Every finding on record at Bridgecrest Rehabilitation Suites

Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature control, and only permit only authorized personnel to have access to the keys for 1 of 5 residents (Resident #3) reviewed for storage of medications.The facility failed to ensure Resident #6 did not have Preparation H Suppositories in her room refrigerator on 08/24/2026.The deficient practice could place residents at risk of not receiving the therapeutic benefit of medications, drug diversion, or ingestion of unprescribed medications to residents, staff, and visitors.Findings included:Record review of Resident #3's undated face sheet revealed she is an [AGE] year-old female who admitted into the facility on [DATE] and readmitted on [DATE]. Diagnoses included constipation (fewer than three bowel movements a week), iron deficiency anemia (the body lacks enough iron to make healthy red blood cells), need for assistance with personal care, and kidney disease (kidneys are damaged and can no longer filter waste)Record review of Resident #3's Quarterly MDS dated [DATE] revealed a BIMS score of 12 out of 15 which indicated the resident has moderate cognitive impairment and was able to complete portions of the assessment but demonstrated deficits in recall and orientation.Record review of Resident #3's Physician Orders dated 08/01/2026- 08/26/2026 revealed.Colace (docusate sodium) [OTC]Capsule; 100mg; amt: 1; oralOnce A Day; 08:00 AMThe orders did not list any medication named Preparation H Hemorrhoidal Suppositories or generic. Resident #6 did not have an order for self-administering medications.Record review of Resident #3's Care Plan revised on 07/27/2025 problem revealed as the resident is at risk for constipation r/t decrease mobility with interventions as to encourage fluid intake, monitor for signs of constipation (decreased bowel sounds/ abdominal pain/ distention/ decreased appetite/fever, etc.). The care plan did not reveal Resident #3 was approved to administer own medications due to constipation.During an observation and interview on 08/24/2026 at 10:03 a.m. Resident #3 gave permission to review contents of her refrigerator. A box of Preparation H Hemorrhoidal Suppositories was observed in the refrigerator door, containing 10 of the original 12 suppositories. Resident #3 stated she received the suppositories from her daughter and used them when she was unable to have a bowel movement. She stated that the suppositories were helpful. She also stated the facility did not check her refrigerator or a daily basis and she did not inform staff- including aides or nurses about having the medication stored.During an interview on 08/24/2026 at 10:11 a.m. with LVN C she stated that Preparation H suppositories should have an order to be administered. She stated that refrigerators in the resident rooms are to be checked by staff or the ambassador daily. She stated if Resident #3 applied the suppository incorrectly or without guidance, it could cause harm to the rectal area.During an interview on 08/24/2026 at 2:22 p.m. the DON stated the expectation for medication storage is that all medications must be kept in the facility's designated storage areas, not in a resident's room. She stated that medications accessible in a resident room pose a risk of harm because any resident could access or ingest them. She also states that residents are permitted to self-administer medications. The appropriate facility policy for medication storage was requested during the interview but was not received. Record Review of Pharmacy Services Policies and Procedures revised 04/17/2024 reflects.1. A Physician's order is required for the Facility to administer medically necessarymedications that are not provided by Pharmacy (e.g., Investigational New Drugs,Over the Counter Naturally Occurring and Herbal Substances, resident returning withleave of absence/discharge medications, etc.).3. Facility staff should return any unused medications brought into the facility to theresident's family and/or responsible party.A. If a resident's Responsible Party/representative is not available, a Facilitynurse should store unused non-controlled substance medicationssecurely.B. The Facility nurse should count the quantity of each unused controlledsubstance and record the quantity in the resident's medical record.C. The Facility nurse should immediately remove the controlled substance fromthe cart and store the unused controlled substances in a double lockedstorage area or cabinet until returned

Based on interview and record review the facility failed to make a referral to the state designated authority when a newly evident or possible serious mental disorder was identified for 1 of 5 (Resident #6) residents review for PASARR.The facility failed to ensure Resident #6 was referred for a PASARR Level I screening as required for a newly identified diagnoses on 07/02/2025 of schizoaffective disorder.This failure could result in not receiving the support necessary to maintain stability, function, and safety.Findings included:Record review of Resident #6's undated admission record revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included schizoaffective disorder, depression, insomnia, psychosis not due to a substance or known physiological condition, and cognitive communication deficit. As of 07/02/2025 schizoaffective disorder, depressive type was added as an official diagnosis for the resident. Record review of Resident #6's MDS Quarterly assessment dated [DATE] revealed a BIMS score of 06 out of 15 indicating he has moderate impairment in cognition. Resident #6 did not exit any physical or verbal behaviors directed towards others.Record review of Resident #6's Care Plan dated 06/18/2026 did not include goals or interventions related to PASARR screening or evaluation related to schizoaffective disorder.Record review did not reveal a 1012 (mental health review form) form was not located in the Physician Orders and was not provided by the facility upon request. The 1012 would be documented in the Physician Orders because it contains PASARR required services for specialized reports, or behavioral health interventions for the physician to acknowledge.Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] revealed schizophrenia diagnosis had been verified and for resident to start the following prescriptions as of 07/02/2025:Risperdal 1 quantity, 0.5mg Tablet/BID dosage/Frequency for schizophrenia and unspecified psychosis not due to a substance or known physiological conditionDuring an interview on 08/25/2026 at 9:53 a.m., the SW stated that since Resident #6 admitted , she had not uploaded PASARR Level I or PASARR Level II. She stated diagnosis that would trigger a PASARR Screening Level I are; mental illnesses, IDD, and psychological diagnoses, including schizophrenia. She states she was aware of Resident #6's diagnosis of schizophrenia and is PASARR positive with receiving services.During an interview on 08/26/2026 at 8:20 a.m., LVN B stated that diagnoses trigger a PASARR Level I include schizophrenia, bipolar disorder, and major depression. She stated that a new PASARR screening should have been initiated once Resident #6 received a new mental health diagnosis, which was before her start date of 03/2026. She stated that Resident #6's schizoaffective disorder diagnosis was not evaluated, and she was not present if any evaluations occurred. She states that Form 1012 must be completed when a resident received a new qualifying diagnosis. She stated she is responsible for PASARR and corporate assists with quarterly audits. She stated Resident #6 does not have a diagnosis for dementia or Alzheimer's disease. She stated PASARR information is not typically added to the care plan and the failure to complete the PASARR process places the residents at risk of missing needed specialized services that they may be eligible for.During an interview on 08/26/2026 at 9:27 a.m., the DON stated PASARR responsibilities are handled by MDS. She stated that she is typically notified of new mental health diagnoses during the morning IDT meeting. She stated she is responsible for completing required documentation and submitting information into the electronic system for the state PASARR representative to conduct the evaluation. The representative determines eligibility and issues a declination letter if services are denied. The DON stated she is unsure of the required timeframe for completing PASARR updates after a new diagnosis but was not aware of the diagnoses for Resident #6 until 08/25/2026. She stated she monitors compliance through the MDS nurse. She stated the risk to the resident is that they may not benefit from PASARR specialized services.Record review of facilities 'PASARR Documentation Policy' revised on 06/09/2023 reads.PASARR requiresthat 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mentaldisorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (inthe community, a nursing facility, or acute care setting); and 3) receive the services they need inthose settings.5. The facility must notify the state-designated mental health or intellectual disability authoritypromptly when a resident with MD or ID experiences a significant change in mental orphysical status.6. Any resident with newly evident or possible serious mental disorder, ID or a related conditionmust be referred, by the facility to the appropriate state-designated mental health orintellectual disability authority for review.Examples of individuals who may not have previously been identified by PASARR to have MD, ID ora related condition include NOTE: this is not an exhaustive list. (RAI Manual) A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting thepresence of a mental disorder (where dementia is not the primary diagnosis). A resident whose intellectual disability or related condition was not previously identified andevaluated through PASARR. A resident transferred, admitted , or readmitted to a NF following an inpatient psychiatric stayor equally intensive treatment.

Based on observation, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety in one of one kitchen reviewed for food procurement, storage, preparation and service. The facility failed to ensure food stored in the kitchen freezer was properly dated. This failure could place residents at risk of food contamination and food borne illness. Findings include: An observation of the kitchen on 08/24/2026 at 8:47 AM revealed the following items opened and not dated:Box of catfish fillet shanksBox of [NAME] Spunkmeyer frozen cookiesContainer of Wholesome Farms classic ice cream During an interview with the DM on 08/24/2026 at 9:17 AM, she said labeling and dating opened food is important because of infection control and cross contamination. She said improper food storage can lead to freezer burn. She said all these things can lead to residents getting sick. She said her staff had been trained upon hire and at least once a month on proper food practices and preparation. She said all kitchen staff were responsible for ensuring food is properly labeled, dated and stored. During an interview with the DON on 08/24/2026 at 2:28 PM, she said the importance of dating open food is to monitor expired foods and freshness of foods. She said the Administrator oversees dietary concerns. She said failing to label to date open food puts residents at risk of getting food that is expired or outdated. During an interview with the Administrator on 08/24/2026 at 2:49 PM, she said the DM is responsible for food storage, labeling and dating. She said she ensures food is properly stored in the kitchen with weekly walk through the kitchen. She said the regional dietary manager comes monthly and does a walk through as well. She said the importance of dating open food was to make sure the residents were not served expired food. She said residents could get sick if food was not labeled or dated. A record review of the facility policy on Nutrition Policies and Procedures dated 08/01/2020 revealed food should be properly covered, labeled, dated with a use-by date and marked clearly to indicate the date by which the food shall be consumed or discarded.

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices for 1 of 4 hallways (Hallway 100) reviewed for supervision.The facility failed to ensure the exit door located at 100 hall was locked and secured on 04/15/2026. The failure resulted in the exit door located at the end of 100 hall observed to be unlocked/unsecured, allowing unrestricted resident access.Findings included:During an observation on 04/15/2026 at 2:38pm on the 100 hall, this surveyor observed CNA C using the key code to open the back exit door on the 100 hall to escort an unidentified resident from outside into the facility. This surveyor also observed CNA C exit through the same back door on the 100 hall without ensuring the door was re-secured or that the alarm system reactivated upon her departure, allowing the wind to repeatedly push the door open and closed.During an interview and observation on 04/15/2026 at 2:52pm with Resident #10, she stated that the exit door had been opening and closing while she was sitting nearby looking outside. When asked whether the door was typically left unlocked, Resident #10 stated it was not, explaining that it was dangerous, and someone could leave out. Resident #10 added that the aide may have forgotten to lock the door because she did so much to help everyone, but stated the door should be always locked. This surveyor was able to enter and exit the 100-hall exit door multiple times, including holding the door open during the resident interview, without the alarm sounding at any point.During an interview on 04/15/2026 at 3:08pm with LVN D, she stated the exit door was not supposed to be open. LVN D stated that the expectation was the employee who used the keycode to unlock the door, should reset the door after bringing a resident into the building and to verify the door was secured after each entry and exit. LVN D stated the risk of the door remaining unsecured was that a resident could leave the building and potentially fall.During an interview on 04/15/2026 at 3:13pm with CNA C, she stated the expectation for securing exit doors included ensuring residents did not see the door code. CNA C stated that when entering or exiting, she positioned herself in front of the door until it locked, and ensured residents could not view the code. She stated the door locked automatically after she left, and that she did not check it. She stated the door would beep when someone exited, and an alarm would sound throughout the building if it failed to lock. She identified the risk of the door not being locked as a resident leaving the building and becoming confused or lost.During an interview on 04/15/2026 at 3:18pm with the DON, she stated the expectation was for exit doors to remain locked. The DON stated the facility does not currently have residents who demonstrate elopement or wandering behaviors because the facility is not equipped with an elopement alarm system. The DON identified the risk of doors not remaining locked as a resident leaving the area unsupervised and a potential elopement.During an interview on 04/15/2026 at 3:19pm with the Administrator, she stated that exit doors were expected to always remain locked. She stated that if a door was unlocked by staff, the staff member is responsible for ensuring the door was locked and secured. The Administrator stated that if the doors are held open even briefly, the alarm should be activated. She identified the risk of the doors not remaining locked as a resident exiting the building and an elopement.A request was made for the facility's policy regarding exit doors remaining locked or otherwise always secured; however, facility staff reported that no such policy exists.

Based on, interview and record review the facility failed to ensure that residents transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. The facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care and the reduction of factors leading to preventable readmissions for 1 of 1 resident (CR #1) reviewed for inappropriate discharges - The facility failed to develop a complete and accurate discharge summary/plan for CR #1's discharge on [DATE].- The facility failed to order necessary equipment (a hospital bed) for CR #1's discharge on [DATE].- The facility failed to provide CR #1's clinical information to the receiving personal care home when she was discharged on 01/23/26. These failures could place residents at risk of not having complete records, necessary services, or information after permanent discharge from the facility. Findings include: Record review of CR #1's Face Sheet dated 02/04/26 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: pressure ulcers, bladder infection, acid reflux, diabetes with neuropathy (nerve damage causing tingling, burning pain and muscle weakness), high blood pressure, generalized muscle weakness and other abnormality of gait (how a person walks) and mobility. CR #1 discharged from the facility on 01/23/26 at 11:16 AM. Record review of CR #1's MDS dated [DATE] revealed, CR #1 admitted after a short-term hospital stay, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, lower extremity functional limitations in range of motion on both sides. Total dependence on helper for lower body dressing, putting on/taking off footwear, toileting, moving from: sit to lying, lying to sitting on side of bed, sit to stand and chair to bed transfer. CR #1 used a manual wheelchair, was totally dependent on helper to wheel 50 feet with two turns or wheel 150 ft and was always incontinent of both bladder and bowel. Record review of CR #1's undated care plan revealed, problem: Neuropathy and is at risk for increased pain d/t impaired cognition and impaired mobility; Approach: Pharmacological interventions as ordered by the provider. Consider factors such as causes,location, and severity of the pain, the potential benefits, risks and adverse consequences of medications, and the resident's desired level of relief and tolerance for adverse consequences. Problem: required assistance to complete ADL tasks d/t impaired cognition, impaired mobility and incontinence; Problems- Transfers- Assist of 2 utilizing a [Mechanical Lift] a device used to safely transfer individuals with limited mobility between a bed, wheelchair, or toilet), Wheelchair for mobility, and bed mobility- Assist of 1. Record review of CR #1's Progress Notes from 12/30/25 to 01/23/26 revealed:- 01/17/26 at 02:29 PM signed by LVN B, Resident continued on skilled services with NAD noted or complaints voiced. Resident able to make needs known and required a [Mechanical Lift] for transfers due to paraplegia. - 01/19/26 at 12:04 PM signed by the former social worker, Resident has remained on skilled services for both PT and OT services.Resident requires assistance with lower body tasks such as dressing and toileting. Resident for these skills is maximum assistance. Resident is able to complete task for upper body. Friday January 16,25 former Home health came to visit and has offered to assist her again upon her discharge. Social Worker was unable to reach family at that time in regard to discharge as resident had previously indicated her desire to go to another facility however at the present she is not meeting all criteria for medical necessity.I had shared this with resident and shared with her about option of a personal care home which she had said she would think about. Have left message [placement coordinator] to contact me. Will follow up with resident and the home health and also her family. Resident has not yet received a NOMNC.- 01/23/202611:13 AM signed LVN A, Resident discharged at this time to home care facility-- Accompanied by facility van driver -Discharge information and medications sent with Resident/driver - Resident verbalized understanding of medication administration--Resident stable at the time of departure. - 01/26/26 at 10:08 AM signed by the former social worker, Resident records were sent to [Home Health] week before resident was discharged on Friday on Friday the 23rd . They are to follow personal care home in the community. Medication list is sent to [Home Health] at this time. Resident is residing at personal care at this time. Will follow up with [Home Health]as to when they will be able to see resident in the community. Records to be sent to physician in the community and make him aware resident as resident is in the personal care home as well.There was no documentation that the facility sent records to the location the facility delivered CR #1 to upon discharge on [DATE], Personal Care Home, no documentation of an order for DME (hospital bed), and no documentation of coordination of home health services. Record review of CR #1's Joint Mobility Screen dated 12/31/25 revealed, movement of CR #1's lower body could not be assessed but she had full mobility of her upper body. Record review of CR #1's OT Discharge Summary for dates of service 12/30/2025 - 1/21/2026 revealed, at time of discharge CR #1 required Maximum Assistance with: dressing, toileting, and lower body bathing. Discharge recommendation: Home health services. Record review of CR #1's discharge documents revealed, the document was faxed on 01/29/26 at 02:58 PM (6 days after CR #1 discharged from the facility on 01/23/26). The document included:- a signed receipt of medication upon discharge form issued on 01/23/26.- continuity of care document which provided the CR #1's: emergency contact information and next of kin, medication list and dates the medications were last administered, diagnoses, insurance information, recent labs, care plan, social history.- Transition of Care/Discharge summary dated [DATE] at 10:47 AM signed by LVN A with the physical functioning and structural problems addressing Mobility Devices, Self-Care and Mobility left blank in the Clinical Discharge and Narrative section.The document did not indicate necessary equipment[Mechanical Lift], or services CR #1 would require upon discharge. Record review of CR #1's Discharge summary dated [DATE] revealed, - The physical functioning and structural problems addressing Mobility Devices, Self-Care and Mobility were all left blank in the Clinical Discharge and Narrative section.- The Care Team section was left blank.- The Scheduled Appointments was left blank.- The Special Instructions section addressing dietary/nutrition and therapy were left blank.- The Medical Equipment section was left blank.- The Continence section was left blank.- The Customary Routine section was left blank.There was no documentation of the address CR #1 would be discharged to. Record review of the facility's undated Internal Investigation completed by the Administrator revealed, 01/24/26- Administrator later received phone call from [Personal Care Homeowner Owner] states that she did not receive any clinical information from the SW like she had requested. Owner states that she CR #1 could transfer herself and did not need a hospital bed which was incorrect. Administrator checked Matrix for social service progress notes. No documented notes of SW setting up DME and HH. Administrator attempted to call SW however she did not answer. Left message requesting a call back. Administrator went on [portal] and ordered hospital bed for residents. Administrator telephoned [Owner] and informed her of ordering a hospital bed. Administrator stated she would continue to update as she received information.01/26/26- Administrator met with SW re: discharge of resident. SW admitted to not ordering DME stating she was told that residents did not need any. She also stated that she did not fax referral for home health. Administrator ordered SW to make HH referral immediately and it was completed. During verbal counseling, SW decided to issue resignation. Administrator later received notification that [DME company] would not be able to fulfill DME order. Administrator made referral for [DME company] DME. That afternoon resident's [Family Member] came to facility and resident requested via phone a copy of medical records for PCH to be given to her. Once she received medical records, she left the facility. In an interview on 02/04/26 at 10:11 AM, the Administrator said CR #1 required maximum assistance for transfers, she had good upper body strength but had a paraplegic lower body. She said after CR #1 discharged , she received a call from the personal care home, who stated the necessary equipment (hospital bed) had not arrived. The administrator said she submitted the order for the hospital bed to the DME company and sent the required clinicals to the personal care home but there were issues with CR #1's insurance which resulted in delay until 01/29/26. She said the Social Worker was responsible for CR #1's discharge on [DATE] but she was no longer employed at the facility. In an interview on 02/04/26 at 10:47 AM, CR #1's family member said, the facility failed to communicate CR #1's lower extremity functional limitations to the admitting facility or order a hospital bed when she discharged to the personal care home on [DATE]. She said the facility CR #1 was transferred to only had a twin bed and did not know the resident could not transfer herself. An attempt was made on 02/04/26 at 11:44 AM to contact the Social Worker by telephone. The number provided by the facility was not in service. In an interview on 02/04/26 at 12:03 PM, The Owner of personal care home said, prior to CR #1's arrival in the facility the former Social Worker failed to send any clinical records on CR #1 and failed to verbally communicate that the resident required maximum assistance or a hospital bed. The Owner of the personal care home said when CR #1 arrived at the facility the home did not have the hospital bed CR #1 required due to her inability to use her legs. She said her facility could not meet CR #1's needs and could not meet the needs of immobile residents that required maximum assistance because they did not have sufficient staff to transfer the resident. In an interview on 02/04/26 at 12:44 PM, the Transportation Staff said, on 01/23/26 she transported CR #1 to Personal Care Home B. She said when she arrived at the care home, CR #1's room did not have a hospital bed, there was a regular twin bed Kids twin bed low to the ground in the room. The Transportation Staff said the personal care home did not have sufficient staff to transfer CR #1 when she arrived so she had to help transfer the resident to her new bed. In an interview on 02/04/26 at 01:06 PM, the PTA said CR #1 required maximum assistance for bed mobility, and sitting up or turning in bed so she would need an adjustable bed to sit up independently. In an interview on 02/04/26 at 01:50 PM, the Administrator said there was no documentation to support the facility sent CR #1's clinical records to the personal care home, or DME orders were submitted prior to CR #1's discharge on [DATE]. She said facility staff are expected to initiate discharge planning at admission and all services should be initiated prior to discharge. The Administrator said the personal care home was not notified of required DME prior to CR #1's arrival. She said the Social Worker was responsible for making sure the discharge facility was appropriate, supplies were available and clinicals were sent but failed to do so. The Administrator said resident's discharge summary should include the name and address of the discharge facility and the information was missing from CR #1's discharge summary. She said based on her review CR #1's discharge summary was incomplete as it did not include where she was going, services or equipment needed or appointments needed post discharge. The Administrator said the Social Worker separated her employment due to this incident but the investigation revealed, clinical information was never sent to the personal care home. The Administrator said failure to develop a complete and accurate discharge plan/summary could place residents at risk of missed care and an inappropriate discharge that is neither successful nor safe. Record review of the facility policy titled Admission, Discharge and Transfer- Code of Ethics revised 10/23/19 revealed, 15- All aspects of transfer and discharge are documented in the medical record, including A- patient/resident and/or family notification. B- Attending physician's written or faxed orders. 18- Sufficient preparation and orientation to the patient/resident are provided for a safe and orderly transfer or discharge. The policy did not provide further details on coordinating safe and orderly transfers for Residents.

Based on observation, interview, and record review, the facility failed to provide care and services to prevent complications for 1 (Resident #58) of 2 resident reviewed for gastrostomy tubes (a surgically implanted tube into the stomach to provide delivery of nutrition). CNA-A paused the tube feeding pump, instead of informing the nurse immediately to turn off the pump for Resident #58, prior to lowering the head of bed (HOB). This failure could place residents with g-tubes at risk of complications such as aspiration, incorrect settings on the pump and delay in receiving feedings as physician ordered. Findings include: Record review of Resident #58's face sheet dated 06/25/25 revealed a [AGE] year-old first admitted to the facility on [DATE]. Diagnoses included multiple sclerosis (a chronic neurological disorder), muscle wasting, Dysphagia (swallowing disorder), Parkinsonism (a nervous system disorder), conversion disorder with seizures or convulsions (a mental health condition that causes physiological symptoms), anxiety, functional quadriplegia (inability to completely move) and gastrostomy status (a surgically implanted tube to allow provision of nutritional support). Record review of Resident #58's quarterly MDS dated [DATE] revealed she had short term and long-term memory problems. She had severely impaired cognitive skills for daily decision making. She had continuous behaviors of alerted level of consciousness. She required total assistance from staff for all ADLs. She required a feeding tube for nutritional support. Record review of Resident #58's June 2025 MARTAR revealed on 6/25/25, every shift, the HOB was elevated 30 - 45 degrees during enteral feeding. On 6/25/25 she received enteral feeding: Formula Jevity 1.5 at 42ml/hr for 22 hours via pump every shift. Record review of Resident #58's undated care plan revealed Problem - category Feeding Tube: Resident #58 receives Jevity 1.5 via g-tube at 50ml/hr x 22 hours, edited on 04/22/25. Goal - Resident #58 will remain free of complications related to G-tube, including aspiration/infection. Approach included: elevate HOB 30 - 45 degrees during feeding and one hour after. Observation and interview on 06/25/25 at 12:40 PM, Resident #58 was leaning over to her left side, head unsupported. The HOB was raised at least 45 degrees and TF pump was infusing Jevity 1.5 formula at 42 cc/hr into resident's g-tube. CNA-A stated 2 hours ago she had changed Resident #58's brief and she was not leaning over in that position. CNA-A repositioned Resident #58 by centering her in the bed, then pressed the pause button on the tube feeding pump. CNA-A did not call for a nurse to assist with the tube feeding pump. CNA- A then lowered the HOB and took the wedge from the chair and positioned it underneath the left side of Resident #58's back. CNA-A raised the HOB and then turned the tube feeding pump back on. CNA-A stated she would get a pillow for Resident #58's head. When she was done with Resident #58, she walked out of the room and walked halfway down the hall to retrieve the meal cart. CNA-A did not notify the nurse about Resident #58. CNA-A stated she would notify the nurse about finding Resident #58 leaning over to one side. CNA-A stated it was her understanding that aides were allowed to pause the tube feeding pump when HOB is lowered to provide ADL care. CNA-A stated only the nurses were allowed to touch/pause the pump. CNA-A stated she paused the pump because sometimes the nurses were busy and could not come to pause the pump for her to complete ADL care tasks. In an interview on 6/25/25 at 12:55PM, LVN-B stated Resident #58 gets bowel rest between 8:00AM and 10:00AM, then she restarted the tube feeding. She stated Resident #58 was sitting upright at almost 90 degrees when she left her. LVN-B stated Resident #58 does move around and can end up leaning to either right or left side. LVN-B stated that only the nurses were allowed to pause the feeding pump and expected the CNAs to call her if they need the pump to be paused. LVN-B stated she believed it was the Board of Nursing policy that only nurses were allowed to touch the pump. LVN-B stated the CNAs were not trained to monitor a resident on tube feeding and they cannot assess residents. LVN-B stated the risks would be aspiration and if she had turned the pump off, she would also check the tubing for kinks. In an interview on 06/25/25 at 2:35PM, the DON stated she expected the CNAs to get the nurse for assistance when pausing the tube feeding pump is needed. The DON then stated she encourages the nursing staff to call for nurse assistance. The DON stated there were multiple risks if a CNA were to pause the pump without nurse assistance. The DON stated the CNAs do not know how to read the pump, settings could get readjusted, and a risk to the resident could be aspiration. The DON stated an in-service and demonstrations were conducted last month (May 2025) for all nursing staff which included do not touch the pump, for the CNAs. Record review of the facility's policy and procedures for Gastrostomy Tubes, revised May 5, 2023, and received on 6/25/25 at 2:45PM, included a G-tube/Nurse, CNA responsibility signature sheet dated 05/31/25. CNA-A signed the sheet. The policy read in part: .2. The patient/resident that is fed by enteral methods receive the appropriate treatment and services to restore oral eating skills and prevent complications of enteral feeding, like aspiration pneumonia . Record review of page 1 of the facility's G-tube policy and procedure, nurses and CNA in-service dated 5/31/25, conducted by the ADON, was received on 6/26/25 at 11:15PM, read: .In general and in emergency situations: CNA do not touch g-tube pump, do not attempt to unhook a resident. Get with nurse for all G-tube related care or while providing care * please get the nurse for assistance, rather than pausing pump** unless an emergency situation arises. Immediately notify the nurse. Record review of the facility's Position Description: Certified Nursing Assistant, revised on 11/2016 read in part .Essential Functions and Responsibilities: .16. Maintains knowledge of equipment set-up, maintenance, and use (ie., restraints, monitors, drain devices, lifts, weight machines, etc.) .17. A. Operates all equipment in a safe manner; only uses equipment for which training has been received . Further review did not include the use of tube feeding pumps.

