Every finding on record at Bluebonnet Rehab at Ennis

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 12 residents reviewed for quality of care. The facility failed, when TD A did not ensure Resident #1 was properly secured in her wheelchair on 05/04/26, which resulted in Resident #1 being thrown from her wheelchair to the front of the vehicle and suffering a closed fracture of shaft of right radius and ulna (broken right forearm, but the skin over the break is not torn open). This failure placed residents at risk of serious harm and diminished quality of life.Findings included: Record review of admission record dated 08/19/26 revealed a [AGE] year-old female who was originally admitted to the facility 10/07/21 and diagnosed with other extraarticular fracture of lower end of left radius (a broken wrist on left side where break is near wrist, but does not enter the actual wrist joint), unspecified fracture of shaft of right radius (broken main thumb-side bone in right forearm), closed fracture with routine healing unspecified fracture of upper end of left humerus (broken left upper arm bone near shoulder that did not break the skin and is currently healing normally on schedule), fall from wheelchair (powered), bus as the place of occurrence of the external cause, and myalgia (muscle pain or aches). Record review of Resident #1's quarterly MDS dated [DATE] and signed by the DON 07/06/26 reflected a BIMS score of 15, indicating intact cognitive function; Mobility Devices: Wheelchair; Functional Abilities. Mobility: A. roll left and right: 03 - partial/moderate assistance (helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.); Active Diagnoses: Cerebral vascular Accident, Transient Ischemic Attack, or Stroke, seizure disorder or epilepsy, bipolar disorder, schizophrenia; Pain interference with day-to-day activities: 02 indicating occasionally; Pain Intensity: 05 on 00-10 pain scale; Recent Surgery Requiring Active SNF Care: 01 indicating yes; Surgical Procedures: repair fractures of the shoulder, repair but not replace joints. Record review of Resident #1's care plan dated 05/06/26 reflected Focus: Resident #1 has had an actual fall has no safety awareness. 5/4/26 actual fall sent to ED. Interventions: 5/4/26 Educated on wearing seat belt when traveling on van Revision 5/4/2026. Record review of Resident #1's care plan dated 05/07/26 reflected Focus: readmitted with unspecified fracture of the lower end of right radius subsequent encounter for closed fracture with routine healing, unspecified fracture of shaft of right radius subsequent encounter for closed fracture with routine healing Date Initiated: 07/08/2025 Revision on: 05/08/2026; Goal: Resident #1 will remain free of complications related to musculoskeletal system such as fracture, contracture formation, embolism and immobility through review date. Target Date: 07/06/26; Intervention: Monitor/document/report to MD PRN s/sx or complications related to arthritis: Joint pain; Joint stiffness, usually worse on wakening; Swelling; Decline in mobility; Decline in self-care ability; Contracture formation/joint shape changes; Crepitus (creaking or clicking with joint movement); pain after exercise or weight bearing. Date Initiated: 07/08/2025. Record review of local hospital discharge summary report dated 05/04/2026 reflected an admission date of 05/04/26 and a discharge date of 05/07/26. The form also reflected the following chief complaint: fall with visit diagnoses that included traumatic closed displaced fracture of distal end of right radius and ulna, (primary), other closed intra-articular fracture of distal end of right radius, closed traumatic nondisplaced fracture of proximal end of left humerus, closed head injury, fracture of the lower end of right radius, fracture of lower end of right ulna, fall from moving wheelchair (powered), bus at the place of occurrence of the external cause; and the following final diagnoses: traumatic closed displaced fracture of distal end of right radius and ulna, closed traumatic nondisplaced fracture of proximal end of left humerus, and closed head injury. She is right-hand dominant. She cannot use a walker, only can ambulate with a power chair. Procedures performed during this hospitalization: XR wrist 3 or more views right, XR shoulder 2 or more views left, XR elbow views left, XR chest 1 view, CT head wo contrast, CT cervical spine wo contrast, XR tibia fibula 2 views right, XR wrist 2 views right, XR fluoro less than1 hour; Consults: HOSP to consult to comprehensive care management, HOSP consult to surgery (orthopedic); Brief hospital Course/Summary: Per admission history and physical dated 5/4/2026: Per (medical provider), - Patient (Resident #1) was on her scooter while riding a bus when the bus drive hit the brakes firmly to avoid the collision causing her to fall off her scooter. Subsequently patient (Resident #1) reported facial swelling and pain along with pain in the right forearm and left upper arm areas. Patient was brought to the ED for further evaluation. Patient (Resident #1) denies fever, loss of consciousness, chest pain, shortness of breath, nausea vomiting abdominal pain diarrhea or dysuria. Patient (Resident #1) was admitted to the hospital for management of traumatic closed fracture of right radius and ulnar fracture after falling from her wheelchair. Patient (Resident #1) had right ORIF on 5/5/2026 by orthopedic surgeon. Patient (Resident #1) was also found to have left humeral fracture that was managed nonoperatively. Patient (Resident #1) was seen by PT and OT in the hospital post-surgery and patient (Resident #1) was recommended to get outpatient PT and OT. Patient (Resident #1) was ultimately discharged back to her SNF with outpatient PT and OT. Significant Findings/Diagnoses: Note: Pt (Resident #1) was seen and examined prior to discharge. Exam was stable. Pt (Resident #1) was stable for discharge. ED Provider Note: Date of Service 5/4/2026: History: Initial H&P: This was a 68 y.o. female who presents with chief complaint of pain after a fall. The patient (Resident #1) presents from the scene of the accident by EMS. The bus had to stop suddenly because somebody else ran a stop sign and the bus had to stop firmly in order to avoid an accident. Although her chair was locked in place, she was not locked into the chair and she fell forward. She hit the right side of her face on the ground. She also hurt her right wrist, left shoulder, and left elbow. She denied any neck pain. Past Medical history: Diagnosis: aneurysm, anxiety, arrythmia palpitations, arthritis, bipolar 2 disorder (HCC), cardiomyopathy (HCC), diverticulosis, encephalopathy, enterocolitis, history of blood transfusion, hyperlipidemia (Rx-HCC), hypertension (Rx-HCC), morbid obesity (CMS-HCC), seizures (HCC), and Syncope. Record review of facility incident report dated 05/04/26 reflected Resident #1 suffered a fall with injury with no additional information provided. Observation of Resident #1 on 08/18/26 at 02:15 PM revealed a plus-sized female who was lying in bed, and unable to walk. During an interview with Resident #1 on 08/18/26 at 02:24 PM, she stated she broke her wrist and left shoulder on May 4th while on the van. Resident #1 stated she was in the hospital for a week after she had surgery because she was thrown from her wheelchair. She stated the driver was TD A and she was the only patient on the van. During an interview with Resident #1 on 08/18/26 at 03:21 PM, she stated her wheelchair was secure, but she was not. She stated he slammed on the brakes, and was thrown to the front of the van. Resident #1 stated she was transported to the hospital via EMS and had surgery. Resident #1 stated she did not want to wear her seatbelt, and added that had not been the first time. She stated sometimes she wore it, while other times she did not. Resident #1 added TD A did not press the issue. She stated she did not recall seeing another vehicle coming, but she could not be sure. During an interview with TD A on 08/18/26 at 02:35 PM, he stated he had been with the facility about one year. He stated some of his duties included transportation and appointment scheduling. TD A stated he took residents to medical visits, and wherever else they wanted to go. He stated protocol for transporting a resident in a wheelchair was load on ramp, lock wheels, put the strap on, put lift up, wheel the resident inside the van, buckle them up, put hooks on and put seat belt on the resident. He stated in May while coming from an appointment, Resident #1's wheelchair was strapped down but refused to wear the seatbelt. TD A stated residents in their right minds had the right to refuse and added Resident had a BIMS of 15. He stated seatbelts were required according to state law. TD A stated he instructed Resident #1 three different times to put on her seatbelt, yet she still refused. TD A stated while driving, he slammed on brakes to avoid hitting an oncoming vehicle that ran a stop sign. He stated there was no collision. TD A stated 911 was called and the police, fire department, and EMS arrived on scene, and Resident #1 was transported via ambulance to the ED. TD A stated he received no traffic citations. He stated nothing like that happened before, or since. TD A stated he received no disciplinary actions from the facility, and added all residents had rights, even though wearing seatbelts was a state law. He stated he was in-serviced on the importance of residents wearing seatbelts, and was retrained on safety for the van. TD A stated if residents refused, he was to call the ADM. Exact instructions were not provided following the ADM notification. TD A stated incidents like what happened to Resident #1 was a consequence of the lack of a safety belt. During interviews with the ADM on 08/18/26 at 03:28 PM, he stated no self-report was called in because although it was lawful, it the resident's right to not wear a seatbelt. The ADM stated TD A was in-serviced. During an interview with the ADM on 08/18/26 at 04:27 PM, the incident was between him and TD A with no other documentation regarding safety. The ADM stated to his knowledge that was the 1st time Resident #1 did not wear her seatbelt and added she wore it to the appointment but it was uncomfortable coming back. The ADM stated he was not aware Resident #1 wore a seatbelt sometimes while other times she did not. He stated he was to be notified of any resident who refused to wear seatbelts. The ADM stated all residents had been 100% compliant since that incident with Resident #1 in May. He stated Resident #1 was the only resident who had refused to wear a seatbelt. The ADM stated TD A did not receive any type of reprimand. He stated the PD and FD were called, but to his knowledge, there was no formal report or report number. The ADM stated TD A was not cited by PD. He stated hours of transports were dependent upon the needs of the facility. The ADM stated there was no documentation related to resident education on wearing seatbelts, and added notifications were all verbal. He stated there was no policy related to seatbelts. He stated, ultimately, TD A should have ensured Resident #1 was secured in a seatbelt. Record review of TD A's personal personnel file reflected:*Wheelchair Van Operator Training & Competency Check-Off Form: Operator - TD A, Evaluator/Trainer Name: the ADM, Date of Training/Evaluation: 12/01/25 1. Pre-Trip Preparation & Safety Mindset 2. Lift/Ramp Operations 3. Boarding & Positioning Inside Van. 4. Wheelchair Securement & Occupant Restraints (Applies occupant restraints: lap belt low on hips/pelvic area, shoulder belt over shoulder (no neck contact, no slack/twists), does not rely soley on postural belt. Verifies all securements are tight and effective (pull-test); 5. Unloading & Post-Trip (Reverses process safely: verbal cues, lowers lifts, unsecures, assists off lift, completes documentation for any incidents, complaints, or maintenance issues). *Undated Employability Status Check Search Results: no results found*Abuse, Neglect & Exploitation Test: 8. Failing to provide basic needs for a resident such as not changing their briefs or soiled linen is considered neglect. (answered correctly). Record review of the facility's in-service dated 05/04/26 reflected, :Topic: Van - All residents to be buckled/strapped in before being transported. If patient refuses, ADM is to be notified. Signed by TD A.

Based on observation, interview, and record review, the facility failed to ensure staff prepared, distributed and served food in accordance with professional standards for food service safety 2 (AC B and DW C) of 3 staff when reviewed for food and nutrition services. 1. The facility failed to ensure AC B and DW C's hair restraints covered their exposed hair. 2. The facility failed to ensure DW C was wearing a mustache and beard covering while preparing lunch and handling food and drinks. 3. The facility failed to ensure DW C did not scratch his hair with latex gloves on, and did not remove the gloves, wash his hands, while preparing drinks for residents. Thes failures places residents at risk of foodborne illnesses.Findings included: Observation of kitchen on 08/20/26 at 10:45 AM revealed AC B had on a hairnet only covering the top of her head with hair that hung down the middle of her back while preparing resident lunches. DW C had on a hairnet that only covered the top of the head with hair exposed. DW C had no mustache/beard cover while preparing resident drinks. DW C scratched the hair on his head while wearing latex gloves and neither removed them, not washed his hands. DW C continued preparing drinks for resident lunches. During an interview with AC B on 08/20/26 at 10:48 AM, she stated facility policy was to wear hairnets without hair hanging out. She stated hair in food could make residents sick. AC B stated she did not know the date of her last training, but she was trained on it. During an interview with DW C on 08/20/26 at 10:50 AM, he stated protocol for scratching his hair was to removed himself from food area, and take off his gloves. He stated he should have washed his hands and got a new pair gloves after he scratched his head. DW C stated he knew his hairnet should have covered his entire head, and he was supposed to have a face covering on. DW C stated he did not always wear them. He stated he did not know when he was last trained or in-serviced on that issue. He stated if hair got in the food, it could make residents get sick. During an interview with the ADM on 08/20/26 at 11:07 AM, he stated facility policy was for kitchen staff to wear hair/beard nets when in the kitchen, and gloves were to be removed and replaced, and hands were to be washed when touching anything other than food. He stated that could result in residents' health being compromised. Record review of the facility's in-service dated 04/24/26 reflected:*Kitchen policies and procedures: Review policies on Preventing Foodborne Illness - food Handling and Employee Hygiene and Sanitary Practices, Food Preparation and Service, Food Receiving and Storage, and Handwashing/Hand Hygiene. Also review topics on storing, preparing, distributing and serving food, hand hygiene, and preventing foodborne illness Signatures included AC B and DW C. Record review of the facility's policy entitled Food Preparation and Service dated July 2014 reflected, Food service employees shall prepare and serve food in a manner that complies with safe food handling practices. Food Preparation Area .5. Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illnesses. Food Service/Distribution 6. Bare hand contact with food is prohibited. Gloves must be won when handing food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks. Disposable gloves are single use items and shall be discarded after each use. 7. Dietary staff shall wear hair restraints (hair net, hat, beard restraint, etc. so that hair does not contact food.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 1 facility reviewed for freedom from abuse, neglect, and exploitation. The facility failed to report allegations of neglect when TD A did not ensure Resident #1 was properly secured in her wheelchair on 05/04/26, which resulted in Resident #1 being thrown from her wheelchair to the front of the vehicle and suffering a closed fracture of shaft of right radius and ulna (broken right forearm, but the skin over the break is not torn open). This failure could result in a lack of oversight of residents' neglect and harm.Findings included: Record review of admission record dated 08/19/26 revealed a [AGE] year-old female who was originally admitted to the facility 10/07/21 and diagnosed with other extraarticular fracture of lower end of left radius (a broken wrist on left side where break is near wrist, but does not enter the actual wrist joint), unspecified fracture of shaft of right radius (broken main thumb-side bone in right forearm), closed fracture with routine healing unspecified fracture of upper end of left humerus (broken left upper arm bone near shoulder that did not break the skin and is currently healing normally on schedule), fall from wheelchair (powered), bus as the place of occurrence of the external cause, and myalgia (muscle pain or aches). Record review of Resident #1's quarterly MDS assessment dated [DATE] and signed by the DON on 07/06/26 reflected a BIMS score of 15, indicating intact cognitive function. Record review of Resident #1's care plan dated 05/06/26 reflected Focus: Resident #1 has had an actual fall has no safety awareness. 5/4/26 actual fall sent to ED. Interventions: 5/4/26 Educated on wearing seat belt when traveling on van Revision 5/4/2026. Record review of Resident #1's care plan dated 05/07/26 reflected Focus: readmitted with unspecified fracture of the lower end of right radius subsequent encounter for closed fracture with routine healing, unspecified fracture of shaft of right radius subsequent encounter for closed fracture with routine healing Date Initiated: 07/08/2025 Revision on: 05/08/2026; Goal: Resident #1 will remain free of complications related to musculoskeletal system such as fracture, contracture formation, embolism and immobility through review date. Target Date: 07/06/26; Intervention: Monitor/document/report to MD PRN s/sx or complications related to arthritis: Joint pain; Joint stiffness, usually worse on wakening; Swelling; Decline in mobility; Decline in self-care ability; Contracture formation/joint shape changes; Crepitus (creaking or clicking with joint movement); pain after exercise or weight bearing. Date Initiated: 07/08/2025. Record review of facility incident report dated 05/04/26 reflected Resident #1 suffered a fall with injury with no additional information provided. Observation of Resident #1 on 08/18/26 at 02:15 PM revealed a plus-sized female who was lying in bed, and unable to walk. During an interview with Resident #1 on 08/18/26 at 02:24 PM, she stated she broke her wrist and left shoulder on May 4th while on the van. Resident #1 stated she was in the hospital for a week after she had surgery because she was thrown from her wheelchair. She stated the driver was TD A and she was the only patient on the van. During an interview with Resident #1 on 08/18/26 at 03:21 PM, she stated her wheelchair was secure, but she was not. She stated he slammed on the brakes, and was thrown to the front of the van. Resident #1 stated she was transported to the hospital via EMS and had surgery. Resident #1 stated she did not want to wear her seatbelt, and added that had not been the first time. She stated sometimes she wore it, while other times she did not. Resident #1 added TD A did not press the issue. She stated she did not recall seeing another vehicle coming, but she could not be sure. During an interview with TD A on 08/18/26 at 02:35 PM, he stated he had been with the facility about one year. He stated some of his duties included transportation and appointment scheduling. TD A stated he took residents to medical visits, and wherever else they wanted to go. He stated protocol for transporting a resident in a wheelchair was load on ramp, lock wheels, put the strap on, put lift up, wheel the resident inside the van, buckle them up, put hooks on and put seat belt on the resident. He stated in May while coming from an appointment, Resident #1's wheelchair was strapped down but refused to wear the seatbelt. TD A stated residents in their right minds had the right to refuse and added Resident had a BIMS of 15. He stated seatbelts were required according to state law. TD A stated he instructed Resident #1 three different times to put on her seatbelt, yet she still refused. TD A stated while driving, he slammed on brakes to avoid hitting an oncoming vehicle that ran a stop sign. He stated there was no collision. TD A stated 911 was called and the police, fire department and EMS arrived on scene and Resident #1 was transported via ambulance to the ED. TD A stated he received no traffic citations. He stated nothing like that happened before, or since. TD A stated he received no disciplinary actions from the facility, and added all residents had rights, even though wearing seatbelts was a state law. He stated he was in-serviced on the importance of residents wearing seatbelts, and was retrained on safety for the van. TD A stated if residents refused, he was to call the ADM. Exact instructions were not provided following the ADM notification. TD A stated incidents like what happened to Resident #1 was a consequence of lack of safety belt. During an interview with the DON on 08/18/26 at 03:21 PM, she was asked the protocol for reporting incidents to HHSC, and stated, regarding Resident #1, 'state' had already been in the building and the incident was investigated. The DON added that incident had been discussed almost every time 'state' had been in the building. When asked for the self-report for the investigation, the DON stated the ADM should have had it in his office. The DON stated she assumed the ADM made the report to HHSC so she did not. During interviews with the ADM on 08/18/26 at 03:28 PM, he stated no self-report was called in because although it was lawful, it the resident's right to not wear a seatbelt. The ADM stated TD A was in-serviced. During an interview with the ADM on 08/18/26 at 04:27 PM, the incident was between him and TD A with no other documentation regarding safety. The ADM stated to his knowledge that was the 1st time Resident #1 did not wear her seatbelt and added she wore it to the appointment but it was uncomfortable coming back. The ADM stated he was not aware Resident #1 wore a seatbelt sometimes while other times she did not. He stated he was to be notified of any resident who refused to wear seatbelts. The ADM stated all residents had been 100% compliant since that incident with Resident #1 in May. He stated Resident #1 was the only resident who had refused to wear a seatbelt. The ADM stated TD A did not receive any type of reprimand. He stated the PD and FD were called, but to his knowledge, there was no formal report or report number. The ADM stated TD A was not cited by PD. He stated hours of transports were dependent upon the needs of the facility. The ADM stated there was no documentation related to resident education on wearing seatbelts, and added notifications were all verbal. He stated there was no policy related to seatbelts. He stated, ultimately, TD A should have ensured Resident #1 was secured in a seatbelt. The ADM stated a reportable incident was anything that placed a resident at risk, such as unwitnessed injuries, sex abuse, theft or misappropriation of property. The ADM stated, This injury was not reportable based on: the injury was not of unknown origin and was witnessed. The resident was asked to put on her seatbelt and she refused. Her BIMS is a 15 and she is able to make informed decisions. She stated to her POA, EMS, and police that she refused to wear her seatbelt when she fell out of her wheelchair which was corroborated with the van driver. There were no citations or ticketing for reckless driving. Record review of the facility's in-services was conducted and reflected the following topics:*08/15/26 Common emergencies of geriatric residents & how to prevent them; Common mental disorders w/related nursing implications/interventions; education of nurses in identification assessment & control of risk of injury to residents & staff during resident handling*05/04/26 Topic: Van - All residents to be buckled/strapped in before being transported. If patient refuses, ADM is to be notified. Signed by TD A. Conducted by the ADM. Record review of the facility's policy entitled Abuse, Neglect and Misappropriation Prevention Program dated 04/2021 reflected, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Policy Interpretation and Implementation: The resident abuse, neglect and exploitation prevention program consists 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 b. neglect of residents. 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property 9. Investigate and report any allegations within timeframes required by federal requirements 10. Protect residents from any further harm during investigations. 13. The abuse Coordinator is the ADM.

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan that described the services to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans.The facility failed to revise Resident #1's care plan to reflect an unwitnessed fall and intervention on 05-15-2026.This deficient practice placed residents at risk of not having their individualized needs met and communicated to providers that could result in a decline in physical well-being. Findings included: Record review of Resident #1's admission record, dated 07/24/2026, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses which included: fall from nonmoving wheelchair, pulmonary embolism without acute cor pulmonale (blood clot blocks a lung artery without causing right-sided heart strain), and major depressive disorder (sadness).Record review of Resident #1's Quarterly MDS assessment, dated 05/02/2026, revealed the resident had a BIMS score of 5, which indicated Resident #1's cognition was severely impaired. Resident #1's assistance needed to sit to stand on the Quarterly MDS revealed helper does all the effort.Record review of Resident #1's care plan, dated 04/28/2026, revealed Resident #1 was care planned on 11/06/2025 for an actual fall with interventions to encourage and educate using the call light and to notify staff for assistance with transfers.There was no care plan update for when Resident #1 had an unwitnessed fall on 05/15/2026.Review of Resident #1's progress note dated 05/15/2026 reflected Resident #1 had unwitnessed fall at the nurses' station and Resident #1 was found lying on the floor on her left side.During an interview on 07/24/2026 at 3:41 PM, the ADON stated she was responsible for updating the care plan when Resident #1 had an unwitnessed fall on 05/15/2026. The ADON said she was expected to have updated the care plan and interventions for the unwitnessed fall for Resident #1 on 05/15/2026. The ADON stated it was important for her to have updated the care plan and when the care plan was not updated the resident's needs would not possibly been met.During an interview on 07/24/2026 at 4:00 PM with Resident #1 she stated she was safe and could not recall the fall incident on 05/15/2026.During an interview on 07/24/2026 at 5:38 PM, the ADM stated it was expected for the ADON to update Resident #1's fall and interventions on the care plan on 05/15/2026. The ADM stated the ADON was responsible for making sure the unwitnessed fall and interventions were updated to prevent further falls. The ADM stated when the care plan was not updated the resident's needs would not have been met.Record review of the facility's policy dated 2001 and Revised December 2016 titled, Care Plan Policy, Comprehensive Person-Centered revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1.The facility failed to ensure sanitation practices (cleaning the ice machine, cleaning the juice machine dispenser, cleaning the inside of the microwave, storing the ice scoop in an ice scoop receptacle that was free from food debris buildup, cleaning the refrigerator unit shelving to ensure they are free of mold). 2.The facility failed to ensure cleaning logs were being completed. 3.The facility failed to ensure all items were covered and stored properly. 4.The facility failed to label and date all food items in the kitchen. These failures could place residents at risk of foodborne illness. Observation on 04/21/2026 at 9:10 a.m., of kitchen refrigerator #1 revealed: -gallon bag of shredded cheese unsealed with a date of 4/1/26 and used by date of 8/16/26. -gallon of sweet pickle relish undated-gallon of ranch dressing undated-gallon of tartar sauce with a date of 3/10/26 unsure if this is open date or discard date. -gallon of mayonnaise with a date of 3/24/26 unsure if this is open date or discard date. Observation on 4/21/26 at 9:14 a.m., of kitchen freezer revealed: -bag of pork chops unsealed with prep date of 4/14/26 and used by date of 4/21/26.-bag of corn dogs in an open unsealed plastic bag unlabeled and undated. - gallon bag of unidentifiable items with a date of 4/20/26 and used by date of 4/28/26. Observation on 4/21/26 at 9:20 a.m., of kitchen dry storage pantry revealed: -box of cream of rice open with a date of 1/6/26 unsure if this is receipt date, open date or discard date. -gallon of white wine vinegar undated. Observation on 4/21/26 at 9:25 a.m., of kitchen refrigerator #2 revealed: -half gallon of chocolate whole milk with a best by date of 5/3/26.-14-ounce can of aerosol whipped topping opened with a best by date of 10/13/26.- shelving to have gray and black mold appearing substance on underside and tops of shelving and on walls behind shelving. Observation on 4/21/26 at 9:30 a.m., of white plastic bins with lids revealed: -plastic bin of what appeared to be sugar unlabeled and undated.- plastic bin of what appeared to be flour unlabeled and undated.- plastic bin of what appeared to be cornmeal unlabeled and undated. Observation on 4/21/26 at 9:33 a.m., of the microwave revealed the interior of the microwave to have dried food debris on the interior top and in the corners. Observation on 4/21/26 at 9:35 a.m., of food mixer revealed what appears to be food build-up or debris on the mixer bowl screen mechanism. Observed on 4/21/26 at 9:37 a.m., of industrial can-opener revealed its internal working parts, and the plastic mounting bracket, which secured it to the food prep table, were coated with a dark brown substance and food particles. Observation on 04/21/2026 9:40 a.m., of juice dispenser machine revealed the underside of the nozzle dispensing area to be covered in red and red sticky buildup with fuzzy mold appearing substance on dispensing nozzles. Observation on 4/21/26 at 9:47 a.m., of ice machine revealed mineral deposit buildup on outside of machine all around door and seal. Further observation revealed black and brown mold appearing substance and a pink and reddish slime appearing substance on the interior of the ice machine on the ice guard, door, door seal, and interior wall. During a follow-up visit to the kitchen on for puree observation on 4/22/26 at 11:38 a.m., the CK was observed washing the blender with hot water and sanitizing it while wearing gloves. The CK did not remove or change gloves between cleaning and sanitizing and preparing pureed food. Interview on 04/23/2026 at 12:45 p.m., the ADM stated the policy about labeling and dating foods meant that all foods that were delivered should have been dated when received, and food prepped should have been labeled and dated with prepared and used by date, food opened should be dated when opened and dated with the used by date. He stated it did depend on what was in the box and if they were individually packaged it would only have affected the one opened. He stated the policy about food sanitation was about how they cleaned and prepared food, hand washing, how they prepared on clean surfaces, a how they prepared as they went. He stated the dietary manager was responsible for ensuring the cleaning log was completed and accurate. He stated in-service training and the dietary manual which staff have access to in the kitchen and what they should be referencing was the training received for sanitation, labeling, and dating foods. He stated his expectation for sanitation, labeling, and dating foods was sanitation should have been recurring and happening throughout their shift, labeling should have been happening in real time as food was received and as changes were made to the food, and dating foods should have been done in real time and as food was received and used and as any changes were made to the packaging, the food should have been updated and labeled as well. He stated it could have negatively affected the residents if food was not labeled and dated correctly and if the kitchen sanitation was not kept up and it could have affected them by causing food born illnesses and they could have gotten sick if food was not labeled correctly and it would have caused that by the incorrect temperatures or if the food was expired and they ingested it. Interview on 4/23/26 at 3:00 p.m., the DM stated she had worked at the facility for 30 years, as dietary manager since 2025. She stated that staff label and date upon receipt and preparation discard date and name of item. The DM stated she was not aware that an open date must be placed on the food items. The DM stated staff are trained upon hire and during in-services. The DM stated all kitchen staff are responsible for ensuring food items are labeled and dated appropriately. The DM stated improper labeling and dating of food items could negatively impact on the residents' health, as it may result in contaminated food and result in illness. Interview on 4/23/26 at 4:00 p.m., the CK stated staff are to label and date upon receipt and preparation discard date and name of item. The CK stated she was not aware that an open date must be placed on the food items. The CK stated she was trained upon hire and during in-services on labeling, dating, and sanitation. The CK stated all kitchen staff are responsible for ensuring food items are labeled and dated appropriately. The CK stated improper labeling and dating food items could negatively impact on the resident health, as it may result in contaminated food and result in a resident getting sick. Record review of kitchen cleaning logs revealed there were no current cleaning logs on file since 2025. Record review of food receiving and storage policy revised date 10/2017 reflected Foods shall be received and stored in a manner that complies with safe food handling practices7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a 'first in-first-out system.8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).Record review of preventing foodborne illness-employee hygiene and sanitary practices policy revised 10/2017 revealed Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illnessAll employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competence in these practices prior to working with food or serving food to residents. 6. Employees must wash their hands: a. after personal body functions (i.e., toileting, blowing/wiping nose, coughing, sneezing, etc.); b. after using tobacco, eating or drinking. c. whenever entering or re-entering the kitchen. d. before coming in contact with any food surfaces. e. after handling raw meat, poultry or fish and when switching between working with raw food and working with ready-to-eat food. f. after handling soiled equipment or utensils. g. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or h. after engaging in other activities that contaminate the hands. 8. Contact between food and bare (ungloved) hands is prohibited. 9. Food service employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness1O. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing. Record review of sanitization policy revised date 10/2008 revealed The food service area shall be maintained in a clean and sanitary manner.2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper clean mg. Seals, hinges and fasteners will be kept in good repair.12. lce machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy. Plasticware China and glassware that cannot be sanitized or are hazardous because of chips. cracks or loss of glaze shall be discarded. Damaged or broken equipment that cannot be repaired shall be discarded. 17. The food services manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks and to clean after each task before proceeding to the next assignment.

Based on interviews and records review, the facility failed to ensure that medical records maintained on each resident were accurately documented for three (3) of seven (7) residents, (Resident #8, Resident #19, and Resident #62) reviewed for accurate clinical records, in that: The facility failed to ensure Resident #8, Resident #19, and Resident #62's EMRs contained orders upon admission to the secured unit that included corresponding clinical criteria for admission to the secured unit. This deficient practice could result in errors in care and treatment and violate resident rights.Resident #8 Review of Resident #8's face sheet dated 4/22/2026, reflected an [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included: alcoholic cirrhosis of liver, (permanent scarring of the liver due to alcohol), sepsis (infection of the blood stream), aphasia (language disorder), depression, anxiety disorder, and high blood pressure. Review of Resident #8's census reflected they he was admitted on [DATE] and moved to the secure unit on 1/8/2026. Review of Resident #8's admission MDS dated [DATE], reflected resident is rarely understood and has short term and long-term memory problems. Review of Resident #8's physician orders reflected an order dated 1/6/2026 stating ADMIT TO SNF UNIT with no indications or directions for the order. Review of Resident #8's elopement assessment dated [DATE], reflected a score of 24; where if the resident has a score of 10 or more, the resident is at risk for elopement, and a care plan needs to be initiated. Review of Resident #8's care plan dated 4/23/2026 reflected a focus: [Resident] Resides in Special Care Unit, _requires 1 :1 Supervision, _exit Seeking, _poor Safety awareness, poor cognition _unable to recognize unsafe parameter, Date Initiated: 02/02/2026. Resident #19 Review of Resident #19's face sheet dated 4/22/2026, reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Alzheimer's (a progressive brain disease), Dementia, (decline in cognitive function), high cholesterol, major depressive disorder, gout (a form of inflammatory arthritis) and spondylosis (age related degeneration of the spine). Review of Resident #19's census reflected they were admitted directly to the secure unit on 12/1/2025. Review of Resident #19's admission MDS assessment dated [DATE], reflected a BIMS score of 9, suggesting moderate cognitive impairment. Further review of the behaviors section of the MDS reflected that the resident had no wandering behaviors exhibited in the last 7 days. Review of Resident #19's physician orders reflected an order dated 12/1/2025 stating ADMIT TO SNF UNIT with no indications or directions for the order. Review of Resident #19's elopement assessment dated [DATE], reflected a score of 18; where if the resident has a score of 10 or more, the resident is at risk for elopement, and a care plan needs to be initiated. Review of Resident #19's care plan dated 4/22/2026 reflected the focus: [Resident] Resides in Special Care Unit, _x Due to elopement risk, requires 1 :1 Supervision, exit Seeking, _poor Safety awareness, poor cognition _unable to recognize unsafe parameter, Date Initiated: 12/3/2026. Resident #62 Review of Resident #62's face sheet dated 4/22/2026, reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Alzheimer's (a progressive brain disease), vascular dementia, (decline in cognitive function due to blood flow issue), heart disease, muscle weakness, anxiety disorder. Review of Resident #62's census reflected they were admitted to the facility on [DATE] and moved to the secure unit on 11/17/2025. Review of Resident #62's admission MDS assessment dated [DATE], reflected a BIMS score of 3, suggesting severe cognitive impairment. Further review of the behaviors section of the MDS reflected resident had wandering that occurred in the last 4-6 days and placed the resident at significant risk of getting to a potentially dangerous place Review of Resident #62's physician orders reflected an order dated 11/17/2025 stating ADMIT TO SNF UNIT with no indications or directions for the order. Review of Resident #62s elopement assessment dated [DATE], reflected a score of 25; where if the resident has a score of 10 or more, the resident is at risk for elopement, and a care plan needs to be initiated. Review of Resident #62's care plan dated 4/22/2026, reflected the following focus: [Resident] resides in the Special Care Unit r/t elopement risk, poor safety awareness and / or poor cognition. Date initiated 11/20/2025. During an interview on 4/23/2026 at 12:10 pm, the DON stated she started as the current DON on 12/15/2025. She confirmed that new orders had been put in yesterday, 4/22/2026, by her for the secure unit because when orders were created there should be a clinical indicator or reason for the order. She stated she was not aware the current orders did not have any indicators and did not list the secure unit. The previous orders for the secure unit called in SNF and there were no clinical indicators or criteria listed for the orders. She discontinued the old orders and put in new orders to correct these issues. She stated corporate provided an in-service yesterday to review what should be on the order for a secure unit - previous orders did not say secure unit and did not have any indicators. She stated all residents back on the secure unit are at risk for wandering and elopement. She stated she called the MD yesterday, 4/22/26 and let him know there were no clinical indicators on the current orders and they needed new orders, he provided new orders. During an interview on 4/23/2026 at 12:27 pm, the ADM stated he was not aware that the current orders as of 4/21/2026 did not have clinical indicators for why residents were being admitted to the secure unit. He stated it has come up since then and they have completed in-services for nursing staff, clarified orders with the MD and put new orders in the EMR. The ADM stated the order should have said residents needed to be on the unit because of (xyz) not a dementia unit but it can contribute to the risk of wandering or elopement. He stated the physician orders should have definitely had that [the residents] were an elopement risk. The ADM stated his concerns with not having orders with clinical criteria for admission to the secure unit would be it may not be an appropriate placement, could be considered seclusion or restraint type scenario, but no one back there fits that bill. He further stated the placement of all residents currently on the secure unit is appropriate. He stated the facility corrected all the orders, standardized what they should look like going forward, nurse education was provided and it will be a standardized process moving forward. During an interview on 4/23/2026 at 1:44 pm, the MD stated he was not aware the current orders as of 4/21/2026 for residents on the secure unit did not include clinical indicators for admission to the secure unit. He stated he was made aware that the orders were incomplete. He stated orders for admission to the secure unit should have clinical indicators for the residents. He further stated he has an NP that works with him that also gives orders for placement on the secure unit. He stated the placement of all current residents on the secure unit is appropriate because all placements are related to elopement risk. The MD stated if the facility puts in an order and did not indicate what it was for not a good thing - should have an order saying why the resident is in there because of elopement risk. During an interview on 4/23/2026 at 2:08 pm, the NP stated she did not know the orders were incomplete and did not have clinical indicators. She stated she had reviewed some orders for the secure unit, and they are due to elopement risk of the resident. She stated orders should have had a reason listed as to why the secure unit was needed. NP stated a potential concern for not having a clinical reason to be on the secure unit would be they wouldn't need to be back there - could be like a restraint type thing - could be a bad thing if they don't have a reason for the order. She stated the placement of all residents back there currently was appropriate as they were all have an elopement risk. Review of an undated Facility Policy titled Placement of Residents on Secure UnitPurpose -To ensure residents are placed on a secure (locked) unit only when clinically appropriate, in accordance with Texas HHSC regulations, while protecting resident rights, safety, and dignity. Policy - Residents will only be placed on a secure unit when clinically indicated, ordered by a physician, and determined to be the least restrictive environment necessary to ensure safety. Criteria - Cognitive impairment (e.g., dementia)- Wandering or exit-seeking behavior- History of elopement- Poor safety awareness Procedure1. Assessment completed and documented2. IDT review of need and alternatives3. Physician order obtained5. Care plan updated6. Placement implemented7. Ongoing monitoring and documentation Documentation Requirements- Assessment findings- Physician order- IDT notes- Care plan- Monitoring notesResident Rights Placement will not be used for discipline or convenience and must comply with restraint regulations.

