Every finding on record at Avir at El Paso

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 6 (Resident #1) residents reviewed for base line care plans.The facility failed to develop Resident #1's baseline care plan within 48 hours of re-admission on [DATE].This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff, increasing resident safety and safeguarding against adverse events that are most likely to occur right after admission.Finding included:Record review of Resident #1's face-sheet dated 06/09/26 revealed a [AGE] year-old female with admission date 06/02/26 and initial admission date 05/23/26.Record review of Resident #1's history and physical dated 04/06/26 revealed a medical history of the following: Traumatic Brain Injury severe with IPH status (intraparenchymal hemorrhage (IPH) is bleeding that occurs directly within the brain); Cranial Diabetes Insipidus (a condition characterized by persistent thirst and frequent urination); Respiratory failure (serious condition that occurs when the lungs cannot adequately exchange gases, leading to insufficient oxygen in the blood or excessive carbon dioxide); Peg tube status (a surgically placed feeding tube inserted through the abdominal wall directly into the stomach to provide nutrition when oral intake is insufficient or unsafe); and, severe physical deconditioning (refers to a decline in physical function, endurance, and muscle mass).Record review of Resident #1's Nursing home PPS MDS 05/23/26 revealed the there was no BIMS score. Under Section K- Swallowing/Nutritional Status, Resident #1 was noted with a feeding tube on admission and while a resident in the nursing facility. Under Section O-Special Treatments, Procedures, and Programs, Resident #1 was noted with Continuous Oxygen therapy on admission and while a resident in the nursing facility.Record review of Resident #1's Order Summary report dated 06/10/26, revealed the following physician orders:-NPO diet, nothing by mouth, start date: 06/02/26-Enteral Feed Order every shift Glucerna 1.5 at 20 cc/hr via g-tube stationary pump. Start date: 06/02/26-Head of Bed to remain 30-45 degrees related to risk for aspiration. Start date: 06/02/26-Oxygen at 2 Liters per Minute via Nasal Cannula (a thin, flexible tube with two small prongs that fit into a person's nostrils, directly administering oxygen to a person from an oxygen source such as an oxygen concentrator). Start date: 06/02/26Record review of Resident #1's care plan with initiated date 06/09/26, and date of admission [DATE], revealed the only focus area included was Resident #1 required encouragement for attend activities by having nursing facility to ensure that the activities the residents were attending were compatible with physical and mental capabilities. The care plan did not include or address Resident #1's medical diagnoses or conditions.In an interview on 06/10/2026 at 10:15 AM, RN A stated that the MDS nurse was responsible for the baseline Care Plan after residents were admitted . RN A stated the MDS nurse reviewed residents care plans on a quarterly basis. RN A stated the purpose of care plans was to have a plan of care that met that specific resident's needs and to make sure the nursing staff were aware. RN A stated if certain medical conditions or resident needs were not included in the care plan, staff would not be aware of the resident's needs, which could place the resident at risk.In an interview on 06/10/2026 at 10:34 AM, LVN B stated that the floor nurses were responsible for the baseline care plan when the residents were admitted into the nursing facility. LVN B stated the purpose of care plans was for direct care staff to be aware of the residents' needs. LVN B stated if a resident was on a feeding tube, it was to be included in the care plan as it would include the type of formula per the physician's order. LVN B stated that the ADON and the MDS nurse were responsible for monitoring resident care plans after admission but was unsure of the timeframe or how often they monitored care plans.In an interview on 06/10/26 at 11:11 AM, the MDS Nurse stated floor nurses were responsible for initiating the baseline care plan for residents upon admission. The MDS Nurse stated Resident #1 was initially admitted to the Nursing Facility on 05/23/26 but was sent to the hospital that same day, per the family's request. The MDS Nurse stated Resident #1 was re-admitted from that hospitalization to the Nursing Facility on 06/02/26 and had been in the facility since. The MDS Nurse stated she was unsure of the Nursing Facility's policy was, or the time frame when completing the Baseline Care Plan. The MDS Nurse stated a baseline care plan would have addressed Resident #1's G-tube status and also mean the resident was a risk for aspiration. She stated potential risk of not including medical conditions in a baseline care plan included risk for falls or injury due to Resident #1's medical history. The MDS Nurse stated Resident #1's care plan only addressed Activities.In an interview on 06/10/26 at 12:35 PM, the DON stated the floor nurse admitting the resident was responsible for initiating the resident's Baseline Care Plan. The DON stated Resident #1 was first admitted to the Nursing Facility on 05/23/26, but left within hours per Resident #1's family's request. The DON stated Resident #1 was re-admitted later, 06/02/26, and had been in the Nursing Facility since then. The DON stated the baseline care plans were developed using the resident hospitalization information provided from the hospitals, such as medical diagnoses, diet or feeding orders. The DON stated it was unacceptable for Resident #1 to not have her medical information not included in the care plan. The DON stated the potential risk to residents of not having their baseline care plan completed, including nursing staff not being aware of the residents' needs.In an interview on 06/10/26 at 1 PM, the Administrator stated that the floor nurse who was admitting the resident was responsible for creating the baseline care plan. The Administrator stated the Care Plan was a plan of care that nursing facility staff utilized to be aware of the residents' needs. The Administrator stated the potential risk of not including a resident's medical diagnoses in the care plan was a potential delay of care. The Administrator stated he was not aware of the Nursing Facility's policy regarding the time frame a resident's care plan was to be completed.Record review of the Nursing Facility's Care Planning- Interdisciplinary Team Policy, dated 03/2022, read in part: The Interdisciplinary team is responsible for the development of resident care plans. Under Policy Interpretation and Implementation, it read in part: 1. Resident care plans are developed according to the timeframes and criteria established by 483.21.Code Federal Regulation S 483.21 - Comprehensive person-centered care planning, read in part:(a) Baseline care plans. (1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-(i) Be developed within 48 hours of a resident's admission.(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to:(A) Initial goals based on admission orders.(B) Physician orders.(C) Dietary orders.(D) Therapy services.(E) Social services.(F) PASARR recommendation, if applicable.

Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 6 residents (Residents #2) reviewed for records.-The facility failed to ensure RN C documented attempts to contact the family of Resident #2 after their fall on 05/26/26.-RN C inaccurately documented she notified the family of Resident #2 after their fall on 05/26/26 at 7AM.This deficient practice could place residents at risk of not having accurate documentation.Findings include:Record review of Resident #2's face-sheet dated 06/09/26 revealed an [AGE] year-old female resident with admission date 08/26/24, and initial admission date 05/09/24.Record review of Resident #2's history and physical dated 06/03/26 revealed the following medical history: Dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities); Muscle wasting; and history of falls.Record review of Resident #2's Comprehensive MDS dated [DATE] revealed a BIMS of 5, indicating severe cognitive impairment. Under Section I- Active Diagnoses, it noted Resident #2 had the following medical diagnoses: muscle weakness, muscle wasting, dementia, difficulty walking, and unsteadiness on feet.Record review of Resident #2's Care Plan with revision date 12/30/25, revealed a focus area including Resident #2 was a fall risk relating to fall history and nursing facility was to follow the facility fall protocol.Record review of Resident #2's Nursing Progress Note dated 05/26/26 at 03:21 AM, documented by RN C, read: At approximate 02:20 [AM] [Resident] was sitting on the floor beside her wheelchair near bathroom door following unwitnessed fall, when asked what happened she stated, 'slipped off the wheelchair trying to get to the bathroom [Patient] denied hitting her head and denies pain or discomfort no visible injuries noted this time [Vital Signs] [Blood Pressure] 137/77 [Pulse] 82 [Temperature] 97.7 F [Oxygen] 94% [Room Air] Neurological checks initiated. ADON and NP notified. In the Nursing Progress Notes, it was not noted if Resident #2's family or Responsible Party was notified or attempted to be contacted after Resident #2's fall.Record review of Resident #2's Incident Report dated 05/26/26 at 2:30 AM, prepared by RN C, read under Incident Description: At approximate 02:20 [AM] [Resident] was sitting on the floor beside her wheelchair near bathroom door, alert and responsive no visible injuries noted resident denies hitting head or pain vital signs stable no acute distress noted. It was noted as an unwitnessed fall. Under Immediate Action Taken, the Description read: Resident assessed for injuries vital signs and [neurological] check initiated Resident assisted back to bed safely NP . and ADON notified. [Family Member] informed. Under Agencies/ People Notified, Resident #2's family member was noted as notified on 05/26/26 at 7 AMPhone interview attempts were made to Resident #2's family on 06/09/2026 at 09:59 AM, 12:19 PM, and 12:20 PM. This investigator was unable to leave a Voice Mail as the system was not set up per phone recording.In an observation on 06/09/26 at 10:45 AM of Resident #2 in a religious service in the Nursing Facility Activity room, participating and interacting with the staff and residents without issue or concern identified.In a phone interview on 06/09/26 at 3:32 PM, RN C stated she recalled Resident #2's fall during her night shift. RN C stated Resident #2 was found on the floor in her room by the bathroom door, Resident #2 was observed next to her wheelchair. RN C stated she assessed Resident #2 and asked her what caused the fall. RN C stated Resident #2 reported wanting to go to the bathroom and slipping out of the wheelchair which caused her to fall. RN C she did not recall any injuries observed, and Resident #2 denied pain or hitting their head. RN C stated she notified the Physician after her assessment and notified the ADON. RN C stated she attempted to call Resident #2's family member to notify them of the fall, but was unable to recall how many attempts or the times of the attempts. RN C stated she documented what she had done during the shift. RN C stated she did not speak with Resident #2's family member until the next scheduled night shift.In an interview on 06/10/26 at 10:18 AM, RN A stated the fall protocol included the nursing staff to notify the listed familly contacts in the electronic charting system of the residents having any change of condition, including a fall. RN A stated nursing staff was to attempt to call the family until there was an answer, and if there was no answer, it was to be documented. RN A stated the purpose of calling the family members of residents that had a fall, so it was for them to be aware of what was going on with the resident. He stated the purpose of documenting attempts was to show the Nursing Facility care staff that the nurse did attempt to notify the family and at what time. RN A stated a failure to document contact attempts to family would reflect the nurse did not make those attempts. RN A stated documenting you notified family when you did not, was false documentation.In an interview on 06/10/26 at 12:33 PM, the DON stated the ADONs and herself, as the DON, reviewed nursing documentation daily, every morning. The DON stated they were to review the nursing progress notes along with the 24-hour report also used by the nursing staff and reviewed accuracy. The DON stated that every nurse was responsible for their own documentation and accuracy. The DON stated documenting actions that were not actually done were considered false documentation.In an interview on 06/10/26 at 1:10 PM, the Administrator stated nurses were expected to document their unsuccessful attempts to contact resident families after a resident had a fall. The Administrator stated a nurse documenting she had notified the family when she did not was false documentation. The Administrator stated the dayshift nurse notified the family member of Resident #2's fall that morning at 7 AM, which is why it was documented in the incident report.Record review of the Nursing Facility's policy, Charting and Documentation, dated 07/2017, read in part: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Under Policy Interpretation and Implementation, it read in part: 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observations, interviews, and record review, the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 6 of 24 residents (Resident #13, Resident #15, Resident #54, Resident #65, Resident #128, Resident #129) reviewed for ADL care. The facility failed to ensure Resident #13's, Resident #15's, Resident #65's, nails were trimmed, cleaned, and filed on 05/04/2026.The facility failed to ensure Resident #54's, Resident #128's, and Resident #129's nails were trimmed and filed on 05/04/2026.The facility failed to ensure Resident #111's toenails were trimmed and filed on 05/04/2026. This failure could place residents at risk of loss of dignity, risk for infections, and a decreased quality of life.1.Record review of Resident #13's face-sheet, dated 05/06/2026, revealed an [AGE] year-old female, admitted [DATE] and readmitted [DATE]. Record review of Resident #13's Quarterly MDS assessment, dated 04/30/2026, revealed a BIMS score of 03, meaning severe cognitive impairment. Under Section GG- Functional Abilities, the resident required partial/moderate assistance for personal hygiene. Record review of Resident #13's care plan, dated 03/18/2026, revealed the resident required assistance with ADLs and was at risk for deterioration and intervention to set-up/assist with nail care per schedule or as needed. Record review of Resident #13's dated 04/29/2026 revealed diagnosis of unspecified dementia (exhibits clear signs of cognitive decline—such as memory loss, confusion, and reduced reasoning), muscle wasting and atrophy (the loss or thinning of muscle tissue, leading to decreased muscle mass and strength), other lack of coordination, and cognitive communication deficit (difficulty with verbal or nonverbal communication caused by underlying cognitive impairments). During observation and interview on 05/04/2026 at 1:57 p.m., Resident #13 stated her nails were currently long but this was not her preference because she like them shorter; her fingernails appeared to be less than half an inch in length, jagged, and black residue underneath them. She stated she had received a shower today but was not offered nail trimming services by staff during or after her shower. She denied experiencing pain or anguish from having long fingernails. She did not know if she had any injuries or infections related to long fingernails; no scratches or swelling were noted on her forearms, ankles, or face. 2. Record review of Resident #15's face-sheet, dated 05/06/2026, revealed an [AGE] year-old male, admitted [DATE]. Record review of Resident #15's Comprehensive MDS assessment, dated 03/24/2026, revealed a BIMS score of 03, meaning severe cognitive impairment. Under Section GG- Functional Abilities, the resident required setup or clean-up assistance for personal hygiene. Record review of Resident #15's care plan, dated 03/25/2026, revealed an ADL self-care performance deficit related to Alzheimer's with an intervention of assistance from staff with personal hygiene needs. Record review of Resident #15's physical and history, dated 04/15/2026, revealed diagnosis of Alzheimer's (progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform daily tasks) and type 2 diabetes (chronic condition where the body resists insulin or fails to produce enough). During an observation and interview on 05/04/2026 at 1:21 PM, Resident #15 stated he had been at the facility for about two months and never received fingernail trimming. Resident #15's nails were observed to be extending beyond the finger and unkept with dark residue underneath. He stated he received assistance with bathing and was on a routine of three showers a week. He stated he received a shower on 05/01/2026 but was not offered the service by staff to cut his fingernails. He denied experiencing pain or anguish from having long fingernails. He stated he did not have skin injuries or infections in relation to his fingernails being long and dirty. 4. Record review of Resident #65's face-sheet, dated 05/06/2026, revealed an [AGE] year-old male, admitted [DATE] and readmitted [DATE]. Record review of Resident #65's Quarterly MDS assessment, dated 04/27/2026, revealed a BIMS score of 13, meaning cognitively intact. Under Section GG- Functional Abilities, the resident required substantial/maximal assistance for personal hygiene. Record review of Resident #65's care plan, dated 02/23/2026, revealed an ADL self-care performance deficit and intervention of required staff assistance for personal hygiene needs. Record review of Resident #65's physical and history, dated 05/04/2026 revealed diagnoses of unspecified dementia (exhibits clear signs of cognitive decline—such as memory loss, confusion, and reduced reasoning) and muscle wasting and atrophy (the loss or thinning of muscle tissue, leading to decreased muscle mass and strength). During an observation and interview on 05/04/2026 at 10:52 a.m., Resident #65 had long dirty fingernails that he was dissatisfied with. He stated he would like the staff to cut them once they get long, but he usually had to request these services from the nurse because he was diabetic. He denied experiencing pain or anguish from having long fingernails. He denied having skin injuries or infections in relation to his fingernails being long and dirty. 3. Record review of Resident #54's face-sheet, dated 05/05/2026, revealed a [AGE] year-old male, admitted [DATE] and readmitted [DATE]. Record review of Resident #54's Health and Physical, dated 10/03/2025, revealed the following medical history: Guillian Barre Syndrome (a rare autoimmune disorder where the immune system attacks the peripheral nerves, leading to muscle weakness and paralysis), Paraplegia (the inability to voluntarily move or control the lower half of the body), Contracture of left hand (scarring of soft tissue causing the muscles to tighten or stiffen affecting the range of motion), and Dementia (a syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities). Record review of Resident #54's Comprehensive MDS assessment, dated 02/21/2026, revealed a BIMS score of 15, meaning cognitively intact. Under Section GG- Functional Abilities, Resident #54 required maximal/substantial assistance with personal hygiene, meaning the helper does more than half of the effort to complete the task. Record review of Resident #54's Care Plan, dated 08/08/2024, revealed an ADL self-care performance deficit and interventions included for staff to check nail length and trim and clean on bath day, and as necessary. 4. Record review of Resident #111's face sheet, dated 05/06/2027, revealed a [AGE] year-old male, admitted [DATE]. Record review of Resident #111's History and Physical, dated 08/25/2024, revealed diagnoses including hypertension (high blood pressure), hearing loss, repeated falls, acute pain (pain that starts suddenly and is usually linked to a specific injury), impaired gait and mobility (difficulty walking and moving safely), generalized weakness, sarcopenia (loss of muscle mass related to aging), and disuse myopathy (muscle weakness from lack of activity). The history and physical revealed the resident was transferred from the hospital following a ground level fall at home and required rehabilitation services including physical therapy and occupational therapy. Record review of Resident #111's quarterly MDS assessment, dated 02/20/2026, revealed a BIMS score of 8 which indicated moderately impaired cognition. The MDS revealed the resident had impaired thought processes and required cueing, supervision, and staff assistance with daily care needs. Record review of Section GG, Functional Abilities and Goals, revealed the resident required extensive staff assistance with ADLs. The assessment revealed Resident #111 had impaired mobility, generalized muscle weakness, repeated falls, difficulty walking, reduced mobility, and muscle wasting. The resident required staff assistance with transfers, toileting, dressing, hygiene, mobility, and other personal care tasks. Record review of Resident #111's care plan, dated 12/19/2025, revealed the resident had episodes of bowel and bladder incontinence with interventions that included staff checking the resident every two hours and as needed for incontinence care, washing and drying the resident after episodes, changing clothing as needed, maintaining unobstructed access to the bathroom, and assisting the resident with personal hygiene and ADLs. The care plan revealed Resident #111 preferred to wear open toe shoes without grip socks and revealed the resident would remain free of falls and injury from wearing open toe shoes. The care plan called for staff intervention in allowing the resident to make choices by wearing the footwear of his choosing and to provide weekly skin assessments to address any concerns caused by wearing open toe shoes. During an observation and interview on 05/04/2026 at 10:05 a.m., Resident #111 was sitting on his bed wearing sandals with his toenails exposed. The toenails were long with yellowish discoloration. Resident #111 stated he did not like his toenails long and did not have nail clippers. He stated staff helped in the past but did not recall the last time his toenails were trimmed. Resident #111 stated he had requested assistance to trim his toenails from CNAs but he had not been helped. During an observation on 05/04/2026 at 09:35 AM, Resident #54 was observed with nails a quarter inch from the nail bed and clean. Resident #54 stated it had been a while, since his nails were last groomed and he would like them to be trimmed. 5. Record review of Resident #128's admission record, dated 05/05/2026, revealed a [AGE] year old male, admitted [DATE]. Record review of Resident #128's History and Physical, dated 05/01/2026, revealed diagnoses of acute respiratory failure ( a sudden inability of the lungs to oxygenate blood or remove carbon dioxide causing severe shortness of breath) and tracheostomy status(surgically created opening in their neck leading to the trachea to facilitate breathing). Record review of Resident #128's comprehensive MDS assessment, dated 04/21/2026, revealed a BIMS of 02 indicating severe cognitive impairment. Section GG- Functional Abilities coded Resident #128 as dependent meaning helper does all of the effort and the resident does none of the effort to complete the activity for personal hygiene. Record review of Resident #128's care plan, revised on 05/04/2026, revealed Resident #128 had an ADL self-care performance deficit. Interventions included assistance from staff with personal hygiene and oral care and to check nail length and trim and clean on bath day, and as necessary. Report any changes to the nurse. During an observation on 05/04/2026 at 9:30 a.m., Resident #128's fingernails were about a quarter inch from the nail bed and were clean. Resident #128 was not able to answer the surveyor's questions. 6. Record review of Resident #129's admission record, dated 05/06/2026, revealed a [AGE] year-old male admitted [DATE]. Record review of Resident #129's History and Physical, dated 04/30/2026, revealed a diagnosis of nontraumatic intracerebral hemorrhage in hemisphere (a sudden spontaneous bleeding into the brain tissue). Record review of Resident #129's Quarterly MDS assessment, dated 04/22/2026, revealed a BIMS of 03 indicating severe cognitive impairment. Section GG- Functional Abilities coded Resident #128 as dependent meaning the helper does all of the effort and the resident does none of the effort to complete the activity for personal hygiene. Record review of Resident #129's care plan, dated 05/04/2026, revealed Resident #128 had an ADL self-care performance deficit. Interventions included assistance from staff with personal hygiene and oral care and to check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. During an observation on 05/04/2026 at 9:15 a.m., Resident #129's fingernails were about a quarter inch from nail bed and clean. Resident #129 was not able to answer the surveyor's questions. During an interview on 05/05/2026 at 11:23 a.m., CNA A stated CNAs could trim or file toenails if the resident was not diabetic. CNA A stated if she observed long toenails, she would offer assistance to the resident. CNA A stated untrimmed toenails could result in injury, bleeding, discomfort, and infection. CNA A stated Resident #111's toenails were long and unclean and it was not acceptable to leave the resident without trimming his toenails. During an interview on 05/05/2026 at 11:43 AM, the DON stated CNAs could trim toenails for non-diabetic residents. She stated if staff were unable to provide care, they were expected to notify the charge nurse or DON so arrangements could be made. The DON stated it was not acceptable for the resident's toenails to remain in that condition and identified risks such as ingrown toenails, pain, and discomfort which could lead to bleeding and infection. During an interview on 05/05/2026 at 12:01 PM, CNA B stated it was the responsibility of CNAs to monitor residents and ensure hygiene needs were met. CNA B stated untrimmed toenails could lead to injury when putting on socks or shoes, including tearing, bleeding, and infection. During an interview on 05/06/2026 at 2:30 p.m., the DON stated the facility did not have a specific policy addressing toenail care. During an interview on 05/06/2026 at 2:30 p.m., the Administrator stated it was the responsibility of all CNAs, LVNs and RNs who worked with the resident to monitor hygiene to include toenail care. The Administrator stated it was not acceptable for Resident #111 to have long toenails because he preferred to wear sandals or open toe shoes and he could potentially hit his foot on a surface and break a toenail, injuring himself, causing bleeding and infection. During an interview on 05/05/2026 at 3:30 p.m., RN C stated there was a possibility for Resident #111 breaking his toenails if he bumped his toes against a bed or a door due to him preferring to wear open toe shoes. RN C stated there was a potential for injury and ingrown toenails, which could lead to bleeding and infection, and stated it was not acceptable for the resident to have long and yellowish toenails and stated Resident #111 needed attention to include trimming his toenails. During an interview on 05/05/2026 at 3:33 PM, CNA O stated all nursing staff were responsible for monitoring residents' nails. She stated residents' fingernails were looked at daily during initial rounds. She stated CNAs trim and clean residents' nails, and nurses monitor them daily. She stated the potential risk of residents having long nails included resident scratching self and possibly cutting self. She stated the cutting of the skin could be a risk for infection if the residents have dirty nails. During an interview on 05/05/2026 at 3:48 PM, CNA G stated that a resident who was dependent on staff received personal care, changing, transfer, and repositioning on a regular basis or as needed. She stated t the Activities department, CNAs, and nurses provided fingernail trimming for nondiabetic residents. She stated usually she provided nail care when she noticed they were long. She stated she reviewed nails whenever she provided showers which was three times a week. She stated it affected residents because they would not receive the services they wanted or needed. She stated residents could scratch themselves, create skin integrity issues, and potentially get infected if their nails were dirty. She stated CNAs and nurses were responsible for ensuring the resident's nails were being trimmed and cleaned to their preference. She stated the ADON and DON were responsible for ensuring staff were providing ADLs to residents. She stated the last in service she received for ADLs was the last week of April 2026. During an interview on 05/06/2026 at 2:03 p.m., the DON stated fingernails should be checked with every shower and trimmed those days or when needed. She stated that the CNAs and the nurse were responsible for ensuring the residents' nails were trimmed. She stated CNAs could cut the fingernails of nondiabetic residents. She stated the residents with long fingernails were at risk of breaking the skin and introducing bacteria into the skin, leading to infection. During an interview on 05/06/2026 at 2:39 PM, the Administrator stated nursing staff were responsible for residents' nails. He stated CNAs were responsible for routine nail care, including cleanliness and trimming. He stated the DON was responsible for monitoring and ensuring residents' nails were groomed appropriately. He stated the potential risks for residents having long nails included residents scratching self and causing injury. The Administrator stated there was also a potential risk for infection if the residents' fingernails were dirty. Record review of the facility's Resident Rights policy, dated 02/2021, read in part: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: 1. a dignified existence.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident # 1 and Resident #39) of 8 resident's reviewed for infection control. The facility failed to ensure Resident #39's nasal canula was properly stored while oxygen was not in use.The facility failed on 05/04/2026 to properly monitor and store Resident #1's dentures and did not placed them in a denture cup, and they were left exposed in a see through plastic clear cup without a lid on it. These failure could place residents at risk of cross contamination resulting in acquired infection or illness. Findings included: Record review of Resident #1's face sheet revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. The face sheet revealed the resident's original admission date was 06/24/2021 with a readmission date of 11/21/2023.Record review of Resident #1's History and Physical dated 06/25/2021 revealed the resident was admitted following hospitalization related to generalized weakness, hyponatremia (low sodium levels), hypoglycemia (low blood sugar), and intra-abdominal sepsis (serious infection in the abdomen). Diagnoses included hypertension (high blood pressure), diabetes mellitus type II (high blood sugar), benign prostatic hyperplasia/BPH (enlarged prostate), generalized weakness, dehydration, hypothyroidism (underactive thyroid), gout (arthritis caused by uric acid buildup), coronary artery disease/CAD (heart disease), osteopenia (decreased bone density), and chronic kidney disease stage III (decreased kidney function). The physical assessment revealed the resident required PT, OT, and speech therapy services.Record review of Resident #1's MDS quarterly assessment dated [DATE] revealed a BIMS score of 13 out of 15, which indicated the resident was cognitively intact. Record review of Section GG, Functional Abilities and Goals revealed Resident #1 required moderate staff assistance with activities of daily living, oral hygiene to include the use of suitable items to clean teeth or dentures, ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with us of equipment, mobility, transfers, personal care, and eating-related tasks.Record review of Resident #1's care plan revealed the resident received a therapeutic mechanical ground texture diet with thin liquids due to nutritional risk and swallowing-related concerns. Interventions included allowing ample time for the resident to participate in activities of daily living, attempting to alleviate barriers to self-performance of ADLs, determining the resident's level of self-feeding impairment, and providing assistance with ADLs to the extent necessary to complete tasks. The care plan also included dental evaluation and intervention as needed and interventions related to eating assistance and monitoring for choking or coughing episodes. The care plan revealed the resident required staff assistance with ADLs and personal care tasks associated with oral hygiene and denture management.During an observation on 05/04/2026 at 10:05 a.m. in Resident #1's room, dentures were observed inside a clear plastic cup on the side table without a lid. Another denture cup containing liquid was observed on the dresser, uncovered and exposed.During an observation and interview on 05/04/2026 at 10:20 a.m., the Speech Therapist was present in the room. The dentures remained exposed while inside the plastic cup. The Speech Therapist stated dentures should not be left uncovered due to the risk of contamination and potential infection if used without proper cleaning. She also stated there was a risk the dentures could fall and break. Resident #1 nodded when asked if he was doing well.During an interview on 5/5/26 at 11:36 AM with CNA A, she stated Resident #1's dentures should be cleaned, disinfected, and stored in a designated container. She stated leaving them exposed created a risk for cross-contamination and infection and potentially damage if the cup with his dentures was to fall to the floor.During an interview on 5/5/26 at 11:52 AM with the DON, she stated dentures should be stored in a denture cup with a disinfecting solution. She stated leaving Resident #1's dentures exposed created a risk for contamination, accidental use by other residents, and illness. She stated dentures could also be lost, which could affect Resident #1's eating intake and weight.During an interview on 5/5/26 at 12:08 PM with CNA B, she stated dentures should be properly washed and stored. She stated leaving Resident #1's dentures exposed created a risk for infection, damage, or loss, which could impact eating and self-esteem.During an interview on 5/5/26 at 3:99 p.m. with RN C, stated there was a potential for cross contamination and infection for leaving the dentures exposed. RN C stated the dentures could break and be lost, which could impact Resident #1's ability to eat right which could potentially result in loss of weight.During an interview on 05/06/2026 at 2:30 p.m. with the Administrator, he stated that dentures that are not being worn by a resident needed to be stored in the denture cup after washing them, to keep them free of dust or debris which could damage the dentures and could potentially make the resident ill if there was something in the dentures that contaminated them. The Administrator stated that all staff who worked with Resident #1 were responsible for reminding the resident of the risks of leaving is dentures without properly storing them which could potentially lead for them to be lost or broken.Record review of Resident #39's face sheet, dated 01/24/2026, revealed a [AGE] year-old female, admitted [DATE]and readmitteed 12/01/2023.Record review of Resident #39's annual history and physical, dated 07/08/2025, revealed the resident was a [AGE] year-old female with diagnoses of hypothyroidism (underactive thyroid), hypertension (high blood pressure), allergic rhinitis (nasal allergies) and insomnia (difficulty sleeping). The history and physical revealed Resident #39 required supplemental oxygen to be given as needed via nasal cannula to maintain oxygen at 90%. Record review of Resident #39's MDS quarterly assessment, dated 03/30/2026, revealed a BIMS score of 9 indicating moderately impaired cognitive skills. Record review of Section GG, Functional Abilities and Goals, revealed the resident required extensive staff assistance with activities of daily living, mobility, transfers, hygiene, and personal care tasks. Record review of Resident #39's care plan, dated 12/19/2025, revealed the resident had potential for altered respiratory status and difficulty breathing with history of pneumonia and revealed interventions by staff were to notify the nurse for an assessment if there was a respiratory change in Resident #39, to maintain a clear airway and encouraging the resident to clear own secretions with effective coughing, to monitor signs of respiratory distress and report it to the doctor and check for decreased pulse with oximetry (a test used to measure how much oxygen is in a person's blood). The care plan revealed the resident was allergic to dust.During an interview and observation on 05/04/2026 at 10:40 a.m., Resident #39 was lying in bed. Her nasal cannula was hanging behind her from the bed's headboard, touching the floor, and the concentrator was on. Resident #39 stated she did not remember when she had last worn her cannula and stated she wanted to put it on, and she needed assistance with her clothes. Resident #39 was confused and could not provide more details and was talking incoherently.During an interview on 5/5/26 at 11:34 AM, CNA A stated when a nasal cannula was not in use, it should be stored in a plastic bag to prevent contamination. She stated leaving it exposed was not acceptable and could result in the residents becoming ill or developing an infection in their nose or lungs.During an interview on 5/5/26 at 11:49 AM, the DON stated the cannula should be stored in a clean plastic bag and not placed on the floor. She stated this created an infection control concern due to exposure to dust and germs and could lead to respiratory infection.During an interview on 5/5/26 at 12:04 PM, CNA B stated the cannula should be disinfected and stored properly when not in use. She stated improper storage created a risk of infection if reused.During an interview on 5/5/26 at 3:99 p.m., RN C stated residents who were in oxygen therapy needed to have their equipment, such as the nasal cannulas, cleaned, bagged, labeled and stored, if they were not in use by the resident. RN C stated it was not acceptable that the cannula was touching the floor because if the resident was confused and put the cannula on without cleaning it, there was a potential risk of the resident aspirating (when food or liquids accidentally goes into the airway or lungs instead of going down the esophagus into the stomach) lint or debris which could potentially make Resident #39 sick.During an interview on 05/06/2026 at 2:30 p.m., the Administrator stated it was not acceptable to leave a nasal cannula handing by a resident's bed and directly touching the floor. The Administrator stated there was a potential risk of contamination that would make the resident sick from her lungs if she was to aspirate lint or dust if it got into the cannula and the resident put it on without properly disinfecting it prior to using it.Record review of the facility's policies and procedures with a revision dated of 2016, titled Dental Services, read in part: Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Direct care staff will assist residents with denture care, including removing, cleaning and storing dentures.Dentures will be protected from loss or damage, to the extent practicable, while being stored.Lost or damaged dentures will be replaced at the resident's expense unless an employee or contractor of the facility is responsible for accidentally or intentionally damaging the dentures.If dentures are damaged or lost, residents will be referred for dental services within 3 days. If the referral is not made within 3 days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services; and the reason for the delay.Record review of the facility's policy and procedures, revised October 2010, titled, Oxygen Administration, read in part: PurposeThe purpose of this procedure is to provide guidelines for safe oxygen administrationPreparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders, facility protocol for oxygen administration.2. Review the resident's care plan to assess any special needs of the resident.3. Assemble the equipment and supplies as needed. General Guidelines 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. b. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head. Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure:2. Nasal cannula, nasal catheter, mask (as ordered);Steps in Procedure9. Place an appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter).10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.Weekly DocumentationOxygen/nebulizer tubing/masks to be changed by nursing department, weekly, and documented in the electronic health record.

