, then elevated her voice and said alright, so why aren't you taking a drink. Resident #1 continued repeating I just want a drink and LVN C said alright Resident #1 that's enough. CNA G said I tried to give her a drink. Resident #1 told LVN C to look at it, look at it and LVN C said, Well you keep sending it back. Then Resident #1 said with her communication device clumps out, clumps out, referring to the drink that requires thickening. LVN C took the drink and brought another back. Resident #1 completed breakfast and breakfast tray removed at 11:43 AM.9. Record review of video footage dated 8/13/25 beginning at 6:40 AM, started with Resident #1 lying in bed with head of the bed elevated, can be heard moaning, then she turned on the alarm on her communication device. At 6:44 AM, LVN C was standing at Resident #1's bedside and said, She has already done that, they fluffed your pillow, both girls have already done that. Resident #1 said through her communication device Push down top and left too. LVN C said No, we are not readjusting your pillow again, she's already done it ten times. Resident #1 says again, Push down top and left too. LVN C said Nope, {Resident #1's name}, and walks out of the camera view. Resident #1 says Push down top and left too and repeats Push down top and left too. LVN C returns to camera view and said in a louder voice I'm going to do it one time {Resident #1's name} and that's all I'm going to do it, what do you want then adjusts the pillow and said, alright it's pushed down and leaves the room. During an observation and interview on 8/12/25 at 11:45 AM, Resident #1 was sitting up in bed and used a communication tablet on a stand in front of her that she used by having a metal like dot on her forehead that acted like a wireless mouse, and she was able to use slight head movements to type her conversations. The communication tablet also allowed for Resident #1 to turn the typed words to be read aloud by the device if she chose to. Resident #1 said it was easier for her to type an email and send her concerns and/or complaints to the DON when she was not rushed and felt by sending an email to the DON, she would ensure her concerns and/or complaints would be given to someone that could help resolve the issues. Resident #1 said she had sent numerous emails to the DON about how staff were mistreating her, the lack of care she was receiving, not allowing her time to complete her meals and/or late meals, not allowing her to time to communicate her needs, and not answering her call light timely. Resident #1 said she did not feel her concerns/complaints were being addressed because the issues continued almost daily. Resident #1 said the problems were complex because there was so much lying and characterizing her as a bad patient, which leads to her poor care and helped staff justify their behavior. Resident #1 said she felt some staff intentionally treated her bad, so they would not have to care for her, so they are getting rewarded for abusing me and she felt like the staff intentionally ignored her at times because they know she took longer than the other residents. Resident #1 said often when staff do come in to assist her with the bed pan or other care, they are rough and talk rudely and made it very apparent they did not want to be providing her care. Resident #1 said she had little to no movement of her body but was able to push the touch pad call light for assistance when needed if it was placed under her hand. Resident #1 said the staff did not take the time to let her explain what she needed due to it took her a while to type out her needs on the tablet. Resident #1 said staff would also come in and turn her light off and then tell her she would have to wait until they finished their rounds on the other residents before they could get her on the bedpan. She said her bladder and bowels were one of the few things she had control over, and she felt that the staff should provide her care when she needed it, so it did not put her in a hardship to be holding it until they finished their rounds. Resident #1 said it was emotionally and physically hard on her. Resident #1 said she often hollers or screams when staff would not give her time to communicate on her tablet, she needed to have her pillow adjusted to position her head so she communicate on her communication device, be able to breathe comfortably, and be able to eat without aspirating (inhaling food into lungs) and she knew once they left her room it would be a long time before they returned. Resident #1 said often times while being fed, she would still be trying to swallow one bite of food and the staff were trying to feed her another bite and when she could not take a bite right then, the staff would say she was refusing to eat and took her food, and she was still hungry. Resident #1 said they would not give her time to respond and let them know she was still hungry and rushed out. Resident #1 said her muscles in her mouth, tongue, and throat were weak and it took her a long time to maneuver the food in her mouth and to be able to swallow it, and they have to often take her food back and re-blend it because it had clumps in it and her food had to be the consistency of baby food. Resident #1 said it did take a long time to feed her, but it was not something she could help or change because of her disease. Resident #1 said at times her head would fall over and she did not have the ability to pick her head up and it makes it difficult to breathe and all she could do was scream in hopes someone would come help her. Resident #1 said when she was not given time to respond on her tablet, the only thing she could do was make hollering type noises and it was very frustrating to her and caused her a lot of anxiety when the staff did not take the time to listen to her needs. During an interview on 8/13/25 beginning at 4:00 PM, Resident #1 said when staff bring her meals in, then moved her communication board where she could not type, then say she refused to eat made her feel powerless to get help and confused about why nobody used common sense, because obviously she wanted and needed to eat, and defeated in realizing it was the staff's intention to misunderstand her. Resident #1 said when staff said things such as: not going to keep going over the same thing over and over, I'm sick of you and don't care about that camera, kick me out of here, you gonna holler at me, I'm gonna leave, Don't act up, I literally just walked in here, don't know why you screaming, staff indicating she should say please and thank you, it made her mad and she wanted to tell them not to talk to her like that and to get out of her room, but she could not because she could not talk and had to accept their help. Resident #1 said she could not do anything, so anger builds up and caused her depression. Resident #1 said when staff keep asking her what do you want, what do you want and did not give her time to communicate on her device or staff chose not to take the time to read her communication device, it made her feel exhausted. Resident #1 said she did not have a hearing problem. Resident #1 said typing was not super easy and it took up long periods of mental and physical effort and she did not know who or if the staff would listen. Resident #1 said she becomes very scared when she realized they do not want to know what she needed or wanted. Resident #1 said some of the staff she trusted and knew they would do what she needed without her having to tell them, but there was not many she trusted left. Resident #1 said when staff enter her room and do not speak to her or do not tell her what they were going to do prior to touching her, was frightening and she absolutely had not way to stop them from whatever it was they were going to do and just hoping they would take a no from the tablet as an answer, and it was especially scary when they just sent new staff she had not ever met in to answer her call light. Resident #1 said when staff come into her room and just move her communication device to the end of the bed without letting her communicate her needs, scared her because they were intending to do whatever they wanted. Resident #1 said it was humiliating to be put on a bed pan, not covered, and left fully exposed with the window blinds open and sometimes staff would leave her room while she was on the bed pan and leave the door open to be seen by any member of the public walking by. Resident #1 said it made her feel angry when staff stood over her talking and laughing while she was on the bed pan, because they had no regard for the fact that she needed their close attention when she was in such a vulnerable position. Resident #1 said she did not want them staring at her while she went to the bathroom, but she needed them to hear her if she needed help. Resident #1 said when one staff member rolled her from side to side using the draw sheet, this is just one of the many ways they tortured me with the sheet, I am being handled like an object and it was isolating, when nobody acknowledges your humanness, you are alone. Resident #1 said continuous issues with her care has caused her to feel dehumanized and not treated as a person, and it had affected her well-being, self-worth, and self-esteem. Resident #1 said staff talk bad to her non-stop, and she does not feel her complaints were taken seriously and resolved. Resident #1 said she just wanted to be able to trust the staff and be treated with respect and kindness and be helped if not. During an interview on 8/13/25 at 11:46 AM, MA K said she had worked at the facility for about a year on the 6 AM-6 PM shift. MA K said they were sometimes a little short staffed, but the staff did the best they could. MA K said they were short staffed because staff have gotten fired due to Resident #1. MA K said she helped feed Resident #1 when she could, to help. MA K said it was time consuming. MA K said Resident #1 normally provided her own food. MA K said Resident #1 would tell you how to do it all and it took Resident #1 time to type it out. MA K said Resident #1 would type what she wanted and if staff did it wrong then she would start screaming and kicking. MA K said she thought Resident #1 wants some things a specific way because it was probably one of the only things Resident #1 could still control. MA K said the resident would be upset if staff did not communicate what they were doing to them prior to providing care. MA K said it was the resident's home. MA K said she would be upset if staff left her fully exposed while on a bed pan and window blinds opened. MA K said it would be a dignity issue. MA K said she would not be happy if she could not communicate her needs, but Resident #1 would usually answer yes or no questions either verbally or by head movements. MA K said if Resident #1 was not allowed time to communicate her needs, the staff would not know what she needed or wanted to say. MA K said it would probably make Resident #1 feel unsafe. MA K said she had not received any training on taking care of a resident with ALS. MA K said she was sure it would affect Resident #1's quality of life and made her feel less than a human if not provided privacy during incontinent care, not allowed time to communicate her needs, and not letting her know what care was going to be provided, and not speaking to her; and they were there to ensure Resident #1's needs were met.During an interview on 8/13/25 at 12:15 PM, CNA J said she had worked at the facility since April 2025 on the 6 AM-2 PM shift. CNA J said they had approximately 3 people on 400 hall that required 2-person assistance. CNA J said she felt she was able to meet the care needs of the residents. CNA J said it would make her feel very uncomfortable if staff did not speak to her and just started providing care. CNA J said it would make her feel uncomfortable, ashamed, and embarrassed if staff did not cover her or close the window blinds while on a bed pan. CNA J said Resident #1 at times wanted to be covered and at other times did not want to be covered and told them no. CNA J said if staff moved Resident #1's communication device out of her reach and did not give her time to communicate, then how was Resident #1 supposed to let her needs known if unable to communicate needs and it would make her angry. CNA J said she would be mad if her momma was done that way. CNA J said it would affect Resident #1's quality of life if she was unable to communicate her needs. CNA J said not being allowed time to communicate needs, providing care without telling the resident what you were going to do, not speaking to the resident during care, would make the resident feel less of a human, and if not able to communicate then you would not get anywhere. CNA J said she had not received any training related to caring for a resident with ALS, just what she had learned working with Resident #1. CNA J said she had not had any in-services related to caring for Resident #1. CNA J denied ever telling Resident #1 to stop crying that they were not running a daycare center. During an interview on 8/13/25 at 12:52 PM, CNA G said she had worked at the facility for about 2 months on the 6 AM-2 PM shift. CNA G said they had 7-8 residents on the 400 hall that required 2-person assistance. CNA G said she felt she was able to meet the needs of the residents sometimes. CNA G said if she had Resident #1 then it was hard to care for the other residents when Resident #1 took 2-2.5 hours to feed twice on her shift sometimes. CNA G said usually no one provided care to her other residents when she was feeding Resident #1, and then she had to come out when she was done feeding Resident #1 and work hard to get her other residents' care completed before the end of her shift. CNA G said one of her other residents pushed their call light while she was feeding Resident #1, then someone may go check them, but usually no one checked on her other residents until she was able to go back when she was done. CNA G said she would feel tortured or abused if staff just walked in and started providing care without speaking. CNA G said she would feel exposed if left on a bed pan fully exposed with the window blinds open to the street. CNA G said it would be a dignity issue. CNA G said if staff did not allow Resident #1 time

