Every finding on record at Brush Country Nursing and Rehabilitation

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 timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of five residents (Resident #1) reviewed for care plans. The facility failed to develop a care plan to reflect that Resident #1 had an Authorized Electronic Monitor (AEM) device in her room after the family consented. This deficient practice could place residents at risk of diminished rights and dignity.Findings include:Record review of Resident #1's face sheet, printed 07/30/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Dementia (a decline in mental abilities severe enough to interfere with daily life. It is not a single disease, but an umbrella term caused by physical changes in the brain. Memory loss is a key sign, but changes in mood, behavior, and communication also occur), adjustment disorder with mixed anxiety and Depressed Mood (Adjustment Disorder is an emotional or behavioral reaction to a specific life stressor-such as a job loss, divorce, or move-that occurs within three months of the event; anxiety is a normal human reaction to stress, involving feelings of fear, tension, or worry; Depressed mood is a continuous feeling of sadness, emptiness, low spirits, or irritability that lasts for a long time. Record review of Resident#1's quarterly MDS assessment, dated 06/24/2026, reflected a BIMS score of 01, which indicated severely impaired cognition. Record review of Resident 1's care plan, revised 06/29/2026, reflected Resident #1 was at risk for Wandering / Elopement identified. The resident had a Wander Guard related to r/t Disoriented to place, impaired safety awareness, Resident wandered aimlessly, exit seeking behaviors. It also reflected Resident #1 had an ADL self-care performance deficit r/t hx of muscle atrophy (the partial or complete wasting away, shrinking, or loss of strength of a body part, tissue, or organ), deconditioning, Dementia; resistive to care r/t resident refuse most care at this time. Resident refused showers. Resident #1's care plan did not address Resident #1 having an AEM device in her room and how Resident #1 constantly removed the AEM device sign from the door and that Resident #1 turn the AEM device or off all the time. Record review of Resident #1's progress notes, from 01/2026 through 07/30/2026, reflected no documentation of Resident #1 having an AEM. Record review of Resident #1's records reflected no consent for Resident #1 to have an AEM device. During an observation and interview on 07/30/2026 at 1:50 PM, Resident #1 pointed to the camera at the top of her closet and stated she had the AEM device for as long as she had been in the facility. Resident #1 stated the camera was brought by her family to monitor her. Observation revealed a white AEM device on top of Resident #1's closet facing Resident #1's roommate's bed. Resident #1 took the AEM device and move the battery within the device and then a blue flashing light went on. There was no sign at Resident #1's door to indicate an AEM device was in use. During an interview on 07/30/2026 at 1:57 PM, the DON stated Resident #1 had an AEM device in her room and there was a sign at the door to alert the staff, but Resident #1 was always taking down the signage. The DON stated Resident #1's RP signed a consent sometime in March of 2026 for Resident #1 to have an AEM device in her room and she would provide a copy of the consent. The DON stated she didn't know why Resident #1's AEM device was not care planned, it should be care planned so everyone knew Resident #1, and her family wished to have a camera in her room. During an interview on 07/30/2026 at 02:25 PM, the Social Worker stated she had been employed at the facility for about 2 months. The Social Worker stated Resident #1 already had an AEM device prior to her being hired at the facility and it should have been care planned. The Social Worker stated Resident #1's AEM device was at the top of her closet and should be pointed at her. The Social Worker stated Resident #1 was in the habit of taking the AEM device down and the staff would put it back. The Social Worker stated she usually care planned AEM devices, but it was there before she started working at the facility. The Social Worker stated it was important for staff to know there was an AEM device in the room. During an interview on 07/30/2026 at 2:51 PM, the MDS Coordinator stated she worked at the facility since mid-January 2026. The MDS Coordinator stated AEM device should be care planned so everyone else knew there was an AEM device for the patient and family; so, it didn't impede anyone else's privacy. The MDS Coordinator stated Resident #1 sometimes took off the signage for the AEM device from her door. The MDS Coordinator stated, I'm assuming it would be my responsibility to care plan the AEM device, I think it just slipped, but we should care plan it. We were told to make sure that everything was care planned. During an interview on 07/30/2026 at 3:11 PM, the Administrator stated Resident #1 had an AEM device and she did not know if the device was on all the time because Resident #1 traveled around with the device. The Administrator stated Resident #1's AEM devices should be care planned and there should be a consent to have the device. The Administrator stated Resident #1's RP put the device in the room and half the time the device was not on due to Resident #1 taking it down. Record review of the facility's policy, revised January 2025, titled Care Plans, Comprehensive Person-Center reflected: Policy Statement: A comprehensive, person-center care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation:The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representatives, develops and implements comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.The Interdisciplinary Team must review and update the care plan:--when there has been a significant change in the residents' condition.--when the desire outcome is not met.--when the resident has been readmitted to the facility from a hospital stay; and--at least quarterly, in conjunction with the required quarterly MDS assessment.The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident #1) reviewed for pharmacy services. The facility failed to administer Resident #1's Biofreeze medication, per the physician's ordered times, and no greater than one hour after the scheduled administration time in March 2026, April 2026, and May 2026. This failure could have placed residents at risk for receiving less than therapeutic benefits from medications and increased pain. Findings included: Record review of Resident #1's face sheet, dated 05/15/2026, reflected Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE]. She was a [AGE] year-old female diagnosed with generalized osteoarthritis (condition that affects the joints characterized by inflammation, pain, and stiffness), age-related osteoporosis (bone disease characterized by loss of bone density and strength), hypertensive heart disease (high blood pressure), spinal stenosis, cervical region (narrowing of spaces within the neck), and anxiety. Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 13 indicating her cognition was intact. Record review of Resident #1's care plan revised on 11/04/2025 reflected that she had potential pain related to neuropathy (nerve damage), arthritis, and generalized discomfort. The intervention indicated administering Biofreeze External Cream 10% to neck and shoulders topically twice a day and monitor, record, report to nurse complaints of pain or requests for pain treatment. Record review of Resident #1's physician's orders dated 01/13/2025 reflected her medication scheduled at 8:00 a.m. and 16:30 (4:30 p.m.) was Biofreeze External Cream 10% (Menthol Topical Analgesic). Record review of Resident #1's March 2026 MAR reflected Resident#1's Biofreeze medication was administered as follows: Scheduled time 8:00 a.m. and was administered at 10:07 a.m. on 03/01/2026Scheduled time 20:00 (8:00 p.m.) and was administered at 21:07 (9:07 p.m.) on 03/01/2026Scheduled time 8:00 a.m. and was administered at 11:13 a.m. on 03/02/2026Scheduled time 8:00 a.m. and was administered at 13:12 (1:12 p.m.) on 03/03/2026Scheduled time 8:00 a.m. and was administered at 9:35 a.m. on 03/05/2026Scheduled time 8:00 a.m. and was administered at 9:21 a.m. on 03/09/2026Scheduled time 20:00 (8:00 p.m.) and was administered at 21:43 (9:43 p.m.) on 03/09/2026Scheduled time 20:00 (8:00 p.m.) and was administered at 22:02 (10:02 p.m.) on 03/10/2026Scheduled time 20:00 (8:00 p.m.) and was administered at 23:03 (11:03 p.m.) on 03/11/2026Scheduled time 20:00 (8:00 p.m.) and was administered at 21:38 (9:38 p.m.) on 03/12/2026Scheduled time 8:00 a.m. and was administered at 10:43 a.m. on 03/13/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 17:39 (5:38 p.m.) on 03/19/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 17:36 (5:36 p.m.) on 03/24/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 18:42 (6:43 p.m.) on 03/27/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 21:32 (9:32 p.m.) on 03/30/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 20:42 (8:42 p.m.) on 03/31/2026 Record review of Resident #1's April 2026 MAR reflected that on 04/15/26 Resident#1's Biofreeze medication was: Scheduled time 16:30 (4:30 p.m.) and was administered at 19:17 (7:17 p.m.) on 04/02/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 17:39 (5:39 p.m.) on 04/03/2026Scheduled time 8:00 a.m. and was administered at 11:54 a.m. on 04/05/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 20:08 (8:08 p.m.) on 04/05/2026Scheduled time 8:00 a.m. and was administered at 9:04 a.m. on 04/06/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 22:29 (10:29 p.m.) on 04/06/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 17:35 (5:35 p.m.) on 04/07/2026Scheduled time 8:00 a.m. and was administered at 9:12 a.m. on 04/09/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 19:22 (7:22 p.m.) on 04/09/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 18:22 (6:22 p.m.) on 04/10/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 17:59 (5:59 p.m.) on 04/12/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 19:08 (7:08 p.m.) on 04/14/2026Scheduled time 8:00 a.m. and was administered at 9:18 a.m. on 04/16/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 18:49 (6:49 p.m.) on 04/18/2026Scheduled time 8:00 a.m. and was administered at 9:40 a.m. on 04/22/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 21:32 (9:32 p.m.) on 04/22/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 18:47 (6:47 p.m.) on 04/26/2026Scheduled time 8:00 a.m. and was administered at 9:32 a.m. on 04/29/2026 Record review of Resident #1's May 2026 MAR reflected that on 04/15/26 Resident#1's Biofreeze medication was: Scheduled time 8:00 a.m. and was administered at 9:07 a.m. on 05/01/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 17:36 (5:36 p.m.) on 05/04/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 17:46 (5:46 p.m.) on 05/08/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 21:24 (9:24 p.m.) on 05/12/2026Scheduled time 8:00 a.m. and was administered at 11:19 a.m. on 05/13/2026Scheduled time 16:30 (4:30 p.m.) and was administered at 3:31 a.m. on 05/13/2026Scheduled time 8:00 a.m. and was administered at 9:52 a.m. on 05/14/2026 During an interview on 05/14/2026 at 9:17 a.m., MA E stated there were three different times for passing medications, including 6 a.m. to 10 a.m., 12 noon, and 4 p.m. to 7 p.m., after which the nurse took over. MA E stated administering medications after those timeframes would be considered late. MA E stated it was important to pass medications timely because certain medications were time-sensitive, such as medications for Parkinson's Disease (progressive neurological disorder). During an interview on 05/14/2026 at 9:22 a.m. and 05/15/2026 at 1:25 p.m., Resident #1 said her Biofreeze was administered late in April because the medication aide used to do it and now it was the nurse's responsibility, but now the problem had been resolved. Resident #1 expected her medications to be administered timely because that was what she was used to, but the delay did not cause her increased pain. During an interview on 05/14/2026 at 10:51 a.m., MA D stated there were various medication administration windows from 6 a.m. to 11 a.m., 11 a.m. to 3 p.m., and 4 p.m. to 10 p.m. and he had one hour before and one hour after the window to administer the medication, otherwise it was considered late. MA D stated it was important to pass medications timely due to the health of the residents. During an interview on 05/14/2026 at 11:24 a.m., LVN A stated she was agency, but knew there were specific medication administration windows from 6 a.m. to 10 a.m., but some medications were scheduled for 6 a.m. or 8 a.m. LVN A stated that medication administered one hour after the scheduled time would be considered late. LVN A stated it was important to pass medications timely because some medications were time-sensitive such as blood pressure medication and other medications needed to be taken before the residents ate. LVN A denied passing medications late. LVN A stated giving Biofreeze late could affect a resident's ability to perform activities of daily living or result in increased pain. During an interview on 05/15/2026 at 2:38 p.m., LVN B stated she was agency. LVN B stated some medication orders were for scheduled times and administering medication one hour before or after the scheduled time would be considered late. LVN B stated that Biofreeze could have been administered late due to being kept in the bottom drawer in the medication cart and using a generic brand that looked different, both of which would make finding the medication harder and caused a delay. Also, LVN B stated that medication aides used to administer the medication and it slowed them down; now it was the nurses responsibility. LVN B denied administering medication late and stated the ADON and DON were responsible for monitoring medication administration times. LVN B stated she thought administering Biofreeze late would have a minimal impact on residents because it was the lowest possible medication intervention for pain compared to narcotics. During an interview on 05/15/2026 at 2:38 p.m., LVN C stated that scheduled medications were for specific times and the facility policy was to give the medication one hour before or one after the scheduled time to be considered timely. LVN C stated the ADON and DON were responsible for monitoring medication administration times and denied administering medications late. LVN C stated she practiced patient center care and gave medication first, and then documented in the system late, which would not reflect the actual time given. LVN C stated that administering medications late could potentially impact residents by not controlling their pain. Attempts to interview the NP and MD via telephone on 05/15/2026 at 3:06 p.m. and 3:09 p.m. were unsuccessful. During an interview on 05/15/2026 at 3:19 p.m., the ADON stated residents had the right to get the correct medication at the correct time. The ADON stated the facility policy had block times for medication administration and scheduled times. The AODN said scheduled medications could be given one hour before and one hour after the scheduled time to be considered timely. The ADON said she and the DON were both responsible for monitoring medication administration times and gave those reports to the nurses. The ADON stated she did not believe medications were being administered late, but rather it was documented late in the system. The ADON stated that potential negative outcome for residents with late medication could be not controlling residents' pain. The ADON stated her expectations were that medication be administered timely and documentation in the chart matched the actual time given. During an interview on 05/15/2026 at 3:28 p.m., the DON stated some medications had scheduled times and administration one hour before or one hour after the scheduled time would be considered timely. The DON stated it was her and the ADON's responsibility to monitor medication administration times. The DON stated that Resident #1's orders for Biofreeze were to be administered at 8:00 a.m. and 16:30 (4:30 p.m.) and giving it more than 1 hour before/after would be late and would not meet her expectations. The DON stated she did not believe the medication was administered late, but rather it was documented in the chart late because nurses had a lot of tasks to do and got busy. The DON stated that Biofreeze was for comfort and pain control, and she did not think there would be any negative impact to Resident #1 if it was administered late. During an interview on 05/15/2026 at 3:43 p.m., the ADM stated she did not have a clinical background and relied on her nursing staff to follow polices for medication administration. The ADM stated they had block times for medications at 6 am to 10 a.m., 11 a.m. to 3 p.m., and scheduled medications could be given one hour before/after to be timely. The ADM stated it was the DON, the ADON, and the nurses responsibility to monitor medication administration times and ensure nursing staff were administering medications timely. Her expectation would be that medications were administered and documented timely. The ADM did not believe medications were administered late, but it was a documentation issue of being clicked off in the system late. The ADM stated she did not believe there would be any negative consequences for Resident #1's Biofreeze being administered late because the medication was for comfort and Resident #1 had other pain medications. Review of the facility policy titled Administering Medications revised in April 2019 reflected: Medications are administered in a safe and timely manner and as prescribed .Medications are administered in accordance with prescriber orders, including any required time frame.Medication administration times are determined by resident need and benefit. Factors that are considered include: Enhancing optimal therapeutic effect of medication.And Honoring resident choices and preferences, consistent with his or her care plan.Medications are administered within one hour of their prescribed time, unless otherwise specified ( for example , before and after meal orders).The individual administering the medication electronically signs or signs with initials on the resident's MAR/EMAR after giving each medication and before administering the next ones.As required or indicated for a medication, the individual administering the medication records in the resident's medical record:The date and time the medication was administered.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen and only nourishment room reviewed for food and nutrition services. The facility failed to label and date food items in the walk-in refrigerator. The facility failed to dispose of expired food items located in the walk-in refrigerator. The facility failed to effectively reseal all food items in the walk-in refrigerator to prevent contamination, spoilage, or exposure to air. The facility failed to maintain a sanitary environment for food storage in the kitchen. The facility failed to maintain a sanitary open front refrigerator in the nourishment room. These failures could place residents at risk of cross contamination, loss of nutritional value, and foodborne illness.Findings included: During the initial tour of the kitchen on 04/09/2026 at 10:27 a.m., the walk-in refrigerator was observed to contain improperly stored and expired food items. Observations revealed two previously opened containers of yogurt with a date of 2/3/26 written on the top of the lid and a manufacturer's date of 03/08/2026. The written date did not indicate if that was the received date, open date, or use by date. Three previously opened containers of cottage cheese had a date of 3-28 and 3/1 written on the top of the lid with a best by/use by date of March 20, 2026. The written date did not indicate if that was the received date, open date, or use by date. An open plastic bag containing what appeared to be cooked bacon was not labeled, dated, or properly sealed. A plastic bag containing sliced deli ham had two dates written on the outside (03/18/2026 and 03/28/2026); the bag was open, not properly sealed, and an inner package of ham had a use or freeze by date of March 21, 2026. Two plastic bags containing what appeared to be thawed fajita meat were not labeled or dated. During an interview and observation on 04/09/2026 at 10:38 a.m., the DM stated today (04/09/2026) was her first day on the job. The DM stated she was trained in properly labeling, dating, and storing food. The DM stated it was the facility's policy for all kitchen staff to properly seal, label, and date food and to discard expired items. The DM stated it was important to prevent expired food and contamination because of the potential risk for foodborne illness. The DM stated that the dates on items in the walk-in refrigerator were probably the receive by date, but all items should list three dates: receive date, open date, and use by date. The DM was observed discarding the expired food items and thawed meat that had not been labeled or dated. During an interview on 04/09/2026 at 10:46 a.m., the [NAME] stated she was trained in labeling, dating, and storing food properly, but could not recall when. She stated all food should have a received date and opened date and that freshly cooked food had to be used or discarded within three days. She stated the expired cottage cheese and yogurt were missed because she did not cook with those items; therefore had not checked them. She stated it was everyone's responsibility to check for expired food and stated expired food could cause contamination and illness. During an interview on 04/09/2026 at 10:54 a.m., the DA stated she was trained in labeling, dating, and storing food properly but had not checked for expired food due to the lack of a dietary manager. She stated serving expired food could cause residents to become ill. During an observation and interview on 04/09/2026 at 11:01 a.m., a large black bin containing approximately 30 individual prune juice containers was observed on a shelf near the serving line. Observation revealed several containers were damaged, leaking, empty, and prune juice residue was present on the outside of several containers. [NAME] patchy, fuzzy, velvety growth was observed on the side of multiple prune juice containers and on the bottom of the bin. The DM stated she was unaware of the condition of that bin and there was only one resident that drank prune juice. The DM stated staff opened the container and poured it into a cup to serve the resident. The DM stated the green growth appeared to be green mold and the entire container and all the juices were contaminated and could not be served to the residents because it could make them sick. The DM was observed throwing the bin and all the juice inside the bin in the trash. During an observation on 04/09/2026 at 11:09 a.m. of the nourishment room refrigerator, one container of mayonnaise with a best if used by date of 02/23/2026 was observed. The refrigerator shelves were observed to be dirty with red and brown stains and food particles. During an interview and observation on 04/09/2026 at 11:11 a.m., the LVN stated she did not know who was responsible for checking or discarding expired food in the nourishment room refrigerator and stated the refrigerator appeared dirty. The LVN stated expired food, and unclean conditions could contribute to foodborne illness. The LVN stated they did not use that refrigerator, and snacks were kept at the nurse's station. During an interview on 04/09/2026 at 1:06 p.m., the Maintenance Director stated the nourishment room refrigerator was cleaned monthly by laundry staff; however, there was no checklist, schedule, or documentation to verify routine cleaning. He stated dietary staff were responsible for monitoring expired food. He stated the refrigerator was cleaned after the state surveyor observed its condition. The Maintenance Director stated a clean refrigerator and disposing of expired food were necessary to avoid bacteria, which could make residents sick. During an interview and observation on 04/09/2026 at 2:28 p.m., the DON stated she was not trained in food labeling, storage, or kitchen sanitization. After being shown a photograph of the prune juice bin from the surveyor's state approved mobile device, the DON identified the substance as appearing to be green mold and stated it could make residents sick and should have resulted in disposal of all affected items. During an interview on 04/09/2026 at 2:36 p.m., the ADM stated dietary staff were responsible for properly labeling, dating, sealing, and discarding expired food. The ADM stated housekeeping staff were responsible for ensuring the nourishment room refrigerator was clean and free of expired food. The ADM stated the facility did not have a policy regarding sanitization specific to the nourishment room refrigerator. She stated the observed conditions did not meet facility expectations and posed a risk to resident health. An attempt to interview the laundry staff by telephone was made on 04/09/2026 at 3:01 p.m. by leaving a voicemail message. A return call was not received. Record review of the kitchen in service training dated 03/30/2026 reflected dietary staff were trained in labeling and dating food. Record review of the facility policy titled, Food Receiving and Storage, dated July 2014, reflected: Foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer will be labeled and dated. Record review of the facility policy titled, Sanitization, dated October 2008, reflected: The food service area shall be maintained in a clean and sanitary manner . The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas.

Based on observation, interview, and record review, the facility failed to ensure drugs are stored properly and only authorized persons have access for 1 of 4 medication carts (MC #1) reviewed for drug storage and labeling.The facility failed to ensure MC #1 was locked, medications secured, and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications. Findings included:During an observation of the nurses' station on 01/07/2026 at 11:32 a.m., revealed MC#1 was unlocked and unattended. A nurse was sitting inside the nurses' station out of view of the medication cart. Residents and staff were walking by the unlocked medication cart. MC #1 contained residents prescribed creams, residents prescribed drugs, over the counter medication, narcotics, catheters, and breathing machine medication. During an interview with LVN A on 01/07/2026 at 11:40 a.m., revealed that he had been trained on medication storage. He said the medication cart policy was staff must lock the medication cart anytime they walked away. He said that the nurse was responsible for locking the medication cart. He also said any staff who walked by could lock the medication cart. He said if the medication cart was left unlocked and unattended a resident might get into the medication cart. He said the DON and ADM monitored to ensure staff were locking the medication carts. He said the DON and ADM monitored by doing observations to ensure the medication carts are locked. He said he did not know why he left the medication cart unlocked. During an interview with the DON on 01/07/2026 at 4:52 p.m., revealed she had been trained on medication storage. She said the medication cart policy was staff must lock the medication cart any time the staff member was not using the cart. She also said staff were to lock the medication cart even if they stepped away for a moment. She said the nurses or the medication aide who was assigned to the medication cart was responsible for ensuring the medication cart was locked. She said the DON and the ADM monitor to ensure the staff lock the medication carts. She said the DON and ADM monitor by doing observation rounds. She said she thought LVN A may have gotten busy or distracted. During an interview with the ADM on 01/07/2026 at 4:58 p.m., revealed she had been trained on medication storage. She said the medication cart policy was the medication cart needed to be always locked when the nurse or medication aide was not using the medication cart. She said the medication aid or nurse on the medication cart was responsible for locking the cart. She also said any staff that saw a medication cart unlocked could lock the medication cart. She said the nursing management team monitored to ensure the medication carts were locked. She said the nursing management team walked through the halls to check the medication carts to ensure the carts were locked. She said she did not know why LVN A did not lock the medication cart. Record review of Storage of Medication Policy dated 4/2019, revealed Drug and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Compartments (including, but not 1imited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals arc locked when not in use. Unlocked medication carts are not left unattended.

Based on observation, interview, and record review, the facility failed make sure that drugs are stored properly and only authorized persons have access for 1 of 3 medication carts (MC #1) and the facility's only medication refrigerator reviewed for drug storage.The facility failed to ensure MC #1, was locked, medications secured, and not accessible to other staff, residents, or visitors. The facility failed to ensure the medication refrigerator was at the correct temperature for medications stored in the refrigerator. These failures could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications. Findings included: 1.During an observation on 11/11/2025 at 1:26p.m., revealed medication refrigerator, had glycerin suppositories, Trulicity, Lantus, NovoLog, and Repatha. The temperature in the refrigerator was 52 F. During an interview with LVN A on 11/11/2025 at 1:57p.m., revealed she had been trained on medication storage. She said the policy for medication stored in the medication refrigerator was that staff were to check to daily to ensure the refrigerator was at the correct temperature. She said the night shift was responsible for checking the temperature on the medication refrigerator. She said if medication was not stored at the correct temperature the medication may not be efficient. She said she did not know who monitored to ensure the medication refrigerator was at the correct temperature. She said she did not know why the medication refrigerator was not at the correct temperature. During an interview with ADON on 11/11/2025 at 2:00p.m., revealed she had been trained on medication storage. She said the policy for the medication refrigerator was the temperature was to be checked daily on the night shift. She said the nurses who worked the night shift were responsible for checking the temperature on the MR. She said medication not stored at the correct temperature could cause unwanted side effects. She said she talked with maintenance and was told the facility recently got a new medication refrigerator. She also said 52 F was not acceptable temperature for the medication refrigerator and the facility was working on getting new medications to replace the ones that were not at the correct temperature in the medication refrigerator. During an interview with the DON on 11/11/2025 at 3:03p.m., the policy for storing medication in the medication refrigerator was the temperature was to be checked daily. She said the temperature range the medication refrigerator was supposed to be at was 36 F to 46 F. She said if the medication refrigerator was not within the correct temperature staff were to notify nursing management. She said the new company had not established who was to monitor the medication refrigerator. She said if the medication was not held at the correct temperature the medication would not be affective. She said the facility used the manufacturer's recommendations on the storage of the medication. She did not know why the medication refrigerator was not at the correct temperature. Record review of How to Use Your Lantus Solostar Pen: Lantus Storage not dated revealed Before opening store Lantus in the refrigerator (36 F to 46 F). Record review of Patient Information Repatha Injection not dated revealed Store REPATHA in the refrigerator between 36 F to 46 F.Record review of NovoLog Storage not dated revealed Store unused NovoLog pens and vials in refrigerator at 36 F to 46 F until expiration. 2.During an observation on 11/11/2025 at 3:24p.m., revealed MC #1, was on the 200-hall, was unattended and unlocked. MC #1 was near room [ROOM NUMBER]. There were no staff in sight of MC #1. MC #1 had residents' prescription medications, over the counter medications, and eye drops in MC #1. During an interview with MA B on 11/11/2025 at 3:27p.m., revealed she had been trained on medication storage. She said the policy for the MC was that the MC was to be locked any time staff were away from it. She said the nurses and medication aides were responsible for ensuring the MC were locked. She said the medication carts were to be always locked when not in use. She said if a MC was left unlocked and unattended a resident could get into the MC. She said all staff monitored to ensure staff were locking the MC. She said staff monitored by observations. She said she was going to see a resident, and she thought she had locked the MC. During an interview with the DON on 11/11/2025 at 4:08p.m., revealed she had been trained on medication storage. She said the policy for the MC was that it needed to be locked any time the nurses and medication aides stepped away from the cart. She also said if the cart is not within the nurses' eyesight it should be locked. She said if the medication was left unlocked and unattended a resident could get into the MC and ingest medication. She said leadership monitors to ensure staff are locking the medication carts. She said all managers monitored to ensure MC were locked. She said management monitored through observations. She said she did not know why the MC #1 was unlocked. During an interview with the ADM on 11/11/2025 at 3:48p.m., revealed she had been trained on medication storage. She said the policy for medication refrigerator was medications needed to be stored at the correct temperature. She said if the temperature was out of range staff were to notify nursing management immediately. She said the nurses on the night shift were responsible for ensuring the MR was at the correct temperature. She also said if medication was not at the correct temperature the medication may not be affective. She said the MC must be locked when the nurse or the medication aide walked away from the MC. She said if the MC was not locked someone could get into the MC and take medication that could harm them. She also said someone could take medication to sabotage an employee. She said nurse management monitored to ensure the MC were locked and the medication refrigerator was at the correct temperature. She said nurse management should monitor through observations for the MC being unlocked and checking the temperature log on the MR. Record review of Storage of Medication Policy dated 4/2019, revealed Drug and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Compartments (including, but not 1imited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals arc locked when not in use. Unlocked medication carts are not left unattended. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location.

Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 9 (Resident #1 and Resident #2) residents reviewed for pharmacy services.The facility failed to order Resident #1's Percocet with Oxycodone timely to ensure Resident #1 did not run out on 11/09/2025. The facility failed to order Resident #2's Oxycodone timely to ensure Resident #2 did not run out on 11/10/2025. This failure could place residents at risk of not receiving the therapeutic benefits of medications which could lead to increased pain, and diminished quality of life. Findings Included:Resident #1 face sheet dated 11/11/2025 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included congenital malformation of nervous system (birth defects that affect the structure and function of the brain and spinal cord), somatization disorder (significant focus on physical symptoms, such as pain, weakness or shortness of breath, to a level that results in major distress and/or problems functioning), and fusion of the spine. Record review of Resident #1's quarterly MDS dated [DATE] revealed Resident #1 had a BIMS of 15 indicating cognitive responses. Record review of Resident #1's care plan dated 11/03/2025 revealed Resident #1 was diagnosed with Somatization disorder defined as a mental health condition where a person experiences significant physical symptoms, such as pain, that cause distress and interfere with daily life, despite a lack of clear medical explanation. Interventions were Monitor for s/s of high levels of anxiety and administer medication as ordered. Notify MD when resident complained of pain. Record review of Resident #1's physician orders dated 7/11/2025 revealed Percocet oral tablet 2.5-325mg (oxycodone w/ acetaminophen) give one tablet by mouth four times a day for chronic pain. Record review of Resident #1's MAR dated 10/2025 revealed Resident #1 was last administered Percocet on 11/09/2025 at 9:00pm. Resident #1 has missed 18 doses of her Percocet from 11/07/2025 to 11/11/2025 at 9:00a.m., 3:00p.m., 9:00p.m., and 3:00am. Resident #1's MAR indicated Other see progress notes. As to why it was not given. During an interview with Resident #1 on 11/11/2025 at 9:32a.m., revealed she was calm, laying on her back on her phone. Resident stated she was fine. Resident also said she had not gotten Percocet since Friday. She said she has extreme headaches, and a sore throat to where she could not talk at one point. She said her eyes are burning and watery. She said that her vagina was burning right now. She said she was having withdrawal from not getting her Percocet. She said her pain level was at a 9/10. She said she had been in pain since 11/4/2025. She also said the facility did offer tramadol once, but she said she does not take the tramadol because it gives her a bad headache. During an interview with Resident #1 on 11/11/2025 at 2:13p.m., revealed that the facility offered her Percocet since the medication came in Resident #1 said that she did not want the medication. She said the NP offered to up her vallum, to give her ibuprofen and Tylenol she said she did not want those medications. She said that the NP said she would find another pain medication for her. Record review of Resident #1's progress notes dated 11/07/2025 revealed Pt called EMS complained of vaginal discomfort. EMS arrived, evaluated pt, spoke with this nurse, and decided pts concern is not an emergency and can be addressed by NP on next business day. This offered pt prn Tramadol but pt refused med. This nurse spoke with NP for the Doctor who stated she will call in triplicate for pts oxycodone. Record review of Resident #1's progress notes dated 10/26/2025 revealed Pt has new complaint stating the oxycodone medication she takes is making her sweat profusely. This nurse points out to pt she is not sweating, and she was dry, but pt persist she is sweating, and it is a side effect of oxycodone.Record review of Resident #1's progress notes dated 10/27/2025 revealed Pt continues with somatic complaints. Pt stating, she has neuropathy, brain malfunctions, kidney malfunctions, vaginal burning, excessive sweating, allergy to Oxycodone, allergy to adult briefs. Pt states psych Dr does not know what he was talking about, NP does not know what she is talking about, and medical drs do not know what they are talking about. Record review of Resident #1's progress notes dated 11/08/2025 revealed Pt complained of vaginal discomfort. This nurse Offered pt her prn Tramadol and Ibuprofen. Pt very adamantly refused with son present stating those medicines make her brain hurt. Pt agreed to take Tylenol only. Record review of Resident #1's progress notes dated 11/09/2025 revealed NP returned call, stated she sent request for refill over this morning. Record review of Resident #1's progress notes dated 11/09/2025 revealed Pt called her husband and asked him to call 911 because she is stating she stating something is wrong with her voice and she cannot talk. 911 dispatch call here to receive report on pt. Pt states her voice is not working. Pt is talking loud and clear without any s/s distress atthis time. Pt asked for her Claritin allergy medicine and received medication. Resident #2 Resident #2 face sheet dated 11/11/2025 revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2's diagnoses included hip fracture, absence of left leg above the knee and Bifascicular block (impairment of electrical signals in two main fascicles of the heart's conduction system). Record review of Resident #2's admission MDS dated [DATE] revealed that Resident #2 had a BIMS of 15 indicating cognitive response. The MDS revealed Resident #2 received scheduled pain medication and PRN medications. Record review of Resident #2's care plan dated 11/04/2025 revealed, Resident #2 had the potential for pain. Interventions were Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal, or resistance to care. Observe/document for probable cause of each pain episode. Remove/limit causes where possible. Observe/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Observe/record/report to Nurse any signs and symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing).Record review of Resident #2's physician orders dated 10/27/2025 revealed Oxycodone HCl Oral Tablet 10 MG give 1 tablet by mouth every 4 hours as needed for Pain.Record review of Resident #2's MAR revealed that he got his Oxycodone at 6:00am and his pain level was documented as a 2 on a scale of 1 to 10. During an interview with Resident #2 on 11/11/2025 at 12:25p.m., revealed he asked staff for his pain medication he said he got the medication at the time he asked for it. He said staff told him that his oxycodone would be in by 1:00pm. He said that he did not know the facility was out of his pain medication. He said that his pain level was at a 4 and the pain was tolerable right now. During an interview with LVN A on 11/11/2025 at 11:14a.m., revealed, Resident #1 had been out of her Percocet for a few days. He said that Resident #2 was also out of his pain medication oxycodone. He said he called Resident #2's medication in this morning. He said Resident #2 had been out for less than 24 hours. He said he did not think there was a policy for ordering medication. He also said he would normally order medication three or four days in advance before the medication ran out. During an interview with the NP on 11/11/2025 at 1:29p.m. revealed she believed Resident #1 had been out of her Percocet since the weekend. She said the doctor sent the triplicate to the pharmacy on Sunday. She said the pharmacy said they did not get the triplicate. She said the doctor sent another triplicate today. She said she verified the pharmacy got the triplicate. She said that the medication was ordered for Stat. She said she expected the medication any time now. She said it was hard to tell with Resident #1 on how it would affect her not getting her Percocet because she usually had the same symptoms with or without the medication. She said the facility did have Resident #2's pain medication in the emergency cart.During an interview with the NP on 11/11/2025 at 2:00p.m., revealed that she had just met with Resident #1. She said Resident #1 now did not want the Percocet, she said she offered Tylenol, increasing her valium and Resident #1 did not want any of those options. She said Resident #1 wanted the Percocet as a PRN. She said she was working on finding another medication Resident #1 might take. During an interview with the ADM on 11/11/2025 at 2:15p.m., revealed the facility did not have a policy for ordering medications. During an interview with the ADM on 11/11/2025 at 3:48p.m., revealed, ordering medication should be ordered timely and if the medication was not received the nurse must follow up. She also said if there was an issue the nurse was to notify nurse management immediately. She said if a resident ran out of pain medication the resident could be in severe pain. she said nurse management was responsible for monitoring to ensure medication was ordered timely. She said she was not sure how nurse management monitored because she had only worked at the facility for two days. She said she knew about Resident #1 being out of medication but did not know about Resident #2 until this morning.