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 1 of 6 residents (Resident #86) reviewed for dignity with meal assistance. The facility failed to ensure MA D did not stand while she assisted Resident #86 with eating. This failure could place residents at risk of loss of dignity.Findings include: Record review of Resident #86's face sheet, dated 04/23/26, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #86's diagnoses included senile degeneration of the brain (a progressive decline in cognitive function that occurs with aging), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), atherosclerotic heart disease of native coronary artery (coronary artery disease) (heart disease involving the reduction of blood flow to the cardiac muscle due to a buildup of atheromatous plaque in the arteries of the heart), and benign prostatic hyperplasia (a common noncancerous enlargement of the prostate gland in men, typically occurring with aging, which causes lower urinary tract symptoms like weak stream, frequency, and nocturia). Record review of Resident #86's Incomplete admission MDS assessment, dated 04/24/26 reflected he had a BIMS score of 03 which indicated severe cognitive impairment. Record review of Resident #86's Care plan, dated 04/15/26 and revised 04/22/26, reflected Focus: Resident #86 had a therapeutic diet. Regular pureed texture, nectar thick liquids. Goal: Diet will be served as ordered by the physician. Interventions: Provide and serve diet as ordered. Resident/Caregiver to express understanding of importance of diet due to diagnosis. In an interview and observation on 04/21/26 at 1:03 pm, Resident #86 stated he was fine and staff treated him well. He stated he is happy and he did not mind the staff standing up when they fed him. He stated he had no concerns. Resident #86 was observed sitting up in a specialized reclining medical chair with wheels and appearing clean and groomed with no sign of pain or distress. In an observation and interview on 04/21/26 at 12:24 pm, MA D was observed standing up over Resident #86 and above his eye level while she fed Resident #86 in the dining room for the entire meal. A chair was observed sitting directly behind MA D. She stated as a medication aid, she helped with feeding and she passed meal trays. She stated she was only standing while she fed resident because of the size of his chair. Resident #86 was observed sitting up in a specialized reclining medical chair with wheels beside the dining table. In an interview on 04/21/26 at 12:52 pm, LVN B stated resident was being fed with the staff standing up because of the awkwardness and size of his chair. In an interview and observation on 04/22/26 at 12:42 pm, CNA E was observed sitting down and feeding Resident #86. She stated staff should always have been sitting down when feeding a resident. Interview on 04/22/26 at 12:44 pm, LVN B stated in regard to the previous day when Resident #86 was being fed by a staff member that was standing, there was another resident that wanted to sit at that table and Resident #86 chair would not have fit under the table to be positioned correctly to have staff sit beside him to be fed. She stated staff typically sat down and fed the residents. She stated she had been trained on sitting down when she fed the residents. She stated if a staff member was standing up and feeding a resident, it could have caused the food or liquids to spill on the resident, or the food or liquids could have been swallowed wrong. In an interview on 04/22/26 at 12:50 pm, MA D stated about the previous day when she was standing up to feed Resident #86, she could have gotten a bedside table so she could have sat down and fed resident. She stated she normally passed trays and it had been a while since she fed the residents. She stated she had been trained on sitting down while she fed residents. She stated she felt as though the way Resident #86 was positioned in his specialized reclining medical chair with wheels on that day, she stood with her hands at his mouth level. She stated she did not feel like any harm could have been caused to the resident due to the position he was sitting in. In an interview on 04/23/26 at 10:02 am, LVN A stated she had worked in the facility for about 2 years. She stated she was in-serviced on abuse and neglect, sitting while feeding residents, and resident rights. She stated anytime she was feeding a resident she should have been sitting down at the same level as the resident. She stated if she was standing to feed a resident, it could have caused a dignity issue with the resident. In an interview on 04/23/26 at 10:14 am, LVN C stated he had worked in the facility for about a year. He stated he was in-serviced on abuse and neglect, sitting while feeding residents, and resident rights. He stated anytime he was feeding a resident he should have been sitting down at the same level as the resident. He stated if he was standing to feed a resident, it could have caused the resident to feel intimidated and for the resident would have had to turn their head and it could have compromised their airway. In an interview on 04/23/26 at 10:33 am, CNA F stated he had worked in the facility for about a year and a half. He stated he was in-serviced on abuse and neglect, sitting while feeding residents, and resident rights. He stated anytime he was feeding a resident he should have been sitting down at the same level as the resident. He stated if he was standing to feed a resident, it could have been a dignity issue or a choking hazard for the resident. In an interview on 04/23/26 10:48 am, CNA G stated she had worked in the facility for about 3 years. She stated she was in-serviced on abuse and neglect, sitting while feeding residents, and resident rights. She stated anytime she was feeding a resident she should have been sitting down at the same level as the resident. She stated if she was standing to feed a resident, it could have caused them to aspirate or could cause messes from spills. In an interview on 04/23/26 at 12:09 pm, DON she stated staff had been in-serviced on abuse and neglect, sitting while feeding residents, and resident rights. She stated if staff were standing to feed a resident, it could have caused distress to the resident due to improper alignment of the esophagus, stress and anxiety for the resident. In an interview on 04/23/26 12:27 pm, ADM stated staff had been in-serviced on abuse and neglect, sitting while feeding residents, and resident rights. He stated anytime staff were feeding a resident they should have been sitting down at the same level as the resident and not above eye level to the resident. He stated if staff were standing to feed a resident, it could have been a choking hazard and it was a safety concern overall. Review of the facility's policy dated 2001 (Revised August 2009) titled Quality of Life - Dignity, reflected Policy Statement: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy Interpretation and Implementation: 1. Residents shall be always treated with dignity and respect. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.Review of the facility's policy dated 2001 (Revised December 2016) titled Resident Rights, reflected Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity

Based on interview and record review, the facility failed to respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service for 1 (Resident #74) of 6 residents reviewed for personal privacy. The facility did not deliver unopened mail for Resident #74. This failure could affect residents' personal privacy and could result in decreased quality of life. Findings included: Record review of Resident #74's face sheet, dated 05/03/21, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a readmit date of 12/11/25. Resident #74's diagnoses chronic obstructive pulmonary disease (a lung disease characterized by chronic respiratory symptoms and airflow limitation), diabetes (a group of diseases that result in too much sugar in the blood), heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), and post-traumatic stress disorder (a mental health condition triggered by experiencing or witnessing terrifying, life-threatening events, such as abuse, accidents, or combat). Record review of Resident #74's Quarterly MDS assessment, dated 03/18/26 reflected he had a BIMS score of 15 which indicated Resident #74 was cognitively intact. MDS assessment reflected Resident #74 was independent for eating, toileting, showering, and personal hygiene. In an interview and observation on 04/21/26 at 1:22 pm, Resident #74 stated he was ok and staff treated him ok. He stated he had not been here long and any concerns he had were addressed. He stated he got opened mail a few times. Observed residents opened mail with note from staff that stated Sorry, I opened by accident and was signed by the BOM. He stated he did not like that he received his mail open and he felt like it could have been avoided and was an invasion of his privacy. In an interview on 04/22/26 at 12:57 pm, Resident #74 stated there had been one episode where another piece of his mail was opened and he believed that was also something from the same place, but he could not be sure. He stated that was the only other time this had happened and he had no other concerns. In an interview on 04/22/26 at 1:08 pm, the BOM stated the facility mail came in on Monday through Friday and she went through it to see what all was there for the business office first. She stated she then took the residents mail and put it on the desk outside of the administrator's office and activities came to get it and passed it out to the residents. She stated she had accidentally opened the residents' mail a few times and if she had done that, she would tape it back up and leave a note on it apologizing for it being opened. She stated that it has not happened often. She stated she may have accidentally put it in the wrong pile and when she did that the mail would have been upside down on her desk and she would have just picked it up and opened it. She stated if that happened, she would have immediately put it back in the envelope and taped it shut when she seen that it was a residents. She stated she would not have normally opened a resident's mail unless it was an alert resident and she asked them and it had been something that they were expecting for the facility, such as payment sources or decisions. She stated she should not have opened a resident's mail without their permission. She stated it would be an invasion of residents' privacy to open their mail. She stated she would not go to someone's mailbox and open their mail, and she believed that it would be a felony. In an interview on 04/23/26 at 12:09 pm, the DON stated staff had been in-serviced on and resident rights and privacy. She stated residents should have received their mail unopened. She stated if a resident's mail was opened prior to them receiving it, it would have been violation of the residents' rights and privacy. In an interview on 04/23/26 12:27 pm, the ADM stated staff had been in-serviced on resident rights and privacy. He stated residents should have received their mail unopened. He stated if a resident's mail was opened when they received it, it would have been a dignity or resident rights issue and could have been HIPAA related and could have invaded their privacy. In an interview on 04/23/26 at 3:37 pm, the ACTV stated she had worked in the facility for about 3 years. She stated she was trained on resident rights and resident privacy. She stated regarding the resident's mail, she picked the mail up and distributed it to the residents after the business office manager went through it and got out what was needed for the facility. She stated resident mail should not have been opened by anyone prior to being delivered to the residents. She stated she had not seen any open mail when she delivered it to the residents. She stated if a resident's mail was opened it could cause a resident to get upset and it would be against resident rights and invasion of their privacy. Review of the facility's policy dated 2001 (Revised August 2009) titled Quality of Life - Telephone and Mail - Mail, reflected Policy Statement: Residents are allowed to communicate privately with individuals of their choice and may send and receive their personal mail unopened unless otherwise advised by the attending physician and documented in the residents' medical records. Policy Interpretation and Implementation: 1. Mail will be delivered to the resident unopened unless otherwise indicated by the Attending Physician and documented in the resident's medical record. 2. Staff members of this facility will not open mail for the resident unless the resident requests them to do so. Such request will be documented in the chart (i.e., on the resident's plan of care) Review of the facility's policy dated 2001 (Revised December 2016) titled Resident Rights, reflected Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: d. communicate in person and by mail, email and telephone with privacy;

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remained free from accident hazards and the residents received adequate supervision and assistance to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to provide Resident #1 with adequate supervision and assistance on 07/10/25 when CNA A began to transfer Resident #1 when using a mechanical lift (specialized device designed to safely transfer individuals with limited mobility). CNA A was conducting a mechanical lift transfer without the required two (2) staff members and stopped the transfer to call for assistance from another staff member while CNA A left Resident #1 suspended in the air in the mechanical lift sling. This failure could place all residents who require mechanical lift assistance at risk for serious injury and accidents. Findings include: Record review of Resident #1's admission record, dated 6/23/25, indicated she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), anxiety (intense, excessive, and persistent worry and fear about everyday situations), hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), osteoarthritis - (a degenerative joint disease that causes the cartilage and bone in a joint to break down over time), and diabetes (a group of diseases that result in too much sugar in the blood). Review of Resident #1's MDS reflected Resident #1 had a BIM's score of 00 which indicated Resident #1 was severely cognitively impaired and had functional limitation impairment on both of her lower extremities in range of motion. It also reflected Resident #1 was dependent for transfer from chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). (- helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.) Record review of Resident #1's comprehensive care plan, dated 1/27/25, indicated she was a high risk for falls and had no safety awareness. Goal: Resident #1 would not sustain serious injury through the review date. Interventions included: Hoyer (mechanical lift) for transfers.Record review of Resident #1's comprehensive care plan, dated 1/27/25, indicated she had an ADL self-care performance deficit r/t dementia and muscle weakness. Goal: Resident #1 would demonstrate the appropriate use of adaptive device(s) to increase ability in bed mobility, transfers, eating, dressing, toilet use and personal hygiene, through the review date. Interventions included: TRANSFER: The resident requires 2 staff participation with transfers and HOYER lift- family aware and educated on need for 2 staff Hoyer for transfers and periodically do no use Hoyer lift when they transfer her. Record review of photo provided by FM reflected Resident #1 was in the mechanical lift's sling suspended in the air and left unattended and CNA A was present in the doorway. In an observation on 07/29/25 at 11:20 AM, Resident #1 was observed in her room lying in bed. Resident #1 was pleasantly confused, and she did not respond to questions. Resident #1 appeared to be clean and was dressed appropriate for the weather. Resident #1 showed no signs of pain or distress and only mumbled a few unintelligible words. In an interview on 07/29/2025 at 8:11 AM, the FM stated Resident #1 was left suspended in the air in the sling of the mechanical lift by the CNA for 31-32 seconds and there was no injury during the transfer. She stated resident had had some bumps, cuts, and bruises with some of the other transfers. She stated she was not aware of any other transfers being done with only one staff member present. In an interview on 07/29/25 at 10:57 AM, CNA A stated he had worked in the facility for about a year, and he usually worked the 8-5 shift, but he also filled in on other shifts when they needed him. He stated he had been in-serviced on abuse and neglect, transfers/mechanical lift transfers, and falls/fall prevention. He stated when he transferred a resident with the mechanical lift, there must be 2 staff members present the entire time from start to finish. He stated if there were not 2 staff member present during the mechanical lift transfer, it could have caused a resident to fall or get hurt. He stated the lift could have tilted or anything could have happened. He stated he was not aware of any falls from the mechanical lift. He stated he knew he should not ever leave a resident hanging suspended in air in the sling of the mechanical lift while he went to go look for help or to do anything else. He stated if a resident were left suspended in the air in the sling of the mechanical lift and staff walked away, it could have caused the resident to fall, or the lift could have tilted. In an interview on 07/29/25 at 11:10 AM Interview with staff CNA B, she stated she had worked in the facility for about 5 years, and she worked the 2-10 shift and extra shifts at times. She stated she had been in-serviced regularly on abuse and neglect, transfers/mechanical lift transfers, and falls/fall prevention. She stated when she transferred a resident with the mechanical lift, there must be 2 staff members present the entire time from start to finish. She stated if there were not 2 staff member present during the mechanical lift transfer, it could have caused a resident to fall, or anything could have happened and that is why there needed to be 2 people in there during the entire process. She stated she was not aware of any falls from the mechanical lift. She stated she would never leave a resident hanging suspended in air in the sling of the mechanical lift while she went to look for help or to do anything else. She stated she should have never had to look for help because there should have always been 2 staff members present when using the lift. She stated if a resident were left suspended in the air in the sling of the mechanical lift and staff walked away, it could have caused a resident to fall. In an interview on 07/29/25 at 11:31 AM, LVN C stated she had worked in the facility for about 5 years, and she worked the 6-2 shift. She stated she had been in-serviced on abuse and neglect, transfers/mechanical lift transfers, and falls/fall prevention. She stated when transferring a resident with the mechanical lift, there should have always been 2 staff members present the entire time from start to finish. She stated if there were not 2 staff members present during the mechanical lift transfer, it could have caused a resident to get an injury and it could have kept the resident from being safe. She stated she was not aware of any falls from the mechanical lift. She stated she would have never left a resident hanging suspended in air in the sling of the mechanical lift while she went to look for help or to do anything else. She stated if a resident were left suspended in the air in the sling of the mechanical lift and staff walked away, it could have caused the resident to fall out of the lift or get injured and it could have been very bad. In an interview on 07/29/25 at 11:43 AM, the DON stated staff were in-serviced regularly on abuse and neglect, transfers/mechanical lift transfers, and falls/fall prevention. She stated it was her expectation that when transferring a resident with the mechanical lift, there was 2 staff members present the entire time from start to finish. She stated if there were not 2 staff members present during the mechanical lift transfer, it could have caused resident injury or death. She stated it was a resident safety and an employee safety issue. She stated she was not aware of any falls from the mechanical lift. She stated it was her expectation that staff never leave a resident hanging suspended in air in the sling of the mechanical lift for any reason. She stated if a resident were left suspended in the air in the sling of the mechanical lift and staff walked away, it could have causes resident injury or death. In an interview on 07/29/25 at 12:02 PM, the ADM stated staff were in-serviced regularly on abuse and neglect, transfers/mechanical lift transfers, and falls/fall prevention. He stated it was his expectation that when transferring a resident with the mechanical lift, there was 2 staff members present the entire time from start to finish. He stated if there were not 2 staff members present during the mechanical lift transfer, it could have caused harm to the resident and could have led to a fall. He stated he was not aware of any falls from the mechanical lift. He stated it was his expectation that staff never left a resident hanging suspended in air in the sling of the mechanical lift for any reason. He stated if a resident were left suspended in the air in the sling of the mechanical lift and staff walked away, it could have caused physical or emotional harm or distress. In an interview on 07/29/25 at 12:11, LVN D stated she had worked in the facility for about 8 months, and she worked the 6-2 shift. She stated she was in-serviced regularly on abuse and neglect, transfers/mechanical lift transfers, and falls/fall prevention. She stated when transferring a resident with the mechanical lift, there must be 2 staff members present the entire time from start to finish. She stated if there were not 2 staff members present during the mechanical lift transfer, it could have caused a fall or injury to a resident, or a staff member could have been hurt as well. She stated she was not aware of any falls from the mechanical lift. She stated she would have never left a resident hanging suspended in air in the sling of the mechanical lift while she went to look for help or to do anything else. She stated if a resident were left suspended in the air in the sling of the mechanical lift and staff walked away, it could cause harm to the resident. In an interview on 07/29/25 at 1:08 PM, the ADM identified CNA A in the picture provided by FM and stated CNA A had been trained on mechanical lift transfers and knew he should not have left Resident #1 suspended in the air for any amount of time. In an interview on 07/29/2025 at 1:17 PM, CNA A stated it was right around dinner time, and he went to get resident up. He stated he put Resident #1 in the mechanical lift sling and lifted resident up and realized he could not do it by himself and went to the door opening and looked out a yelled for the nurse to come help him. He stated the nurse was at the end of the hall, and he went straight back to the resident. He stated Resident #1 was alone for maybe 10 seconds and the nurse came in to assist him and they completed the transfer. He stated there were no issues while resident was suspended in the air and no injuries occurred from the transfer. He stated he knew he should not have tried to transfer the resident by himself, and it was a onetime thing, He stated he was in a hurry, and it was a mistake. He stated he had been trained on mechanical lift transfers and it was just a mistake and a spur of the moment thing, and he would never do it again. During an attempted phone interview on 07/29/25 at 2:30 PM, 2:32 PM, 2:41 PM, with LVN F, there was no answer, and the call went directly to voicemail. A voice message was left after the 3rd call stating the purpose of call and requesting a return call. During a phone interview on 07/30/25 at 12:59 PM, LVN F stated she worked the evening shift on 07/10/25 but she could not remember if CNA A had asked her for help with a transfer for Resident #1. Record review of the facility list of residents that required transfer by the mechanical reflected Resident #1 was to be transferred by the mechanical lift. Record review of undated facility form titled Transferring a resident using a mechanical lift reflected: Two staff members are required to assist when using a mechanical lift, three staff members for larger residents if care plan requires. Reverse the procedure to return the resident to bed. When raising the resident from the chair, ensure that one person guides the feet and legs to ensure the resident does not lean forward and one person to protect the head.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 1 facility reviewed for a clean and homelike environment. The facility failed to ensure hall 100 and hall 200 floors were swept and maintained. These failures could place residents at risk of living in an uncomfortable and unsafe environment, decreased feelings of self-worth, and a diminished quality of life. Findings included: Observation on 03/21/2025 at 10:09 AM on hall 100 revealed a dried sticky substance throughout the 100 hall and the floor was not swept. Hall 100 appeared with little styrofoam pieces from a cup on the floor. Observation on 03/21/2025 at 10:15 AM on hall 200 revealed throughout the hall the floor was not swept. Hall 200 appeared with little pieces of paper on the floor. During an interview with the Housekeeping Supervisor on 03/21/2025 at 5:04 PM, the Housekeeping Supervisor stated that it was expected that all hall floors were kept swept and not sticky. The Housekeeping Supervisor stated there was always housekeeping staff on the halls making sure the floors were cleaned. The Housekeeper Supervisor stated with the floors needing to be swept and sticky, a possible fall could have occurred. During an interview with the DON on 03/21/2025 at 6:29 PM, the DON stated it was expected for all the hall floors to be clean. The DON stated it was housekeeping's responsibility to make sure the floors stayed cleaned. The DON stated it was expected to make sure the floors stayed cleaned to prevent falls. During an interview with the ADM on 03/21/2025 at 7:15 PM, the ADM stated housekeeping was responsible for the floors in the facility. The ADM stated it was expected to make sure the floors were cleaned all the time to prevent falls. Review of the facility policy Quality Of Life-Homelike Environment dated 2001 and revised May 2017 reflected Residents are provided with a safe, clean, comfortable homelike environment and encouraged to use their personal belongings to the extent possible.

Based on observation, interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two(Resident #2 Resident #3) of 5 residents reviewed for care plans. The facility failed to revise Resident #2's care plan to reflect Resident #2 no longer required monitoring when smoking cigarettes. The facility failed to revise Resident #3's care plan to reflect Resident #3 no longer had to return cigarettes to the nursing station. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings Included: Review of Resident #2's face sheet dated 03/21/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including acute kidney failure (sudden and significant decline in kidney function that leads to an accumulation of waste products in the body), anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), essential primary hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying cause), and nicotine dependence cigarettes (a chronic condition characterized by the compulsive use of nicotine-containing products , despite its adverse health effects). Review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS score of 11, indicated he had moderate cognitive impairment. Review of Resident #2 's care plan dated 03/21/2025, reflected an intervention initiated on 02/10/2024 to monitor Resident #2 when smoking to ensure safety. Review of Resident #2's smoking safety evaluation dated 02/28/2025, reflected that Resident # 2 was an independent smoker that did not require assistance with smoking. Review of Resident #3's face sheet dated 03/21/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included hypomagnesemia (low levels of magnesium in the blood), generalized anxiety disorder (severe ongoing anxiety that interferes with daily activities), insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep), and personal history of nicotine dependence. Review of Resident #3's quarterly MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Review of Resident #3 's care plan dated 03/21/2025, reflected Resident #3 was non-compliant with returning cigarettes to the nurse's station with date initiated 6/3/2022 and revised on 10/24/2022. Review of Resident #3's smoking safety evaluation dated 02/28/2025, reflected that Resident # 3 was an independent smoker that did not require returning cigarettes to the nurse's station. During an interview with Resident #3 on 03/21/2025 at 1:42 PM, Resident #3 stated that he was safe going out to the smoking area to smoke and he did not require supervision when he went out to smoke. During an interview with Resident #2 on 03/21/2025 at 2:45 PM, Resident #2 stated she did not need supervision when she smoked cigarettes and she was safe going out to the smoking area to smoke. During an interview with the MDS Coordinator on 03/21/2025 at 5:48 PM, the MDS Coordinator stated she was responsible for updating care plans. The MDS Coordinator stated it was expected the care plans should have been updated when the smoking assessments were completed on 02/28/2025. The MDS Coordinator stated when the care plan was not updated the resident's needs were not met. During an interview with the DON on 03/21/2025 at 6:29 PM, the DON stated the MDS Coordinator was responsible for updating the care plan when the smoking assessment was completed. The DON stated when care plans were not updated after the smoking assessment the resident needs would not have been met. During an interview with the ADM on 03/21/2025 at 7:15 PM, the ADM stated that the MDS Coordinator was responsible for updating the care plans. The ADM stated it was expected for the MDS Coordinator to update the care plan once the smoking assessment was completed. The ADM stated if the care plan was not updated, the resident's needs would not be met. Review of the facility policy Care Plans, Comprehensive Person-Centered dated 2001 and revised December 2016 reflected A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interviews, 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 one (Resident #1) of 5 residents reviewed for medications and pharmacy services The facility failed to ensure Resident #1's physician ordered medication Neurontin was administered on 03/05/2025 at 2:00 PM. The facility failed to monitor Resident # 1 for pain every shift according to physician orders. This failure could place residents at risk of not receiving necessary medical care and hospitalization . This failure could place residents at risk of not receiving the intended therapeutic benefit of the medication or care to maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of Resident #1's face sheet dated 03/21/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (immune system eats away at the protective covering of nerves), Lyme disease (illness caused by borrelia bacteria), essential primary hypertension (condition characterized by persistently high blood pressure without an identifiable underlying cause), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 15, indicating he was cognitively intact. Review of Resident #1's care plan, dated 03/21/2025, reflected Resident #1 was care planned for chronic pain from multiple sclerosis, neuropathy, and general discomfort. Review of Resident #1's physician order, dated 01/21/2025, reflected an order dated 01/25/2024 for Neurontin Oral Tablet 600 MG (Gabapentin) Give 1 tablet by mouth three times a day for neuropathy. Review of Resident #1's MAR dated 03/05/2025, reflected no sign off for 2:00 PM for medication Neurontin. During an interview with Resident #1 on 03/21/2025 at 12:13 PM, Resident #1 stated he could not recall if he had taken the medication Neurontin on 03/05/2025 at 2:00 PM. Resident #1 stated his pain levels were checked on every shift, but he could not recall if the pain level was checked or not on the night of 03/04/2025. During an interview with the NP on 03/21/25 at 1:26 PM, the NP stated the order for the medication Neurontin should be followed per the doctor's order. The NP stated it was expected for the orders to be followed to assist with pain management for Resident #1. The NP stated there would not be an adverse effect with the 1 dose of Neurontin missed. The NP stated the order for pain level checks every shift should be followed per the doctor's order. The NP stated it was expected for the orders to be followed to check Resident # 1's pain levels. The NP stated when pain levels was not monitored the medication would not be managed accordingly without the level of pain known. During an interview with the DON on 03/21/2025 at 6:29 PM, the DON stated it was expected Med Tech B to sign off on the medication Neurontin once it was given on 03/05/2025. The DON stated if the medication was not signed off on it was not given. The DON stated it would not be communicated if the medication was not signed off on to know if it had or had not been received. The DON stated it was expected for the pain assessments to be followed per doctor's orders. The DON stated when pain level was not assessed each shift it would not be determined if medications would need to be increased or decreased. During an interview with the ADM on 03/21/2025 at 7:15 PM the ADM said it was expected for Med Tech B to have signed off on the medication Neurontin. The ADM stated if the Neurontin was not signed off on 03/05/2025 it was not given. The ADM stated not receiving medications can have any effect. The ADM said it was expected for LVN A to have completed the night pain level check on 03/04/2025 per doctor's order. The ADM stated when pain the levels was not not monitored the levels of pain could be worse if not known. During an interview with LVN A on 03/21/2025 at 7:46 PM, LVN A stated she would have been responsible for checking Resident #1's pain level on the night on 03/04/2025. LVN A stated during the week of 03/04/2025 the facility had experienced internet issues. LVN A can't recall the actual night or time that the internet had issues. LVN A stated when there were internet issues, she was not able to document that she had completed the level of pain. LVN A stated it was expected for the pain level for Resident #1 to be signed off on by her that it had been completed. LVN A stated the night pain level not being signed off on would indicate that it was not completed. LVN A stated when the pain level was not signed off on , it was not communicated that the pain level was completed or not for Resident #1. During an interview with Med Tech B on 03/21/2025 at 7:54 PM, Med Tech B stated she was responsible for passing the Neurontin to Resident # 1 at 2:00 PM. Med Tech B stated that Resident #1 will take his Neurontin and if anything, she must have forgotten to sign off on it. Med Tech B stated it was expected for her to sign off on the medication to communicate that Resident # 1 had received the medication. Med Tech B stated if Resident #1 did not receive the Neurontin it may cause an increase in pain. LVN A stated she would have been responsible for checking Resident #1's pain level on the night on 03/04/2025. Review of the facility policy Administering Medications dated 2001 and revised April 2019 reflected Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any time frame. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Based on observation and interview, the facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff and residents for 1 of 1 facility reviewed for medication storage. The facility failed to secure one over-the-counter Tylenol 500 MG tablet that was observed on 03/21/2025 at 10:15 AM in the shower room on the 500 hall. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medication or care to maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Observation of the shower room on 03/21/2025 at 10:00 AM on hall 500 revealed one over-the counter Tylenol 500 MG was lying on a folding chair that was up against the wall. During an interview with the NP on 03/21/2025 at 1:26 PM, the NP stated Over- the -counter Tylenol is used for pain and has no adverse effect if taken. During an interview with the DON on 03/21/2025 at 6:29 PM, the DON stated that an over-the-counter Tylenol just laying around was not normal for the facility. The DON stated it was possible it may have fallen out of a staff member's pocket, but it would be hard to prove whose it was. The DON said Tylenol over the counter is used for pain and would have no adverse effect if taken. During an interview with the ADM on 03/21/2025 at 7:15 PM the ADM stated it no medications were administered in the shower room to any residents. The ADM stated the Tylenol over-the-counter pill possibly was a staff member's for their personal use and no staff had admitted to having a Tylenol. The ADM stated that Tylenol would not have an adverse effect and was used for pain. During an interview with Med Tech B on 03/21/2025 at 7:54 PM, Med Tech B stated that no medications were passed in the shower room to residents. Med Tech B stated it could possibly be a staff member that may had dropped the Tylenol. Med Tech B stated that the Tylenol over-the counter was used for pain and there would not be any adverse side effects if taken. Review of the facility policy Administering Medications dated 2001 and revised April 2019 reflected During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility reviewed for infection control practices. The facility failed to ensure the ice scoopers on hall 100 and hall 600 were not exposed and not covered. This failure placed residents at risk of cross contamination. Findings included: Observation on 03/21/2025 at 10:09 AM on hall 100 revealed an ice scooper was lying on a rolling cart exposed and not covered. Observation on 03/21/2025 at 10:20 AM on hall 600 revealed an ice scooper was lying on a rolling cart exposed and not covered. During an interview with CNA C on 03/21/2025 at 4:42 PM, CNA C stated all CNAs were responsible for making sure the ice scoopers were in the plastic covers. CNA C stated it was expected for the ice scoopers to be covered. CNA C stated if the ice scoopers are exposed, cross contamination could occur that may cause a resident to become ill. During an interview with the DON on 03/21/2025 at 6:29 PM, the DON stated it was expected for all CNAs to make sure the ice scoopers were covered after each use. The DON stated cross contamination could occur that may cause illness if the ice scoopers were not covered. During an interview with the ADM on 03/21/2025 at 7:15 PM, the ADM stated it was expected for all the CNAs to make sure the ice scoopers were covered after they were used. The ADM stated cross contamination could occur that may cause illness with residents. Review of the facility policy Infection Control Guidelines For All Nursing Procedures dated 2001 and revised August 2012 reflected Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for dietary services. 1. The facility failed to ensure that the dry storage items were free from expired foods. 2. The facility failed to ensure kitchen staff followed proper hand hygiene during meal preparations. 3. The facility failed to ensure that the puree blender was cleaned between menu items. These failures could place residents at risk for food contamination and foodborne illness. Findings included: An observation was made on [DATE] at 10:49 AM in the kitchen. The observation in the kitchen's dry storage area revealed expired food. Sysco Imperial thickened orange juice from concentrate had a date labeled and expiration of [DATE]. An observation was made of 4 boxes of thickened dairy drink that did not have an expiration date on them. An observation was made on [DATE] at 11:15AM in the kitchen for the process of hand washing. During this observation Ck #1 had turned the sink water on, scrubbed their hands with soap, grabbed a paper towel to turn off the sink, and used the same dirty paper towel to dry their hands. An observation was made on [DATE] at 11:23AM in the kitchen for the process of puree. During this observation Ck #1 pureed vegetables in the puree blender. Ck #1 completed the puree of the vegetables and placed the lid in the compartment sink. Ck #1 then grabbed the lid and placed it back onto the puree blender and continued to blend the vegetables. Ck #1 did not wash the lid before placing it back onto the blender. An interview was made on [DATE] at 11:33AM with the DM who stated they have been employed at the facility for 1 year. The DM stated that the policy for the puree process was to make sure the blender was clean, put the food in the blender, put beef or chicken broth to give them some flavor, and wash between menu item use. The DM stated a negative impact this could cause for the residents was cross contamination. The DM stated that trainings have not been provided on this specific topic. The DM stated that the policy for handwashing was that staff were to wash their hands anytime they were messing with the food and sanitizing the dishes when using them. The DM described the hand washing process as staff should turn the sink on, wet their hands, rub soap up to the forearm, scrub for a little bit and let the soap sink in, wash their hands off, grab a paper towel, dry their hands, and turn the sink off. The DM stated a negative impact this could have on residents was possibly food borne illnesses. The DM stated that training has been provided for this topic. The DM stated that the expectation for expired food was to throw it away if it was expired. The DM stated that food items should be dated and labeled. The DM stated a negative impact expired food could have on residents were they could get sick. An interview was made on [DATE] at 11:40AM with Ck #1 who stated they have been employed at the facility for 3 years. Ck #1 stated that they had received training on handwashing and sanitizing a couple of months ago. Ck #1 explained the puree process as washing the used dish after every food item. Ck #1 stated you do not want to put meat with vegetables. Ck #1 stated a negative impact that could have on a resident was having food built up on the processor. Ck #1 stated that they had reused the lid after pureeing the item because they believed the water was still on. During this interview Ck #1 identified the handwashing process as turn the water on, use soap, rinse up to elbows, use a napkin to dry your hands, turn off the water with the napkin, and throw the napkin in the trash. Ck #1 stated a negative impact this could have on resident if not followed properly was getting the resident's sick. Ck #1 stated they did not remember doing that. Ck #1 stated the expectation for receiving food items was to date and label the food items. Ck #1 stated that the food should be thrown away if it was expired. An interview was conducted on [DATE] at 11:44 AM with the ADM of the facility. The ADM stated they have been working at the facility since [DATE]. The ADM stated that the expectation for cleaning and sanitizing dishes was to clean the dishes after every meal service to utilize the dishwasher. The ADM stated the expectation was to clean and sanitize the dish item if it was put in the sink and wash it before using it again. The ADM stated a negative impact it could have on a resident would be the dish could have residual food, contamination, and potentially bacteria. The ADM stated the expectation for hand washing was staff should wash their hands, follow the handwashing guidelines after they touch food, touch trays, and they should be consistently washing their hands in the kitchen. The ADM identifies the steps to washing hands as using warm water, scrub your hands with soap, use a paper towel to turn faucet off, and grab a different clean paper towel to dry their hands. The ADM stated a negative impact this could have on a resident was it could cause contamination, food borne illnesses, and potentially allergens. The ADM stated that training for handwashing and dish sanitizing was completed by the dietary manager for the team below them. The ADM stated to refer to the policy for the facility's policy on handwashing and sanitizing. The ADM stated the expectation for expired food was to remove the item from the shelf, fridge, or freezer, and discard the food item. The ADM stated a negative impact this could cause for residents was passing bacteria and possible different food borne allergens. The ADM stated to refer to the policy for the policy on expired food. Record Review of policy Food Preparation and Services dated [DATE] revealed the following information: Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices including: 1. Appropriate measures are used to prevent cross contamination. These include: a. Cleaning and sanitizing work surface and food-contact equipment between uses, following food code guidelines. 2. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Record Review of policy Food Receiving and Storage dated [DATE] revealed the following information. 1. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such foods will be rotated using a first in first out system. 2. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). 3. Opened containers and beverages must be dated when opened and have a use by date. Record Review of policy Sanitation dated [DATE] revealed the following information. 1. All equipment, food contact surfaces, and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. 2. Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical.