Based on observation, interview, and record review, the facility failed to ensure biologicals were stored in locked compartments and accessed by authorized personnel for 3 (Resident #3, Resident #74, and Resident #89) of 24 residents reviewed for medication storage.The facility failed to dispose of a dixie cup on 05/04/2026 by leaving a dixie cup with Zinc Oxide pomade (skin ointment) at Resident #3's, Resident #74's, and Resident #89's bedside, exposed and within reach of other residents.The facility failed to ensure a medication cart was locked when unattended.This failure could place residents at risk of access to medications not approved for administration by their physician. Findings included: 3. Record review of Resident #89's face sheet dated 05/04/2026 revealed a [AGE] year-old female admitted [DATE] and readmitted [DATE] and 02/22/2026. Record review of Resident #89's Annual History and Physical, dated 07/08/2025, revealed the resident had diagnoses which included Non-Alzheimer's dementia (a decline in memory, thinking, and daily functioning that is caused by something other than Alzheimer's disease decline in memory, thinking, and daily functioning that is caused by something other than Alzheimer's disease), hypertension (high blood pressure), hyperlipidemia (high cholesterol), delirium (acute confusion), hypothyroidism (underactive thyroid), decreased mobility, and dependence on a wheelchair for mobility. The history and physical revealed the resident had a history of altered mental status, catatonic symptoms, confusion, and cognitive impairment. Record review of Resident #89's quarterly MDS assessment, dated 04/09/2026, revealed a BIMS score of 00 out of 15, which indicated severe cognitive impairment. The MDS revealed the resident had severely impaired decision-making abilities, memory deficits, impaired communication, and required extensive staff supervision and assistance. Record review of Section B, Hearing, Speech, and Vision, revealed the resident was usually unable to make needs known, had impaired hearing, and had severely impaired vision. Record review of Section GG, Functional Abilities and Goals, revealed the resident required substantial or maximal staff assistance with ADLs including mobility, transfers, hygiene, and personal care tasks. Resident #89 was dependent on lower body dressing and toileting. Record review of Resident #89's care plan dated 04/09/2026 revealed the resident had cognitive impairment with impaired decision-making, difficulty expressing needs, memory deficits, and impaired safety awareness. The care plan was initiated on 02/05/2021 and revised on 03/07/2025. Interventions included explaining procedures in simple terms, repeating information as needed, allowing additional time for responses, involving the resident in care to maintain independence, and ensuring the resident's needs and preferences were anticipated and met by staff. The care plan also revealed the resident was at risk for injury related to cognitive impairment, gait and balance impairment, history of falls, and impaired safety awareness. Interventions included keeping frequently used items within reach, maintaining the bed in the lowest position with brakes locked, ensuring staff awareness of the resident's safety needs, and providing supervision and assistance with transfers and mobility. The care plan revealed the resident required medications as ordered, ongoing monitoring by licensed nursing staff, and staff assistance with hydration, nutrition, and activities of daily living. During an observation on 05/04/2026 at 9:55 AM, a small (nurse only) medication cart was left unlocked and unattended as evidenced by the cylinder lock being fully extended out with its red tab visible and the cabinets were accessible by the surveyor when force was applied. There were eight residents in wheelchairs approximately 15 feet away from the medication cart and RN C was assisting with care in a resident's room. An unidentified resident was observed passing in front of the medication cart and using it as a sturdy surface to propel herself forward; the unidentified resident did not make any effort to investigate or open the medication drawers. RN C returned to his cart at 9:57 AM and reapplied the locking mechanism. During an interview on 05/04/2026 at 9:58 AM, RN C stated it was not okay to leave the medication cart unlocked and unattended because residents or unauthorized employees could access it. He stated only the nurse on duty should have access to the medication cart. He stated he was responsible for ensuring it was locked when he was not using it or when it was out of his immediate reach. He stated he did not know how long he stepped away from the medication cart and approximated it to be a minute. He stated it was not within his line of site and did not have knowledge if anyone accessed his medication cart during the time he could not see it. He stated the ADON and DON were responsible for ensuring that the nurses were adhering to medication storage policy. He stated the last in service he received for medication storage was within the past year. He stated the contents of his medication cart included syringes, injectable medication (example: haloperidol and insulin), over the counter medication (example: vitamins and Tylenol). He stated it affected residents if they obtained a syringe, vial medication and injected themselves or others or if a resident's insulin went missing because someone accessed the cart and took it. He stated the items in his cart had potential for residents to harm themselves or others. During an interview on 05/05/2026 at 2:55 PM, LVN F stated the small (nurse only) medication cart contained a glucose reading instrument, insulin vials, intravenous medications, medications that only a nurse could administer, syringes, haloperidol, Vitamin C, and Tylenol. She stated only the nurse on shift had access to the small medication cart. She stated when she was not in arms reach of the medication cart, it needed to be locked. She stated it was not acceptable for a nurse to leave the cart unlocked because of the potential for a resident, visitor, or staff member to access it. She stated it was a safety issue because a resident could harm themselves, stab themselves, or administer medication not intended for them. She stated the nurse on shift was responsible for ensuring it was locked at all times. She stated it required a key to unlock the cylinder and when the red tab on the cylinder was extended, it signified that it was open. She stated there were residents in the hallway with dementia, habits of wandering, and accessing items that did not belong to them. She stated the last in service for medication storage was last week of April 2026. She stated the ADON and DON were responsible for ensuring nurses were locking the small medication cart when not in use. She stated staff should discard dixie cups with ointment after use and not leave them at bedside because a resident could eat it or access it. She stated whoever used it whether the nurse or CNA was responsible for discarding it after care was provided. She stated it was an infection control issue if it was already used and left at the residents' bedside. During an interview on 05/06/2026 at 2:06 PM, the DON stated the facility's methods of protecting medication was to adhere to medication storage policy by utilizing medication carts, central supply areas, and applying locking mechanisms to prevent access to unauthorized individuals. She stated nurses and CMAs were the only staff members who had access to medication storage room and medication carts. She stated the small medication carts were reserved only for the nurses on shift to have access to it. She stated medication was stored securely to ensure there was no misuse of medication. She stated if the nurse was not in front of the small medication cart it needed to be locked. She stated anytime the small medication cart was out of the nurses reach it needed to be locked. She stated the contents of the small medication cart included: lancers, insulin vials, syringes, gastric tube medications, liquid base medications, ointments, and anything a CMA could not administer to a resident. She stated there were many outcomes for potential for harm to residents and staff if it was left unlocked and unattended but could not further elaborate how it was harmful. She stated the last in service for medication storage practices was two months ago. During an interview on 05/06/2026 at 2:42 PM, the Administrator stated that facility's methods for protecting medication was to adhere to medication storage policy by utilizing locking mechanisms for carts/storage rooms and limiting access to only the nurses and CMAs. He stated that the small medication cart needed to be locked all the times when it was not in the nurse's reach or being used. He stated that the nurses were responsible for locking the small medication carts. He stated if it was not locked medications/narcotics could go missing and injectables/syringes could pose harm to residents and staff. He stated it affected residents because medications could be stolen, misplaced, or ingested without staff's knowledge. He stated the DON was responsible for ensuring nurses were locking the medication carts when they were away from them. During an observation was on 05/04/2026 at 9:52 AM, a medication cup that contained a thick white ointment open to air was on Resident #74's nightstand located next to the head of the bed and within the resident's reach. Resident #74 was observed in bed with her eyes closed. This State Surveyor attempted to speak with Resident #74, but she continued to rest with her eyes closed. During an observation and interview on 05/04/2026 at 11:01 a.m. in Resident #89's room, a dixie cup was observed on the nightstand containing white cream. The medication was uncovered and exposed. The surveyor attempted to interview Resident #89; however, she was confused and did not respond to any questions asked by the surveyor. During an interview on 5/5/26 at 11:32 AM, CNA A stated it was not acceptable to leave medication in an open cup. She stated the cream could become contaminated and pose a risk for infection if applied. She stated another resident could ingest the medication and become ill. During an interview on 5/5/26 at 11:47 AM, the DON stated it was not acceptable to leave medication exposed. She stated residents who were not alert and oriented could mistake it for food and ingest it, which could cause nausea or illness. She stated it was the responsibility of the nurse or wound care nurse to dispose of leftover medication. During an interview on 5/5/26 at 12:04 PM, CNA B stated the cream should not have been left at bedside. She stated contamination could occur if debris entered the cup and could create an infection risk if applied to a wound. She stated staff were responsible for discarding leftover medication after use. During an interview on 5/5/26 at 3:99 p.m., RN C stated whenever a medication has been supervised, if there are leftover medications such as powder with apple sauce from those residents who get their medications crushed, or ointment in a cup, it had to be immediately disposed of in the trash bag located in the med carts to later be thrown away as biohazard waste. RN C stated there was a potential for infection control if a confused resident wondered into the room and mistakenly ingested the contents on the cup which could make them sick to their stomach, or depending on the ointment or medication, if it was contaminated for being left exposed and it was administered to the resident, they could get an infection. During an interview on 05/06/2026 at 2:30 p.m., the Administrator stated leftover medications needed to be immediately discarded in the trash bag. The Administrator stated leaving medications or ointments exposed at bedside created a potential infection control concern and presented a risk that a confused resident could accidentally ingest the contents, which could result in illness or adverse effects. He further stated medications or ointments left exposed could become contaminated and, if later administered or contacted by a resident, could potentially lead to infection or other health complications. Record review of an in-service sheet titled, TOPIC: Locking Med Carts, dated 01/22/2026, revealed RN C signed for acknowledgement of in-service. Record review of the facility policy titled Medication Label and Storage undated read in part, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access keys (Medication Storage) (2) The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner (3) Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others Record review of the facility policy titled, Medication Label and Storage, April 2019, read in part, Medications are administered in a safe and timely manner, and as prescribed. (policy interpretation and implementation) (1) Only persons licenses or permitted by this state to prepare, administer and document the administration of medications may do so (24) Topical medications used in treatment are recorded on the resident's treatment record (TAR). (25) Staff follows established facility infection control procedures (example given, handwashing, antiseptic technique, gloves, isolation precaution, etc.) for the administration of medications, as applicable 2. Record review of Resident #74's face sheet, dated 05/06/2026, revealed a [AGE] year-old female admitted [DATE] and readmitted [DATE]. Record review of Resident #74's Annual History and Physical, dated 05/05/2026, revealed the following medical history: Congestive Heart Failure (a chronic condition where the heart is unable to pump blood to meet the body's need for blood and oxygen). Record review of Resident #74's Quarterly MDS, dated [DATE], revealed a BIMS of 13, meaning resident was cognitively intact. Record review of Resident #74's care plan, with revision date 01/25/2026, had impaired cognitive function/impaired thought processes related to resident's Dementia (a syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities). 1. Record review of Resident #3's admission record, dated 05/04/2026, revealed a [AGE] year old female, admitted [DATE]. Record review of Resident # 3's history and physical, dated 05/06/2026, revealed a diagnosis of type 2 diabetes (a chronic metabolic condition where the body resists insulin or fails to produce enough of it leading to high blood glucose levels). Record review of Resident #3's Quarterly MDS assessment, dated 02/27/2026, revealed a BIMS of 15 indicating intact cognitive function. Record review of Resident #3's physician orders, dated 05/04/2026, revealed an active order with a start date of 12/24/2025 of zinc oxide mixed with collagen particles with every brief change, as needed. Record review of Resident #3's care plan, dated 05/04/2026, revealed an ADL Self Care Performance Deficit. Interventions included assistance from staff with all toileting and incontinent care needs. During an observation on 05/04/2026 at 10:00 a.m., a plastic medicine cup containing an unknown white substance on the bedside table. There were no residents present in the room at this time.

Based on observations, interviews, and record review, the facility failed to distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and food storage. -The facility failed on 05/04/2026 to ensure employee sodas were not stored in the walk-in refrigerator.-The facility failed on 05/04/2026 to ensure a turkey in the walk-in freezer was labeled with a receive and use by date.-The facility failed on 05/04/2026 to ensure Dietary Aide E and Dietary Aide M did not grabbed drinking cups from the opening with barehand 13 times.-The facility failed on 05/04/2026 to ensure [NAME] J did not grabbed 5 bowls with bare hands by the interior portion of the bowl.-The facility failed on 05/04/2026 to ensure Dietary Aide L stored approximately 75 peanut butter and jelly halved sandwiches in the dry storage area after completion for approximately 30 minutes. This failure could place residents at risk for foodborne illness.Findings included: During initial kitchen tour observation and interview on 05/04/2026 at 8:35 AM with the Dietary Director, it was observed that a case of sodas that was only intended for employees (verified with Dietary Director) was being stored in the walk-in refrigerator because there was no space in the employee designated refrigerator. At 8:48 AM, an unlabeled turkey was in the walk-in freezer; as per Dietary Director, they had received it in December 2025 but could not confirm an exact date. A follow-up observation during meal service from 12:07 PM to 12:17 PM, it was observed Dietary Aide E and M were transferring drinking cups with bare hands encountering the opening of uncovered cups 13 times. At 12:23 PM, [NAME] J was observed transferring 5 bowls from the dishwasher area to the serving line with bare hands grabbing the bowls by the interior portion of the bowl. At approximately 12:05 PM, Dietary Aide L had finished preparing approximately 75 peanut butter and jelly halved sandwiches and proceeded to prepare beverages; At 12:35 PM, 75 peanut butter jelly halved sandwiches were in the dry storage pantry. In an interview on 05/04/2026 at 12:36 PM, Dietary Aide L stated she had finished preparing the peanut butter jelly sandwiches about 30 minutes prior and placed them in the dry storage pantry. She stated the peanut butter jelly sandwiches needed to be stored in the refrigerator, but she was unable to put them in there because a cart was blocking the snack and beverage fridge. She stated she did not think about moving the cart or placing them in the walk-in refrigerator and added that she was busy completing other tasks. She stated that she was going to transfer them to the fridge after lunch was done being served; all meals had already been served, and there was no observation of Dietary Aide L retrieving and relocating the peanut butter jelly sandwiches to cold storage without surveyor prompting. She stated peanut butter jelly sandwiches needed to be stored below 41 F to ensure they did not spoil. She stated if spoiled food was served to residents, they could become sick from a food borne illness. She stated the peanut butter jelly sandwiches were going to be saved at the nurse's stations as a snack for residents. During an interview and observation on 05/06/2026 at 10:51 AM, Dietary Aide I stated her responsibilities were to prepare desserts and drinks, answer the kitchen door, review meal tickets, transport meals to the hallways, and assist the line as needed. Using an empty cup and bowl from the kitchen, she provided a demonstration of how to properly grab and transfer bowls and cups; no concerns noted during return demonstration. She stated drinking cups needed to be grabbed from the bottom, otherwise it could contaminate the cups for residents when they drink out of them. She stated it was cross-contamination if staff put their bare hands in the bowl. She stated that it did not affect residents because the staff washed their hands constantly. She stated the method of grabbing the bowels was cross contamination and staff needed to use a tray when transporting more than 2 bowls. She stated that the items in the freezer and fridge needed to be labeled when it was received, to monitor how long they had to use it. She stated that a label needed to be present on the turkey to identify when it was received. She was responsible for ensuring the labels for the food, and everyone was responsible for preventing cross contamination. She stated the peanut butter jelly sandwiches needed to be refrigerated immediately after preparation. She stated it was not appropriate for them to be stored in the dry storage pantry. She stated that nothing would happen to the sandwiches in 30-minutes but it was the dietary aide's responsibility to put them in the fridge immediately. She stated it was not appropriate for employee sodas to be stored in the walk-in fridge because it was only intended for the residents. She stated that there was a separate storage space for employee beverages. She stated the last in-service was in December 2025. During an interview and observation on 05/06/2026 at 12:17 PM, [NAME] K provided a demonstration of how to properly grab and transfer bowls and cups using empty drinkware and plateware from the kitchen; no concerns noted during return demonstration. He stated he would grab the bowl from the bottom and if he was transporting more than 2 bowls, he would use a tray. He stated this needed to be done because the interior portion was where residents' food would go. He stated if bare hands touched the interior of the bowl it would create cross contamination. He stated the cup needed to be grabbed from the bottom away from the opening because it was cross contamination if care hands encountered it. He stated if these practices were continued, it could affect the residents by making them sick and contaminating their food and drinks. He stated the Dietary Director was responsible for ensuring dietary staff were adhering to cross contamination prevention practices. He stated that items in the walk-in refrigerator that were not in their original box needed a label for when it was open or received. He stated that the turkey needed to be labeled so that staff was aware when it arrived and how long it would be good for. He stated that everyone who grabbed an ingredient or removed an item needed to ensure they put a label on it. He stated that the peanut butter jelly sandwiches needed to be placed in the refrigerator once they were prepared. He stated it was not appropriate for the peanut butter jelly sandwiches to be stored in the pantry and they could spoil if left there for too long. He stated that employee sodas could not be stored in the walk-in fridge because that space was reserved for the residents and added there was a separate storage area for employees' beverages. He stated the last in service for food safety and storage was in December 2025. During an interview and observation on 05/06/2026 at 12:32 PM, The Dietary Director provided a demonstration of how to properly grab and transfer bowls and cups using empty drinkware and plateware from the kitchen; no concerns noted during return demonstration. She stated that the bowls and cups needed to be grabbed from the bottom. She stated staff needed to adhere to this standard because they could contaminate the portion that the residents eats or drinks from. She stated a resident could eat cross-contaminated food and potentially sick with symptoms of vomiting, fever, upset stomach, and diarrhea. She stated she was responsible for ensuring drink and serving plates were not cross contaminated by dietary staff. She stated that peanut butter jelly sandwiches needed to be stored in the refrigerator immediately after preparation. She stated it was not appropriate for the peanut butter jelly sandwiches to be stored in dry storage pantry and added they would need to be thrown away. She stated that the peanut butter jelly sandwiches were not thrown away on 05/04/2026 because she was not aware they were stored in the dry storage pantry for approximately 30 minutes. She stated that all consumables and seasonings needed a label in the kitchen. She stated this gave staff a time for when it needed to be used by and inform staff how long it had been there for. She stated that a label would help staff know the exact date when the kitchen received it. She stated herself and dietary staff were responsible for ensuring that all items in the kitchen had an appropriate label. She stated that sodas and all other employee consumables cannot be stored in the walk-in refrigerator because that area was only intended for the ingredients used for resident meals. She stated the last in service to her staff was in November 2025. In an interview on 05/06/2026 at 3:00 PM, The Administrator stated a turkey without a label, employee sodas in the walk-in refrigerator, peanut butter and jelly sandwiches, and dietary staff's bare hands contacting cups and bowls in/near the opening was not appropriate cross-contamination prevention practices. He stated peanut butter and jelly sandwiches needed to be stored in the refrigerator to prevent food-borne illness. He stated it affected residents because it could cause food-borne illness. He stated he and the Dietary Director were responsible for ensuring staff were adhering to safe food handling procedures and facility policy. Record review of the facility's policy titled, Food Preparation and Service revised November 2022 read in part, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices (General Guidelines) (2)Cross-contamination can occur when harmful substances, in example, chemical or disease-causing microorganisms are transferred to food by hands, food contact surfaces. (3) Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness (Food preparation, cooking and holding time/temperature)(1) The 'danger zone' for food temperature is above 41 F and below 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness (Food distribution and Service) (7) Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks (10) snacks are not left on trays or countertops beyond the established safe time and temperature requirements (12) Food that has been served to residents without temperature controls (example give, trays, snacks, etc.) will be discarded if not eaten within two hours (Special events) (1) Food safety requirements apply to facility-sponsored events regardless of where the food was prepared or where it was served Record review of the facility's policy titled, Food Receiving and Storage revised November 2022 read in part, Food shall be received and stored in a manner that complies with safe food handling practices (Refrigerated/Frozen storage) (1) All foods stored in the refrigerator or freezer are covered, labeled and dated ('use by' date) (Food and Snacks Kept on Nursing Units) (1) All food items to be kept at or below 41 F are placed in the refrigerator located at the nurse's station and labeled with a use by date

Based on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters (Dumpster #1 and #2) reviewed for garbage disposal . -The facility failed to ensure the dumpster #1 and #2 was closed on 05/04/2026.-The facility failed to properly dispose/save 2 bed frames (1 nonrepairable), air conditioning unit, and lamp post light housing that was left outside the facility laundry room on 05/04/2026 thru 05/06/2026.- The facility failed to ensure dumpster #1 and was closed on 05/05/2026. This failure could place residents at risk of infestation of rodents and insects.Findings included:During initial kitchen tour on 05/04/2026 at 9:00 AM with the Dietary Director, it was observed dumpster #1 and #2 were left open by the dumpster access doors on both sides. At 9:03 AM, 2 bed frames, an air conditioning unit, and lamp post light housing was observed in a patio area outside the facility laundry room. A follow-up observation on 05/05/2026 at 1:35 PM revealed that the inoperable equipment outside the facility laundry room was still present. At 1:38 PM Dumpster #1 and #2 were left open by the dumpster access doors on 1 side. A follow-up observation on 05/06/2026 at 8:44 AM revealed that the refusal outside the facility laundry room was still present.In an interview on 05/05/2026 at 3:33 PM, Housekeeper H stated housekeeping, nursing, maintenance, dietary, and physical therapy used the facility dumpsters. She stated that it was expected for staff to close the dumpsters and the corral gate when not in use. She stated it needed to be closed to ensure germs don't spread, minimize odor, limit access, and prevent infestation of rodents and insects. She stated that whoever used it last was responsible for ensuring it was closed at all times. She stated it could irritate the residents if the dumpster was not closed by producing odors and an unappealing appearance. She stated she was aware of the items outside the facility laundry room and described it was beds and boxes put there by the Maintenance Director approximately three weeks ago. She stated she did not think it was an appropriate place for refusal because it looked junky . She stated that the Maintenance Director was responsible for organizing refusals and contacting vendors to pick up refusals that were not appropriate for the dumpster. She stated she did not remember the last in service she received for proper waste and refusal removal. In an interview on 05/05/2026 at 3:48 PM, CNA G stated she used the dumpsters in the back to discard waste at the end of every shift. She stated the process was to take trash in the bin with gloves, open the corral doors, close the bags, throw the trash in the dumpster, discard the gloves, and close the dumpster. She stated the dumpster needed to be closed to contain anything in there, and prevent access for cats, rats, roaches, and flies. She stated whoever used the dumpster last was responsible for ensuring it was closed afterward. She stated the beds and boxes outside the facility's laundry room were not an appropriate location for them because it posed a hazard to anyone walking by. She stated The Maintenance Director was responsible for disposing the beds and refusal ensuring they were not left there. She stated the last in service for waste disposal was a week or two ago. She stated refusal placed outside the facility laundry room affected residents by potentially causing an accident or fall to happen. She stated the dumpster being left open affected residents by potentially creating an infestation of pests that could migrate to the facility. In an interview on 05/06/2026 at 11:05 AM, Dietary Aide I stated that the process to discard trash was to take the rolling barrels to the dumpster, throw them away and close the corral door. She stated that the dumpster needed to be closed after every use and when not in use. She stated that it needed to be closed to limit access and to prevent infestation of pests. She stated that cockroaches, mice, flies, and cats could access the trash if it was left open. She stated that if the trash was left open and infested then staff could unintentionally introduce the pest into the building. She stated housekeeping were responsible for closing when not in use and reviewing it throughout the day. She stated that she does not know how long the beds and refusal in front of the facility laundry room had been there. She stated if it had been there for a long time, it was not appropriate. She stated that maintenance was responsible for calling someone to dispose of or repair the refusal that was left in front of the facility laundry room. In an interview on 05/06/2026 at 11:27 AM, The Maintenance Director stated the dumpster should be closed when not in use. He stated that all staff needed to close the dumpster after they disposed of something. He stated that it was an infection control guideline. He stated rodents, flies, and roaches had easy access to a dumpster left open. He stated that infestation could begin if the dumpster was left open throughout the day. He stated it affected residents because it could create an infestation near the building and expose the residents to pests. He stated whenever he passes by it, he stops by and checks it to ensure it's closed when not in use. He stated he had 2 bed frames (1 repairable), an air conditioning unit (used for spare parts), and a light lamppost housing (waste). He stated that the ac unit and beds had been placed in front of the facility laundry room approximately 6 weeks ago. He stated the light lamppost housing had been there since before he became the maintenance director in October 2025. He stated it was the best spot he could find to store long-term items and added it was not the appropriate place for waste and refuse. He stated he had no work orders for pick-ups with contractors and added he was going to take them in his personal truck to a local waste/refusal site. In an interview on 05/06/2026 at 12:45 PM, Dietary Director stated during initial observation on 05/04/2026 the dumpster was open and was not appropriate since it was not in use. She stated it needed to be closed to prevent infestations of mice, cockroaches, flies, and cats. She stated that if there was an infestation in the dumpster, residents could get sick because the infestation could migrate to the building. She stated the beds and air conditioning unit had been there for approximately a month or less. She stated if the items were not working and there was no intent to fix it, they needed to be disposed of properly. She stated the maintenance person was responsible for ensuring the refusal was discarded appropriately. She stated who ever used the trash last was responsible for ensuring it was closed after use. In an interview on 05/06/2026 at 2:57 PM, The Administrator stated the top lids and side doors to the dumpster should be closed when not in use and everyone was responsible for ensuring it was done. He stated it was to prevent the dumpster from being accessible to pests. He stated it affected residents because the pests could enter the facility and create a problem. He stated that the equipment in front of the facility laundry room was being repaired by the Maintenance Director, but if it was not repairable, then the items needed to be discarded properly. He stated the Maintenance Director was responsible for discarding items that were beyond repair. Record review of the facility policy titled Sanitization revised November 2022 read in part, (14) Garbage and refuse containers are in good condition without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered). (15) Areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests

Based on observation, interview, and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 4 of 7 residents (Resident #56, #65, #96, and #109) reviewed for accommodation of needs. The facility failed to ensure resident call light was within reach for Resident #56, #65, #96, and #109 on 05/04/2026. This failure could place residents at risk of having their needs unmet when they were unable to contact staff.1. Record review of Resident #56's face-sheet, dated 05/06/2026, revealed a [AGE] year-old female admitted [DATE] and readmitted [DATE]. Record review of Resident #56's Quarterly MDS assessment, dated 02/20/2026, revealed a BIMS score of 0, meaning severe cognitive impairment. Under Section GG- Functional Abilities, the resident was dependent on staff for assistance for eating, hygiene, showering, dressing, transfers, and repositioning. Under Section H- Bladder and Bowel, the resident was coded for having an indwelling catheter. Under Section K- Swallowing/Nutritional Status, the resident was coded for having a feeding tube in place. Record review of Resident #56's care plan, dated 02/21/2026, revealed the resident was at risk for falls and to prevent another fall the care plan instructed having the call light within reach for the resident. Another focus area was to monitor the resident due to seizure disorder with an intervention of keep call light within reach. Record review of Resident #56's physical and history, dated 05/04/2026, revealed diagnoses of history of falling, Anxiety (excessive, persistent fear or worry that interferes with daily life), dysphagia (difficulty swallowing), and muscle weakness (a perceived or actual lack of physical strength throughout the body). During an observation and interview on 05/04/2026 at 10:12 a.m., Resident #56's call light was draped across her bedside table that was located behind her due to her facing the right side of the bed. Resident #56 was unable to participate in an interview due to her inability to produce speech and limited comprehension to what was being asked. 2. Record review of Resident #65's face-sheet, dated 05/06/2026, revealed an [AGE] year-old male with an original admission date of 03/08/2024 and a readmission dated of 01/02/2026. Record review of Resident #65's Quarterly MDS assessment, dated 04/27/2026, revealed a BIMS score of 13, meaning cognitively intact. Under Section GG- Functional Abilities, the resident required substantial/maximal assistance for personal hygiene, transfers, toileting, and changing clothes. Record review of Resident #65's care plan, dated 02/23/2026, revealed the resident had an ADL self-care performance deficit and intervention of required staff assistance for personal hygiene needs, transfers, incontinent changing, and repositioning. Record review of Resident #65's physical and history, dated 05/04/2026, revealed diagnoses of unspecified dementia (exhibits clear signs of cognitive decline—such as memory loss, confusion, and reduced reasoning) and muscle wasting and atrophy (the loss or thinning of muscle tissue, leading to decreased muscle mass and strength). During an observation and interview on 05/04/2026 at 10:52 a.m., Resident #65's call light was on the nightstand not within reach while he was seated in his bed at a 60-degree angle. He stated he did not know where his call light was and added if it was not on the bed, he would not be able to reach it. He stated that to get the staff's attention without his call light he would yell or scream for help. 3. Record review of Resident #96's face-sheet, dated 05/05/2026, revealed an [AGE] year-old female with an original admission date of 09/22/2018 and a readmission dated of 12/22/2022. Record review of Resident #96's Quarterly MDS assessment, dated 03/05/2026, revealed a BIMS score of 3, meaning the resident had severe cognitive impairment. Under Section GG- Functional Abilities, the resident was partial to moderate assistance on assistance for eating, hygiene, showering dressing, transfers, and reportioning. Record review of Resident #96's care plan, dated 03/15/2026, revealed the resident was at risk for falls and to prevent another fall the care plan instructed having the call light within reach for the resident. Record review of Resident #96's physical and history, dated 05/06/2026, revealed diagnosis of Alzheimer's (progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform daily tasks), difficulty in walking, generalized anxiety (excessive, persistent fear or worry that interferes with daily life), and muscle wasting and atrophy (the loss or thinning of muscle tissue, leading to decreased muscle mass and strength). During an observation and interview on 05/04/2026 at 9:41 a.m., Resident #96's call light was observed clipped to the nightstand while the resident was seated in an upright position at a 70-degree angle. She stated she knew where her call light was and proceeded to extend the upper half of her body off the bed to reach the call light. She denied experiencing a history of falls while attempting to reach her call light. During an observation on 05/04/2026 at 2:09 p.m., Resident #96's call light was still clipped to the nightstand out of reasonable and safe reach for Resident #96. 4. Record review of Resident #109's face sheet, dated 05/04/2026, revealed an [AGE] year-old male with an original admission date of 04/07/2018 with a readmission date of 07/25/2023. Record review of Resident #109's Annual History and Physical, dated 04/20/2026, revealed diagnoses which included diabetes mellitus (high blood sugar), hypertension (high blood pressure), hyperlipidemia (high cholesterol), benign prostatic hyperplasia/BPH (enlarged prostate), gastroesophageal reflux disease/GERD (acid reflux), myasthenia gravis (a condition causing muscle weakness and fatigue), pulmonary hypertension (high blood pressure in the lungs), anemia (low red blood cell count), obstructive and reflux uropathy (blockage and backward flow of urine in the urinary tract), encephalopathy (brain dysfunction/confusion), generalized muscle weakness, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (weakness/paralysis on one side of the body after a stroke), unsteadiness on feet (difficulty maintaining balance), repeated falls, gait abnormalities (difficulty walking), cognitive impairment (memory/thinking problems), blindness to the left eye, and urinary retention (difficulty emptying the bladder). The H&P revealed the resident was wheelchair bound. Record review of Resident #109's quarterly MDS assessment, dated 02/17/2026, revealed Resident #109 had a BIMS score of 09 indicating the resident had moderately impaired cognition. Record review of Section GG, Functional Abilities and Goals, revealed Resident #109 required staff assistance with multiple ADLs consisting on bed mobility, transfers, toileting hygiene, personal hygiene, dressing, and eating setup assistance. The assessment revealed the resident was wheelchair dependent, had unsteady gait/balance issues, generalized muscle weakness, impaired mobility, and required staff assistance for safe movement and repositioning. Record review of the MDS revealed the resident had impaired vision, cognitive impairment, history of repeated falls, and muscle weakness which increased the resident's dependence on staff assistance and need for accessibility to personal items and the call light for safety and communication with staff. Record review of Resident #109's care plan, dated 04/10/2026, revealed the resident required one-person assistance to complete ADLs, except for meals with setup assistance. Interventions included staff assistance with dressing, personal hygiene, oral care, toileting, bed mobility, repositioning, transfers, and eating assistance to maximize the resident's independence. The care plan revealed the resident required assistance by two staff members with transfers and required ongoing assistance with incontinence care, peri-care, skin monitoring, and maintaining personal hygiene. Record review revealed the resident had a care plan for potential injury related to incontinence and gait/balance impairment. Interventions included instructing the resident to call for help before getting out of bed or chair, demonstrating the use of the call light, keeping the call light within reach and visible to the resident at all times, and ensuring the resident was informed of the call light's location and use. Additional interventions included keeping personal items within reach, maintaining the bed in the lowest position with brakes locked, providing a clutter-free environment, toileting assistance during rounds and as needed, and providing proper footwear to reduce the risk of falls and injuries. During an observation on 05/04/2026 at 10:05 a.m., Resident #109 was lying in bed. The call light was positioned behind the bed, hanging from the nightstand, and was not within reach. Resident #109 stated he was unable to reach the call light and reported that if he needed assistance, he would have to shout to call staff. During an observation and interview on 05/05/2026 at 11:15 a.m. in hallway 100, the Activities Director was observed going room to room. During the interview, the Activities Director stated residents could fall while attempting to reach a call light that was not within reach and stated that if Resident #109 had an emergency, he would not be able to call for help. The Activities Director stated call lights were required to remain within reach at all times and that it was the responsibility of all staff, including CNAs, LVNs, and RNs, to ensure compliance. During an interview on 05/05/2026 at 11:20 a.m. with CNA A, she stated call lights needed to remain within reach so residents could request assistance. She stated if the call light was not accessible, the resident would be unable to request help when needed. CNA A stated it was primarily the responsibility of CNAs, although all staff shared responsibility, to ensure call lights were within residents' reach. During an interview on 05/05/2026 at 2:50 PM, LVN F stated the call light was used by residents to call for assistance and inform staff if residents had an urgent matter. She stated that the call light needed to be within reach of the resident's hands. She stated a call light on the nightstand or draped across a bed side table would not be considered within reach. She stated that staff rounded on residents every 2 hours and should be reviewing the placement of the call light. She stated if a resident did not have their call light within reach, they could not have their needs met. She stated all employees who entered a residents room were responsible for ensuring the call light was in reach. She stated the last in service she received for call light placement was the last week of April 2026. She stated the ADON and DON were responsible for ensuring nursing staff were rounding on residents and reveiwing call light pacement. During an interview on 05/05/2026 at 11:41 a.m., the DON stated it was not acceptable for Resident #109's call light to be positioned behind the bed. She stated the resident could attempt to retrieve it and sustain a fall or remain unattended if assistance was needed. The DON stated that all residents needed to always have their call lights within reach while in their bedrooms. During an interview on 05/05/2026 at 11:58 a.m., CNA B stated call lights should be positioned within reach, either at the resident's side or secured to their clothing or lap. She stated leaving it behind the bed created a risk for falls and inability to request assistance. During an interview on 05/05/2026 at 3:99 p.m., RN C stated the location of the call light being behind Resident #109's bed was not appropriate because the resident would not be able to reach it to call for help if he needed assistance and stated Resident #109 could have a fall if he couldn't reach the call light. RN C stated there was also a risk of the resident went unattended for a prolonged period of time if he couldn't reach his call light. During an interview on 05/06/2026 at 1:50 p.m., LVN D stated call lights needed to be within the resident's reach, so they were able to call for assistance if needed. LVN D stated the call light placement for Resident # 109 was inappropriate because he would not be able to reach for it and if he attempted to get up from bed, he could sustain a fall and potentially injure himself. LVN D stated that there was also a potential risk of him not being attended in time because he would not be able to ask for help. During an interview on 05/06/2026 at 3:03 PM, the administrator stated the call light was used for residents to call for assistance. He stated it needed to be placed within resident arm's length to be considered within reach. He stated a call light out of reach affected residents because they could fall trying to get it or not receive assistance. He stated everyone who went into a resident's room was responsible for ensuring the call light was within reach. He stated that staff should be reviewing the call light's placement every time they provided care, entered residents' room, and every two hours when performing rounds on residents. Record review of the facility's policy and procedures, revised on 01/22/2025, titled, Call System, Residents, read in part: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Call system communication may be audible or visual. The system may be wired or wireless. The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights remain functional. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan. The resident call system is routinely maintained and tested by the maintenance department. Calls for assistance are answered timely.