Based on observation and interviews, the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters in that: The facility failed to ensure the dumpster lids were closed on 2 of 2 dumpsters and the area surrounding the dumpsters were free of garbage and debris. These failures could affect residents who resided in the facility and the public by placing them at risk of exposure to germs, disease, and an environment which could attract pests and rodents. The findings include: In an observation on 6/24/25 at 9:35 AM of 2 of 2 dumpsters located outside the nursing facility, the lids were open on both dumpsters. The dumpsters were not full. Two disposable gloves, a mask, a bag of garbage, a tin can, and papers were on the ground next to the dumpsters. The Dietary Manager closed both dumpster lids immediately upon observation. During an interview on 6/24/25 at 9:37 AM, the Dietary Manager stated that the dumpster lids were to always remain closed to maintain pest control. She stated it had been the responsibility of all staff that use the dumpster to close the lid after placing garbage inside. During an interview on 6/25/25 at 8:50 AM, the Housekeeping Manager stated that all the department staff disposed of trash in the dumpsters. The housekeeping staff are trained to close the lid and make sure garbage is in the container and not on the ground. During an interview on 6/26/25 at 3:10 PM, the Administrator stated that dumpster lids were to always remain closed. The maintenance director does rounds outside the facility in the mornings and will pick up garbage if he sees any. She stated that in-service was conducted on 6/25/25 for dietary and nursing staff on placing garbage inside the dumpsters and securing the lids. The number of times the dumpsters are emptied during the week has been increased from 2 to 3 times per week. No policy on garbage and refuse disposal was provided by time of exit on 6/26/25 at 4:30 PM.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 residents (Resident #1) reviewed for pharmacy services. MA K attempted to administer Resident #23's Hydrochlorothiazide (used to treat high blood pressure and fluid retention) to Resident #1 instead of Hydralazine (used to lower blood pressure and improve blood flow) as ordered by the MD. This failure could place residents at risk of medication errors resulting in exacerbation or deterioration in health conditions. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnoses included hyperkalemia (high potassium), hypertension (high blood pressure), and pulmonary heart disease. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. She required assistance from staff with ADL care. Record review of Resident #1's care plan edited 2/7/25 revealed she was at risk for signs and symptoms of hyper/hypotension related to diagnosis of hypertension. Nifedipine (medication used to treat high blood pressure and angina), carvedilol (medication used to treat heart failure, hypertension, and heart attack) as ordered. The approach was to administer medications as ordered. Record review of Resident #1's Physician Orders for February 2025 revealed an order for Hydralazine 25 mg give 75 mg every 6 hours, order date 11/9/24. Record review of Resident #1's MAR dated 1/26/25 - 2/8/25 revealed Hydralazine 25 mg give 3 tablets for hypertension was scheduled 4 times a day at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. In an interview on 2/8/25 at 2:29 p.m., Resident #1 said she received Hydralazine every 6 hours but did not receive the medication on some shifts. In an observation and interview on 2/8/25 at 5:02 p.m., MA K began medication administration for Resident #1. She retrieved Resident #23's Hydrochlorothiazide 25 mg from the cart and placed 3 tablets in the medication cup. MA K locked the medication cart and entered Resident #1's room. This Surveyor intervened and asked MA K to return to the medication cart to verify the medication. Observation revealed the medication in the cup (Resident #23's Hydrochlorothiazide) did not match the medication in Resident #1's blister pack (Hydralazine). MA K said she could not read the imprint on the tablet and said she may have grabbed the wrong blister pack. She said the blister pack was in the wrong spot and the medication she prepared for Resident #1 belonged to Resident #23. She destroyed Resident #23's Hydrochlorothiazide and prepared Hydralazine 25 mg 3 tablets and administered it to Resident #1. In an interview on 2/8/25 at 5:19 p.m., MA K said she checked the MAR and blister pack to verify the correct amount, dosage, and time. She said she reviewed the medication name and the dosage and thought it matched. She said she noticed it was a different medication when the Surveyor said something. She said she must have placed Resident #23's medication in Resident #1's spot on the medication cart. She said Hydralazine was for Resident #1's blood pressure. In an interview on 2/8/25 at 5:24 p.m., the DON said nursing staff should follow the rights of medication administration which included verifying the right patient and to compare the MAR to what was on hand. She said (Hydralazine) was a blood pressure medication and (Hydrochlorothiazide) was a diuretic (used to increase urine production and help lower blood pressure and fluid retention). She said the risk included medication error, and it could be detrimental. Record review of the facility's Medication Management policy dated 4/7/24 read in part, .The staff and practitioners shall strive to minimize potential for medication error by: A. Following the :8 Rights for administering medication: 1. The right patient/resident, 2. The right drug .

Based on interviews and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (CR #1) of 6 residents reviewed for quality of care. The facility failed to ensure CR #1, who was cognitively impaired received adequate supervision when the facility sent her to the doctor's office unsupervised. CR #1 left the doctor's office and was found outside of the building next to a major freeway feeder road by the doctor's office manager. On 5/16/24 at 4:13 p.m. an immediate jeopardy (IJ) was identified. While the IJ was removed on 5/17/24 at 3:31 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure placed facility residents with dementia and impaired cognition at risk of neglect and elopement for lack of supervision during any appointment. Findings included: Record review of CR #1's face sheet dated 5/16/24 revealed a [AGE] year-old female admitted originally 7/9/20 and most recently 5/25/23. Her diagnoses were: Cerebral infarction (of stroke that occurs when a blood vessel in the brain is blocked, causing damage to brain tissue), Glaucoma (group of eye conditions that damage the optic nerve and can cause vision loss), Type 2 diabetes mellitus with hyperglycemia (high blood sugar), unspecified disorientation, hallucinations, unsteadiness of feet, history of falling, anemia (condition of low red blood cells or hemoglobin that can cause fatigue), and congestive heart failure. Record review of CR #1's Annual MDS assessment dated [DATE] revealed a BIMS score of 11 which indicated moderate cognitive impairment. Section E- Behaviors revealed CR #1 had hallucinations. Section GG0170 - Mobility Devices revealed CR #1 used a manual wheelchair. CR #1 required substantial/maximal assistance (helper does more than half the effort) with ADLs. Record review of CR #1's care plan last revised 5/10/24 revealed the following in part: Problem: Communication - CR #1 has impaired communication as evidenced by: Reduced ability to understand others. Impaired daily decision-making ability. Goal: Staff will anticipate and meet all needs. CR #1 is not able to communicate effectively over the next 90 days. Approach: Reduce or remove all interfering environmental stimuli. Problem: Cognitive Loss/ Dementia - CR #1 appeared to have impaired ability to understand others at times and has impaired ability to make daily decisions. Goal: CR #1 will accept helpful reminders, will have needs met by staff as identified or anticipated, will have minimal negative emotional distress related to cognitive issues. Approach: Continue to assess periodically for changes in cognition; adjust approaches to offer more assistance as needed. Record review of CR #1's nursing note dated 5/14/24 at 9:34 a.m. written by LVN A revealed CR#1 was picked up by EMS via wheelchair for a scheduled appointment at 9:00 a.m. Record review of CR #1's nursing note dated 5/14/2024 at 4:57 p.m. written by the ADON revealed CR #1 returned vial EMS. The nursing note did not reflect CR #1's elopement from the doctor's office. Attempted interview on 5/17/24 at 9:40 a.m. in CR #1's room. CR #1 was asleep. CR #1's name was called she rolled over and did not wake up. In an interview on 5/16/24 at 11:21 AM with the Doctor's Office Manager, she said CR #1 had an appointment on 5/14/24 and had finished at approximately 11:43 a.m. She said the resident was placed in a waiting room with a T.V. until transportation picked her up. She said CR #1 had been dropped off by transportation unaccompanied. The Doctor's Office Manager said she received a call, at 2:29 p.m., from the ADMIN, who inquired if CR #1 was still at the appointment. She said the staff looked for the resident inside the building and CR #1 was found at the sidewalk, stuck in the mud next to a major freeway feeder road, in her wheelchair at 3:00 p.m. She said CR #1 was soiled through her pants, sweating, thirsty, and hungry. She said the resident asked for water and peanuts. The Doctor's Office Manager said she notified the ADMIN, and transportation picked up the resident approximately 3:55 p.m. In an interview on 5/16/2024 at 11:34 a.m. with the ADMIN, she said CR #1 went to the doctor's appointment, on 5/14/24, without an escort because the staff that set up transportation thought CR #1's family member was supposed to meet her. The ADMIN said she received a call from the transportation company at approximately 2:00 p.m. and they said CR #1 could not be located. The ADMIN said she called the doctor's office and asked if they knew where CR #1 was. The ADMIN said she called the doctor's office staff and asked them to check the building. She said she did not know how long the doctor's office searched for CR #1, but the doctor's office manager called at approximately 3:00 p.m. and said that the resident had been found. The ADMIN said she was told the resident was thirsty and asked for peanuts. She said the resident returned to the facility between 4:00 p.m. - 5:00 p.m. She said the resident's brief and clothing needed to be changed. She said the resident should have either had an escort from the facility or a family member should have been confirmed that they would be in attendance. She said the resident was at risk because her level of cognition would prevent her from making safe decisions. In an interview on 5/16/24 at 12:15 p.m. with the DON, she said when a doctor's appointment was scheduled, the facility nurses set up transportation and should have called the RP to verify if they will be in attendance. She said a resident's cognitive ability to make decisions was what determined if an escort was needed for a doctor's appointment. She said it was rare that a resident would be sent alone to an appointment. The DON said the transportation company will bring the resident into the doctor's office, leave a card, and advise the doctor's office to call when the appointment was completed for the return pickup. The DON said she was notified by the ADMIN and the transportation company that they were not able to locate CR #1 at approximately 2:00 p.m. The DON said the ADMIN called the doctor's office and asked them to look for CR #1. She said the doctor's office manager said that CR #1 had been placed in a TV room while she waited for pick up. She said the doctor's office manager called about an hour later and said CR #1 had been found near a sidewalk. The DON said CR #1 was transported back to the facility by the transportation company. She said CR #1 was cleaned up and provided dinner. The DON said she was not sure if CR #1 was able to navigate safely in the community alone. She said if the resident was not able to make safe decisions and could not navigate her surroundings, she would be at risk for possible injury. In an interview on 5/16/24 at 12:55 p.m. with the ADON, she said the appointment was scheduled by the NP with the doctor's office. The NP would notify the nursing staff of the scheduled appointment and the nursing staff were responsible for the transportation set-up. She said if family was not able to attend the visit, then facility staff would attend. The ADON said she along with LVN A received CR #1 when she returned. The ADON said CR #1 received a brief change, but stated it was not because she was soiled. She said she did a quick head to toe assessment and checked her blood sugar and it was in normal limits. The ADON said CR #1 did not discuss the details of the visit. In an interview on 5/17/2024 at 1:12 p.m. with the NP, she said she scheduled the orthopedic doctor's appointment for CR #1 and notified LVN B who was responsible for transportation. She said the facility staff that set up transportation was responsible for notifying the family member and should have verified if they would be in attendance at the visit. The NP said CR #1's cognition was in and out and becomes confused. The NP said she would be concerned for CR #1's safety if she was alone in the community. In an interview on 5/17/2024 at 2:16 p.m. with LVN B, she said the nurses were responsible for scheduling resident transportation to doctor visits. She said she notified CR #1's family member about the 5/14/24 doctors' appointment. LVN B said the family answered OK to the notification of the visit, but LVN B said she did not verify if the family member was going to attend the doctor's appointment. She said she was not sure if the family member would meet CR #1 at the doctor's office. LVN B said she did not feel CR #1 was confused and communicate to nursing staff if a resident needed an escort. She said she was not present on the day of the appointment for CR #1. LVN B said she did not recall a training on determining if a resident needed an escort or to verify if a family member would be in attendance. In an interview on 5/17/24 at 2:32 p.m. with LVN A, he said he was the nurse on duty when CR #1 left for her doctor's appointment on 5/14/24. He said he was told by LVN B, CR #1's family member would meet her at the doctor's office. He said CR #1's baseline was that she was confused. He said he had not received training on verifying if a resident needed an escort or had a family member that would meet the resident at a doctor's appointment. He said the ADON received CR #1 when she returned from the doctor's appointment at approximately 5:00 p.m. and the ADON made sure she was cleaned up. He said he did assist with the clean up and did not know if the resident was soiled through her clothing. In an interview on 5/16/24 at 3:01 p.m. with the Transportation Manager, he said CR #1 was dropped off at the doctor's office and wheeled inside of the office on 5/14/24 at 8:57 a.m. He said a card was left with the doctor's office staff to call when the resident needed to be picked up. He said dispatch received a return pick up at 11:48 a.m. He said the driver was not able to locate the resident and the driver was unassigned and left the doctor's office at 12:42 p.m. He said a second driver was assigned to pick up the resident at 3:04 p.m. He said the resident was returned back to the nursing facility at 4:56 p.m. In an interview on 5/16/24 at 3:40 p.m. with CR #1 she said, she did not remember a doctor appointment. She was asked if she knew her family members names and she said, I don't remember do you. She appeared confused and asked this State Surveyor if she knew she had an appointment. She said she did not remember waiting for transportation at her doctor's visit this week. Record review of the doctor's office timestamped video from 5/14/2024 revealed the following: 11:43 a.m. - 1:00 pm 11:43 a.m. - CR #1's doctor's visit was completed. 12:46 p.m. - CR #1 seen waiting at second floor elevator doors. 12:48 p.m. - CR #1 seen exiting the first-floor elevator doors. 12:49 p.m. - CR #1 seen speaking to security guard. 1:00 p.m. - CR #1 seen propelling herself from the parking garage camera towards the major freeway feeder road. In an interview on 5/16/24 at 11:34 a.m. with the ADMIN, a facility policy on transportation and the determination if a resident required an escort to a doctor visit was requested. The ADMIN said the facility did not have policy. Record review of accuweather.com revealed on 5/14/24 the temperature was a high of 88 degrees and a low of 68 degrees. Record review of facility policy on Activities of Daily Living, Optimal Function (revision date 5/5/23) revealed the following in part: The facility provides necessary care to all residents that are unable to carry out activities of daily living on their own. Record review of facility Elopement policy dated 11/1/2017 revealed the following in part: Policy: To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing . .5. If the search fails to locate the missing patient/resident within (30) thirty minutes from the time the patient/resident is found to be missing, the Administrator and/or designee contact the appropriate community agencies (Police, Local Health Department) and Administration, the patient's/resident's legal representative and attending physician. Staff will provide the Police with all physical identifying information including but not limited to physical appearance, height, weight, age, sex, and clothing, if known . This was determined to be an Immediate Jeopardy (IJ) On 5/16/24 at 4:13 p.m. The ADMIN and the DON were notified. The Administrator was provided with the IJ template on 5/16/24 at 4:13pm. The following Plan of Removal (POR) was submitted by the facility and accepted on 5/17/24 at 9:26 a.m.: PLAN OF REMOVAL F689 Name of facility: The facility Date: 5/16/24 Facility failed to ensure CR#1 had adequate supervision when the facility sent her to the doctor's office unsupervised. Immediate action: CR #1 returned to the facility. Resident was assessed by the Assistant Director of Nursing at 4:57pm on 5/14/24 with no injuries identified. Physician and responsible party notified. Review of upcoming appointments were completed by the Director of Nursing/Designee on 5/16/24 to identify upcoming appointments for cognitively impaired residents with a BIMS score of 12 or less. 4 residents identified with a BIMS score less than 12 scheduled for appointments. Those 4 identified residents have someone scheduled to accompany them. Review of resident's recent BIMS scores completed by the Social Services Director on 5/16/24. The cognitively impaired residents with a BIMS score of less than 12 will have their care plan updated by 5/17/274 to include need for accompaniment for outside appointments. The Social Worker will update the care plan for current residents who have a change in BIMS score and new residents who admit who are cognitively impaired with BIMS score <12 beginning 5/17/24. Reeducation provided to the Director of Nursing and the Administrator by the Clinical Consultant on 5/16/24 on need for family/Responsible Party or facility staff to accompany cognitively impaired residents with a BIMS score of less than 12 to outside appointments. Re-education provided to licensed nurses and certified nursing assistants on need for cognitively impaired residents with BIMS score of less than 12 to have a family member/Responsible Party or facility staff accompany them to outside appointments. This education was completed by 5/16/24 by the Director of Nursing. Any licensed nurse or certified nursing assistant not receiving this education by the target date will receive prior to their next scheduled shift. A review of the days outside appointments will be completed in clinical morning meeting Monday - Friday by the Administrator to validate any cognitively impaired resident with a BIMS score of less than 12 has a family member/Responsible Party or facility staff member scheduled to accompany them. This will begin on 5/17/24 and continue Monday - Friday during the morning meeting process. The Nurse Managers will communicate to the licensed nurse verbally and by writing on the 24-hour report that a resident will have a family member/Responsible party or staff member accompany the resident on an appointment. Licensed Nurses will validate cognitively impaired residents with a BIMS score of less than 12 have a family member/responsible party or facility staff accompaniment with them prior to the resident leaving for any outside appointment. Should a cognitively impaired resident with a BIMS score less than 12 have an outside appointment on the weekend, the licensed nurse will validate the resident has as escort to the appointment. Licensed Nurses will validate prior to the end of their shift any resident who has left for an appointment without an accompaniment has returned. If the resident has not returned, the licensed nurse will follow up with the office staff at the appointment for an update on the resident and this will be communicated to the next shift. Elopement Policy was reviewed on 5/16/24 by the Administrator and the Director of Nursing and no changes were indicated. Ad Hoc QAPI was held on 5/16/24 to review the contents of this plan. The Medical Director was notified on 5/16/24 of the Immediate Jeopardy and the contents of this plan. MONITORING Record review of the facility list of 4 residents with upcoming doctor visits via transportation service revealed the following: Interview on 5/17/2024 at 12:38 p.m. with CNA A said she had been trained on 5/16/24 on when a resident should be escorted to a doctor's visit. She said she had to be present with the resident the entire time of the visit. She said she was informed she would escort a resident of (Resident #2) on 5/22/24 to an appointment. She said she was trained to inform family members who took residents to doctor's appointments that they must remain with the resident throughout the entire visit. In an interview on 5/17/24 at 11:57 a.m. with RP of Resident #3 said she was currently at visit with the resident. The RP said the DON had informed her that a family member must remain with a resident throughout a doctor's visit until they return to the facility or are with transportation. In an interview on 5/17/24 at 12:05 p.m. with RP of Resident #4 said she was aware and always stayed with the resident throughout the visit and returned her back to the facility. She was aware to never leave the resident alone. She was aware of the next 4 visits (5/22/24, 5/28/24, 6/5/24, 6/13/24) and would be present. Interview on 5/17/24 at 12:33 p.m. with RP of Resident #5 said she was aware and informed by the facility that she would meet the resident for her doctor's visit and be with her until transportation picked her up. Interviews with the following Nurses and CNA's revealed the following: Nurses and CNA's confirmed they had been educated on the need for cognitively impaired residents with a BIMS score of less than 12 to have a family member/Responsible Party or facility staff accompany them to outside appointments. The Nurses said they would communicate to the licensed nurses verbally and by writing on the 24-hour report that a resident will have a family member/Responsible party or staff member accompany the resident on an appointment. Nurses confirmed they would validate cognitively impaired residents with a BIMS score of less than 12 have a family member/responsible party or facility staff accompaniment with them prior to the resident leaving for any outside appointment. Nurses and CNAs confirmed the same process would be required for weekend appointments. LVN C (day shift) - Interviewed on 5/17/24 at 12:58 p.m. RN A (day shift)- Interviewed on 5/17/24 at 1:10 p.m. LPN A (day shift) - Interviewed on 5/17/24 at 1:22 p.m. LVN D (night shift) - Interviewed on 5/17/24 at 1:37 p.m. CNA D (day shift) - Interviewed on 5/17/24 at 1:48 p.m. LVN E (night shift) - Interviewed on 5/17/24 at 2:08 p.m. PRN CNA B (night shift) - Interviewed on 5/17/24 at 2:42 p.m. LVN F (night shift) - Interviewed on 5/17/24 at 2:55 p.m. CNA C (night shift) - Interviewed on 5/17/24 at 3:01 p.m. In an interview on 5/17/2024 at 2:00 pm with the nurses that were ending their shifts revealed they had verified the residents who had gone out for appointments today had returned by making physical observations. In an interview on 5/17/2024 at 2:26 pm with the SW, she said she had updated all residents with BIMS score of less than 12 to have staff or family member accompany the resident to appointments throughout the visit. Record review of facility audit of resident's recent BIMS scores completed by the Social Services Director on 5/16/24. Cognitively impaired residents with a BIMS score of less than 12 will have their care plan updated by 5/17/274 to include need for accompaniment for outside appointments. Record review of 10 sampled residents revealed their care plans had been updated to reflect the following This resident will need to be accompanied by responsible party or staff for all appointments due to BIMS score less than 12). In an interview on 5/17/2024 at 11:36 AM with ADMIN and DON, the DON said she was reeducated by the Clinical Consultant on 5/16/2024 on the need for family/Responsible Party or facility staff to accompany cognitively impaired residents with a BIMS score of less than 12 to outside appointments. The ADMIN said she was aware that residents with a BIMS score less than 12 had to be escorted to appointments with family members or facility staff. The ADMIN said she would review on the day of the outside appointments in the clinical morning meeting Monday - Friday to validate any cognitively impaired resident with a BIMS score of less than 12 has a family member/Responsible Party or facility staff member scheduled to accompany them. Record review of Ad Hoc QAPI held on 5/16/2024 was completed with the following participants: Medical Director, the DON, the ADMIN, the ADON. The ADMIN was informed the IJ was removed on 5/17/24 at 3:31 p.m. While the IJ was removed on 5/17/24 at 3:31 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on interviews and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately but not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency for 1 of 1 incident reviewed for reporting. The facility failed to report to the State Survey Agency when Resident #1 was known to have been missing for approximately 1 hour after leaving the hospital where she went for a doctor's appointment. This failure could have affected residents by resulting in a delay of identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent harm, or impairment. Findings included: Record review of CR #1's face sheet dated 5/16/24 revealed a [AGE] year-old female admitted originally 7/9/20 and most recently 5/25/23. Her diagnoses were: Cerebral infarction (of stroke that occurs when a blood vessel in the brain is blocked, causing damage to brain tissue) (Glaucoma (group of eye conditions that damage the optic nerve and can cause vision loss), Type 2 diabetes mellitus with hyperglycemia (high blood sugar), unspecified disorientation, hallucinations, unsteadiness of feet, history of falling, anemia(condition of low red blood cells or hemoglobin that can cause fatigue), and congestive heart failure. Record review of CR #1's Annual MDS assessment dated [DATE] revealed a BIMS score of 11 which indicated moderate cognitive impairment. Section E- Behaviors revealed CR #1 had hallucinations. Section GG0170 - Mobility Devices revealed CR #1 used a manual wheelchair. CR #1 required substantial/maximal assistance (helper does more than half the effort) with ADLs. Record review of CR #1's care plan last revised 5/10/24 revealed the following in part: Problem: Communication - CR #1 has impaired communication evidence by: Reduced ability to understand other. Impaired daily decision-making ability. Goal: Staff will anticipate and meet all needs the CR #1 is not able to communicate effectively over the next 90 days. Approach: Reduce or remove all interfering environmental stimuli. Problem: Cognitive Loss/ Dementia - CR #1 appears to have impaired ability to understand others at times and has impaired ability to make daily decisions. Goal: CR #1 will accept helpful reminders, will have needs met by staff as identified or anticipated, will have minimal negative emotional distress related to cognitive issues. Approach: Continue to assess periodically for changes in cognition; adjust approaches to offer more assistance as needed. Record review of CR #1's nursing note dated 5/14/24 at 9:34 a.m. written by LVN A revealed CR#1 was picked up by EMS via wheelchair for a scheduled appointment at 9:00 a.m. Record review of CR #1's nursing note dated 5/14/2024 at 4:57 p.m. written by ADON revealed CR #1 returned vial EMS. The nursing note did not reflect CR #1's elopement from the doctor's office. In an interview on 5/16/24 at 11:21 AM with the Doctor's Office Manager, said CR #1 had an appointment on 5/14/24 and had finished at approximately 11:43 a.m. She said the resident was placed in a waiting room with a T.V. until transportation picked her. She said CR #1 had been dropped off by transportation unaccompanied. The Doctor's Office Manager said she received a call, at 2:29 p.m., from the ADMIN, who inquired if CR #1 was still at the appointment. She said the staff looked for the resident inside the building and CR #1 was found at the sidewalk, stuck in mud next to a major freeway feeder road, in her wheelchair at 3:00 p.m. She said CR #1 was soiled through her pants, sweating, thirsty, and hungry. She said the resident asked for water and peanuts. The Doctor's Office Manager said she notified the ADMIN, transportation picked up the resident approximately 3:55 p.m. In an interview on 5/16/2024 at 11:34 a.m. with the ADMIN, she said CR #1 went to the doctor's appointment, on 5/14/24, without an escort because the staff that set up transportation thought CR #1's family member was supposed to meet her. The ADMIN said she received a call from the transportation company at approximately 2:00 p.m. and they said CR #1 could not be located. The ADMIN said she called the doctor's office to ask if they knew where CR #1 was. The ADMIN said she called the doctor's office staff and asked them to check the building since the resident was missing. She said she did not know how long the doctor's office searched for CR #1, but the doctor's office manager called approximately 3:00 p.m. and said that the resident had been found. The ADMIN said she did not report the incident to the state because the resident was not at the facility. She said if the resident was at the facility, she would have reported the incident. She said she was responsible for reporting facility self-reports. In an interview on 5/16/24 at 3:40 p.m. with CR #1 said she did not remember a doctor appointment. She was asked if she knew her family members names and she said, I don't remember do you. She appeared confused and asked this State Surveyor if she knew she had an appointment. She said she did not remember waiting for transportation at her doctor's visit this week. In an interview on 5/16/24 at 3:51 p.m. with CR #1's family member revealed they were not notified the resident had been missing. She said she was notified of the visit prior to the resident going but she did not confirm she would attend. Record review of the doctor's office timestamped video from 5/14/2024 revealed the following: 11:43 a.m. - 1:00 p.m. 11:43 a.m. - CR #1's doctor's visit was completed. 12:46 p.m. - CR #1 seen waiting at second floor elevator doors. 12:48 p.m. - CR #1 seen exiting the first-floor elevator doors. 12:49 p.m. - CR #1 seen speaking to security guard. 1:00 p.m. - CR #1 seen propelling herself from the parking garage camera towards the major freeway feeder road. Record review of facility Elopement policy dated 11/1/2017 revealed the following in part: Policy: To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing . .5. If the search fails to locate the missing patient/resident within (30) thirty minutes from the time the patient/resident is found to be missing, the Administrator and/or designee contact the appropriate community agencies (Police, Local Health Department) and Administration, the patient's/resident's legal representative and attending physician. Staff will provide the Police with all physical identifying information including but not limited to physical appearance, height, weight, age, sex, and clothing, if known . Review of the facility's policy titled Abuse/Neglect (revised 11/1/17 and email revised 10/23/19) reflected the following: .The facility shall report immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency .where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures . Record review of Long-Term Care Regulatory Provider Letter PL 19-17 dated 7/10/19 revealed the following: .A NF must report to HHSC the following types of incidents in accordance with applicable state and federal requirement: . A missing resident Immediately, but not later than 24 hours after the incident occurs or is suspected .