Based on observation, interviews and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of three residents reviewed for pain. The facility failed to provide effective pain interventions for Resident #1 on 09/14/2025. Resident #1 called for emergency transfer to the ER for pain management. An IJ was identified on10/03/2025. The IJ template was provided to the facility on [DATE] at 12:34 pm. While the IJ was removed on 10/04/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm because the facility needs to evaluate the effectiveness of the corrective systemsThese failures could place residents at risk of increased pain, hospitalization, and a decreased quality of life.These failures could place residents at risk of increased pain, hospitalization, and a decreased quality of life. Findings included Review of Resident #1's face sheet printed 10/02/2025 reflected a [AGE] year-old female who was admitted on [DATE] with the following dx. Chronic pain syndrome (is a long-term condition characterized by persistent pain that lasts for months or years, significantly affecting daily life. It can arise from various causes, including injury, illness, or underlying medical conditions, and may lead to complications such as depression and anxiety), Migraines with aura (is characterized by sensory disturbances that occur before or during a migraine attack, including visual changes, tingling sensations, and sometimes speech difficulties. The auras typically occur 30 to 60 minutes before the onset of a headache.), contracture left wrist (refers to the tightening and stiffening of the soft tissues around the wrist, which can lead to reduced mobility and function), need assistance with personal care and lack of coordination. Review of Resident#1's quarterly minimum data set (MDS) assessment dated [DATE] reflected a brief interview for mental status (BIMS) score 15, indicating no impairment. Section J (Health Conditions) reflected pain presence was continuous, Pain frequency was frequent, pain interference with therapy activities was frequent, pain effect on sleep was frequent and pain Numerical rating was 7 on the scale with 10 being the worst pain. Review of Resident 1's care plan initiated 08/15/2025 reflected Resident #1 had chronic pain, muscle spasms and neuropathy (is a condition that occurs when the peripheral nerves are damaged, leading to symptoms such as tingling, burning, or numbness in the affected areas, typically the legs, feet, arms and hands.) and Resident #1 took pain medication. It was also reflected Resident #1 was at risk for GI upset (Gastrointestinal -GI encompasses various conditions affecting the digestive system) due to abdominal pain, nausea and vomiting and GERD (GERD-Gastroesophageal Reflex Disease is a chronic disease where the stomach contents flow back to the esophagus, leading to symptoms like heart burns, regurgitation, and inflammation.) with intervention to give analgesia (pain) medication as ordered. Review of Resident #1's physician orders reflected an order dated 08/14/2025 for Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for pain. Review of Resident #1's Narcotic count sheet reflected Resident #1 was admitted with 5 pills of Oxycodone 5mg on 08/14/2025. It also reflected that Resident #1 Oxycodone 5 mg was administered on the following dates:08/20/2025 at 7:04 pm08/21/2025 at 5:14 am 08//22/2025 at 11:00 pm08/25/2025 at 5:20 am 08/25/2025 at 10:00 pm Review of Resident #1's MAR/TAR reflected:Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for pain was given on 08/20 and 08/21/2025 for pain level of 7 on the scale 0-10. There was no evidence that Resident #1 was given pain medication in the month of September. Review of Pharmacy receipt for Resident #1 from 08/14/2025 through 10/02/2025 reflected Oxycodone 5 mg was never filled out by the local pharmacy. Review of Resident #1's hospital records reflected the following:Hospital record dated 08/31/2025 reflected: Reason for visit- Abdominal pain. Diagnosis - Diarrhea. Treatment -Morphine (pain medication) given at 4:49 pm and Hydromorphone (Pian medication) at 5:55 pm andHospital record dated 09/14/2025 reflected: Reason for visit-Abdominal pain and diarrhea. Diagnoses-Chronic abdominal pain Review of Resident #1's Progress notes from 08/14/2025 through 10/03/2025 reflected no evidence that staff had attempted to contact Resident #1's NP or MD regarding triplicate for Resident #1's oxycodone 5 mg. Review of Resident #1's progress notes dated 09/14/2025 reflected written by LVN A reflected: RESIDENT COMPLAINT OF ABDOMINAL PAIN, RESIDENT HAS SOME PRN PAIN MEDICATION, WHICH OXYCODONE 5 MG EVERY 8 HOURS AND TYLENOL 500MG PRN, INSIDE THE CONTROL BOX, THERE IS NO OXYCODONE FIND. NURSE OFFER RESIDENT TYLENOL 500MG SINCE THERE IS NO OXYCODONE. RESIDENT REFUSED AND STATED SHE WILL LIKE TO GO TO HOSPITAL FOR EVALUATION. [XX] PHARMACY WAS CALLED TO ASK IF THE CAN AUTHORIZED NURSE TO TAKEOXYCODONE 5MG. PHARMACY PERSON SAID RESIDENT HAS NOT FILL OXYCODONE BEFORE, NURSE CALLED ON CALL NP. NP STATED SHE CAN'T BE ABLE TO AUTHORIZE. SHE SAID TO GIVE RESIDENT TYLENOL 500MG AND TO DO KUB(Kidney, Ureter and Badder-refers to an x-rays or ultrasound that visualizes these organs, often to diagnose conditions of kidney stones, blockages, or abdominal pain). RESIDENT SAID NO AND STATED THAT SHE WOULD LIKE TO GO TO HOSPITAL.911 NONE EMERGENCY CALLED AND THE CAME AND TRANSFER RESIDENT TO ER FOR EVAL AND TREAT. Review of Resident #1's Assessments reflected that no pain assessment was completed on 09/14/2025 when Resident #1 complained of pain and went to the ER for pain management. Observation of the medication cart on 10/02/2025 at 1:32 pm with LVN A revealed there was no oxycodone for Resident #1 in the facility.Review of pharmacy receipt of medication delivery for Resident #1 reflected Oxycodone 5mg was only delivered on the evening of 10/02/2025. During an interview on 10/02/2025 at 11:26 am Resident #1, she stated I have been asking for my oxycodone, and I have not been getting it. They said it required a triplicate from the Doctor; the doctor will take care of it. Sometimes they would say, maybe the pharmacy will send your oxycodone today. They gave me oxycodone at the beginning of my stay here; I had brought some oxycodone pills with me, and they said it was finished. Resident #1 stated her order for Oxycodone was for every 6 hours as needed, 4 pills a day and she only requested Oxycodone when she was hurting, and it was only 4 pills a day. Last time I had to go to the ER to get pain medication. During an interview on 10/02/2025 at 1:32pm LVN A stated she was the nurse on working with Resident #1 on 09/14/2025 when Resident #1 requested pain medication. LVN A stated there was an order for Resident #1 to get pain medication, oxycodone 5 mg every 6 hours as needed, but there was no Oxycodone available on 09/14/2025 when Resident #1 requested. LVN A stated she called the on-call NP for approval for the triplicate for Resident #1's oxycodone but was told by the on-call NP that that they couldn't send the triplicate to the pharmacy. LVN A stated Resident #1 requested to go to the ER for pain management, Resident #1 called EMS for transport to the ER. LVN A stated she had been talking to the NP regarding Resident #1's Oxycodone, the NP had been calling the pharmacy for refill but, and I didn't know why the pharmacy had not yet sent Resident #1's oxycodone. LVN A stated she spoke with the DON and the ADON regarding Resident #1's oxycodone for pain management not being available. LVN A stated Resident #1 always call EMS to go to the ER for pain management. During an interview on 10/02/2025 at 2:07 pm, the DON stated she had been in her position for about 1 month. The DON stated she was not made aware of Resident #1's pain medication not being available. The DON stated Oxycodone is for pain and was very important. The DON stated she was not told Resident #1 went to the ER for pain management but for things other than pain management. The DON stated Resident #1 not getting her pain medication as ordered had impact on her normal functional daily activities, not being happy, not doing anything normal, would cause the resident refuse ADLs. The DON stated a Focused assessment (Pain) on what the resident was complaining of should have been completed, what the pain level and documented to enable staff to know what treatment to provide. On 10/02/2025 at 2: 19 pm LVN A stated she contact Resident #1's MD and requested triplicate for Resident #1's Oxycodone. During an on 10/02/2025 at 2:27 pm the ADON stated he had been in his position for about 1 week. The DON stated If a resident didn't have pain medication as ordered, it would affect the resident's mood and how the Resident interacts with other residents. The ADON stated that the Resident's entire ADLs would be affected, and the Resident wouldn't be able to function. The ADON stated he had not been approached by any nurse or medication aide regarding Resident #1's oxycodone. During an interview on 10/02/2025 at 4:33 pm the MD stated he knew Resident #1 had pain in the past and had been taking pain medication. The MD also stated the facility reached out to him earlier today, 10/02/2025 requesting triplicate/ script for Resident #1's oxycodone. The MD stated he could not remember specifics on if Resident #1 oxycodone had been filled out since she had been in the facility. The MD stated to contact the NP because she had more specific details. During an interview on 10/03/2025 at 09:38 pm the NP stated she was familiar with Resident #1 and Resident #1 had chronic diarrhea that led to abdominal cramps and Resident #1 needed pain medication due to that. The NP stated Resident #1's oxycodone was ordered as needed when Resident #1 was in pain and needed the medication. The NP stated if Resident #1 needed the medication and went to the ER due to the medication not being available, the staff should have contacted her. The NP stated she was not sure if Resident #1's oxycodone was ordered upon admission to the facility. The NP also stated that usually the NP's send the information for triplicate to the MD and the MD signed off on it and sent it to the pharmacy. Review of facility's policy titled Medication Orders dated November 2014 reflected: Purpose The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Review of facility's policy titled Pain Assessment and Management dated reflected: Purpose The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management.2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals.3. Pain management is a multidisciplinary care process that includes the following:a. Assessing the potential for pain;b. Recognizing the presence of pain;c. Identifying the characteristics of pain;d. Addressing the underlying causes of the pain;e. Developing and implementing approaches to pain management;f. Identifying and using specific strategies for different levels and sources of pain;g. Monitoring for the effectiveness of interventions; andh. Modifying approaches as necessary.4. Cognitive, cultural, familial, or gender-specific influences on the resident's ability or willingness to verbalize pain are considered when assessing and treating pain. Comprehensive pain assessments are conducted upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain.5. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained.For stable chronic pain the resident's pain and consequences of pain are assessed at least weekly. Equipment and SuppliesThe following equipment and supplies will be necessary when performing this procedure.Standardized pain assessment tool, as indicated per facility protocol; and 2. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). Assessing Pain1. Assess the resident at admission and during ongoing assessments to help identify the resident who is experiencing pain or for whom pain may be anticipated during specific procedures, care, or treatment.2. Monitor the resident for the presence of pain and the need for further assessment when there is a change of condition.3. Assess the resident whenever there is a suspicion of new pain or worsening of existing pain.4. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level.5. During the pain assessment gather the following information as indicated from the resident (or legal representative):a. History of pain and its treatment, including pharmacological and non-pharmacological interventions.b. History of addiction, past and/or ongoing and related treatment for opioid use disorder (OUD); c. Characteristics of pain: (1) Location of pain;(2) Intensity of pain (as measured on a standardized pain scale);(3) Characteristics of pain (e.g., aching, burning, crushing, numbness, burning, etc.);(4) Pattern of pain (e.g., constant or intermittent); and (5) Frequency, timing and duration of pain;d. Impact of pain on quality of life;e. Factors such as activities, care or treatment that precipitate or exacerbate pain;f. Factors and strategies that reduce pain;g. Symptoms that accompany pain (e.g., nausea, anxiety);h. Physical and psychosocial issues (physical examination of the site of the pain, movement, or activity that causes the pain, as well as any discussion with resident about any psychological or psychosocial concerns that may be causing or exacerbating the pain);i. Current medical conditions and medications including medication assisted treatment for OUD; andj. The resident's goals for pain management and his or her satisfaction with the current level of pain control. Defining Goals and Appropriate Interventions1. The pain management interventions are consistent with the resident's goals for treatment which are defined and documented in the care plan. Pain management interventions reflect the sources, type and severity of pain including whether the pain is acute or chronic.2. Pain management interventions shall address the underlying causes of the residents' pain.3. For those situations where the cause of the resident's pain has not been or cannot be determined, current standards of practice for managing pain are followed to help determine appropriate options. Implementing Pain Management StrategiesEstablish a treatment regimen that is specific to the residents based on consideration of the following: a. The residents' medical condition.b. Current medication regimen. c. History of addiction or opioid use disorder.d. Nature, severity and cause of the pain.e. Course of the illness; andf. Treatment goals. This failure resulted in the identification of an IJ on 10/03/2025. The ADM was notified and provided with the IJ template on 10/03/2025 at 12:34 pm. The following Plan of Removal was submitted by the facility and accepted on 10/03/2025 at 5:00 p m Plan of Removal (POR) - F697 POR Accepted at - 10/03/2025 at 5:00 p m Plan of RemovalImmediate Threat Problem: Medication not available. On 10/3/25, an abbreviated survey was initiated at the facility. On 10/3/25 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that a condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to provide effective pain interventions for Resident #1 on 9/14/2025. Resident called for emergency transfer to the ER for pain management. Interventions: One on One in-service with DON and ADON conducted by Administrator regarding oversight of medication order by nurses on 10/3/2025. All nurses and certified medication aides to include PRN, new staff and agency if present are to be in-serviced regarding medication ordering process. The following in-services were initiated on 10/3/2025 by administrator and DON, and any staff member not present or in-serviced on 10/3/2025, will not be allowed to assume their duties until in-services have been completed. Any new employees or agency staff or PRN staff utilized will receive the following in-services before first shift to be worked. Nurses and certified medication aides Medication Ordering Review of orders for new admission Who to report to when medication is needed or not available from e-kit Pain management interventions Head to toe assessment to be completed on patient 10/3/2025.Staff will be questioned on in-services randomly, 3x a week for 4 weeks or until compliance is met. Random questioning will be documented and maintained in monitoring binder. Administrator will be responsible for oversight of the staff interviews. DON will conduct competency tests to ensure medication order process is understood and completed. Staff will need to complete tests to identify when medication is to be ordered and identify alternate availability of medication i.e. (e-kit, alternate medication from provider) Medication for resident #1 was obtained in the facility 10/2/2025. The medical director was notified of the immediate jeopardy situation on 10/3/2025 by Administration. Ombudsman was notified of the immediate jeopardy situation on 10/3/2025 by Administration. On 10/3/2025 a complete audit of all narcotic medications for residents was completed with a result of 100% availability of all medications. ADHOC QAPI discussed with IDT on 10/3/2025. Head to toe assessment completed by charge nurse for resident #1 no issues or complaints of pain. All residents that receive pain medications to be assessed for pain by charge nurses and documented into clinical progress notes on 10/3/2025. All residents that receive pain medications to have pain levels assessed Q shift by charge nurses and documented on MARS.Monitoring DON/ADON/ADMIN will interview staff nurses and medication aides weekly for 6 weeks regarding medication ordering procedures, status and any additional concerns. DON/ADMIN/Designee will interview 5 residents weekly for 6 weeks to ensure they are receiving their medication. This will be effective 10/4/2025. VP of Clinical Services will review and monitor weekly monitoring tools for 6 weeks. These monitoring tools will include staff interviews and resident interviews. The Quality Assurance committee will review the findings monthly for 3 months and make changes or recommendations as needed. The Administrator will resolve once no further issues have been identified. Effective 10/4/2025. The Surveyor monitored the POR on 10/04/2025 from 12:20 through 4:15 pm as follows: During an interview on 10/04/2025 at 12:20 pm the DON stated that the Administrator provided 1:1 in service training regarding oversight of medication order by nurses on 10/3/2025. The DON stated she was in-serviced 10/3/2025 by the ADM about the proper way to audit med carts, request medications, check e-kits. Notify MD if resident ran out, but DON can also call pharmacy to reorder. DON completed a competency quiz. New orders are handled by NP and in PCC. DON stated she participated in the skin and pain assessment. DON was responsible for acquiring Narcotics pain medication, responsible for ensuring pain assessment was done daily/q-shift and reviewing orders in PCC and checking that nurses were accessing for pain. The DON stated that all nurses and certified medication aides to include PRN, new staff and agency staff present were in-serviced regarding medication ordering process by the ADON or ADM on 10/3/2025. The DON stated staff present staff present today were the same staff that worked on 10/03/2025 as they work Friday/Sat/Sunday rotation. The DON stated the Licensed nurses completed the pain assessment on all residents on 10/3/2025. The DON stated In-service training of the nurses and CMA was done 10/3/2025 regarding: Medication Ordering, Review of orders for new admission, Who to report to when medication is needed or not available from e-kit, and Pain management interventions. New admission yesterday and head-to-the assessment was completed. The DON stated that staff have not been randomly questioned about in-services because in-services were just done. The DON stated she has started conducting competency tests to ensure the medication order process was understood and completed. The DON stated that Medication for Resident #1 was obtained in the facility on 10/2/2025 and proof was provided to the State surveyor yesterday. The DON stated that the medical director and Ombudsman were notified of the immediate jeopardy situation on 10/3/2025 by the Administration. The DON stated that the ADON did a complete audit of all narcotic medications on 10/2/2025 and she did follow up on 10/3/2025. The DON stated that the ADHOC QAPI discussed with IDT on 10/3/2025. DON stated all residents that receive pain medications were assessed for pain by charge nurses and documented on the MARS. The DON stated that staff were aware of the monitoring plan and measures in place, but due to the POR accepted less than 24 hours ago, some monitoring has not been done. During an interview on 10/04/2025 at 1:12 pm the Administrator stated all tasks regarding the POR, except for monitoring, had been completed. The Administrator stated some monitoring had been completed. The Administrator stated she notified the Ombudsman and medical director about the IJ. The Administrator stated she provided an in-service to the DON and ADON about narcotic pain medication. The Administrator stated the VP of clinical services provided in-service training to her (Administrator). The Administrator stated that her responsibility regarding acquiring Narcotic pain medication was to contact the pharmacy director about pain medication if her staff exhausted their change of command and could not obtain the pain medication. The Administrator stated nurses would assess pain every shift on the MARS, pain management interventions. The Administrator stated in- services of all nurses and MAs regarding medication orders, how to obtain pain medications would be completed. The Administrator stated she had oversight for monitoring but no direct resident care. The Administrator confirmed each detail on the POR and monitoring plan. The Administrator provided the POR binder, which showed POR details and in-service training. The Administrator stated that the staff interviews for monitoring were documented in the binder. During an interview on 10/04/2025 at 1:22 pm RN D stated she was in-serviced on 10/2/2024 and 10/3/2025 by the DON and ADM about the review of medication, narcotic ordering process, review of orders for new admissions, and who to report to. RN D stated she would review the medications with the provider (MD/NP), and have the provider call in the pain medication to the pharmacy to have it delivered. RN D stated, if resident ran out of pain medication, she would check the Resident for pain, contact the provider to request refill / Triplicate, follow up with pharmacy, and notify the ADON and DON for support to ensure medications were delivered. RN D stated that she completed a test/questionnaire after in-service, and it was reviewed with the DON and ADM to check for understanding. RN D described pain management intervention: repositioning, cold or warm clothes, therapy involved, referrals to pain management to help. RN D participated in the skin and pain assessment that were done 10/2/2025 and 10/3/2025. During an interview on 10/04/2025 at 1:59 pm, LVN E stated she had been in-serviced on 10/4/2025 by the DON and ADM regarding e-kit, when to pull meds out, who to report to about medication ordering, pain management intervention (if resident low on pain medication, when and who to notify about reordering). LVN E stated for new admission, she would call and discuss with the MD, NP, fax orders, call pharmacist to ensure they received the script/Triplicate. LVN E stated, if a Resident was on a PRN narcotic, she would do a pain tool assessment, verify meds, and try to pull the medication out of e-kit. LVN E stated, if residents ran out of pain medication, she would call the pharmacy to get code to pull out of e-kit, reorder or get new script /triplicate by calling the MD and notify DON and ADON. LVN E stated she took a test regarding the in-service and the DON reviewed it with her. LVN stated she participated in the skin and pain assessment on the new admission. During an interview on 10/04/2025 at 2:27 pm MA F stated she normally works the 6 am to 10 pm shift on the weekends, Saturdays and Sundays. MA F stated she was in-serviced today before she started work by the DON on what to do when they are missing pain medications. MA F stated If medications were missing, she had to report to the charge nurse so that they can get it out of the e-kit. MA F stated she would report to the NP if a resident was running out of pain medication. MA F stated if the nurse was unable to pull the pain medication out of the e-kit, she would notify the ADON and DON to get assessment. MA F stated she took a test about the training, and it was reviewed with her to make sure she understood the material. During an interview on 10/04/2025 at 2:33 pm MA G works weekend doubles from 6 am to 10 pm shift on Saturday and Sunday. MA G stated she was in-serviced today before she started work by the DON on what to do when they are missing pain medications. MA G stated if medications were missing, she would report to her using her chain of command starting with the charge nurse, ADON, and DON. MA G stated she took a test about the training. During an interview on 10/04/2025 at 2:37 pm the ADON stated he was in-serviced by the DON on 10/3/2025 on narcotic medication ordering, orders for new residents, who to report to if medication was not available. The ADON stated he would call NP for new admissions to call in script/triplicate to pharmacy and medications should come in that night. The ADON stated they have an e-kit that dispenses narcotic pain medication and explained the process to get meds (needs code from pharmacy). The ADON stated he received in-service from the DON on pain management interventions, and he would report to DON and NP if unable to get refills or the medication was not in the e-kit. The ADON stated he participated in skin and pain assessments of resident. He stated the wound care nurse will do skin assessment. The ADON stated his responsibility regarding acquiring Narcotic pain medication was to verify the medication, call the pharmacy, call the provider. The ADON stated the floor nurse was responsible for ensuring pain assessment was done daily. He stated he would audit the process by looking in PCC and reviewing the daily physical paperwork. The ADON stated that he did have a questionnaire/test to complete regarding the in-service training. During a phone interview on 10/04/2025 at 2:51 pm LVN H stated he worked 6 pm to 6 am shifts and was in-serviced by the DON on 10/3/2025 regarding the process for reordering pain medication and the process for new orders and new admissions. LVN H stated it was important to reorder the 7 days before (have 7 days left of pain medication). LVN H stated he would notify the ADON, DON, MD and family members if the medication supply was running low. LVN H stated he would try to get the medication out of the e-kit or from pharmacy. LVN H stated he did not participate in the pain and skin assessments, but he took a test, and it was reviewed with him. During a phone interview on 10/04/2025 at 2:57 pm RN I stated she worked the 6pm to 6am and was in-serviced by the DON on 10/3/2025 regarding the process for reordering pain medication and the process for new orders and new admissions. RN I explained reporting to the ADON and DON if she was unable to obtain pain medication after she confirmed orders with the provider and NP, calling the pharmacy, trying to get it out of the e-kit. RN I stated she completed a questionnaire about the training.Observations of Medication carts revealed sampled Residents pain medications being available. Review of Resident #1's pharmacy receipt reflected Resident #1's Oxycodone 5mg was delivered on the evening of 10/02/2025 in the amount of 60 pills. Review of Resident #1 MAR/TAR reflected Resident #1 was administered Oxycodone 5mg on 10/02/2025 for a pain level of 3. Review of Resident #1's progress notes dated 10/03/2025 reflected the MD was contacted for Resident #1 and pain and skin assessments were completed. Review of sampled Residents progress notes reflected pain and skin assessments were completed on 10/03/2025. Reviewed of facility's POR binder reflected: Reviewed in-service training on oversight of medication orders by charge nurses, reviewing orders for new admission, reviewing received medication, monitoring medications for residents; who to report to when medication is needed or unavailable from e-kit; pain management interventions. Reviewed pain assessment for resident #1. Reviewed staff interviews. Reviewed competency tests. Reviewed medication arrival confirmation, MD notification, Ombudsman notification, narcotic audit, ADHOC QAPI meeting, Resident #1 assessment, resident assessments, and monitoring interviews. An IJ was identified on10/03/2025. The IJ template was provided to the facility on [DATE] at 12:34 pm. While the IJ was removed on 10/04/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm because the facility needs to evaluate the effectiveness of the corrective systems

Based on observation and interview, the facility failed to ensure the Residents room was equipped for adequate nursing care, comfort, and privacy for two (Resident #1 and Resident #2) of seven Residents observed for privacy. The facility failed to ensure that there was a privacy curtain in Resident #2 and Resident #3's bedroom to provide privacy. This place Residents at risks for decreased privacy, dignity and quality of life.Findings included: Review of Resident #2's face sheet printed 10/02/2025 reflected a [AGE] year-old female who was admitted on [DATE] with the following dx:. Depression (a mood disorder that causes a persistent feeling of sadness and loss on interest), Essential (Primary) Hypertension (is defined as high blood pressure that occurs without an identifiable medical condition causing it), Hypothyroidism (underactive thyroid, occurs when the thyroid gland does not produce enough thyroid hormones, leading to a slowed metabolism)Review of Resident#2's quarterly minimum data set (MDS) assessment dated [DATE] reflected a BIMS score 5, indicating severe cognitive impairment. Section GG reflected impair mobility on both lower extremities. It also reflected 1 for toileting hygiene which indicated Resident #2 was Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the residents to complete the activity.Review of Resident 2's care plan initiated 08/12/2025 reflected Resident #2 had limited physical mobility related to advanced age, bowel and bladder incontinence related to impaired cognition and mobility with intervention to provide incontinence care after each incontinent episode. There was no evidence of Resident #2 or family not wanting privacy curtains in the room while she shared room with her male family member. Review of Resident #3's face sheet printed 10/02/2025 reflected a [AGE] year-old male who was admitted on 05/292025 with the following dx:. Paraplegia complete (total loss of motor and sensory function in the lower body.), muscle wasting, Neuromuscular dysfunction of bladder (occurs when there is problem with the brain, nerves, or spinal cord that affects the bladder control. This condition can lead to issues such as urinary incontinence or retention, as the nerves that communicate between the bladder and the brain do not function properly.)Review of Resident#3's quarterly minimum data set (MDS) assessment dated [DATE] reflected a brief interview for mental status (BIMS) score 15, indicating no impairment. Section H indicated Resident #3 had an indwelling catheter and an external catheter. Section GG reflected impair mobility on both lower extremities. It also reflected 2 for toileting hygiene which indicated Resident #3 was Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.Review of Resident 3's care plan initiated 08/11/2025 reflected Resident #3 had required assistance from staff with ADLs due to paraplegia, had bowel incontinence with intervention to provide incontinence care with each episode, had indwelling catheterdue to dx of neurogenic bladder. There was no evidence of Resident #3 or family not wanting privacy curtains in the room while he shared room with his female family. During an observation on 10/02/2025 at about 11:12 am, It was observed room [ROOM NUMBER] had had a male and a female resident (Resident's #2 and #3) observation also revealed there was no privacy curtain in the room to provide privacy when performing care personal care. During an interview on 10/02/2025 at 11:15 am, Resident #3 stated Resident #2 was his female family member and they were sharing the same room. Resident #3 stated there had not been a privacy curtains in their room since they were admitted to the facility. Resident #3 stated his family oversaw them and they had been sharing rooms in other facilities so he could look out for his Resident #2. Resident #3 stated he did not complain about privacy curtains to the facility staff, but he was not bothered by not having privacy curtains, but it might bother Resident #2. During an interview on 10/02/2025 at 11:20 am Resident #2 stated Resident #3 was her and they were in the same room. Resident #2 stated staff have to provide incontinent care for her in the room while (Resident #3) was in the room. Resident #2 stated it bothered her a lot, but she did not have a choice, the facility had chosen that way for she and Resident #3to be in the facility. Resident #2 stated, there was no privacy, , we will get back to privacy. Resident #2 stated, I didn't grow up dressing in front of daddy. I get embarrassed sometimes but that is what they have chosen for us. But [Resident #3] doesn't stare at me when they are providing care. The way I know is I look at him. During an interview on 10/02/2025 at 1:24 pm, CNA B stated she usually works on the 200 hall. CNA B stated she sometimes helps CNA C to provide care for Resident's in room [ROOM NUMBER]. CNA B stated she had provided care for Residents #2 and #3 including incontinent care. CNA B stated there were no privacy curtains in room [ROOM NUMBER] to provide privacy when performing personal care. CNA stated it was not ok not to have privacy curtains in a room with 2 residents. CNA B stated every resident was supposed to have privacy, it didn't matter if it was mom and son or husband and wife, everyone deserved privacy. CMA B stated, To be honest, I have not brought it to the attention of others. I will tell someone now since you have said it. During an interview on 10/02/2025 at 1:32 pm, LVN A stated Residents #2 and #3 were mother and son and they shared the same room. LNV A stated both Residents #2 and #3 required incontinence care. LVN A first stated the staff provided privacy by pulling the curtains when providing personal care. LVN A then went into room [ROOM NUMBER] and came out stating, I thought there was a privacy curtain, but there were no curtains. LVN A stated no matter who the person was, it was not ok not to provide privacy, even if it was 2 males or 2 females in the room or family, they still needed to provide privacy. Observation on 10/02/2025 at 1:45 pm revealed the Assistant Maintenance Director hanging privacy curtains in room [ROOM NUMBER]. During an interview on 10/02/2025 at 1:46 pm, CNA c stated he usually worked the first 7 rooms on the 200 hall. CNA C stated he had provided care for the residents in room [ROOM NUMBER] including incontinence care. CNA C stated he tried to use sheets to provide privacy when performing incontinence care. CNA C stated there has not been privacy curtains in room [ROOM NUMBER] and he thought it was ok because Residents #2 and #3 were related. CNA C stated he got uncomfortable whenever he was providing incontinence for either of the Resident in room [ROOM NUMBER], that is why he tried using sheets to provide privacy by covering some part of the body. CNA C stated that he did not tell anyone there were no curtains in room [ROOM NUMBER]. During an interview on 10/02/2025 at 1:52 pm, the Assistant Maintenance Director stated the Maintenance Director was off today. The Assistant Maintenance Director stated he was just made aware that room [ROOM NUMBER] did not have a privacy curtain. The Assistant Maintenance Director stated he was just told about the privacy curtain, he did not know there were no privacy curtains in room [ROOM NUMBER]. The Assistant Maintenance Director stated he would think it would be better to have curtains in the rooms for privacy even if the Residents were related. The Assistance Maintenance Director stated the staff sometimes verbally notify the team or document it in their system. During an interview on 10/02/2025 at 1:56 pm, the Administrator stated she was just told by CNA B that there were no privacy curtains in room [ROOM NUMBER]. The Administrator stated she had heard initially that Residents #2 and #3 requested no privacy curtains, but she had been looking through their clinical records and there was no evidence. The Administrator stated she would reach out to Residents #2 and #3's RP to find out he said no curtains. The Administrator stated the facility had to have a care plan that Residents #2 and #3 did not want privacy curtains. The Administrator later stated, according to the regulation, privacy curtains are needed in every room. During an interview on 10/02/2025 at 2:07 pm, the DON stated she did not know didn't know there were no privacy curtains in room [ROOM NUMBER]. The DON stated it was just brought to her attention that there were no privacy curtains in room [ROOM NUMBER]. The DON stated if the Resident request not have privacy curtains, it shouldn't be in their room. The DON stated she did not look into why there were not privacy curtains in room [ROOM NUMBER]. The DON stated the curtains were in the room to provide privacy.The DON stated, if the residents didn't want the curtains to be pulled, it would be care planned. Review of facility's policy tilted Privacy undated reflected: Policy Statement Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.Policy Interpretation and ImplementationResidents shall be treated with dignity and respect.Staff shall promote, maintain and protect resident privacy, during assistance with personal care and during treatment procedures.

