Every finding on record at Carrollton Health and Rehabilitation Center

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information, for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specification established by CMS for 1 of 4 FY quarters (FY Quarter 1 2026 (October 1 - December 31) reviewed for administration. The facility failed to submit staffing data to CMS for FY Quarter 1 2026 (October 1 - December 31). This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings Included: Review of the CMS PBJ report for CMS for FY Quarter 1 2026 (October 1 - December 31) indicated the facility had failed to submit data for the quarter triggered. During an interview on 06/25/2026 at 11:50 AM, HR stated they have been HR for approximately 5 years. The hours they worked were provided to me via invoices. HR stated they communicated with each employee or the Department head in order to fill out a time adjustment form and submit the form to HR. Then entry was made into the workday system. At the end of the month verified the hours with the DON, ADMIN and verified if there were other adjustments to be made. The service center had access to the Workday program and pulled the hours for the PBJ. The MD, Dietician and Pharmacist, and then CNA (the receptionist) and marketer who worked the floor. Based off of invoices at the end of the month. It was entered into workday; which is the payroll tracking system. After being entered into the Workday system, the Home Office (service center pulls them over). At which point it was uploaded and submitted to CMS. During an interview on 06/25/2026 at 12:50 PM, the DON stated they had been DON at the facility for 4 years. DON stated they got the nursing hour reports from HR, they then verify hours were verified with HR entering the hours into Workday, which is our central hub for managing employee data and HR processes. It covers recruitment, onboarding, payroll, benefits administration, time tracking, and performance management, allowing organizations to handle the entire employee lifecycle efficiently in one platform. The Home Office (Service Center) pulled the hours from this entry and submitted them to CMS for PBJ. It appeared there was a glitch with the submission form from the Service Center which tripped the notification of not being submitted on time. DON stated the potential for the facility to be inadequately or inappropriately staffed, but should not monitoring staffing appropriately, and it can affect the residents negatively. When the facility was notified the DON stated it was added to our QAPI meeting to be reviewed quarterly, to ensure it was accurate to provide the SC the correct information in a timely manner. During an interview on 06/25/2026 at 12:34 PM, the ADMIN stated had had been the ADMIN for 6 months, because it was nursing hours it was usually the DON and HR working together to make sure the hours were correct and accurate. The ADMIN would pull a report to determine if there were any nursing hours that might be missing. This report covered LVNs, CNAs and med aides. Based off of invoices at the end of the month. It was entered into Workday; it was the facility's payroll tracking system. Facility staff entered into Workday, the Home Office (service center pulls them over). At which point it was uploaded and submitted to CMS. The ADMIN stated it would affect the facility's star rating and cause the facility to default to a 1 star for 4 quarters. The ADMIN said it would affect the facility's quality measures by causing the facility to lose stars. When asked how late or omitted PBJ submissions could affect the facility residents, the Administrator said it created the potential for the facility to be inadequately or inappropriately staffed, but should not if monitored staffing appropriately, and it could affect the residents negatively. The ADMIN stated, since that time, no staffing issues were reported. He stated the information was compiled and data submitted to the SC and they in turn submitted it to CMS. Record review of the Facility's Q4 PBJ submission internal investigation revealed. The PBJ data submitted to CMS 2/13/26 at approximately 4:30 PST by facility payroll Vendor.- At 12:26 am 2/14/26 CMS loaded the [NAME] report showed failed submission (Top right of [NAME] report)- Submitted PBJ data for 256 employees. 1 of those employees didn't match due to new software that went live 1/1/26. This caused submission failure. (see page 2 of the [NAME] report 4016/Fatal)- On 2/16/26 realized the report didn't submit and initiated internal root cause analysis while also enlisting Simple LTC to aid in research.- Root Cause Analysis PBJ submission in the correct format occurred prior to the deadline but was rejected due to a coding error attached to employee positions contained within the file. Facility payroll vendor system was upgraded in January and February of 2026, resulting in an unanticipated increased length of time for the Facility to review and validate data to be submitted and facility was not notified of this increased time requirement. The coding issue was not identified or recognized prior to the contracted service submission of the PBJ file. The contracted service did not discover the issue until the submission error occurred and extensive investigation identified the coding error several days past the submission deadline, preventing resubmission. Upgrades to payroll vendors and contracted service providers occurred too close and overlapping with data validation process of the PBJ reporting submission date preventing opportunity for the Facility to complete thorough review and validate submission.- After finding the root cause to be software change issues, on 2/23/26 an appeal was filed with CMS to try and resubmit data. Software issues are one of the few reasons they list for possible appeal.- 2/23/26 AHCA also contacted CMS on 's behalf.- 2/24/26 CMS denied the Appeal- Plan of Correction was created by the Facility leaders in conjunction with. (please see doc Process Improvement Plan: F851 - Payroll-Based Journal (PBJ) Staffing Data Submission)- Plan of Corrections run through QAPI in anticipation of May 15, Q1, deadline. Record review of the facility's Email correspondence with CMS, dated 02/24/26, revealed CMS Nursing Home Staffing RE: Appeal for late PBJ Submissions. Stated the following: Unfortunately, it is not possible to submit or correct PBJ data once a submission deadline has passed. There are no exceptions. To post staffing measures and ratings for all facilities on a set schedule, it is critical that the submission deadline is met. We calculate the measures for all ~15,600 facilities at once {not individual facility's measures one-by-one). We hope you can understand that to maintain a complex system that collects and processes millions of pieces of data effectively, we cannot easily deviate from set processes. Also, in order to maintain fairness and objectivity for all facilities, we need to hold all facilities accountable to the same standards {which have been public for quite some time). All providers should be running the staffing reports that are available in CASPER to check the accuracy and completeness of their final submissions before the submission deadline has passed. Providers are given 45 days from the end of the quarter, and we have cautioned providers that they should not be waiting until the last few days before the deadline to be making their final submissions as they must allow time to deal with any issues that may occur. Providers using a third-party vendor are still ultimately responsible for their PBJ submissions. This Appeal and Request for Reconsideration is being filed on behalf of 45 individual facilities, by their contracted service provider and authorized agent, performs certain administrative services for and on behalf of approximately 357 skilled nursing facilities, including but not limited to the processing and submission of PBJ data. This Request seeks approval for the 45 affected facilities to resubmit their PBJ data for the quarter ending December 31, 2025. It is based on the PBJ Technical Manual and related authority which expressly grants CMS the discretion to rescind, modify or otherwise respond to a submission failure resulting from unexpected circumstances. Each of the 45 facilities that experienced a fatal error relative to their PBJ submission were impacted by the same technical data migration issue which prevented the submission from being successful. We have attached the following documentation in support of this request: 1. Separate appeal documents for each of the facilities with appropriate identifying information(e.g., name, CCN, etc.) as well as a detailed description of the issue and the basis for theappeal. (PBJ Appeal detaLl.s_.zip)2. CMS confirmation report letters for each of the affected facilities. (PBJ ConfirmationReports.zip). Record request from the ADMIN on 05/05/26 at 12:26 PM, for their PBJ policy, the ADMIN stated, We don't have a policy other than following CMS guidelines for PBJ reporting. Record review of the CMS, Electronic Staffing Data Submission Payroll-Based Journal, Long-Term Care Facility Policy Manual, Version 2.7, June 2025, section 1.2 Submission Timeliness and Accuracy, reflected Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. Further review revealed Report Quarter 1 date range as October 1-December 31. Policy manual reflected, Deadline: Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Time) after the last day in each fiscal quarter in order to be considered timely.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for three of six residents (Resident #69, Resident #40 and Resident # 38) reviewed for medication administration. The facility failed to ensure MA D did not give Resident #69's 6:30 a.m. medications at 7:56 a.m. on 06/24/2026. The facility failed to ensure MA D did not give Resident #40's 6:30 a.m. medications at 8:04 a.m. on 06/24/2026. The facility failed to ensure MA D did not give Resident #38's 6:30 a.m. medications at 8:12 a.m. on 06/24/2026. These failures could place residents at risk of not receiving the full therapeutic benefits of the medications and not receiving medications as ordered and could result in adverse effects. Findings include: 1. Record review of Resident #69's face sheet, dated 06/24/26, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason) and Type 2 Diabetes with hyperglycemia (adult-onset diabetes with consistently high blood sugar). Record review of Resident #69's quarterly MDS Assessment, dated 05/22/26, revealed the resident had a severe impairment with cognition with a BIMS score of 06. The resident was diagnosed with Diabetes mellitus and Dementia. Record review of Resident #69's Physician Order, dated 05/28/25, revealed an order for Metformin HCL Oral Tablet 500 MG 9Metformin HCL), give one tablet by mouth two times a day for DM. The medication was scheduled to be administered at 6:30 a.m. and 4:30 p.m. Record review of Resident #69's Comprehensive Care Plan, dated 06/22/25, revealed the resident had potential for altered endocrine status r/t Diabetes Mellitus with intervention: Diabetes medication as ordered by the doctor. Monitor/document for side effects and effectiveness. During an observation and interview on 06/24/26 at 7:56 a.m., revealed MA C was passing medications in hall 200, it was also observed the resident's eMAR was red. Resident #69 was observed in her room eating breakfast. When asked when the medication was supposed to be administered, MA C stated it was scheduled for 6:30 a.m. He stated the residents woke up early and left her room to the foyer. He attempted to administer the medication at the time using the Korean language line to explain the importance of taking the medication to the resident, however, the resident refused. MA C notified the RN C who notified the physician. 2. Record review of Resident #40's face sheet, dated 06/23/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #40 had diagnoses which included: Type 2 Diabetes (high blood sugar levels), Cellulitis of Right Lower Limb (a common bacterial infection of the deeper layers of your skin and the tissues just beneath it) and Dysphagia, oropharyngeal phase (trouble starting a swallow). Record review of Resident #40's quarterly MDS, dated [DATE], revealed the Resident had a BIMS score of 11 (moderate cognitive impairment). Resident #40 was at risk for pressure-ulcer. Record review of Resident #40's current physicians order revealed an order, dated 10/15/25, for Protonix Tablet Delayed Release 40 MG (Pantoprazole Sodium), Give 1 tablet by mouth in the morning for Heartburn ; indigestion. The medication was scheduled to be given at 6:30 a.m. During an observation and interview on 06/24/26 at 8:12 a.m. revealed MA C was passing medications in hall 200, it was also observed that the resident's eMAR was red. Resident #40 was observed in her room sleeping with her breakfast tray untouched. When asked when the medication was supposed to be administered, MA C stated it was scheduled for 6:30 a.m. Resident #40 stated she could take the medication now, MA C proceeded to administer the medication to Resident #40. 3. Record review of Resident #38's face sheet, dated 06/24/26, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included: Gastro-esophageal Reflux Disease - GERD (acid reflux or heartburn) and Dysphagia, oropharyngeal phase (trouble starting a swallow). Record review of Resident #38's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 04 (Severe cognitive impairment). Resident #38 had a diagnosis to include Gastro-esophageal Reflux Disease. Record review of Resident #38's current physicians order revealed an order, dated 10/15/25, revealed an order for Omeprazole 20 MG Capsule delayed release, Give 1 tablet by mouth in the morning for GERD, do not crush. The medication was scheduled to be given at 6:30 a.m. During an observation and interview on 06/24/26 at 8:34 a.m. revealed MA C was passing medications in hall 200, it was also observed the resident's eMAR was red. Resident #38 was observed in her room lying in bed resting. When asked when the medication was supposed to be administered, MA C stated it was scheduled for 6:30 a.m. MA C proceeded to administer the medication to Resident #38. During an interview on 06/25/26 at 9:47 a.m. with MA C, he stated the facility policy was that medications should be given within an hour before or after window of the scheduled time. He stated the doctors' orders should be followed, he stated an example was medications that had to be given before meals, with meals or after meals. He stated giving the medications on time would prevent the drug to drug interaction and provide the best therapeutic effects to the resident. During an interview on 06/25/26 at 10:12 a.m. with RN C, she stated when a medication was late the MA must notify the nurse. If the medication was late the nurse notified the DON and MD and the MD would determine if the medication should still be administered or not. She stated if the medication was given late, it was a medication error. She stated if there was a blood pressure pill due and it's late, the blood pressure could remain high and if a Diabetic medication was not given on time, the resident could experience an increase in sugar levels. She stated the resident blood sugar can could drop and possibly have a fall if the blood sugar was lower than the threshold. During an interview on 06/25/26 at 11:49 a.m. with the DON, she stated for medication passes, the medication should be given within the correct time frame, she stated the time frame for medication should be an hour before or after. She stated the MA should notify the nurse and DON to call the doctor to get an order of what he wanted them to do. She stated it depended on their disease process and the medications should be on time to have the full effects. She stated it could result in side effects depending on the disease process and the medication given or not given. Record review of the facility's, undated, policy and procedure policy Number 7C for Medication Administration revealed the following It is the policy of this Facility, medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant. Medications must be given in accordance with the resident's service plan.Medications must be administered in accordance with the written orders of the attending physician. Should a drug be withheld, refused, or given other than at the scheduled time, the staff administering must indicate the reason on the MAR. For those utilizing eMARs, the appropriate code must be entered with any follow up documentation as appropriate for the situation. Twelve (6) residents were observed during medication pass.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for three of four residents (Resident #39, #46, and #40) reviewed for quality of care. 1.The facility failed to ensure that CNA J would dry up Resident #39's bottom, who had MASD, on 06/23/2026. 2.The facility failed to ensure that Resident #46's kerlix dressings to both feet were changed, as ordered, when they were wet due to the resident's weeping edema on 06/23/2026. 3.The facility failed to ensure that Resident #40's non-pressure right shin wound was cleansed in accord with the facility's wound care policy on 06/24/26. These failures could place the residents at risk for worsening non-pressure injuries and could result in a decline in health. Findings included: 1.Record review of Resident #39's Face Sheet, dated 06/24/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with weakness and muscle wasting (loss of muscle leading to its shrinking and weakening). Record review of Resident #39's Comprehensive MDS Assessment, dated 04/11/2026, reflected that the resident was unable to complete the interview to determine the BIMS score. The staff assessment for mental status denoted that the resident had a memory problem. The Comprehensive MDS Assessment indicated that the resident had moisture associated skin damage. Record review of Resident #39's Comprehensive Care Plan, dated 06/02/2026, reflected that the resident had potential impairment to skin integrity and one of the interventions was to keep it clean and dry. Record review of Resident #39's Physician Order, dated 04/08/2026, reflected MASD (skin damage caused by prolonged exposure to moisture) - Cleanse and apply Calmoseptine (moisture barrier ointment) every shift and PRN soiling every shift for MASD until resolved. During an observation on 06/24/2026 at 1:31 p.m., CNA J was about to transfer Resident #39 from the gerichair (seating device designed for individuals with limited mobility) to her bed. It was observed that the resident's pants were halfway on her legs, that the resident did not have a brief on, and the gerichair did not have any clean towel or blanket to cover the seat of the gerichair. It was observed that the resident's bare perineal area (area between the legs) was touching the seat directly. After transferring the resident, it was observed that the seat of the gerichair was wet. It was also observed that the resident's bottom had scratches on it. During an interview on 06/24/2026 at 1:42 p.m., CNA J said she had just finished Resident #39's shower and she was about to transfer the resident to her bed. She said she would raise the resident's pants once she was transferred to her bed. When asked why the resident did not have any brief on or why the seat did not have any cover, CNA J did not answer. She said she saw scratch marks when she was showering the resident, and she would notify the nurse after she was done transferring the resident. When asked if the scratch marks touched the seat of the gerichair, she did not reply. She said she did not know if the seat of the gerichair was clean. During an interview on 06/24/2026 at 1:47 p.m., LVN D said Resident #39's bottom was sensitive due to MASD, and it should always be dried. Keeping the bottom wet could cause irritation of the skin. She said if the resident had scratch marks, the more that it should not be touching the seat with a bare bottom. She said she would talk to CNA J to educate her and assess the resident's bottom. During an interview on 06/24/2026 at 2:26 p.m., LVN D said Resident #39's bottom did not have an open wound but had abrasions, maybe due to the resident scratching her bottom. She said even though those were abrasions, they should still not be in direct contact with the seat of the gerichair. She said one of the causes of MASD was prolonged exposure to moisture and not drying the skin of the bottom immediately could lead to inflammation of the skin. 2.Record review of Resident #46's Face Sheet, dated 06/24/2026, reflected an 87-year- old male admitted to the facility on [DATE]. The resident was diagnosed with fluid overload (body retains more fluid than is needed) and unsteadiness of the feet. Record review of Resident #46's Comprehensive MDS Assessment, dated 06/08/2026, reflected the resident had moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment indicated that the resident had edema (swelling caused by fluid trapped in the tissues of the body). Record review of Resident #46's Comprehensive Care Plan, dated 06/11/2026, reflected the resident had actual impairment to skin integrity r/t edema to BLE with weeping areas and one of the interventions was to cover with kerlix daily and PRN due to weeping legs. Record review of Resident #46's Physician Order, dated 06/13/2026, reflected Left foot: Cleanse area with wound cleanser, cover with xeroform, apply abd pad, kerlix and secure with tape to dressing not skin. Change daily and prn if leaking every day shift for weeping. Record review of Resident #46's Physician Order, dated 06/13/2026, reflected Right lower extremity: Cleanse area with wound cleanser, cover areas with xeroform apply abd pad, kerlix and secure with tape to dressing not skin. Change daily and prn if leaking everyday shift for weeping. During an observation on 06/23/2026 at 8:56 a.m., Resident #46 was sitting in his wheelchair in the hallway. It was observed that both his feet were wrapped in a wet, white dressing. During an interview on 06/23/2026 at 11:31 a.m., RN A said she had already changed Resident #46's dressings to both feet. She said the dressings were wet because the resident had weeping edema (fluid retention where excess fluid leaks through the skin). She said she did not know that the dressings were wet and for how long they had been wet. She said had she known, she could have changed it immediately. She said the resident had an order to change the kerlix as needed. She said the leakage was a sign of a skin breakdown and if the dressings were wet and saturated, it could impair healing and the fluid could further irritate the skin. During an interview on 06/25/2926 at 6:28 a.m., the DON said Resident #39 had MASD and her bottom should be kept dry to prevent any skin injury. She said she assessed the resident and did not see anything on her bottom. She said Resident #46's kerlix should have been changed promptly for the same reason. She said she had already started an in-service about wound care. During an interview on 06/25/2026 at 6:59 a.m., the Administrator said she was not a clinician, and she would let the DON take the lead about the issue. 3.Record review of Resident #40's face sheet dated 06/23/26 revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Type 2 Diabetes (high blood sugar levels) and Cellulitis of Right Lower Limb (a common bacterial infection of the deeper layers of your skin and the tissues just beneath it). Record review of Resident #40's MDS dated [DATE] revealed that the Resident had a BIMS score of 11 (moderate cognitive impairment) and at risk of pressure-ulcer. Record review of Resident #40's current physicians order revealed an order dated 05/21/26 for the right shin wound care: Cleanse wound with wound cleanser and pat dry. Apply thin layer of Iododorb to Calcium Alginate Sheet, then apply to open wound. Cover with dry dressing. Change daily and as needed for soilage or dislodgement. It also revealed an order date 06/17/26 for Peri-area and inner groin: cleanse area and apply calmoseptine / nystatin mixture three times a day and as needed due to MASD three times a day for MASD. Record review of Resident #40's care plan dated 03/20/26 revealed the resident had arterial/ischemic ulcers (poor circulation sores or blocked blood flow wounds) of the Right Shin, Right Anteromedial Shin (the front-inside part of your lower leg, running along your shinbone) related to History of ulcers, Peripheral Arterial Disease (poor circulation in the legs), Vascular insufficiency (poor blood circulation). With goal of: Will be free from infection or complications related to arterial ulcer through review date and intervention to Treat wound per order. Use non-occlusive wound dressings. Record review of Resident #40's progress note dated 06/18/26 revealed the resident has MASD due to Incontinence Associated Dermatitis. Wound care observation and interview on 06/24/26 at 10:25 a.m. to 10:50 a.m., revealed RN S failed to use proper wound cleaning procedures when cleaning Resident #40's right shin wound, she cleansed the inside of the wound after cleaning the surrounding skin with the same gauze. When asked about the wound care procedure the facility directs, she stated that the proper wound cleaning procedure is to clean from the inside of the wound to the outside of the wound, going from least contaminated area to the most contaminated area. She stated that not following the proper wound cleaning technic could cause delayed wound healing and even sepsis if the wound becomes infected. During an interview on 06/25/26 at 11:49 a.m. with the DON, she stated that it is the policy and procedure for wound care to go from the center, least dirty area to the periphery of the wound which is the most contaminated area. She stated that it is necessary to go from the inside to outside to keep a healthy wound bed and promote wound healing. Record review of the facility's policy Skin and Wound Monitoring and Management Policy & Procedure revised April 2024 reflected Policy: It is the policy of this facility that . 2. A resident having pressure injury(s) receives necessary treatment and services to . prevent infection. Record Review of the facility's undated Policy and Procedure for Wound Care revealed: Cleanse wound with the solution ordered. Use no-touch technique. Do not directly touch any item that will come in contact with the wound. Wash from the center of the wound to the periphery. Always wash from the area of least contamination to the area of most contamination Policy for MASD requested on 06/24/20206 at 2:07 p.m. but was not provided prior to exit.

Based on observation, interview and record reviews the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 11.11%, based on 3 errors out of 27 opportunities, which involved three of six residents (Resident #69, Resident #40, and Resident #38) and one of one staff (MA D) reviewed for medication errors. The facility failed to ensure MA D did not give Resident #69's 6:30 a.m. medications at 7:56 a.m. on 06/24/2026. The facility failed to ensure MA D did not give Resident #40's 6:30 a.m. medications at 8:04 a.m. on 06/24/2026. The facility failed to ensure MA D did not give Resident #38's 6:30 a.m. medications at 8:12 a.m. on 06/24/2026. These failures could place residents at risk for treatment failure, disease progression, reduced effectiveness, and adverse reactions. Findings include: 1. Record review of Resident #69's face sheet, dated 06/24/26, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason) and Type 2 Diabetes with hyperglycemia (adult-onset diabetes with consistently high blood sugar). Record review of Resident #69's Comprehensive MDS Assessment, dated 05/22/26, revealed the resident had a severe impairment with cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated the resident was diagnosed with Diabetes mellitus and Dementia. Record review of Resident #69's Physician Order, dated 05/28/25, revealed an order for Metformin HCL Oral Tablet 500 MG 9Metformin HCL), give one tablet by mouth two times a day for DM. The medication was scheduled to be administered at 6:30 a.m. and 4:30 p.m. Record review of Resident #69's Comprehensive Care Plan, dated 06/22/25, revealed the resident had potential for altered endocrine status r/t Diabetes Mellitus with intervention: Diabetes medication as ordered by the doctor. Monitor/document for side effects and effectiveness. During an observation and interview on 06/24/26 at 7:56 a.m., revealed MA C was passing medications in hall 200, it was also observed the resident's eMAR was red. Resident #69 was observed in her room eating breakfast. When asked when the medication was supposed to be administered, MA C stated it was scheduled for 6:30 a.m. He stated the Residents woke up early and left her room to the foyer. He attempted to administer the medication at the time using the language line to explain the importance of taking the medication to the resident, however, the resident refused. MA C notified RN C who notified the physician. 2. Record review of Resident #40's face sheet, dated 06/23/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #40 had diagnoses which included: Type 2 Diabetes (high blood sugar levels), Cellulitis of Right Lower Limb (a common bacterial infection of the deeper layers of your skin and the tissues just beneath it) and Dysphagia, oropharyngeal phase (trouble starting a swallow). Record review of Resident #40's current physicians order revealed an order, dated 10/15/25, revealed an order for Protonix Tablet Delayed Release 40 MG (Pantoprazole Sodium), Give 1 tablet by mouth in the morning for Heartburn; indigestion. The medication was scheduled to be given at 6:30 a.m. Record review of Resident #40's quarterly MDS, dated [DATE], revealed the Resident had a BIMS score of 11 (moderate cognitive impairment). Resident #40 was at risk for pressure-ulcer. During an observation and interview on 06/24/26 at 8:12 a.m. revealed MA C was passing medications in hall 200, it was also observed the resident's eMAR was red. Resident #40 was observed in her room sleeping with her breakfast tray untouched. When asked when the medication was supposed to be administered, MA C stated it was scheduled for 6:30 a.m. Resident #40 stated she could take the medication now, MA C proceeded to administer the medication to the Resident #40. 3 Record review of Resident #38's face sheet, dated 06/24/26, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included: Gastro-esophageal Reflux Disease - GERD (acid reflux or heartburn) and Dysphagia, oropharyngeal phase (trouble starting a swallow). Record review of Resident #38's current physicians order revealed an order, dated 10/15/25, revealed an order for Omeprazole 20 MG Capsule delayed release, Give 1 tablet by mouth in the morning for GERD, do not crush. The medication was scheduled to be given at 6:30 a.m. Record review of Resident #38'squarterly MDS, dated [DATE], revealed the resident had a BIMS score of 04 (Severe cognitive impairment). Resident #38 was diagnosed with Gastro-esophageal Reflux Disease. During an observation and interview on 06/24/26 at 8:34 a.m. revealed MA C was passing medications in hall 200, it was also observed the resident's eMAR was red. Resident #38 was observed in her room lying in bed resting. When asked when the medication was supposed to be administered, MA C stated it was scheduled for 6:30 a.m. MA C proceeded to administer the medication to Resident #38. During an interview on 06/25/26 at 9:47 a.m. with MA C, he stated the facility policy was medications should be given within an hour before or after window of the scheduled time. He stated the doctors' orders should be followed, he stated an example was medications that had to be given before meals, with meals or after meals. He stated giving the medications on time would prevent drug to drug interaction and provide the best therapeutic effects to the resident. He stated the facility expected he should let the nurse know if the medication was late, if to give the medication or not. He stated giving the medication past the time could affect the resident due to possible medication interactions. During an interview on 06/25/26 at 10:12 a.m. with RN C, she stated when a medication was late the MA must notify the nurse. If the medication was late the nurse notified the DON and MD and the MD would determine if the medication should still be administered or not. She stated if the medication was given late, it was a medication error. She stated if there was a blood pressure pill due and it's late, the blood pressure could remain high and if a Diabetic medication was not given on time, the resident could experience an increase in sugar levels. She stated the resident could bottom out and possibly have a fall if the blood sugar was lower than the threshold. During an interview on 06/25/26 at 11:49 a.m. with the DON, she stated for medication passes, the medication should be given within the correct time frame, she stated the time frame for medication should be an hour before or after. She stated the MA should notify the nurse and DON to call the doctor to get an order of what he wanted them to do. She stated it depended on their disease process the medications should be on time to have the full effects. She stated it could result in side effects depending on the disease process and the medication given or not given. Record review of the facility's, undated, policy and procedure policy Number 7C for Medication Administration revealed the following It is the policy of this Facility, medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant. Medications must be given in accordance with the resident's service plan.Medications must be administered in accordance with the written orders of the attending physician.Should a drug be withheld, refused, or given other than at the scheduled time, the staff administering must indicate the reason on the MAR. For those utilizing eMARs, the appropriate code must be entered with any follow up documentation as appropriate for the situation.

Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during medical treatment and personal care for three of twenty residents (Residents #46, #70, and #81) reviewed for privacy. 1.The facility failed to ensure RN B pulled the privacy curtain or closed the door during Resident #46's blood sugar check on 06/24/2026. 2.The facility failed to ensure RN B pulled the privacy curtain or closed the door during Resident #70's blood sugar check on 06/24/2026. 3.The facility failed to ensure CNA F and CNA G closed pulled the privacy curtain during Resident #81's incontinent care on 06/23/2026. These failures could place the residents at risk of not having their personal privacy maintained while treatment and care were provided that could result to embarrassment.Findings included: 1.Record review of Resident #46's Face Sheet, dated 06/24/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar). Record review of Resident #46's Comprehensive MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 06/08/2026, reflected that the resident had moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS (screening tool used to assess cognitive status) score of 09. The Comprehensive MDS Assessment indicated that the resident had diabetes mellitus and was receiving insulin. Record review of Resident #46's Comprehensive Care Plan, dated 06/11/2026, reflected that the resident had an alteration in endocrine (glands that produce hormones) status related to diabetes mellitus and one of the interventions was to administer diabetes medications as ordered. Record review of Resident #46's Physician Order, dated 06/16/2026, reflected Admelog SoloStar 100 UNIT/ML Solution pen-injector Inject as per sliding scale (a chart of insulin dosages): if 151 - 200 = 2 units FOR BS BELOW 60, PLEASE FOLLOW DIABETIC PROTOCOL ORDERS ; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units FOR BS GREATER THAN 400, GIVE 10 UNITS AND NOTIFY ON-CALL PROVIDER, subcutaneously (administer under the skin) before meals and at bedtime for DM2 Inject subcutaneously per sliding scale before meals and at bedtime (MAX 10 units PER DOSE). During an observation on 06/24/2026 at 7:19 a.m., RN B was about to check Resident #46's blood sugar. She sanitized her hands, put on a pair of gloves, went inside the resident's room, and proceeded with checking blood sugar. She did not close the door nor pull the privacy curtain while checking the resident's blood sugar, and the treatment could be seen from the hallway. 2.Record review of Resident #70's Face Sheet, dated 06/24/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus. Record review of Resident #70's Comprehensive MDS Assessment, dated 05/04/2026, reflected that the resident had moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated that the resident had diabetes mellitus and was receiving insulin. Record review of Resident #70's Comprehensive Care Plan, dated 05/31/2026, reflected that the resident had an alteration in endocrine status related to diabetes mellitus and one of the interventions was to administer diabetes medications as ordered. Record review of Resident #70's Physician Order, dated 06/16/2026, reflected Insulin Aspart Injection Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 150 - 200 = 2 units FOR BS BELOW 60, PLEASE FOLLOW DIABETIC PROTOCOL ORDERS; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units FOR BS GREATER THAN 400, GIVE 10 UNITS ANDNOTIFY ON-CALL PROVIDER, subcutaneously before meals and at bedtime for Diabetes. During an observation on 06/24/2026 at 7:44 a.m., RN B was about to check Resident #70's blood sugar. She sanitized her hands, put on a pair of gloves, went inside the resident's room, and proceeded with blood sugar check. She did not close the door nor pull the privacy curtain while checking the resident's blood sugar, and the treatment could be seen from the hallway. During an interview on 06/24/2026 at 11:21 a.m., RN B said the door should have been closed, or the privacy curtain should have been pulled when doing any treatment to provide privacy for the residents. She said it did not matter if the residents minded it or not, but the staff still needed to practice providing privacy, to prevent embarrassment of any sort. 3.Record review of Resident #81's Face Sheet, dated 06/24/2026, reflected a 74-year- old male admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body). Record review of Resident #81's Comprehensive MDS Assessment, dated 05/04/2026, reflected that the resident had severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated that the resident was incontinent (unable to control) for bladder and bowel. Record review of Resident #81's Comprehensive Care Plan, dated 05/30/2026, reflected that the resident had bowel/bladder incontinence and one of the interventions was to provide incontinent care as required. During an observation on 06/23/2026 at 9:15 a.m., CNA F and CNA G were about to perform Resident #81's incontinent care. They washed their hands, put on a pair of gloves, and proceeded with incontinent care. They did not pull the privacy curtain between the resident and the resident's roommate. It was observed that the roommate was inside the room and the care being done could be seen from the roommate's side of the room. During an interview on 06/23/2026 at 9:38 a.m., CNA F said he forgot to pull the privacy curtain separating the Resident #81 from his roommate while he was performing incontinent care. He said the curtain was to provide privacy while he was changing Resident #81's brief. He said the roommate might see Resident #81's private area because the curtain was not pulled. During an interview on 06/23/2026 at 9:43 a.m., CNA G said she did not notice that CNA F did not pull the privacy curtain between Resident #81 and his roommate. She said she should have pulled the curtain because the resident's roommate was inside the room as well. She said the curtain was inside the room to provide privacy when care was being done. During an interview on 06/25/2926 at 6:28 a.m., the DON said the door should be closed, or the privacy curtain should be pulled every time the staff provided care or treatment to provide privacy and prevent embarrassment. She said other individuals, like non-clinical staff, visitors, and other residents should not see the care and treatments being done. She said closing the door and/or pulling the privacy curtain could make the residents more comfortable during treatment and care. She said the expectation was for the staff to provide privacy during every treatment and every care. She said she already started an in-service about providing privacy during treatment and care. During an interview on 06/25/2026 at 6:59 a.m., the Administrator said the staff must make sure that the residents were provided privacy when care and treatments were being done to prevent embarrassment. She said the expectation was for the staff to be mindful about privacy when providing care and treatment. She said she would collaborate with the DON to re-educate the staff about the importance of providing privacy. Record review of the facility's policy, Resident Rights Policy/Procedure - Nursing Administration, undated, reflected POLICY: It is the policy of this facility that all resident rights be followed . The Resident has the right . 29. To privacy.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for three of eighteen residents (Residents #9, #29, and #40) reviewed for medication storage. 1.The facility failed to ensure Resident #29's zinc oxide was not on top of the resident's side table on 06/23/2026. 2.The facility failed to ensure Resident #9 did not have a Vicks Vapor Stick on her bedside table on 06/23/26 3.The facility failed to ensure Resident # 40 did not have peri-guard wipes and a container of calmoseptine / nystatin mixture on her bedside table on 06/23/26. These failures could place residents at risk of misuse of medications and possible adverse reactions. Findings included: 1. Record review of Resident #29's Face Sheet, dated 06/24/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with urinary tract infection (infection involving the organs that produce urine). Record review of Resident #29's Comprehensive MDS Assessment, dated 06/11/2026, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was incontinent for bladder and bowel. Record review of Resident #29's Comprehensive Care Plan, dated 06/23/2026, reflected the resident was incontinent for bladder and bowel and one of the interventions was to provide incontinent care. The plan did not indicate that the resident could store medications inside her room. Record review on 06/24/2026 of Resident #29's Clinical Assessment List reflected the resident had no assessment for self-administration of medications, an assessment that the resident was competent to apply the barrier cream, or an assessment that the resident could store medications inside her room. During an observation and interview on 06/23/2026 at 9:05 a.m., Resident #29 was in her bed, awake. It was observed a tube of zinc oxide (medicated cream used to prevent skin irritation) was on top of the resident's side table and was in plain view. The resident said the staff would use it when they changed her brief. The resident said the barrier cream had always been in her bedside. During an interview on 06/23/2026 at 11:31 a.m., RN A said she did not notice Resident #29 had a tube of zinc oxide when checked on the resident. She said zinc oxide should not be inside the residents' room because confused residents might accidentally consume it, thinking that the cream was something edible. She said most of the residents already had poor eyesight and might mistakenly use the cream as toothpaste. She said she did not know who left the zinc oxide inside the room of the resident. She said she would talk to the resident regarding the zinc oxide. During an interview on 06/25/2926 at 6:28 a.m., the DON said the zinc oxide should not be within reach of the residents because residents might use them inappropriately and could result in adverse reactions. She said zinc oxide was applied topically and could be harmful when ingested. She said the expectation was for the staff not to leave the zinc oxide accessible to the residents. She said she already started an in-service about medication storage. During an interview on 06/25/2026 at 6:59 a.m., the Administrator said the expectation was for the staff to make sure there were no tubes of zinc oxide inside the rooms of the residents because residents might use them incorrectly like consuming them. She said the facility had a population that would go inside the rooms of other residents and might be able to grab the zinc oxides. She said she would coordinate with the DON about the issue. 2. Record review of Resident #9's face sheet, dated 06/24/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with Type 2 Diabetes (high blood sugar in the blood), chronic kidney disease stage 5 (kidney failure or end-stage kidney disease) and Need for assistance with personal care. Record review of Resident #9's Comprehensive MDS Assessment, dated 04/26/26, reflected the resident was cognitively intact with a BIMS score of 15. The resident was dependent for ADLs. Record review of Resident #9's Comprehensive Care Plan, dated 02/04/26, reflected the resident had an ADL self-care performance deficit, Encourage to participate to the fullest extent possible with each interaction. It reflected the care plan for Self-administration of medication, with intervention to: Evaluate resident could appropriately follow directions and tell time to know when the medication needed to be taken and evaluated the residents ability to ensure the medication was stored safely and securely. Record review of Resident #5's current physician order for June 2026 did not reflect an order for Vicks Vapor Stick. Record review on 06/24/2026 of Resident #9's Clinical Assessment List reflected the resident had no assessment for self-administration of medications, an assessment that the resident was competent to apply the barrier cream, or an assessment that the resident could store medications inside her room. During an observation and interview on 06/23/26 at 10:15 a.m., Resident #9 was lying in bed inside her room. It was observed there was a bottle of Vicks Vapor Stick on top of the resident's overbed table. She stated she used it to clear her sinuses; she stated the nurses knew she used it and had not told her she was not allowed to keep it. 3. Record review of Resident #40's face sheet, dated 06/23/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #40 had diagnoses which included: Type 2 Diabetes (high blood sugar levels), Cellulitis of Right Lower Limb (a common bacterial infection of the deeper layers of your skin and the tissues just beneath it). Record review of Resident #40's Comprehensive MDS Assessment, dated 05/28/26, reflected the resident had a BIMS score of 11 (moderate cognitive impairment). Resident #40 was at risk for pressure-ulcer. Record review of Resident #40's current physicians order reflected an order, dated 06/17/26, for Peri-area and inner groin: cleanse area and apply calmoseptine / nystatin mixture three times a day and as needed due to MASD three times a day for MASD. Record review of Resident #40's care plan, dated 10/05/25, reflected the resident was at risk for impaired cognitive function/dementia (a condition characterized by loss of memory and ability to reason)or impaired thought processes r/t psychoactive medication use. During an observation and interview on 06/23/26 at 10:20 a.m. with Resident #40, revealed she was in bed awake, a sachet of peri-guard wipe and a tub which contained a pink paste was noted on her bed side table. She stated the staff used it when she performed peri-care on her. She stated the items were left on the bedside table after she was cleaned. During an interview on 06/23/26 at 10:25 a.m. with LVN S, she stated the items, Peri Guard and Vicks, should not be in the resident rooms per the facility policy. She stated the nurse and all care staff were responsible for making sure these items were not in the resident's room. She stated confused residents who wandered could get a hold of them and swallow them causing them to be sick since those items could contain toxins and alcohol the resident could react to. During an interview on 06/23/26 at 10:30 a.m. with MA C, he stated he was not sure of what the facility policy was, but Peri Guard and Vicks should not be in the resident's possession for safety reasons. He stated he should tell the nurse if he noticed those items in the residents' rooms. He stated the items could harm residents who were confused and cause them to be hospitalized if swallowed. During an interview on 06/23/26 at 10:34 a.m. with CNA R, she stated the Peri Guard, Vicks and Sani wipes should not be in the residents' rooms. She stated every staff member was responsible for making sure those items were not in the residents' room. She stated it would endanger residents who were confused, they could have an allergic reaction to the items and cause serious harm to themselves or others During an interview on 06/25/26 at 11:49 a.m. with the DON, she stated the residents were not supposed to have any unauthorized items in their rooms, unless they were carefully assessed and care planned to self-administer medications. She stated they started and Inservice right away with the staff. She stated for safety reasons and for residents' who wandered, it could cause harm if they got a hold of those items. She stated they could swallow and cause harm to themselves if they got a hold of them. Record review of the facility's policy Medication Administration Policy/Procedure – Nursing Clinical, revised May 2025, reflected POLICY: It is the policy of this Facility, medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant . procedure . 1. Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record medication administration. Record review of the facility's policy titled, Medication Storage in the Facility P & P, dated March 2025 reflected, Policy: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations . 2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications. Record review of the facility's, undated, policy, Residents' Rights Safety, Resident, reflected the following; Avoid Leaving in the Resident's room any medication or equipment that might cause harm. Ensure all medications, chemicals, cleaning supplies and any potential hazardous materials are kept locked / secure when staff has completed their use and is no longer in attendance. Conduct a room search should there be concern that prohibited /unsafe items are being stored in the room.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for six of eighteen residents (Residents #39, #40, #46, #50, #70 and #81) and for six of ten direct care staff (LVN E, CNA F, CNA G, CNA H, CNA I, and CNA J) reviewed for infection control. 1.The facility failed to ensure CNA J would not assist Resident #39 and Resident #50 at the same time during lunchtime on 06/23/2026. 2.The facility failed to ensure CNA J did not place Resident #39 in her geri-chair without any brief on, with the perineal area touching the seat of the geri-chair directly, after a shower on 06/23/2026. 3.The facility failed to ensure Resident #46's kerlix dressings were not touching the floor on 06/23/2026. 4.The facility failed to ensure CNA H wore a gown when she emptied Resident #70's catheter bag on 06/24/2026. 5.The facility failed to ensure CNA H and CNA I wore gowns when they transferred Resident #70 to her wheelchair on 06/24/2026. 6.The facility failed to ensure CNA F performed hand hygiene and wore a gown during Resident #81's incontinent care, when he repositioned the resident, and when he changed the resident's clothes on 06/23/2026. 7.The facility failed to ensure CNA F and CNA G wore gowns when Resident #81 was transferred to his wheelchair on 06/23/2026. 8.The facility failed to ensure CNA G wore a gown when she stripped Resident #81's beddings on 06/23/2026. 9.The facility failed to ensure LVN E would not place her lunch bag inside the medication room's refrigerator on 06/24/2026. 10.The facility failed to ensure RN S sanitized her hands after removing dirty gloves and before putting on clean gloves while providing wound care for Resident #40 on 06/24/2026. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1.Record review of Resident #39's face sheet, dated 06/24/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with weakness and muscle wasting. Record review of Resident #39's Comprehensive MDS Assessment, dated 04/11/2026, reflected the resident was unable to complete the interview to determine the BIMS score. The staff assessment for mental status denoted the resident had a memory problem. The resident was dependent on staff for eating. Record review of Resident #39's Comprehensive Care Plan, dated 06/02/2026, reflected the resident had an ADL self-care performance deficit and one of the interventions was to spoon feed with meals. Record review of Resident #50's face sheet, dated 06/24/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with weakness and physical debility (weakness). Record review of Resident #50's Comprehensive MDS Assessment, dated 04/13/2026, reflected the resident was unable to complete the interview to determine the BIMS score. The staff assessment for mental status denoted the resident had a memory problem. The resident needed assistance during meals. Record review of Resident #50's Comprehensive Care Plan, dated 06/10/2026, reflected the resident had an ADL self-care performance deficit and one of the interventions was to assist with meals. During an observation on 06/23/2026 at 12:16 p.m., CNA J was sitting between Resident #39 and Resident #50, assisting both residents with lunch at the same time. She first assisted Resident #39 by taking her spoon with her right hand and gave Resident #39 a spoonful of food. She then turned towards Resident #50, picked up her spoon with her right hand, and gave Resident #50's a spoonful of food. CNA J continued to feed the residents with alternating assistance without sanitizing her hands between the residents. During an observation and interview on 06/23/2026 at 12:25 p.m., LVN D said CNA J should not assist two residents at the same time because it could result in cross contamination. LVN D approached CNA J and talked to CNA J. It was observed after LVN D spoke with CNA J, CNA J went on to assist Resident #50 only. During an interview on 06/23/2026 at 1:42 p.m., CNA J said she was supposed to assist one resident only during feeding for infection control. She said she usually assisted only one resident during mealtime and she did not know why she started assisting two residents at the same time. 2.Record review of Resident #39's face sheet, dated 06/24/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with weakness. Record review of Resident #39's Comprehensive MDS Assessment, dated 04/11/2026, reflected the resident was unable to complete the interview to determine the BIMS score. The staff assessment for mental status denoted the resident had a memory problem. The Comprehensive MDS Assessment indicated the resident was dependent on staff for shower and transfer. Record review of Resident #39's Comprehensive Care Plan, dated 06/02/2026, reflected the resident had an ADL self-care performance deficit and one of the interventions was to assist with bathing and transfer. During an observation on 06/24/2026 at 1:31 p.m., CNA J was about to transfer Resident #39 from the geri-chair to her bed. It was observed the resident's pants was halfway on her legs, the resident did not have a brief on, and the geri-chair did not have any clean towel or blanket to cover the seat. It was observed the resident's bare perineal area touched the seat directly. During an interview on 06/24/2026 at 1:42 p.m., CNA J said she had just finished Resident #39's shower and she was about to transfer the resident to her bed. She said she would raise the resident's pants once she was transferred to her bed. When asked why the resident did not have any brief on or why the seat did not have any cover, CNA J did not answer. She said the risk of the resident's perineal area directly touching the seat of the geri-chair could be cross contamination that could lead to infection. She said she did not know if the seat of the geri-chair was clean. During an interview on 06/24/2026 at 1:47 p.m., LVN D said there should be a clean barrier between Resident #39 and the seat of the geri-chair, either a brief or a clean towel because the seat could be dirty. She said putting the resident directly to the seat, with her bare perineal area touching the seat, could cause infection. She said she would talk to CNA J to educate her. 3.Record review of Resident #46's face sheet, dated 06/24/2026, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with fluid overload. Record review of Resident #46's Comprehensive MDS Assessment, dated 06/08/2026, reflected the resident had moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment indicated the resident had an edema. Record review of Resident #46's Comprehensive Care Plan, dated 06/11/2026, reflected the resident had actual impairment to skin integrity r/t edema to BLE with weeping areas and one of the interventions was to cover with kerlix daily and PRN due to weeping legs. Record review of Resident #46's Physician Order, dated 06/13/2026, reflected Left foot: Cleanse area with wound cleanser, cover with xeroform, apply abd pad, kerlix and secure with tape to dressing not skin. Change daily and prn if leaking every day shift for weeping. Record review of Resident #46's Physician Order, dated 06/13/2026, reflected Right lower extremity: Cleanse area with wound cleanser, cover areas with xeroform apply ABD pad, kerlix and secure with tape to dressing not skin. Change daily and PRN if leaking every day shift for weeping. During an observation on 06/23/2026 at 8:56 a.m., Resident #46 was sitting in his wheelchair in the hallway. It was observed both his feet were wrapped in a wet, white dressing. Both of the resident's feet were on the floor, thus the dressings on both feet were touching the floor. During an interview on 06/23/2026 at 11:31 a.m., RN A said she had already changed Resident #46's dressings to both feet. She said she was not aware the resident's dressings to both feet were touching the floor. She said the dressing should not be touching the floor because kerlix dressings were permeable and could absorb dirt and fluid from the floor. She said if the kerlix dressings were wet, the more dirt from the floor could be attached to them and could eventually enter into the breaks in the skin to both feet, which could lead to infection. 4. Record review of Resident #70's face sheet, dated 06/24/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular dysfunction. Record review of Resident #70's Comprehensive MDS Assessment, dated 05/04/2026, reflected the resident had moderate impairment in cognition with a BIMS score of 08. The resident had an indwelling catheter. Record review of Resident #70's Comprehensive Care Plan, dated 05/31/2026, reflected the resident had a suprapubic catheter and one of the interventions was to position the catheter bag and the tubing below the bladder. During an observation on interview on 06/23/2026 at 9:13 a.m., Resident #70 was in her bed, awake. It was observed that the resident had a catheter bag hanging at the side of the bed. The resident said she had a catheter because her bladder was not working. During an observation on 06/24/2026 at 10:29 a.m., CNA H emptied Resident #70's catheter bag without wearing a gown. It was observed that there was a sign on the resident's door that specified a gown was required for catheter care and folded gowns were hanging on the door of the bathroom. 5.During an observation on 06/24/2026 at 10:34 a.m., CNA H and CNA I were about to transfer Resident #70 to her motorized wheelchair via Hoyer lift. Both CNAs hooked the Hoyer sling to the Hoyer lift and prepared to lift the resident. It was observed when they were hooking the Hoyer sling, both CNAs were leaning on the resident's bed, with CNA I directly leaning on the catheter bag. After hooking the Hoyer sling, they transferred the resident. Both CNAs did not have a gown. It was observed there was a sign on the resident's door that specified a gown was required when transferring a resident with a catheter and folded gowns were hanging on the bathroom's door. During an interview on 06/24/2026 at 10:43 a.m., CNA I said he should have worn a gown when they transferred Resident #70 because she had a catheter. He said the gown was to protect the residents from any contaminants the staff could transfer that could eventually lead to infections. During an interview on 06/24/2026 at 10:54 a.m., CNA H said she forgot to wear a gown when she emptied Resident #70's catheter bag and when they transferred her because she was in a hurry. She said the gown was used in addition to the gloves to prevent cross contamination between the staff and the residents. She said gowns were required for residents with indwelling devices like the catheter. 6.Record review of Resident #81's face sheet, dated 06/24/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #81's Comprehensive MDS Assessment, dated 05/04/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00 The resident had a feeding tube. Record review of Resident #81's Comprehensive Care Plan, dated 05/30/2026, reflected the resident required tube feeding and one of the interventions was to use enhanced barrier precautions. Record review of Resident #81's Physician Order, dated 01/10/2026, reflected Enhanced Barrier Precautions (infection control strategy to reduce the spread of resistant organisms): PPE required for high resident contact care activities. Indication: Indwelling Medical Device (a device or tube left inside the body for a period to provide treatment) every shift for monitoring. During an observation on 06/23/2026 at 9:15 a.m., CNA F was about to perform Resident #81's incontinent care, who had a g-tube. He went inside the room, washed his hands, put on a pair of gloves, but did not put on a gown. He pulled the resident's pants down, unfastened the soiled brief, tucked it between the resident's legs, and started to clean the perineal area. After cleaning the perineal area, he changed his gloves without sanitizing his hands. He then assisted the resident to roll, pulled the soiled brief, threw it to the trash can, and cleaned the resident's bottom. After cleaning the resident's bottom, he pulled the draw sheet and threw it in the trash can. He changed his gloves without doing hand hygiene. He then took the new brief, put it under the resident, and fixed it. After fixing the brief, he pulled the pants up, took off the resident's shirt, and put on a new shirt. He then repositioned the resident from a lying position to a sitting position by pivoting the resident to the side of the bed. It was observed that when he pivoted the resident, his upper body was in direct contact with the resident's upper body. There was a sign inside the resident's room that stated a resident with g-tube was on EBP, and a gown was required when changing the brief and clothing. It was also observed there was no sanitizer inside the room. 7.During an observation on 06/23/2026 at 9:34 a.m., CNA F and CNA G were about to transfer Resident #81 to his wheelchair. Both CNAs washed their hands and put on pairs of gloves. CNA F put on the gait belt around the resident's waist and prepared him for transfer. CNA G was assisting CNA F in putting the gait belt and at the same time fixing the resident's shirt. After putting the gait belt around the resident's waist, they both transferred the resident to his wheelchair. Bothe CNAs did not wear gowns during the transfer. There was a sign inside the resident's room that stated a resident with g-tube was on EBP, and a gown was required when transferring the resident. Folded gowns were observed hanging on the bathroom's door. 8.During an observation on 06/23/2026 at 9:38 a.m., after Resident #81 was transferred to his wheelchair, CNA G started to strip the resident's beddings. It was observed she leaned on the resident's bed while removing the bedding. She did not have a gown. There was a sign inside the resident's room that stated a resident with a g-tube was on EBP, and a gown was required when changing the linens of the resident. During an interview on 06/23/2026 at 9:40 a.m., CNA F said he should have sanitized his hands when he changed his gloves, especially after touching the soiled brief to prevent cross contamination. He said, since Resident #81 had a g-tube, then PPE was required during incontinent care, when he changed his t-shirt, when he repositioned him, and when they transferred the resident. He said he knew there was a sign on the resident's door and gowns were available, but he still forgot to wear a gown. He said not wearing a gown could result in the transfer of any microorganism from his scrubs to the resident. During an interview on 06/23/2026 at 9:43 a.m., CNA G said if a resident had a g-tube, the resident required EBP and a gown should be worn even when they transferred the resident and when she removed the linens because it was a high contact activity. She said a gown should have been worn to prevent cross contamination. 9. During an observation on 06/24/2026 at 11:49 a.m., a lunch bag was observed inside the refrigerator inside the medication room. It was observed that thee were several bottles of medications inside the refrigerator. During an observation and interview on 06/24/2026 at 11:50 a.m., RN C said the refrigerator inside the medication room was solely for medications and should not have any food in it. She opened the lunch bag and saw there were several kinds of food inside the lunch bag. She said it could be an infection control issue because it was not known where the lunch bag was last placed. She said the lunch bag, food particles, and spills could contaminate the fridge, thus affecting the containers of the medications. She said there was a refrigerator inside the staff break room for the personal foods and drinks of the staff. She said medications could not be placed where food was stored. She said she would look for the owner of the lunch bag. During an interview on 06/24/2026 at 11:53 a.m., LVN E said the lunch bag inside the refrigerator inside the medication room was hers. She said the refrigerator inside the breakroom was sometimes full so she would put her lunch bag inside the medication room. She said nobody told her she could not put her lunch bag inside the refrigerator of the medication room. She said she would ask around if they were allowed to put their personal food inside the medication room. During an interview on 06/24/2026 at 1:07 p.m., LVN E said she asked another nurse and was told she could not put her lunch bag inside the refrigerator designated for medications due to infection control. She said she had already put her lunch bag in the break room. During an interview on 06/25/2926 at 6:28 a.m., the DON said she was already made aware about the infection control issues and already started the in-services for them, except a resident's catheter bag was emptied and a resident with a catheter was transferred without a gown. She said residents should be assisted with meals one at a time. She said aside from cross contamination, the staff should focus on the resident to see if the resident was choking or was pocketing the food. She said hands should be sanitized before putting on a new pair of gloves; gowns should be worn when a resident had a g-tube and a catheter for activities such as incontinent care, change of clothing, linen change, emptying the catheter, and transfer. She said Resident #46's kerlix should not be touching the floor because the feet could get infected. She said staff should not put the residents in their chairs with bare perineal area because it could also cause infection. She said the expectation was for the staff to practice the policy and procedure of infection control. During an interview on 06/25/2026 at 6:59 a.m., the Administrator said the expectation was for the staff to understand the importance of following the policies and procedure of infection control. She said she would coordinate with the DON about the issues. During an interview on 06/25/2026 at 11:49 a.m., the DON said the lunch box should not have been placed in the refrigerator, she stated it's the policy not to have any personal items in the refrigerator that was used for the resident's nutrition or medication storage. She said the staff had a refrigerator for their use in the breakroom. She said it could be an infection control issue. During an interview on 06/25/2026 at 12:51 a.m., the Administrator said the expectation was for foods and beverages the staff brought were to be in the breakroom fridge. She said for infection control purposes, the staff should not have any personal items in the fridge inside the medication room. She said it was not known what kind of food was in the lunch box and if it was mistakenly given to a resident, it could cause them harm. 10 . Record review of Resident #40's face sheet, dated 06/23/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #40 had diagnoses which included: Type 2 Diabetes (high blood sugar levels) and Cellulitis of Right Lower Limb (a common bacterial infection of the deeper layers of your skin and the tissues just beneath it). Record review of Resident #40's Comprehensive MDS, dated [DATE], reflected the resident had a BIMS score of 11 (moderate cognitive impairment). Resident #40 was at risk for pressure-ulcer. Record review of Resident #40's current physicians order reflected an order, dated 05/21/26, for the right shin wound care: Cleanse wound with wound cleanser and pat dry. Apply thin layer of Iododorb to Calcium Alginate Sheet, then apply to open wound. Cover with dry dressing. Change daily and as needed for soilage or dislodgement. Record review of Resident #40's care plan, dated 03/20/26, reflected the resident Has arterial/ischemic ulcers (poor circulation sores or blocked blood flow wounds) of the Right Shin, Right Anteromedial Shin (the front-inside part of your lower leg, running along your shinbone) related to History of ulcers, Peripheral Arterial Disease (poor circulation in the legs), Vascular insufficiency (poor blood circulation). With goal of: Will be free from infection or complications related to arterial ulcer through review date and intervention to treat wound per order. Use non-occlusive wound dressings. During an observation on 06/24/26 at 10:25 a.m., RN S was observed for wound care on Resident #40, she did not to sanitize her hands after removing dirty gloves and put on clean gloves 6 times during the wound care. During an interview on 06/24/26 at 10:50 a.m. with RN S, she stated per proper hand hygiene protocol she should sanitize her hands every time she changed gloves to prevent cross contamination. She stated the possibility existed that her hands could come in contact with the outside of dirty gloves and picking up a clean glove without sanitizing would contaminate it. She stated not sanitizing her hands after removing dirty gloves and putting on a clean gloves could cause the resident's wound to be contaminated after it had been cleaned and could make the wound worse or delay healing. During an interview on 06/25/26 at 11:49 a.m. with the DON, she stated the protocol was that hands should be washed or sanitized whenever gloves were changed or going from dirty to clean task. She stated it was an infection control issue if the protocol was not followed. She stated it could lead to an infection and the wound could get worse if proper hand hygiene was not followed. Record review of the facility's policy Infection Control IPCP Standard and Transmission-Based Precautions revised March 2024 reflected Policy: It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions . Enhanced Barrier Protection (EBP) . used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs (Multi-Drug Resistant Organisms: refers to microorganisms that are resistant to one or more antibiotics) to staff hands and clothing then indirectly transferred to residents or from resident-to-resident . PPE . for nursing home residents with . urinary catheter . feeding tubes . high-contact resident care activities requiring gown . dressing . transferring . changing linens . changing briefs . device use . urinary catheter . feeding tube. Record review of the facility's policy Hand Hygiene Policy & Procedure, revised April 2025, reflected Policy: It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards . Use an alcohol-based hand rub . Before moving from a contaminated body site to a clean body site during resident care . After contact with blood or bodily fluids . After removing gloves . Before and after assisting a resident with meals. Record review of the facility's policy Skin and Wound Monitoring and Management Policy & Procedure, revised April 2024, reflected Policy: It is the policy of this facility that . 2. A resident having pressure injury(s) receives necessary treatment and services to . prevent infection. Record review of the facility's policy Food Storage Policy & Procedure, revised January 2022, reflected Policy: It is the policy of this facility that food storage areas shall be maintained in a clean . 7 . drugs are not to be stored in the kitchen area or in storerooms for food. Record review of the facility's policy Resident/Personal Food Storage Policy/Procedure revised November 2016 reflected Policy: Food or beverage brought in from outside sources for storage in facility pantries, refrigeration units, or personal/resident room refrigeration units will be monitored by designated facility staff for food safety . 2. Outside foods brought in to residents by visitors will be stored in personal refrigerator or facility refrigerator designated for resident use . Resident and individuals bringing food in from outside sources will be educated on safe food handling.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's kitchen reviewed for food and nutrition services. The facility failed to ensure all food items in the facility's kitchen were dated, discarded prior to their use-by date and were properly sealed. This failure could place residents at risk of food contamination and food-borne illness. Findings include: During an observation on 06/23/26 between 9:10 A.M. and 9:45 A.M. in the facility's kitchen revealed: One gallon bag which contained pasta egg noodles were dated 06/12/2026 had no visible expiration date. One gallon bag which contained spaghetti noodles was dated 05/11/2026 had no visible expiration date. One gallon bag which contained white cake mix was dated 05/12/2026 had no visible expiration date. One gallon bag which contained sliced cheese was dated 06/21/2026 had no visible expiration date. One gallon bag which contained shredded cheese was dated 06/21/2026 had no visible expiration date. One gallon plastic jug which contained purred fruit was dated 06/18/2026 had no visible expiration date. One gallon bag which contained shredded carrots had a brownish spots. During an interview on 06/25/2026 at 1:36 PM, DM stated all staff were responsible for labeling. DM stated the items would be corrected. It could make residents sick and could get a food borne illness. DM stated he and the kitchen aides were responsible for labeling and making sure the items were labeled properly. DM stated the risk of serving foods that were past the use-by date, or serving food that was not labeled or dated could cause food borne illness. DM stated the risk to residents if the policy was not followed was a health risk to the residents. DM stated the items should be labeled, and the risk of the concerns not being addressed could result in food-borne illnesses. DM stated if food items were not dated when opened, then they would not know how long the item would last. DM stated once items were opened, they should be properly sealed and dated. DM stated she encouraged staff to use it or throw it away, there was no reason to keep a small portion if the facility didn't need to keep it. During an interview on 06/25/2026 at 12:45 PM, ADMIN stated she oversaw all departments, and ensured residents were taken care of. ADMIN stated the DM made her aware of the concerns observed in the kitchen. ADMIN stated if items were expired, the risk of serving foods that were past the use-by date, or serving food that was not labeled or dated could cause food borne illness. ADMIN stated the issues could cause food contamination. The ADMIN stated the risk of all those concerns observed in the kitchen could result in residents getting sick. ADMIN stated she would expect the DM to ensure the kitchen followed all guidelines, which included ensuring the food items were labeled properly in the kitchen. She said the risk to residents if the policy was not followed, was they could get sick from food borne illnesses. The ADMIN stated she expected staff to ensure they were following policies and procedures of the facility kitchen policy, to protect residents and to deliver good care. Record review of the facility's Food Storage Policy, Food and Nutrition Services, revised 01/2022, reflected Policy It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner. Procedure 1. Food storage areas shall be clean at all times. 3. All foods shall be labeled and dated prior to being stored. Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICESSUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD.