Based on observation, interview and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the Interdisciplinary Team after each assessment for 4 (Resident #29, Resident #40, Resident #57, and Resident #41) out of 9 residents reviewed for care plan accuracy. -The facility failed to ensure Resident #29's most recent fall was care planned. -The facility failed to ensure Resident #40's hospice was care planned, along with her UTI/antibiotic. -The facility failed to ensure Resident #57's diet was updated on her care plan. -The facility failed to ensure Resident #41's PEG tube feeding was updated on her care plan. These failures could place residents at risk for their medical, physical, and psychosocial needs not being met. Findings include: Resident #29 Record review of Resident #29's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE], with an original admitted [DATE]. She had diagnoses of dementia (impaired ability to remember, think, or make decisions), anxiety, vascular dementia (changes to memory, thinking, and behavior due to blood vessels in brain), pannus of right eye (growth of blood vessels onto the clear surface of the eye), tuberculosis of right eye (bacteria that causes Tuberculosis infects the eye), unsteadiness on feet, abnormalities of gait and mobility, cognitive communication deficit (difficulty with thinking and using language), lack of coordination, iron deficiency anemia (low iron in the blood), muscle weakness, chronic kidney disease (kidneys do not filter anymore), and disorientation. Record review of Resident #29's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 11 out of 15 which indicated moderately impaired cognition. The resident had impairment on one side of her lower extremities and used a wheelchair. She required substantial/max assistance with showers/baths and was dependent with putting on/taking off footwear. She needed partial/moderate assistance with oral hygiene, toileting hygiene, upper/lower body dressing, and personal hygiene. She was always incontinent of bowel and bladder. The MDS revealed there were no falls yet at the time of the assessment. Record review of Resident #29's undated care plan, revealed a Focus: Resident had a fall on 12/15/23 attempting to get herself out of bed (Start: 12/15/23, Edited: 2/9/24). Goal: Resident will remain free from injury with increased supervision thru next review date (Target: 5/9/24, Edited: 2/9/24). Interventions: Keep call light in reach at all times. Provide toileting assistance frequently. It did not have the most recent fall from 3/14/24. Record review of Resident #29's progress notes revealed a note from LVN A on 3/14/24 at 9:45pm, Resident was found alongside of her bed in a high fowlers position [head of the bed raised to 60-90 degrees], Resident showed no s/s of discomfort, no injuries, vitals stable, NP and DON notified along with her relative [family member] Monitor in place. Interview and observation with Resident #29 on 5/1/24 at 1:26pm using interpreter services, she revealed she could only understand some of the staff since she spoke a language other than English. The resident was sitting in her wheelchair and rocking back and forth. Resident #40 Record review of Resident #40's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with an original admitted [DATE]. She had diagnoses of Type 2 diabetes (body does not produce insulin or is resistant to it), urinary tract infection, muscle wasting and atrophy, protein calorie malnutrition (body is not receiving enough nutrition), elevated white blood cell count (usually means an infection), chronic myeloproliferative disease (bone marrow makes too many red blood cells, white blood cells or platelets), history of venous thrombosis and embolism (blood clot in a vein and a clot that travels through the vein to another location), stress fracture (fracture from too much pressure), dementia (impaired ability to remember, think, or make decisions), disorientation, cognitive communication deficit (difficulty with thinking and using language), vascular dementia (changes to memory, thinking, and behavior due to blood vessels in brain), major depression, and need for assistance with personal care. Record review of Resident #40's Significant Change MDS assessment dated [DATE], revealed a BIMS (used to evaluate cognition) was unable to be performed due to her medical condition. According to the staff assessment for mental status, the resident had severely impaired cognitive skills. The resident required substantial/max assist with oral hygiene, toileting hygiene, upper/lower body dressing, personal hygiene, and was dependent with showers/baths. The MDS revealed the resident had a life expectancy of less than 6 months. The MDS also revealed the resident was receiving hospice care. Record review of Resident #40's undated care plan, revealed a Focus: Advanced Care Planning: Resident code status is Do Not Resuscitate, no other advanced directive (Start: 11/30/22, Edited: 3/20/24). Goal: Resident will be informed of his/her right to complete advanced directives to direct his medical care and make his values and treatment goals known. Residents stated desires will be honored (Target: 6/20/24, Edited: 3/20/24). Interventions: Advanced directives of resident's choice completed and placed on medical record under advanced directive tab or in documents. No mention of resident's Hospice. Focus: Resident is at risk for UTI's related to overactive bladder (Start: 11/30/22, Edited: 3/20/22). Goal: Resident will be free of s/s of UTI for the next 90 days (Target: 6/20/24, Edited: 3/20/24). Interventions: Administer medications as ordered. No mention of the current UTI or antibiotic she was on, was mentioned on the care plan. Record review of Resident #40's Physician's Orders revealed the following orders from DO A: -Admit to [name of hospice] with DX: senile degeneration of the brain (symptom of Dementia where the brain shrinks), chronic myeloproliferative disease (bone marrow makes too many red blood cells, white blood cells or platelets). Ordered on 3/22/24 at 5:51am. -Admit to [name of hospice, name of doctor, phone number], Call to report any change in condition. Ordered on 4/15/24 at 12:28pm. -Nitrofurantoin monohyd/m-cryst (type of antibiotic) 100mg capsule, 1 PO QD for UTI. Ordered on 4/26/24 at 11:35am. Record review of Resident #40's progress notes revealed a note from LVN B on 4/27/24 at 3:05am, N/O day 1/10 Nitrofurantn Mono [type of antibiotic] 100mg cap po once daily x 10 days, initial dosed given at 2300. All meds tolerated well . Resident #57 Record review of Resident #57's undated face sheet revealed she was a [AGE] year-old female admitted [DATE], with an original admitted [DATE]. She had diagnoses of dementia (impaired ability to remember, think, or make decisions), major depression, Alzheimer's disease (progressive disease involving memory loss), muscle wasting and atrophy, neurofibromatosis (three genetic diseases caused by mutations in genes that lead to increased risk of developing tumors), dysphagia (trouble swallowing), type 2 diabetes (body does not produce enough insulin or resists it), lack of coordination, and cognitive communication deficit (difficulty with thinking and using language). Record review of Resident #57's Annual MDS assessment dated [DATE] revealed a BIMS (used to indicate cognition) was unable to be completed due to the resident's condition. The Staff Assessment for Mental Status revealed the resident had severely impaired cognitive skills. The MDS revealed the resident was substantial/max assist with eating, oral hygiene, toileting hygiene, upper/lower body dressing, personal hygiene, and dependent with shower/baths, and putting on/taking off footwear. According to the assessment the resident had a loss of 5% or more in the last month or a loss of 10% or more in the last 6 months and was not on a physician prescribed weight loss regimen. She was on a mechanically altered diet (requires a change in texture of food or liquids) while a resident. Record review of Resident #57's undated care plan, revealed a Focus: RD Nutritional Monitoring Note: Wt loss x 180 days 13#, 10%, #/9% x 90 days, Current wt: 124#/BMI: 22.84, despite consuming 51-75-100% meals. (Start: 2/2/23, Edited: 2/5/24). Goal: I will be able to demonstrate proper methods of swallowing without s/s of aspiration (Target: 3/25/24, Edited: 12/26/23). Interventions: Obtain dietary consult: RD rec add 1 ice cream QHS. Focus: Citizen is receiving a Therapeutic Diet of Heart Healthy (Start: 2/2/23, Edited: 12/26/23). Goal: Citizen will have adequate nutrition and fluid intake thru the next review date (Target: 3/25/24, Edited: 12/26/23). Interventions: Offer snacks within diet. Serve diet as ordered per MD. The care plan did not have the updated diet of pureed with large portions, and the 2 Kcal HN. Record review of Resident #57's progress notes revealed a note from LVN C on 3/5/24 at 6:15pm, Resident noted choking on dinner during feeding, diet recently was downgraded to easy to chew further downgrade to puree placed, following ST consult RP, MD notified Record review of Resident #57's progress notes revealed a note from the Dietary Manager on 4/3/24 at 3:44pm, RD Nutritional Monitoring Note: Incurred 6#/5% x 30 days, 9#/7.8% x 90 days wt: 116#/BMI 21.27. Diet: House Pureed Lg portions, health shake all meals, Ice cream cup q HS, 2 Kcal HN [type of nutritional supplement] at 180cc's QID. Intake 51-100% meals consumed, despite receiving mirtazapine [medication to increase appetite] .RD rec increase 2 Kcal HN [type of nutritional supplement] to 200cc's QID, weekly wts x 4 weeks, super pudding q HS. Record review of Resident #57's Medical Nutrition Therapy Recommendation from the Dietary Manager on 4/3/24, revealed .RD rec increase 2 Kcal HN [type of nutritional supplement] to 200cc's QID, weekly wts x 4 weeks, super pudding q HS. The physician checked he agreed and signed off on it on 4/4/24. Record review of Resident #57's Physician's Orders revealed the following orders from DO A: -Add Lg portions at bkf meals. Ordered on 4/4/23 at 1:05pm. -House Pureed. Large breakfast portions 1 health shake all meals 1 ice cream q HS. Ordered 4/19/24 at 1:31pm. Resident #41 Record review of Resident #41's undated face sheet revealed she was an [AGE] year-old female admitted on [DATE], with an original admitted [DATE]. She had diagnoses of osteomyelitis (infection of bone) of right ankle and foot, bacterial infection, gastrostomy (opening into stomach that for nutrition), disorientation, dysphagia (trouble swallowing), cognitive communication deficit (difficulty with thinking and using language), pneumonia (infection in the lungs), muscle wasting and atrophy, depression, and lack of coordination. Record review of Resident #41's Quarterly MDS assessment dated [DATE], revealed a BIMS (used to evaluate cognition) score could not be provided due to her condition. Staff Assessment for Mental Status indicated she had severely impaired cognitive skills. The MDS revealed a diagnosis of gastrostomy (opening into stomach that for nutrition) and dysphagia (trouble swallowing). According to the MDS assessment the resident was receiving nutrition through a feeding tube while a resident. She was receiving 51% or more total calories through the tube feeding and 501cc/day or more through the tube feeding. Record review of Resident #41's undated care plan, revealed a Focus: Resident Wt gain 7#/6.3% x 30 days, 23#/11% x 90 days (Start: 5/2/23, Edited: 3/14/24). Goal: Prevent aspiration (inhaling food or water), choking, dehydration, N/V and dehydration, and excess residuals, wt gain maintain wt +/- 5# x 90 days (Target: 6/14/24, Edited: 3/14/24). Interventions: RD rec decrease rate TF: Jevity 1.5 at 55cc's qhr x 22 hrs, increase water flush 175cc's a 6 hrs .Focus: I am at risk for malnutrition and/or dehydration related to dysphagia. Renal Diet, minced/moist as ordered (Start: 2/1/23, Edited: 3/14/24). Goal: Will maintain nutritional status as evidenced by no significant wight changes through next review. Will receive appropriate diet as ordered by physician (Target: 6/14/24, Edited: 3/14/24). Interventions: Diet as ordered by physician. Encourage intakes of foods and fluids, offer alternatives if intakes do not appear adequate. Focus: I am at risk for malnutrition and dehydration related to enteral feedings secondary to dysphagia (trouble swallowing). Nepro 1 or 2 cans via bolus if less than 50% meal consumed as ordered (Start: 11/4/22, Edited: 3/14/24). Goal: Maintain weight with no significant changes through next review. Will tolerate tube feeding (tube into stomach for nutrition) as ordered as evidenced by no nausea, vomiting, diarrhea, placement checks, residual checks (how much is left in stomach between feedings), and weight stability (Target: 6/14/24, Edited: 3/14/24). Interventions: Provide tube feeding (nutrition via a tube into stomach) and water flush as ordered Record review of Resident #41's Physician's Orders revealed the following orders by DO A: -NPO continuous. Ordered on 12/8/22 at 9:36pm. -Enteral Feeding (feeding into stomach via tube): Formula Jevity 1.5, Strength Flow Rate Jevity 1.5 at 45 cc's q hr x 22 hrs, Every shift. May use Fibersource if Jevity unavailable. Ordered on 12/5/23 at 11:09am. -Enteral Feeding (feeding into stomach via tube): Flush tube with 250cc's water Q 6 hrs, Every 6 hours at 6am, 12pm, 6pm, and midnight. Ordered on 12/5/23 at 11:09am. -Bowel Rest, Once a day from 8am-10am. Ordered on 1/17/24. In an observation of Resident #41 on 5/1/24 at 10:03am, she had Jevity 1.5 running at 45ml/hr with water flush 250ml Q6hr. Interview with the MDS Nurse on 5/3/24 at 10:00am, he said he had been an MDS Nurse since February 2019 but had been at the facility since January 2023. He said he found out about updates in the morning meetings when they discussed changes in residents and then he would update the care plans at that time. He said he updated all aspects of the care plans. He said sometimes the care plans were updated by the nurses, but he usually told them to come to him with all the care plan issues and he would take care of it because he was always there and that was all he did. He said he knew he had 48hrs for a baseline care plan and 14 days for the comprehensive care plan, but he got the care plans updated within a couple hours and did not wait because the care plans would get backed up and it was hard to get caught up again. He said Resident #29's fall should have been on the care plan, Resident #40's hospice and UTI/antibiotic should have been on the care plan, Resident #57's diet should have been updated, and Resident #41's diet/PEG rate should have been updated. He said he missed it out of human error, and he was going to fix it right then. He said care plans were specific modalities of care and specific ways to care for residents. He said if the care plan was wrong or not updated then the resident could get care that was not needed or wrong. Record review of the facility's policies and procedures on Person-Centered Care Plan (revised: 10/1/20) read in part: .Comprehensive Care Plan: Developed after completion of the discipline-specific assessment and within one (1) week after completion of the MDS. Will be reviewed and updated as needs are identified and after each MDS assessment .The person-centered care plan is interdisciplinary and created to guide facility staff in providing the treatment, care and services necessary for the patient/resident to obtain and maintain the highest physical, mental, and psychosocial well-being possible. The plan is also used to promote patient/resident and family involvement in planning care .The MDS department schedules assessment dates and the Social Services department schedules the care plan conference to coordinated follow the assessment reference date (ARD) .

Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for two of eighteen residents (Resident #27 and Resident #41) reviewed for safe, clean, homelike environment. -The facility failed to clean enteral feeding pumps and poles, which were dirty on 4/30/2024, 5/1/2024, and 5/2/2024 for Resident #27 and #41. -The facility failed to ensure the rooms were homelike and did not have peeling paint and well-maintained bedside tables on 4/30/2024, 5/1/2024, and 5/2/2024 for Resident #27 and Resident #41. This failure could affect the residents and place them at risk of an unsafe and an environment that was not homelike. Findings include: Resident #27 Record review of Resident #27's face sheet dated 5/2/2024 revealed a [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included dementia (group of symptoms that affects memory, thinking and interferes with daily life), contractures (permanent shortening of muscles, tendons, skin, and nearby soft tissue that causes joints to shorten and stiffen, preventing normal movement), seizures (sudden, uncontrolled burst of electrical activity in the brain), anxiety disorder (condition with exaggerated tension, worrying, and nervousness about daily life events), gastronomy (surgical procedure for inserting a tube through the abdomen wall into the stomach), GERD (Gastroesophageal Reflux Disease, chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach), and adult failure to thrive (significant decline in physical and/or emotional well-being). Record review of Resident #27's quarterly MDS dated [DATE] with an ARD of 4/15/2024 revealed no BIMS could be conducted because she was rarely or never understood. The MDS documented she had short and long-term memory problems, and she was severely impaired in her ability to make decisions regarding tasks of daily living. Per the MDS, Resident #27 was unable to recall the current season, the location of her room, staff names and/or faces, or that she was in a nursing home. The MDS revealed she had impairments of both upper and lower extremities, and she utilized a wheelchair for mobility. The MDS documented she required extensive assistance, or was totally dependent on staff, for all ADL's except eating. Per the MDS, Resident #27, did not eat. The MDS revealed she was fed via feeding tube, and she received 51% or more of her nutrition and 501cc of fluids daily through the tube. The MDS documented she received OT and ST services. Record review of Resident #27's care plan dated 4/17/2024 revealed a focus on her feeding tube use with interventions including cleaning site with normal saline, patting it dry, and leaving it open to air. The care plan documented a focus on her dementia with interventions including having her needs met by staff. Observation on 4/30/2024 at 9:39 AM of Resident #27 revealed she was lying in her bed on an air mattress. Resident #27 was receiving nutrition via feeding tube at 50ml/hr. Resident #27 had contractures visible of both upper extremities. The room's floor appeared clean, but the walls had peeling and missing paint, the base of the apparatus holding the feeding tube, the electronic monitor for the feeding tube, and the bags of nutrition and hydration had a rust-colored substance on all four wheelbases. Observation on 5/2/2024 at 1:02 PM revealed the walls of Resident #27's room were missing paint and peeling. The base of the apparatus holding her feeding tube, electronic monitor for the feeding tube, and bags of hydration and nutrition had a rust-colored substance on all four wheelbases. Resident #41 Record review of Resident #41's face sheet dated 5/3/2024 revealed an [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included osteomyelitis (infection in the bone caused by bacteria or fungi), gastronomy status (surgical procedure for inserting a tube through the abdomen wall into the stomach), disorientation (altered mental state with loss of sense of time, identity, direction, and place), contractures (permanent shortening of muscles, tendons, skin, and nearby soft tissue that causes joints to shorten and stiffen, preventing normal movement), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #41's quarterly MDS dated [DATE] with an ARD of 4/8/2024 revealed no BIMS was conducted because she was rarely or never understood. The MDS documented she had short and long-term memory problems, and she was severely impaired in her ability to make decisions regarding tasks of daily living. Per the MDS, Resident #41 was unable to recall the current season, the location of her room, staff names and/or faces, or that she was in a nursing home. The MDS revealed she had an impairment of one upper and one lower extremity, and she used a wheelchair for mobility. The MDS documented she totally dependent, or required extensive assistance, with all ADL's except eating. Per the MDS, Resident #41 did not eat during the review period. Per the MDS, resident #41 used a feeding tube, and she received 51% or more of her nutrition and 501cc's or more daily through the feeding tube. The MDS revealed she received PT services. Record review of resident #41's care plan dated 3/20/2024 revealed a focus on her GERD with interventions including diet as ordered and raising the head of her bed as tolerated. The care plan documented a focus on her possible malnutrition with interventions including medication administration, tube feeding, and monitoring for weight loss. Observation on 5/2/2024 at 12:57 PM revealed she was lying in her bed sleeping. The room's floor was clean. Resident #41's bedside table had a white substance on the table which appeared to be adhered to the tabletop. The base of the bedside table was covered by a rust-colored substance. Resident #41 was observed to be receiving nutrition via a feeding tube. The base of the apparatus holding her feeding tube, electronic monitor for the feeding tube, and bags of hydration and nutrition had a rust-colored substance on all four wheelbases. Interview on 5/2/2024 at 1:32 PM with the DON, she said the facility should clean the poles for the resident's feeding tubes as needed, and at least once monthly. The DON said the poles had been cleaned the week previously. The DON said if a pole was not cleaned it could introduce bacteria or dirt into a resident's feeding tube site causing illness. The DON said she was unsure if there was a policy related to ensuring the poles were cleaned. The DON said the Admin was responsible for facility structure and environment concerns. Interview on 5/2/2024 at 2:26 PM with the Admin, she said staff had been provided with training to ensure the rooms were as homelike as possible, and the walls, bedside table, and feeding tube apparatuses in Resident #27 and #41's rooms were not homelike. The Admin said she expected all staff to look for those concerns. The Admin said executive staff also completed angel rounds looking for homelike environment concerns. The Admin said she believed the angels should have seen the concerns in Resident #27 and Resident #41's rooms. The Admin said a concern with the staff not seeing those issues was the residents would not have a homelike environment, and the facility was the home of all its residents. The Admin said the facility did not have a policy related to maintaining a homelike facility, but the angel rounds checklist should provide the information needed to ensure all residents' rooms were homelike. Record review of the facility's Guardian Angel Weekly Round Checklist revealed a statement which read Issues are addressed immediately when possible, by the Guardian Angel. Unresolved issues are documented on a Concern/Resolution form and submitted immediately to the Administrator. The checklist included areas of concern including the following: odors in the rooms, clean floors, clean bathroom, and the supplement pole clean and dated.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #64) of 9 residents viewed for infection control. -LVN D did not wear appropriate PPE when administering Resident #64's PEG (tube into stomach for nutrition) tube medications, when he was on Enhanced Barrier Precautions. This failure could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings include: Record review of Resident #64's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses of multiple sclerosis (immune system attacks covering of nerve cells in brain, optic nerve, and spinal cord), contusion (bruise) of right great toe, muscle wasting and atrophy, need for assistance with personal care, gastrostomy (surgical opening to the outside from the stomach), dysphagia (trouble swallowing), cognitive communication deficit (difficulty with thinking and using language), functional quadriplegia (immobility from medical condition without injury), and conversion disorder with seizures (condition where a mental health issue disrupts how brain works). Record review of Resident #64's Admission MDS assessment dated [DATE] revealed a BIMS (used to evaluate cognition) could not be assessed due to her condition. Staff Assessment for Mental Status revealed she had severely impaired cognitive skills. She had impairment on both sides of her upper and lower extremities and was bed bound. According to the assessment she was dependent with all ADLs. The MDS revealed diagnoses of gastrostomy (surgical opening from stomach to the outside) and dysphagia (trouble swallowing). The MDS assessment revealed she had a swallowing disorder and received nutrition through a feeding tube while a resident. She received 51% or more of her total calories through the tube feeding (tube into stomach for nutrition) and 501 cc/day or more of her fluid intake through the tube feeding. At the time of the assessment, she did not have any pressure ulcers/injuries. Record review of Resident #64's undated care plan revealed a Focus: I am at risk for malnutrition and dehydration related to enteral feedings (tube into stomach for nutrition) secondary to MS (Start: 1/18/24, Edited: 4/25/24). Goal: Maintain weight with no significant changes through next review. Will tolerate tube feeding (tube into stomach for nutrition) as ordered as evidenced by no nausea, vomiting, diarrhea, placement checks, residual checks (how much feeding is left in stomach after last feeding), and weight stability (Target: 7/25/24, Edited: 4/25/24). Interventions: Provide tube feeding (tube into stomach for nutrition) and water flush as ordered. Record review of Resident #64's Physician's Orders revealed the following orders from DO A: -Cephalexin (antibiotic) 500mg capsule, 1 via G-Tube (tube into stomach for nutrition) BID, for contusion (bruise) of right great toe with damage to nail. Ordered on 4/25/24 a 2:08pm. In an observation and interview with LVN D on 5/1/24 at 1:20pm, Resident #64 had an Enhanced Barrier Precaution sign on her door to her room. LVN D went into the resident's room and gave her medication through her PEG (tube into stomach for nutrition) tube with only gloves on and did not put a gown on. LVN D said Resident #64 was on Enhanced Barrier Precautions which required her to don (put on) gloves and a gown during medication administration. LVN D said she forgot to put the required PPE on and said if she did not wear it, contamination to herself or to the resident could occur. Interview with the DON on 5/3/24 at 10:34am, she said the Enhanced Barrier Precaution sign on the resident's door was for whichever resident had a line (PEG [tube into stomach for nutrition], foley [tube into bladder], PICC [type of line to give antibiotics through], trach [hole in trachea to breathe through], etc.) or a wound. She said she expected staff to gown up anytime they performed resident care, like giving medications through a PEG (tube into stomach for nutrition) tube. She said there were no orders for the Enhanced Barrier Precautions in the system because it was a standing protocol depending on the status of each resident. She said if staff did not wear appropriate PPE cross contamination could occur to themselves or the resident. Record review of the facility's policies and procedures on Transmission Based/Standard Precautions, and Enhanced Barrier Precautions (revised 5/15/23) read in part: The facility will use transmission-based precautions when the route of transmission is not completely interrupted using standard precautions alone. These are applied as needed based on the epidemiology of the infecting organism or infectious disease syndrome. There may be some diseases that have multiple routes of transmission which more than one transmission-based precaution may be required. Transmission based precautions will always be used in addition to standard precautions. Health care workers (HCW) will implement Universal/Standard Precautions whenever there is occupational exposure to blood and body fluids .Health care workers will implement enhanced barrier precautions according to policy with additional measures to protect residents and staff from Multidrug-resistant Organisms (MDROs) .Enhanced Barrier Precautions expand the use of PPE (gowns and gloves) during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP will be implemented for All residents with the following: Infection or colonization with an MDRO when Contact Precautions do not otherwise apply. Wounds and/or indwelling medical devices (central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. EBP will be implemented during the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toilet, device care or use: central lines, urinary catheter, feeding tube, tracheostomy/ventilator .EBP requires the following PPE: gloves, gown .The facility will post clear signage on the door or wall outside of the room indicating the type of precautions and required PPE (gowns and gloves). The facility will post signage that clearly indicates the high-contact resident care activities that require the use of gown and gloves .

