Every finding on record at Cedar Hollow Rehabilitation Center

Based on interviews and record reviews, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 1 of 3 residents (Resident #1) reviewed for pressure ulcers.The facility failed to ensure preventative measures were in place to prevent Resident #1 from developing a DTI to his right hip, right foot, and right heel within 2 days of his admission to the facility.This failure placed residents at risk of the development and/or deterioration of pressure ulcers. Findings included:Record review of Resident #1's admission MDS assessment, dated 08/07/26, revealed he was an [AGE] year-old male who admitted to the facility on [DATE] with the following diagnoses: Alzheimer's Disease (progressive brain disease that causes a slow decline in memory, thinking, and reasoning skills), Osteoporosis (weak and fragile bones), and BPH (enlarged prostate). The MDS revealed that he had a BIMS score of 3, indicating severe cognitive function. The MDS also revealed Resident #1 was dependent on staff for all ADLs and admitted to the facility on hospice services. Record review of Resident #1's Care Plan, dated 07/27/26, revealed that he was on hospice services with a diagnosis of Alzheimer's Disease with an intervention of, Skin break down and/or pressure sores are expected the Facility/agency will plan and implement measures that will preserve as much skin integrity as possible. The care plan also revealed that Resident #1 required extensive assistance of 2 staff members for ADL care. The Care plan revealed that Resident #1 had documented pressure ulcer with interventions to, Monitor ulcer for signs of progression or declination, Notify family of new onset finding, Notify provider if no signs of improvement on current wound regimen, Provide wound care per treatment order. Record review of Resident #1's Clinical admission noted completed on 07/25/26 by LVN A revealed that Resident #1 admitted with no skin issues and Skin warm & dry, skin color WNL, turgor normal.Record review of Resident #1's Braden Scale Assessment completed on 07/25/26 by LVN A revealed a score of 13, indicating a moderate risk for developing pressure ulcers. No interventions or suggestions were noted on the assessment. Record review of hospice RN visit note completed on 07/25/26 revealed Resident #1 was pale with poor skin turgor (reduction in skin elasticity), and had purpura (purple, red or brown spots on the skin) and a few small scabs on forearms. Record review of Resident #1's skin assessment completed on 07/27/26 by ADON B revealed that Resident #1 had the following skin issues: Pressure ulcer/injury to right gluteal fold, pressure ulcer/injury to right heel, and pressure injury/ulcer to right dorsum foot. On the assessment, it also noted: Additional care: Pressure reducing device for bed.Skin Issues Note: Requested an air mattress from the hospice provider and applied to bedSkin issue notification: Provider. Skin issue notification: Family. Skin issue notification: Manager. Additional skin issue notification documentation: Hospice Provider NotifiedRecord review of Resident #1's skin assessment completed on 08/08/26 by ADON B revealed the following: Skin Issues Note: The resident arrived at the facility on July 25, 2026. No skin issues were identified during the admission assessment. However, upon my initial skin evaluation on Monday, July 27, 2026, the following wounds were noted: a pressure ulcer on the right gluteal fold (hip), the right dorsum of the foot, and the right heel. Hospice was notified and requested to provide a low air loss mattress. The patient was placed on a low-air-loss mattress, and treatment orders were initiated. The hospice nurse informed the spouse. During a telephone interview on 08/20/26 at 9:40 AM, Resident #1's Family Member stated that he did not have any wounds before going to the facility. She stated Resident #1 was on hospice and was only in the facility for a short time while she had surgery. The Family Member stated that Resident #1 had been bedbound for 3 years and had only had 1 wound prior and it was from being in the hospital. The Family Member stated that his wounds had not improved since he came home on 8/15/26. During an interview on 08/20/26 at 10:35 AM with LVN C, she stated that new admissions get a skin assessment when they first admit and then were seen by the ADON/Treatment nurse afterwards. LVN C stated she did care for Resident #1 while he was at the facility. She stated Resident #1 admitted for respite care and was contracted with his legs crossed and very stiff. LVN C stated Resident #1 did have pressure wounds and received wound care every day. She stated she was not sure if Resident #1 admitted to the facility with the wounds. LVN C stated that when she cared for Resident #1, he had an air mattress, they would put pillows to offload and had a bar to keep the sheets of his feet. She stated she could not recall when those were implemented. She stated Resident #1 had very fragile skin and it would break down if anything touched his skin. LVN C stated no one had reported new wounds to her but that the orders were being updated and changed when she came back to work. LVN C stated the risk of not preventing pressure ulcers was an increased chance of wounds and decreased quality of life. During an interview on 08/20/26 at 11:27 AM with ADON B, she stated she was the treatment nurse and rounded with the wound physician. She stated Resident #1 was admitted on a Saturday (07/25/26) for emergency respite. She stated she evaluated him the following Monday (07/27/26) and ordered a low air loss mattress for his wounds. ADON B stated she had initially assumed the wounds were present on admission, but when she reviewed the records she saw that they were not present on the admission assessment. ADON B stated she just judged by his condition of being thin, fragile, and contracted and had thought he admitted with them. She stated no staff had informed her of the wounds, but that she assessed all new admissions. ADON B stated that there was no pressure wound interventions to prevent sores when he admitted but that she immediately got an air mattress for him. ADON B stated his stiffness worsened while he was at the facility and his wounds continued to decline. She stated there was a wound on his hip that resolved, but he developed new wounds and others were not showing improvement. ADON B stated the pressure wounds were deep tissue injury and unstageable (localized damage to underlying soft tissue caused by pressure). She stated Resident #1 was repositioned and offloaded with pillows. ADON B stated if he had an air mattress on admission, it could have helped prevent the wounds. She stated all the nurses and aides were responsible for ensuring that preventative measures were in place to prevent pressure ulcers. ADON B stated the risk of not having more prevention in place was residents could develop or worsen existing pressure wounds. She stated she wished Resident #1 had an air mattress on admission. During a telephone interview on 08/20/26 at 12:15 PM, the Hospice Case Manager stated that she had cared for Resident #1 for approximately 4 months. She stated Resident #1 went to the facility on [DATE] until 08/15/26 for an emergency respite. The Hospice Case Manager stated that Resident #1 developed the wounds while at the facility and developed them very quickly. She stated Resident #1 was very frail. She stated he had a low air loss mattress once he had the wounds. The Hospice Case Manager stated that when she visited Resident #1, he was repositioned with pillows. She stated he crossed his legs and was very stiff, so the pillows were needed. The Hospice Case Manager also stated that the facility staff put boots on him and had a bar to prevent his feet from getting tangled in the sheets. She stated that he became more rigid and less interactive, so she feels like his disease had progressed. The Hospice Case Manager stated since coming home, he had developed new wounds as well. During a telephone interview on 08/20/26 at 12:24 PM, the Wound Physician stated that he visited Resident #1 three times while he was at the facility. He stated the first visit was on 7/31/26 and that he had 3 pressure wounds at the time. The Wound Physician stated the pressure wounds were DTIs that had not broken the skin. He stated when he first saw them he was not sure if they would improve or worsen based on Resident #1's condition. The Wound Physician stated Resident #1 admitted to the facility on a Saturday and then the wounds were found the following Monday. He stated it was not normal for that many wounds to occur that quickly but was possible with end of life and that the wounds could have potentially occurred within 12 hours. The Wound Physician stated that Resident #1 slowly declined over the 2 weeks and developed 3 new wounds. He stated the new wounds were unavoidable due to having interventions in place and Resident #1's decline. The Wound Physician stated he could not determine if the initial 3 wounds were avoidable or unavoidable. He stated it was impossible to know for sure, but that with more interventions the wounds could have been prevented; however, he stated he did not feel that an air mattress was indicated on admission or any further wound pressure interventions due to him not having wounds on admission. The Wound Physician stated that Resident #1 was deteriorating and had a decline in condition while he was in the facility. During a telephone interview on 08/20/26 at 2:03 PM, CNA D stated that Resident #1 did not initially have wounds when she worked with him on 07/25/26. She stated she reported any new wounds immediately to the nurse. CNA D stated that she rounded on Resident #1 at least every 2 hours and would reposition him with the pillows. She stated Resident #1 was very stiff but would turn with assistance. She stated that the CNAs and nurses were responsible for preventing pressure ulcers. During an interview on 08/20/26 at 3:03 PM, ADON E stated that she did treatments and communicated with the Hospice Nurse when she visited. ADON E stated Resident #1 was a small, malnourished man and had normal wound precautions when he admitted . She stated he came on the weekend on emergency respite and when ADON B assessed him, treatment orders were initiated for the wounds. ADON E stated he did get an air mattress and was being repositioned with pillows. She stated his skin was very fragile and they also added a foot bar to keep the bed sheets off his legs because the sheets would break down his skin. ADON E stated that all staff were responsible for helping prevent pressure wounds. During an interview on 08/20/26 at 3:45 PM, the DON stated that Resident #1 came to the facility on a weekend for emergency respite. She stated when she was originally told about the wounds, she assumed Resident #1 had them on admission. The DON stated she did a deep dive into his wounds and she found that they developed at the facility and were not present on admission. She stated Resident #1's skin broke down with any touching. The DON stated she reviewed his hospice records and did not recall seeing any special equipment. She stated Resident #1 was on a regular mattress when he was admitted and the staff repositioned him. The DON stated once they found the wounds, they put him on a low air loss mattress, repositioned him, and put a foot cradle in place. She stated Resident #1 was very stiff and was difficult to move or separate his legs. The DON stated the nursing staff was responsible for ensuring that prevention was in place to prevent pressure ulcers. The DON stated that the risk of pressure ulcers was causing pain and infection to the resident. Telephone interview attempt on 08/20/26 at 10:53 AM with LVN A was unsuccessful. Record review of the facility's Prevention of Pressure Ulcers/Injuries policy, dated December 2025, revealed the following: .PreventionMoisture1.Keep the skin clean and free of exposure to urine and fecal matter.Nutrition1. Monitor the resident for weight loss and intake of food and fluids.2.Include nutritional supplements in the resident's diet to increase calories and protein, as indicated in the care plan.Mobility/Repositioning1.Choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition and tolerance, and the resident's stated preferences.2.At least every two hours, reposition residents who are reclining and dependent on staff for repositioning.3.Reposition more frequently as needed, based on the condition of the skin and the resident's comfort.4.Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions.Support Surfaces and Pressure RedistributionSelect appropriate support surfaces based the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents. The facility failed to provide Resident #1 with adequate supervision while transferring the resident from a shower to his bed on 06/25/26, which resulted in the resident sustaining a laceration to his leg that required treatment at the hospital. The noncompliance was identified as past noncompliance (PNC). The PNC began on 06/25/26 and ended on 06/26/26. The facility had corrected the noncompliance before the state's survey began. This failure could place residents at risk of being in an unsafe environment and at risk of accidents and injury.Findings included: Record review of Resident #1's undated Face Sheet reflected the resident was an [AGE] year-old male, who admitted to the facility on [DATE]. The resident's diagnoses included: acute kidney failure (sudden and dramatic loss of kidney function), muscle wasting and atrophy (thinning of muscle mass and loss of strength), type two diabetes (sugar builds up in the blood when the body cannot use insulin correctly), polyosteoarthritis (five or more joints have degeneration of cartilage) generalized muscle weakness, difficulty in walking, and unsteadiness on feet. Record review of Resident #1's admission MDS assessment (undated) reflected Resident #1 required substantial assistance with chair to bed transfers, and he had a BIMS score of 12, indicating moderate cognitive impairment. Record review of Resident 1's active Care Plan, undated, reflected he had an ADL self-care performance deficit related to rheumatoid arthritis initiated 04/17/26 with an intervention that he required extensive assistance of two staff participation in transfers. The care plan also reflected that he had an impairment to skin integrity related to laceration of his left lower extremity with the date initiated 06/26/26 which included an intervention to identify and document potential causative factors and eliminate/resolve where possible. Record review of an incident report dated 06/25/26, completed by RN A, reflected Resident #1 had been transferred from the shower chair to the bed by three staff members using a gait belt, and when Resident #1 was turned to be placed to bed, his left lower leg was noted to be cut open. 911 had been called, the physician notified, Resident #1's leg was wrapped to stop the bleeding, and he was transferred via EMS to the local emergency department. The incident report reflected Resident #1 had been oriented to person, place, and situation at the time of the incident. Injuries reported post incident included a laceration to the lower right front leg. The incident report did not identify any predisposing environmental, physiological, or situational factors. Other information included the statement that, More than likely Resident obtained laceration to left lower leg from bed during transfer. No sharp edges were noted on shower chair or bed. Injury not suspicious for abuse or neglect. Resident denies abuse and neglect. Notes included the statement, Bed assessed and no malfunction of bed noted. Transfer inservices in progress with staff involved in incident. Record review of the local hospital discharge instructions reflected Resident #1 was seen at the emergency department where he arrived via EMS at 5:38 p.m. The discharge instructions provided discharge information for a laceration and reflected a new antibiotic medication had been ordered. The discharge instructions reflected that a CAT scan of the head/brain, cervical, lumbar, and thoracic spine were completed as well as a left leg x-ray. The discharge instructions did not include test results, and the hospital records were requested from the local hospital. Review of Resident #1's nurse's progress note by RN A dated 06/25/26 at 08:39 p.m. reflected that a staff member alerted RN A that she needed help transferring Resident #1 from the shower chair to the bed and that Resident #1 stated he was tired, his knees were sore, and he needed more help to get back in bed. A t-shirt and a gait belt were placed on the resident, and three staff attempted to stand Resident #1. Resident #1 grabbed hold of the side rail and attempted to help himself up, at the same time as the staff were transferring him. When the staff had turned to place Resident to bed, his left lower leg was noted to be cut open. 911 was called, the physician was notified, the lower left leg was wrapped securely and bleeding stopped, and Resident #1 was transferred via EMS to the local emergency department. The patient representative and the DON were notified. In a telephone interview on 08/06/26 at 12:03 p.m., Resident #1 reported that he had been discharged from the facility about two weeks after the incident. He stated, on the evening of the injury to his leg, there were 3 female staff in his room, and that later a 4th came in. He stated, They had given me a shower, and I was in the shower chair in my room. They were going to pick me up and they had my feet up on the bed and they started lifting me up and my feet fell off and they tried to push me back on the bed and somehow my leg was in a twist. Resident #1 did not state that he experienced pain during the transfer or that staff had done any part of the transfer wrong. He stated his leg was cut on the bed frame of the bed. He stated his leg was wrapped, 911 was called, and he was sent to the hospital where he received 37 stiches. Resident #1 stated he continued to need home health care for wound care to his leg since his discharge. In an interview on 08/06/26 at 12:49, RN A stated that on 06/25/26 CNA B had come and got her to assist with transferring Resident #1 from the shower chair to his bed. She stated that Resident #1 could stand, but he was tired from his shower. She stated, at that time, it had been in Resident #1's care plan that he was to be transferred with two-person assistance. RN A stated Resident #1 was wearing a shirt and had a gait belt securely in place at the time of the transfer. She stated Resident #1 was positioned close to the bed prior to the transfer and herself, CNA C, and LVN D were assisting Resident #1. RN A stated that when they were turning his bottom to the right and onto the bed, his left leg may have caught something under the bed on the frame. I really don't know. She stated that, as soon as we got him turned and on the bed his leg was sliced, and you could tell he needed sutures. She stated, we did everything right and we used the gait belt. She stated, his leg had to have been too close to the bed and that caused the injury. She stated she had not seen anything sharp on the bed or bedframe or any issues with the bed, but there must have been something under the bedframe. She stated that after Resident #1 returned from the hospital, he had been placed on Hoyer lifter transfers. RN A stated that Resident #1 had a urinary catheter, but it did not play any role in the injury. She stated she had received training on all types of transfers prior to the incident. She stated, at the time of the incident, she had notified the MD, the DON, the resident representative, and the Administrator. She stated that following the incident, the facility again provided all types of transfer training for all nursing staff. She stated she was required to check off on return demonstration. In an interview on 08/06/26 at 01:20 p.m., the Administrator stated that during the transfer in which Resident #1's leg was injured, a CNA had gone and got a nurse to assist with the transfer because Resident #1 was a two-person assist and voiced he was weak. The staff obtained additional staff to assist. The Administrator stated that during the transfer, an injury to Resident's #1's leg had occurred, but that she was not a nurse and did not know the difference between skin tears and lacerations. She stated it was a freak accident and not a failure to follow the care plan. She stated the family was not upset, but that Resident #1 did require stitches. The Administrator stated that Resident #1 continued therapy and had no infection to the wound to her knowledge. She stated an environmental assessment had been done by nursing and they also looked to see if they could find blood somewhere but that no blood and no source of injury had been identified. She stated that the Maintenance Director had checked the beds and equipment, and no potential source of injury and no faulty equipment was identified. She stated that the Maintenance Director made environmental safety rounds each week. She stated that the facility's DON was on vacation and not available for interview. In an interview on 08/06/26 at 2:00 p.m., the Maintenance Director stated that the day after the incident with Resident #1 (6/26/25), he had completed an environmental assessment of the room, the shower chairs, and the bed. He stated he did not find mechanical issues or damage to the equipment, and he did not find anything sharp on or under the bed. He stated that there were plastic caps that sometimes popped off the frame under the residents' beds, but that Resident #1's bed had them in place. He stated that when staff noted that one of them had come off a resident's bed, they had been good about notifying him and he had replaced them right away. He stated this did not occur very often. He stated the beds at this facility were newer and rarely had any issues. He stated that he did environmental rounding for safety on the beds, the rooms, and equipment each week. In an interview on 08/06/26 at 02:51 p.m., CNA C stated that she had received training on transferring residents upon her hire. She stated, on the evening of 06/25/26, CNA B had given Resident #1 a shower and wanted help to transfer him back to the bed from the shower chair, and Nurse A came and got her to assist. She stated she put a shirt on Resident #1 because she knew they were going to use a gait belt. She stated that during the transfer they noticed Resident #1's leg was bleeding. She stated that during the transfer, Nurse A was on his right side and she was behind his chair on the left side. She stated she did not see his leg hurt by the bed or under the bed but, the only thing close to his leg was the bed and he said the