Based on observations, interviews, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen and the facility's only nourishment room reviewed for food and nutrition services. 1. The facility failed to label and date food items in the only walk-in refrigerator. 2. The facility failed to label and date food items in the only nourishment refrigerator.3. The facility failed to maintain the proper temperature of the refrigerator in the nourishment room.4. The facility failed to ensure that the walk-in freezer was maintained at acceptable temperatures which resulted in frozen foods thawing out and then re-freezing without being discarded. 5. The facility failed to ensure that foods were stored away from leaks of malfunctioning cooling fans in the walk-in refrigerator. 6. The facility failed to ensure food products are discarded on or before the expiration date. 7. The facility failed to maintain temperature logs to monitor the nourishment refrigerator to ensure that it is functioning properly. These failures could place residents at risk for health complications, weight loss, foodborne illnesses, and decreased quality of life. Findings include: Observation and interview on 08/19/2025 at 4:30 PM revealed a large metal tray containing opened cooked ham with lid and label of prepared date 08/10/2025 and use by date 08/17/2025 stored in the walk-in refrigerator. The CDM stated the discard date for this food item should be within 7 days of prepared date. She stated it was now 9 days after prepared date and should not be in the refrigerator. She was observed removing the metal tray from the refrigerator to discard food item. Observation on 08/19/2025 at 4:37 PM revealed the walk-in freezer thermometer panel mount temperature was reading 3 . Observation on 08/20/2025 at 10:59 AM revealed the walk-in freezer thermometer panel mount temperature was reading 3 . Observation and interview on 08/20/2025 at 11:00 AM revealed a slow steady water leak from the bottom of the refrigerator cooling fans dripping into a large black plastic bin positioned directly underneath. CDM stated this was a new leak that has been reported to the maintenance staff for immediate repairs. She stated the black plastic bin is to keep the water from leaking onto the food stored on the shelf. She stated all packaged food was removed from this shelf temporarily awaiting repairs. She stated she believes the walk-in freezer temperature is above 0 as staff have been in and out of it this morning prepping foods for the day and organizing frozen foods. Observation on 08/20/2025 at 11:33 AM revealed salad plates with plastic wrap and plastic salad bowls with lids unlabeled and undated in the walk-in refrigerator. CDM immediately grabbed food items and went to add labels to them. During an interview on 08/20/2025 at 1:13 PM, MAIN stated kitchen work orders are handled by him and one other staff. He stated he will reach out to 3rd party contractors if unable to make a repair himself, such as the walk-in refrigerator and walk-in freezer. He stated the leak was reported to him last week some time, the refrigeration contractor visited the facility last week to look at it. He stated there was a delivery last week and staff had the refrigeration doors open, and a lot of condensation was building up when the contractor was assessing. He stated the contractor recommended for him to look at adding some fans to the refrigerator, so it does not create condensation. He stated he also believed since the freezer doors were open for delivery it caused the temperature to rise. He stated kitchen staff are emptying the black plastic bin during morning and night shifts. He stated he has been researching how to run fans for the condensation build up, and he will have to put in an electrical system to install the fans. He stated it would be best if he looked at the inside of the refrigerator, not draining, not sure about the water build up, and look at air curtains for the doors. He stated he has requested invoices and estimates for this work. MAIN stated if water were to leak onto the stored food, staff should not use it as this could affect the residents and make them sick. Surveyor requested work orders submitted for temperatures and water leak concerns, invoices, and estimates from contractors regarding recommendations and repairs and recommended plan to repair the refrigeration systems. These items were not provided prior to exit. Observation on 08/21/2025 at 9:00 AM revealed the walk-in freezer thermometer panel mount temperature was reading 15 and the 2 dial freezer thermometer located in the walk-in freezer was reading 30 . Observation on 08/21/2025 at 9:07 AM revealed the walk-in freezer thermometer panel mount temperature was reading 15 and the 2 dial freezer thermometer located in the walk-in freezer was reading 18 . Observation and interview on 08/21/2025 at 9:11 AM revealed the large black plastic bin positioned directly underneath the cooling fans in the walk-in refrigerator was filled with dirty water that has leaked into it. CDM stated the black bin fills throughout the day and is dumped out every morning and evening shift. She removed the plastic bin to drain water, and the piping of the refrigerator was exposed and had rust and black tape wrapped around the hinges. Observation and interview on 08/21/2025 at 9:12 AM revealed the left side of the cooling fans also had a very slow leak and had dripped into the black large plastic bin that contained cheese blocks. The CDM stated the leak had not been a concern to the left side of the cooling fans and she was not aware of any additional leaks. She stated the cheese is unopened and did not leak into it but believes it would be best to discard. She was observed removing the cheese from walk-in refrigerator. During an interview on 08/21/2025 at 9:14 AM KH N stated she has been employed a year at this facility and the black plastic bin has been there the entire time and staff have been tasked with emptying the water out daily. She stated MAIN has been notified numerous times of this concern. She stated residents can become ill if the food is contaminated with leaking water. She stated all staff are responsible for reporting any faulty equipment to the CDM to submit work orders for repairs. During an interview on 08/21/2025 at 9:16 AM, CDM stated she has been employed at the facility since March 2025. She stated the MAIN has been notified numerous times of the walk-in refrigerator leak and walk-in freezer temperatures. She stated she has entered work orders in TELS (software to manage work orders), and MAIN would have access to these workorders. She stated this was a concern that the dietician had addressed with her during her last visit and quality assurance evaluation on 08/08/2025. She stated she is aware this malfunction can be harmful to residents and insisted she has notified the MAIN and ADM of the concerns. During an interview on 08/21/2025 at 9:30 AM, KH O stated labeling and dating food items are required for every food opened or stored in the walk-in refrigerator and freezer. She stated if food is not labeled it can be expired, be no good and can cause residents to become ill if used. She stated that she has been aware of the walk-in refrigerator leak for 2-3 months now. She stated the CDM is aware of the problem. She stated foods can become dangerous for residents if water drips onto it. During an interview on 08/21/2025 at 9:38 AM, CK L stated she has been employed for 1 year and 8 months at this facility and she has many different duties which include the CDM's right hand as she is new. She stated kitchen labeling and dating training occurred a few months back. She stated the purpose of wrapping and labeling food is to know if the food is good. She stated food can go bad if not labeled, not sure if expired and could make the residents sick if used. CK L stated the leak in the walk-in refrigerator has been ongoing for some time and has not been repaired. She could not recall timeframe but believes a few months. She stated maintenance has assessed the issue and has tried to repair a few times now, but no success. She stated the leak could damage the food stored in the walk-in refrigerator and could make residents sick if water is leaking onto the food. She stated the freezer temperatures have also been reported to CDM and MAIN. She stated MAIN will come in and check the temperature and state the freezer door remains open too long and causes the temperature to go above 0 . She stated the dietitian also addressed this concern a few times during visits. During an interview on 08/21/2025 at 9:53 AM, MAIN stated he talked to a contractor for an estimate to repair the walk-in refrigerator. He stated the parts were not ordered as he had mentioned in an earlier interview. He stated parts have yet to be ordered as the contractor has yet to provide him with an estimate and timeframe to repair the walk-in refrigerator. He stated if the leaking water were to get onto the food stored in the refrigerator it could become contaminated and can cause the residents to become ill. During an interview on 08/21/2025 at 10:00 AM, ADM stated that she was aware of the walk-in refrigerator leak and freezer temperature gauge was having adjustment concerns that were brought to her attention around the 7th or 11th of August 2025. She stated the dietician visited the facility for her monthly evaluations and this concern was discussed and a work order was submitted immediately. She stated KH N is a disgruntled employee and told staff she would be getting people in trouble with the State and is giving an inaccurate timeframe of the walk-in refrigerator leak concerns. She stated her MAIN has been on top of these repairs and it seems to have reached the pinnacle and now needs a contractor that is knowledgeable in repairing refrigeration systems. She stated the MAIN was working on this work order and was trying to get the contractor to provide an estimate for repairs. She stated she was not sure why the delay in getting this estimate to begin the repairs. She stated she will be contacting the contractor herself today to let him know their walk-in refrigerator is a priority and he needs to be here today to repair the leaking refrigerator and the temperature gauge for the walk-in freezer or she would be canceling his contract with the facility. Observation and interview on 08/21/2025 at 11:34 AM, CNA F stated the kitchen staff deliver snacks to the only nurse's station three times a day (10 AM, 2 PM, 6 PM). He stated snacks that are not eaten after 2 hours are returned to the kitchen or discarded. He stated the evening snacks are stored behind a locked door in a small refrigerator. He stated without labels the snacks could be expired, but staff would not know. He stated this could cause the residents to become sick. Observation of the locked nourishment room containing the resident snack refrigerator revealed the refrigerator contained a tray of milk cartons without a label or date, cottage cheese with label with date of 8/12/2025 AM Snack for a specific resident, cartons of Mighty Shakes, Vanilla with label and date of 8/12/2025, pitcher with tape label nectar H2O without date, orange juice with lid without label or date. Also stored in the refrigerator was an unlabeled gallon of ice cream, birthday cake, bag of sodas, and bag of juices. All resident items were unlabeled. The refrigerator did not have a thermometer gauge, there was no temperature log in site, and the refrigerator needed cleaning and to discard expired food. CNA F stated the snack refrigerator stores all resident snacks and items brought in by family to store for a resident. He stated there is no temperature log for the refrigerator that he is aware of, and housekeeping is responsible for cleaning out the refrigerator and getting rid of the expired snacks not eaten. Observation of the freezer on 08/21/2025 at 12:22 PM revealed two 2 dial freezer thermometers were reading 2 and the other reading 36 . During an interview on 08/21/2025 at 3:30 PM, CNA J stated he is the staffing coordinator, he purchases central supplies and is responsible for updating the staffing board daily. He stated he is not aware of a specific staff assigned to the resident snack refrigerator. He believes maintenance is responsible for the temperature logs and housekeeping would be responsible for the upkeep of the refrigerator, and the kitchen staff would be responsible for labeling food. During an interview on 08/21/2025 at 4:40 PM, MAIN stated he is not aware of a temperature log for the resident refrigerator and was not aware that it required one. He stated there is no policy for the nutrition refrigerator specifically. He stated facility staff usually will clean out and discard food items from the nutrition refrigerator but no assigned staff. Review of Work Order #1930 created on 08/11/ 2025 titled, Condensation walker in cooler revealed it was submitted for the kitchen and requested by CDM with a medium priority. Status was set to in-progress by MAIN. No details as to the work order progress. Review of third-party contractor email, 08/20/2025 1:32 PM, titled WIC (walk in cooler) revealed correspondence from contractor to MAIN, Per our recent conversation about our site visit last week, I am still working with the manufacture on upgrading the drainage system and installing additional ventilation. I will reach back out for an update and circle back to you shortly. Review of third-party contractor email, 08/21/2025 10:35 AM, titled Walk in cooler and Freezer revealed correspondence from contractor to MAIN, Touching base again, I was able to produce a resolution with the manufacturer on your Walk In cooler Issues. I have a tech that will be on site today between 3-5, He will also be addressing any temporary issues with your freezer while on site also. Review of facility report, 08/20/2025, titled Work Order revealed closed work orders submitted for repairs from 05/15/2025 to 08/20/2025: Work order #1811 submitted on 06/26/2025 by CDM, summary request adjust temperature of freezer. Work order #1933 submitted on 08/13/2025, no staff listed, summary request sealed cooler cracks. Review of facility reports, 06/10/2025 to 08/08/2025, titled QA I Monitor revealed the kitchen underwent monthly quality assurance evaluations conducted by the facilities' licensed dietician and results were reviewed and shared with the CDM and ADM. Areas of non-compliance and comments provided by dietician include: 08/08/2025 Section 5: Food Storage: Refrigerators (32-41 ) and freezers (0 or lower) at proper temperature; logs complete, internal thermometers present in each cooler/freezer.All other food items covered, labeled, and dated. Received dates present on all items. Foods free from freezer burn, dried out appearance, or other signs of quality change. Shelves, interior fans, gaskets, floors, walls clean and in good repair, shelves not lined with paper. Section 8: General Comments and Progress from Last Report: Fridge/freezer temperatures prefilled for PM; condensation continues with fresh produce continually stored beneath despite RD encouragement to relocate - this is significant contamination risk. Improvement on labeling/dating, must remember to place open dates on all opened items both fridge/dry stock. 07/10/2025 Section 5: Food Storage: Coolers and freezers not overstocked to promote air circulation.Foods free from freezer burn, dried out appearance, or other signs of quality change. Section 6: Meal Service Observation Recipes followed.Nourishment room: clean, not out of date foods, temporary logs in use; N/A Section 8: General Comments and Progress from Last Report: significant condensation in fridge dripping into pan but also outside onto RTE foods - RD encouraged placing in TELS (software to manage work orders) and removing open RTE food from the area. Encouraged organizing freezer and labeling and dating items appropriately. 06/10/2025 Section 5: Food Storage:All other food items covered, labeled, and dated. Received dates present on all items. Food not expired or spoiled. Section 6: Meal Service Observation Nourishment room: clean, not out of date foods, temporary logs in use; N/A Section 8: General Comments and Progress from Last Report: Items addressed with CDM. RD to provide In-services on glove use, labeling and dating. Review of facility spreadsheet, undated, untitled, revealed dietician outlined problem areas in the kitchen, goals to correct, and specific tasks to successfully meet goals: 08/08/2025 Condensation leakage continues onto ready to eat foods despite RD encouragement for relocation of high-risk foods; interior of refrigerators/freezers are clean, and parts are in good repair; REMOVE ALL OPEN/READY TO EAT FOODS FROM BELOW CONDENSER. Comments: improvements in labeling/dating, ensure storage of ready to eat items are free from condensation - no changes in last 3 visits with this issue. Review of facility policy undated, titled Refrigerators and Freezers revealed, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. 1. Refrigerators and/or freezers are maintained in good working condition. 4. The supervisor takes immediate action if temperatures are out of range. Actions necessary to correct the temperatures are recorded on the tracking sheet, including the repair personnel and/or department contacted. 5. All food is appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and ''use by dates are indicated once food is opened. 7. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 4 of 6 residents (Resident #29, #65, #70 and #86) reviewed for infection control. 1. The facility failed to ensure CNA C doffed gloves after giving care to Resident #65 and #86 disposed of PPE properly on 08/19/2025. 2. The facility failed to ensure staff wore PPE while providing high contact resident care (transfers and medication administration through a gastrostomy tube) to Residents #29 and #70 on 08/21/2025. These failures could place residents at risk for infection, hospitalization, or death.Findings included: 1. Record review of Resident #65's face sheet, dated on 08/21/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included local infection of the skin and subcutaneous tissue, unspecified (a bacterial or fungal infection affecting a specific, limited area of the outer skin layers and the tissue beneath it), non-pressure chronic ulcer of skin of other sites limited to breakdown of skin (an open ,non-healing sore on the skin, not caused by prolonged pressure), and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (hemiplegia refers to paralysis- complete inability to move and hemiparesis - weakness). Record review of Resident # 65's admission MDS Assessment, dated 07/31/2025, reflected Resident #65 had a BIMS score of 10, which indicated her cognition was moderately impaired. Resident #65 had stage 4 pressure ulcer. Record review of Resident #65's Comprehensive Care Plan, dated 08/04/2025 reflected Resident #65 had stage 4 pressure ulcer to sacrum. The pressure ulcer was present upon admission. The care plan did not reflect Resident #65 being on contact precautions. 2. Record review of Resident # 86's face sheet, dated on 08/21/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident #86 had a diagnoses which included infection following a procedure, superficial incision surgical site, subsequent encounter (a bacterial or other microorganism infection that develops in the top layers of skin at a surgical wound site, rather than a deep one, for a resident receiving later follow-up medical care for the infection), methicillin resistant staphylococcus aureus infection, unspecified site (a common bacteria enter the body through a cut or wound, causing symptoms like red, painful, swollen areas, possibly with pus. Methicillin resistant- the bacteria has developed a resistance to certain antibiotics which are normally used to kill staph), and chronic pain (a long lasting, continuous, or recurring pain that persists for at least three months, beyond the normal healing time). Record review of Resident #86's Quarterly MDS Assessment, dated 07/26/2025, reflected Resident #86 had a BIMS score of 15 which indicated her cognition was intact. Resident #86 had open lesions and skin tears. She was receiving treatment for skin and ulcer/ injuries (non-surgical dressings and ointments) Record review of Resident #86's Comprehensive Care Plan, dated 08/08/2025, reflected Resident #86 was at risk for skin breakdown and pressure ulcer development due to decreased mobility and obesity. Resident #86 comprehensive care plan did not reflect Resident #86 being on contact isolation. 3. Record review of Resident #29's admission record, dated 08/21/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included acute and chronic respiratory failure with hypoxia (a condition where there is not enough oxygen in the blood), tracheostomy status (a surgical opening in the neck directly to the breathing tube/trachea), hypotension (low blood pressure), gastrostomy status (a surgical opening directly to the stomach through the abdomen), nontraumatic intracerebral hemorrhage (bleeding within the brain without any external injury), and hemiplegia and hemiparesis (weakness and inability to move half of the body). Record review of Resident #29's medical record on 08/21/2025 reflected no submitted and accepted MDS due to Resident #29's recent admission on [DATE]. Record review of Resident #29's care plan, dated 08/19/2025, did not mention Enhanced Barrier Precautions Record review of Resident #29's order summary, dated 08/21/2025, reflected, Enhanced Barrier Precaution: PPE required for high resident contact care activities. Indication: TRACHEOSTOMY AND G-TUBE. 4. Record review of Resident #70's admission record, dated 08/21/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included spina bifida (a birth defect that occurs when the neural tube, which forms the spine and spinal cord, does not close completely during early development in pregnancy), syndrome of inappropriate secretion of antidiuretic hormone (a condition where the body makes too much antidiuretic hormone causing water retention and low sodium levels), elevated white blood cell count (diagnosis can indicate infection, inflammation, or immune system disorders), hypertension (high blood pressure), pressure ulcer of sacral region, stage 4 (a wound that extends through all layers of skin, exposing underlying muscle, tendon, or bone caused by pressure to the lower triangular area of the spine), neuromuscular dysfunction of bladder (when there is a problem with the brain, nerves, or spinal cord that affects bladder control), and colostomy status (a surgical opening for the colon through the abdomen). Record review of Resident #70's comprehensive admission MDS, dated [DATE], reflected a BIMS score of 15, which indicated no cognitive impairment. It reflected she had an indwelling catheter, an ostomy, and a pressure ulcer/injury. Record review of Resident #70's care plan, dated 08/15/2025, reflected [Resident #70] has a documented Pressure Ulcer that was present on admission. Care plan also reflected [Resident #70] is at risk for infection related to foley catheter. Care plan had no mention of Enhanced Barrier Precautions. Record review of Resident #70's order summary dated 08/21/2025 reflected, Enhanced Barrier Precaution: PPE required for high resident contact care activities. Indication: open wounds, catheter, colostomy every shift.Observation on 08/19/2025 at 9:39 AM Resident #65 and Resident #86's room (room [ROOM NUMBER]) had signs outside the door reflecting contact isolation signs. The signs had the proper PPE to wear when giving care and how to don (place gowns and gloves on prior to giving care) and doff (removing gowns and gloves after giving care) the PPE. There was a container outside the room with red bags for disposing PPE, gowns, and gloves. Observation and interview in Resident #86's room on 08/19/2025 at 9:45 AM revealed CNA C doffed her gown and placed it in a clear plastic bag. She was wearing same gloves after giving care to Resident# 65. CNA C pulled back the privacy curtain to speak to Resident # 86. CNA C picked up the call light off the floor and placed it on Resident # 86's bed sheets. Resident #86 stated she accidently knocked it off the bed. CNA C touched Resident #86's left hand while wearing same gloves. CNA C picked up the clear plastic garbage bag with several gowns and gloves in the bag. There was a hole to the right side of the clear plastic garbage bag. CNA C placed the contaminated gowns and gloves in the clear plastic bag on the seat of Resident #86's wheelchair. Interview on 08/19/2025 at 9:58 AM CNA C stated she did not follow the infection control rules. She stated she was to doff the gloves and wash her hands prior to touching the call light and Resident #86's arm. She stated if another staff or visitor came into the room and had a scratch or open area on their fingers or hand, there was a possibility they may become contaminated with MRSA if they touched the call light. She stated the wheelchair was also contaminated after she placed the clear plastic bag in the wheelchair. CNA C stated there was a hole to the right side of the bag and she was going to hold it together as she carried the bag to the dirty utility room. She stated she had been in-serviced on contact isolation and infection control. CNA C stated she did not recall the exact date or time of the in-service.Observation on 08/21/2025 at 09:32 AM revealed LVN E did not wear a PPE gown when administering medication through Resident #29 gastrostomy tube. Observation outside of the room revealed a 3-drawer tote filled with PPE and 2 signs that indicated the use of EBP precautions was needed for Resident #29. Interview on 08/21/2025 at 09:51 AM, LVN E stated she forgot to wear a gown to give medications to Resident #29. She stated EBP were to protect the resident from infection. She stated by not wearing a gown during medication administration through a gastrostomy tube then the resident could be exposed to bacteria and contract an infection. Observation on 08/21/2025 at 12:57 PM revealed CNA F and CNA G transferred Resident #70 using a mechanical lift from the wheelchair to the bed, but the CNAs did not wear a gown for EBP PPE. Observation outside of the room revealed a 3-drawer tote filled with PPE and 2 signs that indicated the use of EBP precautions was needed for Resident #70.Interview on 08/21/2025 at 01:33 PM, CNA G stated resident #70 required PPE including a gown for any direct patient care including transfers with a mechanical lift. She stated she forgot to wear a gown when providing care to Resident #70. She stated the resident could be exposed to bacteria and get an infection if EBP PPE was not used when providing direct resident care. Interview on 08/21/2025 at 01:36 PM, CNA F stated he did not wear PPE including a gown while providing direct care during a mechanical lift transfer for Resident #70. He stated he did not normally work with Resident #70 and did not know she required EBP. CNA F stated he did not see the drawers with PPE or the signs outside the door. He stated he was unsure why a resident would require EBP, but he stated by not wearing PPE he could make the resident sick by transmitting bacteria. Interview on 08/21/2025 at 1:59 PM the MDSN stated infection control protocol was to be followed especially if someone was on contact isolation. She stated touching anything with contaminated gloves was considered cross contamination. The MDSN stated any time someone was on contact isolation it was expected to be care planned. She stated she would need to review Resident # 86 and Resident # 65's care plan to determine if contact isolation were care planned and she would inform the surveyor with the information she gathered from their medical records. She never reported any information to surveyor prior to exit. Interview on 08/21/2025 at 2:24 PM the Treatment Nurse stated Resident #65, and Resident #86 was on contact isolation. She stated both residents had MRSA but in different areas. She stated she would need to review their medical charts and would give the areas on both residents (Resident #65 and Resident #86) and would report to surveyor. The treatment nurse never reported this information to surveyor prior to exit. She stated both residents were on contact isolation. The treatment nurse stated both residents required for gowns and gloves to be worn when giving care to both residents. She stated contact isolation was expected to be care planned. She stated if it was not care planned the staff would not have the information, they needed to know why the residents was on contact isolation. The treatment nurse stated if a staff had contaminated gloves on, picked up call light, and placed it on the bed the call light may become contaminated. She stated if a staff or family member visited the resident and had open area on their fingers or hand the person may become contaminated with MRSA. She stated the staff was not to place clear garbage bag full of contaminated gowns and gloves in a wheelchair. She stated the wheelchair would be considered contaminated. She stated if there was a hole in the clear plastic bag and the staff carried the bag down the hall there was a potential if another resident had open area on their arm and touched the contaminated gowns/gloves in the plastic bag, the resident may become contaminated with MRSA. She stated she had been in-serviced on infection control and she was the infection control preventionist. She did not recall the date of her training. Interview on 08/21/2025 at 2:50 the DON stated the staff was to doff gloves and wash hands prior to doing anything for a resident. She stated the staff did contaminate the call light and possibly the resident's hand. She stated if another staff or visitor touched the call light and had an open area on their hand there was a possibility the staff or visitor may become contaminated with MRSA. She stated Resident #65 and Resident #86 both had MRSA. The DON stated the staff was expected to follow infection control protocol. She stated the staff did not follow infection control protocol when she did not remove her gloves when she picked up the call light. She also stated the staff was not to place the clear plastic bag of gowns and gloves in a resident's wheelchair. She stated this was cross contamination. The DON stated anytime residents were on contact isolation this was required to be care planned. She stated anytime a resident had any type of infection the care plan was to reflect all interventions required to heal the infection. The DON did not respond to other questions related to why it was important for infection and contact isolation needed to be care planned. Interview on 08/21/2025 at 04:49 PM, the TN (who is also the infection preventionist) stated she had worked at the facility for 3 weeks. She stated the purpose of EBP was to prevent transmission of bacteria from staff to the resident who may be immunocompromised (their immune system was not functioning properly). She stated that all residents who have any open wounds or surgical/artificial openings, including a foley catheter and gastrostomy tube, required EBP. The TN stated she expected anyone, including staff and family, to wear PPE, including a gown, when providing direct care to residents with indications for EBP. She stated there were signs up and PPE in drawers outside of the residents' rooms that required EBP. The TN stated staff that were administering medication through a gastrostomy tube or using a mechanical lift to transfer a resident with a catheter or wound to wear a gown when they provided the care. She stated not wearing a gown while providing care to the residents that required it could lead to infection, deterioration of condition, sepsis (a severe infection), or even death. The TN stated she had just taken the role that week to monitor for compliance among staff. She stated she provided monthly in-services and quarterly checkoffs related to infection prevention.Interview on 08/21/2025 at 05:18 PM, RN D stated PPE was used when providing direct care to residents who have a gastrostomy tube or foley catheter. He stated EBP required the use of gown and gloves. RN D stated using such precautions protected the resident from getting an infection. He stated anyone who provided care to the resident was responsible for wearing gown and gloves. Interview on 08/21/2025 at 05:36 PM, the DON stated she took over as DON on 07/21/2025. She stated residents that had open wounds, tracheostomies, catheters, or other invasive lines required EBP. The DON stated she expected anyone who provided direct care to residents with those conditions to wear PPE, which included gown and gloves, when they provided care to the resident. She stated that the charge nurses, the ADON and herself were responsible for monitoring for compliance with using the correct PPE. The DON stated not wearing PPE for the residents that required it could introduce infection to those residents. Interview on 08/21/2025 at 06:02 PM, the ADM stated she took over as ADM approximately 2 months prior. She stated residents that have a catheter, a colostomy, a tracheostomy, or a gastrostomy tube required EBP. She stated that any staff that provide direct care for those residents are required to wear a gown and gloves. The ADM stated nursing management monitored proper usage of EBP during their quality-of-life rounds. She stated not using the correct PPE while providing direct care to those who require it could introduce infection to the resident. Record Review of facility's Policy on Isolation- Initiating Transmission- Based Precautions, dated October 2018, reflected Transmission- Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or had a laboratory confirmed infection; and is at risk for transmitting the infection to other residents. Transmission - Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions. The facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission-Based Precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. Record review of, undated, facility policy titled, Monitoring Compliance with Infection Control reflected: Policy StatementRoutine monitoring and surveillance of the workplace will be conducted to determine compliance with infection prevention and control policies and practices.Policy Interpretation and Implementation1. The infection preventionist or designee shall monitor the effectiveness of our infection prevention and control work practices and protective equipment. This includes, but is not limited to: .f. Effective use of disposable gloves and other personal protective equipment to prevent spread of infection. Record review of facility in-service titled Enhance Barrier Precaution, dated 06/09/2025, reflected: Enhanced Barrier Precautions (EBP) are an infection control intervention that expands the use of gowns and gloves, beyond standard precautions, during high-contact resident care activities to prevent the spread of multi drug-resistant organisms (MDROs). Use gown and glove specific examples of high-contact activities requiring EBP.TransferringDevice care or use (central line, urinary catheter, feeding tube, tracheostomy) .

Based on observations, interviews, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed. 1. The two test tray for lunch meal included foods that were bland, and unappealing. 2. The lunch meal trays being delivered to 300 hall residents were unappealing with small side portions. 3. The meal delivery cart doors left open during delivery of hallway meals and reducing the food temperatures. 4. Watery and mushy vegetables served to residents on 08/20/2025. These failures could place residents at risk of decreased food intake, hungry, unwanted weight loss, and diminished quality of life. Findings included: Observation on 08/19/2025 at 12:00 PM revealed unappealing meal trays with poor arrangement of food and small portions of okra being delivered to hallway 300.Food test tray #1 was received at 12:29 PM on 08/19/2025 and was well-presented and arrangement of food was appealing. The tray contained a large white serving plate with an adequate portion of fried okra placed in a small bowl for appearance, corn bread, chili with beans was arranged in a bowl, 2 portions of shredded cheese, donut holes, tea, water, salt, pepper, butter, and utensils wrapped in napkin.Observation and interview on 08/20/2025 at 11:15 AM revealed the broccoli was sitting in a large steal pan filled with water. CK L was observed monitoring food temperatures and stated the broccoli and water remain in the deep pan until meal service and it is drained before serving.Observation on 08/20/2025 at 11:42 AM revealed CDM instructing CK M to drain out as much water from the steal pan of broccoli. CK M used a perforated portion spoon to remove water from the broccoli pan in a slow pace. He was then instructed to stop and to drain as much water when portioning on plate. Broccoli was served on resident plates.Observation on 08/20/2025 at 12:15 PM revealed the meal delivery cart transporting resident meals to hallway 100 was left wide open. The meal delivery cart doors were left open for several minutes exposing resident meal trays and reducing the food temperatures.Food test tray #2 was received at 1:03 PM on 08/20/2025 and the boiled broccoli was mushy and watery. Surveyor tested the tray, and the broccoli was overcooked, soft and squashy, without any seasoning, and dull. The food was warm.During an interview on 08/21/2025 at 10:00 AM, ADM stated the CDM was responsible for maintaining hot, appealing, and flavorful food. She stated she had not heard of complaints regarding food and would ensure the DM was aware of complaints and working with the dietician to improve meals. During an interview on 08/21/2025 at 3:57 PM, CK L stated that vegetables should not sit in water until they were served. She stated she does not leave water in her vegetables and will drain them. She stated if the vegetables remained in water for too long, she would throw it away, because they become mushy. CK L stated this is not the common practice in the kitchen; however, CK M is a new cook in training, and she is trying to teach him good practices as she knows the residents do not like mushy and flavorless foods and would complain about it. CK L stated she hears a lot of complaints when other cooks prepare food as there is no flavor, and limited seasoning of only salt and pepper is used. She stated residents want meals to look forward to. CK L stated using the correct measuring scoops and spoons for serving is necessary for residents to maintain weight and nutrition. She stated following recipes and seasoning required is necessary for meals to be flavorful.During an interview on 08/21/2025 at 4:18 PM, CDM stated she has received complaints from the resident council regarding food being served cold. She stated she believes food may be cold if not delivered to table immediately or to the resident's room in a reasonable time. She stated she does not understand why food becomes cold quickly but will look into this. She stated the broccoli left in water should have been drained before putting the tray on the serving steam table. She stated she was distracted with training a new cook that she overlooked the broccoli staying in water too long and becoming mushy. She stated vegetables are the last food cooked for any meal as they require less time. She stated residents receiving unflavored and mushy vegetables could affect the resident by reducing their nutrition as they may not eat. CDM stated cooks are expected to use the correct portion sized serving tools when serving plates as anything less could affect the residents with weight loss. She stated that all plates served either in the dining room or in the resident rooms should all be uniformed and be appealing so the resident will want to eat it.Review of facility policy undated, titled Food and Nutrition Services revealed Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. 6. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the Food Service Manager so that a new food tray can be issued.

