Every finding on record at Care Center of Laurel

Based on observation, staff interview, record review, and facility policy review, the facility failed to store, label, and date food items in a sanitary manner and ensure tray line temperatures were consistently documented, for one (1) of two (2) kitchen observations. Findings included:A review of the facility's policy titled Storage of Canned and Dry Food with a revision date of 9/23 revealed, .Procedure.8. Opened packages are stored in tightly covered containers or Ziploc bags.A review of the facility's policy titled Resident Tray Service and Delivery with a revision of 05/18 revealed, .Procedure.g. The temperatures of food is taken with a calibrated thermometer and documented on the Temperature Monitoring Log.On 8/4/25 at 10:32 AM, during an observation of the kitchen with the Dietary Manager (DM), in the dry storage room, there was a partially torn pack of hamburger buns with two missing, an opened pack of coffee filters, American cheese wrapped in saran wrap with a hole exposing slices to air, an open 25-pound box of instant thickener, and a brown box of croissant rolls with one pack torn open. In the freezer, several plastic bags were torn open, including a 10-pound box of pork sausage links, a 10-pound box of turkey sausage links, a 10-pound box of sausage patties, a 15-pound box of fried egg patties, and a 20-pound box of chocolate chip dough. In the refrigerator, a clear plastic container of sliced lemons was observed with visible mold, a gallon container of grape Kool-Aid with lemons had no label or date, and a nearly empty gallon container of ranch dressing had no open date. A record review of the Daily Food Temperature Monitoring Log revealed missing documentation for dinner temperatures on 7/5, 7/18, 7/19, 7/20, and 7/25. It also revealed missing documentation for lunch on 7/22.On 8/4/25 at 11:08 AM, during an interview with the DM, she stated that all open food items should be sealed or placed in plastic bags to prevent contamination. She explained that unsealed food could cause residents to become sick. She stated it was her responsibility to ensure staff followed proper procedures. She also explained that the final cooking temperatures should be recorded for each meal to confirm that food is cooked and served at appropriate temperatures and to reduce the risk of foodborne illness.On 8/6/25 at 10:57 AM, during an interview with the cook, she stated she always checks tray line temperatures but sometimes forgets to write them down.

Based on record review, staff interview, and facility policy review, the facility failed to develop a comprehensive care plan for four (4) of 19 sampled residents. (Resident #3, Resident #4, Resident #17, and Resident #31)Findings included: A review of the facility’s policy, Care Plan Process, revised 12/24, revealed, .Regulations require facilities to complete .a comprehensive, standardized assessment of each resident's functional capacity and needs .The results of the assessment .are to be used to develop .each resident's comprehensive person-centered plan of care .The Care Plan must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #3 A record review of the admission Record revealed the facility admitted Resident #3 on 1/3/24 with diagnoses including Chronic Obstructive Pulmonary Disease and Encounter for Prophylactic Measures. A record review of the Order Review History Report revealed Resident #3 had a Physician's Order, dated 1/3/24 for Apixaban 5 milligrams (mg) two times a day for Atrial Fibrillation (A-fib). A record review of the Comprehensive Care Plan revealed there was no care plan developed to include interventions related to anticoagulant therapy. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/28/25 revealed Resident #3 had Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Further review revealed he had taken anticoagulant medication during the lookback period. Resident #4 A record review of the “admission Record” revealed the facility admitted Resident #4 on 6/3/24 with diagnoses including Type 2 Diabetes Mellitus. A record review of the “Patient Discharge Instructions” dated 4/4/25 revealed, “…New Medications… apixaban (type of anticoagulant medications) … Impression and Plan Diagnosis: New onset A-fib (Atrial fibrillation) with RVR (Rapid Ventricular Rate) …” A record review of the Order Review History Report revealed Resident #4 had a Physician's Order dated 4/4/25 for Apixaban 5 mg two times a day for A-Fib. A record review of the Comprehensive Care Plan revealed there was no care plan developed to include interventions for the diagnosis of Atrial fibrillation, or the risks related to anticoagulant therapy. A record review of the Annual MDS with an ARD of 5/20/25 revealed Resident #4 had a BIMS score of 15, which indicated she was cognitively intact. During an interview on 8/5/25 at 3:51 PM, the Director of Nursing (DON), she stated she is currently performing Quality Assurance (QA) duties and oversees the MDS and care plan nurses. The DON confirmed that Resident #4 returned from the hospital on 4/4/25 with a new diagnosis of A-fib with RVR (Rapid Ventricular Rate). She acknowledged that there was no care plan for the anticoagulant or the diagnosis of A-fib. She stated she expected care plans to be developed daily when new orders or information is received and reviewed quarterly with the comprehensive assessment. She stated the nurse must have missed the new diagnosis since it was not added to the electronic health record (EHR). In a follow up interview on 8/6/25 at 11:00 AM, the DON confirmed that a care plan had not been developed for anticoagulant therapy for Resident #3 and explained the facility had been without a QA nurse for several months which had contributed to the failure to develop the care plans. Resident #17 On 8/4/25 at 3:14 PM, during an interview, Resident #17 reported that she was dependent upon staff to assist with changing her. A record review of the “admission Record” revealed the facility admitted Resident #17 on 6/13/25 and she had current diagnoses including Morbid (Severe) Obesity. A record review of the Quarterly MDS with an ARD of 5/15/25 revealed Resident #17 had a BIMS score of 15, which indicated she was cognitively intact. A review of Section GG revealed Resident #17 was dependent on staff for toileting hygiene. A record review of Resident 17's medical record revealed there was no care plan developed that included bowel and bladder care. On 8/7/25 at 10:05 AM, during an interview, the DON stated she was aware that care plans had not been developed and that the facility was in the process of hiring an MDS nurse. Resident #31 A record review of the “admission Record” revealed the facility admitted Resident #31 on 7/22/21 with diagnoses including Obstructive Uropathy. A record review of the “Order Review History Report” revealed Resident #31 had a Physician’s Order, dated 7/5/24, to change the catheter and catheter bag monthly and as needed. A record review of the Quarterly MDS with an ARD of 6/18/25, revealed Resident #31 had a BIMS score of 15 and had an indwelling catheter. A record review of Resident #31’s medical record revealed there was no care plan developed to address the indwelling urinary catheter. On 8/6/25 at 11:52 AM, during an interview with the DON, she confirmed the care plan did not address the indwelling catheter or any related interventions. She stated the care plan should have been developed to include this information and explained that the facility previously employed a case manager who was responsible for updating care plans, but that person was terminated in January. She added that she and other staff had been trying to correct care plans since that time.

Based on record review, staff interview, and facility policy review, the facility failed to ensure that a resident had trust account funds refunded to their family within 30 days after death for one (1) of three (3) closed records reviewed. (Resident #91)Findings Include:A review of the facility's General Resident Trust Fund Policies, dated 04/25, revealed, .Conveyance Upon Discharge or Death Upon discharge or in the event of death of a resident with personal funds deposited with the facility, the facility must refund within 30 days the funds and a final accounting of those funds to the resident. In the event of death funds must be refunded to the Estate of or sent to the State Unclaimed Property Division if no heir can be identified within 30 days.A record review of the admission Record revealed the facility admitted Resident #91 on [DATE] with diagnoses including Amyotrophic Lateral Sclerosis (ALS).A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #91was coded for Death in facility.A record review of the Progress Notes revealed a Nursing Note, dated [DATE] at 9:31 (AM) indicated Resident #91 expired at the facility.A record review of the Resident Statement revealed Resident #91 had a balance of $2.00 that remained in the account at the time of his death. The account was documented as closed on [DATE].A record review of a facility-issued check written to the resident's family indicated the check was dated [DATE], which was more than 90 days after the resident's death.On [DATE] at 10:38 AM, during an interview with the Nursing Home Administrator (NHA), he stated he recently started the process of refunding families after the death of residents because he was new to the facility. He further stated that he was unaware of the requirement to return trust fund balances within 30 days of a resident's death.

Based on observation, staff interview, and facility policy review, the facility failed to ensure a homelike and comfortable environment by failing to address a persistent, unpleasant noise caused by a malfunctioning resident room door for three (3) of four (4) days of the survey. Findings include: Record review of the facility policy titled Resident Environment, dated 9/15/25 revealed, It is the policy of this facility to provide a safe, clean, comfortable and homelike environment.During observations from 8/4/25 through 8/6/25, multiple times throughout the day, there was a high-pitched, squealing noise heard from the hallway. The noise was very loud and could be heard through the closed door in the training room. The noise occurred multiple times throughout the day of survey and was notably loud and unpleasant. On 8/6/25 at 1:45 PM, during an observation of Percutaneous Endoscopic Gastrostomy (peg) tube care, the wound care nurse closed Resident #53's door to provide privacy during the care. When she closed the door, the metal door rubbed the floor and caused the unpleasant, high-pitched noise that had been heard throughout the survey. On 8/6/25 at 2:32 PM, during interviews with Certified Nurse Aides (CNAs) #1 and #2, both staff were asked to open the door to room [ROOM NUMBER] and acknowledged hearing the loud squealing noise caused by the metal door rubbing the floor. The CNAs stated the issue had been ongoing for a while and that they typically left the door open because the residents were nonverbal and the door was only closed during care. They both agreed the sound was unpleasant and could affect residents but admitted they had not reported the issue to maintenance because no one ever complained. On 8/6/25 at 2:35 PM, during an interview with Licensed Practical Nurse (LPN) #1, she stated the loud noise from the door had been occurring for several months. She explained she had not submitted a maintenance request because no residents had complained, but agreed the sound was unpleasant and could be disturbing to the residents who are unable to voice their concerns. On 8/6/25 at 2:45 PM, during an interview and observation with the Maintenance Director, the door to room [ROOM NUMBER] was closed and it made a loud noise. He stated that typically nurses or CNAs will either submit a work order or notify him verbally of an issue with equipment. He reported that nothing had been brought to his attention regarding the loud, squeaking door. He determined that the problem could be resolved by removing the current kick plate and replacing it.On 8/7/25 at 11:44 AM, in an interview with the Director of Nursing (DON), she stated that any staff who become aware of a problem with functioning equipment should notify the Maintenance Supervisor by submitting a work order. She confirmed that all staff interviewed had been aware of the problem for several months. She stated it is her expectation that staff notify maintenance of such issues so they can be addressed in a timely manner. The DON added that while the resident affected by this problem could not verbally communicate to complain, the noise could have been an irritating stimulus or disrupted the resident's sleep pattern, as the resident is aware of her surroundings but unable to express concerns.