Based on observation, interview and record review; it was determined the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for 1 of 13 residents reviewed for Quality of Life. (Resident #1)The facility failed to provide an environment which supported and enhanced the Resident #1's quality of life, as evidenced by video footage of multiple incidents where direct care staff had inappropriate interactions towards Resident #1, such as staff making inappropriate and disrespectful comments towards the Resident and failing to maintain the Resident's dignity by leaving the Resident exposed and in view of individuals who could have walked by, not allowing the Resident time to communicate her needs, not feeding resident timely, and not identifying when Resident #1's head was not in the appropriate position for using her communication device, ease of breathing and eating. An immediate jeopardy (IJ) was identified on 8/14/25 at 3:25 PM. The IJ template was provided to the facility on 8/14/25 at 3:43 PM. While the IJ was removed on 8/15/25 at 3:34 PM, the facility remained out of compliance at a scope of patterned and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to complete in-service trainings with all staff and evaluate the effectiveness of the corrective systems.The facility's failures could place dependent residents requiring assistance at risk for increased anxiety and depression, weight loss, poor self-esteem and poor self-worth. Findings included:Record review of Resident #1's face sheet dated 8/12/25 indicated she was [AGE] years old and was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Amyotrophic Lateral Sclerosis (ALS) (a nervous system disease that causes muscle weakness and paralysis (unable to move) and impacts physical function, ability to talk and breathe), muscle weakness, lack of coordination, anxiety (feeling of worry, dread, and uneasiness), speech disturbances, dyspnea (difficulty breathing), pain and hypertension (high blood pressure).Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was sometimes understood but was able understand others. The MDS indicated Resident #1 did not complete the BIMS because she was rarely/never understood). The MDS indicated Resident #1 had verbal behavioral symptoms directed toward others 1-3 days and rejected care daily. Resident #1 had impairment to upper and lower extremities. Resident #1 was dependent on staff for all ADLs. Resident #1 was occasionally incontinent of urine and frequently incontinent of bowel. The MDS indicated ALS was Resident #1's primary diagnosis. Resident #1 had shortness of breath or trouble breathing when lying flat. Resident #1 had loss of liquids/solids from mouth when eating or drinking and had coughing or choking during meals or when swallowing medications. Record review of Resident #1's Care Plan revised on 8/14/25 indicated she had a diagnosis of ALS and used a communication device to communicate her needs and would also make gestures with her head and able to say some words with interventions including: allowing resident time to use the communication device to communicate needs; if unable to understand resident when she was speaking then ask her to use her communication device; make sure communication device was in place before and after care needs; make sure resident was positioned properly in bed, with the use of pillows if needed to ensure that she can eat, use her device, breathe easily, and be comfortable; make sure the dot that helps her operate her communication device was in place; offer emotional support as needed; and staff to speak calm, clearly, and slowly. The care plan revised on 4/09/25 indicated Resident #1 had the potential for a nutritional problem and was resistive to care with intervention to provide consistency in care to promote comfort with ADLs, maintain consistency in timing of ADLs, caregivers and routine, as much as possible. 1. Record review of video footage dated 2/26/25 beginning at 4:40 PM, started with Resident #1 sitting up in bed looking at her communication device. CNA A and CNA D enter Resident #1's room. CNA A said, Is she typing something. CNA D looks at the communication device and said Girl, I don't know. CNA A then moves the communication device to the end of the bed, out of the reach of Resident #1. Then CNA A and CNA D without telling or asking, began to pull Resident #1's panties down and Resident #1 began to move her legs and make verbal noises. CNA D said we gonna get you on the bed pan. CNA A said, Don't act up, this gonna be the 2nd time and you on your period. Resident #1 was making vocal noises and grimacing and CNA A and CNA D were carrying on a conversation between themselves. CNA A and CNA D placed the bed pan under Resident #1 and left her lower half of her body fully exposed and the mini blinds open. Resident #1's room was directly in front of the entrance where vehicles entered the parking lot. CNA D kept turning and looking out the window. Both CNA A and D were standing over Resident #1's bed and began to laugh and CNA A said I got to get out of here and both aides left out of the camera view with Resident #1 still fully exposed on a bed pan. CNA D returns and goes and looks out the window. CNA A can be heard talking to the roommate. Then CNA D performs peri care, they both redressed her, and then left the room. 2. Record review of video footage dated 2/26/25 beginning at 4:50 PM, started with Resident #1 in bed, her head was leaning onto her left shoulder, she can be heard moaning loudly and then began screaming. CNA E had entered the room and can be seen sitting down in a chair barely in site of the camera and said {Resident #1's name}, I literally just walked in the room and I don't know why your screaming, then gets up, walks toward her and said I'm listening, but I cannot hear you or do what you need me to do with all that screaming. Resident #1 then began making verbal noises and not screaming. CNA E then walked to the opposite side of the bed and asked Resident #1 What do you want, what do you want, then adjusted her leg, covers, as resident was making verbal noises. CNA E said, I can't understand you with all that screaming you're doing. Resident was not screaming. Then CNA E walked back to other side of bed and adjusted Resident #1's head on pillows and sits her more upright. CNA E then asks Resident #1 What else can I do for you, what else, move what as Resident #1 continued to make verbal noises and then CNA E said I can't do that by myself and you'll have to wait, I can only move you left and right, then asks resident move what, move it out, then she moved Resident #1's communication device out some and then said to Resident #1, Please and Thank you, Please and Thank you. 3. Record review of video footage dated 3/01/25 beginning at 4:50 PM, started with Resident #1 sitting up in bed. CNA A told Resident #1, Tell the truth, cause I'm not doing this with you today and I'm your aide while standing at the end side of the bed with her arms folded I moved you up then and you started screaming, this is why it's hard for us to take care of you. Resident #1 was saying something using her device, but CNA A was speaking over her and unable to hear what Resident #1 was saying. CNA A then said, I'm sick of you, I don't care about that camera, kick me out of here, I wish and walked out of the camera view. CNA A then returned and moved Resident #1's communication device to the end of the bed and placed Resident #1 on a bed pan and left lower half of her body exposed and then stood over resident while she used the bed pan. CNA A then removed the bed pan and cleaned Resident #1's peri area. CNA A pulled the resident toward her and allowed Resident #1's head to hang over the edge of bed against her body and Resident #1 began to scream. Then CNA A repositioned Resident #1 and resident was making verbal noises, and CNA A said {Resident #1's name} you gonna quit hollering at me, or I'm going to leave. Resident #1 continued to make verbal noises and appeared to use her foot to point at her communication device at the end of the bed. CNA A adjusted the pillows. CNA A then No, we not going to keep going back forward, I've already moved your head 3 times. CNA A then moved the communication device back in front of the Resident #1 and told her to type what she needed. 4. Record review of video footage dated 3/13/25 beginning at 8:33 PM, started with Resident #1 sitting up in bed making moaning/crying sounds and her communication device was at the end of the bed out of her reach. CNA E was standing at the end of the bed and told Resident #1 to focus on her breathing and Resident #1 begun to scream. ADON F entered the room at 8:34 PM and said {Resident #1's name} they cannot lift you by your arms, it was unsafe for you and unsafe for them, the staff could not pull her up without a transfer sheet and Resident #1 was making verbal crying noises and ADON F said {Resident #1's name} if you don't listen they would walk out until she calmed down enough. ADON F told CNA E to walk out. The communication device was still at the end of the bed and ADON F moved the device back in front of the resident and told her to use her communication board. The Resident #1's head had fallen down on her left shoulder and chin on her chest, and she began to scream, and her left leg began to shake. ADON F said {Resident #1's name}, use your communication board. Then ADON F walked up and pulled Resident #1's pillow down and around by one corner, which caused her head to go further down and pulled the top part of her head further over and she began to scream. ADON F told Resident #1 multiple times to use her communication board and said, I'm going to walk away until you can use your communication board. Resident #1 began to scream louder. There was no way for her to use the communication device with her head in the position it was in. Then ADON F repositioned her head, but her head kept falling back over. ADON F then placed the touch pad call light over Resident #1's lap and told her to call her when she can use her communication board. Resident #1 is only able to use a touch pad if the pad was placed under her hand, because she cannot raise her arm to place her hand. Resident #1's head was laying over toward her left shoulder with the corner of the pillow between her head and shoulder. Resident #1 began to scream louder when ADON F left the room. ADON F did return and repositioned her head again and said, I keep putting your head up and you keep pushing it down and told resident again multiple times to use her communication board. ADON F told Resident #1 we aren't going to keep going over the same things, I've already discussed it with you, we aren't going to keep going over the same things over, over, and over again. 5. Record review of video footage dated 5/22/25 beginning at 7:05 AM, started with CNA B was at Resident #1's bedside and Resident #1's communication device was at the end of the bed. CNA B used her left hand to push resident's right shoulder away from her as CNA B pushed a blue pad under the resident, Resident #1 began to holler. CNA B then let resident turn back onto her back and then reached over Resident #1 and grabbed the draw sheet and pulled Resident #1 toward her. Resident #1's left leg began to vigorously shake, and her voice was shaky, and CNA B continued to pull the blue pad out of the other side. Resident #1 was hollering and kicking her legs. CNA B did not speak a word to Resident #1 during the interaction. 6. Record review of video footage dated 5/22/25 beginning at 7:06 AM, started with Resident #1 lying in bed with head of the bed elevated. Resident #1's communication device and touch pad call light were at the end of her bed and not in reach. Resident #1's doorbell rang, and CNA B entered the room. CNA B moved the communication device to in front of resident and placed her hand on the touch pad call light. CNA B did not speak to Resident #1 during the interaction. 