Every finding on record at Camelot of Broussard

Based on observations, interviews, and record and policy review, the facility failed to maintain an effective infection prevention and control program by failing to ensure:1. Clean, laundered mop heads and blankets were stored away from soiled linens; and2. Resident #81's urinary catheter drainage bag avoided contact with the floor. The facility had a census of 125 residents.Findings:1.Review of a facility policy titled Laundry and Bedding, Soiled, with a last reviewed date of 01/21/2026, revealed in part, 1. Clean linen is stored separately, away from soiled linens, at all times.3. Clean linen is kept separate from contaminated linen. The use of separate rooms, closets, or other designated spaces with a closing door are used to reduce the risk of accidental contamination.On 04/14/2026 at 2:58 p.m., an observation was made of the soiled linen room of the laundry department with S3HLS. There were 3 covered plastic bins stored on the soiled side of the laundry room. S3HLS stated two of the bins contained clean mop heads and one bin contained clean blankets. S3HLS removed the covers of the plastic bins, an observation was made and revealed clean mop heads in two bins and clean blankets in one bin. S3HLS confirmed that clean laundered items were being stored on the soiled side of the laundry room and should not have been.On 04/14/2026 at 3:59 p.m., an interview was conducted with S2IC. S2IC confirmed that clean laundered items should not have been stored on the soiled side of the laundry room. 2.Resident #81Review of Resident #81's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included, in part, retention of urine, chronic kidney disease stage 4, and other obstructive and reflux uropathy.On 04/13/2026 at 12:45 p.m., an observation was made of Resident #81 in his room. The bottom of Resident #81's urinary catheter drainage bag was touching the fall mat which was on the floor next to his bed. On 04/14/2026 at 5:26 p.m., a second observation was made of Resident #81 in his room. The bottom of Resident #81's urinary catheter drainage bag was touching the fall mat which was on the floor next to his bed.On 04/15/2026 at 8:20 a.m., a third observation was made of Resident #81 in his room. The bottom of Resident #81's urinary catheter drainage bag was noted laying on the floor in his room.On 04/15/2026 at 8:29 a.m., a concurrent observation and interview was conducted with S4CNA. S4CNA confirmed that Resident #81's urinary catheter drainage bag was laying on the floor and it should not have been.On 04/15/2026 at 8:48 a.m., an interview was conducted with S2lC. S2IC confirmed that Resident #81's urinary catheter drainage bag should not have been touching the fall mat or laying on the floor in his room.

Based on observations and interview, the facility failed to maintain professional standards for food service safety by failing to wear appropriate hair restraints. The facility had a census of 125 residents.Findings:A review of the facility's policy titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, with a last review date of 01/21/2026, read in part.Policy Statement: Food Service employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation.12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens.On 04/13/2026 at 8:42 a.m., initial tour of kitchen was conducted with S1DM. Throughout the tour, S1DM was observed with his facial hair exposed and was not wearing a beard restraint.On 04/13/2026 at 9:13 a.m., at conclusion of initial tour, S1DM confirmed that his facial hair should be covered and was not.

Based on record review, observation, and interviews, the facility failed to provide oxygen therapy as ordered for 1 (#34) of 38 residents sampled.Findings:Review of Resident #34's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 11, which indicated resident #34 had moderate cognitive impairment. Resident #34's MDS section O was coded as oxygen therapy, non-invasive mechanical ventilator, and respiratory therapy. Review of Resident #34's EHR (Electronic Health Record) revealed she was admitted on [DATE] and had diagnoses including, but not limited to, insomnia, anxiety disorder, unspecified atrial fibrillation, and heart failure. Review of Resident #34's April 2026 physician's orders revealed an order for Oxygen: CPAP (Continuous Positive Airway Pressure) 5/2L (Liters) at bedtime related to heart failure, with an order date of 06/27/2025. Review of Resident #34's MAR (Medication Administration Record) revealed Oxygen: CPAP 5/2L at bedtime related to heart failure was documented as not administered on the following dates April 1st through April 8th, 2026 and April 11th through April 13th 2026. On 04/13/2026 at 10:35 a.m., an interview was conducted with Resident #34. Resident #34 reported her CPAP machine was broken and she had not been using the machine for a while now; she was unable to recall a specific timeframe. Resident #34 stated the nurse broke her CPAP machine but she could not recall who the nurse was or when it happened. On 04/14/2026 at 8:40 a.m., an interview was conducted with S9DON in Resident #34's room. S9DON stated she was not aware that Resident #34's CPAP was broken. S9DON brought a concentrator and oxygen tubing into Resident #34's room. S9DON attempted to connect the tubing to the CPAP machine and stated she could not connect the oxygen tubing because the CPAP adaptor was broken. S9DON confirmed the oxygen therapy as ordered via CPAP was not able to be delivered to Resident #34 as ordered by physician. On 04/15/2026 at 4:45 p.m., a second interview was conducted with S9DON. S9DON provided MAR documentation to the surveyor. S9DON confirmed that the MAR documentation which read N indicated the physician's order for Oxygen: CPAP 5/2L at bedtime for Resident #34 was not administered on the following dates: April 1st through April 8th 2026, and April 11th through April 13th 2026. S9DON confirmed the nursing staff did not provide oxygen therapy for Resident #34 as ordered by the physician.

Based on observations, interviews, record review, and policy and procedures review, the facility failed to ensure a resident who required assistance, received assistance with activities of daily living (ADLs) to maintain good grooming and personal hygiene for 1 (#76) of 38 sampled residents.Findings:On 04/15/2026, a review of the facility's policy titled Activities of Daily Living (ADL), Supporting with a last reviewed date of 01/21/2026, read in part: Policy Statement .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Policy Interpretation and Implementation .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care).Review of Resident #76's records revealed he was admitted to the facility on [DATE], with diagnoses that included, but were not limited to unspecified urethral stricture, muscle weakness, fatigue, malaise and unspecified abnormalities of gait and mobility. The resident was diagnosed with malignant neoplasm of esophagus on 02/20/2026 and received hospice services.Review of Resident #76's Modification of Significant Change Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/25/2026, revealed in Section C that he had a Brief Interview for Mental Status (BIMS) of 12, indicating moderate cognitive impairment. Further review revealed in Section GG that the resident required partial/moderate assistance to shower/bathe, indicating he needed help to lift, hold, or support his trunk or limbs, but the helper provides less than half the effort. Further review revealed the resident required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity.) for personal hygiene and upper body dressing. Review of Resident #76's current plan of care revealed the following:The resident has an ADL self-care performance deficit R/T (related to) muscle weakness, fatigue, abnormalities of gait and mobility, malaise, Date Initiated: 12/30/2024.Interventions in part:Resident required assistance with dressing.Resident required assistance with bathing. Resident required assistance with personal hygiene.Resident required assistance with transferring.Resident required assistance with walking. The resident has risk for nausea and vomiting Date Initiated: 02/23/2026Interventions in part:Keep resident clean, dry and comfortable with bathing, linen and gown changes as needed. The resident has a terminal prognosis r/t esophageal cancer. Date Initiated: 02/23/2026Interventions in part:Adjust provision of ADLS to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate.On 04/13/2026 at 9:44 a.m., Resident #76 was observed sitting on the side of his bed with a garbage can on his lap throwing up blood tinged fluid. The resident was wearing a gray jacket with splatters of vomit observed on his jacket. The resident stated he was not feeling well and had been coughing and vomiting. S5LPN came into the resident's room and observed him. He stated he had given the resident some medication for nausea and was waiting for it to work. He did not offer to change the resident's jacket.On 04/14/2026 at 8:48 a.m., Resident #76 was observed sitting on the side of his bed attempting to eat breakfast. The resident was wearing the same gray jacket which was now stained with what looks like large amounts of vomit. The resident stated no one offered to give him a bath or changed his jacket. The resident was asked if staff knew his jacket was dirty and he needed help and he stated his nurse knew. On 04/14/2026 at 10:29 a.m., a third observation was made of Resident #76 in his room. The resident was still wearing his stained gray jacket. The resident stated he had been wearing the jacket since yesterday (04/13/2026). He was asked if he had other jackets and he stated he had clean jackets in his closet but needed help to get one. The resident stated his nurse had been in his room and knew he was not feeling well On 04/14/2026 at 11:53 a.m., a fourth observation was made of the resident in his room. The resident was sitting on the side of his bed with his upper body bare. The resident's gray jacket was beside him on his bed and a pink vomit stain observed on the resident's blanket. He stated that he took the jacket off but was not feeling well to get up and get cleaned up and get clean clothes. The resident stated that no staff had offered him a bath or changed him. On 04/14/2026 at 11:55 a.m., S7CNAMR was observed walking outside the resident's room. S7CNAMR stated she was not caring for the resident today. She observed Resident #76 and stated the resident should not have been left in that dirty jacket. She asked the resident if he wanted her to give him a shower and he stated yes. S7CNAMR placed the resident's stained gray jacket in a plastic bag and told the resident she would get it washed for him. On 04/14/2026 at 11:57 a.m., S5LPN and S6CNA who were caring for the resident, both went to the resident's room and confirmed his jacket was soiled and stained. S6CNA stated she thought the resident could care for himself, and did not offer him a bath or changed his jacket. S5LPN confirmed he had been in the resident's room to give him medications and did not offer to change his jacket. On 04/14/2026 at 3:01 p.m., an interview was conducted with S6CNA. She stated that she became a certified nurse assistant (CNA) in February 2026 and had been working at the facility for only a week. She stated last week she worked with the resident and he was doing for himself at that time and wasn't vomiting. S6CNA stated when she returned to work on Monday, no one informed her the resident was not feeling well and was vomiting. She stated the nurse did not tell her the resident needed a bath or his jacket changed.On 04/15/2026 at 8:15 a.m., an interview was conducted with S8CNASup. She stated she was informed of the incident yesterday (04/14/2026) when S6CNA did not change the resident and offered care. She stated that S6CNA should have checked on the resident, bathe him and changed his soiled jacket. She stated staff should not have left the resident like that.