Based on record review, staff interview, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's active diagnoses of Atrial Fibrillation (Resident #4) and failed to ensure the completion of an entry and discharge MDS (Resident #90) for two (2) of 19 sampled residents.Findings included: A review of the facility’s policy MDS Process, revised 12/20, revealed, .The RAI (Resident Assessment Instrument) is the source document to be used for further MDS coding guidelines, time schedules and requirements . The RAI User’s Manual, Chapter 1 requires the assessment accurately reflects the resident's status and Chapter 2 indicates that an Entry Tracking Record must be completed at the time of admission, and a Discharge Tracking Record or Discharge MDS must be completed when the resident is discharged . Resident #4 A record review of the “admission Record” revealed the facility admitted Resident #4 on 6/3/24 with diagnoses including Type 2 Diabetes Mellitus. A record review of the “Patient Discharge Instructions” for Resident #4, dated 4/4/25 revealed, “…New Medications… apixaban (type of anticoagulant medications) … Impression and Plan Diagnosis: New onset A-fib (Atrial fibrillation) with RVR (Rapid Ventricular Rate)” A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/20/25 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Section I – Active Diagnoses did not include Atrial Fibrillation as an active diagnosis, despite documentation in the medical record. On 8/5/25 at 3:51 PM, in an interview with the Director of Nursing (DON), she stated she is currently performing quality assurance (QA) duties and oversees the MDS and care plan nurses. The DON confirmed that Resident #4 returned from the hospital on 4/4/25 with a new diagnosis of A-fib with RVR (Rapid Ventricular Rate) and the Annual MDS failed to reflect the diagnosis. She stated she expected the MDS to be accurate and updated daily when new orders are received and reviewed quarterly with the comprehensive assessment. She stated the nurse must have missed the new diagnosis since it was not added to the resident’s current diagnoses in the electronic health record (EHR). Resident # 90 A record review of the 'admission Record' revealed the facility admitted Resident #90 on 4/4/24 with diagnoses including Cerebral Infarction. A record review of a “Nursing Note” revealed Resident #90 returned from the hospital on 7/16/25. A record review of a “Transfer Out Note” revealed Resident #90 was sent out for evaluation on 7/31/25. A record review of the electronic health record (EHR) for Resident #90 indicated the last activity occurred on the Minimum Data Set (MDS) was a “Discharge Return Anticipated” assessment, dated 7/2/25. There was no entry MDS noted for the return on 7/16/25, nor was a discharge assessment noted for the 7/31/25 discharge to the hospital. On 8/6/25 at 4:25 PM, during an interview with the DON, she stated the MDS assessments with appropriate ARDs should have been completed in a timely manner. She explained the facility was currently recruiting a QA nurse for the MDS/Care Plan department.

Based on observation, interviews, record review, and facility policy review the facility failed to promote the dignity of residents by requiring the residents to use a bedside commode (BSC) in their room instead of a designated restroom when toileting for two (2) of (19) sampled residents. (Resident #29 and Resident #51) Findings Include: Review of the facility's policy, Dignity and Respect, revised 7/22, revealed, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life .The facility shall protect and promote the rights of the resident .2. Each resident of the facility has the right to a dignified existence . Review of the facility's Resident Rights Policy, revised 12/23, revealed, Every resident in this facility has the right to .12. Be treated .with the fullest measure of dignity .17. Be treated with consideration and respect for their personal privacy including but not limited to toileting . During an observation and interview on 3/19/24 at 11:00 AM, with Resident #29 and Resident #51, the residents revealed the toilet in their bathroom did not work. Resident #29 stated the sewage backed up and had overflow issues, so they had been instructed by the facility to use BSCs provided by the facility. The toilet had been in disrepair since January of this year (2024) and both residents expressed they did not feel comfortable using the BSCs because of the odors and the lack of privacy. The staff made sure the curtains were pulled for privacy, but they had to call staff to empty the BSCs after each use. There were two BSCs noted in the residents' room. One BSC was located on each side of the room. During an interview on 3/19/24 at 11:15 AM, with Certified Nursing Aide (CNA) #7, she confirmed the toilet had not worked properly in Resident #29 and Resident #51's bathroom since January 2024. CNA #7 stated the residents used the BSCs that were lined with a clear bag and after use of the BSC, the CNAs removed and disposed of the bags. In an interview on 3/20/24 at 11:00 AM, with the Maintenance Director, he explained that he had installed a new toilet in Resident #29 and Resident #51's room about a week and a half ago and he was unaware the residents were still having problems with the toilet. The Maintenance Director stated that no one had completed a maintenance form indicating the toilet needed to be repaired. During an interview on 3/21/24 at 10:00 AM, with the Director of Nursing (DON), she stated that she did not know the residents were having issues with the toilet. The DON said she understood why using BSCs rather than the toilet would be upsetting to the residents. During an interview on 3/21/24 at 10:15 AM, with the Administrator, she stated that she was aware the toilet was not working properly for Resident #29 and Resident #51, but thought it was repaired when the Maintenance Director installed a new toilet in the residents' room. The Administrator was unaware the residents were currently using BSCs and confirmed this could be a dignity issue for the residents. She reported that she would work to have the toilet flushing issue repaired immediately. Resident #29 A record review of the Face Sheet revealed the facility admitted Resident #29 on 10/11/18 and she had current diagnoses including Hemiplegia, Hypertension, and Anxiety. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/23 revealed Resident #29 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated her cognition was moderately impaired. Resident #51 A record review of the Face Sheet revealed the facility admitted Resident #51 on 12/7/23 and she had current diagnoses including Heart Failure, Renal Disease, and Diabetes Mellitus. A record review of the Admission MDS with an ARD of 12/15/23 revealed a BIMS score of 15, which indicated she was cognitively intact.

Based on observation, interviews, and facility policy review, the facility failed to ensure residents' rights for a comfortable, homelike environment as evidenced by not providing hot water in the shower room and for four (4) of 27 residents residing on the Primary Care Unit (PCU). Resident #17, Resident #42, Resident #66 and Resident #72. Findings include: A review of the facility's policy, Resident Environment, dated 09/15, revealed, It is the policy of this facility to provide a .comfortable and homelike environment . Resident #17 On 03/19/24 at 10:21 AM, during an interview with Resident #17, reported the water in her room and the shower room was not hot. At 9:45 AM on 03/20/24, during an observation of Resident #17's bathroom, the hot water in the sink measured 60 F after three (3) minutes with a thermometer and 64 F after four (4) minutes. Resident #42 On 03/19/24 at 11:50 AM, during an observation and interview with Resident #42, he complained the hot water in his bathroom did not work. The hot water in the bathroom sink was turned on and was not warm after approximately one (1) minute. On 03/20/24 at 09:50 AM, during an observation of Resident #42's bathroom, the hot water in the skin reached 74 F after two (2) minutes and was cool. Resident #66 At 09:55 AM on 03/20/24, during an interview with CNA #4, she explained the water in Resident #66's (PCU) bathroom would not get hot, so she usually got hot water from the other side of the building and brought it back to Resident #66's room to give her a bath. Resident #72 At 11:15 AM on 03/19/24, during an interview with Resident #72, he complained the water in the bathroom sink did not get warm. On 03/20/24 at 9:35 AM, during an interview with Certified Nursing Assistant (CNA) #5, she explained the water in Resident #72's bathroom (PCU) did not get hot. The hot water temperature was checked with a thermometer and after two (2) minutes, the thermometer reading was 60 degrees Fahrenheit (F) and after four (4) minutes it was 64 F. On 03/19/24 at 11:00 AM, during an interview with CNA #6, she confirmed the water on the PCU did not get hot and residents have complained. She stated management was aware of the problem. On 03/20/24 at 2:45 PM, during an interview with the Administrator, she explained a new hot water heater had been installed for the PCU and she was not aware that residents still had complaints regarding hot water since the installation of the new hot water heater. At 3:10 PM on 03/20/24, during an interview and observation with the Maintenance Director, he explained that after the new hot water tank was installed on the PCU, he had some complaints about the hot water. The facility decided to get a different type of recycling pump and was currently waiting on the plumbing company to replace it. During observation of Resident #72's bathroom sink, the hot water reached 64 F after running for three (3) minutes. In Resident #17's bathroom sink, the hot water temperature reached 64 F after running for three (3) minutes. Resident #42's bathroom sink reached 74 F after running for two (2) minutes. The shower room on the PCU reached 64 F after running for two (2) minutes. He confirmed the hot water temperatures were cold and that all residents have the right to hot water. On 03/21/24 at 12:28 PM, during an interview with the Administrator, she stated that she expected all residents to have hot water in their bathrooms and showers.

Based on observations, interviews, record review, and the facility policy review, the facility failed to implement comprehensive care plan interventions for a resident with a feeding tube (Resident #26) and failed to develop a comprehensive care plan for a resident with full length bedrails (Resident #66) for two (2) of 19 sampled residents. Findings include: A review of the facility's policy, Care Plan Process, revised 08/17, revealed, .The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs .The facility staff shall follow the care plan . Resident #26 Cross Reference: F693 A record review of the Face Sheet revealed the facility readmitted Resident #26 on 5/23/23 and he had current diagnoses including Cerebral Infraction, Aphasia, and Dysphagia. A record review of the Care Plan revealed Resident #26 had a Problem/Need of Resident has a feeding tube, with an onset date of 5/3/23, and an approach of Keep HOB (Head of Bed) elevated 30 degrees. On 03/20/24 at 11:00 AM, during an observation, Certified Nursing Assistant (CNA) #9 lowered the head of bed (HOB) until Resident #26 was lying flat. CNA #9 completed incontinent care and the HOB was not elevated during the care. On 03/20/24 at 11:30 AM, during an interview, CNA #9 confirmed she had lowered the HOB and Resident #26 was lying flat while she provided care. CNA #9 said that she was aware Resident #26 had a high risk for aspiration and explained that it was difficult to turn the resident without assistance if the HOB was elevated. CNA #9 confirmed that she had not asked any other staff to assist with providing care to Resident #26. On 3/21/24 at 10:30 AM, in an interview with Licensed Practical Nurse (LPN) #4, she stated she expected the staff to implement care plan approaches and keep Resident #26's HOB elevated at all times due to his high risk for aspiration. Resident #66 Cross Reference: F700 During an observation on 3/20/24 at 8:30 AM, Resident #66 was lying in bed and there were two (2) full length bedrails noted on the bed. The right bedrail was raised, and the left bedrail was lowered at the head of the bed and was slanted. Resident #66 was leaning toward the left side of the bed, and she had her right foot propped up on the middle of the right raised bed rail. Record review of the Face Sheet revealed the facility admitted Resident #66 on 9/29/20 and she had current diagnoses including Dementia. A review of the comprehensive care plans revealed Resident #66 did not have a care plan regarding full length bedrails. On 03/21/24 at 11:29 AM, during an interview with LPN #4, she explained she was not aware until this week that Resident #66 had full length bedrails. She reported that she had not completed a care plan with approaches for bedrails for Resident #66. 43283