Based on observation, interview and record review the facility failed to maintain an effective pest control program so the facility was free of pests and rodents for one of 8 residents' rooms (Resident #69) reviewed for pest control. The facility failed to ensure Resident #69's room was free from gnats. This failure could place residents at risk for the potential spread of infection, cross-contamination, food-borne illness, and a diminished quality of life.Findings include: Record review of Resident #69's face sheet, dated 06/24/26, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason) and Type 2 Diabetes with hyperglycemia (adult-onset diabetes with consistently high blood sugar). Record review of Resident #69's Comprehensive MDS Assessment, dated 05/22/26, revealed the resident had a severe impairment with cognition with a BIMS score of 06. The resident was diagnosed with Diabetes mellitus and Dementia Record review of Resident #69's Comprehensive Care Plan, dated 06/22/25, revealed the resident had potential for altered endocrine status r/t Diabetes Mellitus with intervention: Diabetes medication as ordered by doctor. Monitor/document for side effects andeffectiveness. Observation on 06/24/26 at 8:04 a.m. revealed a gnat observed flying and perching on Resident #69's breakfast, MA C noticed and stated the resident should not have gnats on her breakfast tray while she was eating. During an interview on 06/25/26 at 9:47 a.m. with MA C, he stated when he noticed any pest, he reported to the nurse and maintenance. He stated they had a log book to put down any complaints of bugs. He stated the gnats were in and out, they tried to have the food covered. He stated he made a report in the past. He stated it was important for the residents to have a pest free environment, he stated the bottom line was that they should not have pests around them. He stated the bugs could bite the residents and infect their skin, get into their food, it could make them sick if they ate food that a bug landed on. During an interview on 06/25/26 at 10:07 a.m. with CNA M, he stated he should get a new tray if he noticed a bug on the resident's tray. He stated he would let the nurse know and the maintenance director as well. He stated the insects could carry bacteria and make them sick. He stated the residents might not want to eat the food. He stated no one wanted to live in an environment that had bugs. During an interview on 06/25/26 at 10:12 a.m. with RN C, she stated if she noticed any pest, she put in a request in the log and let them know verbally as well. She stated it was part of infection control, it made the environment unclean, could affect their skin if the bug bit them. During an interview on 06/25/26 at 10:23 a.m. with Housekeeper A, she stated she would correct the situation and clean it up. She stated she reported to maintenance as well. She stated that it was important to have a pest free environment for sanitation and safety. She stated it's the residents home and they should feel comfortable. She stated the residents could feel upset if they had pests in the environment. During an interview on 06/25/26 at 10:30 a.m. with the Maintenance Director, he stated they had a pest control company that came in when they had a pest issue. He stated as housekeeping cleaned and made rounds, they got rid of any open food source and discarded as directed by the pest control company. He stated the residents families brought in food from outside and sometimes came in with pests. He stated the expectation was that the environment should be safe for the residents to live in, he stated they tried the best they could to keep the facility clean. He stated the pest control company came in once a month for a full sweep pest service and spot treated when they called for other pests. He stated pests could be dangerous to health and life and could be annoying to the residents. He stated they could pass disease and bite the residents. During an interview on 06/25/26 at 11:49 a.m. with the DON, she stated the facility had a logbook and verbally let maintenance know and the pest control company came out as needed. She stated it had been reported that there were gnats in the building. She stated due to the demographics of the facility, on Fridays the families of some residents brought in Kimchi that increased the population of the gnats. She stated it was important to have a pest free environment to make the facility feel like home.She stated the residents might not eat their meals or not go to the dining if they saw pests on their trays and that could lead to social isolation. During an interview on 06/25/26 at 12:51 p.m. with the Administrator, she stated she noticed gnats in the building, she stated a report was made to maintenance. She stated it got worse with the recent rain fall in the area. She stated the rooms should be cleaned properly and they did as much cleaning as possible and removed uncovered food to reduce the gnat problems. She stated any staff member who noticed pests should report to a department manager or the maintenance director and put it in the pest logbook. She stated the facility was the residents' home and that it should be made comfortable for them, she stated no one wanted pests in their homes. She stated residents would not feel at home if they noticed pests in the environment and felt it's not clean place to live.

Based observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for one of five residents (Resident #70) reviewed for incontinent care. The facility failed to ensure that CNA H did not place Resident #70's catheter bag on top of the resident, rendering the catheter bag and its tubing to above the bladder during transfer on 06/24/2026 This failure could place the residents at risk of urinary tract infection.Findings included: Record review of Resident #70's Face Sheet, dated 06/24/2026, reflected a 67-year- old female admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular dysfunction of the bladder (the muscles and nerves that control the bladder do not work properly due to illness). Record review of Resident #70's Comprehensive MDS Assessment, dated 05/04/2026, reflected that the resident had moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated that the resident had an indwelling catheter (device that drains urine from the urinary bladder). Record review of Resident #70's Comprehensive Care Plan, dated 05/31/2026, reflected that the resident had a suprapubic catheter (device inserted into the stomach to the bladder to drain urine) and one of the interventions was to position the catheter bag (collects urine from the urinary bladder) and the tubing below the bladder. During an observation and interview on 06/23/2026 at 9:13 a.m., Resident #70 was in her bed, awake. It was observed that the resident had a catheter bag hanging at the side of the bed. The resident said she had a catheter because her bladder was not working. During an observation on 06/24/2026 at 10:34 a.m., CNA H and CNA I were about to transfer Resident #70 to her motorized wheelchair via mechanical lift. Both CNAs hooked the mechanical lift sling to the mechanical lift and prepared to lift the resident. Before raising the mechanical lift, CNA H placed the catheter bag on top of the resident where it remained until the resident was lowered to her motorized wheelchair. When the resident was already in her wheelchair, CNA H started to figure out how to extend the leg rest of the wheelchair. While she was figuring out what to do with the leg rest, the resident's catheter was still on top of the resident. During an interview on 06/24/2026 at 10:43 a.m. CNA I said he saw Resident #70's catheter bag on top of the resident but it did not occur to him to remind CNA H that the catheter bag should always be below the bladder so that the urine, if there was any, would not go back inside the resident's bladder that could result in a UTI. During an observation on 06/24/2026 at 10:47 a.m., Resident #70's catheter bag was still on top of the resident and CNA H was still trying to fix the motorized wheelchair until she said she would just call maintenance to help with the wheelchair. After saying that she would call maintenance she hooked the catheter bag at the side of the wheelchair. During an interview on 06/24/2026 at 10:54 a.m., CNA H said she was busy fixing the wheelchair that she forgot to hook the catheter bag at the side of the motorized wheelchair. She said she was not even supposed to put it on top of the resident because the catheter bag should always be below the bladder to prevent backflow of urine that could cause a UTI. During an interview on 06/25/2926 at 6:28 a.m., the DON said catheter bags should always be below the bladder to prevent backflow of urine from the catheter bag to the bladder. She said if there was a backflow, it could result in a urinary tract infection. She said she already started an in-service to re-educate the staff about catheter care. During an interview on 06/25/2026 at 6:59 a.m., the Administrator said she was not a clinician and would let the DON take the lead about the issue. Record review of the facility's policy Catheter Care, Indwelling Infection Control Policy/Procedure reviewed January 2025 reflected POLICY: It is the policy of this facility that each resident with an indwelling catheter will receive catheter care every shift and PRN . PURPOSE: To promote hygiene, comfort and decrease risk of infection for catheterized residents . PROCEDURES . 12. Keep tubing below level of bladder.

Based on observations, interviews, and record reviews, the facility failed to ensure that the residents' environment remained free of hazards as was possible for two of eight Residents (Resident #65 and #12) reviewed for accident hazard. The facility failed to ensure that Resident #65 did not have a container of germicidal wipes on her shelf on 06/23/2026. The facility failed to ensure that Resident #12 did not have scissors in his room on 06/23/26. These deficient practices placed the residents at risk for accidental injury, exposure to hazardous chemicals and misuse of sharp objects.Findings included: Record review of Resident #65's Face Sheet, dated 06/24/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Dementia (A progressive loss of memory, reasoning, and communication skills) and need for assistance with personal care. Record review of Resident #65's Quarterly MDS Assessment, dated 05/06/26 did not reveal any BIMS score. The Quarterly MDS Assessment indicated that the resident required Substantial / Maximal assistance with eating and dependent with oral hygiene, toileting hygiene, shower / bath self, upper body dressing, lower body dressing, putting on / taking off footwear and personal hygiene. Record review of Resident #65's Comprehensive Care Plan, dated 05/02/18 last revised 05/25/26 revealed the resident is at risk for impaired cognitive function and thought processes related to dementia- recent diagnosis metabolic encephalopathy (a temporary, generalized malfunction of the brain caused by a chemical imbalance in the body), with intervention: Needs supervision/assistance with all decision making-has good family support. During an observation on 06/23/26 at 10:10 a.m. it was observed that Resident #65 had a can of Sani-cloth germicidal disposable wipes on her shelf. During an interview on 06/23/26 at 10:25 a.m. with LVN S, she stated that the Sani wipes should not be in the residents' rooms per the facility policy. She stated that the nurse and all care staff are responsible for making sure that the items are not in the residents' rooms. She stated that confused residents who wander could get a hold of it and swallow them causing them to be sick since those items could contain toxins and alcohol that the resident could react to. During an interview on 06/23/26 at 10:30 a.m. with MA C, he stated he was not sure of what the facility policy was, but that Sani wipes should not be in the resident's possession for safety reasons. He stated that he should tell the nurse if he notices those items in the residents' rooms. He stated that the items can harm residents who are confused and cause them to be hospitalized if swallowed. During an interview on 06/23/26 at 10:34 a.m. with CNA R, she stated that the Sani wipes should not be in the residents' rooms. She stated that every staff member is responsible for making sure those items are not in the residents' rooms. She stated that it will endanger residents who are confused, they could have an allergic reaction to the items and cause serious harm to themselves or others. During an interview on 06/25/26 at 11:49 a.m. with the DON, she stated the residents are not supposed to have Sani-wipes in their rooms, she stated that they started and in-service right away with the staff. She stated that for safety reasons and for residents that wander, it could cause harm if they get a hold of those items. She stated that they can swallow and cause harm to themselves if they get a hold of them. Record review of Resident #12's Face Sheet, dated 06/23/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #12 had diagnoses of Dementia (A progressive loss of memory, reasoning, and communication skills), History of falling, need for assistance with personal care and age-related physical debility. Record review of Resident #12's MDS Assessment, dated 05/13/26, revealed the resident had a BIMS score of 99 (indicating unable to complete BIMS assessment). The MDS Assessment revealed the Resident had active diagnoses of History of falling and need for assistance with personal care. Record review of Resident #12's Comprehensive Care Plan, dated 06/19/25, revealed the resident was at risk for impaired cognitive function or impaired thought processes r/t dementia, needs redirection and assist to find his room and time related activities such asMealtimes, with intervention to Communicate with family/caregivers regarding resident's capabilities and needs. During an observation on 06/23/26 at 1:10 p.m., Resident #12 was observed holding scissors in his hands. The Administrator was called into the room immediately and retrieved the scissors. When she asked the resident how he obtained the scissors, he stated that his daughter gave them to him. During an interview on 06/23/26 at 1:43 p.m. with CNA E who worked in the 200 hall, she stated that the scissors should not be allowed in Resident #12's room for safety reasons, especially since the resident was confused. She stated that if she comes across any dangerous items in the residents' rooms, she will report them to the nurse immediately to have it removed. She stated that she has not noticed the scissors in the Resident's room. She stated that if the scissors remain in the resident's room, he could harm himself or others. During an interview on 06/25/26 at 10:12 a.m. with RN C, she stated that the residents should not have anything sharp in their rooms, they remove the item and notify the DON / Administrator and access if there are any injuries and notify the residents' responsible party. She stated that having any dangerous items can cause injuries to the residents and staff members. She stated that the injury can cause the resident to be sent to the hospital and if it is serous can even cause death. During an interview on 06/25/26 at 11:49 a.m. with the DON, she stated that when residents are admitted and they do care plans, the families are reminded not to bring in items that could cause harm like scissors. She stated that during rounds, the staff checks for such items and remove them, educate the family to not bring such items in the facility. She stated the residents can injure themselves or others if they have possession of dangerous items. During an interview on 06/25/26 at 12:51 p.m. with the Administrator, she stated that the expectation is that all department heads do rounds in addition to the rounds done by the floor staff to make sure the environment is safe for all residents. She stated that if the environment is not safe and they have scissors, they could hurt themselves or their roommates. Record review of the facility's policy, Residents' Rights Safety, Resident undated, revealed the following; Ensure all medications, chemicals, cleaning supplies and any potential hazardous materials are kept locked / secure when staff has completed their use and is no longer in attendance. Conduct a room search should there be concern that prohibited /unsafe items are being stored in the room.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of eight residents (Resident #8) reviewed for care plans. The facility failed to ensure that Resident #8 had a care plan for her oxygen use on 06/23/2026. This failure could place the residents at risk of not receiving the necessary care and services.Findings included: Record review of Resident #8's Face Sheet, dated 06/24/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #8's Comprehensive MDS Assessment, dated 03/24/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 07. The Comprehensive MDS Assessment did not indicate that the resident was receiving oxygen. Record review of Resident #8's Comprehensive Care Plan, dated 06/22/2026, reflected that the resident did not have a care plan for oxygen use. Record review of Resident #8's Physician Order, dated 02/17/2026, reflected O2 AT 2 L/MIN CONTINUOUS PER nasal cannula. every shift for SOB related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED. During an observation on 06/23/2026 at 11:44 a.m., Resident #8 was in her bed with eyes closed. It was observed that the resident was on oxygen therapy. During an observation and interview on 06/24/2026 at 12:06 p.m., the MDS Nurse said if Resident #8 was using oxygen continuously, then there should be a care plan for oxygen use so that everybody taking care of the resident would be aware of how to manage it. She said the care plan should reflect the potential issues of the residents and provide interventions for such issues. She went to Resident #8's care plan and saw that the resident was not care planned for oxygen therapy. She then updated the resident's care plan to reflect that the resident was using some oxygen. She said she would also audit the care plans of the other residents. During an interview on 06/25/2926 at 6:28 a.m., the DON said the MDS Nurse had already updated Resident #8's care plan to reflect her oxygen use. She said care plans should be in place to reflect the realistic goals and interventions, to gauge if the expectations were being met, so that the staff could provide the best care needed. She said the expectation was for all the issues of the residents were care planned appropriately. During an interview on 06/25/2026 at 6:59 a.m., the Administrator said the expectation was that all the residents were care planned specific to their needs so the staff taking care of the residents could provide the care and services needed. She said care plans should be in place so that the individuals providing care for the residents would be on the same page. She said she would coordinate with the MDS Nurse and the DON regarding the care plans of the residents. Record review of the facility's policy Care Planning Policy/Procedure - Nursing Administration reviewed July 2020 reflected POLICY: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident . 9. The resident's plan of care - focus, goals, and interventions - are communicated and implemented by the members of the health care continuum accordingly.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of ten residents (Resident #1 and Resident #14) reviewed for respiratory care. 1.The facility failed to ensure Resident #1's oxygen nasal canula was properly stored on 06/23/26. 2.The facility failed to ensure Resident #14's spirometer was properly stored when not in use on 06/23/2026. These failures could place residents at risk of respiratory infection, respiratory complications, and not having their respiratory needs met.Findings Include 1. Record review of Resident #1's face sheet, dated 06/23/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with the following: Chronic Obstructive Pulmonary Disease - COPD (a progressive, long-term lung disease that makes it hard to breathe), Chronic Respiratory Failure (your lungs or breathing system have long-term damage, making it hard to get enough oxygen into your blood or push out waste gases), Congestive Heart Failure (chronic, progressive condition in which the heart cannot pump blood efficiently enough to meet the body's needs). Record review of Resident #1's Quarterly MDS Assessment, dated 04/07/26, reflected moderately impaired cognition with a BIMS of 10. The Quarterly MDS Assessment indicated the resident was on oxygen therapy. Record review of Resident #1's Comprehensive Care Plan, dated 01/10/25, reflected the resident had oxygen therapy and one of the interventions was to give oxygen at 2 lpm per nasal cannula. Record review of Resident #1's Physician Order, dated 11/08/25, reflected oxygen at 2-4 l/m, continuous, per nasal canula every shift related to COPD, chronic respiratory failure; Change Oxygen Tubing and Humidifier Bottle, Clean filter and pat dry with paper towel on concentrator with weekly tubing change every night shift every Wed. During an observation and interview on 06/23/26 at 1:25 p.m., reflected after Resident #1 was transferred from her wheelchair to her bed by CNA R. CNA R removed the nasal canula connected to the wheelchair oxygen tank, it was exposed and not bagged, per the facility policy. Resident #1 stated CNA R put her in bed after lunch and did not know if the nasal canula should be bagged or not. During an interview on 06/23/26 at 1:30 p.m. with LVN S, she stated the facility policy required oxygen tubing to be bagged when not in use. She stated it was important to have the tubing in a bag to prevent bacteria from contaminating the tubing which could predispose the resident to infection or exacerbate the current medical condition. She stated she would have to discard the old tube, replace it with a new one and provide a bag for it. She stated everyone who cared for the resident was responsible for making sure the tube was bagged when not in use. During an interview on 06/23/25 at 1:35 p.m. with CNA R, she stated the oxygen tube should be bagged when not in use. She stated leaving the tubes exposed would contaminate them and would need to be changed. She stated after she put Resident #1 in bed she should have put the tube in a bag or let the nurse know to provide a bag if there was none. She stated if the tube was exposed to contamination, it could make the resident sick. During an interview on 06/23/26 at 11:49 a.m. with the DON, she stated the tubing should be bagged after the resident was transferred from her wheelchair to the bed if the oxygen was not in use. She stated it should be bagged for infection control. She stated the resident could get some kind of illness if the tube was not bagged. She stated all care staff were responsible for making sure the oxygen nasal canula was bagged per facility policy. 2. Record review of Resident #14's face sheet, dated 06/23/2026, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with atelectasis (collapse of the lungs) and asthma (lung disorder caused by narrowing of the airways). Record review of Resident #14's Comprehensive MDS Assessment, dated 05/04/2026, reflected the resident had severe impairment with a BIMS score of 06. The Comprehensive MDS Assessment indicated the resident had atelectasis and asthma. Record review of Resident #14's Comprehensive Care Plan, dated 04/07/2026, reflected the resident had asthma and one of the interventions was to monitor airway functioning which may indicate hypoxia (insufficient amount of oxygen in the body). Record review on 06/23/2026 of Resident #6's Physician Order reflected the resident did not have an order to use a spirometer (medical device that measures the flow of air inhaled and exhaled by the lungs). During an observation on 06/23/2026 at 9:07 a.m., Resident #14 was in his bed with his eyes closed. It was observed that an unbagged spirometer was on top of the resident's dresser. The mouthpiece of the spirometer was touching the wall. During an observation and interview on 06/23/2026 at 11:31 a.m., RN A said she was not sure if Resident #14 was using the spirometer or if there was an order to use a spirometer. She said, nevertheless, the spirometer should be bagged because it was still inside the resident's room, and it should be kept clean in case the resident needed to use it. She went to her cart, took a plastic bag from one of her drawers, and bagged the resident's spirometer. During an interview on 06/25/2926 at 6:28 a.m., the DON said the spirometer should be bagged even though Resident #14 was not using it to keep it clean. She said the resident did not have a discharge order for the spirometer, that was why the resident did not have an order for the spirometer, but nevertheless, it should still be kept clean. She said she already started an in-service about respiratory care. During an interview on 06/25/2026 at 6:59 a.m., the Administrator said the expectation was for the spirometer to be bagged to keep them clean. She said she would coordinate with the DON about the issue. Record review of the facility's policy Incentive Spirometry Policy & Procedure, revised April 2025, reflected Policy: It is the policy of this facility that an incentive spirometry device may be used by a resident to assist with maximal lung ventilation . 12. Place the mouthpiece in a plastic storage bag between exercises. Record review of the facility's, undated, policy / procedure titled, Oxygen Equipment reflected: Oxygen masks, nasal cannulas, and tubing will be used for one resident only. When used continuously or intermittently, tubing will be routinely changed to prevent the build-up of respiratory secretions, mucous, and bacterial growth. When mask or cannula is temporarily not being used, it will be covered loosely to prevent contamination from airborne microorganisms. It will not be covered tightly.