Based on observations, interviews, and record review the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment for 4 (Residents #17, #37, #3, and #73) of 20 residents reviewed for sufficient staffing. The facility failed to ensure that the facility had sufficient staffing to meet the needs of Residents #17, #37, #3, and #73. This failure could affect and diminish the resident's quality of life by potentially placing the residents at risk of not receiving timely care or receiving nursing interventions to meet the resident's needs, risk of injury, risk of safety, and/or it can make the resident feel neglected affecting their mental health and overall psychosocial well-being not being met by facility staff.Findings include: Record review of Resident #17's admission record, dated 08/21/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included acute cystitis without hematuria (inflammation of the bladder), other benign neoplasm of uterus (noncancerous tumor in women and people assigned female at birth), somatization disorder (mental health condition characterized by significant distress and impairment related to physical symptoms that may not have a clear medical explanation), fusion of spine, muscle weakness, congenital malformation of nervous system (birth defects that affect the structure and function of the brain and spinal cord), lack of coordination, anxiety disorder, and aftercare following joint replacement surgery. Record review of Resident #17 admission MDS, dated [DATE], reflected a BIMS score of 13, which indicated cognition was intact. Section GG - Functional Abilities reflected Resident #17 required Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity for toileting hygiene and chair/bed-to-chair transfer. Record review of Resident #17's care plan, dated 06/20/2025, reflected the following clean peri-area with each incontinence episode. Record review of Resident #37's admission record, dated 08/21/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #37 had diagnoses which included local infection of the skin and subcutaneous tissue, chronic kidney disease, stage 4 (severe), iron deficiency anemia, irritable bowel syndrome, and muscle weakness. Record review of Resident #37's admission MDS, dated [DATE], reflected a BIMS score of 14, which indicated cognition was intact. Section GG - Functional Abilities reflected Resident #37 Needed Some Help - Resident needed partial assistance from another person to complete any activities for self-care and Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort for showers/bathing self. Record review of Resident #37's initial baseline care plan, undated with date initiated 07/10/2025 and last revised 08/19/2025 reflected the following, Resident #37 has limited physical mobility and requires staff assistance for ADLs. Interventions reflected Provide supportive care, assistance with mobility as needed. Further review of Resident #37's initial baseline care plan reflected the following, Resident #37 has occasional bowel and bladder incontinence r/t impaired mobility and IBS (common condition that affects the stomach and intestines). Interventions reflected Clean peri-area with each incontinence episode. Record review of Resident #3's admission record, dated 08/20/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with readmission on [DATE]. Resident #3 had diagnoses which included chronic obstructive pulmonary disease, unsteadiness on feet, cognitive communication deficit, pain in right shoulder, mild cognitive impairment, difficulty in walking, major depressive disorder, insomnia, muscle weakness, heart failure, sleep apnea, morbid obesity. Record review of Resident #3's Quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated cognition was intact. Section GG0115. Functional Limitation in Range of Motion reflected Resident #3 required Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half.the effort for toileting hygiene. Record review of Resident #3's care plan, dated 04/27/2021 and last revised 02/14/2025, reflected the following I have an ADL self-care performance deficit r/t lack of safety awareness and muscle weakness. Interventions reflected TOILET USE: requires assistance by (1) staff for toileting. Record review of Resident #73's admission record, dated 08/21/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #73 had diagnoses which included other sequelae of cerebral infarction (condition of brain swelling, blood clots, trouble swallowing, pneumonia, bladder and bowel problems, seizures, and headaches), muscle weakness, lack of coordination, depression, anxiety disorder, insomnia (common sleep disorder that can make it hard to fall asleep or stay asleep), polyneuropathy (condition characterized by damage to multiple peripheral nerves, leading to symptoms such as pain, weakness, and sensory loss), acute embolism (blood clot that blocks and stops blood flow to an artery in the lung) and thrombosis (condition that involves the formation of a blood clot in blood vessels) of unspecified deep veins, heart failure, obesity, and type 2 diabetes mellitus (condition that happens because of a problem in the way the body regulates and uses sugar as fuel). Record review of Resident #73's admission MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderate cognitive impairment. Section GG - Functional Abilities reflected Resident #73 required Dependent - Helper does ALL the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity for toileting hygiene and chair/bed-to-chair transfer. Record review of Resident #73's care plan, dated 07/25/2025 and last revised 07/31/2025 reflected the following Resident #73 requires assistance from staff with ADLs such as Bed mobility, Transfers, Locomotion, Dressing, Toileting, Personal hygiene, and Bathing. Interventions reflected facility would Provide devices for mobility and assist as indicated. Staff will encourage resident to participate with ADLs as able. Staff to assist with/provide ADLs as needed. Further review of Resident #73's care plan reflected Resident #73 has bowel and bladder incontinence r/t CVA. Interventions reflected Check resident every two hours and assist with toileting as needed. During an interview and observation on 08/19/2025 at 3:40 PM, Resident #73 stated there was not enough staff and he stays wet often and must call his wife to call up to the nurse's station to get staff to answer his call light. He stated he wants staff to figure out to help him get up as he was supposed to be up and out of bed daily. He stated he presses the call light and at times will come into his room to turn it off and leave and do not return. Resident #73's wife was observed reaching behind his bed on the floor to pick up the call light that was out of reach for resident.During an interview on 08/19/2025 at 4:10 PM, Resident #37 stated call light response depends on the day, and at night he must wait 3 hours for a brief change. He stated he is concerned with having to lay in filth for so long. During an interview on 08/20/2025 at 8:40 AM, Resident #17 stated that staff do not answer the call light and when they do, they will come in and turn it off and not come back. During an interview on 08/20/2025 at 9:41 AM, Resident #3 stated call light response time depends on who is working on the shift. She stated call light response times can take more than 30 minutes during the overnight shifts. She stated she does not like to make waves so she would not speak up about the problem and would wait for staff. In an observation on 08/20/2025 at 10:27 AM revealed Resident #17 pressed the call light to ask for assistance with peri care. At 10:53 AM staff responded to call light, shut it off, and asked Resident #17 if she needed assistance. Resident #17 informed her that she needed to be changed. Staff stated she would get the supplies and return. At 10:58 AM, 31 minutes after the call light was originally pressed, staff returned with peri care supplies and stated she was back to change Resident #17. During an interview on 08/21/2025 at 3:30 PM, CNA J stated he has been in-serviced on resident rights and call lights are to be answered by available staff on the hall. He stated call lights are to be answered within a reasonable timeframe of less than 5 minutes. He stated if staff did not answer call lights in a reasonable timeframe this could cause the residents to become upset and could cause them to feel bad. During an interview on 08/21/2025 at 3:42 PM, CNA G stated she receives continuous in-services on resident rights and call lights. She started the expectation of call lights is to be answered right away, with a reasonable timeframe of 2 minutes or less. She stated if a staff cannot provide care immediately then a reasonable time to return is within 5 minutes to provide the necessary care. She stated 20 minutes or more to answer a call light would make the resident feel neglected. She stated that rounding, peri-care and change motion, rotation should be every 2 hours. She stated if rounding and peri-care is not provided for a resident they can develop bed sores. During an interview on 08/21/2025 at 6:31 PM, CNA I stated she has been in-serviced on call light response times and staff should respond within 1-5 minutes. She stated if staff is unable to provide care immediately the reasonable time to return would be 5-10 minutes. She provided an example requiring 2 staff for transfer, the coordination of staff can take time. She stated 20 minutes or more to answer a call light is unreasonable, and anything could happen in this time. She stated unreasonable response times could cause the residents to feel frustrated and neglected or mad. She stated staff are to provide rounding and per-care every two hours and to ensure resident is clean, as that area is a danger area and needs to stay clean, as resident can develop an infection. During an interview on 8/21/2025 at 6:55 PM, LVN K stated he has been employed one month with this facility and was in-serviced on neglect during orientation and it addressed call lights. He stated call lights are expected to be answered within a reasonable time and are not to be ignored. He believes ASAP is reasonable. He stated call lights should not take more than 10-15 minutes to answer and provide care. He stated 15 minutes is usually when staff is with another resident providing care. He stated not answering call lights is neglectful to residents can cause them mental distress. He stated the expectations for rounding and peri-care is to be thorough, make sure area is clean, brief fits, make sure resident is comfortable before, after, and during the change of their brief. He stated if the resident were not provided rounding and peri-care it could affect their wellbeing and can cause infections, infection control concerns if not staying clean and comfortable. He stated he was unfamiliar with Resident #73 and Resident #3's care as he is new to the facility, but he is working on it. Review of facility policy, undated titled Routine Resident Checks & Call Lights Revised July 2013 revealed Staff shall make routine resident checks to help maintain resident safety and well-being. 1. To ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each unit at least every 2 hours. 2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc.4. The Nursing Supervisor/Charge Nurse shall keep documentation related to these routine checks, including the time, identity of the person making checks, and any outcomes of each check. (Note: CNAs may also record this information and provide it to the Nurse Supervisor/Charge Nurse.)5. This also includes answering the call light in a timely manner. Review of facility policy, undated, titled, Resident Rights revealed Employees shall treat all residents with kindness, respect, and dignity: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence.b. be treated with respect, kindness, and dignity.c. be free from abuse, neglect, misappropriation of property, and exploitation.f. communication with and access to people and services, both inside and outside the facility.

Based on observations, interviews, and record review the facility failed to maintain essential kitchen equipment in safe operating conditions and according to manufacturers' specifications for the facility's one walk-in refrigerator and one walk-in freezer. 1. The facility failed to ensure that the walk-in freezer temperature was in safe operating conditions of 0 . 2. The facility failed to ensure the walk-in refrigerator's cooling fans were in safe operating conditions. These failures could place residents at risk for health complications, foodborne illnesses, and decreased quality of life. Findings include: Observation in the kitchen on 08/19/2025 at 4:37 PM revealed the walk-in freezer thermometer panel mount temperature was reading 3 . Observation in the kitchen on 08/20/2025 at 10:59 AM revealed the walk-in freezer thermometer panel mount temperature was reading 3 . Observation and interview in the kitchen on 08/20/2025 at 11:00 AM revealed a slow steady water leak from the bottom of the refrigerator cooling fans dripping into a large black plastic bin positioned directly underneath. CDM stated this was a new leak that has been reported to the maintenance staff for immediate repairs. She stated the black plastic bin is to keep the water from leaking onto the food stored on the shelf. She stated all packaged food was removed from this shelf temporarily awaiting repairs. She stated she believes the walk-in freezer temperature is above 0 as staff have been in and out of it this morning prepping foods for the day and organizing frozen foods. During an interview on 08/20/2025 at 1:13 PM, MAIN stated kitchen work orders are managed by him and one other staff. He stated he will reach out to 3rd party contractors if unable to make a repair himself, such as the walk-in refrigerator and walk-in freezer. He stated the leak was reported to him last week some time, the refrigeration contractor visited the facility last week to look at it. He stated there was a delivery last week and staff had the refrigeration doors open, and a lot of condensation was building up when the contractor was assessing. He stated the contractor recommended for him to look at adding some fans to the refrigerator, so it does not create condensation. He stated he also believed since the freezer doors were open for delivery it caused the temperature to rise. He stated kitchen staff are emptying the black plastic bin during morning and night shifts. He stated he has been researching how to run fans for the condensation build up, and he will have to put in electrical system to install the fans. He stated he looked at the inside of the refrigerator not draining. He said he was not sure about the water build up. He said he was looking getting air curtains for the doors. He stated he has requested invoices and estimates for this work. MAIN stated if water were to leak onto the stored food staff should not use as this could affect the residents and make them sick. Surveyor requested work orders submitted for temperatures and water leak concerns, invoices, and estimates from contractors regarding recommendations and repairs and recommended plan to repair the refrigeration systems. These items were not provided prior to exit. Observation on 08/21/2025 at 9:00 AM revealed the walk-in freezer thermometer panel mount temperature was reading 15 and the 2 dial freezer thermometer located in the walk-in freezer was reading 30 . Observation on 08/21/2025 at 9:07 AM revealed the walk-in freezer thermometer panel mount temperature was reading 15 and the 2 dial freezer thermometer located in the walk-in freezer was reading 18 . Observation and interview on 08/21/2025 at 9:11 AM revealed the large black plastic bin positioned directly underneath the cooling fans in the walk-in refrigerator was filled with dirty water that has leaked into it. CDM stated the black bin fills throughout the day and is dumped out every morning and evening shift. She removed the plastic bin to drain water, and the piping of the refrigerator was exposed and had rust and black tape wrapped around the hinges. Observation and interview on 08/21/2025 at 9:12 AM revealed the left side of the cooling fans also had a very slow leak and had dripped into the black large plastic bin that contained cheese blocks. The CDM stated the leak had not been a concern to the left side of the cooling fans and she was not aware of any additional leaks. During an interview on 08/21/2025 at 9:12 AM KH N stated she has been employed a year at this facility and the black plastic bin has been there the entire time and staff have been tasked with emptying out daily. She stated MAIN has been notified numerous times of this concern. She stated residents can become ill if the food is contaminated with leaking water. She stated all staff are responsible for reporting any faulty equipment to the CDM to submit work orders for repairs. During an interview on 08/21/2025 at 9:12 AM, CDM stated she has been employed at the facility since March 2025. She stated the MAIN has been notified numerous times of the walk-in refrigerator leak and walk-in freezer temperatures. She stated she has entered work orders in TELS (software to manage work orders), and MAIN would have access to these workorders. She stated this was a concern that the dietician had addressed with her during her last visit and quality assurance evaluation on 08/08/2025. She stated she is aware this malfunction can be harmful to residents and insisted she has notified the MAIN and ADM of the concerns. During an interview on 08/21/2025 at 9:30 AM, KH O stated that she has been aware of the walk-in refrigerator leak for 2-3 months now. She stated the CDM is aware of the problem. She stated foods can become dangerous for residents if water drips onto it. During an interview on 08/21/2025 at 9:38 AM, CK L stated the leak in the walk-in refrigerator has been ongoing for some time and has not been repaired. She could not recall timeframes but believes a few months. She stated maintenance has assessed the issue and has tried to repair a few times now, but no success. She stated the leak could damage the food stored in the walk-in refrigerator and could make residents sick if water is leaking onto the food. She stated the freezer temperatures have also been reported to CDM and MAIN. She stated MAIN will come in and check the temperature and state the freezer door remains open too long and causes the temperature to go above 0 . She stated the dietitian also addressed this concern a few times during visits. During an interview on 08/21/2025 at 9:53 AM, MAIN stated he talked to a contractor for an estimate to repair the walk-in refrigerator. He stated the parts were not ordered as he had mentioned in an earlier interview. He stated parts have yet to be ordered as the contractor has yet to provide him with an estimate and timeframe to repair the walk-in refrigerator. He stated if the leaking water were to get onto the food stored in the refrigerator it could become contaminated and can cause the residents to become ill. During an interview on 08/21/2025 at 10:00 AM, ADM stated that she was aware of the walk-in refrigerator leak and freezer temperature gauge was having adjustment concerns that were brought to her attention around the 7th or 11th of August 2025. She stated the dietician visited the facility for her monthly evaluations and this concern was discussed and a work order was submitted immediately. She stated KH N is a disgruntled employee and told staff she would be getting people in trouble with the State and is giving an inaccurate timeframe of the walk-in refrigerator leak concerns. She stated her MAIN has been on top of these repairs and it seems to have reached the pinnacle and now needs a contractor that is knowledgeable in repairing refrigeration systems. She stated the MAIN was working on this work order and was trying to get the contractor to provide an estimate for repairs. She stated she was not sure why the delay in getting this estimate to begin the repairs. She stated she will be contacting the contractor herself today to let him know their walk-in refrigerator is a priority and he needs to be here today to repair the leaking refrigerator and the temperature gauge for the walk-in freezer or she would be canceling his contract with the facility. Observation on 08/21/2025 at 12:22 PM revealed two 2 dial freezer thermometers were reading 2 and the other reading 36 . Review of Work Order #1930 created on 08/11/ 2025 titled, Condensation walker in cooler revealed it was submitted for the kitchen and requested by CDM with a medium priority. Status was set to in-progress by MAIN. No details as to the work order progress. Review of third-party contractor email, 08/20/2025 1:32 PM, titled WIC (walk in cooler) revealed correspondence from contractor to MAIN, Per our recent conversation about our site visit last week, I am still working with the manufacture on upgrading the drainage system and installing additional ventilation. I will reach back out for an update and circle back to you shortly. Review of third-party contractor email, 08/21/2025 10:35 AM, titled Walk in cooler and Freezer revealed correspondence from contractor to MAIN, Touching base again, I was able to produce a resolution with the manufacturer on your Walk In cooler Issues. I have a tech that will be on site today between 3-5, He will also be addressing any temporary issues with your freezer while on site also. Review of facility report, 08/20/2025, titled Work Order revealed closed work orders submitted for repairs from 05/15/2025 to 08/20/2025: Work order #1811 submitted on 06/26/2025 by CDM, summary request adjust temperature of freezer. Work order #1933 submitted on 08/13/2025, no staff listed, summary request sealed cooler cracks. Review of facility reports, 06/10/2025 to 08/08/2025, titled QA I Monitor revealed the kitchen underwent monthly quality assurance evaluations conducted by the facilities' licensed dietician and results were reviewed and shared with the CDM and ADM. Areas of non-compliance and comments provided by dietician include: 08/08/2025 Section 5: Food Storage: Refrigerators (32-41 ) and freezers (0 or lower) at proper temperature; logs complete, internal thermometers present in each cooler/freezer.Foods free from freezer burn, dried out appearance, or other signs of quality change. Shelves, interior fans, gaskets, floors, walls clean and in good repair, shelves not lined with paper. Section 8: General Comments and Progress from Last Report: condensation continues with fresh produce continually stored beneath despite RD encouragement to relocate - this is significant contamination risk. 07/10/2025 Section 5: Food Storage: Coolers and freezers not overstocked to promote air circulation.Foods free from freezer burn, dried out appearance, or other signs of quality change. Section 8: General Comments and Progress from Last Report: significant condensation in fridge dripping into pan but also outside onto RTE foods - RD encouraged placing in TELS (software to manage work orders) and removing open RTE food from the area. Review of facility spreadsheet, undated, untitled, revealed dietician outlined problem areas in the kitchen, goals to correct, and specific tasks to successfully meet goals: 08/08/2025 Condensation leakage continues onto ready to eat foods despite RD encouragement for relocation of high-risk foods; interior of refrigerators/freezers are clean, and parts are in good repair; REMOVE ALL OPEN/READY TO EAT FOODS FROM BELOW CONDENSER. Comments: ensure storage of ready to eat items are free from condensation - no changes in last 3 visits with this issue. Review of facility policy undated, titled Refrigerators and Freezers revealed, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. 1. Refrigerators and/or freezers are maintained in good working condition. 4. The supervisor takes immediate action if temperatures are out of range. Actions necessary to correct the temperatures are recorded on the tracking sheet, including the repair personnel and/or department contacted. 8. Maintenance will inspect refrigerators and freezers for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately. Review of facility policy, undated, titled Maintenance Service revealed, 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include but are not limited to: f. Establishing priorities in providing repair service. h. Providing routinely scheduled maintenance service to all areas.

Based on record reviews and interviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles, for 2 of 3 (SW, and Marketing) staff reviewed for training in Care Plans and PASRR services in that:The facility failed to train the Social Worker in the assigned SW areas in the PASRR, and updating the Care Plans for advance directives. The facility failed to train the Marketing person about ensuring a PASRR was received at admission.This failure could place residents at risk for harm by not having a complete and accurate care plan or having a PASRR completed to support the residents needs and preferences. The finding included:Resident #7 Review of Resident #7's face sheet dated [DATE] revealed an [AGE] year-old male who was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infraction affecting right dominant side (paralysis and weakness on right side after stroke), muscle weakness, dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), lack of coordination, adjustment disorder, hypertensive heart disease without heart failure (damage to heart due to chronic high blood pressure), repeated falls, cerebral infraction (long term effects of a stroke), and protein-calorie malnutrition (inadequate intake of both protein and calories). Review of Resident #7's quarterly MDS dated [DATE] revealed Resident #7 had a BIMS of 08 indicating moderate impairment. The MDS also did not have Resident #7's code status. Record review of Resident #7's care plan dated [DATE] revealed Resident #7 revealed that Resident #7 was a full code. Goal was Resident #7 would be provided with necessary resuscitative measures. Interventions were to advise MD, RP & family of any changes in condition per facility policy. Educate and discuss with resident/family about Full Code status versus OOHDNR code status on an annual basis or as needed. Review Advanced Directives with resident/family annually, upon change in condition andas needed. Record review of Resident #7's Advance Directive Order dated [DATE] revealed Resident #7 was a DNR. Record review of Resident #7's OOHDNR dated [DATE] had all the required signatures. Resident #17 Record review of Resident #17's admission sheet, dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including cystitis without hematuria (inflammation of the bladder), somatization disorder (tendency to experience and express psychological distress as physical symptoms), fusion of the spine (surgical procedure that connect two or more parts in the spine), muscle weakness, congenital malformation of nervous system (birth defect that affects the structure and development of the brain and spinal cord), lack of coordination, anxiety disorder (feeling of uneasiness or worry) and hypertension (high blood pressure). Record review of Resident #17's admission MDS assessment, dated [DATE], revealed Resident #17 had a BIMS score of 13, indicating intact cognitive response; mood indicators were present including little interest or pleasure in doing things, feeling down, depressed, or hopeless. The MDS also had somatization disorder (tendency to experience and express psychological distress as physical symptoms), and anxiety disorder (feeling of uneasiness or worry) as active diagnoses. Record review of Resident #17's care plan, dated on [DATE] noted the resident used an anti-anxiety medication r/t anxiety. The goal was that Resident #17 would be free from discomfort or adverse reactions related to anti-anxiety therapy. The interventions were Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucination. Record review revealed that Resident #17 did not have a PASRR completed. Resident #31 Review of Resident #31's face sheet dated [DATE] revealed an [AGE] year-old male who was admitted on [DATE] with diagnoses including muscle weakness, neurocognitive disorder with Lewy bodies (type of progressive dementia that leads to a decline in thinking, reasoning, and independent function), vascular dementia (lack of blood that carries oxygen and nutrients to a part of the brain), anxiety (feeling of uneasiness or worry), hypertensive heart disease without heart failure (damage to heart due to chronic high blood pressure), hyperlipidemia (high cholesterol), fall and anemia (not enough healthy red blood cells). Review of Resident #31's quarterly MDS dated [DATE] revealed Resident #31 had a BIMS of 12 indicating moderate impairment. The MDS also did not have Resident #31's code status. Record review of Resident #31's care plan dated [DATE] revealed Resident #31 revealed that Resident #31 did not have a code status on his care plan. Record review of Resident #31's Advance Directive Order dated [DATE] revealed Resident #31 was a DNR. Record review of Resident #31's OOHDNR dated [DATE] had all the required signatures. During an interview with the SW on [DATE] at 2:38p.m., revealed that she had not been trained on care plans. She said that she did not know what the policy was for the care plans. She said that she did not know who was responsible for updating the advance directives. She said the code status is in the care plan. She also said that if a resident changed their code status she would wait until she got the completed DNR back before she would update the care plan. She said she had two weeks to update the care plan. She said if the code status were not updated a resident who was a DNR could possibly be given CPR. She said she did not know why Resident #7's code status was not updated. She also said she did not know why Resident #31's code status was not in the care plan. She also stated that she did not have anything to do with PASRR. During an interview with Resident #17 on [DATE] at 11:02 a.m., Resident #17 said that she was diagnosed with her mental disorders when she was [AGE] years old. She said that she is taking anxiety medication. She said that the only other service that she is getting for her mental illness is seeing the psychiatrist. During an interview with Marketing on [DATE] at 11:30pm revealed that she had not been completely trained on PASRR. She said that she was responsible for making sure that the resident had a PASRR when they entered the facility. She said the only training she got on PASRR was that the PASRR needed to be filled out. She said she could not answer the question of the process, or referrals. She also said she did not know when the PASRR should be done. She said all she knew was that the resident needed a PASRR when the resident admitted to the facility for skilled. She said she did not know that she needed a PASRR for long term care. She said she was confused on that part. She said she did not know what to do if a resident had a positive PASRR. She said that her job was to go out and educate the community about the facility's services. She said when a referral came in, she would just send an email with the resident's clinical records. She said she did not know what could happen to the residents if they did not have a PASRR. She said she did not know why the Resident #17 did not have the PASRR on admission. During an interview with the ADM on [DATE] at 11:40 a.m., revealed that she had been trained on PASRR. She said that the SW was responsible for doing PASRRs. She also said that the SW was responsible for ensuring all residents had a PASRR. She said she did not have a policy for PASRR. She said that the facility would get the PASRR for the resident from the hospital and if the resident were coming from the community the facility would have the family fill the PASRR out. She said all residents were to have a PASRR completed prior to admission into the facility. She said the facility would identify residents with possible MI or ID through the PASRR screening. She said the resident with a qualifying diagnosis should be referred to the PASRR person and a meeting set up with PASRR people. She said the facility did not have anyone who ensured staff competency in PASRR. She said if a resident did not have a PASRR the facility would not recognize if the resident were positive or not and the resident could be missing services. She said Resident #17 did not have a PASRR because Marketing did not get the PASRR on admission. During an interview with the ADM on [DATE] at 3:50p.m., revealed that she had been trained on care plans. She said the IDT team, MDS nurse, therapy and nursing were responsible for doing the care plan. She said all the resident's information, goals, focus for the resident and the resident's discharge plans were on the care plan. She said the care plan had to be completed in 7 days and was updated quarterly. She said the SW was responsible for updating the advance directives. She said the advance directives were to be updated immediately. She said if the care plan is not updated or did not have a resident's advance directive it could affect the outcome if something happened to the resident. She said that the SW knew that she was supposed to update the Advance directives. She said she did not know why Resident #7's advance directive was not updated. She also said she did not know why Resident #31's advance directive was not on the care plan. During an interview with the DON on [DATE] at 4:17p.m., revealed she had not been trained on care plans. She said she was knowledgeable from working in PCC and knew how to do the care plans. She said that the RN opened the care plan, the MDS followed up and the DON reviewed the care plan. She said the care plan had the resident's skin integrity, medication, if the resident refused medication, any chronic conditions, advance directives, and infections. She said she did not know how long the facility had to complete the care plan. She did say that the baseline care plan had to be updated within 48 hours. She said that the care plan was updated quarterly or as soon as a significate change happened. She said advance directives did go on the care plan. She said if a resident went from a full code to DNR the facility had to do a document and uploaded. She said then the code status needed to be changed in the care plan. She said if an advance directive was not correct on the care plan staff may do CPR on a resident who should not be getting CPR. She said she did not know why Resident #7's advance directive was not updated. She also said she did not know why Resident #31's advance directive was not on the care plan. Record review of Marketings employee training dated [DATE] revealed she did not have any documentation for PASRR training. Record review of SW employee training dated [DATE] revealed she did not have any documentation of training for PASRR or Care Plans. Staff Training Policy was requested from the ADM on [DATE] at 11:13am. The policy was not provided upon exit.

Based on observation, interview and record review the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 of 15 residents (Resident #17, Resident #35, and Resident #80) reviewed for resident rights. The facility failed to ensure CNA A and LVN B knocked on Resident #17, Resident #35, and Resident #80's doors when going into the residents' rooms. The deficient practice could place residents at risk of poor self-esteem and feeling like their privacy was being invaded or the facility was not their home.Findings include: 1. Record review of Resident #17's admission sheet, dated 08/19/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included cystitis without hematuria (inflammation of the bladder), somatization disorder (tendency to experience and express psychological distress as physical symptoms), fusion of the spine (surgical procedure that connect two or more parts in the spine), muscle weakness, congenital malformation of nervous system (birth defect that affects the structure and development of the brain and spinal cord), lack of coordination, anxiety disorder (feeling of uneasiness or worry) and hypertension (high blood pressure). Record review of Resident #17's admission MDS assessment, dated 06/23/2025, revealed Resident #17 had a BIMS score of 13, which indicated intact cognitive response. Observation of hall meal tray pass on 08/19/2025 at 12:07 p.m., revealed CNA A did not knock on Resident #17's door before entering her room. During an interview with Resident #17 on 08/19/2025 at 11:01 AM revealed staff did not always knock on the door before entering. She said she would like for them to knock all the time before they entered her room. She said she did not get upset when they did not knock. 2. Record review of Resident #35's admission sheet, dated 08/19/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included muscle wasting, muscle weakness, glaucoma (eye disease), hypertensive heart disease without heart failure (damage to heart due to chronic high blood pressure), gastritis (swelling of the lining of the stomach), dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), lack of coordination, abnormalities of gait and mobility, and cognitive communication deficit (problems with communication). Record review of Resident #35's admission MDS assessment, dated 05/09/2025, revealed Resident #35 had a BIMS score of 13, which indicated intact cognitive response. Observation of hall meal tray pass on 08/19/2025 at 12:12 p.m., revealed LVN B did not knock on Resident #35's door before entering her room. During an interview with Resident #35 on 08/19/2025 3:45 PM revealed staff did not knock on the door all the time. She said she would like the staff to knock all the time. She said it bothered her when staff did not knock because it startled her. 3. Record review of Resident #80's admission sheet, dated 08/19/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #80 had diagnoses which included dementia (memory, thinking, difficulty), unsteadiness on feet, paroxysmal atrial fibrillation (irregular heartbeat that comes and goes), chronic obstructive pulmonary disease (chronic progressive lung disease), anxiety (feeling of uneasiness or worry), kidney disease, hypertensive heart disease with heart failure (damage to heart and heart failure due to chronic high blood pressure), hyperlipidemia (high cholesterol), abnormalities of gait and mobility, insomnia (difficulty sleeping) and cognitive communication deficit (problems with communication). Record review of Resident #80's Quarterly MDS assessment, dated 06/14/2025, revealed Resident #80 had a BIMS score of 15, which indicated intact cognitive response. Observation of halls on 08/20/2025 at 10:45a.m., revealed CNA A did not knock on Resident #80's door before entering her room. During an interview with Resident #80 on 08/19/2025 at 3:35 PM revealed staff did not always knock on the resident's door before entering. She said it bothered her when staff did not knock. She said she would like for staff to knock all the time before entering. During an interview with CNA A on 08/21/2025 at 1:16 PM revealed he was trained on resident rights. He stated the policy was to knock and introduce yourself before entering the resident's room because it was there home. CNA A stated staff should always knock on the door. He said anybody who wanted to go into the resident's room should be knocking. He said the residents did not like staff not knocking. He said it would be like just walking into the resident's house and that was not ok. He said no one monitored to ensure staff were knocking. He said they just had an in-service on knocking this week. He said he did not know why he did not knock on the residents' doors. During an interview with LVN B on 08/21/2025 at 1:30 PM revealed she was trained on resident rights. She said the policy was to knock and introduce yourself to the resident for dignity. She said staff did not just enter. Every time staff wanted to enter the resident's room staff should knock. There was no time staff did not have to knock. She said the resident may feel disrespected if staff did not knock. She said the team watched each other through observations. She said the staff would let each other know if someone forgot to knock. She said she did not know why she did not knock. She also said maybe the door was open but even then, she would have to knock. During an interview with the ADM on 08/21/2025 at 3:37 PM, revealed she and staff were trained on resident rights. She said the policy was staff should knock, announce themselves and let the resident know why the staff member was there. She said all staff were to always knock before going into the resident's room. She said if staff did not knock before entering the room the resident may feel scared or not know who is coming in the room. She said there was never a time when staff did not have to knock on the door before entering. She said knocking was monitored by the charge nurses and administration. She said knocking was monitored through observations and doing rounds. She said she did not know why staff did not knock on Resident #17, Resident #35, and Resident #80's door before entering. During an interview with the DON on 08/21/2025 at 3:40 p.m., revealed she and staff were trained on resident rights. She said the policy for knocking was staff should knock before entering, wait for a response, and let the resident tell the staff to come in. She said staff should knock any time they went into the residents' rooms. She said if staff did not knock on the resident's door the resident may feel bad because the facility was the resident's home. She said there was never a time staff did not have to knock on the resident's door. She said the charge nurses and the managers were responsible for monitoring to ensure staff were knocking. She said knocking was monitored by observations. She said she did not know why staff did not knock on Resident #17, Resident #35, and Resident #80's door before entering. Record review of the facility's, undated, Resident Rights Policy revealed employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality.

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 3 residents (Resident #48, Resident #68, and Resident #93) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #48's admission MDS, dated [DATE], accurately reflected his smoking status.2. The facility failed to ensure Resident #68's quarterly MDS, dated [DATE], accurately reflected her smoking status. 3. The facility failed to ensure Resident #93's quarterly MDS, dated [DATE], accurately reflected her smoking status. These failures could place residents at risk of inadequate supervision due to an inaccurate assessment for smoking status. Findings include: 1. Record review of Resident #48's face sheet, dated 08/20/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #48 had a diagnosis which included hemiplegia (paralysis and weakness on one side of the body that can affect the arms, legs, and facial muscles). Record review of Resident #48's admission MDS, dated [DATE], revealed Resident #48 had a BIMS of 14, which indicated intact cognitive response. The MDS also revealed current tobacco use was not checked. Record review of Resident #48's care plan, dated 8/14/2025, revealed Resident #48 was a smoker. The goal in place was the resident will not suffer injury from unsafe smoking practices through the review. Interventions were instructing resident about smoking risks and hazards and about smoking cessation aids that were available. Instruct resident about the facility policy on smoking: locations, times, safety concerns. Smoking assessment per facility Policy. Record review of Resident #48's Smoking Assessment, dated 8/15/2025, revealed Resident #48 required partial physical assistance with mobility and supervision during smoke break. 2. Record review of Resident #68's face sheet, dated 08/19/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #68 had diagnoses which included cerebral infraction (stroke), major depressive disorder (mental health disorder characterized by persistent depressed mood), lack of coordination, viral hepatitis C (a bloodborne virus that causes liver inflammation), Parkinson's disease (a progressive disorder that affects the nervous system), anxiety (feeling of uneasiness or worry), muscle weakness and morbid obesity. Record review of Resident #68's quarterly MDS, dated [DATE], revealed Resident #68 had a BIMS of 15, which indicated intact cognitive response. The MDS also revealed current tobacco use was not on the MDS. Record review of Resident #68's care plan, dated 07/29/2025, revealed Resident #68 did not have her smoking status on the care plan. Record review of Resident #68's Smoking Assessment, dated 06/02/2025, revealed Resident #68 required supervision and one-on-one assistance. The resident needed to be supervised due to contractions. 3. Record review of Resident #93's face sheet, dated 08/20/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #93 had diagnoses which included lack of coordination, anemia (not enough healthy red blood cells), Schizophrenia (mental disorder that affects a person's ability to think, feel and behave clearly), bipolar (extreme mood swings), anxiety (feeling of uneasiness or worry), depressive disorder (mental health disorder characterized by persistent depressed mood), hypertension (high blood pressure), insomnia (difficulty sleeping), muscle wasting, muscle weakness, and lack of coordination. Record review of Resident #93's admission MDS, dated [DATE], revealed Resident #93 had a BIMS of 15, which included intact cognitive response. The MDS also revealed current tobacco use was not checked on the MDS. Record review of Resident #93's care plan, dated 08/14/2025, revealed Resident #93 did not have her smoking status on the care plan. Record review of Resident #93's Smoking Assessment, dated 08/17/2025, revealed Resident #93 required supervision when smoking. The resident could light her own cigarette, but the facility would follow policy and have the resident supervised. During an interview with the MDSN on 08/21/2025 at 2:02 p.m., revealed she was trained on the MDS but not at the facility. She said the IDT was responsible for the MDS, but she completed most of the MDS's. She said information that was on the MDS were assessments, pain, and data collection from a resident's medical records. She said the MDS should be updated when there was a significate change, or a regulatory requirement. She said she had fourteen days from admission to complete the MDS. She said there was a question on the MDS about the resident's tobacco use and if the resident were a smoker, it would be checked yes. She said if the resident's smoking status were not coded correctly it would not get addressed. She said staff may not know who needs supervision. She said she was never told who smokers were did not answer why she did not know. She said the reason Resident #48, Resident #68, and Resident #93's smoking status was not on the MDS, was because she did not know who the smokers were. She also said she assumed there was not a list available or a clear way of knowing who the smokers were. During an interview with the SW on 08/21/2025 at 2:38 p.m., revealed she had not had any formal training on MDS's or care plans. She said she did not have anything to do with the MDS. Said then said she entered behavior notes and she did sections B, C, D, E and Q (section B covered hearing, vision and speech, section C covered cognitive patterns, section D covered mood, section E covered behavior and Q covered participation in assessment and goal setting). She said every department would have a part on the MDS and care plan. She also said she did not put the smoking status on the MDS. She said the MDS would make a list of things that needed to be done on the MDS, or care plan and staff would go through it daily. She said if a resident did not have their smoking status on the MDS the resident may not get the proper supervision. She said she did not know why Resident #48, Resident #68, and Resident #93's smoking status was not on the MDS. During an interview with the ADM on 08/21/2025 at 3:44 p.m., revealed she had not been trained on MDS's. She said the MDS nurse was responsible for doing the MDS. She said the resident's current smoking status was to be on the MDS. She said if the resident's smoking status were not on the MDS the information would be inaccurate and staff would not know the resident was a smoker. She said staff would not know if the resident needed an apron or supervision. She said she did not know why Resident #48, Resident #68, and Resident #93's smoking status was not on the MDS. During an interview with the ADM on 08/20/2025 at 4:17p.m., the MDS Policy and Accuracy of Assessments Policy was requested from the ADM and was not received on exit. Record review of the Smoking Residents provided on 08/19/2025 revealed that Resident #48, Resident #68, and Resident #93 were all smokers. Record review of the Smoking Residents list provided on 08/19/2025 revealed Resident #48, Resident #68, and Resident #93 were all smokers.