bed hurt his leg and there was nothing else between him and the bed. She stated the bed frame could be considered sharp for elderly fragile skin. She stated, we did everything we could to keep him safe. She stated Resident #1's left outer to middle leg had a laceration. She stated that they were able to transfer him to the bed and he had not been on the floor at any time. She stated one of the nurses (name unknown) had gone and gotten a wound care cart to wrap the wound, and he was transferred to the hospital by ambulance. She stated that all staff received transfer training the next day. She stated that staff were required to give return demonstration. In an interview on 08/06/26 at 3:36 p.m., CNA B stated prior to Resident #1's incident, she had received transfer training at the facility. She stated that on the evening of 06/25/26, she had assisted Resident #1 with his shower, and he was tired afterwards. She stated she notified Nurse A for additional help. She stated she had left the room and when she returned, she saw two CNAs and Nurse A transferring Resident #1 back into bed. She stated, That is when he sliced his leg. I think underneath the mattress are those bars and I think that is what he hit. She stated they were able to get him into the bed, and he was never on the floor. She stated she did not see anything sharp or any malfunction in the bed. She stated, they were using the gait belt. She stated that after the incident she and other staff received training on the different types of transfers and she completed a quiz. In an interview on 08/08/26 at 4:00 p.m., LVN D stated she had previously received training on all types of transfers including mechanical lifts. She stated that on 6/25/26, she was asked by a CNA to come assist with Resident 1's transfer and the nurse came and got her too. She stated they had given him a shower and needed to get him back in bed because he was a two-person transfer. She stated she had previously taken care of him, and he had been a two-person transfer, and he did well with that. She stated RN A, CNA B, herself, and another CNA were in the room. She stated she had been behind the wheelchair, kind of guiding with the gait belt, and RN A and CNA B were transferring him. She stated his bed was on the left and his wheelchair was close to the bed. She stated that during the transfer she thought everything was okay until RN A said his leg was cut. She stated she had not seen what had happened. She stated that Resident #1's left leg, had to have hit the bed. She stated there was nothing else between him and the wheelchair. She stated she went back and looked at the bed and there were no signs of anything sharp or broken about the bed and, it was just a normal bed. She stated the next day she, again, received transfer training including a quiz. In an interview on 08/06/26 at 4:29 p.m., ADON G stated that the day following the incident with Resident #1, on 06/26/26, she had begun providing training to all nursing staff for one and two-person assist and mechanical lift transfers with return demonstrations required. She also stated she had provided training in preventing and responding to accidents. Record review of facility in-service training records dated 06/26/26 and titled, Accidents and Hazards reflected staff received training on the safe lifting and movement of residents and the accident and incidents policies. Staff skills checkoffs, quizzes, and return demonstration documentation were reviewed. In an interview on 08/06/26 at 4:30 p.m., the Administrator reported all staff had received training on one and two-person transfers and mechanical lift training and this had been documented. In an observation on 08/06/26 at 4:45 p.m., residents' beds on Hall 100 and Hall 200 were randomly sampled for safety and maintenance concerns with the Maintenance Director. No safety or maintenance concerns were identified. This observation included the bed identified as the former bed of Resident #1. Reviewed the facility's Safe Lifting and Movement of Residents policy, dated December 2025, reflected, In order to protect the safety and well-being of staff and residents and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.

Based on interview and record review, the facility failed to establish and implement an admissions policy that ensured residents were not requested or required to waive potential facility liability for losses of personal property upon admission for 2 of 2 residents (Resident #2 and Resident #3) reviewed for admissions policy. The facility's admission policy had a statement waiving the facility from liability for the security of residents retained personal property for Residents #2 and #3. This failure could place the residents at risk of not having the right to use personal possessions and financial loss. Findings included:Record review of Resident #2's undated face sheet reflected the resident was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including multiple fractures of the ribs (broken ribs) and dementia (condition that affects memory, thinking and the ability to perform daily activities).Record review of Resident #3's undated face sheet reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including multiple fractures of the ribs (broken ribs) and cognitive communication deficit (language comprehension and production difficulty).Record review of Resident #2's admission Agreement, dated 07/27/26, was signed by the resident representative.Record review of Resident #3's admission Agreement, dated 03/16/26, was signed by the resident representative.Record review of the facility's Admissions Policy revealed the statement, .The Facility assumes no liability for the security of personal items retained by Resident or kept in the Resident's room. All articles retained by the Resident (including dentures, hearing aids, eyeglasses, jewelry, and documents) shall be the responsibility of the Resident .In an interview on 08/07/26 at 5:15 PM, the Administrator stated she was unaware that the Admissions Policy could not contain that statement. She stated that the Admissions Director was responsible for having residents sign this policy, but the Admissions Director was on vacation and was not available for an interview. She stated that the facility previously replaced a resident's dentures on at least one occasion.

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 infection for 1 (Resident #1) of 6 residents reviewed for infection control. The facility failed on 06/12/26 to ensure infection control procedures were followed when the Staffing Coordinator, CNA B and CNA C provided perineal care, emptied catheter bag, changed linens and transferred Resident #1, who was on enhanced barrier precautions, from the bed to the wheelchair without donning appropriate PPE. This failure could place residents at risk of infection.Findings included: Record review of the Nursing Home Infection Preventionist Training course (web-based) certificate, revealed IPC completed training on 06/10/2026. Record review of Resident #1's face sheet, dated 06/12/26, reflected a [AGE] year-old female, admitted and readmitted [DATE]. She was diagnosed with acute kidney failure unspecified (kidneys can no longer effectively filter waste and toxins from the blood, leading to serious health complications), difficulty in walking; not classified elsewhere, overactive bladder (sudden urges to urinate that may be hard to control) and heart failure(Heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). Record review of Resident #1's physicians' order summary, dated 06/12/26, revealed, Resident is on EBP and Standard Precautions r/t Catheter. Resident is not limited to room or activities. Every shift for Enhanced barrier precautions medical condition staff must don gown & gloves when performing high contact care such as bathing/showering, peri-care/brief changes, dressing changes, meds via enteral tube or central line, toileting, transfers, providing hygiene, changing linens, device care.initiated on 06/05/26. Record review of Resident #1's care plan, undated, revealed [Resident#1] have a condition that required Enhanced.Barrier Precautions. The care plan indicated EBP were related to catheter initiated on 05/07/2026. Goals reflected infection control intervention to reduce the transmission of multidrug-resistant organisms . Interventions reflected, Staff must don gown and gloves after entering the room to provide high contact resident care activities such as dressing, bathing/showering, transfers, providing hygiene, changing linens, toileting/brief changes, device care, med administration. During an observation on 06/12/26 at 9:40 A.M., Resident#1 had an EBP sign outside of his room that indicated: STOP:Everyone Must:Clean hands with alcohol-based hand rub (ABHR) when entering and leaving the room. Doctors and Staff Must:Wear gloves and a gown for the following high-contact resident care activities:DressingBathing/showeringTransferring (e.g., bed to wheelchair)Changing linensProviding hygieneChanging briefs or assisting with toiletingDevice care or use: central line, urinary catheter, feeding tube, tracheostomy.Wound care: any skin opening requiring a dressing During an observation on 06/12/26 at 9:50 A.M, the Staffing Coordinator and CNA C provided perineal care and changed Resident #1 linens with no disposable gowns. Observed CNA B empty Resident #1's catheter bag with no disposable gown on. Observed the Staffing Coordinator, CNA B and CNA C dress Resident #1 and transferred her from the bed to the wheelchair with no disposable gowns on. During an interview on 06/12/26 at 10:40 A.M., the Staffing Coordinator, CNA B and CNA C stated they were nervous and anxious and realized they did not put on the gown when caring for Resident #1. CNA B stated she let the DON know right afterwards. CNA B stated that when high contact care was provided to residents on EBP gowns and gloves should be worn to prevent the spread of infection. The Staffing Coordinator stated residents with indwelling equipment like G-tube, catheters and wounds were on EBP. CNA C stated high contact care included change of brief and sheets. CNA B stated PPE was worn to protect the residents and protect staff from cross contamination. The Staffing Coordinator stated they were trained on infection control prevention as it seemed monthly. During an interview on 06/12/26 at 1:36 P.M., the DON stated the Staffing Coordinator, CNA B and CNA C were good nurse aides and were nervous and forgot to put on the gown. The DON/IPC stated staff were trained in infection control prevention often to help prevent cross contamination. During an interview on 06/12/26 at 4:15 P.M., Resident #1 stated nursing staff always washed their hands and put on gloves. Resident #1 stated the nursing staff usually did not wear the gowns. Record review of the facility policy titled, Enhanced Barrier Precautions Policy, revised 12/2025, reflected: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing.1. Enhanced Barrier Precautions shall apply to the care of all residents in the facility with an infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or wounds.and/or indwelling medical devices even if the resident is not known to be infected or colonized with aMDRO.8. PPE for Enhanced Barrier Precautions is only necessary when staff are performing high contact care.activities and may not be donned prior to entering the resident's room.