Based on observation, interview, and record review the facility failed to ensure the resident's room was equipped to assure full privacy for each resident by providing ceiling suspended curtain that extended around the bed for 1 of 5 (Resident #75) residents reviewed for privacy. -The facility failed on 05/04/2026 to 05/06/2026 to provide a privacy curtain to Resident #75 in a shared room. This failure placed the resident at risk for not having privacy to his side of the room, experiencing embarrassment, and a decreased sense of self-esteem. Findings included: Resident #75 Record review of Resident #75's admission sheet dated 05/06/2026 revealed an [AGE] year-old male with an admission date on 05/14/2024. Record review of Resident #75's comprehensive MDS dated [DATE] revealed under Section C (Cognitive patterns) revealed the resident had a BIMS score of 3 with the significance being the resident had severe cognitive impairment. Under Section GG (Functional Abilities) the resident was coded for substantial/maximal assistance for toileting, showering, upper/lower body dressing, and personal hygiene. Under Section H (Bladder and Bowel) the resident was coded as frequently incontinent (inability to retain bladder and bowel movements) for urinary and bowel continence. Record review of Resident #75's care plan dated 04/01/2026 revealed the resident had a focus area to address Alzheimer's Dementia with an intervention of provide a homelike environment. An additional focus area of bowel and bladder incontinence with intervention to use disposable briefs and change as needed and check for incontinence every 2 hours. Record review of Resident #75's physical and health dated 06/11/2024 revealed the resident was diagnosed with Dementia (a decline in cognitive function-including memory, language, problem-solving, and thinking-severe enough to interfere with daily life) and physical debility (a state of severe physical weakness, fatigue, or loss of strength, often resulting from illness, injury, aging, or prolonged inactivity). In an observation on 05/04/2026 at 10:45 AM, revealed Resident #75 did not have a privacy curtain in his room; Resident #75 was not in his room at this time to participate in interview. Resident #75 shared a room with Resident #16 who had a privacy curtain. Resident #16 was unable to be interviewed due to severe cognitive impairment. A follow up observation on 05/04/2026 at 2:08 PM revealed no change. Resident #75 was still not in room at this time. A follow-up observation on 05/05/2026 at 3:04 PM, revealed that LVN F entered the room and did not acknowledge Resident #75's privacy curtain was missing until prompted by surveyor In an interview and follow-up observation on 05/06/2026 at 11:47 AM, Resident #75's family member was at bedside and stated the Maintenance Director that morning to applied hooks for the curtain. He stated he did not know how long the privacy curtain had been off because he was visiting from out of town. He stated he had not noticed the privacy curtain was missing until he saw the Maintenance Director working on it. He stated Resident #75 would not be able to remember when it was removed and for how long due to difficulty remembering events. Resident #75 was asleep during interview with family member. In an interview on 05/05/2026 at 3:05 PM, LVN F stated Resident #75 and #16 shared a room. She stated the facility utilized privacy curtains when providing incontinent care, clothes change, repositioning, and transfers to residents. She stated she was not aware of any discrepancies in Resident #75's room. She entered the room and denied there being present concern in Resident #75 and #16's room. She stated Resident #75's privacy curtain was missing after resuming interview. She stated she was previously in Resident #75's room before the surveyor and did not notice the privacy curtain missing. She stated the privacy curtain did not pose a hazard risk to Resident #75 and there was no documentation in progress notes or care plan regarding the privacy curtain posing a potential risk to Resident #75 and needing to be removed. She stated that staff use the privacy curtain every time they provided care throughout the shift and could be noted as missing by any staff member. She stated she would put in a work order with the Maintenance Director to reapply the privacy curtain. She stated she did not know what staff members could remove or change privacy curtains. She stated any staff member could report it to the resident's nurse or leadership to have a new privacy curtain applied in the resident's room. She stated it was a dignity issue if a resident did not have their privacy curtain. She stated the ADON and DON were responsible for ensuring direct care staff were completing rounds and inspecting residents' environment. She stated she did not know for how long the privacy curtain had been missing for. In an interview on 05/05/2026 at 3:43 PM, CNA G stated she provided privacy to the resident by closing the door and drawing the curtain when she provided care. She stated privacy curtains were located in every resident's room. She stated if a resident did not have a privacy curtain she would notify the shift nurse and Maintenance Director. She stated she was not sure who was supposed to monitor and review resident's rooms to ensure there was a privacy curtain in place. She stated the process for the privacy curtains she was familiar with was to notify housekeeping if the curtain was dirty, wrinkled, or missing. She stated that all staff members who entered a resident's room were responsible for ensuring they had a privacy curtain. She stated it affected a residents' dignity, respect, and privacy if they did not have a privacy curtain for 2 days. She stated that a resident who was being dressed, changed, transferring required a privacy curtain when those services were provided. She stated the shift nurse and ADON and DON were responsible for ensuring that residents had privacy curtains at all times. In an interview on 05/06/2026 at 11:27 AM, The Maintenance Director stated that himself and housekeeping were able to take down privacy curtains and replace them as needed. He stated that the curtain was provided to add privacy between roommates during changing, care services, or when a resident wanted to be left alone. He stated he did not have any work orders prior to 5/5/2026 for Resident #75's privacy curtain. He stated he did not remove Resident #75's privacy curtain and he did not know how long the curtain was missing. He stated CNAs and nurses could report work orders to him verbally or on the facility software for any repairs or concerns noted in a resident's room. He stated he did a thorough room check on residents' rooms once every 2 months. He stated this was a full inspection where he reviewed the privacy curtain, door handles, bed, windows, restrooms, etc. He stated in addition to direct care staff rounding on residents every 2 hours that the facility had angel rounds in the morning and they usually conducted environmental inspections while talking with the resident. He stated a resident should always have a privacy curtain. He stated that if staff were to remove the privacy curtain, it was the expectation to replace or notify someone to change it immediately or before removing the original privacy curtain. In an interview on 05/06/2026 at 11:50 AM, Housekeeper H stated Resident #75's privacy curtain had been missing for approximately a week because it was missing additional hooks on the track. She stated she was not allowed to reapply the curtain if there was a maintenance issue. She stated she notified The Housekeeping Director with the expectation that she would notify the Maintenance Director. She stated it affected Resident #75 by not providing a private setting for changing and care. She stated a week was a long time for Resident #75 to go without his privacy curtain. She stated that the curtain hooks or an alternative should have been provided to the resident during the week he did not have a privacy curtain. She stated that housekeeping was responsible for ensuring the residents had a privacy curtain since they washed and reapplied them. She stated the last in service was in April 2026 for resident rights to privacy. In an interview on 05/06/2026 at 12:04 PM, Business Office Manager stated she was the angel round representative for Resident #75's room and she had worked on 05/04/2026 and 05/05/2026. She stated her responsibilities during angel rounds included talking with residents, making sure beds were made, placing call lights within reach, removing leftover food, and reviewing residents' environment. She stated she did not complete her angel round on 05/04/2026 because she was caught up with another resident who needed their concerns addressed with the nurse. She stated she did rounds on 05/05/2026 and did not note any concerns with Resident #75 or his room. She stated she did not remember if Resident #75 had a privacy curtain on 05/04/2026 and 05/05/2026 and could not recall if Resident #75 privacy curtain was missing the week prior. She stated that if a privacy curtain was missing it would be obvious that it's not there. She stated it could affect a resident's dignity and privacy to care if they do not have a privacy curtain. She stated she does not remember when Resident #75 privacy curtain was removed. She stated the privacy curtain or an alternative needed to be placed right away before removing the original curtain. She stated that everyone was responsible for ensuring that residents had privacy curtains at all times. She stated that she could not recall the last in service she received for residents' rights or dignity. In an interview on 05/06/2026 at 2:10 PM, DON stated her direct care staff provided privacy to residents by drawing the privacy curtain, closing the door, and stepping out of the restroom while a resident was using it. She stated residents in a shared room should have a privacy curtain. She stated that the DON, ADON, and Administrator do weekly walkthroughs, but they had not completed their weekly walkthrough on 04/27/2026 to 05/01/2026. She stated privacy curtains were replaced when they were dirty, used in a quarantine/contaminated room, or needed repair. She stated there should been a replacement immediately if the staff were going to change or replace Resident #75's curtain. She stated that the housekeeping and Maintenance Director were the only staff members that could replace it. She stated that it affected a resident's privacy to change, care, and transfers if they were left without a privacy curtain. She stated that care should not be provided without the privacy curtain being used. She stated that a privacy curtain was obvious and could be easily identified as missing. In an interview on 05/06/2026 at 2:46 PM, The Administrator stated the facility utilized privacy curtains and closing resident's doors to provide privacy. He stated that privacy curtains were used anytime the staff provided service to a resident for incontinent care, clothe change, and transfers. He stated that all residents who shared a room with another resident should have a privacy curtain. He stated that the curtain should be applied immediately if it was removed by the Maintenance Director and housekeeping staff. He stated housekeeping staff and Maintenance Director were responsible for replacing the privacy curtain. He stated that it affected Resident #75 because they did not have privacy during care. He stated that all staff members should check the residents' environment whenever they were in their room and report any concerns. Record review of the facility's maintenance work order #456 revealed it was created on 05/06/2026 at 7:20 AM in relation to Resident #75's bedroom. The work order revealed it was resolved and noted as completed at 11:56 AM by the Maintenance Director by replacing the hooks to the curtain track. Record review of the facility's policy titled Resident Rights revised February 2021 read in part, Employees shall treat all residents with kindness, respect and dignity (1) Federal and state laws guarantee certain basic rights to all resident of this facility. These rights include the resident right to: (a) a dignified existence; (b) be treated with respect, kindness, and dignity; (t) privacy and confidentiality Record review of the facility's policy titled Dignity revised February 2021 read in part, Each resident shall be care for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem (1) Residents are treated with dignity and respect at all times (5) when assisting with care, residents are supported in exercising their rights (11) Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on record review and interview the facility failed to maintain an effective training program for all new and existing staff providing services for 2 of 7 employees (CNA A and Dietary Aide E) reviewed for training completions. -The facility failed to ensure CNA A received annual training for 6 training subjects reviewed on 05/06/2026.-The facility failed to ensure Dietary Aide E received annual training for 4 training subjects reviewed on 05/06/2026. This failure places residents at risk to receive services or care from a staff member who was not informed on procedures.Findings included: Record review on 05/06/2026 at 1:07 PM, HR Coordinator provided a completed document of 7 employees sampled for personnel files review. The document revealed that CNA A had a hire date of December 2024 and was missing the following trainings: communication, infection control, compliance and ethics, HIV, restraint reduction, and prevention of falls. Dietary Aide E had a hire date of December 2023 and was missing the following trainings: communication, infection control, HIV, and restraint reduction; amounting to a total of 10 incomplete trainings from CNA A and Dietary Aide E. In an interview on 05/06/2026 at 1:27 PM, HR Coordinator stated she did not have documentation of completed trainings for CNA A and Dietary Aide E. She stated the trainings missing were communication, HIV, infection control, compliance and ethics (CNA A only), restrain reduction, fall prevention (CNA A only). She stated it was not acceptable for staff to be working without completed annual training. She stated that the training needed to be completed annually to ensure staff were refreshed and competent on the regulations and policies of the facility. She stated it affected residents if staff were not up to date on their training because it posed a risk on the care they provided and staff's knowledge of their actions, decisions, and procedures. She stated that staff could get comfortable and fall into a routine that does not adhere to standards. She stated annual training kept employees informed on regulations and requirements. She stated department heads to whom employees reported to were responsible for ensuring employees were up to date on training. She stated that every Monday the Administrator runs the scheduled training modules and if a staff member had not completed the training, they would get removed from the schedule until completion. She stated that the Administrator was made aware today that the 2 employees were not up to date in the training. She stated she had not completed a training audit because the training software was new and initiated facility wide in November 2025. She stated Corporate HR would have to unlock the training and assign them to staff if the training was scheduled for a future date. She stated that corporate HR had not been notified yet to unlock the training since she was aware of CNA A and Dietary Aide E missing training today. She stated there was no policy for training and provided an Employee Handbook in its place. In an interview on 05/06/2026 at 2:16 PM, The DON stated that every day during morning meeting a list was printed of employees with missing trainings who were not in compliance. She stated if the training was incomplete for more than a month, the employee would be relieved of duties until completion of said training. She stated CNA A and Dietary Aide E needed to be pulled from the schedule because they did not have their completed trainings. She stated the trainings included videos, readings, and a test at the end to ensure comprehension. She stated if a staff member did not have completed training, they might not be knowledgeable as to what the procedures were in response to a situation (for example: infection control, falls, restraints). She stated it affected residents because staff may not be equipped with the proper knowledge on how to handle the residents. She stated it was a requirement for the employee to have their training schedule up to date with confirmation of completion within the past year. She stated herself, the HR Coordinator and Administrator were responsible for ensuring that employees had completed all training. In an interview on 05/06/2026 at 2:50 PM, The Administrator stated that the Corporate HR was responsible for unlocking and scheduling trainings to the staff. He stated that the facility monitored training completion by reviewing the software's scheduled training report daily during morning meetings with department heads. He stated this was completed to ensure staff were up to date on training. He stated the software report showed scheduled trainings that were coming up but did not provide a report on all the trainings employees could still pending completion. He stated it affected residents because staff could be uninformed on policy and procedures that pertain to resident safety and wellbeing. He stated if the employee did not completed scheduled trainings within the month, they would be removed from the schedule and not be permitted to return to work until completion. He stated himself and HR Coordinator were responsible for ensuring training was up to date and completed for employees. He stated that training was scheduled every month, and different classes were scheduled by the Corporate HR coordinator on the facility software. He stated HR Coordinator and himself did not have access to the software to assign training for CNA A and Dietary Aide E and they would need to contact Corporate HR. He stated there was no alternative method for training besides the software the facility used. He stated all staff needed to have their training record up to date. Record review of Dietary Aide E's training scheduled revealed Infection Prevention and Control Guidelines with a scheduled due date by 05/31/2026. HIV antibody Testing and Post-Exposure completed with a scheduled course availability date of 08/01/2026 and due date of 08/31/2026. Use of Restraints with a scheduled course availability date of 10/01/2026 and due date of 10/31/2026. Hazard Communication Program with a scheduled due date by 05/31/2026. Record review revealed there were no completed trainings on file for Dietary Aide E for the 4 training subjects reviewed. Record review of CNA A's training scheduled revealed Infection Prevention and Control Guidelines with a scheduled due date by 05/31/2026. HIV antibody Testing and Post-Exposure with a scheduled course availability date of 08/01/2026 and due date of 08/31/2026. Use of Restraints with a scheduled course availability date of 10/01/2026 and due date of 10/31/2026. Hazard Communication Program with a scheduled due date by 05/31/2026. Fall Incident Prevention with a scheduled course availability date of 10/01/2026 and due date of 10/31/2026. Annual Compliance and Training with a scheduled course availability date of 07/01/2026 and due date of 07/31/2026. Record review revealed there was no completed trainings on file for CNA A for the 6 training subjects reviewed under. Record review of the facility's Employee Handbook dated December 2025 read in part, (Employment Ethics and Conduct, page 10-11) The company considers its obligations to comply with all state and federal laws seriously. As such, The Company has a Corporate Compliance Plan designed to assist with compliance with those rules and regulations this Program has been designed to establish the framework by which the organization will use reasonable effort to ensure compliance with all such laws. It is the responsibility of all employees to comply with the Code of Ethics and to use all reasonable efforts to ensure that the organization is in compliance with all applicable laws It is important that an individual reporting to Corporate Compliance misconduct must be able to provide accurate and sufficient detail in order for the Corporate Compliance Officer to evaluate the potential problem. Ongoing training is made available to all employees. Please refer to your Corporate Compliance Plan and/or Administrator for further details The Compliance Process has been created to teach, support, and monitor the commitments of individual employees and The Company. It provides the standards, principles, tools, and the training needed to meet The Company's legal, ethical, and professional responsibilities Each employee is responsible for supporting the Compliance Process in all aspects of his/her individual position. To ensure that each employee has full understanding of The Company's expectations for his/her conduct, each employee will attend a training session covering the Code of Conduct, will read the Code and sign the last page indicating understanding, and acknowledging his/her responsibility along with his/her commitment to the Code of Conduct. In addition, annual training will be conducted. Your signed acknowledgement form and a record of all supplemental training are retained as a permanent part of your employee record

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 1 (Resident #1) of 4 residents reviewed for fall assessment after an unwitnessed fall. The facility failed to ensure LVN P appropriately assessed Resident #1 following an unwitnessed fall on 03/14/2026. This failure could affect others by placing them at risk for complications related to untreated injuries.Record review of Resident #1's face sheet dated 04/21/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and then readmitted on [DATE]. Resident #1's diagnoses included fracture of left pubis (crack or break in the hip bone area), subsequent encounter for fracture with routine healing, fracture of acetabulum (break in the hip socket), pain in left hip, muscle wasting (loss of muscle tissue), attention and concentration deficit (neurodevelopment issue where the brain struggles to filter distractions and sustain focus), cognitive communication deficit (impairment in communication skills), history of falling, dementia(decline in mental ability), anxiety disorder (uncontrol fear or worry), altered mental status (change in persons thinking, awareness, or behavior), Hypertension (high blood pressure), repeated falls. Record review of Resident #1's MDS dated [DATE], reflected a BIMS score of 13, indicating the resident was cognitively intact. The resident had impairment on one side in upper extremity (shoulder, elbow, wrist, hand) and impairment on one side of lower extremities (hip, knee, ankle, foot). Record review of Resident #1's Care Plan dated 01/02/2026 and 04/21/2026, both reveled focus Potential or injury R/T History of falls is at risk for further falls. With a goal Will have no hospitalization fall event through the next review date, interventions/task Administer meds as ordered- monitor labs- report abnormalities to MD, Assure the floor is free of glare, liquids, foreign objects, Attempt to identify cause of fall and alleviate problem to extent possible, Educated on noncompliance with safety interventions and explain possible risks/outcomes R/T noncompliance issues, Family requested to have bed against the wall. Focus; The resident is moderate risk for falls gait/balance problems. Goal: The resident will not sustain serious injury through the review date, interventions/task; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Record review of Resident #1's dated 03/14/2026 incident report was reviewed. Record Review of Resident #1's progress notes dated 03/14/2026 at 22:19 PM, revealed CIC #1 resident vitally stable, ADON, Family, Dr. Notified. Resident did not hit her head slipped onto her bottom. Record Review of Resident #1's Progress notes dated 03/15/2026 at 02:38 AM, releveled CIC #2 Resident is assessed for pain and educated to use call light for assistance, will continue monitoring. Record review of Resident #1's Progress notes dated 03/15/2026 at 03:00 AM, releveled Resident lying in bed with eyes open. She was assessed for pain and she stated me duele al [NAME] estomago (my stomach is hurting) showing left upper quadrant' Tylenol was offered and she stated no porque luego me arde el estomago (no because then my stomach hurts). She was repositioned while in bed and one hour later reassessed and she stated me siento mucho major (I feel a lot better). She continues sleeping. No documentation of pain level noted. Record Review of Resident #1's Physician Progress notes dated 03/15/2026 at 08:16 AM. revealed Met with the patient bedside, lying down in bed, and remains at her baseline mentation. The patient apparently had an unwitnessed fall yesterday evening, denies any head trauma or LOC but does present with L hip pain. On inspection, she does have some L leg shortening with external rotation that may be indicative of a hip fx. She will be provided pain medication and pending a stat pelvis/L femur x-ray. BP looks controlled and eye swelling looks improved on today's visit as well. Record Review of Resident #1's Progress Note dated 03/15/2026 at 14:54 PM, reveled CIC #4 x-rays came back positive for displaced acetabular fracture. NP notified ordered her to get further evaluated by ER, 911 called for further evaluation of displaced acetabular fracture (serious injury where the hip socket (acetabulum) breaks and the bone fragments move out of alignment), Adon & family notified. Record review of Resident #1's X-ray results from the hospital dated 03/15/2026 revealed a fracture of left interior pubic ramus. Record review of Resident #1's MARs on 04/21/2026 reveal resident had pain medication ordered but did not receive any. In an interview on 04/21/2026 at 11:37 AM, RN C stated she had been employed at the facility for 7 months and works the 10:00 PM-6:00 AM shift. RN C stated that during report from the prior shift on 03/14/2026 2 Pm-10 PM shift. She was verbally informed by Nurse (who she can't) that Resident #1 had experienced an unwitnessed fall prior to 10:00 PM. RN C stated that no injuries were reported during handoff. RN C stated that during her shift, the resident complained of pain in her abdominal area/groin area once, but RN C stated in her opinion it was not associated with the unwitnessed fall, RN C did not seek any physician regarding resident's pain. RN C stated she documented the pain on her nursing notes and offered the pain medication, but when she went back into the room Resident #1 was asleep, so the pain medication was never given. RN C stated that the risk of resident not being assessed was none as she did not believe the pain was serious or associated with the fall. RN C stated she reported the fall to the oncoming nurse in the morning on 03/15/2026 and the pain that the resident voiced once at night. In an interview and obervastion on 04/21/2026 at 11:48 AM, Resident #1 was observed in her room with a medication aide present. The resident was AOX3, apperared well groomed, and showed no signs of distress. The call light was within reach and Resident #1 stated shes aware of how it works and when to use it. The resident reported she fell while attempting to go to the restroom. Resident #1 stated that she activated the call light for assitance in the restroom, but no staff responded. Resident #1 stated the fall happened because she attempted to ambulate independetly to the restroom, slipped, and fell on her bottom. Resident stated she was transferred out to the hospital, when staff found her on the floor, staff assisted with getting her up Resident #1 stated that she had been independent with transfers and would be able to amulate alone with no help prior to the fall. In an interview on 04/21/2026 at 12:08 PM, the NP stated he became aware of the fall after being notified by nursing staff the next day on Sunday 03/15/2026 around 9 am. The NP stated that he was unaware whether the resident primary doctor had been notified as staff are to contact them first before notifying NP from facility. NP reported that upon assessment, the resident exhibited signs consistent with injury, including one leg appearing shorter than the other and she complained about pain. The NP stated an x-ray was ordered stat, confirming a fracture of the hip. The NP stated that nursing staff should have completed a head-to-toe assessment prior to moving the resident and should have identified the abnormality during the fall assessment. The NP stated there was really no risk since the resident more than likely got the fracture from the fall. In an interview and observation on 04/21/2026 at 01:51 PM, Resident #2 (Resident #1's old roomate) was observed seated in her wheelchair watching televsion at a high volume. Residnet #2 stated she was generally satisfied with the facility and has had no issues with staff reporting to call lights. Resident #2 described Resident #1 as very needy and demanding and staff had already previosly instructed resident #1 not to ambulate independlty and to utilize her call light for assistance. Resident #2 stated she later heard Resident #1 in the restroom attempting to open the door and yelling for help. She reported staff subsequently respond and assisted Resident #1 back to bed. Resident #2 stated she did not witness the fall or was not able to see her since the privacy curtain was closed all the way. In an interview on 04/21/2026 at 02:36 PM, LVN P stated she had been employed at the facility for two years but has been a LVN for a total of 18 years. LVN P stated she was informed by a CNA E that Resident #1 was on the floor on 03/14/2026. LVN P stated she entered the room and found Resident #1 on the floor in a sitting position in the middle of the room and restroom. LVN P stated she asked for help and placed Resident #1 in the wheelchair and then to bed, prior to completion of a full assessment. LVN P stated that Resident #1 stated, she scooted to the middle of the room to call for help from the restroom, but no one came to help her. LVN P stated she did not recall any light on from the restroom. She said the call lights blink red and there were no lights blinking red because she attends to those as soon as possible. LVN P stated she did not assess Resident #1 before moving her because Resident #1 was so adamant about getting her up. LVN P stated she was aware she was not supposed to move a resident before conducting a head-to-toe assessment. She said her main concern was making sure Resident #1 had not hit her head, which she checked before moving her. LVN P stated she notified the physician and documented, the physician did not order any x-rays due to the resident being alert and oriented and in no pain. LVN P stated she asked Resident #1 if she was in any pain and resident stated No. LVN P stated when she conducted the head-to-toe assessment it was while resident was already in bed and she did not notice anything unusual about her legs. LVN P stated she worked the next morning, on Sunday, and she notified the NP at the facility about the fall. She said the NP entered the room to assess Resident #1 and noticed the shorting of one of the legs. LVN P stated that she called resident's primary physician to notify them of the findings and she received orders for the resident to be sent out. LVN P stated the risk of her not conducting a head-to-toe assessment prior to moving the resident could lead to other injuries. LVN P stated she had been in-serviced and trained on performing a fall assessment prior to moving the resident. In an interview on 04/21/2026 at 02:52 PM, ADON V stated she had been employed at the facility for five years on and off. ADON V stated a review of camera footage did not confirm the call light had been activated at the time of the incident. ADON V stated facility protocol required nursing staff to complete a head-to-toe assessment, obtain vital signs, conduct neuro checks, notify physician, and inform the responsible party following a fall. ADON V stated residents should not be moved prior to assessment unless necessary for safety. ADON V stated that failure to follow procedures could place the resident at risk for further injury. ADON V stated it was the responsibility of ADONs and DONs to make sure nursing staff are doing their best for the residents. ADON stated that they did not have a Quality of care policy or an unwitnessed falls policy. In an interview on 04/21/2026 at 03:23 PM, CNA E, stated she was the one who found Resident #1 on the floor on 03/14/2026. CNA E stated she was assisting a resident across the room from Resident #1 and upon coming out of the room she saw Resident #1 on the floor. She said Resident #1 was waving her down yelling Venga, Venga (come here). CNA E stated she rushed into Resident #1's room and found Resident #1 between the middle of the room and the entrance to the restroom. CNA E stated she made sure the resident was okay and rushed out to call the nurse. She stated LVN P came right away. CNA E stated that night she changed Resident #1's brief and the resident did not show any signs of pain. CNA E stated she assisted with the transfer from the floor to the wheelchair, then to the bed. CNA E stated that LVN P conducted her assessment on the bed after transfer. In an interview on 04/21/2026 at 03:44 pm, the Administrator stated he had been employed at the facility for two years. Administrator stated he became aware of the fall but can't recall the date. It was reported to him that Resident #1 did not hit her head, he is unaware if anyone witnessed the fall or who was working the day of the incident. Administrator stated that they have cameras in certain areas, but they are erased after 10 days. He stated that he reviewed the camera footage of Resident #1s hallway while conducting his investigation and stated there were no red call light flashing. The Administrator stated that staff are being trained on falls and incidents on a system called Relias (Online learning Management System) and get conducted in-services when there is an Incident/Accident that occurs. The Administrator stated the procedure when a resident fall should be to automatically assess the resident from head to toe before they get them up and if they are seriously injured to call 911. He said if they are not injured and everything looks okay from the assessment, they are to get the residents up and notify the family, Physician, and the ADON/DON is on call. He stated an IDT meeting was conducted and care plans, interventions were put into place to prevent residents from falling again. He stated if a nurse did not assess the resident prior to moving her/him the risk would potentially be more injury. In an interview on 04/21/2026 at 04:47 PM, CNA B stated he assisted LVN P to transfer Resident #1 from the floor to the wheelchair and to the bed, but he did not witness the fall. CNA B stated that Resident did not express pain at the time of transfer. CNA B stated that it was the responsibility of the nurse to conduct the assessments not the CNAs. CNA B stated he did not see if LVN P conducted an assessment or not, he just helped with the transfers and left. CNA B stated that he did not change Resident #1's briefs that night. He said Resident #1 would usually ask to be changed when she needs help, but she is able to walk to the bathroom and get off the bed on her. Record Review of facility's policy named Assessing Falls and Their Causes revision date March 2018-revised 12/09/24 reveled The purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Steps in the procedure, after a fall:1) If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injures to the head, neck, spine, and extremities. 4) If an assessment rules out significant injuries, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. Record review of in-services of all staff were reviewed for Falls, Abuse and Neglect, Exploitation, and resident rights.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 (Resident #2, Resident #3 and Resident #4) of 4 residents reviewed for pharmacy services and 3 of 4 medication carts (Halls 100, 200, and 300) reviewed for medications.- The facility failed to ensure timely acquisition of Resident #2's Lyricand was not administered per physician's orders.- The facility failed to ensure timely acquisition of Resident #3's Pregabalin and was not administered per physician's orders.- The facility failed to ensure timely acquisition of Resident #4's Tramadol and was not administered per physician's orders.-The facility failed to ensure licensed staff signed off on the Controlled Drugs-Count Records after verifying all controlled substances in the medication cart were accounted for with the on-coming nurse at the change of shift for 3 of 4 medication carts in Halls 100, 200, and 300.The failure could place residents at risk of inadequate therapeutic outcomes and a decline in health due to not receiving medication as ordered and drug diversion of controlled substances.Findings include:1. -Review of the Face Sheet dated 03/31/26 for Resident #2 revealed an original admission date of 09/15/25 and re-admission date of 12/26/25.-Review of History & Physical dated 09/17/25 for Resident #2 revealed [AGE] year-old-female with past medical history of neuropathy, severe rheumatoid arthritis, history of cervical spinal surgery.-Review of Quarterly MDS dated [DATE] for Resident #2 revealed BIMs Score 15 (cognitively intact), impairment on both sides of upper extremities, substantial/maximal assistance with toileting, shower, dressing, moderate assistance with personal hygiene. Rheumatoid arthritis, cervical disc disorder with myelopathy. Opioid.-Review of Care Plan revised on 09/19/25 for Resident #2 revealed, the resident has chronic pain r/t Arthritis. Approaches: Administer analgesic as per orders. Notify physician if interventions are unsuccessful or if current complaints is a significant change from resident's past experience of pain.-Review of Grievance/Complaint Report dated 03/19/26 for Resident #2 revealed, form was completed by the Activities Director. Description: Resident states that she has not received her Lyrica in four days. Summary Finding: New Rx sent to pharmacy per nurse request on 3/19/25.-Review of Physician's Order Summary dated 03/31/26 for Resident #2 revealed, Pregabalin (Lyrica) oral capsule 50 mg give one capsule by mouth two times a day for nerve pain. Pain assessment to be completed every shift. The Physician's order did not document an order to administer Pregabalin (Lyrica) oral capsule 50 mg give one capsule by mouth three times a day. Recommendations/Action Taken: Resident informed RX sent. Resolution of Grievance. Yes. Form completed by Administrator.-Review of Medication Monitoring/Control Record for Resident #2 revealed, Pregabalin (Lyrica) oral capsule 50 mg give one capsule by mouth two times a day documented resident ran out of medication after the 9:00 a.m. dose was administered on 3/14/26.-Review of Medication Monitoring/Control Record for Resident #2 revealed, Pregabalin (Lyrica) 75 mg one capsule by mouth three times a day did not document date medication was received from the pharmacy. The Control Record documented medication was administered from 3/25/26 to 3/30/26 as ordered.-Review of Medication Administration Record dated March 2026 revealed: -03/14/25 at 3:00 p.m. documented on the MAR code 9 (Other/See Nurses Notes).-03/14/2026 at 9:00 a.m. documented on the MAR code 9 (Other/See Nurses Notes-03/15/2026 at 9:00 a.m. and 3:00 p.m. documented on the MAR code 9 (Other/See Nurses Notes).-03/16/2026 at 9:00 a.m., 3:00 p.m. and 9:00 p.m. documented on the MAR code 9 (Other/See Nurses Notes). Pain Assessments completed during the morning and evening shift documented Pain Level was zero.-03/17/2026 at 9:00 a.m. documented on the MAR code 9 (Other/See Nurses Notes).-03/17/25 at 3:00 p.m. and 9:00 p.m. documented on the MAR code 5 (Hold/See Nurses Notes).-03/18/2026 at 9:00 a.m. documented on the MAR code 9 (Other/See Nurses Notes).-03/18/25 at 3:00 p.m. and 9:00 p.m. documented on the MAR code 5 (Hold/See Nurses Notes).-03/19/2026 at 9:00 a.m. documented on the MAR code 9 (Other/See Nurses Notes).-03/20/2026 at 9:00 a.m., 3:00 p.m. and 9:00 p.m. documented on the MAR code 9 (Other/See Nurses Notes).-03/21/2026 at 9:00 a.m., 3:00 p.m. and 9:00 p.m. documented on the MAR code 9 (Other/See Nurses Notes).-03/22/2026 at 9:00 a.m., 3:00 p.m. and 9:00 p.m. documented on the MAR code 9 (Other/See Nurses Notes).-03/18/2026 at 9:00 a.m. documented on the MAR code 9 (Other/See Nurses Notes).-Review of Medication Administration Record dated March 2026 - Pain Assessment to be completed every shiftrevealed:-03/14/26 Pain Assessment in the morning, evening, night shift was zero.03/15/26 Pain Assessment in the morning was 4 on a scale of 1-10, 10 being the worst pain. Pain assessment in the evening, the night shift was zero.03/16/26 Pain Assessment in the morning, evening, night shift was zero.03/17/26 Pain Assessment in the morning, evening, night shift was zero.03/18/26 Pain Assessment in the morning, evening, night shift was zero.03/19/26 Pain Assessment in the morning, evening, night shift was zero.03/20/26 Pain Assessment in the morning, evening, night shift was zero.03/21/26 Pain Assessment in the morning was zero. Pain Assessment in the evening shift was at 2 on a scale of 1-10, 10 being the worst pain. Pain Assessment in the night shift documented a 6 (hospitalized ).03/22/26 Pain Assessment in the morning, evening, night shift was zero.03/23/26 Pain Assessment in the morning, evening, night shift was zero.03/24/26 Pain Assessment in the morning, evening, night shift was zero.03/25/26 Pain Assessment in the morning, evening, night shift was zero.03/26/26 Pain Assessment in the morning, evening, night shift was zero.03/27/26 Pain Assessment in the morning 3 on a scale of 1-10, 10 being the worst pain.Review of IDT Progress Notes dated 03/31/26 documented Date Range: 03/01/26 to 04/01/26 revealed:-Physician Progress Note dated 3/15/26 at 11:35 a.m. written by NP C revealed, Note Text: NP Follow up Note. Lyrica 75 mg three times a day. RA: Flare up. RA: Monitor for worsening symptoms.-Review of Administration Note dated 3/14/26 at 3:50 p.m. written by Med Aide DD, documented, Lyrica oral capsule 75 mg give 1 capsule by mouth three times a day for nerve pain. Med is not available. -Review of Administration Note dated 3/15/26 at 8:35 a.m. written by Med Aide EE, documented, Lyrica oral capsule 75 mg give 1 capsule by mouth three times a day for nerve pain. Pending delivery. -Review of Administration Note dated 3/16/26 at 10:53 a.m. written by Med Aide Y, documented, Lyrica oral capsule 75 mg give 1 capsule by mouth three times a day for nerve pain. Pending delivery, nurse notified. -Review of Administration Note dated 3/16/26 at 3:25 p.m. written by Med Aide Y, documented, Lyrica oral capsule 75 mg give 1 capsule by mouth three times a day for nerve pain. Pending delivery, nurse notified. -Review of Administration Note dated 3/16/26 at 8:14 p.m. written by Med Aide Y, documented, Lyrica oral capsule 75 mg give 1 capsule by mouth three times a day for nerve pain. Pending delivery, nurse notified. -Review of Administration Note dated 3/17/26 at 9:18 a.m. written by Med Aide Y, documented, Lyrica oral capsule 75 mg give 1 capsule by mouth three times a day for nerve pain. Pending delivery, nurse notified. -Review of Administration Note dated 3/17/26 at 5:43 p.m. written by Med Aide K, documented, Lyrica oral capsule 75 mg give 1 capsule by mouth three times a day for nerve pain. Pending delivery, nurse notified. -Review of Administration Note dated 3/17/26 at 9:38 p.m. written by Med Aide K, documented, Lyrica oral capsule 75 mg give 1 capsule by mouth three times a day for nerve pain. Pending delivery, nurse notified. -Review of Administration Note dated 3/18/26 at 8:24 p.m. written by LVN T documented, Lyrica oral capsule 75 mg give 1 capsule by mouth three times a day for nerve pain. Pending delivery, on order. -Review of Administration Note dated 3/18/26 at 5:22 p.m. written by Med Aide K, documented, Lyrica oral capsule 75 mg give 1 capsule by mouth three times a day for nerve pain. Pending delivery, nurse notified. -Review of Administration Note dated 3/18/26 at 9:16 p.m. written by Med Aide K, documented, Lyrica oral capsule 75 mg give 1 capsule by mouth three times a day for nerve pain. Pending delivery, nurse notified. -Review of Administration Note dated 3/19/26 at 10:56 a.m. written by LVN T documented, Lyrica oral capsule 75 mg give 1 capsule by mouth three times a day for nerve pain. Pending delivery. -During an interview on 3/27/26 at 3:23 p.m. revealed Resident #2 was sitting in a wheelchair in her room by the side of the bed. The resident said, Ianted to tell you, that I did not receive my pain medication for 10-12 days. She said she had rheumatoid arthritis, and they were giving Tylenol, but it did not relieve the pain. She said someone had told her that the pharmacy took a long time to send the medications to the facility and that was the reason that they did not have her pain medication. She said she was diagnosed with Rheumatoid Arthritis when she was [AGE] years old, and now she required total assistance with her personal care. Resident said she had pain but was able to sit in her wheelchair as tolerated.-During an interview and on 3/27/26 at 3:38 p.m., LVN J assigned to the 200 Hall on the evening shift revealed, Resident #2 did not have the Lyrica for two weeks to administer for pain as ordered. She said they used an out-of-town pharmacy, and it took a long time for them to refill medication orders. She said the Lyrica was finally delivered for Resident #2 but could not remember the date. She said that the ADONs were the ones that called in the narcotic refills to the vendor pharmacy for the residents. She said that sometimes they could pull controlled substances from automated medication dispensing system the She said RN CC, attempted to pull the Lyrica from the pyxis for Resident #2 and the request was denied. She said that residents frequently run out of medications because it takes long for medications to be refilled and sent to the facility.-During an interview on 3/27/26 at 3:54 p.m., Med Aide K revealed that Resident #2 had not been administered the Lyrica for nerve pain for several days in March 2026 because the medication had not been sent to the facility by the out-of-town pharmacy. She said the resident complained of pain and was medicated with Tylenol, but the resident would complain that the Tylenol was not effective.-During an interview on 4/02/26 at 9:00 a.m., LVN T revealed Resident #2 has run out of Lyrica a few times. She said that the Med Aides only re-order the non-narcotic medications and the ADONs/nurses reorder the controlled substances. LVN T said that she was not aware of the facility's policy and procedure on re-ordering medications from the pharmacy. She said the Vendor pharmacy was out of town, and it took a long time to receive medications and that was why the residents at times ran out of medications. She said Resident #2 had an order for Lyrica to administer three times a day and for Tylenol for prn pain. She said the resident had rheumatoid arthritis and complained of generalized pain. She said the physician had not been notified that the resident did not have the Lyrica on hand to administer as ordered because the resident had orders for PRN Tylenol Extra Strength two tablets every 8 hours and the Tylenol relieved some of the pain.-During an interview on 4/02/26 at 10:05 a.m., Med Aide Y revealed Resident #2 frequently complained of generalized pain and had orders for Lyrica PRN. She said the resident had not been administered the Lyrica for approximately 10 days due to not having the medication hand to administer as ordered. She said the nurses re-ordered the controlled substances from the out-of-town pharmacy and it took a long time to receive the medications. She said that the nurses were aware that the resident was not getting the Lyrica for pain as ordered. -2. Review of the Face Sheet dated 03/31/26 for Resident #3 revealed an original admission date of 01/27/26.- Review of the History & Physical dated 01/28/26 for Resident #3 revealed [AGE] year-old male with past medical history of s/p left femoral fracture, s/p prosthetic replacement, s/p left hip arthroplasty. admitted for rehab services. Fall precautions.-Review of admission MDS dated [DATE] for Resident #3 revealed, BIMs Score 12 (cognitively moderately impaired), uses wheelchair and walker. Requires substantial/maximal assistance with toileting, shower, dressing, putting on/taking off footwear, sit to lying, sit to stand and chair/bed transfer. Hypertension, Hip Fracture, Pain in Left Hip, Falls prior to admission, one fall since admission with no injury, Hip Replacement, insulin, Physical/Occupational/Speech therapy.-Review of Care Plan initiated on 03/03/26 for Resident #3 revealed, Alteration in Comfort r/t Left Femur Fracture with surgical interventions. Approaches: Administer pain medication as ordered by physician and assess effectiveness.-Review of Order Audit Report dated 3/31/26 provided by DON for Resident #3 revealed, Lyrica Oral Capsule 25 mg (Pregabalin) give one capsule by mouth two times a day for pain.-Review of Medication Administration Record dated March 2026 for Resident #3 revealed, Lyrica Oral Capsule 25 mg (Pregabalin) give one capsule by mouth two times a day for pain was not administered on the following days.-3/25/25 at 9:00 a.m. and 9:00 p.m.-3/26/25 at 9:00 a.m. and 9:00 p.m.-3/27/25 at 9:00 a.m. and 9:00 p.m.-3/28/25 at 9:00 a.m. and 9:00 p.m.-3/29/25 at 9:00 a.m. and 9:00 p.m.-3/30/25 at 9:00 a.m. and 9:00 p.m.-3/31/26 at 9:00 a.m.Review of IDT Administration Progress Notes for Resident #3 revealed:-3/25/26 at 10:56 a.m. written by LVN FF revealed Lyrica Oral Capsule 25 mg (Pregabalin) give one capsule by mouth two times a day for pain-on order.-3/25/26 at 9:46 p.m. written by Med Aide K revealed Lyrica Oral Capsule 25 mg (Pregabalin) give one capsule by mouth two times a day for pain. On order, pending delivery.-3/26/26 at 10:14 a.m. written by Med Aide K revealed Lyrica Oral Capsule 25 mg (Pregabalin) give one capsule by mouth two times a day for pain. Pending delivery.-3/26/26 at 9:12 p.m. written by Med Aide K revealed Lyrica Oral Capsule 25 mg (Pregabalin) give one capsule by mouth two times a day for pain. Pending delivery, nurse notified.-3/27/26 at 10:31 a.m. written by Med Aide K revealed Lyrica Oral Capsule 25 my (Pregabalin) give one capsule by mouth two times a day for pain. on order.-3/27/26 at 8:00 p.m. written by Med Aide K revealed Lyrica Oral Capsule 25 mg (Pregabalin) give one capsule by mouth two times a day for pain. On order pending delivery, nurse notified.-3/28/26 at 8:27 p.m. written by Med Aide DD revealed Lyrica Oral Capsule 25 mg (Pregabalin) give one capsule by mouth two times a day for pain. Med not available.-3/29/26 at 10:14 a.m. written by Med Aide DD revealed Lyrica Oral Capsule 25 mg (Pregabalin) give one capsule by mouth two times a day for pain. Med not available.-3/29/26 at 9:09 p.m. written by Med Aide DD revealed Lyrica Oral Capsule 25 mg (Pregabalin) give one capsule by mouth two times a day for pain. Med not available.-3/30/26at 10:25 a.m. by Med Aide DD revealed Lyrica Oral Capsule 25 mg (Pregabalin) give one capsule by mouth two times a day for pain. Med not available.-Review of Automated Medication dispensing cabinet Transaction Report for Resident #3 revealed:-Pregabalin 25 mg had been removed on 03/05/26 at 9:45 p.m. by RN CC. -Pregabalin 25 mg had been removed on 03/31/25 at 7:08 p.m. by RN CC. -Pregabalin 25 mg had been removed on 04/01/25 at 11:06 a.m. by LVN T.-Pregabalin 25 mg had been removed on 04/01/25 at 6:42 p.m. by RN CC. Review of Medication Monitoring/Control Record revealed Pregabalin capsule 25 mg one capsule by mouth twice a day was received on 04/04/26 and was started on 4/02/26 at 10:00 a.m.During an interview on 3/27/26 at 3:54 p.m., with Med Aide K revealed that Resident #3 had run out of his pain medication and the Lyrica had not been administered as ordered starting 3/25/2026 through 3/27/2026. She said the nurses were responsible for re-ordering the Controlled Substances for the residents and the Med Aides only re-ordered prescribed medications that were not controlled substances. She said the nurses were aware that the resident had run out of medication and were waiting for the pharmacy to send the medication. She said that the resident complained of pain and was medicated with Tylenol as ordered for pain.During an interview on 3/31/26 at 4:40 p.m., Resident #3 revealed he was alert, oriented to person, place, and time. He said he fell and broke a hip approximately 2 months ago. He said he is medicated for pain, and the medication was effective at times. He said he was getting pain medication and did not know the name of the pain medication. He said he was not having any pain at the time of the interview.During an interview on 3/31/26 at 4:43 p.m., Med Aide K revealed she medicated Resident #3 for pain with Tylenol as needed due to not having the Lyrica on hand to administer as ordered. She said that on 3/31/26 the resident's pain level was at 8 out of 10, 10 being the worst pain. She said the Tylenol decreased the pain level to 7 and the nurses were aware of this.During an interview on 4/02/26 at 9:04 a.m., LVN T revealed Resident #3 rarely complained of pain. She said he had an order for Lyrica and on Monday she had to get it from the automated medication cabinet, because he had run out of the medication. She said it took a while to wait for an approval to remove the Lyrica from the automated medication dispensing cabinet and get the triplicate prescription from the physician, so that was why the resident had run out of the Lyrica. She said the Lyrica could not be pulled from the automated medication dispensing cabinet because they did not have the approval code from the pharmacy.During an interview on 4/02/26 at 9:11 a.m., CNA V revealed Resident #3 as alert, oriented x 3, required minimal assistance with ADLs, continent of bowel and bladder, toileted independently. She said the resident did not complain of pain.During an interview on 4/02/26 at 9:14 a.m., CNA V revealed Resident #3 as alert and oriented x 3, ambulated independently in his room and used a wheelchair to propel himself to the dining room. Continent of bowel & bladder and toileted independently. She said the resident did not complain of pain.During an interview on 4/02/26 at 2:13 p.m., the DON revealed, Resident #3 had fallen at home and sustained a hip fracture. She said that the nurses are able to remove controlled substances from the automated medication cabinet dispensing cabinet when the resident does not have the medication on hand to administer as ordered. She said that the nurses would have to get an approval code to remove medications from the pyxis and get a triplicate prescription from the physician for the pharmacy to send the medication. She said this takes time and that is why the residents run out of medications.3. Review of the Face Sheet dated 03/31/26 for Resident #4 revealed an original admission date of 12/18/25.- Review of the History & Physical dated 11/27/25 for Resident #4 revealed 93-yer-old female with history of Dementia, hypertension, recurrent falls, right radial styloid fracture managed non-operatively with a brace and non-weight-bearing instructions. Osteoarthritis.Review of Quarterly MDS dated [DATE] for Resident #4 revealed, BIMs score 10 (moderately cognitively impaired), limited range of motion to one side upper extremity. Dependent with toileting, shower, dressing, sit to lying, sit to stand, chair/bed transfer and toilet transfer. Frequently incontinent of bowel and bladder. Hypertension, other fracture, Non-Alzheimer's Dementia, anxiety disorder, repeated falls and altered mental status. Frequently complains of pain. Antianxiety and antidepressant.Review of Care Plan dated 12/19/25 for Resident #4 revealed, Potential for acute pain. Approaches: Administer analgesic as ordered.Review of Physician Order Summary dated 03/31/26 for Resident #4 revealed, Pain assessment to be completed every shift.Review of Order Audit dated 03/31/26 provided by ADON A revealed Resident #3 had an order dated 03/26/26 for Tramadol HCL tablet 25 mg give one tablet by mouth two times a day for pain for 5 days.Review of the Medication Administration Record (MAR) dated March 2026 for Resident #3 revealed, Tramadol HCL tablet 25 mg give one tablet by mouth two times a day for pain for 5 days. The MAR documented that the Tramadol was not administered on the following days.-03/26/26 at 9:00 p.m. documented on the MAR code 9 (Other/See Nurses Notes). -03/27/26 at 9:00 a.m. and 9:00 p.m. documented on the MAR code 9 (Other/See Nurses Notes).-03/28/26 at 9:00 a.m. documented on the MAR code 9 (Other/See Nurses Notes).-03/29/26 at 9:00 a.m. documented on the MAR code 9 (Other/See Nurses Notes).Review of the Medication Administration Record (MAR) dated March 2026 revealed Pain Assessment every shift revealed:3/26/26 thorough 3/29/26 revealed resident did not have any pain.Review of IDT Administration Notes revealed:-3/26/26 at 9:18 p.m. written by Med Tech K revealed Tramadol HCL tablet 25 mg give one tablet by mouth two times a day for pain for 5 days. On order, pending delivery.-3/27/26 at 9:48 a.m. written by Med Tech K revealed on order, pending delivery.-3/27/26 at 9:29 p.m. written by LVN J revealed Tramadol HCL tablet 25 mg give one tablet by mouth two times a day for pain for 5 days. On order, pending delivery.-3/28/26 at 10:20 a.m. written by Med Aide DD revealed Tramadol HCL tablet 25 mg give one tablet by mouth two times a day for pain for 5 days. Med not available.-3/29/26 at 9:29 a.m. written by Med Aide DD revealed Tramadol HCL tablet 25 mg give one tablet by mouth two times a day for pain for 5 days. Med not available.During an interview on 3/27/26 at 3:54 p.m. with Med Aide K revealed that Resident #4 had run out of her Tramadol on 3/26/26. She said she did not know if the nurses had reordered the medication.During an interview on 4/02/26 at 10:06 a.m., Resident #4 revealed that initially after the fall she was having a lot of pain. She said she occasionally had pain in her left hip area and was medicated for pain as needed. Resident said she was not having pain at the time of the interview. She had a patch the was applied to the left hip for pain and was effective.Review of facility's undated policy and procedures on Reordering medications provided by ADON A on 3/31/26 at 9:48 a.m. revealed, Policy: The facility will communicate any medication reorders, changes or discontinuations to the pharmacy in accordance with pharmacy guidelines and state /federal regulations. Communication may be transmitted through verbal, written, or electronic orders. Procedure: All orders must be clearly communicated to the pharmacy by the facility. Refills can be requested by placing the refill strip portion of the medication on the Refill Order Form and faxing it to the pharmacy. In the event a medication is requested too soon, the pharmacy will send a Refill Too Soon Communication Form to the facility. The facility will automatically receive the medication when it is due unless the form is signed by a nurse and faxed to the pharmacy for immediate delivery. Electronic Orders: Refill orders can be submitted from a prescriber through their escribing software or through a facilities EMAR system as long as the order is not discontinued.During an interview on 3/31/26 at 4:53 p.m., the Administrator, in the presence of the DON and ADONs revealed that he was not aware of any concerns voiced by the Nurses regarding re-ordering of medications and timely delivery of medications. He said their Vendor was out of town and did not have a contract with a local pharmacy. He said having an out-of-town Vendor pharmacy always causes problems with timely delivery of re-ordered medication. The DON said that all the licensed staff were agents which meant the licensed staff could re-order-controlled substances from the pharmacy. She said sometimes the delivery of controlled substances is delayed because some of the medications require a triplicate from the physician. She said that at times the pharmacy would not refill the prescriptions for the controlled substances because it was too soon to ask for a refill. She said she was not aware of the facility's policy and procedure specified when medications needed to be reordered. The Administrator said he had not read the Vendor Pharmacy contract and did not know what it said about re-ordering medications. The state surveyor asked for a copy of the Vendor pharmacy contract. Controlled Substances:During an observation on 3/27/26 at 4:03 p.m., of the Controlled Drug Binder on Hall 300 revealed the Controlled Drugs-Count Record dated 3/26/26 had not been signed by the nurse going off on the 2-10 shift.During an observation and interview on 3/27/26 at 4:03 p.m., of the Controlled Drug Binder on Hall 100 revealed Controlled Substances had already been initialed by RN CC as the Nurse off on the 2-10 shift prior to counting controlled substances with on-coming nurse on the 10-6 shift. He said, I already signed off because I'm going to be here when the night nurse comes. He said they had been trained to count controlled substances at the change of shift with the on-coming nurse at the start of the shift to verify the controlled counts were correct.During an interview and record review on 3/27/26 at 4:14 p.m., the DON, in the presence of the Administrator and ADON B revealed:-RN CC on the 100 Hall had initialed the Controlled Drugs-Count Record prior to counting controlled substances with the on-coming nurse on the 10-6 shift. She said, RN CC already came to tell me what he had done.-The nurse on Hall 200 on the 6-2 shift had not signed the Controlled Drugs-Count Record on 03/08/26 with the off going 10-6 nurse at the start of the 6-2 shift and at the end of the 6-2 shift with the on-coming 2-10 nurse.-The nurse on Hall 300 at the end of the 6-2 shift had not signed off on 3/26/26 at the end of the 2-10 shift. The DON said the nurses had been trained on-going to count controlled substances at the change of shift with the off-going nurse and the on-coming nurse after they had verified that controlled substance counts were correct at the change of shift.The state surveyor requested a copy of the facility's policy and procedure on Controlled Substances.During an observation on 3/31/26 at 4:51 p.m., revealed Controlled substances had been counted at the change of shift on the 300 Hall, and the Controlled Drugs-Count Record had not been signed by the off- going and the on-coming nurse.Review of Vendor Pharmacy Contract dated 11/25/2025 did not document they had contract with a local pharmacy to provide pharmacy services after hours. Review of the facility's policy and procedures on Controlled Substances revised on November 2022 provided by ADON A on 3/30/26 at 12:05 p.m. revealed, Policy Statement: The facility complies with all laws, regulations and other requirements related to handling, storage, disposal and documentation of controlled medications (listed as Schedules II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). Policy Interpretation and Implementation: Control substances are counted upon delivery. The nurse receiving the medication along with the person delivering the medication must count the controlled substances together. Both individuals signed the designated controlled substance record. Dispensing and Reconciling Controlled Substances: Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow -up. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the Director of Nursing Services.