Based on interview and record review, the facility failed to refer all residents with newly evident or possible serious mental disorders, intellectual disabilities, or a related conditions for level II resident review upon a significant change in status assessment for two of eighteen residents (Resident #1 and Resident #72) reviewed for PASARR evaluations. -The facility failed to refer Resident #1 to the appropriate, State-designated authority when she was diagnosed with MDD, intermittent explosive disorder, and psychotic disorder with delusions. -The facility failed to refer Resident #72 to the appropriate, State-designated authority when she was diagnosed with major depression and schizoaffective disorder. This failure could place residents at risk for not receiving necessary PASARR mental health services, causing a possible decline in mental health. Findings include: Resident #1 Record review of Resident #1's face sheet dated 5/3/2024 revealed a [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included dementia (group of symptoms that affects memory, thinking and interferes with daily life), intermittent explosive disorder (behavioral disorder characterized by explosive outbursts of anger and violence in which one reacts out of proportion to the situation), need for assistance with personal care, disorientation (altered mental state with loss of sense of time, identity, direction, and place), cognitive communication deficit (difficulty with any aspect of communication that is affected by a disruption of cognition), malnutrition (condition that results from lack of sufficient nutrients in the body), MDD (major Depressive Disorder, mental health disorder having episodes of psychological depression), GERD (Gastroesophageal Reflux Disease, chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach), and psychotic disorder with delusions (fixed, false conviction in something that is not real or shared by other people). Record review of Resident #1's quarterly MDS dated [DATE] with an ARD of 2/27/2024 revealed a BIMS score of 11 indicating moderate cognitive impairment. The MDS documented she had no impairment of either her upper or lower extremities, and she used a wheelchair for mobility. Per the MDS, Resident #1 required assistance, or was totally dependent on staff, for all ADL's. The MDS revealed she received OT, PT, and ST services, but she had not received any psychological therapy. Record review of Resident #1's care plan dated 12/21/2022 revealed a focus on her behavioral concerns with interventions including attempting non-pharmacological interventions, ensuring physical needs were met, medication administration, and redirection. The care plan documented a focus on her making false allegations with interventions including minimizing her anxiety, orienting her to place and situation as needed, and always having two staff administer her medications. The care plan included a focus on Resident #1's depression and antidepressant medication use with interventions including conducting a GDR for an antianxiety medication, medication administration as ordered, and attempting non-pharmacological interventions. The care plan revealed a focus on diagnosis of psychotic disorder with interventions including medication administration, quarterly GDR attempts, maintaining as calm an environment as possible, and staff not arguing with her. The care plan included a focus on her dementia with interventions including providing a consistent routine and providing time to remember past details. Record review of Resident #1's PASRR dated 10/24/2022 revealed the form was negative for all MI, ID, or DD. Interview on 4/30/2024 at 10:25 AM with Resident #1, she said the staff helped her with any tasks she requested. Resident #1 said the staff assisted her with her ADL's. Resident #1 said she had no concerns with the care provided by the staff. Resident #72 Record review of Resident #72's undated face sheet revealed she was an [AGE] year-old female admitted on [DATE], with an original admission of 8/31/23. She had diagnoses of Alzheimer's Disease (progressive disease involving memory loss), Schizoaffective disorder (combination of delusions, hallucinations, depression, and manic periods), major depressive disorder, and Dementia (impaired ability to remember, think, or make decisions). Record review of Resident #72's Admission MDS assessment dated [DATE] revealed she did not have a serious mental illness. She had a BIMS score of 9 out of 15, which indicated moderate cognitive impairment. The MDS reflected diagnoses of depression and schizophrenia (delusions, hallucinations, and disorganized thinking), and the resident was taking antipsychotics and antidepressants. Record review of Resident #72's undated care plan revealed a Focus: Resident is having mood and behavior needs as evidence by periods of social isolation verbally aggression/agitation and delusions, related to: Dementia (impaired ability to remember, think, or make decisions), Schizoaffective disorder (combination of delusions, hallucinations, depression, and manic periods) and Major Depression (Start: 3/1/24). Goal: Resident will have a reduction in unwanted mood or behaviors, for an increased quality of life as evidenced by documentation in the medical record; Behavior Monitoring Flow record and other documentation over the next 90 days (Target: 6/1/24, Edited: 3/1/24). Interventions: Attempt non-pharmacological interventions and document interventions on the Behavior Monitoring Flow Record. Ensure physical needs are met. Give medications as ordered. Focus: Resident has dx of schizophrenia (delusions, hallucinations, and disorganized thinking) (Start: 9/1/23). Goal: Resident will interact appropriately with staff, other residents, and family members (Target: 2/14/24, Edited: 11/14/23). Interventions: Assess effect of hallucinations on resident's status. Encourage resident to discuss feelings. Provide safe, quiet, low-stimuli environment. Focus: Resident has symptoms related to schizophrenia (delusions, hallucinations, and disorganized thinking). Risperidone (antipsychotic used for schizophrenia) as ordered (Start: 9/1/23, Edited: 11/14/23). Goal: Resident will interact and converse appropriately with staff, other residents, and visitors (Target: 2/14/24, Edited: 11/14/23). Interventions: Administer medications. Focus: I have a diagnosis of depression. Venlafaxine (antidepressant), Trazodone (antidepressant) as ordered (Start: 9/1/23, Edited: 11/14/23). Goal: Will not exhibit signs of isolation thru next review date (Target: 2/14/24, Edited: 11/14/23). Interventions: Assess mood/behavior problems as needed. Record review of Resident #72's previous Nursing Home records from 6/5/23, revealed she had a history of schizoaffective disorder (combination of delusions, hallucinations, depression, and manic periods) with depression for which she was taking Seroquel (antipsychotic used to treat schizophrenia) and Effexor (antidepressant). Record review of Resident #72's PASRR Level 1 Screening performed on 9/1/23, revealed No was marked to the question, Is there evidence or an indicator this is an individual that has a Mental Illness? There was not another PASRR completed to re-evaluate her mental illness. Record review of Resident #72's Physician's Orders revealed the following orders from DO A: -Trazodone 50mg, 1/2 PO QHS. Ordered on 8/31/23 at 10:07pm, for major depressive disorder. -Venlafaxine ER 75mg, 1 PO QD. Ordered on 10/23/23 at 12:52pm, for major depressive disorder. -Risperidone 1mg, 1 PO QD. Ordered on 10/23/23 at 12:51pm, for schizoaffective disorder. Record review of Resident #72's Diagnostic Assessment from 2/21/24 at 1:50pm by LCSW A revealed she was diagnosed with a major depressive disorder and a schizoaffective disorder. Record review of Resident #72's Psychiatric Initial Assessment on 3/12/24 by NP A, revealed she was diagnosed with a schizoaffective disorder and was being treated with Risperidone (antipsychotic for schizophrenia), Trazodone (antidepressant), and Venlafaxine (antidepressant). Interview on 5/1/2024 at 1:11 PM with the MDS Nurse, he said he had been employed since January of 2023. The MDS Nurse said his duties included completing and reviewing the PASRR process, importing the PASRR documents, and uploading them to the facility's EHR. The MDS Nurse said Resident #1's PASRR was completed by family prior to her arrival to the facility and a follow-up PASRR should have been completed based on her diagnoses. The MDS nurse said following a new PASRR Form 1012 should have been completed to indicate she was not eligible for PASRR services due to a primary diagnosis of dementia. The MDS nurse said the Form 1012 documented a resident was not eligible for PASRR services due to a primary diagnosis of dementia or Alzheimer's Disease. The MDS nurse said the purpose of the PASRR was to ensure residents with MI, ID, or DD who were eligible received additional PASRR services, including physical equipment, psychiatric care, and/or outside activities. The MDS Nurse said because Resident #1 was not eligible due to her primary diagnosis of dementia, he was unsure what could have occurred with her inaccurate PASRR documents. Interview on 5/2/2024 at 1:32 PM with the DON, she said the PASRR was required of all residents to determine if they were eligible for additional services based on diagnoses. The DON said Resident #1's PASRR should have been noted as positive due to her diagnoses. The DON said the facility completed an audit of all PASRR documentation on that date to ensure no other residents had inaccurate PASRR documentation. The DON said without accurate PASRR documentation, or a Form 1012, Resident #1 may not have received additional services she was eligible for. The DON said the facility did not have a policy related to PASRR, and it followed the RAI policies from CMS. Interview on 5/2/2024 at 2:26 PM with the Admin, she said if a resident's PASRR was inaccurate, he/she may not receive the services he/she was entitled to. The Admin said the PASRR allowed residents to receive outside services for MI, ID, or DD. The Admin said the facility did not have a policy specific to PASRR, but instead it relied on the RAI instructions provided by CMS.

Based on observation, interview, and record review the facility failed to allow adequate equipment for residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 36 Resident rooms (102, 104, 110, 111, 112, 113, 114, 115, 117, 118, 119, 123, 125, 201, 202, 203, 205, 206, 207, 208, 209, 210, 211, 213, 215, 217, 218, 219, 303, 309, 311, 313, 314, 315, 317 and 319) out of 37 resident rooms reviewed for environment. The facility failed to ensure all portions of the call system were functioning after loss of power by verifying that each resident room call lights were functioning effectively after repairs were made and verifying monthly thereafter. The facility failed to provide alternate means of communication with the staff that was always accessible to all residents while in their beds and in resident bathrooms to allow residents to call when needing staff assistance. An Immediate Jeopardy (IJ) was identified on 11/10/2023. While the immediacy was removed on 11/13/2023, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. This failure could place the residents at risk of injury and of not being able to obtain assistance or care as needed. The findings included: Record review of the facility's undated Resident Room roster received on 11/09/2023 revealed there were 61 resident rooms in the building. Record review of Resident #1's electronic face sheet dated 11/10/2023, revealed a [AGE] year-old male admitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included the following: brain stroke, weakness to one side of body following the stroke, abnormal gait and mobility, fracture to the spine, shortness of breath, muscle weakness, unsteady on feet, history of falling, need for assistance with personal care, seizures, elevated blood pressure and disorientation. Record review of Resident #1's annual MDS assessment dated [DATE], revealed a BIMS score of 5 out of 15 indicating severe cognitive impairment. His vision was moderately impaired. He required supervision with set up help for transfers. He required supervision with one person assist for bed mobility, toilet use and personal hygiene. He had impairment to one side of his upper and lower extremity that interfere with daily function or placed the resident at risk of injury. He used a wheelchair for mobility. He was always incontinent of bowel and bladder. Resident #1 had a fall since reentry prior to assessment. Further review revealed Resident #1 did not have any injury from the fall. Record review of Resident #1's care plan revised on 08/22/2023 revealed: Problem - Resident #1 was at risk for falls d/t impaired cognition, impaired mobility. He had a fall on 06/28/2023 while trying to use the restroom without assistance which resulted in a back fracture. He had a fall on 8/18/2023 trying to use the restroom without assistance, no injury noted. The long-term goal was, Resident #1 will remain free from injury. Approach - place resident in a fall prevention program. Observe frequently and place in supervised area when out of bed. Provide with safety device/appliance if applicable. Provide toileting assistance when needed. Problem - Resident #1 had diagnosis of seizures and at risk for injury. Medication: Levitiracetam. Goal - Resident #1 will not injure self secondary to seizure disorder. Approach included: keep call light within reach. Resident #1 had diagnosis of CVA (brain stroke) with hemiplegia (weakness to one side of the body) and was at risk for decreased cardiac output. Goal - Resident #1 will participate in exercises necessary to maintain muscle strength and tone. Approach included - Place objects (e.g. call bell, tissues) on unaffected side and approach from that side. Problem - Resident #1 required assistance with ADLs and transfers. Goal - Resident #1 will maintain a sense of dignity, being clean, dry, odor free and well groomed. Approach included: toileting - extensive assist with one person assist, transfers - limited/extensive assist with one person assist. Record review of Resident #2's electronic face sheet dated 11/11/2023, revealed a [AGE] year-old male admitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included dementia, cellulitis (bacterial infection) of toe, abnormal gait and mobility, Atherosclerosis (narrowing of arteries' walls d/t buildup of plaques), muscle wasting, lack of coordination, assistance with personal hygiene, depression, anxiety, high blood pressure, chronic pain, heart failure, diabetes and end stage renal disease. Record review of Resident #2's quarterly MDS assessment dated [DATE], revealed a BIMS score of 13 out of 15 indicating intact cognition. He used a walker and wheelchair for mobility. Section GG of the MDS revealed he required supervision or touching assistance with toileting hygiene, dressing, personal hygiene, toilet transfers and walking. His primary medical condition was progressive neurological conditions. Record review of Resident #2's care plan revised on 11/06/2023 revealed: Problem included - Resident #2 had a fall 5/26/23 while attempting to get up from toilet. Goal - Resident #2 will remain free from injury and notify staff of any falls. Approach included -give verbal reminders not to ambulate/transfer without assistance when feeling weak/unsteady. Problem - Resident #2 at risk for falling r/t unsteady gait, diabetes and ESRD. Goal - Resident #2 will remain free from injury. Approach included - Resident #2 on the Falling Star program, identified by a yellow name plate. Keep bed in lowest position with brakes locked. Keep call light in reach at all times. Record review of Resident #3's electronic face sheet dated 11/10/2023, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia, abnormalities of gait and mobility, intermittent explosive disorder, anxiety, cellulitis, UTI, muscle wasting, need for personal care, psychosis, hallucinations, and osteoporosis. Record review of Resident #3's annual MDS assessment dated [DATE], revealed a BIMS score of 11 out of 15 indicating moderate cognitive impairment. She had minimal difficulty with hearing. She required extensive two person assist for toilet use and personal hygiene. She required extensive one person assist for bed mobility, transfers, and dressing. She used a wheelchair for mobility. She was occasionally incontinent of bowel and bladder. Record review of Resident #3's care plan revised on 07/19/2023 revealed: Problem included - Resident #3 at risk for falls r/t impaired cognition, impaired mobility, incontinence of bowel and bladder and use of psychotic medications. Goal - Resident #3 will remain free from major injury through the next review date. Approach included - Encourage to use environmental devices such as hand grips, handrails, etc. Give verbal reminders not to ambulate/transfer without assistance. Observe frequently and place in supervised area when out of bed. Problem - Resident #3 at risk for pain r/t Osteoporosis, neuropathy, and lumbago (persistent discomfort in lower back). Goal - Resident #3 will not experience unaddressed pain r/t osteoporosis and lumbago through the next 90 days. Approach included - encourage resident to request pain medication if not getting relief from what she was currently taking. Further review of the care plan revealed no approach to include placement of call light within reach of Resident #3. Record review of Resident #4's electronic face sheet dated 11/11/2023, revealed a [AGE] year-old female admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included Rhabdomyolysis (rapid muscle breakdown), Glaucoma (eye disease), abnormalities of gait and mobility, need for assistance with personal care, localized edema (fluid retention), high blood pressure, epilepsy (seizures), low blood pressure, pain and osteoarthritis. Record review of Resident #4's quarterly MDS assessment dated [DATE], revealed a BIMS score of 11 out of 15 indicating moderate cognitive impairment. She had impaired vision. She required partial/moderate assistance with the following: rolling left and right from lying on back, moving from sit to lying, lying to sitting, sit to stand, chair/bed-to chair transfer. She required substantial/maximal assistance with toilet transfer. She was occasionally incontinent of bowel and bladder. She had medically complex conditions. Record review of Resident #4's care plan revised on 11/08/2023 revealed: Problem included - Resident #4 at risk of falling r/t unsteady gait at times. Resident #4 had a fall on 11/07/2023, while trying to transfer self. Goal - Resident #4 will be free of falls. Approach included - educate resident on asking for assistance. Further review of the care plan revealed no approach to include placement of call light within reach of Resident #4. Record review of Resident #5's electronic face sheet dated 11/09/2023, revealed an [AGE] year-old female admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included diabetes, intermittent explosive disorder (behavioral disorder characterized by explosive outbursts of anger/or violence), history of abdominal pain, UTI, insomnia, lack of coordination, legal blindness, high blood pressure, anxiety, abnormalities of gait and mobility. Record review of Resident #5's annual MDS assessment dated [DATE], revealed a BIMS score of 11 out of 15 indicating moderate impaired cognition. She had severely impaired vision. She required total assistance with one-person physical assist for walking. She required extensive assistance with one-person physical assist for bed mobility, transfers, locomotion on or off unit, dressing, eating, toilet use and personal hygiene. She used a wheelchair for mobility. She was always incontinent of bowel and bladder. She had medically complex conditions. Record review of Resident #5's care plan revised on 09/11/2023 revealed: Problem included - Resident #5 experienced a witnessed fall on 09/16/23 and on 09/17/23 with no apparent injuries. Resident #5 had an unwitnessed fall on 10/21/23 with no apparent injuries. Long term goal - Resident #5 will remain injury free. Approach included - fall mats in place, increased frequent rounding on resident. Problem - Resident #5 at risk for falling r/t unsteady gait and use of psychotropic medication. Long term goal - Resident #5 will remain free from injury. Approach included - keep call light in reach at all times. Observe frequently and place in supervised area when out of bed. Provide toileting assistance when needed. During an observation and interview on 11/09/2023 beginning at 7:45 AM, Resident #6 and Resident #3 were in their room. Resident #3 was sitting in a wheelchair next to the bed and stated the call light was not working. Resident #3 said she was given a bell, but it was not effective as it was not loud enough. She stated the call lights have not been working for about 3 months. She stated when she needed her brief changed, she would holler loudly. She stated that it was aggravating to have to yell and that she had a low tone to her voice and was afraid no one could hear her because of her soft voice. She stated the staff would come after about an hour of her calling out. She stated she was changed recently and was currently dry. Resident #3 pressed the call light. The call light cord was connected to the box mounted to the wall and it did not light up. The lighting fixture above the resident room in the hallway did not light up. There were no bells observed within reach for Resident #3 or Resident #6 anywhere in the room. During an observation and interview on 11/09/2023 beginning at 10:15 AM in room [ROOM NUMBER], Resident #4 stated the call light did not work for a long time. Resident #4 stated she must holler for help or bang on the wall. She stated she and her roommate Resident #5 were not given anything to use like bells. She stated her roommate was blind and if she needed help, Resident #4 would holler for the staff to come. She stated, If we don't have working call lights, I guess they just don't come. Observation of Resident #4 pressing the call light and no light turned on outside the room. Resident #5 was sitting in a wheelchair next to the bed and was holding the call light box. There were no bells anywhere in the room or within reach of either residents. During an observation and interview on 11/09/2023 beginning at 10:30 AM in room [ROOM NUMBER], Resident #1 was sitting in a wheelchair and Resident #2 was reclining in the bed. Resident #1 pressed call light and it did not light up in the hallway. Resident #2 pressed the call light, and it did not light up in the hallway. Resident #2 stated he did not use the call light, that he would get up and go get a nurse if he needed anything. Resident #1 stated he was able to wheel himself to the nurse station if he needed anything. Resident #2 stated he was not given a bell to use. There were no bells observed in the room or within reach of either resident. During an interview on 11/09/2023 at 10:35 AM, CNA C stated she was new and started working at the facility 11/01/2023. CNA C stated she was assigned to 200 hall and was not aware of any rooms with call lights that were not working. During an interview on 11/09/2023 at 10:40 AM, CNA D stated she was floating in 200 Hall and 400 Hall at the time . CNA D stated as far as she knows there were no rooms with call lights that were not working. CNA D stated if she found a call light that did not work, she would put a work order in the computer system so the Maintenance man could work on it and would give the resident bells to use. During an interview on 11/09/2023 at 10:45 AM, LVN E stated he was in charge of 200 Hall. LVN E stated he put bells out yesterday (11/08/2023) but did not remember which rooms and did not have a list of the rooms. LVN E stated he was unaware of call lights not working in rooms 201, 202 and 213. He stated he did not know why they did not have bells but would make sure residents in 201, 202 and 213 received bells. LVN E stated since the big thunderstorm in September 2023, there had been issues with the call lights. LVN E stated there was no documentation on resident monitoring for residents without working call lights. He stated the documentation logs were more for the exit doors that were not locking after the lightning strike, which had since been repaired. LVN E stated rounds were made on all residents with call lights not working and the CNAs, charge nurses and ADON were all monitoring residents; LVN E did not specify the monitoring schedule. During an interview on 11/09/2203 at 10:58 AM the Maintenance Director stated in September 2023, lighting struck the whole building and knocked out the fire panel system and call light system. He stated currently he did not remember which resident rooms had call lights that were not working and that some may not light up in the hallway but may ring at the nurse station. Maintenance Director stated he was not aware that rooms 201, 202 and 213 call lights were not working but he would check them. During an interview on 11/09/2023 at 11:20 AM, the Maintenance Director stated room [ROOM NUMBER] did light up at the nurse station, 201 and 213 needed new boxes for the wall and that he would be able to replace those. He stated as far as he knew the Service Company told him the call light system was fixed when they replaced the main board in September 2023. He stated he did not have paperwork from the Service Company stating all the call lights were checked. He stated he would not know the call lights were not working unless someone told him. He stated he routinely checks the call light system monthly. He stated he did not check call lights in October 2023. When asked why, he stated, I don't know, I was busy. During an interview on 11/09/2023 at 2:40 PM, LVN E stated residents in rooms 201, 202, 213 had handbells. He stated since the contingency, the bells were put into place, the nursing staff had been checking on residents frequently by walking up and down the halls and checking the rooms. LVN E stated it was the Maintenance Director's responsibility to ensure the call lights were working. During an interview on 11/09/2023 at 2:50 PM, the Administrator stated all the employees were responsible to ensure the call light system was working. The Administrator stated the expectation was that Maintenance Director check the system monthly. The Administrator stated she knew the Maintenance Director did an informal random check of the resident call light system during the first week in October 2023, but that he probably did not have any documentation. The Administrator stated she knew there were issues with the call light system and had several call lights that were not working. The Administrator stated the staff ensure the residents have bells and staff increase monitoring of residents. The Administrator stated the service company technician was supposed to come out to the facility but did not know exactly when so today she contacted the representative and that he was coming out tomorrow (11/10/2023). Surveyor requested email verification of the communication with Service Company. Requested verification was not provided by exit date . During an observation on 11/09/2023 at 3:00 PM, Resident #3 was in her room and had a handheld bell within reach. She stated the technicians were working on the call lights. The light fixture outside the room was flashing . Resident #5 in room [ROOM NUMBER] had a handheld bell on the overbed table that was not in reach of the resident who was lying in bed asleep. Resident #4 stated, look where they put the bell on her table, she cannot reach it. There was no bell near Resident #4. Resident #4 stated she was not given a bell. During an interview on 11/10/2023 at 7:15 AM, the Maintenance Director was asked for a copy of work orders for call lights between the time the Service technicians fixed the call light system on 09/26/2023 and 11/09/2023. The Maintenance Director stated honestly, he did not receive any work orders. He stated if he there were work orders, he would have seen the work orders on his phone and his desk computer. During an observation and interview on 11/10/2023 beginning at 8:20 AM the emergency call light in the bathroom for room [ROOM NUMBER] did not work. Resident #1 stated he used the bathroom himself regularly and had not had to use the call light. He denied falling. Resident #2 stated the call lights have not been working for about 3 weeks now. Resident #2 stated he used the bathroom himself and denied any falls. Resident #2 stated, anything can happen like falls, just like murphy's law: anything that can go wrong will go wrong. During an observation and interview on 11/10/2023 beginning at 8:45 AM in room [ROOM NUMBER], the bathroom call light did not work. Resident #4 stated she liked to use the shower and would prefer the call light work as well. She stated she still had not been given a bell. There was no bell within her reach or anywhere in the room. During an observation and interview on 11/10/2023 at 8:55 AM, Resident #5 was sitting in her wheelchair next to her bed. There was a handheld bell within her reach. She also had the call light box in her hand. Resident #5 stated she was given the bell yesterday (11/09/2023). She stated prior to the bell the call light would never work. She stated she would press the buttons, and no one would come, and she would have to ask Resident #4 to call out for help. During an interview on 11/10/2023 at 9:00 AM, CNA F stated she had a list of rooms with call lights not working. CNA stated she received the list yesterday (11/09/2023) and that usually the nurses would tell her verbally which rooms had call light issues but yesterday was different and she was given a list. During an interview on 11/10/2023 at 9:15 AM, the DON stated the call light system had been a problem since the lighting struck in September 2023. The DON state she was under the impression all the call lights were working d/t it was discussed in one of the morning meetings after the Service Company came out and did their inspection. The DON did not recall the exact dates. The DON stated she learned that some of the call lights were not working last week then the Service Company came and during a meeting, they were told everything was functioning as expected. The DON stated the contingency plan was put in place after the lightning strike and included having bells for the residents. The staff had been in-serviced to do frequent rounds. The DON stated she heard about one call light not working yesterday. She stated the staff were told not to leave residents alone in the restrooms and to give residents bells to use in the restrooms. She stated the residents were educated and reminded to take the bells with them while in the restroom. The DON stated the resident's needs were being met by anticipating their needs and the ones with the call lights out were in the long-term care side. She stated the nursing staff establish a routine with the residents, were able to anticipate their needs and the nurses assessed and made frequent rounds. She stated the managers are out on the floor frequently for extra help. She stated, there are enough staff, and we like to keep the same aides assigned to residents so there is continuation of care. The DON stated the Administrator oversees Maintenance. During a telephone interview and Record Review on 11/10/2023 at 9:30 AM, the Service Company Representative stated the electrical system was red tagged on 9/11/2023 after the lighting strike and the work order was for troubleshooting the damage caused by lightning. The Representative stated the repair was made to the main board to ensure the nursing call system was receiving power supply. The Representative was asked about the note on the invoice dated 09/26/2023, the representative stated it meant that the main board power supply was replaced and was receiving power. The Representative stated the technician would not have tested each individual room and that if they did test it would have been included in the notes. The Representative stated it was entirely possible they would not know whether each call light was functioning unless testing was done where the power was not going through and unfortunately, with lighting strikes it was not unusual to find issues later. During an interview on 11/10/2023 at 10:25 AM, CNA G stated that she had a list of which rooms had call lights that did not work and that was why she rounds frequently. CNA G stated the residents have bells to use and the risk of not having call system would be resident falls. During an interview on 11/10/2023 at 10:30 AM, LVN H stated if the call light system did not work the resident had bells and she would do frequent room checks. LVN H was asked what the risks would be to a resident if there was no call system in place, LVN H stated the residents had bells and she would do frequent room checks. During an interview on 11/10/2023 at 10:35 AM, the Administrator stated if the residents did not have a working call system, they would not be able to call the staff and their needs would not be met and that was why after the lightning strike the residents were given hand bells. During an interview on 11/10/2023 at 2:20 PM, the DON stated with some call lights not working she monitored the residents by rounding and conducting resident interviews. The DON stated she was not aware of any accidents related to the call light system malfunctioning. She stated she conducted daily rounds throughout the day and that the managers do the same. The DON stated she will attend meal service to monitor residents in the dining room and all the managers and department heads will rotate monitoring duties during meal service in the dining room as well as meals in the halls. She stated they also have Guardian Angel rounds who monitor residents. During an observation and interview on 11/10/2023 beginning at 3:20 PM in room [ROOM NUMBER], the call light in the room and in the resident bathroom did not work. Resident #7 had a handheld bell and stated she used once, and staff did come. During an observation and interview on 11/10/2023 beginning at 3:30 PM, observation of the door to room [ROOM NUMBER] was closed. CNA J stated the call light should work. In observation CNA J pressed the call light button at Resident #8's bedside and it did not work. The call light in the bathroom did not work. CNA J stated Resident #8 liked to have his door closed d/t residents yelling and this was why she would check on him every 30 minutes to ensure he did not need anything. Resident #8 had a handheld bell within reach, he was lying on his back in bed watching TV. During an observation on 11/10/2023 at 3:35 PM, the Resident in room [ROOM NUMBER] bed A was non-interviewable and the handheld bell was not in reach of the resident. The resident at the window bed was asleep. There were no handbells visible around the resident. Record review of the list of residents who could not use a call system included the resident in room [ROOM NUMBER] bed A. During an interview on 11/10/2023 at 4:10 PM the DON stated she started the list of rooms with call light malfunctioning yesterday 11/09/2023. She stated prior to that the CNAs were given a verbal report by the nurses on which rooms had call lights that were not working. She stated at that time there were not many rooms with malfunctioning call lights. She did not say which rooms had malfunctioning call lights prior to 11/09/2023. During an observation and interview on 11/10/2023 beginning at 4:15 PM in room [ROOM NUMBER], the call light did not work. Resident #9 had a handheld bell that was not within reach. During an observation and interview on 11/10/2023 beginning at 4:20 PM Resident #3 stated they took her handheld bell away. She pressed the call light, and it was not working. The lighting fixture outside the door was hanging off the wall. The technicians were observed in the building doing their inspection. There was no handbell within reach of the resident. During an observation and interview on 11/10/2023 beginning at 4:25PM, Resident #2 had a handheld bell. Resident #10 did not have the handheld bell within reach. Resident #11 stated the hand bell was useless and was not the answer to the problem. Resident #12 stated she did not know anything about the bell, but she had one at the nightstand. Resident #13 stated that she had to bang the handle of the bell on the overbed table for staff to answer her call. She demonstrated banging the handle on the table hard and loudly. During an observation and interview on 11/10/2023 at 4:30 PM, Resident #5 was asleep in bed and the handheld bell was on the nightstand and not in her reach. Resident #4 stated she could see the bell and would not be able to reach it for Resident #5 and she states she still did not have a bell of her own. During an interview on 11/10/2023 at 4:35 PM, the Administrator stated the Service Company would be giving her a quote to repair the call system but could not fix it today. The Administrator stated the Fire Marshall and Service Company were at the facility on 11/06/2023 and that the Fire Marshall notified her that the system was working. During an interview on 11/10/2023 at 6:15 PM the Administrator stated all residents should have handheld bells and did not know why some did not have them. The Administrator stated there were no monitoring logs for this necessarily and there were no logs regarding which staff members handed out the bells and to which residents. The Administrator stated the bells should be in reach so the residents can notify staff when they need assistance. She stated she expected the call lights to be checked every month by Maintenance and did not know the reason why the checks were not completed in October 2023. During an interview on 11/13/2023 at 10:00 AM, LVN E stated to his knowledge the contingency plan was in effect until further notice. He stated without a functioning call system a lot of things could happen to the residents. He stated their care would not be rendered if they need assistance. He stated it would depend on the level of care, for example if they needed peri care and they did not get the assistance d/t the call lights not functioning then they may develop a rash. During an interview and record review on11/13/2023 beginning at 1:15 PM the Maintenance Director was asked about the workorder report generated 11/10/203 for closed dates of 09/26/2023 to 11/08/2023. He stated the workorder #1382 opened 10/03/2023 at 7:37 PM and for call light broken in 200 Hall, was not specific and he left by the closed date and time of 10/12/2023 at 6:49PM. He stated there was no specific room listed for workorder #1396 for call light blinking red in 100 Hall opened on 10/09/2023 at 6:19 PM and closed on 10/25/2023 at 1:05PM. He did not say anything when asked if he followed up on the two workorders. Further review revealed no room numbers were associated with each call light malfunction. During an interview on 11/14/2023 at 11:45 AM, the Administrator confirmed that lightning struck the building on Saturday 09/09/2023 and the Service Company came to the facility on the same day. Record review of the facility reported incident reported on 09/09/2023 revealed the facility was struck by lightning in the early morning hours of 09/09/2023 which attributed to the alarm system and call light system malfunctioning. The Maintenance Director attempted to reset the system with the aid of the Service Company. This was unsuccessful and therefore the fire marshal was contacted. On 09/09/2023 the staff were in-serviced on elopement of high-risk residents, in-serviced for answering call light frequently, frequent checks of the residents, staff to provide residents with physical bells and staff to answer ringing of bells immediately. Record review of the Service Company invoice for nurse call repair dated 09/11/2023 indicated a quote to replace the main control board/power supply and that the damage to the field device was not determined until the main was replaced. Record review of the Service Company invoice for the fire alarm dated 09/14/2023 indicated a quote for the fire alarm and that damage to other devices was not determined until the mainboard could be replaced. Record review of the Service Company invoice dated 9/26/2023 read in part: .Notes: Replaced main board of power supply. tested and working. Cleared red tag . Record review of the facility Monthly Nurse Call Checks log sheets revealed on 06/14/2023 100 Hall rooms were marked as checked and passed. On 07/20/2023 200 Hall rooms were marked as checked and passed. On 08/15/2023 300 Hall rooms were marked and checked as passed. Further review of the Monthly Nurse Call Checks log sheets revealed there were no Monthly Nurse Call Checks completed for September 2023 and October 2023. Record review of the Service Company invoice dated 11/10/2023 read in part: .service completed: Check nurse call issues .Notes: Service call to check nurse call system. We did a complete audit of the system. We found multiple issues on each hall with devices after facility took a lightning strike. Rooms with issues were 111, 113, 115, 117, 119, 123, 125, 118, 114, 112, 110, 106, 104, 102, 201, 203, 205, 207, 209, 211, 213, 215, 217, 219, 218, 210, 208, 206, 202, 303, 309, 311, 313, 315, 317, 319, and 314. Most bed stations in these rooms will need to be replaced. 2 techs were on site for work. Record review of the facility nursing policy and procedure for call lights, responding to, revised on May 5, 2023, read in part: Policy: the staff will respond to call lights or other requests for assistance to [TRUNCATED]