Based on interview and record review the facility failed to ensure they provided notice to residents when changes in coverage were made to items and services covered by Medicare as soon as reasonably possible for one (Resident #4) of three residents reviewed who received Medicare skilled services but were discharged , in that: Resident #4 was not given a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) when she was discharged from skilled services at the facility. This failure could affect residents who were discharged prior to using all their Medicare benefits and could deny them of their right to be fully informed about services covered or their right to appeal.The findings included: Review of Resident #4's face sheet, dated 05/07/26, revealed the resident was an [AGE] year-old female, initially admitted to the facility on [DATE], and re-admitted on [DATE]. She had diagnoses that included Alzheimer's disease, major depressive disorder (a mood disorder which can affect both emotional and physical health, and interferes with daily functioning), and unspecified encephalopathy (a type of brain dysfunction or damage in which the specific cause is unknown.) Review of a Department of Health and Human Services Centers for Medicare & Medicaid Services SNF Beneficiary Protection Notification Review worksheet reflected Resident #4's Medicare Part A Skilled Services Episode Start Date was 10/14/25, and the last day her part A stay was covered, due to her voluntary discharge was 01/08/26. Section 1 of the form, regarding the SNF ABN form was left blank. Section 2 of the form reflected the resident received a Notice of Medicare Non-coverage (NOMNC) form. A copy of the NOMNC form was attached to the document, but SNF ABN form was attached. Review of the NOMNC form, dated 01/05/26, reflected her Medicare Skilled Services would end on 01/07/26 the document was signed by Resident #4's representative. During an interview with the BOM on 05/07/26 at 1:46 PM she said she had only been in the position since January of 2026, and had not done this job prior to that. She had not been aware she needed to provide the SNF ABN form before this interview. During an interview with the ED on 05/07/26 at 3:44 PM she said the residents who were living there were not living there for free, and it was their right to know what was being covered, and what was not. She said the facility had the responsibility to educate and advise them of this information ,and it was all about communication. Review of an email response by the ED, sent on 05/07/26 at 3:06 PM reflected the facility did not have a policy specifically for SNF ABN and NOMNC noticed, and they used the Medicare documents on the Medicare web site, and instructions such as the Medicare Learning Network (MLN). Review of the undated document Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 (2024), provided by the ED, reflected Overview: [.] Medicare requires Skilled Nursing Facilities (SNFs) to issue the SNF ABN to Original Medicare, also called fee-for-service (FFS), patients prior to providing care that Medicare usually covers, but may not pay for [.] The SNF ABN provides information to the patient so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. [.] It is important to note that the SNF ABN, CMS-10055, is only issued if the beneficiary intends to continue services and the SNF believes the services may not be covered under Medicare.

Based on observations, interviews and record reviews, the facility failed to use proper food handling procedures and chemical storage for * 1of 1 facility kitchen reviewed for food lunch preparation. The facility failed to use proper serving utensil during food preparation.The facility failed to properly store chemicals away from ready-to-eat food.This failure could place residents at risk of cross contamination, food borne illness, and negative effects of ingesting potentially harmful non-food substances. Findings Included:Observation on 05/06/26 at 11:48 AM of [NAME] A picked up a prepared grill cheese sandwich with her gloved hand and placed it on plate for lunch services.Observation on 05/06/26 at 11:59 AM of [NAME] A revealed during lunch observation [NAME] A reached into a plastic bag with her gloved hand, removed ad hamburger bun, separated the bun, and placed it on a resident's plate. Without removing her glove she picked up a cooked ground beef patty and placed it on the bun, then also without changing her glove picked up lettuce, tomato, and cheese, and placed it on the same plate. [NAME] A continued to plate lunch trays without changing gloves, using her hand to pick up grilled cheese sandwiches, hamburger buns, ground beef patties, lettuce and cheese.During an interview on 05/07/26 11:04 AM with [NAME] A revealed she was not supposed to pick up food items with gloved hands. She stated she was supposed to use a utensil, like tongs. She said the risk for using hands to touch multiple food items was cross-contamination of the food. [NAME] A stated she was not supposed to touch food with her hand. Observation on 05/06/26 at12;26 PM of [NAME] B revealed [NAME] B used sanitation wipes to clean the serving line then placed the sanitation wipe container on the service cart that contained pre-made salad and fruit salad plate. [NAME] B did not close the container or place additional the wipes, which were hanging down the side of the open container, back in the container. During an interview on 05/07/26 at 11:10 AM with [NAME] B revealed, I was not supposed to put the wipes there next to the food because it could cause cross-contamination. During an interview on 05/07/26 at 3:16 PM with Dietary Manager he said his expectation was that staff use proper utensils during service, because the use of utensils limited the risk of cross contamination. He stated that he ordered more tongs for the service line. He said the sanitation wipes were safe to use during service because they were food-grade safe, however the cook should have flipped the lid back shut and not placed them next to prepared food. During an interview on 05/07/26 a 3:42 PM with ED revealed the risk of using hands to pick up different food items was cross contamination of the food and/or food borne illnesses. She said the Dietary Manager would buy more utensils to ensure staff had enough utensils for serving. She said staff should follow the chemicals policy and procedure for storing the wipes which was away from food.Record review of the undated policy handling clean equipment and utensils revealed: When handling cleaned and sanitized equipment, staff will avoid touching the parts that come in contact with the food. Record review of the policy Chemical Storage, dated 12/01/25, revealed 3. chemical supplies will be kept separate from food and paper storage.