Based on observations, interviews, record and policy review, the facility failed to ensure staff provided services that meet professional standards, as evidenced by nursing staff:Failing to document administration of a PRN (as needed) medication and the resident response to the medication for Resident #76; andLeaving medications at the bedside of Resident #120 who was not approved to self-administer medications. Findings: 1. On 04/15/2026, a review of the facility's policy titled Documentation of Medication Administration with a last reviewed date of 01/21/2026, read in part: Policy Statement: The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation: 1. A nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication must be documented after .it is given. 3. Documentation must include, as a minimum .f. Signature and title of the person administering the medication; and g. Resident response to the medication, if applicable (e.g., PRN .etc.). Review of Resident #76's records revealed he was admitted to the facility on [DATE], with diagnoses that included, but were not limited to unspecified urethral stricture, muscle weakness, fatigue, malaise and unspecified abnormalities of gait and mobility. The resident was diagnosed with malignant neoplasm of esophagus on 02/20/2026 and received hospice services. Review of Resident #76's Modification of Significant Change Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/25/2026, revealed in Section O that he received hospice care. On 04/13/2026 at 9:44 a.m., Resident #76 was observed sitting on the side of his bed and throwing up in a garbage can. S5LPN walked in the room and stated he gave the resident medication for nausea and vomiting and was waiting for it to work. On 04/15/2026 at 7:50 a.m., an interview and review of Resident #76's medical record was conducted with S5LPN. S5LPN was asked what he gave the resident for nausea and vomiting on 04/13/2026 and if it had worked. He stated he gave the resident Promethazine (a medication used to treat nausea). Review of Resident #76s MAR (Medication Administration Record) with S5LPN revealed no documentation the resident was given Promethazine since 04/01/2026. S5LPN stated he gave the resident the medication on 04/13/2026 and forgot to document it in the resident's MAR. Review of Resident #76's progress notes revealed no documentation of the effectiveness of Promethazine. S5LPN confirmed he did not document the effectiveness of the medication in the resident's progress notes. On 04/15/2026 at 7:55 a.m., an interview was conducted with S9DON. She stated that staff were responsible for documenting PRN medications in the residents' MAR after administering the medication. The MAR then triggers the progress notes that the medication was given and prompts the nurse to follow up with assessing the effectiveness of the medication administered. 2. Review of the facility's policy titled, Administering Medications, with a last review date of 01/21/2026, read in part, Policy Statement: Medications are administered in a safe and timely manner. Policy Interpretation and Implementation: 23. Resident may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision making capacity to do so safely. Review of Resident #120's EHR (electronic health record) revealed she was admitted to the facility on [DATE] and had diagnoses that included in part, macular degeneration, glaucoma, and major depressive disorder. Review of Resident #120's Quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed the resident's BIMS (Brief Interview for Mental Status) score was 15, indicating her cognition was intact. On 04/13/2026 at 10:02 a.m., an observation was conducted of Resident #120's room that revealed a plastic cup of oral medications, in the form of tablets, on the resident's bedside table. Resident #120 picked up the plastic cup and began to take one loose tablet out of the cup. Resident #120 stated S13LPN left her oral medications in her room earlier this morning. On 04/13/2026 at 10:02 a.m., an interview and observation was conducted with S13LPN in Resident #120's room with the resident present. S13LPN confirmed she placed morning medications in a cup for the resident at 9:30 a.m., placed the cup on the bedside table, and left the room. S13LPN confirmed she did not observe Resident #120 swallow the tablets. S13LPN also confirmed the medications should not have been left unattended in Resident #120's room. On 04/14/2026 at 2:30 p.m., an interview was conducted with S9DON. S9DON confirmed that a nurse should not have left the resident's medications unattended at the bedside. S9DON also confirmed all medications should be administered to the resident before the nurse leaves the resident's room. S9DON stated this service provided by the nurse did not meet professional standards of quality. On 04/15/2026 at 9:31 a.m., an interview was conducted with S12NA. She confirmed that Resident #120 had not been assessed for self-administration of medications and she was not considered safe to self-administer medications.

Based on record review and interview, the facility failed to ensure the resident's care plan was accurately updated to reflect the discontinuation of an anticoagulant, a blood thinner medication, for 1 (#114) out of 38 sampled residents. Findings: Review of Resident #114's electronic clinical record revealed the resident was admitted to the facility on [DATE] and his diagnoses included heart disease, peripheral vascular disease, and thrombosis. Review of the resident's physician's orders revealed Eliquis (blood thinner) was ordered on 06/24/2025 and discontinued on 08/21/2025. Review of the resident's current care plan revealed that anticoagulant remained on the resident's care plan and Eliquis was discontinued on 08/21/2025. On 04/14/2026 at 2:40 p.m., an interview was conducted with S10MDS and S11MDS. Both reviewed the resident's physician's orders and confirmed Resident #114's Eliquis was discontinued on 08/21/2025. Both reviewed the resident's care plan and confirmed that anticoagulants remained on the care plan and should have been removed when the anticoagulant was discontinued.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 resident (#115) out of 38 sampled residents as evidenced by failing to develop a plan of care for Resident #115's oral/dental health.Findings:A review of Resident #115's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] and had diagnoses including, but not limited to, Alzheimer's disease with late onset, and mild protein-calorie malnutrition.A review of Resident #115's admission MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 05, which indicated severe cognitive impairment. A review of Resident #115's care plan revealed no focus area related to Dentures, dental/oral care.On 04/15/2026 at 8:35 a.m., an interview was conducted with S14LPN. S14LPN reviewed resident #115's care plan and confirmed he was not care planned for Dentures, dental/ oral care. On 04/15/2026 at 10:25 a.m., an interview was conducted with S16MDS, who stated she was responsible for completing care plans. S16MDS stated that she entered a focus area, goal, and interventions for Resident #115 related to dentures, and oral/dental care health problems on 04/15/2026. She confirmed that she entered this information after it was brought to their attention by the surveyor that Resident #115 wore dentures and had no natural teeth. S16MDS confirmed Resident #115 was not care planned for dentures oral/dental care from admission date 01/22/2026 through 04/14/2026.

Based on interview, record review, and observation, the facility failed to accurately code a resident's MDS (Minimum Data Set) assessment for 1 (#115) out of 38 residents sampled.Findings:Review of Resident #115's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] and had diagnoses including, but not limited to, mild protein-calorie malnutrition, personal history of other venous thrombosis and embolism, benign prostatic hyperplasia with lower urinary tract symptoms, and Alzheimer's disease with late onset. Review of Resident #115's admission MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 05, which indicated severe cognitive impairment. A review of section L - Oral/ Dental Status revealed none of the above were present. On 04/15/2026 at 8:20 a.m., an interview was conducted with Resident #115. Resident #115 was alert and oriented to place and time and able to converse clearly with the surveyor. Resident #115 stated that he had no natural teeth in his mouth and wore upper and lower dentures. On 04/15/2026 at 9:23 a.m., an interview was conducted with S17CNA. S17CNA stated she provided oral care for Resident #115 and confirmed Resident #115 wears upper and lower dentures and has no natural teeth. On 04/15/2026 at 10:00 a.m., an interview was conducted with S15MDS. S15MDS stated she was responsible for coding Resident #115's MDS. S15MDS confirmed that Resident #115's MDS Section L - Oral/ Dental Status was coded incorrectly and should have been coded as B. No natural teeth or tooth fragment(s) (edentulous).

Based on observations, interviews and policy review, the facility failed to maintain an effective 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 as evidenced by failing to: 1. perform proper hand hygiene during medication administration; and 2. wear appropriate PPE (Personal Protective Equipment) to care for Resident #13 who was on Enhanced Barrier Precautions (EBP). The facility's census was 121 residents. Findings: 1. On 03/10/2025, a review of the facility's policy titled Handwashing/Hand Hygiene with a last reviewed date of 12/27/2024, read in part, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors .7. Use an alcohol-based hand rub containing at least 60-90% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .m. after removing gloves .8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene .Applying and Removing Gloves. 1. Perform hand hygiene before applying non-sterile gloves. On 03/10/2025 at 8:06 AM, an observation was made of S4LPN (Licensed Practical Nurse) administering medications on Hall A. S4LPN was preparing medications for Resident #89, when Resident #109 walked out of the neighboring room and asked S4LPN to remove a wristband from her wrist. S4LPN took a pair of scissors from her medication cart drawer and removed the wristband from Resident #109's wrist and immediately returned to continue preparing medications for Resident #89 without sanitizing her hands. S4LPN was then observed as she entered Resident #89's room to administer her medications. The resident refused two of the capsules in the cup. S4LPN returned to the cart, donned a pair of gloves and removed the pills from the medicine cup, then removed the gloves and returned to the resident's room to administer the remaining meds. S4LPN did not sanitize her hands before or after gloving. During an interview on 03/10/2025 at 8:11 AM, S4LPN stated she should have sanitized her hands before and after removing the resident's wrist band and before and after gloving. On 03/10/2025 at 9:34 AM, an observation was made of S5LPN during medication pass on Hall W. S5LPN picked up a pen from a cup on her cart and the pen fell on the floor. She reached down and picked up the pen from the floor and used it to sign a sheet on her cart then continued to prepare medications. S5LPN did not sanitize her hands. During an interview with S5LPN on 03/10/2025 at 9:45 AM, she confirmed that she did not sanitize her hands and stated she should have picked up the pen and cleaned it with a sanitizing wipe then sanitize her hands. During an interview with S10RNIP (Registered Nurse, Infection Preventionist) on 03/10/2025 at 2:32 PM, she confirmed that S4LPN and S5LPN did not maintain good infection control practice. She stated S4LPN should have performed hand hygiene before and after patient contact, and before donning and after removing gloves. She also stated the pen was dirty when it fell on the floor and S5LPN should have sanitized the pen with a wipe then perform hand hygiene. 50950 2. On 03/10/2025, a review of the facility's policy titled, Enhanced Barrier Precautions Cheat Sheet with a last reviewed date of 12/27/2024 read in part, Examples of Enhanced-Based Precaution Residents: Wounds-includes .pressure ulcers .Enhanced-Based Precautions are indicated during: .wound care; any skin opening requiring dressing .Implementation: gowns and gloves are used during high-contact sessions . Review of Resident #13's Admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, chronic obstructive pulmonary disease, peripheral vascular disease, and atrial fibrillation. Review of Resident #13's Medication Review Report revealed an order dated 12/23/2024 that read, Stage 3 pressure ulcer to sacrum: cleanse with wound cleanser, pat dry, apply collagen and calcium alginate and cover with dry clean dressing every day and as needed. Further review revealed an order dated 01/14/2025 that read, Nursing Intervention: Implement and maintain enhanced barrier precautions when performing high contact care activities. Review of Resident #13's Care Plan Report revealed an intervention initiated on 12/30/2024 that read in part, At risk for EBP (Enhanced Barrier Precautions) related to patients are indicated for the following residents who are: known to be colonized or infected with a MDRO (Multidrug-resistant organism) when contact precautions do not otherwise apply, at increased risk of MDRO acquisition resident has a wound. Further review of Resident #13's Care Plan Report revealed in part, Goal: EBP care should be maintained for the resident's entire stay or until wounds have healed or indwelling medical device is no longer needed. On 03/10/2025 at 8:24 AM an observation was made of a sign posted on the wall next to Resident #13's room door indicating she was EBP and staff should wear a gown as part of their PPE (Personal Protective Equipment). On 03/10/25 at 9:07 AM a concurrent observation and interview was conducted with S6ADON (Assistant Director of Nursing) and S9LPN (Licensed Practical Nurse). S6ADON and S9LPN were observed not wearing gowns while providing wound care to Resident #13's sacral pressure ulcer. S6ADON and S9LPN confirmed that Resident #13 is on EBP. S6ADON and S9LPN confirmed they were aware the resident was on EBP and they both failed to wear a gown while providing resident care. On 03/10/2025 at 2:48 PM an interview was conducted with S10RNIP (Registered Nurse Infection Preventionist). She confirmed a gown and gloves must be donned when providing high contact resident care activities such as providing wound care if a resident is indicated for EBP.