Based on observations interviews, record review, and facility policy review, the facility failed to clean, cut, and file fingernails for a resident who required assistance with Activities of Daily Livings (ADLs) for personal hygiene for one (1) of 19 sampled residents. Resident #55 Findings include: A review of the facility's policy Nail Care, revised 01/24, revealed Purpose .To promote cleanliness, safety and a neat appearance . On 03/19/24 at 10:22 AM, Resident #55 was lying in bed and had long fingernails on both hands. The resident was able to respond to questions and answered yes when asked if she would like to have her nails trimmed. On 03/20/24 at 10:05 AM, during an observation of Resident #55 and an interview with Certified Nurse Aide (CNA) #3, she confirmed Resident #55 had long nails that were dirty. CNA #3 explained Resident #55 had a diagnosis of Diabetes and CNAs were not allowed to trim her nails. At 10: 15 AM on 03/20/24, during an observation of Resident #55 and an interview with Licensed Practical Nurse (LPN) #2, she explained LPNs were not allowed to clip Resident #55's nails because she had a diagnosis of Diabetes, and a Registered Nurse (RN) clipped the resident's nails on weekends and as needed. LPN #2 observed Resident #55's fingernails and confirmed the resident's fingernails were long, jagged, and dirty and asked Resident #55 if a nurse could trim her nails, and the resident replied yes. LPN #2 reported that the resident's nails had not been clipped recently. On 03/20/24 at 03:35 PM, during an interview with the Director of Nursing (DON), she explained the weekend RNs are to assess resident nails weekly and they only checked the condition of the nail and cleaned and clipped as needed. She explained she was not sure if Resident #55 refused nail care but if so, it would be documented in the medical chart. She stated she expected staff to adequately complete ADL care for all residents, which included clipping and cleaning their fingernails. At 4:00 PM on 03/20/24, during a phone interview with RN#2, she explained she worked at the facility on the weekend on a part-time basis. She explained that she looked at the at the nails for residents with Diabetes, but she did not clip all the resident's nails in the facility every week and rotated nail care from week to week. She confirmed that she did not clip Resident #55's nails this month, but she did observe them to ensure they were clean. She was unable to recall if Resident #55 ever refused to have her nails clipped. Record review of the Face Sheet revealed the facility admitted Resident #55 on 12/15/21, and she had current diagnoses including Type 2 Diabetes Mellitus. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/08/24 revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of six (6), which indicated her cognition was severely impaired. Further review revealed she required moderate assistance with personal hygiene.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide incontinent care in a manner to prevent complications for one (1) of two (2) residents reviewed for care. (Resident #26) Findings Include: Review of the facility's policy, Perineal Care, revised 1/24, revealed, .Purpose .To prevent irritation or infection .Male-Without Catheter .4. Hold the shaft of the penis with on hand. 5. Using the other hand gently cleanse from the tip to the base of the penis . On 03/20/24 at 11:00 AM, Certified Nurse Aide (CNA) #9 provided incontinent care for Resident #26 after he had an incontinent episode and had a soiled brief. During the care, the CNA did not clean the resident's penis. In an interview on 03/20/24 at 11:30 AM with CNA #9, she confirmed she failed to cleanse the resident's penis during care. She explained that she had forgotten and confirmed that not cleansing the penis after an incontinent episode could have caused the resident to acquire an infection. During an interview on 3/21/24 at 10:00 AM, with the Director of Nursing (DON), she stated she expected the staff to follow the standards of practice while providing incontinent care and she reported the staff received training regarding how to appropriately provide care, including cleaning the penis. A record review of the Face Sheet revealed the facility admitted Resident #26 on 5/23/23 and he had current diagnoses including Cerebral Infraction, Aphasia, and Dysphagia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/10/24 revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident was severely cognitively impaired.

Based on observation, interviews, record review and facility policy review, the facility failed to ensure the head of the bed (HOB) was properly elevated for a resident who required enteral feedings and was at high risk for aspiration for one (1) of nine (9) residents observed who received nutrition by a feeding tube. Resident #26 Findings include: Record review of the facility's policy, Tube Feedings revised 12/15, revealed, .4. A resident who is fed by nasogastric, jejunostomy or gastrostomy tubes will receive appropriate treatment and services to prevent aspiration pneumonia . During an interview on 03/19/24 at 01:07 PM, a family member for Resident #26 stated the staff provided care to the resident by laying him flat, even though he had a high risk for aspiration. She stated the feeding tube was not infusing while staff provided care, but the resident could not tolerate lying flat at any time and the HOB must be kept elevated. During an observation on 03/20/24 at 11:00 AM, Certified Nursing Assistant (CNA) #9 lowered the HOB until Resident #26 was lying flat. CNA #9 completed incontinent care and the HOB was not elevated during the care. During an interview on 03/20/24 at 11:30 AM, with CNA #9, she confirmed she had lowered the HOB and Resident #26 was lying flat while she provided care. CNA #9 said that she was aware Resident #26 had a high risk for aspiration and explained that it was difficult to turn the resident without assistance if the HOB was elevated. CNA #9 confirmed that she had not asked any other staff to assist with providing care to Resident #26. During an interview on 3/21/24 at 10:00 AM, with the Director of Nursing (DON), she said she expected the staff to follow the standards of practice while providing care to residents. The DON confirmed the CNA should have kept the Resident #26's HOB elevated at least 30 degrees and stated she should have asked for assistance rather than lying the resident flat. A record review of the Face Sheet revealed the facility readmitted Resident #26 on 5/23/23 and he had current diagnoses including Cerebral Infraction, Aphasia, and Dysphagia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/10/24 revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident was severely cognitively impaired.

Based on observation, interviews, record review, and the facility policy review, the facility failed to adequately assess a resident for bedrail use, failed to attempt alternative measures prior to the placement of full bedrails, and failed to ensure bedrails were properly installed and assessed for the risk of entrapment for one (1) of 19 sampled residents. Resident #66 Findings include: Record review of a statement provided by the Administrator on facility letterhead, dated March 21, 2024 revealed, The facility does not have a specific policy and procedure that only states Bed/Side Rails . On 3/20/24 at 8:30 AM, during an observation, Resident #66 was lying in bed and there were two (2) full length bedrails noted on the bed. The right bedrail was raised, and the left bedrail was lowered at the head of the bed and was slanted. Resident #66 was leaning toward the left side of the bed, and she had her right foot propped up on the middle of the right raised bed rail. On 03/20/24 at 9:55 AM, in an interview and observation, Resident #66 was lying in bed and Certified Nursing Assistant (CNA) #4 confirmed the resident had full length bedrails. CNA #4 reported the resident had full bedrails for the past couple of months because the resident was crawling out of the bed. At 2:35 PM on 03/20/24, during an interview with Licensed Practical Nurse (LPN) #2, she explained Resident #66 had gotten a new bed approximately two (2) months ago because the resident had falls. On 03/20/24 at 2:45 PM, during an interview with the Director of Nursing (DON), she explained she was unaware that Resident #66 had full length bedrails. Resident #66 received hospice services and the hospice provider brought the resident a new bed. At 11:04 AM on 3/21/24, during an interview with the DON, she explained Resident #66 had not been assessed for bedrail use or entrapment. The DON further explained that when the resident's bed was delivered and set up, a new bedrail assessment was not completed. The DON reported that Resident #66's family member had signed a bedrail consent on admission, but it was not updated to indicate the resident had full length bedrails. Record review of the Face Sheet revealed the facility admitted Resident #66 on 9/29/20 and she had current diagnoses including Dementia. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/05/24 revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated her cognition was severely impaired. Record review of Resident #66's Device/Physical Restraint Consent signed 09/18/20 revealed I (Proper Name of Resident #66) have been informed . that a side rails device will be used . The consent does not indicate the type of siderails to be used or the benefits of using siderails. The consent was signed by the Resident Representative. Record review of the Nurse Data Collection and Screening, dated 12/11/23 revealed the bed rail was Not used

Based on interviews, record review, and facility policy review, the facility failed to implement care plan approaches or interventions related to notifying the physician of feeding tube complications for one (1) of four (4) resident care plans reviewed. Resident #1. Findings Include: Record review of the facility's Care Plan Process policy, revised 08/17, revealed, .The facility staff shall follow the care plan .The Physician Orders, Medication Administration Record, and Treatment Administration Record are part of the Comprehensive Care Plan . Record review of the Face Sheet revealed the facility admitted Resident #1 on 6/5/23 with a diagnosis of Cerebral infarction, unspecified, and Gastrostomy status. Record review of Physician Orders for the month of July 2023 revealed Resident #1 had a Physician's Order with an order date of 6/5/23 to Check residual; notify MD (Medical Doctor) if greater than 100 ml (milliliters). In a record review of the Care Plan for Resident #1 revealed a Problem Onset date of 6/16/23 with a Problem/Need of .has a feeding tube . and Approaches included Notify MD (Medical Doctor) of any complications. In a record review of the Departmental Notes revealed on 7/2/23 at 6:45 AM and 7:45 AM, License Practical Nurse (LPN) #1 and Registered Nurse (RN) #1 had no documentation of notifying the MD of Resident #1 feeding tube residual of greater than 100 ml. On 7/24/23 at 2:37 PM, an interview with RN #1 confirmed she did not follow the care plan of informing the physician that Resident #1 gastrostomy tube residual was greater than 100 ml. During the interview, she conveyed that she is the day shift supervisor the night nurse should have informed the resident's physician of the information because it was part of the care plan. On 7/24/23 at 3:37 PM, an interview with LPN #1 confirmed she did not follow the care plan on Resident #1 to notify the MD of the residual of greater than 100 ml. She relayed she should have followed the care plan to notify the MD because it is the process for staff to take care of the residents. On 7/24/23 at 4:00 PM, an interview with RN #2 reported that care plans were developed and individualized to ensure consistency in the nursing care of the resident, which helps improve services. RN #2 added that she expects all nursing staff in the facility to follow care plans for the residents. On 7/25/23 at 10:35 AM, an interview with Director of Nursing (DON) revealed it is my expectation that the nursing staff follow the care plans of all residents. The care plans provide a detailed and effective personalized outline of care to be provided to our residents.