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 residents rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 8 of 16 (Resident #7, Resident #10, Resident #17, Resident #21 Resident #31, Resident #65, Resident #68 and Resident #86) reviewed for care plans. 1. The facility failed to ensure Resident #7's comprehensive care plan was updated after the code status was changed from full code to DNR on [DATE]. 2. The facility failed to ensure Resident # 10, Resident #17 and Resident #21's comprehensive care plan was updated with Resident #10, Resident #17, and Resident #21's in room activity needs. 3. The facility failed to ensure Resident #31's comprehensive care plan was updated with Resident #31's advance directive when the care plan was completed on [DATE].4. The facility failed to ensure Resident #65 and Resident #86's comprehensive care plan was updated to include contact isolation.5. The facility failed to ensure Resident #68's comprehensive care plan was updated with her smoking status when the care plan was completed on [DATE]. This deficient practice could place residents at risk of not being provided with the necessary care or services and the implementation of personalized plan of care developed to address their specific needs. The findings include: 1. Record review of Resident #7's face sheet, dated [DATE], revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included hemiplegia and hemiparesis following cerebral infraction affecting right dominant side (paralysis and weakness on right side after stroke), muscle weakness, dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), lack of coordination, adjustment disorder, hypertensive heart disease without heart failure (damage to heart due to chronic high blood pressure), repeated falls, cerebral infraction (long term effects of a stroke), and protein-calorie malnutrition (inadequate intake of both protein and calories). Record review of Resident #7's quarterly MDS, dated [DATE], revealed Resident #7 had a BIMS of 08, which indicated moderate impairment. The MDS did not document Resident #7's code status. Record review of Resident #7's care plan, dated [DATE], revealed Resident #7 was a full code. The Goal was Resident #7 would be provided with necessary resuscitative measures. Interventions were to advise MD, RP & family of any changes in condition per facility policy. Educate and discuss with resident/family about Full Code status versus OOHDNR code status on an annual basis or as needed. Review Advanced Directives with resident/family annually, upon change in condition andas needed. Record review of Resident #7's Advance Directive Order, dated [DATE], revealed Resident #7 was a DNR. Record review of Resident #7's OOHDNR, dated [DATE], had all the required signatures (doctor signature, RP signature and witness signatures). 2. Record review of Resident #10's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident#10 had a diagnosis which included depression (when a person experiences a persistent sad mood), cognitive communication deficit (communication skills that results from impaired memory, attention, reasoning, and problem-solving which are necessary for effective communication), and generalized anxiety disorder (excessive, persistent, and unrealistic worry about everyday things). Record review of Resident#10's admission MDS Assessment, dated [DATE], reflected Resident #10 had a BIMS score of 15, which indicated her cognition was intact. The following activities were very important to Resident #10: reading, music, being around animals, keep up with the news, going outside for fresh air and participating in religious practices. Record review of Resident#10's Comprehensive Care Plan, revised on [DATE], did not reflect Resident #10's activity plan. 3. Record review of Resident #17's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had a diagnosis which included somatization disorder (a mental health condition characterized by excessive focus on physical symptoms, causing significant distress and functional impairment. Intense worry and preoccupation with these symptoms), congenital malformation of nervous system, unspecified (a birth defect affecting the structure or function of the brain, spinal cord, or other parts of the nervous system, but the specific type of malformation is not known), and anxiety disorder ( a mental health condition characterized by excessive and persistent fear, worry or tension that interferes with daily life causing distress). Record review of Resident #17's admission MDS Assessment, dated [DATE], reflected Resident #15 had a BIMS score of 13, which indicated her cognition was intact. The following activities were important to Resident#17: listening to music, being around animals, keep up with the news, go outside when the weather was good and participate in religious services and practices. Record review of Resident #17's Comprehensive Care Plan, dated [DATE], reflected the resident's current activity plan was not documented. 4. Record review of Resident # 21's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #21 had a diagnoses which included cognitive communication deficit (communication skills that results from impaired memory, attention, reasoning, and problem-solving which are necessary for effective communication), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety ( it is a group of symptoms that can affect thinking, memory, and reasoning without behaviors), and adult failure to thrive ( a syndrome of general decline in an older adult's physical and functional capabilities, marked by symptoms like weight loss, poor appetite, and decrease in physical activity). Record review of Resident #21's admission MDS Assessment, dated [DATE], reflected Resident #21 had a BIMS score of 15, which indicated her cognition was intact. The following activities were very important to Resident #21: reading, listen to music, being around animals, keep up with the news, going outside to get fresh air when weather permits. Record review of Resident #21's Quarterly MDS Assessment, dated [DATE], reflected Resident #21 had a BIMS score of 11, which indicated her cognition was moderately impaired. Record review of Resident #21's Comprehensive Care Plan, dated [DATE], reflected Resident #21 did not have an activity care plan. 5. Record review of Resident #31's face sheet, dated [DATE], revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #31 had diagnoses which included muscle weakness, neurocognitive disorder with Lewy bodies (type of progressive dementia that leads to a decline in thinking, reasoning, and independent function), vascular dementia (lack of blood that carries oxygen and nutrients to a part of the brain), anxiety (feeling of uneasiness or worry), hypertensive heart disease without heart failure (damage to heart due to chronic high blood pressure), hyperlipidemia (high cholesterol), fall and anemia (not enough healthy red blood cells). Record review of Resident #31's quarterly MDS, dated [DATE], revealed Resident #31 had a BIMS of 12, which indicated moderate impairment. The MDS also did not have Resident #31's code status. Record review of Resident #31's care plan, dated [DATE], revealed Resident #31 did not have a code status documented on his care plan. Record review of Resident #31's Advance Directive Order, dated [DATE], revealed Resident #31 was a DNR. Record review of Resident #31's OOHDNR, dated [DATE], had all the required signatures (doctor signature, RP signature and witness signatures). 6. Record review of Resident #65's face sheet, dated on [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #65 had diagnoses which included local infection of the skin and subcutaneous tissue, unspecified (a bacterial or fungal infection affecting a specific, limited area of the outer skin layers and the tissue beneath it), non-pressure chronic ulcer of skin of other sites limited to breakdown of skin (an open ,non-healing sore on the skin, not caused by prolonged pressure), and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (hemiplegia refers to paralysis- complete inability to move and hemiparesis - weakness). Record review of Resident # 65's admission MDS Assessment, dated [DATE], reflected Resident #65 had a BIMS score of 10, which indicated her cognition was moderately impaired. Resident #65 had stage 4 pressure ulcer. Record review of Resident #65's Comprehensive Care Plan, dated [DATE], reflected Resident #65 had stage 4 pressure ulcer to sacrum. The pressure ulcer was present upon admission. The care plan did not reflect Resident #65 required contact precautions. 7. Record review of Resident #68's face sheet, dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #68 had diagnoses which included cerebral infraction (stroke), major depressive disorder (mental health disorder characterized by persistent depressed mood), lack of coordination, viral hepatitis C (a bloodborne virus that causes liver inflammation), Parkinson's disease (a progressive disorder that affects the nervous system), anxiety (feeling of uneasiness or worry), muscle weakness and morbid obesity. Record review of Resident #68's quarterly MDS, dated [DATE], revealed Resident #68 had a BIMS of 15, which indicated intact cognitive response. The MDS also revealed current tobacco use was not on the MDS. Record review of Resident #68's care plan, dated [DATE], revealed Resident #68 did not have her smoking status on the care plan. Record review of Resident #68's Smoking Assessment, dated [DATE], revealed Resident #68 required supervision and one-on-one assistance. The resident needed to be supervised due to contractions. 8. Record review of Resident # 86's face sheet, dated on [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #86 diagnoses which included infection following a procedure, superficial incision surgical site, subsequent encounter (a bacterial or other microorganism infection that develops in the top layers of skin at a surgical wound site, rather than a deep one, for a resident receiving later follow-up medical care for the infection), methicillin resistant staphylococcus aureus infection, unspecified site (a common bacteria enter the body through a cut or wound , causing symptoms like red, painful, swollen areas, possibly with pus. Methicillin resistant- the bacteria has developed a resistance to certain antibiotics which are normally used to kill staph), and chronic pain (a long lasting, continuous, or recurring pain that persists for at least three months, beyond the normal healing time). Record review of Resident #86's Quarterly MDS Assessment, dated [DATE], reflected Resident #86 had a BIMS score of 15, which indicated her cognition was intact. Resident #86 had open lesions and skin tears. She received treatment for skin and ulcer/ injuries (non-surgical dressings and ointments) Record review of Resident #86's Comprehensive Care Plan, dated [DATE], reflected Resident #86 was at risk for skin breakdown and pressure ulcer development due to decreased mobility and obesity. Resident #86 comprehensive care plan did not reflect Resident #86 being on contact isolation. During an interview on [DATE] at 1:00 PM the Activity Director did not respond why Resident #21, Resident#17, and Resident #10's activities plan for the next quarter was not documented on the comprehensive care plan. She did not respond why it was important to have the residents in room activities on their care plan. During an interview on [DATE] at 1:59 PM, the MDSN stated infection control protocol was to be followed especially if someone was on contact isolation. She stated touching anything with contaminated gloves was considered cross contamination. The MDS RN stated any time someone was on contact isolation it was expected to be care planned. She stated she would need to review Resident #86 and Resident # 65's care plan to determine if contact isolation were care planned and she would inform the state surveyor with the information she gathered from their medical records. She said that she was responsible for updating the care plans and the IDT developed the care plan. She never reported any information to the state surveyor prior to exit. During an interview with the MDSN on [DATE] at 2:14 p.m., revealed she was trained on care plans. She said IDT was responsible for doing the care plan. She said the care plan had to be opened by the RN, but she did most of the care plan. She said smoking could be nursing or social services. She said the SW was responsible for doing the advance directives. She said she looked for special medication, diagnosis, and high-risk medication. She said she would also put the family dynamics on the care plan. She said the facility had 7 days to complete the care plan. She said the care plan should be updated when there was a change to the resident's care. She said the care plans were updated as needed or when the MDS was due. She said depending on the issue with the care plan depended on who was responsible. She said a resident's advance directive went on the care plan. She said if a resident changed their advance directive the care plan should be updated immediately. She also said smoking went on the care plan. She said if the advance directive and smoking status were not correct on the care plan the person looking at the care plan would not have the appropriate information. She said she assumed the SW did not update the care plans for Resident #7, Resident #31, and Resident #68. During an interview on [DATE] at 2:24 PM, the Treatment Nurse stated Resident #65, and Resident #86 were on contact isolation. She stated both residents had MRSA but in different areas. She stated she would need to review their medical charts and would give the areas on both residents (Resident #65 and Resident #86) and would report to state surveyor. The Treatment Nurse never reported this information to state surveyor prior to exit. She stated both residents were on contact isolation. The Treatment Nurse stated both residents required for gowns and gloves to be worn when giving care. She stated contact isolation was expected to be care planned. She stated if it was not care planned the staff would not have the information, they needed to know why the residents were on contact isolation. The Treatment Nurse stated if the staff had contaminated gloves on, picked up the call light, and placed it on the bed, the call light may become contaminated. She stated if a staff or family member visited the resident and had an open area on their fingers or hand the person may become contaminated with MRSA. he stated if there was a hole in the clear plastic bag and the staff carried the bag down the hall there was a potential if another resident had an open area on their arm and touched the contaminated gowns/gloves in the plastic bag, the resident may become contaminated with MRSA. She stated she had been in-service on infection control, and she was the infection control preventionist. She did not recall the date of her training. During an interview with the SW on [DATE] at 2:38 p.m., revealed she had not been trained on care plans. She said she did not know what the policy was for the care plans. She said she did not know who was responsible for updating the advance directives and smoking status. She said the code status was in the care plan. She said the resident's smoking status was also in the care plan. She said she was not responsible for put a resident's smoking status in the care plan. She said she did not know who put smoking status on the care plan. She also said if a resident changed their code status she would wait until she got the completed DNR back before she would update the care plan. She said she had two weeks to update the care plan. She said if the code status were not updated a resident who was a DNR could possibly be given CPR. She said she did not know why Resident #7's code status was not updated. She said she did not know why Resident #31's code status was not in the care plan or why Resident #68's smoking status was not in the care plan. During an interview on [DATE] at 2:50 p.m. The Director of Nurses stated anytime residents were on contact isolation this was required to be care planned. She stated anytime a resident had any type of infection the care plan was to reflect all interventions required to heal the infection. The Director of Nurses did not respond to other questions related to why it was important for infection and contact isolation needing to be care planned. During an interview with the ADM on [DATE] at 3:50 p.m., revealed she was trained on care plans. She said the IDT team, MDS nurse, therapy and nursing were responsible for doing the care plan. She said all the resident's information, goals, focus for the resident and the resident's discharge plans were on the care plan. She said the care plan had to be completed in 7 days and were updated quarterly. She said the care plan would also be updated in the event of a significate change. She said she thought nursing was responsible for putting a resident's smoking status on the care plan. She said the SW was responsible for updating the advance directives. She said the advance directives were to be updated immediately. She said if the care plan were not updated or did not have a resident's advance directive it could affect the outcome if something happened to the resident. She said if the smoking status was not on the care plan staff would not be able to identify the resident as a smoker. She said she did not know why Resident #7's advance directive was not updated. She also said she did not know why Resident #31's advance directive was not on the care plan. She said she did not know why Resident #68's smoking status was not on the care plan. During an interview with the DON on [DATE] at 4:17p.m., revealed she had not been trained on care plans. She said she was knowledgeable from working in PCC and knew how to do the care plans. She said the RN opened the care plan, the MDS followed up and the DON reviewed the care plan. She said the care plan had the resident's skin integrity, medication, if the resident refused medication, any chronic conditions, advance directives, and infections. She said she did not know how long the facility had to complete the care plan. She said the care plan was updated quarterly or as soon as a significate change happened. She said advance directives and smoking status went on the care plan. She said if a resident went from a full code to DNR the facility had to do a document and uploaded it. She said then the code status needed to be changed in the care plan. She said if an advance directive was not correct on the care plan, staff may do CPR on a resident who should not be getting CPR. She said if the smoking status were not on the care plan there was a possibility the resident would not be monitored or a new issue with smoking identified. She said she did not know why Resident #7's advance directive was not updated. She also said she did not know why Resident #31's advance directive was not on the care plan. She said she did not know why Resident #68's smoking status was not on the care plan. Record review of the facility's, undated, Care Plans, Comprehensive Person-Centered Policy reflected a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Record review of the facility's, undated, Advance Directives Policy reflected the plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. The Interdisciplinary Team will conduct ongoing review of the resident's decision-making capacity and communicate significant changes to the resident's legal representative. Such changes will be documented in the care plan and medical record. The Interdisciplinary Team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS). Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The Attending Physician will not be required to write orders for which he or she has an ethical or conscientious objection. Record review of the facility's Activity Director Job Description, dated [DATE], reflected this person provides for an ongoing program of activities designed to meet, following the comprehensive assessment, the interests, and the physical, mental, and psycho-social well-being of each resident. Contribute to facility efforts to maintain and/or improve quality of care through participation in care plan meetings. Assess resident needs and develop resident activities goals for the written care plan. Signed by: Activity Director on [DATE].

Based on interview and record review the facility failed, to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three of six residents ( Resident #10, Resident #17, and Resident #21) reviewed for activities. The facility failed to provide Resident # 3, Resident #10, Resident #17, and Resident #21 in room activities during July 2025 and August 1st thru August 22, 2025.This failure could place residents at risk for boredom, depression, and a diminished quality of life.Findings include:Record review of Resident #10's face sheet, dated 08/21/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #10 had diagnoses which included depression (when a person experiences a persistent sad mood), cognitive communication deficit (communication skills that results from impaired memory, attention, reasoning, and problem-solving which are necessary for effective communication), and generalized anxiety disorder (excessive, persistent, and unrealistic worry about everyday things). Record review of Resident#10's admission MDS Assessment, dated 05/19/2025, reflected Resident #10 had a BIMS score of 15, which indicated her cognition was intact. The following activities were very important to Resident #10: reading, music, being around animals, keep up with the news, going outside for fresh air and participating in religious practices. Record review of Resident#10's Comprehensive Care Plan, revised on 08/28/2025 did not reflect Resident #10's activity plan. Record review of Resident #17's face sheet, dated 08/21/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included somatization disorder (a mental health condition characterized by excessive focus on physical symptoms, causing significant distress and functional impairment. Intense worry and preoccupation with these symptoms), congenital malformation of nervous system, unspecified (a birth defect affecting the structure or function of the brain, spinal cord, or other parts of the nervous system, but the specific type of malformation is not known), and anxiety disorder (a mental health condition characterized by excessive and persistent fear, worry or tension that interferes with daily life causing distress). Record review of Resident #17's admission MDS Assessment, dated 06/23/2025, reflected Resident #17 had a BIMS score of 13 which indicated her cognition was intact. The following activities were very important to Resident#17: listening to music, being around animals, keep up with the news, go outside when the weather was good and participate in religious services and practices. Record review of Resident #17's Comprehensive Care Plan, dated 07/01/2025 reflected Resident current activity plan was not documented. Record review of Resident # 21's face sheet, dated 8/21/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #21 had diagnoses which included cognitive communication deficit (communication skills that results from impaired memory, attention, reasoning, and problem-solving which are necessary for effective communication), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety (it is a group of symptoms that can affect thinking, memory, and reasoning without behaviors), and adult failure to thrive (a syndrome of general decline in an older adult's physical and functional capabilities, marked by symptoms like weight loss, poor appetite, and decrease in physical activity). Record review of Resident #21's admission MDS Assessment, dated 04/24/2025, reflected Resident #21 had a BIMS score of 15, which indicated her cognition was intact. The following activities were very important to Resident #21: reading, listen to music, being around animals, keep up with the news, going outside to get fresh air when weather permits. Record review of Resident #21's Quarterly MDS Assessment, dated 07/25/2025, reflected Resident #21 had a BIMS score of 11, which indicated her cognition was moderately impaired. Record review of Resident #21's Comprehensive Care Plan, dated 08/08/2025 reflected Resident #21 did not have an activity care plan. Record review of in room activity participation records, dated July 2025 and August 1, 2025, thru August 22, 2025, reflected Resident # 10, Resident #17 and Resident #21 did not receive in room activities. Record review of residents to receive in room activities for the month of July 2025 and August 2025 reflected Resident #10, Resident #17, and Resident #21 names were on the in-room record. During an interview with Resident #17 on 08/19/2025 at 10:27 AM, revealed that she does not get any activities. She said staff do not give her any books, puzzles, or anything else. She said she is bed bound and her roommate does not like to talk so she felt like she was just lying there to die.Interview on 08/21/2025 at 1:00 PM, the Activity Director stated Resident #3 did not receive in room activities from 07/03/2025 thru 08/11/2025. The Activity Director stated she was expected to ensure all residents received activities based on their preferences and their physical abilities. She stated if residents were not coming out of their room, the residents were to be provided in room activities. The Activity Director stated she provided in room activities at least twice a week. She stated there was not an excuse why Resident #10, Resident #17 or Resident #21 did not receive in room visits. The Activity Director stated if a resident was not receiving activities on a consistent basis there was a potential a resident may become bored, depressed, or have a decline in their quality of life. She stated she was responsible for ensuring all residents received their activity needs including in room activities. Interview on 08/21/2025 at 1:30 PM, the Administrator stated she expected in room activities be provided to the residents needing these types of activities. She stated if a resident was not receiving in room activities there was a possibility a resident may become depressed, bored, and isolated. She stated the Activity Director was responsible for all activities in the facility. She stated she was responsible for monitoring the Activity Director. The Administrator stated it was very important for all residents to receive the activities they needed to enhance their overall quality of life. Record review of the facility's Activity Documentation Policy, not dated, reflected the Activity Director shall coordinate and supervise all documentation and be ultimately responsible for all areas of documentation, according to required timeframes and practice guidelines. The following areas are considered documentation responsibilities of the Activity Director and staff and should be completed in a comprehensive and timely manner such as: resident participation records. All documentation is completed in a manner consistent with health care center policy and applicable state and federal laws.Record review of the facility's Activity Director Job Description, dated 01/30/2025, reflected this person provides for an ongoing program of activities designed to meet, following the comprehensive assessment, the interests, and the physical, mental, and psycho-social well-being of each resident. Provide an activities program daily including evenings and weekends. Provide a plan of activities appropriate to the needs of the residents that includes but is not limited to one-to one attention. Encourage resident participation in activities and document outcomes. Signed by: Activity Director on 01/30/2025.

Based on observation, interview and record review the facility failed to ensure the resident had a right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident # 31) reviewed for medical record confidentiality.The facility failed to ensure RN D kept Resident # 31's medical information confidential.This failure could place residents at risk of their medical information being provided to unauthorized personnel, other residents, or visitors.Findings include: Observation on 08/20/2025 from 9:08 AM until 9:12 AM revealed RN D was not at the medication cart. The computer screen was left open and facing the hallway which exposed Resident confidential medical information which included name and medications. Interview on 08/20/2025 at 9:14 AM, RN D stated resident name and monitoring were on the open screen; however, he could not remember if his diagnosis was on the screen. He stated he received in-service to always lock the computer screen when not standing at the medication cart. He stated he did not recall the date he received the in-service on HIPPA. He stated he did not follow HIPPA protocol. RN D stated a visitor, another resident or anyone not an employee at the facility had access to a resident's medical information if they passed by the medication cart. He stated if another resident saw any information and shared with Resident #31, this may be embarrassing to the resident for other residents to see the resident's medical information. Interview on 08/21/2025 at 1:30 PM, the Administrator stated her expectation was for confidentiality of the residents to be protected. She stated computer screens should have been closed when not in use and any paperwork with the resident information should have been covered. She stated that was protected confidential information and it could have been a HIPAA violation.In an interview on 08/21/2025 at 2:50 PM, the DON stated resident information should be kept confidential and if it were not, it would be a HIPAA violation. She stated all computer screens were expected to be locked if a nurse was not viewing a resident's information. She said because if the screen is left open with the resident's information anyone could get that residents information. Record review of the facility's, undated, Policy on Protected Health Information, Safeguarding Electronic, reflected Electronic protected health information is safeguarded by administrative, technical, and physical means to prevent unauthorized access to protected health information. All workstations are protected from unauthorized access by physical barriers that discourage attempts to tamper with or violate security rules, including:a. Placing computer terminals and workstations away from high- traffic areas of the facility.Automatically locking computer screens.

Based on interview and record review, the facility failed to ensure a new resident was not admitted with mental illness unless the state mental health authority determined, based on independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission for 1 of 12 residents (Resident #17) reviewed for PASRR services. The facility failed to ensure a PASRR screening was completed for Resident #17. This deficient practice could place residents at risk for not obtaining the services needed to treat their mental health diagnoses.The findings include: Record review of Resident #17's admission sheet, dated 08/19/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included cystitis without hematuria (inflammation of the bladder), somatization disorder (tendency to experience and express psychological distress as physical symptoms), fusion of the spine (surgical procedure that connect two or more parts in the spine), muscle weakness, congenital malformation of nervous system (birth defect that affects the structure and development of the brain and spinal cord), lack of coordination, anxiety disorder (feeling of uneasiness or worry) and hypertension (high blood pressure). Record review of Resident #17's admission MDS assessment, dated 06/23/2025, revealed Resident #17 had a BIMS score of 13, which indicated intact cognitive response. Resident #17's mood indicators were present which included little interest or pleasure in doing things, feeling down, depressed, or hopeless. The MDS also documented somatization disorder (tendency to experience and express psychological distress as physical symptoms), and anxiety disorder (feeling of uneasiness or worry) as active diagnoses. Record review of Resident #17's care plan, dated on 07/01/2025, noted the resident used an anti-anxiety medication r/t anxiety. The goal was Resident #17 would be free from discomfort or adverse reactions related to anti-anxiety therapy. The interventions were Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucination. Record review revealed Resident #17 did not have a PASRR completed. During an interview with Resident #17 on 08/21/2025 at 11:02 a.m., Resident #17 said she was diagnosed with her mental disorders when she was [AGE] years old. She said she was taking anxiety medication. She said the only other service she was getting for her mental illness was seeing the psychiatrist. She said she did not know if there were other services she might want. During an interview with Marketing on 08/21/2025 at 11:30 p.m. revealed she had not been completely trained on PASRR. She said she was responsible for making sure the resident had a PASRR when they entered the facility. She said the only training she got on PASRR was the PASRR needed to be filled out. She said she could not answer the question of the process, or referrals. She also said she did not know when the PASRR should be done. She said all she knew was the resident needed a PASRR when the resident admitted to the facility for skilled. She said she did not know she needed a PASRR for long term care. She said she was confused on that part. She said she did not know what to do if a resident had a positive PASRR. She said her job was to go out and educate the community about the facility's services. She said when a referral came in, she would send an email the nursing team with the resident's clinical records. She said she did not know what could happen to the residents if they did not have a PASRR. She said she did not know why Resident #17 did not have the PASRR on admission. During an interview with the SW on 08/21/2025 at 2:38 p.m. revealed she had not been trained on PASRR. She also said she did not have anything to do with the PASRR's. During an interview with the MDSN on 08/21/2025 at 2:20 p.m. revealed she was trained on PASRR. She said she did not know what the policy was for PASRR. She said she knew she must have a PASRR before a resident was admitted . She also said if the resident was coming from the community a PASRR needed to be done prior to admission. She said marketing was responsible for ensuring each resident had a PASRR prior to admission. She also said she would ask for the PASRR level one to see if the resident had a qualifying diagnosis. She said if the resident had a qualifying diagnosis, she would submit to the portal so the mental health case worker could come do an assessment on the resident. She said the purpose of the PASRR was to make sure the resident got the services they required and were in the least restrictive environment. She said the facility would have an IDT meeting if the resident had a positive PASRR. She said in the IDT meeting it would discuss the services for the resident and did the referral for the services the resident wanted. She said if the PASRR was not done the facility could not bill Medicaid. She said she monitored the PASRRs on admission and looked at all referrals when she did an admission, and the resident had a qualifying diagnosis, she would do another PASRR. Said she did not know who ensured competency. She said she did not know why Resident #17 did not have a PASRR at admission. During an interview with the ADM on 08/21/2025 at 11:40 a.m., revealed she was trained on PASRR. She said the SW was responsible for doing PASRRs. She also said the SW was responsible for ensuring all residents had a PASRR. She said she did not have a policy for PASRR. She said the facility would get the PASRR for the resident from the hospital and if the resident were coming from the community, the facility would have the family fill the PASRR out. She said all residents were to have a PASRR completed prior to admission into the facility. She said the facility would identify residents with possible MI or ID through the PASRR screening. She said the resident with a qualifying diagnosis should be referred to the PASRR person and a meeting set up with PASRR people. She said the facility did not have anyone who ensured staff competency in PASRR. She said if a resident did not have a PASRR, the facility would not recognize if the resident were positive or not, and the resident could be missing services. She said Resident #17 did not have a PASRR because Marketing did not get the PASRR on admission. During an interview with the ADM on 08/21/2025 at 9:21am the ADM said the facility did not have a PASRR policy. Record review of, undated, Form 1012 Policy and Procedure with Instructions revealed the following: Purpose: Form 1012 assists nursing facilities (NF) in determining whether a resident with a negative Preadmission Screening and Resident Review (PASRR) Level I Screening form submitted into the Long-Term Care (LTC) Portal, needs further evaluation for Mental Illness (Ml). This form is used to determine whether the individual has a primary dementia diagnosis or if the individual has a mental illness diagnosis. This form also serves as the NF's documentation for the individual's medical record as to why further evaluation was or was not completed. Only a physician, which includes a psychiatrist, can complete Section D this form. A Nurse Practitioner or Physician's Assistant cannot complete Section D. Procedure When to Prepare The NF completes Form 1012 following: A determination that a resident with a negative PASRR level 1 screening form submitted into the LTC Portal needs further evaluation for Ml. An individual's diagnosis is changed. The PL 1 on file remains negative. The resident does not need a new PL 1 or further evaluation at this time. A new PL 1 is needed at this time. A full PASRR Evaluation will be conducted after the NF submits a new positive PL 1. After form submission on the LTC Online Portal, include the date of submission and the positive PL 1 document locator number (DLN) on this form. The NF staff completing Form 1012 will complete this section with their name, title, signature, and the date the form was signed. Maintain the completed 1012 form in the individual's medical record.

Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one (Resident #1) of five residents reviewed for pressure injuries. The facility failed to: - Complete weekly skin assessments for Resident #1 or provide treatments from 04/18/25 - 05/06/25 to a pressure area on his left foot which developed into a pressure wound. - Provide wound care consistently to Resident #1's sacral wound causing it to worsen. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 05/06/25 at 4:54 PM, and an IJ template was given. While the IJ was removed on 05/07/25 at 3:45 PM, the facility remained out of compliance at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including complete paraplegia (a form of paralysis that affects the lower half of the body), muscle weakness, and sepsis (a serious condition when the body has an extreme reaction to an infection) to sacral wound. Review of Resident #1's EMR, on 05/06/25, reflected neither his admission nor 5-day MDS assessment had not been completed. Review of Resident #1's EMR, on 05/06/25, reflected his baseline care plan had not been completed. Review of Resident #1's admission skin assessment, dated 04/15/25, reflected he had open areas/lesions: Stage IV pressure ulcer to the sacrum measuring 6.8 cm x 4.7 cm x 5.9 cm. Unstageable pressure area to the left heel measuring 6.0 cm x 8.5 cm x nmcm. Review of Resident #1's Braden Scale, dated 04/16/25, reflected a score of 15, indicating he was a mild risk of developing pressure injuries. Review of Resident #1's physician order, dated 04/15/25, reflected treatment to sacrum: stage 4 pressure: Cleanse wound bed with normal saline or wound cleanser. Pat dry. Apply skin prep to peri wound. Cut foam to fit shape of wound. Place foam in wound bed. Cut foam to buttocks. Cut and apply transparent dressing over foam. Cut a dime size hole in transparent dressing over foam. Apply suction bell/pad over cut hole. Connect the dressing tubing to wound vac. Turn on wound vac to 124mmgh continuous very day shift every Monday, Wednesday, and Friday. Review of Resident #1's TAR, April of 2025, reflected he did not receive treatment to his sacral wound on 04/18/25 and 04/28/25 (two of seven opportunities). Review of Resident #1's TAR, May of 2025, reflected he did not receive treatment to his sacral wound on 05/05/25 (one of two opportunities). Review of Resident #1's physician order, dated 04/16/25, reflected treatment to left heel: unstageable (due to necrosis): Cleanse wound bed with normal saline or wound cleanser. Pat dry. Swab wound bed with betadine. Leave open to air every day shift and as needed. Review of Resident #1's TAR, April of 2025, reflected he did not receive treatment to his left heel on 04/20/25, 04/27/25, 04/28/25, and 04/29/25 (four of 14 opportunities). Review of Resident #1's TAR, April of 2025, reflected he did not receive treatment to his left heel on 05/03/25 and 05/05/25 (two of five opportunities). Review of Resident #1's WCD assessment, dated 04/21/25, reflected a stage 4 pressure wound to his sacrum, measuring, 6.5 cm x 5.5 cm x 5.0 cm (surface area 35.75 cm). There was no assessment of the pressure area to his left heel. Review of Resident #1's WCD assessment, dated 04/30/25, reflected a stage 4 pressure wound to his sacrum, measuring, 6.5 cm x 6 cm x 4.0 cm (surface area 39.0 cm). There were no assessments of the pressure area to his left heel. From his admission skin assessment on 04/15/25 his wound increased from the surface area measuring 31.96 cm to 39.0 cm on 04/30/25. Review of Resident #1's WCD assessment, dated 05/05/25, reflected his visit had been rescheduled. Review of Resident #1's assessments in his EMR, on 05/06/25, reflected no weekly skin assessments had been conducted since the initial skin assessment upon admission. During observation and interview on 05/06/25 at 10:22 AM revealed Resident #1 laying in his bed with his wound vac on and running. He stated he was not sure if he had a wound to his left heel because, due to his paralysis, he could not feel anything. He stated no one had been treating his left heel. He stated the WCD did not see him the day before (05/05/25) because he was eating lunch in the dining room. He stated when he went back to his room, he was told the WCD had already left for the day. He stated he did not believe his wound vac was changed three times a week, but did state it had been changed a few times. He stated it would be okay for his left heel to be observed after lunch. During a telephone interview on 05/06/25 at 11:30 AM, Resident #1's NP stated her expectations were that weekly skin assessments were done weekly by the WCD. She stated if the WCD could not complete an assessment, for whatever reason, the nurses should be conducting the assessment. She stated if resident's skin/wounds were not monitored, they could get worse. She stated if a resident missed one wound vac treatment in a week, they would be okay. During a telephone interview on 05/06/25 at 12:42 PM, the WCD stated he completed wound assessments on the residents weekly. He stated he was at the facility the day prior (05/05/25) and he was told the wound vac had already been changed so he did not complete an assessment because he assumed the nurse who changed the wound vac had completed one. He stated weekly skin assessments were important to determine if there were any changes or if anything was worsening. He stated if a resident had a pressure area, he would expect to be notified so he could assess the area weekly. He stated he was not aware Resident #1 had a pressure area to his left heel. During an interview on 05/06/25 at 1:55 PM, the DON stated it was her second day at the facility. She stated weekly skin assessments should be completed by nurses weekly, regardless of if the resident was seen by the wound care doctor. She stated it was important for the nurses to see all areas of the skin to ensure it was intact. She stated if not, something could be missed or go untreated. She stated it did not meet her expectations that any skin treatments get missed. An observation and interview on 05/06/25 at 2:00 PM revealed Resident #1 laying in his bed. This Surveyor asked permission to have a nurse help to observe his left foot and he agreed. LVN A and the DON entered the room and stated she (LVN A) did wound care rounds with the WCD weekly. She stated she was not sure if the WCD had been assessing his left foot. LVN A left the room and this Surveyor requested she (DON) remove Resident #1's pressure-relieving boot and sock from his left foot. The sock appeared dirty, and she had a difficult time taking it off. When the sock was removed, there was a dressing on his left heel dated 04/18/25. The DON's face was shocked, and she stated having a dressing on with a date from weeks ago, did not meet her expectations. While the DON began peeling/ripping the dressing off, flakes of dislodged skin were seen all around his foot. When the dressing was fully removed, there was a full thickness open wound surrounded by thick white peeling edges with irregular shaped black peri wound. During an interview on 05/06/25 at 3:32 PM, LVN A stated the WCN walked out two weeks ago, and she was trying to pick up the pieces. She stated her first time rounding with the WCD was the week prior. When asked why she had been checking off the treatment to Resident #1's left foot in his TAR, she stated it had been a mistake, she felt horrible, and she could not believe she had missed that. She stated she did not even know why he had a bandage to his left heel because upon admission there was just brown eschar to the area. She stated since they did not have a WCN, skin assessments should be done weekly by the floor nurses. She stated all orders should be followed and completed as ordered and it was unacceptable what happened to Resident #1's heel. Review of the facility's Pressure Ulcers/Skin Breakdown Policy, revised April of 2018, reflected the following: . 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. Review of the facility's Prevention of Pressure Ulcers/Injuries, revised July of 2017, reflected the following: . Risk Assessment: . 4. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. . b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) . Monitoring: 1. Evaluate, report and document potential changes in the skin. The ADM and DON were notified on 05/06/25 at 4:54 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 05/07/25 at 10:17 AM: All items listed will be completed by 7:00PM on 5/6/2025 with continued follow-up for scheduled staff. 1.R#1 immediately received a head-to-toe assessment including skin by the DON, findings of a worsening left heel were relayed to Medical Director and new orders received to clean wound with normal saline, pat dry, apply alginate with silver and cover with non-adherent dressing daily. 2. Findings were relayed to the Medical Director immediately. 3. Emotional Distress Assessment completed for R#1 by the Social Worker on 5/6/2025 with no emotional distress observed. 4. R#1's Care Plan was updated by Corporate MDS Nurse regarding wound care and observations to be performed by staff. All nursing staff were in-serviced including PRN, agency staff and all newly hired staff prior to their shift. 5. On 5/6/2025 charge nurses on staff conducted a 100% skin audit on 78 residents overseen by the DON. Charge nurses were in-serviced on proper skin assessment by the DON prior to the conduction of assessments. No other residents were identified as having unidentified skin issues. 6. Administrator/DON initiated Staff in-service for ALL NURSING STAFF on 5/6/2025 on Prevention of Pressure Ulcers, Pressure Ulcers/Skin Breakdown - Clinical Protocol & Abuse and Neglect. DON trained by VP of Clinical Services prior to start of in-service on 5/6/2025 If staff are unable to attend any of the in-services, they will be required to complete them before starting their assigned shift to include PRN staff, agency staff and any new hires. The Medical Director was first made aware of the Immediate Jeopardy 5/6/2025 at 5:45:00PM and has been involved in developing the Plan of Removal. These conversations are considered a part of the QA process. A QAPI meeting was held on 5/6/2025 with attendance of the Company President, Director of Nursing & VP of Clinical Services. This plan was initially implemented 5/6/2025 and will be monitored through completion by corporate staff. Plan of Removal completion date is 5/7/2025 by 5:00 pm with continuation of oncoming staff and follow up. The Surveyor monitored the POR on 05/07/25 as followed: Observations on 05/07/25 from 2:14 PM - 2:48 PM revealed the VPO conducting a skin assessment on two residents. Both had skin that was intact, no redness, and no concerns. During interviews on 05/07/25 from 11:09 AM - 3:25 PM, four LVNs and three CNAs from different shifts all stated they had been in-serviced before working the floor. The nurses were able to describe how to conduct a head-to-toe skin assessment and the importance of them being completed once a week. The nurses all stated they looked for skin tears, open areas, redness, and focused on areas such as heels and the coccyx. The nurses stated they would notify the NP immediately of any new skin concerns and that weekly skin assessments were important to ensure there were no new skin areas and wounds were not worsening. The nurses stated it was important to ensure staff were only signing off on orders they completed. The aides stated whenever they gave care or showers to residents, they were to notify the nurses immediately of any changes in the skin such as rashes, bruises, or redness. The aides stated any kind of bath/shower, including a bed bath, should include washing the whole body, including the residents' feet. Review of the facility's QAPI minutes, dated 05/06/25, reflected the ADM, the DON, the MDSC, and the MD were in attendance. Review of Resident #1's Emotional Distress Assessment, dated 05/06/25 and conducted by the SW, reflected no emotional distress observed. Review of five residents' EMRs (including Resident #1), on 05/07/25, reflected a weekly skin assessment had been conducted on 05/06/25 with no concerns. Review of Resident #1's physician order, dated 05/06/25, reflected to cleanse the left heel with normal saline, apply alginate with silver, and cover with non-adherent dressing every day shift. Review of Resident #1's TAR, May 2025, reflected treatments had been completed on 05/06/25 and 05/07/25 to both his sacral and heel wounds. Review of Resident #1's initial care plan, initiated 05/07/25, reflected he was at risk for complications related to existing wounds (sacral stage IV and unstageable to left heel) with interventions of weekly and PRN skin assessments. Review of an in-service, dated 05/06/25 - 05/07/25 and conducted by the DON, reflected all nurses were being in-serviced on weekly skin assessments, wound treatments, pressure ulcer prevention, comprehensive care plans, and abuse and neglect. Review of an in-service, dated 05/06/25 - 05/07/25 and conducted by the ADM, reflected all aides were being in-serviced on recognizing skin changes and informing their charge nurses. The ADM and ADON were notified on 05/07/25 at 3:45 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to provide a resident with urinary incontinence appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents reviewed for urinary catheters (Resident #1) in that, RN A failed to transcribe Resident #1's foley catheter order correctly and LVN B did not insert Resident #1's foley catheter according to physician orders and Resident #1 was sent to the local hospita ER, was admitted in ICU for sepsis after experiencing a change of condition on 02/04/2024. This failure could place residents with indwelling catheters at risk for infections, discomfort, and sepsis . Findings included: Review of Resident #1's undated face sheet revealed a 67-year- male with admitted [DATE]. Diagnoses included neuromuscular dysfunction of bladder (Neurogenic bladder -is the name given to a number of urinary conditions in people who lack bladder control due to brain, spinal cord or nerve problems.), acute kidney failure (occurs when the kidney suddenly become unable to filter waste products from the blood), quadriplegic (affected by or relating to paralysis of all four limbs), other muscle spasm (a muscle cramp is an uncontrollable and painful spasm of a muscle). Review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. It was also indicated Resident #1 had an indwelling catheter. Review of Resident#1's Care Plan dated 06/14/2023 revealed Resident #1 was at risk for infection related to foley catheter for neurogenic bladder (is the name given to a number of urinary conditions in people who lack bladder control due to brain, spinal cord or nerve problems) with intervention of Refer to/or follow up with Urologist as ordered/indicated. Record review of Resident #1's physician order dated 01/05/2024 reflected: Flush foley catheter with 60ml NS QD PRN every 24 hours as needed for hematuria (blood in the urine). Record review of Resident #1's MAR reflected: Nitrofurantoin Macrocrystal (an antibiotic that treats urinary Tract Infection) Oral Capsule 100 MG (Nitrofurantoin Macrocrystal) Give 1 capsule by mouth every 12 hours for UTI until 01/14/2024 started on 1/08/2024. Record review of Resident #1's progress notes written by RN A reflected: Resident has a 16F foley catheter that is leaking around it. This nurse flushed the foley with 100ml and the leaking has appeared to stop. Will continue to monitor. Record Review of Resident #1's Urologist order dated 01/26/2024 reflected: Neurogenic bladder : Neuromuscular dysfunction of bladder, unspecified Note to Provider: Mandatory Exchange 16Fr Coude foley catheter every 30 days (coude catheter is specifically designed to maneuver around obstructions or blockage in the urethra. Coude is the French word for bend or elbow and coude catheters are slightly bent at the tip which helps them move past a blockage.) Also noted on document was needs to be changed in 3 days 1/29/2024 (written in pen). Record review of Resident #1's progress notes dated 01/26/2024 written by RN A reflected: Resident went to see a urologist today and he ordered his foley cath [catheter] to be changed on Monday January 29th. Record review of Resident #1's TAR reflected an order undated: change foley q month on 29th every night shift starting on the last day of month and ending on the last day of month every month for foley care. Record review of Residednt #1's progress notes reflected no documentation on 01/29/2024 of Resident #1's foley catheter being inserted and how Resident #1 tolerated the procedure. Record review of Resident #1's progress notes written by LVN B dated 02/04/2024 reflected: resident observed with abnormal vital signs as followed: BP 124/72 HR 89 RR 20 Temp 99.9 78% O2 on room air. Resident appears drowsy and is not communicative as normal to baseline. Called on call for [company name], NP ordered to send to hospital for eval [evaluation] and treat. Family made aware and requested to send to [local hospital]. Resident transferred to hospital at 6pm. Record review of Resident #1's local hospital records dated 02/04/2024 reflected: CTs performed looking for infectious source note the Foley catheter to be in the patient's prostate with the balloon inflated in the prostate. As such the catheter was deflated and then removed, there is some bleeding and difficulty replacing the catheter. We discussed with urology who recommended attempting a coude catheter. Coude was successful and is now draining purulent urine. Patient was accepted by the ICU for admission. Patient with neurogenic bladder, has indwelling catheter that was replaced day of admission with balloon inflated and prostate causing obstruction. On removal purulent drainage was observed. AKI possibly due to prerenal secondary to sepsis versus intrinsic due to infection versus obstructive due to foley positioning . During an interview on 02/07/2024 at 09:47 am LVN B stated she worked with Resident #1 on 01/29/2024 . She also stated she was notified by the Wound care nurse that Resident #1 had an order to change his foley catheter that day. LVN B stated she did not see the order from the urologist visit on 01/26/2024 but went by what was indicated on the TAR. LVN B stated she used a regular foley catheter with 16fr on Resident #1. After reviewing the orders from the urologist office, LVN B stated if she had seen the order from the urologist before inserting the foley catheter, she would have used a coude catheter because coude catheters are shaped in a way to help with easy insertion and they also help when there is difficulty in draining urine. LVN B stated she worked on 02/04/2024 and was the nurse on duty when Resident #1 was sent to the local hospital ER. During an interview on 02/07/2024 at 10:06 am the Wound care nurse stated on 01/29/2024 she informed LVN B that Resident #1's foley catheter needed to be changed on that day. She stated she did not see a copy of the order brought from the urologist on 01/26/2024 but saw the consolidated orders in the computer . The Wound care nurse stated if she had seen the copy of the order from the Urologist visit, she would have told LVN B to use a coude catheter. She stated coude catheters were used for residents with prostate issues and difficulty with insertion. She stated the order in the computer should have indicated, use a coude catheter. During an interview on 02/07/2024 at 10:21 am the DON stated Resident #1 had problems with his foley catheter leaking all the time, bladder spasm causing obstruction and the catheter not draining well, and so Resident #1 was referred to the urologist. The DON stated she did not see Resident #1's orders from the urologist visit, she heard about it. The DON stated the order from the urologist office was put in the computer by RN A and LVN B followed what was in the computer. The DON stated coude catheters helped with insertion and placement and should have been switched according to the order. The DON stated it was her expectation staff follow physician orders and transcribe as indicated. During an interview on 02/07/2024 at 10:59 am RN A stated he worked with Resident #1 on the day he went to the urologist appointment. RN A said there was an order to change Resident #1's foley catheter in 3 days which was on 01/29/2024 and he transcribed the order into the computer. RN A stated he did not remember the part where the order indicated to use a coude catheter. RN A stated coude catheters were used on men who had difficulties with insertion. RN A also stated Resident #1 had episodes of bladder spasm, his foley catheter clogged a few times and urine was coming out around the foley. RN A said staff got orders to flush the foley catheter and an appointment with the urologist was made. Review of facility's policy undated titled Catheter Care, Urinary reflected: Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Preparation: Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed. Review of facility's policy undated titled Physician Services reflected: Policy Statement --The medical care of each resident is under the supervision of a Licensed Physician. -Physician orders will be followed by nursing staff and progress notes shall be maintained at the facility. -Consultative services shall be made available from community-based consultants or from a local hospital or medical center if clinically indicated.

Based on interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three (Resident #1, Resident #2, and Resident #6) of 19 residents reviewed for quality of care, in that: A.) The facility failed to ensure that R1 with physical debilities and severe cognitive impairment was checked on as needed throughout the night shift as she was found with active ants crawling on her while she was in bed with ant bites throughout her body causing resident pain, red welts, and hives that required immediate medical intervention and treatment. B.) The Facility failed to assist feeding R2 and R6 who had physical debilities, cognitive impairments and who required extensive assistance from staff with eating caused these residents to go without meals for multiple extended days without notifying the residents' physician, dietitian and administration of the residents' lack of nutrition and possible subsequent health decline. These failures placed residents at risk of physical harm, pain, mental anguish, emotional distress, weight loss, malnutrition, and a decreased quality of life. Failure A resulted in an identification of an Immediate Jeopardy (IJ) on 9/8/21 at 5:14 PM. While the IJ was removed on 9/11/21 at 2:55 PM, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy identified due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: A.) Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's most recent MDS, dated [DATE], reflected a BIMS of 99, indicating the resident was unable to complete the interview due to severe cognitive impairment. Review of Resident #1's most recent care plan, last revised 4/8/21, reflected she had impaired communication due to her Alzheimer's diagnosis. Staff was to ensure optimal comfort and positioning every shift and as needed. Review of Resident #1's tasks log for 9/6/21 - 9/7/21 reflected the only documentation of checking on the resident for the overnight shift (10:00 PM - 6:00 AM) was entered at 5:59 AM on 9/7/21. During an observation on 9/7/21 at 4:38 AM, CNA A came running out of Resident #1's room yelling that there were ants crawling on Resident #1. RN C and the Surveyor went into the room and observed Resident #1 in her recliner, with ants still on her. RN C knocked off the remaining ants. There were 10-15 ants crawling on Resident #1's mattress and the wall beside her bed. Resident #1 had red ant bites from her right knee to her thigh, and several on her right arm. Resident #1, who was non-verbal, was grimacing with her jaw clenched and her legs were shaking as if she was in pain. During an interview on 9/7/21 at 4:40 AM, CNA A stated she last checked on Resident #1 within the last few hours but could not give a specific time. She stated she observed the ants crawling on Resident #1 and tried to knock all of them off before assisting her into her recliner. CNA A acknowledged the remaining ants crawling on her mattress and the wall beside her bed. She stated due to the facility always being short-staffed, it was impossible to check on every resident every two hours. During an interview on 9/7/21 at 4:52 AM, CNA D stated it was impossible to complete all of their tasks with the number of staff they have on the floor. She stated there was currently four CNAs working for four halls. She stated if a resident's shower schedule is an evening shower, they almost always refuse. She stated by the time they finish assisting with feeding and assisting residents back to their rooms, it would be close to 8:00 PM or 9:00 PM and the residents did not want to receive a shower that late. She stated it was impossible to check on the residents regularly while answering call lights and helping other aides. She stated there was residents that fell all the time due to the aides not being able to get to them quickly enough. During an interview on 9/7/21 at 4:58 AM, CNA B stated they were too short-staffed. She stated the 200 and 300 hall were the heaviest halls, as in more two-person transfers and having 10 residents requiring hoyer lifts, which was a mobility tool used to help individuals with mobility challenges get out of bed, which required two people. She stated it was difficult to find someone when a hoyer lift was needed to be conducted. During an interview on 9/7/21 at 5:02 AM, RN E stated the lack of care residents are receiving due to being short staff was heart-breaking. She stated there was a lot of falls, wounds not being treated appropriately, and medications missed. She stated the night nurses also worked as medication aides. She stated it was impossible to pass all medications on time, provide treatments and assessments on the residents, and provide wound care when you were working two halls with not enough aides. Observation on 9/7/21 at 5:32 AM, revealed several ants still crawling on Resident #1's mattress and the wall beside her bed. Resident #1 was bleeding on her hip areas where she had been scratching the bites. The skin was red and irritated with swollen red welts. She conitinued to grimace with a clenched jaw as if she was in pain. During an interview on 9/7/21 at 5:45 AM, RN F stated she had called the doctor for an order of antihistamine for Resident #1. The Surveyor asked if she would conduct a brief skin assessment on Resident #1. RN F assessed Resident #1 and told the Surveyor that the ant bites continued from her thigh to her mid-back, and also in her peri area. During an interview on 9/7/21 at 6:15 AM, the ADM stated their staffing schedule normally had three nurses, five CNAs, and two MAs during the day shift (6:00 AM - 6:00 PM) and three nurses and four CNAs for the night shift (6:00 PM - 6:00 AM). He stated he believed the staffing was sufficient to be able to care for all of the residents appropriately. During a confidential interview with Staff S, she stated when the aides arrived at 6:00 PM for their shift, they had to assist with feeding, provide showers, and get all residents changed and into bed. She stated it was often that residents went without showers or incontinent care regularly. She stated if a resident is a two-person assist for transfer, it is difficult to find a CNA to assist with putting them to bed. During an interview on 9/7/21 at 2:32 PM, the ADM stated Resident #1's hospice nurse had been notified of the ant incident earlier in the day. He stated after he learned of the incident, he had contacted pest control and they had been out earlier to spray inside and outside of her room. He stated her room had been deep cleaned by housekeeping staff. Review of Resident #1's Weekly Skin Integrity Review that was completed by nurse, dated 9/7/21 at 5:37 PM, reflected the following: Resident with ant bites to bilateral arms and thighs, abdomen, back, inner thighs, and groin area. Rash noted to bilateral thighs and groin area. Review of Resident #1's physicians orders reflected an order, dated 9/7/21, reflecting [MEDICATION(S)] Cream 1% was to be applied to her body topically two times a day for ant bites/itching for five days. During an interview on 9/8/21 at 9:15 AM, with the ADM, the Surveyor requested the invoice from the pest control service that had been completed the day before (9/7/21). He stated he would call the company to see what they could provide. During an interview on 9/8/21 at 11:45 AM. the DON stated it was unacceptable that Resident #1 was found with ants on her. She stated all residents should be checked on at a minimum of every two hours, and some residents prefer to be checked on more often. She stated all nurses were performing skin checks on their residents. She stated residents from the 200/300 hall were assessed yesterday (9/7/21) and residents from the 400/500 hall were being assessed that day for any possible insect bites. During an interview on 9/8/21 at 1:20 PM, RN H stated he was currently working the 300 hall (Resident #1's hall). He stated he had completed a skin assessment on most of the residents on the 300 hall yesterday (9/7/21), and was completing the rest that day, per the DON's request. He stated all of the other residents were not having skin assessments completed on them, just the residents that resided on the 300 hall, the hall where ants were observed on Resident #1. During an interview on 9/8/21 at 1:28 PM, RN I who was working the 500 hall, stated she had not been asked by the DON to complete skin assessments on her residents. During an interview on 9/8/21 at 1:41 PM, the DON did not produce or state she had a plan to inservice all nursing staff as a direct result of the ant bite incident or to conduct an internal investigation of the root case of issue. The Surveyor asked if she knew where she could find the invoice from the pest control service that had been completed the day before. She stated she did not know but would ask the Maintenance Director. During an interview on 9/8/21 at 1:45 PM, the ADM said he had not received the invoice or documentation for the pest control service that was completed the day before he stated he would reach out to the company again. Record review of the residents' medical charts reflected skin assessments had only been completed on 20 residents residing on the 300 hall. An invoice or documentation for the pest control service that was completed on 9/7/21 was requested on multiple occasions, but not provided prior to calling the IJ. The ADM and DON were notified on 9/8/21 at 5:15 PM that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to the Administrator on 9/7/21 at 5:15 PM. A Plan of Removal was first submitted by the ADM on 9/8/21 at 7:06 PM and the following POR was accepted on 9/10/21 at 12:54 PM: Immediacy Plan of Removal F-600 9.7.2021 Facility staff immediately assessed (Resident #1). Notified the NP with orders received for [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. Resident's husband was also notified. 9.7.2021 DON and ADON completed an audit of all resident rooms-no additional ants noted in any resident rooms. 9.7.2021 All other resident's skin was assessed. No insect related skin concerns noted. The rooms and skin audits are in a folder in the administrator office. 9.7.2020 The administrator called the exterminator to complete an additional monthly visit. Requested service as soon as possible. 9.7XXX Facility administrator conducted a facility wide room to room audit to inspect for any insects and documented on a resident roster. 9.8.2021 Exterminator visited the facility and completed pest control in every resident room. Documentation of visit left with the facility administrator. 9.8.2021 DON and ADON completed an audit of all resident rooms-no additional ants noted in any resident rooms. 9.8.2021 Facility administrator completed a self- reported incident to HHSC after initiating an investigation into the insect incident. 9.8.2021 The RP refused for resident to be sent out for evaluation despite the facility request. All residents had the potential to be affected. Systemic Changes 9.8.2021 All Nurses and C.N.A's on duty were in-serviced by the Director of Nursing/designee about the incident regarding the pest control, and resident assessment, notification, and follow up and will continue until all staff are in-serviced. No nurses or CAN's will be allowed to work until the training has been completed. All newly hired staff will receive training in general orientation prior to starting on the floor. All staff will receive on-going training for a period of 60 days and as needed. 9.8.2021 Effective immediately, Nurses and C.N.A's including any PRN/Agency staff will be in-serviced and documented on the in- service sheet prior to their shift by the Director of Nursing/designee. The DON/Designee will verify all nurses and CNA's have been in-serviced and document on staff roster to ensure compliance. The in-service subject matter: Pest control, reporting, change and condition/notification, follow up daily until all staff have been in-serviced. Any new hires will also be in-serviced in general orientation prior to starting on the floor. 9.8.2021 The Administrator was in-serviced by the EVP to ensure that all pest control services are conducted on a monthly basis and as needed. 9.8.2021 Facility administrator conducted a facility wide room to room audit to inspect for any insects and documented on a resident roster. 9.9.2021 The DON/designee were in-serviced on the new daily skin observations added to the TAR by the VP of Clinical Services. They have been trained and educated on monitoring system to ensure continued compliance with nursing staff. 9.9.2021 All nursing staff will be in-serviced on new daily skin observations that have been added to the TAR by the VP of Clinical Services/designee. The skin observations will be completed by the licensed nursing staff and documented on the TAR for 60 days. 9.9.2021 The DON/ADON were in-serviced by the VP of Clinical Services on the completion of User defined skin assessments. Each resident will have a weekly skin assessment completed by the DON/designee for 60 days. 9.9.2021 All nursing staff will be in-serviced by the VP of Clinical/designee on daily skin observations during care, change in condition, reporting and notification. 9.9.2021 One to one in-services were completed with C.N.A 1 and 2 by the EVP and VP of Clinical Services regarding ADL documentation completion/routine rounding per individualized residents' plan of care. 9.9.2021 Facility administrator has contacted Exterminator and requested frequency be increased to twice a month to include facility exterior and all resident rooms Monitoring 9.8.2021 Effective immediately, the DON/designee will monitor in-service documentation/signature sheet and ensure that no nurses will be allowed to work until the above in-service has been completed. 9.9.2021 The DON/Designee will verify all nurses and CNA's have been in-serviced and document on staff roster. The in-service subject matter: Pest control, reporting, change and condition/notification, follow up until all staff have been in-serviced. Any new hires will also be in-serviced in general orientation prior to starting on the floor. 9.8.2021 Effective immediately, Administrator/designee will audit resident rooms to ensure rooms are without pests. 9.9.2021 The DON/Designee will conduct unannounced visits on both shifts to monitor CNA documentation compliance for 60 days. 9.9.2021 Pest control audits will be conducted in all resident rooms daily by the Administrator/Designee and documented on the resident roster form, any concerns will be immediately addressed, and exterminator will be notified for 60 days and then monthly thereafter. 9.9.2021 All daily skin observations and room audits will be overseen by the EVP and VP of Clinical daily to ensure continued compliance. 9.9.2021 All monitoring and audits will be reviewed in the monthly QAPI monthly and reviewed with the Medical Director. The Surveyor monitored the plan of removal from 9/10/21 through 9/11/21 as follows: During an interview on 9/10/21 at 2:05 PM, the ADM stated each staff member was being in-serviced on conducting skin assessments, pest control audits, and reporting pests to the DON and Administrator. He stated they are in-serviced before their shift, and no staff member will be able to work until they are in-serviced. Observation on 9/10/21 from 2:22 PM - 2:58 PM of the facility and resident rooms revealed no ants or pests of any kind. Review of the facility's in-services reflected in-services conducted reflected the following: - 9/8/21 - In-service on Pest Control Audits: Ensure all resident rooms are audited daily to inspect presence of any insects. - 9/9/21 - In-service on Weekly Skin Assessments: DON/designee will complete skin assessments for all facility residents weekly. - 9/9/21 - In-service on Skin Observations: Daily skin observations will be conducted daily by the licensed nurse and documented in the TAR. Review of the facility's implemented Room and Skin Audit reflected each resident and resident rooms were inspected for ants on 9/8/21 and 9/9/21. Review of resident skin assessments reflected all residents had a completed skin assessment by 9/8/21. Review of the facility's Daily skin Observations reflected all residents had skin observations for ants or ant bites on 9/9/21. Review of a pest control invoice reflected the facility was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 9/11/21 at 1:05 PM, the ADM produced the signatures of staff members for the in-services. He stated all staff members had been in-services except for four PRN staff members that he had not been able to get ahold of. He stated they would not be able to work until they were in-serviced. Review of the pest control audits, and skin assessments reflected that they were being done daily on all residents and resident rooms. Review of the facility's undated Recognizing Signs and Symptoms of Abuse/Neglect Policy reflected the following: 6. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. During an interview on 9/11/21 at 1:38 PM, CNA J stated she was in-serviced on pest audits for resident and resident rooms and knew that all staff had been. She stated she had not seen any ants or any other pests in resident rooms or anywhere in the facility. During an interview on 9/11/21 at 1:47 PM, RN H stated the ADM and DON were in-servicing all staff before their shifts. He stated when staff are getting residents up for the day by the aides in the morning, that was when he performed his skin checks. He had not seen any ant bites or ants in any of the resident rooms. The ADM and DON were notified on 9/11/21 at 2:55 PM, that the IJ had been lowered. The facility remained out of compliance at a severity of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. B. Review of Resident #2's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's most recent MDS, dated [DATE], reflected a BIMS of 99, indicating the resident was unable to complete the interview due to a severe cognitive deficit. Review of Resident #2's most recent care plan, last revised 6/28/21, reflected that he had an ADL self-care performance deficit related to activity intolerance, Alzheimer's, dementia, and limited mobility with interventions of requiring extensive assistance by one staff to eat. Review of Resident #2's Eating Task in his medical records reflected there were eight days where he ate only two meals each day from 8/12/21 - 9/9/21. Review of Resident #2's weights reflected he weighed 155 pounds on 7/1/21 and 146.4 pounds on 9/2/21, which is a severe perecentage of weight loss of 5.5%. Review of Resident #2's most recent care plan, last revised 6/28/21, reflected he was at risk for imbalanced nutrition with interventions of referring to the dietician as indicated and supplements are to be offered as ordered/indicated. Review of Resident #2's asessments reflected no recent assessments were made by the dietician. Review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 9/9/21 at 11:02 AM, revealed video footage from 8/17/21 where an aide attempted to feed Resident #1 one bite of food. He did not accept the food and she immediately got up and left the room. Observation on 9/9/21 at 11:10 AM revealed video footage from 8/19/21 where Resident #2 sat in his wheelchair from 12:30 PM until 7:30 PM without anyone checking on him or assisting him with dinner. He did not receive a dinner tray. Two aides were seen going into his room at 7:30 PM to start putting him to bed. A family member who saw this footage intervened and stated that he had not had dinner. When the family member told Resident #1, she would make sure he got some food, he started smiling. During a confidential interview with Staff S, she stated when Resident #1's eating tasks had a blank, it meant he had not been fed a specific meal for that day. Review of Resident #6's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's most recent MDS, dated [DATE], reflected a BIMS of 9, indicating a mild cognitive impairment. Review of Resident #6's most recent care plan, dated 5/27/21, reflected she had an ADL self-care performance deficit related to [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left non-dominant side with interventions of being totally dependent one on staff for eating. Review of Resident #6's Eating Task in his medical records reflected there were five days where she had only two meals each day, and eight days where he only had one meal each day during the time frame of 8/29/21 - 9/11/21. Review of Resident #6's weights in her electronic medical chart reflected no weight loss. Observation on 9/8/21 at 3:05 PM, revealed Resident #6 in the doorway of her room, her lunch tray in front of her on a bedside table, and a butter knife in her hand. Her head was down, and she was sleeping. Approximately 20% of her lunch had been consumed. During an observation and interview on 9/8/21 at 3:10 PM, CNA Q stated Resident #6 usually just ate on her own and did not really need assistance. When her tray was pointed out, he stated he assumed she was just not that hungry that day. Observation on 9/11/21 at 1:28 PM, revealed Resident #6 in the hallway with oatmeal all over her face and clothes. During an interview on 9/7/21 at 4:22 AM, RN F stated due to being short-staffed, there are many times residents go without being fed. She stated she knew for a fact Resident #2 had not been fed the night before (9/6/21), as her peers had told her. During an interview on 9/11/21 at 2:48 PM, the DON stated her expectations were the residents who needed assistance with feeding were being assisted for every meal. She stated without being fed, residents could experience weight loss and a deterioration in their health. During an interview on 9/11/21 at 2:32 PM, the ADM stated his expectations were that residents who needed assistance with feeding were being assisted. He stated he was not aware that residents were going without meals or being assisted. Review of the facility's undated Assistance with Meals Policy reflected the following: Dining Room Residents: 2. Facility staff will serve resident trays and will help residents who require assistance with eating. 3. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity . . Residents Requiring Full Assistance: 2. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity . Review of the facility's undated Recognizing Signs and Symptoms of Abuse/Neglect Policy reflected the following: 6. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. . Signs of Actual Physical Neglect: (1) Malnutrition and dehydration (unexplained weight loss)