Based on observation, interview and record review, the facility failed to provide accurate acquiring and administration of drugs and biologicals to meet the needs for 1 of 6 sampled residents (Resident #6), in that: - LVN G failed to administer medications and left Resident #6 in possession of Nystatin to administer to himself, although the resident was not approved to self-administer. - Resident #6 was found to be in possession of prescribed medication acquired outside of the facility. This failure could place residents at risk of not receiving adequate treatment and at risk of injury from drugs/biologicals. Findings included: Record review of Resident #6's face sheet revealed a [AGE] year-old male who was admitted in the facility on 02/26/2020 and was diagnosed with cerebral infarction, tinea cruris and unspecified skin changes. Record review of Resident #6's MDS, dated [DATE], revealed the resident had a BIMS score of 13, indicating the resident's cognition was moderately intact. The MDS also revealed the resident needed extensive assistance for bed mobility and transfers, limited assistance with personal hygiene. Record review of Resident #6's MD orders, dated 06/01/2023, revealed the resident had an order for Nystatin powder; 100,000unit/gram; [amount]: generous amount; topical for diagnosis of tinea cruris. Record review of Resident #6's MAR revealed the Nystatin powder was documented as administered by LVN G on 05/28/2023. Observations and interview with Resident #6, on 05/31/2023 at 11:41AM, revealed the resident lying in bed, the resident had 3 medications on his bedside table. - an unidentified light-yellow powder in med cup the resident later identified as Nystatin powder - chlorhexidine gluconate 0.12% oral rinse (dispensed 4/13/2023), and - diclofenac sodium 1% topical gel (dispense date unknown) Resident #6 stated he got these medications himself from a local pharmacy store while being out after a doctor's appointment. He stated he never brought those medications to the nursing staff, nor did he know to bring it to them, he just kept it at his bedside. He stated the powder was Nystatin powder prescribed by his doctor for jock itch and was given to him by the LVN G. He stated it had been there for over a day or so and the nurse left it there for him to apply it himself. Resident #6 said it was his own fault for forgetting to apply it on himself. Observations and an interview with LVN R, on 05/31/2023 at 3:54PM, she stated she worked with Resident #6 and was not aware Resident #6 was keeping medications at his bedside. She was observed confiscating all three medications from the bedside. In an interview with the DON on 06/01/2023 at 8:33AM, she stated Resident #6 had behaviors of acquiring medications on his own in the past and has been educated on the importance of turning in all prescriptions to the nursing department, but he was very noncompliant. She stated the resident was not capable of administering medications to himself due to memory issues and uncertainty in his capability to read fine prints of doses and instructions. She stated the medications should not have been at his bedside due to the risk of not receiving treatment as prescribed. The DON also stated LVN G was not supposed to leave Nystatin powder in the possession of the Resident #6 but instead mark it as not administered because it was not administered. She said she talked with LVN G and the reason he gave for not administering it was because Resident #6 insisted in doing it himself. She stated the risk of leaving medication with a resident who was not permitted to self-administer was the medication not being administered correctly as prescribed, and the rash not being treated. In a phone interview with LVN G 06/01/2023 at 9:28AM, he stated he last worked with Resident #6 on Sunday 05/27/2023. LVN G stated he did not pass any prescribed medications that day except for Nystatin powder that described as an off-white colored powder. He said he was going to apply the powder to the resident #6's groin but the resident stated that he wanted to wait and apply it to himself after his shower so that it would not get washed away. LVN G stated typically he passed the medication to him and watched the resident apply it on himself. He stated the standard was for the nurse to apply powders themselves, but since the resident was so alert and wishes to do it himself he allowed him to do it. He stated he did niether noticed any creams or medicated mouthwash in the resident's possession nor was made aware of the resident's behavior of acquiring and keeping medications for himself. He stated the risk was that the resident might not get his medication and the diagnosis of jock itch may continue on without being effectively treated, and also there was risk of overdosing or incorrect administration of the medication. In a phone interview with LVN B on 06/01/2023 at 10:45AM, she stated Resident #6 had orders for Nystatin and Ketocanazole for jock itch. She stated she went in and out because he can be inappropriate at times. She stated his bedside was cluttered but did not notice anything out of the ordinary. She said she was not aware of medications being kept at bedside and the resident often went out a lot on appointments he set himself. She stated any resident who acquire medications outside from other pharmacies should turn those medications in to them. In an interview with the Executive Director on 06/10/2023 at 11:30AM, she stated she did not know that Resident #6 went to the pharmacy but was aware that he went out for his appointments at his physician's office, where he was capable of receiving prescriptions directly. She stated what typicially should have occurred is that all changes be communicated to the charge nurse who then would communicate new prescriptions to the physician, who would confirm or disagree to the change. She stated LVN G should have at least stayed to watch the resident apply it on himself and the risk was exactly what happened, which was that he did not apply it, which could cause further decline of the condition being treatment. Record review of the facility's policy on medication administration, dated 05/05/2023, stated, . person authorized medical or licensed person prepares, administers and records the medication . and . A resident choosing to self-administer medications will be assessed and evaluated . to determine if its safe for him/her to self-administer medication .

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 4 of 12 residents (Residents #24, #25, #35 and #46) reviewed for respiratory care. 1. The facility failed to ensure Resident #24's nasal cannula tubing was dated and prefilled humidifier was dated. 2. The facility failed to ensure Resident #25's nasal cannula tubing was changed according to physician orders and the prefilled humidifier was dated. 3. The facility failed to ensure Resident #35's oxygen nasal cannula was changed according to physician orders. 4. The facility failed to ensure Resident #46's nebulizer face mask was bagged, labeled and tubing was changed according to physician orders. These deficient practices could place residents at risk of developing respiratory infections and complications. Findings include: 1. Record review of Resident #24's face sheet, dated 01/31/2023, indicated Resident # 24 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure and pneumonia (lung infection). Record review of Resident #24's physician orders, dated 01/31/2023, indicated oxygen at 3-5 liters per nasal cannula with start date of 11/04/2022 and change oxygen tubing every week on Sunday with start date of 11/04/2022. Record review of the admission MDS, dated [DATE], indicated Resident # 24 required oxygen therapy. Record review of Resident #24's care plan, dated 11/22/2022, indicated Resident # 24 had acute and chronic respiratory failure with hypoxia (low blood oxygen) and required oxygen and oxygen setup per facility protocol. During an observation on 01/30/2023 at 11:54 AM revealed Resident # 24 was receiving oxygen at 3 liters per nasal cannula and the oxygen tubing was not dated and the prefilled humidifier (bubbler) was dated 01/18/2023. 2. Record review of Resident #25's facility face sheet, dated 01/31/2023, indicated Resident #25 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included hyponatremia (low sodium) and shortness of breath. Record review of Resident #25's physician orders, dated 01/31/2023, indicated oxygen 2 liters per nasal cannula with a start date of 12/01/2022 and change oxygen tubing weekly on Sunday start date 12/01/2022. Record review of Resident #25's care plan, dated 11/09/2022, indicated Resident # 25 with ineffective breathing pattern and required oxygen therapy. Record review of annual MDS, dated [DATE], indicated Resident # 25 required oxygen therapy. During an observation on 01/30/23 at 10:58 AM revealed Resident # 25 had oxygen in place at 2 liters per nasal cannula connected to a prefilled humidifier bottle (bubbler). The Nasal cannula tubing was dated 01/21/2023 and the prefilled humidifier was undated. During an interview on 01/30/2023 at 11:00 AM, Resident # 25 stated she wore her oxygen all the time and was not sure when her oxygen supplies were changed. 3. Record review of Resident #35's face sheet, dated 01/31/2023, indicated Resident #35 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar), shortness of breath, and wheezing. Record review of Resident #35's physician orders, dated 01/31/2023, indicated oxygen at 2-4 liters per nasal cannula at bedtime with start date of 09/19/2022 and change oxygen tubing weekly on Sunday with start date of 07/28/2021. Record review of Resident #35's quarterly MDS, dated [DATE], indicated oxygen therapy. Record review of Resident #35's care plan, dated 12/07/2022, indicated Resident #35 had shortness of breath related to respiratory disease and required oxygen therapy with intervention to administer oxygen via nasal cannula. During an observation on 01/30/23 at 10:38 AM revealed Resident # 35's oxygen tubing was dated 01/21/2023. During an interview on 01/30/2023 at 10:40 AM, Resident # 35 stated he wore his oxygen at night. He was unsure how often the tubing was changed. 4. Record review of Resident #46's face sheet, dated 01/31/2023, indicated Resident # 46 was a [AGE] year-old female admitted to facility on 08/20/2022 with diagnoses which included dementia (memory loss) and shortness of breath. Record review of Resident #46's physician orders, dated 01/31/2023, indicated Resident #46 received budesonide nebulization suspension two times a day with a start date of 08/24/2022 and formoterol fumarate nebulization solution two times a day with start date of 08/24/2022. Record review of Resident #46's care plan, dated 11/23/2022, indicated Resident # 46 had ineffective breathing related to chronic obstructive pulmonary disease (lung disease) and nebulized medications ordered. During an observation on 01/30/2023 at 10:30 AM revealed Resident #46 had a nebulizer face mask laying across the bedside table and was unbagged or labeled and the tubing was dated 01/17/2023. During an interview on 01/30/2023 at 10:32 AM revealed Resident #46 was not sure when the nurses changed out her nebulizer supplies and could not recall if she ever had a bag. During an interview on 01/30/2023 at 09:50 AM, LVN A stated oxygen tubing and nebulizer setups were changed on the night shift each week but each nurse was responsible for their patients on each shift. She stated she was not aware any tubing was out of date and the risk could be infections. During an interview on 01/30/2023 at 11:48 AM, LVN D stated every nurse was responsible for checking that oxygen and nebulizer supplies were in date. She stated the nurse at night changed out the tubing and nebulizer setups every week on Sunday. She stated the risk could be infections. During an interview on 02/01/2023 at 8:38 AM, the DON stated the nurses on the night shift were responsible for changing out the oxygen tubing and nebulizer setups each Sunday night or as needed. She stated the ADON was responsible for hall checks and ensuring tasks were completed. She stated the risk could be infection and improper distribution of oxygen. She stated she had put new processes in place and in-serviced all staff on the facility policy and expected the policy to be followed. During an interview on 02/01/2023 at 10:45 AM, the Interim Administrator stated the DON and ADON were responsible for oversight in the nursing department. He stated he would assist with overseeing the DON and ADON were retraining nursing staff on policy and procedures and his expectation was that the policy was followed. Record review of the facility policy and procedure titled Respiratory equipment change schedule, dated 04/01/2022, indicated .nasal cannula to change per state regulation and bubbler changed with circuit. Record review of the facility policy and procedure titled Respiratory Equipment change schedule, dated 04/01/2022, indicated .aerosol tubing to be changed weekly or per state regulations. Nebulizer setup to be placed in a clean, dry plastic bag labeled with patient/resident name.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and failed to ensure the comprehensive care plan described services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 16 residents (Resident #378) reviewed for care plans. The facility failed to ensure Resident #378's comprehensive person-centered care plan addressed the resident's risk, interventions or goals for dressing and care of a central line. This failure could place residents at risk of not receiving appropriate treatment and services. The findings were: Record review of physician orders, dated January 2023, indicated Resident #378, admitted to the facility on [DATE]. Resident #378 was a 63-year--old male with diagnoses which included osteomyelitis (infection to the bone), diabetes mellitus (high blood glucose) with diabetic neuropathy (nerve damage). The resident was ordered cefepime 1000 mg, give 1 gm IV (intravenously) TID (three times every day). Record review of an order, dated 1/30/23, indicated the catheter dressing was to be changed, once weekly every Sunday. The order was obtained after state surveyor intervention. Record review of an admission MDS assessment for Resident #378, dated 01/10/23, indicated DX of Acute Osteomyelitis, with treatment of IV Cefepime. Resident #378 was cognitively intact and required extensive assistance for ADL care. In Section M skin conditions indicated; application of nonsurgical dressings was not captured. Record review of the comprehensive care plan, dated 01/26/23, indicated Resident #378 had no interventions related to antibiotic therapy and central line care due to his Dx. of Osteomyelitis. During an interview on 02/01/23 at 8:30 a.m., the MDS Coordinator stated he was responsible for developing and revising the comprehensive person-centered care plan. The MDS Coordinator said the comprehensive person-centered care was important because it contained information on how to care for Resident #378 and identified what kind of services the resident needed. The MDS Coordinator said Resident #378 interventions and goals for central line care had been left off his care plan because there was no order for dressing changes obtained upon admission. He said he missed capturing Section M skin conditions indicated, application of nonsurgical dressings during the admission assessment, if he would have included the CVC dressing, the assessment would have trigger care and interventions to the care plan. He said he was responsible for making a physical assessment and review of orders of Resident #378 to capture interventions on the MDS that would flow to the care plan, but he missed the CVC for infusing the antibiotics. During an interview on 02/01/23 at 9:00 a.m., the DON said her expectations were for the admitting nurse to review all orders and initiated a baseline care plan. The MDS Coordinator would complete the MDS, and the assessment would flow to the comprehensive care plan. She said residents could be at harm because staff may not be able to meet the needs of the residents due to not having a comprehensive care plan available to staff. Record Review of Person Centered Care Plan Process policy, dated 07/01/2016, Indicated the Interdisciplinary Team (IDT) will review for effectiveness and revise the care plan after each assessment. The includes both the comprehensive and quarterly assessments .10.Thru ongoing assessment, the facility will initiate care plans when the resident's clinical status or change in condition dictates the need of such .12. The person-centered care plan will include A. Date B. Problem C. Residents goals for admission and desired outcomes. D. Time frames for achievement.

Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 2 of 16 residents (Residents #76 and #378) reviewed for baseline care plans. 1. The facility failed to develop a baseline care plan or comprehensive care plan to address person-centered care for Resident #76. 2. The facility failed to develop a baseline care plan with interventions and goals for Resident #378's Central Venus Catheter (CVC) care. These failures could place residents at risk of not receiving care and services to meet their needs. Findings include: 1.Record review of a face sheet, dated 02/01/23 revealed Resident #76 was an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included bacterial infection, hyperlipidemia (high fat in the blood) and edema (fluid retention-swelling). He was discharged on [DATE]. Record review of Resident #76's closed clinical record revealed no baseline care plan or comprehensive care plan. During an interview on 02/01/23 at 11:09 a.m., the Interim Admin said there was no baseline care plan for Resident #76 in his chart and he was unable to produce one. He said residents could be at harm because staff may not be able to meet the needs of the residents due to not having a baseline care plan available to staff. 2. Physician orders, dated January 2023, indicated Resident #378 was admitted to the facility on [DATE]. Resident #378 was a [AGE] year-old male with diagnoses which included osteomyelitis (infection to the bone), diabetes mellitus (high blood glucose) with diabetic neuropathy (nerve damage). The resident was ordered cefepime 1000 mg give 1 gm IV (intravenously) TID (three times every day). Record review of the baseline care plan, dated 01/09/23, indicated Resident #378 had no interventions on his baseline care plan related to antibiotic therapy and central line care due to his Dx. of Osteomyelitis. Record review of the comprehensive care plan, dated 01/26/23, indicated Resident #378 had no interventions related to antibiotic therapy and central line care due to his Dx. of Osteomyelitis During an interview on 02/01/23 at 9:00 a.m., the DON said her expectations were for all residents to have an accurate baseline care plan. She said residents could be at harm because staff may not be able to meet the needs of the residents due to not having a baseline care plan available to staff. During an interview on 02/01/23 at 2:00 p.m., the Interim Admin said the DON informed him Resident #378 did not have an accurate baseline care plan. He said residents could be at harm because staff may not be able to meet the needs of the residents due to not having a baseline care plan available to staff. Record Review of Person Centered Care Plan Process policy, dated 07/01/2016, indicated . Procedures: 1. Develop and implement the baseline care plan within 48 hours of a resident's admission. 2. The baseline care plan will include the minimum healthcare information necessary to properly care for the resident including, but limited to initial goals on admission orders, residents' goals, physician orders, dietary orders, therapy services, and PASARR recommendations, if applicable. 3. Following the RAI Guidelines and implement a comprehensive assessment. 4. Provide the resident and their legal representative a copy of the baseline care plan summary by completion of the comprehensive assessment. 46273

Based on interview and record review the facility failed to ensure assessments accurately reflected the residents status for 1 of 16 residents (Resident #378) reviewed for accuracy of assessments. The facility failed to accurately assess Resident #378 for Central Venous Catheter dressing changes and capture dressing on the admission MDS. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings include: Record review of physician orders, dated January 2023, indicated Resident #378, admitted to the facility on [DATE]. Resident #378 was a [AGE] year-old male with diagnoses which included osteomyelitis (infection to the bone), diabetes mellitus (high blood glucose) with diabetic neuropathy (nerve damage to the lower extremities). The resident was ordered cefepime 1000 mg give 1 gm IV (intravenously) TID (three times every day). Record review of an order, dated 1/30/23, indicated the catheter dressing was to be changed, once weekly every Sunday. The order was obtained after State Surveyor intervention. Record review of an admission MDS assessment, dated 01/10/23, indicated Resident #378 was cognitively intact. The resident required extensive assistance for ADL care. The MDS Section M: Skins conditions: had no entry for application of non-surgical dressings (with or without topical medications) other than the feet. Section M skin conditions indicated; application of nonsurgical dressings was not captured. Record review of the baseline care plan, dated 01/09/23, indicated Resident #378 had no interventions related to antibiotic therapy and central line care due to his Dx. of Osteomyelitis. Record review of the comprehensive care plan, dated 01/26/23, indicated Resident #378 had no interventions related to antibiotic therapy and central line care due to his Dx. of Osteomyelitis. Record review of the TAR, dated 01/05/23 to present, did not indicate Resident #22 received a dressing change to the midline catheter until 01/30/23, after state surveyor intervention, which was 25 days after the last dressing change. There was no documentation to indicate the resident received an assessment of the central vascular insertion site. Record review of a nurse note, dated 01/05/23, indicated Resident #378 was admitted to the facility with a central venous catheter. There was no documentation from 01/05/23 to present in the medical record to indicate the resident's midline catheter dressing had been changed until 01/30/23, after state surveyor intervention. During an interview on 02/01/23 at 8:30 a.m., the MDS Coordinator said Resident #378 had no MD order for a central line dressing or other interventions related to antibiotic therapy and central line care due to his Dx. of Osteomyelitis to trigger the assessment. He said he missed capturing Section M skin conditions indicated, application of nonsurgical dressings during the admission assessment, because the admission nurse had failed to obtain an order for the care of the central line. During an interview on 02/01/23 at 2:00 p.m., the Interim Admin said the DON informed him Resident #378 had not received a central venous dressing change since admission from the hospital. The interim Admin said his expectations were for the resident's assessment to be completed correctly. He said the ADON and the DON are responsible for ensuring staff are assessing residents needs and obtaining orders. He said if the assessment was not accurate, the resident may not receive the appropriate care. He said the MDS assessments were completed according to the RAI (Resident Assessment Instrument) guidance. Record review of Nursing Policies and Procedures, dated 10/01/2019, revealed Policy Minimum Data Set (MDS) . 3. Interview, observe and physically assess the resident to obtain validation of items identified on the medical record and to collect information for items where no documentation exists. Documentation of participation must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts.