Based on interviews, record review, and facility policy review, the facility failed to notify the physician of feeding tube complications for one (1) of two (2) residents reviewed with feeding tubes. Resident #1. Findings Include: Record review of the facility's Gastrostomy/Jejunostomy/Nasogastric Tube policy, revised 01/22, revealed, .Administration of Tube Feedings .6. For Gastrostomy and Nasogastric tubes .C. If more than 100 (cc) cubic centimeter of residual is aspirated, return the residual to the stomach, discontinue the tube feeding, and notify the physician . Record review of the Face Sheet revealed the facility admitted Resident #1 on 6/5/23 with a diagnosis of Cerebral infarction, unspecified, and Gastrostomy status. Record review of Physician Orders for the month of July 2023 revealed Resident #1 had a Physician's Order with an order date of 6/5/23 to Check residual; notify MD (Medical Doctor) if greater than 100 ml (milliliters). A record review of the Departmental Notes revealed on 7/2/23 at 6:45 AM and 7:45 AM, License Practical Nurse (LPN) #1 and Registered Nurse (RN) #1 have no documentation of notifying the MD of Resident #1 feeding tube residual of greater than 100 ml. On 7/24/23 at 2:37 PM, an interview with RN #1 confirmed she is the day shift supervisor, and she did not notify the physician on 7/2/23 when she reported on duty that Resident #1's gastrostomy tube residual was greater than 100 ml. RN #1 revealed that the resident was not in any distress and was not gurgling, vomiting, or having shortness of breath when she arrived on duty at 7:00 AM. On 7/24/23 at 3:37 PM, an interview with LPN #1 confirmed she did not follow the physician's orders to notify the MD of the residual of greater than 100 ml on 7/2/23. She relayed she should have followed the physician's orders to notify him of the resident residual. On 7/25/23 at 10:35 AM, an interview with the Director of Nursing (DON) stated it is my expectation that the nurses follow the physician's orders. LPN #1 should have notified the physician of Resident #1 residual or any acute problems. On 7/25/23 at 11:00 AM, an interview with the MD confirmed on 7/2/23, the nurses did not notify him of Resident #1 residual of greater than 100 ml and that the tube feeding was placed on hold. During the interview, the MD stated that he would not have done anything differently since the resident was not in any acute distress.

Based on staff interviews, record reviews, and facility policy review, the facility failed to complete a Level II Preadmission Screening and Resident Review (PASARR) for a resident with a new major mental illness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #28 Findings include: Record review of the facility's policy Preadmission Screening PAS/PASRR (MS only) with a revision date of 10/18 revealed .The Level II evaluation must occur prior to admission and whenever the resident has a significant change in status . A change in status referral for Level II Resident Review Evaluations is also required for individuals who may not have previously been identified by PASRR to have mental illness . Record review of the Face Sheet revealed the facility originally admitted Resident #28 on 05/07/15 and readmitted him on 05/05/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the medical record for Resident #28 revealed a Level I PAS was completed on 05/6/15. There was no Level II PASARR evaluation for Resident #28 in the medical record. Record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/05/2021, revealed Resident #28 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order start date was 05/05/20. Record review of the Behavioral Health Service note for 12/30/21 revealed use of antipsychotics, antidepressants, and medication for Dementia. Resident #28 was seen for Anxiety, [CONDITION(S)], and Depression. The current medication on 12/30/21 included [MEDICATION(S)] (which is used for Dementia), [MEDICATION(S)] (which is used for Depression), [MEDICATION(S)] (which is used for [CONDITION(S)]), and [MEDICATION(S)] (which is used for Dementia). The recommendations were to discontinue [MEDICATION(S)] due to resident is without [CONDITION(S)] and may benefit from med discontinued. Record review of Resident #28's Care Plan with a problem onset date of 12/28/17 revealed resident has a history of hearing voices/auditory hallucinations with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/05/22 at 3:30 PM, during an interview with the Director of Nursing (DON), she explained Resident #28 had a PAS Level I completed prior to his admission on 05/6/2015 and reported no PASARR Level II has been competed since admission. The DON reviewed Resident #28's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She further reported Resident #28 had not been out to Geri-psych since she became the DON in February 2019, but Resident #28 does see psychiatric services related to his diagnosis.

Based on staff interview, record review and facility policy review the facility failed to ensure a comprehensive person-centered care plan was revised to accurately reflect the Resident's continence status for one (1) of (23) care plans reviewed. Resident #42. Findings include: Review of the facility's Comprehensive Care Plan Policy, revealed it is the policy of this facility to develop, revise and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The facility's policy also revealed the comprehensive care plan will be reviewed and revised periodically, on an ongoing basis to reflect the services provided or arranged and must be consistent with each resident written plan of care. The facility shall use the results of the assessment to develop, review, and revise the resident's comprehensive plan of care. The facility shall follow the care plan. Record review of the comprehensive care plan with a problem onset dated 10/20/21 revealed Resident #42 is at risk for urinary incontinence. The goal is for Resident # 42 is to remain continent through the next review 1/20/22. The facility's approaches included to evaluate Resident #42's bladder control and pattern PRN (as needed). Observation on 01/04/22 at 03:29 PM, of incontinent care with Certified Nursing Assistant (CNA) #1 revealed the CNA failed to change wipes with each stroke. CNA #1 also cleansed the penis with the same wipe wiping multiple times in the same area. CNA #1 also failed to cleanse Resident #42 with the wipes from front to back. During an interview on 01/06/22 at 03:58 PM, with the Director of Nursing (DON) confirmed the facility failed to revise the care plan to reflect the resident's incontinent episodes. During an interview on 01/06/22 at 04:22 PM, with Registered Nurse (RN) #1 confirmed she failed to revise the residents care plan to reflect the resident having incontinent episodes. RN #1 said she thought the resident was still continent of bowel and bladder. RN #1 also confirmed the resident's care plan did not reflect the resident's current bladder status at this time. During an interview on 01/06/22 at 05:12 PM with CNA #1 confirmed Resident #42 has incontinent episodes all the time. Record review of Resident #42's five (5) day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/12/21 revealed in Section H that Resident #42 is always continent of bladder. Record review of the Face Sheet revealed Resident #42 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, interviews, record reviews and facility policy review, the facility failed to ensure the residents' environment is free from possible accidents by not providing adequate supervision while smoking for one (1) of five (5) observations of residents smoking. Resident #14, Resident #58, and Resident #67. Findings include: Record review of the facility's policy, Smoking Policies and Regulations, with a review date of 8/2021, revealed the facility will provide matches and will light cigarettes upon request in designated areas set aside for smoking. These areas will be monitored by designated staff. On 1/3/22 at 3:44 PM, the State Agency (SA) observed residents smoking in the designated area without supervision. Resident #58 stated, she went to get her coat, she was cold. The SA observed Laundry Aide #1 return to the designated smoking area at 3:52 PM. On 1/3/22 at 3:53 PM, in an interview with Laundry Aide #1, she stated she was cold, and she went to use the restroom and get her coat. She acknowledged she should have stayed with the residents because something could have happened when the residents are left alone, and they could get burned. On 1/5/22 at 1:58 PM, in an interview with the Administrator, she stated that staff are supposed to be with residents when they are smoking and by staff not supervising the residents, it could cause a resident to fall or to get burned. She stated the facility policy is that staff are supposed to be with residents at all times when residents are smoking. Resident #14 On 1/5/22 at 4:50 PM, in an interview with Resident #14, she stated the residents have often been left alone while smoking. She stated the staff takes them out to light their cigarettes and leaves and she could get hurt being left outside alone. Record review of Resident #14's Face Sheet revealed the facility admitted her on 9/24/21. Record review of Resident #14's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/4/21 revealed a Brief Interview for Mental Status score of 13, which indicated the resident is cognitively intact. Resident #58 On 1/4/22 at 10:30 AM, during Resident Council meeting, Resident #58 stated that residents are left unattended during smoke breaks and that it has happened all the time. Record review of the Resident #58's Face Sheet revealed the facility admitted the resident on 10/10/19. Record review of the Quarterly MDS with an ARD of 11/23/21 revealed Resident #58 had a BIMS score of 12, which indicated the resident has moderate cognitive impairment. Resident #67 On 1/6/22 at 4:40 PM, in an interview with Resident #67, she stated staff will leave them and step inside the building when it is cold outside. She stated the staff goes inside to sit at the tables while the residents are smoking and that the staff cannot see what is going on outside when they are sitting inside. She stated it has happened a couple of times. Record review of Resident #67's Face Sheet revealed the facility admitted her on 9/7/21. Record review of the admission MDS with an ARD of 9/14/21 revealed a BIMS score of 15, which indicated the resident is cognitively intact.

Based on observation, staff interview, record review and facility policy review the facility failed to provide incontinent care utilizing correct technique for one (1) of five (5) incontinent care observations. Resident #42. Findings include: The facility policy, Perineal Care, revised 10/2018 revealed the purpose is to cleanse the perineum, to eliminate odor, to prevent irritation or infection and to enhance the Resident's dignity and self-esteem. Under male- without catheter the policy revealed while providing perineal care the staff should hold the shaft of the penis with one hand. Using the other hand gently cleanse from the tip to the base of the penis. Use a clean portion of the washcloth or pre-moistened wash wipe after each stroke. Observation on 01/04/22 at 03:29 PM, of incontinent care with CNA #1 revealed the CNA, cleansed the resident's perineal area with one wipe. CNA #1 wiped the same area multiple times without changing the wipes. CNA #1 also cleansed Resident #42's penis with the same wipe, wiping multiple times in the same area. CNA #1 turned Resident #42 over and wiped the resident with a wet wipe from back to front. CNA #1 failed to change wipes with each stroke and failed to wipe from front to back while providing incontinent care. During an interview on 01/06/22 at 03:58 PM, with the Director of Nursing (DON) confirmed CNA #1 could have caused an infection. The DON also said Resident #42 could become septic from an infection. The DON stated CNA #1 was trained on the appropriate steps to providing incontinent care. During an interview on 01/06/22 at 05:07 PM, with License Practical Nurse (LPN)#1 confirmed CNA #1 failed to follow the facility policy by cleansing the resident's perineal area with the same wipe and wiping the residents' buttocks from back to front. LPN #1 said CNA #1 has been trained how to provide incontinent care properly, and this could cause urinary tract infections (UTIs). During an interview on 01/06/22 at 05:12 PM, CNA #1 confirmed she failed to change wipes with each stroke while providing perineal care. CNA #1 said she was nervous and was thrown off her regular routine. CNA #1 also said the resident has incontinent episodes all the time. CNA #1 confirmed that by not cleaning the resident appropriately, this could cause the resident to get UTIs. Record review of the Face Sheet revealed Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the five (5) day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/12/21 revealed Resident#42 had a Brief Interview for Mental Status (BIMS) of 15 that indicted Resident #42 is cognitively intact. Record review of Certified Nursing Assistant (CNA) #1 Perineal care in-service dated 11/07/21 revealed CNA #1 was in-serviced on providing perineal care appropriately.