7. Record review of video footage dated 8/03/25 beginning at 6:42 AM, started with Resident #1 sitting up in bed and said with the communication device, I need you to stop what you are doing to CNA G who was at the end of the bed. CNA G interrupted and said {Resident #1's name} if you're done, let me know so I can go, I have a lot to do today and I can't sit in here and go up and down, up and down, side to side while making hand gestures. Resident #1 said Oh, Oh with her communication device. CNA G then adjusted Resident #1's pillow and said I will let the nurse do your pillow, can't keep doing your pillow every thirty minutes as she was walking out of the room. 8. Record review of video footage dated 8/03/25 beginning at 8:10 AM, started with Resident #1 sitting up in bed. CNA G brought breakfast tray into Resident #1's room and said I'm here to feed you. Resident #1 said with her communication device need top corners pushed down around my head and CNA G said {Resident #1's name} I'm here to feed you, OK and started asking what she wanted to eat, and Resident #1 said get the nurse and as CNA G walked away, she said O, Okay, that's a refusal. Then LVN C was at Resident #1's bedside 8:15 AM and asked, what's wrong {Resident #1's name}. Resident #1 said with her communication device, I need pillow supporting head, before I can eat and LVN C said, it is supporting your head, got it fixed just right and Resident #1 shakes her head. LVN C asked, how is it not right and then pushed the pillow down behind her back and said, alright, it's tucked as good as it's going to tuck and asked Resident #1 you ready to eat now? LVN C and another staff member started to grab the draw sheet to reposition Resident #1 and Resident #1 started making noises and shaking her head no. LVN C said if you want me to move you over, I have to use your sheet, I'm not going to pull on you and Resident #1 continued to shake her head no. LVN C said alright {Resident #1's name} then we are not moving over, cause I'm not going to pull on you. LVN C then repositioned Resident #1 and said alright, your shoulders are over, you're ready to start eating. Resident #1 said need pillow tucked and LVN C tucked her pillow behind her back. Resident #1 was asking them to move her arm over and LVN C said, I don't know what that means. Resident #1 was looking at her device and appeared to be trying to communicate something and at 8:22 AM, LVN C said OK, let's leave and told Resident #1 when you are ready to eat, we will come back and left the room. Resident #1 sounded the alarm on her communication device at 8:22 AM and someone out of the view of the camera told her to shut the alarm off. At 8:35 AM, the housekeeper came into the room to clean. Resident #1's meal tray continued to sit on the bedside table. At 8:51 AM, CNA G was at the bedside and said, I'll go tell them, OK and left the room. At 9:04 AM, RN H entered the room and said yes, ma'am, how can I help you. Resident #1 told RN H using her communication device, they need to come feed me, they need to come feed me and RN H said, yes ma'am, they are getting all the other . CNA G returned to the room at 9:53 AM and asked {Resident #1's name} are you ready to eat now. Resident #1 asked CNA G to see if she had some yogurt. Then at 9:55 AM, a police officer entered Resident #1's room with LVN C and asked what he could do for her. Resident #1 told the officer that they put my breakfast in here two hours ago, but they won't feed it to me and I'm not able to feed myself. LVN C said {Resident #1's name} you know we have been in here multiple times trying to feed you. Resident #1 said it was two hours . it needed to be warmed and LVN C said okay, we'll warm it, it's not a problem, we have a microwave, are you going to eat it if we warm it. At 9:58 AM, LVN C and CNA G then begin taking items off the breakfast tray that had been sitting on the bedside table since 8:10 AM asking which items she wanted warmed. The police officer said, they are going to warm it up and they were going to feed you. At 10:00 CNA G said I have to go get a cup to mix it (holding a plastic bag with a white substance in it, later identified as thickener) and then she returned and said it was not in her scope to mix it and would have to take it to dietary to have them mix it and that was the way it had to be, so her food or whatever you want your thickener in, I'll have to take it to them, so they can do it. CNA G asked Resident #1 how do you want your coffee and Resident #1 said I'll take as it is and CNA G said OK, I'll be back and left the room at 10:04 AM. Then at 10:04 AM, LVN C entered the room and placed items on the bedside table and left without speaking to Resident #1. At 10:17 AM, CNA G returned and said OK, they mixed it and Resident #1 said head up and CNA G raised the head of the bed. At 10:19 AM, CNA G sat down in a chair at bedside and at 10:21 AM, Resident #1 said using her communication device will you move me over, move me forward away from the bed first, then over and then back. CNA G then asked resident #1, you want to be moved over, you want moved over here. At 10:22 AM, LVN C entered the room and said, what's wrong now {Resident #1's name} and CNA G said, it's everything but eating, I don't know. LVN C said {Resident #1's name} what's wrong. CNA G then pulls resident over toward her as she was telling LVN C that Resident #1 wanted to be pulled over and LVN C said, I already pulled her over and CNA G said, I know. LVN C said, are you ready to eat now {Resident #1's name}. CNA G tells LVN C in front of Resident #1, it takes two hours, it takes a while to feed her, so it doesn't really matter how long it takes to feed anyone else, then asked Resident #1 so you ready now, you ready. At 10:54 AM, Resident #1 started making crying noises while CNA G was feeding her and CNA G went and got LVN C. As LVN C entered the room, Resident #1 said with her communication device, I just want a drink, I just want a drink, I just want a drink LVN C said, she's been trying to give you a drink since 7:30 this morning, then elevated her voice and said alright, so why aren't you taking a drink. Resident #1 continued repeating I just want a drink and LVN C said alright Resident #1 that's enough. CNA G said I tried to give her a drink. Resident #1 told LVN C to look at it, look at it and LVN C said, Well you keep sending it back. Then Resident #1 said with her communication device clumps out, clumps out, referring to the drink that requires thickening. LVN C took the drink and brought another back. Resident #1 completed breakfast and breakfast tray removed at 11:43 AM. 9. Record review of video footage dated 8/13/25 beginning at 6:40 AM, started with Resident #1 lying in bed with head of the bed elevated, can be heard moaning, then she turned on the alarm on her communication device. At 6:44 AM, LVN C was standing at Resident #1's bedside and said, She has already done that, they fluffed your pillow, both girls have already done that. Resident #1 said through her communication device Push down top and left too. LVN C said No, we are not readjusting your pillow again, she's already done it ten times. Resident #1 says again, Push down top and left too. LVN C said Nope, {Resident #1's name}, and walks out of the camera view. Resident #1 says Push down top and left too and repeats Push down top and left too. LVN C returns to camera view and said in a louder voice I'm going to do it one time {Resident #1's name} and that's all I'm going to do it, what do you want then adjusts the pillow and said, alright it's pushed down and leaves the room. During an observation and interview on 8/12/25 at 11:45 AM, Resident #1 was sitting up in bed and used a communication tablet on a stand in front of her that she used by having a metal like dot on her forehead that acted like a wireless mouse, and she was able to use slight head movements to type her conversations. The communication tablet also allowed for Resident #1 to turn the typed words to be read aloud by the device if she chose to. Resident #1 said it was easier for her to type an email and send her concerns and/or complaints to the DON when she was not rushed and felt by sending an email to the DON, she would ensure her concerns and/or complaints would be given to someone that could help resolve the issues. Resident #1 said she had sent numerous emails to the DON about how staff were mistreating her, the lack of care she was receiving, not allowing her time to complete her meals and/or late meals, not allowing her to time to communicate her needs, and not answering her call light timely. Resident #1 said she did not feel her concerns/complaints were being addressed because the issues continued almost daily. Resident #1 said the problems were complex because there was so much lying and characterizing her as a bad patient, which leads to her poor care and helped staff justify their behavior. Resident #1 said she felt some staff intentionally treated her bad, so they would not have to care for her, so they are getting rewarded for abusing me and she felt like the staff intentionally ignored her at times because they know she took longer than the other residents. Resident #1 said often when staff do come in to assist her with the bed pan or other care, they are rough and talk rudely and made it very apparent they did not want to be providing her care. Resident #1 said she had little to no movement of her body but was able to push the touch pad call light for assistance when needed if it was placed under her hand. Resident #1 said the staff did not take the time to let her explain what she needed due to it took her a while to type out her needs on the tablet. Resident #1 said staff would also come in and turn her light off and then tell her she would have to wait until they finished their rounds on the other residents before they could get her on the bedpan. She said her bladder and bowels were one of the few things she had control over, and she felt that the staff should provide her care when she needed it, so it did not put her in a hardship to be holding it until they finished their rounds. Resident #1 said it was emotionally and physically hard on her. Resident #1 said she often hollers or screams when staff would not give her time to communicate on her tablet, she needed to have her pillow adjusted to position her head so she communicate on her communication device, be able to breathe comfortably, and be able to eat without aspirating (inhaling food into lungs) and she knew once they left her room it would be a long time before they returned. Resident #1 said often times while being fed, she would still be trying to swallow one bite of food and the staff were trying to feed her another bite and when she could not take a bite right then, the staff would say she was refusing to eat and took her food, and she was still hungry. Resident #1 said they would not give her time to respond and let them know she was still hungry and rushed out. Resident #1 said her muscles in her mouth, tongue, and throat were weak and it took her a long time to maneuver the food in her mouth and to be able to swallow it, and they have to often take her food back and re-blend it because it had clumps in it and her food had to be the consistency of baby food. Resident #1 said it did take a long time to feed her, but it was not something she could help or change because of her disease. Resident #1 said at times her head would fall over and she did not have the ability to pick her head up and it makes it difficult to breathe and all she could do was scream in hopes someone would come help her. Resident #1 said when she was not given time to respond on her tablet, the only thing she could do was make hollering type noises and it was very frustrating to her and caused her a lot of anxiety when the staff did not take the time to listen to her needs. During an interview on 8/13/25 beginning at 4:00 PM, Resident #1 said when staff bring her meals in, then moved her communication board where she could not type, then say she refused to eat made her feel powerless to get help and confused about why nobody used common sense, because obviously she wanted and needed to eat, and defeated in realizing it was the staff's intention to misunderstand her. Resident #1 said when staff said things such as: not going to keep going over the same thing over and over, I'm sick of you and don't care about that camera, kick me out of here, you gonna holler at me, I'm gonna leave, Don't act up, I literally just walked in here, don't know why you screaming, staff indicating she should say please and thank you, it made her mad and she wanted to tell them not to talk to her like that and to get out of her room, but she could not because she could not talk and had to accept their help. Resident #1 said she could not do anything, so anger builds up and caused her depression. Resident #1 said when staff keep asking her what do you want, what do you want and did not give her time to communicate on her device or staff chose not to take the time to read her communication device, it made her feel exhausted. Resident #1 said she did not have a hearing problem. Resident #1 said typing was not super easy and it took up long periods of mental and physical effort and she did not know who or if the staff would listen. Resident #1 said she becomes very scared when she realized they do not want to know what she needed or wanted. Resident #1 said some of the staff she trusted and knew they would do what she needed without her having to tell them, but there was not many she trusted left. Resident #1 said when staff enter her room and do not speak to her or do not tell her what they were going to do prior to touching her, was frightening and she absolutely had not way to stop them from whatever it was they were going to do and just hoping they would take a no from the tablet as an answer, and it was especially scary when they just sent new staff she had not ever met in to answer her call light. Resident #1 said when staff come into her room and just move her communication device to the end of the bed without letting her communicate her needs, scared her because they were intending to do whatever they wanted. Resident #1 said it was humiliating to be put on a bed pan, not covered, and left fully exposed with the window blinds open and sometimes staff would leave her room while she was on the bed pan and leave the door open to be seen by any member of the public walking by. Resident #1 said it made her feel angry when staff stood over her talking and laughing while she was on the bed pan, because they had no regard for the fact that she needed their close attention when she was in such a vulnerable position. Resident #1 said she did not want them staring at her while she went to the bathroom, but she needed them to hear her if she needed help. Resident #1 said when one staff member rolled her from side to side using the draw sheet, this is just one of the many ways they tortured me with the sheet, I am being handled like an object and it was isolating, when nobody acknowledges your humanness, you are alone. Resident #1 said continuous issues with her care has caused her to feel dehumanized and not treated as a person, and it had affected her well-being, self-worth, and self-esteem. Resident #1 said staff talk bad to her non-stop, and she does not feel her complaints were taken seriously and resolved. Resident #1 said she just wanted to be able to trust the staff and be treated with respect and kindness and be helped if not. During an interview on 8/13/25 at 11:46 AM, MA K said she had worked at the facility for about a year on the 