Based on observations and interviews, the facility failed to maintain professional standards for food service safety by failing to wear appropriate hair restraints. This deficient practice had the potential to affect the 124 residents who consumed food from the kitchen. A review of the facility's policy titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices with a last review date of 12/27/2024, read in part, Policy Statement: Food Service employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation .12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. On 03/09/25 at 09:30 AM, an observation was made in the kitchen of S1DM (Dietary Manager) not wearing a beard restraint, with facial hair exposed. On 03/09/25 at 11:00 AM, an observation was made in the kitchen of S2MD (Maintenance Director). S2MD was observed wearing a hair net on the top of his head, but with a large amount of hair exposed, hanging to his shoulders. On 03/09/2025 at 11:00 AM, an interview was conducted with S1DM. He confirmed that he should have been wearing a beard restraint. S1DM also confirmed that S2MD should have been wearing all of his hair under the hair net.

Based on record review and interviews, the facility failed to provide care and services that met professional standards of quality by failing to ensure rounding was conducted every two hours for 1 (#99) resident out of a final sample of 39 residents. Findings: Review of Resident #99's medical record revealed she was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, anxiety, and vascular dementia. Review of Resident #99's plan of care initiated on 11/15/2023 revealed the resident was moderate risk for falls related to psychoactive drug use. Further review of the resident's plan of care revealed the resident had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's, Dementia. On 03/09/2025 at 12:48 PM, an interview was conducted with Resident #99's RP (Responsible Party) who stated the staff were not rounding on the resident as they should. She further stated that the resident had a fall on 01/30/2025 and was not rounded on for six hours. On 03/11/2025 at 11:10 AM, a follow up interview was conducted with Resident #99's RP who provided video footage from the resident's electronic monitoring device in her room. The device was positioned facing the resident's bed with visualization of the bed and the resident's room door. The surveyor observed the following video evidence: On 01/29/2025 at 11:00 PM, S7LPN (Licensed Practical Nurse) entered Resident #99's room, conversed with the resident, and exited the room. At 2:29 AM on 01/30/2025, the resident was observed moving in bed before eventually sliding out of bed at 2:30 AM. The resident was on her knees and then slid to the floor. On 01/30/2025 at 5:16 AM, S7LPN and S8CNA (Certified Nursing Assistant) entered the resident's room and found her on the floor. Resident #99 was not rounded on between 11:00 PM on 01/29/2025 and 5:16 AM on 01/30/2025. On 03/11/2025 at 11:32 AM, an interview was conducted with S3DON (Director of Nursing) who confirmed the resident fell on [DATE]. She stated they were able to review the facility's video footage on 01/30/2025, and confirmed there were some issues with staff rounding. She further stated that staff was expected to at least look into the resident's room and check for positioning and safety when rounding at night, and rounding every two hours was a general guideline. S3DON stated that after reviewing the facility's video footage evidence, it was confirmed that two hour rounds were not conducted on Resident #99. A review of the facility's video footage review provided by S11ADM (Administrator) for 01/30/2025, revealed two hour rounds were not conducted on Resident #99 until 5:16 AM.

Based on record review, observations, and interview, the facility failed to ensure individual resident's narcotic records were maintained and reconciled for 1 (Cart A) of 2 (Cart A and Cart B) medication carts reviewed. The facility failed to ensure an accurate count of controlled medications was maintained. Findings: Review of the facility's policy, Controlled Substances, with a last reviewed date of 12/27/2024, revealed the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. On 03/11/2025 at 11:51 AM, a narcotic count review was conducted of Cart A with S6ADON (Assistant Director of Nursing). The following discrepancies were found: Resident #45- Oxycodone APAP 10-325mg (milligram). S6ADON stated in the lockbox they had 72 pills and on the narcotic record sheet the count was 73. Resident #8- Lorazepam 2mg. S6ADON stated in the lockbox they had 17 pills and on the narcotic record sheet the count was 16. On 03/11/2025 at 12:11 PM, S6ADON stated the nurse passed out the medications that morning and did not sign it out on the narcotic record sheet. She stated the nurse should have recorded the medications on the narcotic record sheet as soon as it was administered for accurate reconciliation.

Based on observations, interviews and record review, the facility failed to ensure resident were cared for in a manner and in an environment that maintained or enhanced his or her dignity by placing a sign outside the residents door visible to the public indicating she required feeding assistance for 1 (Resident #14) out of 39 sampled residents, This failure could have caused decreased feeling of self-worth, feelings of embarrassment and a diminished quality of life. Findings: Review of the facility's policy, Quality of Life- Dignity, with a reviewed date of 12/27/2024 revealed: read in part, Policy statement, each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality 9. Staff shall maintain an environment in which confidential clinical information is protected, for example .b. signs indicating the resident's clinical status or care needs shall not be openly posted . Review of Resident #14's medical records revealed an admitted [DATE] with diagnoses that included: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. The resident's daughter was designated as her RP (responsible party). Review of Resident #14's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 12/24/2024 revealed a BIMS (Brief Interview for Mental Status) of 05 indicating severe impaired cognition. Resident #14 required partial to moderate assistance with eating. An observation conducted on 03/09/2025 at 2:05 PM, revealed a sign on the outside of Resident #14's room door visible to anyone who passed by in the hall that stated, Resident is to be fed for all meals as tolerated to not leave food near resident without supervision. On 03/10/2025 at 8:05 AM, a phone interview was conducted with Resident's #14 RP (Responsible Party). She stated she did not ask the facility to put a sign outside of the resident's door that stated Resident is to be fed for all meals as tolerated to not leave food near resident without supervision She stated she had them to put signs inside of her room to help with care specifically if the facility were to have agency staff working, but not outside of the residents room door visible to the public. On 03/10/2025 at 10:23 AM, a second observation noted the sign on the outside of the resident's room door facing the public. The sign read Resident is to be fed for all meals as tolerated to not leave food near resident without supervision. On 03/11/2025 at 10:10 AM, an interview was conducted with S3DON (Director of Nursing). She confirmed Resident #14 had a sign outside of her room door that stated Resident is to be fed for all meals as tolerated to not leave food near resident without supervision. She stated the RP had requested to place the sign outside of the door awhile back.

Based on record review and interview, the facility failed to ensure that services were provided to meet professional standards of quality as evidenced by S2LPN (Licensed Practical Nurse) borrowing medication from one resident to give to 1 (Resident #1) out 3 (Resident #,d+[DATE]) sampled resident investigated during a complaint survey. This deficient practice had the potential to affect the 127 residents in the nursing home. Findings: Review of Resident #1's clinical record revealed he was admitted on [DATE]. His diagnoses included in part, Generalized Osteoarthritis, Morbid Obesity, Muscle Weakness, Essential Hypertension and Benign Prostatic Hyperplasia with lower urinary tract symptoms. He expired on [DATE]. Review of the Resident #1's [DATE] MAR (Medication Administration Record) revealed an order dated [DATE] for Zofran (nausea medication) 4mg (milligram) by mouth three times a day for nausea until [DATE]. The start date was [DATE]. Review of a list of medications available in the facility's medication pyxis machine (an automated dispensing system that helps clinicians safely and effectively provide right medications to the right patient at the right time) provided revealed that Zofran 4mg was available in the pyxis machine. On [DATE] at 12 p.m., a phone interview was conducted with S2LPN. S1DON (Director of Nursing) was present. S2LPN was asked if she obtained the Zofran from the facility's medication pyxis machine, she replied, I don't remember if I did. She stated that she was more concerned with getting the resident the medication quickly to relieve his symptoms and she borrowed the medication from another resident's medication. When asked if she knew that Zofran was available in the medication pyxis machine, she stated she knew but she wanted to give the resident the Zofran as quickly as possible and repeated that she had borrowed the medication from another resident's medication. On [DATE] at 12:05 p.m., an interview was conducted with S1DON. She confirmed that Zofran was available in the facility's medication pyxis machine. She confirmed that S2LPN should have used the Zofran in the emergency medication pyxis machine and should not have borrowed another resident's medication.