Based on observation, interviews, record reviews, and facility policy review the facility failed to prevent the possible spread of infection during incontinent care for two (2) of five (5) residents reviewed. Resident #49 and Resident #21. Finding include: Record review of facility's policy for Infection Prevention and Control Surveillance revealed It is the policy of this facility to prevent infections whenever possible . Record review of the facility's policy for Hand Hygiene revealed the purpose of the policy is to cleanse hands to prevent transmission of infection or other conditions . Indications for hand washing . 3. Before and after procedures. 4. Before and after applying gloves. 5. When hands are visibly soiled .Selecting hand washing method .2. When to wash with soap and water a. when hands are visibly soiled/dirty .d. when hands are visibly contaminated with blood or body fluids . Resident #49 On 1/5/22 at 11:40 AM, the SA observed catheter and perineal care provided by Certified Nursing Assistant (CNA) #4 and assisted by CNA #5 and Registered Nurse (RN) #2. During the procedure, as RN #2 and both CNA's were positioning and turning Resident #49, a bag containing soiled items that had been used during care fell on to the floor and the contents of the bag spilled. RN #2 picked up the spilled contents and placed them back into the bag. She then placed the contaminated bag onto the resident's bed. On 1/6/21 at 4:46 PM, in an interview with RN #2, she confirmed she picked the bag up off the floor after it fell from the resident's bed. The bag landed upside down and the soiled contents fell on to the floor. She acknowledged that she then picked the bag up and placed it back onto the resident's bed. She stated she should have left the bag on the floor and not put the contaminated bag onto the resident's bed because her actions could have caused the resident to have multiple health issues related to infection control. RN #2 was unable to recall the last in-service she had received on infection control. On 1/6/21 at 6:15 PM, in an interview with the Director of Nursing (DON), she stated RN #2 should not have put the contaminated bag back onto Resident #2's bed. She confirmed RN #2 should have left the room and disposed of the bag and the actions of RN #2 could have caused the resident to acquire and spread a bacterial infection. On 1/6/22 at 6:25 PM, in an interview with Licensed Practical Nurse #1 (LPN)/Infection Control Nurse, she confirmed RN #2 should have left the bag on the floor and that by picking up the bag of soiled items and placing it back on the bed, she contaminated the bed and could have caused the resident to acquire an infection. Record review of Resident #49's Face Sheet revealed the facility admitted the resident on 10/5/19, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the In-service training sheet revealed an in-service was conducted on 12/8/21 with the topic of infection control. RN #2's signature was on the sign in sheet indicating she has been trained on infection control. Resident #21 During an observation of incontinent care, on 01/03/21 at 12:45 PM, CNA #2 did not change her visibly soiled gloves, wash or sanitizer her hands, or don clean gloves after cleaning feces from Resident #21 and before applying a clean brief. On 01/03/21 at 1:00 PM, during an interview with CNA #2, she acknowledged she did not remove her soiled gloves and wash her hands. CNA #2 explained she should have changed her gloves after cleaning resident, washed or sanitized her hands, and applied clean gloves before applying the clean brief. On 01/06/21 at 4:00 PM, during interview with the Director of Nursing (DON), she explained CNA #2 came to her right after she completed incontinent care and advised that she didn't change her gloves before placing the clean brief on the resident. The DON confirmed CNA #2 should have changed gloves when they were visibly soiled with feces and these actions could have caused the resident to have a urinary tract infection. The DON reported that CNA #2 had completed a check off list related to Infection Control when hired. On 01/06/22 at 5:30 PM, during an interview with LPN #1/Infection Preventionist, she confirmed CNA #2 should have changed her gloves and washed her hands after cleaning the resident and before applying a clean brief. The CNA's actions caused an infection control breach, and this could have caused a urinary tract infection and the spread of bacteria. Record review of the Face Sheet for Resident #21 revealed the facility admitted Resident #21 on 10/14/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the admission Five Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/21/21, revealed a Brief Interview for Mental Status (BIMS) score of 07 which indicated Resident #21 had severe cognitive impairment. Section G revealed Resident #21 required extensive assistance with personal hygiene and was frequently incontinent of bowel and bladder.

Based on record review, interviews, and facility policy review, the facility failed to report an allegation of Quality of Care/Supervision, related to an incident which resulted in a resident sustaining major injuries, within the two (2) hour required timeframe for one (1) of six (6) residents reviewed, Resident #1. On 02/15/2020, Resident #1 was being transported to an appointment in the facility's van by Driver #1. Resident #1 fell from her wheelchair due to Driver #1's failure to ensure proper shoulder seat belt usage, which resulted in the resident sustaining bilateral femur fractures. The facility's Administrative staff was notified immediately, however it was not reported to the required State agencies until 02/17/2020. Driver #1 was suspended from work pending investigation on 02/15/2020, and employment was terminated 02/18/2020. The failure of the facility to notify the appropriate State agencies in a timely manner of an allegation of Quality of Care related to Supervision, and to ensure proper measures had been addressed, placed Resident #1 and other residents at risk for serious injury, harm, impairment or death. Based on the facility's implementation of an Immediate Jeopardy (IJ) Removal Plan and corrective actions on 02/15/2020, the SA determined the IJ and Substandard Quality of Care (SQC) was Past Non-Compliance (PNC) and the IJ was removed as of 02/18/2020, prior to the State Agency (SA) entrance on 03/11/2020. The SA notified the facility's Administrator of the PNC IJ and SQC on 03/11/2020 at 2:33 PM. Findings include: A review of the facility's Incident Investigation and Reporting policy, dated 05/2018, revealed: The facility administrator shall ensure that any incident involving an allegation or suspicion of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported not later than two (2) hours after the allegation is made to local law enforcement and the State Agency. If the events of the allegation involve abuse or result in serious bodily injury to the State Survey Agency and the Adult Protective Services where state law provides for jurisdiction in long-term care facilities in accordance with state law. Review of the facility's Elder Justice Act: Policy and Procedure for Reporting Suspected Crimes Under the Federal Elder Justice Act policy, dated 08/2013, revealed, if the reportable event results in serious bodily injury, the staff member shall report the suspicion immediately, but not later than two (2) hours after forming the suspicion. Review of the facility's Resident Incident Report, dated 02/15/2020 at 10:20 AM, revealed, Driver #1 reported he and Resident #1 were on their way to [MEDICAL TREATMENT], when a car pulled out in front of them and the resident came out of her wheelchair. Resident #1 was sent to a local hospital. The report documented the Physician and Resident #1's family member was notified. The report further documented the facility staff was educated on van safety and proper seat belt use while securing residents' in the van. A review of Resident #1's Departmental Notes, dated 02/15/2020 at 3:09 PM, Licensed Practical Nurse (LPN) #1 documented, at 10:25 AM, Driver #1 reported to her that while transporting Resident #1 to [MEDICAL TREATMENT], she had come out of her wheelchair when he slammed on brakes, after a car pulled out in front of them. LPN #1 documented Driver #1 reported Resident #1 complained of head pain and bilateral leg pain, and he was instructed by [MEDICAL TREATMENT] staff to take Resident #1 to the hospital. LPN #1 documented the Responsible Party (RP), Medical Doctor (MD), Administrator, Director of Nursing (DON), and Registered Nurse (RN) Supervisor were made aware of the incident. Review of the MFCU Crimes Web Submission document, generated by the Attorney General's (AG) office, revealed the facility reported the incident involving Resident #1 on 02/17/2020 at 11:02 AM. A review of the Administrator's typed statement, undated, on the facility letterhead, revealed, on 02/17/2020 at approximately 10:00 AM, the Mississippi State Department of Health (MSDH) was notified via the telephone hotline of the incident that occurred (02/15/2020) when Driver #1 failed to properly secure Resident #1 in the facility's van, which resulted in bilateral femur fractures. During an interview, on 03/11/2020 at 11:35 AM, the Administrator stated she did not report the incident that occurred on Saturday, 02/15/2020, to anyone until Monday, 02/17/2020. The Administrator revealed she called her Corporate office on 02/15/2020 and was instructed not to call the incident to the MSDH hotline until it was further investigated. The Administrator confirmed she notified the Attorney General's Office (AGO) and the local Police Department on 02/17/2020. The Administrator revealed she should have called the incident in to the appropriate agencies within the two (2) hour timeframe. The facility implemented the following Immediate Jeopardy (IJ) Removal Plan and Corrective Actions on 02/15/2020, prior to the State Agency (SA) entrance on 03/11/2020. In response to the PNC IJ and SQC that was cited at 2:33 PM on 03/11/2020, the facility submitted a brief summary of the event, including the IJ Removal Plan and Corrective Actions taken by the facility to remove the IJ. Description of Incident: On February 15, 2020 at approximately 10:25 AM, Licensed Practical Nurse #1 received a call from van Driver #1 stating that while transporting Resident #1, a car pulled out in front of him and he had to slam on brakes. Resident #1 came out of the chair and fell to the floor of the van, immediately complaining of bilateral leg pain and head pain. Resident #1 was taken to the local emergency department on February 15, 2020 at 10:25 AM and was noted to have bilateral femur fractures. Resident #1 was then transported and admitted to an area trauma hospital for further care on February 15, 2020 at 5:50 PM. Van Driver #1 admitted that he did not buckle Resident #1's seat belt during transport which resulted in the fall to the floor. No other staff was present on the van at the time of the incident. 1. On February 15, 2020, the Facility Administrator suspended Van Driver #1 from his duties pending investigation of this incident. During the investigation, other residents that had been taken to appointments by van Driver #1 were interviewed in relation to wearing seatbelts. Three (3) residents confirmed that van Driver #1 had not used a seatbelt during transport on February 14, 2020. 2. On February 17, 2020, the Facility Administrator notified the Mississippi State Department of Health, two (2) days after the event occurred, and the Mississippi Attorney General's Office at approximately 10:00 AM of the fall with injury, in the transport van when Van Driver #1 failed to buckle Resident #1's seatbelt. Also, on February 17, 2020, the Facility Administrator notified the local police department at approximately 11:00 AM. 3. On February 15, 2020, A Quality Assurance (QA) Meeting was held at approximately 2:45 PM to discuss Abuse and Neglect, Accident/Incident Reporting, as well as safety while driving the facility van. The Facility QA Committee members which consisted of the Facility Administrator, Medical Director, Staff Development Nurse, Infection Control Prevention Officer, Director of Nursing, Assistant Director of Nursing, Housekeeping Supervisor/Approved Van Driver #1, Medical Record Nurse, Case Manager, and Social Service Director, discussed topics of: (a) Abuse and Neglect, (b) Accident/Incident Reporting, (c) safety while driving the facility van, and (d) supervision to prevent accident and incidents. The Facility Action Plan was reviewed and approved by the QA Committee Members. The facility's policies and procedures regarding abuse and neglect and supervision to prevent accidents and incidents were reviewed and accepted with no changes indicated. 4. On February 18, 2020, the Facility Administrator terminated Van Driver #1 due to him not ensuring that residents were properly secured into the van before transportation which resulted in Resident #1 receiving bilateral femur fractures major injuries. 5. On February 15, 2020 an in-service training was initiated by the Director of Nursing (DON) along with the Facility Administrator which included 13 Registered Nurses (RN), 29 Licensed Practical Nurses (LPN), 43 Certified Nursing Assistants (CNA), seven (7) Housekeeping staff, five (5) Laundry staff, 11 Dietary staff, seven (7) Office Personnel, six (6) contract Therapy Department staff, two (2) Activities staff and one (1) Maintenance Director on the following: Abuse and Neglect, Accident/incident Reporting, seven components to reduce, detect, and prevent Abuse and Neglect, and abuse/crime reporting (Elder Justice Act), and accident and incident prevention. 6. On February 15, 2020, an in-service was initiated by the Facility Administrator for all four (4) van drivers on safety while driving the facility van with return demonstration on buckling resident's seatbelt and securing wheelchairs. A copy of the policies for company owned vehicle operation was reviewed as well and the drivers were given a copy. New drivers that are hired will be trained on the Company Owned Vehicle Driver In-Service Checklist as well as the proper securing and buckling of resident safely in the facility van with return demonstration on fastening/unfastening seatbelts, wheelchair tie downs and shoulder straps. 7. On February 17, 2020, the Administrator contacted our agency personnel provider and informed them that no agency staff will be allowed to work until the in-service training has been conducted identifying and reporting abuse and neglect. Agency personnel will not be allowed to work until these in-services have been conducted by licensed facility staff. 8. On February 15, 2020, the Facility Administrator audited all approved driver's license verification as well as their education/training on how to operate the vehicle which includes fastening/unfastening seatbelts and wheelchair tie downs and shoulder straps. There were no discrepancies during this audit. 9. No staff was allowed to work until in-servicing has been complete on: Abuse and Neglect, Accident/Incident Reporting, seven components to reduce, detect, and prevent abuse and neglect, and abuse/crime reporting (Elder Justice Act), and accident and incident prevention. The facility corrective actions were initiated on February 15, 2020. All activities to remove the IJ was initiated on 02/15/2020 and completed on 02/18/2020 and the facility alleges the IJ was removed on 02/18/2020. The State Agency validated the facility's investigation of the incident and implementation of the IJ Removal Plan/Corrective Action through observation, facility record review and interview. 1. The SA validated through record review and interview that Driver #1 was suspended from his duties on February 15, 2020 and terminated on February 18, 2020. It was validated through record review that three (3) residents confirmed that Driver #1 had not used a seat belt during transport on February 14, 2020. 2. The SA validated through record review the facility notified the Mississippi Department of Health, the Attorney general's Office and the local police Department on February 17, 2020, two (2) days after the incident occurred on February 15, 2020. 3. The SA validated through record review and interview that a Quality Assurance (QA) was held on February 15, 2020 to discuss abuse and neglect, Incident reporting, and incident regarding facility vehicle. The Administrator verified, through interview, that policies and procedures were discussed during the meeting and no changes were issued. 4. The SA validated through record review and interview that Van Driver #1 was terminated on February 18, 2020. 5. The SA validated through record review and interview that staff had been in-serviced on abuse/neglect, accident/incident reporting, seven components to reduce, detect, and prevent abuse and neglect, and abuse/crime reporting (Elder Justice Act) and accident/incident prevention. 6. The SA validated through record review and interview that all four (4) van drivers were in-serviced on van safety with return demonstrations on buckling residents seatbelt and securing wheelchairs. A review of document revealed the drivers were in-serviced on the Company Owned Vehicle Driver Checklist. An observation was made on four (4) wheelchair residents on their arrival to the facility in the facility van. It was observed that all four (4) residents were strapped into the facility van using manufactures recommendations. 7. The SA validated through interview with the Administrator that they contacted the agency personnel provider and informed them that no staff would be allowed to work until they received an in-service training on identifying and reporting abuse and neglect. 8. The SA validated through record review that the driver's licenses were audited, along with proof of education on how to operate a vehicle which included fastening seatbelts and shoulder straps. 9. The SA validated through an interview with the Facility Administrator that no staff would be or had been allowed to work without completing the in-service on abuse/neglect, Accident/Incident reporting, seven components to reduce, detect, and prevent abuse and neglect, abuse/crime reporting (Elder Justice Act) and accident/Incident prevention. The Administrator stated that they had no new employees since the in-service was initiated.