Based on observations, interviews, and record review, the facility failed to follow their own established smoking policy for 5 (Residents #4, #27, #35, #48, and #50) of 8 residents reviewed for smoking. 1. The facility failed to ensure that Residents #4, #48, and #50 did not keep their personal cigarette lighters in their rooms per facility policy. 2. The facility failed to ensure that Resident #35 only used his e-cigarettes inside the designated smoking areas. 3. The facility failed to address where e-cigarettes should be stored, how to handle the devices, batteries, and refill cartridges. This failure could place residents at risk of an unsafe smoking environment and injury. Findings included: Review of the facility's Smoking Residents updated 02/21/2025, provided by the facility, identified Resident #4, #27, #35, #48, and #50 as smokers. Review of Resident #4's quarterly MDS assessment dated [DATE] revealed she was a [AGE] year-old female who initially admitted to the facility on [DATE]. Her diagnoses included: high cholesterol, anxiety, depression, bipolar, schizophrenia, low back pain, and need for assistance with personal care. Her BIMS score was a 14 indicating she was cognitively intact. Review of Resident #4's care plan dated last revised 02/24/2025 revealed she was care planned for being addicted to smoking cigarettes, dipping snuff, and vaping. Interventions included showing resident where designated smoking areas were, and to keep all smoking materials in designated area. Review of Resident #4's safe smoking assessment dated [DATE] revealed the resident was safe to smoke without supervision and was informed of smoking policies/procedures. An interview and observation on 02/24/2025 at 11:06 AM with Resident #4 revealed that she kept her cigarette's and the lighter inside her purse that hung on her wheelchair. She stated that she could go outside whenever she wanted to smoke, if it was too cold, she would just grin and bear it by staying inside and skipping her smoke breaks. She typically smoked about 3 cigarettes a day. She used an oxygen concentrator at night while sleeping. She stated that she has not been told to turn her lighter into the nurse's station but that she would never smoke inside. Review of Resident #27's annual MDS assessment dated [DATE] revealed he was a [AGE] year-old male who initially admitted to the facility on [DATE]. His diagnoses included: cancer, diabetes mellitus (increased blood sugar levels), anxiety (a feeling of fear, tension, or worry), bipolar, schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), alcohol abuse, and high blood pressure. His BIMS score was a 15 indicating he was cognitively intact. Review of Resident #27's care plan dated last revised 2/05/2025 revealed he was addicted to smoking cigarettes, dipping snuff, and recently only used a vape. Interventions included to show resident where designated smoking areas were, keep all smoking materials in designated area at the nurse's station, and to monitor resident when smoking to ensure resident safety. Review of Resident #27's safe smoking assessment dated [DATE] revealed the resident was safe to smoke his vape without supervision and was informed of smoking policies/procedures. In an interview on 02/24/2025 at 11:23AM with Resident #27he stated that he did not smoke cigarettes but did use a vape. He stated that the facility had an alarm that would set off if they smoked inside. Resident #27 stated that he had a heavy coat for the cold weather for outside for smoking. Resident #27 stated that they could go outside and vape whenever they would like to. In an observation on 02/24/2025 at 11:30AM Resident #27 pointed to his vape on his table. He had access to the vape and kept it in his room. Review of Resident #35's quarterly MDS assessment dated [DATE] revealed he was a [AGE] year-old male who admitted to the facility 02/08/2021. His diagnoses included: high blood pressure, multiple sclerosis, anxiety (a feeling of fear, tension, or worry), depression, psychotic disorder, Lyme disease, nicotine dependence, adjustment disorder, and pseudobulbar affect (inappropriate involuntary laughing and crying). His BIMS score was a 15 indicating he was cognitively intact. Review of Resident #35's care plan dated last revised 2/04/2025 revealed he was addicted to smoking tobacco in the form of cigarettes, pipe, or cigars; as well as using nicotine pouches/chewing tobacco, vaping, and has a history & recently smoked marijuana/cannabis. He has a history of keeping a cigar cutter and scissors at bedside and has been found smoking inside his room. He also periodically uses chewing tobacco/smokeless tobacco and a vape. He was noncompliant with keeping smoking products and materials at nurses' desk and periodically return smoking items to nursing desk. An occurrence on 4/15/24 where resident insisted on growing Marijuana in smoking area. The ADM removed it each time it was found which made the resident angry and caused behaviors. Interventions included to show Resident #35 where designated smoking areas were. Keep all the smoking materials in designated area. The resident was instructed to stop acquiring marijuana buds, seeds etc. for planting in the facility. The resident was instructed to stop planting marijuana in facility pots. Instructed it was a hazard to his health and against the law to have with each episode of finding his plants growing, Smoking assessment to be completed monthly. Review of Resident #35's safe smoking assessment dated [DATE] revealed the resident was safe to smoke without supervision and was informed of smoking policies/procedures. In an interview on 02/24/2025 at 2:38PM Resident #35 stated that they did not smoke cigarettes, but they did use a vape. Resident #35 stated that the facility staff did not allow the residents to smoke inside the facility. Resident #35 stated that if it was cold, they would put on a jacket, and smoke outside if they wanted to. He stated they were allowed to smoke whenever they would like to. In an observation on 02/24/2025 at 12:05PM Resident #48 pulled a pack of cigarettes out of her jacket pocket and inside the cigarette container were cigarettes and a lighter. Resident #48 had access to the cigarettes and lighter and kept it in her room. Review of Resident #48's annual MDS assessment dated [DATE] revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included: low blood sodium levels, anxiety, psychotic disorder, cataracts, and cachexia (a condition which causes significant weight loss and muscle loss). Her BIMS score was a 13 which indicated she was cognitively intact. Review of Resident #48's care plan dated last revised 01/02/2025 revealed she was addicted to smoking cigarettes and drinking alcohol. She was periodically non-compliant with returning smoking supplies to the nurse's desk. Smoking safety assessment shows the resident was safe to smoke unsupervised. Interventions included to explain and show the resident where designated smoking areas were. Keep all smoking materials in designated area. Smoking assessment to be completed monthly. Review of Resident #48's safe smoking assessment dated [DATE] revealed the resident was safe to smoke without supervision and was informed of smoking policies/procedures. In an observation on 02/24/2025 at 02:40PM, in Resident #35's bedroom, Resident #35 pointed to a vape that was on his bedside table. Resident #35 had access to the vape and kept it in his room. In an interview on 02/24/2025 at 11:58AM with Resident #48 she stated that she kept her lighter and cigarettes in her smoking jacket. She stated she did not smoke inside the facility. She stated that she smoked outside and if it was cold, she would use a jacket to smoke outside. Resident #48 stated they were able to smoke whenever they would like to. Review of Resident #50's MDS assessment dated [DATE] revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included: thyroid disorder, non-Alzheimer's dementia, high blood pressure, seizure disorder, bipolar, prediabetes, repeated falls, lack of coordination, and muscle weakness. His BIMS score was an 11, indicating moderate cognitive impairment. Review of Resident #50's care plan dated last revised 01/28/2025 revealed he was addicted to smoking a pipe. Interventions included showing the resident where designated smoking areas were, keep all smoking materials in designated area at the nurse's station, and to monitor resident when smoking to ensure resident safety. Review of Resident #50's safe smoking assessment dated [DATE] revealed resident was safe to smoke his pipe without supervision and was informed of smoking policies/procedures. In an interview on 02/24/2025 at 2:09 PM with Resident #50 he stated he smoked cigars and a pipe. He stated the facility frequently assessed and educated him on smoking safety and smoking safety around oxygen. He stated he had a brown suitcase or got other cases that he kept his tobacco products and spare pipes in. He kept the box with him or in his room. He further stated, I keep my lighter (Zippo) and my butane (disposable lighter) in my pocket or if I go to sleep, I place them on the table next to me. He stated that the facility has not tried to collect the lighter and butane but if they try someone is going to get hurt. The Zippo lighter used liquid lighter fuel which he stated that he keeps with him also. He stated, my butane was sealed by the factory, only fuel I keep is Zippo lighter fuel to refill the cotton type material in the Zippo lighter. An observation on 02/24/2025 at 11:42 AM revealed there were 2 residents (Resident #48 and #50) in the outside middle courtyard smoking. Resident #48 lit her own cigarette and was sitting in her wheelchair smoking it. Resident #50 lit his tobacco pipe and was sitting in his wheelchair smoking it. No staff were present. An observation on 02/24/2025 at 12:16 PM revealed Resident #35 pulled an e-cigarette out of his sock and smoked it while waiting on his lunch tray in the facility dining room. In an interview on 02/25/2025 at 10:37 AM with CNA A she stated that she was not sure if residents could keep smoking materials in their rooms. She stated that residents could go out to smoke when they wanted, and that staff followed behind them with the lighter. She stated that Resident #35 stayed in trouble and that using e-cigarettes were not allowed inside the building. In an interview on 02/25/2025 at 10:45 AM the CRN stated that the staff working at the nurse's station will use a binder to mark residents out when going to smoke, and mark them back in when they come in. She stated that residents know to look for her when she was here so that they could turn their smoking materials back into the nurse's station. She said that staff was supposed to follow the residents outside with a lighter to light the cigarettes. When she looked in the smoking box for Resident #4's cigarette's and lighter she could not locate them. In an interview on 02/26/2025 at 11:02 AM, the ADM stated his expectation was that lighters were to be kept at the nurse's station and not in any resident's possession, but that residents could keep their cigarettes in their rooms. He stated that all residents get evaluated monthly using a safe smoking evaluation and all residents deemed safe to smoke without supervision may smoke without staff present in the designated smoking area. Review of the facility policy titled Smoking Policy- Residents last revised July 2017 reflected the following: The facility shall establish and maintain safe resident smoking practices. 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Electronic cigarettes may be permitted inside designated areas only. 12. No resident is allowed to keep combustible smoking materials (lighter, matches, etc.) in their possession at any time.

Based on interviews and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 (Resident #31) of 6 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #31's significant change MDS accurately reflected his hospice status. This failure could place residents at risk of not having their individual needs met when a significant change in condition occurs. Findings included: Review of Resident #31's closed record significant change MDS dated [DATE] revealed he was a [AGE] year-old male who initially admitted to the facility on [DATE] with a re-admitted [DATE]. His diagnoses included: cancer, malnutrition, schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), adult failure to thrive, lack of coordination, and acute pain due to trauma. His BIMS was 03, which indicated severe cognitive impairment. In Section O - Special Treatments, Procedures, and Programs, K1. Hospice Care was not checked, rather, Z1. None of the Above had been checked indicating resident had no special treatments, procedures, or programs. Review of Resident #31's care plan revealed he was admitted to hospice services for diagnoses of malignant neoplasm of the left kidney, except renal pelvis (a disease in which kidney cells grow out of control, not affecting the pelvis) on 10/25/2024. Review of Resident #31's clinical physician's order dated 10/25/2024 revealed he was admitted to hospice services due to malignant neoplasm of the left kidney, except renal pelvis (a disease in which kidney cells grow out of control, not affecting the pelvis). In an interview on 02/26/2025 at 1:32 PM with the MDSC who has worked at the facility for almost 7 years, she stated that hospice should have been checked in Section O in Resident #31's significant change MDS. She said she was trained by the reimbursement specialist on doing the MDS assessments accurately. She stated that if a significant change MDS was not done accurately it could impede payments given to the facility, as well as impeding care that the resident was to receive that she could not see. In an interview on 02/26/2025 at 12:16 PM with the DON who has worked at the facility for 5 years, she stated that the MDS coordinator was responsible for completing a significant change MDS after discussion with the IDT, the family, and hospice. She stated that the MDSC was trained in accurately conducting MDS assessments. She stated that her responsibilities (regarding MDS) as the DON, included reviewing records and ensuring DNR's were completed. Review of facility's Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy policy undated reflected, The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being. According to CMS's RAI Version 3.0 Manual; the MDS is a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The items in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and outside agencies. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that: 2. The assessment accurately reflects the resident's status. Review of the RAI dated October 2024 reflected, An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being at whatever stage of the disease process the resident is experiencing. o If a resident is admitted on the hospice benefit (i.e., the resident is coming into the facility having already elected hospice), or elects hospice on or prior to the ARD of the Admission assessment, the facility should complete the admission assessment, checking the Hospice Care item, O0110K1.

Based on observations, interviews, and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change of condition for 1 of 6 (Resident #3) residents reviewed for comprehensive assessments. The facility did not complete a significant change MDS for Resident #3 after she was admitted to hospice services. This failure could place residents at risk of not having their individual needs met when a significant change in condition occurs. Findings included: Review of Resident #3's comprehensive MDS, dated [DATE], reflected an [AGE] year-old female originally admitted to the facility on [DATE]. Her diagnoses included unspecified dementia (memory loss), anxiety (a feeling of fear, tension, or worry), depression (persistent feelings of sadness), hypothyroidism (when the thyroid gland does not produce enough thyroid hormone), and diabetes mellitus (increased blood sugar levels). Resident #3 had a BIMS score of 00, indicating severe cognitive impairment. Review of Resident #3's care plan revealed she was admitted to hospice services for diagnoses of senile degeneration of the brain (progressive deterioration of brain tissue and function that occurs beyond what is considered normal aging) on 2/6/25. Review of Resident #3's clinical physician's order dated 02/06/2025 revealed she was admitted to hospice services due to a diagnosis of senile degeneration of the brain (progressive deterioration of brain tissue and function that occurs beyond what is considered normal aging). Review of Resident #3's MDS assessments in the EHR revealed no significant change assessment was conducted after Resident #3 was admitted to hospice services. In an observation on 2/25/2025 at 9:20am Resident #3 was sitting in her wheelchair in her room watching television. She had what appeared to be a baby fidget blanket in her lap and she was moving some of the flaps with her fingers. She appeared clean and well kempt. An interview was attempted but Resident #3 was unable to hold a conversation with the state surveyor. In an interview on 02/26/2025 at 11:58 AM with the MDSC who has worked at the facility for almost 7 years, she stated that she had just completed Resident #3's annual MDS assessment on 12/28/24 and she probably forgot to do the significant change assessment after the physician's order on 2/6/25. She stated that hospice was considered a significant change. When a resident had a significant change, she was to speak with the resident, family, and hospice about their goals. She physically assesses residents to see what has changed, she will ask about the diagnoses, and why the decision to obtain hospice services was made. She said she was trained by the reimbursement specialist on doing MDS assessments accurately. She stated that if a significant change MDS was not done it could impede payments given to the facility, as well as impeding care that the resident was to receive that she could not see. In an interview on 02/26/2025 at 12:16 PM with the DON who has worked at the facility for 5 years, she stated that the MDS coordinator was responsible for completing a significant change MDS after discussion with the IDT, the family, and hospice. She stated that hospice was considered a significant change, and that the MDSC was trained in accurately conducting MDS assessments. She stated that her responsibilities (regarding MDS) as the DON, included reviewing records, ensuring DNR's were completed, and that she just assumed that the significant change assessment gets completed. She stated that negative impacts could be that goals could potentially not get done on the care plan and that problems in the MDS would trigger different things on the care plan. Review of the facility's Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy policy undated reflected, The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being. According to CMS 's RAI Version 3.0 Manual; the MDS is a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The items in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and outside agencies. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that: 1. The assessment accurately reflects the resident's status. Review of the RAI dated October 2024 reflected, If a nursing home resident elects the hospice benefit, the nursing home is required to complete an MDS Significant Change in Status Assessment (SCSA). For the other comprehensive MDS assessments, Significant Change in Status Assessment and Significant Correction to Prior Comprehensive Assessment, the CAA Completion Date must be no later than 14 days from the ARD and no later than 14 days from the determination date of the significant change in status or the significant error, respectively. A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting. 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, which was observed for dietary services. The facility failed to: 1. Clean and sanitize kitchen surfaces and kitchen equipment to reduce food-borne pathogens. 2. Ensure snack refrigerators and individual resident refrigerators maintained adequate temperature to reduce food borne pathogens. This failure placed residents at risk for ingesting food-borne pathogens. Finding included: Observation and interview on 1/2/2024 at 9:10 AM reflected [NAME] A removing items from the exiting side of the facility's dishwasher and drying them with a towel before placing them in their respective locations. [NAME] A stated that she learned to wipe items, that came out of the dishwasher, from other people in the kitchen. She stated that having dried the equipment, there was less water spilled on the floor, so people would not slip and fall. Observations on 1/2/2024 at 9:15 AM reflected the facility's beverage dispensing system, which consisted of two beverage dispensers at the end of two separate hoses, had an accumulation of dirt and grime on the sides and on top of the machine. One of the beverage dispensers was placed on top of the beverage dispensing machine and had an accumulation of a dark sticky substance leaking from the beverage dispenser itself. The beverage dispensing machine had a small section of metal fins, as part of the cooling mechanism, which were covered by a small plastic grate. The metal fins and the small plastic grate had an accumulation of dust and debris. Observation on 1/2/2024 at 9:35 AM of the kitchen's only industrial can opener reflected a dark sticky substance on the sharp metal mechanism used to pierce metal cans. The internal working parts of the industrial can opener reflected the same dark stick substance. Observations on 1/2/2024 at 9:40 AM reflected the inside of the facility's only ice machine had internal mechanical parts that were not clean. Inside the machine, there was a white 20-degree angle shelf affixed to the sides of the machine with two metal bolts. The 20-degree angled white shelf channeled the ice from the top of the machine to the lower accumulation bin. The metal bolts were discolored with a dark brown substance that left a discolored stain that led downwards into the ice. Observations on 1/2/2024 at 9:45 AM reflected two metal electric fans on separate sides of the facility's only kitchen. Each fan had an accumulation of dust and dirt between the circular metal safety bars as well as coating each of the three internal fan blades. Interview on 1/2/2024 at 9:50 AM with [NAME] B revealed that the kitchen did not have a posted cleaning schedule. [NAME] B stated the DM told them, the kitchen staff, what needed to be cleaned. Interview on 1/2/2024 at 9:52 AM with [NAME] C revealed the kitchen did not have a posted cleaning schedule. She stated that the kitchen staff worked as a team to make sure the kitchen was clean. Interview, observation, and record review on 1/4/2024 at 9:00 AM with CNA M revealed snacks for residents, along with food brought to residents from friends and family, were stored in the snack refrigerator in the storeroom in the 200 hallway (refrigerator A.) CNA M stated the nursing staff was responsible for Refrigerator A, and its contents. The Refrigerator A had a sheet of paper affixed to its outside, which indicated the refrigerator was monitored for temperature daily. The log sheet indicated [designated staff and volunteers will record the time, air temperature, and their initials. Refrigerators should be between 36 Degrees F and 41 Degrees F.] The Refrigerator A was checked on 1/1/2024 at 12:00 midnight, with a logged temperature of 32 degrees F; 1/2/2024 at 1:00 AM, with a logged temperature of 30 degrees F; 1/3/2024 at 12:00 AM, with a logged temperature of 30 degrees F; and 1/4/2024 at 12:00 AM, with a logged temperature of 30 Degrees F. At the time of the observation, a state issued temperature and humidity monitor, Smart Pro SC42, was utilized to obtain the internal temperature, which reflected 46 Degrees F. The Refrigerator A had a thermometer inside, which registered the same temperature as the Smart Pro SC42, which was 46 Degrees F. Interview and observation 1/4/2024 at 9:15 AM with the DON at Refrigerator A revealed that the Smart Pro SC42, which read 46 Degrees F, and the internal thermometer of Refrigerator A, which read 46 Degrees F, were the same. The DON reached in the refrigerator and turned the cooling mechanism dial in the direction to make Refrigerator A colder. There were 18 pudding cups, a personal lunch box for a staff member, and two unopened bottles of juice in the refrigerator. The pudding cups, and the two unopened bottles of juice, were not marked with labels to signify the product name, the date they were placed in the refrigerator, or the date they would expire. Interview on 1/4/2024 at 9:20 AM with MW revealed that he has not been asked by nursing staff to check the Refrigerator A for any issues or concerns with it having not cooled to a proper temperature. Interview on 1/4/2024 at 9:25 AM with HK A revealed that housekeeping staff was supposed to be checking the refrigerators in each resident's room for proper temperature; however, HK A stated she had not been checking the refrigerators, and logging the temperatures, since December, because she did not have any temperature log sheets. Interview on 1/4/2024 at 9:22 AM with HK B revealed she had been checking temperature daily but had not been recording any for January because she did not have any log sheets. Interview and observation on 1/4/2024 at 9:27 AM with HK C revealed she was the housekeeping supervisor. HK C confirmed that housekeeping staff was responsible to check the refrigerator temperatures in the rooms and to log the temperature on a log sheet, but she did not have any log sheets to give to her staff. The Refrigerator A, which was in a nearby room, had log sheets in a plastic sleeve taped to the Refrigerator A. HK C was observed getting a blank copy of the log sheet so she could make copies. Observations on 1/4/2024 at 9:45 AM in room [ROOM NUMBER] reflected the internal temperature of the refrigerator was 49 Degrees F. The foods inside of the refrigerator did not possess any labels or dates to signify the item name or the date the product would expire. Observations on 1/4/2024 at 9:55 AM in room [ROOM NUMBER] reflected the internal temperature of the refrigerator was 50 Degrees F. The foods inside of the refrigerator did not possess any labels or dates to signify the item name or the date the product would expire. Observations on 1/4/2024 at 10:04 AM in room [ROOM NUMBER] reflected the internal temperature of the refrigerator was 72 Degrees F. There was no food in the refrigerator, only bottles of water. Observations on 1/4/2024 at 10:10 AM in room [ROOM NUMBER] reflected the internal temperature of the refrigerator was 53 Degrees F. The foods inside of the refrigerator did not possess any labels or dates to signify the item name or the date the product would expire. Interview on 1/4/2024 at 10:15 AM with HK D revealed housekeeping staff was supposed to check the refrigerators in each resident's room and write down the temperatures, but she did not have any log sheets to write the temperature down. Interview on 1/4/2024 at 1:15 PM with the ADON M stated the nursing staff was responsible for the temperature logs and the foods in the 200-hallway snack refrigerator, Refrigerator A. If the Refrigerator A was not keeping the correct temperatures, she stated that staff was supposed to notify a supervisor or maintenance about the issue. The ADON M stated that food was supposed to be stored at the correct temperatures in Refrigerator A because food could go bad, and residents could get sick if eaten. The ADON M stated that negative outcomes of residents eating spoiled food could be nausea, vomiting, diarrhea, and abdominal pain. She stated that there have not been any singular, or multiple, events of residents having had complained about gastrointestinal problems. Interview on 1/4/2024 at 1:23 PM with the DON revealed housekeeping staff was provided with a log sheet and were supposed to check temperatures of the refrigerators in the resident's rooms daily; as well, housekeeping staff were to make sure all food products in the resident's rooms were labeled with product names and a date when they would be expected to expire. The DON stated that foods not stored in proper containers, or at the proper temperature, could grow food borne pathogens and make residents sick. The DON stated the failure for missing temperature logs, and foods not being labeled properly, in the resident's rooms was that the housekeeping supervisor was not following up and checking on the staff's work. surfaces in the kitchen needed to be kept clean to prevent both food borne pathogens and the spread of germs. She stated the failure on the kitchen's part to keep surfaces clean and sanitized was the DM and the lack of staff training. She described negative outcomes of ingesting bacteria and food borne pathogens could lead to nausea, diarrhea, abdominal pain, weight loss, and dehydration. The DON stated there have been no singular, or multiple, events of residents complaining of gastrointestinal issues. Interview on 1/4/2024 at 2:17 PM with the DM revealed it was important to clean and sanitize kitchen surfaces to prevent bacteria, food borne pathogens, and cross contamination. If a resident ingested bacteria or food borne pathogens, they could get sick and experience stomach pain, diarrhea, and vomiting. The DM stated the failure to keep kitchen equipment and surfacers sanitized was a result of staff not doing what they were supposed to do. Interview on 1/4/2024 at 2:55 PM with the ADM revealed he expected his kitchen staff to be cleaning the kitchen both before and after meals. He stated the facility was feeding residents, who might already have compromised immune systems, and the consumption of bacteria and food borne pathogens could make the residents' sick. The ADM stated the failure to keep kitchen surfaces clean and sanitized, regulate refrigerator temperatures, and store food correctly was that staff simply failed to perform their job duties as instructed. Record review of the facility's [Food Preparation and Service Policy], dated July 2014, indicated foods stored between 41 Degrees F and 135 Degrees F promotes the rapid growth of pathogenic microorganisms that cause foodborne illnesses; residents should be discouraged from saving anything from their meals for later consumption; and residents are strongly discouraged from keeping potentially hazardous foods in their rooms. Record review of the facility's [Foods Brought by Family/Visitors], dated February 2014, indicated perishable food must be stored in sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item, and the [use by] date; the nursing staff was responsible for discarding perishable foods on or before the [use by] date; and potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than two hours will be discarded. Record review of the facility's [Sanitization Policy], dated October 2008, indicated all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from (2) breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be in good repair; (3) all equipment, food contact surfaces, and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water or chemical sanitizing solution; (10) food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical; (12) ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy; (16) kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime; and (17) the food service manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Record review of the kitchen's cleaning schedule, undated, indicated to clean the can opener after every use.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs for 3 of 6 residents (Resident #59, Resident #68, and Resident #39) who were reviewed for accommodation of needs. The facility failed to ensure Resident #59's, Resident #68's, and Resident #39's call lights were placed within their reach. This failure could place dependent residents at risk of injuries and unmet needs. Findings included: A) Review of Resident #59's face sheet, dated 1/04/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of Protein calorie malnutrition, Unspecified Dementia (loss of cognitive Functioning that affects reasoning and thinking), and Hypertension (elevated blood pressure). Review of Resident #59's Quarterly MDS Assessment, dated 10/27/23, reflected she had a BIMS score of 06 indicating severe cognitive impairment. Further review reflected Resident #59 had highly impaired vision. Record review of Resident #59's care plan dated 05/19/23 and revised 12/19/23 reflected Resident #59 requires one person assistance with toileting, dressing, and grooming. The care plan also reflected Resident #59 requires assistance of one staff member for toilet use, transfers, dressing, and grooming. Resident #59 used a wheelchair for her mobility. In an Observation and interview of Resident #59 on 01/02/24 at 9:13 AM the resident's call light was observed pinned to the right top hand corner of the bed falling between the headboard and mattress out of reach from the resident. Resident #59 reported sometimes she would call her family member on the phone, and her family member would call the nurses and have them come into the room. In an observation 01/02/24 at 01:35 PM Resident #59s call light was clipped to the very top right-hand side of the sheet out of reach of the resident. Resident #59 stated she doesn't know where her call light is. B) Review of Resident #68's face sheet, dated 1/04/24, reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of Adult Failure to Thrive, Unspecified Dementia (loss of cognitive Functioning that affects reasoning and thinking), Hypertension (elevated blood pressure), and Depression. Review of Resident #68's Quarterly MDS Assessment, dated 12/20/23, reflected he had a BIMS score of 10 indicating moderate cognitive impairment. Further review reflected Resident #68 was dependent for transfers, locomotion on and off unit, toilet use, and personal hygiene. Record review of Resident #68's care plan dated 11/20/23 reflected Resident #68 had a communication. problem related to expressive aphasia (difficulty speaking) and hard of hearing. Resident #68's care plan also reflected he had a self-care performance deficit and required assistance of two staff members for toilet use, and transfers. Interventions listed on the care plan included to encourage Resident #68 to use bell to call for assistance. In an observation and interview on 01/02/24 at 9:20 AM Resident #68's call light was observed on the floor out of reach of the Resident. Resident #68 reported he uses his call light to call for help but must wait sometimes an hour or more for someone to come in the room. In an observation on 01/03/24 at 09:27 AM Resident #68's call light was attached to his roommate's bed. C) Review of Resident #39's face sheet, dated 1/04/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes (elevated blood sugar), Major Depressive Disorder, Essential Hypertension (elevated blood pressure), Left Leg Below Knee Amputation. Review of Resident #39's Quarterly MDS Assessment, dated 12/05/23, reflected he had a BIMS score of 14 indicating he was cognitively intact. Record review of Resident #39's care plan dated 07/30/23 and revised 12/18/23 reflected Resident #39 has had an actual fall and had poor safety awareness. Resident #39s goal was to resume his usual activities without further incidents of falls. Resident #39's care plan also reflected he had a self-care performance deficit, was totally dependent on staff for toilet use and staff were to encourage him to use his call bell to call for assistance. In an observation on 01/02/24 at 9:29 AM Resident #39s call light was on the floor out of the residents reach. Resident #39 was in his bed resting. In an observation and interview on 01/02/24 at 01:33 PM - Resident #39's call light was on the floor. Resident #39 reported if he needs help, he can just yell for staff. In an interview with CNA C on 01/03/24 at 09:30 AM CNA C reported call lights should always be attached to the bed or in reach of residents. She reported the staff were educated with in-services to ensure call lights were within reach. CNA C reported the risk for Residents not having their call light within reach was the residents would not be able to get assistance when needed which could lead to residents falling. She reported the CNA should have made sure the call light was in reach all the time. In an Interview with LVN B on 01/03/24 at 09:37 AM she stated it was her expectation that call lights would be in residents' reach while the resident was in the room. She reported the risk for the resident was falls with injury, related to unsafe transfers. LVN B reported all staff were trained regularly on making sure the call lights are within reach and all staff were responsible for monitoring. In an interview with DON on 01/04/24 at 12:09 PM she reported it was the facility policy that call lights should have always been within reach of the resident. The DON reported the risk to residents for not having their call light within reach would have been lack of needs met and risk for falls. She reported staff were educated in In-Services on having call lights within reach of residents. The DON reported she is responsible for staff education, but all staff should have been looking and monitoring to ensure call lights were in place. Review of the facility's Answering the Call Light policy, dated October 2010, reflected: .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

