Every finding on record at Briar Hill Rest Home

Based on observation, facility policy review, and interviews, the facility failed to ensure residents were provided with reasonable accommodations to maintain a safe and functional environment by failing to keep call lights within physical reach for seven (7) of ten (10) sampled residents. Residents #4, #5, #6, #7, #8, #9, and #10.Findings Included:Record review of the facility policy Call Light Policy, revised January 12, 2015, revealed, .1. All facility personnel must be aware of call lights at all times.11. Be sure all call lights are placed conveniently for the resident.On 5/28/26 at 4:01 PM, observation revealed Resident #7 and Resident #10 did not have their call lights within their reach.On 5/28/26 at 4:05 PM, observation and interviews revealed that Resident #5 and Resident #8's call lights were out of reach and stuck (could not be pulled out easily) under Resident #5's bed. Observation revealed that Resident #5 had to get off her bed and it took Licensed Practical Nurse (LPN) #1 two minutes and moved the bed several times for LPN #1 to retrieve the call lights from under the resident's bed. During observation when asked if call lights should be in residents' reach, LPN #1 stated, It's not like we don't know that.On 5/28/26 at 4:10 PM, observation revealed that both Resident #4 and Resident #9's call lights were out of their reach. Both call lights were on the floor under the wall mounted call light receptacle (where the call light cord plugs into the wall).On 5/28/26 at 4:15 PM, observation revealed Resident #6 was resting on her bed, and her call light was not within her reach. Both call lights were coiled up on the floor under the wall mounted call light receptacle. Her roommate was not in the room.On 5/28/26 at 4:20 PM, observation and interview revealed the Director of Nursing (DON) confirmed that the call light for Resident #7 was not within the resident's reach. The DON placed the call light in her reach. On 5/28/26 at 4:30 PM, interview with LPN #1 revealed he stated that he was aware that it was the responsibility of the nursing staff to ensure each resident had their call light within their reach. He confirmed that he was assigned to the care for all residents in the locked dementia unit on 5/28/26 from 7:00 AM through 7:00 PM and they did not have their call lights within their reach. He stated, I know about keeping call lights in reach, it's a safety risk if they need to get help. He confirmed that he had to struggle to retrieve the call lights for both residents in Resident #5 and Resident #8's room.On 5/28/26 at 4:39 PM, during an interview the DON revealed that it is the responsibility of all staff to ensure that each resident had their call light within reach to summon assistance as needed.On 5/28/26 at 4:45 PM, interview with Certified Nursing Assistant (CNA) #4 revealed she was assigned to the care of residents on the locked dementia unit and that she was aware that all residents in their rooms should have their call lights within reach.On 5/28/26 at 5:00 PM, interview with the Administrator revealed she expected each resident to have their call light within reach, the department heads and nurses to monitor for correct call light placement and that the call light placement was important for residents as it was their means to summon assistance as needed.

Based on observation, interviews, and facility policy review, the facility failed to provide a safe, functional, and sanitary environment for residents as evidenced by failing to maintain sharps containers in a safe manner for two (2) of four (4) observed sharps containers.Findings Included:Record review of the facility policy Sharps Container Policy, undated, revealed The facility will utilize sharp container as follows: For disposal of all sharp items, (not all inclusive) .Lancets.Sealed with tape and dated when disposed of. The facility policy did not address when or how often the sharps containers should be emptied. On 5/28/26 at 3:40 PM, during an observation and interview the Director of Nursing (DON) revealed the sharps container in the shower room on the locked dementia unit was full to the point of being unable to be opened and there were three uncapped used aqua-blue disposable razors on the top of the container. The DON confirmed that the sharps container should have been properly disposed of and replaced with a new one and that the razors on top of the container could pose a potential safety hazard to residents. She said that it was the responsibility of the Certified Nursing Assistants (CNAs) to report the full sharps container to the nurses and the responsibility of the nurses to monitor the containers and replace them as needed.On 5/28/26 at 4:15 PM, observation revealed the sharps' container on the medication cart for the locked dementia unit was full to the point of being unable to be opened. The sharps containers in shower room were overfilled to the point of being unusable with three used, unsheathed disposable razors atop the sharp's container in the shower room. On 5/28/26 at 4:30 PM, interview with Licensed Practical Nurse (LPN) #1 revealed that the sharps' container on the medication cart was full to maximum capacity. He reported that there were two residents that required routine blood glucose monitoring on the unit and that the lancets used to obtain blood specimen would need to be disposed of in a sharps' container. He stated that the sharps' container on the medication cart was not an option because it was so full it could no longer be opened. Concerning the lancets used for glucose monitoring he stated, they would be thrown in the sharps' container, but obviously not this one because you can't open it. On 5/28/26 at 4:45 PM, interview with CNA #4 confirmed that she was assigned to the care of residents on the locked dementia unit and that residents on the unit used the shower room.On 5/28/26 at 5:00 PM, interview with the Administrator revealed she expected staff to provide for the safety of residents in the shower room and anywhere sharps' containers were located, dispose of them as needed and confirmed that leaving uncapped/unsheathed disposable razors on top of the sharps' container in the locked dementia unit shower room could pose a safety hazard for residents.

Based on observation, interview, and record review, and facility policy review the facility failed to ensure that services were provided in accordance with professional standards of practice and within staff scope of practice for one (1) of four (4) residents reviewed for enteral nutrition services. (Resident #6) Findings Include:Record review of the facility policy Tube Feeding undated revealed, .Responsibility: All licensed Nursing personnel monitored by the Charge Nurse .On 1/21/26 at 2:30 PM, an observation of Certified Nursing Assistant #2 (CNA) doing incontinent check on Resident #6 revealed she placed feeding pump on hold prior to checking the resident. CNA #2 left the room to obtain supplies for incontinent care.On 1/21/26 at 2:35 PM, during an interview with CNA #2 revealed they let us place the pump on hold when do incontinent check on resident before we let the bed down flat. She stated when they finished, they were told to turn the pump back on. She stated she watched the nurses operate pump and know how to put it on hold.On 1/21/26 at 2:56 PM, CNA #2 returned with supplies and CNA #3 to assist with turning. The feeding pump was still on hold and beeping. CNA #2 told CNA #3 to go get nurse to stop pump from beeping. Licensed Practical Nurse #1 (LPN) entered the room and placed pump back on hold. On 01/21/26 at 3:20 PM, during an interview with LPN #1 she confirmed when she entered Resident #6's room the feeding pump was already on hold. She stated she does not know who placed pump on hold. She stated the CNAs are not allowed to operate feeding pump. She stated CNAs are not trained to operate pumps and can cause the residents to be overfed, underfed or aspirated. She stated the peg feeding is ordered by the physician and considered a medication.On 1/21/26 at 3:28 PM, in an interview with CNA #2 she stated she turned the feeding pump off in error. She stated she should not have turned it off. She confirmed that she was practicing outside of her scope.On 01/22/26 at 1:45 PM, during an interview, the Director of Nursing (DON) stated that CNAs are not authorized to place feeding pumps on hold and that only licensed nurses are permitted to operate enteral feeding pumps. The DON stated CNAs are not trained to operate pumps and could cause residents to receive incorrect amounts of feeding or flushes. The DON stated her expectation is that CNAs notify licensed nursing staff to manage feeding pumps.A record review of the admission Record revealed the resident was admitted on [DATE] with diagnoses including hemiplegia, unspecified, affecting the left nondominant side, and adult failure to thrive. A record review of the Order Listing Report revealed an order dated 7/25/25 for enteral nutrition via pump: Nutren 2.0 at 35 milliliter (mL) per hour providing 1980 calories daily, with 150 cubic centimeters (cc) water flushes every four (4) hours.A record review of the Order Listing Report revealed an order dated 7/25/25 for enteral nutrition via pump: Nutren 2.0 at 35 milliliter (mL) per hour providing 1980 calories daily, with 150 cubic centimeters (cc) water flushes every four (4) hours.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/25, revealed the resident was rarely understood.

Based on observation, interview, record review, and facility policy review the facility failed to provide information for pertinent state agencies and advocacy groups, specifically the ombudsman for two (2) of three (3) days of survey. Findings include: Record review of facility grievance policy Resident and Family Grievances reviewed 2/24/19 revealed, .Information on how to file a grievance or complaint will be available to the resident. Information may include but is not limited to. 7.a. The contact information of the grievance official with whom a grievance can be filed, including his or her name. business address (mailing and email) and business phone number. b. The contact information of independent entities with whom grievances may be filed, that is, the pertinent State Survey Agency and Local Long-Term Care Ombudsman program or protection and advocacy system. c. The time frame that a resident may reasonably expect completion of the review of the grievance and a written decision regarding his or her grievances. On 1/20/26 at 3:05 PM, the State Agency (SA) toured the entire facility and observed there was no information posted displaying the ombudsman's contact information. On 1/21/26 at 9:50 AM, the State Agency (SA) toured the entire facility and observed there was no information posted displaying the ombudsman's contact information. On 01/21/2026 at 10:00 AM, in an interview with the Social Worker, she provided the SA with the ombudsman's information. She was asked if the facility had a sign displaying the ombudsman info and she said yes. She was asked to take the state agency surveyor to the sign; she then took the SA to a hallway where she said the sign normally was but confirmed that no sign was there. Upon looking at the site, she concluded that the maintenance supervisor must have removed the sign to paint the wall and had not replaced it. She stated that the importance of keeping the ombudsman's information readily available via a sign for the residents is that residents will know how to contact the ombudsman with questions about their care or can go to them with concerns that they're not comfortable telling their staff members about and for information to get in touch with the state department of health for other concerns. On 1/21/2026 at 1:15 PM, during a Resident Council Meeting, the residents had concerns about the Ombudsman poster not being posted. Resident #1 stated the poster has been missing for over a month now. She stated they were painting the walls and did not replace the poster after they finished the painting the wall. On 1/22/26 at 8:20 AM, in an interview the Director of Nursing (DON), stated that the importance of ombudsman information being available to the residents is that they are able to contact them at any time to report their concerns about care and are able to report it to the state department of health. A record review of Resident #1's admission Record revealed she was admitted on [DATE] with diagnoses that included hypothyroidism. A record review of Resident #1's Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 10/17/25 revealed a Brief Interview for Mental Status (BIMS) score of (15) which indicated the resident was cognitively intact.

Based on observation, interview, record review and facility policy review, the facility failed to ensure a resident received necessary grooming assistance in accordance with her preferences for one (1) of (15) residents reviewed for Activities of Daily Living (ADLs). Resident #41Findings include:A review of the facility policy, Resident Rights, undated, revealed .5. Respect and dignity. The resident has the right to be treated with respect and dignity During an interview with Resident #41 on 1/20/26 at 11:20 AM, she stated that the staff do not shave under her arms. She reported that when she lived at home, she shaved under her arms every day or as often as needed. She added that if staff shaved under her arms at least once a week, she would be satisfied.During an observation on 1/20/26 at 11:21 AM, revealed Resident #41's underarm hair to be thick and approximately two and one-half (2.5) inches long.During an interview with Certified Nursing Assistant (CNA) #1 at 10:20 AM on 1/21/26, the CNA stated that shaving under the arms is part of the ADLs for residents. She explained that it is important to ensure this task is completed because it helps maintain residents' dignity and reflects what they would typically do at home.In a follow up interview at 10:34 AM, on 1/21/26 while assessing Resident #41, CNA #1 stated that the hair under Resident #41's arm appeared not to have been shaved in a while, adding, It is really long and needs to be cut.On 1/21/26 at approximately 1:30 PM, during an interview the Director of Nursing (DON), explained that shaving under residents' arms is part of the ADLs provided by CNAs. She added that this task is performed for hygienic purposes and is part of maintaining residents' dignity.A record review of the admission Record revealed the facility admitted the resident on 12/2/25 with diagnoses including Generalized Muscle Weakness and Other Lack of Coordination.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/4/26 revealed a Brief Interview Mental Score (BIMS) of 12 indicating the resident has moderate cognitive impairment.