Based on observation, interview, and record review the facility failed to promptly notify the ordering physician of results that fell outside of clinical range for 1 of 5 residents (CR #1 ) reviewed for diagnostic services. - The facility failed to timely report Resident #1's radiology findings of an acute left [CONDITION(S)] resulting in a delay of treatment in the hospital by over 36 hours This failure could place residents at risk for delayed identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Include: Record review of CR #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's MDS dated [DATE] revealed, severe cognitive impairment as indicated by a BIMS score of 7 out of 15, extensive assistance with most activities of daily living, use of a wheelchair and was always continent of both bladder and bowel. Record review of CR #1's care plan dated 06/08/22 revealed, Focus- risk of falling, use of a wheelchair, requires assistance with ADLs and transfers and a risk of pain. In an interview on 07/27/22 at 12:50 PM, the NP said she was alerted of CR #1's fracture on 06/26/22, since the resident was already on PRN pain medication and it was a fracture of indeterminate age she told the ADON to schedule a follow up appointment with an orthopedic specialist. She said the ADON said she would schedule an appointment for CR #1 once she returned to work on 06/27/22. The NP said that on 06/27/22 the ADON informed her that the next available ortho appointment was on 6/29/22 so she approved the facility to send CR #1 immediately to the hospital for a CT on 6/27/22. She said the X-ray result she received on 06/26/22 resulted on 06/24/22 and nursing staff are expected to notify providers of any acute laboratory or radiology findings immediately in order to initiate treatment in a timely manner. In an interview on 07/27/22 at 01:10 PM, the Radiology Representative said CR #1's xray results were sent to the facility on [DATE] at 6:20 PM and their computer system confirmed receipt. An observation and interview of the fax room on 07/27/22 at 1:30 PM with LVN B revealed, patient laboratory and radiology reports received by the fax on 07/27/22 at 10:49 AM, 10:51 AM, 11:50 AM and 12:12 PM lying on the top of a table in front of the department mail boxes. Inspection of the fax machine revealed the time and date on the machine and reports to be accurate. LVN B said that the faxes located on the nursing floor did not work and all lab and radiology reports printed in the lobby. She said nursing staff are expected to check the fax machine multiple times a shift for pending lab/radiology reports. In an Interview on 07/27/22 at 1:35 PM, LVN A said that on the morning of Monday 6/26/22 and employee brought documents from the fax located in the lobby for her to review and it included CR #1's xray showing a fracture. She said once she identified the fracture she immediately contacted the NP and sent the results to the NP via fax. LVN A said when an xray is ordered nursing staff are expected to track the pending result in the 24 hour report as well as a tracking sheet created by the DON and nurses are to check for results multiple times during their shift for any new xray results. She said she did not remember who brought her CR #1's results from the fax but she took immediate action once she received it. In an interview on 07/27/22 at 01:48 PM, the DON said that once a xray is ordered nursing staff are expected to document it in the lab tracking sheet which is used to communicated pending results from shift to shift. She said that faxed lab/radiology records were received on the machine located in the front lobby and nursing staff were expected to check the fax multiple times a shift for pending results, or log into the lab portal on their computers to retrieve results. The DON said she was not sure why the faxed result was missed over the weekend from 06/24/22 to 06/26/22 but once the fracture was identified on 06/26 the facility took immediate reaction and notified the NP. She said that late identification of acute fracture findings could place residents at risk for delay of treatment, increased health concern, impaired mobility and pain. Record review of CR #1's Physician Order Report dated 05/27/22 revealed, [MEDICATION(S)] 4 mg- take 1 tablet by mouth every 4 hours as needed for other chronic pain. Record review of CR #1's Physician Order Report dated 05/27/22 revealed, Acetaminophen 325 mg- take 2 tables by mouth every 6 hours as needed for other chronic pain. Record review of CR #1's Progress Notes dated 06/24/22 revealed at 12:15 AM revealed, Resident complained of bilateral hip pain. Repositioned in bed for comfort. PRN pain medication given and ordered . Effective, NP informed, stated she will be in 06/24/22 to evaluated. Record review of CR #1's Physician Order Report dated 06/24/22 at 5:30 PM revealed, the resident's physician ordered an X-ray of the right hip due to chronic pain . Record review of CR #1's Radiology report dated 06/24/22 at 6:16 PM revealed, Conclusion: Femoral Neck fracture of indeterminate age. The report had a hand written note that read 06/26/22 sent to NP 07:20 AM signed by LVN A. Record review of CR #1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . He had pain in his right hip when he applied pressure and they did not fit him properly . R hip xray, follow up with ortho and await PT/OT, continue to follow pain management Record review of CR #1's Progress Notes dated 06/26/22 at 6:12 AM revealed, CR #!1 complained of pain the previous night (06/25/22) and was given PRN pain medication. Record review of CR #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of CR #1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . He will need to follow up with ortho, no weight bearing at this time. Record review of the facility policy titled Physician and Other Communication/Change in Condition revised 7/01/16 revealed . 3- Notify the physician of the change in medical condition. (The physician notification grid may be used as a reference tool regarding acceptable notification timeframes). Condition-Xray, treatment required within 1 hour for New or unspecified findings.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent injuries for 5 of 9 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for accidents/supervision in that; -CNA A attempted to independently transfer Resident #1 from bed to wheelchair when Resident #1 required a 2-person gait belt transfer; which resulted in the resident falling, causing a laceration to her head which required sutures. -CNA D tilted Resident #1's wheelchair back and did not have all four wheels secured on the floor while lowering and positioning Resident #1 from the mechanical lift to the wheelchair. -CNA B did not lock the wheelchair's wheels when transferring Resident #2 from her bed to wheelchair; causing the wheelchair to move while positioning the resident in the wheelchair. -CNA C began an unsafe transfer by using a gait belt that was too large for Resident #3. -Resident #4, who required the assistance of two staff for transfers, experienced knee pain and swelling after a CNA transferred her alone. -Resident #5, who required extensive assistance from two staff members for transfers, bumped her leg and reopened a skin tear when a CNA transferred her alone. These failures resulted in an immediate jeopardy on 02/12/20. While the IJ was lowered on [DATE] the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. The IJ template was provided to facility staff at this time. These failures could affect any resident who require transfers by mechanical lift, or by gait belt and place them at risk of injury, pain, and psychological harm and possible hospitalization . Findings include: Resident #1 Record review of Resident #1's Face sheet revealed, a [AGE] year-old-female admitted originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS dated [DATE] revealed, a BI[CONDITION] score of 8 indicating moderate cognitive impairment. She required extensive assistance of two or more persons for transfers. Record review of Resident #1's Care plan date 08/08/19 read in part, Category: ADL Functional/Rehabilitation Resident #1 requires assist that varies throughout the day with ADLs and transfers, Approach TRANSFER: Requires extensive to total assist. Record review of Resident #1's facility investigation report dated 1/31/2020 revealed that staff notified the DON that Resident #1 had a laceration on her forehead. The investigation discovered that CNA A had transferred Resident #1 between her bed and chair. CNA A initially said that CNA B had assisted her with the transfer. CNA B denied assisting, saying that when she entered Resident #1's room, she was already on the floor. Record review of Resident #1's hospital history and physical dated 01/31/20 read in part: Patient is a [AGE] year old female who presented via Emergency Management Services (E[CONDITION]) from a nursing facility after a fall that occurred today. Patient reported right knee pain with palpation but denied any other pain. E[CONDITION] reported that the patient was being transferred from her wheelchair to a stretcher and fell . The Patient hit her right forehead but denied loss of consciousness (LOC). History was limited due to the patient's dementia. Further record review of Resident #1's hospital focused physical exam dated 01/31/20 read in part, [CONDITION] (musculoskeletal) head 2 cm laceration to the right forehead with an underlying hematoma. Observation on 02/11/20 at 10:04 AM of Resident #1 revealed, she was lying supine in bed, the bed was in the low position with the call light within reach. There was a linear laceration approximately 2 cm with sutures to the right side of her forehead. Interview on 02/11/20 at 10:37 AM with the DON, when about the incident that occurred with Resident #1, he stated ADON A said a resident just fell out of bed and cut her head opened. He said he went into her room and assessed her. He said Resident #1 had a laceration on her forehead with no bleeding or swelling. He said he asked CNA A what happened and she stated she pushed the resident over in the bed and she hit her head on the enabler bar. He said he then asked CNA A,how hard did you roll her over to cause that [MEDICATION NAME] trauma? He stated the CNA A stuck to her story, claiming Resident #1 hit her head when rolled over. He stated CNA A lied because CNA B entered the resident's room to answer the call light and said CNA A panicked and asked her to help the resident off the floor. He said he asked CNA B what happened because he did not believe CNA A. The DON said the laceration could have been caused from hitting the bar. Further interview on 02/11/20 at 10:37 AM with the DON, he stated CNA B came into his office and said that was not what happened with Resident #1. CNA B said she entered the resident's room after the fall happened and the resident was already on the floor with a gait belt around her waist. He stated that he and the Administrator called CNA A that Friday to clarify the story and then she changed her story. CNA A now said she had Resident #1 near the side of the bed and the enabler bar was down. When she turned to reach for the gait belt, the Resident #1 fell out of the bed. He stated she was terminated because she lied initially and tried to cover it up then dragged someone else into her lie. He stated he still thought that was not the full story because CNA B said the gait belt was already on the resident and she was leaning up against the bed and CNA A when she entered the room. He stated what he thought happened was that CNA A attempted to transfer the resident by herself and dropped her instead of doing a 2- person transfer. Further interview on 02/11/20 at 10:37 AM with the DON, when asked who initially assessed residents to determine how to transfer the resident, he said therapy did the assessments. The DON said if the resident had had a hip or knee fracture or replacement, the facility did not move the resident until the resident was evaluated by PT. When asked how nursing staff knew how to transfer a particular resident, he stated nursing staff looked on the profile to determine the type of transfer. When asked if a resident had a change in mobility, how did staff know how to transfer the resident, the DON said therapy re-evaluated residents after a significant change or new bone fracture. Further interview on 02/11/20 at 10:37 AM with the DON, when asked what type of training nursing staff received for transfers and who provided the training, The DON stated therapy provided on the spot training for one-person and two-person gait belt transfers. All nursing management provided in-services for mechanical lift transfers. He said therapy did not do mechanical lift training. When asked if the training was documented when completed, The DON stated he would have to ask. Transfer training documentation for all nursing staff was requested at this time. Telephone interview on 02/11/20 at 11:36 AM, CNA B, said she was coming down the hall because the residents' call light was on. Resident #1's door was closed. She said the resident usually pressed the call light if she needed water or her television turned on. She stated she knocked on the door and entered the room and Resident #1 was sitting on the floor and with her back was up against CNA A legs. She said Resident #1 was holding her head and it was bleeding and she had blood in her hair. She stated she asked CNA A what happened, noting that CNA A appeared to her to be scared and freaked out. CNA B stated CNA A told her Resident #1 slipped out of bed. CNA B said the two CNAs assisted the resident off the floor and put her into her wheelchair. She said she left the room and got the Charge Nurse. The Charge Nurse entered the room and then left the room and got the DON. She said Resident #1 had a gait belt around her waist when she was on the floor. Further telephone interview on 02/11/20 at 11:36 AM with CNA B, said the Resident #1 required assistance from two people using a gait belt because she could hardly stand. CNA B said Resident #1 could be transferred into bed by one person, but to transfer her out of the bed, two people were required. She said CNA A told her Resident #1 just slipped. She said the resident was not a light weight lady and you needed two people to transfer her. CNA B stated she thought CNA A probably tried to transfer Resident #1 by herself and the resident fell . When asked how the nursing staff determined how to transfer each resident, she said staff looked on the kiosk in the resident's profile. CNA B said if a CNA thought there needed to be a change in the type of transfer, they were supposed to tell the charge nurse. The charge nurse relayed this information to therapy and therapy would complete an assessment. She said the facility staff all knew that this Resident #1 required a two-person assist transfer. Interview and observation on 02/11/20 at 12:02 PM revealed Resident #1 was eating lunch in her wheel chair with the bedside table in front of her. The resident was alert and oriented to self and place. When asked what happened to her head, she stated, My head met the floor and the floor won. Resident #1's remaining answers were not consistent with the actual event. Telephone interview on 02/11/20 at 12:15 PM, CNA A said she stated she was doing her last rounds that Friday. She said she normally got Resident #1 up for breakfast and lunch. On the day of the fall, Resident #1 complained that her stomach was upset so CNA A left her in bed. Just before the fall, she asked Resident #1 if she wanted to get up, and Resident #1 said she did. CNA A got her dressed and put the resident on her right side and put the right-side rail down (facing the door on her right side). She stated she had left her gait belt on the shelf in Resident #1's room. CNA A left Resident #1's side and went over to get the belt. Before she turned around, she heard a loud thump and Resident #1 was on the floor. She said she went to see if she was ok and she saw Resident #1 had hit her head. Resident #1 had had an injury in the same place and so it looked like the area re-opened. CNA A stated she started to get the charge nurse, but CNA B walked into the room. CNA A asked CNA B to assist the resident to the wheelchair (w/c). She stated they put Resident #1 in the w/c and CNA B went to get LVN B to tell her what happened. She stated when LVN B entered the room, she was in the restroom with the resident cleaning her face from where she was bleeding. Further telephone interview on 02/11/20 at 12:15 PM with CNA A, when asked if the gait belt was already on the resident when CNA B entered the room, she said she was getting the gait belt but when the other aide came into the room the belt was already on her because she had put it on her to get her up off the floor. When asked if she was going to transfer the resident by herself, she stated, yes. CNA A said she knew that Resident #1 required two people using the gait belt for transfers at the time of the incident. She added Resident #1 was easy to transfer by one staff member using the gait belt or mechanical lift. When asked how she should have been transferred, she stated she was supposed to be transferred by two-people because she did not have much strength in her legs. She again stated she felt it was going to be an easy transfer to do by herself so that was why she decided to transfer the resident without a 2nd person assisting. CNA A said she would look in the Kiosk or resident profile to see what type of assistance a person required: mechanical lift, 1-person, or 2-person transfer. When asked if she received transfer training while working at the facility, she stated for the two years she had worked at the facility, she never received any type of training or in-services on transfers. She learned how to transfer residents from working at other facilities. Observation of a two-person mechanical lift transfer on 02/12/20 at 10:22 AM revealed, CNA D tilted Resident #1's w/c back causing the front two wheels to come off the floor. The w/c was leaning back as the resident was lowered into the chair by CNA F using the mechanical lift. CNA D supported the tilted w/c with her leg and kept the w/c leaning back with the front two wheels off the floor until the resident was completely lowered onto the w/c. Once the resident was lowered completely onto the w/c, CNA D lowered the w/c back onto the floor. Interview on 02/12/20 at 10:31 AM with CNA D and CNA F, when asked if the wheels of the w/c were supposed to be on the floor and locked, they both stated yes, all wheels should be on the floor. CNA D said she leaned the w/c back to position Resident #1 in the chair and so the mechanical lift was in the correct position for Resident #1. When asked if that was the appropriate and safe way to transfer a resident, they both stated no. CNA F said there were two mechanical lifts in the building. She said one was not working so they currently only had one working lift. CNA F said there were a total of 5 slings/pads available for use; three were too large. Interview on 02/12/20 at 10:38 AM, ADON B said all wheels should be on the floor during the transfer and the w/c should not be tilted. When asked how long the mechanical lift was inoperable, she stated she was not sure and would have to ask the DON or ADON A. She said every resident should have a sling, but she was not sure how many were in the facility. Resident #2 Record review of Resident #2's face sheet revealed, a [AGE] year-old-female originally admitted on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #2's Quarterly MDS dated [DATE] revealed, the resident required assistance from two or more people for transfers. She had a BI[CONDITION] of 12 indicating she had moderately impaired cognitive skills. Record review of Resident #2's Care plan dated 04/04/19 read in part, Category: ADL Functional/Rehabilitation, Resident #2 requires assist that varies throughout the day with ADLs and transfers, TRANSFER: Requires total assistance with Hoyer lift X2 with all transfer Observation and interviews of a two-person mechanical lift transfer from bed to w/c on 02/11/20 at 1:14 PM, revealed, CNA E was positioned at the back of the Resident #2's w/c and supporting the chair with her right leg. The chair's wheels were not locked during Resident #2's transfer. This caused Resident #2's w/c to move as the resident was lowered onto the w/c. CNA E assisted Resident #2 onto the chair and removed the sling straps from the lift and the wheels remained unlocked. When CNA C and CNA E were asked if the w/c legs should be locked during a mechanical lift transfer, they stated yes, both sides should be locked. CNA C locked both wheels after surveyor intervention. Interview on 02/11/20 at 11:13 AM with CNA E, she stated she had been working at the facility for one year. She said she was verbally trained on 2-person and 1-person gait belt technique and Hoyer lift transfer. She stated the training was completed by the DON, ADON, and Therapy. When asked how often transfer training was completed, she stated, If there is a change or if we notice something a little off, the facility will have an in-service on transfer training. When asked if a skill check off was completed to determine proficiency, she stated training was done verbally. Resident #3 Record review of Resident #3's face sheet revealed, a [AGE] year-old-female originally admitted on [DATE] and re-admitted on [DATE]. her [DIAGNOSES REDACTED]. Record review of Resident #3's Quarterly MDS dated [DATE] revealed, the resident was totally dependent on one person for transfers. Record review of Resident #3's Care plan dated 03/13/19 read in part, Category: ADL Functional/Rehabilitation Potential; Resident #3 requires assist that varies throughout the day with ADLs and transfers. Approach: TRANSFER: Requires extensive to total assistance x1 with all transfers. Observation and interview of a one-person gait belt transfer from w/c to bed on 02/11/20 at 1:48 PM revealed Resident #3 was positioned in her w/c at the foot of the bed at an angle. CNA C removed the w/c leg rests, lowered the bed and locked the w/c. CNA C stated she only had an extra-large gait belt because she left hers at home. When asked if she requested an extra-large, she said it was a loaner and that was all the facility had available for her to use. As she was applying the gait belt around the residents' waist, she stated, This is dangerous because the belt is too long, you can trip and fall on this. As CNA C adjusted the gait belt, she attempted to wrap the excess belt behind the resident, stating it was too loose, she again stated, This isn't' safe. When asked by the surveyor if the belt was tight enough to safely transfer the resident, she again stated it was not safe. The Surveyor asked CNA C to stop. CNA C stopped the transfer and obtained a gait belt that properly fit the resident. The CNA stated, Really we can't use this belt for nobody, so I don't know why they give it to us. Resident #4 Record review of Resident #4's face sheet revealed, an [AGE] year-old-female originally admitted on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #4's Quarterly MDS dated [DATE] revealed, the resident required assistance from two or more people for transfers. She had a BI[CONDITION] score of 6 indicating she had severely impaired cognitive skills. Record review of Resident #4's Care plan dated 05/02/19 read in part, Category: ADL Functional/Rehabilitation, Resident #4 requires assist that varies throughout the day with ADLs and transfers Approach [ENTITY]t Date: 05/02/2019 TRANSFER: Requires total assistance X 2 with Hoyer with all transfers. Record review of the facility Incident Detail Report dated 12/26/19 revealed, documentation of RIGHT KNEE during transfer/positioning of Resident #4. Record review of Resident #4's nursing progress notes dated [DATE] read in part, This nurse called to neighbor's (neighbor was Resident #4) room by CNA, CNA states that neighbor is complaining of knee pain. This nurse went to neighbors room and spoke with neighbor. Neighbor is complaining of right knee pain. This nurse asked neighbor if she knew what was causing the pain, did she need her leg repositioned. Neighbor states, yesterday morning after breakfast that girl that they had in here helping me, feeding me, i told her i wanted to get up in the wheelchair for a little while. She started to get me ready to get OOB and i told her she couldn't get me up by herself. She told me that she could and told me to put my arms around her neck. she lifted me to the wheelchair but when she did my leg got under the wheelchair and bent wrong. Neighbor states it bent under the wheel chair and she had to lift the wheelchair to get it off my leg. Neighbor states that it was hurting really bad but the cna rubbed my knee for a little while and it quit hurting but now its hurting bad and I have to keep a pillow under it. On Assessment of right knee, outer top knee appears slightly swollen, no redness or bruising. Neighbor grimaces when touching knee. complains pain is mostly in swollen area and inner knee area. Neighbor has prn order for biofreeze. Applied biofreeze to right knee, Neighbor states that it is helping. NP is in facility at this time. Notified of incident and received order for xray right knee and tib (tibula)/fib (fibula). Called mobile xray and placed xray order. Resident #5 Record review of Resident #5's face sheet revealed, an [AGE] year-old-female admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #5's Quarterly MDS dated [DATE] revealed, the resident required extensive assistance from two or more people for transfers. She scored a 1 on the BI[CONDITION] indicating she had severely impaired cognitive skills. Record review of Resident #5's Care plan dated 05/20/19 read in part, Category: ADL Function/Rehabilitation: Resident #5 requires assist that varies throughout the day with ADLs and transfers .Approach: TRANSFER: Requires extensive to total assistance X1 or 2 with all transfers. Record review of the facility Incident Detail Report dated 10/28/19 revealed, Resident #5 received a right leg skin tear during a transfer. Record review of Resident #5's nursing progress note dated 10/28/19 read in part, Upon transferring Resident #5 onto bed, cna bumped res (resident's) r (right) leg and reopened existing skin tear noted to r posterior shin. Area cleansed with wound cleanser, TAO (triple antibiotic ointment) applied, and covered with band aide. NP notified, NNO (no new orders). Fall and safety measures maintained. Will continue to monitor and provide care. BP 124/76 P [AGE] R 18 T 96.8. Interview on 02/11/20 at 11:03 AM with CNA D, she said she had been working at the facility for 2 ½ years. When asked how she knew the transfer type a resident requires, she stated she checked the resident's profile and also therapy told staff. When asked when and who did the transfer training, she stated one CNA would train the other CNAs; new CNAs were trained by a CNA who had been at the facility for some time. She stated they had in-services on the mechanical lift, the stand up lift, and gait belt transfers. When asked if there was a skill check off, she could not recall. She could not recall how often the training occurred. Interview on 02/11/20 at 11:31 AM with CNA H, she stated she had been working at the facility for three months. When asked if she had been trained on transfers, stated she had not received any training on transfers at this facility. She said she was trained at other facilities where she worked, but was not trained at this facility. When asked how she knew the type of transfer a resident required, she stated another CNA would tell her, or she will look in the resident's profile. Interview on 02/11/20 at 12:41 PM with the Administrator, when asked what type of training the nursing staff receive when they were new to the facility, she stated they shadow a CNA who had been here for a period of time. She said they were trained for three days and the CNA showed them how to transfer. She stated some training was completed online such as abuse and neglect. She said if a CNA was not familiar with some type of transfer, like a Hoyer lift then the experienced CNA or ADON would train the CNA on the Hoyer lift. She stated they had a mass transfer training completed in December or January with PT B on all types of transfers. Then, after the incident with Resident #1 there was an in-service completed on transfers. She said she was not sure how often nursing staff were trained on transfers as far as keeping track of CNA training she would ask nursing staff because she did not want to contradict herself. Transfer training documentation for all nursing staff was requested by surveyor for review. Interview on 02/11/20 at 12:54 PM with PTA C, when asked what type of training transfer therapy provided to nursing staff, he stated he was not sure because he never did any type of training with nursing staff. The previous therapy director used to do the training. Interview on 02/11/20 at 12:57 PM with the Director of Rehabilitation, when asked who trained the nursing staff on transfers, she stated if transfer training was requested by the DON, therapy will do the training. She said she was not sure if transfer training was part of the nursing staff's new hire orientation. When asked if should transfer training should be part of nursing orientation and periodically to ensure proficiency, she stated yes. She said she felt it should be part of orientation. She stated prior to her starting, an in-service was given on gait belt transfers in December by PT B. She stated nursing staff trained aides how to use the mechanical lift. She could not state when mechanical lift training was last completed by nursing staff. Interview on 02/11/20 at 1:05 PM, PT B stated she had been working at the facility for almost two years and had only completed transfer training for the first time in December 2019. That training was a demonstration on gait belt transfers. When asked if all nursing staff were part of the training, she stated staff who were available that day were present, but she could not state if all nursing staff were present during the training. She stated she did not do mechanical lift transfer training because the nursing staff were supposed to train staff on mechanical lifts. Interview on 02/11/20 at 1:25 PM with CNA F, when asked if nursing staff receive transfer training, she stated training was completed once a year. They do the training before they check us on full book. She stated transfer training covered Hoyer lift and gait belt transfers. When asked who did the training, she stated she and CNA J did the training. The DON and ADON sometimes did the transfer training. When asked if transfer training was part of new hire orientation, she said the new CNA shadowed a veteran CNA, so whoever they shadowed would train the new CNA. When asked if there was a skill checkoff to show proficiency in transfers, she stated there was no skills checkoff. The lead CNA who did the training just verbally checks off the orientee. She stated she was not sure if there was a skills checkoff list. When asked how the facility would determine if nursing staff required additional training, she stated the CNA, DON or ADON would do further training if the CNA did not follow the transfer profile. If a resident fell , or complained, or if another staff noticed staff transferring a resident incorrectly; then they would verbally state that staff needs additional training. She said there was not a real orientation other than the veteran CNA showing the orientee how to do the transfers. She said they had three days of training and each day the training was with different residents, transfers and care. She said the responsibility was on the lead CNA to train on transfer. After the third day, the new CNA would start working on the floor. Interview on 02/11/20 at 2:20 PM with the Administrator, when asked if the facility had a staffing training coordinator, she stated We do not have a SDC. Surveyor did not receive any training documentation that was previously requested for review. Surveyor again requested transfer training documentation for all nursing staff. Interview on 02/11/20 at 2:35 PM, CNA G said she had been working at the facility for one year. She said she received a three-day orientation. During the first two days, she learned the residents in her assigned hall. She stated she was trained on the 100 Hall but placed on the 200 Hall to work. She said they paired her with another CNA on the 200 hall for one day and she watched the CNA and helped as needed. When asked if she was trained on transfers during her orientation, she stated she was trained on the specific transfer for that specific hall, stated they touched basis on the transfers, but since she had been a CNA with previous training, she already knew how to do transfers. When asked what Touch basis meant, she stated she did not remember if a check off list was completed but thought the aide she was training with may have had a checkoff list. When asked who did transfer training, she stated the CNAs did the training. She said she could not remember if there was an in-service or training on transfers this year; last year therapy provided a verbal in-service on transfers. Interview on 02/11/20 at 3:32 PM, ADON A stated all the new hire orientation and in-services were done on-line. She said there had been so many changes at the facility and she would have to look to see if the training binder was still in there. Surveyor requested the training binder with the skills checkoff list and/or any training completed on transfers for new and current nursing staff. Interview on 02/11/20 at 3:43 PM with the DON, when asked for documentation showing transfer competencies were completed on all nursing staff, the DON stated there was no written transfer competency form stating, This is something they already know from school. When asked about the Fall Protocol, an in-service training documented in Resident #1's incident, he stated the Fall protocol was doing neuro checks and head to toe assessments. The transfer competency was done verbally after the incident. He stated anytime a resident had a fall, they review what caused the fall and, in this case, it was the staff not following procedures. He said they did a post fall protocol on what was done improperly so it does not happen again. He stated the Fall Protocol was specific to CNA B and so she was only the only staff in-serviced. He stated he verbally reiterated with everyone on 1/31/20 in-service how to do proper gait belt and Hoyer transfers. He stated even after the in-service, he had to tell a CNA that she should not ask another CNA what type of transfer a resident required because things change, and they needed to look in the resident's profile. Interview on 02/11/20 at 3:32 PM with the Administrator, she stated there was no return demonstrations completed for transfers stating they were currently working with nursing to set up an annual return demonstration competency for transfers because it was a new year and staff need refreshers. Interview on 02/12/20 at 8:25 AM, LVN A stated there was not an official person who trained CNAs on mechanical lifts. New CNAs were trained on transfers during the three-day orientation when they were paired up with a veteran CNA. Transfer training was more of an OJT and word of mouth process. When asked if there was any type of training on transfers throughout the year, he stated no, he said during orientation, there was online training which included transfers. Training was completed throughout the employment process. New CNAs, just out of school, received the same three-day training as experienced CNAs. When asked if there was a skill check off list, to check for transfer competency, he said yes, it's included in the orientation packet. He was not sure when the skills check off had to be completed. When asked if he completed a transfer skill check off, he stated he completed one a couple of weeks after he started in 2018. When asked if he had any refresher training, he stated no. When asked how proficiency was determined on transfers for nursing staff, he stated a Hoyer was always a two-person assist. If a CNA voiced concern or stated they were not comfortable using the Hoyer or doing a transfer, a nurse would then re-educate the CNA. He stated they would have to verbally express that he/she needs additional training because it was not something that was just done by the facility. Interview on 02/12/20 at 8:41 AM with the DON, he stated he talked to the Regional office and they stated they could not pull up the transfer skills check off list stating they were going to send it to him. He again stated the DON and two ADONs complete the Hoyer lift training. Surveyor requested all documentation of in-services, skills check off for transfer training that was completed on all nursing staff. Interview on 02/12/20 at 8:58 AM with ADON B, she said she had been working at the facility for three weeks, sta