Based on record review, interview, and facility policy review the facility failed to provide residents with supervision to prevent accidents, during van transport for one (1) of four (4) residents reviewed for van transport, Resident #1. Resident #1 was being transported to [MEDICAL TREATMENT] when she fell out of her wheelchair onto the floor of the van. Driver #1 failed to secured Resident #1 with the shoulder/seat belt strap. Resident #1 was taken to the local emergency room for evaluation and later transferred to a local trauma hospital for evaluation and treatment. The facility's failure to provide supervision and proper securing of a wheelchair during transport, led to Resident #1 receiving bilateral femur fractures and placed other residents being transported in a situation likely to cause serious harm, injury, impairment or death. Based on the facility's implementation of an Immediate Jeopardy (IJ) Removal Plan and Corrective Actions, as of 02/18/2020, prior to the State Agency (SA) entrance on 03/11/2020, the SA determined the IJ and Substandard Quality of Care (SQC) was Past Non-Compliance (PNC) and the IJ was removed as of 02/18/2020. The SA notified the Administrator of the PNC IJ and SQC on 03/11/2020 at 2:33 PM. Findings include: A review of the facility's Policies for Company Owned Vehicles policy, dated May 2018, revealed, the driver and all passengers in the company/facility owned vehicle must be safely restrained by buckled seat belts, wheelchair floor tie downs and wheelchair harness type seatbelts at all times the vehicle is in use. A qualified individual shall assist patients/residents/clients with seatbelts and wheelchair tie downs and belts and is responsible for ensuring that all person (s) in the vehicle are safely seat belted and remain safely seat belted until the vehicle reaches it's assigned destination. A review of the manufacturer's recommendation revealed to attach lap belt by using intergraded stiffeners to feed belts through openings between seat backs and bottoms and or armrests to ensure proper belt fit around occupant. The manufacturers recommendations also stated to attach a shoulder belt by extending shoulder belt over passengers' shoulder and across upper torso and fasten pin connector onto lap belt. Combination lap/shoulder belts serve as both window-side lap belt and shoulder belt. Ensure belt are adjusted as firmly as possible, but consistent with use comfort. A review of the facility's Resident Incident Report for Resident #1, dated 02/15/2020 at 10:20 AM, revealed Driver #1 reported to Licensed Practical Nurse (LPN) #1, that while transporting Resident #1 to [MEDICAL TREATMENT], she came out of her wheelchair when a car pulled out in from of them. Driver #1 reported Resident #1 complained of pain to her head and both legs. The investigation narrative from the Resident Incident Report, revealed, Resident #1 had a fall on the facility van when she was being transported to [MEDICAL TREATMENT]. The van driver had to slam on brakes to keep from hitting a car that pulled out in front of him. The narrative further revealed Resident #1 tipped from her wheelchair and onto the floor causing injury. Resident #1 was transported to the hospital. Staff was educated on van safety and proper seat belt use while securing resident's into the van. A review of the hand-written statement by LPN #1 revealed, Driver #1 called the facility and reported to her that while transporting Resident #1 to [MEDICAL TREATMENT], a car pulled out in front of him causing him to slam on brakes. Driver #1 reported, when he slammed on brakes, Resident #1 flew out of her wheelchair. LPN #1 documented, Driver #1 stated to her that a good Samaritan stopped and assisted him with getting Resident #1 back into her wheelchair. LPN #1 further documented that Driver #1 told her he continued to transport Resident #1 to [MEDICAL TREATMENT] and the nurse at the [MEDICAL TREATMENT] unit came out and told him to take Resident #1 to the local emergency room . LPN #1 documented Driver #1 stated he took Resident #1 to the emergency room and then contacted the facility to report the incident. LPN #1 documented she called the [MEDICAL TREATMENT] unit, and spoke with the Registered Nurse (RN). The RN told her that she went out to the van to check on Resident #1 herself, and Resident #1's legs were deformed looking, like they were broken. LPN #1 documented the RN told her that she instructed Driver #1 to carry Resident #1 to the emergency room . Record review of the hospital's Final Report of Resident #1's x-rays, dated 02/15/2020, revealed Resident #1 had an acute comminuted [MEDICAL CONDITION] distal femur and an acute [MEDICAL CONDITION] distal femur just superior to the level of the condyles. During an interview, on 03/11/2020 at 9:55 AM, Resident #1 stated on the day of the incident (02/15/2020), she was launched from her wheelchair when Driver #1 slammed on brakes. Resident #1 stated Driver #1 did not fasten her into the van correctly. Resident #1 revealed Driver #1 fastened the wheels of her wheelchair with the clips on the van floor, but he did not put the belt across her shoulders. Resident #1 stated she told Driver #1 that she wanted and needed him to fasten the shoulder seat belt, but he still didn't do it. Resident #1 confirmed she has two broken legs from being launched from her wheelchair. During an interview, on 03/11/2020 at 11:25 AM, Driver #1 stated he and Resident #1 were going up 16th Ave to the [MEDICAL TREATMENT] clinic. Driver #1 stated a car came out of the car wash in front of him and he hit his brakes. He stated Resident #1 came out of the wheelchair onto the floor of the van. Driver #1 stated a man stopped and helped him pick Resident #1 up and put her back in the wheelchair and he took Resident #1 on to [MEDICAL TREATMENT]. Driver #1 stated the [MEDICAL TREATMENT] nurse told him to take Resident #1 on to the local emergency room . Driver #1 stated he called the facility and told what had happened after he got her to the emergency room . Driver #1 stated he had the bottom of the wheelchair strapped to the floor of the van. Driver #1 further stated that he did not have Resident #1 buckled down into the chair. He confirmed that he did not have the shoulder strap/seat belt on Resident #1 during the transport. A review of the facility's Company Owned Vehicle Driver In-Service Checklist, dated 06/18/2019, revealed Driver #1 was in-serviced on Patient/Passenger Safety and Special Equipment , and demonstrated how to safely and adequately perform each of the following functions: 1) properly securing a patient/passenger in the vehicle with seatbelts, 2) properly securing a wheelchair in the vehicle, and 3) properly securing the wheelchair occupant with safety and/or shoulder harness belts. Review of the facility's Vehicle lift Operations Proficiency Checklist for Driver #1, dated 06/18/2019, revealed he was in-serviced and demonstrated how to safely secure resident/transport chair as per manufacturer's instructions. During an interview, on 3/11/2020 at 11:35 AM, the Administrator stated Driver #1 should have stopped the van and called an ambulance to come assist with Resident #1, once he realized she had fallen out of the wheelchair. The Administrator stated Driver #1 should have never picked Resident #1 up from the floor and certainly should have not carried her on to [MEDICAL TREATMENT]. The Administrator confirmed Driver #1 should have strapped the shoulder seat belt on Resident #1. She stated Driver #1 told her that he did not have the shoulder seat belt fastened on Resident #1, just the chair to the bottom of the van. She stated Resident #1 was not secured in the wheelchair without the shoulder strap, and so she went forward out of the chair. The Administrator revealed that by the shoulder seat belt not being secured on Resident #1, allowed the resident to fall from the wheelchair, and assisted with Resident #1 receiving bilateral femur fractures. A review of the facility's, Termination Report, dated 02/18/2020, revealed Driver #1 was terminated from employment on 02/18/2020 for acts of dangerous or destructive nature including carelessness. The document further revealed, Driver #1's last day of employment was 02/15/2020. The facility implemented the following Immediate Jeopardy (IJ) Removal Plan/Corrective Actions prior to the State Agency (SA) entrance on 03/11/2020. In response to the PNC IJ and SQC cited at 2:33 PM on 03/11/2020, the facility submitted a brief summary of the event, including an IJ Removal Plan and Corrective Actions, taken by the facility, to remove the Immediate Jeopardy (IJ): Description of Incident: On February 15, 2020 at approximately 10:25 AM, Licensed Practical Nurse #1 received a call from van Driver #1 stating that while transporting Resident #1, a car pulled out in front of him and he had to slam on brakes. Resident #1 came out of the chair and fell to the floor of the van, immediately complaining of bilateral leg pain and head pain. Resident #1 was taken to the local emergency department on February 15, 2020 at 10:25 AM and was noted to have bilateral femur fractures. Resident #1 was then transported and admitted to an area trauma hospital for further care on February 15, 2020 at 5:50 PM. Van Driver #1 admitted that he did not buckle Resident #1's seat belt during transport which resulted in the fall to the floor. No other staff was present on the van at the time of the incident. 1. On February 15, 2020, the Facility Administrator suspended Van Driver #1 from his duties pending investigation of this incident. During the investigation, other residents that had been taken to appointments by van Driver #1 were interviewed in relation to wearing seatbelts. Three (3) residents confirmed that van Driver #1 had not used a seatbelt during transport on February 14, 2020. 2. On February 17, 2020, the Facility Administrator notified the Mississippi State Department of Health, two (2) days after the event occurred, and the Mississippi Attorney General's Office at approximately 10:00 AM of the fall with injury, in the transport van when Van Driver #1 failed to buckle Resident #1's seatbelt. Also, on February 17, 2020, the Facility Administrator notified the local police department at approximately 11:00 AM. 3. On February 15, 2020, A Quality Assurance (QA) Meeting was held at approximately 2:45 PM to discuss Abuse and Neglect, Accident/Incident Reporting, as well as safety while driving the facility van. The Facility QA Committee members which consisted of the Facility Administrator, Medical Director, Staff Development Nurse, Infection Control Prevention Officer, Director of Nursing, Assistant Director of Nursing, Housekeeping Supervisor/Approved Van Driver #1, Medical Record Nurse, Case Manager, and Social Service Director, discussed topics of: (a) Abuse and Neglect, (b) Accident/Incident Reporting, (c) safety while driving the facility van, and (d) supervision to prevent accident and incidents. The Facility Action Plan was reviewed and approved by the QA Committee Members. The facility's policies and procedures regarding abuse and neglect and supervision to prevent accidents and incidents were reviewed and accepted with no changes indicated. 4. On February 18, 2020, the Facility Administrator terminated Van Driver #1 due to him not ensuring that residents were properly secured into the van before transportation which resulted in Resident #1 receiving bilateral femur fractures major injuries. 5. On February 15, 2020 an in-service training was initiated by the Director of Nursing (DON) along with the Facility Administrator which included 13 Registered Nurses (RN), 29 Licensed Practical Nurses (LPN), 43 Certified Nursing Assistants (CNA), seven (7) Housekeeping staff, five (5) Laundry staff, 11 Dietary staff, seven (7) Office Personnel, six (6) contract Therapy Department staff, two (2) Activities staff and one (1) Maintenance Director on the following: Abuse and Neglect, Accident/incident Reporting, seven components to reduce, detect, and prevent Abuse and Neglect, and abuse/crime reporting (Elder Justice Act), and accident and incident prevention. 6. On February 15, 2020, an in-service was initiated by the Facility Administrator for all four (4) van drivers on safety while driving the facility van with return demonstration on buckling resident's seatbelt and securing wheelchairs. A copy of the policies for company owned vehicle operation was reviewed as well and the drivers were given a copy. New drivers that are hired will be trained on the Company Owned Vehicle Driver In-Service Checklist as well as the proper securing and buckling of resident safely in the facility van with return demonstration on fastening/unfastening seatbelts, wheelchair tie downs and shoulder straps. 7. On February 17, 2020, the Administrator contacted our agency personnel provider and informed them that no agency staff will be allowed to work until the in-service training has been conducted identifying and reporting abuse and neglect. Agency personnel will not be allowed to work until these in-services have been conducted by licensed facility staff. 8. On February 15, 2020, the Facility Administrator audited all approved driver's license verification as well as their education/training on how to operate the vehicle which includes fastening/unfastening seatbelts and wheelchair tie downs and shoulder straps. There were no discrepancies during this audit. 9. No staff was allowed to work until in-servicing has been complete on: Abuse and Neglect, Accident/Incident Reporting, seven components to reduce, detect, and prevent abuse and neglect, and abuse/crime reporting (Elder Justice Act), and accident and incident prevention. The facility corrective actions were initiated on February 15, 2020. All activities to remove the IJ was initiated on 02/15/2020 and completed on 02/18/2020 and the facility alleges the IJ was removed on 02/18/2020. The State Agency validated the facility's investigation of the incident and implementation of the IJ Removal Plan/Corrective Action through observation, facility record review and interview. 1. The SA validated through record review and interview that Driver #1 was suspended from his duties on February 15, 2020 and terminated on February 18, 2020. It was validated through record review that three (3) residents confirmed that Driver #1 had not used a seat belt during transport on February 14, 2020. 2. The SA validated through record review the facility notified the Mississippi Department of Health, the Attorney general's Office and the local police Department on February 17, 2020, two (2) days after the incident occurred on February 15, 2020. 3. The SA validated through record review and interview that a Quality Assurance (QA) was held on February 15, 2020 to discuss abuse and neglect, Incident reporting, and incident regarding facility vehicle. The Administrator verified, through interview, that policies and procedures were discussed during the meeting and no changes were issued. 4. The SA validated through record review and interview that Van Driver #1 was terminated on February 18, 2020. 5. The SA validated through record review and interview that staff had been in-serviced on abuse/neglect, accident/incident reporting, seven components to reduce, detect, and prevent abuse and neglect, and abuse/crime reporting (Elder Justice Act) and accident/incident prevention. 6. The SA validated through record review and interview that all four (4) van drivers were in-serviced on van safety with return demonstrations on buckling residents seatbelt and securing wheelchairs. A review of document revealed the drivers were in-serviced on the Company Owned Vehicle Driver Checklist. An observation was made on four (4) wheelchair residents on their arrival to the facility in the facility van. It was observed that all four (4) residents were strapped into the facility van using manufactures recommendations. 7. The SA validated through interview with the Administrator that they contacted the agency personnel provider and informed them that no staff would be allowed to work until they received an in-service training on identifying and reporting abuse and neglect. 8. The SA validated through record review that the driver's licenses were audited, along with proof of education on how to operate a vehicle which included fastening seatbelts and shoulder straps. 9. The SA validated through an interview with the Facility Administrator that no staff would be or had been allowed to work without completing the in-service on abuse/neglect, Accident/Incident reporting, seven components to reduce, detect, and prevent abuse and neglect, abuse/crime reporting (Elder Justice Act) and accident/Incident prevention. The Administrator stated that they had no new employees since the in-service was initiated.