6 AM-6 PM shift. MA K said they were sometimes a little short staffed, but the staff did the best they could. MA K said they were short staffed because staff have gotten fired due to Resident #1. MA K said she helped feed Resident #1 when she could, to help. MA K said it was time consuming. MA K said Resident #1 normally provided her own food. MA K said Resident #1 would tell you how to do it all and it took Resident #1 time to type it out. MA K said Resident #1 would type what she wanted and if staff did it wrong then she would start screaming and kicking. MA K said she thought Resident #1 wants some things a specific way because it was probably one of the only things Resident #1 could still control. MA K said the resident would be upset if staff did not communicate what they were doing to them prior to providing care. MA K said it was the resident's home. MA K said she would be upset if staff left her fully exposed while on a bed pan and window blinds opened. MA K said it would be a dignity issue. MA K said she would not be happy if she could not communicate her needs, but Resident #1 would usually answer yes or no questions either verbally or by head movements. MA K said if Resident #1 was not allowed time to communicate her needs, the staff would not know what she needed or wanted to say. MA K said it would probably make Resident #1 feel unsafe. MA K said she had not received any training on taking care of a resident with ALS. MA K said she was sure it would affect Resident #1's quality of life and made her feel less than a human if not provided privacy during incontinent care, not allowed time to communicate her needs, and not letting her know what care was going to be provided, and not speaking to her; and they were there to ensure Resident #1's needs were met.During an interview on 8/13/25 at 12:15 PM, CNA J said she had worked at the facility since April 2025 on the 6 AM-2 PM shift. CNA J said they had approximately 3 people on 400 hall that required 2-person assistance. CNA J said she felt she was able to meet the care needs of the residents. CNA J said it would make her feel very uncomfortable if staff did not speak to her and just started providing care. CNA J said it would make her feel uncomfortable, ashamed, and embarrassed if staff did not cover her or close the window blinds while on a bed pan. CNA J said Resident #1 at times wanted to be covered and at other times did not want to be covered and told them no. CNA J said if staff moved Resident #1's communication device out of her reach and did not give her time to communicate, then how was Resident #1 supposed to let her needs known if unable to communicate needs and it would make her angry. CNA J said she would be mad if her momma was done that way. CNA J said it would affect Resident #1's quality of life if she was unable to communicate her needs. CNA J said not being allowed time to communicate needs, providing care without telling the resident what you were going to do, not speaking to the resident during care, would make the resident feel less of a human, and if not able to communicate then you would not get anywhere. CNA J said she had not received any training related to caring for a resident with ALS, just what she had learned working with Resident #1. CNA J said she had not had any in-services related to caring for Resident #1. CNA J denied ever telling Resident #1 to stop crying that they were not running a daycare center. During an interview on 8/13/25 at 12:52 PM, CNA G said she had worked at the facility for about 2 months on the 6 AM-2 PM shift. CNA G said they had 7-8 residents on the 400 hall that required 2-person assistance. CNA G said she felt she was able to meet the needs of the residents sometimes. CNA G said if she had Resident #1 then it was hard to care for the other residents when Resident #1 took 2-2.5 hours to feed twice on her shift sometimes. CNA G said usually no one provided care to her other residents when she was feeding Resident #1, and then she had to come out when she was done feeding Resident #1 and work hard to get her other residents' care completed before the end of her shift. CNA G said one of her other residents pushed their call light while she was feeding Resident #1, then someone may go check them, but usually no one checked on her other residents until she was able

Based on observation, interview and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections was maintained for the facility related to COVID-19 (a new respiratory disease which can cause mild to severe illness with most severe illness in adults [AGE] years and older). The facility did not: *prevent CNA B who tested positive for COVID-19 from returning to work and exposing residents and staff who tested negative. *CNA B did not disclose she was under investigation due to a positive COVID-19 test on the screening form. *have designated staff for their warm unit (unknown COVID-19 status). An Immediate Jeopardy (IJ) situation was identified on 10/6/20. While the IJ was identified on 10/6/20, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for being exposed to COVID-19, health complications, and death. Findings included: The Texas Health and Human Services COVID-19 RESPONSE FOR NURSING FACILITIES version 3.6 dated 10/8/2020 indicated .Actively screen, monitor, and surveil everyone who comes into the facility . Staff who are confirmed or probable to have COVID-19 must stay at home . Implement protocols for cohorting residents based on their COVID-19 status: COVID19 positive, COVID-19 negative, and unknown COVID-19 status. NF providers should designate HCWs for each cohort and staff should not work with more than one cohort. A Infection Control Guidelines Related to Covid 19 policy, revised 9/1/20 indicated .Facility shall actively screen essential personnel and persons for contact with someone or under investigation for Covid-10.Patient Placement: as a measure to limit employee exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated employees, to care for known or unknown Covid-19. Dedicated means those employees are assigned only to care for those patients during their shift. During an interview on 10/6/20 at 10:30 a.m., the administrator said during weekly COVID-19 testing on 10/5/20 two employees (CNA B and CMA C) tested positive using the rapid result method and they retested on the same day and both were negative. The administrator said both employees were given a PCR test at the facility and told to leave the facility until told otherwise, she said neither employee had worked since receiving the positive result. The administrator said the facility had one COVID-19 positive resident who had been in the hospital for a month, she said there were no active cases in the building. A COVID-19 testing employee record dated 10/5/20 indicated CNA B tested positive on 10/5/20. A timecard sheet dated 10/6/20 indicated CNA B clocked in for work on 10/5/20 at 9:32 p.m. and clocked out at 6:00 a.m. An employee and visitor screening log dated 10/5/20 indicated CNA B signed in at 9:51 p.m. and she answered no to all questions including have you had contact with or under investigation for COVID-19. CNA B's temperature was documented as 98.8 degrees. A daily assignment sheet dated 10/5/20 indicated CNA B was scheduled to work the 10:00 p.m. to 6:00 a.m., shift on the 400 hall, she signed in on 10/5/20. An undated facility map indicated warm zones (unknown COVID-19 status) as rooms 100-104 (3 residents) and rooms 400-403 (3 residents). Cold zones (negative COVID-19 status) were rooms 300-309 (18 residents) and rooms 404-410 (13 residents). During an observation and interview on 10/6/20 at 11:10 a.m., LVN A went into the warm zone on 400 hall several times and returning to the cold zone of 400 hall. She said that she worked both warm halls (6 residents) and the cold hall (13 residents). She said she administered medications, checked vital signs, and performed assessments on all of her residents. LVN A said the facility did not have staff strictly for the warm units. She said when they had COVID-19 positive residents on the hot hall they did have dedicated staff for that unit. During an observation and interview on 10/6/20 at 11:18 a.m., CNA D left the warm zone and went into a resident's room on the cold zone to answer a call light. CNA D said she worked the warm halls (6 residents) and the cold hall (13 residents). During an interview on 10/6/20 at 2:10 p.m., CNA B said she worked the night shift on 10/5/20. She said she was not informed not to come back to work. She said she was told someone would call her with her PCR results. CNA B said she worked the warm and cold units on the 400 hall and she said she had worn all PPE. CNA B said she did not realize she answered the screening questions incorrectly. During an interview on 10/6/20 at 2:30 p.m., CMA C said she was told by the ADON to wait for her results before returning to work. During an interview on 10/6/20 at 2:25 p.m., the ADON said the warm zones did not have dedicated staff because there were only a few residents in the warm zones. She said they did not have COVID-19 and could work on the warm and cold zones in the same shift. She said that herself and the DON were responsible for making the schedule. She said they did not check the schedule to see if CNA B was on the schedule to work the same day she tested positive. During an interview on 10/6/20 at 2:35 p.m., the DON said she did not realize CNA B worked the night before. She said it was her understanding CNA B was told to quarantine at home. The DON said there was no dedicated staff for the warm and cold zones. She said only dedicated staff were provided for the hot zone. During an interview on 10/6/20 at 2:40 p.m., the administrator said CNA B should not have been allowed access inside the building and she was not made aware CNA B had in fact worked after testing positive. She said CNA B was terminated for not following directions. The administrator was notified on 10/5/20 at 4:20 p.m., an IJ situation was identified due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 10/6/20 at 8:15 a.m. and included: 1. Immediate actions a. The staff member was terminated for failing to follow instructions related to self-isolation following a disputed positive test result. b. The facility will call and provide telephonic education to any other currently positive staff that they may not return to work or enter the facility until approved by the administrator. The facility currently has one other staff member out with a positive result. c. Infection control policy was updated to indicate that dedicated staffing for warm units is preferred and that staff should not change designation from one day to another unless required in order to maintain adequate staffing for a cohort. Staff have been previously educated on how to safely enter / exit the warm unit, using proper PPE and hygiene techniques to reduce the risk of infection spreading. 2. Education a. Staff who test positive will be provided written and signed education after receiving a positive test that they may not return to work until approved by the administrator, including in cases where the positive result was in question and follow-up testing in process to confirm. b. Staff will be re-educated on the active screening process that employees must undergo prior to entering the facility for their shift, including: 1. Staff must be screened by the on-duty charge nurse or other individual designated by the administrator. The screening shall be logged on our Employee and Visitor Log and initialed off by the person doing the screening (see attached log). 2. Any staff member who answer yes to any question or has a fever of 99.4 or greater (using the temporal method), will not be allowed to enter until the administrator has reviewed and made a determination. Note: while we discourage staff from working at multiple facilities, those who are compliant with and test negative during the mandatory testing requirement (based on our county positivity rate) shall be allowed to work so long as they pass the other screening questions. c. Administrative staff will be educated on the written education to be provided as discussed in item 2(a) above. d. Administrative staff will be educated on the Infection Control Policy update discussed in item 1(c). e. DON or ADON will provide this training starting 10/6/2020 and will ensure all staff nurses and other designated screeners are educated by 10/7/2020. 3. Monitoring a. The Director of Nursing or Designee monitor the following items 5 days per week for 2 weeks, weekly for 4 weeks and then monthly and reported to the facility QAPI committee. 1. That staff on self-isolation for positive results do not work until approved by the administrator 2. That staff on self-isolation for positive results have received written and signed education at the time of the positive result 3. That staff are adhering to the re-education provided on the active screening process 4. The updated infection control policy is being followed. 4. Medical Director - The Medical Director has been notified of the Immediate Jeopardy. 5. QAPI Committee Review - The Director of Nursing/Designee will present findings to the Quality Assurance Performance Committee monthly for 3 months until the Quality Assurance Performance Committee deems it no longer necessary. Any recommendations will be implemented and monitored until compliance is achieved. On 10/6/20 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Eight LVNs (on all shifts - 6 a.m. to 2 p.m.; 2 p.m. to 10 p.m.; 10 p.m. to 6 a.m.; and weekends), two RNs (8 a.m. to 5 p.m. and weekend RN), 10 CNAs (all shifts), 2 MAs (6 a.m. to 2 p.m., 2 p.m. to 10 p.m., and weekends), two laundry staff, two housekeeping staff, two dietary staff, and one hospitality aide said they were in-serviced on actions to take if they tested positive including signing a form indicating acknowledgement of the protocol to follow after testing positive. All staff were able to inform surveyor of the active screening process at the front door to be performed by the charge nurse or assigned designee, and that dedicated staff would be implemented on the warm unit as much as staffing allowed. All staff were able to answer the questions with correct information to the above in-service training topics. On 10/6/20 at 9:20 a.