Based on observation interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 82 of 82 residents (Residents #1 - 82) reviewed for infection control. A. The facility failed to have dedicated staff caring for positive residents in the isolation hall. B. The facility failed to ensure staff were properly utilizing PPE, staff were moving from the isolation hall to the rest of the building without changing their gown and coveralls. C. The facility failed to separate residents (Resident #63, Resident #76, and Resident #37) with pending COVID-19 test results from positive COVID-19 residents (Resident#14, Resident #26, Resident #31, Resident #36, Resident #57, Resident #73, Resident #75). This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. This failure could place residents at risk for the transmission of COVID-19 and death. Findings included: A. Review of COVID-19 testing line list dated [DATE], reflected Resident#14, Resident #31, Resident #36, Resident #51 Resident #57, Resident #73, Resident #75, Resident #83 were positive for COVID-19. Review of a progress note for Resident #14 dated [DATE], reflected a COVID-19 test was requested. Review of NP's progress notes for Resident #14 dated [DATE], reflected resident had diarrhea. Review of the face sheet for Resident #14 dated [DATE] reflected a [DIAGNOSES REDACTED]. Review of a progress note for Resident #14 dated [DATE], reflected Resident's Family were notified resident tested positive for COVID-19. Review of physician's orders for Resident #14 dated [DATE], reflected resident is under isolation with droplet precautions. Review of Resident #26's laboratory results with a collection date of [DATE], reflected resident was positive for COVID-19. Review of NP's progress notes for Resident #31 dated [DATE], reflected resident had loss of appetite and malaise. Review of a progress note for Resident #31 dated [DATE], reflected Resident's Family were notified resident tested positive for COVID-19 and she was moved to the isolation wing. Review of physician's progress notes for Resident #31 dated [DATE], reflected resident was positive for COVID-19 and had minimal respiratory symptoms. Review of the face sheet for Resident #36 dated [DATE] reflected a [DIAGNOSES REDACTED]. Review of NP's progress notes for Resident #36 dated [DATE], reflected resident tested positive for COVID-19 on [DATE]. Review of a progress note for Resident #36 dated [DATE], reflected Resident was on isolation droplet precautions for COVID-19. Review of a progress note for Resident #51 dated [DATE], reflected Resident had a temperature of 102.7. Review of a progress note for Resident #51 dated [DATE], reflected Resident was tested for COVID-19 and placed under isolation droplet precautions. Review of Resident #51's laboratory results with a collection date of [DATE] reflected resident was positive for COVID-19. Review of NP's progress notes for Resident #51 dated [DATE], reflected patient expired. Review of a progress note for Resident #57 dated [DATE], reflected Resident's son was notified resident tested positive for COVID-19 and transferred to the isolation wing. Review of a progress note for Resident #57 dated [DATE], reflected Resident remains in isolation with droplet precautions as per facility protocol. Review of NP's progress notes for Resident #73 dated [DATE], reflected There are currently positive COVID-19 patients in the facility. There has been no direct evidence of exposure however there have been several patients who have tested positive on this hallway. Review of a progress note for Resident #73 dated [DATE], reflected Resident's Family were notified resident tested positive for COVID-19 Review of the face sheet for Resident #73 dated [DATE], reflected a [DIAGNOSES REDACTED]. Review of orders for Resident # 73 dated [DATE], reflected resident was under isolation with droplet precautions. Review of a progress note for Resident #73 dated [DATE], reflected resident had cough and lethargy. Resident was placed on oxygen and moved to room [ROOM NUMBER]-A isolation wing with droplet precautions. Review of a physician's progress note for Resident #73 dated [DATE], reflected Resident was seen to monitor COVID-19 with bacterial pneumonia. Review of the face sheet for Resident #75 dated [DATE], reflected a [DIAGNOSES REDACTED]. Review of physician's progress notes for Resident #75 dated [DATE], reflected patient was confirmed COVID-19. Review of a progress note for Resident #75 dated [DATE], reflected resident is under droplet isolation droplet precautions as per protocol for positive COVID-19 results. Review of Resident #83's laboratory results with a collection date of [DATE], reflected resident was positive for COVID-19. Review of a progress note for Resident #83 dated [DATE], reflected resident was discharged to the hospital. Review of Hospital progress notes for Resident #83 dated [DATE], reflected resident was admitted for shortness of breath and consulted for COVID -19 pneumonia. Review of a progress note for Resident #83 dated [DATE], reflected resident expired in the hospital on [DATE]. Review of Resident #56's laboratory results with a collection date of [DATE], reflected resident was positive for COVID-19. Review of the In-services dated [DATE] with the title Isolation, reflected 400 hall is being converted into an isolation hallway; Staff on 400 will not move to other halls during shifts. Review of facility staffing schedule dated [DATE], reflected - LVN G was assigned to work the 200 wing and resident rooms 401 through 404 on the isolation wing. LVN A was assigned to work the 300 wing and resident rooms 405 through 408 on the isolation wing. LVN C was assigned to work the 500 wing and resident rooms 409 through 415 on the isolation wing. CMA A and CMA B were assigned to work the 300 wing, resident rooms 201 through 208 and the rooms 401 through 407 on the isolation wing. CMA D and CMA C were assigned to work the 500 wing, resident rooms 209 through 215, and resident rooms 408 through 413 on the isolation wing. During an interview on [DATE] at 2:24 p.m. ADON, acting DON, and ICP, stated the plan for staff working in the isolation hall (400 hall) was for them to enter the facility using the back door and for them to only work with residents in the isolation hall. They stated they were developing the contingency plan for staffing and added the ADM was working with a staffing agency to cover possible shortages. Observations conducted in the 400-isolation wing on [DATE] at 5:45 p.m. revealed LVN A exiting resident room # 405 which was occupied by Resident #26 who tested positive for COVID-19. During an interview on [DATE] at 5:50, LVN A stated she was providing care to Resident # 26 and stated she had to provide care to other residents on the regular hall. The surveyor asked her if she was the nurse assigned to the isolation wing and she stated there were three nurses providing care in the isolation hall and in the regular halls. She stated they were assigned to work the isolation hall and the regular halls. During an interview on [DATE] at 7:18 p.m., the ICP stated the nurses on the floor are working both the isolation and non-isolation halls. She stated she was new at the facility, so she didn't know why there was not dedicated staff for the isolation wing. Review of Brush Country Nursing and Rehabilitation staffing schedule dated [DATE], reflected LVN B was assigned to work the 200 wing and resident rooms 401 through 404 on the isolation wing. LVN E was assigned to work the 300 wing and resident rooms 405 through 408 on the isolation wing. LVN D was assigned to work the 500 wing and resident rooms 409 through 415 on the isolation wing. CMA A and CMA B were assigned to work the 300 wing, resident rooms 201 through 208 and resident rooms 401 through 407 on the isolation wing. CMA D and CMA C were assigned to work 500 wing, resident rooms 209 through 215, and resident rooms 408 through 413 on the isolation wing. Observations conducted in the 400-isolation wing on [DATE] between 9:03 a.m. 9:20 a.m. reflected LVN B in the isolation hall providing assistance to Resident #57 and Resident #31 with the O2 concentrator. CMA A was in the isolation hall at the med cart. During an interview on [DATE] at 9:10 a.m., LVN B stated he didn't feel comfortable providing care to residents in the isolation hall and in the regular halls since they could spread [MEDICAL CONDITION] but he was assigned to both halls. During an interview on [DATE] at 9:11 a.m., CMA A stated she was administering medications to residents in the isolation hall and to residents in the regular halls. Observations conducted on [DATE] in the 200 and 300 halls between 9:36 a.m. and 9:44 a.m revealed LVN B checking resident's temperatures on the 200 hall and CMA A passing medications on the 300 hall. Observation conducted on [DATE] in the 200 hall at 9:44 a.m., revealed Resident #56 in her sofa being assisted by LVN B. During an interview on [DATE] at 10:33 a.m. LVN D stated the nursing plan for having dedicated staff in the isolation plan was not being implemented. She stated her understanding was to have a dedicated staff to work only the isolation wing but for some reason this was not happening. She stated all staff were putting residents at risk by migrating between units. She stated management informed med-aids that they were responsible for passing medications in the isolation hall even though there should only be one person assigned to pass medications in the isolation hall and not various staff going in and out of the isolation hall. She stated prior to the facility having any positive cases there was a designated CNA assigned to the isolation hall. During an interview on [DATE] at 10:55 a.m., RN and ICP stated they had dedicated staff and that staff dedicated to the isolation unit was not allowed to provide care to residents outside of the unit. They were having trouble finding staff to work that unit and had to require that all staff work the unit. Review of the facility COVID-19 Response P and P manual to avoid transmission within long-term care facilities, facilities should use separate staffing teams for COVID-19 positive resident to the best of their ability. 1. Assignment should exercise as best as possible consistent (meaning the assignment of staff to certain patients and residents) for all patients and residents regardless of symptoms or COVID-19 status. This practice can enhance staff's familiarity with their assigned patients and residents, helping them detect emerging conditions changes that unfamiliar staff may not notice. The goal is to decrease the number or different staff interacting with each patient and resident as well as the number of times of times those staff interact with the patient and resident. 2. When possible, facilities should exercise consistent assignment, or have separate staffing teams for COVID-19 positives and COVID-19 negative patients. Review of the facility COVID-19 Response P and P manual COVID-19 response staffing plan, reflected In the event staff are reduced due to the onset of respiratory illness, or not passing screening questions set forth in the CMS guidelines for screening, the following will be instituted: Staff caring for those residents that have respiratory illness will be consistently assigned to those residents and areas so that the likelihood of spreading is reduced B. Observations conducted in the 400-isolation hall on [DATE] at 5:49 p.m. revealed an unidentified staff member exiting room [ROOM NUMBER] and then leaving the isolation wing without removing her coverall. During an interview on [DATE] at 5:20 p.m., ICP stated she was going to provide an in-service to the staff about where to don and doff PPE before entering and exiting the isolation wing. Review of the In-services dated [DATE] with the title Isolation, reflected 400 hall was being converted to an isolation hallway; PPE will be donned upon entry to hall. Review of the in-services dated [DATE] by the title PPE, reflected the in-service content was gowns should be changed if they are soiled, torn or after entering an isolation room. Review of the in-service dated [DATE] by the title changing PPE, reflected the in-service content was All staff entering and exiting 400 hall COVID-19 unit must have full PPE upon entering and change the gown and gloves upon exiting. Observations conducted on [DATE] between 9:03 a.m. and 9:20 a.m. LVN B was observed leaving resident room [ROOM NUMBER] on the isolation wing without changing PPE. CMA A was observed leaving the isolation wing without removing her PPE. During an interview on [DATE] at 9:10 a.m., LVN B stated he was not changing his PPE because there was not enough PPE available and the PPE provided to him was too small for his size. During an interview on [DATE] at 9:11 a.m., CMA A stated she was told to wear the same coverall her entire shift since there was not enough PPE available. She asked the surveyors if she was supposed to be changing her coverall. During an interview on [DATE] at 10:49 a.m. ICP and RN stated staff should be changing PPE after providing care to each resident and added there was adequate PPE in stock. ICP stated she provided an in-service yesterday [DATE] regarding donning and doffing of PPE before leaving the isolation hall. She stated if the staff were not utilizing PPE properly then staff would be spreading [MEDICAL CONDITION]. Review of the facility Policy titled Monitoring compliance with infection control reflected Effective use of disposable gloves and other personal protective equipment to prevent spread of infection. C. Review of a progress note for Resident #75 dated [DATE], reflected Resident was moved to room [ROOM NUMBER] from the isolation wing due to roommate testing positive for COVID-19. Review of NP's progress notes for Resident #75 dated [DATE], reflected patient is now in quarantine. She is suspected to have COVID-19; her roommate tested positive. She is not eating well. Review of a progress note for Resident #63 dated [DATE], reflected resident was discharged off droplet isolation and moved from isolation area to room [ROOM NUMBER]-B. Resident remains afebrile and COVID-19 symptom free. Will remain in a private room for 14 days for observations as per state of Texas. Review of a progress note for Resident #37 dated [DATE], reflected resident was discharged off droplet isolation and moved from isolation area to room [ROOM NUMBER]-B. Resident remains afebrile and COVID-19 symptom free. Will remain in a private room for 14 days for observations as per state of Texas. Review of a progress note for Resident #47 dated [DATE], reflected facility notified resident's wife that resident will be placed on droplet isolation due to resident coming from COVID-19 wing although 1st COVID-19 test was negative. Resident's 2nd specimen for 2nd COVID-19 test in the fridge awaiting pickup by the health department. Resident afebrile and no s/s of SOB. Review of a progress note for Resident #47 dated [DATE]. Reflected resident presented with low grade fever of 99.9 F. Review of a progress note for Resident #47 dated [DATE], reflected resident's COVID-19 swab came back positive. Resident was moved to 406 on COVID unit. Review of a progress note for Resident #47 dated [DATE], reflected resident had a temperature of 99.5 F. Review of History and physical for Resident #76 dated [DATE], reflected resident was readmitted to the facility from the hospital with two negative test results for COVID-19, test results from [DATE] and [DATE]. Review of orders for Resident #76 dated [DATE], reflected resident was placed on droplet precautions due to COVID-19 exposure for 14 days. During an interview on [DATE] at 2:24 p.m., the ADON, Acting DON, ICP stated residents with symptoms are on the COVID-19 unit in a single room and residents whose roommates tested positive were placed in the isolation wing. They stated the facility protocol for new admissions was to isolate them for 3 days if they have a negative test result prior to admission and 14 days of isolation was required if there was no test completed prior to admission. Observations conducted in the 400-isolation hall on [DATE] at 9:10 a.m. reflected Resident #37 occupying resident room [ROOM NUMBER], Resident #47 occupying resident room [ROOM NUMBER], and Resident #76 occupying resident room [ROOM NUMBER]. During an interview on [DATE] at 10:33 a.m., LVN D provided the surveyors a copy of the requested floor plan, she stated the following residents were all housed on the 400 hall (isolation wing). She stated Resident #57, Resident #31, Resident #36, Resident #75, Resident #76, Resident #14, Resident #73, Resident #26 were positive. She stated Resident #63 was a new admission and pending COVID-19 test results and Resident #37 was pending COVID-19 test results, he was tested because his roommate tested positive. During an interview on [DATE] at 9:47 a.m., ICP and RN stated the residents who were pending COVID-19 test results in the isolation wing were moved off the isolation wing per order of the NP. They stated residents were now placed in a private room under droplet precautions. Review of facility roster on [DATE] reflected 82 residents resided in the building. Review of the facility COVID-19 Response P and P manual reflected Long-term facilities should separate patients and residents who have COVID-19 from patients and resident who do not, or have unknown status. Review of the facility COVID-19 Response P and P manual COVID-19 control reflected MD/PCP will be notified of symptomatic resident and the resident will be required to take appropriate measurement [MEDICATION NAME] Droplet precaution and remaining in their room until assess by PCP or order are received for testing and test results are received. ADM was notified on [DATE] at 10:29 a.m., an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to ADM on [DATE] at 10:52 a.m. The facility's Plan of Removal (POR) was submitted by the ADM on [DATE] at 2:41 p.m. The following POR was accepted by the survey team on [DATE] at 8:42 p.m. Actions Taken/Plan included: All staff starting on [DATE] will be re-educated per the proper use of PPE, and the proper method to move between the COVID-19 unit and the rest of the facility. The ADON or IPN will monitor twice daily until [DATE]. If staff is noted to not be donning and doffing PPE correctly ADON/IPN will provide 1:1 education to staff and monitor the educated staff when they are on shift until proper PPE use is completely correctly. Residents pending COVID-19 testing starting on [DATE] will be quarantined in their room until test results are received. If resident(s) test positive the resident(s) will be moved to the assigned COVID-19 hall immediately and quarantined per CDC and CMS guidelines. If residents who are pending COVID-19 are not quarantined per direction given ADON/IPN will provide 1:1 education to staff involved and monitor effectiveness of education when staff is on shift until proper quarantine guidelines are followed. All staff starting on [DATE] will be re-educated on placement of COVID-19 pending residents. The ADON or IPN will monitor twice daily until [DATE]. All staff will be reeducated on keeping the residents' doors in the COVID-19 unit closed starting on [DATE]. ADON and/or IPN will monitor twice daily until [DATE] All staff starting on [DATE] will be re-educated on the Emergency Preparedness plan for an outbreak of COVID-19 The ADON or IPN will monitor and in-service as necessary, until [DATE] or longer if necessary. The facility will be thoroughly cleaned and sanitized to aid in the reduction of spreading COVID-19 throughout the building. Facility is in contact with Janiking for quote to clean facility and in contact with HHSC to receive help from Task Force to assist with disinfecting facility. Once building is disinfected by professional facility staff will be disinfecting hourly. The facility will continue to monitor temperature on all residents and staff twice per shift, and all other signs and symptoms related to COVID-19 Per CDC and CMS regulations and guidelines. All staff will be re-educated on the signs and symptoms of COVID-19 by ADON/IPN starting on [DATE] through [DATE] or longer if needed. All residents and staff tested negative for COVID-19 prior will be retested for COVID-19 and monitored for signs and symptoms. Staff will be given a log to monitor their temperature twice daily while at home and to immediately report to ADON and/or the Infection Control nurse any increased temperature or other signs and symptoms of COVID-19. All staff and residents will continue to be given the proper PPE to help prevent the spread of COVID-19 at all times while in the facility. The survey team monitored the plan of removal from [DATE] through [DATE] as follows: Observations from [DATE] through [DATE] revealed compliance with wearing PPE appropriately, pending resident for COVID-19 results were placed on isolation/droplet precautions in a private room outside the isolation wing. There was dedicated staff working just the 400-isolation wing and regular staff were not allowed to go to the isolation wing unless an emergency occurred. Staff were able to identify the number of pending and positive residents for COVID-19 test results. Review of in-services conducted from [DATE] through [DATE] regarding putting on and removing, wearing PPE appropriately, positive and pending resident for COVID-19 results were placed on isolation/droplet precautions, dedicated staff assigned to work the COVID-19 unit. In-services were appropriate and contained all necessary information for staff. Observations conducted on [DATE] reflected pending residents were not housed on the isolation wing but instead were placed in a private room. PPE cart was available before entering the isolation hall. A dedicated nurse and a dedicated CNA were assigned to provide care to residents on the isolation wing. Interview conducted on [DATE] at 7:30 p.m., CMA B stated only the staff assigned to work the isolation wing could be there. She stated she was not allowed to go in the isolation hall. Interview conducted on [DATE] at 7:30 p.m., CMA D stated she was in-serviced on the facility emergency plan and stated all positive residents had to be transferred to the isolation wing. She stated she had to check resident temperatures twice a day and explained the process when she had to enter a resident room under droplet precautions. Observations conducted on [DATE] at 8:40 p.m. reflected LVN H entering a resident room under droplet precaution donning the PPE properly. Interview conducted on [DATE] at 1:35 p.m., LVN D stated there was a total of 10 positives resident and 7 of them were at the facility in the isolation wing. She stated the isolation wing had dedicated staff and added she was in-serviced of donning and doffing PPE. Interview conducted on [DATE] at 1:56 p.m., CNA A stated positive residents were placed on the 400-isolation wing. She provided the sequences on how to don and doff PPE correctly. She stated the list of residents who were positive were posted at the end of the halls. Interview conducted on [DATE] at 2:10 p.m., CMA F stated the facility had a total of 10 positives and 7 of them were on the isolation wing. She provided examples of signs and symptoms of COVID-19. She stated they received handouts and a demonstration during the in-service in how to put and remove PPE. ADM was notified on [DATE] at 6:12 p.m. the Immediate Jeopardy was removed, and that the facility remained out of compliance at a severity of actual harm and a scope identified as pattern due to a need for ongoing monitoring.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit neglect for 1 of 7 residents reviewed for mechanical hoyer lift transfers (Resident #2). The facility failed to ensure that Certified Nurse Aide (CNA) E transferred Resident #2 according to the facility ' s policy and procedure and the resident ' s care plan when she failed to ensure a second staff member was present during a mechanical hoyer lift transfer on [DATE]. The result of this was a failed transfer where the resident fell 4 feet from the lift to the tile resulting in a fractured right foot, right parenchymal hemorrhage (extension of [MEDICATION NAME] hemorrhage with bleeding within brain parenchyma), 8 centimeters (cm) laceration to left eye requiring 8 stitches, and a 2.5 cm laceration to the right forehead requiring 2 stiches. This was the second occurrence where CNA E failed to follow the facility ' s policy and Resident #2 ' s care plan using two people to transfer the resident with a mechanical hoyer lift. The first occurrence was on [DATE] and the resident sustained [REDACTED]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern. This deficient practice could place 17 residents, who are care planned to transfer using two people with a mechanical hoyer lift, at risk for being transferred with only one person using the mechanical hoyer lift which could result in a failed transfer and severe injuries from a fall from the lift including death. The Findings Include: Review of the facility ' s undated policy and procedure on Abuse and Neglect reflected " Every resident has the right to be from mistreatment, neglect, and misappropriation of property. This includes the facility ' s identification of residents, who personal histories render them at risk for abusing other residents, and development of strategies to prevent occurrences, monitoring for changes that would trigger abusive behaviors, and reassessment on a regular basis. " " Prevention: ... Staff is required to intervene, identify and correct situations where any type of abuse may occur. " Review of Resident #2 ' s face sheet reflected an [AGE] year old female admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2 ' s Minimum Data Set ((MDS) dated [DATE] reflected " Section C: Cognitive Patterns: Staff Assessment for Mental Status: Short Term Memory ok: 1- Memory Proble; Long Term Memory Ok: 1 Memory Problem; Cognitive Skills for Daily Decision Making: 3- Severely Impaired- Never/rarely made decisions. " " Section G: Functional Status: B. Transfer- how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. 1. Self- Performance: 4 (Total Dependence) 2. Support: 3 (Two+ persons physical assist). " " Balance during Transitions and Walking: E. Surface-to-surface transfer (transfer between bed and chair or wheelchair): 2 (Not steady, only able to stabilize with staff assistance). Review of Resident #2 ' s Care Plan dated [DATE] reflected " Problems/strengths: ADL1- (Resident #2) was readmitted to facility. Significant change to MDS was done, due to MCRA admit. She continues to require assistance from staff with all (activities of daily living). Requires assistance from 1 staff, except 2 with transfers and bed mobility. Bed mobility ,[DATE], Transfers ,[DATE] (4= total dependence, 3=Two person physical assist) ... " Interventions: ...Staff will provide assistance with (activities of daily living). " Observation on [DATE] at 12:15 PM, Resident #2 was observed in the Immediate Care Unit of the hospital. The resident was not able to communicate. The resident had a fractured right foot with yellow bruising near the toes and left and right sides of the foot, a 5cm by 5 cm yellow bruise on her right mid shin, bruised left eye that was red in color with yellow bruising along the corner of the eye and at the bridge of the nose. The resident also had an 8 cm laceration on her left upper cheek that extended from the bridge of her nose, passed her eye and to the side of her cheek. This laceration had 8 stitches in it. There was also another laceration to the right top of her forehead that was 2.5 cm long with 2 stitches and some yellow bruising surrounding it. Interview on [DATE] at 2:10 PM, the Administrator stated that CNA E was transferring Resident #2 by herself using the mechanical hoyer lift when she should have assistance from another staff member. The Administrator stated that CNA E did not secure the hoyer sling and the resident slipped out while the sling was elevated into the air. The Administrator stated that CNA E was suspended currently but they would be terminating her that afternoon. The Administrator stated that she had one previous incident with CNA E on [DATE] the CNA transferred Resident #2 by herself using the hoyer lift and injured the resident causing a bruise to her upper lip. The Administrator stated that this incident was not reported to the state agency and that CNA E received a verbal and written counseling to remind her to always have 2 staff members operating the hoyer lift. Interview on [DATE] at 2:15 PM, the Director of Nursing (DON) stated that Resident #2 was a 2 person hoyer lift only and that the resident was not cognitively or physically able to assist in the transfer in any way. The DON stated that they stress to all of their staff in in-services that residents who require the hoyer lift should always have 2 staff members operating the lift. The DON stated that after the incident, CNA E tried to say that another aide was in the room with her, but later that aide denied being in the room and CNA E took it back. The DON stated that the other aides that were on the hall at the time said that CNA E never asked them for assistance with transferring Resident #2 that day. The DON stated that CNA E also tried to say that the hoyer lift malfunctioned at first but then told the nurse later that she had placed the sling improperly causing the resident to slip out. Interview on [DATE] at 2:50 PM, LVN S stated that she was the nurse who CNA E reported the failed hoyer lift transfer to. LVN S stated that when she entered the room, there was " lots of blood around her coming from her cheek and at the top of her head. LVN S stated that she did not move the resident but immediately had another nurse call an ambulance. LVN S stated that she grabbed gauze to control the bleeding and began taking vital signs. LVN S stated that the hoyer lift was still in the room and it was in its highest position " about 4 feet in the air. " LVN S stated that " if she fell from that high then she didn ' t want to move her. " LVN S stated that part of the sling was hanging down from the lift " like she had fallen out of the sling. " LVN S stated that Resident #2 was lying face up on the floor; she kept trying to close her eyes and was making an " awful sound. " LVN S stated that Resident #2 was normally " nonverbal. " LVN S stated that after the ambulance took Resident #2 to the hospital she began to question CNA E about what happened. LVN S stated that CNA E first told her that the hoyer lift malfunctioned and that CNA N was in the room helping her with the hoyer lift. LVN S stated that she went to question CNA N and he denied being in the room and that he was not involved in the incident. LVN S stated that she went back to CNA E who then admitted that CNA N was not in the room with her and she admitted that she was by herself while operating the hoyer lift. LVN S stated that CNA E also confessed that it was not the hoyer lift that malfunctioned; instead she had not placed the resident into the sling properly. LVN S stated that she wasn ' t sure why CNA E was operating the lift by herself because there were 3 aides on the hall to help and they can always ask the nurses for assistance also. Observation on [DATE] at 3:30 PM revealed the hoyer lift that was used during the transfer of Resident #2. The DON demonstrated that the hoyer lift was working properly. Observation on [DATE] at 9:45 AM revealed a medical supplies technician examining the hoyer lift. The Medical Supplies Technician revealed that the hoyer lift was working properly. Interview on [DATE] at 1:40 PM the DON stated that following CNA E ' s previous hoyer lift incident with Resident #2 on [DATE] no additional monitoring of the CNA was done to ensure CNA E did not transfer residents by herself using the hoyer lift. The DON stated that CNA E was counseled after the incident on [DATE] but she was not the DON at the time and no other measures were implemented. The DON stated that training on hoyer lift transfers was done on [DATE] and [DATE] but CNA E did not attend the training on [DATE]. The DON stated that CNA E did attend the training on [DATE]. Interview on [DATE] at 2:15 PM CNA E stated that Resident #2 was the last resident she needed to get up for breakfast on the morning of [DATE]. CNA E stated that she " put the hoyer sling on, but didn ' t put it all the way up under her buttocks. " CNA E stated that the sling is " supposed to be up under her buttocks " and she " honestly didn ' t know it wasn ' t all the way up under her buttocks. " CNA E stated that she then began to operate the hoyer by lifting it sling into the air, unlocked the wheels and legs to move the sling over her chair to prepare to lower the resident into the chair. CNA E stated that Resident #2 all of sudden tilted and slid all the way up and out of the sling and onto the tile floor. CNA E stated that she did not move the resident but instead " hollered for the nurse. " CNA E stated that she " doesn ' t normally transfer by herself " using the hoyer lift. CNA E stated that she went down the hall looking for another staff member before she started transferring Resident #2 by herself. CNA E stated that she also went to the nurse ' s station but the nurses were " getting report " from the previous shift so she didn ' t bother asking them. CNA E stated that she was " just trying to get my job done. " CNA E stated that Resident #2 was the last one she had to get up for breakfast that morning and that " if she waited for help the resident would have been late to breakfast " and she " tries to be on time " but that she was " not really in a hurry " and " don ' t know why I didn ' t wait for someone " to become available to help her with the lift. CNA E stated that she had been trained on how to use the hoyer lift and she had been trained on using two people to operate the lift. CNA E stated that there are multiple types of slings at the facility and that she hadn ' t been trained on how to place each type of sling properly on the resident. CNA E stated that she " got written up and it taught her a lesson to not work by herself " when referring to the previous incident with Resident #2 and the hoyer lift on [DATE]. CNA E stated that she didn ' t know why she operated the hoyer lift by herself again with the same resident. CNA E stated that " all the CNA ' s (use the hoyer lift) by themselves if they can ' t find help. " Interview on [DATE] at 3:10 PM CNA F stated that there are multiple types of slings in the facility including a cloth one that " criss crosses " between the legs, a blue mesh full body sling that goes on the outside of the legs, and another triangle one that " is not used often " because it doesn ' t support the neck. CNA F stated that she had been trained on using all of the slings at a previous facility she worked at but prior to the [DATE] in-service she had not been trained at the facility to use all three slings- only the blue mesh full body sling. Interview on [DATE] at 3:25 PM, the DON stated that on [DATE] they went over how to use all three types of slings, but prior to that they had not specifically provided training materials on each type. The DON stated that they had already decided after the incident on [DATE] that they are only going to use one type of sling, the blue mesh full body sling, to prevent any confusion and to ensure proper placement of the sling. Review of CNA E ' s " Disciplinary Warning Notice " dated [DATE] reflected " Type of violation: Violation of company policy, Violation of Safety Rules. " " Employer ' s Statement: Employee failed to do a hoyer lift with 2 people resulting in injury to resident. " " Any Previous Warnings/Actions: [DATE]; Verbal; Incident: Attendance. " Signed by CNA E, the previous DON and the Administrator on [DATE]. Attached to this was a written statement by CNA E which reflected " I (CNA E) was getting (Resident #2) up with the Hoyer Lift letting it down it was too close and it accidentally hit her lip and her teeth have always been (unknown) like that Sorry I apologize. " Signed CNA E. Review of hospital records reflected that the resident fell from hoyer lift and sustained injuries to her right foot including fractures to all five metatarsals, one laceration to the face that required stitches, one laceration to the scalp requiring stitches and a right parenchymal hemorrhage to the head. The Neurosurgery note dated [DATE] at 11:00 AM reflected " seems to have right basal ganglia hemorrhage ... CT (computed tomography of head) reviewed. Lots of atrophy, patients hemorrhage is classic [MEDICAL CONDITION](hypertension) hemorrhage (a hemorrhage caused by long term high blood pressure), not traumatic. She has lots of atrophy, lots of room in head. " Interview on [DATE] at 2:50 PM the Family Member revealed that Resident #2 had died following the incident on the morning of [DATE]. Review of the facility ' s Incident Report from the previous incident on [DATE] reflected the following: " Encourage CNA to always careful when using hoyer and always 2 person transfer with hoyer. " " Aide was doing hoyer lift by herself and strap (unknown) and hit resident in the face, Aide written up and counseled. " Review of the facility In-services reflected the following: [DATE]: " Hoyer lift transfers are always done with two staff members. No exceptions!! " (CNA E did not sign this in-service.) [DATE] on " Hoyer lift Transfers " reflected pictures of 2 staff members performing the hoyer lift together and how to operate the lift properly. This in-service also demonstrates the proper way to perform sling placement for one type of sling but it referred to a sling that crossed between the resident ' s legs rather than the full body sling which is designed to go on the outside of the legs. CNA E did sign this in-service. [DATE] an electronic message was sent out to staff members via their computer system that reflected " Please remember that hoyer lifts are always done with two staff members. The two staff members can be a combination of CNAs, CMAs, nurses. You are never to do a hoyer transfer alone. Please keep in mind that some sections have a large amount of hoyer lifts and will require additional assistance from other staff members. All resident care is the responsibility of each and every one of us. Our jobs are to keep the residents clean, dry, safe and protected. Part of that is to transfer safely. Please keep this in mind when your fell ow employees ask for help. " This was electronically signed by CNA E on [DATE] and by all other staff by [DATE]. On [DATE]- " Safe lifts, Transfers and Mobility Assistanc " however CNA E did not attend this in-service. On [DATE]- " Transfer Training/Abuse/Neglect " reflected training on the use of a hoyer lift sling that crossed between the resident ' s legs rather than the full body sling. CNA E did not attend this in-service either. Review of the facility Investigation Report dated [DATE] reflected Resident #2 ' s Functional Ability as " Total Assistance; " Level of supervision as " within arm ' s length. " Description of allegation reflected " Resident was being transferred to wheelchair during routine transfer. Hoyer lift was improperly placed under resident and resident slid from sling onto floor. " Injury/Adverse Effect reflected " Injuring sustained to head and eye. Transported to (hospital) for evaluation. Provider Response reflected " Staff member immediately placed on suspension until further investigation. Hoyer lift taken off the floor and placed in DON ' s office. Re-inacted the hoyer transfer. Took statements from everyone on 200 hall. " Investigation Summary " (DON) in the building and started the investigation. Upon arrival 200 hall hall nurse (LVN S) told her that a resident had fallen and sustained a head injury and was sent out to Brackenride hospital. DON called Administrator. Hoyer lift taken off the floor, because originally it was reported that the hoyer had malfunctioned. Upon further investigation, it was determined by the DON to be user error. Aide admitted not getting sling all the way underneath the resident. Statements taken from other staff from 200 hall. Hoyer removed from service and place in DON ' s office. Staff member, (CNA E) suspended until investigation is complete. Third party called to come inspect the hoyer lift to see if it was broken or was malfunctioning in any way. " Provider action taken Post-Investigation " 1. Suspended staff member- will be terminated. 2. Additonal Staff inservice on sling placement and how to do a safe hoyer transfer. 3. Third party to investigate functioning of hoyer lift. " Review of the facility ' s policies and procedures on " Lifting Machine, Using a Portable " dated [DATE] reflected " General Guidelines: The portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures, If not, two (2) nursing assistants will be required to perform the procedure. " IJ components: The facility Administrator and DON were notified on [DATE] at 3:18 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on [DATE] at 4:20 PM. The final Plan of Removal was accepted by the investigator on [DATE] at 6:10 PM. " On Monday [DATE] at 2 pm Mandatory In-service held and all nursing staff were: 1. Informed that Hoyer lifts were to be performed by two persons. 2. Observed by therapy on sling placement. 3. Observed by therapy that they could properly transfer a resident. How will we remove the immediacy? 1. Suspended employee on [DATE] and terminated employee on [DATE]. 2. Therapy will teach, train and verify Hoyer sling placement and transfer technique procedure upon new hire orientation. This will be performed by Therapy Director or her designee starting at our next new hire orientation on [DATE]. 3 Adon or designee to perform ongoing random room checks for Hoyer lift transfers at peak times of the day. (Getting up for Meals and laying down for naps.) Adon or designee will be responsible for signing off on a verification form. He will also document concerns with the transfers on a separate piece of paper. All nursing staff and the residents on all 4 halls will be observed on a rotating basis using random checks. We will start this procedure today. 4 As of today Hoyer lift slings will be standardized. We are switching to all Invacare Solid Fabric Slings: Full Body Solid Fabric Sling. Product ID: R112 HCPCS Code E0621** HMESA Code: [DATE]-01. Order placed for at least ten new slings on [DATE]. 5 Nursing Management will immediately start re-checking all nursing staff to determine they are competent to transfer with the Hoyer and competent in sling placement. Staff members that haven ' t been checked off will not be able to work the floor until they are checked off and deemed competent. 6 All other slings have been taken out of service. 7 We will continue to conduct in-service staff annually and as needed on the Hoyer lift. 8 We will continue to do Hoyer competency skills annually. 9 We will continue to do yearly Nursing Skills checks. Anytime we have an incident: 1. If the employee is at fault, employee will be disciplined up to and including termination. 2. We will have that employee perform a return demonstration immediately. 3. Director of Nurses and or her designee will conduct random Hoyer lift checks weekly on that particular employee the first week after an incident and periodically after that. Checks will be documented on a verification form. " The investigator monitored the current plan of removal as follows: Interviews with CNA ' s F,G,H,I,J, L and M on [DATE] at 2:45 PM-3:30 PM and on [DATE] from 9:35 AM- 4:35 PM revealed all CNA ' s had received training on [DATE] on proper sling placement of each type of sling and hoyer lift use with two people. Review of an invoice presented by the facility at 6:05 PM confirmed the order for 10 new full body slings. Observation on [DATE] at 6:15 PM revealed CNA ' s [MEDICATION NAME] hoyer sling placement of the full body sling. The ADON was ensuring each CNA completed the sling placement task. On [DATE] at 6:50 PM, the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope as pattern due to the facility requiring time to train all staff prior to the start of their shift and monitor their Plan of Removal. The DON provided a list of 17 residents who require a two person mechanical Hoyer lift transfer.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit neglect for 1 of 7 residents reviewed for mechanical hoyer lift transfers (Resident #2). The facility failed to ensure that Certified Nurse Aide (CNA) E transferred Resident #2 according to the facility ' s policy and procedure and the resident ' s care plan when she failed to ensure a second staff member was present during a mechanical hoyer lift transfer on [DATE]. The result of this was a failed transfer where the resident fell 4 feet from the lift to the tile resulting in a fractured right foot, right parenchymal hemorrhage (extension of [MEDICATION NAME] hemorrhage with bleeding within brain parenchyma), 8 cm laceration to left eye requiring 8 stitches, and a 2.5 cm laceration to the right forehead requiring 2 stiches. This was the second occurrence where CNA E failed to follow the facility ' s policy and Resident #2 ' s care plan using two people to transfer the resident with a mechanical hoyer lift. The first occurrence was on [DATE] and the resident sustained [REDACTED]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern. This deficient practice could place 17 residents, who are care planned to transfer using two people with a mechanical hoyer lift, at risk for being transferred with only one person using the mechanical hoyer lift which could result in a failed transfer and severe injuries from a fall from the lift including death. The Findings Include: Review of the facility ' s undated policy and procedure on Abuse and Neglect reflected " Every resident has the right to be from mistreatment, neglect, and misappropriation of property. This includes the facility ' s identification of residents, who personal histories render them at risk for abusing other residents, and development of strategies to prevent occurrences, monitoring for changes that would trigger abusive behaviors, and reassessment on a regular basis. " " Prevention: ... Staff is required to intervene, identify and correct situations where any type of abuse may occur. " Review of Resident #2 ' s face sheet reflected an [AGE] year old female admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2 ' s Minimum Data Set ((MDS) dated [DATE] reflected " Section C: Cognitive Patterns: Staff Assessment for Mental Status: Short Term Memory ok: 1- Memory Proble; Long Term Memory Ok: 1 Memory Problem; Cognitive Skills for Daily Decision Making: 3- Severely Impaired- Never/rarely made decisions. " " Section G: Functional Status: B. Transfer- how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. 1. Self- Performance: 4 (Total Dependence) 2. Support: 3 (Two+ persons physical assist). " " Balance during Transitions and Walking: E. Surface-to-surface transfer (transfer between bed and chair or wheelchair): 2 (Not steady, only able to stabilize with staff assistance). Review of Resident #2 ' s Care Plan dated [DATE] reflected " Problems/strengths: ADL1- (Resident #2) was readmitted to facility. Significant change to MDS was done, due to MCRA admit. She continues to require assistance from staff with all (activities of daily living). Requires assistance from 1 staff, except 2 with transfers and bed mobility. Bed mobility ,[DATE], Transfers ,[DATE] (4= total dependence, 3=Two person physical assist) ... " Interventions: ...Staff will provide assistance with (activities of daily living). " Observation on [DATE] at 12:15 PM, Resident #2 was observed in the Immediate Care Unit of the hospital. The resident was not able to communicate. The resident had a fractured right foot with yellow bruising near the toes and left and right sides of the foot, a 5cm by 5 cm yellow bruise on her right mid shin, bruised left eye that was red in color with yellow bruising along the corner of the eye and at the bridge of the nose. The resident also had an 8 cm laceration on her left upper cheek that extended from the bridge of her nose, passed her eye and to the side of her cheek. This laceration had 8 stitches in it. There was also another laceration to the right top of her forehead that was 2.5 cm long with 2 stitches and some yellow bruising surrounding it. Interview on [DATE] at 2:10 PM, the Administrator stated that CNA E was transferring Resident #2 by herself using the mechanical hoyer lift when she should have assistance from another staff member. The Administrator stated that CNA E did not secure the hoyer sling and the resident slipped out while the sling was elevated into the air. The Administrator stated that CNA E was suspended currently but they would be terminating her that afternoon. The Administrator stated that she had one previous incident with CNA E on [DATE] the CNA transferred Resident #2 by herself using the hoyer lift and injured the resident causing a bruise to her upper lip. The Administrator stated that this incident was not reported to the state agency and that CNA E received a verbal and written counseling to remind her to always have 2 staff members operating the hoyer lift. Interview on [DATE] at 2:15 PM, the Director of Nursing (DON) stated that Resident #2 was a 2 person hoyer lift only and that the resident was not cognitively or physically able to assist in the transfer in any way. The DON stated that they stress to all of their staff in in-services that residents who require the hoyer lift should always have 2 staff members operating the lift. The DON stated that after the incident, CNA E tried to say that another aide was in the room with her, but later that aide denied being in the room and CNA E took it back. The DON stated that the other aides that were on the hall at the time said that CNA E never asked them for assistance with transferring Resident #2 that day. The DON stated that CNA E also tried to say that the hoyer lift malfunctioned at first but then told the nurse later that she had placed the sling improperly causing the resident to slip out. Interview on [DATE] at 2:50 PM, LVN S stated that she was the nurse who CNA E reported the failed hoyer lift transfer to. LVN S stated that when she entered the room, there was " lots of blood around her coming from her cheek and at the top of her head. LVN S stated that she did not move the resident but immediately had another nurse call an ambulance. LVN S stated that she grabbed gauze to control the bleeding and began taking vital signs. LVN S stated that the hoyer lift was still in the room and it was in its highest position " about 4 feet in the air. " LVN S stated that " if she fell from that high then she didn ' t want to move her. " LVN S stated that part of the sling was hanging down from the lift " like she had fallen out of the sling. " LVN S stated that Resident #2 was lying face up on the floor; she kept trying to close her eyes and was making an " awful sound. " LVN S stated that Resident #2 was normally " nonverbal. " LVN S stated that after the ambulance took Resident #2 to the hospital she began to question CNA E about what happened. LVN S stated that CNA E first told her that the hoyer lift malfunctioned and that CNA N was in the room helping her with the hoyer lift. LVN S stated that she went to question CNA N and he denied being in the room and that he was not involved in the incident. LVN S stated that she went back to CNA E who then admitted that CNA N was not in the room with her and she admitted that she was by herself while operating the hoyer lift. LVN S stated that CNA E also confessed that it was not the hoyer lift that malfunctioned; instead she had not placed the resident into the sling properly. LVN S stated that she wasn ' t sure why CNA E was operating the lift by herself because there were 3 aides on the hall to help and they can always ask the nurses for assistance also. Observation on [DATE] at 3:30 PM revealed the hoyer lift that was used during the transfer of Resident #2. The DON demonstrated that the hoyer lift was working properly. Observation on [DATE] at 9:45 AM revealed a medical supplies technician examining the hoyer lift. The Medical Supplies Technician revealed that the hoyer lift was working properly. Interview on [DATE] at 1:40 PM the DON stated that following CNA E ' s previous hoyer lift incident with Resident #2 on [DATE] no additional monitoring of the CNA was done to ensure CNA E did not transfer residents by herself using the hoyer lift. The DON stated that CNA E was counseled after the incident on [DATE] but she was not the DON at the time and no other measures were implemented. The DON stated that training on hoyer lift transfers was done on [DATE] and [DATE] but CNA E did not attend the training on [DATE]. The DON stated that CNA E did attend the training on [DATE]. Interview on [DATE] at 2:15 PM CNA E stated that Resident #2 was the last resident she needed to get up for breakfast on the morning of [DATE]. CNA E stated that she " put the hoyer sling on, but didn ' t put it all the way up under her buttocks. " CNA E stated that the sling is " supposed to be up under her buttocks " and she " honestly didn ' t know it wasn ' t all the way up under her buttocks. " CNA E stated that she then began to operate the hoyer by lifting it sling into the air, unlocked the wheels and legs to move the sling over her chair to prepare to lower the resident into the chair. CNA E stated that Resident #2 all of sudden tilted and slid all the way up and out of the sling and onto the tile floor. CNA E stated that she did not move the resident but instead " hollered for the nurse. " CNA E stated that she " doesn ' t normally transfer by herself " using the hoyer lift. CNA E stated that she went down the hall looking for another staff member before she started transferring Resident #2 by herself. CNA E stated that she also went to the nurse ' s station but the nurses were " getting report " from the previous shift so she didn ' t bother asking them. CNA E stated that she was " just trying to get my job done. " CNA E stated that Resident #2 was the last one she had to get up for breakfast that morning and that " if she waited for help the resident would have been late to breakfast " and she " tries to be on time " but that she was " not really in a hurry " and " don ' t know why I didn ' t wait for someone " to become available to help her with the lift. CNA E stated that she had been trained on how to use the hoyer lift and she had been trained on using two people to operate the lift. CNA E stated that there are multiple types of slings at the facility and that she hadn ' t been trained on how to place each type of sling properly on the resident. CNA E stated that she " got written up and it taught her a lesson to not work by herself " when referring to the previous incident with Resident #2 and the hoyer lift on [DATE]. CNA E stated that she didn ' t know why she operated the hoyer lift by herself again with the same resident. CNA E stated that " all the CNA ' s (use the hoyer lift) by themselves if they can ' t find help. " Interview on [DATE] at 3:10 PM CNA F stated that there are multiple types of slings in the facility including a cloth one that " criss crosses " between the legs, a blue mesh full body sling that goes on the outside of the legs, and another triangle one that " is not used often " because it doesn ' t support the neck. CNA F stated that she had been trained on using all of the slings at a previous facility she worked at but prior to the [DATE] in-service she had not been trained at the facility to use all three slings- only the blue mesh full body sling. Interview on [DATE] at 3:25 PM, the DON stated that on [DATE] they went over how to use all three types of slings, but prior to that they had not specifically provided training materials on each type. The DON stated that they had already decided after the incident on [DATE] that they are only going to use one type of sling, the blue mesh full body sling, to prevent any confusion and to ensure proper placement of the sling. Review of CNA E ' s " Disciplinary Warning Notice " dated [DATE] reflected " Type of violation: Violation of company policy, Violation of Safety Rules. " " Employer ' s Statement: Employee failed to do a hoyer lift with 2 people resulting in injury to resident. " " Any Previous Warnings/Actions: [DATE]; Verbal; Incident: Attendance. " Signed by CNA E, the previous DON and the Administrator on [DATE]. Attached to this was a written statement by CNA E which reflected " I (CNA E) was getting (Resident #2) up with the Hoyer Lift letting it down it was too close and it accidentally hit her lip and her teeth have always been (unknown) like that Sorry I apologize. " Signed CNA E. Review of hospital records reflected that the resident fell from hoyer lift and sustained injuries to her right foot including fractures to all five metatarsals, one laceration to the face that required stitches, one laceration to the scalp requiring stitches and a right parenchymal hemorrhage to the head. The Neurosurgery note dated [DATE] at 11:00 AM reflected " seems to have right basal ganglia hemorrhage ... CT (computed tomography of head) reviewed. Lots of atrophy, patients hemorrhage is classic [MEDICAL CONDITION](hypertension) hemorrhage (a hemorrhage caused by long term high blood pressure), not traumatic. She has lots of atrophy, lots of room in head. " Interview on [DATE] at 2:50 PM the Family Member revealed that Resident #2 had died following the incident on the morning of [DATE]. Review of the facility ' s Incident Report from the previous incident on [DATE] reflected the following: " Encourage CNA to always careful when using hoyer and always 2 person transfer with hoyer. " " Aide was doing hoyer lift by herself and strap (unknown) and hit resident in the face, Aide written up and counseled. " Review of the facility In-services reflected the following: [DATE]: " Hoyer lift transfers are always done with two staff members. No exceptions!! " (CNA E did not sign this in-service.) [DATE] on " Hoyer lift Transfers " reflected pictures of 2 staff members performing the hoyer lift together and how to operate the lift properly. This in-service also demonstrates the proper way to perform sling placement for one type of sling but it referred to a sling that crossed between the resident ' s legs rather than the full body sling which is designed to go on the outside of the legs. CNA E did sign this in-service. [DATE] an electronic message was sent out to staff members via their computer system that reflected " Please remember that hoyer lifts are always done with two staff members. The two staff members can be a combination of CNAs, CMAs, nurses. You are never to do a hoyer transfer alone. Please keep in mind that some sections have a large amount of hoyer lifts and will require additional assistance from other staff members. All resident care is the responsibility of each and every one of us. Our jobs are to keep the residents clean, dry, safe and protected. Part of that is to transfer safely. Please keep this in mind when your fell ow employees ask for help. " This was electronically signed by CNA E on [DATE] and by all other staff by [DATE]. On [DATE]- " Safe lifts, Transfers and Mobility Assistanc " however CNA E did not attend this in-service. On [DATE]- " Transfer Training/Abuse/Neglect " reflected training on the use of a hoyer lift sling that crossed between the resident ' s legs rather than the full body sling. CNA E did not attend this in-service either. Review of the facility Investigation Report dated [DATE] reflected Resident #2 ' s Functional Ability as " Total Assistance; " Level of supervision as " within arm ' s length. " Description of allegation reflected " Resident was being transferred to wheelchair during routine transfer. Hoyer lift was improperly placed under resident and resident slid from sling onto floor. " Injury/Adverse Effect reflected " Injuring sustained to head and eye. Transported to (hospital) for evaluation. Provider Response reflected " Staff member immediately placed on suspension until further investigation. Hoyer lift taken off the floor and placed in DON ' s office. Re-inacted the hoyer transfer. Took statements from everyone on 200 hall. " Investigation Summary " (DON) in the building and started the investigation. Upon arrival 200 hall hall nurse (LVN S) told her that a resident had fallen and sustained a head injury and was sent out to Brackenride hospital. DON called Administrator. Hoyer lift taken off the floor, because originally it was reported that the hoyer had malfunctioned. Upon further investigation, it was determined by the DON to be user error. Aide admitted not getting sling all the way underneath the resident. Statements taken from other staff from 200 hall. Hoyer removed from service and place in DON ' s office. Staff member, (CNA E) suspended until investigation is complete. Third party called to come inspect the hoyer lift to see if it was broken or was malfunctioning in any way. " Provider action taken Post-Investigation " 1. Suspended staff member- will be terminated. 2. Additonal Staff inservice on sling placement and how to do a safe hoyer transfer. 3. Third party to investigate functioning of hoyer lift. " Review of the facility ' s policies and procedures on " Lifting Machine, Using a Portable " dated [DATE] reflected " General Guidelines: The portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures, If not, two (2) nursing assistants will be required to perform the procedure. " IJ components: The facility Administrator and DON were notified on [DATE] at 3:18 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on [DATE] at 4:20 PM. The final Plan of Removal was accepted by the investigator on [DATE] at 6:10 PM. " On Monday [DATE] at 2 pm Mandatory In-service held and all nursing staff were: 1. Informed that Hoyer lifts were to be performed by two persons. 2. Observed by therapy on sling placement. 3. Observed by therapy that they could properly transfer a resident. How will we remove the immediacy? 1. Suspended employee on [DATE] and terminated employee on [DATE]. 2. Therapy will teach, train and verify Hoyer sling placement and transfer technique procedure upon new hire orientation. This will be performed by Therapy Director or her designee starting at our next new hire orientation on [DATE]. 3 Adon or designee to perform ongoing random room checks for Hoyer lift transfers at peak times of the day. (Getting up for Meals and laying down for naps.) Adon or designee will be responsible for signing off on a verification form. He will also document concerns with the transfers on a separate piece of paper. All nursing staff and the residents on all 4 halls will be observed on a rotating basis using random checks. We will start this procedure today. 4 As of today Hoyer lift slings will be standardized. We are switching to all Invacare Solid Fabric Slings: Full Body Solid Fabric Sling. Product ID: R112 HCPCS Code E0621** HMESA Code: [DATE]-01. Order placed for at least ten new slings on [DATE]. 5 Nursing Management will immediately start re-checking all nursing staff to determine they are competent to transfer with the Hoyer and competent in sling placement. Staff members that haven ' t been checked off will not be able to work the floor until they are checked off and deemed competent. 6 All other slings have been taken out of service. 7 We will continue to conduct in-service staff annually and as needed on the Hoyer lift. 8 We will continue to do Hoyer competency skills annually. 9 We will continue to do yearly Nursing Skills checks. Anytime we have an incident: 1. If the employee is at fault, employee will be disciplined up to and including termination. 2. We will have that employee perform a return demonstration immediately. 3. Director of Nurses and or her designee will conduct random Hoyer lift checks weekly on that particular employee the first week after an incident and periodically after that. Checks will be documented on a verification form. " The investigator monitored the current plan of removal as follows: Interviews with CNA ' s F,G,H,I,J, L and M on [DATE] at 2:45 PM-3:30 PM and on [DATE] from 9:35 AM- 4:35 PM revealed all CNA ' s had received training on [DATE] on proper sling placement of each type of sling and hoyer lift use with two people. Review of an invoice presented by the facility at 6:05 PM confirmed the order for 10 new full body slings. Observation on [DATE] at 6:15 PM revealed CNA ' s [MEDICATION NAME] hoyer sling placement of the full body sling. The ADON was ensuring each CNA completed the sling placement task. On [DATE] at 6:50 PM, the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope as pattern due to the facility requiring time to train all staff prior to the start of their shift and monitor their Plan of Removal. The DON provided a list of 17 residents who require a two person mechanical Hoyer lift transfer.