Based on record review and interview, the facility failed to assure the accurate administering of a medication for 1 (Resident #1) out of 3 (Resident #,d+[DATE]) sampled residents investigated during a complaint survey. This deficient practice has the potential to affect the 127 resident in the nursing home. Findings: Review of Resident #1's clinical record revealed he was admitted on [DATE]. His diagnoses included in part, Generalized Osteoarthritis, Morbid Obesity, Muscle Weakness, Essential Hypertension and Benign Prostatic Hyperplasia with lower urinary tract symptoms. He expired on [DATE]. Review of the facility's Documentation of Medication Administration policy with a revision date of [DATE] read the following in part .The facility shall maintain a medication administration record to document all medication administered. A Nurse .shall document all medications administered to each resident on the resident's medication administration record (MAR). Administration of medication must be documented after (never before) it is given. Documentation must include, at a minimum .d. date and time of administration .f. signature and title of the person administering the medication and resident response to the medication, if applicable. Review of the Resident #1's [DATE] MAR (Medication Administration Record) revealed an order dated [DATE] for Zofran (nausea medication) 4mg (milligram) by mouth three times a day for nausea until [DATE]. The start date was [DATE]. Further review of the MAR revealed there was no documentation that the resident was administered Zofran after S2LPN (Licensed Practical Nurse) called the NP (Nurse Practitioner) on [DATE] at 3:42 a.m. and no documentation of the resident's response to the medication. On [DATE] at 11:50 a.m., an interview and record review was conducted with S1DON (Director of Nursing). S1DON reviewed Resident #1's [DATE] MAR and confirmed that S2LPN had failed to document on the Resident #1's MAR and/or in his progress notes for [DATE] the date and time she administered the Zofran and a follow up of the resident's symptoms after he received the Zofran. She confirmed that S2LPN did not follow proper procedure for medication administration and had not accurately documented in the resident's clinical record. On [DATE] at 12 p.m., a phone interview was conducted with S2LPN (Licensed Practical Nurse). S1DON (Director of Nursing) was present. S2LPN stated on [DATE], she called the on-call NP and received an order for Zofran 4mg by mouth TID (3 times/day) x (for) 3 days for the resident's complaint of nausea. She stated that she administered the Zofran as ordered to the resident. She confirmed that she did not follow the correct procedure for the administration of the Zofran by not documenting on the resident's MAR and/or nurse's notes and not documenting a follow-up of the resident's response to the medication. She confirmed that she should have documented on the MAR the administration of the Zofran and documented in the nurse's notes a follow-up on the resident's symptoms.

Based on record reviews and interviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for 1 (#1) out of 3 (#2 and #3) sampled residents. S2LPN failed to accurately document on the EMAR (Electronic Medication Administration Record) and/or nurse's notes the administration of a medication. This deficient practice had the potential to affect the 127 residents in the nursing home. Findings: On 12/10/2024, a review of the facility's policy titled Documentation of Medication Administration with a last revision date of April 2007, read in part, Policy Interpretation and Implementation: A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's EMAR (electronic medication administration record). The policy also indicated that the following information is to be documented in the resident's medical record: Name and strength of the drug, dosage, method of administration, date and time of administration, reason(s) why a medication was withheld, not administered, or refused, signature and title of the person administering the medication, and resident response to the medication. Resident #1's medical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Generalized Osteoarthritis, Morbid Obesity, and BPH (Benign Prostatic Hyperplasia) with Lower Urinary Tract Symptoms. A review of Resident #1's progress notes documented by S2LPN (Licensed Practical Nurse) indicated on 10/30/2024 at 3:42 a.m., resident complained of nausea and vomited twice. S2LPN called the Nurse Practitioner and received a new order for Zofran (nausea medication) 4 mg (milligrams) every 8 hours for 3 days . Review of a telephone order dated 10/30/2024 written by S2LPN revealed an order for Zofran 4mg po (by mouth) TID (three times a day) x (for) 3D (days). A review of Resident #1's October 2024 EMAR failed to reveal documentation that Zofran 4 mg was administered on 10/30/2024 by S2LPN. The review also failed to reveal documentation that S2LPN conducted a follow up on the resident's response to the medication. On 12/10/2024 at 11:55 a.m., an interview and record review was conducted with S1DON (Director of Nursing). A review of Resident #1's October 2024 EMAR and S2LPN's nurse's note from 10/30/2024 at 3:42 a.m. was conducted with S1DON. S1DON confirmed that S2LPN had failed to document on Resident #1's EMAR and/or in his nurse's notes that she administered the resident Zofran and the resident's response to the medication. S1DON stated that S2LPN should have documented the administration of the Zofran and the resident's response to the medication on the resident's EMAR, or at least in the nurse's notes. S1DON agreed that S2LPN had not accurately documented in the resident's clinical record.

Based on record reviews, observations, interviews, and facility policy and procedure review, the facility failed to protect the residents' right to be free from abuse. The facility failed to protect: 1. Resident #2 from verbal abuse and mental abuse by S6CNA (Certified Nursing Assistant), and 2. Resident #1 from physical abuse by Resident #3. Findings: On 11/06/2024, a review of the facility's policy titled, Abuse and Neglect - Clinical Protocol with a last reviewed date of 12/27/2023, read in part, . Policy Statement: The facility will ensure that each resident had the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Policy interpretation and Implementation: . Staff to Resident Abuse of any Types: . The facility assumes the responsibility upon admission of ensuring safety and well-being of the resident . Staff are expected to be in control of their behavior and behave professionally . Definitions: Abuse, is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse . Verbal Abuse - the use of oral, written or gesture language that willfully include disparaging and derogatory terms to residents . regardless of their age, ability to comprehend . Physical Abuse - this includes but not limited to hitting, slapping, pinching, and kicking . Mental Abuse - this includes but is not limited to humiliation, harassment, and threats of punishment or deprivation . 1. Resident #2: Review of Resident #2's record revealed she was admitted to the facility on [DATE] with diagnoses that included in part Disease of Basal Ganglia, Muscle Weakness, Cognitive Communication Deficit, and Depression. Review of Resident #2's most recent Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 12, indicating her cognition was moderately impaired. Section GG: Functional Status read in part, Transfers, toileting and bed mobility was coded as Extensive assistance/2. One person physical assist. Review of Resident #2's comprehensive plan of care, read in part, the resident has impaired cognitive function/dementia or impaired thought process r/t (related to) degenerative diseases of Basal Ganglia with interventions that read in part, ask yes/no questions in order to determine the resident's needs, . communication: use the resident preferred name, identify yourself at each interaction, face the resident when speaking and make eye contact, reduce any distractions ., the resident understands consistent, simple, directive sentences, provide the resident with necessary cues- stop and return if agitated. The resident has an ADL self-care performance deficit r/t . Muscle Weakness with interventions . Bed Mobility: Resident requires assistance with bed mobility . Transferring: Resident requires assistance with transferring. Review of video surveillance in Resident #2's room revealed: On 09/04/2024 at 10:25 p.m.: S6CNA was observed walking with Resident #2 and assisting her back to her bed after using the restroom. S6CNA stated, Go all the way to the top of the bed, all the way .Don't you sit down until I tell you, walk, walk all the way to the top grab that rail . all the way to the top grab that rail . don't you lay your big butt down . go up some more cause ain't nobody got time pulling up on you, you're too heavy . Resident #2 stated, Are you mad at me? CNA stated, I ain't never mad I'm just not going to let you waste my time cause I don't play that .I got things to do . On 9/27/2024 at 11:28 p.m.: Resident #2 set off bed alarm by sitting up in bed. S6CNA came into the room and stated, Where you going? Resident #2 stated, I'm going walk for a little bit. S6CNA stated, No you're not get back in the bed .not playing with you and I already told you that .get yourself back in that bed get back in the bed. Resident #2 is seen attempting to lay down by herself without assistance from S6CNA was seen hovering over the resident. She displayed signs of struggling to lay back down without assistance and can be heard grunting. S6CNA stated, You're going to figure it out. S6CNA walked away from resident and leaned against the wall and put her hands in her pockets and stated, Next time you're going to know how hard it is to get back in the bed .go to sleep, go to bed .don't get out that bed . cause you going put yourself right back in. On 10/16/2024 at 9:46 p.m.: Resident #2 was seen sitting up in the bed. S6CNA walked in and stated, Why are you getting up? . No, you're not you just went to the bathroom .I don't care what your daughter got going on I just took you to the bathroom and I am not going to be in this room all night with you I came in here at 10:00 (p.m.), 10:15 (p.m.), and its 10:49 (p.m). S6CNA then pointed at to resident and then pointed to the bed and said Lay down. I'm not straining on you all night and I can go home .I can find me another job .I'm not dealing with you all night every night .get back in the bed, get yourself back in the bed how you got up .they got other patients around here not just you. S6CNA then exits Resident #2's room. On 11/06/2024 at 2:12 p.m. a phone interview with Resident #2's RP (Responsible Party) who stated that Resident #2 is her mom. She stated her mom has Fahr's Disease or Basal Ganglia Disease which affected her memory at times. She stated Resident #2 had a history of being verbally abused in her marriage of [AGE] years. She stated when her mother experienced this verbal abuse she would have nervous tics in her face caused by her increased anxiety. She stated she noticed her mom started having nervous tics which alerted her to start reviewing the video surveillance camera footage of Resident #2's room in October 2024. She stated Resident #2 would feel terrible about being spoken to in that manner by S6CNA if her cognition was not impaired. She stated on occasion she would hear her mom say, I'm not being bad am I? She stated she was scared for her mom and that is why she was transferred out of the facility. On 11/06/2024 at 2:46 p.m. a phone interview was conducted with Resident #2. She stated she does remember living at the previous facility. She stated the CNA's would talk to her very ugly but she does not remember their names. She reported after they spoke to her in an ugly way she was a little scared of them. She stated she left the facility because of the way they were treating her. On 11/06/2024 at 4:34 p.m. a review of video surveillance from the dates listed above and joint interview was conducted with S1ADM (Administrator), S2DON (Director of Nursing), and S3QI (Quality Insurance Nurse). They confirmed S6CNA was unprofessional, had communication problems, and a gruffness to her voice towards Resident #2. S2DON confirmed when S6CNA stated things such as you're too heavy was insulting to Resident #2. 2. Resident #3: Review of Resident #3's record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Anxiety Disorder, Major Depressive Disorder, and Alzheimer's Disease. Review of Resident #3's most recent Annual Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 00, indicating her cognition was severely impaired. Section GG: Functional Status read in part, coded yes for wheelchair use, and coded as no impairment to her upper and lower extremity. Review of Resident #3's comprehensive plan of care, read in part, The resident is/has potential to be physically aggressive r/t (related to) Resident hit another resident. Date Initiated: 10/18/2024 . Review of Resident #3's nurse's note dated 10/16/2024 at 12:15 p.m. by S8LPN (Licensed Practical Nurse) read in part, Summoned to dining room by CNA (Certified Nursing Assistant) . states that resident noted on front of Hall W way where she was witnessed hitting another resident repeatedly .resident unable to say what happened but verbalized that she knew hitting people is wrong . On 11/04/2024 at 3:17 p.m. an interview was conducted with Resident #3. She was unable to recall an incident with Resident #1. Resident #1: Review of Resident #1's record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Alzheimer's Disease, Cognitive Communication Deficit, and Muscle Weakness. Review of Resident #1's most recent Admission Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 3, indicating her cognition was severely impaired. Section GG: Functional Status read in part, coded yes for wheelchair use. Review of Resident #1's nurse's note dated 10/16/2024 at 12:15 p.m. by S7LPN (Licensed Practical Nurse) read in part, noted by staff that resident was in an altercation with another resident, ask resident what transpired, resident denied any incident. No bruises to the upper/lower extremities. No complaints of pain. On 11/04/2024 at 3:32 p.m. an interview was conducted with Resident #1. She was unable to recall the incident in which she was struck by Resident #3. On 11/04/2024 at 2:36 p.m., a joint interview with S1ADM (Administrator) and S9AsstADM (Assistant Administrator) was conducted. They stated that they reviewed the video surveillance after the incident and Resident #1's back was towards the camera Resident #3 wheeled by Resident #1 and slapped her on the arm. S1ADM stated based off of the video surveillance Resident #3 was the aggressor and it looked like Resident #3 was meaning to strike at Resident #1. On 11/04/2024 at 2:39 p.m., review of video surveillance with no time stamps on S9AsstADM phone with permission. Resident #1's back was faced towards the camera, she was sitting on her wheelchair. Resident #3 passed by Resident #1 in her wheelchair and slapped Resident #1 on her arm. On 11/04/2024 at 2:44 p.m., an interview with S2DON (Director of Nursing) was conducted. She stated she reviewed video surveillance and Resident #1 and Resident #3 were on Hall W where the incident took place. S2DON stated that based off the video surveillance Resident #3 was wheeling towards Resident #1 and started hitting her. Regarding Resident #3's willful action, S2DON stated that's hard to say but yes, we didn't know if she wanted to hurt her but she did want to hit her. S2DON stated Resident #3 does have a history of aggressive behavior.