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one of eight (Resident #12) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #12's room was in a position that was accessible to the resident on 06/23/26. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Record review of Resident #12's Face Sheet, dated 06/23/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #12 had diagnoses of Dementia (A progressive loss of memory, reasoning and communication skills), History of falling, need for assistance with personal care and age-related physical debility. Record review of Resident #12's MDS Assessment, dated 05/13/26, revealed the resident had a BIMS score of 99 (indicating unable to complete BIMS assessment). The MDS Assessment revealed the Resident had active diagnoses of History of falling, need for assistance with personal care. Record review of Resident #12's Comprehensive Care Plan, dated 06/19/25, revealed the resident was a fall risk and an intervention included ensuring call light was within reach of the resident and encourage Resident to use it. During an observation on 06/23/26 at 9:44 a.m. and 10:55 a.m., Resident #12 was observed lying in his bed and his call light was located on the floor, under his bedside table and out of his reach. During an interview on 06/23/26 at 10:55 a.m., Housekeeper G was shown Resident #12's call light being on the floor, under the bedside table out of the resident's reach. She stated that the call bell should not be on the floor but should be clipped to the Resident's bed and within reach. She stated that everyone is responsible for making sure the call bell is within reach of the residents. She stated that she should have picked it up after cleaning the floor in Resident #12's room and put it within reach of the resident and report the missing clip to the maintenance personnel. She stated that if the call bell is not within reach the resident could fall. During an interview on 06/23/26 at 11:00 a.m. with CNA E, she stated that according to the facility policy, the call bell should always be within reach of the Resident. She stated that everyone is responsible for making sure the call bell is within reach of the resident. She stated that if the call bell is not within reach of the resident and they try to get out of bed, they could fall or could go a long time without help. During an interview on 06/23/26 at 11:05 a.m. with LVN S, she stated that the facility policy is that the call bell should be within reach of the resident at all times. She stated that it is important that it is to prevent delays in providing care or if the resident is having an emergency without the call bell within reach they could be dangerous for the Resident #12 and cause him harm. She stated that it could also affect them emotionally if they wet themselves and are unable to call for help. During an interview on 06/25/26 at 11:49 a.m. with the DON, she stated that it was care planned after the surveyor observation that Resident #12 takes the call light off his bed and throws it on the floor. Now they hook it to the back of the bed but within reach. She stated that it is expected that the call light should be within reach at all times. She stated that it should be within reach for him to call for assistance. She stated that he would not be able to get help when he needs it if the call light is not within reach. She stated that all staff are responsible for making sure the call light is within reach. During an interview on 06/25/26 at 12:51 p.m. with the Administrator, she stated that the expectation is that the call light should be within reach and frequent rounding to make sure it is in place. She stated that the call bell should be within reach so the residents can call for help when needed. She stated that if they are a fall risk it is an added risk if the call bell is not within reach. She stated that Resident #12 is a fall risk and due to that he is kept in the room across from DON's office. Record Review of the facility's undated policy on Resident Rights revealed The resident has the right 'To be encouraged and assisted throughout his or her stay in the Center to exercise these Resident Rights as well as those which Residents are entitled as a U.S. citizen'.

Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for one of eight residents (Residents #8) reviewed for accuracy of assessments. The facility failed to ensure Resident #8's Comprehensive MDS Assessment, dated 03/24/2026, accurately reflected that the resident was receiving oxygen therapy. This failure could place the residents at risk for not receiving care and services to meet their needs, diminished function of health, and regression in their overall health. Record review of Resident #8's Face Sheet, dated 06/24/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #8's Comprehensive MDS Assessment, dated 03/24/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 07. The Comprehensive MDS Assessment did not indicate that the resident was receiving oxygen. Record review of Resident #8's Comprehensive Care Plan, dated 06/22/2026, reflected that the resident did not have a care plan for oxygen use. Record review of Resident #8's Physician Order, dated 02/17/2026, reflected O2 AT 2 L/MIN CONTINUOUS PER nasal cannula. every shift for SOB related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED. During an observation on 06/23/2026 at 11:44 a.m., Resident #8 was in her bed with eyes closed. It was observed that the resident was on oxygen therapy. During an observation and interview on 06/24/2026 at 12:06 p.m., the MDS Nurse said if Resident #8 was using oxygen continuously, then the resident should be coded that she was on oxygen therapy. She opened the resident's physician order for oxygen and saw that the resident was using the oxygen every day. She then checked on the resident's MDS and saw that the resident was not coded for oxygen therapy. She then changed the code, so the MDS would reflect that the resident was using oxygen. She said it was an oversight on her part. She said the MDS was a form of a clinical assessment to capture the needs of the residents that needed to be addressed. She said if the assessment was not accurate, then there could be a probability that the needs would not be met. She said she would also audit the MDS of the other residents. During an interview on 06/25/2926 at 6:28 a.m., the DON said she was made aware that Resident #8 was not coded for the oxygen use. She said the MDS Nurse had already modified it. She said the MDS should reflect the current status of the residents to provide the necessary care needed by the residents. During an interview on 06/25/2026 at 6:59 a.m., the Administrator said the MDS must be updated to capture the diagnoses of the residents to provide the appropriate interventions. She said she would coordinate with the MDS Nurse and the DON regarding the MDS of the residents. Record review of the facility's policy Resident Assessment and Associated Processes Policy & Procedure revised December 2023 reflected Policy: It is the policy of this facility that resident's will be assessed and the findings documented in their clinical health record . comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified.

Based on observation, interview, and record review, the facility failed to ensure residents did not get ice from the ice cooler used for 1 of 1 (Resident #1) resident reviewed for infection control.Resident #1 got ice for her cup from an ice cooler, without the help of staff.This failure could result in contaminated ice that could transmit organisms to other residents, resulting in waterborne illnesses.Findings included:Record review of Resident #1's face sheet, dated 03/26/2026, revealed a [AGE] year-old woman admitted to the facility with a primary diagnosis of epilepsy (brain condition causing seizures). Other pertinent diagnoses included down syndrome, major depressive disorder, and mild intellectual disabilities (below-average intellectual functioning).Record review of Resident #1's MDS, dated [DATE], revealed she had a BIMs score of 07, indicating severe cognitive impairment.During an observation on 03/26/2026, the ADON had assisted Resident #1 with opening the lid on her cup. Resident #1 proceeded to walk down the hall near the dining room. Resident #1 poured a can of soda into her cup, and the cup and lid from her cup sat on top of the ice cooler. Resident #1 said she got ice for her cup herself, indicating staff did not assist. Resident #1 did not state how she got the ice. At that time, RN A assisted Resident #1 to the therapy room.During an interview on 03/26/2026 at 11:05 AM with RN A revealed Resident #1 did sometimes get ice from the cooler herself but other residents did not. She said staff did try to assist Resident #1 with getting ice if they saw her walking around, because Resident #1 may be walking to get ice. RN A said Resident #1 needed assistance and staff usually caught her (before she got ice herself) but she got upset if staff tried to help her. RN A said the risk of residents getting ice from the ice cooler was contamination to the ice and risk of infection.During an interview on 03/26/2026 at 12:10 PM with the DON, she revealed she had been notified about Resident #1 getting ice out of the ice cooler herself. The DON said she had an in-service going around and dietary staff cleaned the coolers. She said normally CNAs passed out ice in the mornings and evenings, and ice coolers were not left near the dining room. During an interview on 03/26/2026 at 12:54 PM with CNA B, he indicated Resident #1 did get her own ice often residents were not supposed to get their own ice because of cross contamination. He said the risk was residents could get sick.During an interview on 03/26/2026 at 1:57 PM with the ADON revealed she had opened Resident #1's cup for Resident #1 and indicated she did not think that Resident #1 was going to get ice because Resident #1 did not always get ice (for her cup). She said the risk of residents getting their own ice was infection. She said staff strongly encouraged residents to ask for help, but Resident #1 would listen for about 15 minutes and then say she forgot, but staff would reeducate.During an interview on 03/26/2026 at 2:50 PM with the DON, she said she talked to staff and created a task in Resident #1's care plan for staff to check to see if Resident #1 needed ice when doing rounds every 2 hours. The DON said staff were to get ice for residents because staff did not know if Resident #1 had cleaned her hands, did not know if her cup was clean, and staff used a scoop (to prevent contamination).During an interview on 03/26/2026 at 3:30 PM with the ADM revealed staff were supposed to check in with residents during rounds to see if they needed ice. The ADM said she helped with getting ice for residents. The ADM said the ice coolers were cleaned and new ice was put in, and indicated staff were made aware that if they saw Resident #1 going towards the ice cooler, to redirect her, ask her to request ice, and provide it. She said residents could not get their own ice because of the concern with infection control.The facility's Infection Prevention and Control Program dated 05.2025 reflected: PolicyThe infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management; prevention of infection, and employee health and safety.The program will be carried out by the facility infection preventionist. It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards.GoalsDecrease the risk of infection to residents and personnel.Recognize infection control practices while providing care.Identify and correct problems relating infection control.Ensure compliance with state and federal regulations related to infection control.Promote individual resident's rights and well-being while trying to prevent and control the spread of infection.Monitor personnel health and safety.

Based on observation, interview, and record review, the facility failed to establish a system of disposition of controlled drugs to enable an accurate reconciliation and failed to maintain account of controlled drugs for 1 of 5 residents reviewed for pharmacy services.MA A was unaware of how to dispose controlled medication. MA B failed to update count sheet for Resident #1 after administering controlled medication to the resident, causing discrepancy between medication card and count sheet. These failures could lead to suspected drug diversion and medication error. Findings included:An observation on 3/5/2026 at 8:30am revealed MA A was passing medication to residents in hall 400.In an interview on 3/5/2026 at 8:30am, MA A stated she had not had a refusal of narcotics or controlled medication from residents before. MA stated if the resident refused controlled medication, she would waste the medication in the sharp bin on her medication cart. She stated she could do it with or without a witness. She stated she did not think a witness was needed to waste controlled medication. She stated after wasting the medication, she would report to the nurse. She stated she was not sure what the risk would be if it was done without a witness. MA A also stated the count sheet should always be documented immediately after a controlled medication was given to the resident to prevent the risk of forgetting to log it later which could cause discrepancy in medication count. She stated she had not had in-service on controlled medication count and disposing of controlled medication since she started in September 2025.An observation on 3/5/2026 at 9:00am of 200 hall cart, managed by MA B, revealed discrepancy of Lorazepam (a controlled medication for anxiety) card and count sheet for Resident #1. Resident#1's card showed 18 tablets of Lorazepam while the count sheet for the medication showed 19 tablets.In an interview on 3/5/2026 at 9:00am, MA B stated he administered Lorazepam to Resident #1 earlier this morning but he forgot to document the count sheet right away. He stated he always documented the count sheet as soon as a controlled medication was given to prevent forgetting documentation but today he stated he got busy and forgot. He stated the risk of not documenting right away was he could be suspected of drug diversion. MA B also stated if he noticed discrepancy when counting medication, he would report to the DON right away. He also stated he always needed a witness to waste a controlled medication to prevent drug diversion. He stated the medication could not be wasted in a sharp bin. He stated all controlled medication must be wasted by putting them in a drug buster (a medication disposal system that included ingredients to deactivate the effectiveness of the medication). In an interview on 3/5/2026 at 9:20am with Resident #1, she stated she took all medication this morning. She stated MA B gave her all medication and she did not notice any missed dose.Record review of Resident#1's MAR on 3/5/2026 revealed Lorazepam was given to the resident this morning at 0700. In an interview on 3/5/2026 at 9:30am, LVN C stated she always needed a witness when a controlled medication needed to be wasted. She stated all controlled medication must be wasted in a drug buster. She also stated once a controlled medication was taken from the cart, the count sheet needed to be documented right away. She stated those actions prevented drug diversion and medication count discrepancy. She stated the last in-service on controlled medication was provided about 2 weeks ago. In an interview on 3/5/2026 at 10:10am, the DON stated all med aides and nurses were trained to waste controlled medication with a nurse witness to avoid drug diversion. She stated controlled medication could not be discarded in a sharp bin. She stated each medication cart had a drug buster bottle that staff used to waste medication. She also stated as soon as a controlled medication was pulled from a med cart, the count sheet of that medication needed to be updated with the correct count immediately to prevent count discrepancy. She stated all counts had been completed at shift changes with signatures of both staff who did the medication count. He stated MA A and MA B reported to her immediately after their interviews with this surveyor and education was provided for both staff. She stated the last in-service on narcotic and controlled medication administration was provided on 2/19/2026. Record review of facility's in-service training report, dated 2/19/2026, revealed an in-service was provided on narcotics and controlled medication. The summary of in-service stated, when narcotics are pulled from the cart you must correct the count sheet. Both MA A and MA B attended the training. Record review of facility's Medication administration - Destruction of Medication policy, dated 5/2025, revealed the following methods of destroying medications are utilized by this facility. two personnel licensed or registered in the health field shall document that drugs were destroyed by a. co-signing the medication record, b. recording the date, and drugs destroyed in the resident's medication count sheet. The policy also stated, dispose of medication in a manner that will render the drug unusable.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 3 of 6 residents (Resident #5, #6, and #7) reviewed for accident prevention.The facility failed to ensure Resident #5 did not have a can of Lysol spray in his room on 01/30/2026.The facility failed to ensure Resident #6 did not have a can of aerosol air freshener spray in her room on 01/30/2026. The facility failed to ensure Resident #7's cell phone charging cord was plugged correctly into the outlet in her room on 01/30/2026.These failures could prevent the residents from having an environment that was free from hazards. Findings included:Record review of Resident #5's Face Sheet, dated 01/30/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #5 had diagnoses of Dementia (memory decline) and depressionRecord review of Resident #5's Quarterly MDS Assessment, dated 12/21/25, reflected Resident #5 had severe cognitive impairment. The Quarterly MDS Assessment reflected the resident had an active diagnosis of Dementia.Record review of Resident #5's Comprehensive Care Plan, dated 01/13/26, reflected a plan of care for an impaired cognitive function. In an observation on 01/30/26 at 9:28 AM, Resident #5 was observed with a can of Lysol in his room sitting on top of a 5-drawer chest. Record review of Resident #6's Face Sheet, dated 01/30/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses of major depression disorder.Record review of Resident #6's Quarterly MDS Assessment, dated 12/06/25, reflected Resident #6 had moderate cognitive impairment. The Quarterly MDS Assessment reflected the Resident #6 had an active diagnosis of depression.Record review of Resident #6's Comprehensive Care Plan, dated 12/28/25, reflected a plan of care for an impaired cognitive function. In an observation on 01/30/26 at 9:30 AM, Resident #6 was observed with a can of aerosol air freshener spray sitting on top of her nightstand. In an observation and interview on 01/30/26 at 9:28 AM, RN A was shown Resident #5 and Resident #6 with having the can of Lysol and can of aerosol air freshener spray in their rooms and she stated they were not to have the items in the room because it was an biohazard and dangerous for the residents. Record review of Resident #7's Face Sheet, dated 01/30/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had diagnoses of Dementia and conduct disorder.Record review of Resident #7's Quarterly MDS Assessment, dated 12/12/25, reflected Resident #7 had severe cognitive impairment. The Quarterly MDS Assessment reflected the resident had active diagnoses of Dementia and conduct disorder.Record review of Resident #7's Comprehensive Care Plan, dated 12/28/25, reflected a plan of care for an impaired cognitive function. In an observation on 01/30/26 at 1:55 PM, Resident #7 was observed lying in bed. She was pointing at a phone charger cord that she stuck directly into an electrical outlet on a wall alongside her bed, without the charging plug. The phone charging plug was observed on top of her 5-drawer chest. The resident had a sign on the wall above the outlet, which stated Please help mom with these things. Phone: make sure her phone is plugged in and turned on. In an interview and observation on 01/30/26 at 2:06 PM, RN A and CNA L were shown Resident #7's phone charger cord that she stuck directly into an electrical outlet. They stated staff should have connected the resident's phone to the charger after placing the resident into her bed, because the resident wanted her phone near her so she could contact the Responsible Party. RN A stated the resident could injure herself if she attempted to charge the phone herself.In an interview on 01/30/26 at 2:06 PM, The Administrator and DON were informed of Resident #7 having the phone charger cord stuck directly into an electrical outlet and staff not following the Resident's Responsible Party request to have the phone charger connected by staff for the resident. The DON stated staff should have plugged in the charger for the resident once they placed her back in bed. The DON stated the resident could have harmed herself by plugging the charging cord directly into the outlet. The facility's policy Resident Rights (undated) reflected The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide--1. A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.a. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.

Based on observations, interviews, and record reviews the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for four of six residents (Resident #1, #2, #3 and #4) reviewed for respiratory care.The facility failed to ensure Resident #1 and #2's breathing treatment mask was properly stored in a bag when not in use on 01/30/26. The facility failed to ensure Resident #3 and #4's nasal canula was properly stored in a bag when not in use on 01/30/26. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #1's Face Sheet, dated 01/30/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had a diagnosis of COPD (obstructed airflow).Record review of Resident #1's Quarterly MDS Assessment, dated 12/21/25, reflected Resident #1 had severe cognitive impairment. The Quarterly MDS Assessment reflected the resident had an active diagnosis of COPD.Record review of Resident #1's Physician Orders, dated 01/30/26, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML inhale every 6 hours as needed for shortness of breath. In an observation on 01/30/26 at 9:14 AM, Resident #1's nebulizer mask was observed sitting on top of her nightstand unbagged.Record review of Resident #2's Face Sheet, dated 01/30/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had a diagnosis of COPD (obstructed airflow). Record review of Resident #2's Quarterly MDS Assessment, dated 12/24/25, reflected Resident #2 had severe cognitive impairment. The Quarterly MDS Assessment reflected the resident had an active diagnosis of Chronic Respiratory Failure (low blood oxygen).Record review of Resident #2's Physician Orders, dated 01/30/26, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML inhale every 8 hours as needed for shortness of breath.In an observation on 01/30/26 at 9:18 AM, Resident #2's breathing treatment mask was observed sitting on top of her nightstand unbagged Record review of Resident #3's Face Sheet, dated 01/30/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had a diagnosis of COPD (obstructed airflow). Record review of Resident #3's Quarterly MDS Assessment, dated 12/24/25, reflected Resident #3 had severe cognitive impairment. The Quarterly MDS Assessment reflected the resident had an active diagnosis of COPD.Record review of Resident #3's Physician Orders, dated 01/30/26, reflected no physician orders for oxygen use.In an observation and interview on 01/30/26 at 9:26 AM, Resident #3's nasal canula was observed hanging on his oxygen concentrator unbagged. The resident stated he did not use the oxygen device much and had not used it in a few days.In an observation and interview on 01/30/26 at 9:28 AM, RN A observed Resident #4's nasal canula hanging on his oxygen concentrator unbagged. She stated the resident used the oxygen device on an as needed basis and the nasal canula should be bagged when not in use to avoid infection. Record review of Resident #4's Face Sheet, dated 01/30/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had a diagnosis of chronic kidney disease. Record review of Resident #4's Initial MDS Assessment, dated 01/30/26, reflected Resident #4 had severe cognitive impairment. The MDS Assessment reflected no active diagnoses.Record review of Resident #4's Physician Orders, dated 01/30/26, reflected O2 AT 2 L/MIN CONTINUOUS PER Nasal cannulaIn an observation and interview on 01/30/26 at 9:34 AM, Resident #4's nasal canula was observed hanging on his oxygen tank, attached to the wheelchair, unbagged.In an observation and interview on 01/30/26 at 9:28 AM, RN A observed Resident #4's nasal canula hanging on his oxygen tank, attached to the wheelchair, unbagged. She stated the nasal canula should be bagged when not in use to avoid the resident getting an infection. In an interview on 01/30/26 at 10:00 AM, the DON was informed of Resident #1, #2, #3 and #4 not having not having their breathing mask or canula bagged. She stated the items needed to be bagged to avoid the resident getting an infection. She stated a nurse had already brought this to her attention and she was going to -In-service them on the expectation.In an interview on 01/30/26 at 2:14 PM, LVN U stated she works at a different facility but was helping today. She stated she covered the hall of Resident #1 and #2. She was informed of Resident #1 and #2 not having their breathing mask bagged. She stated nasal canula's and breathing mask should be in a plastic bag when not in use to keep them from getting contaminated. She stated nurses should be checking for this when they make their rounds.Review of the facility's policy Oxygen Administration, 10/2010, reflected The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.2. Review the resident's care plan to assess any special needs of the resident.The policy had no reference to bagging the breathing devices when not in use.