Based on interview, record review, and policy review, the facility failed to ensure the resident's right to be free from neglect when staff failed to both assist during use of a full body lift to transfer a resident from bed to the geriatric chair, which resulted in the resident being transferred to the hospital with injuries for one (1) of (30) residents who are assessed to use a full body lift. Resident #1 Findings include: A review of the facility policy titled Modified Lifting Policy, updated 2/3/23, reveals, Facility will provide a safe work environment for patient care areas by providing and requiring the use of safety materials, equipment and training designed to prevent personnel and patient injury .Procedure.1. Staff will follow the documented lifting protocol deemed appropriate for each resident. A review of the facility policy titled Total Lift Vanderlift II, updated 2/3/23, revealed, .Responsibility: Two people are required to operate the Total Lift. On 4/9/25 at 10:04 AM, the State Agency (SA) conducted a phone interview with Certified Nursing Assistant (CNA) #1. During the interview, she recalled that she was asked by CNA #2 to spot her with a resident transfer to the geri-chair on 4/7/25. Upon entering Resident #1's room, she noted the resident was already attached to the total body lift. She further stated that facility policy allows CNAs to attach a resident to the lift independently; however, the actual transfer necessitates a second person present in the room only. Therefore, as CNA #2 operated the lift, she turned her back to them to retrieve the geri-chair. At that point, she heard a loud pop followed by CNA #2's exclamation of, Oh my god, she is sliding! CNA #1 stated that she initially suspected a sling malfunction but observed it remained intact. Upon turning, she saw the resident's head resting at the foot end of the sling while her feet remained elevated within it, and there was blood near the resident's head. She reported that CNA #2 instructed her to get Licensed Practical Nurse (LPN) #1, who then directed her to notify the Director of Nursing (DON). Subsequently, she lowered the lift to remove the sling from under the resident's shoulders, with nurses assisting in its complete removal. She noted blood on CNA #2's hand, which was supporting the resident's head. Initially, the resident was unresponsive but later began yelling for help and continued to do so until paramedics arrived. She believed all actions taken were consistent with her training; however, CNA #2 reported that the resident began sliding after pushing back against the lift with her foot. On 4/9/25 at 10:38 AM, in a phone interview with CNA #2, stated that she entered Resident # 1's room to assist with dressing for therapy on 4/7/25. She reported placing the sling under the resident before CNA #1 entered the room, noting a dot on the lift that indicates the sling size (small, medium, or large). A medium sling was used. She then lowered the lift to the resident, attached the four hooks, and began to move the resident backward. She confirmed the lift legs were open and all four sling hooks were attached. While waiting for CNA #1 to position the geri-chair, she heard two loud boom sounds. She stated the resident was pushing against the lift, subsequently slid, and she was unsuccessful in catching her. The resident's head struck the lift. She went to secure the resident's head with her hands as she observed bleeding. CNA #1, who by this time was standing beside her, was instructed to get help. CNA #2 stated she does not recall everyone who responded due to being in shock. She estimated the resident lost consciousness for approximately one minute before regaining it and beginning to scream for help. CNA #2 reassured the resident. She expressed that she was still processing the incident, as nothing similar had ever occurred. She indicated that the resident is designated as a two-person assist according to the facility kiosk. She understood this to mean that two CNAs must be present in the room before connecting the resident to the lift and denied connecting the resident prior to CNA #1's arrival. She suggested that the only potential for a different outcome could be if CNA #1 had been standing directly beside her to maybe help catch the resident before she slid out. She confirmed the sling did not break. She also stated that the Administrator had her perform a reenactment using the same sling, which showed no signs of damage. On 4/9/25 at 11:02 AM, in an interview with Lift Trainer, who conducts lift transfer training for CNAs, revealed the standard procedure for transferring a resident using the total body lift. While one CNA supports the resident's head with a hand on the lift, the second CNA guides the resident into the geri-chair. The Trainer emphasized that this is the method she uses for all CNA training and, based on her experience, considers it the safest approach to resident transfers, minimizing the risk of injury. She reiterated the importance of both CNAs being strategically positioned at the lift throughout the transfer to ensure the resident's safety. During the interview on 4/9/25 at 11:27 AM, with Licensed Practical Nurse (LPN) #1, she explained to SA that two-person assist to her does require two CNAs positioned on the lift to attach the resident. She said once the resident is attached, one person maneuvers the lift while the other stands at the bottom with hands on, holding the resident in place to ensure the resident does not swing or sway and to keep them in a safe position during transfer. During the interview with the DON on 4/9/25 at 11:41 AM, she said a two-person assist using the total body lift means the CNAs must first enter the room together and collaboratively initiate the process. Working as a team, they then position the sling under the resident. During the lift, one CNA guides the equipment while both CNAs secure the lift straps on either side of the resident; one CNA stays with the resident, and the other operates the remote to elevate them. Once lifted, one CNA controls the remote while the other physically supports the resident as they are moved towards the chair. Both CNAs then carefully guide the resident into the chair, maintaining contact with the sling for safety, before jointly removing it. A record review of the Admission Record reveals the facility admitted Resident # 1 on 3/26/25 with diagnoses including Other Fracture of Left Lower Leg, Subsequent Encounter for Closed Fracture with Routine Healing. A record review of Resident # 1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/1/25 reveals a Brief Interview for Mental Status (BIMS) score of five (5), indicating the resident could not fully participate in the interview. A record review of the CT (Computed Tomography) Head revealed IMPRESSION: Interval scattered small volume bifrontial subarachnoid hemorrhage (bleeding in the space around the brain). This was after the fall from the lift on 4/7/25. A record review of the Lift Transer Eval (Evaluation) dated 3/26/25 revealed a two-person assist during transfer.

Based on observation, interviews, and facility policy review, the facility failed to store food and maintain sanitary practices in accordance with professional standards for food safety related to unlabeled foods, foods without identified dates, exposed foods, and overly ripe produce for one (1) of two (2) kitchen observations. Findings Include: A review of the facility's policy, Storage of Refrigerated Food, revised ,d+[DATE], revealed, The facility ensures the quality and safety and sanitation of refrigerated foods through accepted storage practices. Procedure .4. No food is left uncovered. 5. All opened foods are labeled with common name of food, date stored, and use-by date . On [DATE] at 9:19 AM, during an observation of the kitchen and interview with the Certified Dietary Manager (CDM), Refrigerator #1 had nine (9) overly ripe tomatoes containing white biological growth on each tomato. There was (1) unopened bag of salad mix with a facility received sticker of [DATE], with no manufacturer's date, and a brown discolored liquid inside the bag. There was (1) opened block of cream cheese inside a plastic food storage bag with a written-on date of [DATE]. The CDM explained that this was the date it came in and most likely the date it was opened. Additionally, there was (1) plastic storage bag of sliced ham with a handwritten date of ,d+[DATE], (1) plastic storage bag of bologna dated [DATE], (1) plastic storage bag of bologna with a date of [DATE], and (1) plastic storage bag of bologna dated [DATE]. The CDM stated these were the dates the sliced ham and bologna were opened and placed in the bags. An observation of Refrigerator #3 revealed four (4) eight (8) ounce containers of chocolate milk wrapped in plastic wrap with a manufacturer's date of [DATE] and a received-on date of ,d+[DATE]. An observation of the freezer revealed (1) bag of shrimp that was opened, and the shrimp was exposed. On [DATE] at 01:00 PM, during an interview, the CDM acknowledged the overly ripe produce, outdated milk, and unlabeled food items in the kitchen. The CDM stated it was his responsibility to check for outdated foods and to insure proper labeling. He expressed that food should be checked daily and confirmed that he in-serviced the staff monthly on food safety. On [DATE] at 12:20 PM, an interview with the Administrator revealed he was aware of the findings during the kitchen observations regarding unlabeled and out of date food items, as well as expired and exposed foods. The Administrator stated he expected the kitchen staff to monitor the foods daily for expired items and to inspect the produce daily.

Based on observation, interview, record review, and policy review the facility failed to ensure a two-person transfer, as evidenced by video evidence of a Certified Nursing Assistant (CNA) transferring a resident from the bed to the geriatric chair by herself. The resident required a 2-person transfer. This was for one (1) of 16 sampled residents. Resident # 12. Findings Include: A review of the facility policy titled Modified Lifting Policy, no date, reveals, .Facility will provide a safe work environment for patient care areas by providing and requiring the use of safety materials, equipment and training designed to prevent personnel and patient injury .It is crucial that health care professionals practice safe lifting, transporting . At 1:05 PM on 8/13/24, as Certified Nursing Aide (CNA) #2 recapped what she saw in the social media video, she specifically pointed out that she saw CNA #1 put the geriatric chair in front of the resident's bed. She remembers seeing CNA #1 grab the resident under the arms and move her to the geriatric chair by hand. She stated the transfer was unsafe because the resident should have been transferred by two people, as the resident was an extensive two person assist for transfer. On 8/13/24 at 1:16 PM during an observation of the social media video footage, which was filmed live and posted online, CNA #1, lifted the resident without assistance and transferred her to a geriatric chair. On 8/13/24 at 2:36 PM, during an interview with the Administrator, he confirmed that on 7/15/24 at approximately 8:45 AM, CNA #2 informed him of a video posting from a current CNA on social media. He stated that he watched the video that morning. He continued by saying that CNA #1 was scheduled to come in that afternoon to work, so he let her come in he explained to her that he had seen the video that she had posted that involved the care of Resident #12. At time, her reported that he told CNA #1 that he was terminating her employment and that she needed to leave the building. On 8/14/24 at 9:28 AM, in an interview with Minimum Data Set (MDS) Nurse, she confirmed that for transfers, Resident #12 is care planned as an extensive two person assist. She stated this was put into place to ensure the safety of the resident to prevent the resident from falling and having any injuries. She added that the CNAs can use the kiosk (interactive computer terminal) on the wall to identify the plan of care for residents. Therefore, with this resident they should never attempt to lift or transfer the resident by themselves. On 8/14/24 at 2:01 PM in an interview with CNA #3, she confirmed that Resident #12 is one her residents that she is assigned to from time-to-time. She explained that this resident is a total body lift and requires an extensive two person transfer when moving her out of the bed. A record review of the Facesheet revealed Resident #12 was admitted on [DATE] by the facility. Her diagnosis includes Cognitive Communication Deficit and Unspecified Dementia. A record review of the quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 7/12/24 revealed a Brief Interview Mental Status (BIMS) score of 99, which indicated that the resident was unable to participate in the interview.

Based on observation, staff interview, and facility policy review, the facility failed to post the direct care daily staffing numbers in a location accessible to residents and visitors for two (2) of three (3) days of survey. Findings Include: Review of the facility ' s policy, Nurse Staffing Posting Information, revised 2/3/2023, revealed, .It is the policy of this facility to make staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The nurse staffing information will be posted on a daily basis .2. The facility will post the nursing staffing data at the beginning of each shift . On 8/13/24 at 9:30 AM, there were no direct care daily staffing numbers posted in the facility. On 8/14/24 at 8:30 AM, there were no direct care daily staffing numbers posted in the facility. On 8/15/24 at 10:15 AM, in an interview with the Director of Nursing, she stated she was aware the nursing staffing had to posted in a prominent place that was readily accessible to residents and visitors at the beginning of the shift. On 8/13/24 at 2:45 PM, in an interview with Licensed Practical Nurse (LPN) #1, she revealed she was aware that staffing should be posted and stated that it was usually posted at the front desk. She stated that on Tuesday and Wednesday of this week there must have been a breakdown in communication since the staffing numbers did not get posted. On 08/15/24 at 10:34 AM, an interview with the Administrator revealed it was the policy of the facility to post the facility staffing information to ensure it was readily available in a manner that was readable by residents and visitors at any given time. The Administrator was unsure why the staffing information was not posted on the first and second day of the survey and he commented that it was normally posted at the nursing station for visitors and residents and that it was an important aspect of resident care and customer service.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure their medication error rate was less than five percent as evidenced by three (3) errors were observed out of twenty-six (26) medication administration opportunities. This affected two (2) of seven (7) residents observed during medication pass, resulting in a medication error rate of 11.54%. (Residents #48 and #13) Findings include: A review of the facility's policy titled, Medication Administration General Guidelines, (undated) revealed, Medications are to be administered as prescribed in accordance with good nursing principles and practices .Procedure .2. Medications are to be administered in accordance with the written orders of attending physicians, taking into consideration manufacturer's specifications, and professional standards of practice . A review of the facility's policy titled, Ordering and Receiving Medications from Pharmacy, (undated) revealed, Medications are ordered and received from the pharmacy in a timely manner .Procedure . 2. A. Re-order medication in advance of need to ensure an adequate supply is on hand . Resident #48 On 8/13/24 at 2:46 PM, during an observation with Licensed Practical Nurse (LPN) #2 as she administered medications to Resident #48 via PEG(Percutaneous Endoscopic Gastrostomy) tube, it was noted the medications due at that time were Gabapentin 400 milligrams (mg) capsule (three times a day) and Bethanechol Chloride 25 mg tablet (three times a day) via PEG tube. LPN #2 stated that the Bethanechol Chloride was not in the medication cart. The nurse checked her cart twice and checked the Omnicell (an automated medication dispensing cabinet) in the medication room, but the medication was unavailable. Record review of Resident #48's Order Summary Report with active orders as of 8/15/24 revealed an order dated 4/19/24 for Bethanechol Chloride Tab 25 mg Give 1 tablet via PEG-tube three times a day related to Essential (primary) hypertension. A record review of Resident #48's Admission Record revealed that the facility admitted the resident on 4/2/24, with diagnoses that included Essential Hypertension and Chronic Systolic Heart Failure. A record review of Resident #48's August 2024 Electronic Medication Administration Record (eMAR) documentation revealed Bethanechol Chloride was documented as unavailable for two doses on 8/13/24 and the morning dose on 8/14/24. On 8/14/24 at 9:07 AM, during an interview, LPN #2 stated it was the responsibility of the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the cart nurses to ensure that medications were available for residents. She stated that if a resident was out of medications, the nurses must report it. She usually ordered medications when she noticed the supply was down to five (5) days. She emphasized the importance of residents receiving medications as ordered by the physician. She also stated that she usually ordered medications stat (meaning that the pharmacy was to deliver them the same day), but admitted she forgot to order Resident #48's blood pressure medication stat, which should have been done. Resident #13 At 8:35 AM on 08/14/23, during medication administration an observation and interview with Licensed Practical Nurse (LPN) #2 revealed that (LPN) #2 reported and confirmed Fluticasone Propionate nasal spray and Saline nasal spray was out of stock. Therefore, Resident #13 was unable to receive the ordered medications. On 8/14/24 at 9:05 AM, during an observation of Resident #13 receiving his inhaler medication, the resident asked LPN #2 if they had found his nasal spray. The nurse stated, No, and the resident commented that the last time he had received it was yesterday. A record review of Resident #13's Admission Record revealed that the facility admitted the resident on 2/15/23, with diagnoses that included Chronic Obstructive Pulmonary Disease and Acute and Chronic Respiratory Failure with Hypoxia. A record review of Resident #13's Order Summary Report, with active orders as of 8/15/24, revealed a physician's order, with an order date of 4/2/24, for Nasal Spray (sodium chloride) 0.65% aerosol: one (1) spray in each nostril twice a day, every day, related to Chronic Respiratory Failure with Hypoxia and an order, with an order date of 2/15/23, for Fluticasone Propionate 50 MCG (microgram) Spray for two (2) sprays in each nostril daily, related to Chronic Obstructive Pulmonary Disease. Record review of the August 2024 eMAR documentation revealed Resident #13 had not received the Saline Nasal Spray at 9 PM on 8/13/24 and the 9 AM dose on 8/14/24. Fluticasone Propionate nasal spray was not documented as received at 8 AM on 8/14/24. A record review of Resident #13's eMAR revealed that this was the second (2nd) dose of saline nasal spray and first (1st) dose of Fluticasone Propionate nasal spray that the resident had missed. On 8/14/24 at 1:52 PM, during an interview with the ADON, it was confirmed that medications should be reordered when the supply reached five (5) days. On 8/14/24 at 2:56 PM, in a phone interview, LPN #2 confirmed that she did not administer Resident #48's Bethanechol Chloride medication the previous day. However, she also added that she had spoken to the NP (Nurse Practitioner) and the NP clarified the order was for urine retention and not blood pressure. She stated she informed the Administrator, DON, and ADON about Resident #48's medication and Resident #13's medications being out of stock. She mentioned that she was unaware of the backup pharmacy and had charted it as a 9 on the eMAR because the medication was not in stock. On 08/14/24 at 4:03 PM, during an interview with the DON, it was confirmed that cart nurses were responsible for informing her and the ADON when medications were out of stock. The DON stated that cart nurses should ensure that medications are in stock for residents to receive their medications as scheduled. She expressed uncertainty about why the nurses ran out of medications but confirmed that nurses were supposed to order medications when the supply was down to a five-day supply to avoid running out. She also stated that nurses were expected to follow physician orders. The DON mentioned she was unaware of a backup pharmacy but stated that medications should arrive the day they are ordered unless they are special-order medications. She emphasized that the out-of-stock medications were not special-order medications and reiterated her expectation that nurses administer medications per physician orders, as not receiving medications as prescribed could harm residents due to their health conditions.