Based on record reviews, observations, interviews, and review of facility's manual the facility failed to report to the administrator of the facility an event involving verbal abuse for 1 (#2) out of 3 (#1, #2, and #3) sampled resident reviewed for reporting alleged violations. Findings: On 11/06/2024, a review of the facility's manual titled, Abuse Neglect Reporting with a last revision date of 09/01/2016, read in part, Verbal Abuse - the use of oral, written or gesture language that willfully include disparaging and derogatory terms to residents . regardless of their age, ability to comprehend . Mental Abuse - this includes but is not limited to humiliation, harassment, and threats of punishment or deprivation . additional definitions: mistreatment: means to inappropriately treat or exploit a resident.In the event of any evidence involving mistreatment, exploitation, neglect or abuse, or other crime, including injuries of an unknown source, and an occurrence will be reported to the administrator of the facility . Findings: Review of Resident #2's record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Disease of Basal Ganglia, Muscle Weakness, Parkinson's Disease, and Tremor. Review of Resident #2's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 12, indicating her cognition was moderately impaired. Review of video surveillance in Resident #2's room revealed: On 10/16/2024 at 9:51 p.m. S4RN (Registered Nurse), S5LPN (Licensed Practical Nurse) and S6CNA (Certified Nursing Assistant) walk into Resident #2's room and Resident #2 is sitting on the floor. S6CNA stated this is what happens when they don't put their foot down with family members, and they play too many games they can find them another CNA tonight, and that's on my momma cause they will never work me like this S5LPN stated What's going on Resident #2? S6CNA stated to Resident #2 not listening for no reason she had just got up and 10 (p.m.), 10:15 (p.m.) you didn't have no reason to get up, you didn't have to use the bathroom and I'm not even with all of this, Resident #2 can beg me picking up on her like this . On 11/06/2024 at 9:34 a.m., an interview with S4RN. Reviewed video surveillance from 10/16/2024 involving what was said by S6CNA and how she spoke to Resident #2 and she confirmed that is a not a way to talk to a resident. She confirmed that speaking to a resident in that manner is not acceptable and she did not report it to her ADON (Assistant Director of Nursing), DON (Director of Nursing), or administrator. She confirmed that the S6CNA speaking to the resident in this manner in front of others could have caused the resident to feel humiliated. On 11/06/2024 at 10:06 a.m. an interview was conducted with S5LPN. Reviewed video surveillance on 10/16/2024 involving what was said by S6CNA and how she spoke to Resident #2. He confirmed S6CNA mistreated the resident. He confirmed that he did not report this to the ADON, DON, or administrator and should have. On 11/06/2024 at 4:34 p.m. a review of video surveillance from 10/16/2024 and joint interview was conducted with S1ADM (Administrator), S2DON (Director of Nursing), and S3QI (Quality Insurance Nurse). They confirmed S6CNA was unprofessional with Resident #2 and this was not reported to them by S4RN and/or S5LPN.

Based on record reviews, observations, interviews, and review of facility policy and procedure the facility failed to ensure a resident was provided privacy during personal care for 1 (#2) out of 3 (#1, #2, and #3) sampled residents reviewed for resident rights. Findings: On 11/06/2024, a review of the facility's policy titled, Quality of Life - Dignity with a last reviewed date of 12/27/2023, read in part, . Policy Statement: Each resident shall be care for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Policy Interpretation and Implementation . 10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care . Review of Resident #2's record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Disease of Basal Ganglia, Muscle Weakness, Parkinson's Disease, and Tremor. Review of Resident #2's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 12, indicating her cognition was moderately impaired. Section GG: Functional Status read in part, Toilet use was coded as Extensive assistance/2. One person physical assist. Section H- Bladder and Bowel read in part, urinary continence was coded as occasionally incontinent Review of Resident #2's comprehensive plan of care, read in part, The resident has an ADL self-care performance deficit r/t (related to) . Muscle Weakness with interventions . dated 11/02/2023; Personal Hygiene: Resident requires assistance with personal hygiene Review of video surveillance in Resident #2's room revealed: 1. On 08/31/2024 at 9:52 p.m. S7CNA (Certified Nursing Assistant) was changing resident's brief with the door open. Resident #2's lower half of her body was uncovered and exposed from the hallway during personal care. 2. On 10/16/24 at 11:11 p.m. S7CNA was checking resident's brief to see if she was soiled. Resident #2's lower half of her body was uncovered and exposed from the hallway during personal care. On 11/06/2024 at 4:41 p.m. a review of video surveillance from 08/31/2024 and 10/16/2024 and interview was conducted with S2DON (Director of Nursing) who confirmed Resident #2's door should have been closed during personal care.