Based on observation, interview, and record review, the facility failed to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 5 of 9 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for Administration, in that: -The Administrator failed to: -Supervise the DON in the hiring and training of newly hired and current nursing staff to ensure they were properly trained on mechanical lift, 1-person, and 2-person gait belt transfers prior to working on the floor and transferring residents who required assistance. -Supervise the DON in the supervision, monitoring and evaluating of current nursing staff to ensure proficiency in mechanical lift, 1-person, and 2-person gait belt transfers to prevent injuries during resident transfers. -Ensure the facility had adequate quality and quantity of supplies needed to safely transfer residents who required mechanical lift and gait belt transfers. -The DON failed to: -Ensure newly hired and current nursing staff were properly trained on mechanical lift, 1-person, and 2-person gait belt transfers prior to working on the floor and transferring residents who required assistance. -Ensure current nursing staff were routinely monitored and evaluated to ensure proficiency in mechanical lift, 1-person, and 2-person gait belt transfers to prevent injuries during resident transfers. -Ensure the facility had adequate quality and quantity of supplies needed to safely transfer residents who required mechanical lift and gait belt transfers. -These failures resulted in an immediate jeopardy on 02/12/20. While the IJ was lowered on [DATE] the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. -These failures could affect any resident who require transfers by mechanical lift, or by gait belt and place them at risk of injury, pain, and psychological harm and possible hospitalization . Findings include: Further interview on 02/11/20 at 10:37 AM with the DON, when asked what type of training nursing staff received for transfers and who provided the training, The DON stated therapy provided on the spot training for one-person and two-person gait belt transfers. All nursing management provided in-services for mechanical lift transfers. He said therapy did not do mechanical lift training. When asked if the training was documented when completed, The DON stated he would have to ask. Transfer training documentation for all nursing staff was requested at this time. Interview on 02/11/20 at 11:03 AM with CNA D, she said she had been working at the facility for 2 ½ years. When asked when and who did the transfer training, she stated one CNA would train the other CNAs; new CNAs were trained by a CNA who had been at the facility for some time. She stated they had in-services on the mechanical lift, the stand-up lift, and gait belt transfers. When asked if there was a skill check off, she could not recall. She could not recall how often the training occurred. Interview on 02/11/20 at 11:13 AM with CNA E, she stated the training was completed by the DON, ADON, and Therapy. When asked how often transfer training was completed, she stated, If there is a change or if we notice something a little off, the facility will have an in-service on transfer training. When asked if a skill check off was completed to determine proficiency, she stated training was done verbally. Interview on 02/11/20 at 11:31 AM with CNA H, she stated she had been working at the facility for three months. When asked if she had been trained on transfers, stated she had not received any training on transfers at this facility. She said she was trained at other facilities where she worked but was not trained at this facility. When asked how she knew the type of transfer a resident required, she stated another CNA would tell her, or she will look in the resident's profile. During a telephone interview on 02/11/20 at 12:15 PM with CNA A, when asked if she received transfer training while working at the facility, she stated for the two years she had worked at the facility, she never received any type of training or in-services on transfers. She learned how to transfer residents from working at other facilities. Interview on 02/11/20 at 12:41 PM with the Administrator, when asked what type of training the nursing staff receive when they were new to the facility, she stated they shadow a CNA who had been here for a period of time. She said they were trained for three days and the CNA showed them how to transfer. She said if a CNA was not familiar with some type of transfer, like a Hoyer lift then the experienced CNA or ADON would train the CNA on the Hoyer lift. She stated they had a mass transfer training completed in December or January with PT B on all types of transfers. She said she was not sure how often nursing staff were trained on transfers as far as keeping track of CNA training she would ask nursing staff because she did not want to contradict herself. Transfer training documentation for all nursing staff was requested by surveyor for review. Record review of facility in-services dated 2/02/19 and 04/12/19 revealed, documentation of in-services completed on 02/02/19 and 04/12/19 by ADON A. The in-service title on 2/02/19 was Falls and on 04/12/19 the in-service topic was Falling [ENTITY]s. On both days, the in-services were not specific to transfers and did not address proper or safe transfers. Further review of the in-service revealed current nursing staff were not present during the training. Further record review of an in-service dated 4/15/19 and completed by ADON A revealed, an in-service tiled Transfers. The in-service objectives included: independent and dependent assistance with transfers, bed mobility, safe transfers, proper use of devices, and incorrect transfers. There was no further evidence or documentation showing nursing staff were trained by skills checkoff or return demonstration on proper transfers. Further review of the in-service revealed current nursing staff were not present during the training. Further record review of an in-service dated 12/6/19 revealed, a mandatory in-service, topics of included; chain of command, when to notify DON, time off request, on-call staffing phone, introduction of new DON, expectations of the DON, switching of shifts without notification and approval, transfer training, gait belts, calling off for shift, reporting tardies, and vacation request. Further record review of an in-service dated 1/31/20, completed by the DON, revealed an in-service on proper transfers completed after the incident with Resident #1 occurred. There was no further documentation showing nursing staff received skills checkoff or return demonstration as part of their transfer training. Record review of the facility Course Completion History dated 6/01/19-9/30/19 revealed, a 64-page documentation of online training. The report did not specify if the training was for new hires or a review for current nursing staff. There was a total of 34 nursing staff who completed a form of transfer training out of a total [AGE] current nursing staff. Not all nursing staff completed training on all types of transfers. The documentation of training was only provided for the months of June, July, August, and September 2019. There was no further documentation of transfer training for nursing staff the months of January through May 2019, and October 2019 to the current year. The Administrator and DON were unable to provide any further documentation of transfer training for nursing staff. Record review of the facility Staff Education/Orientation Policies and Procedures revised 7/1/2013 revealed, a nursing skill checkoff list for, assisting resident to a sitting position while in bed, assisting resident to a sitting position on side of bed, assisting resident from bed to chair, Gait belt, use of, & Lifts, Use of Mechanical. The Administrator, DON, and ADONs did not provide any completed competency check list for current nursing staff for the surveyor to review after multiple requests. There was no further transfer training documentation provided for review. Interview on 02/11/20 at 12:54 PM with PTA C, when asked what type of training transfer therapy provided to nursing staff, he stated he was not sure because he never did any type of training with nursing staff. The previous therapy director used to do the training. Interview on 02/11/20 at 1:05 PM, PT B stated she had been working at the facility for almost two years and had only completed transfer training for the first time in December 2019. That training was a demonstration on gait belt transfers. When asked if all nursing staff were part of the training, she stated staff who were available that day were present, but she could not state if all nursing staff were present during the training. She stated she did not do mechanical lift transfer training because the nursing staff were supposed to train staff on mechanical lifts. Interview on 02/11/20 at 1:25 PM with CNA F, when asked if nursing staff receive transfer training, she stated training was completed once a year. They do the training before they check us on full book. She stated transfer training covered Hoyer lift and gait belt transfers. When asked who did the training, she stated she and CNA J did the training. The DON and ADON sometimes did the transfer training. When asked if transfer training was part of new hire orientation, she said the new CNA shadowed a veteran CNA, so whoever they shadowed would train the new CNA. When asked if there was a skill checkoff to show proficiency in transfers, she stated there was no skills checkoff. The lead CNA who did the training just verbally checks off the orientee. She stated she was not sure if there was a skills checkoff list. She said there was not a real orientation other than the veteran CNA showing the orientee how to do the transfers. She said they had three days of training and each day the training was with different residents, transfers and care. She said the responsibility was on the lead CNA to train on transfer. After the third day, the new CNA would start working on the floor. Interview on 02/11/20 at 2:35 PM, CNA G said she had been working at the facility for one year. She said she received a three-day orientation. During the first two days, she learned the residents in her assigned hall. She stated she was trained on the 100 Hall but placed on the 200 Hall to work. She said they paired her with another CNA on the 200 hall for one day and she watched the CNA and helped as needed. When asked if she was trained on transfers during her orientation, she stated she was trained on the specific transfer for that specific hall, stated they touched basis on the transfers, but since she had been a CNA with previous training, she already knew how to do transfers. When asked what Touch basis meant, she stated she did not remember if a check off list was completed but thought the aide she was training with may have had a checkoff list. When asked who did transfer training, she stated the CNAs did the training. She said she could not remember if there was an in-service or training on transfers this year; last year therapy provided a verbal in-service on transfers. Interview on 02/12/20 at 8:25 AM, LVN A stated there was not an official person who trained CNAs on mechanical lifts. New CNAs were trained on transfers during the three-day orientation when they were paired up with a veteran CNA. Interview on [DATE] at 8:36 AM with the Administrator, when asked why she thought the IJ occurred, she stated if the forms were made available for the Surveyor to review she did not think it would have went this way or there may have been a different outcome. She stated organization was a problem, stating the forms were not organized. She said she could not say anything regarding what was observed during the transfers but said in hindsight she thought the staff were not comfortable while being observed. She stated she was not aware there was a mechanical lift that was not working. She said the mechanical lift slings/pads were ordered several times last year, but she could not state if they were delivered or why there were not enough slings available to all residents who required mechanical lift transfers. The DON was not available to interview, after the IJ was called, he did not return to the facility the following day. Interview on [DATE] at 9:19 AM with the Director of Rehab, when asked why she thought the IJ occurred, she stated the staff should have been utilizing the correct size gait belts during transfers for the transfer to be safe. She said the w/c should not have been tilted back during the mechanical lift transfer stating the only time she ever tilted a w/c was when the w/c was able to be reclined. She stated there was a lack of staff training on transfers and the facility was relying on nursing staff having previous training from school curriculum or other facilities and that may not be the case now because they may not have been trained at school and/or properly trained on transfers. Interview on [DATE] at 10:25 AM with the Maintenance Director, when asked why he thought the IJ occurred, he stated he has only been working at the facility for one month and that he did not understand what happened with the mechanical lift. He stated he was made aware the lift was not working when CNA F told him on 02/12/20 which was after an observed transfer with a working mechanical lift occurred. He said CNA F told him the lift was not going down and that was when he took it off the floor to repair it, but he was unable to fix the lift. When asked what the policy was regarding identifying equipment that was not working, he stated the staff should tell him immediately if the equipment was not working so it can be taken off the floor for repair. He stated he would now check equipment weekly for preventative maintenance, stating nursing staff were also responsible for following the lock out-tag policy by placing a tag on non-operable equipment and remove it from the floor to be repaired. He stated he would also be responsible for informing the Administrator about any equipment that is not working. Interview on [DATE] at 11:28 AM with ADON A, when asked why she thought the IJ occurred, she stated training needed to be more streamlined stating the more prepared and trained the staff were, the more comfortable they would be in their skills set. She stated she thought more spot checks should have been done to ensure staff were comfortable further stating doing more consistent skills checkoffs would make staff more comfortable. Interview on [DATE] at 12:07 PM with the interim DON, when asked why he thought the IJ occurred, he stated because he just walked into the IJ he could not state for sure. He said from what he needed to correct and set up now he thought the facility was lacking organization and did not have the appropriate documentation showing training and competencies were completed to ensure oncoming DONs had this available to review and to ensure staff were properly trained. He stated he was now setting up binders with all staff competencies completed, ensuring staff are completing training by watching transfer videos and would complete competency skills checkoff. He stated equipment audits will be completed to ensure the equipment is in working condition and there is sufficient amount of supplies to safely transfer residents. For evidence of the deficient practice, refer to F0689. The facility Administrator and the DON were notified on 02/12/20 at 3:10 PM that an IJ situation had been identified due to the above failures. The IJ template was provided. A Plan of Removal was submitted by the Administrator on 02/12/20. After several revisions, the final Plan of Removal was accepted on [DATE] at 8:34 AM. The plan of removal included the following: -The identified residents are being transferred per the plan of care and were assessed for injuries, bruises or skin tears on February 13, 2020. -The identified Certified Nursing Assistants (sic) who attempted to transfer the resident independently when she was a 2-person gait belt transfer resulting in a laceration to the residents' head requiring sutures no longer works in the facility. Termination was on February 6, 2020. -The Director of Rehabilitation assessed on February 13, 2020 the identified 51 residents requiring gait belt transfer for the correct size gait belt. New admissions to the facility will be assessed by Physical Therapy for the correct size gait belt. The correct size gait belt will be communicated to the direct care staff through the Resident's profile. -A new mechanical lift was delivered on February 12, 2020. The Maintenance Director has ordered a new part to repair the identified non-working facility mechanical lift. Two lift pads were delivered on February 12, 2020. The current number of lift pads in the facility is 9. The administrator has ordered 13 lift pads: 4 mediums, 5 large, and 4 extra-large. The expected delivery date is February 18, 2020 with guarantee of February 20, 2020. Compliance letter from vendor provided to surveyor. -The Physical Therapist re-educated the nurse managers on proper technique for transfers with the mechanical lift, 1 and 2-person gait belt transfers on February 12, 2020. Nurse managers receiving the training were Director of Nursing, 2 Assistant Directors of Nursing, 1 infections Preventionist, and 2 Nursing Assessment Coordinators. -The identified Certified Nursing Assistant (sic) who transferred the resident independently when she was a 2-person gait belt transfer resulting in a laceration to the residents' head requiring sutures no longer works in the facility. Termination was on February 6, 2020. -A nurse manager re-educated the two Certified Nursing Assistants (sic)who failed to lock the wheels prior to positioning the resident in the wheelchair on locking wheels of wheelchair during mechanical lift transfers with return demonstration. This education was conducted on February 12, 2020 for one and February 13, 2020 for the second one. -A nurse manager re-educated the Certified Nursing Assistant (sic) who transferred the identified resident from the lift to the wheelchair and did not have all four wheels secured on the floor was re-educated on proper placement of wheels during mechanical lift transfers with return demonstration. This education was conducted on February 12, 2020. Date of Completion: February 13, 2020 -The Nurse Managers who received re-education from the Physical Therapist began conducting re-education using competency checkoffs on the Mechanical Lift, 1 and 2-person gait belt transfers with facility Certified Nursing Assistants (sic) and Licensed Nurses on February 12, and 13, 2020. Any certified nursing assistant (sic) or licensed nurse not successfully completing this education on this date will complete prior to next scheduled shift. Competencies will be done in hew hire orientation, annually and as needed based on facility needs. Regional Vice President of Operations will re-educate facility Administrator that the facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This education will include the expectation that the administrator will validate that staff is trained on transfers appropriately, that mechanical lift checked routinely for safety, that supplies needed: slings, gait belts, etc. are adequate in quality and quantity. This education will take place on February 13, 2020. -Regional Vice President of Operations will re-educate Facility Administrator on Abuse and Neglect Policy on February 13, 2020. This will include the expectation of validating the facility staff receive abuse policy education upon hire, annually and as needed. -Regional Vice President of Operations will re-educate Facility Administrator, Director of Nursing, and Human Resource Director on the Orientation Policy and expectation that new hires will demonstrate transfer competency prior to transferring residents. This re-education will take place on February 13, 2020. -Administrator/designee will complete re-education for Abuse and Neglect prevention to facility staff on February 13, 2020. Anyone not receiving this education by February 13, 2020, will receive prior to next scheduled shift. -Director of Nursing/Designee will re-educate Certified Nursing Assistants (sic) and Licensed Nurses on the lock out-tag policy and to report any issues with equipment to include mechanical lifts to nurse management or the administrator on February 13, 2020. Anyone not receiving this education by February 13, 2020 will receive prior to next scheduled shift. -Administrator will re-educate Maintenance Director on the expectation of performing Preventative Maintenance on the Mechanical Lifts monthly and reporting the results to the Administrator. This education was completed on February 13, 2020. -Administrator will re-educate Central Supply staff on minimum lift pad PAR (maintaining an expected supply) level 3 per six and the sizes are medium, large and extra-large and if the number of lift pads falls below the PAR level the Administrator will be notified. This education was completed on February 13, 2020. -Administrator will re-educate Laundry staff on to pull frayed lift pads out of circulation and to report it to central supply to have new one ordered. This education will begin on [DATE]20. Anyone not receiving this education by February 13,2020 will receive prior to next scheduled shift. Administrator will re-educate Certified Nursing Assistants to pull frayed lift pads out of circulation and to report to Director of Nursing/designee who will have new one ordered. This education will begin on [DATE]20. Anyone not receiving this education by February 13,2020 will receive prior to scheduled shift. Date of Completion: February 13, 2020 -The medical director was notified on this February 12, 2020. -An Ad Hoc Quality Assurance Performance Improvement meeting was held on February 12, 2020 regarding the contents of this plan. The surveyor confirmed the Plan to lower the immediate Jeopardy had been implemented sufficiently by: Record review of head to toe assessments completed on [DATE]20 for all three residents observed during transfers and two residents identified for improper transfers causing injury. Record review of facility invoice dated [DATE] revealed, a mechanical lift was delivered to the facility. Record review of facility invoice dated [DATE] revealed, 13 slings, 4 mediums, 5 large, and 4 extra-large slings were ordered. Record review of facility invoice dated [DATE] revealed, 100 belt transfers ordered. Record review of facility in-services dated 2/12/20 revealed, transfer training, gait belt training by PT B for all nursing management. Record review of facility in-service dated 2/12/20 revealed, gait belt, mechanical lift in-services with staff who were observed transferring residents incorrectly. Record review of facility in-service dated [DATE] revealed, in-services with central supply on maintaining slings, PAR level and notifying administrator when PAR level falls below 3 for any size. Record review of facility in-service dated [DATE] revealed, staff were in-serviced on preventative maintenance of mechanical lifts with the Maintenance Director. Record review of facility in-service dated [DATE] revealed, facility service practice education, orientation policy, Abuse and Neglect policy with the Administrator. Record review of facility in-service dated [DATE] revealed, Abuse and Neglect re-education with facility staff, orientation policy with Human Resources services, and lock out tag policy with facility staff, PAR level/slings policy with facility staff, and frayed slings/pads policy with facility staff on all shifts. Record review of facility skills checkoff on gait belt, 1-person, 2-person, and mechanical lift transfers completed on 02/12, 02/13, and on 02/14 with nursing staff on all shifts. Observation of 2-person mechanical lift transfer on [DATE] at 1:12 PM, revealed a proper transfer by CNA J and CNA B. Observation of a 1-person gait belt transfer on [DATE] at 1:28 PM revealed a proper transfer by CNA L Observation of a 2-person gait belt transfer on [DATE] at 1:35 PM revealed, a proper transfer by CNA E and CNA K. Observation on [DATE] between noon and 2:32 PM of mechanical lifts and gait belts, and mechanical lift slings revealed, a total of two working mechanical lifts in the 100-200 hall, and one working mechanical lift in the 300-400 hall. New and the appropriate sized gait belts were in residents' rooms who required gait belt transfers, and there was a total of 6 mechanical lift slings in the facility with 13 ordered and to be delivered no later than February 20, 2020. Interviews on [DATE] between noon and 2:32 PM with the interim DON, ADON, and MDS nurses, wound care nurse revealed, they were trained on transfers by therapy and trained nursing staff after they completed skills checkoffs on mechanical lift, 1-person, 2-person gait belt transfers. Interviews on [DATE] between noon and 2:32 PM with nursing staff revealed, nursing management trained staff along with a skills checkoff completed on 1-person, 2-person, and mechanical lift transfers. All nursing staff interviewed were able to state the lock out-tag policy, and the Abuse and Neglect policy and procedures. Interview on [DATE] at 10: 14 AM with the Central supply director revealed, she was able to state the policy on maintaining PAR level of lift pads and when to notify the administrator if levels are below 3 for each size. Interview on [DATE] at 10:25 AM with the Maintenance Director revealed, he was able to state responsibilities for mechanical lift maintenance and when to perform Preventative Maintenance on the Mechanical Lifts and who to report findings to. Interview on [DATE] between noon and 2:32 p.m. with laundry staff and Certified Nursing Assistants revealed, they were able to state the policy on will observing for frayed or broken lift pads and when to pull damaged slings from circulation and replaced as needed. Interview on [DATE] at 12:07 PM with the interim DON, he was able to state the policies on new hire competencies, audits on transfers and equipment and reporting findings to the administrator. On 2/14/2020 at 2:32 PM, the Administrator and Interim DON were informed that the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope of pattern. The facility was continuing to monitor transfers.

Based on observation, interview and record review the facility failed to provide adequate supervision to prevent accidents for 1 (Resident # 1) of 5 residents reviewed for accidents and supervision in that: -Resident # 1 slid off the bed during incontinent care with only one CNA assisting her resulting in fractured knee and skin tears. This failure affected one resident and placed her at risk for serious injury, pain and decline in health status. Findings include: Intake # 5 Resident # 1 Record review of Resident # 1's medical records revealed an [AGE] year old female admitted to the facility on [DATE], and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident # 1's annual MDS assessment dated [DATE] revealed she had a BIMS of 10. She required extensive, two-person assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. She required supervision with set up help for eating. She was always incontinent of bowel and bladder. Her weight on the annual assessment was 273 pounds. Record review of Resident # 1's Care Plans revealed that it was not updated to reflect Resident #1's current needs. The Care plan revealed: Problem Start Date: 10/15/2018 Category: ADL Functional/Rehabilitation Potential. Requires assistance with ADL's and transfers. Approach Start Date: 02/22/2018 Apply trapeze bar to assist with independence with repositioning in adls. Approach: Approach Start Date: 04/13/2016 BED MOBILITY: Requires extensive assist x 1 with turning for incontinent care and repositioning. Bilateral grab bars as an enabler for the benefit self-sufficient bed mobility .Edited: 04/22/2018 . Approach Start Date: 04/13/2016 TOILETING: Requires extensive assistance x 1 with incontinent care on scheduled rounds and PRN. Approach Start Date: 4/13/2016 .Edited: 04/22/2018 . Approach Start Date: 04/13/2016 TRANSFER: Requires weight bearing total assistance x 2 with use of mechanical hoyer lift for all transfers. Edited: 04/22/2018 . Problem Start Date: 02/07/2019. Resident has skin tear on right forearm . Problem Start Date: 02/02/2019. (Resident # 1) had a fall on 02/02/19, with fracture to left knee. Record review of Resident # 1's quarterly MDS assessment dated [DATE] revealed she had a BIMS of 10, indicating her cognition was moderately intact. She required extensive two-person assistance for bed mobility, transfers, locomotion off unit, dressing, and toilet use. She required supervision with one person assist for eating, and extensive one-person assistance for personal hygiene. She was always incontinent of bowel and bladder. She was 62 inches tall and 275 pounds. Record review of Resident # 1's weights revealed on 2/01/19 she weighed 265.8 pounds. Record review of the Provider Investigation Report for Resident #1 revealed the incident occurred on 2/02/19 at 9:00 AM. The Investigation Summary read, CNA was performing incontinent care on (Resident # 1). (Resident # 1) stated that while she was attempting to roll over in the bed to grab the bar she rolled too far and fell off of the bed. The CNA went and got the nurse who assessed (Resident # 1) and notified the family and physician. Vitals were taken the skin tear was cleaned and covered. X-rays were ordered, and pain medication was given. Record review of a Radiology Report for Resident #1 dated 2/02/19 revealed x-rays taken of Resident # 1's left knee. It read, Results: There is a lucency and cortical irregularity along the inferior aspect of the patella suspicious for a nondisplaced fracture. Advanced tricompartmental [MEDICAL CONDITION] changes and osteopenia noted in the knee joint. [MEDICAL CONDITION] calcifications noted in the soft tissue. X-rays of Resident # 1's Left Foot revealed no fractures or dislocation. Record review of Resident # 1's nurse's notes read in part: 2/02/19 9:54 AM CNA C notified writer .that while providing incontinent care to Resident #1, Resident #1 slid to from mattress to floor. Resident #1assessed made comfortable. assisted Resident #1back to bed via Hoyer lift. Resident #1 has skin tear on right forearm, left knee and small scratch noted on right middle back. V/S stable. Skin tears cleansed with N/S. applied TAO, and covered with dressing. Resident #1 c/o pain on right leg. PRN Tylenol given. R/P and MD notified. Awaiting call back from MD. DON also notified. Will continue to monitor. 02/02/2019 11:56 AM MD and both N/P called again left messages awaiting call back. Will continue to monitor. 02/02/2019 12:18 PM Resident has stat order for x rays for lumber spine and full leg and foot on right and left extremities . 02/02/2019 07:39 PM Charge nurse showed ADON x-ray results. ADON called (DR B) with results of fracture to left knee. Informed charge nurse of order for ice pack Q 3hr per MD. 02/02/2019 08:06 PM Resident #1 has noted fracture to Left knee. Resident #1 has new order for cold pack q 3 hours as tolerated. Charge nurse updated MAR. Resident #1 resting in bed. Resident #1 c/o pain on L knee. PRN Tylenol given effective. B/P 119/78, P 82, Resp 18, Temp 97.9 oral and O2 SAT 98% via N/C @ 2LPM. Will f/u with oncoming nurse. Observation and interview with Resident # 1 on 2/14/19 at 10:07 AM revealed she was lying on her back in the middle of a large, wide bariatric bed with an air mattress on it. The bed had short handle bars at the head of the bed on both sides. There was no trapeze bar observed in the room. Resident # 1 stated before, she had a bed that was a little narrower than this bed, but the Administrator changed it out for a smaller bed that was just slightly wider than the twin bed used by her roommate. She stated the bed they gave her was too narrow for her. She stated after she fell off of it they gave her the wide bed that she was using now. She stated the day she fell there was only one CNA helping her. She stated the CNA was cleaning her and asked her if she could lift her bottom up and she did and that's when she slid off of the bed. She stated she fell off the bed by the window and air conditioner. She stated the air mattress was slippery and she couldn't stop her feet and legs from sliding off. She stated as soon as the CNA realized she was falling she ran to get help. Resident # 1 stated she got a large skin tear about the size of a silver dollar on her right forearm and her right foot and toes were somehow jammed when she hit the floor and her foot hurt a lot. A dressing was observed on Resident # 1's right wrist/forearm area dated 2/14/19. Resident # 1 stated sometimes two CNAs provide care to her, but often times it was only one CNA. In an interview with CNA C on 2/14/19 at 11:10 AM she stated she was doing incontinent care on Resident # 1 on the day of the incident. She stated she realized at the last moment that Resident #1 was sliding and it was too late. She stated she tried to stop her from falling. She stated she reached over to try to stop her from sliding on off the bed, but her legs and feet were off the bed and on the floor while her upper body was still on the bed and she couldn't stop her from sliding on off. She stated her gloves made it too slippery. CNA C stated she ran around the bed and lowered Resident # 1 on down to the floor. CNA C stated she didn't hit the air conditioner. She stated Resident # 1 flung her arm and may have hit something then with her arm causing the large skin tear. CNA C stated Resident # 1's bed mobility said X 1 person in the care tracker they used. She stated they started using two-person assistance now since she fell . CNA C stated the Resident #1 was able to turn and lift herself up. She was just not able to help them get her up, so they use the Hoyer lift. Resident # 1 does not get up on the weekends. CNA C stated she went and got the nurse and the nurse brought the hoyer lift and put Resident # 1 back in bed. CNA C stated the bed they had her on that day was too narrow for her. In an interview with the DON on 2/14/19 at 11:30 AM he stated that Resident # 1 had a fall during incontinent care and they let the physician and RP know and got x-rays and pain medication. He stated the MDS Nurse did the care planning, but it was also done by the floor nurses too, based on the observations of the staff. In an interview with the MDS Nurse on 2/14/19 at 11:39 AM, when asked why the MDS assessments coded Resident # 1 as an extensive two person assist, but the care plan reads that she was a one person assist. She stated on the MDS, the coding goes by the last three times the resident was assisted and they are to use the most dependent level of care. She stated for the ADLs they go by what they can do on their best day, or their usual. The last three times might not be their usual. She stated the MDS pulls data from the last seven days of the P[NAME] care tracker entries from the CNAs. She was asked with Resident # 1's large size and limited mobility if she thought she should be a one person assist. The MDS Nurse stated that Resident # 1 was able to grab the side handle bars on the bed and she had always done that. In an interview with Resident # 1 on 2/14/19 at 12:37 PM she stated the trapeze bar was taken out of her room because it was just in the way and she was not using it. She stated it was too high up and she couldn't reach it and I never used it. She stated it also got in the way of the hoyer lift. She was asked if she can turn over in bed by herself. She stated she can usually turn over with a little help from staff, but not really by herself. She stated she had the handle bars to grab onto, but she didn't get time to grab them that day because it was her legs and feet that started sliding off of the narrow bed and there was nothing there at the foot of the bed to help her from sliding. In a telephone interview on 2/14/19 at 1:31 PM with LVN C she stated on 2/02/19 she was making her rounds while the CNA C came and notified her that Resident # 1 was on the floor. She stated she went to her room and found Resident #1 lying on her left side on the floor by the window. She stated that CNA C said she slid off the bed onto the floor. She stated they got her off of the floor with the Hoyer lift and put her in bed. She stated she called the doctor and got orders for x-rays. She stated Resident # 1 had a fracture to the left knee, and a skin tear to her right forearm, and a skin tear on her left knee also. She stated the skin tear on her arm started swelling. She stated she did not see another CNA in the room. She stated she asked CNA C if she was by herself cleaning the resident and she said yes. LVN C stated she thought that Resident # 1 should be a two person assist for incontinent care. She stated, common sense tells you that because she's a heavy woman and requires a bariatric bed she's a two person assist. LVN C stated the fall could have probably been avoided if she would have had two people assisting her and someone on the other side of the bed to stop her from falling. In an interview with the Administrator on 2/14/19 at 2:05 PM he stated they switched out the frame on Resident # 1's bed and it was still a bariatric bed. He stated the bed had four different sections. He stated the mattress has zippers and a section of mattress for each side to make the bed wider. He stated the frame also extended further out. He stated when they put the bed in the room they did not have all the extensions on the mattress, so the bed was much narrower. He stated they extended the bed out after the fall and added the additional sections. In an interview with the Administrator on 2/14/19 at 4:10 PM he stated he believed Resident # 1 required only one-person assistance for incontinent care and they should not be cited for this accident. Policies were requested for Accidents and supervision but not provided by the facility.