45831 Based on observations, interviews, and record review, the facility failed to provide adequate supervision to prevent accidents for 10 of 11 residents (Resident #11, Resident #15, Resident #24, Resident #27, Resident #34, Resident #36, Resident #50, Resident #53, Resident #55, and Resident #68) while smoking in designated smoking areas. The facility did not provide adequate supervision to 10 residents that smoke outside in the designated smoking area. The facility failed to ensure adequate supervision was provided to Resident #11, Resident #15, Resident #24, Resident #27, Resident #34, Resident #36, Resident #50, Resident #53, Resident #55, and Resident #68 to ensure safe smoking and smoking materials were maintained by facility staff for all 10 residents and while they smoked outside in the designated smoking area. The facility did not comply to their policy and resident's care plans of securing all the smoking materials in the designated area at the nursing station. All of the resident's care plans stated smoking materials would be kept at the nursing station. An Immediate Jeopardy (IJ) situation was identified on 10/19/22 at 4:30 PM. While the IJ was removed on 10/22/22 at 5:10 PM, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of widespread due to the facility continuing to monitor their implementation plan and need to evaluate the effectiveness of the corrective systems that were put into place. This failure could place residents who smoke at risk of injury and/or all the residents in the facility at the risk of fire and safety hazard that could cause serious harm or death. Findings included: Review of Resident #11's undated face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE] with a diagnosis of seizures, unsteadiness on feet, neoplasm of meninges (abnormal growth of tissues on meninges), other lack of coordination, cataract (cloudy lens in the eyes), and anxiety disorder. Review of Resident #11's care plan last revised on 07/25/2022 stated he will be monitored for safety when outside smoking and he will keep all smoking materials at the nurses station. Review of Resident #11's MDS revealed he has a BIMS Score of 14 showing he was cognitively intact. Review of Resident #11's smoking safety evaluations dated 08/25/21, 11/29/21, 03/15/22, 06/7/22, and 09/13/22, listed him as demonstrating the ability to safely smoke without supervision. Review of Resident #15's undated face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] with a diagnosis of Parkinson's Disease, Major Depressive Disorder, and anxiety disorder. Review of Resident #15's care plan last revised on 8/29/22 stated to keep all smoking materials in designated area at the nurses station and to monitor resident when smoking and ensure resident's safety. Review of Resident #15's MDS revealed a BIMS Score of 15 showing she was cognitively intact. Review of Resident #15's smoking safety evaluations dated 08/29/22 and 10/18/22 states, Resident is a safe smoker and can smoke without supervision. Review of Resident # 24's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Major Depressive disorder, Recurrent, in partial remission, Anxiety disorder, Dependence on wheelchair, Panic Disorder, Other lack of coordination, Bipolar II Disorder, Primary insomnia, Muscle weakness (generalized), Unsteadiness on feet, Other abnormalities of gait and mobility and Nicotine dependence. Review of Resident #24's smoking safety evaluations dated 04/05/22, 07/12/22, and 09/20/22, revealed no concerns. Review of Resident #27's undated face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] with a diagnosis of Dementia, anxiety, insomnia, muscle weakness, unsteadiness on feet, chronic a fib, and TIA. Review of Resident #27's care plan last revised 08/24/22 stated she is sometimes noncompliant with returning smoking materials to nurses desk and to keep all smoking materials in designated area at the nurses station and to monitor resident when smoking and ensure resident's safety. Review of Resident #27's MDS revealed a BIMS Score of 12 showing she was cognitively intact. Review of Resident #27's smoking safety evaluations dated 12/21/21, 03/29/22, 06/27/22, and 08/24/22, stated, Resident is a safe smoker. Review of Resident #34's undated face sheet revealed an [AGE] year-old male was admitted to the facility on [DATE] with a diagnosis of Dementia, Major Depressive Disorder, Unspecified Psychosis, Adjustment Disorder with Disturbance of Conduct, Other Psychoactive Substance use, unspecified with other Psychoactive Substance-Induced Disorders. Review of Resident #34's care plan last revised on 09/06/22 stated to keep all smoking materials in designated area at the nurses station and that supervision is needed while he is smoking and to ensure his safety. Review of Resident #34's MDS revealed a BIMS Score of 08 indicating he is moderately impaired. Review of Resident #34's smoking safety evaluation dated 11/29/21, stated, Resident has smoked in non-designated areas. Recommend supervision and for staff to store his lighter and cigarettes. Review of his smoking safety evaluations on 06/27/22 and 09/06/22 states, Resident needs to be supervised during smoking. Review of Resident #36's undated face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE] with a diagnosis of Dementia, Bipolar, Anxiety, Major Depressive Disorder, other impulsive disorders, and delusional disorders. Review of Resident #36's care plan last revised 08/30/2022 stated to keep all smoking materials in designated area at the nurses station and to monitor him when smoking and to ensure his safety. Review of Resident #36's MDS revealed a BIMS Score of 06 which indicated severely impaired cognition. Review of Resident #36's smoking safety evaluations dated 04/12/22, 07/19/22, and 10/18/22 stated, Resident is safe when smoking with staff assistance and supervision. Review of Resident #50's undated face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE] with a diagnosis of Multiple Sclerosis, Cannabis abuse with Psychotic Disorder with Delusions, Lyme Disease, Unspecified, Major Depressive Disorder, Adjustment Disorder with Mixed Anxiety and Depressed Mood, and Attention-Deficit Disorder. Review of Resident #50's care plan last revised 09/14/2022 stated he is keeping a cigar cutter and scissors at bedside and has been found smoking inside his room and is noncompliant with keeping smoking products and materials at nurses desk. The interventions included to keep all smoking materials in designated are at the nurses station and to monitor him when smoking to ensure his safety. Review of Resident #50's MDS dated [DATE] revealed a BIMS Score of 15 showing he was cognitively intact. Review of Resident #50's smoking safety evaluations dated 08/23/21, 11/29/21, 02/15/22, 05/31/22, and 08/30/22 did not list any concerns for the resident. Review of Resident #53's undated face sheet revealed an [AGE] year-old female was admitted to the facility on [DATE] with a diagnosis of Dementia, Bipolar Disorder, Major Depressive Disorder, Lack of Coordination, Essential Tremor, and anxiety disorder. Review of Resident #53's care plan last revised 09/20/22 stated she is noncompliant with keeping smoking products at nurses desk. Her interventions included keep all smoking materials in designated area at the nurses station. Review of Resident #53's MDS dated [DATE] revealed a BIMS Score of 12 which indicated moderately impaired cognition. Review of Resident #53's smoking safety evaluations dated 08/23/21, 11/29/21, 03/01/22, 06/07/22, and 09/20/22, did not list any concerns for the resident. Review of Resident #55's undated face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE] with a diagnosis of cognitive impairment, alcohol abuse, insomnia, anxiety disorder, hx of falls, muscle weakness, and CVA (cerebrovascular accident) (Stroke). Review of Resident #55's care plan last revised 09/20/22 stated he is periodically noncompliant with keeping smoking products at nurses desk. His interventions included to keep all smoking materials in designated area at the nurses station and to monitor while smoking to ensure resident's safety. Review of Resident #55's MDS dated [DATE] revealed a BIMS Score of 11 which indicated moderately impaired cognition. Review of Resident #55's smoking safety evaluations dated 04/19/22, 07/19/22, 09/20/22, stated, Resident smokes safely and does not require staff supervision. Review of Resident #68's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of 2x12 Low Vision Right Eye Category 1, Low Vision Left Eye Category 2, Bilateral Unspecified Hearing loss, Alcohol Dependence, Unspecified Speech Disturbances and Personal history of Nicotine Dependence. Review of Resident #68's smoking safety evaluation dated 08/17/22, states, Resident is able to smoke without supervision. In an observation on 10/18/22 at 8:07 AM, 8:52 AM, and 9:14 AM, Resident #55 was seen smoking in the smoking courtyard area without staff supervision. In an observation on 10/18/22 at 9:12 AM, 10:46 AM, and 11:12 AM, Resident #11 was seen smoking in the smoking courtyard area without staff supervision. In an observation on 10/18/22 at 9:52 AM, 10:44 AM, and 11:46 AM, Resident #50 was seen smoking in the smoking courtyard area without staff supervision. In an observation on 10/18/22 at 11:45 AM, 1:452 and PM, 3 PM, Resident #68 was seen smoking in smoking courtyard area without staff supervision. In an observation on 10/19/22 at 9:34 AM, 10:26 AM, and 11:19 AM, Resident #50 was seen smoking in the smoking courtyard area without staff supervision. In an observation on 10/19/22 at 11:05 AM, 1:05PM, 1:35PM, 2:02PM, 2:48PM, 3:42PM, and 4:12PM, Resident #55 was seen smoking in smoking courtyard area without staff supervision. In an observation on 10/19/22 at 11:25 AM, 1:32 PM, 2:42 PM, and 3:41 PM, Resident #11 was seen smoking in smoking courtyard area without staff supervision. In an observation on 10/19/22 at 10:30 AM, 1:20 PM and 2:30 PM Resident #24 was seen smoking in smoking courtyard area without staff supervision. In an observation on 10/19/22 at 11:20 AM, an overstock of smoking supplies was observed to be kept in an unsecured drawer at the nurses' station. Plastic trash cans and metal trash cans with cigarette butts mixed with trash was located in designated smoking areas outside of the 400 hall, the front of the building, and the therapy area. In an observation and interview on 10/18/22 at 2:53 PM, Resident #53 was observed smoking and she said she keeps her cigarettes and lighter with her. She uses oxygen at night and her room has a board posted that says, Do not smoke, oxygen in use. In an observation and interview on 10/19/22 at 08:50 AM Resident #50 was observed to be asleep in his room. There was a strong smell of smoke. Investigator A asked CNA #1 to step into the room to identify the smell and she said, It smelled like it could be coming from his body, his clothes, and/or definitely smoking in the room. At 9:30 AM Investigator B visited Resident #50's room with ADM. ADM confirmed the smell of smoke and stated that Resident #50 had the history of smoking in his room and noncompliance to facility staff directives regarding safe smoking practices. In an observation and interview on 10/19/22 at 11:25 AM, Resident #11 was observed with visible tremors to his bilateral upper extremities. He said he had a difficult time holding onto things at times. In an observation and interview on 10/19/22 at 10:05 AM in her room, Resident #15 said she kept her cigarettes and lighter in her walker and displayed the items. She was informed that there was a Smoking Policy about where you were allowed to smoke. In an interview on 10/19/22 at 10:25 AM Resident #36 said the nurse rolled him out to smoke and she stayed most of the time. In an interview on 10/19/22 at 10:42 AM Resident #50 said his cigarettes and lighter fluid for his cigars were kept at the nursing station. He kept his cigars in his room in the brown box above his safe. He kept his cigarette lighter in his jacket. He stated the nurses, the ADMIN, and the DON were aware that he kept the cigars in his room. In an interview on 10/19/22 at 10:50 AM Resident #55 said he smoked on his own and displayed his cigarettes and lighter. He said the facility did not keep any of his supplies. He stated he did not have to adhere to smoking times and he smoked whenever he wanted. He did not have issues with burns on him, or his clothing. In an interview on 10/18/22 at 11:15 AM Resident #68 said she kept her cigarettes and lighter with her and displayed the cigarette packet and lighter that was with her in her room. In an interview on 10/19/22 at 1:00 PM Resident #24 said she secured the cigarettes and lighter in her room. She said she never smoked in her room as it was not safe. In an interview on 10/19/22 at 11:20 AM, the ADON stated that 8 residents kept their cigarettes and lighters on them or in their room (Resident #11, Resident #15, Resident #24, Resident #27, Resident #50, Resident #53, Resident #55, and Resident #68) and one of these residents were not allowed to keep smoking supplies because of previously smoking in his room. Staff were aware he kept his own supplies. Two additional residents required supervision (Resident #36 and Resident #34, but they had not smoked for several months). If an aide or nurse were available, they would take these two residents outside to smoke or leave them with other residents to supervise them while they smoked. In an interview on 10/20/22 at 3:30 PM with the RNA, she said without a proper Smoking Assessment, placed residents in jeopardy of harm. They have to monitor their residents. In an interview on 10/20/22 at 3:40 PM the ADMIN stated noncompliance to smoking policies and procedures lead to the risk of fire hazards that could cause serious harm to the residents. He said they have changed their policy to include supervision for all residents and checking their rooms daily. He said they cannot search personal items but would search around to avoid injuries and unnecessary fires inside of trash bins. Record Review on 10/19/22 of policy titled [facility name] Smoking Policy (undated) stated: All smoking materials (lighters, matches, cigarettes, cigars, pipes, electronic cigarettes) are to be kept at the nurses' station in a secure container. Staff will be required to supervise/assist those residents identified as having risk factors that require supervision/assistance during smoking. Smoking assessments are to be done on admission, quarterly, annually, and as needed for changes Record Review of policy titled Smoking Policy - Residents [facility name] (dated: Revised July 2017) stated: 11. Any resident with restricted smoking restrictions requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 12. No resident is allowed to keep smoking materials, to include lighters in their possession at any time. 13. Residents will be provided their smoking materials at designated smoking times by the staff member supervising the smoke time. The ADM was notified on 10/19/22 at 04:30 PM an IJ situation was identified due to the above failures. The facility's Plan of Removal was accepted on 10/22/2022 at 5:10 PM and included: Revisions were made to the policy to include safe smoking assessments that will be done monthly and on an as need basis started on 10/19/22. These assessments will be completed by the social worker. In-services on the revised smoking policy were started on 10/19/22 at 5:45 PM and completed the following morning on 10/20/22 at 9:00 AM by the ADON for all facility staff, including direct nursing staff, charge nurses, dietary staff, SW, MDS nurses, maintenance, and the receptionist. No employee will be allowed to work until they have been in-serviced on the revised smoking policy. This will be monitored for compliance daily by the ADM and the ADON and was in compliance on 10/20/22. All new employees will be in serviced; on the smoking policy before they begin their employment. The SW and the ADON completed new smoking assessments on the 8 residents that choose to smoke, and no resident required supervision except for one resident due to noncompliance with the smoking policy. Revisions were made to the policy to include safe smoking assessments that will be done monthly by the social worker. This will be monitored for initial and continued compliance by the ADM and /ADON. All 8 residents were observed by the social worker when the smoking assessment were completed. There are 4 additional residents that have not smoked for the past 2 to 3 months that had the resident status portion of the smoking assessment completed with documentation that the resident no longer smokes. This was completed by the SW on 10/19/22. The SW observed each of the 8 smokers while they were smoking for a new baseline assessment on 10/19/22. All new residents will also be given smoking assessments on arrival, and as needed. The ADM met with each resident that smoke on 10/19/22 to review the smoking policy which include supervision of smoking for any residents requiring supervision per their care plan. If they are unable to appropriately answer smoking safety evaluation questions, and or exhibit unsafe physical ques that could lead to possible harm and require supervision to be noted in their care plan. Each resident verbalized understanding of the smoking policy as explained by the ADM. All residents that smoke signed the revised smoking policy on 10/19/22. This will be monitored for initial and continued compliance by the ADM and ADON for six weeks or until achieved compliance. After review of the new smoking assessments, all residents were cleared to smoke with exception of one resident. To achieve safety compliance, and ensure all fire and accidental hazards are removed, a tackle box with a lock was purchased on 10/19/22 and all smoking materials for one non-compliant resident were placed inside. This resident is non-compliant due to ordering and using lighters and potential hazardous materials via mail and using these items in an unsafe environment. This resident also has past and recent history of smoking in his room, which could lead to fire hazards. No smoking materials were visually observed in this resident's room on 10/19/22 at 7:00 PM, or on 10/20/22 at 7:00 AM. The ADM confirmed that this resident's lighters or any combustible items were collected on 10/20/22 at 7:00 AM. These items were placed in the lock box at that time on 10/20/22 at 7:00 AM and will remain until resident demonstrates compliancy. Nurses will keep a key to the lock box and provide access per the resident's request. All nursing staff were in-serviced on the items that are to be kept in the locked box belonging to this resident. This will be monitored for compliance by the ADM and ADON. Rounding on one will be done to ensure the resident remains compliant, and not in possession of lighters or any combustible items two times per day by the SW, ADM or ADON starting on 10/19/22 on an as need basis for six weeks or until achieved compliance. The resident agreed for the ADM to remove smoking materials from his room on 10/20/22. This resident has been put on 1 on 1 observation due to a history of non-compliance due to ordering and using lighters and potential hazardous materials via mail and using these items in an unsafe environment. Resident #50 has past and recent history of smoking in his room, which could lead to fire hazards. Resident #50 will continue 1 on 1 supervision until safety concerns are met (related to non-compliance due to purchasing and maintaining lighters via mail). A hospitality aide will provide 1 on 1 supervision to this one resident. Only one resident has been placed on one-on-one supervision and his care plan has been updated by the MDS nurse on 10/20/22. This will be monitored for compliance by the ADM and ADON until safety concerns are met via IDT meetings. The ADM and MDIR rounded all smoking areas on 10/19/22 at 7:00 PM and replaced all regular trash cans and replaced them with metal trash bins that are covered and non-flammable. All facility staff were in-serviced on the proper disposal of cigarette butts. In-service was completed on 10/19/22 and 10/20/22 by the ADON and the ADM 10/20/22. All new employees will be in-serviced on cigarette butts not being emptied into trash cans at orientation by human resources. Safety concerns will be monitored for compliance by the administrator and the ADON daily until compliance is attained or as needed to ensure all residents and resident environment is free from fire hazards and potential harm. Record Review on 10/21/22 at 5:20 PM of the new Smoking Safety Evaluations revealed assessments had been completed for all smokers. Record Review on 10/21/22 at 5:45 PM revealed in-services on the Smoking Policy had been completed for all staff. In an interview on 10/21/22 at 6:30 PM, Resident 11 stated his cigarettes and lighter were at the nurse's station. He stated he follows the smoke schedule and is supervised while smoking. He did not need help while smoking and his hands only shook when they were cold. He demonstrated with his hands on how he smoked a cigarette, and observation revealed his hands were not shaking. In an interview on 10/21/22 at 7:13 PM, OT #1 stated she had been in-serviced on the Smoking Policy and made aware of the supervised smoking times and that all smoking supplies were to remain at the nurse's station. In an interview on 10/21/22 at 7:24 PM, LVN #2 stated she had been in-serviced on the Smoking Policy and made aware there were now posted smoke times and a staff member must be present to observe the residents at all times. She understood it must be done for safety purposes. In an interview on 10/22/22 at 1:05 PM, CNA #2 stated she had been in-serviced on the Smoking Policy by the ADM. She understood the residents were to be taken outside every 2 hours to smoke and they must be monitored at all times. In an interview on 10/22/22 at 2:15 PM with Resident #15, she stated they were monitored, and her cigarettes and lighters were left at the nurse's station at all times. In an interview on 10/22/22 at 2:30 PM with Resident #50, he stated he was not allowed to keep smoking materials in his room. He stated he was supervised and was only allowed to smoke during the designated times. During an observation on 10/22/22 at 3:11 PM revealed CNA #2 outside with the smokers and monitoring them while they were smoking. On 10/22/22 at 5:10 PM the ADM was notified the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of widespread due to the facility's need to complete in-service training and evaluate their corrective actions. 46545

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases in response to a COVID-19 [MEDICAL CONDITION] outbreak. 35 of 69 residents had tested positive for COVID-19 in October 2020. Further review reflected the facility had five resident deaths related to COVID-19. 1. The facility failed to appropriately screen employees for signs and symptoms of COVID. 2. The facility failed to ensure staff did not cross-contaminate when facility staff entered and exited the COVID unit without donning and doffing PPE. 3. The facility failed to ensure dedicated staff worked for each cohort of residents. 4. The facility failed to sanitize high touch/high traffic areas frequently per facility protocols. 5. The facility failed to ensure staff wore appropriate PPE when providing care for positive COVID-19 residents. 6. The facility failed to ensure dishes were sanitized appropriately. 7. The facility failed to maintain an infection control policy for COVID-19. An IJ was identified on 10/29/20 at 2:10 PM. While the IJ was lowered on 11/02/20 at 3:30 PM, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not IJ identified as widespread due to the facility's need to evaluate the effectiveness of their Plan of Removal. The facility was provided the IJ Template on 10/29/20. These failures placed residents at risk of exposure to COVID-19, which could result in illness, hospitalization , or death. Findings included: 1. In an observation on 10/24/2020 at 10:57 AM, a surveyor rang the bell at a back door of the facility. Kitchen staff DA Allowed the surveyor entry into a back hallway outside the kitchen. She led the surveyor through the kitchen, up the 300 hallway, to the front of the building, where ADON asked staff at the front door to conduct the screening process. In an observation on 10/27/20 between 5:40 AM and 7:18 AM, four individuals were seen parking their vehicles in the facility's back parking lot. The drivers of each vehicle entered the facility through the back door at the end of the 400 hall. This door is across from the facility laundry area. A second surveyor observing the front main entrance door of the facility saw no individuals park, be screened by the facility, then return to their vehicle and drive toward the back-parking lot. In an interview on 10/27/20 at 8:27 AM, the ADON and the facility ADM stated that all staff are expected to be screened at the front entrance before beginning their shift. The ADM and ADON stated the facility procedure is to utilize only the main front entrance of the facility and that all other doors are locked and can only be unlocked from the inside with a code. They emphasized no staff could simply walk into the building through the back exits. Staff can be screened at the front entrance and drive around the back to park and enter through the back door, however, staff in the facility would ask the arriving staff about their screening at the main entrance. They further stated the staff responsible for screening is supposed to stop individuals outside of the entrance and screen them before being allowed into the building. In an interview on 10/28/20 at 12:11 PM, the ADM was informed of the observations of the four staff entering the building through the back door the previous morning. She stated, If y'all saw it, it happened. The ADM stated this was the first time this issue had been brought up. Record review of staff assignment sheets and screening logs dated 10/26/20 and 10/27/20 revealed three facility staff (MA E, HK N, and CNA I) on 10/26/20 and three on 10/27/20 (MA E, the ADON, and SM) appeared on the assignment sheets as working and present in the building but did not appear on the facility screening log. The ADM and DON were not able to provide evidence that those staff were screened at all on those days. In an observation on 10/28/20 at 9:45 AM, HA V took the surveyors' temperatures before allowing entrance to the building to complete the questionnaire part of the screening process. The screener granted full entrance to a surveyor without looking at the surveyor's written responses to the screening questions. In an interview on 10/28/20 at 11:00 AM the facility AD stated she felt the facility could enforce screening better. She said, there are people that slip through the back door without screening, people who come in and don't get screened. She did not know the names of individual staff who did this but said there were people that park in the back of the facility and come in without going to the front first. When asked if she had brought this up with facility administration, she said the screening issue was discussed several times. She added about anyone in the building could talk about the effectiveness of the screening process. In an interview on 10/28/20 at 12:47 PM, the DR acknowledged that she would at times enter through the back door of the facility and walk through the facility to the front entrance to get screened. She said, I did that yesterday. The DR also said, I actually think it's before entering that we should be screened. In an interview on 10/28/20 at 12:54 PM, MA E stated she did not get screened the past couple of days. She said she came in the back door by the laundry, adding that it stays unlocked. She said, Yeah, others do too. She said that everybody is supposed to come to the table at the front entrance to get screened no matter what door they come in. Observations were made at various times on 10/28/20 of staff coming and going through the back door on the 400 hall across from the laundry without having to enter a code or use a key. The door remained unlocked during each observation. A sign on the door indicated an alarm would sound if the door was opened, but the alarm was never heard. Review of the facility's provided COVID-19 documents revealed no specific COVID-19 infection control plan. Further review reflected the only documentation provided was from CMS guild lines dated March 2020. Review of the facility's in-service records for October 2020 revealed no documented in-services regarding COVID-19 after the facility had a COVID 19 outbreak. 2. An observation on 10/24/2020 at 11:42 revealed DA K, with gloves already on, fill disposable serving dishes with lunch and load them on a kitchen rolling cart. With the same gloves, she pushed the cart down the 400 hall (resident hallway), out the back door, and followed the sidewalk to the outside entrance of the COVID unit which was on the 200 hall. She knocked at the door, staff from the COVID unit accepted the cart. DA K walked back down the sidewalk, entered the door at the end of the 400 hall and returned to the kitchen, still having on the same soiled gloves. She pulled a clean plate cover from the line and placed it on a plate of food prepared by another staff. In an interview on 10/24/2020 at 11:50 AM DA K was asked if she had changed gloves since returning from delivering the cart to the COVID unit. She stated she had not but should have. In an interview on 10/27/20 at 8:27 AM the ADM and ADON stated the facility has two COVID units on halls 200 and 500. They stated the two COVID units are sealed off from the rest of the facility. The only way to enter those Units is through the exit doors on the end of the halls. They stated there is a plastic barrier separating the COVID units from the non-COVID area. In an interview on 10/27/20 at 1:51 PM the ADON stated there is no reason for any staff who to go onto the COVID unit if they are not scheduled to work there. She stated there is a room, referred to as the old therapy room, that connects the COVID unit on the 500 hall to the non-COVID area. She stated the doors to each area are kept closed. In the room there are Personal Protective Equipment (PPE) supplies for staff to utilize in an emergency situation only. No staff should go through the old therapy room for any other reason. She stated if the COVID units require medications or supplies, staff must exit the building though the front door and bring items to the exit doors of the COVID Unit. An observation on 10/27/20 at 10:20 AM on the 500 hall revealed an open door at the start of the 500 hall that lead to an old therapy room. A few feet from the open door to the old therapy room was the sealed-off barrier to the 500 hall COVID unit. The old therapy room had a second open door that entered into the 500 hall COVID unit. Both doors were observed to remain open for approximately four hours. In the old therapy room there was no barrier separating the COVID unit from the non-COVID side. An observation on 10/27/20 at 11:12 AM revealed LVN B entered the old therapy room from the COVID-negative area of the facility and entered the COVID unit through the second door without donning proper PPE. The LVN did not wear an N95 respirator, a face shield, gloves, or a gown. The LVN walked down the COVID unit, spoke to a nurse, and grabbed a hand-written list from the LVN. The LVN remained on the unit for approximately 10 minutes, exited the COVID unit through the old therapy room, and entered the non-COVID area. The LVN did not sanitize her hands. She assisted a resident down hall 600 and returned to the nurse's station. She answered the phone and continued touch the counter, supplies, and pens at the nurse's station. An observation on 10/27/20 at 11:25 AM revealed CNA H walked out of the positive COVID-19 unit through the old therapy room in full PPE including a KN95 mask with earloops, not appropriate for working with residents who are positive for COVID-19. The aide came into the entrance of the non-COVID unit never doffing PPE. A resident in a wheel chair was approximately six feet away. The aide leaned and touched the hand rail and door frame of the door to the non-COVID unit. She appeared to search for another staff member for a couple minutes. After she observed the state investigator she immediately walked back into the COVID unit through the old therapy room without sanitizing areas she touched. Both doors entering each unit remained wide open. Record review of the facility's COVID-19 lab results dated 10/26/20 revealed CNA H tested positive for COVID-19. Results were returned to the facility on [DATE]. An observation on 10/27/20 at 11:52 AM revealed LVN B entered the positive COVID-19 unit through the old therapy room again without donning and doffing PPE. The LVN was observed to go down the COVID-unit hall without a gown, gloves, or a face shield. The LVN was wearing a KN95 respirator with earloops. She was on the unit for approximately 10 minutes speaking to the nurse on the COVID unit. She grabbed a hand-written note from the nurse, while not wearing gloves, and reentered the non-COVID area through the old therapy room. The LVN did not sanitize her hands upon leaving the unit or reentering the other. The LVN spoke to a couple staff and touched counter at the nurse's station and supplies. After interviewing the LVN she was observed walking down the 600 hall. In an interview on 10/27/20 at 11:59 AM, LVN B described herself as a runner. She stated she works all over the building providing assistance to residents when needed. She stated she had to go onto the COVID unit to grab a list of medications the staff needed for that unit. Staff are instructed to not cross-contaminate by crossing back and forth from the COVID unit to the COVID-negative area. She stated it was easier for her to go onto the COVID unit to grab the list of medications from the nurse than for that nurse to doff PPE and come to the negative COVID area. She stated typically the nurse on that station will hand-write a list of medications and supplies they require on the COVID unit, and it was just easier for staff in the COVID-negative area to enter and grab the list through the old therapy room. The LVN further stated she did not don and doff PPE when entering and leaving the COVID unit. She stated she only wears PPE when providing resident care on the COVID unit. She stated the hand-written list of medications in her hand was from the nurse who is currently working on the COVID unit. She stated she did not don gloves when obtaining the list in the COVID unit and she did not sanitize her hands. She added she has hand sanitizer on her cart down the hall. She further stated management staff are aware that staff utilize the old therapy room as a way to enter the COVID unit. She stated the ADON works on both units and often provides needed medications and supplies through the same room as well. She stated she has been in-serviced on COVID-19 procedures and was aware she should don PPE when entering the COVID unit. She stated she did not have to wear a face shield because she wears prescription glasses. In a follow up interview on 10/27/20 at 1:51 PM the ADON acknowledged that she did enter the old therapy room to provide items, supplies, or medications. She stated she enters the room and drops off the items at the door to the entrance of the COVID unit. Record review of the facility's COVID-19 lab results dated 10/26/20 revealed the ADON tested positive for COVID-19. Results were returned to the facility on [DATE]. Observations on 10/27/20 from 10:00 AM to 1:00 PM revealed the ADON provided care to multiple residents on the 100 hall and 600 hall, including providing medications and assisting with ADLS In an interview on 10/27/20 at 2:30 PM LVN A stated most of the time facility staff provide medications to the COVID unit through the old therapy room. She stated they will often bag the medications and drop them at the door that enters into the COVID unit. She stated at times, due to how busy everyone is, staff simply walk all the way into the COVID unit to grab the list of medications and return with those medications. She stated staff do not always don PPE when entering the COVID unit because it's just easier to come in and grab the list of medications instead of exiting the main building, walking on to the COVID unit from the appropriate entrance and donning PPE. She stated the staff are aware they should not cross-contaminate from COVID to non-COVID areas. In an interview on 10/28/20 at 11:17 AM, the AD said there was a lack of staffing in the facility. She said there were times when there might be only two or three nurses and one CNA in the building. She said, I did see folks go from the COVID hall to another hall. She said, I witnessed staff go into other areas and reported this to the ADM. She said, all I could think about was cross-contamination. She felt the facility could do better with their screening practices and staff not going between COVID-positive and COVID-negative areas of the building. In an interview on 10/29/20 at 1:20 PM the Director of Nursing (DON) stated no staff should ever cross-contaminate the facility by walking into the COVID unit to provide medications or supplies and return to the non-COVID area regardless if they don or doff PPE. Staff are trained on COVID-19 infection control practices and are aware staff are dedicated to specific cohort areas. Staff must provide medications and supplies to the COVID unit at the proper unit entrance, at the exit door of the COVID halls. Staff who do not work on the COVID unit should never enter the COVID wing. She added you run the risk of cross-contaminating a communicable disease. 3. In an interview on 10/27/20 at 8:27 AM the ADM stated specific staff are assigned to work with each cohort. Staff are only assigned to work with the positive COVID-19 residents, negative COVID-19 residents, or residents on quarantine. She stated the facility utilizes staff from sister facilities to help and work with the COVID units when needed. In an interview on 10/27/20 at 1:51 PM the ADON stated the facility has dedicated staff for each COVID-19 unit. She stated staff who work on the COVID unit never work in the non-COVID area. She stated the facility utilizes other sister-facility staff to work specifically the COVID unit when they are short staffed. Those additional staff from the sister facility only work on the COVID units and do not work in any other hall. Observation on 10/19/2020 at 5:18pm revealed ADON working on 500 Hall COVID unit as the nurse. In an interview on 10/19/2020 at 5:20 PM ADON stated she was working the COVID unit with one CNA, she had arrived on the unit around 3:00 that day. There were eleven residents on the 500 Hall COVID unit on this day. Observation on 10/21/2020 at 1:20pm revealed ADON working as the charge nurse in the cold area of the building. In an interview on 10/27/20 at 11:59 AM LVN B stated she worked on the COVID unit the previous day. She stated she provided care to residents while on the COVID unit and wore her PPE. She stated the ADON works on both units and often provides needed medications and supplies through the same room. In an interview on 10/29/20 at 1:20 PM the DON stated staff are trained on COVID-19 infection control practices and are aware staff are dedicated to specific cohort areas. She stated she was informed staffing needs on the COVID unit are met by utilizing sister facilities to provide staff for the COVID units only. She stated it was her expectation that staff are fully dedicated to only one cohort at all times. 4. In an interview on 10/27/20 at 8:27 AM the ADM stated facility staff conduct infection control rounds as needed. They further stated high touch areas such as hand rails, door handles, counters, phones are disinfected every two hours to ensure proper sanitation. Observations throughout the investigation on 10/27/20 through 10/28/20 from 8:00 AM to 4:00 PM revealed no staff disinfected high-touch surface areas outside of resident rooms such as handrails, door knobs, telephones, and with one exception, counter tops. The DON was observed wiping down much of the nurse's station counter on 10/28/20. Observations of the 500 hall old therapy room revealed staff entering and exiting the COVID unit without disinfecting any areas. Residents were observed in and around the 500 hall area. Uninterrupted observations on 10/27/20 from 10:00 AM to 1:00 PM, from the nurse's station with a clear view all non-COVID halls, revealed no staff disinfected high-touch surface areas outside of resident rooms such as handrails, door knobs, telephones, and counter tops. Observations of the 500 hall old therapy room revealed staff entering and exiting the COVID unit without disinfecting any areas. Multiple residents were observed touching hand rails and the nurses station counter. Uninterrupted observations on 10/28/20 from 12:30 to 3:00 PM, from the nurse's station with a clear view all non-COVID halls, revealed no staff disinfected high-touch surface areas outside of resident rooms such as handrails, door knobs, telephones, and, with one exception, counter tops. Further observations revealed HK staff only clean the interior of resident's rooms. A floor tech swept the floors in the main lobby. Multiple residents were observed touching hand rails and the nurses station counter. Observation on 10/28/2020 at 2:00pm, revealed a resident sitting in her wheelchair, in the common area around the center nurses station. She stopped a staff member and told them I am ready to leave. The staff member turned the wheelchair toward the resident's hall and told her she could return to her room. The resident then used the hand rails on the hall to help propel herself toward her room. In an interview on 10/28/20 at 3:19 PM HK N, HK O, HK P, and HK Q all stated they only clean and sanitize the inside of the residents' rooms. They stated they only work on the non-COVID side and clean each room once a day. They stated they have never sanitized high-touch surfaces such as hand rails, doorknobs, telephones or anything outside of the resident rooms. They stated there is no documentation or log to reflect work done in the facility. They believed a floor tech is responsible for cleaning areas outside of resident rooms. In an interview on 10/28/20 at 3:50 PM the FT stated he is only responsible for cleaning the floors of the facility including sweeping, mopping, and waxing, if needed, once a day. He stated there is no log where he would document his work for the day. When asked if he ever cleans the handrails or high-touch surfaces, he stated he will wipe down hand rails once a day only. In an interview on 10/29/20 at 1:30 PM the ADM stated the FT is responsible for cleaning all high-touch surfaces every two hours. She stated she created a log for them to document what task they have completed. She stated she had not reviewed the log but was pretty sure HK staff and FT were aware of the log. She stated staff should disinfect high-touch surfaces to prevent the spread of infection. The facility could not provide Sanitation logs for HK staff and the FT by the time of exit. 5. In an observation on the 200 hall on 10/27/20 at 2:26 PM, a box was seen containing several boxes labeled KN95 High Efficiency Respirator (Non-Medical). The front of each box stated 20 pcs/box and Heavy-Duty Earloop. The manufacturer identified on the box was Guangzhou Medical Supplies Store Medical Technology Co., LTD. There was no indication on the boxes that they were approved or rated by the National Institute for Occupational Safety and Health (NIOSH). The boxes were located in an area just inside the outside exit door that was separated from the rest of the 200 hall by sheets of plastic hung from the ceiling. The area contained a clipboard used to document the screening process before allowing admission to the 200 hall which was housing residents who had tested positive for COVID-19. The area also included gowns and hand sanitizer. LVN brought gloves and goggles to the area when asked if they were available. In additional observations on the 200 hall on 10/27/20 at 2:26 PM, LVN C and CNA G were observed wearing the KN95 respirators with earloops in addition to their gowns, gloves, and face shields while entering resident rooms on the 200 hall. Both staff practiced proper hand hygiene in between resident rooms. During the observations, both staff were seen entering three different resident rooms and interacting with the residents to different degrees. The observed interactions with the residents did not include medical care or interventions but did involve both staff being within six feet of residents and at times making physical contact to help with ambulation or moving a wheelchair. In interviews on 10/27/20 at 2:37 PM, LVN C and CNA G said that with the exception of therapists who only work with COVID-positive residents, no one else comes back on that unit. An observation on 10/27/20 at 2:15 PM on the COVID unit, 500 hall, revealed one staff LVN A worked the COVID unit. The nurse wore a KN95 respirator with earloops while providing care to residents. She was observed going into a resident's room, to physically help the resident back on her bed. The nurse touched the residents upper body and grabbed her hips to assist in sliding the resident back on to her bed. In an interview on 10/28/20 at 10:15 AM, the DON said that nobody uses the KN95 respirators with earloops. When told that the KN95 respirators were observed on the 200 hall, she said that facility staff do not use them. She further stated a KN95 mask was not acceptable to wear on COVID unit. An observation on 10/28/20 at 11:17 AM, a box of KN95 respirators with earloops was observed in an administrative office near the front entrance of the facility. In an observation on 10/29/20 at 2:03 PM, the ADM was observed in the facility conference room wearing a KN95 mask with ear loops. A review of the U. S. FDA website on 11/04/20 revealed that the FDA has concluded, based on the totality of scientific evidence available, that certain imported respirators that are not NIOSH-approved are appropriate to protect the public health or safety. In a document titled Authorized Imported, Non-NIOSH Approved Respirators Manufactured in China (Updated: October 15, 2020), KN95 respirators made by the Guangzhou Medical Supplies Store Medical Technology Co., LTD. were not listed as authorized. 6. In an interview on 10/27/20 at 8:27 AM the ADM and ADON stated the dietary department conduct all their normal disinfection check list including checking the sanitation level of the dishwasher at every meal. They stated the dishwasher is a chemical dishwasher for all regular dishes. Observations on 10/27/20 at 11:20 AM revealed residents on the COVID unit received meals on disposable platters, however, the meals were served on the platters with regular non-disposable utensils. Residents who resided in the rest of the facility received meals on non-disposable plates and were provided regular silverware. An Observation on 10/27/2020 at 11:50 revealed a cart, in the kitchen, in front of the hand washing sink, full of dirty dishes. There were no paper towels available at that hand washing sink. The other hand washing sink, near the dishwashing area had no paper towels either. An observation on 10/27/2020 at 12:02 PM revealed DA Z attempt to check the temperature of the water in the dishwasher. There were no test strips in the box so she requested additional strips from DM and was told they were out of strips. In an interview on 10/27/2020 at 12:02 PM DA K stated the dishwasher chemicals were checked twice per day. She stated there were no paper towels in the dispenser because the ones ordered were too large and would not fit. The correct size had been ordered. An observation on 10/27/2020 at 12:04 PM revealed the temperature log for the dishwasher had an entry on 10/27/2020 with DA K's initials In an interview on 10/27/2020 at 12:04 PM DA K confirmed her initials on the log. In an interview on 10/27/2020 at 12: 09 PM DM stated she was not aware the facility was out of test strips for the dishwasher. In an interview on 10/27/2020 at 12:28 PM DA K stated the last time she had test strips to check the chemical sanitizing of the dishwasher was on her shift last Saturday on 10/24/2020. (In a previous interview DA K stated she had logged temperatures that morning) In an interview on 10/28/20 at 10:55 AM DA K stated she first realized the facility ran out of test strips on Saturday night 10/24/20. She used the last one that was available. She stated dietary staff are to check the dishwasher sanitation three times a day at every meal. She stated she did not check the dishwasher sanitation level on the morning of 10/27/20 because the facility had not replaced the sanitation strips. She reviewed the sanitation log for the dishwasher and stated another staff signed her name for the morning sanitation on 10/27/20. She stated there was no possible way to test the dishwasher that morning because the test strips had not been refilled. Review of the dishwasher sanitation log revealed staff had documented appropriate sanitation levels for all three meals on 10/25/20, 10/26/20, and 10/27/20. Further review reflected dishwasher DA K's initials were signed in on Tuesday 10/27/20, however, on further inspection, the initials did not match any previous initials by the dishwasher. In an interview on 10/28/20 at 11:45 AM DA L stated she initialed the log sheet for the dishwasher because the staff often forget to do it. When asked how she knew if the sanitation level was checked on the dishwasher, she stated she didn't know but she personally checked it on 10/25/20 through 10/27/20. She stated she didn't initial her name because it's not her job. She further stated she was not aware the facility ran out of test strips. She stated she did check the sanitation levels for the dishwasher. When asked how, she stated, I just did and signed another staff's name. She stated test strips were ordered and arrived on 10/27/20 at 4:00 PM for the dinner sanitation schedule. She could not answer how the sanitation for the dishwasher was checked prior to meal service when the facility ran out of test strips. In an interview on 10/28/20 at 1:00 PM the DM stated the dishwashers are trained to check dishwashing sanitation once per meal at breakfast, lunch, dinner. She is responsible for monitoring the dishwasher sanitation log but has not checked it often recently. She was informed the kitchen ran out of test strips the day before on 10/27/20. She stated the dishwasher sanitation level was not checked at breakfast and lunch on 10/27/20, however, the test strips arrived for the evening meal. She stated there is no reason the log should have any documentation for the meals missed. She was only aware the strips were gone for the two meals and was not informed staff ran out of test strips Saturday night on 10/24/20. She stated the DA L should never document staff's initials on the log especially when she does not check the dishwasher sanitation level. The DM further stated she was unaware of any facility policies regarding kitchen sanitation. She stated the facility continued to use regular non-disposable dishes and silverware even though the dietary staff were unable to check the dishwasher sanitation level. She asked the investigator if she should have done something different with the dishes. In an interview on 10/29/20 at 1:30 PM the ADM stated she had a book of polices the investigator could review. Upon further inspection no dietary polices were found. The ADM stated she was sure corporate had polices regarding the Dietary department and she would reach out to them. The facility did not provide corporate policies regarding kitchen sanitation by the time of exit. Review of the facilities CMS form 672 (resident census and condition) reflected three residents who received [DEVICE] feedings. 7. Review of the facility's provided COVID-19 documents revealed no specific COVID-19 infection control plan. Further review reflected the only documentation provided was from CMS guild lines dated March 2020. In an interview on 10/29/20 at 1:20 PM the DON stated she has been in the facility for only three weeks and that is the only COVID-19 information she has available. She stated the ADM would be the only person who might have a COVID-19 policy somewhere In an interview on 10/29/20 at 1:30 PM the ADM stated she had a book of polices the investigator could review. Upon further inspection COVID-19 polices were not found. The ADM asked if the CMS guidance, dated March 2020 would suffice. In an interview on 10/29/20 at 1:50 PM the DON stated going forward she will take the COVID-19 policy from her previous employment, update it with the current facility information, and implement it at the current facility. She stated Remove the facility should have COVID-19 infection control plan to ensure proper infection control procedures are followed. Review of the facility's in-service records for October 2020 revealed no documented in-services regarding COVID-19 after the facility had a COVID 19 outbreak. In an interview on 10/25/2020 at 3:00 PM DON could not find inservices for October and stated she hadn't personally provided any. In an interview on 10/29/20 at 1:20 PM the DON stated five additional residents tested positive for COVID-19 on the most recent test, dated 10/26/20. All five residents resided on the 600 hall. She stated of the three staff test results received, three additional staff tested positive for COVID-19 including the ADON, CNA H, and LVN D. Review of the facilities lab results for COVID-19 reflected 35 residents had tested positive for COVID-19 in October 2020. Further review reflected the facility had five resident deaths related to COVID-19. The ADM and DON were notified of an IJ situation was identified on 10/29/20 at 2:10 PM The first POR was submitted 10/29/2020 at 5:04 PM and was not accepted. T (TRUNCATED)