Based on interviews and record review, the facility failed to ensure a resident's change in condition was immediatley reported for 2 (#1, #2) residents out of 3 (#1, #2, #3) sampled residents as evidenced by: 1. S8VD/CNA (Van Driver/Certified Nursing Assistant) failing to report complaints of pain for Resident #1 and; 2. S6RN (Registered Nurse) failing to notify Resident #2's responsible party (RP) and physician of a significant change in Resident #2's physical condition. Findings: Review of the facility's policy titled Change in Resident's Condition or Status, with a last reviewed date of 12/27/2023, read in part .Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician Nurse Practitioner and the resident representative of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the resident's Attending Physician, Nurse Practitioner, or physician on call when there has been a(n): d. significant change in the resident's physical, emotional, mental condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self- limiting); 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b. There is a significant change in the resident's physical, mental, or psychosocial status. Resident #1 Review of Resident #1's EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Alzheimer 's Disease, Pain, and Dorsalgia. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 2, indicating her cognition was severely impaired. Review of the facility's transportation log revealed Resident #1 had a MD (Doctor of Medicine) appointment on 09/16/2024 at 1:30 p.m. Review of Resident #1's progress notes revealed a note dated 09/16/2024 by S4NurseAuditor that read in part, resident was being propelled in wheelchair with footrest present from elevator into hallway when her left leg slipped onto the ground. She complained of left lower leg pain once in her room. Hall nurse assessed and noted with left knee swelling, no bruising or discoloration noted but was unable to palpated d/t (due to) resident stating, It hurts. NP (Nurse Practitioner) notified with new order for x-ray to left knee. Prn (as needed) Pain med administered but pain was unrelieved. MRI of left knee ordered and carried out which showed a nondisplaced fracture of proximal tibia . Review of Resident #1's care plan revealed a focus that read in part, The resident had a bone fracture r/t (related to) left leg . Review of Witness Statement by S8VD/CNA dated 09/16/2024, read in part, We had went to the doctor we got back I was pushing her to her room in the elevator. Both of her legs was on the leg rest in the elevator. When we got back to out the elevator she was complaining her leg was hurting . On 10/07/2024 at 9:21 a.m., a telephone discussion was conducted with Resident #1's RP (Responsible Party). He stated that Resident #1 resided upstairs and to get to her room she utilized the elevator with assistance from staff. He stated on 09/16/2024 after lunch, he called Resident #1 to see how her physician's appointment went. He said as soon as Resident #1 answered the phone, she was crying and stated that her leg was hurting. Resident #1 notified her RP when the van driver was backing her out of the elevator her foot fell off and was caught under the wheelchair. He stated that Resident #1 said the van driver was supposed to go get help, but no one came into the room to help her. On 10/07/2024 at 11:25 a.m., an interview was conducted with S9LPN (Licensed Practical Nurse). She stated she was the nurse caring for Resident #1 on 09/16/2024. She stated Resident #1 went to a MD appointment and when she arrived back S8VD/CNA wheeled Resident #1 to her room and walked out. S9LPN stated she stopped the S8VD/CNA in the hall and retrieved Resident #1's paperwork from the MD appointment. She stated she was never notified from S8VD/CNA that anything abnormal happened with transferring Resident #1 back to her room, or that Resident #1 told her that she was in pain. S9LPN stated she went on lunch break and was relieved by S5StaffDeveloper. S9LPN stated that Resident #1 was able to let you know when something is wrong. S9LPN spoke to Resident #1 when she was off her lunch break, and Resident #1 informed her when she was getting off the elevator her left foot fell off the foot rest and went back and she heard something pop, and she told S8VD/CNA and also told her that she was in pain. S9LPN confirmed that S8VD/CNA failed to report Resident #1's new onset of pain to her from the incident that caused her left leg to fall off the foot rest. On 10/07/2024 at 12:34 p.m., an interview was conducted with S10CNA (Certified Nursing Assistant). She stated on 09/16/2024 she heard Resident #1's room number being called overhead and she went in the room to see what Resident #1 needed. She stated that Resident #1 told her she was ready to get in the bed and at the same time was rubbing her left knee. S10CNA stated she moved Resident #1's wheelchair and the resident started screaming in pain. She stopped moving the wheelchair and asked Resident #1 what was wrong and she stated her knee popped while the van driver was getting her off the elevator and she told the van driver she was in pain. She stated the van driver was supposed to get help but she never did. S10CNA stated she was never notified by S8VD/CNA that Resident #1 was in pain. She confirmed if a resident reports any type of change in condition such as new pain the nurse should be notified right away. On 10/07/2024 at 1:14 p.m., an interview was conducted with S8VD/CNA. She stated when she was taking Resident #1 off the elevator her legs were on the footrest and then she heard Resident #1 scream in pain and when she looked down she saw Resident #1's left leg was off the footrest. She stated she noticed this before she got to the nurse's station. She stated she put the resident's leg back on the footrest and wheeled her to her room. She stated she brought her paperwork back to the nurse's station, but did not notify S9LPN that Resident #1's left leg fell off of the wheelchair's foot rest or that she screamed in pain. On 10/07/2024 at 2:11 p.m., an interview was conducted with S2DON (Director of Nursing). She stated Resident #1 was returning from an appointment and when the resident was being pushed to her room in her wheelchair her leg slipped off the foot rest and she started experiencing knee pain with swelling. She stated a MRI of her left leg was done and she was diagnosed with a left tibia fracture. She stated she reviewed video camera surveillance and it was seen that S8VD/CNA was a few feet from coming out of the elevator and Resident #1's foot slipped off of the foot rest. S2DON stated, Yes and no if she should have notified the nurse, and on S8VD/CNA point of view it could have been confusing on her part to notify the nurse of the resident's pain. On 10/07/2024 at 2:45 p.m., an interview was conducted with S1ADM (Administrator). S1ADM stated Resident #1 and S8VD/CNA came off the elevator and she made a turn facing the camera, and Resident #1's leg fell off the foot rest and got caught under the wheelchair. He stated S8VD/CNA stopped and put her leg back on the foot rest. S8VD/CNA stopped at the nurse's station and then she pushed Resident #1 to her room. S1ADM stated, In hindsight 20/20 yeah she should have reported it to the nurse but the resident could have reported her own pain. On 10/07/2024 at 3:49 p.m., an interview was conducted with Resident #1. She stated that her left lower leg was broken and she had a brace on it. She stated it happened a few weeks ago when she was coming back from her MD appointment and her foot fell off the foot rest and got caught under the wheelchair. She stated she heard a pop, and immediately screamed and notified S8VD/CNA that she was in pain. She stated she was wheeled into her room and S8VD/CNA told her she was going to get help, but never came back to her room and no one else came into her room until she called for help. Resident #2 Review of Resident #2's EHR (Electronic Health Record) revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, Overactive Bladder, Cognitive Communication Deficit, and Acute Cystitis without Hematuria. Review of Resident #2's nursing progress notes revealed a note written by S6RN (Registered Nurse) on 09/13/2024 at 9:07 p.m., that read in part: Summoned to resident's room by aide concerning resident having a high temperature of 102.0 accompanied with chills. Arrived to resident's room and assessed vitals BP (Blood Pressure) 164/80, Pulse 83, T (Temperature) 102.8, O2 (Oxygen) 89%. Resident was placed on O2 concentrator via NC (Nasal Cannula) on 1 liter to elevate O2 levels .Two Tylenol 325 mg (milligrams) tablets were administered PO (by mouth) at 1945(7:45 p.m.) for fever Care ongoing. Further review of Resident #2's progress notes failed to reveal documented evidence that the resident's family or physician was notified of the resident's change in condition. On 10/07/2024 at 9:05 a.m., a phone interview was conducted with Resident #2's family member who stated that they were surprised to learn that the resident was placed on oxygen over the weekend prior to her hospitalization on [DATE]. She stated that neither she nor the resident's RP were notified that the resident had been placed on oxygen. Attempts were made to conduct a phone interview with S6RN on 10/07/2024 at 1:41 p.m. and 3:57 p.m. with no response. On 10/07/2024 at 2:05 p.m., an interview was conducted with S2DON (Director of Nursing). S2DON stated the resident began experiencing shortness of breath and had a fever on the night of 09/13/2024. S6RN administered Tylenol for the resident's fever, and placed the resident on oxygen. S2DON stated that in her opinion, S6RN did not think to call the physician or nurse practitioner (NP) because she believed the resident improved. S2DON confirmed the resident's family member's assertion that Resident #2 remained on supplemental oxygen over the weekend. S2DON further confirmed that the resident's family, NP, nor physician were not notified. S2DON stated the resident's family and attending physician should have been notified of the resident's change in condition.

Based on observation, interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to ensure the well-being of residents by failing to provide oversight in the kitchen after unsanitary findings were discovered by the Registered Dietitian on [DATE] and [DATE] and reported to the administrator. This lack of administrative oversight resulted in an Immediate Jeopardy on [DATE] at 4:01 p.m. when the kitchen was observed to have equipment; food storage, preparation practices; and dinnerware storage practices that were unsanitary and unsafe for meal distribution to residents. S1Administrator was notified of the Immediate Jeopardy on [DATE] at 4:01 p.m. The Immediate Jeopardy was removed on [DATE] at 9:39 a.m., after it was verified through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal, prior to the survey exit. This deficient practice had the potential to cause foodborne illness in 127 residents who consumed meals from the kitchen. Findings: Cross Reference F812 Review of Nutrition Report completed by S23RD dated [DATE] titled: Quality Assurance Monitor 10 Kitchen/Food Service Observation Findings: garbage disposal not currently working; 0 ppm (parts per million) chemical running through line; some bowls/plates on drying rack need to be turned upside down; main handwashing sink broken others with running water maintenance aware; and employee making sandwiches with no hairnet. Review of Nutrition Report completed by S23RD dated [DATE], titled: Quality Assurance Monitor 10 Kitchen/Food Service Observation Findings: Stove drip pans soiled; oven needs to be cleaned; several leftovers in walk-in cooler not labeled/dated; sandwiches made this morning not dated; expired thickened orange juice; moldy pancakes; several items expired in the freezer; several expired breads; boxes of bread on floor; some expired seasonings; found dented can; and also label/date bulk bins of rice/flour. Review of email dated [DATE] at 4:37 p.m. from S23RD (Registered Dietitian) to S1Administrator, S2DON (Director of Nursing), S3ADON (Assistant Director of Nursing), S5DM (Dietary Manager), and S6AIT (Administrator in Training) read attached is my tracking and recommendation sheet from today's visit .that was completed in the kitchen. On [DATE] at 11:00 a.m., an interview was conducted with S23RD. She stated the first week of every month she conducts an overview of the kitchen which consists of following a check list of her observations, potential hazards, and cleanliness of the kitchen. After kitchen observation, she meets with the S5DM and reviews everything that was observed in the kitchen. She stated then she has a meeting with S1Administrator about her recommendations, and she then emails her report to the administration team. She stated she had a verbal meeting about these findings with S1Administrator and S6AIT on [DATE]. On [DATE] at 2:13 p.m., a joint interview was conducted with S1Administrator S6AIT, and S4CorpRN (Corporate Registered Nurse). S1Administrator verified and confirmed he was informed via email of the findings made by S23RD on [DATE]. He stated he did not initiate any corrective action for the kitchen findings identified by S23RD. S1Adminsitrator was unsure of the time he had been in the facility's kitchen. S1Administrator stated he failed to ensure the unsanitary condition of the kitchen was corrected after he was notified of S23RD findings on [DATE] and [DATE].