Based on observation, interview and record review the facility failed to ensure residents were adequately equipped to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from three of six residents (Resident #7, #8, and #9) reviewed for Resident Call System. The facility failed to ensure the call light system in Resident #7, #8, and #9's rooms were in a position that was accessible to the residents on 01/30/26.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Record review of Resident #7's Face Sheet, dated 01/30/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had diagnoses of lack of coordination and history of falling.Record review of Resident #7's Quarterly MDS Assessment, dated 12/12/25, reflected Resident #7 had severe cognitive impairment. The Quarterly MDS Assessment reflected the resident had active diagnoses of lack of coordination and need for assistance with personal care. Record review of Resident #7's Comprehensive Care Plan, dated 12/28/25, reflected the resident was a fall risk and an intervention was to have call system within the resident's reach. In an observation on 01/30/26 at 2:00 PM, Resident #7 was observed lying in her bed. She did not have a call light, but she did have a bell attached to a bedside table. The bedside table was observed across the room, near a 5-drawer chest, out of reach from the resident. In an interview and observation on 01/30/26 at 2:06 PM, RN A and CNA L stated the resident used a bell, attached to a bedside table, to contact staff if she needed any assistance. They stated the resident was unable to self-transfer in and out of bed and needed staff assistance. RN A stated when staff placed the resident back in bed, they should have placed the bedside table near the resident. RN A stated the resident kept yanking the call light cord out of the wall and destroying it. Record review of Resident #8's Face Sheet, dated 01/30/26, reflected he was an [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included muscle weakness and lack of coordination. Record review of Resident #8's Quarterly MDS assessment, dated 12/21/25, reflected severe cognitive impairment. For ADL care, it reflected the resident required extensive assistance. Active diagnoses included muscle weakness and lack of coordination. Record review of Resident #8's Comprehensive Care Plan, dated 6/30/25, reflected the resident was a fall risk and one of the interventions was to ensure call light was within reach of the resident. Record review of Resident #9's Face Sheet, dated 01/30/26, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination and unsteadiness on feet. Record review of Resident #9's Quarterly MDS assessment, dated 12/22/25, reflected severe cognitive impairment. For ADL care, it reflected the resident required substantial assistance. Active diagnoses included lack of coordination and unsteadiness on feet. Record review of Resident #9's Comprehensive Care Plan, dated 08/05/25, reflected the resident was a fall risk and one of the interventions was to ensure call light was within reach of the resident. In an observation on 01/30/26 at 9:16 AM, Resident 8's call light was observed on the floor behind the bed, out of reach of the resident, and Resident #9's call light was observed hanging down from the head of the bed, out of reach of the resident. In an interview and observation on 01/30/26 at 9:18 AM, CNA E observed Residents #8 and #9's call light not being within reach of the residents. She stated the residents often knock the call light off the bed, but she would get a clip to clip it to the bed. She stated the call lights needed to be within reach of the resident so they could call for assistance if needed.In an interview on 01/30/26 at 02:10 PM, the DON was advised of the call lights for Resident #7, #8, and #9 not being within reach of the resident so they could be able to contact staff if they needed help. She stated all staff were responsible for ensuring the call lights were within reach of the residents.In an interview on 01/30/26 at 02:14 PM, LVN U stated she works at a different facility but was helping today. She stated she covered the hall of Resident #8 and #9. She was informed the residents were lying in bed and their call lights were not within their reach. She stated call lights should be within the resident's reach so they could call for help.Record review of the facility's policy on Call System, Residents, January 2025, revealed Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on interviews and record review, the facility failed to ensure the right to be free from abuse was provided for one (Resident #1) of seven residents reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse. On 5/18/2024 at 2:10 p.m., CNA A hit Resident #1 with an open hand on the outer left thigh causing a red handprint. The noncompliance was identified as past noncompliance (PNC). The past noncompliance began on 05/18/24 and ended on 05/20/24. The facility had corrected the noncompliance before the state's investigation began. This failure could place residents at risk for abuse and psychological harm. Findings included: Record review of Resident #1's Annual MDS dated [DATE] revealed Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia, stroke, and aphasia (disorder that affects a person's ability to communicate). Section E indicated there have been no changes in Resident #1's behavior, and Resident #1 was not exhibiting any behaviors. BIMS assessment was incomplete. Record review of Resident #1's BIMS assessment prior to the incident dated 4/25/2024 revealed a BIMS score of 0 (indicated severe cognitive impairment). Record review of Resident #1's care plan revealed Resident #1 had right sided weakness, impaired cognitive function, and was resistive to care. Interventions listed for being resistive to care included leaving the room, approaching the resident at a later time, and seeking assistance from another staff member. Another focus listed was that Resident #1 had a potential for behavior problems and interventions included to ensure the resident's safety and not jeopardize the staff's safety with care. Record review of PIR dated 5/20/2024 revealed on 5/18/2024 at 2:10 p.m., CNA A reported to MA B that Resident #1 hit her twice in the arm, and she reacted by hitting him back. CNA A was suspended and escorted out of the building by staff. In an interview on 1/14/2025 at 11:19 a.m., MA B reported on 5/18/2024 that CNA A came to her office and stated she had hit Resident #1 back after he hit her. MA B stated she immediately notified the DON and the ADM and MA B told CNA A to go to her car. MA B reported she saw a red handprint on Resident #1's left thigh, but it was gone when she went to change him two hours later. MA B stated Resident #1 did not slap at her hand or give her any indication that it hurt when she changed him. MA B stated Resident #1 was combative with care at times and hit hard. MA B stated there were no changes in Resident #1's behavior after the incident. MA B stated Resident #1 could have become afraid of staff but did not. In an attempted interview on 1/14/2025 at 12:10 p.m., a telephone call was made to CNA A and voicemail left. No return call received. In an interview on 1/14/2025 at 12:24 p.m., the DON reported CNA A was providing care for Resident #1. CNA A walked out of the room and told MA B that she had hit Resident #1. The DON stated CNA A told her it was a reaction, and she was sorry. The DON stated CNA A knew what abuse was and knew not to hit the residents. The DON stated CNA A had received abuse and neglect training, and CNA A was able to state what should have happened in the situation. The DON reported CNA A was walked out of the building and terminated after the investigation. The DON reported the red mark on Resident #1's leg was gone by the next day and Resident #1 did not have any behavior changes after the incident. The DON reported Resident #1 did not appear to be fearful of staff. The DON stated all staff received abuse and neglect training that was updated to include de-escalation techniques. The DON stated the risks to the residents if they were hit by staff would be behaviors, depression, isolation, and risk for fear. The DON reported everyone was responsible for monitoring staff interactions with residents, and everyone was trained to say something if they saw something. Record review of a skin assessment dated [DATE] at 2:25 p.m., revealed Resident #1 had a slight red discoloration to the outer left thigh. Record review of nursing progress note dated 5/18/2024 at 8:20 p.m., revealed Resident #1 did not have any bruises and did not have any signs or symptoms of pain. Record review of nursing progress note dated 5/19/2024 at 6:15 p.m., revealed Resident #1 did not have any bruises and did not have any signs or symptoms of pain. In an observation and attempted interview on 1/14/2025 at 1:19 p.m., Resident #1 was sitting up in his bed looking around the room. Resident #1 was unable to participate in an interview. Resident #1 did not verbally respond to questions and only grunted. Resident #1 appeared calm but gestured for people to leave by waving his hand at the door when he was spoken to. In an attempted interview on 1/14/2025 at 1:29 p.m., a telephone call was made to Resident #1's POA and voicemail left. No return call received. In an interview on 1/14/2025 at 5:29 p.m., the ADM stated he was immediately notified of the incident and interviewed CNA A with the DON over the phone. The ADM stated CNA A told him that she hit Resident #1 because it was a reaction to him hurting her. The ADM stated CNA A had training on abuse and neglect and was terminated after the incident because it was abuse. The ADM stated he did not remember if there initially a red mark on Resident #1 was, but there was nothing long-term. The ADM stated the risks to the residents if staff were to hit them would be that they could be hurt emotionally or physically. The ADM stated everyone was responsible for monitoring staff to resident interactions, and the expectation was that there was no tolerance for physical or verbal abuse. Review of training dated 05/18/25 and labeled 'Teachable Moment' and presented by the DON reflected the training included the Abuse Policy, Steps of de-escalation, residents with increased behaviors use two staff for all cares and notify the nurse. An interview on 01/14/25 at 3:25 p.m. with CNA C revealed she received training regarding abuse and neglect. She received abuse and neglect training on computer and during in-service. She stated it takes two aides to provide care due to Resident #1's behavior. An interview on 01/14/25 at 4:07 p.m. with CNA D revealed she received in-service training regarding abuse and has not seen any staff hit any residents, if she saw abuse she would report to the Administrator. She stated it takes two staff to provide care to Resident #1. An interview on 01/14/25 at 4:019 p.m. with CNA E revealed she received in-service training and received monthly on computer and in-services. She stated if the resident is aggressive staff should walk away and come back when resident is calm. She stated she has never seen a staff hit a resident. Record review of facility policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, with a revision date of 10/01/2024, revealed it is the policy of this facility that each resident has the right to be free from abuse and definitions included abuse - willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on observations, record reviews and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that residents received adequate supervision to prevent accidents for one (Resident #1) resident of five residents reviewed for elopement. The facility failed to provide Resident#1 with adequate supervision to prevent him from eloping from the facility on 01/04/24. Resident #1 was able to leave the building without staff being aware that he left the building early morning on 01/04/24 and made it down the street, approximately 2/10ths of a mile from the facility. It was determined a past non-compliance Immediate Jeopardy existed from 01/04/24 to 01/05/24. The Immediate Jeopardy was determined to have been removed on 01/05/24 due to the facility's implemented actions that corrected the non-compliance. This failure placed residents at risk for harm and /or serious injury. Findings included: Record review of quarterly MDS assessment for Resident #1, dated 12/08/2023 reflected the Resident was a [AGE] year old male who admitted to the facility on [DATE] with a diagnosis of Schizophrenia, cerebral infarction, limited use of right side and limited use of left side, PTSD , aphasia (language disorder), and need for assistance with personal care. Resident #1 had a BIMS score of 7, which indicated severe cognitive impairment. MDS Section GG reflected Resident#1 required transfer assistance to wheelchair but was independent once in wheelchair. Record Review of Resident #1's Quarterly Care plan dated December 2023 reflected resident was placed on 15minute checks after the 05/06/23 incident but no current special supervision precautions. There were no current checks in place for elopement. Record review of Resident #1's Elopement assessment completed 11/28/2023 scored Resident #1 as low risk for elopement with a score of 4 of 15. Record review of Resident #1's Elopement assessment completed on 01/04/2024 scored Resident #1 as high risk for elopement with a score of 13 of 15. This assessment was completed after the elopement. Review of Provider Investigation Report dated 01/10/2024 reflected a finding of Unfounded for Neglect. Upon the return of the Resident to the facility by a staff member, the facility completed a physical head to toe assessment and the resident had no injuries. He was then placed on 1:1 supervision until transfer to new facility, referrals were placed to facilities with wander guard availability. The doors were checked for proper function, codes to the doors were changed. The facility started education on the elopement policy with all staff and conducted 4 elopement drills over 2 days for each shift. Facility timeline (attached to the Provider Investigation Report) 05:35 am Agency LVN notified CNAG that Resident #1 was unable to be located. 05:35 am CNA G notified LVN B of Resident #1's possible Elopement. 05:36 am LVN B gathered staff and started in house and perimeter search for Resident #1. 05:47 am LVN B notified ADON of possible elopement. 05:55 am CNA A Returned to the facility with Resident #1. 06:00 am Resident #1 assessed and vitals taken. 06:05 am Resident placed on 1:1 supervision until discharge. Description Environment; weather 38 degrees. Resident Dressed in red t-shirt, jeans, shoes and socks. In manual wheelchair with orange bag on the back with a cellphone. Record review of progress notes reflected Resident #1 had a previous elopement on 05/06/2023. Resident found in front of the building by a passerby. Resident had been observed in the building 15 minutes prior to being returned to the building. Facility put 15-minute checks in place for 3 days. Facility also requested a psychological assessment and an assessment by the Physician's Assistant. An Interview with CNA D on 03/18/2024 at 3:15 pm revealed the CNA was coming in to work, and night staff was looking for Resident #1. She volunteered to go look for him. She stated she got in her car and found him on the corner about a block away from the facility. She stated that he was on the sidewalk when she saw him. She stated she parked her car and walked him back to the building. She stated that was the second time he had done that. The first time he did it, she was not at the facility. She stated she did not know how he got out of the building. He told her he was going to the store. She stated he did not leave the building regularly. CNA D said they had 1:1 monitoring, and he sat with her most of the time. She said they were able to move him to a sister facility with Wander guard. CNA D said they have a book at the nurses' station with those people (Wander Risks) in it. She stated that none of the residents are exit seeking at this time. The facility did an in-service on elopement and had elopement drills. She stated they watch the residents and doors closer. When the alarms on the doors go off, they have to respond to the alarm. An interview with the DON on 03/18/2024 at 4:55 pm. The DON reported they paid staff to monitor Resident #1 one on one. She stated they maintained the one-to-one supervision until the resident left the facility. She stated they spoke with resident and his representative and placed him in their sister facility that has Wander guard. She stated they felt that a facility with Wander guard could better serve the resident's needs. She stated that Resident#1 told them that he wanted to go to the store. She stated that he was not one to sign himself out and leave the facility. She stated that since the incident back in May they had no indication that he would leave the facility. She stated the May incident was around the time his father was admitted to the hospital and had stopped visiting him daily. At that time, he told them he was going to see his father. This time there was no explanation or indication that Resident#1 would leave the building. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from 01/04/24 to 01/05/24. The facility took the following action to correct the non-compliance on 01/05/24. Review of In-service dated 01.4.24 and 01/05/24 reflected All staff attend and the subject matter was regarding Facility policy on elopement, and Reducing the risk for elopement. An interview with CNA E on 03/18/2024 at 3:33 pm, revealed she knew Resident #1 and has cared for him. She stated she was not there the morning when he got out. She did not know that he could get out. She had never seen him trying to leave the building. None of the residents try to get out. She stated the last in-service was sometime last month (February 2024), and they get in-services all the time. She stated after Resident#1's elopement they all had to take in services and had drills about preventing elopement. An interview with CNA F on 03/18/24 at 3:45 pm revealed she works the 6am-6pm shift. She stated she does not work the overnight shifts at all. She stated she was not at the facility when Resident #1 eloped. Resident #1 was not exit seeking or trying to leave the building during the shifts she worked prior to his elopement. She stated there was in-service trainings on Elopement and drills after Resident #1 eloped. Now staff watch the doors more closely and do headcounts each shift. An interview with LVN C on 03/18/2024 at 4:20 pm revealed she works 6am-6pm shift. She stated the rotation requires work some weekends too. She revealed that she was aware of Resident#1 eloping. She stated it did not happen on her shift. She stated that she is unaware of any previous issues with him getting out. She stated none of the residents are exit seekers. They have had multiple in services trainings about Elopement, and they also have drills every so often. She stated that they discuss elopement risks during their daily meeting at the start of the shift. An interview with the DON on 03/19/24 9:30 am, revealed the facility implemented two in service trainings on 01/04/24. These trainings were for both the 6 am shifts and the 6 pm shifts. The Don stated that they conducted elopement drills for all staff on both shifts on that day. The facility also had an in service and an elopement drill for all staff on 01/05/2024 for both the 6 am and 6 pm shifts as well. She stated the in-service training included the facility elopement policy and additional information on reducing the elopement risk training for all staff. She stated the facility also conducts monthly elopement drills and provided the documentation for all drills to date. The facility has added the elopement policy to the new hire packet and added it to the agency LMF training packet. She reveals that they review elopement in the weekly meetings. She added that none of the current residents exhibit wandering or exit seeking habits. She stated the facility maintains an Elopement Book, this book contains profiles of 7 residents who are known to walk up and down the halls. It also contains profiles of all other residents in the facility who have current wandering assessments in a separate section. The DON provided copies of the in-service training sign in sheets. She was able to provide dates and times of the elopement drills. An Interview with the Administrator on 03/20/2024 at 04:30 PM revealed he personally changed the door codes. He stated the security provider came out and taught him how to change the codes. He stated that he personally changes the codes every so often. He stated at the time of the elopement all doors were in working order. He stated there were no orders or notification of non-working doors. He stated the resident must have gotten the code, but he cannot be sure how he got out of the facility. An observation was made inside the facility on 03/20/2024 at 4:45 pm. There are 6 doors leading to the outside that are accessible to the residents. These 6 doors all have magnetic 15 second delay locks. All of these doors were tested , these doors emit an alarm when the bars are touched. They will not open until the 15 seconds have elapsed, or a code is entered on the keypad. The doors are locked at all times. An observation was made on the exterior of the facility on 03/20/2024 at 7:00 pm, Observation of the surrounding area, parking lot, and streets adjacent to the facility. The facility sits off a residential street with a very large grassy area in front of it. There is a street leading to the facility 75 yards from the door. The street is older with some rough spots, there are cars parked on one side of the street. There is another residential street that crosses the street leading to the facility, it has cars parked on both sides. The main street is about one block from the facility, it is a four lane street. There is an apartment complex on the left side of the facility that extends to the residential street in front of the facility. There is a sidewalk in front of the apartment complex that extends to the four-lane road. Traffic is moderate during the day. Review of Facility Policy's Section Administration Subject Elopement- Exit Seeking Profile , date January 2023 reflected the following: .Procedures: 1. An Exit seeking profile will be completed for every resident identified as and wander risk. The Exit Seeking Profile will be reviewed annually for continued accuracy. 2. Obtain a current photograph of the resident and attach to the page. 3. Determine the significant physical characteristics of the resident and record Physical characteristics may include but are not limited to eye color, gait variances or physical deformity

Based on interview and record review the facility failed to ensure residents were free of significant medication errors for 1(Resident #1) of 7 residents reviewed for anticonvulsant medication. The facility failed to discontinue Resident #1's previous order for [MEDICATION(S)], an anticonvulsant medication, which included 200mg in the morning and 300mg at night prior to administering the updated and correct dose of [MEDICATION(S)] per physician's orders, which included 200mg every 12 hours. As a result, Resident #1 was receiving a total of 900 mg of [MEDICATION(S)] per day for 6 days and had to be transferred to the hospital due to having [CONDITION(S)] like activity and unsteady gait. An Immediate Jeopardy (IJ) was identified to have occurred from [DATE] to [DATE]. This was determined to be past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the survey. This failure placed residents who received anticonvulsant medications at risk of uncoordinated movement, weakness, disorientation, hallucinations, lethargic, coma, and death. Findings included: Record review of the Face Sheet revealed Resident #1 was a [AGE] year-old female, who initially admitted to the facility on [DATE] from an acute care hospital. Resident's advance directive was, Full Code: Use AED with CPR during sudden [CONDITION(S)]. Resident #1's active diagnoses were: [CONDITION(S)] and or seizures, down syndrome, which is a genetic disorder caused by the present of all or part of a third copy of chromosome 21; diabetes, seizures, abnormalities of gait and mobility, [CONDITION(S)], which is a group of eye conditions that damage the optic nerve; major depressive disorder, and convulsions, which is an episode in which you experience rigidity and uncontrolled muscle spasms along with altered consciousness. Record review of Resident#1's MDS, dated [DATE] revealed resident required some assistance with activities of daily living, such as bed mobility, transfer, dressing, walking, eating, toilet use and personal hygiene. Resident #1'S BIMS score or level of cognition was not reflected in the MDS assessment. Resident#1 did utilize a walker for mobility. Resident #1 received antidepressants once in the morning and once before bed; anticoagulant once per day, and opioids once per day. Resident #1 had a history of [CONDITION(S)] disorder or [CONDITION(S)]. Record review of Resident #1's Care Plan, undated reflected she had diagnosis of [CONDITION(S)] disorder and or [CONDITION(S)]. Based on care plan, Resident #1 had a history of seizures, which included, jerks, convulsive movements, trembling, duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after [CONDITION(S)] activity. Record review of Resident #1's physician orders dated [DATE] reflected the resident received [MEDICATION(S)] 200mg by mouth of one time per day related to [CONDITION(S)]. It was not discontinued until [DATE]. Record review of Resident #1's physician orders dated [DATE] reflected the resident received [MEDICATION(S)] 300mg of by mouth at bedtime for [CONDITION(S)]. It was not discontinued until [DATE]. Record review of Resident #1's physician orders dated [DATE] reflected the resident received [MEDICATION(S)] 200mg by mouth every 12 hours, which totaled 400 mg per day. It was not discontinued until [DATE]. Record review of Resident #1's MAR, dated for the month of [DATE] reflected, Resident #1 was receiving the following dosages: -200mg of [MEDICATION(S)] at 7:00 AM; -200mg of [MEDICATION(S)] at 9:00 AM; -300mg of [MEDICATION(S)] at 7:00PM and -200mg of [MEDICATION(S)] at 9:00PM; Resident #1 received a total of 900mg of [MEDICATION(S)] per day for the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. An interview on [DATE] at 12:27 PM with the Hospital Representative, revealed Resident #1 was transferred to the hospital on [DATE]. Hospital Representative stated Resident #1's [MEDICATION(S)] levels were extremely high and according to the lab results the hospital ordered, Resident #1's [MEDICATION(S)] level was 48.6. She stated the normal range for [MEDICATION(S)] levels was 10 to 20 mcg/ml. She stated she contacted poison control for further instruction on how to treat the patient. She stated the patient appeared to have been overmedicated and was admitted into the hospital. She stated Resident #1 stayed in the hospital for approximately, 6 days. An interview with the DON on [DATE] at 12:45 PM revealed, LVN A, initiated a new order of [MEDICATION(S)] for [DATE], which was 400mg per day before discontinuing the old order of [MEDICATION(S)] from [DATE], which was 500mg per day. She stated Med Aide E had given Resident #1 [MEDICATION(S)] based on the old order, which was dated for [DATE], which included 500mg per day while LVN A was giving Resident #1 [MEDICATION(S)] based on the new order, dated for [DATE], which included 400mg per day. The DON stated there was only supposed to be one order of [MEDICATION(S)] for the resident, which was the new order, dated for [DATE], which included 400mg per day or 200mg every 12 hours. DON stated the Nurse LVN A had given the resident the new order of [MEDICATION(S)] without Discontinuing the old order. She stated Resident #1 received a total of 900mg of [MEDICATION(S)] for 7 days instead of 400mg per day. DON stated LVN C and LVN H contacted her and stated the resident did not look well. She stated she was informed resident was having [CONDITION(S)] like activity and unsteady gait. She stated prior to the resident being transferred to the hospital, she told LVN C and LVN H to contact the physician or physician assistant to inform them of Resident 1's change of condition. DON stated prior to the resident being transferred to the hospital, she did not know the resident was overmedicated until she received a call from the hospital. She stated Resident #1 was transferred to the hospital per the PA's orders. She stated once she received a call from the hospital, she reviewed Resident #1's MAR and noticed the resident had several orders for [MEDICATION(S)] and stated she noticed LVN A did not discontinue the resident's previous orders of [MEDICATION(S)] prior to initiating the new order of [MEDICATION(S)]. DON stated the result of receiving too much [MEDICATION(S)] included: unsteady gait, weakness, lethargic, [CONDITION(S)] like activity and possible death. She stated during the time of the incident, she could not recall if LVN A had been trained on discontinuing medications and accepting new orders. An interview with Resident #1 on [DATE] at 1:25 PM revealed she was receiving her medication and stated she was feeling fine. She stated she could not recall what happened prior to going to the hospital or while she was in the hospital. She stated she was doing just fine now and the nurses and CNAs were nice to her and gave her what she needed. An interview with CNA F and CNA G on [DATE] from 3:57 PM to 4:15 PM revealed they did not notice any change of condition in Resident #1. CNA F and CNA G stated they never observed Resident #1 for signs and symptoms of being overly medicated or notice a change in the resident's condition during the time leading up to Resident #1 being transferred to the hospital. An interview with the PA on [DATE] at 2:00 PM, revealed, on [DATE] she had put in a new order of [MEDICATION(S)] for Resident #1. She stated Resident #1 was supposed to receive 200mg of [MEDICATION(S)] in the morning and 200mg at night or every 12 hours. She stated on the new order for the [MEDICATION(S)] medication, she ordered the old order of 200 mg in the morning and 300mg at night of [MEDICATION(S)] to be discontinued. She stated she sent the order via text on the facility's nurses cell phone at 6:16 PM on [DATE]. She stated the new meds should have started on ,d+[DATE] and the old meds should have been discontinued prior to starting the new order. She stated as soon as she orders medication, it should be effective immediately. PA stated the potential risk for receiving too much of [MEDICATION(S)] could result in seizures, [CONDITION(S)] like activity and possible death. PA stated she was contacted on [DATE] and was told the Resident #1 had an unsteady gait and was having [CONDITION(S)] like activity. She stated she informed the nursing staff to send patient out to the hospital to ensure Resident #1 was okay. She stated she was unaware of Resident #1 being over medicated with the medication of [MEDICATION(S)] prior to being sent out to the hospital. Record review of the nurses' phone revealed no picture of the new order. Record review revealed a physical copy and verbal order for [MEDICATION(S)] had been given to the nurses and a physical copy was provided by the facility, as well as PA had given a copy of the new [MEDICATION(S)] order of 400mg per day. Record review of the hospital's notes revealed, Patient is 54 yof admitted for observation for [MEDICATION(S)] toxicity. Per report, she was brought to hospital for possible [CONDITION(S)]. she is resident at [facility's name]. She has history of seizures, and per report, [MEDICATION(S)] dose was recently changed and there is concern that she has been receiving double dosage of [MEDICATION(S)] (both old and new dosage). Hospital notes indicated upon admission, Resident #1's lab results for [MEDICATION(S)] levels was 48.6. An interview with LVN C on [DATE] at 3:24 PM revealed, she worked on the day of [DATE], the day Resident #1 was transferred to the hospital. LVN C stated Resident #1 had [CONDITION(S)] like activity and could not stand. She stated the resident was in bed and did not look well. She stated the resident was not running a fever. She stated Resident #1 appeared lethargic, which meant sluggish. She stated Resident #1 did not appear to be her normal self. She stated, she asked another nurse (LVN H) to check on Resident #1 with her. An interview with LVN H on [DATE] at 3:38 PM revealed, she had worked the day, Resident #1 was sent out to the hospital. She stated she was not her nurse on that particular day. She stated her colleague (LVN C) asked her to come and look at Resident #1, Because she was not acting according to her baseline. LVN H stated LVN C wanted to ensure the resident was okay. LVN H stated during her observation of Resident #1, she noticed the resident looked lethargic. She stated she and LVN C checked Resident #1's blood pressure and it was determined Resident #1's blood pressure was low. She stated Resident #1 was drowsy and was having [CONDITION(S)] like activity but would not call it an actual [CONDITION(S)]. LVN H stated they called 911 and stated the patient was sent out. She stated the PA and DON were notified. An interview with LVN A on [DATE] at 4:41 PM revealed, she was recently informed, when she received a new order from a doctor or a PA, she was supposed to discontinue the previous order of the same medication. LVN A did not give a specific date as to when she was informed. She stated at the time, she did not know the mistake she made. She stated she was off on the day Resident #1 was sent out to the hospital. She stated, But now I know to discontinue any previous doctor or PA's orders if it is involving the same medication prior to creating the new order in the resident's chart. She stated prior to the incident involving Resident #1, she did not know she was supposed to discontinue an old order after receiving a new order from the physician or PA. She stated she never received training on accepting and discontinuing orders. LVN A stated she recently learned, giving a resident too much [MEDICATION(S)] could result in a resident, such as Resident #1 being admitted into the hospital. She stated too much of [MEDICATION(S)] could result in seizures, weakness, lethargic and possible death. LVN A stated she did not recall Resident #1 having any adverse effect. A telephone interview on [DATE] at 4:20 PM with Med Aid E was attempted but was unsuccessful. The Administrator was notified on [DATE] at 5:14 PM of the past noncompliance IJ situation had been identified due to the above failures. It was determined theses failures placed Resident #1 in an IJ situation on [DATE]. The facility implemented the following interventions: During interviews with 4 nurses and the DON (LVN A, LVN B, LVN C, and RN D), across various shifts from [DATE] at 12:45 PM to [DATE] at 3:38 PM revealed all staff members reported being recently in-serviced on medication administration, transcribing physician orders, reviewing the MAR prior to administering medication, ensuring resident are receiving the right medications through the correct route and in a timely manner. It was also stated they were in-serviced on discontinuing medications prior to initiating a new order, when and if the physician says so. During an interview with 10 nursing staff (LVN A, LVN B, LVN C, RN D, CNA F, CNA G, DON, ADON H, ADON I, and the Administrator) from [DATE] at 12:45 PM to [DATE] at 4:50 PM revealed the nursing staff were in-serviced on the signs and symptoms of a resident being overmedicated. Each of the staff members was aware of what steps to take in situations such as a resident being overmedicated or venturing out of their baseline or had a change in condition. The staff members were aware of who to report to if a resident is showing signs of lethargic, unsteady gait, [CONDITION(S)] like activity, or medication error. No current concerns were noted as a result of these interviews. An interview on [DATE] at 1:45 PM with the DON revealed she had reviewed all residents on high-risk medications, re-educated nurses on transcribing medication orders, as well as re-educated nurses on the 12 drug rights. She stated she watched medication administration to ensure it was given correctly to residents. The DON stated she educated nurses on medication errors and to report any errors immediately. She stated she performed cart audits to match medications with administration. The DON stated she designated a nurse manager to review medication orders daily and discussed orders daily during their daily meetings. The DON stated the daily monitoring of medication administration orders included: new, completed and discontinued orders. A telephone interview on [DATE] at 4:27 PM with the nurse manager was attempted but was unsuccessful. Record review of the Daily Education and Monitoring from [DATE] to current [DATE] reflected, how medication error occurred, discussed new orders, medication administration monitoring, discharged orders and monitored written orders by nurses. It reflects labs reviews and the importance of follow up, re-educated on medication administration, offered more training/Practice by allowing nurse to transcribe all orders written by PA. Record review of in-services, which were completed from [DATE] to [DATE] covered the following: Drug Rights: right drug, right patient, right dose, right time and frequency; right documentation, right history and assessment; right drug approach, right to refuse, right drug interaction and evaluation, right education and information; and right preparation. In-servicing also included transcribing orders by transcribing medication orders accurately per physician. In-service documents reflected transcriber of medication must follow certain rules to ensure accuracy of orders for possible duplicates and ensure medication be administered upon order entry. Medication pass: Keep cart locked when not in use. Hand wash/ sanitize before and after each med administration, date all fluids and supplements, verify medication to order prior to administration and sign the MAR after each medication administered, report medication errors immediately to DON. An interview with the Administrator on [DATE] at 4:50 PM revealed, he expected all nurses to follow the doctor's orders, follow the MAR and signs off on the MAR. He stated to prevent the incident from occurring again, he and the DON would continue to monitor nurses while they conducted medication administration and to review the MAR of each resident to ensure they received the correct medication, the correct dose and the correct route for the medication. The Administrator stated he would work closely with the DON and the Medical Director to ensure the transcription of the medication orders were followed and medications are administered as ordered. The Administrator stated the risk of given the wrong medication or dosage to a resident could potentially result from nothing to death. The Administrator stated the nursing facility received a past non-compliance IJ because, essentially a resident received a double dose of the medication [MEDICATION(S)] for 7 days based on a medication error and transcription error made by a nurse. Record review of 13 residents' MAR and the significant medications they were receiving. There were no discrepancies with the medication, route, dosage or the time the medication was given. Record review of the facility's Nursing Policy and Procedure for Medication Error Reporting and Follow up, dated [DATE], reflected, It is the policy of the Facility to ensure Medication Error are reported timely with appropriate follow up. Procedure: 1. Medication errors must be reported to the resident's attending physician. A. Errors may be report to the physician by fax only for omission with non-adverse reaction potential. B. Errors may be reported to the physician by fax and follow up phone call for omissions with adverse reaction potential. C. Error with adverse drug reaction and adverse clinical consequences must be reported the physician by telephone call. 2. The Nursing Department must immediately implement and follow the physician's orders. 3. A detailed account of the incident must be recorded on an incident report. (The incident report is an internal facility document and is used for Quality monitoring). 4. Relevant information about follow up of the resident should be recorded in the medical record which may include: a. Any adverse effects noted; b. Other information as necessary or appropriate . The Administrator, The Director of Nursing and Pharmacist must be informed of all medication errors and adverse reactions.