Based on observation, interview and record review the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 (Residents #1) of 8 resident reviewed for accidents and supervision. The facility failed to ensure adequate supervision to prevent accidents for Resident #1 when, on 8/3/25, Receptionist A allowed him to leave the building without confirming with staff whether he could be outside independently or verifying if he was a visitor. Resident #1 made it across the border to another state and then to the port of entry to another country. Resident #1 required hospital treatment for dehydration. The noncompliance was identified as PNC. The IJ began on 8/3/25 and ended 8/4/25. The facility had corrected the noncompliance before the survey began. These failures placed residents at risk of injuries, hospitalization, and death.Findings included: Record review of Resident #1's face sheet dated 8/13/25 revealed a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #1's History and Physical dated 7/7/25 revealed diagnoses of Schizophrenia (a brain disorder that makes it hard to know what's real, sometimes causing people to hear voices or believe things that aren't true), Anxiety (a condition where a person feels overly worried or fearful, even when there's no real danger), Dementia/Alzheimer's (disease that slowly damages memory and thinking, making it hard to do daily activities), and Depression (long-lasting sadness that affects mood, energy, and interest in everyday life). Resident #1 admission MDS dated [DATE] revealed a BIMS score of 2, indicating his cognition was severely impaired, no wandering behavior was noted and was dependent on ADLs. Record review of Resident #1's elopement assessment dated [DATE] revealed he was not a risk. Record review of Resident #1's incident report dated 8/3/25 written by RN B revealed [Resident #1] was observed at breakfast time, having a meal in the morning in the dining room, around 9:30 am, med aid gave his medication. [Resident #1] is ambulatory, continent of bladder and bowel. When lunch time was coming around 11:30 hours, [Resident #1] was unable to be located, this nurse and CNA started looking for him on every room, every restroom, activities room and therapy room. After that Code Silver (missing person) was announced, Weekend supervisor and HR present at that time were notified. Searching was extended around the building and streets. RP was notified also. He was marked as oriented to person only, confused, and ambulating without assist. Record review of Resident #1's local hospital records dated 8/3/25 revealed Resident #1 was transported by ambulance to the ED from Santa [NAME] Port of Entry with heat exhaustion. He had left physical therapy, decided to walk, became lost, and was later found along the roadside. EMS reported he had been dropped off near the port and began walking in the wrong direction. On arrival at 3:27 MDT, he was alert, warm, and dry, with vitals notable for HR 122 bpm (Normal: 60-100 beats per minute; heart is beating faster than normal ), RR 24 (Normal: 12-20 breaths per minute; is breathing faster than normal), SpO 89% on room air (Normal: 95-100%; Oxygen in the blood is lower than normal), and BP 98/66 (Normal: Around 120/80; The blood pressure is on the lower side but not critically low). Labs showed leukocytosis (this usually means the body is fighting an infection, stress, or inflammation), elevated creatinine (if it's high, it can mean the kidneys are under stress or not working as well as they should), low magnesium (too little magnesium can cause weakness, cramps, or irregular heartbeats), hypophosphatemia (low levels can cause fatigue, muscle weakness, or breathing problems), and elevated glucose (blood sugar is higher than normal). A chest X-ray showed central vascular congestion without consolidation (lungs are showing signs of fluid overload (like early heart failure or too much IV fluid), but there's no infection or collapse in the lung tissue). Treatment included two 1,000 mL IV Lactated Ringer's boluses (they're giving IV fluids rapidly to keep blood pressure up and prevent dehydration), oral Tylenol 1,000 mg, and oral potassium phosphate-sodium phosphate for low phosphate. He was diagnosed with dehydration, elevated creatinine, and heat exposure. After IV fluid resuscitation and clinical improvement, he was discharged back to his prior living arrangement with instructions for follow-up and return precautions.Record review of accuweather.com revealed local weather for August 3, 2025, was a low 76F and high 105F. Record review of accuweather.com revealed bordering city and state weather for August 3, 2025, was a low 76F degrees and high 105F degrees. Record review of Maps (ipone cell phone application) revealed by car, the driving distance from the facility to the Santa[NAME] Port of Entry to Mexico was approximately 13 miles, taking about 19 minutes via I10 and US180.During an interview on 8/13/25 at 11:37 am, Resident #1 stated the incident happened the previous week. He stated he had been sitting outside, decided to go for a walk, got a haircut, then went to a corner store for a soda. He stated he had not planned to leave; it was a spur of the moment decision. He stated he became dehydrated, passed out in a truck, and the driver took him to the hospital where he was treated and returned. He stated staff were worried when he got back, and he felt bad. He stated he felt comfortable at the facility, had no desire to leave, and had been drinking water before leaving.During an interview on 8/13/25 at 6:56 pm, Receptionist A stated she was working on 08/03/2025 when Resident #1 left. She stated she opened the door for him, assuming he was a visitor because she did not recognize him. She stated he smiled and pointed to the door without speaking. She later saw on camera the time was about 9:30 a.m. (the video footage was unavailable for review due to it only going back 7 days). She stated she had been trained to verify with staff before letting someone out but admitted she did not follow procedure, which could place the resident at risk. She stated he was wearing pants, a long sleeve shirt, and had shoes on.During an interview on 8/13/25 at 6:44 pm, RN B stated he last saw Resident #1 around 9:15-9:20 a.m. in the lounge after breakfast. He stated the resident was independent and usually visited friends. He noticed Resident #1 was missing before lunch (approximately 11:30 am), searched his usual spots, and learned from another resident that he had purchased a soda and chips before leaving. RN B stated he notified his supervisors, directed staff to search the facility, and then searched outside up to the fence near a local high school without finding him. RN B stated he was later returned to the facility after he finished his shift. RN B stated Resident #1 had not voiced wanting to leave the facility in the past and did not have history of wandering or exit seeking. During an interview on 8/14/25 at 12:01 pm, the Administrator stated the expectation was for the receptionist to get a sign out sheet signed by the nurse or whoever was taking the resident out and then open the door for him. The Administrator stated Receptionist A did not follow the procedure because she did not get a sign-out sheet signed, and she opened the door for Resident #1. He stated the facility changed the procedure to sign-in/sign-out where everyone needed to sign, the receptionist was educated on the new policy. The Administrator stated Resident #1 had not voiced wanting to leave the facility and did not have exit seeking/ wandering behaviors. The Administrator stated this was the first time Resident #1 had attempted to leave the facility and there had not been any indication for it. The Administrator stated the facility contacted local hospitals to inquire about the resident's whereabouts and was able to locate him. A police report was also filed.Record review of the facility's Signing Resident's Out policy dated August 2006 revealed in part All residents leaving the premises must be signed out. #1- Each resident leaving the premises (excluding transfers/discharges) must be signed out; #6- Staff observing a resident leaving the premises and having doubts about the resident being properly signed out, should notify their supervisor at once.Record review of the facility's Wandering and Elopements policy dated 2001 revealed in part The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. #2- If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner; b. get help from other staff members in the immediate vicinity, if necessary; and c. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises The facility completed the following corrective actions to address the non-compliance after the incident occurred and prior to the surveyor entering on 8/13/25.Record review: Record review of an in-service dated 8/3/25 revealed the topic was resident sign-out procedure and had the Signing Resident's Out policy dated August 2006 policy attached for reference was signed by all staff.Record review of Resident #1's elopement assessment dated [DATE] revealed he was a high risk. Record review of Resident #1 physician order dated 8/3/25 revealed Resident has exit seeking behaviors. Wander Guard to be placed for resident safety. Placement location - right wrist.Record review of Resident #1's progress notes revealed no other elopement's were attempted/ reported. Record review of Resident #1's care plan dated 8/3/25 revealed focus area for elopement risk/wander risk as evidenced by history of wandering off in last 30 days. Impaired safter awareness and require a wander guard for safety with interventions that included Check wander guard placement every shift to ensure wander guard is functioning to right wrist; Visually check wander guard placement every 2 hours. Observations: Observation on 8/13/25 at 11:37 am, revealed Resident #1 was observed with a wander guard to his right wrist. Observation on 8/14/25 at 2:20 pm, recalled Resident #1 was observed with a wander guard to right wristThe facility posted signs at the door All visitors must sign in upon entering and must sign out upon exiting the facility, by entrance door and the reception desk informing all visitors must sign in and out of the facility.Interviews:During an interview on 8/14/25 at 2:30 pm, Resident #1 verbalized understating on the need to sign out and notify the nurse of his outing. He stated he was ok with wearing the wander guard in case he got confused and got out the facility, they would know and get him back inside. He stated he felt ok and felt safe inside the facilityInterviews from 8/13/25 at 6:37 pm- 8/14/25 at 12:01 pm with Receptionist A, RN B, Receptionist C, BOA, LVN D, RN E, and LVN F reflected they had received the in-service on visitor sign in and out sheet on 8/3/25 and verbalized they needed to ask the residents if their nurses were aware of their outing and confirm with the nurses this was signed by all staff. The staff reported that they would reference the elopement binder located in the receptionist area and verify with the nurses. During an interview on 8/14/25 at 12:01 pm, the Administrator stated that the receptionist along with the rest of the staff received an in-service regarding the procedure of signing in and out of the facility. He stated that in order for the incident to not repeat itself again, the facility implemented the process that day for signing in/out, they put Resident #1 on a wander guard and the facility updated his care plan and the elopement assessment to reflect there was a risk of him eloping.

Based on interview and record review, the facility failed to ensure that incidents and investigations were complete and accurately documented for 2 of 6 (Resident #1 and #2) residents reviewed for accuracy and completeness of records. 1. The facility failed to have complete and accurate documentation and investigation for an allegation of misappropriation and exploitation for Resident # 1. 2. The facility failed to complete an incident report or accurately document progress notes, when Resident # 2 exited the facility. These deficient practices could put residents at risk of not receiving needed services such as monitoring or supervision, and incident investigations. Findings included: Resident # 1 Record Review of the admission record dated 6/30/25, revealed an [AGE] year-old male with an original admission date of 11/27/24 and a readmission date of 12/18/24.Record Review of the Initial Evaluation dated 11/27/24 revealed an [AGE] year-old male with a diagnosis of type two diabetes, coronary artery disease (a common and serious condition that affects the heart. It occurs when the coronary arteries, which are the blood vessels responsible for supplying oxygen-rich blood to the heart muscle, become narrowed or blocked), hypertension (a medical condition where the force of blood pushing against the walls of your arteries is consistently too high), and hypothyroidism (or underactive thyroid, is a medical condition where the thyroid gland does not produce enough thyroid hormones to meet the body's needs).Record Review of Resident # 1's initial MDS record dated 11/27/24 revealed a BIMS score of 2 reflecting severe cognitive impairment. MDS revealed Resident #1 had short-term memory problems and was moderately impaired to make decisions regarding tasks of daily life. It described the resident as lethargic (a state of extreme tiredness, sluggishness, and lack of energy or enthusiasm. It implies a noticeable decrease in physical and mental activity). MDS indicated Resident #1 had anxiety disorder and depression.Record Review of Resident # 1's Care Plan initiated on 11/29/24 revealed Resident #1 had a diagnosis of depression and at risk of fluctuating moods with little interest or pleasure in doing things with decreased socialization. The care plan called for interventions to encourage frequent socialization, to be an active participant in decision making, and to voice feelings and thoughts. The care plan revealed Resident #1 had episodes of adverse behaviors such as being verbally aggressive evidenced by cursing, racial yelling and screaming and becoming physically aggressive by hitting staff, kicking, and throwing objects.Record Review of the facility's grievances binder on 6/27/25 at 3:30 PM revealed there were no records of the facility investigation on the allegations of exploitation for Resident # 1.Record Review of Resident #1s EMR from 12/27/24 to 7/1/25, revealed there were no progress notes created to document the Exploitation allegation regarding Resident # 1. In an Interview on 6/26/25 at 3:24 PM with ADON A, she stated she did not know anything about this incident. ADON A said she had not discussed the possible misappropriation of the resident's funds with the Administrator or anyone in the facility. ADON A stated any suspicion of exploitation was expected to be thoroughly investigated by gathering information with staff, residents, and family members. ADON A said if she had been overseen the investigating of the incident, she would have documented attempts to contact the family members and would have conducted in-services to employees to make sure everyone knew how to report ANE if they suspected something.In an Interview on 6/26/25 at 3:38 PM with the Administrator, he explained the facility made several attempts to contact the family but were not successful, and the family did not return their calls. The Administrator admitted there were no records of the facility's attempts to contact the family. He stated the investigation was concluded and was deemed unfunded since there was no way to gather information from the family members.In an interview on 6/27/25 at 9:30 AM with the Ombudsman revealed he had no knowledge of the incident in which it was alleged that a staff member from the facility had stolen money from Resident # 1. He stated the facility had not provided information on this incident to him. In an interview on 6/30/25 at 10:06 AM with SW, revealed she remembered Resident # 1 being discharged from the facility in December 2024. SW said she had no knowledge of the incident in which it was reported that someone from the facility had stolen money from Resident # 1. SW stated that whenever there's an allegation of abuse, neglect or exploitation, it was expected for the facility to investigate and make the effort to contact family members and other residents and determine if they felt safe in the facility. SW explained that after an investigation of this nature, the facility gives training to staff to ensure they know how and when to report any suspicions of ANE. In an interview on 6/30/25 at 1:03 PM with LVN D, she stated she was the charge nurse of the hallway on which Resident # 1 resided while admitted in the facility. LVN D said she had no knowledge of missing funds from the resident and that she was not approached by anyone in the facility to ask her if she knew anything about it. In an Interview on 7/1/25 at 3:18 PM, the Administrator revealed he had not documented anywhere the attempts the facility had done to contact Resident # 1's family members and that he did not interview staff or other residents from the facility to thoroughly investigate the allegation of exploitation. The administrator admitted that he had not gathered enough information to find the investigation unfounded, as stated in his Provider Investigation Report. Resident # 2Record Review of Resident #2's admission record dated 6/26/25, revealed a [AGE] year-old female with an admission date of 4/22/25.Record Review of Resident #2's History and Physical dated 4/24/25 revealed a [AGE] year-old female with a diagnosis of atrial fibrillation (An irregular and often rapid heart rate that can lead to symptoms like palpitations, shortness of breath, and fatigue), hypothyroidism (A condition in which the thyroid gland doesn't produce enough crucial hormones. Symptoms can include fatigue, weight gain, constipation, dry skin, and increased sensitivity to cold), morbid obesity and falls with recent right humerus fracture (A break in the humerus bone, which is the long bone in the upper arm that extends from the shoulder to the elbow), impaired gait and mobility (deviation from a normal, healthy walking pattern), generalized weakness, sarcopenia (A progressive and generalized skeletal muscle disorder involving the accelerated loss of muscle mass and function).Record Review of the admission MDS dated [DATE] revealed a [AGE] year-old female with a diagnosis of anxiety disorder and depression. MDS revealed under section GG for Functional Abilities that Resident #2 had LROM on lower extremities and required a wheelchair for mobility. It revealed Resident #2 required substantial assistance with personal hygiene and upper body dressing, sitting to standing, transferring to toilet and from chair to bed and for walking ten feet on uneven surfaces. Functional Abilities revealed Resident # 2 was dependent on staff for toileting hygiene, showering, lower body dressing and putting on footwear. MDS revealed under section V for Care Area Assessment that Resident #2 triggered for cognitive loss, dementia, and falls.Record Review of Resident #2's Care Plan initiated on 4/23/25 revealed Resident #2 had episodes of anxiety and was at risk for fluctuations in mood related to a diagnosis of bipolar disorder (a mental health condition that causes extreme and unusual shifts in a person's mood, energy, activity levels, and concentration), episodes of adverse behaviors evidenced by being verbally aggressive, cursing and using racial slurs, yelling and screaming and being physically aggressive evidenced by hitting, pinching, kicking and throwing objects. It revealed Resident # 2 had a tendency for fabricating facts, manipulating staff, and displaying accusatory behavior towards staff. The resident was at risk of complications due to refusing assistance with ADLS and refusing medications.In an Interview on 6/26/25 at 8:45 AM with the DON, she explained the incident should have been recorded at least in a progress note, but to her knowledge, there was no incident report created or recorded about the incident regarding Resident # 2.In an Interview on 6/26/25 at 8:50 AM with ADON A, she stated that to her knowledge, there had been no progress notes entered into EMR regarding Resident # 2 leaving the facility's parking lot on her own. She explained she believed an incident report was not needed because the incident happened while the resident was under the family's care and not the facilities.In an interview on 7/1/25 at 8:30 AM with the Admissions Coordinator, revealed she had not created documentation on her involvement with the incident related to Resident # 2 arguing with her family members and refusing to get into their vehicle. She stated that since she worked on business operations in the facility, she did not have access to EMR to write progress notes in the residents' charts. The Admissions Coordinator said she believed either the Social Worker, ADON A or the Administrator should have documented the incident either in the progress notes or in an incident report.In an interview on 7/1/25 at 8:40 AM with the Administrator, he stated he had not documented anything related to the incident with Resident # 2 because she was under the family's care at that time, but admitted that on hindsight, either progress notes or an incident report should have been completed either by him or ADON A.In an interview on 7/1/25 at 10:12 AM with ADON B stated she was not in the facility the day the incident occurred with Resident # 2 and her family members, however, she expressed that an incident such as this should have been documented in the resident's progress notes by ADON A or as an incident report by the Administrator or the DON. She stated that whenever there's an unusual incident involving a resident from the facility, it should be documented somewhere.In an interview on 7/1/25 at 10:24 AM with CNA I, he stated he assisted ADON A and the Guest Relations staff to get Resident # 2 into the vehicle to then transport her shopping and afterwards, back to the facility. He explained he did not document the incident in the resident's progress notes because he was not directed to document it. CNA I said he had received training in proper documentation but said he thought that either ADON A or the Administrator would create an incident report for the resident.In an interview on 7/1/25 at 10:37 AM the Guest Relations staff revealed she had not created documentation in the resident's progress notes or anywhere else because she was not sure she had to document it. The Guest Relations staff admitted she did not follow up to ask for guidance with ADON A or the Administrator and asked if she needed to write a witness statement or any other documentation explaining what happened with Resident # 2 on 6/23/25.In an interview on 7/1/25 at 10:50 AM with DON revealed she did not document anything because she was not directly involved in the incident with Resident # 2 leaving the facility without her family members. The DON stated the expectation was that someone wrote the incident in the progress notes to have documentation of it or to create an incident report explaining everything that happened that day.Record Review of the facility's policy and procedures dated 2001 titled Charting and Documentation read in part:1. Documentation in the medical record may be electronic, manual, or combination.2. The following information is to be documented in the resident medical record: e. Events, incidents or accidents involving the resident; and3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.4. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LPN/LVN, physicians, therapists, etc.) in accordance with state law and facility policy. Certified nursing assistants may only make entries in the resident's medical chart as permitted by facility policy. Record Review of the facility's policy and procedures revised in February 2021 and titled Change in a Resident's Condition or Status, read in part:Policy Statement: our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).Policy Interpretation and Implementation.1. The nurse will notify the resident's attending physician or physician on call when there has been a(n):a. Accident or incident involving the resident.2. A significant change of condition is a major decline or improvement in the resident's status.3. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