Based on observations, interviews, and policy and procedure reviews the facility failed to maintain a clean and sanitary kitchen to prevent cross contamination and the likelihood of foodborne illnesses to the 127 residents who ate meals prepared from the facility's kitchen. This deficient practice resulted in an Immediate Jeopardy on [DATE] at 8:45 a.m. when the following was observed in the facility's kitchen: 1.Equipment: a. The six-burner stove and deep fryer was observed with thick layer of debris and grease build-up on the top, front, inside, and sides. Plastic bubble wrap and debris was observed on the floor underneath the six-burner stove. The doors that enclosed the deep fryer noted on the outside was held together by rubber bands. The deep fryer's cooking oil collection area was observed to be full. A thick layer of oil and debris noted on the floor underneath the deep fryer. b. Build-up of grease and residue on the outside of all refrigerators and all walk-in coolers. c. Build-up of debris on the outside of all ice machines and brown substance noted on the inside the ice machine near the food prep station. d. Trolleys being used to bring food items or dishes from one part of the kitchen to another had debris and food residue on them. e. All food preparation counters and stations noted with food residue from the breakfast meal service while lunch was being prepared. f. Food residue noted on the steam table where tray covers and plates were stored for plating resident meals. 2. Dish and cookware storage and cleanliness: a. Clean dish storage racks noted with large steam pans, large pots, and serving pan with buildup of rust and hard water. b. Bowls noted on the clean dish storage rack with water and soap suds on them. c. A ladle that had been previously washed remained with a dried brown substance on it. 3. Food storage: A. Refrigerated items: 1. A bag of lettuce not labeled with the date it had been opened. 2. A bag of ready to eat boiled eggs not labeled with the date it had been opened. 3. Two bags of gravy were not labeled with the date it had been prepared. 4. An outdated leftover container of gumbo labeled [DATE]. 5. A tomato with changes noted to the color of the skin to brown and a cucumber with texture change in the refrigerator indicated the items were spoiled. 6. A bag of tropical fruit with an expiration date of ,d+[DATE]. B. Dry Storage 1. Four dented canned goods in the dry storage room. 2. Exterior and interior of lids of the dry food storage bins noted with build-up of grease and residue. 4. Handwashing stations a. Handwashing stations near located by dishwashing sinks were out of order. b. No paper towels noted above the hand washing station near the steam table. c. No self-opening trash cans near all hand washing stations which increased the risk for recontamination of hands after washing. 5. Debris and caked on food residue on large portions of the kitchen floor. 6. Dishes, old towels, and missing tiles noted under the dishwashing area. These failures placed residents at risk for of food-borne illnesses. S4CorpRN (Corporate Registered Nurse), S6AIT (Administrator in Training), and S15ADM (Administrator), was notified of the Immediate Jeopardy on [DATE] at 5:53 p.m. The Immediate Jeopardy was removed on [DATE] at 1:33 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implementing an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice had the likelihood to cause more than minimum harm to the 127 residents who eat out of the kitchen. Findings: Review of the facility's policy, General Kitchen Sanitation, dated [DATE], revealed in part, the following: Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All nutrition & food service employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Procedure: 1. Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware and food-contact surfaces of equipment . 2. Clean food-contact surfaces of grills, griddles, and similar cooking devices . 3. Keep food-contact surfaced of all cooking equipment free of encrusted grease deposits and other accumulated soil . 12. Make sure hand-washing facilities are easily accessible and supplied with soap and paper towels. Review of the facility's policy, Food Storage, dated [DATE], revealed in part, the following: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored accord to the state, federal and US food Codes . Refrigerators: d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage . e. Use all leftovers within 72 hours . Review of the facility's policy, Food Deliveries, dated [DATE], revealed in part, the following: . Procedure: . c. All cans must be in good condition and not dented. Review of the facility's policy, Cutting Boards, dated [DATE], revealed in part, the following: Policy: the facility will maintain counters and tabletops in a clean and sanitized condition to minimize the risk of food hazards . Food resides on food contact surfaces and equipment can provide an ideal environment for the growth of disease causing bacteria which can easily contaminate other foods . cleaning and sanitizing of food contact surfaces and equipment is necessary to prevent the spread of bacteria. Review of the facility's policy, Floors, Tables and Chairs, dated [DATE], revealed in part, the following: Policy: The facility will maintain floors, tables and chairs in a clean and sanitary condition to minimize the risk of food hazards . Procedure: . 7. Sweep kitchen floors after each meal. Clean thoroughly with a disinfectant at least twice a week. Move major appliances at least once a month when disinfecting kitchen floors. Review of the facility's policy, Ovens, dated [DATE], revealed in part, the following: Policy: The facility will maintain ovens in a clean and sanitary manner to minimize the risk of food hazards . Thorough cleaning will be done once each week. Procedure: . 3. Wipe off . grease on racks and in oven . Review of the facility's policy, Refrigerators, Coolers and Freezers, dated [DATE], revealed in part, the following: Policy: The facility will maintain refrigerators, coolers and freezers in a clean and sanitary manner to minimize the risk of food hazards . Procedure: . 2. Dispose of all outdated food and discard all leftover items greater than 72 hours old . 9. Wipe exterior of refrigerator or freezer with approved cleaner or clean cloth wet with sanitizing solution. Review of the facility's policy, Steam Table, dated [DATE], revealed in part, the following: Policy: The facility will maintain the steam table in a clean and sanitary manner to minimize the risk of food hazards. Procedure: . 2. Clean inside and outside of each unit of steam table with a cloth soaked in warm water and detergent. Review of Nutrition Report completed by S23RD (Registered dietician) dated [DATE], titled: Quality Assurance Monitor 10 Kitchen/Food Service Observation Findings: garbage disposal not currently working; 0 ppm (parts per million) chemical running through line; some bowls/plates on drying rack need to be turned upside down; main handwashing sink broken others with running water maintenance aware; and employee making sandwiches with no hairnet. Review of Nutrition Report completed by S23RD dated [DATE], titled: Quality Assurance Monitor 10 Kitchen/Food Service Observation Findings: Stove drip pans soiled; oven needs to be cleaned; several leftovers in walk-in cooler not labeled/dated; sandwiches made this morning not dated; expired thickened orange juice; moldy pancakes; several items expired in the freezer; several expired breads; boxes of bread on floor; some expired seasonings; found dented can; and also label/date bulk bins of rice/flour. An initial tour of the kitchen was conducted on [DATE] at 8:45 a.m. with S5DM (Dietary Manager). On [DATE] at 10:15 a.m. an interview was conducted with S5DM. S5DM confirmed the findings listed above throughout the kitchen tour. S5DM stated that he had a hard time managing the kitchen and holding kitchen staff accountable for responsibilities. He confirmed that the kitchen was not clean and sanitary causing the potential for food-borne illnesses to the residents that eat out of the kitchen. On [DATE] at 11:00 a.m. an interview was conducted with S23RD who stated that on the first Thursday of the month she conducted an overview of the kitchen by following a premade check list which consists of following a check list of her observations, potential hazards, and cleanliness of the kitchen. After completing her kitchen observations, she then reviewed any abnormal findings and recommendations with S5DM. The observations of the kitchen made on [DATE] was discussed. She confirmed that these findings had the potential to cause food-borne illnesses to residents. On [DATE] at 11:55 a.m. an interview was conducted with S15ADM (Administrator). He confirmed that he had observed the condition of the kitchen and that it was not sanitary. He stated that the kitchen not being cleaned and sanitized has the potential to cause food borne illnesses to residents. On [DATE] at 2:13 p.m., a joint interview was conducted with S1Administrator, S6AIT (Administrator in Training), and S4CorpRN (Corporate Registered Nurse). S1Administrator verified and confirmed he was informed via email of the findings made by S23RD on [DATE]. He stated he did not initiate any corrective action for the kitchen findings identified by S23RD. S1Adminsitrator was unsure of the time he had been in the facility's kitchen. S1Administrator stated he failed to ensure the unsanitary condition of the kitchen was corrected after he was notified of S23RD findings on [DATE] and [DATE]. 46149 On [DATE] at 9:35 a.m., an observation was made in the facility's kitchen. S5DM (Dietary Manger) pureed vegetable medley for residents using the food processor. S5DM wore gloves at this time. S5DM transferred the pureed vegetable medley into a pan, and proceeded to rinse the food processor out in the kitchen's two compartment sink. S5DM did not remove his gloves and did not wash the food processor with soap and water. S5DM then scooped chicken breast from a pot on the stove and added it to the food processor. He did not change his gloves or wash his hands. S5DM proceeded to puree the chicken breast. On [DATE] at 9:43 a.m., an observation was made of a handwashing sink in the kitchen that contained a pitcher of water sitting in ice. S22Dietary was asked why the pitcher of water was in the handwashing sink. S22Dietary stated that she was using the pitcher of water to fill up the beverage cups that were on the preparation counter, and that is where she places the water pitcher. On [DATE] at 9:55 a.m., an observation was made of the kitchen's two compartment sink in the food preparation area. There was a cart with dirty dishes next to the sink. S5DM stated that the right compartment of the sink was used for washing or rinsing dishes and the left compartment of the sink was used for thawing meat. He also stated that the cart with the dirty dishes was used to separate glass dishes that needed to be washed separately. Further observation of the two compartment sink revealed a spoon and ladle with food particles in the left compartment of the sink that was used for thawing meat. S5DM stated that those dishes were not supposed to be there.