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to immediately consult with the physician regarding a change in condition for 1 of 6 residents reviewed for change of condition. (Resident #100) The facility did not immediately notify the physician when Resident #100 had a decreased appetite, oral intake and urinary output. Resident #100 was hospitalized and placed in the intensive care unit with severe dehydration and electrolyte imbalance. This failure could place residents at risk for altered hydration and nutritional status, hospitalization and death. Findings included: The physician order [REDACTED].#100 was [AGE] years old and readmitted [DATE] with the [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #100 was rarely understood, was rarely able to make himself understood and had severe cognitive impairment. The MDS indicated Resident #100 required extensive assistance with bed mobility, transfers, locomotion in his wheelchair, dressing, eating, toilet use and personal hygiene. The MDS indicated Resident #100 was always incontinent of bowel and bladder and had no signs or symptoms of a swallowing disorder. The care plan dated 9/10/19 did not indicate Resident #100 was at risk for altered nutrition or hydration status and did not include interventions to prevent altered nutrition or hydration status. The care plan dated 12/10/19 (the date the resident was discharged ) indicated Resident #100 was at risk for altered nutritional status and weight loss, due to decreased meal intake, mechanically altered diet of pureed foods/thickened liquids. The care plan interventions included, monitor meal intake, assist with meal intake, encourage fortified foods, monitor weight weekly, registered dietician consults as required and as needed, provide 8 ounces of water on each meal tray and administer supplements with and between meals. The face sheet dated 12/14/19 indicated Resident #100 was discharged (did not indicate location) 12/10/19 at 11:30 p.m. The hospital history and physical dated 12/10/19 indicated Resident #100's blood pressure on admission to the hospital was 76/42. The record indicated Resident #100 had an elevated sodium level of 172 which was likely due to dehydration. The record indicated the resident had a free water deficit of 9.7 liters (the amount of water replacement needed to correct an elevated sodium level) and a creatinine of 2.3 and indicated acute kidney injury. The record indicated Resident #100's altered mental status was likely due to his elevated sodium level. The critical care consultation record dated 12/11/19 stated Resident #100 was to be moved to the ICU (intensive care unit) due to [MEDICAL CONDITION] (low blood pressure) and profound (severe) dehydration. During an observation on 12/14/19 at 11:07 a.m., Resident #100 was at a local hospital. Resident #100 was receiving nutrition threw a nasogastric tube and hydration threw an IJ (internal jugular central venous line). The facility intake/output record for Resident #100 had no documented food or fluid intake for any meals or throughout the day on the following dates: *12/6/19; *12/7/19; *12/8/19; *12/9/19; The facility intake/output record dated 12/10/19 for Resident #100 indicated he ate 51-75% of breakfast and 26-50% of lunch was consumed. There was no documented fluid intake. The facility intake/output record for Resident #100 indicated the following output: *12/1/19 at 4:14 a.m. large urine output. *12/2/19 no documented output *12/3/19 no documented output *12/4/19 no documented output *12/5/19 at 10:37 a.m., large urine output *12/6/19 at 5:34 a.m. large urine output *12/7/19 at 5:18 a.m., large urine output *12/8/19 at 5:16 a.m., large urine output; *12/9/19 at 1:27 a.m., small urine output; *12/10/19 at 1:15 a.m., small urine output; *12/10/19 at 1:53 p.m. no urine output. The facility blood pressure readings for Resident #100 indicated the following: *12/3/19 at 11:42 a.m. -126/85 *12/4/19 at 8:50 p.m. -154/72 *12/5/19 at 9:47 a.m. -122/73 *12/6/19 at 10:40 a.m. -127/76; 6:55 p.m. -164/82 *12/7/19 at 9:30 a.m. - 103/62; 4:01 p.m. -154/74 *12/8/19 at 8:55 a.m. - 104/72; 4:03 p.m. -164/76 *12/9/19- no blood pressures documented in the vital sign record or nursing notes *12/11/19- at 12:20 a.m. - 96/55 (Resident went to the hospital on [DATE]) During an interview on 12/14/19 at 11:45 a.m., Resident #100's sister said she was notified on 12/10/19 her brother had not been eating or drinking well for several days and had a decreased level of consciousness. Resident #100's sister said she was not told the exact number of days Resident #100 had not been eating or drinking well. She said she was not notified prior to 12/10/19 her brother had not been eating or drinking well. She said she told the staff she wanted her brother to be sent to the emergency room when she was notified of his decreased level of consciousness on 12/10/19. Resident #100's sister said the facility staff told her the resident's laboratory results would have to come back before a decision was made to send him to the hospital. During an interview on 12/14/19 at 1:30 p.m., Resident #100's personal sitter and family friend said she went to check on Resident #100 for the family on 12/10/19. She said she sat with or checked on the resident about every 2 weeks. The sitter said when she arrived a nurse was reading off the computer, telling her he had been eating 50% of his meals. The sitter said a nurse aide spoke up and said he had not been eating or drinking well for several days. The sitter said when she visited Resident #100 on 12/10/19, he was not his usual self. She said the resident did not seem to be aware she was in the room and was only grunting occasionally when she spoke to him. The sitter said normally Resident #100 would squeeze her hand and say some words to her. A nursing note dated 12/9/19, written by LVN A, indicated Resident #100 had not eaten breakfast or taken his morning medications. A nursing note dated 12/10/19 written by LVN A at 9:51 a.m., indicated Resident #100 had a decreased level of consciousness and had not eaten breakfast or taken his morning medications. A nursing note dated 12/10/19 written by LVN A at 12:55 p.m., indicated Resident #100 was still not eating or drinking. The note indicated LVN A notified the NP Resident #100 had a decreased level of consciousness, was not eating and not taking medication. The note indicated orders were received to obtain laboratory tests. A physician order [REDACTED].#100 was to have the following 1 time laboratory tests: CBC (complete blood count), CMP (complete metabolic panel), [MEDICATION NAME] level, [MEDICATION NAME] level, and ammonia level. Laboratory results obtained by the facility dated 12/10/19 indicated Resident #100 had a white blood cell count of 14.4 (normal 4,500 1 11,000), a sodium level of 167.5 (normal 135-145) and creatinine of 2.20 (indicator of kidney function) (normal 0.84 to 1.21) a BUN (indicator of kidney function) of 62.7 (normal 8-24). A nursing note dated 12/11/19 at 12:20 a.m. indicated Resident #100 was sent to ER due to an increased white blood cell count. A nursing note dated 12/10/19 written by LVN A at 1:17 p.m., indicated Resident #100's sister called and spoke with LVN [NAME] The note indicated Resident #100's sister had asked about sending Resident #100 to the hospital. The nursing note indicated LVN A informed Resident #100's sister the current orders were for bloodwork to be obtained. The note indicated LVN A told Resident #100's sister if the bloodwork indicated Resident #100 needed to be sent to the hospital he would be sent at that time. During an interview on 12/14/19 at 2:26 p.m., LVN A said she had taken care of Resident #100 in the days leading up to his hospitalization . LVN A said on 12/10/19 Resident #100 was not eating or drinking at all. She said he was spitting out his food and his medications. LVN A said Resident #100 had a decreased level of consciousness on 12/10/19. LVN A said because he continued to not eat or drink during her shift she notified the nurse practitioner and obtained orders for laboratory test. LVN A said she did report the decreased level of consciousness to the nurse practitioner when she called to report his decreased appetite. LVN A said before 12/10/19, Resident #100 was not eating or drinking well but could not remember if it was continuous. LVN A said she could not remember if Resident #100 ate or drank at lunch on 12/9/19. LVN A said she did not notify the family or the nurse practitioner prior to 12/10/19 about Resident #100's decreased intake. She said she was not notified Resident #100 had decreased urinary output. She said she told the resident's sister they needed to wait on the laboratory results to see if the resident needed to go to the hospital. During an interview on 12/14/19 at 4:49 p.m., LVN C said she had taken care of Resident #100 on 12/6/19, 12/7/19 and 12/8/19. She said on 12/8/19 Resident #100 ate pretty well during breakfast but at lunch he ate and drank very poorly. LVN C said she did not know if he ate or drank at dinner on 12/8/19. She said she should have followed up on Resident #100 to see if ate and drank during the dinner meal on 12/8/19. LVN C said she left the facility in (MONTH) 2019 and returned on 11/1/19. She said she noticed a marked decline in Resident #100's intake in that time frame. LVN C said when she returned in (MONTH) 2019 she noticed Resident #100 would rarely eat and drink well. LVN C said she did not notify the family or physician because she assumed they already knew. LVN C said she was not notified Resident #100 had a decreased urinary output. She said no one reported to her he had a decreased urinary output and she did not look at the clinical record to see what his output was. She said she should have checked the output documentation. During an interview on 12/14/19 at 4:05 p.m., CNA D said CNAs were to document resident intake and output. CNA D said she worked at the facility four months and was shown on Tuesday, 12/10/19 where to document intake and output. She said prior to Tuesday 12/10/19 she was not recording the intake and output of residents anywhere because she did not know where to document it. CNA D said she would notify a nurse if a resident was not eating well. CNA D said she would notify the nurse if a resident had no urine output. CNA D said she did not remember if Resident #100 had a decreased appetite or output prior to going to the hospital on [DATE]. During an interview on 12/14/19 at 4:00 p.m., CNA B said he worked at the facility for 3 or 4 weeks. He said he did not think CNAs were supposed to document resident's meal intake. CNA B said he was not sure if they documented resident output. He said he did not know where to document input and output, but would notify the nurse if a resident was not eating or drinking or had no urine output. CNA B said he did not remember Resident #100 and could not say for sure if he had taken care of him. During an interview on 12/14/19 at 4:45 p.m., the nurse practitioner said she had not been notified prior to 12/10/19 that Resident #100 had not been eating or drinking well. She said if she had been notified she would have ordered laboratory test and he would have gone to the hospital sooner. The nurse practitioner said she had not given an order or instructed staff not to send Resident #100 to the hospital until the laboratory results were back. The nurse practitioner said she was not aware the family had requested Resident #100 be sent to the hospital on the afternoon of 12/10/19. The nurse practitioner said she would have sent Resident #100 to the hospital if she knew the family had requested it. During an interview on 12/14/19 at 4:55 p.m., the physician said he did not give an order or instruct the facility staff not to send Resident #100 to the hospital until the laboratory results were back. The physician said if a resident was not eating or drinking he wanted to be notified that day. He said he had not been notified of Resident #100 having a decreased intake prior to 12/10/19. During an interview on 12/14/19 at 5:13 p.m., the DON said she expected CNAs to accurately document intake and output on all residents. The DON said she expected staff to notify the physician and family if a resident was having ongoing decreased intake even if it was not with consecutive meals. The DON said she expected staff to notify the physician if there was a decrease in urinary output. She said there should have been documentation of Resident intake and output and nurses should have been notified of any changes in appetite and urinary output. The facility policy titled Resident Hydration and Prevention of Dehydration, dated (MONTH) of 2019, stated . (7) Nurse Aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aides will report intake of less than 1200ml/day to nursing staff . (10) The Dietitian, nursing staff and the physician will assess factors that may be contributing to inadequate fluid intake. Orders for medications that may exacerbate dehydration (e.g., diuretics) will be reviewed and held if medically appropriate. (11) Laboratory tests may be ordered to assess hydration if intake and symptoms indicate possible significant dehydration .(13) Nursing will monitor and document fluid intake and the dietician will be kept informed of status . The facility policy titled Change in a Resident's Condition or Status, dated (MONTH) of 2019, stated .the nurse will notify the resident's attending physician or physician on call when there has been a (an): .(f) refusal of treatment or medications two or more consecutive times .