Based on observation, interviews, record review, and facility policy review, the facility failed to serve therapeutic portion sizes of foods as planned per the facility's menu for one (1) of seven (7) food items requiring specific portions on the lunch meal tray line. Resident #40 Findings Include: A review of the facility's policy, Tray Assembly, revised 6/17, revealed, .Prepared foods are portioned and assembled for individual meals in the food and nutrition services department. Procedure .6. Menu items and equipment are positioned in reach of the food service employees. These items include .c. Serving utensils as specified on the menu and equipment needed for correct portions .10. Portions are .weighed on portion scales . A record review of the facility's Menu Guide Report for Spring/Summer 2024 revealed the following portion sizes to be served at lunch: 3 ounces of country meatloaf, 1/3 cup of mashed potatoes,1-ounce brown gravy, 1/3 cup of buttered green peas, one (1) fresh baked roll, one (1) piece of confetti cake with icing, and one (1) cup of iced tea. On 08/13/24 at 10:51 AM, during an interview, Resident #40 complained her meals had inconsistent portion sizes and stated she had mentioned this concern to the facility staff. On 08/13/24 at 12:35 PM, an observation of two (2) sampled meal trays with the Certified Dietary Manager (CDM) revealed the meal consisted of meatloaf, mashed potatoes, green peas, roll, cake and tea. The portion sizes for the meatloaf were notably different. On 08/13/24 at 12:50 PM, during an interview, Dietary Staff #1 acknowledged that she sliced the meatloaf freehand, resulting in each slice being visibly different in size. The cook confirmed that a serving of meatloaf should be 3 ounces and reported that the facility had not provided any means for her to measure a serving of meatloaf. On 08/13/24 at 1:00 PM, during an interview with the Certified Dietary Manager (CDM), he stated that he was unaware the meatloaf was not evenly sliced. The CDM confirmed that a serving of meatloaf should be 3 ounces and reported that the facility had a scale available to measure portions of meatloaf. However, he confirmed that no scale was present during the serving of that day's meatloaf. On 08/15/24 at 10:34 AM, during an interview with the Administrator, it was confirmed that he had already been made aware of the inconsistent portions of food served during lunch on 08/13/24. The Administrator stated that he expected the dietary staff to follow the portion sizes identified on the menu. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/01/2024 revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Record review of the Care Profile revealed a physician order that Resident #40 was to receive a Regular diet, Regular texture, and Large portions.

Based on interviews, record reviews, and facility policy reviews, the facility failed to implement/follow the care plan for three (3) of sixteen (16) sampled residents. Resident #12, Resident #13, Resident #48 Findings Include: A review of the facility policy titled Care Plans, updated 2/3/23 revealed, Policy: Each resident will have a person-centered plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care .Resident Care Summary-part of the Comprehensive Care Plan is used as the tool to make staff aware of the resident's daily care needs . Resident #12 A record review of the ADL (Activities of Daily Living) comprehensive Care Plan dated 1/29/24, revealed an intervention related to transfers as Transfers: Extensive Two Person Assist At 1:05 PM on August 13, 2024, as Certified Nursing Assistant (CNA) #2 recapped what she saw in the social media video, she specifically pointed out that she saw CNA #1 grab the resident under the arm and move her to the geriatric chair without assistance. She stated the transfer was unsafe because the resident should have been lifted by two people. On 8/14/24 at 9:28 AM, in an interview with Minimum Data Set (MDS) Nurse, she reviews and confirms with that the care plan for Resident #12 states that for transfers, the resident is an extensive two person assist. She said this intervention was put into place to ensure the safety of the resident. The MDS Nurse further added that care written and available on the kiosk (interactive computer terminal) of the wall in the hall of resident care areas, so that CNAs (Certified Nurse Aides) will know how to care for residents. Resident #13 A record review of Resident #13's comprehensive Care Plan dated 2/23/23 revealed At risk for Dyspnea/Shortness of Breath/Difficulty Breathing related to COPD and Respiratory Failure with Hypoxia .Interventions .Fluticasone Prop (Propionate) 50 mcg (micrograms) Spray, spray two (2) sprays in each nostril daily .Nasal Spray (sodium chloride), spray one (1) spray intranasally twice daily every day in each nostril . At 8:35 AM on 08/14/23, during an observation of medication administration with an observation and interview of medication administration with Licensed Practical Nurse (LPN) #2 reported and confirmed Fluticasone Propionate nasal spray and Saline nasal spray was out of stock. Therefore, Resident #13 was unable to receive the ordered medications. A record review of Resident #13's Admission Record revealed that the facility admitted the resident on 2/15/23, with diagnoses that included Chronic Obstructive Pulmonary Disease and Acute and Chronic Respiratory Failure with Hypoxia. A record review of Resident #13's Order Summary Report, with active orders as of 8/15/24, revealed a physician's order, with an order date of 4/2/24, for Nasal Spray (sodium chloride) 0.65% aerosol: one (1) spray in each nostril twice a day, every day, related to Chronic Respiratory Failure with Hypoxia and an order, with an order date of 2/15/23, for Fluticasone Propionate 50 MCG (microgram) Spray for two (2) sprays in each nostril daily, related to Chronic Obstructive Pulmonary Disease. Record review of the August 2024 Electronic Medication Administration Record (eMAR) documentation revealed Resident #13 had not received the Saline Nasal Spray at 9 PM on 8/13/24 and the 9 AM dose on 8/14/24. Fluticasone Propionate nasal spray was not documented as received at 8 AM on 8/14/24. Resident #48 A record review of Resident #48's comprehensive Care Plan dated 4/18/24 revealed Hypertension, controlled .Care Plan Goal . Reduce complications from Hypertensive symptoms .Bethanechol Chloride 25 mg tablet: Give 1 tablet via peg (Percutaneous Endoscopic Gastrostomy) tube before meals every day . On 8/14/24 at 2:46 PM, during an observation and interview with LPN #2 administering medications via PEG tube to Resident #48, his medications included Bethanechol Chloride. LPN #2 stated the Bethanechol Chloride was not available on her medication cart. The nurse checked her medication cart twice and checked the Omnicell (an automated medication dispensing cabinet) in the medication room, however, the medication was not available. Review of Resident #48's Admission Record revealed an admitted [DATE] with diagnosis of Essential (Primary) Hypertension and Chronic Systolic (Congestive) Heart Failure. Record review of Resident #48's Order Summary Report with active orders as of 8/15/24 revealed an order dated 4/19/24 for Bethanechol Chloride Tab 25 mg Give 1 tablet via PEG-tube three times a day related to Essential (primary) hypertension. A record review of Resident #48's August 2024 Electronic Medication Administration Record (eMAR) documentation revealed Bethanechol Chloride was documented as unavailable for two doses on 8/13/24 and the morning dose on 8/14/24. On 8/14/24 at 1:52 PM, in an interview with Assistant Director of Nursing (ADON) stated they should reorder medications when it gets down to five (5) days left. She confirmed the residents' medications are listed on the care plans and the care plan is not followed if the medications are not given. On 08/14/24 at 4:03 PM, during an interview with the Director of Nurses (DON), she explained her expectations of nurses are to give medications per physician orders and follow care plans. She stated residents should receive medications as prescribed for their health conditions. 48669

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident was free from exploitation for one (1) of 16 sampled residents. Resident #12. Findings Include: A review of the facility's policy, Resident Rights, dated 2018, revealed: 1. Resident Rights. The resident has the right to a dignified existence, self-determination .5. Respect and Dignity. The resident has a right to be treated with respect and dignity . A review of the facility's policy, Abuse, Neglect and Exploitation, reviewed/revised 5/25/24, revealed: Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Definitions: Exploitation means taking advantage of a resident for personal gain .Mistreatment means inappropriate treatment or exploitation of a resident . IV. Identification of Abuse, Neglect and Exploitation . B. Possible indicators of abuse include, but are not limited to: 9. Evidence of photographs or videos of a resident that are demeaning or humiliating in nature, regardless of whether the resident provided consent and regardless of the resident's cognitive status . A record review of the Facesheet revealed that the facility admitted Resident #12 to the facility on [DATE]. The resident had diagnoses that included Unspecified Dementia and Cognitive Communication Deficits A record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/12/24 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 99, indicating that the resident was unable to participate in the interview. A record review of the facility's Reportable Incident Form, dated 7/19/24, revealed on 7/15/24 at 8:45 AM, two (2) Certified Nurse Aides (CNAs) reported to the Administrator that CNA #1 had made a video in which she forcefully and manually transferred Resident #1 to a Geri (geriatric) chair from her bed. Resident #1's extremities and lower body were exposed during the video, but her private lower body parts could not be seen. Upon receiving the information, the Administrator reported the incident to the state agency, AGO's office, local police, the Resident Representative (RR), the Medical Director, and the resident's Hospice agency. At 1:05 PM on 8/13/24, during an interview, CNA #2 stated she did not know CNA #1 personally because their work schedules differed. She reported that a former coworker called her on the evening of 7/14/24 and told her to watch a live video on social media involving CNA #1 and Resident #12. CNA #2 logged onto the social media account and saw the live video of CNA #1 in the resident's room dancing. She observed CNA #1 put the Geri (Geriatric) chair in front of the resident's bed and then grab the resident under the arms and manually transferred her to the Geri chair. CNA #2 stated that the transfer was unsafe because the resident should have been lifted by two people. She recalled that people watching the video made comments praising CNA #1 and called her CNA of the year, and CNA #1 showed her thanks by clapping, which made it appear that she enjoyed the attention. The resident stayed seated in the chair, and while her body was visible in the background, she was not naked. The video ended when CNA #1 looked toward the door, as if she thought someone was coming into the room. CNA #2 stated that she reported the video that she had watched to the Administrator on the morning of 7/15/24. On 8/13/24 at 1:16 PM during an observation of the social media video footage, which was filmed live and posted online, CNA #1, who posted the video using another name, was observed lifting Resident #12 from her bed into the Geri chair. The resident's thighs, legs, and feet were visible to viewers, but her face was not disclosed. Once Resident #12 was seated in her geriatric chair, CNA #1 turned to the camera, clapped her hands, smiled, and shook her buttocks while the audience praised her. CNA #1 then moved in the video, exposing the resident's face and bottom half of her body. As she continued communicating with the audience, CNA #1 waved her hand in front of her face, indicating that Resident #12 had an odor coming from her body. The audience responded with obscenities, and CNA #1 laughed. In response to viewer comments, CNA #1 said, Lord forgive me, and the video ended. The live video lasted one minute and seven seconds. On 8/13/24 at 2:36 PM, during an interview with the Administrator, he reported that a 7/15/24 at approximately 8:45 AM, CNA #2 informed him of a video posting from a current CNA on social media. He stated that he watched the video that morning. He further stated that he personally conducted the investigation, as the current Director of Nurses (DON) was not a part of the investigation. He continued by saying that CNA #1 was scheduled to come in that afternoon to work, so he let her come in and that is when he told her that he had seen the video and that he was terminating her employment at the facility and that she needed to leave the building. At 8:32 AM on 8/15/24, during a telephone interview with CNA #1, she revealed she had been a licensed CNA for about three years and had worked at the facility where Resident #12 lives for about two months. She vehemently denied appearing in the social media video with Resident #12 in the background. She claimed the Administrator called her into the building and told her about a video, but he never allowed her to watch it to ensure it was her. In the interview, she explained that she would not do such a thing because she knew it was wrong to video residents. Since CNA #1 denied it was her in the video, she was asked to explain why it would be wrong for residents to be posted on social media by any staff in general. CNA#1 said it would violate the resident's rights and patient confidentiality. She said it would be wrong since she understood that to video a resident, you must first have the resident's or the responsible party's consent first. At 8:54 AM on 8/15/24, in a follow-up interview with CNA #1, she was informed that according to the picture of the driver's license in her personnel file, it was her on the live social media. CNA #1 got quiet and responded, I did not do a video on that particular social media site live. I just want to make sure you do not put that on your paper. On 8/15/24 at 11:40 AM, during an interview with Resident #12's family, the family member stated that the resident was very private and would not have wanted or allowed someone to make such a video of her. He stated that she would have been offended.