Based on observation, interview, record review, and policy review, the facility failed to implement the care plan for two (2) of 22 residents reviewed, Resident #6, as evidenced by not providing toenail care for Resident #6 and not providing pain medication during treatment for [REDACTED]. Findings include: Record review of the facility's Quality of Care policy, dated (MONTH) (YEAR), revealed each resident shall receive optimal care to attain and/or maintain the highest possible mental physical functional status as determined by the comprehensive assessment and person-centered plan of care. Resident #15 Review of Resident #15's care plan initiated 7/31/19, revealed a potential for pain related to a stage 4 ulcer to the coccyx. Interventions included to administer pain medications as ordered. Review of the current Physician Orders, revealed orders for Resident #15's Sacral stage 4 wound to be cleaned with normal saline, pat dry, pack with 1/2 strength Dakins soaked kerlix, and cover with border gauze dressing daily and as needed. Resident #15 had orders for [MEDICATION NAME] HCL 100 milligram (mg) every six (6) hours for pain routinely, with orders for Tylenol with [MEDICATION NAME] #3 orally every 12 hours (ordered 10/4/19), as needed for pain. Observation on 10/28/19 at 11:04 AM, revealed Registered Nurse (RN) #1 initiated care to Resident #15's stage 4 wound with normal saline. Resident #15 started crying, holding onto the bed rail saying that it hurt. The nurse said, I'm almost finished. RN #1 proceeded to measure the 3.0 centimeter (cm) x 3.0 cm x 5.0 cm sacral wound. RN #1 packed the wound with 4 x 4 gauze, soaked in half strength Dakin's solution. RN #1 applied sure prep around peri area and foam gauze. RN #1 did not stop the treatment or offer the resident any pain medication during the treatment. In an interview during wound care, on 10/28/19 at 11:04 AM, RN #1 said Resident #15 cries all the time, even if she gets pain medication. RN #1 said the resident was medicated at 6:00 AM with [MEDICATION NAME] and was not due any more pain medicine until 12:00 PM. During an interview on 10/31/2019 at 9:30 AM, the Director of Nursing (DON) confirmed RN #1 failed to address Resident #15's pain during wound care, by not stopping the wound care and offering more pain medication. The DON said RN #1 should have asked the nurse to give Resident #15 the Tylenol #3 with [MEDICATION NAME], that was ordered as needed (and care planned) before finishing the wound care. Resident #6 Review of the Comprehensive Care Plan, dated 2/22/11, revealed Resident #6 had a care plan to check/trim toe nails weekly, to be done by the Registered Nurse (RN). Observation on 10/28/19 at 4:21 PM, revealed Resident #6 lying supine in bed, with feet uncovered. Resident #6's toenails were long, thick, and yellow, with dried blood on the left great toe. During an interview on 10/28/19 at 4:23 PM, Resident #6 stated the Podiatrist normally comes to see him in his room. Resident #6 stated he had reminded the nurse for a month that he needed the Podiatrist to come cut his toenails. Interview on 10/31/19 at 10:55 AM, with the Director of Nursing (DON), confirmed Resident #6's toe nails were long, with thickened yellow toe nails on both feet and should be trimmed. Interview on 10/31/19 at 11:07 AM, with License Practical Nurse (LPN #1), revealed she does body audits on Resident #6 weekly. LPN #1 said she had noticed the long thick yellow toe nails and had informed the Treatment Nurse the resident's toenails needed to be cut, but did not inform the DON that the resident's nails weren't cut. Review of a Podiatry Note revealed Resident #6 was seen by a Podiatrist on 9/23/2017. The note revealed Resident #6's nails were elongated, deformed, and thickened, with fungus nail plates which were yellow. The podiatrist trimmed the resident's toenails and recommended Resident #6 be seen again, as needed, per physicians order, or sooner, if adverse changes in foot condition or foot status.