Based on observation, interview, and record review, the facility failed to ensure acceptable parameters of nutritional status was maintained for 1 of 6 residents reviewed for nutritional status. (Resident #100) The facility did not monitor Resident #100's input and output, implement interventions and immediately notify the physician when the resident had a decreased oral intake and urine output. Resident #100 was hospitalized and placed in the intensive care unit with severe dehydration and electrolyte imbalance. This failure could place residents at risk for altered hydration and nutritional status, hospitalization and death. The physician order [REDACTED].#100 was [AGE] years old and readmitted [DATE] with the [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #100 was rarely understood, was rarely able to make himself understood and had severe cognitive impairment. The MDS indicated Resident #100 required extensive assistance with bed mobility, transfers, locomotion in his wheelchair, dressing, eating, toilet use and personal hygiene. The MDS indicated Resident #100 was always incontinent of bowel and bladder and had no signs or symptoms of a swallowing disorder. The care plan dated 9/10/19 did not indicate Resident #100 was at risk for altered nutrition or hydration status and did not include interventions to prevent altered nutrition or hydration status. The care plan dated 12/10/19 (the date the resident was discharged ) indicated Resident #100 was at risk for altered nutritional status and weight loss, due to decreased meal intake, mechanically altered diet of pureed foods/thickened liquids. The care plan interventions included, monitor meal intake, assist with meal intake, encourage fortified foods, monitor weight weekly, registered dietician consults as required and as needed, provide 8 ounces of water on each meal tray and administer supplements with and between meals. The face sheet dated 12/14/19 indicated Resident #100 was discharged (did not indicate location) 12/10/19 at 11:30 p.m. The hospital history and physical dated 12/10/19 indicated Resident #100's blood pressure on admission to the hospital was 76/42. The record indicated Resident #100 had an elevated sodium level of 172 which was likely due to dehydration. The record indicated the resident had a free water deficit of 9.7 liters (the amount of water replacement needed to correct an elevated sodium level) and a creatinine of 2.3 and indicated acute kidney injury. The record indicated Resident #100's altered mental status was likely due to his elevated sodium level. The critical care consultation record dated 12/11/19 stated Resident #100 was to be moved to the ICU (intensive care unit) due to [MEDICAL CONDITION] (low blood pressure) and profound (severe) dehydration. During an observation on 12/14/19 at 11:07 a.m., Resident #100 was at a local hospital. Resident #100 was receiving nutrition threw a nasogastric tube and hydration threw an IJ (internal jugular central venous line). The facility intake/output record for Resident #100 had no documented food or fluid intake for any meals or throughout the day on the following dates: *12/6/19; *12/7/19; *12/8/19; *12/9/19; The facility intake/output record dated 12/10/19 for Resident #100 indicated he ate 51-75% of breakfast and 26-50% of lunch was consumed. There was no documented fluid intake. The facility intake/output record for Resident #100 indicated the following output: *12/1/19 at 4:14 a.m. large urine output. *12/2/19 no documented output *12/3/19 no documented output *12/4/19 no documented output *12/5/19 at 10:37 a.m., large urine output *12/6/19 at 5:34 a.m. large urine output *12/7/19 at 5:18 a.m., large urine output *12/8/19 at 5:16 a.m., large urine output; *12/9/19 at 1:27 a.m., small urine output; *12/10/19 at 1:15 a.m., small urine output; *12/10/19 at 1:53 p.m. no urine output. The facility blood pressure readings for Resident #100 indicated the following: *12/3/19 at 11:42 a.m. -126/85 *12/4/19 at 8:50 p.m. -154/72 *12/5/19 at 9:47 a.m. -122/73 *12/6/19 at 10:40 a.m. -127/76; 6:55 p.m. -164/82 *12/7/19 at 9:30 a.m. - 103/62; 4:01 p.m. -154/74 *12/8/19 at 8:55 a.m. - 104/72; 4:03 p.m. -164/76 *12/9/19- no blood pressures documented in the vital sign record or nursing notes *12/11/19- at 12:20 a.m. - 96/55 (Resident went to the hospital on [DATE]) During an interview on 12/14/19 at 11:45 a.m., Resident #100's sister said she was notified on 12/10/19 her brother had not been eating or drinking well for several days and had a decreased level of consciousness. Resident #100's sister said she was not told the exact number of days Resident #100 had not been eating or drinking well. She said she was not notified prior to 12/10/19 her brother had not been eating or drinking well. She said she told the staff she wanted her brother to be sent to the emergency room when she was notified of his decreased level of consciousness on 12/10/19. Resident #100's sister said the facility staff told her the resident's laboratory results would have to come back before a decision was made to send him to the hospital. During an interview on 12/14/19 at 1:30 p.m., Resident #100's personal sitter and family friend said she went to check on Resident #100 for the family on 12/10/19. She said she sat with or checked on the resident about every 2 weeks. The sitter said when she arrived a nurse was reading off the computer, telling her he had been eating 50% of his meals. The sitter said a nurse aide spoke up and said he had not been eating or drinking well for several days. The sitter said when she visited Resident #100 on 12/10/19, he was not his usual self. She said the resident did not seem to be aware she was in the room and was only grunting occasionally when she spoke to him. The sitter said normally Resident #100 would squeeze her hand and say some words to her. A nursing note dated 12/9/19, written by LVN A, indicated Resident #100 had not eaten breakfast or taken his morning medications. A nursing note dated 12/10/19 written by LVN A at 9:51 a.m., indicated Resident #100 had a decreased level of consciousness and had not eaten breakfast or taken his morning medications. A nursing note dated 12/10/19 written by LVN A at 12:55 p.m., indicated Resident #100 was still not eating or drinking. The note indicated LVN A notified the NP Resident #100 had a decreased level of consciousness, was not eating and not taking medication. The note indicated orders were received to obtain laboratory tests. A physician order [REDACTED].#100 was to have the following 1 time laboratory tests: CBC (complete blood count), CMP (complete metabolic panel), [MEDICATION NAME] level, [MEDICATION NAME] level, and ammonia level. Laboratory results obtained by the facility dated 12/10/19 indicated Resident #100 had a white blood cell count of 14.4 (normal 4,500 1 11,000), a sodium level of 167.5 (normal 135-145) and creatinine of 2.20 (indicator of kidney function) (normal 0.84 to 1.21) a BUN (indicator of kidney function) of 62.7 (normal 8-24). A nursing note dated 12/11/19 at 12:20 a.m. indicated Resident #100 was sent to ER due to an increased white blood cell count. A nursing note dated 12/10/19 written by LVN A at 1:17 p.m., indicated Resident #100's sister called and spoke with LVN [NAME] The note indicated Resident #100's sister had asked about sending Resident #100 to the hospital. The nursing note indicated LVN A informed Resident #100's sister the current orders were for bloodwork to be obtained. The note indicated LVN A told Resident #100's sister if the bloodwork indicated Resident #100 needed to be sent to the hospital he would be sent at that time. During an interview on 12/14/19 at 2:26 p.m., LVN A said she had taken care of Resident #100 in the days leading up to his hospitalization . LVN A said on 12/10/19 Resident #100 was not eating or drinking at all. She said he was spitting out his food and his medications. LVN A said Resident #100 had a decreased level of consciousness on 12/10/19. LVN A said because he continued to not eat or drink during her shift she notified the nurse practitioner and obtained orders for laboratory test. LVN A said she did report the decreased level of consciousness to the nurse practitioner when she called to report his decreased appetite. LVN A said before 12/10/19, Resident #100 was not eating or drinking well but could not remember if it was continuous. LVN A said she could not remember if Resident #100 ate or drank at lunch on 12/9/19. LVN A said she did not notify the family or the nurse practitioner prior to 12/10/19 about Resident #100's decreased intake. She said she was not notified Resident #100 had decreased urinary output. She said she told the resident's sister they needed to wait on the laboratory results to see if the resident needed to go to the hospital. During an interview on 12/14/19 at 4:49 p.m., LVN C said she had taken care of Resident #100 on 12/6/19, 12/7/19 and 12/8/19. She said on 12/8/19 Resident #100 ate pretty well during breakfast but at lunch he ate and drank very poorly. LVN C said she did not know if he ate or drank at dinner on 12/8/19. She said she should have followed up on Resident #100 to see if ate and drank during the dinner meal on 12/8/19. LVN C said she left the facility in (MONTH) 2019 and returned on 11/1/19. She said she noticed a marked decline in Resident #100's intake in that time frame. LVN C said when she returned in (MONTH) 2019 she noticed Resident #100 would rarely eat and drink well. LVN C said she did not notify the family or physician because she assumed they already knew. LVN C said she was not notified Resident #100 had a decreased urinary output. She said no one reported to her he had a decreased urinary output and she did not look at the clinical record to see what his output was. She said she should have checked the output documentation. During an interview on 12/14/19 at 4:05 p.m., CNA D said CNAs were to document resident intake and output. CNA D said she worked at the facility four months and was shown on Tuesday, 12/10/19 where to document intake and output. She said prior to Tuesday 12/10/19 she was not recording the intake and output of residents anywhere because she did not know where to document it. CNA D said she would notify a nurse if a resident was not eating well. CNA D said she would notify the nurse if a resident had no urine output. CNA D said she did not remember if Resident #100 had a decreased appetite or output prior to going to the hospital on [DATE]. During an interview on 12/14/19 at 4:00 p.m., CNA B said he worked at the facility for 3 or 4 weeks. He said he did not think CNAs were supposed to document resident's meal intake. CNA B said he was not sure if they documented resident output. He said he did not know where to document input and output, but would notify the nurse if a resident was not eating or drinking or had no urine output. CNA B said he did not remember Resident #100 and could not say for sure if he had taken care of him. During an interview on 12/14/19 at 4:45 p.m., the nurse practitioner said she had not been notified prior to 12/10/19 that Resident #100 had not been eating or drinking well. She said if she had been notified she would have ordered laboratory test and he would have gone to the hospital sooner. The nurse practitioner said she had not given an order or instructed staff not to send Resident #100 to the hospital until the laboratory results were back. The nurse practitioner said she was not aware the family had requested Resident #100 be sent to the hospital on the afternoon of 12/10/19. The nurse practitioner said she would have sent Resident #100 to the hospital if she knew the family had requested it. During an interview on 12/14/19 at 4:55 p.m., the physician said he did not give an order or instruct the facility staff not to send Resident #100 to the hospital until the laboratory results were back. The physician said if a resident was not eating or drinking he wanted to be notified that day. He said he had not been notified of Resident #100 having a decreased intake prior to 12/10/19. During an interview on 12/14/19 at 5:13 p.m., the DON said she expected CNAs to accurately document intake and output on all residents. The DON said she expected staff to notify the physician and family if a resident was having ongoing decreased intake even if it was not with consecutive meals. The DON said she expected staff to notify the physician if there was a decrease in urinary output. She said there should have been documentation of Resident intake and output and nurses should have been notified of any changes in appetite and urinary output. The facility policy titled Resident Hydration and Prevention of Dehydration, dated (MONTH) of 2019, stated . (7) Nurse Aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aides will report intake of less than 1200ml/day to nursing staff . (10) The Dietitian, nursing staff and the physician will assess factors that may be contributing to inadequate fluid intake. Orders for medications that may exacerbate dehydration (e.g., diuretics) will be reviewed and held if medically appropriate. (11) Laboratory tests may be ordered to assess hydration if intake and symptoms indicate possible significant dehydration .(13) Nursing will monitor and document fluid intake and the dietician will be kept informed of status . The facility policy titled Change in a Resident's Condition or Status, dated (MONTH) of 2019, stated .the nurse will notify the resident's attending physician or physician on call when there has been a (an): .(f) refusal of treatment or medications two or more consecutive times .