The facility failed to maintain a system to prevent Resident #1's personal money from being taken by a staff member.Findings included:Record Review of the admission record dated 6/30/25, revealed an [AGE] year-old male with an original admission date of 11/27/24 and a readmission date of 12/18/24. Record Review of Resident # 1's admission MDS record dated 11/27/24 revealed a BIMS score of 2 reflecting severe cognitive impairment. MDS revealed Resident #1 had short-term memory problems and was moderately impaired to make decisions regarding tasks of daily life. It described the resident as lethargic (a state of extreme tiredness, sluggishness, and lack of energy or enthusiasm. It implies a noticeable decrease in physical and mental activity). MDS indicated Resident #2 had anxiety disorder and depression.Record Review of Resident # 1's Care Plan initiated on 11/29/24 revealed Resident #1 had a diagnosis of depression and at risk of fluctuating moods with little interest or pleasure in doing things with decreased socialization. The care plan called for interventions to encourage frequent socialization, to be an active participant in decision making and to voice feelings and thoughts. The care plan revealed Resident #1 had episodes of adverse behaviors such as being verbally aggressive evidenced by cursing, racial yelling and screaming and becoming physically aggressive by hitting staff, kicking, and throwing objects.Record Review of CNA C's bank account Deposits and other Additions from 11/20/24 to 12/19/24 revealed the following Mobile on-line banking deposits made by from Resident # 1's smart phone:*12/04/24 Mobile online bank payment of 3,500.00*12/05/24 Mobile online payment of 1,800.00*12/09/24 Mobile online payment of 1,480.00*12/13/24 Mobile online payment of 500.00*12/16/24 Mobile online payment of 500.00*12/18/24 Mobile online payment of 3,000.00The total amount deposited into CNA C's bank account from the Mobile-Online banking deposits was $10,780.00 made by resident # 1.Record Review of CNA C's bank account Withdrawals and other subtractions dated 1/23/25 revealed the following transactions were done by Resident # 1's bank account:*01/23/25 CLAIMS PROCESSING -3,500.00*01/23/25 CLAIMS PROCESSING -3,000.00*01/23/25 CLAIMS PROCESSING -1,800.00*01/23/25 CLAIMS PROCESSING -1,480.00*01/23/25 CLAIMS PROCESSING -1,200.00*01/23/25 CLAIMS PROCESSING -800.00*01/23/25 CLAIMS PROCESSING -500.00*01/23/25 CLAIMS PROCESSING -500.00Total amount withdrawn from CNA C's bank account. Total Amount: -12,780.00 Record Review on 7/1/25 at 9:33 AM of the SW progress notes dated 12/23/24 revealed she had a meeting with the DON informing her Resident # 1 had a change of condition and was very confused. Progress notes indicated the facility discussed the possibility of having the resident on palliative care (specialized medical care for people living with a serious illness). Progress notes revealed the SW called the family to discuss this possibility, and the family had agreed with the plan. SW informed DON and LVN D that family had agreed to place Resident # 1 under palliative care.Record Review on 7/1/25 at 11:33 AM of the medical progress notes dated 11/25/24 revealed Resident # 1 was an [AGE] year-old male who seemed slightly confused on that date but was alert to time, place and person.In an Interview on 6/26/25 at 3:38 PM with the Administrator, revealed, he was informed by his superiors that a Google review was posted in the facility's website by the resident's family, that stated that a nurse, name unknown, had stolen thirteen thousand dollars from the resident. The Administrator said the facility made several attempts to contact the family but were not successful, and the family did not return their calls. The Administrator said the investigation was concluded and was deemed unfunded since there was no way to gather information. He said that he had not conducted any investigation to determine if a staff member had taken money from the resident, because had had not been able to contact the resident's family member.Telephone interview on 6/30/25 at 11:36 AM with Resident #1's family member, stated Resident #1 had been admitted to the facility for about a month and they visited him frequently. The family member said Resident #1 was very confused and unable to carry meaningful conversations, remember passwords or easily operate his smartphone, so she had removed the passwords to allow him to use the phone without issues. The family member also stated that during one visit, she accessed Resident #1's Bank account app on his smartphone to monitor for activity and observed several transactions made from Resident #1's phone through the Mobile banking on-line application (a popular money transfer service that allows individuals to send and receive money directly between eligible U.S. bank accounts) to a recipient identified as CNA C. These transactions totaled almost thirteen thousand dollars. The family member reported that after noticing these transactions, she reported it to the police and was informed the financial crimes department would investigate the incident. The family member stated she had reported these transactions to Resident # 1's bank on 1/23/25 after Resident # 1 had been discharged from the facility. The family member said on that same date she had contacted the Police department to make a report and stated the Police had advised her to not contact the facility or the administrator to ask questions and to allow the police to investigate.In an interview on 6/30/25 at 12:03 PM with CNA C, stated she started receiving money from Resident #1 around November 2024 through the Mobile banking on-line application, totaling around ten thousand dollars. CNA C explained she was assigned to Resident #1's care and often interacted with him. She stated one day, Resident #1 saw her crying and asked what was wrong, to which she explained she was having financial problems. CNA C said Resident #1 offered her money to help, and she accepted his assistance. CNA C explained Resident # 1 continued to send her money throughout November 2024 and December 2024. CNA C then stated she considered keeping and using the money but became scared and returned it to Resident #1's account. CNA C also stated she had been trained on ANE (Abuse, Neglect, and Exploitation) and misappropriation upon being hired at the facility in 2021 and had been in-serviced several times on ANE, though she could not remember her last training date. CNA C stated she understood she had done something wrong and should not have accepted money from Resident #1, as it could have been perceived as taking advantage of him. CNA C explained she had not informed the Administrator or anyone at the facility that Resident #1 had given her money, nor did she disclose this information to her coworkers, other residents, or Resident #1's family members.In an interview on 6/30/25 at 1:03 PM with LVN D, revealed she was the charge nurse that was assigned to Resident # 1 resided while he was at the facility. LVN D said she remembered Resident # 1 was able to have small talk and answer simple questions such as how are you? and answering, good morning but he was not alert enough to make his own decisions. LVN D stated she had no knowledge of missing funds from the resident and that she was not approached by anyone in the facility to ask her if she knew anything about it.In an interview on 6/30/25 at 3:11 PM with the Bank Teller, revealed that CNAC's bank account had been closed at that bank on 4/8/25 after the account was over drafted. The bank teller stated that in the system he was able to see that on 1/23/25, a claim was made from a different bank account and the amounts that had been deposited via the Mobile-Online bank account had been extracted and returned to the original bank account. The bank teller explained that this happens when a bank gets a fraud report and they put a stop to the transactions from one bank account to the other.Record Review of the facility's policy and procedures revised in February 2021 and titled Resident Rights, read in part: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be free from abuse, neglect, misappropriation of property, and exploitation.Record Review of the Team Member Handbook Receipt and Acknowledgement, signed and initialed by CNA C on 10/28/21 read in part: By signing in the space below, I am indicating that I have received a copy of this facility Team Member Handbook and agree to abide by the guidelines outlined in the Handbook. Additionally, I specifically acknowledge the following. I understand and agree to comply with [facility] guideline forbidding abuse, neglect and/or exploitation of a patient/resident, including misappropriation of patient/resident property and I understand my obligation to immediately report such behavior including injuries of an unknown source or alleged behavior, as set forth in [facility] guideline.Record Review of the facility's policy and procedures dated April 2025 and titled Gifts and Gratuities, in the employee handbook read in part: The Company strongly discourages accepting gifts, gratuities, or tips from residents or donors and/or giving gifts or gratuities to residents or donors. If a question arises regarding this issue, speak with your supervisor or Administrator. Business and Financial Practices: Fraud is an intentional deception or misrepresentation made by a person who knows the deception could result in some unauthorized benefit or financial gain. The act does not have to be successful; it is enough that the person attempted the deception.Record Review of the Facility's ANE Policy revised in April 2021 read in part: Abuse, Neglect, Exploitation and Misappropriation Prevention Program.Policy Statement:Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.Policy Interpretation and ImplementationThe resident abuse, neglect and exploitation prevention program consist of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:a. Facility Staff 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; c. theft, exploitation or misappropriation of resident property.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.

Based on interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 (Resident #2) of 6 residents reviewed for accident prevention. The facility failed to provide supervision when Resident #2 exited the facility on 6/23/25 and propelled herself in her wheelchair down towards the sidewalk exiting the parking lot of the facility. This failure could place residents at risk of a fall, weather exposure, or being run over by a moving vehicle, which could result in injuries. Scope and Severity D Findings include:Record Review of Resident #2's admission record dated 6/26/25, revealed a [AGE] year-old female with an admission date of 4/22/25.Record Review of Resident #2's History and Physical dated 4/24/25 revealed diagnoses of atrial fibrillation (An irregular and often rapid heart rate that can lead to symptoms like palpitations, shortness of breath, and fatigue), hypothyroidism (A condition in which the thyroid gland doesn't produce enough crucial hormones. Symptoms can include fatigue, weight gain, constipation, dry skin, and increased sensitivity to cold), morbid obesity and falls with recent right humerus fracture (A break in the humerus bone, which is the long bone in the upper arm that extends from the shoulder to the elbow), impaired gait and mobility (deviation from a normal, healthy walking pattern), generalized weakness, sarcopenia (A progressive and generalized skeletal muscle disorder involving the accelerated loss of muscle mass and function).Record Review of the admission MDS dated [DATE] revealed a [AGE] year-old female with a diagnoses of anxiety disorder and depression. MDS revealed under section GG for Functional Abilities that Resident #2 had limited ROM on lower extremities and required a wheelchair for mobility. It revealed Resident #2 required substantial assistance with personal hygiene and upper body dressing, sitting to standing, transferring to toilet and from chair to bed and for walking ten feet on uneven surfaces. Functional Abilities revealed Resident # 2 was dependent on staff for toileting hygiene, showering, lower body dressing and putting on footwear. MDS revealed under section V for Care Area Assessment that Resident #2 triggered for cognitive loss, dementia, and falls.Record Review of Resident #2's Care Plan initiated on 4/23/25 revealed Resident #2 had care areas as follows:*episodes of anxiety and was at risk for fluctuations in mood related to a diagnosis of bipolar disorder (a mental health condition that causes extreme and unusual shifts in a person's mood, energy, activity levels, and concentration), episodes of adverse behaviors evidenced by being verbally aggressive, cursing and using racial slurs, yelling and screaming and being physically aggressive evidenced by hitting, pinching, kicking and throwing objects.*tendency for fabricating facts, manipulating staff, and displaying accusatory behavior towards staff.* at risk of complications due to refusing assistance with ADLS and refusing medications.*on psychotropic medications and was at frequent fall risk.In an Interview on 6/26/25 at 8:45 AM with the DON revealed she received a report from the admissions coordinator that a family member had called the receptionist from the facility stating Resident # 2 was down the street and was requesting assistance. DON stated the ADON, and other staff left the building to look for Resident # 2 and they were able to find her about a block away and after taking her to the store, staff returned to the facility along with Resident # 2. DON stated the incident should have been recorded at least in a progress note, but to her knowledge, there was nothing recorded about the incident.In an Interview on 6/26/25 at 8:50 AM with ADON A stated the family members were talking to an LVN at the nurse's station. She said that later at 1:46 PM, the Administrator sent a group text message to staff informing them that Resident #2 was away from the building exiting the parking lot and requesting their assistance to locate Resident # 2. ADON A said the Admissions Coordinator told her that the family had gone back to the facility to request assistance because Resident # 2 was refusing to get into her vehicle and was propelling herself in her wheelchair to the store. ADON A stated she and the Admissions Coordinator went looking for Resident #2 and found her at a business parking lot next to the facility. Resident # 2 was arguing with her family member and was shouting and refusing to get into the family's vehicle. ADON A said she stood with the resident for about ten minutes, trying to de-escalate and convince her to go back to the facility, but Resident # 2 declined and insisted on being taken to the store.In an Interview on 6/26/25 at 10:14 AM Resident # 2, revealed she remembered the incident that happened on 6/23/25. Resident # 2 said her family had gone to the facility to pick her up and take her to the store. She stated after having lunch, her family kept talking to a nurse and were taking too long to take her out and she became upset. Resident # 2 said she exited through the front door while a man (name unknown) opened the door, and she took off in her wheelchair to try to get to the store. Resident # 2 said one of her family members came running after her and another family member caught up with them in a nearby parking lot trying to get her in her family's vehicle, but she wanted to go to the store and refused to get into the vehicle. Resident # 2 said some nurses and staff (she did not know their name) went to the parking lot and told her they would take her to the store, and she agreed to get into the vehicle. Resident # 2 said she did some shopping and was taken back to the facility and said she went about her day without concerns.In an Interview on 6/26/25 at 10:51 AM with Family Member J, revealed that she had gone to the facility with another family member to sign out Resident # 2 and take her to the store for groceries. She stated she was talking to a nurse, and Resident # 2 got upset because she was taking too long to take her out and left on her own. Family Member J said a receptionist (name unknown) had opened the door for Resident # 2, and she had gone out unsupervised. Family Member J said she got worried because Resident # 2 could get into an accident if left unsupervised, so she ran out of the facility along with the other family member to look for the Resident. Family Member J said while she got into her vehicle, the other family member ran after Resident # 2, who had already left the facility parking lot and was propelling herself towards the sidewalk. Family Member J said she caught up with Resident # 2 and her family member around the corner in a business parking lot and started to ask Resident # 2 to get into the vehicle, but she kept refusing. Family Member J said she went back to the facility and requested their assistance to get Resident # 2 into her vehicle and went back to the parking lot where Resident #2 and her family were. Family Member J said once she arrived back at the resident's location, the facility staff was already there with her family member, trying to de-escalate the situation and trying to convince Resident # 2 to get back to the facility. Family Member J said she told the facility staff that she needed to leave because Resident # 2 would stay upset while she was in her presence and told them to take care of the Resident. Family Member J said she left the Resident under the facility staff care, and she and the other family member left Resident # 2 with the staff. Family Member J stated the incident would have been avoided if Resident # 2 was supervised while outside the facility or by not allowing her to exit on her own.In an Interview on 6/26/25 at 1:48 PM with Receptionist F revealed she did not go outside the facility to check if Resident #2 was still by the front door or if she was leaving the facility's parking lot. Receptionist F stated she did not receive official training which talked about timeframes for checking on residents who wished to be outside the facility by the front door. Receptionist F stated she had been informed that before letting a resident go out the door she needed to check with a nurse before, and admitted she failed to do so. Receptionist F stated she should have kept the resident inside and in line of sight before allowing her to exit the facility and admitted she failed to report to the Administrator, DON or ADON that she let the resident exit the facility and did not check on her after. In an Interview on 6/26/25 at 11:38 AM with the Administrator revealed that on 6/23/25 the family members talked to LVN D to inform her they were taking the resident out. He stated that later that day at around 1:30, the Admissions Coordinator went into his office and told him Resident # 2's family member was requesting for the facility to assist her because the resident was refusing to get into her vehicle, and she had left the facility parking lot on her own. The Administrator said he sent a group text message to the facility staff so they could assist the family members with the resident. The Administrator said that to his knowledge, a family member had signed Resident # 2 out and after they left the facility, they got into an argument which led to the resident leaving the parking lot on her own and refusing to get into the family' vehicle. The Administrator said the family members left Resident # 2 under the facility staff care, and they took the resident shopping and took her back to the facility later that evening. The Administrator said there was no incident report created for the incident because the resident was under the family's care once they had signed her out but that in hindsight, Him, the DON or ADON should have recorded the incident to have accountability and statements from those who were involved.In an Interview on 6/26/25 at 11:50 AM with LVN D revealed Resident # 2 should not be left outside the facility unsupervised because the resident was impulsive and had the tendency to make rash decisions which could place her in danger, such as leaving the facility on her own in her wheelchair.In an Interview on 6/26/25 at 2:00 PM with the Admissions Coordinator, stated she did not know if Resident # 2 should be left unsupervised outside the facility and said that the facility should train staff better for them to be able to know which residents can be out of the facility by themselves.In an Interview on 6/27/25 at 11:30 AM with the Director of Rehabilitation, explained that Resident #2 was able to propel on her own while in her wheelchair. She stated Resident #2 required supervision while outside the facility due to her history of cognitive deficit. She said the resident could be forgetful and could be non-compliant with treatment and therapy by refusing to do the exercises needed for her recovery. She stated the resident could become agitated, belligerent, and could potentially get confused and not know how to go back to the facility if she left the premises and she could potentially fall off her wheelchair sustaining injuries.In an Interview on 6/27/25 at 2:38 PM with ADON A revealed that Resident # 2 was impulsive and should not be outside the facility without supervision. ADON A said the resident could potentially attempt to leave on her own if left alone outside and could potentially sustain a fall, injuring herself and there was a possibility of dehydration due to the hot weather.In an Interview on 6/27/25 at 2:53 PM with the DON revealed Resident # 2 should not have been left out of the facility on her own without proper supervision. DON said there was a potential for the resident to fall off her wheelchair and sustain injuries and there was a risk of heatstroke due to the hot weather.In an Interview on 6/27/25 at 3:06 PM with LVN G she stated Resident # 2 should not be outside the facility without supervision, and said the resident had strong opinions about things and could be stubborn. LVN G said she had seen the resident argue with her family in the past and said Resident # 2 more than likely would leave the facility if she had the opportunity and was left unsupervised. LVN G explained the resident could potentially fall from her wheelchair if she left on her own. LVN G said the expectation was if a resident exited the building, staff would ask them if they needed help, ask them where they were going, ask them where their family member was, try to redirect and get them back into the building, and contact immediate supervisor for assistance if needed.In an Interview on 6/27/25 at 3:21 PM with CNA H, stated he had been working at the facility for two years and he was familiar with Resident # 2. He stated CNAs knew that if a resident wished to go outside to sit by the entrance of the facility, they needed to consult with a nurse first and ask if it was permitted for the resident to go outside. CNA H stated he would not make the decision on his own if a resident could go outside by themselves. CNA H explained that he believed Resident # 2 should not be outside on her own because she can get confused sometimes and if she was left unsupervised, there was a possibility for her to leave without telling anyone in the facility. He stated there was a possibility of the resident getting hurt from having an accident by falling off her wheelchair or if she went on the street there was a risk of a traffic accident.In an Interview on 6/27/25 at 3:35 PM with the Administrator, he said staff should periodically check on those residents who are able to go outside to the front on their own. The Administrator stated the facility did not have a written policy which stated a concrete timeframe for staff to check on residents who are outside. The Administrator explained that staff should have checked if Resident # 2 stayed in the parking lot or if she attempted to leave on her own. The Administrator stated Resident # 2 could potentially leave the premises if she was left unchecked for a long period of time due to resident being impulsive. The Administrator stated there was no policy, procedure or training for staff, including receptionists, on how to check residents' safety while they were outside in front of the facility. In an interview on 6/30/25 at 10:01 AM with the SW she stated Resident # 2 should not be outside on her own because the resident might not be aware of danger. The SW said Resident # 2 should have staff supervising her while outside the facility because there was a potential outcome of her trying to get up from her wheelchair and potentially fall resulting in injuries. SW explained there was the potential of the resident trying to leave the premises if she was left unsupervised.Record Review of the facility's policy and procedure dated 2001 and titled Signing Residents Out, stated in part: Staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once. Inquiries concerning the signing-out of residents should be referred to the director of nursing services or to the administrator.

Based on interview and record review, the facility failed to ensure labratory services were provided to meet the needs of the resident in accordance with professional standards of practice, and for 1 of 6 residents (Resident #1) reviewed for labratory service. The facility failed to ensure LVN A followed up with diagnostic lab for Resident #1's stat KUB order. This failure could place residents at risk of delayed treatment, unmet medical needs, and a decreased in quality of life. The findings included: Record review of Resident #1's hospital transfer form not dated revealed a [AGE] year-old female who was admitted to the facility on [DATE] and had diagnoses of: Attention and concentration deficit (Difficulty staying focused or paying attention, which can affect daily tasks and communication); Cognitive communication deficit (Problems with thinking and using language, such as trouble understanding, speaking, or remembering words); Unspecified dementia (general decline in memory and thinking skills, often due to aging or disease, that affects daily life); Alzheimer's disease (progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks); Cervical disc disorder with radiculopathy (problem with a disc in the neck that is pressing on nerves, causing pain, numbness, or weakness in the arms or shoulders); Type 2 diabetes with diabetic neuropathy (nerve damage caused by high blood sugar levels, leading to tingling, pain, or numbness, usually in the feet or hands); Other specified depressive episodes (period of depression with symptoms like sadness, loss of interest, or fatigue that doesn't exactly fit the standard categories but still significantly impacts well-being); Gastronomy status (person has feeding tube directly placed in their stomach); Gastroesophageal reflux disease (GERD) without esophagitis (stomach acid flows back into the esophagus (food pipe), causing heartburn or discomfort, but without damage to the esophagus lining); Epigastric pain (pain or discomfort in the upper belly area, just below the ribs, often related to digestion); Mild protein-calorie malnutrition (not getting enough calories and protein, which can lead to weakness, weight loss, and poor healing); Essential (primary) hypertension (high blood pressure with no known specific cause, which can increase the risk of heart problems over time); Atherosclerotic heart disease without angina (buildup of plaque in the heart's arteries, reducing blood flow, but without causing chest pain yet); Peripheral vascular disease (poor circulation in the arms or legs due to narrowed blood vessels, often leading to leg pain when walking) Record review of Resident #1's physician order dated 07/06/24 revealed every shift for adequate nutrition related to mild protein-calorie malnutrition, Glucerna 1.2 at 45ml/hr with water flush 140ml/hr. Record review of Resident #1's physician order dated 6/29/23 revealed mechanical ground texture, nectar consistency, finely chopped/minced may have thin small quantities with spoon only, hold feeding 30 minutes before and 30 minutes after. Record review of Resident #1's physician order dated 3/3/25 revealed Lasix oral tablet 20mg, give 1 tablet by mouth one time a day for swelling. Record review of Resident #1's physician order dated 5/19/23 revealed Plavix tablet 75mg, give one tablet via g-tube one time a day related to peripheral vascular disease. Record review of Resident #1's MARS for May 2025 revealed Lasix 20mg tablet and Plavix 75 mg were not administered on 5/14/25. Record review of Resident #1's SBAR dated 5/14/25 revealed situation: gastronomy tube blockage or displacement; vitals: blood pressure 104/48, pulse 62, respiration 17, temperature 98.2 Fahrenheit, weight 96.2 lbs, blood sugar 187; Code status: DNR; Primary care clinician notified yes, date 5/14/25 at 6:55 am, recommendations of primary clinician KUB Xray. Record review of Resident #1's progress note dated 5/14/25 written by RN C revealed Notified ADON on-call, RP, and Dr. r/t resident pulling out her G-tube. New order for STAT KUB placed. Pending Xray in order to re-start tube feedings. RT with no s/s of pain or discomfort lying in bed, awakens easily to voice. Record review of Resident #1's progress note dated 5/14/25 written by LVN A revealed Nurse received on report that the resident removed her peg tube during the night. This nurse replaced new 27F/20mL peg tube with no problems. No pain or discomfort note or reported. Placement auscultate with 30 mL of residuals noted. STAT KUB was ordered to confirm placement. MD, ADON and [RP] all aware, evening nurse notified on report. During an interview on 5/20/25 at 11:50 am, LVN A stated that Resident #1's stat KUB order was placed around 7:00 a.m., but the imaging was not completed during his shift. LVN A stated that stat x-ray orders were typically addressed promptly but may have been delayed depending on the imaging service's availability. LVN A stated that he contacted the local diagnostic lab and was informed they were booked but would arrive as soon as possible. LVN A stated that he documented the follow-up but later noted that his entry did not appear in the system, only in the 24-hour report. LVN A stated that he checked the 24-hour report and found no documentation completed either. LVN A stated that he could not recall if he reported the matter to the ADON or DON. During an interview on 5/20/25 at 1:31 pm, The Dr. stated that the imaging vendor typically responded within 2-3 hours for stat orders, depending on location, technician availability, and competing priorities. The Dr. stated that she was not contacted about a delay in imaging after the stat order was placed early on May 14. The Dr. stated that had she been notified by mid-morning (e.g., around 10-11 a.m.) that imaging was still pending, she might have directed that Resident #1 be sent out to the hospital sooner for timely intervention. The Dr. stated the potential risk for delayed stat KUB would be risk of delayed treatment. During an interview on 5/20/25 at 3:08 pm, The imaging representative stated that she reviewed the KUB X-ray reports associated with the resident's G-tube placement verification. The imaging representative stated that the first STAT order was entered on May 14, 2025, at 7:20 am CDT (6:20 am MST) The imaging representative stated that the order was assigned to a technician at 11:29 am CDT (10:29 am MST), The imaging representative stated that the imaging was completed at 3:41 pm CDT (2:41 pm MST), and the report was signed by the interpreting physician at 8:18 pm CDT (7:18 pm MST). The imaging representative stated that two prior time slots had been assigned but were unsuccessful. The imaging representative stated that she did not recall receiving any follow-up calls from the facility regarding the STAT order. During an interview on 5/20/25 at 3:28 pm, ADON stated that she received a text message at 5:34 a.m. on May 14, 2025, from RN C, who was on night shift. ADON stated that RN C reported Resident #1's G-tube had dislodged and that she was preparing to send the resident to the hospital. ADON stated that shortly afterward, RN C contacted the Responsible Party who requested that nursing staff attempt reinsertion. ADON stated that she was later informed around 6:30 am that the G-tube had been reinserted and that a stat KUB had been ordered to confirm placement. ADON stated that the order was submitted through the facility's portal system. ADON stated that although stat imaging orders were submitted electronically, nursing staff were expected to follow up with a phone call to notify the imaging provider that the request was urgent. ADON stated that while stat responses typically occurred within a few hours, delays could happen, and staff should monitor and follow up. During an interview on 5/21/25 at 9:21 am, the DON stated that she was notified by LVN C around 5:45 to 6:00 a.m. that Resident #1's G-tube had become dislodged, and that Resident #1 RP had requested for LVN A to replace it. The DON stated that by the time she arrived at the facility, the G-tube had already been replaced and they were awaiting the stat KUB. The DON stated that the imaging contract required a response within four hours; however, reading the film could take additional time depending on the availability of the physician. The DON stated she expected the nurses to follow up if diagnostic personnel had not arrived within the four-hour timeframe and report it to her and the physician. The DON stated failure to follow up could delay treatment based on results. Record review of the facility's Test Results policy dated 04/2007 did not address STAT orders. Record review of the facility's contract agreement with local imaging services read in part Addendum No. 1 Additional Terms and Conditions: #2 Services will be provided twenty-four hours a day for STAT ordered exams (Radiology) .#4 STAT exams will be performed within 60 minutes of the call to [local imaging services]. A verbal report will be provided within 120 min or less of completion of the exam. Routine exams will be provided within 120 min or less of completion of the exam.

Based on interview and record review, the facility failed to immediately inform the resident, consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of four residents reviewed for resident rights. The facility failed to ensure LVN A and LVN B communicate to the physician the need to administer medications while pending G-Tube placement result from KUB. This failure could place residents at risk of unmet medical needs and a decreased in quality of life. The findings included: Record review of Resident #1's hospital transfer form not dated revealed a [AGE] year-old female who was admitted to the facility on [DATE] and had diagnoses of: Attention and concentration deficit (Difficulty staying focused or paying attention, which can affect daily tasks and communication); Cognitive communication deficit (Problems with thinking and using language, such as trouble understanding, speaking, or remembering words); Unspecified dementia (general decline in memory and thinking skills, often due to aging or disease, that affects daily life); Alzheimer's disease (progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks); Cervical disc disorder with radiculopathy (problem with a disc in the neck that is pressing on nerves, causing pain, numbness, or weakness in the arms or shoulders); Type 2 diabetes with diabetic neuropathy (nerve damage caused by high blood sugar levels, leading to tingling, pain, or numbness, usually in the feet or hands); Other specified depressive episodes (period of depression with symptoms like sadness, loss of interest, or fatigue that doesn't exactly fit the standard categories but still significantly impacts well-being); Gastronomy status (person has feeding tube directly placed in their stomach); Gastroesophageal reflux disease (GERD) without esophagitis (stomach acid flows back into the esophagus (food pipe), causing heartburn or discomfort, but without damage to the esophagus lining); Epigastric pain (pain or discomfort in the upper belly area, just below the ribs, often related to digestion); Mild protein-calorie malnutrition (not getting enough calories and protein, which can lead to weakness, weight loss, and poor healing); Essential (primary) hypertension (high blood pressure with no known specific cause, which can increase the risk of heart problems over time); Atherosclerotic heart disease without angina (buildup of plaque in the heart's arteries, reducing blood flow, but without causing chest pain yet); Peripheral vascular disease (poor circulation in the arms or legs due to narrowed blood vessels, often leading to leg pain when walking) Record review of Resident #1's physician order dated 07/06/24 revealed every shift for adequate nutrition related to mild protein-calorie malnutrition, Glucerna 1.2 at 45ml/hr with water flush 140ml/hr. Record review of Resident #1's physician order dated 6/29/23 revealed mechanical ground texture, nectar consistency, finely chopped/minced may have thin small quantities with spoon only, hold feeding 30 minutes before and 30 minutes after. Record review of Resident #1's physician order dated 3/3/25 revealed Lasix oral tablet 20mg, give 1 tablet by mouth one time a day for swelling. Record review of Resident #1's physician order dated 5/19/23 revealed Plavix tablet 75mg, give one tablet via g-tube one time a day related to peripheral vascular disease. Record review of Resident #1's MARS for May 2025 revealed Lasix 20mg tablet and Plavix 75 mg were not administered on 5/14/25. Record review of Resident #1's SBAR dated 5/14/25 revealed situation: gastronomy tube blockage or displacement; vitals: blood pressure 104/48, pulse 62, respiration 17, temperature 98.2 Fahrenheit, weight 96.2 lbs, blood sugar 187; Code status: DNR; Primary care clinician notified yes, date 5/14/25 at 6:55 am, recommendations of primary clinician KUB Xray. Record review of Resident #1's progress note dated 5/14/25 written by RN C revealed Notified ADON on-call, RP, and Dr. r/t resident pulling out her G-tube. New order for STAT KUB placed. Pending Xray in order to re-start tube feedings. RT with no s/s of pain or discomfort lying in bed, awakens easily to voice. Record review of Resident #1's progress note dated 5/14/25 written by LVN A revealed Nurse received on report that the resident removed her peg tube during the night. This nurse replaced new 27F/20mL peg tube with no problems. No pain or discomfort note or reported. Placement auscultate with 30 mL of residuals noted. STAT KUB was ordered to confirm placement. MD, ADON and [RP] all aware, evening nurse notified on report. During a follow up interview on 5/20/25 at 2:38 pm, LVN A stated that he did not administer any medications to Resident #1 during his shift based on the report he received from the outgoing nurse (RN C). LVN A stated that he was informed the physician had directed staff to hold all medications at that time. LVN A stated that although Resident #1 was on pleasure feedings and might have tolerated medications in crushed form, no such attempts were made during his shift, as the prior report indicated a hold on all medications. During a follow up interview on 5/20/25 at 2:23 pm, The Dr. stated that she did instruct staff to withhold medications following the dislodgement of Resident #1's G-tube due to that being the primary source of medication administration until KUB placement was completed to verify placement. The Dr. stated that the facility had the option to crush and administer medications orally if the resident was able to tolerate it. The Dr. stated that this was a common alternative when a G-tube was temporarily unavailable, provided the patient could safely ingest the medication. The Dr. stated that she was not specifically informed whether this practice was carried out in this case. The Dr. stated that had there been difficulty administering medications, she expected to have been notified by the facility. The Dr. stated that she did not receive any communication indicating that medications were withheld or that administration was interrupted during that period. The Dr. stated that failing to administer medications, even in crushed form, could pose a concern if not reported. The Dr. stated that although medication administration had not previously been problematic, the facility should have reported any inability to administer medications. The Dr. stated that she did not receive any such report. The Dr. stated that while regular administration of Lasix or anticoagulants such as Plavix was important, a single missed dose was unlikely to cause significant harm. The Dr. stated that not administering Lasix while the resident was not eating or drinking adequately could potentially prevent dehydration. The Dr. stated that missing one dose of an anticoagulant generally did not result in immediate complications. The Dr. stated that she had not seen any indications in the hospital records of coagulation-related issues. During an interview on 5/20/25 at 2:46 pm, LVN B stated she worked the 2-10 shift on May 14th, 2025. LVN B stated the KUB for Resident #1 was completed at the beginning of her shift. LVN B stated that while waiting for verification of tube placement, staff were unable to administer anything via the G-tube. LVN B stated she did not give medications by mouth, as the resident had difficulty swallowing and the physician had not cleared oral administration. LVN B stated she did not call the physician to clarify if oral administration was an option. LVN B stated she did not believe there was a risk by not administering the medications due to learning that Resident #1 was diagnosed with kidney failure her medications may have led to a more rapid decline. During an interview on 5/20/25 at 3:28 pm, ADON stated that she did not receive any report indicating delays in imaging on May 14, 2025. ADON stated that while G-tube administration was not possible due to the tube's status, medications could have been crushed and administered orally as Resident #1 was receiving pleasure feedings. ADON stated that in such cases, it was expected that nursing staff follow up with the physician to clarify whether medications could be given orally . ADON stated that she was not made aware that medication had been withheld and did not find documentation indicating the physician had been contacted regarding alternative administration routes. ADON stated that she reviewed the MAR and found no medications were administered on the day of the G-tube dislodgement. ADON stated that Resident #1 was prescribed Plavix and Lasix for fluid retention and swelling and had a history of heart-related conditions. ADON stated that the risks included fluid overload and heart problems. During an interview on 5/21/25 at 9:21 am, The DON stated that Resident #1 received pleasure feedings and was not NPO, stating she ate well. The DON stated that medications had been placed on hold, and while crushed medications could have been considered, she was informed they were held, likely out of concern that the daughter may not have approved of crushed administration. The DON stated that she expected nursing staff to follow physician orders and document accordingly. The DON stated that missing a single dose of medications such as Plavix and Lasix would likely not have posed significant risk, as Plavix was a long-acting medication.