Based on record review and interview, the facility failed to develop and implement an accurate plan of care based on the comprehensive resident assessment consistent with Resident #4's specific risks and needs to ensure Resident #4 received two person assist with transfers. Care plan review revealed Resident #4 was care planned for one person assist with transfers. This failed practice resulted in actual harm to Resident #4 when Resident #4 sustained an acute spiral [MEDICAL CONDITION] shaft of the right tibia when transferring from bed to wheelchair with only one person assist for 1 out 6 sampled residents. (#4) Findings: 1. Resident #4. Review of resident #4's clinical record revealed that the resident was admitted to the facility on [DATE]. The resident's admitting [DIAGNOSES REDACTED]. Review of resident #4's Quarterly MDS (Minimum Data Sheet) with a target date of 8/8/11 revealed that the resident's cognition was moderately impaired. Also, further review of the MDS revealed that the resident was assessed requiring extensive assistance for transfer and that she required 2 plus persons for physical assist for transfers. Review of resident #4's Care Plan dated 9/21/11 and 11/1/11 revealed that the resident was a one person physical assist for transfers. The care plan did not correctly reflect the assessment from the MDS dated [DATE], requiring the resident for a 2 plus person physical assist for transfers. Review of resident #4's Incident Note dated 11/6/11 at 20:49 revealed, "Resident sitting in day room during family visit. Resident started crying when family member attempted to lift resident's leg. Staff then brought resident back to room in w/c and asst resident to chair and called nurse. Rt ankle and foot noted swollen. Dr. _____ notified. New order noted to obtain x-ray of ext. (1145) x-ray performed. (1245) x-ray results noted: Spiral fx of distal tibia......." Review of resident #4's x-ray report dated 11/10/11 revealed that the x-ray was done on 11/6/11 at 11:50 am. Review of the x-ray findings revealed, "Etiology of the tibial fracture is indeterminate but could be related to transportation of the patient or other causes ... ... ... There is a spiral [MEDICAL CONDITION] tibial shaft and with an additional vertical component noted. There is slight lateral displacement of the distal component measuring approximately 4 mm..................... IMPRESSION: Acute spiral [MEDICAL CONDITION] shaft of the tibia URGENT FINDINGS: !!!!!!!!!!!!!!" Review of nursing progress notes created 11/9/11 at 09:55 revealed, "............. After investigation and witness statement the fracture likely occurred during transfer from bed to w/c.........." Review of the OTIS report revealed that the incident was discovered on 11/6/11 at 12:45 pm and was entered in the system on 11/7/11 at 5:52 pm. Review of the OTIS report revealed, "Description: (Resident #4's) right ankle and foot were noted to be swollen. Her physician was notified and a new order was noted to obtain an x-ray of the extremity. The x-ray was performed and the results noted a spiral [MEDICAL CONDITION] tibia. Her doctor was notified of the results and gave a new order to send to (hospital). (The hospital) was notified and report was given. (The ambulance) transferred (resident #4) from the facility to the hospital. The hospital gave her a splint and put her on non weight bearing status......... Summary: An investigation was conducted immediately following the report. Witness statements were obtained and surveillance footage was reviewed. The most likely moment and scenario when the injury occurred was when her aide pivoted (resident #4) during her transfer from the bed to the wheelchair. (Resident #4) has severe intellectual disabilities and also has a [DIAGNOSES REDACTED]. The facility obtained an expert opinion from a physician and he concurred that this particular injury is consistent with a twisting motion such as a foot not pivoting during transfer............" Interview with S5CNA (certified nursing assistant) and with S6CNA on 11/28/11 at 11:10 am stated that resident #4 was a one person assist before the resident sustained [REDACTED]. Interview with S4CNA Supervisor on 11/28/11 at 11:20 am stated that resident #4 was a 1 person assist before she fractured her right leg. S4CNA Supervisor stated that the nurses let her know what needs the resident's have and then she informs the CNAs of the resident's needs. Interview with S7CNA on 11/28/11 at 12:40 pm stated that resident #4 was a 1 person assist for transfer before she sustained a fracture of her right leg. Interview with S1DON (Director of Nurses) on 11/28/11 at 2:10 pm stated that from the investigation, S8CNA was the last staff person to transfer the resident out of bed to the wheelchair. S1DON stated that they came to the conclusion that the resident did not pivot her leg during the transfer from the bed to the wheelchair which caused the fracture to the resident's right leg. Interview with S3LPN (licensed practical nurse) MDS Coordinator on 11/29/11 at 1:30 pm confirmed that resident #4 was coded as a 2 plus person assist for transfers on the MDS dated [DATE]. S3LPN MDS Coordinator confirmed that the care plan dated 9/21/11 and 11/1/11 revealed that the resident was care planned as 1 person assist for transfer. Also, S3LPN MDS Coordinator confirmed that based on the review of the resident's Intervention/Task form for October 2011 that the resident was documented as being totally dependent for transferring for the majority of time in October. S3LPN MDS Coordinator confirmed that resident #4's care plan dated 9/21/11 and 11/1/11 did not reflect the resident's MDS assessment in that the resident was assessed as a 2 plus person assist for transfer. S3LPN MDS Coordinator confirmed that resident #4 was care planned as a 1 person assist for transfer instead of a 2 plus person assist for transfer per the assessment from the resident's MDS. Interview with S1DON on 11/29/11 at 1:35 pm confirmed that the resident was coded as a 2 plus person assist for transfer and that based on the review of the resident's Intervention/Task form for October 2011 that the resident was documented as being totally dependent for transferring for the majority of month of October. Also, S1DON confirmed that resident #4's care plan dated 9/21/11 and 11/1/11 did not reflect the resident's MDS assessment in that the resident was assessed as a 2 plus person assist for transfer. Also, S1DON confirmed that resident #4 was transferred with 1 CNA when the resident sustained [REDACTED].

Based on record review and interview, the facility failed to ensure that each resident receives adequate supervision and assistance to prevent accidents as evidenced by resident #4 being assessed as a 2 plus person assist for transfer, was transferred from the bed with 1 person assistance. This failed practice resulted in actual harm when Resident #4 sustained an acute spiral fracture of the distal shaft of the right tibia during the transfer from the bed for 1 out 6 sampled residents. (#4) Findings: 1. Resident #4. Review of resident #4's clinical record revealed that the resident was admitted to the facility on [DATE]. The resident's admitting [DIAGNOSES REDACTED]. Review of resident #4's Quarterly MDS (Minimum Data Sheet) with a target date of 8/8/11 revealed that the resident's cognition was moderately impaired. Also, further review of the MDS revealed that the resident was assessed requiring extensive assistance for transfer and that she required 2 plus persons for physical assist for transfers. Review of resident #4's Care Plan dated 9/21/11 and 11/1/11 revealed that the resident was a one person physical assist for transfers. The care plan did not correctly reflect the assessment from the MDS dated [DATE], requiring the resident for a 2 plus person physical assist for transfers. Review of resident #4's Incident Note dated 11/6/11 at 20:49 revealed, "Resident sitting in day room during family visit. Resident started crying when family member attempted to lift resident's leg. Staff then brought resident back to room in w/c and asst resident to chair and called nurse. Rt ankle and foot noted swollen. Dr. _____ notified. New order noted to obtain x-ray of ext. (1145) x-ray performed. (1245) x-ray results noted: Spiral fx of distal tibia......." Review of resident #4's x-ray report dated 11/10/11 revealed that the x-ray was done on 11/6/11 at 11:50 am. Review of the x-ray findings revealed, "Etiology of the tibial fracture is indeterminate but could be related to transportation of the patient or other causes ... ... ... There is a spiral fracture of the distal tibial shaft and with an additional vertical component noted. There is slight lateral displacement of the distal component measuring approximately 4 mm..................... IMPRESSION: Acute spiral fracture of the distal shaft of the tibia URGENT FINDINGS: !!!!!!!!!!!!!!" Review of nursing progress notes created 11/9/11 at 09:55 revealed, "............. After investigation and witness statement the fracture likely occurred during transfer from bed to w/c.........." Review of the OTIS report revealed that the incident was discovered on 11/6/11 at 12:45 pm and was entered in the system on 11/7/11 at 5:52 pm. Review of the OTIS report revealed, "Description: (Resident #4's) right ankle and foot were noted to be swollen. Her physician was notified and a new order was noted to obtain an x-ray of the extremity. The x-ray was performed and the results noted a spiral fracture of the distal tibia. Her doctor was notified of the results and gave a new order to send to (hospital). (The hospital) was notified and report was given. (The ambulance) transferred (resident #4) from the facility to the hospital. The hospital gave her a splint and put her on non weight bearing status......... Summary: An investigation was conducted immediately following the report. Witness statements were obtained and surveillance footage was reviewed. The most likely moment and scenario when the injury occurred was when her aide pivoted (resident #4) during her transfer from the bed to the wheelchair. (Resident #4) has severe intellectual disabilities and also has a [DIAGNOSES REDACTED]. The facility obtained an expert opinion from a physician and he concurred that this particular injury is consistent with a twisting motion such as a foot not pivoting during transfer............" Interview with S5CNA (certified nursing assistant) and with S6CNA on 11/28/11 at 11:10 am stated that resident #4 was a one person assist before the resident sustained [REDACTED]. Interview with S4CNA Supervisor on 11/28/11 at 11:20 am stated that resident #4 was a 1 person assist before she fractured her right leg. S4CNA Supervisor stated that the nurses let her know what needs the resident's have and then she informs the CNAs of the resident's needs. Interview with S7CNA on 11/28/11 at 12:40 pm stated that resident #4 was a 1 person assist for transfer before she sustained a fracture of her right leg. Interview with S1DON (Director of Nurses) on 11/28/11 at 2:10 pm stated that from the investigation, S8CNA was the last staff person to transfer the resident out of bed to the wheelchair. S1DON stated that they came to the conclusion that the resident did not pivot her leg during the transfer from the bed to the wheelchair which caused the fracture to the resident's right leg. Interview with S3LPN (licensed practical nurse) MDS Coordinator on 11/29/11 at 1:30 pm confirmed that resident #4 was coded as a 2 plus person assist for transfers on the MDS dated [DATE]. S3LPN MDS Coordinator confirmed that the care plan dated 9/21/11 and 11/1/11 revealed that the resident was care planned as 1 person assist for transfer. Also, S3LPN MDS Coordinator confirmed that based on the review of the resident's Intervention/Task form for October 2011 that the resident was documented as being totally dependent for transferring for the majority of time in October. S3LPN MDS Coordinator confirmed that resident #4's care plan dated 9/21/11 and 11/1/11 did not reflect the resident's MDS assessment in that the resident was assessed as a 2 plus person assist for transfer. S3LPN MDS Coordinator confirmed that resident #4 was care planned as a 1 person assist for transfer instead of a 2 plus person assist for transfer per the assessment from the resident's MDS. Interview with S1DON on 11/29/11 at 1:35 pm confirmed that the resident was coded as a 2 plus person assist for transfer and that based on the review of the resident's Intervention/Task form for October 2011 that the resident was documented as being totally dependent for transferring for the majority of month of October. Also, S1DON confirmed that resident #4's care plan dated 9/21/11 and 11/1/11 did not reflect the resident's MDS assessment in that the resident was assessed as a 2 plus person assist for transfer. Also, S1DON confirmed that resident #4 was transferred with 1 CNA when the resident sustained [REDACTED].