Based on interview and record review, it was determined the facility failed to implement its written policies and procedures that prohibit abuse of residents one (Resident #1) of twelve residents reviewed for neglect. 1. CNA H failed to properly transfer Resident #1 to the restroom. CNA H transferred Resident #1 without a sit/stand lift and without a second staff as required. 2. CNA H failed to provide resident with proper supervision while toileting. Resident #1 was a high fall risk and confused when CNA H left the resident unsupervised on the commode. Resident #1 fell from the commode and was transported to the hospital where he was diagnosed with [REDACTED]. Resident #1 was readmitted with severe pain and died approximately 2 days later. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to still in-servicing staff and monitoring the implementation of the Plan of Removal. These failures could affect the facility's nineteen residents in the facility, who required assistance with transfers and toileting by placing them at risk for falling, injuries, pain and stress on their well-being and causing other serious mental/physical harm and/or death. Findings included: Review of Resident #1's Face Sheet, received [DATE], revealed Resident #1 was a [AGE] years old admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan, dated [DATE], revealed Resident #1 was cognitively impaired with short and long term memory problems. Resident #1 had an impaired ability to understand others and make daily decisions. Resident #1 was high risk for falls requiring a 2 person assist with transfers with use of a mechanical lift. Resident #1 required 2 person assist with toileting and with activities of daily living. Care Plan revised on [DATE] revealed interventions of bed/chair alarm to alert staff " resident rising unassisted, " and " low bed and mat on floor at all times in bed. " Review of Resident #1's Fall Risk Assessment, dated [DATE], revealed Resident #1 received a score of 18 indicating resident is high risk for falls. Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained a fall without injury [DATE]." Resident #1 wheeled himself down the administrative wing and fell out of his wheelchair. No injuries noted on assessment. " The section titled "medical risk factors" had the following risk factors checked: a history of falls. Section of report noting resident ' s current mental status was left blank. Post action interventions taken following the fall were a wander guard was placed on Resident #1 ' s right wrist to alert staff when Resident #1 was near an exit. Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained a fall without injury on [DATE]. " Resident was attempting to use the restroom without assist and hit bottom on the floor." The section titled "medical risk factor" was left blank. Section titled "mental status" was blank. The report indicated there was no post action interventions following Resident #1's fall. Review of Resident #1's MDS, dated [DATE], revealed Resident #1 was severely cognitively impaired. Resident #1 was total dependenece, full staff performance, required 2 person physical assist for transfers and toileting. Review of Resident #1's PT Evaluation and Plan of Treatment, dated [DATE], revealed "Patient needs max assist during transfers with poor standing balance." Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained a fall with injury on [DATE]. " Resident tried to get up from his wheelchair in his room and fell . He hit his forehead on the wood floor and hit his left elbow on the floor. " The section titled "medical risk factors" had the following risk factors checked: fall history, inability, confusion and disorientation. The section titled "mental status" revealed Resident #1 was confused. Post action interventions reflected Resident #1 was to be kept near nurse's station to supervise from future falls. Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained an unwitnessed fall in the bathroom on [DATE]. Resident #1 reported he fell from the commode. Incident and accident report did not note any additional information. Review of Resident #1's nurses notes revealed the following: [DATE] - 7:10AM "Observed resident in floor in bathroom. Resident continues to state he fell . Assisted into w/c X3 staff members. Abrasion noted to forehead measuring approximately 5X7 (measurement not noted). Abrasion to top of head with small laceration. Abrasion to top of head measuring 1.5X 3.2, laceration measuring approximately 1.5 X 1(method of measurement not noted). Skin tear to left elbow noted. All areas cleaned with NS applied. Multiple bruising noted to extremities...... Resident complained of head hurting. Pupils equal. Resident alert and able to follow directions but is confused per normal self. Assisted resident into recliner X 2 staff members. Alarm in place and working neuro checks started. 07:20 DON notified 07:30AM PA notified. 7:40AM RP notified. [MEDICATION NAME] ,[DATE] administered at 8:00AM due to complaints of pain." 8:30AM - Resident up in recliner eating breakfast. No complaints of pain at this time. 10:10AM - "Resident up in recliner in room. BP at this ,[DATE].54{pulse rate}. Set resident up at 90 degree angle and rechecked BP. ,[DATE].57 {pulse rate}. Assisted resident to bed x2 staff members. Laid head down with feet up. BP then ,[DATE].55.{pulse rate} Resident complained of dizziness and pain to head. Lethargic and slurred speech noted. Notified supervisor. N/O {new order} send resident to local hospital for evaluation and notified at 10:25AM. Ambulance service arrived at 10:35AM. Resident left facility via stretcher 2 person emergency transport personnel at 10:45AM." Review of Interdisciplinary Resident Screen for Resident #1, dated [DATE] revealed the following: "pt sustained a fall this morning while attempting to stand up from toilet. Pt his(sic) head and was found by staff (nursing) lying on the floor. Therapist will speak to maintenance to lower sear (sic) of wheelchair to prevent falling forward will also discuss safety with nursing staff - i.e. pt should not be left unattended while using the bathroom." Interview with LVN E on [DATE] at 9:05 AM revealed when Resident #1 went to the restroom you usually had to stay with Resident #1 depending on the day. LVN E stated some days Resident #1 was very compliant and other day's Resident #1 was not compliant with care. Interview with four CNAs on [DATE] (CNA I at 10:48AM, CNA J at 11:05AM, CNA K at 11:10AM, CNA L at 11:45AM, and CNA M at 2:35PM) revealed Resident #1 was very confused. Resident #1 was not stable enough to sit on the commode unsupervised. Resident #1 required supervision while toileting. Resident #1 would often try to stand up without staff assistance. Interview with CNAs on [DATE] (CNA N at 3:00PM and CNA O at 3:10PM) on [DATE] revealed when transferring Resident #1 you always had to use the stand-up lift. Staff had to stay with Resident #1 in the restroom because Resident #1 would fall. Interview with CNA H on [DATE] at 11:50AM revealed the morning of [DATE] she got Resident #1 out of bed, dressed and in his wheelchair. CNA H explained CNA G helped him/her get Resident #1 up from bed. CNA H explained the fall occurred before 7:00AM because it was before breakfast, but was unsure of the exact time. CNA H explained Resident #1 was sitting in his/her wheelchair by the bathroom door. She had turned around to make the bed and that is when Resident #1 started to stand up to go to the bathroom. She took Resident #1 to the bathroom, pulled down his pants and sat Resident #1 on the toilet. CNA H stated she did not use the stand-up lift to put Resident #1 on the toilet. CNA H stated she left the room to find the stand-up lift on the hall without success. CNA H went to find the stand-up lift and saw Resident #1's call light on. CNA H stated when she went into the room she found Resident #1 on the bathroom floor. CNA H stated she asked Resident #1 if he was okay and he said "get me up." CNA H got the nurse and then they lifted Resident #1 off the floor. CNA H stated that normally when she assisted Resident #1 to the bathroom she would stand by the bathroom door to give Resident #1 his privacy. CNA H stated she was gone less than a minute to get the stand-up lift when Resident #1 fell . Interview with LVN C on [DATE] at 8:45AM revealed between 6:15AM - 6:30AM on [DATE] CNA H found Resident #1 on the bathroom floor. LVN C stated she was called to the bathroom by CNA H. LVN C was told by CNA H that Resident #1 had been transferred to the bathroom using the stand-up lift and placed on the commode. CNA H then left the bathroom taking the stand-up lift because CNA H had to assist another resident. LVN C stated when CNA H returned to assist Resident #1 off of the commode she found Resident #1 on the floor. LVN C stated she completed an assessment on Resident #1. Resident #1 had an abrasion to his forehead; Resident #1 had no complaints of pain. LVN C explained it then took 3 staff to assist Resident #1 off of the floor and back into his wheelchair. LVN C stated she continued to monitor Resident #1, his vital signs and neuro checks were good and Resident #1 ate all of his breakfast. LVN C explained Resident #1 shared a suite with his family member who is also a resident. The suites consist of 2 separate bedrooms, small living area and a bathroom. LVN C stated Resident #1's family member was alert and oriented. LVN C explained later in the morning Resident #1 began to complain that he was feeling dizzy and complaining of pain. At this time she took his blood pressure and noticed it had dropped. Resident #1 was then sent to the hospital. LVN C stated Resident #1 returned to the facility with a fractured C1 and C2 cervical. LVN C explained Resident #1 had a [DIAGNOSES REDACTED].#1 was confused and could be combative at times. Interview with Family Member, also Resident #1's roommate on [DATE] at 10:50AM revealed the morning of [DATE] he/she did not know Resident #1 was in the bathroom. Family Member stated he/she heard Resident #1 yelling. It sounded very muffled. He/she pressed the call light for help. Family Member explained LVN C came into the room and did an assessment. Family Member stated he/she figured out that Resident #1 had fallen. He/she heard LVN C asking Resident #1 questions. Family Member stated that he/she found out later that an aide had left Resident #1 on the commode without the stand-up lift. Family Member explained normally an aide would stay in the bathroom with Resident #1 or leave the stand-up lift in the restroom so he would not get up. After the fall Resident #1 immediately complained of pain. Family Member stated the aides got Resident #1 off the floor and laid him in bed. Later Resident #1 was transported to the hospital. First he was sent to the local hospital then transferred to another hospital in a different city. Resident #1 came back to the facility later that night about 1:00AM. Family Member stated he/she spoke with additional family members who were with Resident #1 at the hospital and they agreed not to do surgery. Family Member stated Resident #1 would not have wanted to live the rest of his life paralyzed. When the Resident #1 returned to the facility he/she had never seen him in so much pain, nothing they (facility nurses) gave him worked for the pain. Family Member stated the next day a care plan meeting was held with family members and facility staff and it was decided to get hospice services for Resident #1. He/she was told hospice could offer something different for Resident #1's pain than the facility could. Resident #1 was in so much pain that he/she did not think Resident #1 recognized Family Member. Family Member stated Resident #1 would not wear the neck brace and would throw it and did not want to take the medication. Family Member stated he/she woke up Saturday and the nurse stated Resident #1 had passed away in his sleep. Follow-up interview with LVN C on [DATE] at 11:30AM revealed Resident #1 complained of pain around 7:00AM following the fall. At that time she administered [MEDICATION NAME] to Resident #1. Resident #1 was transported to the hospital at around 10:00AM. LVN C stated Resident #1 went to the hospital because Resident #1 became lethargic. LVN C stated she would not have expected the CNA H to stay in the restroom with Resident #1 the entire time. LVN C stated the CNA H should have left the stand-up lift in the restroom. If CNA H would have left the lift Resident #1 would not have gotten up. LVN C stated it was a mistake on the part of CNA H and a lesson learned. Interview with CNA G on [DATE] at 8:48 AM revealed she assisted CNA H in getting Resident #1 out of bed on [DATE]. CNA G stated they both sat Resident #1 on the commode. CNA G stated she then left the room and CNA H was still with Resident #1. CNA H stated she went to the dining room to pass trays for lunch and approximately ,[DATE] minutes later she was told that Resident #1 had fallen. CNA G stated Resident #1 was a fall risk. Follow-up interview with CNA G on [DATE] at 2:53PM revealed CNA G was asked again to explain what occurred the morning that Resident #1 was found in the restroom. CNA G explained she was passing by Resident #1's room and saw Resident #1 standing up from his wheelchair. CNA G stated CNA H was in the room, so CNA G informed CNA H Resident #1 was attempting to stand-up and asked CNA H if she needed help. CNA G stated CNA H told CNA G that she did not need any assistance. CNA G then left the room to go pass trays in the dining room. Follow-up interview with LVN C on [DATE] at 12:05PM revealed LVN C was asked to explain exactly what CNA H told her occurred regarding Resident #1's fall. LVN H explained CNA H told her that she used the stand-up lift to put Resident #1 on the toilet. She then left Resident #1 in the bathroom, taking the stand-up lift with her because she had to use the lift on another Resident #1. When she came back Resident #1 was on the floor. Review of Resident #1's hospital records, dated [DATE], revealed Resident #1 was admitted with abrasion to top of head and forehead. Resident #1 complained of throbbing pain in head and pain level 5 out of 10. Resident #1 was transferred to hospital via helicopter with a [DIAGNOSES REDACTED]. Review of hospital Discharge Instructions for Resident #1, dated [DATE], revealed the Resident #1 received a [DIAGNOSES REDACTED]. Discharge paperwork states "Family comfortable with risk and prefers pt be discharged back to the facility." Special Notes revealed the following: "Pt's spine fractures were found to be unstable, but of undetermined age - general information provided on stable fractures (because we don't have premade discharged instructions for unstable fractures). Extensive conversation between trauma surgery and family and patient would have preferred quality of life without surgery and understand and accept risk of cord injury and potential [MEDICAL CONDITION] (inability to move all extremities) and potential death. Don't hesitate to return to the ER for any concerning symptom development. Please discuss closely with pcp (primary care physician) - pt likely should be placed on hospice with DNR given expressed wishes at this times." Review of nurse's notes for Resident #1, dated [DATE], revealed 1:30AM - Resident #1 arrived via ambulance with C1 & C2 fracture present. "Family notified by hospital staff. Family refused treatment at the hospital for him. N/O {new order}for [MEDICATION NAME] 50mg 1 tab q8 {ever 8 hours} hours PRN. Takes [MEDICATION NAME] ,[DATE] 1 tab PO for pain. Resident #1 lying flat in bed. Towel around neck to help support neck injury. Maintain c spine during all transfers/movements. Multiple bruising present. Abrasion to head. Skin tear to left elbow. Bed in lowest position. Floor mat in place. Call light within reach. Will continue to monitor." 5:30AM - Resident being combative. Signs and symptoms of pain. Refusing medication. Received ABH gel ([MEDICATION NAME] topical gel applied to skin) at 5:00AM will continue to monitor. [DATE] - 6:15AM resident has agitation attempting to get out of bed. Resident combative when encouraged to lie down. Resident refusing to take any medications PRN [MEDICATION NAME] injection ([MEDICATION NAME] is an antipsychotic used to treat dementia) administered at 6:30AM. Safety mat and alarm in place. 7:52AM - Signs and symptom of pain and discomfort. Resident yelling out. Resident noncompliant. Administered PRN ABH gel at 8:00AM. 9:00AM - Resident refused medication. Attempt to administer [MEDICATION NAME]. PA stated will order [MEDICATION NAME]. Aide continues to be at bedside. 10:30AM - ADON (assistant director of nursing) and aide at bedside. Signs and symptoms of pain and discomfort. Continues to be combative. 12:00PM - Resident continues to be agitated. Rejecting any type of care. 12:30PM - Family at bedside. Resident continues to be agitated. 1:35PM - [MEDICATION NAME] ([MEDICATION NAME] is used to treat anxiety) 1mg (milligram) administered, [MEDICATION NAME] injection administered. Resident tolerated well. Attempted to dress resident. Resident refuses and becomes combative. 8:00PM - Resident very agitated and combative, attempting to get out of bed. ABH gel administered at 5:30PM. Not effective. Hospice nurse administered ABH gel [DATE]ml (milliliter) one time dose for severe agitation. 10:20PM - PRN [MEDICATION NAME] sulfate ([MEDICATION NAME] sulfate is used to treat moderate to severe pain) administered at 10:20PM and [MEDICATION NAME] 0.5mg for anxiety. Continues to have agitation and combative. Resident kicking wall causing abrasion to pinky toe. 10:30PM - Family at bedside entire shift agreeing to treatments and medications 11:45PM - Resident has increased confusion and agitation 1:00AM - Resident continues to be agitated and combative [DATE] - restless, PRN [MEDICATION NAME] and 1.0ml [MEDICATION NAME] administered [DATE] - resident was found unresponsive at 8:10PM. Nurse was unable to obtain vitals. Hospice nurse notified at 8:15AM. Hospice nurse pronounced death at 9:22AM. Interview with LVN D, ADON on [DATE] at 9:00AM revealed Resident #1 fell on [DATE] at approximately 7:30AM. LVN D stated that she was notified of the Resident #1's fall by LVN C who completed the assessment following Resident #1 ' s fall on [DATE]. LVN D stated CNA H put resident on the commode in the bathroom then walked away from Resident #1 for a minute and that is when Resident #1 attempted to get up from the commode without assistance and fell and broke his neck. LVN D stated Resident #1 was sent out to the hospital for further evaluation and then transferred to another hospital for further evaluation. LVN D stated Resident #1 was in the emergency room for approximately 12 hours and then sent back to the facility at around 1:00AM. Resident #1 was sent back to the facility because his family elected not to go through with surgery. When Resident #1 returned to the facility he/she was very agitated all day and night. The facility met with the family and decided to try hospice services. Review of Resident #1's Care Plan Conference Summary, dated [DATE], revealed "family feels surgery not an option due to age and health." Resident #1 has soft vertical collar, multiple attempts to put on/keep on ineffective. [DATE] n/o [MEDICATION NAME] injection, n/o [MEDICATION NAME], n/o 2 [MEDICATION NAME] PRN. Discussed possible hospice with family and ok with family for evaluation. " Review of physician follow-up visit for Resident #1, dated [DATE], revealed Resident #1 recently sustained a fall with cervical fracture. "Family opted against surgery. Pt returned here for comfort care. Very agitated and possibly in pain. Will add [MEDICATION NAME] and continue [MEDICATION NAME]. Family at bedside." Record review of Death Report for Resident#1 dated [DATE] revealed Resident #1 expired at 9:22AM on [DATE]. Review of Interdisciplinary Discharge Summary for Resident #1, dated [DATE], revealed Resident #1 was admitted to the facility for multiple injuries related to falls. Resident #1 was originally admitted to short stay rehab for falls and transferred to long term care. Treatment provided was medication administration, physical and occupational therapy, various courses for falls, behavior and elopement prevention management and ST for cognition. Progress at the facility stated "had improvements and declines over a year." Reason for discharge was Resident #1 expired. Interview with DON on [DATE] at 12:35AM revealed she was told that Resident #1 had a unwitnessed fall. DON stated she was told Resident #1 was okay and a couple of hours later she was told he was complaining of pain. When Resident #1 began complaining of pain he/she was sent out to the hospital. DON stated she was never told that Resident #1 was left unsupervised in the restroom therefore she did not follow-up with the incident or initiate any additional training with staff at the time. Interview with LVN D, ADON, on [DATE] at 10:08AM revealed she conducts incident investigations. LVN D stated she conducts investigations following resident incidents and accidents. LVN D stated she sometimes conducts investigation with the DON. She stated when she conducts a fall investigation he/she talks to the nurses and aides as to how the fall occurred. LVN D stated she did not get a timeline from CNA H as to the exact time Resident #1 was taken to the restroom and how long she was left unsupervised in the bathroom. LVN D stated from talking to CNA H following the incident she does not believe it was more than a few minutes. LVN D stated due to the fact that Resident #1 was such a high fall risk most aides would have stayed in the doorway of the bathroom with Resident #1. LVN D stated Resident #1 had multiple falls over the last several months. Review of undated Policy on Safe Patient Lifting and Repositioning received on [DATE] revealed "...5. Manuel lifting of patients is discouraged in all but exceptional medical emergencies of life threatening situations. If some degree of lifting is unavoidable, caregivers should first seek assistance from other staff members and /or employ mechanical aids whenever possible ..." Review of undated Falls-Clinical Protocol received on [DATE] revealed that as part of the initial assessment the staff will assist in identifying residents that have history of falls or have risk factor for subsequent falls. Following a resident fall, nurse should document the precipitating factors in detail as to how the fall occurred. " 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. " " 1. Based on the preceding assessment, the staff will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) " " The staff will monitor and document the individual ' s response to interventions intended to reduce falling or the consequences of falling ...If the individual continues to fall, the staff will re-evaluate the situation and consider other possible reasons for the resident ' s falling (besides those they have already been identified) and will re-evaluate the continued relevance of current interventions. " Review of undated Incident Investigation and Follow-Up received [DATE] revealed that facility policy and procedure stated " actions taken to prevent further reoccurrences of the incident. " " The investigation requires the review of the following as applicable to the incident ... What did the discovering person or witness see, hear, or smell? What was the mental, emotional, physical and cognitive status or the victim before and after the incident? What information is available about the person(s) who may have contributed to the occurrence of the incident? ... " Review of undated facility abuse and neglect policy received [DATE] revealed facility has policy and procedure for training employees on identifying and reporting allegations of neglect. Review of undated facility abuse and neglect policy received [DATE] revealed facility has policy and procedure for training employees on identifying and reporting allegations of neglect. Administrator was informed of Immediate Jeopardy on [DATE] at 1:10PM. Interview with Administrator on [DATE] at 12:00PM revealed she was writing new policies and procedure for investigating and reporting incidents and accidents. Going forward she will be reviewing every policy and procedure in the facility and making changes or developing new policies as needed. Administrator expressed understanding as to why Immediate Jeopardy was called regarding facility's failure to transfer resident and provide supervision with toileting. Interview with DON on [DATE] at 1:35PM revealed she expressed understanding of why Immediate Jeopardy was called at the facility. DON stated she understood the incident should have been investigated and reported to DADS. The Plan of Removal was accepted on [DATE]. PLAN OF REMOVAL: All nursing staff, including nurses and aides, will be in-serviced on: proper handling of Hoyer and standup lifts during transfers transferring without a lift training involving physical assessment after a fall incident reporting and proper documentation including statements and interviews Abuse and Neglect Who is appropriate to leave unattended in the bathroom Training regarding physical assessment after falls and incident reporting and proper documentation including statements and interviews were held on [DATE] at 4:00 pm and [DATE] at 11:00 am by DON and LVN F. LVN D and LVN E will be testing all nurses and CNA's during their shifts on proper handling of Hoyer and stand up lifts during transfers to be completed by noon on Thursday [DATE]. Return demonstration deadline is Thursday [DATE] at noon. Any staff member who has not completed the return demonstration check off will be removed from the schedule and not be permitted to work until they complete the return demonstration check off. The in-service on transferring without a lift will be held by Therapist A and Therapist B on Wednesday [DATE] throughout the day. Return demonstration will be required and employees will be removed from the schedule and not permitted to work until all return demonstration check-offs are completed by noon on Thursday [DATE]. LVN D will be tracking completion of all in-services. Going forward, all of these return demonstration check offs will also be required of any new hire, Nurse or CNA. In-service on Abuse and Neglect being given by LVN D throughout the day on [DATE]. DON reviewed the incident report but did not further investigate the fall. New Administrator, initiated, conducted and implemented a new procedure for incident and accident reporting and investigating on [DATE]. Including fall risk intervention/assessment, provider letter ,[DATE], physical assessment following fall, what to report immediately to DON and facility internal investigation follow up, and handout who is appropriate to leave unattended in the bathroom. Administrator conducted one-on-one training with DON, LVN D and LVN E on [DATE]. Interview with 15 direct care staff on various shifts on [DATE] (CNA G at 2:00PM, CNA L at 2:10PM, CNA N at 2:20PM, CNA M at 2:30PM, CNA O at 2:40PM, CNA R at 2:50PM, CNA S at 3:00PM, CNA T at 3:10PM, CNA U at 3:20PM, CNA V at 3:30PM, CNA W at 3:40PM, CNA X at 3:50PM, CNA Y at 4:00PM, CNA Z at 4:10PM, CNA AA at 4:20PM) on [DATE] revealed interviews were conducted with staff following facility training over sit/stand lift, Hoyer lift, proper transfers and abuse and neglect. All were able to relay and demonstrate proper techniques for stand-up lift transfers and Hoyer transfers. All were knowledgeable of individual resident care needs that require 2 person transfers and/or the use of stand-up lifts and Hoyer lifts. All were knowledgeable regarding allegations of abuse and neglect. All were knowledgeable regarding facility policy and procedure regarding identifying and reporting allegations of abuse and neglect. Review of untitled and undated list of residents provided as an attachment with the Plan of removal by DON on [DATE], revealed 19 residents were identified to require assistance with stand up lift and/or Hoyer lift. Form CMS-672, Resident Census and Conditions of Residents, signed by the signed by LVN F on [DATE], reflected the facility identified 19 residents required ambulation with assistance or assistive device.