Based on observation, interview and record review, the facility failed to accommodate the needs and preferences of one of five residents (Resident #1 ) reviewed for accommodation of needs in that: -Resident # 1 was not provided a bariatric bed as needed, which caused the resident to slide off the bed during incontinent care resulting in fractured knee and skin tears. This failure affected one resident and placed her at risk for not having her needs and preferences met and a decreased quality of life. Findings include: Intake # 5 Resident # 1 Record review of Resident # 1's medical records revealed an [AGE] year old female admitted to the facility on [DATE], and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident # 1's annual MDS assessment dated [DATE] revealed she had a BIMS of 10. She required extensive, two-person assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. She required supervision with set up help for eating. She was always incontinent of bowel and bladder. Her weight on the annual assessment was 273 pounds. Record review of Resident # 1's Care Plans revealed that it was not updated to reflect Resident #1's current needs. The Care plan revealed: Problem Start Date: 10/15/2018 Category: ADL Functional/Rehabilitation Potential. Requires assistance with ADL's and transfers. Approach Start Date: 02/22/2018 Apply trapeze bar to assist with independence with repositioning in adls. Approach: Approach Start Date: 04/13/2016 BED MOBILITY: Requires extensive assist x 1 with turning for incontinent care and repositioning. Bilateral grab bars as an enabler for the benefit self-sufficient bed mobility .Edited: 04/22/2018 . Approach Start Date: 04/13/2016 TOILETING: Requires extensive assistance x 1 with incontinent care on scheduled rounds and PRN. Approach Start Date: 4/13/2016 .Edited: 04/22/2018 . Approach Start Date: 04/13/2016 TRANSFER: Requires weight bearing total assistance x 2 with use of mechanical hoyer lift for all transfers. Edited: 04/22/2018 . Problem Start Date: 02/07/2019. Resident has skin tear on right forearm . Problem Start Date: 02/02/2019. (Resident # 1) had a fall on 02/02/19, with fracture to left knee. Record review of Resident # 1's quarterly MDS assessment dated [DATE] revealed she had a BIMS of 10, indicating her cognition was moderately intact. She required extensive two-person assistance for bed mobility, transfers, locomotion off unit, dressing, and toilet use. She required supervision with one person assist for eating, and extensive one-person assistance for personal hygiene. She was always incontinent of bowel and bladder. She was 62 inches tall and 275 pounds. Record review of Resident # 1's weights revealed on 2/01/19 she weighed 265.8 pounds. Record review of the Provider Investigation Report for Resident #1 revealed the incident occurred on 2/02/19 at 9:00 AM. The Investigation Summary read, CNA was performing incontinent care on (Resident # 1). (Resident # 1) stated that while she was attempting to roll over in the bed to grab the bar she rolled too far and fell off of the bed. The CNA went and got the nurse who assessed (Resident # 1) and notified the family and physician. Vitals were taken the skin tear was cleaned and covered. X-rays were ordered, and pain medication was given. Record review of a Radiology Report for Resident #1 dated 2/02/19 revealed x-rays taken of Resident # 1's left knee. It read, Results: There is a lucency and cortical irregularity along the inferior aspect of the patella suspicious for a nondisplaced fracture. Advanced tricompartmental [MEDICAL CONDITION] changes and osteopenia noted in the knee joint. [MEDICAL CONDITION] calcifications noted in the soft tissue. X-rays of Resident # 1's Left Foot revealed no fractures or dislocation. Record review of Resident # 1's nurse's notes read in part: 2/02/19 9:54 AM CNA C notified writer .that while providing incontinent care to Resident #1, Resident #1 slid to from mattress to floor. Resident #1assessed made comfortable. assisted Resident #1back to bed via Hoyer lift. Resident #1 has skin tear on right forearm, left knee and small scratch noted on right middle back. V/S stable. Skin tears cleansed with N/S. applied TAO, and covered with dressing. Resident #1 c/o pain on right leg. PRN Tylenol given. R/P and MD notified. Awaiting call back from MD. DON also notified. Will continue to monitor. 02/02/2019 11:56 AM MD and both N/P called again left messages awaiting call back. Will continue to monitor. 02/02/2019 12:18 PM Resident has stat order for x rays for lumber spine and full leg and foot on right and left extremities . 02/02/2019 07:39 PM Charge nurse showed ADON x-ray results. ADON called (DR B) with results of fracture to left knee. Informed charge nurse of order for ice pack Q 3hr per MD. 02/02/2019 08:06 PM Resident #1 has noted fracture to Left knee. Resident #1 has new order for cold pack q 3 hours as tolerated. Charge nurse updated MAR. Resident #1 resting in bed. Resident #1 c/o pain on L knee. PRN Tylenol given effective. B/P 119/78, P 82, Resp 18, Temp 97.9 oral and O2 SAT 98% via N/C @ 2LPM. Will f/u with oncoming nurse. Observation and interview with Resident # 1 on 2/14/19 at 10:07 AM revealed she was lying on her back in the middle of a large, wide bariatric bed with an air mattress on it. The bed had short handle bars at the head of the bed on both sides. There was no trapeze bar observed in the room. Resident # 1 stated before, she had a bed that was a little narrower than this bed, but the Administrator changed it out for a smaller bed that was just slightly wider than the twin bed used by her roommate. She stated the bed they gave her was too narrow for her. She stated after she fell off of it they gave her the wide bed that she was using now. She stated the day she fell there was only one CNA helping her. She stated the CNA was cleaning her and asked her if she could lift her bottom up and she did and that's when she slid off of the bed. She stated she fell off the bed by the window and air conditioner. She stated the air mattress was slippery and she couldn't stop her feet and legs from sliding off. She stated as soon as the CNA realized she was falling she ran to get help. Resident # 1 stated she got a large skin tear about the size of a silver dollar on her right forearm and her right foot and toes were somehow jammed when she hit the floor and her foot hurt a lot. A dressing was observed on Resident # 1's right wrist/forearm area dated 2/14/19. Resident # 1 stated sometimes two CNAs provide care to her, but often times it was only one CNA. In an interview with CNA C on 2/14/19 at 11:10 AM she stated she was doing incontinent care on Resident # 1 on the day of the incident. She stated she realized at the last moment that Resident #1 was sliding and it was too late. She stated she tried to stop her from falling. She stated she reached over to try to stop her from sliding on off the bed, but her legs and feet were off the bed and on the floor while her upper body was still on the bed and she couldn't stop her from sliding on off. She stated her gloves made it too slippery. CNA C stated she ran around the bed and lowered Resident # 1 on down to the floor. CNA C stated she didn't hit the air conditioner. She stated Resident # 1 flung her arm and may have hit something then with her arm causing the large skin tear. CNA C stated Resident # 1's bed mobility said X 1 person in the care tracker they used. She stated they started using two-person assistance now since she fell . CNA C stated the Resident #1 was able to turn and lift herself up. She was just not able to help them get her up, so they use the Hoyer lift. Resident # 1 does not get up on the weekends. CNA C stated she went and got the nurse and the nurse brought the hoyer lift and put Resident # 1 back in bed. CNA C stated the bed they had her on that day was too narrow for her. In an interview with the DON on 2/14/19 at 11:30 AM he stated that Resident # 1 had a fall during incontinent care and they let the physician and RP know and got x-rays and pain medication. He stated the MDS Nurse did the care planning, but it was also done by the floor nurses too, based on the observations of the staff. In an interview with the MDS Nurse on 2/14/19 at 11:39 AM, when asked why the MDS assessments coded Resident # 1 as an extensive two person assist, but the care plan reads that she was a one person assist. She stated on the MDS, the coding goes by the last three times the resident was assisted and they are to use the most dependent level of care. She stated for the ADLs they go by what they can do on their best day, or their usual. The last three times might not be their usual. She stated the MDS pulls data from the last seven days of the P[NAME] care tracker entries from the CNAs. She was asked with Resident # 1's large size and limited mobility if she thought she should be a one person assist. The MDS Nurse stated that Resident # 1 was able to grab the side handle bars on the bed and she had always done that. In an interview with Resident # 1 on 2/14/19 at 12:37 PM she stated the trapeze bar was taken out of her room because it was just in the way and she was not using it. She stated it was too high up and she couldn't reach it and I never used it. She stated it also got in the way of the hoyer lift. She was asked if she can turn over in bed by herself. She stated she can usually turn over with a little help from staff, but not really by herself. She stated she had the handle bars to grab onto, but she didn't get time to grab them that day because it was her legs and feet that started sliding off of the narrow bed and there was nothing there at the foot of the bed to help her from sliding. In a telephone interview on 2/14/19 at 1:31 PM with LVN C she stated on 2/02/19 she was making her rounds while the CNA C came and notified her that Resident # 1 was on the floor. She stated she went to her room and found Resident #1 lying on her left side on the floor by the window. She stated that CNA C said she slid off the bed onto the floor. She stated they got her off of the floor with the Hoyer lift and put her in bed. She stated she called the doctor and got orders for x-rays. She stated Resident # 1 had a fracture to the left knee, and a skin tear to her right forearm, and a skin tear on her left knee also. She stated the skin tear on her arm started swelling. She stated she did not see another CNA in the room. She stated she asked CNA C if she was by herself cleaning the resident and she said yes. LVN C stated she thought that Resident # 1 should be a two person assist for incontinent care. She stated, common sense tells you that because she's a heavy woman and requires a bariatric bed she's a two person assist. LVN C stated the fall could have probably been avoided if she would have had two people assisting her and someone on the other side of the bed to stop her from falling. In an interview with the Administrator on 2/14/19 at 2:05 PM he stated they switched out the frame on Resident # 1's bed and it was still a bariatric bed. He stated the bed had four different sections. He stated the mattress has zippers and a section of mattress for each side to make the bed wider. He stated the frame also extended further out. He stated when they put the bed in the room they did not have all the extensions on the mattress, so the bed was much narrower. He stated they extended the bed out after the fall and added the additional sections. In an interview with the Administrator on 2/14/19 at 4:10 PM he stated he believed Resident # 1 required only one-person assistance for incontinent care and they should not be cited for this accident. Policies were requested for Accidents and supervision but not provided by the facility.

Based on interview and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental or psycho-social well being according to the plan of care and comprehensive assessment for 1 of 5 residents (CR #1)reviewed for care and services. -CR #1, sustained an injury to her left leg on 9/22/2014 after being transferred from her wheelchair to her bed by a facility staff with the assistance of a vendor who was not employed by the facility (x-ray technician). CR #1 was admitted to the hospital on [DATE] for an unrelated health issue. -CR #1, had increased of pain to her left lower extremity as a result of the injury on 9/22/2014. CR #1 used 16 times [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 5-325 mg from 9/22/2014 to 10/19/2014. This failure affected one discharged resident and could place 47 residents at risk a decline in physical, mental and psychosocial well-being. Findings Include: Intake # 0 Closed record review of the facility face sheet revealed CR #1 was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the admission MDS dated [DATE] revealed CR#1 required extensive assistance of two persons for bed mobility, transfers, personal hygiene and was total dependent on staff for toilet use and bathing. CR #1 received scheduled pain medications regimen and did not have indicators of pain or possible pain. Record review of the care plan dated 07/6/2014 for CR #1 revealed:- Problem- resident requires assistance with ADL's. Approach start date: 5/07/2014: Transfer: Assist of one person. Record review of the facility incident/accident report dated 9/22/2014 at 1:00 p.m. revealed: Type of incident/accident secondary injury: Transfer knee injury. Describe exactly what happened: CR #1 was transferred from her wheelchair to the bed by CNA A and an x-ray technician. During the transfer CR #1 complained of knee pain. When CR #1 was describing what happened she stated her knee gave out on her. Findings and analysis: sliding board was used during transfer. Follow up/steps taken to prevent reoccurrence and person responsible: Transfer CR #1 with two people using mechanical device due to decreased mobility. Record review of CR #1 nurse's notes dated 9/26/2014 revealed in part: "Late entry for 9/22/2014: upon entering (CR #1's) room for wound care. (CR #1) reports pain to left knee. Tylenol as ordered. (CR #1) was asked if pain to left knee was different pain than she normally have? (CR #1) reported yes, they hurt it when they moved me back to bed. (CR #1) was asked how and when and who and (CR #1) reported when they came to do my ultrasound, staff and radiology technician transferred me back to bed and heard a pop in my knee and it has hurt since. Informed nurse practitioner, she assessed and ordered x-rays. Radiology called and x-ray ordered". Record review of radiology report for CR #1 dated 9/22/2014 at 10:36 pm revealed: History: left knee pain. Impression: Osteoarthritic changes without evidence of acute osseous pathology. Record review of the MRI report for CR #1 dated 9/29/2014 at 3:29 pm revealed in part: Clinical history: Severe left knee pain. Findings: This exam is significantly limited by patient condition and patient motion. Impression: Probable nondisplaced stress fractures involving the 2 lower bones to the left lower bones. Signal abnormalities involving the posterior aspect of the left lower bones may also reflect nondisplaced fractures. Record review of CR #1's care plan revealed an entry on 10/14/2014 that read: Problem: resident is not weight bearing to her left lower extremity related to fracture. In continued review revealed no new approaches noted in care plan related to fracture to left lower extremity. Record review of CR #1's physician orders dated 8/4/2014 revealed the following order: [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 5-325 mg 1 tablet every 8 hours as needed for pain. Further record review revealed that [MEDICATION NAME] was used 16 times from 9/22/2014 to 10/16/2014 for pain to her left leg/knee that was rated from 6 to 10 out of 10 and at one time CR #1 was crying of pain on 10/16/2014. In an interview on 10/24/2014 at 12:20 pm with CR #1 at a local hospital revealed she had been having severe pain to her left leg "from an injury at the facility". She further stated, while pointing at her left leg, "I've been wearing that brace on my leg since they hurt my left leg" (no date specified). CR #1 had a long metal brace on her left leg. In an interview on 10/24/2014 at 3:40 p.m. the DON revealed on 9/22/2014 CR #1 was transferred from the wheelchair to the bed by a CNA A and an x-ray technician. She further stated they used a gait belt and a sliding board and CR #1's left knee gave out. The DON stated CR #1 had stated when CNA A and the x-technician were going to pivot her body was when her left knee gave out. In continued interview, the DON stated after the incident all transfers for CR #1 were done using 2 person assistance and a mechanical lift. The DON stated CR #1 was ordered an x-ray the same day and the x-ray came back negative. She stated due to the increased pain to CR #1's left knee, the MD ordered an MRI which came back positive for a fracture. Continued interview, the DON further stated the facility protocol for patient care including transferring was to get assistance from another facility staff and not from outside vendors. She stated the facility does not know the training qualifications of the vendor that assisted with the transfer of CR #1. She stated "that was not a good call of the CNA to get assistance from the x-ray technician (oustide vendor)". In a phone interview on 10/27/2014 at 7:20 p.m. CNA A revealed on 9/22/2014 she assisted CR #1 to transfer from the wheelchair to the bed with the assistance of the x-ray technician. She stated CR #1 required 2 person assistance for transfer and she thought using the x-ray technician was OK. CNA A stated that the nurse asked her to go and help CR #1 to go to bed for an ultrasound (for an unrelated health issue) and that she needed another person to help her. She further stated they used the gait belt and the sliding board (to transfer CR #1) and when CR #1 was in bed she started complaining of pain to her leg and CNA A called the nurse right away. In an interview on 10/28/2014 at 11:40 a.m. LVN B revealed she was the MDS nurse and that she was involved in patient assessment and care planning. LVN B stated CR #1 had always been a 2 person extensive assistance because she had trouble bearing her own weight due to the weakness. LVN B further stated "(CR #1) actually needed to be lifted up for transferring and that's why she needed 2 person assistance". In continued interview, LVN B stated after CR #1 had her injury to the left leg she required a lift transfers "because now she was non-weight bearing to her left lower extremity". Continued interview, LVN B was asked about the entry on CR #1's care plan which read : "Transfer: Assist of one person". LVN B stated "I don't agree with that; (CR #1) required extensive assistance of 2 people. She could not bear her own weight and she was 200+ pounds". LVN B was asked if care plan was updated after CR #1 had her injury to her left leg and she replied "No, it was not updated with the new approaches, she is now lift with 2 person extensive assistance. It needed to be updated with the new approaches". Record review of CR #1's MD progress notes from a local hospital dated 10/20/2014 revealed : Leg pain is persistent. Further record review of history and physical revealed in part: Past medical history: recent left leg fracture. In continued record review of the hospital history and physical dated 10/22/2014 revealed in part: admitted via ER with chest pain and short of breathness. History of acute [MEDICAL CONDITION] infaction. Reason for admission: bilateral feet osteomylitis. Patient was started on antibiotics and needs surgical debridement. Record review of the facility policy and procedure "abuse, neglect and misappropriation of property" dated 2012 revealed no definition of neglect. Record review of the facility policy and procedure "restorative nursing" revised 11/2009 revealed in part: Subject: Ambulation/transfer - 9.- Do not guard or assist a patient/resident alone if he/she is too large for you. Ask a co-worker for help. According to the CMS Form 672, the facility census was 47.

Based on interview and record review the facility failed to implement their policies and procedures to prohibit neglect for 1 of 5 residents (CR #1) reviewed for neglect. CR #1, sustained an injury to her left leg on 9/22/2014 after being transferred from a wheelchair to the bed by a facility staff with the assistance of a vendor who was not a facility staff member (x-ray technician). -CR #1, had increased of pain to her left lower extremity as a result of the injury on 9/22/2014. CR #1 increased her use of [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 5-325 mg to using it 16 times from 9/22/2014 to 10/19/2014. This failure affected one resident and placed 47 residents at risk of being injured while receiving care from staff members and outside persons who are not staff members. Findings Include: Intake # 0 Closed record review of the facility face sheet revealed CR #1 was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the admission MDS dated [DATE] revealed CR#1 required extensive assistance of two persons for bed mobility, transfers, personal hygiene and was total dependent on staff for toilet use and bathing. CR #1 received scheduled pain medications regimen and did not have indicators of pain or possible pain. Record review of the care plan dated 07/6/2014 for CR #1 revealed:- Problem- resident requires assistance with ADL's. Approach start date: 5/07/2014: Transfer: Assist of one person. Record review of the facility incident/accident report dated 9/22/2014 at 1:00 p.m. revealed: Type of incident/accident secondary injury: Transfer knee injury. Describe exactly what happened: CR #1 was transferred from her wheelchair to the bed by CNA A and an x-ray technician. During the transfer CR #1 complained of knee pain. When CR #1 was describing what happened she stated her knee gave out on her. Findings and analysis: sliding board was used during transfer. Follow up/steps taken to prevent reoccurrence and person responsible: Transfer CR #1 with two people using mechanical device due to decreased mobility. Record review of CR #1 nurse's notes dated 9/26/2014 revealed in part: "Late entry for 9/22/2014: upon entering (CR #1's) room for wound care. (CR #1) reports pain to left knee. Tylenol as ordered. (CR #1) was asked if pain to left knee was different pain than she normally have? (CR #1) reported yes, they hurt it when they moved me back to bed. (CR #1) was asked how and when and who and (CR #1) reported when they came to do my ultrasound, staff and radiology technician transferred me back to bed and heard a pop in my knee and it has hurt since. Informed nurse practitioner, she assessed and ordered x-rays. Radiology called and x-ray ordered". Record review of radiology report for CR #1 dated 9/22/2014 at 10:36 pm revealed: History: left knee pain. Impression: Osteoarthritic changes without evidence of acute osseous pathology. Record review of the MRI report for CR #1 dated 9/29/2014 at 3:29 pm revealed in part: Clinical history: Severe left knee pain. Findings: This exam is significantly limited by patient condition and patient motion. Impression: Probable nondisplaced stress fractures involving the 2 lower bones to the left lower bones. Signal abnormalities involving the posterior aspect of the left lower bones may also reflect nondisplaced fractures. Record review of CR #1's care plan revealed an entry on 10/14/2014 that read: Problem: resident is not weight bearing to her left lower extremity related to fracture. In continued review revealed no new approaches noted in care plan related to fracture to left lower extremity. Record review of CR #1's physician orders dated 8/4/2014 revealed the following order: [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 5-325 mg 1 tablet every 8 hours as needed for pain. Further record review revealed that [MEDICATION NAME] was used 16 times from 9/22/2014 to 10/16/2014 for pain to her left leg/knee that was rated from 6 to 10 out of 10 and at one time CR #1 was crying of pain on 10/16/2014. In an interview on 10/24/2014 at 12:20 pm with CR #1 at a local hospital revealed she had been having severe pain to her left leg "from an injury at the facility". She further stated, while pointing at her left leg, "I've been wearing that brace on my leg since they hurt my left leg" (no date specified). CR #1 had a long metal brace on her left leg. In an interview on 10/24/2014 at 3:40 p.m. the DON revealed on 9/22/2014 CR #1 was transferred from the wheelchair to the bed by a CNA A and an x-ray technician. She further stated they used a gait belt and a sliding board and CR #1's left knee gave out. The DON stated CR #1 had stated when CNA A and the x-technician were going to pivot her body was when her left knee gave out. In continued interview, the DON stated after the incident all transfers for CR #1 were done using 2 person assistance and a mechanical lift. The DON stated CR #1 was ordered an x-ray the same day and the x-ray came back negative. She stated due to the increased pain to CR #1's left knee, the MD ordered an MRI which came back positive for a fracture. Continued interview, the DON further stated the facility protocol for patient care including transferring was to get assistance from another facility staff and not from outside vendors. She stated the facility does not know the training qualifications of the vendor that assisted with the transfer of CR #1. She stated "that was not a good call of the CNA to get assistance from the x-ray technician (outside vendor)". In a phone interview on 10/27/2014 at 7:20 p.m. CNA A revealed on 9/22/2014 she assisted CR #1 to transfer from the wheelchair to the bed with the assistance of the x-ray technician. She stated CR #1 required 2 person assistance for transfer and she thought using the x-ray technician was OK. CNA A stated that the nurse asked her to go and help CR #1 to go to bed for an ultrasound (for an unrelated health issue) and that she needed another person to help her. She further stated they used the gait belt and the sliding board (to transfer CR #1) and when CR #1 was in bed she started complaining of pain to her leg and CNA A called the nurse right away. In an interview on 10/28/2014 at 11:40 a.m. LVN B revealed she was the MDS nurse and that she was involved in patient assessment and care planning. LVN B stated CR #1 had always been a 2 person extensive assistance because she had trouble bearing her own weight due to the weakness. LVN B further stated "(CR #1) actually needed to be lifted up for transferring and that's why she needed 2 person assistance". In continued interview, LVN B stated after CR #1 had her injury to the left leg she required a lift transfers "because now she was non-weight bearing to her left lower extremity". Continued interview, LVN B was asked about the entry on CR #1's care plan which read : "Transfer: Assist of one person". LVN B stated "I don't agree with that; (CR #1) required extensive assistance of 2 people. She could not bear her own weight and she was 200+ pounds". LVN B was asked if care plan was updated after CR #1 had her injury to her left leg and she replied "No, it was not updated with the new approaches, she is now lift with 2 person extensive assistance. It needed to be updated with the new approaches". Record review of CR #1's MD progress notes from a local hospital dated 10/20/2014 revealed : Leg pain is persistent. Further record review of history and physical revealed in part: Past medical history: recent left leg fracture. In continued record review of the hospital history and physical dated 10/22/2014 revealed in part: admitted via ER with chest pain and short of breathness. History of acute [MEDICAL CONDITION] infaction. Reason for admission: bilateral feet osteomylitis. Patient was started on antibiotics and needs surgical debridement. Record review of the facility policy and procedure "abuse, neglect and misappropriation of property" dated 2012 revealed no definition of neglect. Record review of the facility policy and procedure "restorative nursing" revised 11/2009 revealed in part: Subject: Ambulation/transfer - 9.- Do not guard or assist a patient/resident alone if he/she is too large for you. Ask a co-worker for help. According to the CMS Form 672, the facility census was 47.