Based on observation, interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for 1 of 13 residents reviewed for physician orders. (Resident #303) The facility did not apply TED hose (stockings worn to prevent blood clots in the legs) as ordered by the physician for Resident #303. The resident developed a [MEDICAL CONDITION] (blood clot) behind her knee requiring medical intervention. This failure could place residents at risk of developing [MEDICAL CONDITIONS] embolism, hospitalization and death. Findings included: The consolidated physician orders [REDACTED].#303 was [AGE] years old, admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The physician orders [REDACTED]. A baseline care plan dated 6/11/19 indicated Resident #303 had a recent fall which resulted in a fracture to her left hip for which she had hip replacement surgery. The care plan indicated Resident #303 was to receive wound care to the surgical incision and pain medication as ordered and indicated. There was nothing on the care plan that indicated Resident #303 was at risk for a [MEDICAL CONDITION] or was to wear TED hose. The discharge MDS dated [DATE] indicated Resident #303 was discharged to the hospital on [DATE] with anticipated return. The MDS dated [DATE] indicated Resident #303 had severe cognitive impairment and no behaviors of rejecting care. The MDS indicated Resident #303 required supervision with eating, bed mobility and transfers and required limited assistance with locomotion in her wheelchair, dressing, toileting and personal hygiene. The MDS indicated Resident #303 had impairment of ROM to one lower extremity and had [DIAGNOSES REDACTED]. The MDS indicated Resident #303 had a fall which resulted in a fracture within the past month and had major surgery within the last 100 days of admission. The MDS indicated Resident #303 was not on anticoagulant therapy. A care plan with a start date of 6/19/19 and last reviewed/revised on 7/19/19 indicated Resident #303 had a potential to develop a [MEDICAL CONDITION] due to a recent [MEDICAL CONDITION]. The care plan indicated Resident #303 had a doppler on 7/3/19 which indicated she had a left [MEDICAL CONDITION]. Care plan approaches with a start date of 6/19/19 included the following: *Assess circulation, motion and sensation of both lower extremities and document. *Assess for signs and symptoms of redness, skin hot to touch, pain, shortness of breath and swelling at extremity site; *Avoid [MEDICATION NAME] of the blood supply at the knees; *Discourage resident from sitting with legs crossed; and *Obtain labs as ordered. A care plan approach with a start date of 7/4/19 indicated Resident #303 was to receive Eliquis and to evaluate, record, report effectiveness and any adverse side effects. The care plan did not indicate Resident #303 was to have TED hose applied daily. The treatment flowsheet for (MONTH) and (MONTH) 2019 for Resident #303 indicated TED hose were not applied daily on the following dates: *6/16/19; *6/17/19; *6/18/19; *6/25/19; *6/26/19; *6/27/19; *6/28/19; *6/29/19; *6/30/19; *7/1/19; *7/2/19; *7/3/19; *7/4/19; *7/5/19; and *7/6/19. The treatment flowsheet for the month of (MONTH) 2019 indicated Resident #303 had TED hose placed on 7/7/19 and 7/8/19. The nursing notes dated 6/14/19 to 6/18/19 did not indicate TED hose had been applied to or refused by Resident #303. The nursing notes did not indicate an assessment of the legs had been completed. The nursing notes dated 6/25/19 to 7/10/19 did not indicate TED hose had been applied to or refused by Resident #303. The nursing notes did not indicate an assessment of the legs had been completed. A provider note completed by a nurse practitioner dated 7/2/19 indicated Resident #303 had a chief compliant of pain in her left hip that radiated to the back of her knee. The note indicated the residents left thigh, extending to below the knee was warm to the touch, swollen and painful. The note indicated Resident #303 was to receive a doppler (a test used to check for a blood clot) of her the left leg. The nursing note dated 7/2/19 at 9:00 p.m., indicated Resident #303 was assessed by a nurse practitioner and a venous doppler was ordered because of swelling and warmth to the left lower leg. A finalized report of a lower extremity (leg) [MEDICAL CONDITION] study dated 7/3/19 for Resident #303 indicated the following: Partially occluding acute [MEDICAL CONDITION] of the left popliteal vein (a major blood vessel in the lower body) with mild reduction of the venous return in the left lower extremity. Totally occluding acute [MEDICAL CONDITION] of the left gastrocnemius (the major muscle of the calf of the leg) vein with severe reduction of the venous return in the left lower extremity. Totally occluding acute SVT (superficial vein blood clot) of the left SSV (superficial vein in the back of the leg) with severe reduction of the venous return. A physician order [REDACTED].#303 was to receive Eliquis10 mg by mouth twice a day for 7 days followed by Eliquis 5 mg by mouth twice a day. The nursing note dated 7/4/19 at 12:23 p.m. indicated the results from the doppler revealed Resident #303 had a blood clot behind her left knee. During an observation on 7/8/19 at 12:02 p.m., Resident #303 was sitting in her wheelchair in her room. She did not have TED hose on her legs. During an observation and interview on 7/9/19 at 2:21 p.m., Resident #303 was lying in her bed. She did not have TED hose or any compression devices to her legs. Resident #303 said she had not had anything on her legs since arriving at the facility. During an observation on 7/10/19 at 9:00 a.m., Resident #303 was in physical therapy sitting in her wheelchair. She did not have TED hose on her legs. During an interview on 7/10/19 at 10:30 a.m., CNA F said she worked for the facility for 3 months. CNA F said she worked the 6 a.m. to 2 p.m. shift and worked with Resident #303 often. CNA F said Resident #303 never had TED hose or compression devices on her legs when she worked with her. CNA F said if Resident #303 had TED hose they would most likely be in her dresser drawer. CNA F looked for the TED hose in the dresser drawer and throughout the room and could not find any. During an interview on 7/10/19 at 1:45 p.m., CNA H said she was the CNA supervisor. CNA H said if a resident had an order for [REDACTED]. During an interview on 7/10/19 at 2:14 p.m., RN [NAME] said CNAs or nurses would place TED hose on residents. He said it was the responsibility of the nurse to make sure TED hose had been placed. RN [NAME] said if Resident #303 had refused TED hose placement it should be documented in the nursing notes. During an interview on 7/10/19 at 2:48 p.m., the DON said she expected staff to follow physician orders. She said nurses may document the placement of TED hose on the residents' TAR or in the nursing notes. The DON said any refusal of treatment should be documented in the nursing notes. She said in the event a resident continued refusal of treatment the physician should be notified. During an interview on 7/10/19 at 3:20 p.m., the administrator said she expected staff to follow physician orders. The website https://www.cdc.gov/ncbddd/[MEDICAL CONDITION]/facts.html accessed on 7/12/19 and titled Venous [MEDICAL CONDITION] (Blood Clots) indicated . anyone can have a [MEDICAL CONDITION]. However, certain factors can increase the chance of having this condition. The chance increases even more for someone who has more than one of these factors at the same time. The following is a list of factors that increase the risk of developing [MEDICAL CONDITION]: Injury to a vein, often caused by fractures, severe muscle injury, or major surgery (particularly involving the abdomen, pelvis, hip, or legs). Slow blood flow, often caused by: Confinement to bed (e.g., due to a medical condition or after surgery); limited movement (e.g., a cast on a leg to help heal an injured bone); sitting for a long time . The most serious complication of [MEDICAL CONDITION] happens when a part of the clot breaks off and travels through the bloodstream to the lungs, causing a blockage called [MEDICAL CONDITION] embolism (PE). If the clot is small, and with appropriate treatment, people can recover from PE. However, there could be some damage to the lungs. If the clot is large, it can stop blood from reaching the lungs and is fatal .about 30% of people who have had a [MEDICAL CONDITION] or PE are at risk for another episode.

Based on observation, interview, and record review, the facility failed to provide assessments and care in accordance with standards of practice and based on the comprehensive assessment for 1 of 6 residents reviewed for assessments. (Resident #1) The facility did not assess Resident #1 for injury after a fall, when she was found partially out of bed. She was sent to the hospital 2 days later, where it was determined the resident had fractures on her lower left leg. This failure to provide care in accordance with professional standards of practice affected 1 resident and had the potential to affect 14 residents who were dependent on staff for transfers at risk for injury and not receiving care and services to meet their needs. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 was rarely or never understood, her cognition was severely impaired. Resident #1 had no behaviors. Resident #1 required extensive assistance with most ADLs, including bed mobility and transfers. A care plan initiated 9/11/17 indicated Resident #1 was at risk for falls and required extensive assistance of two staff for transfers via Hoyer lift, and extensive assistance of one staff for bed mobility. An incident report dated 5/6/18 (regarding an incident that occurred on 5/4/18) indicated Resident #1 had 2+ [MEDICAL CONDITION] and increased bruising noted to her lower left leg. The DON and ADON were notified on 5/6/18 that on 5/4/18, Resident #1 was found half out of the bed. Witness statements were obtained after the notification of the incident. It was determined the resident was hanging off her bed on 5/4/18 with the lower half of her body hanging off the bed and the upper half of her body still on the bed, and was sent out to the emergency roiagnom on [DATE]. Resident #1's physician was aware and called and talked to the charge nurse per LVN A. There was a section of the incident report which asked whether a fall assessment was completed, and this section was left blank. A nursing note dated 5/4/18 indicated Resident #1 was observe with bruising to her lower left leg. The note indicated will inform MD and family and monitor. A nursing note dated 5/6/18 indicated Resident #1's left leg was discolored with 1+ or 2+ [MEDICAL CONDITION]. An order was received to send the resident to the ER for an evaluation. A radiology report dated 5/6/18 indicated Resident #1 had lower left leg fractures. A care plan initiated 5/8/18 indicated Resident #1 had a lower left leg fracture and was not a surgical candidate. During an observation on 6/11/18 at 6:17 p.m., Resident #1 was observed lying in bed. Her left leg was in a brace. Resident #1 was awake but did not respond to questions. During a telephone interview on 6/11/18 at 10:45 p.m., CNA B said on 5/4/18 during the 6 a.m. to 2 p.m. shift, she and CNA C transferred Resident #1 into bed with a Hoyer lift. CNA B and CNA C both left to care for another resident, and when CNA B came back minutes later to undress Resident #1, she found the resident in a kneeling position, her torso leaned against the bed, and her legs on the floor. She said Resident #1 slid partially off the bed. She said she did not see Resident #1 hit the floor. She said she and CNA C lifted Resident #1 with a gait belt and put her back in bed, and then she notified LVN A. She was not sure if LVN A ever went into Resident #1's room. During a telephone interview on 6/12/18 at 4:13 p.m., LVN A said during the 6 a.m. to 2 p.m. shift on 5/4/18, CNA B reported to her Resident #1 was turned around in bed, and the CNA turned Resident #1 back around into a supine position. LVN A said CNA B did not mention Resident #1 had a fall or was partially on the floor. LVN A said if CNA B told her Resident #1 was found partially on the floor, she would have done a fall assessment, would have checked her vitals, checked for range of motion, and notified the family and physician. She said she did none of those things because CNA B did not describe the event as a fall or incident. She said the ADON went to check on Resident #1 after CNA B reported turning her in bed on 5/4/18. LVN A did not know if the ADON assessed Resident #1. LVN A said they began monitoring the bruising to Resident #1's lower left leg on 5/5/18. LVN A said by 5/6/18, the bruising increased, and the resident's lower left leg started to swell. LVN A said she notified the physician and family on 5/6/18, and the resident was sent to the hospital, where it was determined the resident had a fracture to the lower left leg. LVN A said CNA B told the DON she reported Resident #1's fall to LVN A on 5/4/18. LVN A told the DON CNA B only reported moving the resident in bed but did not report finding her partially on the floor. LVN A said she was not aware Resident #1 was found partially on the floor until 5/6/18 when the DON started to question the staff about the incident. During a telephone interview on 6/13/18 at 10:23 a.m., the ADON said during the 6 a.m. to 2 p.m. shift on 5/4/18, CNA B came to her distraught because Resident #1 twisted herself out of bed and was half in bed and half off the bed. The ADON said she did not know why CNA B was distraught. The ADON said Resident #1 was a mover and came out of the bed one other time. The ADON said CNA B told her she reported the incident to LVN A. The ADON said LVN A should have assessed the resident for range of motion, took the resident's vitals, and called the physician and family. The ADON did not know whether LVN A did those things on 5/4/18. The ADON said she looked at Resident #1's legs on 5/4/18 and there was no bruising or swelling, she did not assess further or call the physician. She said the resident was unable to say what happened. During a telephone interview on 6/13/18 at 4:19 p.m. LVN D said she went into Resident #1's room to check on her the night of 5/4/18 and saw a very large bruise on Resident #1 that covered most of Resident #1's lower left leg. LVN D said she assessed Resident #1 at that time and Resident #1's leg was not cold and had a pulse. LVN D said she did not check for range of motion because she was unaware of a fall or any other incident. LVN D said she called the ADON because the extent of the bruising was alarming. LVN D said the ADON was already aware of the bruise and said it was handled. LVN D said she did not know if Resident #1 had a fall earlier that day. LVN D said if she was aware of an unwitnessed fall, she would have sent Resident #1 out to the hospital. LVN D said a few days later, she learned Resident #1 had a fractured lower left leg and was told the fracture had something to do with CNA B, but did not remember if it was related to a transfer or a fall. LVN D said Resident #1 was not able to say how the bruising occurred. LVN D said after she saw the bruising on 5/4/18, she called the on-call physician regarding the bruise and an x-ray was not ordered. During an interview on 6/11/18 at 10:30 p.m., the DON said she was told Resident #1 was put in bed by two CNAs using the Hoyer lift. The DON said the CNAs left the room after the transfer, and when the CNAs returned to provide additional care, Resident #1 was halfway on the floor and halfway on the bed. The DON said she assumed Resident #1 hit her knee when she fell . The DON said Resident #1 was found with bruising and swelling pretty soon after the incident. The DON said the facility did not report the incident because they knew how the fracture happened and it was caused during that incident. The DON said there was no assault or abuse involved. The DON said Resident #1 was not able to say what happened. During a telephone interview on 6/12/18 at 4:48 p.m., the administrator said he was the abuse coordinator. He said Resident #1 flops her legs in and out of bed. He said he did not report the fractured leg because Resident #1 had an incident before the fracture was discovered of Resident #1 found halfway on the floor and halfway on the bed. The administrator said the CNAs notified the nurse and he expected the nurse to notify the doctor and assess Resident #1 at that time. An Fall's Guidelines policy revised 1/27/18 addressed assessing a resident's risk for falls but did not address assessing a resident's injury after a fall. The CMS 672 dated 6/11/18 indicated 14 residents were dependent on staff for transfers.