Based on observation, interview and record review it was determined the facility failed to ensure violations are thoroughly investigated, The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) for one (Resident #1) of twelve residents reviewed for neglect. 1. LVN D, ADON failed to conduct a thorough investigation regarding Resident #1's fall. 2. Facility failed to report incident to State survey and certification agency in accordance with state law. Resident #1 fell from the commode and was transported to the hospital where he was diagnosed with [REDACTED]. Resident #1 was readmitted with severe pain and died approximately 2 days later. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to still in-servicing staff and monitoring the implementation of the Plan of Removal. These failures could affect the facility's nineteen residents in the facility, who required assistance with transfers and toileting by placing them at risk for falling, injuries, pain and stress on their well-being and causing other serious mental/physical harm and/or death. Findings included: Review of Resident #1's Face Sheet, received [DATE], revealed Resident #1 was a [AGE] years old admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan, dated [DATE], revealed Resident #1 was cognitively impaired with short and long term memory problems. Resident #1 had an impaired ability to understand others and make daily decisions. Resident #1 was high risk for falls requiring a 2 person assist with transfers with use of a mechanical lift. Resident #1 required 2 person assist with toileting and with activities of daily living. Care Plan revised on [DATE] revealed interventions of bed/chair alarm to alert staff " resident rising unassisted, " and " low bed and mat on floor at all times in bed. " Review of Resident #1's Fall Risk Assessment, dated [DATE], revealed Resident #1 received a score of 18 indicating resident is high risk for falls. Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained a fall without injury [DATE]." Resident #1 wheeled himself down the administrative wing and fell out of his wheelchair. No injuries noted on assessment. " The section titled "medical risk factors" had the following risk factors checked: a history of falls. Section of report noting resident ' s current mental status was left blank. Post action interventions taken following the fall were a wander guard was placed on Resident #1 ' s right wrist to alert staff when Resident #1 was near an exit. Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained a fall without injury on [DATE]. " Resident was attempting to use the restroom without assist and hit bottom on the floor." The section titled "medical risk factor" was left blank. Section titled "mental status" was blank. The report indicated there was no post action interventions following Resident #1's fall. Review of Resident #1's MDS, dated [DATE], revealed Resident #1 was severely cognitively impaired. Resident #1 was total dependenece, full staff performance, required 2 person physical assist for transfers and toileting. Review of Resident #1's PT Evaluation and Plan of Treatment, dated [DATE], revealed "Patient needs max assist during transfers with poor standing balance." Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained a fall with injury on [DATE]. " Resident tried to get up from his wheelchair in his room and fell . He hit his forehead on the wood floor and hit his left elbow on the floor. " The section titled "medical risk factors" had the following risk factors checked: fall history, inability, confusion and disorientation. The section titled "mental status" revealed Resident #1 was confused. Post action interventions reflected Resident #1 was to be kept near nurse's station to supervise from future falls. Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained an unwitnessed fall in the bathroom on [DATE]. Resident #1 reported he fell from the commode. Incident and accident report did not note any additional information. Review of Resident #1's nurses notes revealed the following: [DATE] - 7:10AM "Observed resident in floor in bathroom. Resident continues to state he fell . Assisted into w/c X3 staff members. Abrasion noted to forehead measuring approximately 5X7 (measurement not noted). Abrasion to top of head with small laceration. Abrasion to top of head measuring 1.5X 3.2, laceration measuring approximately 1.5 X 1(method of measurement not noted). Skin tear to left elbow noted. All areas cleaned with NS applied. Multiple bruising noted to extremities...... Resident complained of head hurting. Pupils equal. Resident alert and able to follow directions but is confused per normal self. Assisted resident into recliner X 2 staff members. Alarm in place and working neuro checks started. 07:20 DON notified 07:30AM PA notified. 7:40AM RP notified. [MEDICATION NAME] ,[DATE] administered at 8:00AM due to complaints of pain." 8:30AM - Resident up in recliner eating breakfast. No complaints of pain at this time. 10:10AM - "Resident up in recliner in room. BP at this ,[DATE].54{pulse rate}. Set resident up at 90 degree angle and rechecked BP. ,[DATE].57 {pulse rate}. Assisted resident to bed x2 staff members. Laid head down with feet up. BP then ,[DATE].55.{pulse rate} Resident complained of dizziness and pain to head. Lethargic and slurred speech noted. Notified supervisor. N/O {new order} send resident to local hospital for evaluation and notified at 10:25AM. Ambulance service arrived at 10:35AM. Resident left facility via stretcher 2 person emergency transport personnel at 10:45AM." Review of Interdisciplinary Resident Screen for Resident #1, dated [DATE] revealed the following: "pt sustained a fall this morning while attempting to stand up from toilet. Pt his(sic) head and was found by staff (nursing) lying on the floor. Therapist will speak to maintenance to lower sear (sic) of wheelchair to prevent falling forward will also discuss safety with nursing staff - i.e. pt should not be left unattended while using the bathroom." Interview with LVN E on [DATE] at 9:05 AM revealed when Resident #1 went to the restroom you usually had to stay with Resident #1 depending on the day. LVN E stated some days Resident #1 was very compliant and other day's Resident #1 was not compliant with care. Interview with four CNAs on [DATE] (CNA I at 10:48AM, CNA J at 11:05AM, CNA K at 11:10AM, CNA L at 11:45AM, and CNA M at 2:35PM) revealed Resident #1 was very confused. Resident #1 was not stable enough to sit on the commode unsupervised. Resident #1 required supervision while toileting. Resident #1 would often try to stand up without staff assistance. Interview with CNAs on [DATE] (CNA N at 3:00PM and CNA O at 3:10PM) on [DATE] revealed when transferring Resident #1 you always had to use the stand-up lift. Staff had to stay with Resident #1 in the restroom because Resident #1 would fall. Interview with CNA H on [DATE] at 11:50AM revealed the morning of [DATE] she got Resident #1 out of bed, dressed and in his wheelchair. CNA H explained CNA G helped him/her get Resident #1 up from bed. CNA H explained the fall occurred before 7:00AM because it was before breakfast, but was unsure of the exact time. CNA H explained Resident #1 was sitting in his/her wheelchair by the bathroom door. She had turned around to make the bed and that is when Resident #1 started to stand up to go to the bathroom. She took Resident #1 to the bathroom, pulled down his pants and sat Resident #1 on the toilet. CNA H stated she did not use the stand-up lift to put Resident #1 on the toilet. CNA H stated she left the room to find the stand-up lift on the hall without success. CNA H went to find the stand-up lift and saw Resident #1's call light on. CNA H stated when she went into the room she found Resident #1 on the bathroom floor. CNA H stated she asked Resident #1 if he was okay and he said "get me up." CNA H got the nurse and then they lifted Resident #1 off the floor. CNA H stated that normally when she assisted Resident #1 to the bathroom she would stand by the bathroom door to give Resident #1 his privacy. CNA H stated she was gone less than a minute to get the stand-up lift when Resident #1 fell . Interview with LVN C on [DATE] at 8:45AM revealed between 6:15AM - 6:30AM on [DATE] CNA H found Resident #1 on the bathroom floor. LVN C stated she was called to the bathroom by CNA H. LVN C was told by CNA H that Resident #1 had been transferred to the bathroom using the stand-up lift and placed on the commode. CNA H then left the bathroom taking the stand-up lift because CNA H had to assist another resident. LVN C stated when CNA H returned to assist Resident #1 off of the commode she found Resident #1 on the floor. LVN C stated she completed an assessment on Resident #1. Resident #1 had an abrasion to his forehead; Resident #1 had no complaints of pain. LVN C explained it then took 3 staff to assist Resident #1 off of the floor and back into his wheelchair. LVN C stated she continued to monitor Resident #1, his vital signs and neuro checks were good and Resident #1 ate all of his breakfast. LVN C explained Resident #1 shared a suite with his family member who is also a resident. The suites consist of 2 separate bedrooms, small living area and a bathroom. LVN C stated Resident #1's family member was alert and oriented. LVN C explained later in the morning Resident #1 began to complain that he was feeling dizzy and complaining of pain. At this time she took his blood pressure and noticed it had dropped. Resident #1 was then sent to the hospital. LVN C stated Resident #1 returned to the facility with a fractured C1 and C2 cervical. LVN C explained Resident #1 had a [DIAGNOSES REDACTED].#1 was confused and could be combative at times. Interview with Family Member, also Resident #1's roommate on [DATE] at 10:50AM revealed the morning of [DATE] he/she did not know Resident #1 was in the bathroom. Family Member stated he/she heard Resident #1 yelling. It sounded very muffled. He/she pressed the call light for help. Family Member explained LVN C came into the room and did an assessment. Family Member stated he/she figured out that Resident #1 had fallen. He/she heard LVN C asking Resident #1 questions. Family Member stated that he/she found out later that an aide had left Resident #1 on the commode without the stand-up lift. Family Member explained normally an aide would stay in the bathroom with Resident #1 or leave the stand-up lift in the restroom so he would not get up. After the fall Resident #1 immediately complained of pain. Family Member stated the aides got Resident #1 off the floor and laid him in bed. Later Resident #1 was transported to the hospital. First he was sent to the local hospital then transferred to another hospital in a different city. Resident #1 came back to the facility later that night about 1:00AM. Family Member stated he/she spoke with additional family members who were with Resident #1 at the hospital and they agreed not to do surgery. Family Member stated Resident #1 would not have wanted to live the rest of his life paralyzed. When the Resident #1 returned to the facility he/she had never seen him in so much pain, nothing they (facility nurses) gave him worked for the pain. Family Member stated the next day a care plan meeting was held with family members and facility staff and it was decided to get hospice services for Resident #1. He/she was told hospice could offer something different for Resident #1's pain than the facility could. Resident #1 was in so much pain that he/she did not think Resident #1 recognized Family Member. Family Member stated Resident #1 would not wear the neck brace and would throw it and did not want to take the medication. Family Member stated he/she woke up Saturday and the nurse stated Resident #1 had passed away in his sleep. Follow-up interview with LVN C on [DATE] at 11:30AM revealed Resident #1 complained of pain around 7:00AM following the fall. At that time she administered [MEDICATION NAME] to Resident #1. Resident #1 was transported to the hospital at around 10:00AM. LVN C stated Resident #1 went to the hospital because Resident #1 became lethargic. LVN C stated she would not have expected the CNA H to stay in the restroom with Resident #1 the entire time. LVN C stated the CNA H should have left the stand-up lift in the restroom. If CNA H would have left the lift Resident #1 would not have gotten up. LVN C stated it was a mistake on the part of CNA H and a lesson learned. Interview with CNA G on [DATE] at 8:48 AM revealed she assisted CNA H in getting Resident #1 out of bed on [DATE]. CNA G stated they both sat Resident #1 on the commode. CNA G stated she then left the room and CNA H was still with Resident #1. CNA H stated she went to the dining room to pass trays for lunch and approximately ,[DATE] minutes later she was told that Resident #1 had fallen. CNA G stated Resident #1 was a fall risk. Follow-up interview with CNA G on [DATE] at 2:53PM revealed CNA G was asked again to explain what occurred the morning that Resident #1 was found in the restroom. CNA G explained she was passing by Resident #1's room and saw Resident #1 standing up from his wheelchair. CNA G stated CNA H was in the room, so CNA G informed CNA H Resident #1 was attempting to stand-up and asked CNA H if she needed help. CNA G stated CNA H told CNA G that she did not need any assistance. CNA G then left the room to go pass trays in the dining room. Follow-up interview with LVN C on [DATE] at 12:05PM revealed LVN C was asked to explain exactly what CNA H told her occurred regarding Resident #1's fall. LVN H explained CNA H told her that she used the stand-up lift to put Resident #1 on the toilet. She then left Resident #1 in the bathroom, taking the stand-up lift with her because she had to use the lift on another Resident #1. When she came back Resident #1 was on the floor. Review of Resident #1's hospital records, dated [DATE], revealed Resident #1 was admitted with abrasion to top of head and forehead. Resident #1 complained of throbbing pain in head and pain level 5 out of 10. Resident #1 was transferred to hospital via helicopter with a [DIAGNOSES REDACTED]. Review of hospital Discharge Instructions for Resident #1, dated [DATE], revealed the Resident #1 received a [DIAGNOSES REDACTED]. Discharge paperwork states "Family comfortable with risk and prefers pt be discharged back to the facility." Special Notes revealed the following: "Pt's spine fractures were found to be unstable, but of undetermined age - general information provided on stable fractures (because we don't have premade discharged instructions for unstable fractures). Extensive conversation between trauma surgery and family and patient would have preferred quality of life without surgery and understand and accept risk of cord injury and potential [MEDICAL CONDITION] (inability to move all extremities) and potential death. Don't hesitate to return to the ER for any concerning symptom development. Please discuss closely with pcp (primary care physician) - pt likely should be placed on hospice with DNR given expressed wishes at this times." Review of nurse's notes for Resident #1, dated [DATE], revealed 1:30AM - Resident #1 arrived via ambulance with C1 & C2 fracture present. "Family notified by hospital staff. Family refused treatment at the hospital for him. N/O {new order}for [MEDICATION NAME] 50mg 1 tab q8 {ever 8 hours} hours PRN. Takes [MEDICATION NAME] ,[DATE] 1 tab PO for pain. Resident #1 lying flat in bed. Towel around neck to help support neck injury. Maintain c spine during all transfers/movements. Multiple bruising present. Abrasion to head. Skin tear to left elbow. Bed in lowest position. Floor mat in place. Call light within reach. Will continue to monitor." 5:30AM - Resident being combative. Signs and symptoms of pain. Refusing medication. Received ABH gel ([MEDICATION NAME] topical gel applied to skin) at 5:00AM will continue to monitor. [DATE] - 6:15AM resident has agitation attempting to get out of bed. Resident combative when encouraged to lie down. Resident refusing to take any medications PRN [MEDICATION NAME] injection ([MEDICATION NAME] is an antipsychotic used to treat dementia) administered at 6:30AM. Safety mat and alarm in place. 7:52AM - Signs and symptom of pain and discomfort. Resident yelling out. Resident noncompliant. Administered PRN ABH gel at 8:00AM. 9:00AM - Resident refused medication. Attempt to administer [MEDICATION NAME]. PA stated will order [MEDICATION NAME]. Aide continues to be at bedside. 10:30AM - ADON (assistant director of nursing) and aide at bedside. Signs and symptoms of pain and discomfort. Continues to be combative. 12:00PM - Resident continues to be agitated. Rejecting any type of care. 12:30PM - Family at bedside. Resident continues to be agitated. 1:35PM - [MEDICATION NAME] ([MEDICATION NAME] is used to treat anxiety) 1mg (milligram) administered, [MEDICATION NAME] injection administered. Resident tolerated well. Attempted to dress resident. Resident refuses and becomes combative. 8:00PM - Resident very agitated and combative, attempting to get out of bed. ABH gel administered at 5:30PM. Not effective. Hospice nurse administered ABH gel [DATE]ml (milliliter) one time dose for severe agitation. 10:20PM - PRN [MEDICATION NAME] sulfate ([MEDICATION NAME] sulfate is used to treat moderate to severe pain) administered at 10:20PM and [MEDICATION NAME] 0.5mg for anxiety. Continues to have agitation and combative. Resident kicking wall causing abrasion to pinky toe. 10:30PM - Family at bedside entire shift agreeing to treatments and medications 11:45PM - Resident has increased confusion and agitation 1:00AM - Resident continues to be agitated and combative [DATE] - restless, PRN [MEDICATION NAME] and 1.0ml [MEDICATION NAME] administered [DATE] - resident was found unresponsive at 8:10PM. Nurse was unable to obtain vitals. Hospice nurse notified at 8:15AM. Hospice nurse pronounced death at 9:22AM. Interview with LVN D, ADON on [DATE] at 9:00AM revealed Resident #1 fell on [DATE] at approximately 7:30AM. LVN D stated that she was notified of the Resident #1's fall by LVN C who completed the assessment following Resident #1 ' s fall on [DATE]. LVN D stated CNA H put resident on the commode in the bathroom then walked away from Resident #1 for a minute and that is when Resident #1 attempted to get up from the commode without assistance and fell and broke his neck. LVN D stated Resident #1 was sent out to the hospital for further evaluation and then transferred to another hospital for further evaluation. LVN D stated Resident #1 was in the emergency room for approximately 12 hours and then sent back to the facility at around 1:00AM. Resident #1 was sent back to the facility because his family elected not to go through with surgery. When Resident #1 returned to the facility he/she was very agitated all day and night. The facility met with the family and decided to try hospice services. Review of Resident #1's Care Plan Conference Summary, dated [DATE], revealed "family feels surgery not an option due to age and health." Resident #1 has soft vertical collar, multiple attempts to put on/keep on ineffective. [DATE] n/o [MEDICATION NAME] injection, n/o [MEDICATION NAME], n/o 2 [MEDICATION NAME] PRN. Discussed possible hospice with family and ok with family for evaluation. " Review of physician follow-up visit for Resident #1, dated [DATE], revealed Resident #1 recently sustained a fall with cervical fracture. "Family opted against surgery. Pt returned here for comfort care. Very agitated and possibly in pain. Will add [MEDICATION NAME] and continue [MEDICATION NAME]. Family at bedside." Record review of Death Report for Resident#1 dated [DATE] revealed Resident #1 expired at 9:22AM on [DATE]. Review of Interdisciplinary Discharge Summary for Resident #1, dated [DATE], revealed Resident #1 was admitted to the facility for multiple injuries related to falls. Resident #1 was originally admitted to short stay rehab for falls and transferred to long term care. Treatment provided was medication administration, physical and occupational therapy, various courses for falls, behavior and elopement prevention management and ST for cognition. Progress at the facility stated "had improvements and declines over a year." Reason for discharge was Resident #1 expired. Interview with DON on [DATE] at 12:35AM revealed she was told that Resident #1 had a unwitnessed fall. DON stated she was told Resident #1 was okay and a couple of hours later she was told he was complaining of pain. When Resident #1 began complaining of pain he/she was sent out to the hospital. DON stated she was never told that Resident #1 was left unsupervised in the restroom therefore she did not follow-up with the incident or initiate any additional training with staff at the time. Interview with LVN D, ADON, on [DATE] at 10:08AM revealed she conducts incident investigations. LVN D stated she conducts investigations following resident incidents and accidents. LVN D stated she sometimes conducts investigation with the DON. She stated when she conducts a fall investigation he/she talks to the nurses and aides as to how the fall occurred. LVN D stated she did not get a timeline from CNA H as to the exact time Resident #1 was taken to the restroom and how long she was left unsupervised in the bathroom. LVN D stated from talking to CNA H following the incident she does not believe it was more than a few minutes. LVN D stated due to the fact that Resident #1 was such a high fall risk most aides would have stayed in the doorway of the bathroom with Resident #1. LVN D stated Resident #1 had multiple falls over the last several months. Review of undated Policy on Safe Patient Lifting and Repositioning received on [DATE] revealed "...5. Manuel lifting of patients is discouraged in all but exceptional medical emergencies of life threatening situations. If some degree of lifting is unavoidable, caregivers should first seek assistance from other staff members and /or employ mechanical aids whenever possible ..." Review of undated Falls-Clinical Protocol received on [DATE] revealed that as part of the initial assessment the staff will assist in identifying residents that have history of falls or have risk factor for subsequent falls. Following a resident fall, nurse should document the precipitating factors in detail as to how the fall occurred. " 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. " " 1. Based on the preceding assessment, the staff will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) " " The staff will monitor and document the individual ' s response to interventions intended to reduce falling or the consequences of falling ...If the individual continues to fall, the staff will re-evaluate the situation and consider other possible reasons for the resident ' s falling (besides those they have already been identified) and will re-evaluate the continued relevance of current interventions. " Review of undated Incident Investigation and Follow-Up received [DATE] revealed that facility policy and procedure stated " actions taken to prevent further reoccurrences of the incident. " " The investigation requires the review of the following as applicable to the incident ... What did the discovering person or witness see, hear, or smell? What was the mental, emotional, physical and cognitive status or the victim before and after the incident? What information is available about the person(s) who may have contributed to the occurrence of the incident? ... " Review of undated facility abuse and neglect policy received [DATE] revealed facility has policy and procedure for training employees on identifying and reporting allegations of neglect. Review of undated facility abuse and neglect policy received [DATE] revealed facility has policy and procedure for training employees on identifying and reporting allegations of neglect. Administrator was informed of Immediate Jeopardy on [DATE] at 1:10PM. Interview with Administrator on [DATE] at 12:00PM revealed she was writing new policies and procedure for investigating and reporting incidents and accidents. Going forward she will be reviewing every policy and procedure in the facility and making changes or developing new policies as needed. Administrator expressed understanding as to why Immediate Jeopardy was called regarding facility's failure to transfer resident and provide supervision with toileting. Interview with DON on [DATE] at 1:35PM revealed she expressed understanding of why Immediate Jeopardy was called at the facility. DON stated she understood the incident should have been investigated and reported to DADS. The Plan of Removal was accepted on [DATE]. PLAN OF REMOVAL: All nursing staff, including nurses and aides, will be in-serviced on: proper handling of Hoyer and standup lifts during transfers transferring without a lift training involving physical assessment after a fall incident reporting and proper documentation including statements and interviews Abuse and Neglect Who is appropriate to leave unattended in the bathroom Training regarding physical assessment after falls and incident reporting and proper documentation including statements and interviews were held on [DATE] at 4:00 pm and [DATE] at 11:00 am by DON and LVN F. LVN D and LVN E will be testing all nurses and CNA's during their shifts on proper handling of Hoyer and stand up lifts during transfers to be completed by noon on Thursday [DATE]. Return demonstration deadline is Thursday [DATE] at noon. Any staff member who has not completed the return demonstration check off will be removed from the schedule and not be permitted to work until they complete the return demonstration check off. The in-service on transferring without a lift will be held by Therapist A and Therapist B on Wednesday [DATE] throughout the day. Return demonstration will be required and employees will be removed from the schedule and not permitted to work until all return demonstration check-offs are completed by noon on Thursday [DATE]. LVN D will be tracking completion of all in-services. Going forward, all of these return demonstration check offs will also be required of any new hire, Nurse or CNA. In-service on Abuse and Neglect being given by LVN D throughout the day on [DATE]. DON reviewed the incident report but did not further investigate the fall. New Administrator, initiated, conducted and implemented a new procedure for incident and accident reporting and investigating on [DATE]. Including fall risk intervention/assessment, provider letter ,[DATE], physical assessment following fall, what to report immediately to DON and facility internal investigation follow up, and handout who is appropriate to leave unattended in the bathroom. Administrator conducted one-on-one training with DON, LVN D and LVN E on [DATE]. Interview with 15 direct care staff on various shifts on [DATE] (CNA G at 2:00PM, CNA L at 2:10PM, CNA N at 2:20PM, CNA M at 2:30PM, CNA O at 2:40PM, CNA R at 2:50PM, CNA S at 3:00PM, CNA T at 3:10PM, CNA U at 3:20PM, CNA V at 3:30PM, CNA W at 3:40PM, CNA X at 3:50PM, CNA Y at 4:00PM, CNA Z at 4:10PM, CNA AA at 4:20PM) on [DATE] revealed interviews were conducted with staff following facility training over sit/stand lift, Hoyer lift, proper transfers and abuse and neglect. All were able to relay and demonstrate proper techniques for stand-up lift transfers and Hoyer transfers. All were knowledgeable of individual resident care needs that require 2 person transfers and/or the use of stand-up lifts and Hoyer lifts. All were knowledgeable regarding allegations of abuse and neglect. All were knowledgeable regarding facility policy and procedure regarding identifying and reporting allegations of abuse and neglect. Review of untitled and undated list of residents provided as an attachment with the Plan of removal by DON on [DATE], revealed 19 residents were identified to require assistance with stand up lift and/or Hoyer lift. Form CMS-672, Resident Census and Conditions of Residents, signed by the signed by LVN F on [DATE], reflected the facility identified 19 residents required ambulation with assistance or assistive device.