Based on observation, interviews, record reviews, and facility policy review,the facility failed to provide incontinent care in a manner to prevent possible urinary tract infections for one (1) of five (5) observations of incontinent care. Resident #49. Findings include: Review of the facility's policy, Incontinent Care, undated, revealed, To provide routine, preventative skin, perineal care to residents after an incontinent episode .When washing perineal area, wash the perineal area from front to back. For the male resident retract the foreskin while using clean area of the washcloth or adult wipes for each stroke . During an observation of incontinent care on 1/17/23, at 11:33 AM, Certified Nurse Aide (CNA) #1 failed to use a clean area of the adult wipe while cleaning the penis of Resident #49. CNA #1 cleansed the resident's scrotum with an adult wipe by wiping several times with the same wipe, then used the same wipe and same area of the wipe to cleanse the head of Resident #49's penis. During an interview on 1/19/23, at 11:00 AM, CNA #1 confirmed while providing perineal care to Resident #49, she failed to change the area of the adult wipe to clean the resident's penis after cleansing his scrotum. CNA #1 confirmed this could cause Resident #49 to get an infection. Review of the facility's checkoff, Incontinent & or Catheter Care of Observation dated 11/17/22, revealed CNA #1 was trained to change area of wash cloth or wipe for each stroke when providing incontinent care. Record review of the medical records for Resident #49 on 1/17/23, revealed the resident did not have an infection and was not receiving an antibiotic at that time. During an interview on 1/19/23 at 12:29 PM, the Director of Nursing (DON) confirmed CNA #1 should have changed the adult wipe after cleansing the scrotum, before cleaning the head of the penis of Residents # 49. The DON confirmed that this action could possibly cause a urinary tract infection. During an interview on 1/19/23 at 2:47 PM, License Practical Nurse (LPN) #2 confirmed CNA #1 should have changed the wipe after cleansing the scrotum of Resident #49, as cleansing the penis with the same wipe could cause urinary tract infections. During an interview on 1/19/23 at 2:53 PM, LPN #1 confirmed she expected the staff to cleanse Resident #49's perineal area in a manner to prevent infection. LPN #1 confirmed Resident #49 is high risk for infection due to his diagnosis of Diabetes Mellitus and End Stage Renal Disease (ESRD). Record review of the facility Face Sheet revealed the facility admitted Resident #49 on 12/13/22, with the diagnoses that included End Stage Renal Disease (ESRD) and Diabetes Mellitus (DM). Record review of the admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 12/19/22, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated Resident #49 had moderate cognitive impairment. Section H revealed Resident #49 is always incontinent of bowel and bladder.

Based on interviews, record review, and facility policy review, the facility failed to protect residents from misappropriation of a medication for four (4) of nine (9) sampled residents. Resident #1, #7, #8, and #9. Findings Include: A record review of the facility's policy, CONTROLLED MEDICATIONS ADMINISTRATION (undated), revealed the policy stated POLICY: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subjected to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations. RESPONSIBILITY: All Licensed Nursing Personnel/Executive Director/Pharmacy Consultant. PROCEDURE .Only authorized licensed nursing and pharmacy personnel have access to controlled medications .4. Medications listed in Schedules II, III IV and V dispensed by the pharmacy are adequately documented and reconciled consistent with law and regulations .6. When administering controlled medication, the authorized personnel records the administration on the MAR (Medication Administration Record) or EMAR (Electronic MAR) and enters all of the following information on the controlled Drug Record: a. Date and time of administration b. Amount administered c. Signature of the person preparing the dose d. Quantity reconciled . A record review of the facility's guidelines, MEDICATION ADMINISTRATION GENERAL GUIDELINES (undated), stated .RESPONSIBILITY: All Licensed Nursing Personnel .PROCEDURE: .4. Medications are administered at the time they are prepared for each resident one at a time. Medications are not pre-poured .11. The resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .on the line for that specific medication dose following medication administration . A record review of the facility's Abuse Program revised on 5/23/17, revealed the document stated It is the policy of this facility to take all steps necessary to maintain an environment free of abuse and neglect. Each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, exploitation, misappropriation of resident property, .The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff . A record review of the facility's Reportable Incident Form, completed by the Interim Director of Nursing (DON) and dated 9/22/22, revealed that she had received a call from the Mississippi Board of Nursing on 9/21/22 at approximately 4:00 PM. The Mississippi Board of Nursing stated that they had received an anonymous call that the facility had a nurse that was possibly diverting medications. The caller had identified the nurse as Licensed Practical Nurse (LPN) #1. Copies were made of the Narcotic sheets for the cart that LPN #1 had been working. In review of the narcotic sheets, the Interim DON's report stated that there were medications that were only given when LPN #1 worked, there were medications signed out that the resident knew nothing about and denies taking, and there were medications that LPN #1 signed out for future times. The investigation notes included a statement written by the Administrator to the Interim DON revealing that he had interviewed two (2) residents, per her request, inquiring about their medication schedule. His statement disclosed that upon asking Resident #1 how often he took [MEDICATION(S)] for pain, the resident told him that he has only taken [MEDICATION(S)] maybe once since he has been a resident at the facility. The Administrator wrote that when he interviewed Resident #7, the resident told him that he only took [MEDICATION(S)] once at night for rest and sleep. The results of LPN #1's urine drug screen that was done 9/22/22 at 10:05 AM, tested positive for opiates and [MEDICATION(S)]. LPN #1 was unable to provide a valid prescription to account for the positive drug screen. At this point LPN #1 was asked to leave the facility and was put on Investigative Leave pending completion of the investigation. The report stated that the Administrator and Staff Development Nurse found additional issues with the narcotic count once the med cart was turned over from LPN #1. LPN #1 was scheduled to work a double shift on 9/22/22 and had already signed out medications on the Narcotic Log for two (2) residents that were scheduled to receive those medications later in the shift and those medications were unaccounted for. The investigation documentation identified four (4) residents identified by the facility that were affected by the reported drug diversion (Resident #1, #7, #8, and #9). Record review of the Personnel Termination Notice, revealed that LPN #1 was terminated on 9/23/22 for violating the facility drug policy. It stated the employee was found not to be giving prescribed narcotic medication. On 10/03/22 at 5:10 PM, during an interview with Resident #1, he stated he was aware that he had a prescription for [MEDICATION(S)], but he doesn't take it. He stated If someone recorded that I took that [MEDICATION(S)], that wasn't correct. I don't know who took it, but I didn't. Record review of the Face Sheet for Resident #1 revealed the resident was admitted by the facility on 2/25/21. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly Minimum Data Set (MDS) for Resident #1 with Assessment Reference Date (ARD) of 9/19/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. On 10/03/22 at 5:20 PM, during an interview with Resident #7, he explained that he had phantom limb pain in his left above the knee amputation. He stated [MEDICATION(S)] was prescribed for the pain, but he didn't like to take it because of his fear of becoming addicted. He said he never asked for it except at bedtime to help him to sleep. Record review of the Face Sheet for Resident #7 revealed the resident was admitted by the facility on 10/18/19. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Annual MDS for Resident #7 with an ARD of 10/3/22 revealed a BIMS score of 15, which indicates no cognitive impairment. Record review of the Face Sheet for Resident #8 revealed the resident was admitted by the facility on 10/20/20. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8's Quarterly MDS with an ARD of 7/15/22 revealed the resident had BIMS score of 99, as the resident was unable to complete the assessment. The assessment revealed that the resident had problems with both short- and long-term memory. Record review of the Face Sheet for Resident #9 revealed the resident was admitted by the facility on 2/22/22. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 9's Quarterly MDS with ARD of 8/22/22, revealed he had a BIMS score of 11, which indicates moderate cognitive impairment. On 10/03/22 at 5:30 PM, during an interview, LPN #2 confirmed that she had been provided training and had competency checkoffs at the facility regarding medication administration. She said the procedure for administration of as needed mediations included preparing the medication at the time the resident requested the medication. On 10/03/22 at 5:40 PM, during an interview, LPN #3 confirmed that she had been provided training and had competency checkoffs at the facility regarding medication administration. She confirmed that pain medication ordered as needed, should not be prepared in advance or at all if not requested by the resident. She said that Resident #1, Resident #8, and Resident #9 rarely if ever requested pain medication and that Resident #7 usually asked for his pain medication at bedtime. On 10/04/22 at 10:30 AM, during an interview with the Interim DON, she confirmed that on 9/21/2022, she received a call from the Board of Nursing regarding an anonymous report that LPN #1 was diverting medications. She explained that a thorough investigation had be completed and confirmed that the Facility Investigative Report provided for review, was accurate and that there were not new developments post completion of the report. The Interim DON reported that appropriate agencies were notified, and LPN #1 was terminated, a 100% audit of all narcotic drawers on medication carts were completed, and in-service training was completed for all nurses on the administration and documentation of controlled medications. She further stated that all residents with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/05/22 at 11:00 AM, during an interview with the Administrator, he confirmed that he had conducted a thorough investigation along with the Interim DON following notification from the Mississippi Board of Nursing of an anonymous report that LPN #1 was diverting drugs. He stated he conducted interviews with residents and was able to identify and confirm that there were four (4) residents who denied receiving controlled medications at times documented on the Narcotic Count Sheets by LPN #1. He confirmed that LPN #1 tested positive for opioids and [MEDICATION(S)] on a drug screen and was unable to provide a current prescription for medication containing opiates. The Administrator confirmed LPN #1 was suspended and ultimately terminated from employment at the facility. A record review of Resident #1's Physician's Telephone Order revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Controlled Substances Proof of Use (Narcotic Sheet created for each prescription) for days and times LPN #1 signed out for Resident #1's [MEDICATION(S)] 50 mg tablets, one (1) was documented as QTY (Quantity) Used on 9/1/22 at 6:15 PM and 1:30 PM, 9/2/22 at 6:15 AM, 9/5/22 at 7:10 AM, 1:40 PM, and 8:30 PM, 9/6/22 at 6:00 AM and 12:40 PM, 9/7/22 at 7:10 AM, 1:30 PM, and 8:30 PM, 9/8/22 at 5:55 AM and 1:15 PM, 9/9/22 at 7:10 AM, 1:40 PM, and 8:00 PM, 9/12/22 at 7:13 AM and 1:25 PM, 9/13/22 at 5:50 AM and 1:15 PM, 9/14 at 6:49 AM, 1:30 PM, and 8:00 PM, 9/15/22 at 5:10 AM and 12:40 PM, 9/16/22 at 7:20 AM, 1:35 PM, and 7:40 PM, 9/19/22 at 7:15 AM and 1:30 PM, 9/20/22 at 6:00 AM and 1:45 PM, 9/21/22 at 5:50 AM and 1:25 PM. The total number of times LPN #1 signed out for [MEDICATION(S)] 50 mg for Resident #1 for these dates totaled 34 tablets. A record review of the EMAR (electronic medicine administration record) for Resident #1 for September 2022, revealed the dates and times LPN #1 documented administration of [MEDICATION(S)] 50 mg tablets were on 9/1/22 at 1:21 PM, 9/5/22 at 8:36 PM, 9/7/22 at 1:29 PM and 8:36 PM, 9/8/22 at 1:18 PM, 9/9/22 at 1:39 PM, 9/12/22 at 1:27 PM, 9/13/22 at 1:15 PM, 9/19/22 at 1:33 PM, 2/21/22 at 1:20 PM. The total number of times LPN #1 documented the administration of [MEDICATION(S)] 50 mg to Resident #1 for these dates totaled 10 tablets. A record review of Resident #7's Physician's Telephone Order revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Controlled Substances Proof of Use (Narcotic Sheet created for each prescription) for days and times LPN #1 signed out for Resident #7's [MEDICATION(S)] 10-325 mg tablets, one (1) was documented as QTY (Quantity) Used on 9/1/11 at 6:00 AM, 1:20 PM, and 8:19 PM, 9/2/22 at 6:00 AM and 12:15 PM, 9/5/22 at 7:00 AM, 1:20 PM, and 7:50 PM, 9/6/22 at 5:50 AM, 12:15 PM, and 7:00 PM, 9/7/22 at 6:00 AM, 1:45 PM, and 8:25 PM, 9/8/22 at 6:00 AM and 12:45 PM, 9/9/22 at 7:05 AM, 1:30 PM, and 8:15 PM, 9/12/22 at 7:00 AM, 1:15 PM, and 7:20 PM, 9/21/22 at 6:00 AM and 1:20 PM. The total number of times signed out by LPN #1 for [MEDICATION(S)] 10-325 mg for Resident #7 for these dates totaled 24 tablets. A record review of the EMAR (electronic medicine administration record) for Resident #7 for September 2022, revealed the dates and times LPN #1 documented administration of [MEDICATION(S)] 10-325 mg tablets were on 9/1/22 at 1:23 PM, 9/5/22 at 1:21 PM and 7:41 PM, 9/7/22 at 8:25 PM, 9/9/22 at 1:28 PM and 8:13 PM, 9/12/22 at 1:16 PM, 9/14/22 at 7:43 PM, 9/20/22 at 1:38 PM, 9/21/22 at 1:20 PM. The total number of times LPN #1 documented the administration of [MEDICATION(S)] 10-325 mg to Resident #7 for these dates totaled 10 tablets. A record review of Resident #8's Physician's Telephone Order revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Controlled Substances Proof of Use (Narcotic Sheet created for each prescription) for dates and times LPN #1 signed out for Resident #8's [MEDICATION(S)] 50 mg tablets, two (2) was documented as QTY (Quantity) Used (to equal the 100 mg dosage) on 9/7/2 at 6:45 AM, 1:20 PM, and 8:35 PM, 9/8/22 at 6:15 AM and 1:15 PM, 9/9/22 at 7:30 AM, 1:30 PM, and 8:20 PM, 9/12/22 at 7:30 AM and 2:00 PM, 9/13/ at 6:45 AM and 1:15 PM, 9/14/22 at 7:15 AM, 2:15 PM, and 8:00 PM, 9/15/22 at 6:40 AM and 12:55 PM, 9/16/22 at 7:40 AM, 2:10 PM, and 8:20 PM, 9/19/22 at 7:30 AM and 2:15 PM, 9/20/22 at 5:55 AM and 1:40 PM, 9/21/22 at 6:30 AM and 1:30 PM. The total number of times LPN #1 signed out for two (2) tablets [MEDICATION(S)] 50 mg to equal the 100 mg dosage for Resident #8 for these dates totaled 52 tablets (26 times at 2 tablets each time). A record review of the EMAR (electronic medicine administration record) for Resident #8 for September 2022, revealed the dates and times LPN #1 documented administration of [MEDICATION(S)] 100 mg (250 mg tablets) tablets were on 9/7/22 at 1:27 PM, 9/8/22 at 1:16 PM, 9/9/22 at 1:28 PM, 9/12/22 at 7:28 AM. 9/13/22 at 1:14 PM, 9/20/22 at 1:37 PM, 9/21/22 at 1:20 PM. The total number of times LPN #1 documented the administration of [MEDICATION(S)] 50 mg to Resident #8 for these dates totaled 14 tablets (7 times at 2 tablets each time). A record review of Resident #9's Physician's Telephone Order revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident # 9's Controlled Substances Proof of Use (Narcotic Sheet created for each prescription) revealed that on 9/22/22 and 2:00 PM and 10:00 PM, LPN #1 had documented removal of one (1) [MEDICATION(S)] 5-325 tablet from Resident #9's medication card containing one (1) blister-packed tablet of [MEDICATION(S)] 5-325 mg (totaling (two) 2 tablets). As LPN #1's drug screen dated 9/22/22 at 10:05 AM tested positive for opiate and [MEDICATION(S)] and she was removed from the medication cart at that time and placed on Investigative Leave, LPN #1 and was not in the facility on the time and date of the removal of the [MEDICATION(S)] 5-325 tablets from the resident's medication card.