Based on, interviews, and record review 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 medical, nursing and mental and psychosocial needs for 2 (Residents #1 and 2) of 4 residents reviewed for care plans. -The facility failed to ensure Resident #1 and 2's diagnoses of dysphagia (difficulty swallowing) was addressed on their care plan. This failure could place resident at risk for not having their individual needs met in a timely manner injury, and a decline in physical well-being. Findings included. Review of Resident #1 face sheet, dated 04/10/2025, reflected a [AGE] year-old female with an original admitted [DATE] and a readmitted [DATE] to the facility with a diagnosis of dysphagia oropharyngeal phase(difficulty moving food and liquids from back of the mouth to esophagus). Review of Resident #1's Annual MDS, dated [DATE], reflected Resident #1 had moderate impairment of cognitive skills for daily decision making (decisions poor; cues/supervision required). Resident #1 needed supervision or touching assistance with eating (Helper provides verbal cues and or touching/ steady and or contact guard assistance as resident completes activity. Assistance may be provided throughout activity or intermittently). MDS did not reflect resident had any signs and symptoms of possible swallowing disorder. Review of Resident # 1's comprehensive Care plan dated 01/09/25 did not reflect the dysphagia diagnosis. Resident #2 Review of Resident #2 face sheet, dated 04/10/2025, reflected an [AGE] year-old male with an admitted [DATE] to the facility with a diagnosis of dysphagia oropharyngeal phase (difficulty moving food and liquids from back of the mouth to esophagus). Review of Resident #2's quarterly MDS, dated [DATE], reflected Resident #2 had a BIMS score of 07 indicating severe cognitive impairment. Resident #1 needed supervision or touching assistance with eating(Helper provides verbal cues and or touching/ steady and or contact guard assistance as resident completes activity. Assistance may be provided throughout activity or intermittently). MDS did not reflect resident had any signs and symptoms of possible swallowing disorder. Review of Resident # 2's comprehensive Care plan dated 02/04/25 did not reflect the dysphagia diagnosis. Interview on 04/09/25 at 1:43 p.m. with DON, revealed the purpose of the care plan was to show the kind of care the resident needed. She stated dysphagia was supposed to be included in the care plan because it was in both residents' diagnosis upon admission to the facility. She stated that MDS coordinator was responsible for completing care plan assessments. She stated nursing interventions were being done such as sitting residents at assisted feeding table in the dining room, CNAs observed her for any food pocketing or trouble swallowing and prompting to eat meals. The risk of not having dysphagia included in the care plan was that signs of dysphagia could be missed by the staff and could have resulted in signs not being reported to nurse. Interview with MDS coordinator on 4/09/25 at 2:07p.m. revealed that dysphagia was a therapy diagnosis for both residents and therefore this did not need to be added in the care plan because it was not a medical diagnosis. This diagnosis was rationalized with the therapeutic diet which was puree foods for both residents. She stated both residents are seated at the assisted feeding table and monitored by the staff for any signs of trouble swallowing. Review of facility policy Care Plans - Comprehensive Person Centered revised on 03/2022, reads in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident. the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 (Residents #5, #16 and #26 ) of 9 residents reviewed for dignity. Resident #16 did not have a privacy bag on his catheter bag. Resident# 5 and Resident# 26 had their names written on their clothes with black marker across their chest. This failure could place residents at risk of diminished quality of life. Findings included: Resident #5 Record Review of Resident # 5's Admission Record dated 3/6/25 revealed he was an [AGE] year-old male with an initial admission of 8/1/23 and a readmission on 12/10/24. His diagnoses included attention and concentration deficit, depression, unspecified dementia, anxiety, cognitive communication deficit and depressive episodes. Record Review of Resident # 5's quarterly MDS dated [DATE] reflected a brief interview for mental status score of 12 (moderate cognitive impairment). It indicated he had present symptoms of depression, hopelessness, trouble falling or staying asleep and feeling bad about himself with a frequency of seven to eleven days in a period of two weeks. Record Review of Resident # 5's Care Plan revised 2/4/25 reflected Resident # 5 was at risk of depression and he was to be encouraged to socialize frequently, to participate in his decision makings, to voice his thoughts and feelings. It reflected Resident # 5 would maintain a sense of dignity by being clean, dry, odor free and well groomed. During an observation on 03/03/25 at 11:59 AM at the dining room, Resident # 5 was observed eating his lunch at the left side of the dining hall sitting by himself. Resident # 5 was eating a pureed meal at this time. He was wearing a long sleeve gray sweater, and, on his chest, he had his last name written with black marker. The letters spelling his name were between two to three inches in length and width. During an observation and interview on 03/04/25 at 02:50 PM at Resident #5's room, he was in bed watching TV. Resident # 5 had challenges with his speech. Resident # 5 was asked if he liked to have his name written on his clothes on his chest and he said no. Resident # 5 was not able to provide more information and he kept watching TV. Resident #16 Record Review of Resident #16's Admission Record dated 3/4/25 revealed he was a [AGE] year-old male with an initial admitted [DATE] and a readmitted [DATE]. His diagnoses included end stage renal disease, fluid overload, renal dialysis (a life-sustaining treatment that replaces the function of failing kidneys), urinary tract infection and type 2 diabetes. Record Review of Resident #16's initial MDS dated [DATE] reflected a brief interview for mental status score of 12 (moderate cognitive impairment). His MDS was still in progress and was not completed at this time. Record review of Resident #16's care plan dated 3/1/25 reflected Resident #16 had altered urinary elimination related to urinary retention; he was to be administered with antibiotics as prescribed. Resident #16 was at risk for edema related to his diagnosis of renal failure and refusals of dialysis. During an observation on 03/03/25 at 10:52 AM Resident # 16 was laying on his bed watching TV. Resident # 16's foley bag was hanging from his bed frame and was not covered with a privacy bag. The bag was also touching the floor. During an observation and interview on 03/04/25 at 11:36 AM Resident # 16 was laying on bed watching TV, his foley bag was not covered by a privacy bag and was touching the floor. Resident # 16 said he had not been educated to know his foley bag should not be touching the floor and said he did not know the risk of infection it posed. Resident # 16 said he did not know his foley bag should be in a privacy bag and said he would feel ashamed if other people saw the contents of the bag especially at this time since he had a urinary tract infection and blood was visible in the tubbing and inside the bag. Resident #26 Record review of Resident #26's Admission record dated 3/5/25 revealed he was an [AGE] year-old male with an admitted [DATE]. Record review of Resident #26's quarterly MDS dated [DATE] reflected a brief interview for mental status score of 14 (cognitively intact). Resident # 26's mood interview revealed symptoms of depression and hopeless for two to six days in a period of two weeks. Record review of Resident #26's Care Plan revised on 11/10/24 revealed he was taking antianxiety medication, and he was to be monitored for depression. It revealed Resident # 26 had cognitive impairment with memory problems and staff was to meet and anticipate his needs by maintaining his dignity encouraging him to attend activities of his preference and to encourage him to maintain a home like environment in his room. During an observation and interview on 03/03/25 at 10:17 AM with Resident # 26 in his room, he was exercising using his peddler, sitting down on his wheelchair. He was wearing a yellow and gray sweater and across his chest, he had his last name written with black marker. The letters were around 3 to 6 inches in length and width. The resident stated did not know who had written his name on his sweater and that his clothes were labeled for the most part on the back of his shirts where the brand tag could be found. Resident # 26 said he did not like to have his name displayed on the open, but that he was going to change clothes after taking a shower later in the day. In an interview on 03/04/25 at 11:40 AM with LVN A he said the facility has their own laundry and they are supposed to label the resident's clothes on the inside where only laundry staff can see it. LVN A said the facility was not supposed to label residents with their names on their chest or a visible area because it could violate their rights or dignity making them feel like they are being labeled. In an interview on 03/04/25 at 11:52 AM with CNA B, she said she the facility trained the staff to label the resident's clothes on the back where the tag or brand label is located inside of the shirts. CNA B staff was not supposed to write the residents names on a visible area because that violates their privacy. CNA B stated residents could feel ashamed and exposed if they had labels that were visible for everyone to see. In an interview on 03/04/25 03:05 PM with CNA C, stated she had been trained that clothes should have the residents name on the inside because their privacy needed to be protected. CNA C said a resident could feel labeled or ashamed by having their name displayed to the public in general and all staff was responsible for ensuring the resident's rights were respected. In an interview on 03/06/25 10:44 AM with RN D he said the residents should not have their names displayed for everyone to see because it could potentially violate their privacy or dignity making them feel as if they were labeled, signaled or identified without their consent. In an interview on 03/06/25 at 01:09 PM with the ADON, she stated the facility staff labeled the residents clothes on the back where the tag was. The ADON said she had observed on that date the resident council president wearing a shirt with the resident's name displayed. The ADON said if the resident's family [NAME] in the clothes pre-labeled, she would not tell them anything because it was their right to bring in clothes for their loved ones. In an interview on 03/06/25 at 03:37 PM the DON she said facility wrote the names of the residents inside and on the back of the clothes where the tags were. The DON said that if a resident had their name written on an exposed area such as on their chest or any part of their clothes that was visible to everyone, it could result on residents fell ing like they were singled out or signaled and this could potentially be a violation of their right to privacy. In an interview on 03/06/25 at 02:52 PM with the Administrator, he stated the facility label the resident's clothes on the back by the tag. The Administrator said he was not aware there were residents with their names written with their names across their chests. The Administrator said there was a dignity issue with the resident having their name written on their clothes across their chest for everyone to read. The Administrator stated if a family member was to take clothes to a resident with their name written with marker on their chest, he would have let them know that it was not acceptable and that it was a violation of their loved one's rights to privacy and dignity. The administrator said his expectation was that if a staff member observed a resident with a piece of clothing labeled like that, they needed to report it to him so the resident's dignity could be protected and for the facility to correct the issue. In an interview on 3/6/25 at 1:10 PM a policy for labeling the resident's clothes to protect their dignity and privacy was requested from the ADON. At 3:37 PM on 3/6/25, the DON went into the conference room and informed the ADON the facility did not have policies addressing these topics. Record review of the facility's policy titled Catheter Care dated 07/2022 stated in part: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. Ensure drainage bag is located below the level of the bladder to discourage backflow of urine.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #1) reviewed for change in condition. On [DATE] around 2PM, CNA B failed to report to LVN D that CNA B observed Resident #1 had blue lips and difficulty breathing. CNA B failed to report Resident #1's change in condition to LVN D so that LVN D could reassess Resident #1. LVN D, when notified by the family that they were requesting 911 called responded that they (the family) could call 911 if they wanted. LVN D failed to re-assess Resident #1 by not checking her lung sounds, attempting the Heimlich maneuver, and staying with the Resident #1 to determine if she was choking, aspirating, or developing difficulty with chewing or swallowing. The Family contacted 911 and EMS arrived and transferred Resident #1 to the hospital. Resident #1 was intubated at the local hospital, and expired on [DATE]. An IJ (immediate jeopardy) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 1:15 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of more than minimal harm at a scope of isolated because all staff had not been trained on reporting changes in condition. This failure placed residents at risk for not being assessed by nursing staff, and serious changes of condition going unrecognized and untreated. Findings included: Record review of Resident #1 ' s face sheet dated [DATE], revealed, an [AGE] year-old female admitted on [DATE], diagnosed with Muscle weakness, Acute Respiratory failure with Hypoxia (not enough oxygen in the blood) she was a full code status. Record review of Resident #1 ' s quarterly MDS dated [DATE], revealed ADLs for feeding to be Independent to setup or clean up assistance. Resident #1 ' s BIMS score was a 15 score, indicating no cognitive impairment. There was no indication of swallowing issues. Record review of Resident #1 ' s physician order dated [DATE] revealed no concentrated sweets, diet regular texture, thin consistency. Record review of Resident #1 ' s Nutrition Risk assessment dated [DATE], revealed Regular Diet and Thin liquids. Record review of Resident #1 ' care plan dated [DATE] revealed focus area of receiving a therapeutic or altered consistency diet and it at risk for nutritional impairment with no concentrated sweets, regular texture and thin liquid Record review of Resident #1 ' s Progress Note written by LVN D dated [DATE] revealed Resident #1 choked on a piece of meat. Resident #1 was able to spit the meat out. Did not appear aspirate. Resident #1 ' s family member called local police because he felt Resident #1 was Not Doing Well. Resident #1 is vitally stable and blood sugar level is 129. Oxygen via nasal intact, oxygen 93% on 3LPM. EMS arrived and will be taking residents to local hospital. Record review of Resident #1 ' s EMS record dated [DATE] revealed they arrived at resident at 2:13 pm, patient is unresponsive with rapid breathing presented to be laying supine on her bed in nursing home. Patient had trouble breathing and was breathing rapidly. Family called 911 and gave report to EMS. Patient was assessed and did have rapid breathing at about 35 breathes per minute and did have wheezing on the left side of her lungs with diminished lung sounds to the right. Patient was placed on a mass nonrebreather at 15 ml per minute. Patient had an initial saturation of 58%. Record review of Resident #1 ' s local hospital emergency department dated [DATE] revealed diagnoses of altered mental status, aspiration of food, and respiratory failure (difficulty to breathe) Record review of Resident # ' s1 local hospital consultation note dated [DATE] revealed reason for consultation patient sedated and intubated upon evaluation. History of present illness revealed patient was emergently intubated in the emergency department and bronchoscopy was performed by Doctor but unable to remove the entire choked material. Record review of Resident #1 ' s local hospital discharge summary dated [DATE] revealed palliative following morning, the patients RP came to bedside and change to code status to DNR. The patient died at 2:53 am on [DATE]. Record review of Resident #1 ' s Death Certificate dated [DATE], indicated cause of Death was Acute on chronic Respiratory failure with hypoxia, Aspiration Pneumonia, Aspiration of food, and Sequelae of choking. During an interview on [DATE] at 10:21 AM with CNA C revealed on [DATE] at 1:30 PM-2:00 PM, CNA C was told by Resident #1 ' s family member, who was present in Resident #1's room, that Resident #1 had stopped eating and speaking when he was feeding her as they were conversing. CNA C gave Resident #1 water and patted Resident #1 on the back, just in case she had food in her throat. CNA C denied seeing Resident #1 turning blue, struggling for air, nor coughing. CNA C stated she went to get LVN D at that time. During an interview on [DATE] at 12:58 PM, with LVN D revealed she assessed Resident #1 on [DATE] around 1:30 PM-2:00 Pm and found no sign or symptoms of choking or aspiration. LVN D stated she took vital signs that were within normal range and had not seen any respiratory distress and Resident #1 was able to talk. LVN D stated she took Resident #1 vitals and oxygen level, she stated she did not have her stethoscope with her to listen to lung sounds because it was missing. LVN D stated Resident #1 did not appear to be in respiratory distress. LVN D stated Resident #1 did not have any swallowing issues and was redirected to eat slow. LVN D stated there were no restrictions to her diet she had a regular diet with thin consistency. LVN D stated Resident #1 son went to let her know he would be calling 911; she stated she went to assess her again and did not see any distress and told Resident #1 family to call 911 while she got Resident #1 paperwork ready. During an interview on [DATE] at 10:57 AM with CNA B revealed at around 2:00P on [DATE], CNA B initiated initial rounds starting her evening (,d+[DATE]pm). CNA B stated when entered Resident #1 ' s room CNA B observed Resident #1 was slouching down in her bed, was turning blue around her lips, Resident #1 appeared rigid and loose, and was struggling to breathe. CNA B repositioned Resident #1 to see if it would help improve her breathing. CNA B did not notify LVN D as she was told by the family member that LVN D had already completed an assessment of Resident #1 and found nothing to be wrong with Resident #1. CNA B stated she told Resident #1 family member if i were you I'd call 911. During an interview on [DATE] at 12:25 PM the Family member stated he was told by CNA B to go call 911 on [DATE] little after 2 PM. The Family member went to the nurse's station to notify LVN D to call 911 but LVN D stated if he wanted to call he could. The Family member called 911. During an interview on [DATE] at 1:31 pm, the DON stated she would have expected for LVN D to have checked Resident #1 airway and use stethoscope to listen to lung sounds. DON stated she was not aware that CNA B saw the resident in distress and did not report it to the nurse. During an interview on [DATE] at 3:31 pm, the Physician stated if Resident #1 was seen turning blue and with difficulty in breathing the staff should had taken immediate action to call 911 to get further evaluation at the emergency room . Record review of the Facility Foreign Body Airway Obstruction Management (Choking) dated ,d+[DATE], revealed, If a resident is coughing forcefully and is able to speak, monitor the situation and intervene if the condition doesnt improve, following the guidelines for performing Heimlich maneuver. If the resident becomes unconscious, lower resident to the ground, call for help and activate the emergency response system. Clear the airway only if the object is seen using the finger sweep motion. Initiate CPR if indicated. The policy did not specify what type of assessment to conduct. The Administrator and the DON were informed on [DATE] at 1:15 PM, that an Immediate Jeopardy (IJ) had been identified and a copy of the IJ Template identifying the areas of non-compliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] and read: Alleged Issues: The facility failed to ensure resident #1 was free from neglect when they failed to implement their system for a choking resident, when they failed to activate the emergency response system. Goal: Facility will be in compliance with federal health, safety, and/or quality regulations. Its employees or service providers are to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Approaches: The Director of Nursing, Clinical Support Specialist, and ADON ' s will deliver all following in service education to nurses one on one. Nursing staff will be in-serviced to respond to medical emergencies for residents, staff, and visitors. The employee who first witnesses or is first on site of a medical emergency, will initiate immediate action, (if trained), including CPR as appropriate, basic first aid, or (if not trained), summon for assistance immediately. Staff will not leave the resident unattended until appropriate nursing personnel are on site. A nurse will assess the situation and determine the severity of the emergency. If necessary, designate a staff member to perform emergency response including calling EMS if necessary. This in-service was initiated on [DATE]. All nursing staff will be in serviced prior to them arriving to the facility for their next shift. The Director of Nursing, Clinical Support Specialist, and ADON ' s will deliver all following in service education to nurses one on one. The facility medical Director was informed of the IJ on [DATE] by the Facility Administrator. Resident #1 expired in the hospital [DATE]. All nursing staff will be in serviced, that if they are notified of a change in condition, they must immediately go assess the resident. This in-service was initiated on [DATE]. The Director of Nursing, Clinical Support Specialist, and ADON ' s will deliver all following in service education to nurses one on one. All nursing staff will be in serviced prior to them arriving to the facility for their next shift. All nurses will be required to notify the DON of any changes in condition that require higher level of care, prior to transfer The DON will review new hire orientation packet to ensure these above in services are completed prior to the first shift on the floor. DON will provide in-service to nurses to Changes in condition will be reviewed using the SBAR/E-Interact Change of Condition form will be utilized in the EMR, and a change of condition note will be opened every shift for at least 72 hours to monitor. The Director of Nursing, Clinical Support Specialist, and ADON ' s will deliver all following in service education to nurses one on one. All nursing staff will be in serviced prior to them arriving to the facility for their next shift. The DON has completed in-service education on [DATE], with the RN weekend supervisor regarding supervisor to round on all residents on the weekend, on all residents in facility to ensure no changes in condition are in progress, that have not been previously addressed. Monitoring: The 24-hour report in the EMR which runs all progress notes in real time, will be monitored daily in the clinical meeting for changes in condition by the clinical team, DON/ADON/MDS. The DON or designee will perform random in person audits with nursing staff to ensure they understand the emergency response procedure, as well as notification of changes in condition, at least 3 nursing staff daily X1 month. This process began [DATE]. Changes in condition will be reviewed using the SBAR/E-Interact Change of Condition form will be utilized in the EMR, and a change of condition note will be opened every shift for at least 72 hours to monitor. The DON/Clinical team will monitor daily in clinical meeting to ensure changes in condition are addressed and interventions in place. This process began [DATE]. DON/ADON ' s will make rounds daily M-F, the weekend RN supervisor will round on all residents on the weekend, on all residents in facility to ensure no changes in condition are in progress, that have not been previously addressed, daily X 1 month. This process began [DATE]. Assessment: The Director of Nursing reviewed the 24-hour report on [DATE], to ensure there were no changes in condition that she was not aware of. On [DATE] the DON made rounds on all residents in the facility to ensure there were no residents who had a change in condition that was not already identified. On [DATE], the Regional Clinical Support Specialist added at risk residents with respiratory disorders or dysphagia to the CNA Kardex for increased monitoring during meals. QAPI Committee review: An interim QAPI committee meeting will be completed on [DATE]. IDT will review for compliance monthly in QAPI X3 months. The Plan of Removal revealed the facility took the following actions: Record review [DATE]: 1. QAPI dated [DATE]: this QAPI meeting is being conducted to discuss the plan of removal for IJ received on [DATE]. Attached is the plan of removal and the steps we will follow to ensure compliance has been met. attendance: Administrator, DON, medical director, IPC, regional clinical. 2. In-service dated [DATE]: making rounds on all residents on the Saturday and Sunday to assess for change of condition and report to DON. This is documented in midnight census. signed by RN S. 3. In-service dated [DATE]: DON will be notified of each change in condition that may require a higher level of care, immediately and transfer as needed. DON will ask staff if a head-to-toe assessment was completed and results. signed by DON. 4. In-service dated [DATE]: change in condition reporting (MD/nurse/RP) and response to medical emergencies. CNA to contact DON if nurse does not assess resident. signed by staff on several shifts. 5. In-service dated [DATE]: providing care to include assessing, evaluating, and responding to resident needs. signed by staff on several shifts. 6. Midnight census dated [DATE]: tool used by the DON and checked off on all stating she laid on eyes on all residents, stated 1 was in the hospital and 2 were ordered UA ' s. No respiratory/dysphagia concerns identified. Interviews on [DATE] started from 8:54 am- 10:58 am revealed: CNA G, LVN H, CNA I, CNA J, LVN D, CNA K, CNA N, LVN O, CNA P, CNA Q, LVN R, CNA T, CNA U, CNA V confirmed receiving in-services for reporting changes in condition to the charge nurse; when changes in condition are reported to the nurse, they will conduct a head to toe assessment and report changes and condition and head to toe assessment to ADON/DON, RP, and MD. CNA to contact DON if nurse does not assess resident. Providing care to include assessing, evaluating, and responding to resident's needs. If a medical emergency the CNA is to stay by resident ' s bedside and yell out for help. RN S confirmed receiving in-service on making rounds on all residents on the Saturday and Sunday to assess for change of condition and report to DON and would documented in midnight census. DON stated staff were in-serviced on: RN would be making rounds on all residents on Saturdays and Sundays using the midnight census and any findings would be documented on the midnight census. She will be notified of each change in condition that may require a higher level of care, immediately and transfer as needed. The DON will ask staff if a head-to-toe assessment was completed and results. Change in condition reporting (MD/nurse/RP) and response to medical emergencies. CNA to contact DON if nurse does not assess resident. Providing care to include assessing, evaluating, and responding to resident needs. The DON stated she checked all residents off on the census stating she laid on eyes on all residents, stated 1 was in the hospital and 2 were ordered UA ' s. No respiratory/dysphagia concerns identified. The DON stated she was in-serviced on being notified of changes in condition and ask for head-to-toe assessment results. The Physician stated he was notified of the IJ. The Administrator stated the physician was notified of the IJ. The Administrator stated the DON did all the in-services and he held the QAPI meeting on [DATE]. Observations on [DATE] from 9:47 am- 10:48 am revealed: CNA P was able to identify Resident #6 with respiratory distress and showed Resident #6 ' s kardex that revealed if resident appears to have respiratory change, staff member to notify nurse for assessment. CNA Q was able to identify Resident #11 with respiratory distress and showed Resident #11 ' s kardex that revealed if resident appears to have respiratory change, staff member to notify nurse for assessment. CNA T was able to identify Resident #12 with dysphagia and showed Resident #12 ' s kardex that revealed monitor/ document/ report as needed any signs and symptoms of dysphagia. Pocketing, choking, coughing, drooling, holding food in mouth. Several attempts at swallowing. Refusing to eat. Appears concerned during meals. CNA U was able to identify Resident #13 ' s with dysphagia and showed Resident #13 ' s kardex that revealed monitor/ document/ report as needed any signs and symptoms of dysphagia. Pocketing, choking, coughing, drooling, holding food in mouth. Several attempts at swallowing. Refusing to eat. Appears concerned during meals. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 11:15 AM. The facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure that services provided or arranged by the facility met professional standards of quality for 1 of 8 (Resident #1) residents reviewed for care, in that: The facility failed to provide care that included but not limited to assessing, evaluating, and responding to residents needs for Resident #1. On [DATE], LVN D did not conduct a thorough assessment of Resident #1 when informed by CNA C that Resident #1's family informed her the resident had stopped talking while eating and spit out a piece of meat. LVN D did not have her stethoscope to check lung sounds. LVN D, when the family requested 911 be called, responded that they (the family) could call 911 if they wanted. LVN D did not go back to re-assess Resident #1 to determine if the resident needed the Heimlich maneuver, or stay with the resident to observe her eating to determine if there was a problem with her eating or swallowing. The family contacted 911, and EMS took Resident #1 to the hospital where she was intubated, and expired on [DATE]. An IJ (immediate jeopardy) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 1:15 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of potential for more than minimal harm at a scope of isolated because all staff had not been trained on reporting changes in condition. This failure placed Residents at risk for abuse and neglect. Findings included: Record review of Resident #1 ' s face sheet dated [DATE], revealed, an [AGE] year-old female admitted on [DATE], diagnosed with Muscle weakness, Acute Respiratory failure with Hypoxia (not enough oxygen in the blood) she was a full code status. Record review of Resident #1 ' s quarterly MDS dated [DATE], revealed ADLs for feeding to be Independent to setup or clean up assistance. Resident #1 ' s BIMS score was a 15 score, indicating no cognitive impairment. There was no indication of swallowing issues. Record review of Resident #1 ' s physician order dated [DATE] revealed no concentrated sweets, diet regular texture, thin consistency. Record review of Resident #1 ' s Nutrition Risk assessment dated [DATE], revealed Regular Diet and Thin liquids. Record review of Resident #1 ' care plan dated [DATE] revealed focus area of receiving a therapeutic or altered consitency diet and it at risk for nutritional impairment with no concentrated sweets, regular texture and thin liquid Record review of Resident #1 ' s Progress Note written by LVN D dated [DATE] revealed Resident #1 choked on a piece of meat. Resident #1 was able to spit the meat out. Did not appear aspirate. Resident #1 ' s family member called local police because he felt Resident #1 was Not Doing Well. Resident #1 is vitally stable and blood sugar level is 129. Oxygen via nasal intact, oxygen 93% on 3LPM. EMS arrived and will be taking residents to local hospital Record review of Resident #1 ' s EMS record dated [DATE] revealed they arrived at resident at 2:13 pm, patient is unresponsive with rapid breathing presented to be laying supine on her bed in nursing home. Patient had trouble breathing and was breathing rapidly. Family called 911 and gave report to EMS. Patient was assessed and did have rapid breathing at about 35 breathes per minute and did have wheezing on the left side ofver lungs with diminshed lung sounds to the right. Patient was placed on a mass nonrebreather at 15 ml per minute. Patient had an initial saturation of 58%. Record review of Resident #1 ' s local hospital emergency department dated [DATE] revealed diagnoses of altered mental status, aspiration of food, and respiratory failure (difficulty to breathe) Record review of Resident # ' s1 local hospital consultation note dated [DATE] revealed reason for consultation patient sedated and intubated upon evaluation. History of present illness revealed patient was emergently intubated in the emergency department and bronchoscopy was performed by Doctor but unable to remove the entire choked material. Record review of Resident #1 ' s local hospital discharge summary dated [DATE] revealed palliative following morning, the patients RP came to bedside and change to code status to DNR. The patient died at 2:53 am on [DATE]. Record review of Resident #1 ' s Death Certificate dated [DATE], indicated cause of Death was Acute on chronic Respiratory failure with hypoxia, Aspiration Pneumonia, Aspiration of food, and Sequelae of choking. During an interview on [DATE] at 10:21 AM with CNA C revealed on [DATE] at 1:30 PM-2:00 PM, CNA C was told by Resident #1 ' s family member , who was present in Resident #1 ' s room, that Resident #1 had stopped eating and speaking when he was feeding her as they were conversing. CNA C gave Resident #1 water and patted Resident #1 on the back, just in case she had food in her throat. CNA C denied seeing Resident #1 turning blue, struggling for air, nor coughing. CNA C stated she went to get LVN D at that time. During an interview on [DATE] at 12:58 PM, with LVN D revealed she assessed Resident #1 on [DATE] around 1:30 PM-2:00 Pm and found no sign or symptoms of choking or aspiration. LVN D stated she took vital signs that were within normal range and had not seen any respiratory distress and Resident #1 was able to talk. LVN D stated she took Resident #1 vitals and oxygen level, she stated she did not have her stethoscope with her to listen to lung sounds because it was missing. LVN D stated Resident #1 did not appear in respiratory distress. LVN D stated Resident #1 did not have any swallowing issues and was redirected to eat slow. LVN D stated there were no restrictions to her diet she had a regular diet with thin consistency. LVN D stated Resident #1 son went to let her know he would be calling 911; she stated she went to assess her again and did not see any distress and told Resident #1 family to call 911 while she got Resident #1 paperwork ready. During an interview on [DATE] at 10:57 AM with CNA B revealed at around 2:00P on [DATE], CNA B initiated initial rounds starting her evening (,d+[DATE]pm). CNA B stated when entered Resident #1 ' s room CNA B observed Resident #1 was slouching down in her bed, was turning blue around her lips, Resident #1 appeared rigid and loose, and was struggling to breathe. CNA B repositioned Resident #1 to see if it would help improve her breathing. CNA B did not notify LVN D as she was told by the family member that LVN D had already completed an assessment of Resident #1 and found nothing to be wrong with Resident #1. CNA B stated she told Resident #1 family member if i were you I'd call 911. During an interview on [DATE] at 12:25 PM the Family member stated he was told by CNA B to go call 911 on [DATE] little after 2 PM. The Family member went to the nurse ' s station to notify LVN D to call 911 but LVN D stated if he wanted to call he could. The Family member called 911. During an interview on [DATE] at 1:31 pm, the DON stated she would have expected for LVN D to have checked Resident #1 airway and use stethoscope to listen to lung sounds. DON stated she was not aware that CNA B saw the resident in distress and did not report it to the nurse. During an interview on [DATE] at 3:31 pm, the Physician stated if Resident #1 was seen turning blue and with difficulty in breathing the staff should had taken immediate action to call 911 to get further evaluation at the emergency room . Record review of the Facility Foreign Body Airway Obstruction Management (Choking) dated ,d+[DATE], revealed, If a resident is coughing forcefully and is able to speak, monitor the situation and intervene if the condition doesn't improve, following the guidelines for performing Heimlich maneuver. If the resident becomes unconscious, lower resident to the ground, call for help and activate the emergency response system. Clear the airway only if the object is seen using the finger sweep motion. Initiate CPR if indicated. The policy did not specify what type of assessemnet to conduct. The Administrator and the DON were informed on [DATE] at 1:15 PM, that an Immediate Jeopardy (IJ) had been identified and a copy of the IJ Template identifying the areas of non-compliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] and read: Alleged Issues: The facility failed to ensure resident #1 was free from neglect when they failed to implement their system for a choking resident, when they failed to activate the emergency response system. Goal: Facility will be in compliance with federal health, safety, and/or quality regulations. Its employees or service providers are to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Approaches: The Director of Nursing, Clinical Support Specialist, and ADON ' s will deliver all following in service education to nurses one on one. Nursing staff will be in-serviced to respond to medical emergencies for residents, staff, and visitors. The employee who first witnesses or is first on site of a medical emergency, will initiate immediate action, (if trained), including CPR as appropriate, basic first aid, or (if not trained), summon for assistance immediately. Staff will not leave the resident unattended until appropriate nursing personnel are on site. A nurse will assess the situation and determine the severity of the emergency. If necessary, designate a staff member to perform emergency response including calling EMS if necessary. This in-service was initiated on [DATE]. All nursing staff will be in serviced prior to them arriving to the facility for their next shift. The Director of Nursing, Clinical Support Specialist, and ADON ' s will deliver all following in service education to nurses one on one. The facility medical Director was informed of the IJ on [DATE] by the Facility Administrator. Resident #1 expired in the hospital [DATE]. All nursing staff will be in serviced, that if they are notified of a change in condition, they must immediately go assess the resident. This in-service was initiated on [DATE]. The Director of Nursing, Clinical Support Specialist, and ADON ' s will deliver all following in service education to nurses one on one. All nursing staff will be in serviced prior to them arriving to the facility for their next shift. All nurses will be required to notify the DON of any changes in condition that require higher level of care, prior to transfer The DON will review new hire orientation packet to ensure these above in services are completed prior to the first shift on the floor. DON will provide in-service to nurses to Changes in condition will be reviewed using the SBAR/E-Interact Change of Condition form will be utilized in the EMR, and a change of condition note will be opened every shift for at least 72 hours to monitor. The Director of Nursing, Clinical Support Specialist, and ADON ' s will deliver all following in service education to nurses one on one. All nursing staff will be in serviced prior to them arriving to the facility for their next shift. The DON has completed in-service education on [DATE], with the RN weekend supervisor regarding supervisor to round on all residents on the weekend, on all residents in facility to ensure no changes in condition are in progress, that have not been previously addressed. Monitoring: The 24-hour report in the EMR which runs all progress notes in real time, will be monitored daily in the clinical meeting for changes in condition by the clinical team, DON/ADON/MDS. The DON or designee will perform random in person audits with nursing staff to ensure they understand the emergency response procedure, as well as notification of changes in condition, at least 3 nursing staff daily X1 month. This process began [DATE]. Changes in condition will be reviewed using the SBAR/E-Interact Change of Condition form will be utilized in the EMR, and a change of condition note will be opened every shift for at least 72 hours to monitor. The DON/Clinical team will monitor daily in clinical meeting to ensure changes in condition are addressed and interventions in place. This process began [DATE]. DON/ADON ' s will make rounds daily M-F, the weekend RN supervisor will round on all residents on the weekend, on all residents in facility to ensure no changes in condition are in progress, that have not been previously addressed, daily X 1 month. This process began [DATE]. Assessment: The Director of Nursing reviewed the 24-hour report on [DATE], to ensure there were no changes in condition that she was not aware of. On [DATE] the DON made rounds on all residents in the facility to ensure there were no residents who had a change in condition that was not already identified. On [DATE], the Regional Clinical Support Specialist added at risk residents with respiratory disorders or dysphagia to the CNA Kardex for increased monitoring during meals. QAPI Committee review: An interim QAPI committee meeting will be completed on [DATE]. IDT will review for compliance monthly in QAPI X3 months. The Plan of Removal revealed the facility took the following actions: Record review [DATE]: 1. QAPI dated [DATE]: this QAPI meeting is being conducted to discuss the plan of removal for IJ received on [DATE]. Attached is the plan of removal and the steps we will follow to ensure compliance has been met. attendance: Administrator, DON, medical director, IPC, regional clinical. 2. In-service dated [DATE]: making rounds on all residents on the Saturday and Sunday to assess for change of condition and report to DON. This is documented in midnight census. signed by RN S. 3. In-service dated [DATE]: DON will be notified of each change in condition that may require a higher level of care, immediately and transfer as needed. DON will ask staff if a head-to-toe assessment was completed and results. signed by DON. 4. In-service dated [DATE]: change in condition reporting (MD/nurse/RP) and response to medical emergencies. CNA to contact DON if nurse does not asses resident. signed by staff on several shifts. 5. In-service dated [DATE]: providing care to include assessing, evaluating, and responding to resident needs. signed by staff on several shifts. 6. Midnight census dated [DATE]: tool used by the DON and checked off on all stating she laid on eyes on all residents, stated 1 was in the hospital and 2 were ordered UA ' s. No respiratory/dysphagia concerns identified. Interviews on [DATE] started from 8:54 am- 10:58 am revealed: CNA G, LVN H, CNA I, CNA J, LVN D, CNA K, CNA N, LVN O, CNA P, CNA Q, LVN R, CNA T, CNA U, CNA V confirmed receiving in-services for reporting changes in condition to the charge nurse; when changes in condition are reported to the nurse, they will conduct a head to toe assessment and report changes and condition and head to toe assessment to ADON/DON, RP, and MD. CNA to contact DON if nurse does not assess resident. Providing care to include assessing, evaluating, and responding to residents needs. If a medical emergency the CNA is to stay by resident ' s bedside and yell out for help. RN S confirmed receiving in-service on making rounds on all residents on the Saturday and Sunday to assess for change of condition and report to DON and would documented in midnight census. DON stated staff were in-serviced on: RN would be making rounds on all residents on Saturdays and Sundays using the midnight census and any findings would be documented on the midnight census. She will be notified of each change in condition that may require a higher level of care, immediately and transfer as needed. The DON will ask staff if a head-to-toe assessment was completed and results. Change in condition reporting (MD/nurse/RP) and response to medical emergencies. CNA to contact DON if nurse does not assess resident. Providing care to include assessing, evaluating, and responding to resident needs. The DON stated she checked all residents off on the census stating she laid on eyes on all residents, stated 1 was in the hospital and 2 were ordered UA ' s. No respiratory/dysphagia concerns identified. The DON stated she was in-serviced on being notified of changes in condition and ask for head-to-toe assessment results. The Physician stated he was notified of the IJ. The Administrator stated the physician was notified of the IJ. The Administrator stated the DON did all the in-services and he held the QAPI meeting on [DATE]. Observations on [DATE] from 9:47 am- 10:48 am revealed: CNA P was able to identify Resident #6 with respiratory distress and showed Resident #6 ' s kardex that revealed if resident appears to have respiratory change, staff member to notify nurse for assessment. CNA Q was able to identify Resident #11 with respiratory distress and showed Resident #11 ' s kardex that revealed if resident appears to have respiratory change, staff member to notify nurse for assessment. CNA T was able to identify Resident #12 with dysphagia and showed Resident #12 ' s kardex that revealed monitor/ document/ report as needed any signs and symptoms of dysphagia. Pocketing, choking, coughing, drooling, holding food in mouth. Several attempts at swallowing. Refusing to eat. Appears concerned during meals. CNA U was able to identify Resident #13 ' s with dysphagia and showed Resident #13 ' s kardex that revealed monitor/ document/ report as needed any signs and symptoms of dysphagia. Pocketing, choking, coughing, drooling, holding food in mouth. Several attempts at swallowing. Refusing to eat. Appears concerned during meals. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 11:15 AM. The facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents. The facility failed to place Resident #1's bed low to the ground and place the fall mat next to the bed while Resident #1 was in bed. This led to Resident #1 on 06/22/24 having her left arm/hand caught in between the grab bars (enablers) and the mattress, her right back shoulder hit the tray table, her right arm hit the trash can, and her rear hit the ground while her legs slid underneath the bed. An Immediate Jeopardy (IJ) was identified on 07/26/24 at 4:24 PM. While the IJ was removed on 07/27/24, the facility remained out of compliance at a scope of no actual harm and a severity level of isolated because the facility was continuing to monitor its plan of removal for effectiveness. This failure could place residents who are at risk for falls, injury, or death. The findings included: Record review of Resident #1's Admission Record dated 07/08/24 revealed, Resident #1 was initially admitted on [DATE] and readmitted [DATE]. Record review of Resident #1's Hospital History & Physical dated 06/23/24 revealed, Chief Complaint: Right Hip Fracture. [AGE] year-old-female with PMH of DM II (insulin dependent), recurrent UTI, dementia, hypertension was brought to our hospital due to fall. Patient had an accidental mechanical fall 2 days ago from her bed, when she rolled from her bed. Her left hand was caught in the handrail and landed on her left lower limb. She was able to move well after the fall, no head strike/LOC. She had complained of generalized pain/was fatigued during the next day. Record review of Resident #1's hospital MRI dated 06/23/24, revealed, it was reported that the x-ray along with the CT scan and MRI, did not see any evidnce of a fracture on the MRI. There was questionable concern of CT scan of an area of the lesser trochanter that was fractuered. However she does have a chronic great trochanter fracture along with bruising. There was no evidnce of fracture here. Record review of Resident #1's Physician Progress Note dated 07/10/24 written by attending for Resident #1 revealed, Chief Complaint: s/p hospitalization secondary to fall and right hip contusion (a bruise caused by a direct blow or an impact, such as a fall.) and complain of LBP and review of X-rays. The patient was seen in LTC facility, as per nursing she had been complaining of LBP for last few days and she has been medicated with PRN Oxycodone. (Oxycodone is used to relieve pain severe enough to require opioid treatment and when other pain medicines did not work well enough or cannot be tolerated.) Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed hearing adequate, clear speech, usually understood, usually understands others, vision impaired, BIMS Score 06, (severely cognitively impaired), no behavior symptoms, wheelchair, ADLs-partial/moderate assistance with toileting hygiene, upper body dressing, hygiene; Functional Abilities: Requires partial/moderate assistance with roll left and right, sit to lying, lying to sitting on side of bed; substantial/maximal assistance with sit to stand, chair/bed-to-chair transfer, toilet transfer, shower transfer; always incontinent of urine; frequently incontinent of bowel; No falls since admission. Record review of Resident #1's Physical Therapy Evaluation and Plan of Treatment dated 04/08/24, revealed, Resident #1 was supervision with transfers prior but was now a high fall risk due to trying to transfer without adequate strength. : Gross Motor Coordination = Impaired. Clinical Impressions: [AGE] year-old female who has decreased strength, coordination, and balance. Instructed patient and primary caregivers in safety sequencing techniques, safe bed mobility/transfers techniques, safety precautions and compensatory strategies to increase safety Record review of Resident #1's Fall assessment dated [DATE], revealed, intermittent confusion, 1-2 falls in the past 3 months, with a High-Risk Score of 13.0. Record review of Resident #1's Fall assessment dated [DATE], revealed, intermittent confusion, 1-2 falls in the past 3 months, with a High-Risk Score of 13.0. Record review of Resident #1's Enabler assessment dated [DATE] revealed, that it was incomplete. Commented that Resident #1's, level of consciousness or cognitive deficit was yes and stated forgetful/confused at times. Was there a risk to the resident if enablers are used? - Was left blank. There was no signature of Resident, guardian, or Legal Representative. Record review of Resident #1's Enabler assessment dated [DATE], revealed, that it was incomplete. The digital form was not signed nor was there any input in the questions such as, Was there a risk to the resident if enablers are used? (all left blank). Record review of Resident #1's Care Plan revised 02/10/21 revealed Cognitive Impairment-short term memory r/t dementia. Revised 06/26/24 Risk for injury r/t history of falls and is at risk for further falls r/t noncompliance with safety interventions, cognitive impairment, impaired safety awareness, incontinence urgency, gait/balance impairment. Interventions: 08/25/23 Continue with bed to lowest position with floor mat next to bed. 06/22/24 Actual Fall. Interventions: Sent to emergency room . Ordered x-rays. 2/25/24 Bed will continue to be kept to lowest position while pt. is on bed to prevent further falls. 02/10/21 Fall mat next to bed. 12/12/23 Instruct resident to call for help before getting out of bed or chair. Always keep call light in reach, visible to resident and the resident is informed of its location and use. Revised 02/10/21 Require one person assistance with ADLs r/t cognitive deficit. Revised: 07/07/23 May use enablers x 2 to assist with turning & repositioning and enhance independence. Record review of Resident #1's Physician Order Recap reviewed on 07/24/24, revealed, there were no orders for fall mat nor lowering of bed. Record review of Resident #1's Physician Order Summary Report dated 07/08/24 at 5:28 PM revealed, Order Date Range: 04/01/24 - 07/31/24 Physician Order Summary did not document an order for use of grab bars. Record review of Resident #1's Event Report dated 06/22/24 at 1:00 AM written by LVN I revealed, Incident Description Nursing Description: heard yelling from hall. Nurse entered room and observed her on the floor with left arm in[sic] the siderail. Resident Description: She doesn't know what she was doing. She thinks she was just turning over and slipped off the bed. Immediate Action Taken Description: Assessed for injuries. X2 [sic] assist to bed. Assessed left arm and found 3-inch skin tear to forearm. Area cleansed with normal saline. Skin protectant applied. Edges approximated and secured with steri-strips. Nonstick dressing and kerlix applied as secondary dressing. Neuro checks initiated. Predisposing Situation Factors-Other, Side Rails up. Record review of Resident #1's electronic Nurse Progress Note dated 06/22/24 at 1:44 AM, written by LVN I revealed, heard resident yelling from hallway. Nurse went to investigate. Found resident on resident on the sitting [sic] on the floor with her left arm in the enabler. With 2 assist, [sic] was removed from enabler. Assessment conducted. 2 assist [sic] to bed. Resident doesn't know what happened. She thinks she was just rolling over. She was soiled with BM. This nurse believes she may have been trying to go to the restroom. This nurse pulled up her sleeve and found a 3-inch skin tear to her left forearm. She had a Fall Risk band in place. Arm band removed. As it may have contributed to the skin tear. Area cleansed with NS. Skin prep barrier. Edges approximated and secured with steri-strips (thin adhesive bandages used for skin closure). Secondary dressing applied, non-stick dressing and kerlix. Neuro checks initiated and WNL (within normal limits). [family member], MD and DON notified. Record review of Resident #1's SBAR INTERACT form dated 06/22/24 at 1:30 AM for Resident #1 written by LVN I revealed, The Change of Condition: Fall. Since this started it has gotten: Stayed the same. Primary Diagnoses is Urinary Tract Infection, dementia, diabetes mellitus. Outcome of Physical Assessment: Mental Status Evaluation: No changes observed. Functional Status Evaluation: Fall (one or more). Skin Status Evaluation: Skin Tear. Record review of Resident #1's Nurse Progress Note dated 06/22/24 at 7:59 AM, written by RN L, revealed Per attending nurse pt. s/p fall resulting in a skin tear to left forearm. Area assessed and measured L 4 cm x W 1.5 cm, unable to assess depth. Noted skin tear with edges well approximated with steri-strips in place. Wound care performed as ordered. Pt. tolerated well. Record review of the Nurse Progress Note dated 06/23/24 at 1:00 PM written by LVN E, for Resident #1 revealed, resident had a fall on 6/22 prior to day shift. Ordered stat x-ray of lumbar spine, pelvis, bilateral hips, left forearm for pain related to fall. X-ray completed on 06/23/24 with abnormal results, acute and suspected fractures. Consulted with attending physician and [family member]. ADON notified. Resident to be transferred to hospital. Record review of Resident #1's Provider Investigation Report dated 06/23/24 revealed incident date 06/22/24 at 1:00 AM in resident room. Incident Category: Other. If other specify: Bruise of unknown origin. Resident x-ray showed osteopenia (loss of bone density). Description of allegation: Resident fell out of bed resulting in a skin tear to the left forearm. Assessment: 06/22/24 at 1:15 AM, by LVN I, documented resident received a skin tear to her left forearm as a result from the fall. Nurse provided treatment to left forearm for the skin tear. Investigation summary: Resident was assessed at the time of the fall and had complete range of motion. Later in the day the resident complained about having pain in her leg. Stat x-ray were ordered and they performed the x-rays on the 23rd of the lumbar spine, pelvis, both hips, and left forearm. The results of the x-ray were her left wrist had a fracture and her right hip had a fracture. Upon further tests at the hospital, it was determined that the right hip may or may not have a fracture. We are awaiting results from the MRI. The left [sic] was fractured and was treated with pain management. Provider Response: Provide all steps taken immediately to make sure resident(s) are protected including evaluating if resident feels safe, room relocation, increased supervision, immediate notification to physician and responsible party when involving an injury or change in condition, removal of alleged perpetrator and other measures to prevent further abuse, neglect, exploitation, and misappropriation. The resident returned to the facility and is receiving pain management for her fractured arm. Facility Investigation Findings: Inconclusive. Provider action taken Post-Investigation: Facility will continue to monitor the resident for any other adverse effects [sic]. During an interview on 07/08/24 at 8:43 AM, with LVN J, revealed, stated Resident #1 was alert, oriented to person and place. Resident #1 was chairbound and propels her wheelchair with her feet independently. Resident #1 transfers independently from bed to chair and chair to bed. Resident #1 toilets independently and uses call-light for assistance. Residents are checked every two hours by nurses and CNAs. LVN J reported CNAs stay at the decentralized stations to monitor residents and answer call-lights when they are doing their charting. LVN J reported that Resident #1 was impulsive and requires close supervision and re-direction. Resident #1 can verbalize needs. Resident #1's family member visits daily. Resident #1 uses grab bars on side of bed to get in and out of bed and to turn and reposition. Resident #1 sustained a fall on the weekend (06/22/24). After the fall, the grab bars were discontinued. Resident #1 was still able to get in and out of bed. During an interview on 07/08/24 at 4:58 PM, with LVN D, revealed, stated Resident #1's family member visits daily on the evening shift. LVN D reported resident was alert, oriented to person, place, and recognized familiar people. Resident #1 was able to verbalize needs and was able to make decisions. It was reported that the Resident bangs on the wall with a cup for help. Resident #1 can use her call light and does not know why Resident #1 bangs on the wall for help. LVN D reported resident frequently attempts to toilet without assistance. Resident #1 was sent to the hospital 2 weeks ago on the night shift because she was found on the floor and sustained a skin tear to the left arm and a fractured left wrist. Resident #1 had Grab Bars on her bed to turn and reposition, and to get in and out of bed on her own. After the incident she got a different bed, and the Grab Bars were removed. Resident #1 was still able to get in and out of bed on her own. She continues to require close supervision and re-direction, so she does not attempt to use the toilet without assistance. During an interview and observation on 07/09/24 at 6:09 AM, with LVN B, stated on the 10-6 shift revealed, she was assigned to Resident #1 on the day of the incident on 06/22/24. LVN B demonstrated to the surveyor, that Resident #1 was found on the floor on the fall mat, her legs were bent at the knees, and her buttocks were on lower legs, on her calfs in a sitting position facing the bed and was holding the grab bar with her left hand, and her arm was stuck slightly above the elbow joint between the mattress and the grab bar. The plastic bracelet on her left arm was caught in the skin tear on the left arm. LVN B stated, she was walking down the hall towards the decentralized nursing station, two doors from resident's room and heard someone moaning and yelling out. When I went to check to see who was yelling. Upon entering Resident #1's room, I noted that her left arm was stuck between the mattress and the Grab Bar on the side of the bed. I told the resident that I needed to go and get help. As I was walking out of the room, I noted the CNA was charting at the decentralize station, so I called her to come and help me. There was not a gap between the mattress or the Grab Bar. We had to slightly lift the mattress to release the arm. Resident #1 did not complain of pain upon assessment and did not have guarded movement. Resident had a superficial skin tear to the left arm, wound was cleaned with normal saline and applied steri-strips. I completed an Event Report and Interact SBAR Communication Form and notified physician, responsible party, and DON. The family member did not voice any concerns on that day. LVN B reported putting the resident back to bed, she appeared to be very sleepy and was not fully awake, she kept grabbing down the side of the bed with her right arm, like if she was looking for something. We noted resident had had a bowel movement when we put her back to bed. An x-ray was done on the morning shift on that day. On that day, she had complained of knee pain prior to the incident and was medicated with Acetaminophen as ordered for pain. Medication was effective. Resident did not complain of pain, the rest of the shift on that day. LVN B reported that prior to the incident, resident was able to get in and out of bed by using the Grab Bar on the sides of the bed, had an unsteady gait, was confused at times, was oriented to person, place, and recognizes familiar people, and was able to verbalize needs. The resident sleeps most of the night, occasionally gets out of bed and propels her wheelchair to the bathroom and attempts to toilet without assistance. Sometimes, she gets up at night and will propel her wheelchair up and down the halls. Resident requires close supervision and re-direction as needed. It was reported that resident had a history of falls. Rounds were made every 2 hours by the nurses and CNAs. It was reported that resident was at Risk for falls prior to incident. Resident occasionally uses the call light or bangs on the wall with her hand or the call light when she wants help. During an interview on 07/09/24 at 11:22 AM, with CNA A, revealed, Resident #1 was alert, confused at times, able to verbalize needs, very impulsive, frequently gets in and out of bed by holding on the grab bars on the side of the bed and uses the grab bars to turn and reposition in bed. Resident #1 also frequently attempts to toilet without assistance. Resident #1 requires close supervision and re-direction. CNA A stated nursing staff encourage Resident #1 to go to the toilet when they go to her room during scheduled rounds. She does not call for help. Observation and interview on 07/09/24 at 3:28 PM, revealed, the family member was visiting Resident #1. The Family member reported that Resident #1 had fallen from the bed, sustained a big skin tear on her left arm, fractured her arm and hip. After the fall, they changed her bed and removed the grab bars on side of the bed. The Family member stated, Now, the resident is no longer able to get out of bed on her own or turn and re-position while in bed since they removed the grab bars on the side of the bed. The Family member reported Resident #1 did not feel safe without the Grab Bar on the side of the bed and was afraid of falling when she got out of bed. Resident #1 was sent to the emergency room , and they kept her over-night. The x-ray and CT scan revealed a hip fracture. In the hospital they did an MRI and the doctor reported that there was no right hip fracture, and that Resident #1 had a large contusion (is a bruise caused by a direct blow to the body that causes damage to the surface of the skin and to deeper tissues as well depending on the severity of the blow) on her hip. Interview and record review on 07/10/24 at 1:05 PM, with the DON, stated Resident #1's bed was changed to a high/low bed and that was not as wide as the bed that she had when she sustained the fall on 06/22/2024. The DON reported the day of the incident on 06/22/24, Resident #1 was found by LVN B, the night nurse on the floor, by the side of the bed with one of her arms caught between the mattress and the grab bar that was attached to the side of the bed. Resident #1 sustained a skin tear to the left forearm. The DON reported that the resident had not complained of pain at the time of the initial assessment that was completed by the night nurse (LVN B). Later in the day, Resident #1 complained of having pain to her right leg and x-rays were ordered. The X-Rays revealed Resident had a fracture to the left wrist and right hip. Resident #1 was sent to the hospital for evaluation and was admitted . The hospital reported MRI revealed Resident #1 did not have a hip fracture and had a contusion to the right hip. Resident #1 returned to the facility on [DATE] with a diagnosis of left wrist fracture and contusion to right hip. The DON reported facility had a meeting with Resident #1's family member and the Ombudsman when the decision was made to remove the Grab Bars on the side of the bed and Resident #1's family member had agreed with the recommendation to remove the Grab Bars. The DON stated, the facility did not document this meeting in the resident's electronic clinical record, we should have. The DON stated she did not remember the date of the meeting. The DON stated, she did not find a physician's order listed in the Physician Order Summary Report dated July 08, 2024, Order Date Range: 04/01/24 - 07/31/24 to use Grab bars on the side of the bed as an enabler. The DON stated, the facility needed to have a physician's order to use the Grab Bars on the side of the bed as an enabler, according to facility's policy on use of bed rails. We do not have a signed consent from the responsible party for Resident #1 to use Grab Bars on the side of the bed. During a telephone interview on 07/11/24 at 10:16 AM, with CNA K, reported she was on duty on the day of the incident involving Resident #1. CNA K stated, she was making rounds and went to check if resident was asleep, because she has the tendency to get out of bed without assistance. The resident was asleep, and noted that her legs were uncovered, so she covered her feet with her blanket and left the room. CNA K went to the decentralize nurse's station to do my charting because it was almost time for me to make my next round. The decentralized station is at the end of the hall, two rooms from Resident #1's room. CNA K was charting, when I heard someone was yelling louder than before, I thought it was Resident #1 that was yelling. That is when LVN B was coming down the hall towards the decentralize nurse's station, and she went to check the rooms to see who was yelling. When LVN B entered Resident #1's room, she came out right away and asked me to go to the room to help her. Upon entering the room, CNA K noted resident was on her knees and her buttocks were resting on her calfs, on the floor facing her bed and noted resident's arm was caught between the Grab Bar and the mattress. It appeared like she had flipped out of bed. We slightly lifted the mattress to remove the left arm from between the mattress and the Grab Bar. CNA K reported that there was no gap between the mattress and the Grab Bar. Resident #1 had a big skin tear to her left arm, that was caused by the Fall Risk bracelet that was stuck on her skin where the skin tear was on the arm. It appeared that the bracelet had sliced the skin to the arm, where the bracelet got stuck. We cut the bracelet off, and LVN I treated the skin tear. LVN B and CNA K put the resident back to bed and was not fully awake. The resident kept saying her family member and kept saying the family member had fallen with her and wanted to know where he was. Then the resident kept saying that her family member had also fallen with her and wanted to know where he was. The incident happened approximately, 1 minute after I had left the room and went across her room to room [ROOM NUMBER] to check on Resident #2. The incident with Resident #1 happened real fast right after I left her room. The Resident #1 was still able to get out of bed after the incident, without the Grab Bars. It was reported that the resident sleeps most of the night, but occasionally she does get out of bed to attempt and use the toilet unassisted. She will sit in her wheelchair and propel the wheelchair with her feet to the bathroom. CNA K reported that in between rounds, she made visual rounds to check up on those residents that attempt to get up without assistance and require close supervision and re-direction. It was reported that Resident #1 requires close supervision and re-direction, because she has a history of falls and will get out of bed without assistance to attempt to use the bathroom without assistance. CNA K reported Resident #1 has had the Grab Bars on her bed, since she started working at the facility 7 months ago. Record review of the facility Incidents and Accents policy not dated, revealed, It was policy of this facility for staff to utilize to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Accident - refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. Policy Explanation: Assuring that appropriate and immediate interventions are implemented, and corrective actions are taken to prevent recurrences and improve the management of resident care. Conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement to avoid further occurrences. Record review of the facility Fall Prevention Program policy dated 07/01/22, revealed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. High Risk Protocols: Indicate fall risk on care plan. Provide interventions that address unique risk factors measured by the risk assessments tool. Provide additional interventions as directed by the resident's assessment including but not limited to - low bed and assistive devices. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness. Record review of facility's policy & procedure on Proper Use of Bed Rails implemented 07/2022 revealed, Topic: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use and maintenance of the rails. Bed Rails are adjustable or rigid plastic bars that attach to the bed. Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. Entrapment - was an event in which a resident was caught, trapped, or entangled in the space in or about the bed rails. Resident Assessment: As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meet those needs: medical diagnosis, conditions, symptoms, and/or behavioral symptoms, sleep habits, ability to toilet self safely, cognition, communication, mobility (in and out of bed), risk for falling. The resident assessment must also assess the resident's risk from using bed rails. Examples of the potential risks with the use of bed rails include - Accident hazards (e.g., falls, entrapment, and other injuries sustained from attempts to climb over, around, between, or through the rails, or over the footboard). Barriers to resident from safely getting out of bed. The resident assessment should assess the resident's risk of entrapment between the mattress and bed rails or in the bed rail itself. Observation and interview on 07/24/24 at 11:23 AM, of hall 110 revealed, room [ROOM NUMBER] had Resident #1 in bed A. Resident #1 was in bed A with the bed low, but no fall mat placed next to her. There were no grab bars (enablers) attached to Resident #1's bed either. Resident #1 was mumbling words but could not understand what was being said. During an interview on 07/24/24 at 1:11 PM, with the ADON, she stated Resident #1 had a fall on 06/22/24. The ADON stated the facility placed Resident #1's bed low and placed a fall mat next to the bed anytime Resident #1 was in bed. The ADON stated the staff had been trained to place the fall mat next to the bed when Resident #1 was in bed. The ADON stated during Resident #1's fall she had acquired a fracture on her left wrist. The ADON stated when state agency observed no fall mat on 07/24/24, that there should have been a fall mat placed. The ADON stated the grab bars (enablers) were removed due to Resident #1 getting her hand caught when having the fall, and they were no longer appropriate. During an interview on 07/25/24 at 8:27 AM, with the Physician, she stated Resident #1 was a high risk for falls. The Physician stated the bed should have been lowered towards the ground and the fall mat placed next to the bed to prevent the risk of Resident #1 hitting the hard floor which could add to the impact of the fall. The Physician stated she was uninformed of the laceration to the left forearm and the left hand being caught on the bed for Resident #1 by LVN B. The Physician stated it was expected for the nursing staff to inform her of all the information of a fall regarding Resident #1. During an interview on 07/25/24 at 3:10 PM, with the DON, she stated the day of the incident 06/22/24, Resident #1 did not have a high low bed like she has right now. The DON stated the Resident #1's bed would not go all the way down. During an interview on 07/25/24 at 3:17 PM, with MDS Coordinator CC, she stated the purpose of a care plan was designed for the type of care the residents are to get. MDS Coordinator CC stated if a resident had it in their care plan to place the fall mat next to the bed and lower the bed when resident was in it then it would have to be done. MDS Coordinator stated the risk of not following the care plan not placing the fall mat next to the bed and not lowering the bed could result in harm to the resident(s). During an interview on 07/25/24 at 3:20 PM, with the MDS Coordinator BB and Director of Reimbursement. The Director of Reimbursement stated she could not find physician orders for the fall mat and lowering of the bed for Resident #1. The Director of Reimbursement stated the care plan orders were not discontinued and Resident #1's intervention to place the fall mat next to the bed and lower the bed were still active. The Director of Reimbursement stated the risk of not lowering the bed and placing the fall mat next to the bed could result in harm to the resident. Record review of Resident #1's video reviewed on 07/25/24 at 8:55 PM - Video was review for 06/22/24 fall incident of Resident #1. - 12:30:53 AM - Resident #1's right arm was dangling downwards as if to pick up something off the ground. There was a trash can next to the head of bed area, a tray table next to the bed of Resident #1, and no fall mat was placed next to the bed. Bed was not in a low position. Next to the trash can was a dark unknown substance. - 12:30:55 AM - Resident #1 is seen grabbing the bed rail with her right hand. Cannot see left hand/arm. - 12:31:00 AM - Resident #1 was on bed closest to the restroom and entrance door. - 12:31:00 AM - Resident #1 was seen turning to her left side (body). Tray table was seen close to resident. No floor mat seen. Bed is raised (not low position). Bed rail is up. - 12:31:02 AM - Resident #1 was wearing dark socks. Residents' feet touched the floor. - 12:31:03 AM - Resident #1 tried to stand up, but legs gave out. - 12:31:04 AM - Resident #1 hit the tray table with her right arm moving the tray table and hit the trash can also moving the trash can that was on the floor next to the bed. Left hand was stuck (trapped) in between the mattress and the bed rail. Resident's feet slid underneath the bed and butt hit the floor. Loud sounds could be heard as Resident #1 hit the tray, trash can, and floor. - 12:31:23 AM - Resident #1 could be seen moving and moved the tube feeding stand as the flush bag was seen moving back and forth. - 12:31:31 AM - Resident #1's right side arm was on the trash can and then the trash can tips sideways causing Resident #1 to fall down from her shoulders and head to the floor making a loud sound. The feeding stand was also moved at the same time. The flush bag was seen moving back and forth. - 12:31:38 AM - There was another loud sound that was made but nothing could be seen to know what was moved. - 12:31:58 PM - Resident was lying on her right-side hip and head was seen moving downwards and upwards in the air. Right shoulder arm was not [NAME] in the lying down position. Both legs and half of her body sideways was underneath the bed. Left arm/hand was still caught between the mattress and grab bars (enablers). - 12:32:21 AM - Resident #1's height of bed was at the mid-section of the white scratches that were on the wall exposing the white wall where paint was coming off. - 12:32:46 AM - Resident #1 was seen moving her legs upwards into a fetal position underneath the bed. Resident #1 was not heard calling for help. Resident #1 was still hook and lying sideways on her right side. - 12:33:11 AM - Resident moves her right arm and positions herself to lean on it. Resident #1's right elbow was touching the floor and her head was raised upwards in a diagonal angle to the right side of her body. - 12:34:06 AM - Resident #1 was seen leaning backwards and still on her right elbow, legs underneath the bed towards the headboard area. - 12:35:22 AM - Resident #1 was not yelling and in the same position as above. - 12:37:27 A [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and Each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 14 (Resident #13) residents reviewed for supervision. The facility failed to respond to door alarm that resulted in Resident #13 elopement on [DATE]. Resident #1, who had dementia and a history of wandering, was last seen by CNA at 5 pm and left the facility through an alarmed door on [DATE] at unknown time. Staff did not hear or respond to the alarm. CNA B realized Resident #1 was missing when they were unable to locate her at 5:45 pm and a search was initiated. The resident wandered 0.2 miles down the street, in 103-degree Fahrenheit heat, and entered a neighbor's garage. The neighbor's returned her to the facility at 6:16 pm. An IJ was identified to have existed from [DATE] to [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of isolated and a severity level of potential for more an minimal harm due to the need for the facility to monitor it corrective action for effectiveness. This failure could place residents at risk of not being properly supervised resulting in injury or death. Findings included: Record review of Resident #13's facility's initial assessment dated [DATE] revealed a [AGE] year-old female with diagnosis of dementia with history of psychosis. She required extensive assistance with two person assist for transfer and required limited assistance with one person physical assist when walking in unit. Record review of Resident #13's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00, indicating she was severely cognitive impaired. Record review of Resident #13's care plan dated [DATE] (day created) revealed focus area for wanders throughout building, goes into other residents' room and attempts to leave building with interventions that included assess quarterly and as needed for wandering/ elopement risk, assist with reorientation to room and facility with verbal cues, encourage group activities and attempt to keep occupied. Review of wunderground.com revealed facility town temperature on [DATE] at 4:51 PM was 103 degrees Fahrenheit. Record review of Resident #13's quarterly elopement risk assessment dated [DATE] revealed she was high risk. Record review of nursing schedule and staff timecards for [DATE] revealed 8 CNAs, 4 LVNs, 2 med-aides, and 1 RN were working 2p-10p shift. Record review of Resident #13 incident report dated [DATE] revealed incident description revealed at 5:00 PM on [DATE] Resident #13 left the facility shortly after being fed at 5:00 PM and walked 0.3 miles past the property to near by street. Resident #13 was found by neighbors and brought back to the facility at 6:18 PM. Resident #13 was unable to described her events. Immediate action taken section revealed Resident #13 was taken back to her assigned hallway, a head to toe assessment was completed and water was provided for hydration. Resident #13 RP and NP were notified, vitals were taken and were normal range. Mental status section revealed she was oriented to person only. Injuries section revealed no injuries were noted. Predisposition factors section revealed Resident #13 was a active exit seeker. People Notified section revealed RP and NP. Interview on [DATE] at 3:53 PM Director of Clinical Operations stated she was notified by weekend supervisor that Resident #13 had eloped on [DATE] at around 5 PM. The Director of Clinical Operations stated Resident #13 had exited the building, she was not sure how and had ended up at a neighbor's house who had brought her back. The Director of Clinical Operations stated when Resident #13 was brought back she was assessed by LVN G and was provided fluids to hydrate and was placed 1:1 the rest of the evening until she fell asleep. The Director of Clinical Operations stated LVN G reported no injuries were noted during his assessment. The Director of Clinical Operations stated she had started a 100% elopement assessment that was completed by [DATE]. The Director of Clinical Operations stated she updated elopement risk binder and placed it by the receptionist area for easy access. The Director of Clinical Operations stated the receptionist were in-serviced on calling nurse prior to letting a resident out to verify leave status and to ensure someone was aware of the leave. The Director of Clinical Operations stated she started in-service on re-enforcing response to door alarms and completed in-servicing full-time employees by [DATE] and PRN staff that were pending would not be allowed to work until they were in-serviced on elopements. Interview on [DATE] at 4:21 AM LVN J who works the night shift (10p-6a) stated she had recently received elopement in-service by nursing administration. LVN J stated nursing administration re-enforced door alarm response and hourly checks for elopement risk residents. LVN J stated she had been trained on verbally redirecting residents to their room when seen wandering during the night, ask if they need or want anything, not leave their side until they are back in their room. LVN J stated the Director of Clinical Operations had updated the elopement binder and placed it in the receptionist area for easy access. LVN J stated when conducting hourly rounds checking on elopement risk residents, they were to check the doors to ensure that they were properly locked. LVN J stated she also received training on activating and deactivating door alarms. LVN J denied any concerns with doors not locking properly and/or issues with door alarms not working. Observation and interview on [DATE] at 5:46 AM CNA H (worked 10p-6a) stated he had recently received an in-service on elopement that covered expectations to door alarm response, how to deactivate door alarm, where to find elopement risk binder, reminder to conduct hourly check on elopement risk residents at night, if he sees residents wandering to verbally redirect them to their room. CNA H denied any concerns with doors not locking or alarms not working. CNA H showed surveyor how to deactivate the door alarm, he pushed the 400 hall exit door and stated it does not open, he then pushed on the bar and the door alarm sounded off. 3 staff were observed coming down the hall to check on the door. CNA H deactivated then deactivated the door alarm. Observation on [DATE] at 5:54 AM surveyor pushed all hallway exit door (100 hall, 200 hall, 300 hall, 400 hall) and entrance door, they were all locked. No concerns. Interview on [DATE] at 6:03 AM CNA I (works 10p-6a) stated she had recently received an in-service on elopement that covered expectations to door alarm response, how to deactivate door alarm, where to find elopement risk binder, reminder to conduct hourly check on elopement risk residents at night, if she sees residents wandering to verbally redirect them to their room. Interview on [DATE] at 6:42 AM the ADON stated elopement in-service was started on [DATE] by the Director of Clinical Operations and responding to door alarms was reinforced and hourly checks to be completed by all floor staff. The ADON stated Resident #13 was placed 1:1 for several hours when she was returned on [DATE] until she fell asleep. The ADON stated Resident #13 room was right next to nurses' station on the hallway and she had seen staff try to keep her busy with activities. Interview on [DATE] at 8:37 AM LVN D stated she had recently received an in-service on elopement that covered an updated binder with elopement risk residents were located in the receptionist area, hourly checks on elopement risk residents and checking door to ensure they were locked, and how to deactivate the door alarm system. Interview on [DATE] at 3:36 PM the Weekend Receptionist stated she had recently received elopement in-service that covered elopement binder that was located on her desk that had residents' pictures and diagnoses. The Weekend Receptionist stated she was not to let residents out before verifying with the nurse that they were aware they were leaving the facility and to ensure they were cleared to leave. The Weekend Receptionist stated she would approach resident ask for name and hallway they were at and call the nurse on the floor. Interview on [DATE] at 3:44 PM LVN G stated he worked on [DATE] the day when Resident #13 eloped. LVN G stated that day he came in at 6 AM and Resident #13 was in bed sleeping, he woke her up around 8AM to administer morning medication and she went back to bed to sleep. LVN G stated he woke the Resident up again around noon for lunch meal to eat because she required assistance with eating. LVN G stated he was pulled to dining room for meal observation around 5 PM, stated an unidentified CNA woke up Resident #13 to assist her with dinner meal. LVN G stated that was the last time a staff member had eyes on Resident #13. LVN G stated at around 5:45 PM when he was walking back to 100 hall he was approached by unidentified CNA who notified him that Resident #13 was not in her room. LVN G stated unidentified stated she had gone to check on Resident #13 and had not seen her in her bed and had checked the restroom then went to alert him. LVN G stated he went to Resident #13 room and double checked the room and restroom and did not see her. LVN G stated he then called a code silver for assistance in looking for Resident #13 whereabouts. LVN G stated at around 6 PM when Resident #13 was not seen in the building he alerted staff he would go drive around near areas to search for her. LVN G stated he drove down towards that shopping center down the street and had not seen her. LVN G stated when he was on his way back to check on the other side of the facility where a neighborhood was, he received a call from the Weekend Receptionist at 6:18 Pm who stated Resident #13 had been returned to the facility by neighbors. LVN G stated he drove back to facility and the Weekend Supervisor had Resident #13 by the receptionist area, he then took her back to her room to assessed her. LVN G stated she had no injuries noted and vitals were in normal range, Resident #13 was provided fluids for hydration because it was a hot day. LVN G stated he informed Resident #13 RP, NP and she was placed 1:1 until she had fallen asleep. 1:1 placement was in intervention placed by the facility. Interview on [DATE] at 4:14 PM CNA K stated she had worked on [DATE] the day of Resident #13 eloped. CNA K stated she had been assigned to dining room for assistance with feeding. CNA K stated she was made aware of Resident #13 was missing when a coworker went to the dining room asking staff if they had seen Resident #13 and was asked to continue assistance with meals. CNA K stated she did not recall hearing a door alarm due to music playing in dining room for residents to enjoy. CNA K stated she had received elopement in-service training prior to incident and was notified of binder with elopement risk residents was located in receptionist area. CNA K stated her coworkers and nurses had been good about pointing out which residents had tendencies of trying to leave the facility and was informed about constant monitoring at least every hour. CNA K stated she tried to conduct 30-minute checks on elopement risk residents. CNA K stated she had been informed if a resident requested to leave, she had to verify with the charge nurse about residents leave status. Interview on [DATE] at 4:29 PM the Weekend Receptionist stated on [DATE] she had been asked by a staff member if she had seen Resident #13 in which she had said no and was told she was not in the building. The Weekend Receptionist stated shortly after she had been approached, she had received a call from someone stating they believed they had a resident that belonged to the facility. The Weekend Receptionist stated she asked for their information and wrote in down to report to LVN G who was driving around looking for her. The Weekend Receptionist stated when she called LVN G to provide the address that was left by the people who called, the neighbors showed up to the facility with Resident #13; she alerted LVN G that Resident #13 had been returned to the facility. The Weekend Receptionist stated she called the Weekend Supervisor to notify her, and she went to the front to greet and assess Resident #13. The Weekend Receptionist stated LVN G arrived within minutes and took Resident #13 to her room and assessed her. Interview on [DATE] at 4:36 PM MA L said he had worked on [DATE] the day Resident #13 eloped. MA L stated he was assigned to 200 hall and when the elopement happened, he was busy assisting with a code blue down his hall. MA L stated 2 nurses and weekend supervisor and himself were providing CPR. MA L stated when EMS arrived at facility and took over CPR, he stepped aside and was approached by staff asking him for help in looking for Resident #13. MA L stated he did not recall hearing a door alarm because he was focused on assisting with CPR. MA L stated he had received an in-service on elopement that covered re-enforcement on responding to door alarm, checking doors to ensure they were locked, elopement binder at receptionist area, and continuous rounding on elopement risk residents. Observation on [DATE] at 4:45 PM a male resident was observed walking to the entrance door, the Weekend Receptionist approached the male resident. The Weekend Supervisor was observed saying something to male resident and then walked to the receptionist area to place a call. The male resident waited patiently by the door and seconds later the Weekend Supervisor opened the door for the male resident to go outside. Interview on [DATE] at 4:47 PM the Weekend Supervisor stated the day of the incident, [DATE], was her first day working for the facility. The Weekend Supervisor stated that afternoon a code blue was called, and she responded to it to assisted. The Weekend Supervisor stated the nurse assigned to 400 hall had responded to the code blue as well. The Weekend Supervisor stated when EMS arrived at the facility, she was approached by a staff member and was notified Resident #13 was not in the building. The Weekend Supervisor stated when she had been notified there was already staff searching for her and started assisting with search. The Weekend Supervisor stated she went down 400 hall looking for Resident #13 and Resident #11 had told her she had seen Resident #13 walk out the door several minutes ago. The Weekend Supervisor stated there was one unidentified CNA in the 400 hall that had been providing perineal care to a resident when she was looking in the 400 hall. The Weekend Supervisor stated she had been called over to the receptionist area and had seen neighbors with Resident #13. The Weekend Supervisor stated she was informed Resident #13 had walked into their garage and had called the facility to notify them, but opted to bring her back. The Weekend Supervisor stated LVN G had arrived shortly and took Resident #13 to her room for head-to-toe assessment. The Weekend Supervisor said she received a report that there were no injuries noted and the resident was provided liquids for hydration. The Weekend Supervisor stated she had reported to Director of Clinical Operations of Resident #13 elopement. The Weekend Supervisor stated she had received training on elopement binder and hourly checks. Observation and Interview on [DATE] at 5:06 PM Resident #11 was alert and oriented to person, time, place and event. Resident #11 stated she remembered the incident last Saturday, [DATE]. Resident #11 stated she saw Resident #13 walk to the exit door and the door alarm went off but she did not see Resident #13 walk back to the hallway. Resident #11 stated she had pressed on her call light for help to notify them of what she saw. Resident #11 stated it took several minutes for staff to respond and a staff finally walked towards the door, and she called her over. Resident #11 could not remember who the staff was, but she notified her that Resident #13 had walked out the door few minutes ago. Resident #11 bed was by the window and privacy curtain was opened and had clear view to the hallway. Observation on [DATE] at 5:26 PM the Director of Clinical Operations and surveyor tracing the steps of Resident #13 revealed: walked out thru the 400 hall, door alarms go off, 3 staff were seen responding to the 400-hall door alarm. Director of Clinical Operations and surveyor walked down thru the parking lot towards the sidewalk, it was about a minute walk. Director of Clinical Operations and surveyor then turned left on main street, there was an approximately 12-foot sidewalk with no holes or bumps noted to gravel. 7 cars noted to have passed us with 35 m/h sped noted to road. Director of Clinical Operations and surveyor then turned left to the street name where Resident #13 was found, the neighborhood was calm, and no cars passed. Director of Clinical Operations and surveyor walked up the street to the neighbor house where Resident #13 was found, the time we arrived was 5:30 PM. The temperature on record for the day was 104 Fahrenheit degrees. Interview on [DATE] at 10:41 AM the Administrator stated she had received a call on [DATE] and was notified of Resident #13's elopement. The Administrator stated she drove to the facility and when she arrived Resident #13 had already been back and had been assessed. No injuries were reported. The Administrator stated when she arrived she heard an alarm going off still. The Administrator stated she checked all hallways exit doors and all were locked. The Administrator stated the 400 hall door alarm was off. The Administrator stated she could not figure out what the alarm was for, and she called Maintenance for help. The Administrator stated Maintenance had told her it was the second door alarm on the panel that was still on and gave her instructions on turning it off. The Administrator stated Maintenance ended up showing up at the facility and started in-service on how to deactivate the door alarms and alarm panel. The Administrator stated her and Maintenance checked the hallway exit doors again and no issues were identified with alarms or locked doors. Interview on [DATE] at 3:18 PM the Maintenance Director stated he was called on [DATE] by the Administrator on an alarm that was going off. The Maintenance Director stated he came to the facility and started in-services on deactivating the door alarm and alarm on panel located by middle nurses' station. The Maintenance Director stated the door alarms have 2 sets of alarms. The Maintenance Director stated he had also checked all doors to ensure they were locking properly and found no issues. The Maintenance Director stated he had been conducting daily checks on doors and alarm every morning when he came in to work and had not found issues with doors not locking and alarms not working. The Maintenance Director stated he kept records of daily checks and provided copies as well as in-services he had initiated with staff regarding deactivating alarms. Record review on Elopement and wandering Residents policy dated 2022 revealed This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. 4: monitoring and managing residents at risk for elopement or unsafe wandering: A- residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. The administrator was informed on [DATE] at 3:20 pm that an Immediate Jeopardy (IJ) existed on [DATE], and a copy of the IJ Template was provided. The following Plan of Removal was accepted on [DATE] at 5:10pm. - A 100% elopement audit was conducted by Director of Clinical Operations and was completed by [DATE]. - In-service dated [DATE] topic: elopement, wandering, and resident safety that covered report as soon as it's discovered to administrator and DON immediately, in-serviced on elopement policy. daily, report any concerns to administrator/maintenance, monitor high risk elopement. This was confirmed with observations on door alarm response on different shifts, interviews with staff on different shift were able to verbalize expectations. - In-service dated [DATE] topic: door locking procedures. - In-service dated [DATE] topic: receptionist will verify a residents leave status with prior to letting resident out. - Record review of exit door monitoring log for June and July were completed and up to date. Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from [DATE] at 3:20pm to [DATE] at 5:10pm as follows: - Record review of 14 residents revealed elopement audit conducted by Director of Clinical Operations by [DATE]. - Review of in-services dated [DATE] were completed on elopement, wandering, and resident safety that covered report as soon as it's discovered to administrator and DON immediately, in-serviced on elopement policy. Interviews with staff on different shifts confirmed by being able to verbalize expectations; door alarms, response times to alarms, angel rounds, door rounds daily, report any concerns to administrator/maintenance, monitor high risk elopement. This was confirmed with observations on door alarm response on different shifts, interviews with staff on different shift were able to verbalize expectations; receptionist will verify a residents leave status with prior to letting resident out. This was confirmed with receptionist interviews being able to verbalize expectations and observation of her stopping a resident and calling for verification. - Interviews on [DATE] at 3:20pm to [DATE] at 5:15pm with multiple staff on various shifts revealed confirmatory knowledge of in-services dated [DATE]. - Review of in-services dated [DATE] were completed on door locking procedures was confirmed with observations on doors locked, interviews with staff confirmed by verbalizing expectations. - Interviews on [DATE] at 3:20pm to [DATE] at 5:15pm with multiple staff on various shifts revealed confirmatory knowledge of in-services dated [DATE] - Review of In-service dated [DATE] topic: receptionist will verify a residents leave status with prior to letting resident out. - Interviews on [DATE] at 3:20pm to [DATE] at 5:15pm with multiple staff on various shifts revealed confirmatory knowledge of in-services dated [DATE]. - Review exit door monitoring log for June and July were completed and up to date. - Interview on [DATE] at 4:00 PM Administrator and Director of Clinical Operations stated all full-time staff had been in-serviced and completed by [DATE]. Pending PRN staff that had yet to be interviewed would not be allowed to work until they were in-serviced on elopement interventions and expectations. The administrator was informed on [DATE] at 5:10 pm the IJ was removed effective [DATE]. The facility remained out of compliance at a scope and severity of isolated potential for more than minimal harm due to the need for the facility to monitor its corrective actions for effectiveness.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible, and that each resident received adequate supervision to prevent accidents for two (Resident #2 and Resident #3) of five residents reviewed for accident hazards and supervision to prevent accidents. 1. The facility failed to prevent Resident #2 from suffering a cut, requiring 25 stiches in her leg, when she was improperly transferred from her wheelchair to bed. The CNA failed to transfer the resident via a mechanical lift. 2. The facility did not take action to replace the cap on the end of the enabler bar on Resident #3's bed from 12/15/2022 to 12/19/2022. These failures placed residents at risk of injury and could result in injury to other residents. Findings include: Record review of Resident #2's face sheet, dated 12/19/2022, documented that she was [AGE] years old, was initially admitted on [DATE] and readmitted on [DATE]. Her diagnoses included COVID 19. Record review of Resident #2's Medical Diagnoses listing, dated 12/19/2022, documented in part that her diagnoses included cardiac arrythmia (abnormal heart beat), diabetes, hypertension and Parkinson's disease (worsening problems with the nervous and parts of the body controlled by the nerves). Record Review of Resident #2's annual MDS assessment, dated 9/21/2022, documented that her BIMS was 13 (cognitively intact). She had no behavioral symptoms. She required extensive assistance from two people to move around in bed and to transfer between surfaces. She did not walk and required extensive assistance from one person to move around the facility. She required extensive assistance from one person to dress, use the toilet, and for personal hygiene. She used a wheel chair as a mobility device. Record review of Resident #2's care plan, dated 09/13/2022, documented in part that she needed bed enablers to help her with repositioning in bed or for transfer in and out of bed. Interventions included to inspect and evaluate the enablers for malfunction and maintenance. Her care plan, dated 12/22/2022, documented that she had a skin tear to her left lower extremity related to transfer from wheelchair to bed. Interventions included to identify potential causative factors and eliminate or resolve thm when possible. Record review of Resident #2's Skin Assessment, dated 12/11/2022 ,documented that she had a skin tear to the front of the left lower leg. Comments included that the resident was being transferred by staff when her left leg came in contact with an enabler with no protective cover causing a six-inch laceration to the left mid lower leg. Record review of Resident #2's physician's order, dated 12/11/2022, said it was OK to send her to the emergency department for evaluation and possible treatment after as skin tear/laceration to the left lower extremity (leg). Record review of the facility's daily census for 12/11/2022 documented that Resident #2 was in Room [#] at the time of her injury. Record review of the facility's daily census for 12/19/2022 documented that Resident #3 now occupied the room that Resident #2 had occupied. Record review of Resident #3's face sheet, dated 12/20/2022, documented that he was [AGE] years old. Record review of Resident #3's Medical Diagnoses sheet, accessed 12/20/2022, documented that he had a traumatic subdural hemorrhage (bleeding in the brain), had a history of falling, dementia, anxiety, Parkinson's Disease and COVID-19. Record review of Resident #3's admission MDS assessment, dated 10/12/2022, documented he was admitted to the facility on [DATE]. His BIMS was 11 (moderate cognitive impairment). He required extensive assistance from one person to move around in bed, to transfer between surfaces, dress, use the toilet and for personal hygiene. Record review of Resident #3's census sheet on 12/20/2022 documented in part that he was moved to Resident #2's old room on 12/15/2022. In an interview and observation on 12/19/2022 at 9:22 AM, Resident #2 said that she cut her left leg on the bed when a man helped her transfer from the wheelchair into the bed. She said that usually a mechanical lift was used for transfers but that on that occasion it was not. Observation revealed a 4-inch by 4-inch dressing on the resident's left lower leg. She said she had the dressing because she gotten stiches when she cut her leg. She said she had changed rooms since she got cut and did not think that the bed had been moved with her. Observation of the resident's bed revealed no safety-related issues. In an interview and observation on 12/19/2022 at 9:41 AM, LVN D was observed while changing the dressing on Resident #2's left lower leg. The wound on her leg was shaped like a Y with right and left upper arms measuring 7.5 CM each and lower upright measuring 4 CM and had multiple surgical sutures. LVN D said that he had first dressed her wound, which had 25 stiches, on 12/12/2022 when she returned from the hospital. In interview, record review and observation on 12/19/2022 beginning at 10:12 AM, the Maintenance Director said that he received information regarding needed repairs from the Maintenance Log book, or by staff and residents approaching him with concerns. He said he had not received any report about a female resident who had cut her leg on the bed, or needing to repair a bed in the 200 hall. Review of the Maintenance Log book for the month of December 2022 revealed no notations regarding a bed needing repair. The Maintenance Director said he would have been in charge of moving the bed from the room if that had taken place. In interview and observation on 12/19/2022 at 10:21 AM in [Resident #2's old room] Resident #3 was sitting cross-legged on the bed. It was observed that the bed had enabler bars attached to each side of the bed and that the enabler bars were folded down and not in use. Resident #3 said that he had not had any problems with the bed and had not gotten scratched or injured by the bed. Observation of the left enabler bar revealed that one end did not have a rounded black plastic guard inserted in the open end of the tubing. The Maintenance Director who was present in the room said he was not aware that the enabler lacked the plastic guard and that if he were aware it was missing, he would have replaced it. He said that he did not think the unprotected end of the enabler bar posed a risk to residents but that those little things needed to be fixed. He left and returned shortly with a black plastic guard which he was observed to put in the open end of the enabler bar. In an interview on 12/19/2022 at 3:43 PM, NA E said that, on 12/11/2022, he had just started his shift and the other NA that worked on his hallway had not yet arrived. He said that the nurse on the floor told him to put Resident #2 to bed. He went to transfer Resident #2 from the wheelchair into bed, planning to use the mechanical lift by himself, but noticed that the sling in which the resident would lay during the transfer was improperly placed in the wheelchair and would that the Resident she might fall if he tried to transfer her using it. The resident said she was tired and asked that he please put her in bed. He was able to stand her up and swivel her from the wheelchair into the bed but when she was in bed she said that she had been cut. He looked at her leg and it was bleeding. He put pressure on the wound and called for help. He said that he had received training on the proper transfer of residents, but had transferred Resident #2 without the help because she was tired and wanted to go to bed. In an interview on 12/20/2022 at 4:23 PM, the DON said that Resident #2 was cut when she was improperly transferred from the wheelchair to the bed and her leg rubbed against the open end of the grab bar [enabler]. She said that the condition of bed was a causative factor to be considered when evaluating the incident, and that part of the facility action would be to address it as an environmental factor. She said that the process for repair of the bed would be to place a request in the Maintenance Log book. She was not aware that the enabler had not been repaired before it was brought to the attention of Maintenance Director by the surveyor earlier that day, or that another resident was occupying the unrepaired bed. She said that the unrepaired bed posed a risk for skin tears or cuts to residents. Record review of the facility policy Accidents and Supervision dated 03/2022 documented in part that the resident environment would remain as free of accident hazards as possible, and that each resident would receive adequate supervision and assistive devices to prevent accidents. This included identifying hazards and risk, evaluation and analyzing hazards and risks and implementing interventions to reduce hazards and risks.