Based on observation, interview and record review it was determined the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. for one (Resident #1) of twelve residents reviewed for neglect. 1. LVN D, ADON failed to conduct a thorough investigation regarding Resident #1's fall. 2. Facility failed to report incident to State survey and certification agency in accordance with state law. Resident #1 fell from the commode and was transported to the hospital where he was diagnosed with [REDACTED]. Resident #1 was readmitted with severe pain and died approximately 2 days later. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to still in-servicing staff and monitoring the implementation of the Plan of Removal. These failures could affect the facility's nineteen residents in the facility, who required assistance with transfers and toileting by placing them at risk for falling, injuries, pain and stress on their well-being and causing other serious mental/physical harm and/or death. Findings included: Review of Resident #1's Face Sheet, received [DATE], revealed Resident #1 was a [AGE] years old admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan, dated [DATE], revealed Resident #1 was cognitively impaired with short and long term memory problems. Resident #1 had an impaired ability to understand others and make daily decisions. Resident #1 was high risk for falls requiring a 2 person assist with transfers with use of a mechanical lift. Resident #1 required 2 person assist with toileting and with activities of daily living. Care Plan revised on [DATE] revealed interventions of bed/chair alarm to alert staff " resident rising unassisted, " and " low bed and mat on floor at all times in bed. " Review of Resident #1's Fall Risk Assessment, dated [DATE], revealed Resident #1 received a score of 18 indicating resident is high risk for falls. Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained a fall without injury [DATE]." Resident #1 wheeled himself down the administrative wing and fell out of his wheelchair. No injuries noted on assessment. " The section titled "medical risk factors" had the following risk factors checked: a history of falls. Section of report noting resident ' s current mental status was left blank. Post action interventions taken following the fall were a wander guard was placed on Resident #1 ' s right wrist to alert staff when Resident #1 was near an exit. Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained a fall without injury on [DATE]. " Resident was attempting to use the restroom without assist and hit bottom on the floor." The section titled "medical risk factor" was left blank. Section titled "mental status" was blank. The report indicated there was no post action interventions following Resident #1's fall. Review of Resident #1's MDS, dated [DATE], revealed Resident #1 was severely cognitively impaired. Resident #1 was total dependenece, full staff performance, required 2 person physical assist for transfers and toileting. Review of Resident #1's PT Evaluation and Plan of Treatment, dated [DATE], revealed "Patient needs max assist during transfers with poor standing balance." Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained a fall with injury on [DATE]. " Resident tried to get up from his wheelchair in his room and fell . He hit his forehead on the wood floor and hit his left elbow on the floor. " The section titled "medical risk factors" had the following risk factors checked: fall history, inability, confusion and disorientation. The section titled "mental status" revealed Resident #1 was confused. Post action interventions reflected Resident #1 was to be kept near nurse's station to supervise from future falls. Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained an unwitnessed fall in the bathroom on [DATE]. Resident #1 reported he fell from the commode. Incident and accident report did not note any additional information. Review of Resident #1's nurses notes revealed the following: [DATE] - 7:10AM "Observed resident in floor in bathroom. Resident continues to state he fell . Assisted into w/c X3 staff members. Abrasion noted to forehead measuring approximately 5X7 (measurement not noted). Abrasion to top of head with small laceration. Abrasion to top of head measuring 1.5X 3.2, laceration measuring approximately 1.5 X 1(method of measurement not noted). Skin tear to left elbow noted. All areas cleaned with NS applied. Multiple bruising noted to extremities...... Resident complained of head hurting. Pupils equal. Resident alert and able to follow directions but is confused per normal self. Assisted resident into recliner X 2 staff members. Alarm in place and working neuro checks started. 07:20 DON notified 07:30AM PA notified. 7:40AM RP notified. [MEDICATION NAME] ,[DATE] administered at 8:00AM due to complaints of pain." 8:30AM - Resident up in recliner eating breakfast. No complaints of pain at this time. 10:10AM - "Resident up in recliner in room. BP at this ,[DATE].54{pulse rate}. Set resident up at 90 degree angle and rechecked BP. ,[DATE].57 {pulse rate}. Assisted resident to bed x2 staff members. Laid head down with feet up. BP then ,[DATE].55.{pulse rate} Resident complained of dizziness and pain to head. Lethargic and slurred speech noted. Notified supervisor. N/O {new order} send resident to local hospital for evaluation and notified at 10:25AM. Ambulance service arrived at 10:35AM. Resident left facility via stretcher 2 person emergency transport personnel at 10:45AM." Review of Interdisciplinary Resident Screen for Resident #1, dated [DATE] revealed the following: "pt sustained a fall this morning while attempting to stand up from toilet. Pt his(sic) head and was found by staff (nursing) lying on the floor. Therapist will speak to maintenance to lower sear (sic) of wheelchair to prevent falling forward will also discuss safety with nursing staff - i.e. pt should not be left unattended while using the bathroom." Interview with LVN E on [DATE] at 9:05 AM revealed when Resident #1 went to the restroom you usually had to stay with Resident #1 depending on the day. LVN E stated some days Resident #1 was very compliant and other day's Resident #1 was not compliant with care. Interview with four CNAs on [DATE] (CNA I at 10:48AM, CNA J at 11:05AM, CNA K at 11:10AM, CNA L at 11:45AM, and CNA M at 2:35PM) revealed Resident #1 was very confused. Resident #1 was not stable enough to sit on the commode unsupervised. Resident #1 required supervision while toileting. Resident #1 would often try to stand up without staff assistance. Interview with CNAs on [DATE] (CNA N at 3:00PM and CNA O at 3:10PM) on [DATE] revealed when transferring Resident #1 you always had to use the stand-up lift. Staff had to stay with Resident #1 in the restroom because Resident #1 would fall. Interview with CNA H on [DATE] at 11:50AM revealed the morning of [DATE] she got Resident #1 out of bed, dressed and in his wheelchair. CNA H explained CNA G helped him/her get Resident #1 up from bed. CNA H explained the fall occurred before 7:00AM because it was before breakfast, but was unsure of the exact time. CNA H explained Resident #1 was sitting in his/her wheelchair by the bathroom door. She had turned around to make the bed and that is when Resident #1 started to stand up to go to the bathroom. She took Resident #1 to the bathroom, pulled down his pants and sat Resident #1 on the toilet. CNA H stated she did not use the stand-up lift to put Resident #1 on the toilet. CNA H stated she left the room to find the stand-up lift on the hall without success. CNA H went to find the stand-up lift and saw Resident #1's call light on. CNA H stated when she went into the room she found Resident #1 on the bathroom floor. CNA H stated she asked Resident #1 if he was okay and he said "get me up." CNA H got the nurse and then they lifted Resident #1 off the floor. CNA H stated that normally when she assisted Resident #1 to the bathroom she would stand by the bathroom door to give Resident #1 his privacy. CNA H stated she was gone less than a minute to get the stand-up lift when Resident #1 fell . Interview with LVN C on [DATE] at 8:45AM revealed between 6:15AM - 6:30AM on [DATE] CNA H found Resident #1 on the bathroom floor. LVN C stated she was called to the bathroom by CNA H. LVN C was told by CNA H that Resident #1 had been transferred to the bathroom using the stand-up lift and placed on the commode. CNA H then left the bathroom taking the stand-up lift because CNA H had to assist another resident. LVN C stated when CNA H returned to assist Resident #1 off of the commode she found Resident #1 on the floor. LVN C stated she completed an assessment on Resident #1. Resident #1 had an abrasion to his forehead; Resident #1 had no complaints of pain. LVN C explained it then took 3 staff to assist Resident #1 off of the floor and back into his wheelchair. LVN C stated she continued to monitor Resident #1, his vital signs and neuro checks were good and Resident #1 ate all of his breakfast. LVN C explained Resident #1 shared a suite with his family member who is also a resident. The suites consist of 2 separate bedrooms, small living area and a bathroom. LVN C stated Resident #1's family member was alert and oriented. LVN C explained later in the morning Resident #1 began to complain that he was feeling dizzy and complaining of pain. At this time she took his blood pressure and noticed it had dropped. Resident #1 was then sent to the hospital. LVN C stated Resident #1 returned to the facility with a fractured C1 and C2 cervical. LVN C explained Resident #1 had a [DIAGNOSES REDACTED].#1 was confused and could be combative at times. Interview with Family Member, also Resident #1's roommate on [DATE] at 10:50AM revealed the morning of [DATE] he/she did not know Resident #1 was in the bathroom. Family Member stated he/she heard Resident #1 yelling. It sounded very muffled. He/she pressed the call light for help. Family Member explained LVN C came into the room and did an assessment. Family Member stated he/she figured out that Resident #1 had fallen. He/she heard LVN C asking Resident #1 questions. Family Member stated that he/she found out later that an aide had left Resident #1 on the commode without the stand-up lift. Family Member explained normally an aide would stay in the bathroom with Resident #1 or leave the stand-up lift in the restroom so he would not get up. After the fall Resident #1 immediately complained of pain. Family Member stated the aides got Resident #1 off the floor and laid him in bed. Later Resident #1 was transported to the hospital. First he was sent to the local hospital then transferred to another hospital in a different city. Resident #1 came back to the facility later that night about 1:00AM. Family Member stated he/she spoke with additional family members who were with Resident #1 at the hospital and they agreed not to do surgery. Family Member stated Resident #1 would not have wanted to live the rest of his life paralyzed. When the Resident #1 returned to the facility he/she had never seen him in so much pain, nothing they (facility nurses) gave him worked for the pain. Family Member stated the next day a care plan meeting was held with family members and facility staff and it was decided to get hospice services for Resident #1. He/she was told hospice could offer something different for Resident #1's pain than the facility could. Resident #1 was in so much pain that he/she did not think Resident #1 recognized Family Member. Family Member stated Resident #1 would not wear the neck brace and would throw it and did not want to take the medication. Family Member stated he/she woke up Saturday and the nurse stated Resident #1 had passed away in his sleep. Follow-up interview with LVN C on [DATE] at 11:30AM revealed Resident #1 complained of pain around 7:00AM following the fall. At that time she administered [MEDICATION NAME] to Resident #1. Resident #1 was transported to the hospital at around 10:00AM. LVN C stated Resident #1 went to the hospital because Resident #1 became lethargic. LVN C stated she would not have expected the CNA H to stay in the restroom with Resident #1 the entire time. LVN C stated the CNA H should have left the stand-up lift in the restroom. If CNA H would have left the lift Resident #1 would not have gotten up. LVN C stated it was a mistake on the part of CNA H and a lesson learned. Interview with CNA G on [DATE] at 8:48 AM revealed she assisted CNA H in getting Resident #1 out of bed on [DATE]. CNA G stated they both sat Resident #1 on the commode. CNA G stated she then left the room and CNA H was still with Resident #1. CNA H stated she went to the dining room to pass trays for lunch and approximately ,[DATE] minutes later she was told that Resident #1 had fallen. CNA G stated Resident #1 was a fall risk. Follow-up interview with CNA G on [DATE] at 2:53PM revealed CNA G was asked again to explain what occurred the morning that Resident #1 was found in the restroom. CNA G explained she was passing by Resident #1's room and saw Resident #1 standing up from his wheelchair. CNA G stated CNA H was in the room, so CNA G informed CNA H Resident #1 was attempting to stand-up and asked CNA H if she needed help. CNA G stated CNA H told CNA G that she did not need any assistance. CNA G then left the room to go pass trays in the dining room. Follow-up interview with LVN C on [DATE] at 12:05PM revealed LVN C was asked to explain exactly what CNA H told her occurred regarding Resident #1's fall. LVN H explained CNA H told her that she used the stand-up lift to put Resident #1 on the toilet. She then left Resident #1 in the bathroom, taking the stand-up lift with her because she had to use the lift on another Resident #1. When she came back Resident #1 was on the floor. Review of Resident #1's hospital records, dated [DATE], revealed Resident #1 was admitted with abrasion to top of head and forehead. Resident #1 complained of throbbing pain in head and pain level 5 out of 10. Resident #1 was transferred to hospital via helicopter with a [DIAGNOSES REDACTED]. Review of hospital Discharge Instructions for Resident #1, dated [DATE], revealed the Resident #1 received a [DIAGNOSES REDACTED]. Discharge paperwork states "Family comfortable with risk and prefers pt be discharged back to the facility." Special Notes revealed the following: "Pt's spine fractures were found to be unstable, but of undetermined age - general information provided on stable fractures (because we don't have premade discharged instructions for unstable fractures). Extensive conversation between trauma surgery and family and patient would have preferred quality of life without surgery and understand and accept risk of cord injury and potential [MEDICAL CONDITION] (inability to move all extremities) and potential death. Don't hesitate to return to the ER for any concerning symptom development. Please discuss closely with pcp (primary care physician) - pt likely should be placed on hospice with DNR given expressed wishes at this times." Review of nurse's notes for Resident #1, dated [DATE], revealed 1:30AM - Resident #1 arrived via ambulance with C1 & C2 fracture present. "Family notified by hospital staff. Family refused treatment at the hospital for him. N/O {new order}for [MEDICATION NAME] 50mg 1 tab q8 {ever 8 hours} hours PRN. Takes [MEDICATION NAME] ,[DATE] 1 tab PO for pain. Resident #1 lying flat in bed. Towel around neck to help support neck injury. Maintain c spine during all transfers/movements. Multiple bruising present. Abrasion to head. Skin tear to left elbow. Bed in lowest position. Floor mat in place. Call light within reach. Will continue to monitor." 5:30AM - Resident being combative. Signs and symptoms of pain. Refusing medication. Received ABH gel ([MEDICATION NAME] topical gel applied to skin) at 5:00AM will continue to monitor. [DATE] - 6:15AM resident has agitation attempting to get out of bed. Resident combative when encouraged to lie down. Resident refusing to take any medications PRN [MEDICATION NAME] injection ([MEDICATION NAME] is an antipsychotic used to treat dementia) administered at 6:30AM. Safety mat and alarm in place. 7:52AM - Signs and symptom of pain and discomfort. Resident yelling out. Resident noncompliant. Administered PRN ABH gel at 8:00AM. 9:00AM - Resident refused medication. Attempt to administer [MEDICATION NAME]. PA stated will order [MEDICATION NAME]. Aide continues to be at bedside. 10:30AM - ADON (assistant director of nursing) and aide at bedside. Signs and symptoms of pain and discomfort. Continues to be combative. 12:00PM - Resident continues to be agitated. Rejecting any type of care. 12:30PM - Family at bedside. Resident continues to be agitated. 1:35PM - [MEDICATION NAME] ([MEDICATION NAME] is used to treat anxiety) 1mg (milligram) administered, [MEDICATION NAME] injection administered. Resident tolerated well. Attempted to dress resident. Resident refuses and becomes combative. 8:00PM - Resident very agitated and combative, attempting to get out of bed. ABH gel administered at 5:30PM. Not effective. Hospice nurse administered ABH gel [DATE]ml (milliliter) one time dose for severe agitation. 10:20PM - PRN [MEDICATION NAME] sulfate ([MEDICATION NAME] sulfate is used to treat moderate to severe pain) administered at 10:20PM and [MEDICATION NAME] 0.5mg for anxiety. Continues to have agitation and combative. Resident kicking wall causing abrasion to pinky toe. 10:30PM - Family at bedside entire shift agreeing to treatments and medications 11:45PM - Resident has increased confusion and agitation 1:00AM - Resident continues to be agitated and combative [DATE] - restless, PRN [MEDICATION NAME] and 1.0ml [MEDICATION NAME] administered [DATE] - resident was found unresponsive at 8:10PM. Nurse was unable to obtain vitals. Hospice nurse notified at 8:15AM. Hospice nurse pronounced death at 9:22AM. Interview with LVN D, ADON on [DATE] at 9:00AM revealed Resident #1 fell on [DATE] at approximately 7:30AM. LVN D stated that she was notified of the Resident #1's fall by LVN C who completed the assessment following Resident #1 ' s fall on [DATE]. LVN D stated CNA H put resident on the commode in the bathroom then walked away from Resident #1 for a minute and that is when Resident #1 attempted to get up from the commode without assistance and fell and broke his neck. LVN D stated Resident #1 was sent out to the hospital for further evaluation and then transferred to another hospital for further evaluation. LVN D stated Resident #1 was in the emergency room for approximately 12 hours and then sent back to the facility at around 1:00AM. Resident #1 was sent back to the facility because his family elected not to go through with surgery. When Resident #1 returned to the facility he/she was very agitated all day and night. The facility met with the family and decided to try hospice services. Review of Resident #1's Care Plan Conference Summary, dated [DATE], revealed "family feels surgery not an option due to age and health." Resident #1 has soft vertical collar, multiple attempts to put on/keep on ineffective. [DATE] n/o [MEDICATION NAME] injection, n/o [MEDICATION NAME], n/o 2 [MEDICATION NAME] PRN. Discussed possible hospice with family and ok with family for evaluation. " Review of physician follow-up visit for Resident #1, dated [DATE], revealed Resident #1 recently sustained a fall with cervical fracture. "Family opted against surgery. Pt returned here for comfort care. Very agitated and possibly in pain. Will add [MEDICATION NAME] and continue [MEDICATION NAME]. Family at bedside." Record review of Death Report for Resident#1 dated [DATE] revealed Resident #1 expired at 9:22AM on [DATE]. Review of Interdisciplinary Discharge Summary for Resident #1, dated [DATE], revealed Resident #1 was admitted to the facility for multiple injuries related to falls. Resident #1 was originally admitted to short stay rehab for falls and transferred to long term care. Treatment provided was medication administration, physical and occupational therapy, various courses for falls, behavior and elopement prevention management and ST for cognition. Progress at the facility stated "had improvements and declines over a year." Reason for discharge was Resident #1 expired. Interview with DON on [DATE] at 12:35AM revealed she was told that Resident #1 had a unwitnessed fall. DON stated she was told Resident #1 was okay and a couple of hours later she was told he was complaining of pain. When Resident #1 began complaining of pain he/she was sent out to the hospital. DON stated she was never told that Resident #1 was left unsupervised in the restroom therefore she did not follow-up with the incident or initiate any additional training with staff at the time. Interview with LVN D, ADON, on [DATE] at 10:08AM revealed she conducts incident investigations. LVN D stated she conducts investigations following resident incidents and accidents. LVN D stated she sometimes conducts investigation with the DON. She stated when she conducts a fall investigation he/she talks to the nurses and aides as to how the fall occurred. LVN D stated she did not get a timeline from CNA H as to the exact time Resident #1 was taken to the restroom and how long she was left unsupervised in the bathroom. LVN D stated from talking to CNA H following the incident she does not believe it was more than a few minutes. LVN D stated due to the fact that Resident #1 was such a high fall risk most aides would have stayed in the doorway of the bathroom with Resident #1. LVN D stated Resident #1 had multiple falls over the last several months. Review of undated Policy on Safe Patient Lifting and Repositioning received on [DATE] revealed "...5. Manuel lifting of patients is discouraged in all but exceptional medical emergencies of life threatening situations. If some degree of lifting is unavoidable, caregivers should first seek assistance from other staff members and /or employ mechanical aids whenever possible ..." Review of undated Falls-Clinical Protocol received on [DATE] revealed that as part of the initial assessment the staff will assist in identifying residents that have history of falls or have risk factor for subsequent falls. Following a resident fall, nurse should document the precipitating factors in detail as to how the fall occurred. " 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. " " 1. Based on the preceding assessment, the staff will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) " " The staff will monitor and document the individual ' s response to interventions intended to reduce falling or the consequences of falling ...If the individual continues to fall, the staff will re-evaluate the situation and consider other possible reasons for the resident ' s falling (besides those they have already been identified) and will re-evaluate the continued relevance of current interventions. " Review of undated Incident Investigation and Follow-Up received [DATE] revealed that facility policy and procedure stated " actions taken to prevent further reoccurrences of the incident. " " The investigation requires the review of the following as applicable to the incident ... What did the discovering person or witness see, hear, or smell? What was the mental, emotional, physical and cognitive status or the victim before and after the incident? What information is available about the person(s) who may have contributed to the occurrence of the incident? ... " Review of undated facility abuse and neglect policy received [DATE] revealed facility has policy and procedure for training employees on identifying and reporting allegations of neglect. Review of undated facility abuse and neglect policy received [DATE] revealed facility has policy and procedure for training employees on identifying and reporting allegations of neglect. Administrator was informed of Immediate Jeopardy on [DATE] at 1:10PM. Interview with Administrator on [DATE] at 12:00PM revealed she was writing new policies and procedure for investigating and reporting incidents and accidents. Going forward she will be reviewing every policy and procedure in the facility and making changes or developing new policies as needed. Administrator expressed understanding as to why Immediate Jeopardy was called regarding facility's failure to transfer resident and provide supervision with toileting. Interview with DON on [DATE] at 1:35PM revealed she expressed understanding of why Immediate Jeopardy was called at the facility. DON stated she understood the incident should have been investigated and reported to DADS. The Plan of Removal was accepted on [DATE]. PLAN OF REMOVAL: All nursing staff, including nurses and aides, will be in-serviced on: proper handling of Hoyer and standup lifts during transfers transferring without a lift training involving physical assessment after a fall incident reporting and proper documentation including statements and interviews Abuse and Neglect Who is appropriate to leave unattended in the bathroom Training regarding physical assessment after falls and incident reporting and proper documentation including statements and interviews were held on [DATE] at 4:00 pm and [DATE] at 11:00 am by DON and LVN F. LVN D and LVN E will be testing all nurses and CNA's during their shifts on proper handling of Hoyer and stand up lifts during transfers to be completed by noon on Thursday [DATE]. Return demonstration deadline is Thursday [DATE] at noon. Any staff member who has not completed the return demonstration check off will be removed from the schedule and not be permitted to work until they complete the return demonstration check off. The in-service on transferring without a lift will be held by Therapist A and Therapist B on Wednesday [DATE] throughout the day. Return demonstration will be required and employees will be removed from the schedule and not permitted to work until all return demonstration check-offs are completed by noon on Thursday [DATE]. LVN D will be tracking completion of all in-services. Going forward, all of these return demonstration check offs will also be required of any new hire, Nurse or CNA. In-service on Abuse and Neglect being given by LVN D throughout the day on [DATE]. DON reviewed the incident report but did not further investigate the fall. New Administrator, initiated, conducted and implemented a new procedure for incident and accident reporting and investigating on [DATE]. Including fall risk intervention/assessment, provider letter ,[DATE], physical assessment following fall, what to report immediately to DON and facility internal investigation follow up, and handout who is appropriate to leave unattended in the bathroom. Administrator conducted one-on-one training with DON, LVN D and LVN E on [DATE]. Interview with 15 direct care staff on various shifts on [DATE] (CNA G at 2:00PM, CNA L at 2:10PM, CNA N at 2:20PM, CNA M at 2:30PM, CNA O at 2:40PM, CNA R at 2:50PM, CNA S at 3:00PM, CNA T at 3:10PM, CNA U at 3:20PM, CNA V at 3:30PM, CNA W at 3:40PM, CNA X at 3:50PM, CNA Y at 4:00PM, CNA Z at 4:10PM, CNA AA at 4:20PM) on [DATE] revealed interviews were conducted with staff following facility training over sit/stand lift, Hoyer lift, proper transfers and abuse and neglect. All were able to relay and demonstrate proper techniques for stand-up lift transfers and Hoyer transfers. All were knowledgeable of individual resident care needs that require 2 person transfers and/or the use of stand-up lifts and Hoyer lifts. All were knowledgeable regarding allegations of abuse and neglect. All were knowledgeable regarding facility policy and procedure regarding identifying and reporting allegations of abuse and neglect. Review of untitled and undated list of residents provided as an attachment with the Plan of removal by DON on [DATE], revealed 19 residents were identified to require assistance with stand up lift and/or Hoyer lift. Form CMS-672, Resident Census and Conditions of Residents, signed by the signed by LVN F on [DATE], reflected the facility identified 19 residents required ambulation with assistance or assistive device.

Based on observation, interview and record review, the facility failed to ensure the environment remained as free of accident hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of twelve residents reviewed for accident supervision. 1. CNA H failed to properly transfer Resident #1 to restroom. CNA H transferred Resident #1 without sit/stand lift and without second staff as required. 2. CNA H was aware Resident #1 was a high fall risk and had a history of [REDACTED]. Resident #1 fell from the commode and was transported to the hospital where he was diagnosed with [REDACTED]. Resident #1 was readmitted with severe pain and died approximately 2 days later. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to still in-servicing staff and monitoring the implementation of the Plan of Removal. These failures could affect the facility's nineteen residents in the facility, who required assistance with transfers and toileting by placing them at risk for falling, injuries, pain and stress on their well-being and causing other serious mental/physical harm and/or death. Findings included: Review of Resident #1's Face Sheet, received [DATE], revealed Resident #1 was a [AGE] years old admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan, dated [DATE], revealed Resident #1 was cognitively impaired with short and long term memory problems. Resident #1 had an impaired ability to understand others and make daily decisions. Resident #1 was high risk for falls requiring a 2 person assist with transfers with use of a mechanical lift. Resident #1 required 2 person assist with toileting and with activities of daily living. Care Plan revised on [DATE] revealed interventions of bed/chair alarm to alert staff " resident rising unassisted, " and " low bed and mat on floor at all times in bed. " Review of Resident #1's Fall Risk Assessment, dated [DATE], revealed Resident #1 received a score of 18 indicating resident is high risk for falls. Review of undated Incident Investigation and Follow-Up received [DATE] revealed that facility policy and procedure stated " actions taken to prevent further reoccurrences of the incident. " " The investigation requires the review of the following as applicable to the incident ... What did the discovering person or witness see, hear, or smell? What was the mental, emotional, physical and cognitive status or the victim before and after the incident? What information is available about the person(s) who may have contributed to the occurrence of the incident? ... " Review of undated facility abuse and neglect policy received [DATE] revealed facility has policy and procedure for training employees on identifying and reporting allegations of neglect. Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained a fall without injury [DATE]." Resident #1 wheeled himself down the administrative wing and fell out of his wheelchair. No injuries noted on assessment. " The section titled "medical risk factors" had the following risk factors checked: a history of falls. Section of report noting resident ' s current mental status was left blank. Post action interventions taken following the fall were a wander guard was placed on Resident #1 ' s right wrist to alert staff when Resident #1 was near an exit. Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained a fall without injury on [DATE]. " Resident was attempting to use the restroom without assist and hit bottom on the floor." The section titled "medical risk factor" was left blank. Section titled "mental status" was blank. The report indicated there was no post action interventions following Resident #1's fall. Review of Resident #1's MDS, dated [DATE], revealed Resident #1 was severely cognitively impaired. Resident #1 was total dependenece, full staff performance, required 2 person physical assist for transfers and toileting. Review of Resident #1's PT Evaluation and Plan of Treatment, dated [DATE], revealed "Patient needs max assist during transfers with poor standing balance." Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained a fall with injury on [DATE]. " Resident tried to get up from his wheelchair in his room and fell . He hit his forehead on the wood floor and hit his left elbow on the floor. " The section titled "medical risk factors" had the following risk factors checked: fall history, inability, confusion and disorientation. The section titled "mental status" revealed Resident #1 was confused. Post action interventions reflected Resident #1 was to be kept near nurse's station to supervise from future falls. Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained an unwitnessed fall in the bathroom on [DATE]. Resident #1 reported he fell from the commode. Incident and accident report did not note any additional information. Review of Resident #1's nurses notes revealed the following: [DATE] - 7:10AM "Observed resident in floor in bathroom. Resident continues to state he fell . Assisted into w/c X3 staff members. Abrasion noted to forehead measuring approximately 5X7 (measurement not noted). Abrasion to top of head with small laceration. Abrasion to top of head measuring 1.5X 3.2, laceration measuring approximately 1.5 X 1(method of measurement not noted). Skin tear to left elbow noted. All areas cleaned with NS applied. Multiple bruising noted to extremities...... Resident complained of head hurting. Pupils equal. Resident alert and able to follow directions but is confused per normal self. Assisted resident into recliner X 2 staff members. Alarm in place and working neuro checks started. 07:20 DON notified 07:30AM PA notified. 7:40AM RP notified. Norco ,[DATE] administered at 8:00AM due to complaints of pain." 8:30AM - Resident up in recliner eating breakfast. No complaints of pain at this time. 10:10AM - "Resident up in recliner in room. BP at this ,[DATE].54{pulse rate}. Set resident up at 90 degree angle and rechecked BP. ,[DATE].57 {pulse rate}. Assisted resident to bed x2 staff members. Laid head down with feet up. BP then ,[DATE].55.{pulse rate} Resident complained of dizziness and pain to head. Lethargic and slurred speech noted. Notified supervisor. N/O {new order} send resident to local hospital for evaluation and notified at 10:25AM. Ambulance service arrived at 10:35AM. Resident left facility via stretcher 2 person emergency transport personnel at 10:45AM." Review of Interdisciplinary Resident Screen for Resident #1, dated [DATE] revealed the following: "pt sustained a fall this morning while attempting to stand up from toilet. Pt his(sic) head and was found by staff (nursing) lying on the floor. Therapist will speak to maintenance to lower sear (sic) of wheelchair to prevent falling forward will also discuss safety with nursing staff - i.e. pt should not be left unattended while using the bathroom." Interview with LVN E on [DATE] at 9:05 AM revealed when Resident #1 went to the restroom you usually had to stay with Resident #1 depending on the day. LVN E stated some days Resident #1 was very compliant and other day's Resident #1 was not compliant with care. Interview with four CNAs on [DATE] (CNA I at 10:48AM, CNA J at 11:05AM, CNA K at 11:10AM, CNA L at 11:45AM, and CNA M at 2:35PM) revealed Resident #1 was very confused. Resident #1 was not stable enough to sit on the commode unsupervised. Resident #1 required supervision while toileting. Resident #1 would often try to stand up without staff assistance. Interview with CNAs on [DATE] (CNA N at 3:00PM and CNA O at 3:10PM) on [DATE] revealed when transferring Resident #1 you always had to use the stand-up lift. Staff had to stay with Resident #1 in the restroom because Resident #1 would fall. Interview with CNA H on [DATE] at 11:50AM revealed the morning of [DATE] she got Resident #1 out of bed, dressed and in his wheelchair. CNA H explained CNA G helped him/her get Resident #1 up from bed. CNA H explained the fall occurred before 7:00AM because it was before breakfast, but was unsure of the exact time. CNA H explained Resident #1 was sitting in his/her wheelchair by the bathroom door. She had turned around to make the bed and that is when Resident #1 started to stand up to go to the bathroom. She took Resident #1 to the bathroom, pulled down his pants and sat Resident #1 on the toilet. CNA H stated she did not use the stand-up lift to put Resident #1 on the toilet. CNA H stated she left the room to find the stand-up lift on the hall without success. CNA H went to find the stand-up lift and saw Resident #1's call light on. CNA H stated when she went into the room she found Resident #1 on the bathroom floor. CNA H stated she asked Resident #1 if he was okay and he said "get me up." CNA H got the nurse and then they lifted Resident #1 off the floor. CNA H stated that normally when she assisted Resident #1 to the bathroom she would stand by the bathroom door to give Resident #1 his privacy. CNA H stated she was gone less than a minute to get the stand-up lift when Resident #1 fell . Interview with LVN C on [DATE] at 8:45AM revealed between 6:15AM - 6:30AM on [DATE] CNA H found Resident #1 on the bathroom floor. LVN C stated she was called to the bathroom by CNA H. LVN C was told by CNA H that Resident #1 had been transferred to the bathroom using the stand-up lift and placed on the commode. CNA H then left the bathroom taking the stand-up lift because CNA H had to assist another resident. LVN C stated when CNA H returned to assist Resident #1 off of the commode she found Resident #1 on the floor. LVN C stated she completed an assessment on Resident #1. Resident #1 had an abrasion to his forehead; Resident #1 had no complaints of pain. LVN C explained it then took 3 staff to assist Resident #1 off of the floor and back into his wheelchair. LVN C stated she continued to monitor Resident #1, his vital signs and neuro checks were good and Resident #1 ate all of his breakfast. LVN C explained Resident #1 shared a suite with his family member who is also a resident. The suites consist of 2 separate bedrooms, small living area and a bathroom. LVN C stated Resident #1's family member was alert and oriented. LVN C explained later in the morning Resident #1 began to complain that he was feeling dizzy and complaining of pain. At this time she took his blood pressure and noticed it had dropped. Resident #1 was then sent to the hospital. LVN C stated Resident #1 returned to the facility with a fractured C1 and C2 cervical. LVN C explained Resident #1 had a [DIAGNOSES REDACTED].#1 was confused and could be combative at times. Interview with Family Member, also Resident #1's roommate on [DATE] at 10:50AM revealed the morning of [DATE] he/she did not know Resident #1 was in the bathroom. Family Member stated he/she heard Resident #1 yelling. It sounded very muffled. He/she pressed the call light for help. Family Member explained LVN C came into the room and did an assessment. Family Member stated he/she figured out that Resident #1 had fallen. He/she heard LVN C asking Resident #1 questions. Family Member stated that he/she found out later that an aide had left Resident #1 on the commode without the stand-up lift. Family Member explained normally an aide would stay in the bathroom with Resident #1 or leave the stand-up lift in the restroom so he would not get up. After the fall Resident #1 immediately complained of pain. Family Member stated the aides got Resident #1 off the floor and laid him in bed. Later Resident #1 was transported to the hospital. First he was sent to the local hospital then transferred to another hospital in a different city. Resident #1 came back to the facility later that night about 1:00AM. Family Member stated he/she spoke with additional family members who were with Resident #1 at the hospital and they agreed not to do surgery. Family Member stated Resident #1 would not have wanted to live the rest of his life paralyzed. When the Resident #1 returned to the facility he/she had never seen him in so much pain, nothing they (facility nurses) gave him worked for the pain. Family Member stated the next day a care plan meeting was held with family members and facility staff and it was decided to get hospice services for Resident #1. He/she was told hospice could offer something different for Resident #1's pain than the facility could. Resident #1 was in so much pain that he/she did not think Resident #1 recognized Family Member. Family Member stated Resident #1 would not wear the neck brace and would throw it and did not want to take the medication. Family Member stated he/she woke up Saturday and the nurse stated Resident #1 had passed away in his sleep. Follow-up interview with LVN C on [DATE] at 11:30AM revealed Resident #1 complained of pain around 7:00AM following the fall. At that time she administered Norco to Resident #1. Resident #1 was transported to the hospital at around 10:00AM. LVN C stated Resident #1 went to the hospital because Resident #1 became lethargic. LVN C stated she would not have expected the CNA H to stay in the restroom with Resident #1 the entire time. LVN C stated the CNA H should have left the stand-up lift in the restroom. If CNA H would have left the lift Resident #1 would not have gotten up. LVN C stated it was a mistake on the part of CNA H and a lesson learned. Interview with CNA G on [DATE] at 8:48 AM revealed she assisted CNA H in getting Resident #1 out of bed on [DATE]. CNA G stated they both sat Resident #1 on the commode. CNA G stated she then left the room and CNA H was still with Resident #1. CNA H stated she went to the dining room to pass trays for lunch and approximately ,[DATE] minutes later she was told that Resident #1 had fallen. CNA G stated Resident #1 was a fall risk. Follow-up interview with CNA G on [DATE] at 2:53PM revealed CNA G was asked again to explain what occurred the morning that Resident #1 was found in the restroom. CNA G explained she was passing by Resident #1's room and saw Resident #1 standing up from his wheelchair. CNA G stated CNA H was in the room, so CNA G informed CNA H Resident #1 was attempting to stand-up and asked CNA H if she needed help. CNA G stated CNA H told CNA G that she did not need any assistance. CNA G then left the room to go pass trays in the dining room. Follow-up interview with LVN C on [DATE] at 12:05PM revealed LVN C was asked to explain exactly what CNA H told her occurred regarding Resident #1's fall. LVN H explained CNA H told her that she used the stand-up lift to put Resident #1 on the toilet. She then left Resident #1 in the bathroom, taking the stand-up lift with her because she had to use the lift on another Resident #1. When she came back Resident #1 was on the floor. Review of Resident #1's hospital records, dated [DATE], revealed Resident #1 was admitted with abrasion to top of head and forehead. Resident #1 complained of throbbing pain in head and pain level 5 out of 10. Resident #1 was transferred to hospital via helicopter with a [DIAGNOSES REDACTED]. Review of hospital Discharge Instructions for Resident #1, dated [DATE], revealed the Resident #1 received a [DIAGNOSES REDACTED]. Discharge paperwork states "Family comfortable with risk and prefers pt be discharged back to the facility." Special Notes revealed the following: "Pt's spine fractures were found to be unstable, but of undetermined age - general information provided on stable fractures (because we don't have premade discharged instructions for unstable fractures). Extensive conversation between trauma surgery and family and patient would have preferred quality of life without surgery and understand and accept risk of cord injury and potential quadriplegia (inability to move all extremities) and potential death. Don't hesitate to return to the ER for any concerning symptom development. Please discuss closely with pcp (primary care physician) - pt likely should be placed on hospice with DNR given expressed wishes at this times." Review of nurse's notes for Resident #1, dated [DATE], revealed 1:30AM - Resident #1 arrived via ambulance with C1 & C2 fracture present. "Family notified by hospital staff. Family refused treatment at the hospital for him. N/O {new order}for Tramadol 50mg 1 tab q8 {ever 8 hours} hours PRN. Takes Norco ,[DATE] 1 tab PO for pain. Resident #1 lying flat in bed. Towel around neck to help support neck injury. Maintain c spine during all transfers/movements. Multiple bruising present. Abrasion to head. Skin tear to left elbow. Bed in lowest position. Floor mat in place. Call light within reach. Will continue to monitor." 5:30AM - Resident being combative. Signs and symptoms of pain. Refusing medication. Received ABH gel (Ativan Benadryl Haldol topical gel applied to skin) at 5:00AM will continue to monitor. [DATE] - 6:15AM resident has agitation attempting to get out of bed. Resident combative when encouraged to lie down. Resident refusing to take any medications PRN Haldol injection (Haldol is an antipsychotic used to treat dementia) administered at 6:30AM. Safety mat and alarm in place. 7:52AM - Signs and symptom of pain and discomfort. Resident yelling out. Resident noncompliant. Administered PRN ABH gel at 8:00AM. 9:00AM - Resident refused medication. Attempt to administer Norco. PA stated will order Fentanyl patch. Aide continues to be at bedside. 10:30AM - ADON (assistant director of nursing) and aide at bedside. Signs and symptoms of pain and discomfort. Continues to be combative. 12:00PM - Resident continues to be agitated. Rejecting any type of care. 12:30PM - Family at bedside. Resident continues to be agitated. 1:35PM - Ativan (Ativan is used to treat anxiety) 1mg (milligram) administered, Haldol injection administered. Resident tolerated well. Attempted to dress resident. Resident refuses and becomes combative. 8:00PM - Resident very agitated and combative, attempting to get out of bed. ABH gel administered at 5:30PM. Not effective. Hospice nurse administered ABH gel [DATE]ml (milliliter) one time dose for severe agitation. 10:20PM - PRN morphine sulfate (morphine sulfate is used to treat moderate to severe pain) administered at 10:20PM and lorazepam 0.5mg for anxiety. Continues to have agitation and combative. Resident kicking wall causing abrasion to pinky toe. 10:30PM - Family at bedside entire shift agreeing to treatments and medications 11:45PM - Resident has increased confusion and agitation 1:00AM - Resident continues to be agitated and combative [DATE] - restless, PRN Ativan and 1.0ml morphine administered [DATE] - resident was found unresponsive at 8:10PM. Nurse was unable to obtain vitals. Hospice nurse notified at 8:15AM. Hospice nurse pronounced death at 9:22AM. Interview with LVN D, ADON on [DATE] at 9:00AM revealed Resident #1 fell on [DATE] at approximately 7:30AM. LVN D stated that she was notified of the Resident #1's fall by LVN C who completed the assessment following Resident #1 ' s fall on [DATE]. LVN D stated CNA H put resident on the commode in the bathroom then walked away from Resident #1 for a minute and that is when Resident #1 attempted to get up from the commode without assistance and fell and broke his neck. LVN D stated Resident #1 was sent out to the hospital for further evaluation and then transferred to another hospital for further evaluation. LVN D stated Resident #1 was in the emergency room for approximately 12 hours and then sent back to the facility at around 1:00AM. Resident #1 was sent back to the facility because his family elected not to go through with surgery. When Resident #1 returned to the facility he/she was very agitated all day and night. The facility met with the family and decided to try hospice services. Review of Resident #1's Care Plan Conference Summary, dated [DATE], revealed "family feels surgery not an option due to age and health." Resident #1 has soft vertical collar, multiple attempts to put on/keep on ineffective. [DATE] n/o Haldol injection, n/o fentanyl patch, n/o 2 Norco PRN. Discussed possible hospice with family and ok with family for evaluation. " Review of physician follow-up visit for Resident #1, dated [DATE], revealed Resident #1 recently sustained a fall with cervical fracture. "Family opted against surgery. Pt returned here for comfort care. Very agitated and possibly in pain. Will add Fentanyl patch and continue Norco. Family at bedside." Record review of Death Report for Resident#1 dated [DATE] revealed Resident #1 expired at 9:22AM on [DATE]. Review of Interdisciplinary Discharge Summary for Resident #1, dated [DATE], revealed Resident #1 was admitted to the facility for multiple injuries related to falls. Resident #1 was originally admitted to short stay rehab for falls and transferred to long term care. Treatment provided was medication administration, physical and occupational therapy, various courses for falls, behavior and elopement prevention management and ST for cognition. Progress at the facility stated "had improvements and declines over a year." Reason for discharge was Resident #1 expired. Interview with DON on [DATE] at 12:35AM revealed she was told that Resident #1 had a unwitnessed fall. DON stated she was told Resident #1 was okay and a couple of hours later she was told he was complaining of pain. When Resident #1 began complaining of pain he/she was sent out to the hospital. DON stated she was never told that Resident #1 was left unsupervised in the restroom therefore she did not follow-up with the incident or initiate any additional training with staff at the time. Interview with LVN D, ADON, on [DATE] at 10:08AM revealed she conducts incident investigations. LVN D stated she conducts investigations following resident incidents and accidents. LVN D stated she sometimes conducts investigation with the DON. She stated when she conducts a fall investigation he/she talks to the nurses and aides as to how the fall occurred. LVN D stated she did not get a timeline from CNA H as to the exact time Resident #1 was taken to the restroom and how long she was left unsupervised in the bathroom. LVN D stated from talking to CNA H following the incident she does not believe it was more than a few minutes. LVN D stated due to the fact that Resident #1 was such a high fall risk most aides would have stayed in the doorway of the bathroom with Resident #1. LVN D stated Resident #1 had multiple falls over the last several months. Review of undated Policy on Safe Patient Lifting and Repositioning received on [DATE] revealed "...5. Manuel lifting of patients is discouraged in all but exceptional medical emergencies of life threatening situations. If some degree of lifting is unavoidable, caregivers should first seek assistance from other staff members and /or employ mechanical aids whenever possible ..." Review of undated Falls-Clinical Protocol received on [DATE] revealed that as part of the initial assessment the staff will assist in identifying residents that have history of falls or have risk factor for subsequent falls. Following a resident fall, nurse should document the precipitating factors in detail as to how the fall occurred. " 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. " " 1. Based on the preceding assessment, the staff will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) " " The staff will monitor and document the individual ' s response to interventions intended to reduce falling or the consequences of falling ...If the individual continues to fall, the staff will re-evaluate the situation and consider other possible reasons for the resident ' s falling (besides those they have already been identified) and will re-evaluate the continued relevance of current interventions. " Review of undated facility abuse and neglect policy received [DATE] revealed facility has policy and procedure for training employees on identifying and reporting allegations of neglect. Administrator was informed of Immediate Jeopardy on [DATE] at 1:10PM. Interview with Administrator on [DATE] at 12:00PM revealed she was writing new policies and procedure for investigating and reporting incidents and accidents. Going forward she will be reviewing every policy and procedure in the facility and making changes or developing new policies as needed. Administrator expressed understanding as to why Immediate Jeopardy was called regarding facility's failure to transfer resident and provide supervision with toileting. Interview with DON on [DATE] at 1:35PM revealed she expressed understanding of why Immediate Jeopardy was called at the facility. DON stated she understood the incident should have been investigated and reported to DADS. The Plan of Removal was accepted on [DATE]. PLAN OF REMOVAL: All nursing staff, including nurses and aides, will be in-serviced on: proper handling of Hoyer and standup lifts during transfers transferring without a lift training involving physical assessment after a fall incident reporting and proper documentation including statements and interviews Abuse and Neglect Who is appropriate to leave unattended in the bathroom Training regarding physical assessment after falls and incident reporting and proper documentation including statements and interviews were held on [DATE] at 4:00 pm and [DATE] at 11:00 am by DON and LVN F. LVN D and LVN E will be testing all nurses and CNA's during their shifts on proper handling of Hoyer and stand up lifts during transfers to be completed by noon on Thursday [DATE]. Return demonstration deadline is Thursday [DATE] at noon. Any staff member who has not completed the return demonstration check off will be removed from the schedule and not be permitted to work until they complete the return demonstration check off. The in-service on transferring without a lift will be held by Therapist A and Therapist B on Wednesday [DATE] throughout the day. Return demonstration will be required and employees will be removed from the schedule and not permitted to work until all return demonstration check-offs are completed by noon on Thursday [DATE]. LVN D will be tracking completion of all in-services. Going forward, all of these return demonstration check offs will also be required of any new hire, Nurse or CNA. In-service on Abuse and Neglect being given by LVN D throughout the day on [DATE]. DON reviewed the incident report but did not further investigate the fall. New Administrator, initiated, conducted and implemented a new procedure for incident and accident reporting and investigating on [DATE]. Including fall risk intervention/assessment, provider letter ,[DATE], physical assessment following fall, what to report immediately to DON and facility internal investigation follow up, and handout who is appropriate to leave unattended in the bathroom. Administrator conducted one-on-one training with DON, LVN D and LVN E on [DATE]. Interview with 15 direct care staff on various shifts on [DATE] (CNA G at 2:00PM, CNA L at 2:10PM, CNA N at 2:20PM, CNA M at 2:30PM, CNA O at 2:40PM, CNA R at 2:50PM, CNA S at 3:00PM, CNA T at 3:10PM, CNA U at 3:20PM, CNA V at 3:30PM, CNA W at 3:40PM, CNA X at 3:50PM, CNA Y at 4:00PM, CNA Z at 4:10PM, CNA AA at 4:20PM) on [DATE] revealed interviews were conducted with staff following facility training over sit/stand lift, Hoyer lift, proper transfers and abuse and neglect. All were able to relay and demonstrate proper techniques for stand-up lift transfers and Hoyer transfers. All were knowledgeable of individual resident care needs that require 2 person transfers and/or the use of stand-up lifts and Hoyer lifts. All were knowledgeable regarding allegations of abuse and neglect. All were knowledgeable regarding facility policy and procedure regarding identifying and reporting allegations of abuse and neglect. Review of untitled and undated list of residents provided as an attachment with the Plan of removal by DON on [DATE], revealed 19 residents were identified to require assistance with stand up lift and/or Hoyer lift. Form CMS-672, Resident Census and Conditions of Residents, signed by the signed by LVN F on [DATE], reflected the facility identified 19 residents required ambulation with assistance or assistive device.