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for one (Resident #1) of 7 residents reviewed for medication administration. The facility failed to discontinue Resident #1's previous order for [MEDICATION(S)], an anticonvulsant medication, which included 200mg in the morning and 300mg at night prior to administering the updated and correct dose of [MEDICATION(S)] per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result, Resident #1 was receiving a total of 900 mg of [MEDICATION(S)] per day for 6 days and had to be transferred to the hospital due to having [CONDITION(S)] like activity and unsteady gait. An Immediate Jeopardy (IJ) was identified to have occurred from [DATE] to [DATE]. This was determined to be past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the survey. This failure placed residents who received anticonvulsant medications at risk of uncoordinated movement, weakness, disorientation, hallucinations, lethargic, coma, and death. Findings included: Record review of the Face Sheet revealed Resident #1 was a [AGE] year-old female, who initially admitted to the facility on [DATE] from an acute care hospital. Resident's advance directive was, Full Code: Use AED with CPR during sudden [CONDITION(S)]. Resident #1's active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident#1's MDS, dated [DATE] revealed resident required some assistance with activities of daily living, such as bed mobility, transfer, dressing, walking, eating, toilet use and personal hygiene. Resident #1'S BIMS score or level of cognition was not reflected in the MDS assessment. Resident#1 did utilize a walker for mobility. Resident #1 received antidepressants once in the morning and once before bed; anticoagulant once per day, and opioids once per day. Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Care Plan, undated reflected she had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Based on care plan, Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It was not discontinued until [DATE]. Record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It was not discontinued until [DATE]. Record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It was not discontinued until [DATE]. Record review of Resident #1's MAR, dated for the month of [DATE] reflected, Resident #1 was receiving the following dosages: -200mg of [MEDICATION(S)] at 7:00 AM; -200mg of [MEDICATION(S)] at 9:00 AM; -300mg of [MEDICATION(S)] at 7:00PM and -200mg of [MEDICATION(S)] at 9:00PM; Resident #1 received a total of 900mg of [MEDICATION(S)] per day for the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. An interview on [DATE] at 12:27 PM with the Hospital Representative, revealed Resident #1 was transferred to the hospital on [DATE]. Hospital Representative stated Resident #1's [MEDICATION(S)] levels were extremely high and according to the lab results the hospital ordered, Resident #1's [MEDICATION(S)] level was 48.6. She stated the normal range for [MEDICATION(S)] levels was 10 to 20 mcg/ml. She stated she contacted poison control for further instruction on how to treat the patient. She stated the patient appeared to have been overmedicated and was admitted into the hospital. She stated Resident #1 stayed in the hospital for approximately, 6 days. An interview with the DON on [DATE] at 12:45 PM revealed, LVN A, initiated a new order of [MEDICATION(S)] for [DATE], which was 400mg per day before discontinuing the old order of [MEDICATION(S)] from [DATE], which was 500mg per day. She stated Med Aide E had given Resident #1 [MEDICATION(S)] based on the old order, which was dated for [DATE], which included 500mg per day while LVN A was giving Resident #1 [MEDICATION(S)] based on the new order, dated for [DATE], which included 400mg per day. The DON stated there was only supposed to be one order of [MEDICATION(S)] for the resident, which was the new order, dated for [DATE], which included 400mg per day or 200mg every 12 hours. DON stated the Nurse LVN A had given the resident the new order of [MEDICATION(S)] without Discontinuing the old order. She stated Resident #1 received a total of 900mg of [MEDICATION(S)] for 7 days instead of 400mg per day. DON stated LVN C and LVN H contacted her and stated the resident did not look well. She stated she was informed resident was having [CONDITION(S)] like activity and unsteady gait. She stated prior to the resident being transferred to the hospital, she told LVN C and LVN H to contact the physician or physician assistant to inform them of Resident 1's change of condition. DON stated prior to the resident being transferred to the hospital, she did not know the resident was overmedicated until she received a call from the hospital. She stated Resident #1 was transferred to the hospital per the PA's orders. She stated once she received a call from the hospital, she reviewed Resident #1's MAR and noticed the resident had several orders for [MEDICATION(S)] and stated she noticed LVN A did not discontinue the resident's previous orders of [MEDICATION(S)] prior to initiating the new order of [MEDICATION(S)]. DON stated the result of receiving too much [MEDICATION(S)] included: unsteady gait, weakness, lethargic, [CONDITION(S)] like activity and possible death. She stated during the time of the incident, she could not recall if LVN A had been trained on discontinuing medications and accepting new orders. An interview with Resident #1 on [DATE] at 1:25 PM revealed she was receiving her medication and stated she was feeling fine. She stated she could not recall what happened prior to going to the hospital or while she was in the hospital. She stated she was doing just fine now and the nurses and CNAs were nice to her and gave her what she needed. An interview with CNA F and CNA G on [DATE] from 3:57 PM to 4:15 PM revealed they did not notice any change of condition in Resident #1. CNA F and CNA G stated they never observed Resident #1 for signs and symptoms of being overly medicated or notice a change in the resident's condition during the time leading up to Resident #1 being transferred to the hospital. An interview with the PA on [DATE] at 2:00 PM, revealed, on [DATE] she had put in a new order of [MEDICATION(S)] for Resident #1. She stated Resident #1 was supposed to receive 200mg of [MEDICATION(S)] in the morning and 200mg at night or every 12 hours. She stated on the new order for the [MEDICATION(S)] medication, she ordered the old order of 200 mg in the morning and 300mg at night of [MEDICATION(S)] to be discontinued. She stated she sent the order via text on the facility's nurses cell phone at 6:16 PM on [DATE]. She stated the new meds should have started on ,d+[DATE] and the old meds should have been discontinued prior to starting the new order. She stated as soon as she orders medication, it should be effective immediately. PA stated the potential risk for receiving too much of [MEDICATION(S)] could result in seizures, [CONDITION(S)] like activity and possible death. PA stated she was contacted on [DATE] and was told the Resident #1 had an unsteady gait and was having [CONDITION(S)] like activity. She stated she informed the nursing staff to send patient out to the hospital to ensure Resident #1 was okay. She stated she was unaware of Resident #1 being over medicated with the medication of [MEDICATION(S)] prior to being sent out to the hospital. Record review of the nurses' phone revealed no picture of the new order. Record review revealed a physical copy and verbal order for [MEDICATION(S)] had been given to the nurses and a physical copy was provided by the facility, as well as PA had given a copy of the new [MEDICATION(S)] order of 400mg per day. Record review of the hospital's notes revealed, Patient is 54 yof admitted for observation for [MEDICATION(S)] toxicity. Per report, she was brought to hospital for possible [CONDITION(S)]. she is resident at [facility's name]. She has history of seizures, and per report, [MEDICATION(S)] dose was recently changed and there is concern that she has been receiving double dosage of [MEDICATION(S)] (both old and new dosage). Hospital notes indicated upon admission, Resident #1's lab results for [MEDICATION(S)] levels was 48.6. An interview with LVN C on [DATE] at 3:24 PM revealed, she worked on the day of [DATE], the day Resident #1 was transferred to the hospital. LVN C stated Resident #1 had [CONDITION(S)] like activity and could not stand. She stated the resident was in bed and did not look well. She stated the resident was not running a fever. She stated Resident #1 appeared lethargic, which meant sluggish. She stated Resident #1 did not appear to be her normal self. She stated, she asked another nurse (LVN H) to check on Resident #1 with her. An interview with LVN H on [DATE] at 3:38 PM revealed, she had worked the day, Resident #1 was sent out to the hospital. She stated she was not her nurse on that particular day. She stated her colleague (LVN C) asked her to come and look at Resident #1, Because she was not acting according to her baseline. LVN H stated LVN C wanted to ensure the resident was okay. LVN H stated during her observation of Resident #1, she noticed the resident looked lethargic. She stated she and LVN C checked Resident #1's blood pressure and it was determined Resident #1's blood pressure was low. She stated Resident #1 was drowsy and was having [CONDITION(S)] like activity but would not call it an actual [CONDITION(S)]. LVN H stated they called 911 and stated the patient was sent out. She stated the PA and DON were notified. An interview with LVN A on [DATE] at 4:41 PM revealed, she was recently informed, when she received a new order from a doctor or a PA, she was supposed to discontinue the previous order of the same medication. LVN A did not give a specific date as to when she was informed. She stated at the time, she did not know the mistake she made. She stated she was off on the day Resident #1 was sent out to the hospital. She stated, But now I know to discontinue any previous doctor or PA's orders if it is involving the same medication prior to creating the new order in the resident's chart. She stated prior to the incident involving Resident #1, she did not know she was supposed to discontinue an old order after receiving a new order from the physician or PA. She stated she never received training on accepting and discontinuing orders. LVN A stated she recently learned, giving a resident too much [MEDICATION(S)] could result in a resident, such as Resident #1 being admitted into the hospital. She stated too much of [MEDICATION(S)] could result in seizures, weakness, lethargic and possible death. LVN A stated she did not recall Resident #1 having any adverse effect. A telephone interview on [DATE] at 4:20 PM with Med Aid E was attempted but was unsuccessful. The Administrator was notified on [DATE] at 5:14 PM of the past noncompliance IJ situation had been identified due to the above failures. It was determined theses failures placed Resident #1 in an IJ situation on [DATE]. The facility implemented the following interventions: During interviews with 4 nurses and the DON (LVN A, LVN B, LVN C, and RN D), across various shifts from [DATE] at 12:45 PM to [DATE] at 3:38 PM revealed all staff members reported being recently in-serviced on medication administration, transcribing physician orders, reviewing the MAR prior to administering medication, ensuring resident are receiving the right medications through the correct route and in a timely manner. It was also stated they were in-serviced on discontinuing medications prior to initiating a new order, when and if the physician says so. During an interview with 10 nursing staff (LVN A, LVN B, LVN C, RN D, CNA F, CNA G, DON, ADON H, ADON I, and the Administrator) from [DATE] at 12:45 PM to [DATE] at 4:50 PM revealed the nursing staff were in-serviced on the signs and symptoms of a resident being overmedicated. Each of the staff members was aware of what steps to take in situations such as a resident being overmedicated or venturing out of their baseline or had a change in condition. The staff members were aware of who to report to if a resident is showing signs of lethargic, unsteady gait, [CONDITION(S)] like activity, or medication error. No current concerns were noted as a result of these interviews. An interview on [DATE] at 1:45 PM with the DON revealed she had reviewed all residents on high-risk medications, re-educated nurses on transcribing medication orders, as well as re-educated nurses on the 12 drug rights. She stated she watched medication administration to ensure it was given correctly to residents. The DON stated she educated nurses on medication errors and to report any errors immediately. She stated she performed cart audits to match medications with administration. The DON stated she designated a nurse manager to review medication orders daily and discussed orders daily during their daily meetings. The DON stated the daily monitoring of medication administration orders included: new, completed and discontinued orders. A telephone interview on [DATE] at 4:27 PM with the nurse manager was attempted but was unsuccessful. Record review of the Daily Education and Monitoring from [DATE] to current [DATE] reflected, how medication error occurred, discussed new orders, medication administration monitoring, discharged orders and monitored written orders by nurses. It reflects labs reviews and the importance of follow up, re-educated on medication administration, offered more training/Practice by allowing nurse to transcribe all orders written by PA. Record review of in-services, which were completed from [DATE] to [DATE] covered the following: Drug Rights: right drug, right patient, right dose, right time and frequency; right documentation, right history and assessment; right drug approach, right to refuse, right drug interaction and evaluation, right education and information; and right preparation. In-servicing also included transcribing orders by transcribing medication orders accurately per physician. In-service documents reflected transcriber of medication must follow certain rules to ensure accuracy of orders for possible duplicates and ensure medication be administered upon order entry. Medication pass: Keep cart locked when not in use. Hand wash/ sanitize before and after each med administration, date all fluids and supplements, verify medication to order prior to administration and sign the MAR after each medication administered, report medication errors immediately to DON. An interview with the Administrator on [DATE] at 4:50 PM revealed, he expected all nurses to follow the doctor's orders, follow the MAR and signs off on the MAR. He stated to prevent the incident from occurring again, he and the DON would continue to monitor nurses while they conducted medication administration and to review the MAR of each resident to ensure they received the correct medication, the correct dose and the correct route for the medication. The Administrator stated he would work closely with the DON and the Medical Director to ensure the transcription of the medication orders were followed and medications are administered as ordered. The Administrator stated the risk of given the wrong medication or dosage to a resident could potentially result from nothing to death. The Administrator stated the nursing facility received a past non-compliance IJ because, essentially a resident received a double dose of the medication [MEDICATION(S)] for 7 days based on a medication error and transcription error made by a nurse. Record review of 13 residents' MAR and the significant medications they were receiving. There were no discrepancies with the medication, route, dosage or the time the medication was given. Record review of the facility's Nursing Policy and Procedure for Medication Error Reporting and Follow up, dated [DATE], reflected, It is the policy of the Facility to ensure Medication Error are reported timely with appropriate follow up. Procedure: 1. Medication errors must be reported to the resident's attending physician. A. Errors may be report to the physician by fax only for omission with non-adverse reaction potential. B. Errors may be reported to the physician by fax and follow up phone call for omissions with adverse reaction potential. C. Error with adverse drug reaction and adverse clinical consequences must be reported the physician by telephone call. 2. The Nursing Department must immediately implement and follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A detailed account of the incident must be recorded on an incident report. (The incident report is an internal facility document and is used for Quality monitoring). 4. Relevant information about follow up of the resident should be recorded in the medical record which may include: a. Any adverse effects noted; b. Other information as necessary or appropriate . The Administrator, The Director of Nursing and Pharmacist must be informed of all medication errors and adverse reactions.

Based on observation, interview and record review, it was determined the facility failed to ensure two (Resident #5 and Resident # 11) of nine residents reviewed for falls received adequate supervision to prevent accidents. 1. The facility failed to develop and implement interventions to decrease the potential for falls. Resident #5 experienced falls and a fractured wrist while attempting to transfer to the toilet without assistance. 2. The facility failed to develop and implement interventions to decrease fall and the potential for falls. Resident #11 experienced falls and a fractured hip while up in wheelchair. These failures had the potential to affect the 52 residents who required staff assistance with transfers by placing them at risk for injuries including fractures, pain and decreased quality of life. Findings included: 1. Resident #5's most recent Minimum Data Set assessment was dated 02/16/15. The Minimum Data Set assessment reflected the resident was readmitted to the facility on [DATE] and [DIAGNOSES REDACTED]. The Minimum Data Set Assessment further reflected the resident's Brief Interview for Mental Status score was 2 (severe impairment). The Minimum Data Set assessment reflected Resident #5 was frequently incontinent of bowel/bladder and required extensive assistance of two persons to transfer. Additionally, the Minimum Data Set assessment reflected no toileting program had been attempted and no toileting program was currently being used to manage the resident's incontinence. Review of Resident #5's care plan related to falls revealed it had been initiated 07/19/13 and had a current revision date of 12/12/14. The intervention added 12/12/14 was to monitor the resident for increased weakness while she was receiving an antibiotic to treat a urinary tract infection. The intervention to respond promptly was listed on the care plan and dated initiated 11/24/14. An observation of Resident #5 during initial round with Licensed Vocational Nurse (LVN) A on 02/25/15 at 10:25 a.m. revealed the resident was sitting in a wheelchair in her room with a brace on her left wrist/arm. The nurse identified the resident as being incontinent of bowel/bladder and requiring staff assistance for transfers. The nurse stated the resident had a history of [REDACTED]. The nurse further stated the resident did not speak English and the facility's interpreter assisted with communication. LVN A further stated no resident on Hall 200 where Resident #5 resided was participating in an individualized toileting program. Resident #5's fall risk assessments dated 12/06/14, 12/14/14, 12/17/14, 01/20/15 and 01/25/15 reflected the resident was a high risk for falls. Fall risk assessments dated 01/03/15 and 01/04/15 reflected Resident #5 was a medium risk for falls. The fall risk assessment dated [DATE] reflected the resident was a high risk for falls. Review of the facility's incident tracking log for the past three months revealed Resident #5 had sustained nine falls. The most recent fall was 02/13/15 and resulted in a fracture of the resident's left wrist. An interview with the facility's Interpreter/Liaison, Staff B on 02/26/15 at 9:10 a.m. revealed he assisted staff to communicate with the facility's non-English speaking population. He stated he knew Resident #5 and the resident had falls attempting to go the bathroom. He further stated the resident's mind was "mixed up" and she (the resident) did not remember to ask for help to transfer and to use the bathroom. During an interview with the Director of Nurses (DON) on 02/26/15 at 9:50 a.m. she stated Resident #5 would not use the call light to call for assistance with transfers. Review of Resident #5's incident reports and care plan with the DON, on 02/26/15 at 10:15 a.m. revealed the following: (1) On 11/21/14 at 7:12 a.m. Resident #5 was observed on the floor of her room underneath her wheelchair. The report reflected the resident sustained [REDACTED]. The report did not reflect if the resident fell from the bed or the wheelchair. The report reflected the resident was unable to provide any information related to the fall. There was no documentation of any investigation in an effort to determine the cause of the fall or to assist in planning/implementing interventions to prevent further falls. The DON stated the intervention was implemented to address the resident's fall on 11/21/14 was to respond promptly to the resident's call light. The DON ws reminded she had stated the resident did not use the call light. When queried if she thought the intervention was appropriate for Resident #5 the DON replied "No." The DON stated no other interventions had been implemented to address the fall on 11/21/14. (2) On 12/06/14 at 9:57 a.m. Resident #5 was found on the floor of her room on the floor mat. The resident was assessed with [REDACTED]. There was no documentation of any investigation in an effort to determine the cause of the fall or to assist in planning/implementing interventions to prevent further falls. The DON stated there was no evidence in the resident's clinical record including the care plan of any interventions implemented to address Resident #5's fall on 12/06/14. The DON stated the only revision in the care plan was an update on 12/12/14 to reflect an antibiotic had been initiated to treat a urinary tract infection. The DON further stated the resident's fall on 12/06/14 "Probably didn't get looked at" because she (the DON) had been in the hospital in December 2014. (3) On 12/14/14 at 12:06 a.m. Resident #5 was found lying on the floor of the shower room. The resident was assessed with [REDACTED]. There was no documentation of any investigation in an effort to determine the cause of the fall or to assist in planning/implementing interventions to prevent further falls. The DON stated she was not aware of the fall on 12/14/14 and was unable to verbalize what if any interventions had been implemented to address the fall. The care plan did not reflect any review or revision to address the fall on 12/14/14. (4) On 12/17/14 at 7:30 p.m. Resident #5 was found sitting on the floor next to her wheelchair on the floor mat in her room. The resident was assessed with [REDACTED]. There was no documentation of any investigation in an effort to determine the cause of the fall or to assist in planning/implementing interventions to prevent further falls. The DON stated there was no evidence the resident's care plan had been reviewed and/or revised to address the fall on 12/17/14. The DON was unable to provide any information about what, if any intervention had been implemented to address the fall. (5) On 01/03/15 at 3:55 a.m. Resident #5 was found lying on the floor of her room next to her wheelchair. The resident was assessed with [REDACTED]. There was no documentation of any investigation in an effort to determine the cause of the fall or to assist in planning/implementing interventions to prevent further falls. There was no review or revision of the resident's care plan to address the fall on 01/03/15. (6) On 01/04/15 at 2:30 a.m. Resident #5 was found on the floor of the bathroom. The resident sustained [REDACTED]. There was no documentation of any investigation in an effort to determine the cause of the fall or to assist in planning/implementing interventions to prevent further falls. The DON stated Resident #5 went out to the hospital on [DATE] after the fall for evaluation and was admitted due to congestive heart failure exacerbation. She confirmed there was no revision of the resident's care plan to address the fall on 01/03/15. Additionally, the DON stated the resident was readmitted on [DATE]. (7) On 01/20/15 at 1:53 p.m. Resident #5 was found sitting on the floor mat and halfway under the wheelchair in her room. The resident was assessed with [REDACTED]. There was no documentation of any investigation in an effort to determine the cause of the fall or to assist in planning/implementing interventions to prevent further falls. There was no documented evidence the resident's care plan had been reviewed and/or revised to address the fall on 01/20/15. (8) On 01/25/15 at 9:21 a.m. Resident #5 was found sitting on the foot of her wheelchair in the bathroom. The resident was assessed with [REDACTED]. There was no documentation of any investigation in an effort to assist in planning/implementing interventions to prevent further falls. There was no review or revision of the resident's care plan to address the fall on 01/25/15. The DON was unable to provide any information about what if any intervention had been implemented to address the fall. (9) On 02/13/15 at 10:30 p.m. Resident #5 was found on the floor beside the bathroom door. The report did not reflect if the resident fell while transferring from the bed or the wheelchair. The DON stated the resident's care plan had not been updated but she was able to recall Resident #5 was moved on 02/14/15 to a room closer to the nurse's station to address the fall on 02/13/15. There was no documentation of any investigation in an effort to determine the cause of the fall or to assist in planning/implementing interventions to prevent further falls. The DON stated according to the most recent bowel/bladder assessment dated [DATE] Resident #5 was a good candidate for a toileting program. According to the DON a toileting program should have been initiated for the resident. During an interview with the DON on 02/26/15 at 10:30 a.m. she stated there should be investigations after a fall. The DON stated there were no investigations attached to or documented on the incident reports. The DON was queried during this interview about why there were no investigations related to the falls or interventions to address the residents falls. The DON further stated she did not know what happened but would go "investigate." No additional information was provided about why interventions had not been implemented and/or modified to in an effort to prevent the resident from further falls. In an interview with the Director of Rehab (DOR) on 02/26/15 at 11:05 a.m. he revealed the resident was not safe to transfer alone. He stated "We have made recommendations to the resident (Resident #5) to ask for help." According to the DOR the resident began receiving therapy services after she returned from the hospital on [DATE]. The DOR stated resident falls were discussed in the morning meetings. He further stated no specific interventions had been discussed as a means to prevent further falls for Resident #5. The DOR stated the Therapy Department's involvement was to evaluate for the potential to receive therapy services. An attempt was made to interview Resident #5 with the assistance of the facility's interpreter Staff B, on 02/26/15 at 1:30 p.m. The resident was sitting in her room in a wheelchair with a brace on her left arm/wrist. When quereid how the fracture of her wrist had occurred, the resident stated she did not know. When queried if she used the call bell, the resident stated she never used it and did not know how to use it. The call bell string was shown to the resident and the resident was queried about her knowledge of its use. The resident stated the string was used to turn the lights on in the room. During an interview on 02/27/15 at 10:50 a.m. the DON was queried if she had considered possible modifications to Resident #5's wheelchair such as tilted or dropped seats. The DON stated she had not thought about it. On 02/26/15 at 3:05 p.m. the DON provided notes and identified them as additional information and part of Resident #5's incidents. When queried if the additional notes contained an investigation of the resident's falls, she replied "No." An observation on 2/27/2015 at 11:00 AM Resident #11 was sitting at the nurse's station in a reclining Broda chair. No tab alarm was noted on the chair for the resident if she made an attempt to get out of the chair. The Minimum Data Set (MDS) assassment dated 1/20/15 reflected Resident #11 an [AGE] years old female who was re-admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Further review of the Nursing Progress Notes revealed Resident # 11 continued to have falls on the following dates:11/15/14 at 5:42 AM, 11/19/14, 11/24/14, 12/6/14, 12/15/14, and 1/20/15. Nursing Progress Notes dated 10/19/14 at 2:41 PM reflected Resident # 11 complained of right upper leg pain. An x-ray was obtained and noted to be suspicious for fracture of right femur. Resident #11 was sent to the hospital with a possible hip fracture. 1. The Incident Report dated 10/16/14 at 3:49 PM and revised on 10/20/14 at 6:23 PM reflected Resident #11 was found on the floor by the nurse's station. Resident #11 was assessed and no injuries were found. Predisposing Physiological Factors had the resident was confused, incontinent, and impaired memory. Notes on the Incident report revealed, Resident remains at hospital- Fracture Femur. The Fall Risk Evaluation done on 10/16/14 reflected Resident #11 was a high risk for falls. There was no documentation of any investigation in an effort to determine the cause of the fall or to assist in planning/implementing interventions at the time of the fall to prevent further falls. The computerized care plan Created on 5/28/14 and revised on 10/24/14 reflected the intervention was to redirect resident away from unsupervised areas. 2. The Incident Report dated 11/15/14 at 5:27 AM and revised on 11/21/14 at 3:08 PM reflected the following information: Resident #11 was found lying on bed mat the floor in resident's room. Resident #11 was assessed and noted a skin tear to the top of right forearm. Notes reflected remains on low bed with floor mat. The resident was unable to give details of fall. The report did not reflect if the resident was transferring or rolled out of the bed. There was no documentation of any investigation in an effort to determine the cause of the fall or to assist in planning/implementing interventions at the time of the fall to prevent further falls. 3. Review of an Incident Report dated 11/19/14 at 6:32 AM and revised on 11/21/14 at 3:36 PM. revealed Resident #11 was found on the floor crying lying on her left side. The report reflected the resident had been up in the wheelchair. Resident #11 was assessed for injuries and had a skin tear to the L(left) elbow and L posterior wrist. The report did not reflect if the resident was attempting to transfer. There was no documentation of any investigation in an effort to determine the cause of the fall or to assist in planning/implementing new or different interventions to prevent further falls. 4. Review of an Incident Report dated 11/24/14 at 12:32 AM and revised on 12/01/14 at 12:36 PM. revealed Resident #11 was found on the floor crying lying on her left side but no injuries were noted. Review of the Fall Risk Evaluation done on 11/24/14 revealed Resident #11 was a high risk for falls. There was no documentation of any investigation in an effort to determine the cause of the fall or to assist in planning/implementing new or different interventions to prevent further falls. 5. Review of an Incident Report dated 12/6/14 revealed Resident #11 was sitting on the floor mat leaning against the bed. Resident #11 was assessed for injuries and none were noted. There was no documentation of any investigation in an effort to determine the cause of the fall or to assist in planning/implementing new or different interventions to prevent further falls. 6. Review of Incident Report dated 12/15/14 at 7:39 PM and revised 12/18/2014 at 4:32 PM revealed Resident #11 was on the floor lying on her left side. Resident #11 was assessed and no injuries were noted at that time and she was assisted into the wheelchair. There was no documentation of any investigation in an effort to determine the cause of the fall or to assist in planning/implementing new or different interventions at the time of the fall to prevent further falls. (7) Review of the Incident Report dated 1/20/15 revealed Resident #11 was found on the floor mat at 3:00 a.m. There were no apparent injuries according to the report. The Fall Risk Evaluation done on 01/20/15 reflected Resident #11 continued to be a high risk for falls. There was no documentation of any investigation in an effort to determine the cause of the fall or to assist in planning/implementing new or different interventions at the time of the fall to prevent further falls. Review of the computerized care plan, revealed the problem of falls was addressed. The date of the care plan being initiated was 11/6/14 with revision on 12/18/14. There were no new interventions noted at the time of the falls for falls which occurred on 11/15/14, 11/19/14, 11/24/2014, 12/6/14, 12/15/14, and 1/20/15. On 2/27/15 at 10:45 AM the DON was interviewed regarding the multiple falls and the fracture which occurred on 10/19/15 on Resident #11. The DON proceeded to give history of the resident would come to the nurse's station and pull herself up in a standing position. She revealed this was what occurred on 10/16/14 and she felt this was when the fractured hip occurred. The DON was queried about interventions for Resident #11. The DON revealed Resident #11 would scoot off the bed and her legs were extended. The surveyor asked the DON if she had tried a drop seat, wedges, or bolsters in the wheelchair, or a scoop mattress for the low bed, and she stated she had not and she thought they were restraints. She revealed she was going to get a "noodle" (foam tubes used in the water to float on) and put under the mattress to help keep the resident from coming out of the bed. When asked about a bed alarm she stated they took the alarm off because it was not working. On 12/18/2014 there was a mention of a tab alarm but it was not noted on Resident #11 when the resident was observed sitting up in the broda chair. A P/P entitled "Falls" with a revision date of May/2007 provided by the Administrator on 02/27/15 as current. The P/P contained no information related to implementing interventions to reduce the risk of falls, reviewing and/or updating the resident's care plan in response to a fall. A P/P entitled "Accident Intervention" with a revision date of May 2007 provided by the Administrator as current. The policy reflected "That the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents, to ensure the facility provided an environment free from hazards over which the facility had control and provide appropriate supervision to each resident to prevent avoidable accidents."This included systems and processes designed to: Identify hazards and risks; Evaluate and analyze hazards and risks; Implement interventions to reduce hazards and risks; and Monitor for effectiveness and modify approaches as indicated. According to the P/P all incidents and accidents should be investigated and documented. The CMS-672 (Resident Census and Conditions of Residents), dated and signed by the Director of Nurses on 02/25/15, reflected 10 residents were totally dependent on staff for transfers, and 42 residents required the assistance of one or two staff for transfers.