Based on observation, interview and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety in one kitchen for 6 (Residents #8, #12, #13, #33, #34 and #113) of 33 residents observed for dining services. A. On 9/5/18, Cook I prepared fried eggs using unpasteurized eggs. The egg yolks were runny. The eggs were served to Residents #8, #12, #13, #33, #34 and #113. These residents had [DIAGNOSES REDACTED]. An Immediate Jeopardy (IJ) was identified and the Administrator was notified on 9/6/18. While the IJ was removed on 9/7/18, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that was not immediate jeopardy at a pattern. This failure could place 40 residents who request soft-cooked eggs at risk for Salmonella food poisoning which could include severe gastrointestinal illness, fever, diarrhea, and even death. B. The facility failed to thaw meat following their policy and procedure. A large piece of frozen meat was in the process of thawing under running water. The water temperature was too warm and the meat was not submerged. This failure could place 71 residents who eat food prepared in the kitchen at risk of food-borne illness. The findings include: A. Egg Preparation Review of the website https://www.cdc.gov/features/salmonella/index.html, last reviewed on 6/14/18, stated the following, in part: Poultry may carry bacteria such as Salmonella that can contaminate the inside of eggs before the shells are formed. Eggs can also become contaminated from the droppings of poultry through the laying process or from the environment. Cook eggs until both the yolk and white are firm. Egg dishes should be cooked to an internal temperature of 160 degrees F or hotter. Make sure that foods that contain raw or lightly cooked eggs, such as hollandaise sauce, Caesar salad dressing and tiramisu are made only with pasteurized eggs. Older adults, infants and people with weakened immune systems, such as those with HIV/AIDS, diabetes or an organ transplant, may get a more serious illness that can even be life-threatening. Observation on 9/5/18 at 7:49 AM revealed an opened carton of unpasteurized eggs in the walk-in refrigerator. Observation and interview on 9/5/18 at 8:01 AM revealed Cook I preparing fried eggs on the cook top. Cook I was asked if the facility had pasteurized eggs. He walked to the walk-in refrigerator and pointed to an unopened carton of pasteurized eggs behind the opened egg carton. Cook I said the facility had pasteurized eggs but he was using the eggs (unpasteurized) from the open carton to prepare the fried eggs for breakfast. Cook I said the facility had run short of supplies and the Dietary Manager had bought the unpasteurized eggs over the week-end so there would be eggs available for the residents. Cook I said the facility usually only had pasteurized eggs but had run out. He said there was no risks involved in using the unpasteurized eggs to make soft-cooked eggs (eggs where the white or the yolk are not cooked all the way through - runny). In an interview on 9/5/18 at 9:13 AM, the Dietary Manager said pasteurized eggs should be used for eggs prepared over easy or fried. She said unpasteurized eggs could be used if they were cooked right which she clarified to mean the yolk must be 155 degrees F which would be a solid, not runny, yolk. When asked if there was any problems if residents were served runny-yolked eggs made with unpasteurized eggs, the Dietary Manager said the residents request their eggs that way. She then added that there was a risk of Salmonella. In an interview on 9/5/18 at 5:11 PM, the Dietary Manager said the pasteurized eggs were usually delivered at 7:00 AM, but breakfast service starts before that so she picked up the unpasteurized eggs Monday, 9/3/18, on her way to work. She said the cook was using the unpasteurized eggs to prepare the eggs for breakfast because the carton was already opened. She said most of the residents eat their eggs fried, over easy or sunny side up. She said there were 40 residents who regularly ate soft-cooked eggs. 1) Resident #13 Review of Resident #13's Admission Record dated 09/06/2018 documented in part that she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #13's History and Physical dated 04/30/2018 documented in part that her [DIAGNOSES REDACTED]. Observation on 09/05/2018 at 07:57 AM revealed that she had consumed about 30% of two eggs with uncooked yolks. In an interview on 9/5/18 at 8:03 AM, Resident #13 said she ate some of the egg but she did not like uncooked egg yolk. 2) Resident # 12 Review of Face Sheet dated 9/6/2018 documented Resident #12 was an [AGE] year-old female admitted on [DATE]. Review of Resident #12's History and Physical dated 9/22/2017 documented in part [DIAGNOSES REDACTED]. Observation on 9/5/18 at 8:35 AM revealed Resident #12 was served and ate over easy eggs with runny egg yolks. In an interview on 09/05/18 at 03:56 PM Resident #12 said she gets over easy eggs for breakfast by choice and enjoys them. 3) Resident #113 Review of Resident #113's Admission Record dated 09/06/2018 documented in part that she was a [AGE] year-old female and was admitted to the facility on [DATE]. Review of Resident #113's History and Physical dated 06/01/2018 documented in part that her [DIAGNOSES REDACTED]. Observation and interview on 09/05/2018 at 09:05 AM, Resident #113 had uncooked egg yolk on her plate. She said she ate over easy eggs for breakfast. 4) Resident # 34 Review of Face Sheet dated 9/6/2018 documented Resident #34 was a [AGE] year-old male admitted on [DATE]. Review of Resident #34's physician progress notes [REDACTED]. Observation on 9/5/18 at 9:07 AM revealed Resident #34 had been served fried eggs with runny yolks. He was being fed by a Certified Nurse Aide. 5) Resident # 33 Review of Face Sheet dated 9/6/2018 documented Resident #33 was an [AGE] year-old male admitted on [DATE]. Review of Resident #33's physician progress notes [REDACTED]. Observation on 9/5/18 at 9:07 AM revealed Resident #33 was served and ate fried eggs with runny yolks 6) Resident # 8 Review of Face Sheet dated 9/6/2018 documented Resident #8 was a [AGE] year-old male admitted on [DATE]. Review of Resident #8 's History and Physical dated 2/28/2018 documented in part [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. In an interview on 9/5/2018 at 10:01 AM Resident #8 said he had over easy eggs with runny yolks yesterday (9/4/18) for breakfast. Review of a receipt from a food wholesaler documented a flat of unpasteurized eggs was purchased on 9/2/18 (Sunday) at 7:00 AM. Review of a delivery invoice from the facility food supplier documented 15 dozen pasteurized eggs were delivered on 9/2/18 (Sunday). Review of the facility policy Food Preparation and Service, revised (MONTH) 2014, stated in part only pasteurized shell eggs will be cooked and served when residents request undercooked, soft-served or sunny side up eggs and preparing foods that will not be thoroughly cooked (e.g. hollandaise sauce, French toast, ice cream, etc.). Unpasteurized eggs will be cooked until all parts of the egg (yolk and whites) are completely firm (internal temperature of 160 degrees F) and eaten promptly after cooking. Review of the website https://www.foodsafety.gov/blog/spring_eggs.html dated 4/12/11 stated in part: Cooking reduces the number of bacteria present in an egg; however, a lightly cooked egg with a runny egg white or yolk still poses a greater risk than a thoroughly cooked egg. Lightly cooked egg whites ad yolks have bot caused outbreaks of Salmonella infections. Eggs should be cooked thoroughly until both the yolk and white are firm. Recipes containing eggs mixed with other foods should be cooked to an internal temperature of 160 degrees F. For recipes that call for raw or lightly coked eggs, consider using pasteurized shell eggs. The elderly, infants and those wit impaired immune systems nay have a more severe illness. The Salmonella infection may spread from the intestines to the blood stream and then to other body sites and can cause death unless the person is treated promptly with antibiotics. That's why the consumption of raw or undercooked eggs should be avoided, especially by young children, elderly persons, and persons with weakened immune systems or debilitating illness. The Administrator was notified of the Immediate Jeopardy on 9/6/18 at 10:58 AM. The facility submitted a plan of removal that was accepted on 9/6/18 at 5:39 PM. The Plan of Removal documented the following: Immediate Actions: 1. All unpasteurized eggs were removed from Dietary on 9/5/18. 2. In-serviced dietary staff on the proper use and handling of eggs - Completion 9/6/18 3. One-on-one education with Dietary Manager by the Administrator regarding non-use of unpasteurized eggs in the facility, regardless of reason. Completion 9/6/18. 4. Disciplinary Action to Dietary Manager for having unpasteurized eggs in the building. Completion 9/6/18 5. Final Disciplinary Action for cook on regarding use of unpasteurized eggs for over-easy eggs when pasteurized were available. Completion 9/6/18 6. Four affected residents were observed for side-effects, none were noted from 9/5 - 9/6/18. 7. Policy for facility has been revised to no unpasteurized eggs to be used in the facility. Completed 9/6/18 Oversight: 1. Daily check by Administrator and/or Designee for thirty (30) days of the Dietary cooler to assure compliance of no pasteurized eggs in the he Dietary. 2. Once a week check of the Dietary cooler by Dietician on weekly visits to assure compliance of no unpasteurized eggs in the Dietary. 3. After 30 days Dietary cooler will be checked twice weekly for two (2) weeks for compliance of no unpasteurized eggs in the Dietary by the Administrator and/or Designee. 4. Then once a week for four (4) weeks and prn thereafter. Administrator will check the Dietary cooler for compliance of no unpasteurized eggs in the Dietary during unannounced Dietary rounds. 5. Administrator/ and/or Designee will report findings of rounds and checks to the IDT team during the daily IDT meeting for a month and to the QA for three meetings for compliance and outcomes. Observation on 9/6/18 at 8:33 AM and 9/7/18 at 9:51 AM revealed there were no unpasteurized eggs in the walk-in refrigerator. Pasteurized eggs were used for soft cooked eggs. In an interview on 9/7/18 at 9:52 AM Cook J said if unpasteurized eggs were used they must be thoroughly cooked with firm whites and yolks. He said only pasteurized eggs can be used for soft-cooked eggs. Review of In-Service Training Report dated 9/6/18 documented the dietary staff received training on the proper use and cooking methods of eggs, thawing of meat and menu compliance and appropriate substitutions. The training was conducted by the facility Consultant Dietician and the Dietary Manager. Through observation, interview and record review it was determined the facility's plan of removal was in place. The IJ was lifted on 9/7/18 at 9:57 AM, at which time the scope and severity was reduced to a level of no actual harm with potential for more than minimum harm that is not immediate jeopardy at a pattern. B) Thawing Meat Observation on 9/5/18 at 7:49 AM during the initial observation of the kitchen revealed a large piece of meat was being thawed in a pot in a sink. The pot was under 2 streams of running water. The meat was not submerged. The water felt lukewarm to the touch. The meat still felt frozen. Observation and interview on 9/5/18 at 7:55 AM, Cook I measured the temperature of the running water. If was 80 degrees F. Only the cold running water was turned on. Cook I said thawing should be done under cold running water or in the refrigerator. In an interview on 9/5/18 at 9:13 AM, the Dietary Manager said frozen meat should be thawed under cold running water - 70 degrees F - and should be submerged. Review of the facility policy Food Preparation and Service revised (MONTH) 2014, stated in part: Foods will not be thawed at room temperature. Thawing procedures include: a. Thawing in the refrigerator in a drip-proof container; b. Submerging the item in cold running water (70 degrees F or below); c. Thawing in a microwave oven and then cooking and serving immediately; or d. Thawing as part of a continuous cooking process. The 40 residents who regularly request undercooked eggs was obtained through interview with the Dietary Manager on 9/5/18 at 5:11 PM. The 71 residents who eat food prepared in the kitchen was obtained from the CMS 672 dated 9/5/18.