Based on interviews, record reviews, and facility policy review, the facility failed to prevent the verbal abuse of one (1) out of nine (9) sampled residents. Resident #2. Findings Include: A record review of the facility's Abuse Program revised on 5/23/17, revealed the document stated It is the policy of this facility to take all steps necessary to maintain an environment free of abuse and neglect. Each resident has the right to be free from verbal, sexual, physical and mental abuse .The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff .Verbal Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents . Record review of the Reportable Incident Form dated 8/24/22, revealed that on Resident #2 reported to the facility Social Worker that Registered Nurse (RN) #1 had yelled at her, called her a (curse name) and made her feel uncomfortable and threatened on 8/22/22. Review of the facility investigation notes revealed that following Resident #1's report of the actions of RN #1, the Interim Director of Nursing and Administrator terminated RN #1. The Personnel Termination Notice, dated 8/24/22, stated that RN #1 was terminated for calling Resident #2 a curse name. The investigative notes also revealed documentation that the incident was reported to the Attorney General's Office on 8/24/22. Record review of the Face Sheet for Resident #2 revealed the resident was admitted by the facility on 8/04/22. According to the Face Sheet, Resident #2 was listed as her own Responsible Party. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS)for Resident #2, with an Assessment Reference Date (ARD) of 10/01/22, revealed the resident had a BIMS score of 15, indicating the resident was cognitively intact. On 10/03/22 at 5:30 PM, during an interview, Licensed Practical Nurse (LPN) #2 confirmed that on 8/22/22, she heard RN #1 yell at Resident #2 and call her a (curse name). On 10/04/22 at 10:30 AM, during an interview with the Director of Nursing (DON), she confirmed that on 8/22/22, she was made aware of a complaint by Resident #2 that RN #1 had yelled at her and called her a (curse name). The DON said RN #1 was immediately suspended to protect residents and an investigation was conducted. The allegation was substantiated by the investigation and RN #1 was terminated. The DON stated yelling at a resident, cursing at a resident, and calling residents inappropriate names were considered verbal abuse and not tolerated. On 10/05/22 at 10:05 AM, a telephone interview with Resident #2 revealed she recounted how on 8/22/22, RN #1 came into her room and the resident tried to ask the RN about her wound vac. She said the RN ignored her question and when she asked about it again, the RN started yelling at her, called her a curse name, and pointed a syringe with liquid in it at her, causing some of the liquid to get on her. She said at the end of the confrontation, RN #1 told her that if she needed anything else to just watch. She said that when RN #1 pointed at her with the syringe and the liquid got on her and told her to just watch she felt uncomfortable and threatened. She said she did not want RN #1 to provide care for her following the incident, as she felt threatened by her. She said she was not sure what the RN had meant by just watch, but she interpreted the statement as a threat. On 10/05/22 at 11:00 AM, during an interview with the Administrator, he confirmed that he had conducted a thorough investigation, along with the DON following the allegations by Resident #2 of verbal abuse by RN #1. He stated yelling at a resident, cursing a resident, and calling residents inappropriate names were considered verbal abuse. As a result of the investigation, the Administrator confirmed RN #1's employment at the facility had been terminated.

Based on record review and staff interviews, the facility failed to ensure the care plan was followed for a two person mechanical lift transfer resulting in a fall and fracture for one (1) of four (4) care plans reviewed. Resident #2 Findings include: Record review of the facility policy titled CARE PLANS, undated revealed POLICY: Each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. RESPONSIBILITY: All members of the Interdisciplinary team. Monitored by the MDS (Minimum Data Set) and Director of Nurse's. DEFINATIONS (Definition): Interdisciplinary-all disciplines work together to develop approaches to help residents meet needs or resolve problems. Care Plan- contains resident problems/needs/strengths, resident goals and interdisciplinary approaches PROCEDURE: .6. Staff approaches are to be developed for each problem/strength/need. Assigned disciplines will be identified to carry out the intervention . Record review of the 'Care Plan' dated 2/19/18 for Resident #2 revealed Care Plan Goal of Perform ADL's (Activities of Daily Living) as independently as possible with intervention dated 4/06/21, revealed TOTAL LIFT X (times) 2 (two) FOR ALL TRANSFERS. Record review of the facility 'Lift/Transfer Assessment' dated 11/01/21 thru 1/28/22 for Resident #2 completed by Registered Nurse (RN) #1, revealed Level of Assistance Required: Dependent. Record review of Resident Incident Report dated 1/24/21 revealed the report stated on 1/21/22 at 3:36 PM CNA (NA #1) stated that she was putting resident back to bed with the lift. Her pants were sliding down, and staff stated that as resident started to slide, she then cradled to the floor. The report stated the immediate response of facility staff was to notify the primary physician who issued an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The report included a statement by the Administrator which included documentation that the investigation performed by the facility showed the sling was improperly placed to prevent the resident from sliding out of the sling. According to the report, the Staff Development Nurse's interview of NA #1 confirmed she had not properly placed the sling according to manufacturer's instructions, or facility training, policy, or procedures. It was determined the root cause of the fall was failure of NA #1 to ensure there was two (2) staff members involved in the use of the mechanical lift before initiating Resident #2's transfer and failure to position the sling according to the manufacturers recommendations or Resident #2's needs and care plan or the facility training, policies, and procedures. Review of a written statement dated 1/21/22 and signed by NA #1 revealed, I started to operate the two-person lift on alone .While holding her, her left leg was caught bent which made me lay her completely flat on the floor .her left leg was in pain. On 1/27/22 at 10:30 AM, an interview with the Administrator revealed he had reported the fall and injury to the State Agency (SA) by telephone on 1/21/22 and submitted further information following an investigation on 1/25/21. The Administrator stated NA #1 was immediately suspended pending the conclusion of the investigation and following the investigation NA #1 was terminated. The Administrator stated NA #1 admitted to attempting to perform the mechanical lift transfer alone, which he confirmed was not in agreement with the care plan for Resident #2. He said during the investigation NA #1 confirmed she had not crossed the lower straps according to facility training and policies and procedures. The Administrator stated Our investigation determined the fall resulted because the CNA didn't have another person assisting her and she didn't cross the straps to prevent the resident from sliding out of the sling. On 1/27/22 at 11:40 AM, during an interview with the Staff Development Nurse revealed all NAs had access to resident records on a computer kiosk mounted to the wall in the hallway to access residents' care plans. On 1/27/22 at 2:40 PM, an interview with the Staff Development Nurse revealed NA #1 was hired on 1/5/21 and he had provided orientation in-services and training which included training on the use of the mechanical lifts; he confirmed this training included a video provided by the manufacturer on the safe operation of the lifts. He stated she had completed Nurse's Aide training but had not yet taken her state certification exam (the exam was scheduled for February 2022). He reported she was working on her own. The Staff Development Nurse explained that the total lift used a four (4) point system of straps which required the straps under the lower extremities (legs) to be crossed and then attached to the lift hooks. He stated NA #1 had admitted to him she had failed to cross the straps under the legs of Resident #2 and she attempted to perform the bed to wheelchair transfer alone. He stated she told him during the investigation she knew she was supposed to have two (2) people for using the lift. The Staff Development Nurse stated he was not aware why NA#1 did not follow the proper procedure for using the lift, and NA #1 was unable to explain her actions at the time of the investigation. He stated the NA #1 was immediately suspended during the investigation and terminated upon the conclusion of the investigation. He said the Task List on the kiosk communicated care instruction to the CNAs and the Task List was updated by the MDS nurses if a resident's care plan changed. Record review of the Diagnostic Radiology report dated 1/21/22 revealed, Reason for Exam left upper leg pain swelling. Report EXAM: XR (X-ray) Femur 2 (two) V (view) LT (left) .Indication: left upper leg pain swelling .Findings: There is an angulated complete fracture of the mid diaphysis of the femur. Intramedullary rod is seen in the mid and distal femur with a total knee arthroplasty. Osteopenia . Record review of the Skills Checkoff for Vander and Vander II dated 1/05/22, signed by the Staff Development Nurse, revealed NA #1 had performed a skills checkoff on the competent use of the total lift. Review of the Skills Checkoff revealed the instructions included Note .Follow any specific lift/transfer instructions for the individual. Use number of staff required for the procedure. Step 5 revealed Extend leg straps alongside the individual, carefully working forward and under his hips. Step 6 revealed Lift one thigh and place leg strap under, carefully bringing up and around inner thigh between knees. Repeat with other leg. Cross one leg strap through the other at the loop closest the sling. Record review of the 'Face Sheet' for Resident #2 revealed she had been admitted by the facility on 12/17/10 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/12/22 revealed her Brief Interview of Mental Status (BIMS) score was nine (9) which indicated she had moderate cognitive impairment. Further review of the MDS revealed she required extensive two-person assistance for surface-to-surface transfers. She was not able to ambulate (walk) and used a wheelchair for mobility.