Based on interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice based on the comprehensive assessment for 1 of 6 residents reviewed for assessment. (Resident #1) The facility did not assess, develop interventions, and treat constipation for Resident #1 who was at risk of impaction. The facility did not monitor Resident #1's elimination patterns. Resident #1 had a distended abdomen and was in pain on [DATE]. He was sent to the emergency room where attempts were made to clear a bowel obstruction. He was placed on a ventilator and expired on [DATE], from a large bowel obstruction [MEDICAL CONDITION]. An Immediate Jeopardy was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at isolated actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 6 residents who were receiving pain medication and had recent surgeries at risk for impaction, bowel obstruction, and/or death. Findings included: 1. Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A Care Plan dated [DATE] for Resident #1 did not address the risk of impaction or the need for monitoring bowel movements, or the potential side effects of pain medication. Physician orders [REDACTED].#1. [MEDICATION NAME] ,[DATE]mg was ordered every 6 hours as needed for pain. Resident #1's MAR indicated [REDACTED]. Resident #1's MAR indicated [REDACTED]. The MDS dated [DATE] indicated Resident #1 was usually understood and usually understood others. He had behaviors including inattention and disorganized thinking. During an interview on [DATE] at 8:42 a.m., Resident #1's wife said he had been on [MEDICATION NAME] (laxative) every day at home for years before his hospitalization due to his constipation issues. She said she asked the DON several times for [MEDICATION NAME] and thought he was receiving the [MEDICATION NAME]. She said the staff refused to get him up to the toilet because he was heavy and she was told he had already hurt two staff trying to get him to the toilet. Resident #1's wife said the staff insisted on placing a bedpan underneath him and he just could not have a bowel movement on the bedpan. She said on [DATE] Resident #1 was in pain and his abdomen was swollen and hard. She said she wanted him sent to the hospital and he was taken by ambulance. She said he was diagnosed with [REDACTED]. She said he was placed on a ventilator and died on [DATE] when the ventilator was discontinued. The ADL flow sheets, dated [DATE] through [DATE] in Resident #1's closed record had no documentation of any bowel movements within the 30 days. The physician orders [REDACTED]. Nursing Progress Notes in Resident #1's closed record dated [DATE] through [DATE] indicated he fell at the facility on [DATE], and was sent to the hospital for evaluation, after hip surgery on [DATE], but was returned to the facility the same day. He fell a second time, on [DATE], and was sent to the hospital for evaluation again, and returned to the facility that same day. A third fall on [DATE] resulted in a skin tear, but Resident #1 was not sent out for evaluation following the fall on [DATE]. The Nursing Progress Note in this record dated [DATE] at 7:00 p.m. indicated the resident was complaining of pain and discomfort in his abdomen. His abdomen was distended, and the nurse was unable to hear bowel sounds. He was checked for impaction and hard dry stool was felt near the anal opening. The PA was notified and ordered an enema and repeat in 20 minutes if no results. There were no results from the enema and documentation indicated the family insisted Resident # 1 be sent to the hospital. He was sent to the hospital via ambulance. During an interview on [DATE] at 12:50 p.m., CNA D said staff were supposed to document daily on the ADL flow sheets and report to the charge nurse if a resident had not had a bowel movement in three days. CNA D said she took care of Resident #1 and she changed him when he was incontinent of urine. CNA D said he did not have a bowel movement and he was complaining his stomach was hurting as early as [DATE]. CNA D said she reported to the charge nurse (LVN E) and she said okay. CNA D said she did not follow up to ensure any treatment was provided for Resident #1. CNA D said she was not always able to document on the ADL flow sheets because she forgot or did not have time and sometimes she would catch up the next week. During an interview on [DATE] at 12:55 p.m., CNA F said staff were supposed to document daily on the ADL flow sheets and report to the charge nurse if a resident had not had a bowel movement in three days. CNA F said she took care of Resident #1 for a few days and he was always trying to get out of bed to either go to work or home; she said he was very confused. CNA F said he did not have a bowel movement and he was complaining his stomach was hurting. She said Resident #1 complained of his stomach hurting whenever she took care of him, she was unsure of the dates CNA F said when she was tending to residents she reported their bowel movements daily to the charge nurse (LVN E) and she said okay. CNA F said it took three staff to get Resident #1 up to the toilet, and it was more convenient for staff to place a bed pan underneath him; however, she could not recall him having a bowel movement. CNA F said she was not always able to document on the ADL flow sheets due to she forgot or did not have time and sometimes she would catch up her documentation at another time. During an interview on [DATE] at 1:05 p.m., CNA G said staff were supposed to document daily on the ADL flow sheets and report to the charge nurse if a resident had not had a bowel movement in three days. CNA G said she took care of Resident #1 and he required total care. CNA G said he was always trying to get out of bed to either go to work or home; she said he was very confused. CNA G said he did not have a bowel movement and he was complaining his stomach was hurting on [DATE]. CNA G said she reported to the charge nurse (LVN E) Resident #1's stomach was big and he was sick, and LVN E said okay. CNA G said it took three staff to get Resident #1 up to the toilet and it was more convenient to place a bed pan underneath him; however, she could not recall him having a bowel movement. CNA G said she was not always able to document on the ADL flow sheets because she ran out of time. CNA G said sometimes she would catch her documentation up on the weekend, and she acknowledged the ADL flow sheets were not accurate. During an interview on [DATE] at 1:30 p.m., CNA H said staff were supposed to document daily on the ADL flow sheets and report to the charge nurse if a resident had not had a bowel movement in three days. CNA H said he took care of Resident #1 and he required total care. CNA H said the resident was always trying to get out of bed to either go to work or home; he said he was very confused. CNA H described Resident #1 as big, heavy, and stubborn. CNA H said he was not going to hurt his shoulder trying to get the resident to the toilet, because he could not get hurt again. CNA H said Resident #1 hated the Hoyer lift and it was just easier to place him on a bedpan. CNA H said he Resident #1 did not have a bowel movement and he was complaining his stomach was hurting, but he could not remember dates. CNA H did not report Resident #1's stomach was big and he was sick to the charge nurse. CNA H said it took three staff to get Resident #1 up to the toilet. CNA H said he was not always able to document on the ADL flow sheets. He said sometimes he would catch up his documentation on the weekend, and he could not always remember to document everything. During an interview on [DATE] at 3:19 p.m., CNA I said staff were supposed to document daily on the ADL flow sheets and report to the charge nurse if a resident had not had a bowel movement in three days. CNA I said she took care of Resident #1 and at first he had bowel movements and then he stopped but she did not document the date of the bowel movements. She said she did not report bowel issues or document on the ADL flow sheets. During an interview on [DATE] at 11:36 a.m., LVN E said she took care of Resident #1 and none of the nurse aides reported any issues with his bowel movements. She said she did not look at the ADL flow sheets or the residents' care plans. She denied having any knowledge of Resident #1's stomach being distended or him being in pain. She said she would have reported to the physician or NP if a resident went three days without having a bowel movement. LVN E said she did not check the ADL flow sheets, but relied on the CNAs to make her aware of any issues related to elimination. During an interview on [DATE] at 10:55 a.m., the ADON said she did not know much about Resident # 1 and said the DON was out for the day. She said she did not check the ADL flow sheets and was not sure who was responsible for monitoring and checking the CNA's daily documentation. The ADON confirmed no bowel movements for Resident #1 were documented from [DATE] thru [DATE]. During an interview on [DATE] at 11:10 a.m., CNA C said staff were supposed to document daily on the ADL flow sheets and report to the charge nurse if a resident had not had a bowel movement in three days. CNA C confirmed Resident #1 had no documented bowel movements in 30 days, but she had no actual knowledge of any. During an interview on [DATE] at 12:04 p.m., LVN A said she was currently the treatment nurse, but would have reported to the physician or NP if a resident went three days without having a bowel movement. During an interview on [DATE] at 12:09 p.m., LVN B said she took care of Resident #1 two days and did not remember him having a bowel movement. She could not remember the dates she took care of Resident #1. She said she would have reported to the physician or NP if a resident went three days without having a bowel movement. LVN B said she did not check the ADL flow sheets, but relied on the CNAs to make her aware of any issues related to elimination. During an interview on [DATE] at 1:30 p.m., the NP said she saw Resident #1 three times, but did not examine him. She said she only completed an exam on the new residents. She said she was not aware he was not having bowel movements or she would have ordered medication immediately. She said she was not notified by the nursing staff that Resident #1 was having any issues with bowel elimination. During an interview on [DATE] at 11:36 a.m., the DON said the CNA supervisor was responsible for checking the ADL flow sheets. The DON said she was too busy and just did not have time. She denied having any knowledge of Resident #1's stomach being distended or him being in pain. She said she relied on the CNAs to make her aware of any issues related to elimination. The Abuse/Neglect prohibition policy undated, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. On [DATE] at 3:05 p.m., the administrator was informed that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 4:25 p.m., and included: 1. In-service staff on comprehensive assessments, monitoring for bowel movements, bowel sounds, and abdominal distention and reporting of concern to nursing staff. This will begin on [DATE] and continue until all shifts and nursing staff have been in-serviced, by [DATE] any staff not in-serviced will not be allowed to work without first receiving the in-service. This will be accomplished by the DON, ADON, Night Charge Nurse and the MDS RN. 2. The facility will add bowel movement tracking to the resident EMAR, to ensure daily documentation of bowel movements. The facility will begin adding the bowel movement tracking to the EMAR on [DATE] and have all EMARS changed by [DATE]. 3. The facility will update ADL flow sheets to more clearly document the frequency and consistency of patient bowel movements. This will be completed [DATE]. 4. All ADL sheets will be reviewed to ensure that no residents have missed a bowel movement for longer than 72 hours. This will begin on [DATE] and continue nightly. 5. The facility will update care plans for all post operation residents to include bowel elimination patterns. This will be completed by [DATE]. On [DATE], the surveyors confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: During an interview on [DATE] at 10:42 a.m., the DON said she called all the nurses for in-services on when to do assessments, and on assessing/monitoring for bowel elimination. She said almost everyone had been in-serviced and she would have all in-services completed by [DATE]. During interviews on [DATE] from 10:56 a.m. -12:35 p.m., 9 nurses (three from each shift) and 9 CNAs (three from each shift) and one MA were interviewed and said they received training on change in condition, assessments, calling the physician, and documentation of bowel movements in the computer. On [DATE] at 1:40 p.m., the administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list completed by the DON on [DATE], indicated there were 6 residents who were receiving pain medication and/or had a recent surgical procedure.