Based on observation, interview and record review the facility failed to implement ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 7 residents reviewed for mechanical hoyer lift transfers (Resident #2). The facility failed to ensure that Certified Nurse Aide (CNA) E transferred Resident #2 according to the facility ' s policy and procedure and the resident ' s care plan when she failed to ensure a second staff member was present during a mechanical hoyer lift transfer on [DATE]. The result of this was a failed transfer where the resident fell 4 feet from the lift to the tile resulting in a fractured right foot, right parenchymal hemorrhage (extension of intracerebral hemorrhage with bleeding within brain parenchyma), 8 cm laceration to left eye requiring 8 stitches, and a 2.5 cm laceration to the right forehead requiring 2 stiches. This was the second occurrence where CNA E failed to follow the facility ' s policy and Resident #2 ' s care plan using two people to transfer the resident with a mechanical hoyer lift. The first occurrence was on [DATE] and the resident sustained [REDACTED]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern. This deficient practice could place 17 residents, who are care planned to transfer using two people with a mechanical hoyer lift, at risk for being transferred with only one person using the mechanical hoyer lift which could result in a failed transfer and severe injuries from a fall from the lift including death. The Findings Include: Review of the facility ' s undated policy and procedure on Abuse and Neglect reflected " Every resident has the right to be from mistreatment, neglect, and misappropriation of property. This includes the facility ' s identification of residents, who personal histories render them at risk for abusing other residents, and development of strategies to prevent occurrences, monitoring for changes that would trigger abusive behaviors, and reassessment on a regular basis. " " Prevention: ... Staff is required to intervene, identify and correct situations where any type of abuse may occur. " Review of Resident #2 ' s face sheet reflected an [AGE] year old female admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2 ' s Minimum Data Set ((MDS) dated [DATE] reflected " Section C: Cognitive Patterns: Staff Assessment for Mental Status: Short Term Memory ok: 1- Memory Proble; Long Term Memory Ok: 1 Memory Problem; Cognitive Skills for Daily Decision Making: 3- Severely Impaired- Never/rarely made decisions. " " Section G: Functional Status: B. Transfer- how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. 1. Self- Performance: 4 (Total Dependence) 2. Support: 3 (Two+ persons physical assist). " " Balance during Transitions and Walking: E. Surface-to-surface transfer (transfer between bed and chair or wheelchair): 2 (Not steady, only able to stabilize with staff assistance). Review of Resident #2 ' s Care Plan dated [DATE] reflected " Problems/strengths: ADL1- (Resident #2) was readmitted to facility. Significant change to MDS was done, due to MCRA admit. She continues to require assistance from staff with all (activities of daily living). Requires assistance from 1 staff, except 2 with transfers and bed mobility. Bed mobility ,[DATE], Transfers ,[DATE] (4= total dependence, 3=Two person physical assist) ... " Interventions: ...Staff will provide assistance with (activities of daily living). " Observation on [DATE] at 12:15 PM, Resident #2 was observed in the Immediate Care Unit of the hospital. The resident was not able to communicate. The resident had a fractured right foot with yellow bruising near the toes and left and right sides of the foot, a 5cm by 5 cm yellow bruise on her right mid shin, bruised left eye that was red in color with yellow bruising along the corner of the eye and at the bridge of the nose. The resident also had an 8 cm laceration on her left upper cheek that extended from the bridge of her nose, passed her eye and to the side of her cheek. This laceration had 8 stitches in it. There was also another laceration to the right top of her forehead that was 2.5 cm long with 2 stitches and some yellow bruising surrounding it. Interview on [DATE] at 2:10 PM, the Administrator stated that CNA E was transferring Resident #2 by herself using the mechanical hoyer lift when she should have assistance from another staff member. The Administrator stated that CNA E did not secure the hoyer sling and the resident slipped out while the sling was elevated into the air. The Administrator stated that CNA E was suspended currently but they would be terminating her that afternoon. The Administrator stated that she had one previous incident with CNA E on [DATE] the CNA transferred Resident #2 by herself using the hoyer lift and injured the resident causing a bruise to her upper lip. The Administrator stated that this incident was not reported to the state agency and that CNA E received a verbal and written counseling to remind her to always have 2 staff members operating the hoyer lift. Interview on [DATE] at 2:15 PM, the Director of Nursing (DON) stated that Resident #2 was a 2 person hoyer lift only and that the resident was not cognitively or physically able to assist in the transfer in any way. The DON stated that they stress to all of their staff in in-services that residents who require the hoyer lift should always have 2 staff members operating the lift. The DON stated that after the incident, CNA E tried to say that another aide was in the room with her, but later that aide denied being in the room and CNA E took it back. The DON stated that the other aides that were on the hall at the time said that CNA E never asked them for assistance with transferring Resident #2 that day. The DON stated that CNA E also tried to say that the hoyer lift malfunctioned at first but then told the nurse later that she had placed the sling improperly causing the resident to slip out. Interview on [DATE] at 2:50 PM, LVN S stated that she was the nurse who CNA E reported the failed hoyer lift transfer to. LVN S stated that when she entered the room, there was " lots of blood around her coming from her cheek and at the top of her head. LVN S stated that she did not move the resident but immediately had another nurse call an ambulance. LVN S stated that she grabbed gauze to control the bleeding and began taking vital signs. LVN S stated that the hoyer lift was still in the room and it was in its highest position " about 4 feet in the air. " LVN S stated that " if she fell from that high then she didn ' t want to move her. " LVN S stated that part of the sling was hanging down from the lift " like she had fallen out of the sling. " LVN S stated that Resident #2 was lying face up on the floor; she kept trying to close her eyes and was making an " awful sound. " LVN S stated that Resident #2 was normally " nonverbal. " LVN S stated that after the ambulance took Resident #2 to the hospital she began to question CNA E about what happened. LVN S stated that CNA E first told her that the hoyer lift malfunctioned and that CNA N was in the room helping her with the hoyer lift. LVN S stated that she went to question CNA N and he denied being in the room and that he was not involved in the incident. LVN S stated that she went back to CNA E who then admitted that CNA N was not in the room with her and she admitted that she was by herself while operating the hoyer lift. LVN S stated that CNA E also confessed that it was not the hoyer lift that malfunctioned; instead she had not placed the resident into the sling properly. LVN S stated that she wasn ' t sure why CNA E was operating the lift by herself because there were 3 aides on the hall to help and they can always ask the nurses for assistance also. Observation on [DATE] at 3:30 PM revealed the hoyer lift that was used during the transfer of Resident #2. The DON demonstrated that the hoyer lift was working properly. Observation on [DATE] at 9:45 AM revealed a medical supplies technician examining the hoyer lift. The Medical Supplies Technician revealed that the hoyer lift was working properly. Interview on [DATE] at 1:40 PM the DON stated that following CNA E ' s previous hoyer lift incident with Resident #2 on [DATE] no additional monitoring of the CNA was done to ensure CNA E did not transfer residents by herself using the hoyer lift. The DON stated that CNA E was counseled after the incident on [DATE] but she was not the DON at the time and no other measures were implemented. The DON stated that training on hoyer lift transfers was done on [DATE] and [DATE] but CNA E did not attend the training on [DATE]. The DON stated that CNA E did attend the training on [DATE]. Interview on [DATE] at 2:15 PM CNA E stated that Resident #2 was the last resident she needed to get up for breakfast on the morning of [DATE]. CNA E stated that she " put the hoyer sling on, but didn ' t put it all the way up under her buttocks. " CNA E stated that the sling is " supposed to be up under her buttocks " and she " honestly didn ' t know it wasn ' t all the way up under her buttocks. " CNA E stated that she then began to operate the hoyer by lifting the resident into the air, unlocked the wheels and legs to move the sling over her chair to prepare to lower the resident into the chair. CNA E stated that Resident #2 all of sudden tilted and slid all the way up and out of the sling and onto the tile floor. CNA E stated that she did not move the resident but instead " hollered for the nurse. " CNA E stated that she " doesn ' t normally transfer by herself " using the hoyer lift. CNA E stated that she went down the hall looking for another staff member before she started transferring Resident #2 by herself. CNA E stated that she also went to the nurse ' s station but the nurses were " getting report " from the previous shift so she didn ' t bother asking them. CNA E stated that she was " just trying to get my job done. " CNA E stated that Resident #2 was the last one she had to get up for breakfast that morning and that " if she waited for help the resident would have been late to breakfast " and she " tries to be on time " but that she was " not really in a hurry " and " don ' t know why I didn ' t wait for someone " to become available to help her with the lift. CNA E stated that she had been trained on how to use the hoyer lift and she had been trained on using two people to operate the lift. CNA E stated that there are multiple types of slings at the facility and that she hadn ' t been trained on how to place each type of sling properly on the resident. CNA E stated that she " got written up and it taught her a lesson to not work by herself " when referring to the previous incident with Resident #2 and the hoyer lift on [DATE]. CNA E stated that she didn ' t know why she operated the hoyer lift by herself again with the same resident. CNA E stated that " all the CNA ' s (use the hoyer lift) by themselves if they can ' t find help. " Interview on [DATE] at 3:10 PM CNA F stated that there are multiple types of slings in the facility including a cloth one that " criss crosses " between the legs, a blue mesh full body sling that goes on the outside of the legs, and another triangle one that " is not used often " because it doesn ' t support the neck. CNA F stated that she had been trained on using all of the slings at a previous facility she worked at but prior to the [DATE] in-service she had not been trained at the facility to use all three slings- only the blue mesh full body sling. Interview on [DATE] at 3:25 PM, the DON stated that on [DATE] they went over how to use all three types of slings, but prior to that they had not specifically provided training materials on each type. The DON stated that they had already decided after the incident on [DATE] that they are only going to use one type of sling, the blue mesh full body sling, to prevent any confusion and to ensure proper placement of the sling. Review of CNA E ' s " Disciplinary Warning Notice " dated [DATE] reflected " Type of violation: Violation of company policy, Violation of Safety Rules. " " Employer ' s Statement: Employee failed to do a hoyer lift with 2 people resulting in injury to resident. " " Any Previous Warnings/Actions: [DATE]; Verbal; Incident: Attendance. " Signed by CNA E, the previous DON and the Administrator on [DATE]. Attached to this was a written statement by CNA E which reflected " I (CNA E) was getting (Resident #2) up with the Hoyer Lift letting it down it was too close and it accidentally hit her lip and her teeth have always been (unknown) like that Sorry I apologize. " Signed CNA E. Review of hospital records reflected that the resident fell from hoyer lift and sustained injuries to her right foot including fractures to all five metatarsals, one laceration to the face that required stitches, one laceration to the scalp requiring stitches and a right parenchymal hemorrhage to the head. The Neurosurgery note dated [DATE] at 11:00 AM reflected " seems to have right basal ganglia hemorrhage ... CT (computed tomography of head) reviewed. Lots of atrophy, patients hemorrhage is classic for HTN (hypertension) hemorrhage (a hemorrhage caused by long term high blood pressure), not traumatic. She has lots of atrophy, lots of room in head. " Interview on [DATE] at 2:50 PM the Family Member revealed that Resident #2 had died following the incident on the morning of [DATE]. Review of the facility ' s Incident Report from the previous incident on [DATE] reflected the following: " Encourage CNA to always careful when using hoyer and always 2 person transfer with hoyer. " " Aide was doing hoyer lift by herself and strap (unknown) and hit resident in the face, Aide written up and counseled. " Review of the facility In-services reflected the following: [DATE]: " Hoyer lift transfers are always done with two staff members. No exceptions!! " (CNA E did not sign this in-service.) [DATE] on " Hoyer lift Transfers " reflected pictures of 2 staff members performing the hoyer lift together and how to operate the lift properly. This in-service also demonstrates the proper way to perform sling placement for one type of sling but it referred to a sling that crossed between the resident ' s legs rather than the full body sling which is designed to go on the outside of the legs. CNA E did sign this in-service. [DATE] an electronic message was sent out to staff members via their computer system that reflected " Please remember that hoyer lifts are always done with two staff members. The two staff members can be a combination of CNAs, CMAs, nurses. You are never to do a hoyer transfer alone. Please keep in mind that some sections have a large amount of hoyer lifts and will require additional assistance from other staff members. All resident care is the responsibility of each and every one of us. Our jobs are to keep the residents clean, dry, safe and protected. Part of that is to transfer safely. Please keep this in mind when your fell ow employees ask for help. " This was electronically signed by CNA E on [DATE] and by all other staff by [DATE]. On [DATE]- " Safe lifts, Transfers and Mobility Assistanc " however CNA E did not attend this in-service. On [DATE]- " Transfer Training/Abuse/Neglect " reflected training on the use of a hoyer lift sling that crossed between the resident ' s legs rather than the full body sling. CNA E did not attend this in-service either. Review of the facility Investigation Report dated [DATE] reflected Resident #2 ' s Functional Ability as " Total Assistance; " Level of supervision as " within arm ' s length. " Description of allegation reflected " Resident was being transferred to wheelchair during routine transfer. Hoyer lift was improperly placed under resident and resident slid from sling onto floor. " Injury/Adverse Effect reflected " Injuring sustained to head and eye. Transported to (hospital) for evaluation. Provider Response reflected " Staff member immediately placed on suspension until further investigation. Hoyer lift taken off the floor and placed in DON ' s office. Re-inacted the hoyer transfer. Took statements from everyone on 200 hall. " Investigation Summary " (DON) in the building and started the investigation. Upon arrival 200 hall hall nurse (LVN S) told her that a resident had fallen and sustained a head injury and was sent out to Brackenride hospital. DON called Administrator. Hoyer lift taken off the floor, because originally it was reported that the hoyer had malfunctioned. Upon further investigation, it was determined by the DON to be user error. Aide admitted not getting sling all the way underneath the resident. Statements taken from other staff from 200 hall. Hoyer removed from service and place in DON ' s office. Staff member, (CNA E) suspended until investigation is complete. Third party called to come inspect the hoyer lift to see if it was broken or was malfunctioning in any way. " Provider action taken Post-Investigation " 1. Suspended staff member- will be terminated. 2. Additonal Staff inservice on sling placement and how to do a safe hoyer transfer. 3. Third party to investigate functioning of hoyer lift. " Review of the facility ' s policies and procedures on " Lifting Machine, Using a Portable " dated [DATE] reflected " General Guidelines: The portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures, If not, two (2) nursing assistants will be required to perform the procedure. " IJ components: The facility Administrator and DON were notified on [DATE] at 3:18 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on [DATE] at 4:20 PM. The final Plan of Removal was accepted by the investigator on [DATE] at 6:10 PM. " On Monday [DATE] at 2 pm Mandatory In-service held and all nursing staff were: 1. Informed that Hoyer lifts were to be performed by two persons. 2. Observed by therapy on sling placement. 3. Observed by therapy that they could properly transfer a resident. How will we remove the immediacy? 1. Suspended employee on [DATE] and terminated employee on [DATE]. 2. Therapy will teach, train and verify Hoyer sling placement and transfer technique procedure upon new hire orientation. This will be performed by Therapy Director or her designee starting at our next new hire orientation on [DATE]. 3 Adon or designee to perform ongoing random room checks for Hoyer lift transfers at peak times of the day. (Getting up for Meals and laying down for naps.) Adon or designee will be responsible for signing off on a verification form. He will also document concerns with the transfers on a separate piece of paper. All nursing staff and the residents on all 4 halls will be observed on a rotating basis using random checks. We will start this procedure today. 4 As of today Hoyer lift slings will be standardized. We are switching to all Invacare Solid Fabric Slings: Full Body Solid Fabric Sling. Product ID: R112 HCPCS Code E0621** HMESA Code: [DATE]-01. Order placed for at least ten new slings on [DATE]. 5 Nursing Management will immediately start re-checking all nursing staff to determine they are competent to transfer with the Hoyer and competent in sling placement. Staff members that haven ' t been checked off will not be able to work the floor until they are checked off and deemed competent. 6 All other slings have been taken out of service. 7 We will continue to conduct in-service staff annually and as needed on the Hoyer lift. 8 We will continue to do Hoyer competency skills annually. 9 We will continue to do yearly Nursing Skills checks. Anytime we have an incident: 1. If the employee is at fault, employee will be disciplined up to and including termination. 2. We will have that employee perform a return demonstration immediately. 3. Director of Nurses and or her designee will conduct random Hoyer lift checks weekly on that particular employee the first week after an incident and periodically after that. Checks will be documented on a verification form. " The investigator monitored the current plan of removal as follows: Interviews with CNA ' s F,G,H,I,J, L and M on [DATE] at 2:45 PM-3:30 PM and on [DATE] from 9:35 AM- 4:35 PM revealed all CNA ' s had received training on [DATE] on proper sling placement of each type of sling and hoyer lift use with two people. Review of an invoice presented by the facility at 6:05 PM confirmed the order for 10 new full body slings. Observation on [DATE] at 6:15 PM revealed CNA ' s practicing hoyer sling placement of the full body sling. The ADON was ensuring each CNA completed the sling placement task. On [DATE] at 6:50 PM, the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope as pattern due to the facility requiring time to train all staff prior to the start of their shift and monitor their Plan of Removal. The DON provided a list of 17 residents who require a two person mechanical Hoyer lift transfer.