Based on staff and resident representative interviews, record review, and facility policy review, the facility failed to ensure that two (2) staff members were involved in a mechanical lift transfer for a resident who required 2 person assistance and failed to secure the resident in a mechanical lift correctly for one (1) of four (4) sampled residents reviewed for supervision to prevent accidents during transfers. Resident #2 fell from the total mechanical lift, onto the floor and sustained a femur fracture. Findings included: Record review of the VANCARE Vanderlift Operating Manual dated November 2017 page 8 Patient Assessment Criteria for Transfers .WARNING Although one person can perform patient transfers, certain patients or situations may require the help of one or more additional staff members. For example, patients with unpredictable behavior due to dementia may require additional help. Page 15 revealed Transfer from a Bed or Stretcher .3) .Make sure the required number of staff members are present. Record review of the facility Modified Lifting Policy, no date, revealed the copy was signed by Nurse Aide (NA) #1 on 1/05/22, indicating I have read and fully understand the modified lifting policy for (Proper Name of Facility). The policy revealed, will provide a safe work environment for patient care areas by providing and requiring the use of safety materials, equipment and training designed to prevent personnel and patient injury,,, It is crucial that health care professionals practice safe lifting .at all times .Procedures 1. Staff will follow the documented lifting protocol deemed appropriate for each resident. This information is documented in the resident's chart and via a sticker system which is located on lift at Nurses' Station for reference to each resident. This information should be referred to prior to lifting/transferring or assisting each resident. This documentation will also include which sling(s) is appropriate for each resident. 2. Staff will utilize proper transfer/lifting/assistance procedures for each resident to include use of mechanical transfer devices . Record review of Resident Incident Report dated 1/24/21 revealed on 1/21/22 at 3:36 PM CNA (NA #1) stated that she was putting resident back to bed with the lift. Her pants were sliding down, and staff stated that as resident started to slide, she then cradled to the floor. The report revealed the immediate response of facility staff was to notify the primary physician who issued an order for the resident to be transferred to the hospital by ambulance for assessment due to a bulge on the resident's leg pain following the fall. The report included a statement by the Administrator which included documentation that the investigation performed by the facility showed the sling was improperly placed to prevent the resident from sliding out of the sling. According to the report, the Staff Development Nurse's interview of NA #1 confirmed she had not properly placed the sling according to manufacturer's instructions, or facility training, policy, or procedures. It was determined the root cause of the fall was failure of NA #1 to ensure there was two (2) staff members involved in the use of the mechanical lift before initiating Resident #2's transfer and failure to position the sling according to the manufacturers recommendations or Resident #2's needs and care plan or the facility training, policies, and procedures. Record review of the Diagnostic Radiology report dated 1/21/22 revealed, Reason for Exam left upper leg pain swelling. Report EXAM: XR (X-ray) Femur 2 (two) V (view) LT (left) .Indication: left upper leg pain swelling .Findings: There is an angulated complete fracture of the mid diaphysis of the femur. Intramedullary rod is seen in the mid and distal femur with a total knee arthroplasty. Osteopenia . Record review of the 'Care Plan' dated 2/19/18 for Resident #2 revealed Care Plan Goal of Perform ADL's (Activities of Daily Living) as independently as possible with intervention dated 4/06/21, revealed TOTAL LIFT X (times) 2 (two) FOR ALL TRANSFERS. Record review of the facility 'Lift/Transfer Assessment' dated 11/01/21 thru 1/28/22 for Resident #2 revealed on 1/11/22 she was assessed as TOTAL lift for transfers to and from: bed to chair, chair to toilet, chair to chair Level of Assistance Required: Dependent. The assessment was documented as Reported by Registered Nurse (RN) #1. Review of a written statement dated 1/21/22 and signed by NA #1 revealed, I started to operate the two-person lift on alone .While holding her, her left leg was caught bent which made me lay her completely flat on the floor .her left leg was in pain. On 1/27/22 at 10:30 AM, an interview with the Administrator revealed he had reported the fall and injury to SA by telephone on 1/21/22 and submitted further information following an investigation on 1/25/21. The Administrator stated NA #1 was immediately suspended pending the conclusion of the investigation and following the investigation NA #1 was terminated. The Administrator stated NA #1 admitted to attempting to perform the mechanical lift transfer alone, which he confirmed was not in agreement with the care plan for Resident #2. He said during the investigation NA #1 confirmed she had not crossed the lower straps according to facility training and policies and procedures. The Administrator stated Our investigation determined the fall resulted because the CNA (NA#1) didn't have another person assisting her and she didn't cross the straps to prevent the resident from sliding out of the sling. On 1/27/22 at 11:40 AM, during an interview with the Staff Development Nurse revealed all NAs had access to resident records on a computer kiosk mounted to the wall in the hallway to access residents' care plans. On 1/27/22 at 2:40 PM, an interview with the Staff Development Nurse revealed NA #1 was hired on 1/5/21, and he had provided orientation in-services and training which included training on the use of the mechanical lifts. He confirmed this training included a video provided by the manufacturer on the safe operation of the lifts. He stated she had completed Nurse's Aide training but had not yet taken her state certification exam (the exam was scheduled for February 2022). He reported she was working on her own. The Staff Development Nurse explained that the total lift used a four (4) point system of straps which required the straps under the lower extremities (legs) to be crossed and then attached to the lift hooks. He stated NA#1 had admitted to him she had failed to cross the straps under the legs of Resident #2 and she attempted to perform the bed to wheelchair transfer alone. He stated she told him during the investigation she knew she was supposed to have two (2) people for using the lift. The Staff Development Nurse stated he was not aware why NA#1 did not follow the proper procedure for using the lift, and the NA was unable to explain her actions at the time of the investigation. He stated NA#1 was immediately suspended during the investigation and terminated upon the conclusion of the investigation. He said the Task List on the kiosk communicated care instruction to the CNAs and the Task List was updated by the MDS nurses if a resident's care plan changed. On 1/27/22 at 4:54 PM, a telephone interview with the Resident Representative (RR) (daughter) revealed she was notified immediately following the fall of Resident #2 on 1/25/22. She stated that her mother was currently in traction in a hospital waiting for transfer to another hospital for surgery. She stated, It shouldn't have happened. She stated she had been told that her mother had slipped out of the canvas sling during a transfer. She said They said it was a new CNA. She stated the hospitalization of her mother had been quite an ordeal. The RP for Resident #2 stated that her mother is eighty-nine (89) years old and has been living at the nursing home for almost thirteen (13) years. The RR stated The CNA should have had someone with her that was experienced with taking care of these fragile, elderly patients. She stated I'm one hundred percent (100%) sure it was not intentional, but there is no excuse for what happened. They need people trained with use of these lifts. Record review of the Skills Checkoff for Vander and Vander II dated 1/05/22, signed by the Staff Development Nurse, revealed NA#1 had performed a skills checkoff on the competent use of the total lift. Review of the Skills Checkoff revealed the instructions included Note .Follow any specific lift/transfer instructions for the individual. Use number of staff required for the procedure. Step 5 stated Extend leg straps along side the individual, carefully working forward and under his hips. Step 6 stated Lift one thigh and place leg strap under, carefully bringing up and around inner thigh between knees. Repeat with other leg. Cross one leg strap through the other at the loop closest the sling. Record review of the 'Face Sheet' for Resident #2 revealed she had been admitted by the facility on 12/17/10 with diagnoses including Lack of Coordination, Generalized Muscle Weakness, Presence of Left Artificial Hip Joint, and [CONDITION(S)]. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/12/22 revealed her Brief Interview for Mental Status (BIMS) score was 9 out of 15 which revealed she was moderately cognitively impaired. Section G revealed she required extensive two-person assistance for surface-to-surface transfers. She was not able to ambulate (walk) and used a wheelchair for mobility.