Based on observation, interview, and record review the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence for 1 of 33 Residents (Resident #8) reviewed for mobility. Resident #8 was not provided restorative services after being discharged from physical and occupational therapies and experienced a significant deterioration in mobility. This failure affected Resident #8 and could place 9 other residents who were discharged from therapies and remained in the facility at risk for further decline in mobility. Findings Include: Review of Face Sheet dated 9/6/2018 documented Resident #8 was a [AGE] year-old male admitted on [DATE]. Review of Resident #8 's History and Physical dated 2/28/2018 documented in part [DIAGNOSES REDACTED]. Review of Care Plan dated as initiated 4/25/2018 with a target date of 10/25/2018 documented in part; Focus: I am at risk for deterioration in Activities of Daily Living (ADL) such as bed mobility, transfer, walking in room, walking in corridor, and locomotion on and off unit. Goal: Will show no measurable decline in functional ability through next review date. Review of Quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. In an interview on 9/5/2018 at 10:29 AM Resident #8 said he was receiving physical and occupation therapy but since his 100 days of Medicare were up he had not gotten any type of therapy. He said he was waiting for his Medicaid to be approved. Resident #8 said the facility told him once his Medicaid was approved they would get authorization for therapy through Medicaid and he would get therapy again. He said they told him he just had to wait. Resident #8 said since his therapy stopped he requires more assistance getting up out of bed or chair and getting to the bathroom. Resident #8 said he had lost his independence. He said he could stand and pivot to wheelchair, but not any longer because he had lost his strength. Resident #8 said he was walking with a walker when therapy stopped, but not anymore. Resident #8 said now he cannot even stand up. He said it was a horrible feeling to be stuck and not be able to do anything for yourself just because his 100 days were up. Resident #8 said he had talked to everyone in the facility about getting worse since therapy stopped and they had never mentioned restorative to him, he had never heard of that, they had just told him there was nothing they could do until his Medicaid was approved. Resident said physically declining and depending on others for his basic needs was very depressing, he had deteriorated over that time. He said that he could no longer stand up and pivot to the wheelchair or to the toilet and he could no longer walk. He said he stays in bed all of the time except for seven hours a day. He said the aide puts him in the wheelchair at 11:00 AM each day where he stays until 6:00 PM when the staff get him back into bed. Review of Physical Therapy - Therapist Progress and Discharge Summary dated as end of care 5/18/2018 documented the short term and long-term goals had been met. The goal of bed mobility, transfers and ambulation were met on 5/18/2018. The summary documented Resident #8 could complete bed mobility, functional transfers and could ambulate 50 feet with a front wheeled walker. The summary also documented Resident #8 was only supervision and contact guard for gait. Review of Occupational Therapy - Therapist Progress and Discharge Summary dated as end of care 5/18/2018 documented Resident #8 demonstrates standing static balance and required handheld support to maintain balance for 25 minutes. The summary documented Resident #8 for toilet transfer required supervision or touching assistance as the resident completes the activity, assistance may be provided throughout the activity or intermittently. Review of Nursing Home Part A Medicare Discharge MDS dated [DATE] documented in part: Lying to sitting on side of bed = supervision or touching/steadying assistance as resident completes activity Chair to Bed/Bed to Chair = supervision or touching/steadying assistance as resident completes activity Toilet transfer = supervision or touching/steadying assistance as resident completes activity Walk 50 feet with two turns = supervision or touching/steadying assistance as resident completes activity Walk 150 feet = supervision or touching/steadying assistance as resident completes activity Review of most recent Quarterly MDS dated [DATE] documented in part: Bed Mobility = Extensive Assistance of two (2) staff physical assist Transfer = Extensive Assistance of two (2) staff physical assist Toilet = Extensive Assistance of one (1) staff physical assist Walk in room = Activity did not occur Walk in corridor = Activity did not occur In an interview on 9/7/2018 at 10:55 AM Certified Nurse Aide (CNA) H said she physically lifts Resident #8 for all transfers. She said Resident #8 cannot walk and can barely stand for her to transfer him. CNA H said even in the bathroom he cannot hold onto the bar and stand for her to clean him and pull up his pants. She said she wants to use a mechanical lift but Resident #8 refuses. Observation on 9/7/2018 at 11:00 AM CNA H physically rolled Resident #8 side to side to provide incontinent care. She physically lifted his head and torso while turning his legs to a seated position on the side of the bed. CNA H placed a gait belt around Resident #8's waist, she grabbed the gait belt and Resident #8 placed his arms around her neck to hold on. CNA H then physically picked Resident #8 up from the side of the bed and swung him over to the wheelchair. In an interview on 9/6/2018 at 4:30 PM the Director of Nursing (DON) said the facility did not have a restorative program. He said he put some staff through restorative training about two weeks ago. He said he had not started the program yet. Review of Policy and Procedure Rehabilitative Nursing Care dated as revised (MONTH) 2013 documented in part: Rehabilitative nursing care is provided for each resident admitted . Our facility has an active program of rehabilitative nursing which is developed and coordinated through the resident's care plan. The facility's rehabilitative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. Rehabilitative nursing techniques are included in the orientation program and the ongoing Staff Development Program. Review of Beneficiary Notice - Residents discharged within the Last Six Months provided by the Nursing Home Administrator on 9/5/2018 documented ten residents where discharged from a Medicare covered Part A stay and remained in the facility.

Based on observation, interview, and record review the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living (ADL) did not diminish, based on the comprehensive assessment and consistent with the resident's needs and choices, for 1 of 33 Residents (Resident #8) reviewed for ADLs. Resident #8 did not receive restorative services after being discharged from physical and occupational therapies and experienced a significant deterioration in ADL's. This failure affected Resident #8 and could place 9 other residents who were discharged from therapies and remained in the facility at risk of declines in their abilities to engage in activities of daily living. Findings Include: Review of Face Sheet dated 9/6/2018 documented Resident #8 was a [AGE] year-old male admitted on [DATE]. Review of Resident #8 's History and Physical dated 2/28/2018 documented in part [DIAGNOSES REDACTED]. Review of Care Plan dated as initiated 2/27/2018 with a target date of 10/25/2018 documented in part; Focus: I am at risk for urinary tract infections and skin breakdown related to functional status, incontinent of bowel and bladder. My self-care performance fluctuates, Goal: Resident #8 will participate, self-performance, in ADL and will have no measurable decline in toileting ADL functional ability through next review date. Review of Care Plan dated as initiated 4/24/2018 with a target date of 10/25/2018 documented in part; Focus: Resident #8 requires assistance with ADL's and is at risk for deterioration in ADL's (bed mobility, bathing, transfer, walking in room, walking in corridor, locomotion on and off unit, dressing, eating, toilet use and personal hygiene related to immobility. Self-care performance fluctuates due to debility. Goal: Resident #8 will maintain a sense of dignity by being clean, dry, odor free, well groomed and will show no measurable decline in transferring/bed mobility, ADL functional ability through next review date. Review of Quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. In an interview on 9/5/2018 at 10:29 AM Resident #8 said he was receiving physical and occupation therapy but since his 100 days of Medicare were up he had not gotten any type of therapy. He said he was waiting for his Medicaid to be approved. Resident #8 said the facility told him once his Medicaid was approved they would get authorization for therapy through Medicaid and he would get therapy again. He said they told him he just had to wait. Resident #8 said since his therapy stopped he requires more assistance getting up out of bed or chair and getting to the bathroom. Resident #8 said he had lost his independence. He said he could stand and pivot to wheelchair, but not any longer because he had lost his strength. Resident #8 said he was walking with a walker when therapy stopped, but not anymore. Resident #8 said now he cannot even stand up. He said it was a horrible feeling to be stuck and not be able to do anything for yourself just because his 100 days were up. Resident #8 said he had talked to everyone in the facility about getting worse since therapy stopped and they had never mentioned restorative to him, he had never heard of that, they had just told him there was nothing they could do until his Medicaid was approved. Resident said physically declining and depending on others for his basic needs was very depressing, he had deteriorated over that time. He said that he could no longer stand up and pivot to the wheelchair or to the toilet and he could no longer walk. He said he stays in bed all of the time except for seven hours a day. He said the aide puts him in the wheelchair at 11:00 AM each day where he stays until 6:00 PM when the staff get him back into bed. Review of Physical Therapy - Therapist Progress and Discharge Summary dated as end of care 5/18/2018 documented the short term and long-term goals had been met. The goal of bed mobility, transfers and ambulation were met on 5/18/2018. The summary documented Resident #8 could complete bed mobility, functional transfers and could ambulate 50 feet with a front wheeled walker. The summary also documented Resident #8 was only supervision and contact guard for gait. Review of Occupational Therapy - Therapist Progress and Discharge Summary dated as end of care 5/18/2018 documented Resident #8 demonstrates standing static balance and required handheld support to maintain balance for 25 minutes. The summary documented Resident #8 for toilet transfer required supervision or touching assistance as the resident completes the activity, assistance may be provided throughout the activity or intermittently. Review of Nursing Home Part A Medicare Discharge MDS dated [DATE] documented in part: Lying to sitting on side of bed = supervision or touching/steadying assistance as resident completes activity Chair to Bed/Bed to Chair = supervision or touching/steadying assistance as resident completes activity Toilet transfer = supervision or touching/steadying assistance as resident completes activity Walk 50 feet with two turns = supervision or touching/steadying assistance as resident completes activity Walk 150 feet = supervision or touching/steadying assistance as resident completes activity Review of most recent Quarterly MDS dated [DATE] documented in part: Bed Mobility = Extensive Assistance of two (2) staff physical assist Transfer = Extensive Assistance of two (2) staff physical assist Toilet = Extensive Assistance of one (1) staff physical assist Walk in room = Activity did not occur Walk in corridor = Activity did not occur In an interview on 9/7/2018 at 10:55 AM Certified Nurse Aide (CNA) H said she physically lifts Resident #8 for all transfers. She said Resident #8 can not walk and can barely stand for her to transfer him. CNA H said even in the bathroom he can not hold onto the bar and stand for her to clean him and pull up his pants. She said she wants to use a mechanical lift but Resident #8 refuses. Observation on 9/7/2018 at 11:00 AM CNA H physically rolled Resident #8 side to side to provide incontinent care. She physically lifted his head and torso while turning his legs to a seated position on the side of the bed. CNA H placed a gait belt around Resident #8's waist, she grabbed the gait belt and Resident #8 placed his arms around her neck to hold on. CNA H then physically picked Resident #8 up from the side of the bed and swung him over to the wheelchair. In an interview on 9/6/2018 at 4:30 PM the Director of Nursing (DON) said the facility did not have a restorative program. He said he put some staff through restorative training about two weeks ago. He said he had not started the program yet. Review of Policy and Procedure Rehabilitative Nursing Care dated as revised (MONTH) 2013 documented in part: Rehabilitative nursing care is provided for each resident admitted . Our facility has an active program of rehabilitative nursing which is developed and coordinated through the resident's care plan. The facility's rehabilitative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. Rehabilitative nursing techniques are included in the orientation program and the ongoing Staff Development Program. Review of Beneficiary Notice - Residents discharged within the Last Six Months provided by the Nursing Home Administrator on 9/5/2018 documented ten residents where discharged from a Medicare covered Part A stay and remained in the facility.