Based on observation, interview and record review it was determined the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest physical well-being for one (Resident #1) of twelve residents reviewed for neglect. 1. LVN D/ADON failed to conduct a thorough investigation regarding Resident #1's fall. 2. DON failed to adequately supervise facility investigations regarding allegations of neglect. 3. DON failed to report incident to State survey and certification agency in accordance with state law. Resident #1 fell from the commode and was transported to the hospital where he was diagnosed with [REDACTED]. Resident #1 was readmitted with severe pain and died approximately 2 days later. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to still in-servicing staff and monitoring the implementation of the Plan of Removal. These failures could affect the facility's nineteen residents in the facility, who required assistance with transfers and toileting by placing them at risk for falling, injuries, pain and stress on their well-being and causing other serious mental/physical harm and/or death. Findings included: Review of Resident #1's Face Sheet, received [DATE], revealed Resident #1 was a [AGE] years old admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan, dated [DATE], revealed Resident #1 was cognitively impaired with short and long term memory problems. Resident #1 had an impaired ability to understand others and make daily decisions. Resident #1 was high risk for falls requiring a 2 person assist with transfers with use of a mechanical lift. Resident #1 required 2 person assist with toileting and with activities of daily living. Care Plan revised on [DATE] revealed interventions of bed/chair alarm to alert staff " resident rising unassisted, " and " low bed and mat on floor at all times in bed. " Review of Resident #1's Fall Risk Assessment, dated [DATE], revealed Resident #1 received a score of 18 indicating resident is high risk for falls. Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained a fall without injury [DATE]." Resident #1 wheeled himself down the administrative wing and fell out of his wheelchair. No injuries noted on assessment. " The section titled "medical risk factors" had the following risk factors checked: a history of falls. Section of report noting resident ' s current mental status was left blank. Post action interventions taken following the fall were a wander guard was placed on Resident #1 ' s right wrist to alert staff when Resident #1 was near an exit. Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained a fall without injury on [DATE]. " Resident was attempting to use the restroom without assist and hit bottom on the floor." The section titled "medical risk factor" was left blank. Section titled "mental status" was blank. The report indicated there was no post action interventions following Resident #1's fall. Review of Resident #1's MDS, dated [DATE], revealed Resident #1 was severely cognitively impaired. Resident #1 was total dependenece, full staff performance, required 2 person physical assist for transfers and toileting. Review of Resident #1's PT Evaluation and Plan of Treatment, dated [DATE], revealed "Patient needs max assist during transfers with poor standing balance." Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained a fall with injury on [DATE]. " Resident tried to get up from his wheelchair in his room and fell . He hit his forehead on the wood floor and hit his left elbow on the floor. " The section titled "medical risk factors" had the following risk factors checked: fall history, inability, confusion and disorientation. The section titled "mental status" revealed Resident #1 was confused. Post action interventions reflected Resident #1 was to be kept near nurse's station to supervise from future falls. Review of Incident and Accident Report, dated [DATE], revealed Resident #1 sustained an unwitnessed fall in the bathroom on [DATE]. Resident #1 reported he fell from the commode. Incident and accident report did not note any additional information. Review of Resident #1's nurses notes revealed the following: [DATE] - 7:10AM "Observed resident in floor in bathroom. Resident continues to state he fell . Assisted into w/c X3 staff members. Abrasion noted to forehead measuring approximately 5X7 (measurement not noted). Abrasion to top of head with small laceration. Abrasion to top of head measuring 1.5X 3.2, laceration measuring approximately 1.5 X 1(method of measurement not noted). Skin tear to left elbow noted. All areas cleaned with NS applied. Multiple bruising noted to extremities...... Resident complained of head hurting. Pupils equal. Resident alert and able to follow directions but is confused per normal self. Assisted resident into recliner X 2 staff members. Alarm in place and working neuro checks started. 07:20 DON notified 07:30AM PA notified. 7:40AM RP notified. [MEDICATION NAME] ,[DATE] administered at 8:00AM due to complaints of pain." 8:30AM - Resident up in recliner eating breakfast. No complaints of pain at this time. 10:10AM - "Resident up in recliner in room. BP at this ,[DATE].54{pulse rate}. Set resident up at 90 degree angle and rechecked BP. ,[DATE].57 {pulse rate}. Assisted resident to bed x2 staff members. Laid head down with feet up. BP then ,[DATE].55.{pulse rate} Resident complained of dizziness and pain to head. Lethargic and slurred speech noted. Notified supervisor. N/O {new order} send resident to local hospital for evaluation and notified at 10:25AM. Ambulance service arrived at 10:35AM. Resident left facility via stretcher 2 person emergency transport personnel at 10:45AM." Review of Interdisciplinary Resident Screen for Resident #1, dated [DATE] revealed the following: "pt sustained a fall this morning while attempting to stand up from toilet. Pt his(sic) head and was found by staff (nursing) lying on the floor. Therapist will speak to maintenance to lower sear (sic) of wheelchair to prevent falling forward will also discuss safety with nursing staff - i.e. pt should not be left unattended while using the bathroom." Interview with LVN E on [DATE] at 9:05 AM revealed when Resident #1 went to the restroom you usually had to stay with Resident #1 depending on the day. LVN E stated some days Resident #1 was very compliant and other day's Resident #1 was not compliant with care. Interview with four CNAs on [DATE] (CNA I at 10:48AM, CNA J at 11:05AM, CNA K at 11:10AM, CNA L at 11:45AM, and CNA M at 2:35PM) revealed Resident #1 was very confused. Resident #1 was not stable enough to sit on the commode unsupervised. Resident #1 required supervision while toileting. Resident #1 would often try to stand up without staff assistance. Interview with CNAs on [DATE] (CNA N at 3:00PM and CNA O at 3:10PM) on [DATE] revealed when transferring Resident #1 you always had to use the stand-up lift. Staff had to stay with Resident #1 in the restroom because Resident #1 would fall. Interview with CNA H on [DATE] at 11:50AM revealed the morning of [DATE] she got Resident #1 out of bed, dressed and in his wheelchair. CNA H explained CNA G helped him/her get Resident #1 up from bed. CNA H explained the fall occurred before 7:00AM because it was before breakfast, but was unsure of the exact time. CNA H explained Resident #1 was sitting in his/her wheelchair by the bathroom door. She had turned around to make the bed and that is when Resident #1 started to stand up to go to the bathroom. She took Resident #1 to the bathroom, pulled down his pants and sat Resident #1 on the toilet. CNA H stated she did not use the stand-up lift to put Resident #1 on the toilet. CNA H stated she left the room to find the stand-up lift on the hall without success. CNA H went to find the stand-up lift and saw Resident #1's call light on. CNA H stated when she went into the room she found Resident #1 on the bathroom floor. CNA H stated she asked Resident #1 if he was okay and he said "get me up." CNA H got the nurse and then they lifted Resident #1 off the floor. CNA H stated that normally when she assisted Resident #1 to the bathroom she would stand by the bathroom door to give Resident #1 his privacy. CNA H stated she was gone less than a minute to get the stand-up lift when Resident #1 fell . Interview with LVN C on [DATE] at 8:45AM revealed between 6:15AM - 6:30AM on [DATE] CNA H found Resident #1 on the bathroom floor. LVN C stated she was called to the bathroom by CNA H. LVN C was told by CNA H that Resident #1 had been transferred to the bathroom using the stand-up lift and placed on the commode. CNA H then left the bathroom taking the stand-up lift because CNA H had to assist another resident. LVN C stated when CNA H returned to assist Resident #1 off of the commode she found Resident #1 on the floor. LVN C stated she completed an assessment on Resident #1. Resident #1 had an abrasion to his forehead; Resident #1 had no complaints of pain. LVN C explained it then took 3 staff to assist Resident #1 off of the floor and back into his wheelchair. LVN C stated she continued to monitor Resident #1, his vital signs and neuro checks were good and Resident #1 ate all of his breakfast. LVN C explained Resident #1 shared a suite with his family member who is also a resident. The suites consist of 2 separate bedrooms, small living area and a bathroom. LVN C stated Resident #1's family member was alert and oriented. LVN C explained later in the morning Resident #1 began to complain that he was feeling dizzy and complaining of pain. At this time she took his blood pressure and noticed it had dropped. Resident #1 was then sent to the hospital. LVN C stated Resident #1 returned to the facility with a fractured C1 and C2 cervical. LVN C explained Resident #1 had a [DIAGNOSES REDACTED].#1 was confused and could be combative at times. Interview with Family Member, also Resident #1's roommate on [DATE] at 10:50AM revealed the morning of [DATE] he/she did not know Resident #1 was in the bathroom. Family Member stated he/she heard Resident #1 yelling. It sounded very muffled. He/she pressed the call light for help. Family Member explained LVN C came into the room and did an assessment. Family Member stated he/she figured out that Resident #1 had fallen. He/she heard LVN C asking Resident #1 questions. Family Member stated that he/she found out later that an aide had left Resident #1 on the commode without the stand-up lift. Family Member explained normally an aide would stay in the bathroom with Resident #1 or leave the stand-up lift in the restroom so he would not get up. After the fall Resident #1 immediately complained of pain. Family Member stated the aides got Resident #1 off the floor and laid him in bed. Later Resident #1 was transported to the hospital. First he was sent to the local hospital then transferred to another hospital in a different city. Resident #1 came back to the facility later that night about 1:00AM. Family Member stated he/she spoke with additional family members who were with Resident #1 at the hospital and they agreed not to do surgery. Family Member stated Resident #1 would not have wanted to live the rest of his life paralyzed. When the Resident #1 returned to the facility he/she had never seen him in so much pain, nothing they (facility nurses) gave him worked for the pain. Family Member stated the next day a care plan meeting was held with family members and facility staff and it was decided to get hospice services for Resident #1. He/she was told hospice could offer something different for Resident #1's pain than the facility could. Resident #1 was in so much pain that he/she did not think Resident #1 recognized Family Member. Family Member stated Resident #1 would not wear the neck brace and would throw it and did not want to take the medication. Family Member stated he/she woke up Saturday and the nurse stated Resident #1 had passed away in his sleep. Follow-up interview with LVN C on [DATE] at 11:30AM revealed Resident #1 complained of pain around 7:00AM following the fall. At that time she administered [MEDICATION NAME] to Resident #1. Resident #1 was transported to the hospital at around 10:00AM. LVN C stated Resident #1 went to the hospital because Resident #1 became lethargic. LVN C stated she would not have expected the CNA H to stay in the restroom with Resident #1 the entire time. LVN C stated the CNA H should have left the stand-up lift in the restroom. If CNA H would have left the lift Resident #1 would not have gotten up. LVN C stated it was a mistake on the part of CNA H and a lesson learned. Interview with CNA G on [DATE] at 8:48 AM revealed she assisted CNA H in getting Resident #1 out of bed on [DATE]. CNA G stated they both sat Resident #1 on the commode. CNA G stated she then left the room and CNA H was still with Resident #1. CNA H stated she went to the dining room to pass trays for lunch and approximately ,[DATE] minutes later she was told that Resident #1 had fallen. CNA G stated Resident #1 was a fall risk. Follow-up interview with CNA G on [DATE] at 2:53PM revealed CNA G was asked again to explain what occurred the morning that Resident #1 was found in the restroom. CNA G explained she was passing by Resident #1's room and saw Resident #1 standing up from his wheelchair. CNA G stated CNA H was in the room, so CNA G informed CNA H Resident #1 was attempting to stand-up and asked CNA H if she needed help. CNA G stated CNA H told CNA G that she did not need any assistance. CNA G then left the room to go pass trays in the dining room. Follow-up interview with LVN C on [DATE] at 12:05PM revealed LVN C was asked to explain exactly what CNA H told her occurred regarding Resident #1's fall. LVN H explained CNA H told her that she used the stand-up lift to put Resident #1 on the toilet. She then left Resident #1 in the bathroom, taking the stand-up lift with her because she had to use the lift on another Resident #1. When she came back Resident #1 was on the floor. Review of Resident #1's hospital records, dated [DATE], revealed Resident #1 was admitted with abrasion to top of head and forehead. Resident #1 complained of throbbing pain in head and pain level 5 out of 10. Resident #1 was transferred to hospital via helicopter with a [DIAGNOSES REDACTED]. Review of hospital Discharge Instructions for Resident #1, dated [DATE], revealed the Resident #1 received a [DIAGNOSES REDACTED]. Discharge paperwork states "Family comfortable with risk and prefers pt be discharged back to the facility." Special Notes revealed the following: "Pt's spine fractures were found to be unstable, but of undetermined age - general information provided on stable fractures (because we don't have premade discharged instructions for unstable fractures). Extensive conversation between trauma surgery and family and patient would have preferred quality of life without surgery and understand and accept risk of cord injury and potential [MEDICAL CONDITION] (inability to move all extremities) and potential death. Don't hesitate to return to the ER for any concerning symptom development. Please discuss closely with pcp (primary care physician) - pt likely should be placed on hospice with DNR given expressed wishes at this times." Review of nurse's notes for Resident #1, dated [DATE], revealed 1:30AM - Resident #1 arrived via ambulance with C1 & C2 fracture present. "Family notified by hospital staff. Family refused treatment at the hospital for him. N/O {new order}for [MEDICATION NAME] 50mg 1 tab q8 {ever 8 hours} hours PRN. Takes [MEDICATION NAME] ,[DATE] 1 tab PO for pain. Resident #1 lying flat in bed. Towel around neck to help support neck injury. Maintain c spine during all transfers/movements. Multiple bruising present. Abrasion to head. Skin tear to left elbow. Bed in lowest position. Floor mat in place. Call light within reach. Will continue to monitor." 5:30AM - Resident being combative. Signs and symptoms of pain. Refusing medication. Received ABH gel ([MEDICATION NAME] topical gel applied to skin) at 5:00AM will continue to monitor. [DATE] - 6:15AM resident has agitation attempting to get out of bed. Resident combative when encouraged to lie down. Resident refusing to take any medications PRN [MEDICATION NAME] injection ([MEDICATION NAME] is an antipsychotic used to treat dementia) administered at 6:30AM. Safety mat and alarm in place. 7:52AM - Signs and symptom of pain and discomfort. Resident yelling out. Resident noncompliant. Administered PRN ABH gel at 8:00AM. 9:00AM - Resident refused medication. Attempt to administer [MEDICATION NAME]. PA stated will order [MEDICATION NAME]. Aide continues to be at bedside. 10:30AM - ADON (assistant director of nursing) and aide at bedside. Signs and symptoms of pain and discomfort. Continues to be combative. 12:00PM - Resident continues to be agitated. Rejecting any type of care. 12:30PM - Family at bedside. Resident continues to be agitated. 1:35PM - [MEDICATION NAME] ([MEDICATION NAME] is used to treat anxiety) 1mg (milligram) administered, [MEDICATION NAME] injection administered. Resident tolerated well. Attempted to dress resident. Resident refuses and becomes combative. 8:00PM - Resident very agitated and combative, attempting to get out of bed. ABH gel administered at 5:30PM. Not effective. Hospice nurse administered ABH gel [DATE]ml (milliliter) one time dose for severe agitation. 10:20PM - PRN [MEDICATION NAME] sulfate ([MEDICATION NAME] sulfate is used to treat moderate to severe pain) administered at 10:20PM and [MEDICATION NAME] 0.5mg for anxiety. Continues to have agitation and combative. Resident kicking wall causing abrasion to pinky toe. 10:30PM - Family at bedside entire shift agreeing to treatments and medications 11:45PM - Resident has increased confusion and agitation 1:00AM - Resident continues to be agitated and combative [DATE] - restless, PRN [MEDICATION NAME] and 1.0ml [MEDICATION NAME] administered [DATE] - resident was found unresponsive at 8:10PM. Nurse was unable to obtain vitals. Hospice nurse notified at 8:15AM. Hospice nurse pronounced death at 9:22AM. Interview with LVN D, ADON on [DATE] at 9:00AM revealed Resident #1 fell on [DATE] at approximately 7:30AM. LVN D stated that she was notified of the Resident #1's fall by LVN C who completed the assessment following Resident #1 ' s fall on [DATE]. LVN D stated CNA H put resident on the commode in the bathroom then walked away from Resident #1 for a minute and that is when Resident #1 attempted to get up from the commode without assistance and fell and broke his neck. LVN D stated Resident #1 was sent out to the hospital for further evaluation and then transferred to another hospital for further evaluation. LVN D stated Resident #1 was in the emergency room for approximately 12 hours and then sent back to the facility at around 1:00AM. Resident #1 was sent back to the facility because his family elected not to go through with surgery. When Resident #1 returned to the facility he/she was very agitated all day and night. The facility met with the family and decided to try hospice services. Review of Resident #1's Care Plan Conference Summary, dated [DATE], revealed "family feels surgery not an option due to age and health." Resident #1 has soft vertical collar, multiple attempts to put on/keep on ineffective. [DATE] n/o [MEDICATION NAME] injection, n/o [MEDICATION NAME], n/o 2 [MEDICATION NAME] PRN. Discussed possible hospice with family and ok with family for evaluation. " Review of physician follow-up visit for Resident #1, dated [DATE], revealed Resident #1 recently sustained a fall with cervical fracture. "Family opted against surgery. Pt returned here for comfort care. Very agitated and possibly in pain. Will add [MEDICATION NAME] and continue [MEDICATION NAME]. Family at bedside." Record review of Death Report for Resident#1 dated [DATE] revealed Resident #1 expired at 9:22AM on [DATE]. Review of Interdisciplinary Discharge Summary for Resident #1, dated [DATE], revealed Resident #1 was admitted to the facility for multiple injuries related to falls. Resident #1 was originally admitted to short stay rehab for falls and transferred to long term care. Treatment provided was medication administration, physical and occupational therapy, various courses for falls, behavior and elopement prevention management and ST for cognition. Progress at the facility stated "had improvements and declines over a year." Reason for discharge was Resident #1 expired. Interview with DON on [DATE] at 12:35AM revealed she was told that Resident #1 had a unwitnessed fall. DON stated she was told Resident #1 was okay and a couple of hours later she was told he was complaining of pain. When Resident #1 began complaining of pain he/she was sent out to the hospital. DON stated she was never told that Resident #1 was left unsupervised in the restroom therefore she did not follow-up with the incident or initiate any additional training with staff at the time. Interview with LVN D, ADON, on [DATE] at 10:08AM revealed she conducts incident investigations. LVN D stated she conducts investigations following resident incidents and accidents. LVN D stated she sometimes conducts investigation with the DON. She stated when she conducts a fall investigation he/she talks to the nurses and aides as to how the fall occurred. LVN D stated she did not get a timeline from CNA H as to the exact time Resident #1 was taken to the restroom and how long she was left unsupervised in the bathroom. LVN D stated from talking to CNA H following the incident she does not believe it was more than a few minutes. LVN D stated due to the fact that Resident #1 was such a high fall risk most aides would have stayed in the doorway of the bathroom with Resident #1. LVN D stated Resident #1 had multiple falls over the last several months. Review of undated Policy on Safe Patient Lifting and Repositioning received on [DATE] revealed "...5. Manuel lifting of patients is discouraged in all but exceptional medical emergencies of life threatening situations. If some degree of lifting is unavoidable, caregivers should first seek assistance from other staff members and /or employ mechanical aids whenever possible ..." Review of undated Falls-Clinical Protocol received on [DATE] revealed that as part of the initial assessment the staff will assist in identifying residents that have history of falls or have risk factor for subsequent falls. Following a resident fall, nurse should document the precipitating factors in detail as to how the fall occurred. " 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. " " 1. Based on the preceding assessment, the staff will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) " " The staff will monitor and document the individual ' s response to interventions intended to reduce falling or the consequences of falling ...If the individual continues to fall, the staff will re-evaluate the situation and consider other possible reasons for the resident ' s falling (besides those they have already been identified) and will re-evaluate the continued relevance of current interventions. " Review of undated Incident Investigation and Follow-Up received [DATE] revealed that facility policy and procedure stated " actions taken to prevent further reoccurrences of the incident. " " The investigation requires the review of the following as applicable to the incident ... What did the discovering person or witness see, hear, or smell? What was the mental, emotional, physical and cognitive status or the victim before and after the incident? What information is available about the person(s) who may have contributed to the occurrence of the incident? ... " Review of undated facility abuse and neglect policy received [DATE] revealed facility has policy and procedure for training employees on identifying and reporting allegations of neglect. Review of undated facility abuse and neglect policy received [DATE] revealed facility has policy and procedure for training employees on identifying and reporting allegations of neglect. Administrator was informed of Immediate Jeopardy on [DATE] at 1:10PM. Interview with Administrator on [DATE] at 12:00PM revealed she was writing new policies and procedure for investigating and reporting incidents and accidents. Going forward she will be reviewing every policy and procedure in the facility and making changes or developing new policies as needed. Administrator expressed understanding as to why Immediate Jeopardy was called regarding facility's failure to transfer resident and provide supervision with toileting. Interview with DON on [DATE] at 1:35PM revealed she expressed understanding of why Immediate Jeopardy was called at the facility. DON stated she understood the incident should have been investigated and reported to DADS. The Plan of Removal was accepted on [DATE]. PLAN OF REMOVAL: All nursing staff, including nurses and aides, will be in-serviced on: proper handling of Hoyer and standup lifts during transfers transferring without a lift training involving physical assessment after a fall incident reporting and proper documentation including statements and interviews Abuse and Neglect Who is appropriate to leave unattended in the bathroom Training regarding physical assessment after falls and incident reporting and proper documentation including statements and interviews were held on [DATE] at 4:00 pm and [DATE] at 11:00 am by DON and LVN F. LVN D and LVN E will be testing all nurses and CNA's during their shifts on proper handling of Hoyer and stand up lifts during transfers to be completed by noon on Thursday [DATE]. Return demonstration deadline is Thursday [DATE] at noon. Any staff member who has not completed the return demonstration check off will be removed from the schedule and not be permitted to work until they complete the return demonstration check off. The in-service on transferring without a lift will be held by Therapist A and Therapist B on Wednesday [DATE] throughout the day. Return demonstration will be required and employees will be removed from the schedule and not permitted to work until all return demonstration check-offs are completed by noon on Thursday [DATE]. LVN D will be tracking completion of all in-services. Going forward, all of these return demonstration check offs will also be required of any new hire, Nurse or CNA. In-service on Abuse and Neglect being given by LVN D throughout the day on [DATE]. DON reviewed the incident report but did not further investigate the fall. New Administrator, initiated, conducted and implemented a new procedure for incident and accident reporting and investigating on [DATE]. Including fall risk intervention/assessment, provider letter ,[DATE], physical assessment following fall, what to report immediately to DON and facility internal investigation follow up, and handout who is appropriate to leave unattended in the bathroom. Administrator conducted one-on-one training with DON, LVN D and LVN E on [DATE]. Interview with 15 direct care staff on various shifts on [DATE] (CNA G at 2:00PM, CNA L at 2:10PM, CNA N at 2:20PM, CNA M at 2:30PM, CNA O at 2:40PM, CNA R at 2:50PM, CNA S at 3:00PM, CNA T at 3:10PM, CNA U at 3:20PM, CNA V at 3:30PM, CNA W at 3:40PM, CNA X at 3:50PM, CNA Y at 4:00PM, CNA Z at 4:10PM, CNA AA at 4:20PM) on [DATE] revealed interviews were conducted with staff following facility training over sit/stand lift, Hoyer lift, proper transfers and abuse and neglect. All were able to relay and demonstrate proper techniques for stand-up lift transfers and Hoyer transfers. All were knowledgeable of individual resident care needs that require 2 person transfers and/or the use of stand-up lifts and Hoyer lifts. All were knowledgeable regarding allegations of abuse and neglect. All were knowledgeable regarding facility policy and procedure regarding identifying and reporting allegations of abuse and neglect. Review of untitled and undated list of residents provided as an attachment with the Plan of removal by DON on [DATE], revealed 19 residents were identified to require assistance with stand up lift and/or Hoyer lift. Form CMS-672, Resident Census and Conditions of Residents, signed by the signed by LVN F on [DATE], reflected the facility identified 19 residents required ambulation with assistance or assistive device.

Based on observation, interview and record review, the facility failed to ensure one (Resident #1) of three residents received adequate supervision and assistance devices to prevent accidents. a) The Restorative Aide (RA) transferred Resident #1 using a standing lift without the assistance of another staff member. b) The RA did not know how to transfer Resident #1 and had imitated other Certified Nurse Aides (CNAs) when she transferred Resident #1. c) Resident #1 had not been assessed for the appropriate assistive/supportive device to be used when transferred. d) The Comprehensive Care Plan reflected one person was required to transfer Resident #1 (instead of two) and did not specify an assistive/supportive device. These failures resulted in Resident #1 sustaining a fracture of the right clavicle (shoulder). These failures could affect the facility's 33 residents, identified as requiring staff assistance with transfers, at risk for falls and injury. Findings included: 1. Review of the facility statement obtained by RA revealed on 02/09/11 at 1:20 p.m., RA transferred Resident #1 independently with a standing lift to her bed and positioned the resident on her bed. 2. Review of the facility Investigation Report dated 02/15/11 revealed the following: On 02/09/11 at approximately 9:30 p.m., a CNA reported a bruise on the right shoulder area of Resident #1. On 02/10/11, the resident was sent to a doctor's office for a scheduled appointment. While at the physician's office on 02/10/11, an x-ray was taken and reflected Resident #1 had a fractured right clavicle. 3. An interview with the Acting Director of Nursing (DON) on 02/23/11 at 11:12 a.m. revealed Resident #1 was currently at the hospital. The Acting DON further stated, "___ (RA) transferred ____ (Resident #1) by herself in the stand-up lift. She (RA) knew not to do that. None of the CNAs did that. ____ (Resident #1) is a two-person transfer. Not a one-person transfer. She (RA) should not do it. She (RA) was not working on the floor as a CNA. She (RA) didn't know how to transfer the resident. She (RA) was just helping and took it upon herself to transfer ____ (Resident #1)." The Acting DON admitted during this same interview, the facility should have done a better assessment of determining the proper equipment for transferring Resident #1. 4. An interview on 02/23/11 at 11:40 a.m. with CNA A, who routinely worked with Resident #1, revealed the resident was weak in her right arm and lower extremities. CNA A stated two staff members always transferred the resident using a stand-up lift and the resident was only able to grab onto the bar of the stand-up lift when instructed to do so. During this same interview, the surveyor asked CNA A how it was determined to use the stand-up lift for transferring Resident #1. CNA A responded, "I was told by another CNA during shift change how to transfer the resident. It is not written anywhere for me." 5. An interview with the Rehabilitation Director (RD), on 02/23/11 at 11:55 a.m. revealed the facility recently asked therapy to evaluate all residents for the use of appropriate transfer equipment after Resident #1 fractured her right clavicle. The RD stated Resident #1 should have been transferred with a Hoyer lift and not a stand-up lift. 6. During an interview on 02/28/11 at 1:30 p.m., RA stated she transferred Resident #1 the way she had seen other CNAs transfer the resident, with a stand-up lift. She stated she did not intentionally hurt Resident #1. 7. Review of the Admission Nursing Evaluation dated 01/28/11 revealed Resident #1 was a [AGE] year-old female, who weighed 227 pounds. Resident #1's admitting [DIAGNOSES REDACTED]. Resident #1 was disoriented, incontinent of bowel and bladder, and she required two staff for transfer. Resident #1 was unable to move both of her legs independently and was able to use her left arm with only limited range of motion. 8. The corresponding Interim Plan of Care dated 01/28/11 reflected Resident #1 required two staff members to transfer the resident, however, the section under how staff was to perform the transfer did not specify what equipment to use during the transfer. It reflected, "Total Care." 9. Review of the initial Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was a total transfer with the assistance of two staff members. The corresponding Comprehensive Care Plan with the same date reflected the resident was at risk for falls, due to weakness and difficulty with her gait. The care plan reflected the resident required only one person for transfers. The section under approaches reflected, "Assess resident's need for assistive/supportive device." There was no information on the care plan as to what equipment the CNAs were to use during the transfer of Resident #1. Furthermore, there was no evidence in the entire clinical record of any assessment completed, which indicated the type of supportive device required for Resident #1. 10. The facility provided evidence the facility's dependent residents had been assessed by physical therapy for safe transfers, and their plans of care were updated to reflect the proper use of transfer equipment as needed. 11. The facility's policy/procedure on Safe Lifting and Movement of Residents was provided by the Acting DON as current on 02/23/11. It reflected in part: Policy: Assessment of Transfer. "...3. Nursing staff in conjunction with the rehabilitation staff shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: ...c. Resident's size; d. Weight-bearing ability...." 12. The Resident Census and Conditions of Residents (CMS Form 672) dated 02/23/11 reflected the census was 76 residents and 33 residents received assistance with transfers by one or two facility staff members.