Based on record reveiws, staff interviews, facility policy review, and family interviews, the facility failed to thoroughly investigate all alleged incidents of abuse/neglect for three (3) of five (5) residents reviewed for abuse and neglect. Residents #1, #2, and #3. Findings include: The facility policy titled: Abuse Program dated Revised [DATE] read: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, sponsors, visitors, surrogates, and other care givers who provide care and services on behalf of the facility. Neglect occurs when facility staff fail to monitor and/or supervise the delivery of resident care and services to assure that care is provided as needed by residents. Neglect occurs when a facility fails to provide necessary care for residents, such as situations in which residents are left to lie in urine or feces. The facility will thoroughly investigate, under the direction of the administrator or Director of Operations/Director of Clinical Operations the time of any findings of potential abuse or neglect to determine the cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation. The Administrator of designee shall report any suspected abuse and neglect outlined in this policy to the Department of Health as required. In an interview on [DATE] at 11:00 AM,. the facility Administrator (ADM) stated that the facility had none of the previous staff currently working in the facility that were working in [DATE] or [DATE]. ADM stated that the previous administrator and the previous Director of Nursing (DON) left the facility suddenly and never returned. The current ADM stated that he took over as the new administrator in [DATE] as did the new DON. The current Administrator stated that he and the current DON have no knowledge of the alleged incidents of alleged verbal/physical abuse. The Covid -19 Pandemic caused a no visitors policy and caused numerous staff and residents to become ill. The current ADM stated that the facility utilized outside agencies for staffing during the Covid-19 pandemic in 2020 and he stated that it was doubtful that there were any current staff working in the facility that were employed in 2020. In an interview on [DATE] at 11:00 AM, with the current DON revealed that she had only been working at the facility since [DATE]. DON stated that she had no knowledge of any alleged incidents of abuse/neglect of any resident at the facility. DON stated that she would have to try and look through the records that were left by the previous staff, but was doubtful that documentation would be available since there was no staff left working at the facility that were working in [DATE] and [DATE]. Resident #1: Record review of the facility Grievance Logs for 2020 revealed that there were written reports in the Grievance Logs that documented alleged incidents of abuse/neglect for Resident #1 on [DATE] that documented that the family member had witnessed the staff bump the head of Resident #1 while pulling him up in the bed and that the staff failed to check his head. The grievance report for Resident #1 read: Summary Statement of Grievance: (Name of witness) stated that the staff bumped the resident's head in the bed and failed to check it. (Name of witness) stated that they all went back and fourth conversing about the bed arrangement. Steps Taken to Investigate the Grievance: The DON spoke to the staff and received statements from them. Summary of Pertinent Findings or Conclusions: The DON Staff Development will do an Inservice on effective communication with the staff. Decision: Grievance was confirmed. (Describe resolution.) Inserviced Staff The grievance reports did not document the name or names of any staff involved in the incident of [DATE]. The record review did reveal that on [DATE] an inservice and staff sign in sheet was documented and signed by 11 staff members. The title of the in-service on [DATE] was documented by the DON and was titled: Effective communication with residents and families The record review of the grievance reports did not provide the name of the staff involved nor how many staff were involved. No staff names were given and/or documented. Interview on [DATE] at 12:30 PM with a family member, of Resident #1 revealed that she was at the facility with the Resident Representative (RR) visiting Resident #1 when staff (unknown names) pulled Resident #1 up from under his arms and bumped his head on the head board. Family mamber does not know the names of the two (2) staff that repositioned Resident #1 and bumped his head. Family member feels that the situation was upsetting.She stated that Resident #1 was a very sick man and he was paralyzed and was totally dependent upon others for all of his needs. She stated that Resident #1 was transferred to the hospital in February 2020 from the nursing home and that he died in the hospital due to his poor health, not because the facility staff bumped him on his head. Interview on [DATE] with the RR, revealed that she was sitting in Resident #1's room on [DATE] when she noticed that Resident #1 was sliding down in the bed, and he needed to be changed due to the fact that he had soiled himself. The head of the bed was elevated, which was causing him to slide down in the bed. RR stated that she pushed the call light to get staff to come and change resident #1 and to adjust the bed, and to re-position Resident #1 in the bed. She stated that she was often at the facility and would sit with Resident #1 for long periods of time because his health was so compromised. RR stated that she pushed the call system at Resient #1's bedside for staff to come and assist resident #1. RR stated that the staff were rough with handling Resident #1 and they pulled him from under his arms with such force that his head hit the head board of the bed and made a loud bump. She stated that they did not check Resident #1 and did not report his head getting bumped nor did they access him or his bumped head. RR stated that she did not know the names of the staff but it was two (2) staff and she never saw either of them again after the incident. RR reported the incident to the DON, and she thought that maybe they had been disciplined and or terminated for the rough manner in which they handled Resident #1. RR stated that she had been greatly upset by the way Resident #1 had been mistreated at the facility. Record review of Resident #1's closed record Face Sheet revealed that he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 had been discharged from the facility on [DATE]. Record review of the Minimum Data Set Coordinator Brief Interview for Mental Status report dated [DATE] revealed Resident #1 had a BIMS score of 4 which indicated that he had severe cognitive deficits. Resident #2: Interview on [DATE] at 2:00 PM,. with the current facility Administartor (ADM) and the current Director of Nursing (DON) revealed that the facility had no documentation of a thourough investigation for Resident #2 and had no documentation of the alleged report of neglect/abuse of Resident #2 by staff on [DATE] and had no names of the staff that were involved in the alleged incident of [DATE]. Record review of the facility Grievance Logs maintained by the social worker contained a written report for resident #2 which alleged that on [DATE] Resident #2 asked the staff to be changed and the staff stated, I have thirty other people and you will have to wait your turn and wasn't changed for hours. The Grievance Report for Resident #2 documented: Summary Statement of Grievance: Family stated that the resident went without getting changed for hours. The staff told the resident to wait her turn via family member. Steps Taken to Investigate the Grievance: Talked to staff -Inservice Staff Summary of Pertinent Findings or Conclusions: No staff admitted to saying it. Inserviced staff on effective communication and answering residents request in a timely manner. Decision: Grievance was confirmed. (Describe resolution.) Inservice staff on effective communication. The record review did not reveal the names of any staff involved with the incident of [DATE]. Interview with the RR of Resident #2 was attempted on [DATE] at 1:45 PM via telephone. There was no answer to the telephone and no voice mail was available. Record review of the Minimum Data Set Coordinator Brief Interview for Mental Status report dated [DATE] revealed Resident #2 had a BIMS score of 14, which indicated that she was cognitively intact. Record review of the Face Sheet revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3: Record review of the facility Grievance Logs/reports maintained by the facility social worker, revealed a grievance placed by Resident #3's grand son, for alleged verbal and physical abuse/neglect of resident #3 dated [DATE]. The grievance report dated [DATE] read: (name of gramdson) stated that the person helping his grand mother after waking her up grabbed her and pulled her up. Date Complaint/Grievance Occurred: weekend Summary Statement of Grievance: (grandson of resident #3) stated that he was outside the window while on the phone with nurse and that she said wake up wake up your grandson here and he tapped on the window saying don't talk to her like that and she pulled her by her arm. Steps Taken to Investigate the Grievance: Social spoked with nurse and listened to the grandson. Social also spoked with Power of Attorney (POA) and Corporate nurse. Decision : Grievance was confirmed. (Describe resolution.) State came in on Monday 14th about a previous concern of the resident the resident stated that she had no problems with anything that everything was fine. Interview on [DATE] at 12:00 PM, with the Ombudsman revealed that she had received a report from the grandson, for Resident #3. The Ombudsman stated that the grandson reported that he witnessed the staff member (first name given) (no last name) verbally abuse and physically abuse his grandmother as he was at his grandmother's window awaiting a window visit during Covid-19 restrictions on [DATE]. The Ombudsman stated that she reported the alleged abuse of Resident #3 to the appropriate State agencies as soon as she received the report from the family on [DATE]. Interview on [DATE] at 12:15 PM,. with grandson of Resident #3, revealed that he did not like what he saw through the window of Resident #3. He stated that the staff member was a nurse and she was loud and angry sounding and that she grabbed his grandmother by the arm and pulled very hard attempting to pull her up by her arms. The grandson stated that he witnessed verbal and physical abuse of his grand mother through the window. He stated that his grandmother was totally blind and was lying in her bed when he came for a window visit during Covid-19, because he was not allowed inside the building. He stated that when he tapped on the window to get the nurse to stop her abuse, she stopped when she saw him witness what she was doing to his grand mother. He stated that he asked the DON to not allow that nurse, (he gave her first name but did not know last name, only that she was a nurse) to work with his grandmother because of how she abused his grandmother. The grandson stated that because his grand mother is totally blind and has numerous high level care issues and poor health, there have been several concerns with the quality of care his grandmother received at the facility. Record review of the Accident and Incident (A&I) reports from [DATE]-[DATE] contained no documentation of the alleged verbal/physical abuse on [DATE] for resident #3. There were no A&I's found for Resident #1's alleged incident of [DATE]. There was no facility thorough investigation found for Resident #1's incident of [DATE].There was no documentation of an incident and/or investigation on [DATE], in the facility records for Resident #2's incident of [DATE] or any records of an A&I and thorough investigation found for Resident #3's incident of [DATE]. No documentation found in the facility records that the Department of Health had been notified of the incidents for Resident's #1, #2, and #3. Interview with the DON on [DATE] at 2:00 PM,.confirmed that the A&I documentation had been reviewed and there was no A&I reports and no investigation reports/documentation for the alleged incident of [DATE] of Resident #3. The DON stated that she had searched all through the documentation and through the medical records for Resident #3 and was unable to obtain any information of an event on [DATE] and no investigation and no A&I for [DATE] was found. The DON confirmed that she has not been able to locate any thorough investigations or documentation that was completed by the facility for Resident #1's incident of [DATE] and none for Resident #2's incident dated [DATE].The DON stated that she can not provide documentation that there were any thorough investigations completed on Resident #1, Resident #2, or Resident #3 prior to her employment at the facility in [DATE]. The DON stated that she was not able to locate any documentation of an investigation or of the State agencies timely notification of the incidents for Resident #1, #2, or #3. The DON stated that she called the Corporate office to inquire with the Nurse Consultant, who had served as the Interim DON, and that she also had no knowledge and had not located any documentation for the alleged incidents of Resident #1, #2, and/or #3. The DON stated that the Corporate nurse had no information that the appropriate State agencies were notified in a timely manner after the alleged abuse incidents of Resident #1, #2, or #3. Interview on [DATE] at 3:45 PM,. the current ADM revealed that he was not employed at the facility in [DATE]. The ADM stated that on [DATE] the former facility Administrator, at that time, had walked out of the facility and did not return to work. The ADM stated that there were no staff working in the facility currently that were working in the facility in March of 2020 or [DATE]. The ADM stated that he was unable to provide any names of staff to go along with the alleged incidents of abuse/neglect for Resident #1, #2, or #3. Record review of the Face Sheet for Resident #3 revealed that she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS Coordinator Facility BIMS report dated[DATE] revealed Resident #3 had a BIMS score of 11 which indicates mild cognitive impairment . Interview on [DATE] at 4:30 PM, with the facility Licensed Masters Social Worker (LMSW), revealed that she was newly employed in [DATE]. LMSW confirmed that she was responsible for the grievances and displayed a large book of reported grievances that she was responsible for maintaining. LMSW stated that she had no names of staff involved in the alleged incidents of abuse that were maintained in the grievance reports for Residents #1, #2, or #3. LMSW stated that the only employee that was currently working at the facility that was employeed in 2020, during the incidents for Resident #1, #2, and #3, was the MDS nurse. LMSW stated that the non-nursing staff were all pitching in to assist with residents and to help meet their needs in the absence of nursing staff. LMSW stated that since she had come to work at the facility she had no reports of alleged abuse or neglect of a resident. Interview with MDS Nurse on [DATE] at 5:00 PM, revealed the MDS Nurse stated that he had no knowledge of the alleged incident of [DATE] for Resident #1. MDS nurse stated that he did have knowledge of the nurse that was alleged to have verbally and physically abused resident #3 on [DATE]. The staff that was alleged in the incident of [DATE], for Resident #3, was the current weekend Licensed Practical Nurse (LPN). MDS confirmed that the LPN was currently employed at the facility. Interview on [DATE] at 5:00 PM, with. LPN #6 via telephone, revealed that she denies receiving any discipline issued to her as a result of the incident with Resident #3 on [DATE]. LPN#6 stated that she did not verbally or physically abuse Resident #3 and the grandson did not see her do anything incorrect. She stated that the grandson did knock on the window at her as she was trying to awaken Resident #3. LPN#6 did confirm that Resident #3 was totally blind.LPN#6 stated that she was not suspended from work while an investigation was conducted because she was not working except on the weekends and she assumed that the facility completed the investigation during the week while she was not at work. LPN#6 does not remember if she gave a written statement as to what happened on [DATE] with Resident #3. LPN#6 denies verbal and physical abuse of Resident #3 on [DATE]. LPN#6 stated that the grandson was mistaken in what he witnessed from the window of Resident #3's bedroom.

Based on record reviews, staff interviews, family interviews, and facility policy and procedure reviews, the facility failed to report all incidents of alleged abuse/neglect of a resident to the appropriate State agencies in a timely manner for three (3) of five (5) residents reviewed for incidents of abuse and neglect. Resident #1, Resident #2, and Resident #3. Findings include: The facility policy and procedure titled: Abuse Program dated revised [DATE] stated, It is the policy of this facility to take all steps necessary to maintain an environment free of abuse and neglect .The Administrator of designee shall report any suspected abuse and neglect .to the Department of Health as required . Individual state reporting requirements will be adhered to. The results of the facility investigation will be reported to appropriate regulatory officials within the time frames established at the state level. In an interview on [DATE] at 11:00 AM, the facility Administrator (ADM) stated that the facility had none of the previous staff currently working in the facility that were working in [DATE] or [DATE]. The ADM stated that the previous Administrator and the previous Director of Nursing (DON) left the facility suddenly and never returned. The current ADM stated that he took over as the new administrator in [DATE] as did the new DON. The current administrator stated that he and the current DON have no knowledge of the alleged incidents of verbal/physical abuse of residents. In an interview on [DATE] at 11:00 AM, with the current DON revealed that she had only been working at the facility since [DATE]. The DON stated that she had no knowledge of any alleged incidents of abuse/neglect of residents. The DON stated that she would have to try and look through the records that were left by the previous staff, but was doubtful that documentation would be available since there was no staff left working at the facility that were working in 2020. The DON stated that most of the past staff had been replaced with completely different staff since she had arrived at the facility in [DATE]. Resident #1: Record review of the facility Grievance Logs for 2020 revealed that there were written reports in the grievance logs that documented alleged incidents of abuse/neglect for Resident #1 on [DATE] that documented that the family member had witnessed the staff bump the head of Resident #1 while pulling him up in the bed and that the staff failed to check his head. The grievance report for Resident #1 read: Summary Statement of Grievance: (name of witness) stated that the staff bumped the resident's head in the bed and failed to check it (name of witness) stated that they all went back and fourth conversing about the bed arrangement. Steps Taken to Investigate the Grievance: The DON spoke to the staff and received statements from them. Summary of Pertinent Findings or Conclusions: The DON Staff Development will do an Inservice on effective communication with the staff. Decision: Grievance was confirmed. (Describe resolution.) Inserviced Staff The grievance reports did not document the name or names of any staff involved in the incident of [DATE]. The record review did reveal that on [DATE] an inservice and staff sign in sheet was documented and signed by 11 staff members. The title of the in-service on [DATE] was documented by the DON and was titled: Effective communication with residents and families The record review of the grievance reports did not provide the names of the staff involved nor how many staff were involved. No staff names were given and/or documented in the social workers records and/or facility grievance reports. Record review of Resident #1's closed record Face Sheet revealed that he was admitted to the facility on [DATE]. The closed record Discharge Summary revealed that Resident #1 was discharged on [DATE]. Resident #1 had medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Minimum Data Set MDS Coordinator's Brief Interview of Mental Status (BIMS) report dated [DATE] revealed Resident #1 had a BIMS score of 4, which indicated severe cognitive deficits. Record review of an inservice conducted by the DON, dated [DATE] and titled Effective Communication with Residents and Families revealed there were 11 staff signatures on the sign in sheet. Interview on [DATE] at 12:30 PM, with a family member of Resident #1,revealed that she was at the facility visiting Resident #1 when staff (unknown names) pulled Resident #1 up from under his arms and bumped his head on the head board of Resident #1's bed. The family member did not know the names of staff and she feels that the situation was upsetting. She stated that this incident happened prior to the Covid-19 pandemic and that it was in [DATE] prior to Resident #1's death in February 2020. The family member stated that Resident #1 was a very sick man and he was paralyzed and was totally dependent upon others for all of his needs. She stated that Resident #1 was transferred to the hospital in February 2020 from the nursing home and that Resident #1 died in the hospital due to his poor health not because of the facility bumping his head. Interview on [DATE] at 1:00 PM,. with (RR) of Resident #1 revealed that she was sitting in resident #1's room on [DATE] when she noticed that Resident #1 was sliding down in the bed, and he needed to be changed due to the fact that he had soiled himself. The head of the bed was elevated which was causing Resident #1 to slide down in the bed. RR stated that she pushed the call light to get staff to come and change Resident #1, adjust the bed and to re-position Resident #1 in the bed. RR stated that no one answered the call light after it was pushed for a long period of time (in excess of 30 minutes) so she left the room to go to the nursing station to get help. RR told the nurse that she had used the call system and that it had been over 30 minutes and no one had come to assist with changing Resident #1 and to reposition him in the bed. RR stated that the nurse went and got staff from the break room to go and assist Resident #1. RR stated that the two (2) staff that came to Resident #1's room were angry when they came in and was angry that their breaks had been interrupted to assist Resident #1. RR stated that the staff were rough with handling Resident #1. She stated they pulled him from under his arms with such force that his head hit the head board and made a loud bump and he yelled out in pain. RR stated that they did not check Resident #1 and did not report his head getting bumped nor did they assess him or his bumped head. RR stated that she did not know the names of the staff but it was two (2) staff and RR never saw either of them again after the incident. RR reported the incident to the DON and she thought that maybe they had been disciplined and or terminated for the rough manner in which they handled Resident #1. The record review of Resident #1 Grievance Report revealed no evidence of the alleged incident of [DATE] being reported to the appropriate State agencies as documented in the facility policy and procedure under the section of the policy titled: Investigations. Resident #2: Record review of the facility grievance logs maintained by the social worker contained a written report for Resident #2 which alleged that on [DATE] the resident asked the staff to be changed and the staff stated I have thirty other people and you will have to wait your turn.Resident #2 wasn't changed for hours. The grievance report for Resident #2 documented: Summary Statement of Grievance: Family stated that the resident went without getting changed for hours. The staff told the resident to wait her turn via family member. Steps Taken to Investigate the Grievance: Talked to staff -Inservice Staff Summary of Pertinent Findings or Conclusions: No staff admitted to saying it. Inserviced staff on effective communication and answering residents request in a timely manner. Decision: Grievance was confirmed. (Describe resolution.) Inservice staff on effective communication. The record review of the grievance report did not reveal the names of any staff involved with the incident of [DATE]. There was no evidence on [DATE] that the incident had been reported to the appropriate State agencies in a timely manner. Record review of the Face Sheet for Resident #2 revealed that she had an admitted [DATE] and had been discharged home with family on [DATE]. Record review of the Minimum Data Set MDS Coordinator's Brief Interview of Mental Status (BIMS) report dated [DATE] revealed Resident #2 had a BIMS score of 14 which indicated that Resident #2 was cognitively intact. On [DATE] at 1:45 PM, attempted to interview the RR via telephone. The RR did not answer the telephone and no voice mail was available. Interview on [DATE] at 5:00 PM. with the MDS nurse revealed that he was the only employee currently working at the facility that was working in the facility in 2020. MDS nurse had no knowledge of Resident #2's alleged incident on [DATE]. Resident #3: Record review of the facility grievance logs/reports, revealed a grievance placed by Resident #3's grandson, for alleged verbal and physical abuse/neglect of Resident #3 dated [DATE] for Resident #3. The grievance report dated [DATE] read: (Name of Grandson) stated that the person helping his Grandmother (Resident #3) after waking her up grabbed her and pulled her up. Date Complaint/Grievance Occurred: weekend Summary Statement of Grievance: (Name of Grandson of Resident #3) stated that he was outside the window while on the phone with nurse and that she said wake up wake up your grandson is here. He tapped on the window saying don't talk to her like that and she pulled Resident #3 by her arm. Steps Taken to Investigate the Grievance: Social spooked with nurse and listened to the grandson. Social also spoke with the Power of Attorney(POA) and Corporate nurse. Decision : Grievance was confirmed. (Describe resolution.) State came in on Monday 14th about a previous concern of the resident the resident stated that she had no problems with anything that everything was fine. Interview on [DATE] at 12:00 PM, with the Ombudsman, revealed that she had received a report from the grandson, for Resident #3. The Ombudsman stated that the grandson reported that he witnessed the staff member (no last name) verbally abuse and physically abuse his grandmother as he was at his grandmother's window awaiting a window visit during Covid-19 restrictions on [DATE]. The Ombudsman stated that she reported the alleged abuse of Resident #3 to the appropriate State agencies as soon as she received the report from the family on [DATE]. Interview on [DATE] at 12:15 PM, with the grandson of Resident #3, he stated that he did not like what he saw through Resident #3's window. He stated that the staff member was a nurse and she was loud and angry sounding and that she grabbed his grandmother by the arm and pulled very hard attempting to pull her up by her arms. The Grandson stated that he witnessed verbal and physical abuse of his Grandmother through the window. He stated that his grandmother was totally blind and was lying in her bed when he came for a window visit during Covid-19, because he was not allowed inside the building. He stated that when he tapped on the window to get the nurse to stop her abuse, she stopped when she saw him witness what she was doing to his Grand mother. He stated that he asked the DON to not allow that nurse (did not know last name, only that she was a nurse) to work with his Grand- mother because of how she abused her. The Grandson stated that because his Grandmother is totally blind and has numerous high level care issues and poor health, there have been several concerns with the quality of care his grand mother received at the facility. He stated that his mother is now totally responsible for his Grandmother and that his mother is now the RR. Record review of the Accident and Incident (A&I) reports from [DATE]-[DATE] contained no documentation of the alleged verbal/physical abuse on [DATE] for Resident #3. There were no A&I's found for Resident #1's alleged incident of [DATE]. No documentation found in the facility records that the appropriate State agencies were notified of the incidents for Residents #1, #2, and #3. Interview with the DON on [DATE] at 2:00 PM, confirmed that the A&I documentation had been reviewed and there was no A&I reports and no investigation reports/documentation for the alleged incident of [DATE] of Resident #3. The DON stated that she had searched all through the documentation and through Resident #3's medical record and was unable to obtain any information of an event on [DATE] and no investigation and no A&I for [DATE] was found. The DON stated that the Corporate nurse had no information that the State agencies were notified in a timely manner after the alleged abuse incidents of Resident #1, #2, or #3. Record review of the Face Sheet for Resident #3, revealed that she was admitted to the facility on [DATE]. Resident #3 had medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Minimum Data Set MDS Coordinator's Brief Interview of Mental Status (BIMS) report dated [DATE] revealed Resident #3 had a BIMS score of 11,which indicated she had some mild cognitive impairments Interview on [DATE] at 4:30 PM. with the Licensed Master Social Work (LMSW), revealed that she was newly employed at the facility in [DATE]. The LMSW confirmed that she was responsible for the grievances and displayed a large book of reported grievances that she was responsible for maintaining. LMSW stated that she had no names of staff involved in the alleged incidents of abuse that were maintained in the grievance reports for resident #1, #2, or #3.