Based on observation, interview, record review, and policy review, the facility failed to ensure pressure ulcer treatment was provided in a manner to allow the resident to be as pain free as possible during the care. This affected one (1) of six (6) resident wound care observations, Resident #15, as evidenced by the resident crying and holding on to the bed rail during the wound care of the pressure ulcer. The nurse did not stop the care and/or offer additional pain medication. Findings include: A review of the facility's Guidelines for Pain Management of Wounds, dated (MONTH) 2014, revealed: The staff should perform routine pressure ulcer pain assessments with dressing changes and periodically as consistent with the individual's wishes. If consistent with treatment plan, provide opioids and/or non-steroidal anti-[MEDICAL CONDITION] drugs 30 minutes prior to dressing changes or procedures and afterward. Utilize dressings less likely to require less frequent dressing changes ([MEDICATION NAME], hydrogel alginates, polymeric membrane foams, foam, soft silicone dressings). Please note gauze dressings are more likely to cause pain. Systemic treatment for [REDACTED]. Step two: If pain is persisting or increasing give mild opioids ([MEDICATION NAME]), plus if necessary non episodes and or adjuvant. Step Three: If pain is persisting or increasing give opioids for moderate to severe pain ([MEDICATION NAME]), plus if necessary non-opioid and/or adjuvant (step 1 medications and [MEDICATION NAME], discontinue step 2). Observation of Resident #15's wound care, on 10/28/19 at 11:04 AM, revealed Registered Nurse (RN) #1 cleaned the resident's stage 4 pressure ulcer wound with normal saline. Resident #15 started crying and held on to the bed rail saying that it hurt. RN #1 stated, I'm almost finished. RN #1 proceeded to measure the 3.0 centimeter (cm) x 3.0 cm x 5.0 cm sacral pressure ulcer, which had a red wound bed and no odor. RN #1 packed the wound with 4 x 4 gauze, soaked in half strength Dakin's solution. RN #1 applied sure prep around peri area and foam gauze. RN #1 did not stop the treatment or offer the resident any pain medication. During an interview on 10/28/19 at 11:04 AM, during the resident's wound care, RN #1 stated Resident #15 cried all the time, even if she had pain medication. RN #1 said the resident was medicated at 6:00 AM, and was not due any more pain medicine until 12:00 PM. He stated Resident #15 was given the routine [MEDICATION NAME] orally at 6:00 AM, for pain. Review of the Physician Orders, dated (MONTH) 2019, revealed the wound care orders for Resident #15: Wound to be cleaned with normal saline, pat dry, pack with 1/2 strength Dakins soaked kerlix, and cover with border gauze dressing daily and as needed. Resident #15 had routine orders for two (2) 50 milligram (mg) [MEDICATION NAME] HCL tablets orally every six (6) hours for pain routinely, with orders for Tylenol with [MEDICATION NAME] #3 orally ever 12 hours, as needed for pain. Review of the Medication Administration Record [REDACTED]. The resident had not received Tylenol with [MEDICATION NAME] #3 for the month of (MONTH) 2019, per the MAR. Review of Resident #15's Pain Assessment, dated 10/17/2019, revealed Resident #15 was unable to verbalize pain, however, she expressed pain through facial grimacing and crying. Review of the facility's Wound Assessment Reports, dated 7/16/2019, 8/20/2019, 9/17/2019, and 10/22/2019, revealed Resident #15 complained of pain by moaning, grimacing and crying. During an interview on 10/30/19 at 11:16 AM, Resident #15's niece confirmed the resident complained of pain to her sacrum all the time. The niece stated she was told by the nurses that they give the resident pain medicine all the time. The niece said it bothers her to hear her aunt cry in pain. During an interview on 10/30/19 at 4:02 PM, Certified Nursing Assistant (CNA) #1 stated she takes care of Resident #15 on the day shift and the evening shift. She stated Resident #15 cried all the time. She stated the resident said her buttocks hurt whenever staff repositions her. CNA #1 said she reported the resident's complaint of pain to the nurse. During an interview on 10/30/19 at 4:13 PM, CNA #2 stated she provided care to Resident #15 on evening shift. CNA #2 stated Resident #15 complained of pain to her buttocks all the time when care is provided. CNA #2 stated she reported the resident's pain to the nurse. During an interview on 10/30/19 at 4:18 PM, the Medical Doctor (MD) confirmed he was not aware Resident #15 complained of pain during wound care. The MD said he would address this with the nurses during his visit to the facility. During an interview on 10/31/2019 at 9:30 AM, the Director of Nursing (DON) confirmed RN #1 failed to address Resident #15's pain during treatment of [REDACTED].#1 to assess Resident #15's pain prior to providing the wound care. The DON said RN #1 should have asked the Medication Nurse to give Resident #15 the Tylenol #3 with [MEDICATION NAME] before finishing the wound care, as it was ordered as needed. A review of Resident #15's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/25/2019, revealed Resident #15 complains of pain with vocal complaints and facial grimacing. The resident's Brief Interview for Mental Status (BIMS) revealed a score of zero (0), which indicated severe cognitive impairment.

Based on observation, interview, record review, and policy review, the facility failed to ensure a resident was free from pain during wound care for one (1) of six (6) wound care observations, Resident #15, as evidenced by the resident crying and holding on to the bed rail during wound care and the nurse did not stop the care and/or offer additional pain medication. Findings include: A review of the facility's Guidelines for Pain Management of Wounds, dated (MONTH) 2014, revealed: The staff should perform routine pressure ulcer pain assessments with dressing changes and periodically as consistent with the individual's wishes. If consistent treatment plan, provide opioids and/or non-steroidal anti-[MEDICAL CONDITION] drugs 30 minutes prior to dressing changes or procedures and afterward. Utilize dressings less likely to require less frequent dressing changes ([MEDICATION NAME], hydrogel alginates, polymeric membrane foams, foam, soft silicone dressings). Please note gauze dressings are more likely to cause pain. Systemic treatment for [REDACTED]. Step two: If pain is persisting or increasing give mild opioids ([MEDICATION NAME]), plus if necessary non episodes and or adjuvant. Step Three: If pain is persisting or increasing give opioids for moderate to severe pain ([MEDICATION NAME]), plus if necessary non-opioid and/or adjuvant (step 1 medications and [MEDICATION NAME], discontinue step 2). Observation of wound care, on 10/28/19 at 11:04 AM, with Registered Nurse (RN) #1, revealed the nurse cleaned Resident #15's stage 4 wound with normal saline. Resident #15 started crying, holding onto the bed rail saying that it hurt. The nurse said, I'm almost finished. RN #1 proceeded to measure the 3.0 centimeter (cm) x 3.0 cm x 5.0 cm sacral wound, which had a red wound bed and no odor. RN #1 packed the wound with 4 x 4 gauze, soaked in half strength Dakin's solution. RN #1 applied sure prep around peri area and foam gauze. RN #1 did not stop the treatment or offer the resident any pain medication. During an interview on 10/28/19 at 11:04 AM, during the resident's wound care, RN #1 stated Resident #15 cried all the time, even if she had pain medication. RN #1 said the resident was medicated at 6:00 AM, and was not due any more pain medicine until 12:00 PM. He stated Resident #15 was given the routine [MEDICATION NAME] orally at 6:00 AM, for pain. Review of the Physician Orders, dated (MONTH) 2019, revealed the wound care orders for Resident #15: Wound to be cleaned with normal saline, pat dry, pack with 1/2 strength Dakins soaked kerlix, and cover with border gauze dressing daily and as needed. Resident #15 had orders for [MEDICATION NAME] HCL 100 milligram (mg) orally every six (6) hours for pain routinely, with orders for Tylenol with [MEDICATION NAME] #3 orally ever 12 hours, as needed for pain. Review of the Medication Administration Record [REDACTED]. The resident had not received Tylenol with [MEDICATION NAME] #3 for the month of (MONTH) 2019. Review of Resident #15's Pain Assessment, dated 10/17/2019, revealed Resident #15 was unable to verbalize pain, but expressed pain through facial grimacing and crying. Review of the facility Wound Assessment Reports, dated 7/16/2019, 8/20/2019, 9/17/2019, and 10/22/2019, revealed Resident #15 complained of pain by moaning, grimacing and crying. During an interview on 10/30/19 at 11:16 AM, Resident #15's niece confirmed the resident complained of pain to her sacrum all the time. The niece stated the nurses told her that they give the resident pain medicine all the time. The niece said it bothers her to hear her aunt cry in pain. During an interview on 10/30/19 at 4:02 PM, Certified Nursing Assistant (CNA) #1 stated she takes care of Resident #15 on day shift and evening shift. She stated Resident #15 cries all the time, stating her buttocks hurt, whenever the staff repositions her. CNA #1 said she reported the resident's complaint of pain to the nurse. During an interview on 10/30/19 at 4:13 PM, CNA #2 revealed she is Resident #15's care giver on evening shift. CNA #2 stated Resident #15 complains of pain to her buttocks all the time during care. CNA #2 said she reports the resident's pain to the nurse. During an interview on 10/30/19 at 4:18 PM, the Medical Doctor (MD) confirmed he did not know Resident #15 complained of pain during wound care. The MD said he would address this with the nurses during his visit to the facility. During an interview on 10/31/2019 at 09:30 AM, the Director of Nursing (DON) confirmed RN #1 failed to address Resident #15's pain during wound care, by not stopping the wound care. The DON said she told RN #1 to assess Resident #15's pain prior to providing the wound care. The DON said RN #1 should have asked the Medication Nurse to give Resident #15 the Tylenol #3 with [MEDICATION NAME], that was ordered as needed, before finishing the wound care. A review of Resident #15's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/25/2019, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident is severely cognitively impaired. The MDS revealed Resident #15 complains of pain with vocal complaints and facial grimacing.