Based on observation, interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit neglect of residents for one (Resident #1) of 14 residents reviewed for accidents. 1. Driver B failed to properly secure Resident #1's wheelchair in the van before transporting the resident to [MEDICAL TREATMENT] on 02/19/14. While being transported the straps securing Resident #1's wheelchair in place came loose and Resident #1 fell backwards in his wheelchair against the rear door of the facility van. Driver B removed Resident #1 from the wheelchair and laid him on the floor of the van, and then transported the resident to the local hospital emergency room . Resident #1 sustained a spinal injury causing paralysis to his legs. 2. The facility failed to properly train facility staff on how to secure residents' wheelchair in the van before transporting residents. An Immediate Jeopardy (IJ) was identified on 03/04/14. While the IJ was removed on 03/05/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "pattern" because the facility was still implementing the Plan of Removal. These failures could affect the 13 residents in wheelchairs by placing them at risk for injury while being transported in the facility van by Driver B, which could result in resident injuries, falls, other serious mental/physical harm and/or death. Findings included: Resident #1's MDS assessment, dated 02/01/14, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE], and his [DIAGNOSES REDACTED]. He was 65 inches tall and weighed 242 pounds. The MDS assessment further reflected Resident #1 was able to be understood by others, was not cognitively impaired, and walked in his room and walked in the corridor with the assistance of one person. He was able to transfer himself between surfaces with supervision and the assistance of one person. Resident #1 walked with the use of an assistive device and was able to stabilize himself without the assistance of staff. He had no impairment to his lower or upper extremities. Resident #1's Care Plan, printed 03/04/14, reflected he was a fall risk due to "abnormality of gait/balance." The Care Plan did not reflect Resident #1's need for transportation to [MEDICAL TREATMENT] appointments. The facility's Provider Investigation Report, dated 02/25/14, reflected, "On February 19, 2014, at approx (approximately) 12:30 PM, (Resident #1) was being transported to a doctor's appointment via the Facility van. The van was being driven by (Driver B). Prior to departing the Facility, (Driver B) secured (Resident #1's) wheelchair in the van, and secured (Resident #1) in his wheelchair; (Resident #1) was seated in the wheelchair near the back of the van. (Driver B) stopped the van on the way to the office at the railroad tracks (street names), at an uphill incline. As the van began moving again, (Resident #1) unexpectedly tipped back in the wheelchair which caused his head to come into contact with the back door of the vehicle. (Driver B) estimated that, at the time of the event, the van was moving at less than 5 miles per hour. In response to the above, (Driver B) immediately pulled the van over into the closest parking lot and tended to the Resident. (Resident #1) was noted to be in his wheelchair, which was tipped at approximately a 30-45 degree angle, with his head still against the door. The back of the wheelchair was strapped securely to the van, and the back wheels were locked into place. The strap for the front right wheel of the wheelchair was no longer attached to the floor of the van; the left front strap, while still connected and strapped to the wheelchair, was observed to be loose. It was (Driver B's) recollection that the straps were secure, in place, and free from obvious or observed defect before he left the faciity on [DATE]. (Driver B) assisted (Resident #1) out of the wheelchair, laid him on the floor of the van. Per his observations at the time, there was no sign of bleeding, bruising, skin discoloration or other visible injury. (Driver B) immediately called the Facility and advised the nursing staff of the event; he was instructed to, and did, take (Resident #1) promptly to the Emergency Department at (local hospital) for further evaluation and treatment...However, immediately following the incident, the two front straps were found to be loose or not secure while the back straps remained in place. Upon further assessment of the vehicle when it returned to the Facility, the pin on the locking mechanism of the right front strap was found to have broken off. Additional investigation revealed that the front straps could be released by the application of pressure, whether from a foot or some other mechanism...." Interview with Driver B on 03/04/14 at 12:50 PM revealed on 02/19/14 at 11:15 AM, he was taking Resident #1 to an appointment. He stated he loaded the resident in the van, and the resident was facing the front of the van. Driver B revealed Resident #1 was in his wheelchair which was locked and secured in place by the straps. He stated he stopped at the railroad tracks, and when he accelerated, he saw Resident #1 in the rearview mirror flip backwards. Driver B said Resident #1's head was against the back door of the facility van. He stated he pulled the van over and removed the wheelchair and laid Resident #1 flat on the floor of the van and placed a pillow, which was in Resident #1's wheelchair, underneath his head and contacted the facility. Driver B revealed the nurse told him to take Resident #1 to the emergency room because he was only five minutes away from the hospital. He stated he asked the resident what his pain level was and Resident #1 replied his pain level was at 8. Driver B stated he asked Resident #1 questions from the resident's Face Sheet, for example Resident #1's Social Security Number, and the resident was able to recall the information. Driver B revealed once he arrived at the emergency room , a male nurse came to the van with a flat board, and he assisted the nurse in rolling Resident #1 onto the flat board and carrying the resident into the hospital. He revealed now that he had taken the training regarding transporting residents, he knew he could not transport a resident without a foot rest on the wheelchair. Driver B stated Resident #1 did not have a foot rest on his wheelchair because he would propel himself using his legs. Driver B revealed he had worked at the facility for seven years and had never had a resident fall in the van. He stated he had some training when he first started working at the facility and some training every two years. Driver B revealed following the incident he was suspended for one week. Observation of Driver B on 03/04/14 at 12:50 PM revealed he showed the investigator the inside of the van and how the straps were locked into place inside the van with a locking mechanism. There were four straps that connected to the wheelchair to secure it in place. Two straps in the back and two straps in the front. The straps in the back came up from the floor and hooked onto the lower side of the wheelchair. The right front strap connected to the wall of the van and the left front strap connected to the floor of the van. Driver B stated on the left side of the wheelchair, he had to hook the strap to the front of the wheelchair versus the side of the wheelchair where it would be normally be hooked because Resident #1 had padding wrapped on the wheelchair on the left side. Further interview/observation with Driver B on 03/04/14 at 3:00 PM revealed he demonstrated how Resident #1's wheelchair was secured on 02/19/14, the day of the accident. He explained that normally the straps were supposed to be secured wide to the wheelchair, but since Resident #1's wheelchair was wrapped on the bottom left side with padding, the left front strap was secured to the middle of the wheelchair versus the widest part from the wheelchair to the locking mechanism. Driver B explained he had strapped Resident #1 in the van like that before. He demonstrated on the wheelchair how the two back straps securing the wheelchair were placed on the furthest locking device from the wheelchair and then pulled to secure the wheelchair. By pulling the straps from the widest point from the wheelchair, it created tension allowing the wheelchair to be held in place. Driver B secured the right front side of the wheelchair using the strap and securing it to the furthest locking device located on the wall of the van. When securing the left side of the wheelchair, Driver B placed the strap in the middle locking device located in front of the wheelchair and attached the strap to the middle bar of the wheelchair. The strap placed in the middle of the wheelchair was located where the resident would place his/her feet on the floor. Driver B revealed when Resident #1 fell back in the wheelchair, the middle strap had been released and the right front strap "popped out of the lock" causing only the back two straps of the wheelchair to remain in place. He demonstrated how the wheelchair was placed when the incident occurred. The wheelchair was leaning against the back door of the van almost parallel to the floor of the van with both of the front straps not attached to the wheelchair. Driver B stated he believed Resident #1 dropped his cell phone and while reaching down to pick the phone up off the floor, stepped on the release mechanism on the strap located in the middle of the chair next to his feet. Driver B stated he did not know why the right front strap came unlocked. He revealed he thought that was what happened because Resident #1 said "stupid phone" when he (Driver B) went to help him. Interview with the DON on 03/04/14 at 3:20 PM revealed Resident #1 wrapped his wheelchair himself because it was hurting his legs. Resident #1's Nursing Progress Note, dated 02/19/14, reflected Driver B said during transport the resident slid from his seat and complained of his back hurting. Driver B reported he was close to the local hospital emergency room and the resident was taken there. Resident #1's Nursing Progress Note, dated 02/19/14, reflected his family member was notified by the nurse that the resident was at the emergency room . Resident #1's family member informed the nurse he/she was already called by the resident, who said his back was hurting. He/She stated he/she was at the emergency room . Resident #1's family member stated he/she was not aware at that time exactly where the spinal problem was, but the resident would have some type of surgery to repair it that day. Resident #1's Nursing Progress Note, dated 02/19/14, the nurse received a call from the emergency room physician requesting information regarding Resident #1. The note reflected, "This nurse told him he can transfer from W/C to bed, Bed to W/Chair, and in the bathroom as well with supervision. Dr said 'PT (Resident #1) is saying now he can not move his legs. If he was not walking independently before, does not look anything is wrong. He should be fine to come back. We are still working with him.'" Resident #1's hospital Consultation Report, dated 02/19/14, reflected, "...CHIEF COMPLAINT: Quadriparesis (muscle weakness affecting all four limbs)...Afterwards he had severe neck pain and he was unable to move his arms or legs. He was brought to the (hospital) emergency room where he was found to have severe weakness of his upper extremities...He had no sensation below approximately C6 dermatome (cervical vertebrae in the neck) and severe numbness above that up to C4 (cervical vertebrae in the neck) ...IMPRESSION: Central cord syndrome (acute cervical spinal cord injury) and spinal cord compression (occurs when a mass places pressure on anywhere along the cord) due to cervical stenosis (narrowing of the spinal canal in the neck) and head trauma. PLAN: The patient will immediately be transported to the MRI to undergo an MRI of the complete spine...We will take him back for immediate surgical intervention. He will undergo posterior cervical laminectomy with decompression (surgery to remove the lamina which is a thin plate of bone at the back of the neck that makes up the roof of the spine, rods are then implanted to stabilize the neck) of his spinal cord. Afterwards, he will be observed in the intensive care unit." Resident #1's Consultation Report, dated 02/20/14, reflected, "...REASON FOR CONSULTATION: ICU management secondary to [MEDICAL CONDITION] status [REDACTED]. The patient postoperatively is still on the vent support in ICU...." On 03/05/14 at approximately 9:30 AM the Investigator went to the local hospital. The Investigator was unable to see Resident #1 due to he was still in ICU with a family member at bedside. Interview with DON on 03/04/14 at 9:15 AM revealed Resident #1 was at the local hospital with multiple fractures sustained from the fall in the facility van. The DON stated since the incident occurred, the facility was no longer using the van and training had been conducted. Interview with Administrator on 03/04/14 at 10:35 AM revealed Resident #1 was currently in ICU at the local hospital, and did not know the resident's exact [DIAGNOSES REDACTED]. The Administrator explained the family communicated to the facility Resident #1 did want to return to the facility on ce he was discharged from the hospital. The Administrator's understanding was Resident #1 leaned over in his wheelchair to pick up his cell phone from the floor of the van and when doing so triggered the release with his foot which released the front strap causing the resident's wheelchair to fall backwards. Interview with Resident #1's Family Member 03/04/14 at 10:57 AM revealed the resident broke his spine, had swollen blood vessels in his spine and blood clots in his arm. The Family Member stated Resident #1 was on a ventilator, the vent was taken out of his mouth and placed it in his throat. He/She explained Resident #1 would never be the same person he was before the accident. The Family Member revealed Resident #1 would never be able to use his legs again. He/She felt the facility should take responsibility for the accident. The Family Member stated he/she felt the facility should have done more regarding looking at the procedure for transporting residents. The Provider Response section of the Provider Investigation Report, dated 02/25/14, reflected, "...Van suspended from use for Facility transport, or for any other reason Van scheduled to undergo a full and complete inspection by a qualified outside contractor who specializes in transportation safety restraints and systems. Van driver suspended, pending further investigation...Outside transportation service contracted by the Facility for purposes of patient or other transportation pending van inspection and certification...." The Provider Action Taken Post-Investigation section of the Provider Investigation Report, dated 02/25/14, reflected, "Van taken in for inspection - updated wheelchair straps installed into van, tested by outside company specializing in transportation safety restraints, and deemed safe and appropriate for use. Training video on resident transport and securing resident in vehicle purchased for use in training all staff involved in resident transportation. Training to be done on hire and annually thereafter, and staff required to successfully pass competency developed in connection with resident safety during transport. Staff will not be permitted to work in transporting residents until they have demonstrated aptitude in this area. One-on-one training to be done with (Driver B), followed by administration of competency on resident safety during transport; (Driver B) will not be permitted to return to work until he has successfully demonstrated aptitude in this area...Training provided to facility staff and van drivers regarding procedures and protocol to follow in the event of a resident emergency, especially as related to a transport situation...." An interview with the Administrator on 03/04/14 at 1:30 PM revealed the last training reference on the Provider Investigation Report, dated 02/25/14, would be provided by the corporate office, but it had not started yet. He stated they ordered all new parts for the van. Another interview with the Administrator on 03/04/14 at 3:00 PM revealed the facility did not have a facility manual or a manufacturer's manual on how to properly secure a wheelchair in the van using the straps. The facility's training records reflected Driver B attended "Van Safety and Restraints" training on 03/03/14. The facility's current undated Resident Securement Training materials reflected the front straps should be anchored "on the floor track 3" outside front wheels. 30-45 degree angle. Secure close to seat surface to a welded junction. Ensure track fittings and straps are secure." The back straps should be anchored to the "inside of the rear wheels. 30-45 degree angle. Secure straps to welded junction of the wheelchair frame. Ensure track fittings and straps are secure." Interview with Human Resources F on 03/04/14 at 2:02 PM revealed there were no training records regarding transportation for Driver B and there was no department of motor vehicle driving record checks. Interview with the Administrator on 03/04/14 at 3:40 PM revealed he was aware there had not been any trainings regarding transporting residents and no checks of staff, who would be transporting residents, driving records. Further interview with the Administrator on 03/04/14 at 11:34 AM revealed the facility was in the process of developing policies and procedures regarding transporting residents. Prior to the incident, the facility did not have policies and procedures in place regarding transporting residents in the facility van. The Administrator stated the facility van had not been used since the incident on 02/19/14, and new parts had been ordered for the van. The Administrator revealed once the parts arrived, the straps in the van would be replaced. Interview with SW C on 03/04/14 at 3:55 PM revealed she arranged all transportation for residents to their appointments. She stated since 02/19/14, the facility had not transported any residents in the facility van. SW C revealed the facility was using a transportation company to transport the residents to appointments. Interview with SW C on 03/04/14 at 10:30 AM revealed the last time Driver D drove the van was in January 2014. SW C stated Driver D D did not receive training on transporting residents. Interview with Driver D on 03/05/14 at 10:45 AM revealed he had been working at the facility for five years. He stated he was trained on how to strap resident's wheelchairs in the van and transport residents in the van by Driver B. Driver D revealed the first time he drove the van was three or four years ago. He stated he drove residents in the van in January 2014 when Driver B was on leave. The facility's current policy, Abuse Prevention and Reporting, revised May 2007 reflected Neglect was defined as "Action or inaction that avoids or prevents physical, mental harm, pain, demonstrates disregard or consequences that may constitute a clear and present danger." An IJ was identified on 03/04/14. On 03/04/14 at 4:30 PM, the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. Interview with Administrator on 03/05/14 at 12:15 PM revealed the facility would be getting rid of the van on the advice of the corporate attorneys and the parts previously ordered for the van were returned. He stated the facility would be using a third party company to transport all residents. Interview with Administrator on 03/05/14 at 2:00 PM revealed SW C and Driver D would be watching the training video and then demonstrating how to properly use the straps to secure a wheelchair in the van. He stated he was not aware Driver B strapped in Resident #1's wheelchair incorrectly. Driver B told the Administrator and Investigator after watching the training video it was recommended the straps be placed from the widest point from the wheelchair to the point strap was locked into place and not lock the strap close to the wheelchair and place in the middle of the wheelchair. The facility's training records,dated 03/05/14, reflected SW C and Driver D attended "Van Safety and Restraints" Training on 03/05/14. The facility's transportation appointment book from 02/19/14 through 03/05/14 reflected resident transportation was arranged with a private transportation company. The facility's Plan of Removal, accepted on 03/05/14, reflected: The following 13 residents, who were also in wheelchairs, could have been affected: Resident #2, Resident #3, Resident #4, Resident #6, Resident #7, Resident #8, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, and Resident #18. On 03/05/2014, the Administrator decided to remove the facility van from any future resident transportation services. As such, no further investment would be made to train staff or purchase harness equipment for the van. The facility would keep the existing transportation providers. Driver B was suspended immediately following the incident on 02/19/14, and he returned to work on 02/26/14, but not to drive the van. On 02/24/14, the facility acquired a training video on safe resident transportation which demonstrated proper use and application of wheelchair safety harnesses. Although the training video would no longer be used since the facility van would not be transporting residents, the following employees watched the video on these dates: Driver B (03/03/2014), SW C (03/05/2014), and Driver D (03/05/2014). Observation of SW C on 03/05/14 at 3:40 PM revealed she demonstrated how to properly strap a wheelchair in the van by strapping the wheelchair in at four points. She strapped two in the front and two in the back using the widest points to lock the straps in place. Observation of Driver D on 03/05/14 at 3:50 PM revealed he demonstrated how to properly strap a wheelchair in the van by strapping the wheelchair in at four points, with two in the front and two in the back using the widest points to lock the straps in place. On 03/05/14 the IJ was removed. On 03/05/14 at 4:28 PM, the Administrator and DON were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility still implementing the Plan of Removal. The facility's Plan of Removal, accepted on 03/05/14, reflected 13 residents, who were in wheelchairs and could have been affected by the facility failures.