Based on observation, interview, record review, and policy review, the facility failed to prevent accidents for Resident #1 by the facility's failure to use two (2) person assistance and use a mechanical lift for transfer, for one (1) of four (4) residents reviewed, Resident #1. A Certified Nursing Assistant transferred the resident without assistance of two (2) staff and the lift as assessed and care planned, and Resident #1 sustained a [MEDICAL CONDITION] hip during the transfer, which required hospitalization with non-surgical treatment. Findings include: Review of the facility policy, Accidents and Supervision, dated 10/3/18, revealed the resident environment remains as free of accident hazards as is possible; and each resident receives the adequate supervision and assistive devices to prevent accidents. This includes .Implementing interventions to reduce hazard(s) and risk(s). Review of Resident #1's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/3/18, revealed Resident #1 was assessed for two (2) plus (+) persons for transfer. Review of the care plan, dated 5/11/18, revealed Resident #1 was care planned for two (2) person assist, with the use of a mechanical lift for transfers. Review of the facility's incident report and investigation, dated 10/24/18, revealed that CNA #1 did not used a lift or assistance when transferring Resident #1 on 10/21/18, while attempting to put a clean shirt on the resident. The facility's investigation determined that CNA #1 was careless and non-compliant with the Policy and procedure that resulted in a safety violation. The report noted Resident #1 fell during a transfer by one (1) person (CNA #1) and no mechanical lift was used, resulting in a [MEDICAL CONDITION] for the resident. This investigation revealed CNA #1 was terminated on 10/24/18 (for failure to follow the policy). Record review of the local Hospital's Adult Daily Progress Note, for Resident #1, revealed the Resident was admitted to the hospital on [DATE], with a Displaced Intratrochanteric Fracture of Right Femur, after a reported mechanical fall at the nursing home. X-ray results for the right hip, dated 10/21/18, revealed a moderately displaced right femoral neck fracture with suspected intratrochanteric fracture component. Interview with Certified Nursing Assistant (CNA) #1, on 1/3/19 at 8:04 AM, confirmed she was transferring Resident #1 alone and without a lift on 10/21/18, when Resident #1 fell to the floor, which resulted in a [MEDICAL CONDITION] for the resident. CNA #1 stated, I didn't intend for her (Resident #1) to get hurt. CNA #1 confirmed she transferred Resident #1 by herself and without the use of a lift. Review of CNA #1's written statement, dated 10/22/18, revealed she had transferred Resident #1 to the Geri-chair by herself, and the resident slid out of the chair, with her legs crossed and under her body, as she placed the resident on the floor. Interview with RN #1 on 1/3/19 at 12:25 PM, revealed on 10/21/18, she was called to Resident #1's room by CNA #1, and Resident #1 was on the floor. RN #1 stated that CNA #1 reported to her that she was transferring Resident #1 when Resident #1 grabbed onto her arm and the CNA eased the resident to the floor. RN #1 stated there was no one in the room, nor was there a lift present, when she entered the room. In an interview on 1/2/19 at 3:25 PM, the facility Administrator stated that CNA #1 first lied to them about the incident and said she was using and lift and two (2) people were present during the lift; but after review of the video, CNA #1 was seen entering Resident #1's room alone and without a lift. The Administrator stated CNA #1 changed her story and admitted she was alone when she transferred Resident #1 without a lift. The Administrator stated this action resulted in CNA #1's termination. Interview with Registered Nurse (RN) #1 on 1/2/19 at 11:22 AM, revealed it is the facility's policy to use at least two (2) people when using any lift. Interview with the Director of Nursing (DON) on 1/3/19 at 10:30 AM, revealed that Resident #1 fell and sustained a [MEDICAL CONDITION] when CNA #1 lifted/transferred her by herself. When asked if she considered this willful, the DON responded, Yes. In an interview with the DON on 1/3/19 at 12:00 PM, she stated during the investigation, it was determined that CNA #1 transferred Resident #1 on 10/21/18, by herself, without a lift, and the video recording revealed CNA #1 never took a lift into Resident #1's room. Interview with the Medical Director on 1/3/19 at 11:37 AM, revealed he was notified of the incident when Resident #1 fell and was transported to the hospital. He stated he did not remember details of the event at this time. Review of the facility's disciplinary report, dated 10/24/18, revealed CNA #1 was terminated from employment after the facility's investigation of Resident #1's fall/fracture. It was determined, during the investigation, that CNA #1 transferred Resident #1 from the bed to the chair alone, and without the use of a lift, resulting in a fall with [MEDICAL CONDITION] for Resident #1. Categories included: carelessness, safety violation, and non-compliance of policy and procedure. Review of a signed acknowledgment, dated 6/15/18, revealed CNA #1 signed the acknowledgement of the facility's policies for the use of the Daily Care Guide and the Employee Handbook. Review of Resident #1's ECARE TASK sheet and Daily Care Guide, dated 5/16/17, revealed Resident #1 was Care Planned for a total lift for all transfers, with two (2) person assistance, using a medium sized sling. The Face Sheet indicated the facility admitted Resident #1 on 5/15/17, with the [DIAGNOSES REDACTED].

Based on observation, interview, record review and policy review, the facility failed to implement/follow the plan of care for the use of a lift with two (2) person assist for one (1) of four (4) residents reviewed, Resident #1. This resulted in a fall with Femoral Fracture for Resident #1, with hospitalization and non-surgical treatment. Findings include: Review of the facility's policy for Care Plans, undated, revealed: Each resident will have a plan of care to identify how the interdisciplinary team will provide care. Review of Resident #1's Care Plan, dated 5/16/17, revealed the facility identified Resident #1's ECARE TASK QUESTIONS, for Activities of Daily Living (ADL) with the approach listed to use the total lift for all transfers, with two (2) person assist, and with a medium sized sling. Review of Resident #1's Care Plan, dated 5/15/17, revealed Resident #1 needed assistance with ADL's as indicated in the Care Guide. One (1) approach listed: Assist with transfers as needed and as indicated per the ADL Care Guide. In a review of Resident #1's ECARE TASK sheet, noted on 5/16/17, Resident #1 was Care Planned for a total lift for all transfers, with two (2) person assistance, using a medium sized sling. Review of an incident report and the facility's investigation, dated 10/24/18, revealed CNA #1 had not used a lift or had assistance when transferring Resident #1 on 10/21/18. The facility's investigation determined that CNA #1 was careless and non-compliant with the Policy and procedure that resulted in a safety violation and Resident #1 fell during a transfer, resulting in a [MEDICAL CONDITION]. CNA #1 was terminated on 10/24/18. Record review of the local Hospital's Adult Daily Progress Note, revealed Resident #1 was admitted to the hospital on [DATE], with X-ray results of a Displaced Intratrochanteric Fracture of Right Femur, after a reported mechanical fall at the nursing home. In an interview on 1/3/19 at 8:04 AM, Certified Nursing Assistant (CNA) #1 confirmed on 10/21/18, she transferred Resident #1 alone and without a lift. She stated Resident #1 fell to the floor, which resulted in a [MEDICAL CONDITION]. CNA #1 stated, I didn't intend for her (Resident #1) to get hurt. CNA #1 confirmed she transferred Resident #1 by herself and without a lift, as care planned. In an interview with Registered Nurse (RN) #1 on 1/2/19 at 11:22 AM, she stated the care plan wasn't followed if the correct lift or the correct number of people, which is always at least two (2), is not used during a transfer. Interview with RN #1 on 1/3/19 at 12:25 PM, revealed on 10/21/18, she was called to Resident #1's room by CNA #1. She stated Resident #1 was on the floor. RN #1 stated there was no one in the room, nor was there a lift present in the room, when she entered. Interview with the facility Administrator, on 1/2/19 at 3:25 PM, revealed during the facility investigation, CNA #1 admitted to transferring Resident #1 by herself and without the lift, resulting in Resident #1's fall and fracture. The Administrator stated this action resulted in CNA #1's termination; for not following policy (and care plan). Interview with the Director of Nursing (DON), on 1/3/19 at 10:30 AM, revealed Resident #1 fell , which resulted in a [MEDICAL CONDITION], when CNA #1 transferred her by herself. The DON confirmed CNA #1 did not follow Resident #1's care plan for transfers. Review of the facility's disciplinary report, dated 10/24/18, revealed CNA #1 was terminated from employment after the facility's investigation, for not following policy, when CNA #1 transferred Resident #1 alone and without the use of a lift, resulting in a fall with [MEDICAL CONDITION] for Resident #1. Review of a signed document, dated 6/15/18, revealed CNA #1 signed the acknowledgement of the facility's policies for the use of the Daily Care Guide and the Employee Handbook. A review of the Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 9/3/18, noted the facility admitted Resident #1 on 6/7/17, with [DIAGNOSES REDACTED]. Staff assessment identified Resident #1 as severely impaired and never/rarely made decisions.