Based on observation, interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit neglect of residents for one (Resident #1) of 14 residents reviewed for accidents. 1. Driver B failed to properly secure Resident #1's wheelchair in the van before transporting the resident to [MEDICAL TREATMENT] on 02/19/14. While being transported the straps securing Resident #1's wheelchair in place came loose and Resident #1 fell backwards in his wheelchair against the rear door of the facility van. Driver B removed Resident #1 from the wheelchair and laid him on the floor of the van, and then transported the resident to the local hospital emergency room . Resident #1 sustained a spinal injury causing paralysis to his legs. 2. The facility failed to properly train facility staff on how to secure residents' wheelchair in the van before transporting residents. An Immediate Jeopardy (IJ) was identified on 03/04/14. While the IJ was removed on 03/05/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "pattern" because the facility was still implementing the Plan of Removal. These failures could affect the 13 residents in wheelchairs by placing them at risk for injury while being transported in the facility van by Driver B, which could result in resident injuries, falls, other serious mental/physical harm and/or death. Findings included: The facility's current policy, Abuse Prevention and Reporting, revised May 2007 reflected Neglect was defined as "Action or inaction that avoids or prevents physical, mental harm, pain, demonstrates disregard or consequences that may constitute a clear and present danger." Resident #1's MDS assessment, dated 02/01/14, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE], and his [DIAGNOSES REDACTED]. He was 65 inches tall and weighed 242 pounds. The MDS assessment further reflected Resident #1 was able to be understood by others, was not cognitively impaired, and walked in his room and walked in the corridor with the assistance of one person. He was able to transfer himself between surfaces with supervision and the assistance of one person. Resident #1 walked with the use of an assistive device and was able to stabilize himself without the assistance of staff. He had no impairment to his lower or upper extremities. Resident #1's Care Plan, printed 03/04/14, reflected he was a fall risk due to "abnormality of gait/balance." The Care Plan did not reflect Resident #1's need for transportation to [MEDICAL TREATMENT] appointments. The facility's Provider Investigation Report, dated 02/25/14, reflected, "On February 19, 2014, at approx (approximately) 12:30 PM, (Resident #1) was being transported to a doctor's appointment via the Facility van. The van was being driven by (Driver B). Prior to departing the Facility, (Driver B) secured (Resident #1's) wheelchair in the van, and secured (Resident #1) in his wheelchair; (Resident #1) was seated in the wheelchair near the back of the van. (Driver B) stopped the van on the way to the office at the railroad tracks (street names), at an uphill incline. As the van began moving again, (Resident #1) unexpectedly tipped back in the wheelchair which caused his head to come into contact with the back door of the vehicle. (Driver B) estimated that, at the time of the event, the van was moving at less than 5 miles per hour. In response to the above, (Driver B) immediately pulled the van over into the closest parking lot and tended to the Resident. (Resident #1) was noted to be in his wheelchair, which was tipped at approximately a 30-45 degree angle, with his head still against the door. The back of the wheelchair was strapped securely to the van, and the back wheels were locked into place. The strap for the front right wheel of the wheelchair was no longer attached to the floor of the van; the left front strap, while still connected and strapped to the wheelchair, was observed to be loose. It was (Driver B's) recollection that the straps were secure, in place, and free from obvious or observed defect before he left the faciity on [DATE]. (Driver B) assisted (Resident #1) out of the wheelchair, laid him on the floor of the van. Per his observations at the time, there was no sign of bleeding, bruising, skin discoloration or other visible injury. (Driver B) immediately called the Facility and advised the nursing staff of the event; he was instructed to, and did, take (Resident #1) promptly to the Emergency Department at (local hospital) for further evaluation and treatment...However, immediately following the incident, the two front straps were found to be loose or not secure while the back straps remained in place. Upon further assessment of the vehicle when it returned to the Facility, the pin on the locking mechanism of the right front strap was found to have broken off. Additional investigation revealed that the front straps could be released by the application of pressure, whether from a foot or some other mechanism...." Interview with Driver B on 03/04/14 at 12:50 PM revealed on 02/19/14 at 11:15 AM, he was taking Resident #1 to an appointment. He stated he loaded the resident in the van, and the resident was facing the front of the van. Driver B revealed Resident #1 was in his wheelchair which was locked and secured in place by the straps. He stated he stopped at the railroad tracks, and when he accelerated, he saw Resident #1 in the rearview mirror flip backwards. Driver B said Resident #1's head was against the back door of the facility van. He stated he pulled the van over and removed the wheelchair and laid Resident #1 flat on the floor of the van and placed a pillow, which was in Resident #1's wheelchair, underneath his head and contacted the facility. Driver B revealed the nurse told him to take Resident #1 to the emergency room because he was only five minutes away from the hospital. He stated he asked the resident what his pain level was and Resident #1 replied his pain level was at 8. Driver B stated he asked Resident #1 questions from the resident's Face Sheet, for example Resident #1's Social Security Number, and the resident was able to recall the information. Driver B revealed once he arrived at the emergency room , a male nurse came to the van with a flat board, and he assisted the nurse in rolling Resident #1 onto the flat board and carrying the resident into the hospital. He revealed now that he had taken the training regarding transporting residents, he knew he could not transport a resident without a foot rest on the wheelchair. Driver B stated Resident #1 did not have a foot rest on his wheelchair because he would propel himself using his legs. Driver B revealed he had worked at the facility for seven years and had never had a resident fall in the van. He stated he had some training when he first started working at the facility and some training every two years. Driver B revealed following the incident he was suspended for one week. Observation of Driver B on 03/04/14 at 12:50 PM revealed he showed the investigator the inside of the van and how the straps were locked into place inside the van with a locking mechanism. There were four straps that connected to the wheelchair to secure it in place. Two straps in the back and two straps in the front. The straps in the back came up from the floor and hooked onto the lower side of the wheelchair. The right front strap connected to the wall of the van and the left front strap connected to the floor of the van. Driver B stated on the left side of the wheelchair, he had to hook the strap to the front of the wheelchair versus the side of the wheelchair where it would be normally be hooked because Resident #1 had padding wrapped on the wheelchair on the left side. Further interview/observation with Driver B on 03/04/14 at 3:00 PM revealed he demonstrated how Resident #1's wheelchair was secured on 02/19/14, the day of the accident. He explained that normally the straps were supposed to be secured wide to the wheelchair, but since Resident #1's wheelchair was wrapped on the bottom left side with padding, the left front strap was secured to the middle of the wheelchair versus the widest part from the wheelchair to the locking mechanism. Driver B explained he had strapped Resident #1 in the van like that before. He demonstrated on the wheelchair how the two back straps securing the wheelchair were placed on the furthest locking device from the wheelchair and then pulled to secure the wheelchair. By pulling the straps from the widest point from the wheelchair, it created tension allowing the wheelchair to be held in place. Driver B secured the right front side of the wheelchair using the strap and securing it to the furthest locking device located on the wall of the van. When securing the left side of the wheelchair, Driver B placed the strap in the middle locking device located in front of the wheelchair and attached the strap to the middle bar of the wheelchair. The strap placed in the middle of the wheelchair was located where the resident would place his/her feet on the floor. Driver B revealed when Resident #1 fell back in the wheelchair, the middle strap had been released and the right front strap "popped out of the lock" causing only the back two straps of the wheelchair to remain in place. He demonstrated how the wheelchair was placed when the incident occurred. The wheelchair was leaning against the back door of the van almost parallel to the floor of the van with both of the front straps not attached to the wheelchair. Driver B stated he believed Resident #1 dropped his cell phone and while reaching down to pick the phone up off the floor, stepped on the release mechanism on the strap located in the middle of the chair next to his feet. Driver B stated he did not know why the right front strap came unlocked. He revealed he thought that was what happened because Resident #1 said "stupid phone" when he (Driver B) went to help him. Interview with the DON on 03/04/14 at 3:20 PM revealed Resident #1 wrapped his wheelchair himself because it was hurting his legs. Resident #1's Nursing Progress Note, dated 02/19/14, reflected Driver B said during transport the resident slid from his seat and complained of his back hurting. Driver B reported he was close to the local hospital emergency room and the resident was taken there. Resident #1's Nursing Progress Note, dated 02/19/14, reflected his family member was notified by the nurse that the resident was at the emergency room . Resident #1's family member informed the nurse he/she was already called by the resident, who said his back was hurting. He/She stated he/she was at the emergency room . Resident #1's family member stated he/she was not aware at that time exactly where the spinal problem was, but the resident would have some type of surgery to repair it that day. Resident #1's Nursing Progress Note, dated 02/19/14, the nurse received a call from the emergency room physician requesting information regarding Resident #1. The note reflected, "This nurse told him he can transfer from W/C to bed, Bed to W/Chair, and in the bathroom as well with supervision. Dr said 'PT (Resident #1) is saying now he can not move his legs. If he was not walking independently before, does not look anything is wrong. He should be fine to come back. We are still working with him.'" Resident #1's hospital Consultation Report, dated 02/19/14, reflected, "...CHIEF COMPLAINT: Quadriparesis (muscle weakness affecting all four limbs)...Afterwards he had severe neck pain and he was unable to move his arms or legs. He was brought to the (hospital) emergency room where he was found to have severe weakness of his upper extremities...He had no sensation below approximately C6 dermatome (cervical vertebrae in the neck) and severe numbness above that up to C4 (cervical vertebrae in the neck) ...IMPRESSION: Central cord syndrome (acute cervical spinal cord injury) and spinal cord compression (occurs when a mass places pressure on anywhere along the cord) due to cervical stenosis (narrowing of the spinal canal in the neck) and head trauma. PLAN: The patient will immediately be transported to the MRI to undergo an MRI of the complete spine...We will take him back for immediate surgical intervention. He will undergo posterior cervical laminectomy with decompression (surgery to remove the lamina which is a thin plate of bone at the back of the neck that makes up the roof of the spine, rods are then implanted to stabilize the neck) of his spinal cord. Afterwards, he will be observed in the intensive care unit." Resident #1's Consultation Report, dated 02/20/14, reflected, "...REASON FOR CONSULTATION: ICU management secondary to [MEDICAL CONDITION] status [REDACTED]. The patient postoperatively is still on the vent support in ICU...." On 03/05/14 at approximately 9:30 AM the Investigator went to the local hospital. The Investigator was unable to see Resident #1 due to he was still in ICU with a family member at bedside. Interview with DON on 03/04/14 at 9:15 AM revealed Resident #1 was at the local hospital with multiple fractures sustained from the fall in the facility van. The DON stated since the incident occurred, the facility was no longer using the van and training had been conducted. Interview with Administrator on 03/04/14 at 10:35 AM revealed Resident #1 was currently in ICU at the local hospital, and did not know the resident's exact [DIAGNOSES REDACTED]. The Administrator explained the family communicated to the facility Resident #1 did want to return to the facility on ce he was discharged from the hospital. The Administrator's understanding was Resident #1 leaned over in his wheelchair to pick up his cell phone from the floor of the van and when doing so triggered the release with his foot which released the front strap causing the resident's wheelchair to fall backwards. Interview with Resident #1's Family Member 03/04/14 at 10:57 AM revealed the resident broke his spine, had swollen blood vessels in his spine and blood clots in his arm. The Family Member stated Resident #1 was on a ventilator, the vent was taken out of his mouth and placed it in his throat. He/She explained Resident #1 would never be the same person he was before the accident. The Family Member revealed Resident #1 would never be able to use his legs again. He/She felt the facility should take responsibility for the accident. The Family Member stated he/she felt the facility should have done more regarding looking at the procedure for transporting residents. The Provider Response section of the Provider Investigation Report, dated 02/25/14, reflected, "...Van suspended from use for Facility transport, or for any other reason Van scheduled to undergo a full and complete inspection by a qualified outside contractor who specializes in transportation safety restraints and systems. Van driver suspended, pending further investigation...Outside transportation service contracted by the Facility for purposes of patient or other transportation pending van inspection and certification...." The Provider Action Taken Post-Investigation section of the Provider Investigation Report, dated 02/25/14, reflected, "Van taken in for inspection - updated wheelchair straps installed into van, tested by outside company specializing in transportation safety restraints, and deemed safe and appropriate for use. Training video on resident transport and securing resident in vehicle purchased for use in training all staff involved in resident transportation. Training to be done on hire and annually thereafter, and staff required to successfully pass competency developed in connection with resident safety during transport. Staff will not be permitted to work in transporting residents until they have demonstrated aptitude in this area. One-on-one training to be done with (Driver B), followed by administration of competency on resident safety during transport; (Driver B) will not be permitted to return to work until he has successfully demonstrated aptitude in this area...Training provided to facility staff and van drivers regarding procedures and protocol to follow in the event of a resident emergency, especially as related to a transport situation...." An interview with the Administrator on 03/04/14 at 1:30 PM revealed the last training reference on the Provider Investigation Report, dated 02/25/14, would be provided by the corporate office, but it had not started yet. He stated they ordered all new parts for the van. Another interview with the Administrator on 03/04/14 at 3:00 PM revealed the facility did not have a facility manual or a manufacturer's manual on how to properly secure a wheelchair in the van using the straps. The facility's training records reflected Driver B attended "Van Safety and Restraints" training on 03/03/14. The facility's current undated Resident Securement Training materials reflected the front straps should be anchored "on the floor track 3" outside front wheels. 30-45 degree angle. Secure close to seat surface to a welded junction. Ensure track fittings and straps are secure." The back straps should be anchored to the "inside of the rear wheels. 30-45 degree angle. Secure straps to welded junction of the wheelchair frame. Ensure track fittings and straps are secure." Interview with Human Resources F on 03/04/14 at 2:02 PM revealed there were no training records regarding transportation for Driver B and there was no department of motor vehicle driving record checks. Interview with the Administrator on 03/04/14 at 3:40 PM revealed he was aware there had not been any trainings regarding transporting residents and no checks of staff, who would be transporting residents, driving records. Further interview with the Administrator on 03/04/14 at 11:34 AM revealed the facility was in the process of developing policies and procedures regarding transporting residents. Prior to the incident, the facility did not have policies and procedures in place regarding transporting residents in the facility van. The Administrator stated the facility van had not been used since the incident on 02/19/14, and new parts had been ordered for the van. The Administrator revealed once the parts arrived, the straps in the van would be replaced. Interview with SW C on 03/04/14 at 3:55 PM revealed she arranged all transportation for residents to their appointments. She stated since 02/19/14, the facility had not transported any residents in the facility van. SW C revealed the facility was using a transportation company to transport the residents to appointments. Interview with SW C on 03/04/14 at 10:30 AM revealed the last time Driver D drove the van was in January 2014. SW C stated Driver D D did not receive training on transporting residents. Interview with Driver D on 03/05/14 at 10:45 AM revealed he had been working at the facility for five years. He stated he was trained on how to strap resident's wheelchairs in the van and transport residents in the van by Driver B. Driver D revealed the first time he drove the van was three or four years ago. He stated he drove residents in the van in January 2014 when Driver B was on leave. An IJ was identified on 03/04/14. On 03/04/14 at 4:30 PM, the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. Interview with Administrator on 03/05/14 at 12:15 PM revealed the facility would be getting rid of the van on the advice of the corporate attorneys and the parts previously ordered for the van were returned. He stated the facility would be using a third party company to transport all residents. Interview with Administrator on 03/05/14 at 2:00 PM revealed SW C and Driver D would be watching the training video and then demonstrating how to properly use the straps to secure a wheelchair in the van. He stated he was not aware Driver B strapped in Resident #1's wheelchair incorrectly. Driver B told the Administrator and Investigator after watching the training video it was recommended the straps be placed from the widest point from the wheelchair to the point strap was locked into place and not lock the strap close to the wheelchair and place in the middle of the wheelchair. The facility's training records,dated 03/05/14, reflected SW C and Driver D attended "Van Safety and Restraints" Training on 03/05/14. The facility's transportation appointment book from 02/19/14 through 03/05/14 reflected resident transportation was arranged with a private transportation company. The facility's Plan of Removal, accepted on 03/05/14, reflected: The following 13 residents, who were also in wheelchairs, could have been affected: Resident #2, Resident #3, Resident #4, Resident #6, Resident #7, Resident #8, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, and Resident #18. On 03/05/2014, the Administrator decided to remove the facility van from any future resident transportation services. As such, no further investment would be made to train staff or purchase harness equipment for the van. The facility would keep the existing transportation providers. Driver B was suspended immediately following the incident on 02/19/14, and he returned to work on 02/26/14, but not to drive the van. On 02/24/14, the facility acquired a training video on safe resident transportation which demonstrated proper use and application of wheelchair safety harnesses. Although the training video would no longer be used since the facility van would not be transporting residents, the following employees watched the video on these dates: Driver B (03/03/2014), SW C (03/05/2014), and Driver D (03/05/2014). Observation of SW C on 03/05/14 at 3:40 PM revealed she demonstrated how to properly strap a wheelchair in the van by strapping the wheelchair in at four points. She strapped two in the front and two in the back using the widest points to lock the straps in place. Observation of Driver D on 03/05/14 at 3:50 PM revealed he demonstrated how to properly strap a wheelchair in the van by strapping the wheelchair in at four points, with two in the front and two in the back using the widest points to lock the straps in place. On 03/05/14 the IJ was removed. On 03/05/14 at 4:28 PM, the Administrator and DON were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility still implementing the Plan of Removal. The facility's Plan of Removal, accepted on 03/05/14, reflected 13 residents, who were in wheelchairs and could have been affected by the facility failures.

Based on observation, interview and record review, it was determined the facility failed to ensure each resident received assistance devices to prevent accidents for one (Resident #1) of 14 residents reviewed for accidents. 1. Driver B failed to properly secure Resident #1's wheelchair in the van before transporting the resident to dialysis on 02/19/14. While being transported the straps securing Resident #1's wheelchair in place came loose and Resident #1 fell backwards in his wheelchair against the rear door of the facility van. Driver B removed Resident #1 from the wheelchair and laid him on the floor of the van, and then transported the resident to the local hospital emergency room . Resident #1 sustained a spinal injury causing paralysis to his legs. 2. The facility failed to properly train facility staff on how to secure residents' wheelchair in the van before transporting residents. An Immediate Jeopardy (IJ) was identified on 03/04/14. While the IJ was removed on 03/05/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "pattern" because the facility was still implementing the Plan of Removal. These failures could affect the 13 residents in wheelchairs by placing them at risk for injury while being transported in the facility van by Driver B, which could result in resident injuries, falls, other serious mental/physical harm and/or death. Findings included: Resident #1's MDS assessment, dated 02/01/14, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE], and his [DIAGNOSES REDACTED]. He was 65 inches tall and weighed 242 pounds. The MDS assessment further reflected Resident #1 was able to be understood by others, was not cognitively impaired, and walked in his room and walked in the corridor with the assistance of one person. He was able to transfer himself between surfaces with supervision and the assistance of one person. Resident #1 walked with the use of an assistive device and was able to stabilize himself without the assistance of staff. He had no impairment to his lower or upper extremities. Resident #1's Care Plan, printed 03/04/14, reflected he was a fall risk due to "abnormality of gait/balance." The Care Plan did not reflect Resident #1's need for transportation to dialysis appointments. The facility's Provider Investigation Report, dated 02/25/14, reflected, "On February 19, 2014, at approx (approximately) 12:30 PM, (Resident #1) was being transported to a doctor's appointment via the Facility van. The van was being driven by (Driver B). Prior to departing the Facility, (Driver B) secured (Resident #1's) wheelchair in the van, and secured (Resident #1) in his wheelchair; (Resident #1) was seated in the wheelchair near the back of the van. (Driver B) stopped the van on the way to the office at the railroad tracks (street names), at an uphill incline. As the van began moving again, (Resident #1) unexpectedly tipped back in the wheelchair which caused his head to come into contact with the back door of the vehicle. (Driver B) estimated that, at the time of the event, the van was moving at less than 5 miles per hour. In response to the above, (Driver B) immediately pulled the van over into the closest parking lot and tended to the Resident. (Resident #1) was noted to be in his wheelchair, which was tipped at approximately a 30-45 degree angle, with his head still against the door. The back of the wheelchair was strapped securely to the van, and the back wheels were locked into place. The strap for the front right wheel of the wheelchair was no longer attached to the floor of the van; the left front strap, while still connected and strapped to the wheelchair, was observed to be loose. It was (Driver B's) recollection that the straps were secure, in place, and free from obvious or observed defect before he left the faciity on [DATE]. (Driver B) assisted (Resident #1) out of the wheelchair, laid him on the floor of the van. Per his observations at the time, there was no sign of bleeding, bruising, skin discoloration or other visible injury. (Driver B) immediately called the Facility and advised the nursing staff of the event; he was instructed to, and did, take (Resident #1) promptly to the Emergency Department at (local hospital) for further evaluation and treatment...However, immediately following the incident, the two front straps were found to be loose or not secure while the back straps remained in place. Upon further assessment of the vehicle when it returned to the Facility, the pin on the locking mechanism of the right front strap was found to have broken off. Additional investigation revealed that the front straps could be released by the application of pressure, whether from a foot or some other mechanism...." Interview with Driver B on 03/04/14 at 12:50 PM revealed on 02/19/14 at 11:15 AM, he was taking Resident #1 to an appointment. He stated he loaded the resident in the van, and the resident was facing the front of the van. Driver B revealed Resident #1 was in his wheelchair which was locked and secured in place by the straps. He stated he stopped at the railroad tracks, and when he accelerated, he saw Resident #1 in the rearview mirror flip backwards. Driver B said Resident #1's head was against the back door of the facility van. He stated he pulled the van over and removed the wheelchair and laid Resident #1 flat on the floor of the van and placed a pillow, which was in Resident #1's wheelchair, underneath his head and contacted the facility. Driver B revealed the nurse told him to take Resident #1 to the emergency room because he was only five minutes away from the hospital. He stated he asked the resident what his pain level was and Resident #1 replied his pain level was at 8. Driver B stated he asked Resident #1 questions from the resident's Face Sheet, for example Resident #1's Social Security Number, and the resident was able to recall the information. Driver B revealed once he arrived at the emergency room , a male nurse came to the van with a flat board, and he assisted the nurse in rolling Resident #1 onto the flat board and carrying the resident into the hospital. He revealed now that he had taken the training regarding transporting residents, he knew he could not transport a resident without a foot rest on the wheelchair. Driver B stated Resident #1 did not have a foot rest on his wheelchair because he would propel himself using his legs. Driver B revealed he had worked at the facility for seven years and had never had a resident fall in the van. He stated he had some training when he first started working at the facility and some training every two years. Driver B revealed following the incident he was suspended for one week. Observation of Driver B on 03/04/14 at 12:50 PM revealed he showed the investigator the inside of the van and how the straps were locked into place inside the van with a locking mechanism. There were four straps that connected to the wheelchair to secure it in place. Two straps in the back and two straps in the front. The straps in the back came up from the floor and hooked onto the lower side of the wheelchair. The right front strap connected to the wall of the van and the left front strap connected to the floor of the van. Driver B stated on the left side of the wheelchair, he had to hook the strap to the front of the wheelchair versus the side of the wheelchair where it would be normally be hooked because Resident #1 had padding wrapped on the wheelchair on the left side. Further interview/observation with Driver B on 03/04/14 at 3:00 PM revealed he demonstrated how Resident #1's wheelchair was secured on 02/19/14, the day of the accident. He explained that normally the straps were supposed to be secured wide to the wheelchair, but since Resident #1's wheelchair was wrapped on the bottom left side with padding, the left front strap was secured to the middle of the wheelchair versus the widest part from the wheelchair to the locking mechanism. Driver B explained he had strapped Resident #1 in the van like that before. He demonstrated on the wheelchair how the two back straps securing the wheelchair were placed on the furthest locking device from the wheelchair and then pulled to secure the wheelchair. By pulling the straps from the widest point from the wheelchair, it created tension allowing the wheelchair to be held in place. Driver B secured the right front side of the wheelchair using the strap and securing it to the furthest locking device located on the wall of the van. When securing the left side of the wheelchair, Driver B placed the strap in the middle locking device located in front of the wheelchair and attached the strap to the middle bar of the wheelchair. The strap placed in the middle of the wheelchair was located where the resident would place his/her feet on the floor. Driver B revealed when Resident #1 fell back in the wheelchair, the middle strap had been released and the right front strap "popped out of the lock" causing only the back two straps of the wheelchair to remain in place. He demonstrated how the wheelchair was placed when the incident occurred. The wheelchair was leaning against the back door of the van almost parallel to the floor of the van with both of the front straps not attached to the wheelchair. Driver B stated he believed Resident #1 dropped his cell phone and while reaching down to pick the phone up off the floor, stepped on the release mechanism on the strap located in the middle of the chair next to his feet. Driver B stated he did not know why the right front strap came unlocked. He revealed he thought that was what happened because Resident #1 said "stupid phone" when he (Driver B) went to help him. Interview with the DON on 03/04/14 at 3:20 PM revealed Resident #1 wrapped his wheelchair himself because it was hurting his legs. Resident #1's Nursing Progress Note, dated 02/19/14, reflected Driver B said during transport the resident slid from his seat and complained of his back hurting. Driver B reported he was close to the local hospital emergency room and the resident was taken there. Resident #1's Nursing Progress Note, dated 02/19/14, reflected his family member was notified by the nurse that the resident was at the emergency room . Resident #1's family member informed the nurse he/she was already called by the resident, who said his back was hurting. He/She stated he/she was at the emergency room . Resident #1's family member stated he/she was not aware at that time exactly where the spinal problem was, but the resident would have some type of surgery to repair it that day. Resident #1's Nursing Progress Note, dated 02/19/14, the nurse received a call from the emergency room physician requesting information regarding Resident #1. The note reflected, "This nurse told him he can transfer from W/C to bed, Bed to W/Chair, and in the bathroom as well with supervision. Dr said 'PT (Resident #1) is saying now he can not move his legs. If he was not walking independently before, does not look anything is wrong. He should be fine to come back. We are still working with him.'" Resident #1's hospital Consultation Report, dated 02/19/14, reflected, "...CHIEF COMPLAINT: Quadriparesis (muscle weakness affecting all four limbs)...Afterwards he had severe neck pain and he was unable to move his arms or legs. He was brought to the (hospital) emergency room where he was found to have severe weakness of his upper extremities...He had no sensation below approximately C6 dermatome (cervical vertebrae in the neck) and severe numbness above that up to C4 (cervical vertebrae in the neck) ...IMPRESSION: Central cord syndrome (acute cervical spinal cord injury) and spinal cord compression (occurs when a mass places pressure on anywhere along the cord) due to cervical stenosis (narrowing of the spinal canal in the neck) and head trauma. PLAN: The patient will immediately be transported to the MRI to undergo an MRI of the complete spine...We will take him back for immediate surgical intervention. He will undergo posterior cervical laminectomy with decompression (surgery to remove the lamina which is a thin plate of bone at the back of the neck that makes up the roof of the spine, rods are then implanted to stabilize the neck) of his spinal cord. Afterwards, he will be observed in the intensive care unit." Resident #1's Consultation Report, dated 02/20/14, reflected, "...REASON FOR CONSULTATION: ICU management secondary to respiratory failure status [REDACTED]. The patient postoperatively is still on the vent support in ICU...." On 03/05/14 at approximately 9:30 AM the Investigator went to the local hospital. The Investigator was unable to see Resident #1 due to he was still in ICU with a family member at bedside. Interview with DON on 03/04/14 at 9:15 AM revealed Resident #1 was at the local hospital with multiple fractures sustained from the fall in the facility van. The DON stated since the incident occurred, the facility was no longer using the van and training had been conducted. Interview with Administrator on 03/04/14 at 10:35 AM revealed Resident #1 was currently in ICU at the local hospital, and did not know the resident's exact [DIAGNOSES REDACTED]. The Administrator explained the family communicated to the facility Resident #1 did want to return to the facility on ce he was discharged from the hospital. The Administrator's understanding was Resident #1 leaned over in his wheelchair to pick up his cell phone from the floor of the van and when doing so triggered the release with his foot which released the front strap causing the resident's wheelchair to fall backwards. Interview with Resident #1's Family Member 03/04/14 at 10:57 AM revealed the resident broke his spine, had swollen blood vessels in his spine and blood clots in his arm. The Family Member stated Resident #1 was on a ventilator, the vent was taken out of his mouth and placed it in his throat. He/She explained Resident #1 would never be the same person he was before the accident. The Family Member revealed Resident #1 would never be able to use his legs again. He/She felt the facility should take responsibility for the accident. The Family Member stated he/she felt the facility should have done more regarding looking at the procedure for transporting residents. The Provider Response section of the Provider Investigation Report, dated 02/25/14, reflected, "...Van suspended from use for Facility transport, or for any other reason Van scheduled to undergo a full and complete inspection by a qualified outside contractor who specializes in transportation safety restraints and systems. Van driver suspended, pending further investigation...Outside transportation service contracted by the Facility for purposes of patient or other transportation pending van inspection and certification...." The Provider Action Taken Post-Investigation section of the Provider Investigation Report, dated 02/25/14, reflected, "Van taken in for inspection - updated wheelchair straps installed into van, tested by outside company specializing in transportation safety restraints, and deemed safe and appropriate for use. Training video on resident transport and securing resident in vehicle purchased for use in training all staff involved in resident transportation. Training to be done on hire and annually thereafter, and staff required to successfully pass competency developed in connection with resident safety during transport. Staff will not be permitted to work in transporting residents until they have demonstrated aptitude in this area. One-on-one training to be done with (Driver B), followed by administration of competency on resident safety during transport; (Driver B) will not be permitted to return to work until he has successfully demonstrated aptitude in this area...Training provided to facility staff and van drivers regarding procedures and protocol to follow in the event of a resident emergency, especially as related to a transport situation...." An interview with the Administrator on 03/04/14 at 1:30 PM revealed the last training reference on the Provider Investigation Report, dated 02/25/14, would be provided by the corporate office, but it had not started yet. He stated they ordered all new parts for the van. Another interview with the Administrator on 03/04/14 at 3:00 PM revealed the facility did not have a facility manual or a manufacturer's manual on how to properly secure a wheelchair in the van using the straps. The facility's training records reflected Driver B attended "Van Safety and Restraints" training on 03/03/14. The facility's current undated Resident Securement Training materials reflected the front straps should be anchored "on the floor track 3" outside front wheels. 30-45 degree angle. Secure close to seat surface to a welded junction. Ensure track fittings and straps are secure." The back straps should be anchored to the "inside of the rear wheels. 30-45 degree angle. Secure straps to welded junction of the wheelchair frame. Ensure track fittings and straps are secure." Interview with Human Resources F on 03/04/14 at 2:02 PM revealed there were no training records regarding transportation for Driver B and there was no department of motor vehicle driving record checks. Interview with the Administrator on 03/04/14 at 3:40 PM revealed he was aware there had not been any trainings regarding transporting residents and no checks of staff, who would be transporting residents, driving records. Further interview with the Administrator on 03/04/14 at 11:34 AM revealed the facility was in the process of developing policies and procedures regarding transporting residents. Prior to the incident, the facility did not have policies and procedures in place regarding transporting residents in the facility van. The Administrator stated the facility van had not been used since the incident on 02/19/14, and new parts had been ordered for the van. The Administrator revealed once the parts arrived, the straps in the van would be replaced. Interview with SW C on 03/04/14 at 3:55 PM revealed she arranged all transportation for residents to their appointments. She stated since 02/19/14, the facility had not transported any residents in the facility van. SW C revealed the facility was using a transportation company to transport the residents to appointments. Interview with SW C on 03/04/14 at 10:30 AM revealed the last time Driver D drove the van was in January 2014. SW C stated Driver D D did not receive training on transporting residents. Interview with Driver D on 03/05/14 at 10:45 AM revealed he had been working at the facility for five years. He stated he was trained on how to strap resident's wheelchairs in the van and transport residents in the van by Driver B. Driver D revealed the first time he drove the van was three or four years ago. He stated he drove residents in the van in January 2014 when Driver B was on leave. An IJ was identified on 03/04/14. On 03/04/14 at 4:30 PM, the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. Interview with Administrator on 03/05/14 at 12:15 PM revealed the facility would be getting rid of the van on the advice of the corporate attorneys and the parts previously ordered for the van were returned. He stated the facility would be using a third party company to transport all residents. Interview with Administrator on 03/05/14 at 2:00 PM revealed SW C and Driver D would be watching the training video and then demonstrating how to properly use the straps to secure a wheelchair in the van. He stated he was not aware Driver B strapped in Resident #1's wheelchair incorrectly. Driver B told the Administrator and Investigator after watching the training video it was recommended the straps be placed from the widest point from the wheelchair to the point strap was locked into place and not lock the strap close to the wheelchair and place in the middle of the wheelchair. The facility's training records,dated 03/05/14, reflected SW C and Driver D attended "Van Safety and Restraints" Training on 03/05/14. The facility's transportation appointment book from 02/19/14 through 03/05/14 reflected resident transportation was arranged with a private transportation company. The facility's Plan of Removal, accepted on 03/05/14, reflected: The following 13 residents, who were also in wheelchairs, could have been affected: Resident #2, Resident #3, Resident #4, Resident #6, Resident #7, Resident #8, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, and Resident #18. On 03/05/2014, the Administrator decided to remove the facility van from any future resident transportation services. As such, no further investment would be made to train staff or purchase harness equipment for the van. The facility would keep the existing transportation providers. Driver B was suspended immediately following the incident on 02/19/14, and he returned to work on 02/26/14, but not to drive the van. On 02/24/14, the facility acquired a training video on safe resident transportation which demonstrated proper use and application of wheelchair safety harnesses. Although the training video would no longer be used since the facility van would not be transporting residents, the following employees watched the video on these dates: Driver B (03/03/2014), SW C (03/05/2014), and Driver D (03/05/2014). Observation of SW C on 03/05/14 at 3:40 PM revealed she demonstrated how to properly strap a wheelchair in the van by strapping the wheelchair in at four points. She strapped two in the front and two in the back using the widest points to lock the straps in place. Observation of Driver D on 03/05/14 at 3:50 PM revealed he demonstrated how to properly strap a wheelchair in the van by strapping the wheelchair in at four points, with two in the front and two in the back using the widest points to lock the straps in place. On 03/05/14 the IJ was removed. On 03/05/14 at 4:28 PM, the Administrator and DON were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility still implementing the Plan of Removal. The facility's Plan of Removal, accepted on 03/05/14, reflected 13 residents, who were in wheelchairs and could have been affected by the facility failures.