Based on 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 1 of 5 residents (Residents #1) reviewed for pharmacy services. On 01/06/26 during bedtime, CMA A administered medications to Resident #1; thereafter, the resident vomited.The facility failed to ensure Resident #1's Tramadol HCl was administered according to physician's orders, which caused the resident to miss 1 dose on 01/06/26 for pain. The facility failed to ensure Resident #1's Atorvastatin Calcium was administered according to physician's orders, which caused the resident to miss 1 dose on 01/06/26 for hyperlipidemia (high cholesterol).The facility failed to ensure Resident #1's Farxiga was administered according to physician's orders, which caused the resident to miss 1 dose on 01/06/26 for DM.The facility failed to ensure Resident #1's Remeron was administered according to physician's orders, which caused the resident to miss 1 dose on 01/06/26 for depression. The facility failed to ensure Resident #1's Eliquis was administered according to physician's orders, which caused the resident to miss 1 dose on 01/06/26 for cerebral infraction (blood clots in the brain).The facility failed to ensure Resident #1's Protein Oral Liquid was administered according to physician's orders, which caused the resident to miss 1 dose on 01/06/26 for wound healing. These failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased health status and decreased quality of life.Findings include: Record review of Resident #1's face sheet, dated 01/14/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: fracture of shaft of left tibia (broken bone along the length below knee and above ankle), acute respiratory failure (lungs not providing enough oxygen), type 2 diabetes (body does not produce enough insulin), hypokalemia (lack of potassium), paroxysmal atrial fibrillation (irregular heart rhythm), cerebral infarction (brain tissue dead), orthostatic hypotension (low blood pressure), acute respiratory failure with hypoxia (inability of the respiratory system to maintain an adequate blood oxygen level to preserve normal organ function), chronic kidney disease (loss of kidney function), muscle wasting and atrophy (loss of muscle tissue), lack of coordination (difficulty with movement), hyperlipidemia (excess fats in the blood), depression (mood disorder), edema (swelling from excess fluid in body tissues), and presence of cardiac pacemaker (device to regulate the heart's rhythm). Record review of Resident #1's Admissions MDS Assessment, dated 12/09/25, reflected Resident #1 had a BIMs score of 15 out of 15, which indicated the resident was cognitively intact. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required partial to moderate assistance with some self-care ADLs. Further review under J-Health Conditions, reflected the resident received a scheduled pain medication regimen with pain being present occasionally. Record review of Resident #1's care plan, dated 12/02/25, reflected the resident was on pain medication therapy r/t injury (L.tibia and Fibula Fx). Interventions included: administering medication as ordered, asking physician to review medication if side effects persist, monitoring respirations, monitoring for altered mental status and adverse reactions, monitoring for increased risk for falls, and reviewing pain medication efficacy (desired results). Resident #1 had type 2 diabetes mellitus with diabetic neuropathy (nerve damage caused by long-term high blood sugar). Interventions included: checking all the body for breaks in skin and treating promptly as ordered, administering medication as order, monitoring and documenting side effects and effectiveness, dietary consultation for nutritional regimen and ongoing monitoring, and referring to podiatrist/foot care nurse to monitor/document foot care needs and cutting toenails. Resident #1 had dehydration and potential fluid deficit. Interventions included: administrating medications as ordered, monitoring for side effects and effectiveness, monitoring vital signs as ordered/per protocol and record, notifying MD of significant abnormalities, and notifying physician of persistent symptoms of diarrhea, nausea/vomiting unresolved past 48 hours. Resident #1 used antidepressant medication (Remeron/sertraline) r/t depression. Interventions included: giving antidepressant medications ordered by physician and documenting/monitoring side effects and effectiveness. Resident #1 was on diuretic therapy (Lasix) r/t edema. Interventions included: administrating medication as ordered, asking physician to review medication for possible dose reduction every three months, monitoring other medications for interactions/adverse consequences, observing for possible side effects q-shift, monitoring dose, and reporting pertinent lab results to MD. Record review of Resident #1's order summary, dated 01/08/26, reflected the resident was ordered the following medications: -Tramadol HCl Tablet 50 MG-give 1 tablet by mouth every 6 hours for pain. Start date: 12/09/25. - Atorvastatin Calcium Oral Tablet 20 MG-give 1 tablet by mouth at bedtime for hyperlipidemia. Start date: 12/02/25. - Farxiga Oral Tablet 5 MG (Dapagliflozin Propanediol)-give 1 tablet by mouth at bedtime for DM. Start date: 12/02/25. - Remeron Oral Tablet 30 MG (Mirtazapine)-give 1 tablet by mouth at bedtime for depression. Start date: 12/02/25. - Eliquis Oral Tablet 2.5 MG (Apixaban)-give 1 tablet by mouth every morning and at bedtime for cerebral infarction. Start date: 12/02/25. - Protein Oral Liquid-give 30 ml by mouth every morning and at bedtime for wound healing. Start date: 12/05/25. Record review of Resident #1's Medication Administration Record for 01/06/2026, reflected the following: -Tramadol HCl Tablet 50 MG was administered at 3:00 PM and 9:00 PM by CMA A. -Atorvastatin Calcium Oral Tablet 20 MG was administered at bedtime by CMA A. -Farxiga Oral Tablet 5 MG (Dapagliflozin Propanediol) was administered at bedtime by CMA A. -Remeron Oral Tablet 30 MG (Mirtazapine) was administered at bedtime by CMA A. -Eliquis Oral Tablet 2.5 MG (Apixaban) was administered at bedtime by CMA A. -Protein Oral Liquid was administered at bedtime by CMA A. Record review of Resident #1's Medication Administration Record for 01/06/2026, reflected that CMA A administered all medications with CMAs initials. The CMA A did not document the episode of vomiting. In an interview with the Administrator and DON on 01/16/26 at 10:05 AM, Surveyor requested a policy on medication administration, but a policy on medication administration schedule was received which did not address the deficient practice. In an interview on 01/16/26 at 1:49 PM, CMA A stated she had been working at the facility for over 5 years. She stated she worked on the skilled unit. She also stated she worked 6:00 AM-2:00 PM and occasionally worked the evening shifts. She stated she was a medication aide and passed as well as reordered residents' medications. CMA A stated she worked with Resident #1 on 01/06/26. CMA A stated each time she administered Resident #1's medications that day, she would regurgitate the medication. She stated she medicated Resident #1 on the evening of 01/06/26 which included Tramadol HCl, Atorvastatin, Farxiga, Remeron, Eliquis and Protein. She made three attempts to medicate Resident #1 but she was unable to state which medications. CMA A stated on the first attempt, Resident #1 refused to take the medications. CMA A revealed on the second attempt of administering, Resident #1 spit the medications out but was unaware of exactly which medications. CMA A stated she tried to administer the third and final time while Resident #1's family member was in the room. She stated on the last attempt; Resident #1 regurgitated the medication again. She stated at the last attempt, she gave Resident #1 half the medication. When Resident #1 could not keep the medication down, CMA A threw the remaining away but unable to determine which medications. CMA A stated Resident #1's family member asked where the remaining medication was, and she told the family member she threw it away. CMA A stated she explained to the family member Resident #1 vomited the first half of the medication, so it was not like she was going to take the rest. CMA A stated protocol if a resident vomited or did not take the medications, was to report to the nurse. She stated if the medication was crushed, then they threw away the remaining of the medication that was not taken.CMA A confirmed awareness of vomiting episode; however, review of the MAR, nursing notes, and clinical record revealed no documentation of the vomiting episode, assessment of Resident #1's condition, physician notification, or monitoring for adverse events. In an interview on 01/16/26 at 2:41 PM, the DON stated she received a call on 01/19/26 from Resident #1's family complaining about medication being administered. She stated she was informed by the family that resident vomited the medication CMA A attempted to administer on 01/06/26. She stated prior to that she was not aware of Resident #1 vomiting any medications. The DON stated protocol was to document if a resident refused medications or vomited. An attempted interview on 01/06/26 at 3:00 PM with LVN B, who CMA A stated she reported to, was unsuccessful due to no response to call. In an interview on 01/14/26 at 3:15 PM, Resident #1's family member stated she visited the resident on 01/06/26 after 5:00 PM. Resident #1's family member stated when it was time for Resident #1's medication to be administered, she heard CMA A crushing it. The family member stated they were unaware of the medication being crushed. Resident #1's family member stated CMA A administered medications that were pasty and chalky in a medication cup. Resident #1's family member also stated it was thick as if CMA A did not add enough liquid. Resident #1's family revealed CMA A started with administering half the cup of medications with a spoon. The family member stated they witnessed Resident #1 regurgitating the medications. The family member stated CMA A stated, She does this all the time. She could eat food and ice cream but cannot keep her meds down. The family member stated she asked CMA A when Resident #1 would get the rest of the medication. The family member stated CMA A told them it was not much left, and she threw it away because Resident #1 was not going to keep it down anyway. The family member stated it was later reported to the DON, who stated she would investigate.

Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of four residents (Resident #1) reviewed for accidents and hazards.The facility failed to ensure Resident #1 was properly transferred from her bed to her wheelchair. CNA B attempted to transfer the resident by himself, instead of using a mechanical lift, which resulted in a fall. Resident #1 was hospitalized and required surgery for a fracture of the left femur.The non-compliance was identified as PNC. The noncompliance began on 11/30/2025 and ended 12/01/2025. The facility had corrected the non-compliance before the survey began.This failure could place the residents at risk of accident, injury or serious harm. Findings include:Record review of Resident #1's Face Sheet, dated 12/30/2025, reflected a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included dementia (decline in cognitive function that interferes with daily life), age-related osteoporosis (bone density decreases as people age, leading to fragile bones), and initial encounter for a left femur (long bone in upper leg) closed fracture (broken bone with intact skin).Record review of Resident #1's Quarterly MDS Assessment, dated 12/19/2025, reflected the resident was cognitively intact with a BIMS score of 13. Section I (Active Diagnoses) reflected a fracture of the left femur with routine healing. Record review of Resident #1's Comprehensive Care Plan, dated 09/09/2025, reflected ADL Self Care Performance Deficit r/t muscle weakness, Dementia, pain. One intervention was TRANSFER: I require Hoyer lift for transfers. Record review of Resident #1's Comprehensive Care Plan, dated 09/09/2025, reflected Alteration in musculoskeletal status r/t fracture of the left femur. Date Initiated:12/09/2025. One intervention was to Follow MD orders for weight bearing status.I currently have orders for WBAT to LLE with immobilizer in place. Initiated 12/09/2025.Record review of CNA B's statement in the incident report, dated 11/30/2025, reflected Resident #1 confirmed that she was ready to get up and was assisted to the side of the bed. Resident stood up and almost immediately her legs gave up and I assisted her to the floor. I immediately got the nurse for the nursing assessment. Resident was placed back in bed for nurse to complete her assessment. Once she got in bed, resident began complaining of pain to left leg.Record review of LVN B's statement in the incident report, dated 11/30/2025, reflected While resident was being changed and being put in wc she was lowered to the floor by CNA. Resident was put back into her bed after being assessed. No complaints of pain initially. After she was back in bed she began complaining of left leg pain. Unable to determine if injury had occurred. 911 was called d/t the extent of the pain when touching and moving left leg. The incident report indicated the resident was sent to the hospital for further evaluation. Record review of the facility's self-report of the incident, dated 11/30/2025, reflected CNA B transferred Resident #1 without using a mechanical lift. The report reflected Resident #1's legs gave out, and CNA B lowered her to the floor. Resident #1 was transferred to the hospital for evaluation. Record review of Resident #1's Hospital Report, dated 11/30/2025, reflected a left distal femur fracture which required surgery.Record review of Resident #1's Comprehensive Care Plan, dated 12/01/2025, reflected the care plan was updated to include the use of a Hoyer lift with 2 staff members. An observation on 12/30/2025 at 1:40 PM revealed CNA D and CMA E appropriately completed a Hoyer lift transfer.In an observation and interview on 12/30/2025 at 10:09 AM, Resident #1 was lying in bed awake. When asked about a recent fall, Resident #1 stated a guy was trying to move her from her bed to her wheelchair when she fell and broke her leg. She was not sure if it was a CNA. She stated it did not happen here but she did not remember where the incident occurred. Resident #1 denied pain and stated she could tell someone if she needed pain medication. During an interview on 12/30/25 at 10:29 AM, RN A stated she cared for Resident #1 but was not working when the incident occurred. She stated LVN C and CNA B were working at the time, but it was their day off. RN A stated Resident #1 had become weaker and could not bear weight on her legs. She stated it was a safety issue. She stated staff transferred Resident #1 with a Hoyer lift to/from the bed and wheelchair. She stated prior to the fall, Resident #1 would be up for about 30 minutes and wanted to go back to bed. Attempted interview on 12/30/2025 at 11:07 AM was unsuccessful. A voicemail was left for CNA B requesting a return call. Attempted interview on 12/20/2025 at 11:17 AM was unsuccessful. A voicemail was left for LVN C requesting a return call. During an interview on 12/30/25 at 11:28 AM, the DON stated CNA B should have used a Hoyer lift to transfer Resident #1 instead of attempting to transfer her by himself from the bed to the wheelchair. She stated Resident #1 was sent to the hospital and had surgery for a fracture. She stated Resident #1 returned from the hospital with an order for weight bearing as tolerated with a knee immobilizer in place. The DON stated in-service training was provided to all nursing staff, including CNA B. She stated new nurse aides were required to have training during orientation before caring for residents. During an interview on 12/30/2025 at 11:49 AM, the Executive Director stated Resident #1's care plan stated to use a Hoyer lift for transfers. She stated CNA B did not follow the care plan when he attempted to transfer Resident #1 himself. She stated the injury was of known origin, but staff failed to follow protocol, so the facility self-reported the incident. She stated it was uncommon for Resident #1 to want to get up but she asked to get up that day. She stated CNA B typically worked on a different hall but had known Resident #1 a long time and cared for her in the past. She stated Resident #1 had not always required a Hoyer lift for transfers. She stated CNA B received corrective action, and one on one in-service training on resident transfers, and accessing and implementing a resident's plan of care.In a follow up interview on 12/30/2025 at 3:55 PM, the Executive Director stated she reviewed all falls with the Interdisciplinary Team to discuss appropriate interventions. She stated she reviewed interventions weekly with the leadership team. She stated it was important to follow interventions in residents' care plans, related to transfers, to prevent injury to the resident and employee. She stated residents' needs may change. She stated therapy could evaluate a resident upon returning from the hospital and change the transfer status. She stated it was important to monitor, update, and implement care plans. She stated prior to the fall, Resident #1's care plan stated to use a Hoyer lift for transfers. She stated after the fall, it was updated to include Hoyer lift x 2 staff. She stated that was to be more specific regarding the intervention and not related to a failure to ensure 2 staff transferred a resident. She stated the appropriate intervention was included in Resident #1's care plan, but it was not followed at the time of the incident. In a follow up interview at 12/30/2025 at 4:33 PM, the DON stated it was important for staff to know the appropriate care to provide residents. She stated staff must follow the care plan interventions to prevent injury to the resident and to promote quality of life. She stated staff received in-service training on the importance of following residents' plans of care. She stated staff received in-service training on how to transfer residents and were required to demonstrate their ability to complete safe transfers.Interviews on 12/30/2025, between 1:24 PM and 4:29 PM, were conducted with multiple staff members which included the Executive Director, Director of Nurses, Assistant Director of Nurses, RN A, CNA B, LVN C, Director of Rehabilitation, CNA D, CMA E, CNA F, LVN G, LVN H, CNA/Staff Coordinator, LVN I, RN J, CNA K, CMA L, CNA M, and CNA N. Interviews revealed staff received in-service training with the therapy department and were required to demonstrate gait belt and Hoyer lift transfers. Interviews revealed staff members knew how to locate a resident's transfer status in the plan of care and understood it was important to follow appropriate interventions to prevent injury to the resident and staff. The facility initiated the following preventions prior to the state surveyor entry on 12/30/2025:On 12/01/2025 the interdisciplinary team completed a review of all residents' transfer status.Record review of the facility provided documentation, dated 12/01/2025, reflected all nursing staff received in-service training on resident neglect, where to locate residents' transfer status, and how to properly transfer with a gait belt and Hoyer lift.Record review of the facility provided documentation, dated 12/01/2025, reflected one on one in-servicing provided to CNA B with return demonstration related to mechanical lift transfers, one person and two person transfers. The employee corrective action form, dated 12/01/2025, reflected CNA B received disciplinary action for failure to use proper transfer technique with one resident. Record review of the facility provided monitoring logs, dated 12/05/2025 to 12/30/2025, reflected 2 nursing staff were observed per week for proper use of resident transfers. No concerns were noted. Record review of the facility provided monitoring log, dated 12/01/2025 to 12/30/2025, reflected clinical records were monitored for accurate transfer status five times a week. No concerns were noted.Record review of the facility provided monitoring log, dated 12/01/2025 to 12/30/2025, reflected at least 15 staff members were interviewed each week regarding resident transfer status. No concerns were noted.Record review of the facility's policy Safe Lifting and Movement of Residents, revised December 2024, reflected In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. 11. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth 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 four residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan was implemented when CNA B attempted to transfer the resident himself, instead of using a mechanical lift, which resulted in a fall. Resident #1 was hospitalized and required surgery for a fracture of the left femur.The non-compliance was identified as PNC. The noncompliance began on 11/30/2025 and ended 12/01/2025. The facility had corrected the non-compliance before the survey began.This deficient practice could place residents at risk of harm and serious injury due to not receiving the appropriate care and services.Findings include:Record review of Resident #1's Face Sheet, dated 12/30/2025, reflected a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included dementia (decline in cognitive function that interferes with daily life), age-related osteoporosis (bone density decreases as people age, leading to fragile bones), and initial encounter for a left femur (long bone in upper leg) closed fracture (broken bone with intact skin). Record review of Resident #1's Quarterly MDS Assessment, dated 12/19/2025, reflected the resident was cognitively intact with a BIMS score of 13. Section GG (Functional Abilities) indicated Resident #1 was dependent on staff for self-care and mobility needs.Record review of Resident #1's Comprehensive Care Plan, dated 09/09/2025, reflected ADL Self Care Performance Deficit r/t muscle weakness, Dementia, pain. One intervention was TRANSFER: I require Hoyer lift for transfers. Record review of Resident #1's Comprehensive Care Plan, dated 09/09/2025, reflected Alteration in musculoskeletal status r/t fracture of the left femur. Date Initiated:12/09/2025. One intervention was to Follow MD orders for weight bearing status.I currently have orders for WBAT to LLE with immobilizer in place. Initiated 12/09/2025.Record review of CNA B's statement in the incident report, dated 11/30/2025, reflected Resident #1 confirmed that she was ready to get up and was assisted to the side of the bed. Resident stood up and almost immediately her legs gave up and I assisted her to the floor. I immediately got the nurse for the nursing assessment. Resident was placed back in bed for nurse to complete her assessment. Once she got in bed, resident began complaining of pain to left leg.Record review of LVN B's statement in the incident report, dated 11/30/2025, reflected While resident was being changed and being put in wc she was lowered to the floor by CNA. Resident was put back into her bed after being assessed. No complaints of pain initially. After she was back in bed she began complaining of left leg pain. Unable to determine if injury had occurred. 911 was called d/t the extent of the pain when touching and moving left leg. The incident report indicated the resident was sent to the hospital for further evaluation. Record review of the facility's self-report of the incident, dated 11/30/2025, reflected CNA B transferred Resident #1 without using a mechanical lift. The report reflected Resident #1's legs gave out and CNA B lowered her to the floor. Resident #1 was transferred to the hospital for evaluation. Record review of Resident #1's Hospital Report, dated 11/30/2025, reflected a left distal femur fracture which required surgery.Record review of Resident #1's Comprehensive Care Plan, dated 12/01/2025, reflected the care plan was updated to include the use of a Hoyer lift with 2 staff members. An observation on 12/30/2025 at 1:40 PM revealed CNA D and CMA E appropriately completed a Hoyer lift transfer.In an observation and interview on 12/30/2025 at 10:09 AM, Resident #1 was lying in bed awake. When asked about a recent fall, Resident #1 stated a guy was trying to move her from her bed to her wheelchair when she fell and broke her leg. She was not sure if it was a CNA. She stated it did not happen here but she did not remember where the incident occurred. Resident #1 denied pain and stated she could tell someone if she needed pain medication. During an interview on 12/30/25 at 10:29 AM, RN A stated she cared for Resident #1 but was not working when the incident occurred. She stated LVN C and CNA B were working at the time, but it was their day off. RN A stated Resident #1 had become weaker and could not bear weight on her legs. She stated it was a safety issue. She stated staff transferred Resident #1 with a Hoyer lift to/from the bed and wheelchair. She stated prior to the fall, Resident #1 would be up for about 30 minutes and wanted to go back to bed. Attempted interview on 12/30/2025 at 11:07 AM was unsuccessful. A voicemail was left for CNA B requesting a return call. Attempted interview on 12/20/2025 at 11:17 AM was unsuccessful. A voicemail was left for LVN C requesting a return call. During an interview on 12/30/25 at 11:28 AM, the DON stated CNA B should have used a Hoyer lift to transfer Resident #1 instead of attempting to transfer her by himself from the bed to the wheelchair. She stated Resident #1 was sent to the hospital and had surgery for a fracture. She stated Resident #1 returned from the hospital with an order for weight bearing as tolerated with a knee immobilizer in place. The DON stated in-service training was provided to all nursing staff, including CNA B. She stated new nurse aides were required to have training during orientation before caring for residents. During an interview on 12/30/2025 at 11:49 AM, the Executive Director stated Resident #1's care plan stated to use a Hoyer lift for transfers. She stated CNA B did not follow the care plan when he attempted to transfer Resident #1 himself. She stated the injury was of known origin, but staff failed to follow protocol, so the facility self-reported the incident. She stated it was uncommon for Resident #1 to want to get up but she asked to get up that day. She stated CNA B typically worked on a different hall but had known Resident #1 a long time and cared for her in the past. She stated Resident #1 had not always required a Hoyer lift for transfers. She stated CNA B received corrective action, and one on one in-service training on resident transfers, and accessing and implementing a resident's plan of care.In a follow up interview on 12/30/2025 at 3:55 PM, the Executive Director stated she reviewed all falls with the Interdisciplinary Team to discuss appropriate interventions. She stated she reviewed interventions weekly with the leadership team. She stated it was important to follow interventions in residents' care plans, related to transfers, to prevent injury to the resident and employee. She stated residents' needs may change. She stated therapy could evaluate a resident upon returning from the hospital and change the transfer status. She stated it was important to monitor, update, and implement care plans. She stated prior to the fall, Resident #1's care plan stated to use a Hoyer lift for transfers. She stated after the fall, it was updated to include Hoyer lift x 2 staff. She stated that was to be more specific regarding the intervention and not related to a failure to ensure 2 staff transferred a resident. She stated the appropriate intervention was included in Resident #1's care plan, but it was not followed at the time of the incident. In a follow up interview at 12/30/2025 at 4:33 PM, the DON stated it was important for staff to know the appropriate care to provide residents. She stated staff must follow the care plan interventions to prevent injury to the resident and to promote quality of life. She stated staff received in-service training on the importance of following residents' plans of care. She stated staff received in-service training on how to transfer residents and were required to demonstrate their ability to complete safe transfers.Interviews on 12/30/2025, between 1:24 PM and 4:29 PM, were conducted with multiple staff members which included the Executive Director, Director of Nurses, Assistant Director of Nurses, RN A, CNA B, LVN C, Director of Rehabilitation, CNA D, CMA E, CNA F, LVN G, LVN H, CNA/Staff Coordinator, LVN I, RN J, CNA K, CMA L, CNA M, and CNA N. Interviews revealed staff received in-service training with the therapy department and were required to demonstrate gait belt and Hoyer lift transfers. Interviews revealed staff members knew how to locate a resident's transfer status in the plan of care and understood it was important to follow appropriate interventions to prevent injury to the resident and staff. The facility initiated the following preventions prior to the state surveyor entry on 12/30/2025:On 12/01/2025 the interdisciplinary team completed a review of all residents' transfer status.Record review of the facility provided documentation, dated 12/01/2025, reflected all nursing staff received in-service training on resident neglect, where to locate residents' transfer status, and how to properly transfer with a gait belt and Hoyer lift.Record review of the facility provided documentation, dated 12/01/2025, reflected one on one in-servicing provided to CNA B with return demonstration related to mechanical lift transfers, one person and two person transfers. The employee corrective action form, dated 12/01/2025, reflected CNA B received disciplinary action for failure to use proper transfer technique with one resident. Record review of the facility provided monitoring logs, dated 12/05/2025 to 12/30/2025, reflected 2 nursing staff were observed per week for proper use of resident transfers. No concerns were noted. Record review of the facility provided monitoring log, dated 12/01/2025 to 12/30/2025, reflected clinical records were monitored for accurate transfer status five times a week. No concerns were noted.Record review of the facility provided monitoring log, dated 12/01/2025 to 12/30/2025, reflected at least 15 staff members were interviewed each week regarding resident transfer status. No concerns were noted.Record review of the facility's policy Care Planning - Interdisciplinary Team, reviewed December 2024, reflected Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team.

Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of five (Resident #1) residents reviewed for medication storage.The facility failed to ensure over the counter medication was not on Resident #1's bedside table on 12/30/2025. This failure could place the residents at risk of accidental overdose or misuse of medication.Findings include: Record review of Resident #1's Face Sheet, dated 12/30/2025, reflected a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included dementia (decline in cognitive function that interferes with daily life), age-related osteoporosis (disease that weakens bones), and initial encounter for a left femur (long bone in upper leg) closed fracture (broken bone with intact skin). Record review of Resident #1's Quarterly MDS Assessment, dated 12/19/2025, reflected the resident was cognitively intact with a BIMS score of 13. Section GG indicated Resident #1 was dependent on staff for self-care and mobility needs. Record review of Resident #1's Comprehensive Care Plan, dated 12/01/2025, did not reflect the resident self-administered her medication.During an observation and interview on 12/30/2025 at 10:09 AM, revealed Resident #1 was lying in bed awake. The bedside table was placed over the right side of her bed. A plastic container on the bedside table held a tube of Voltaren cream (treats arthritis pain), a box of Pepto Bismol chewable tablets (used to treat nausea and heartburn), saline nasal spray (moistens and clears the nasal passage), Icy Hot pain relief cream (used for muscle and joint pain), and Mentholatum ointment (used to relieve minor aches, pain, and congestion). The plastic container also held other personal items. Resident #1 stated the medicine was there in case she needed it. During an interview on 12/30/25 at 10:29 AM, RN A stated Resident #1 had several family members who came to see her and at times went to the store and brought items the resident requested. She stated medication should not be left in Resident #1's room unless she was assessed and checked off to self-administer it. RN A removed the over-the-counter medications. Resident #1 asked what she was doing with the medication and RN A replied to ensure everyone's safety, the medications could not be left in her room. During an interview on 12/30/2025 at 11:28 AM, the DON stated Resident #1 should not have over the counter medications in her room. She stated the resident had multiple family members and facility staff had conversations with them about bringing items into her room. The DON stated the resident did not self-medicate and it was also important to ensure no one else had access to the medication. During an interview on 12/30/2025 at 3:55 PM, the Executive Director stated Resident #1 should not have medication in her room. She stated it was important for the nurse to know what medication the resident took. She stated someone else might take the medication and potentially have an adverse reaction. She stated she would send a reminder email out to all family members reminding them not to bring medication to the facility. Record review of the facility's policy Storage of Medications, reviewed December 2024, reflected The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

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 one of four (Resident #1) residents reviewed for respiratory care.The facility failed to ensure Resident #1's nebulizer mask (device used to deliver medication in a mist form through the nose and mouth) was properly stored when not in use on 12/30/2025.This failure could place residents at risk for respiratory infection and not having their respiratory needs met.Findings include: Record review of Resident #1's Face Sheet, dated 12/30/2025, reflected a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included acute and chronic respiratory failure with hypoxia (not enough oxygen in the blood) and shortness of breath. Record review of Resident #1's Quarterly MDS Assessment, dated 12/19/2025, reflected the resident was cognitively intact with a BIMS score of 13. Section I (Active Diagnoses) reflected respiratory failure. Section O (Special Treatments, Procedures, and Programs) reflected Resident #1 received oxygen therapy. Record review of Resident #1's Comprehensive Care Plan, dated 12/30/2025, reflected Resident #1 had oxygen therapy as needed related to respiratory failure. One intervention was to give medication as ordered and monitor for signs of respiratory distress.Record review of Resident #1's Physician Order, dated 12/05/2025, reflected Budesonide Inhalation Suspension 0.5 MG/2ML Budesonide (Inhalation) 1 vial inhale orally two times a day for acute and chronic respiratory failure with hypoxia.During an observation on 12/30/2025 at 10:09 AM, revealed Resident #1 was lying in bed. Resident #1 was receiving oxygen therapy via nasal cannula (device used to deliver oxygen into the nostrils). An empty plastic bag hung from the nightstand drawer handle. Resident #1 gave permission for the drawer to be opened. A nebulizer machine with connected tubing and a face mask was in the drawer with other personal items. The nebulizer mask was not in a bag. Resident #1 stated she did not know if the nebulizer mask was supposed to be in a bag. During an interview on 12/30/25 at 10:29 AM, RN A stated the nebulizer mask should have been stored in a bag when not in use. She stated as the resident's nurse, she was responsible for ensuring it was stored in a bag when the resident was not receiving a breathing treatment. She stated the risk to the resident was respiratory infection.During an interview on 12/30/25 at 11:28 AM, the DON stated the nebulizer mask should have been stored in a bag when not in use. She stated that any staff member could notice if it was not bagged and notify the nurse. She stated ultimately the nurse was responsible. She stated it was important to prevent infection. Record review of the facility's policy Departmental (Respiratory Therapy) - Prevention of Infection, reviewed December 2024, reflected Infection Control Considerations Related to Nebulizer/Continuous Aerosol. Store the circuit in plastic bag, marked with date and resident's name, between uses.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 8 residents (Resident #21 and #64) reviewed, in that: 1. The facility failed to create and implement a care plan that reflected Resident #21 used chewing tobacco and kept it at bedside. 2. The facility failed to create and implement a care plan that reflected Resident #64's right-hand contracture and OT services. These failures place all residents at risk of not receiving care and services related to their identified needs to maintain or reach their highest practicable physical, mental, and psychosocial well-being. The findings included: 1. Record review of Resident #21's Comprehensive MDS dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE], he had a BIMS score of 13 (intact cognition) and the diagnoses of paraplegia (leg paralysis), seizure disorder, and spina bifida (spinal cord defect). Review of Section J- Health Conditions revealed resident did not currently use tobacco. Record review of Resident #21's care plan, dated initiated 01/31/2025, did not reflect the resident use of tobacco. Observation and interview on 03/04/2025 at 10:09 AM of Resident #21 revealed he was seated in bed watching television with a small tin of Red Seal long cut tobacco (a loose cut smokeless tobacco also known as dip, chewing tobacco, or snuff) and he was spitting a dark brown substance into a diet coke bottle during the interview. He stated that he admitted to the facility with the chewing tobacco and a nurse tried to give him a hard time about it and then the Executive Director came and looked around and no one had talked to him about it since then. In an interview on 03/04/2025 at 12:12 PM with CNA EE she said she was aware Resident #21 used chewing tobacco and stated the DON and the Executive Director were aware. In an interview on 03/05/2025 at 5:20 PM with CNA FF she said she was aware Resident #21 used chewing tobacco and had informed the DON shortly after he first admitted to the facility. In an interview on 03/05/2025 at 6:25 PM with the DON she said she was aware Resident #21 had chewing tobacco. She stated it had been discussed during a meeting with the Executive Director and there was no policy against it so they let him keep it. She was not sure if the resident's use of tobacco was care planned. She stated it probably would not hurt to have it care planned. In an interview on 03/06/2025 at 4:44 PM with MDS Coordinator DD she said she was not aware of Resident #21's use of chewing tobacco. She stated it should be care planned to ensure that he is allowed to have it on his person or if it needed to be on the nurse's cart and to ensure he had been counseled to not give it to other residents. She stated it was important for care plans to be person centered and specific to the resident. In an interview on 03/06/2025 at 5:27 PM with the Executive Director she said she was aware Resident #21 had chewing tobacco, the facility was a non-smoking facility and it was not a tobacco that was smoked and was not a vape so there were no concerns. She stated that care plans need to be person centered and they did not think to care plan it at the time. She stated they were going to add it to his care plan. She stated that there was no policy for tobacco use. 2. Review of Resident #64's Admission MDS Assessment, dated 12/24/24, reflected she was a [AGE] year-old female with an admitted [DATE]. Resident #64 was moderately cognitively impaired, and her BIMS score was 10. She had impairments on both sides to her upper and lower extremities. She was significantly dependent for most of her ADLs. Resident had the following active diagnoses: Alzheimer's' Disease, Rheumatoid Arthritis (chronic inflammatory disorder usually affecting small joints in the hands and feet), Pain in unspecified joint, Age related Osteoporosis (a condition in which bones become weak and brittle), and Age-related Physical debility. Review of Resident #64's Care Plan revised 7/25/24 revealed .I have (acute/chronic) pain r/t rheumatoid arthritis, sciatica, wedge comp fX T11-T12, osteoporosis Date Initiated: 07/10/2024 The Care Plan did not address issues related to resident's contracture in her right hand or OT services. Review of Resident #64's OT Evaluation and Plan of Treatment dated 6/6/24 reflected the following .RUE ROM=Impaired (impaired ROM of digits and wrist) . Review of Resident #64's OT Evaluation and Plan of Treatment dated 7/22/24 reflected the following .RUE ROM=WFL; LUE ROM=WFL . Observation of Resident #64 on 03/04/25 at 11:06 AM revealed possible contracture to her right hand. She was unable to open her pinky and ring finger when asked to. She had no splint or any other device on the right hand. Interview with CNA V on 3/5/25 at 11:21am revealed that she was unaware if Resident #64 had a contracture. Interview and observation with Director of Rehab on 3/5/25 at 2:45 pm revealed that OT had worked with Resident #64 on strengthening, activity tolerance, self-feeding, upper body dressing and oral hygiene. She stated there was no note of contracture at time of discharge. The only recommendation that she saw, was the continued use of build up utensils for all meals to assist with decrease in strength. Resident #64's Range of motion at time of discharge evaluation was within functional limits but does note that she had limited active range to bilateral hands. Director of Rehab observed Resident #64's hands and she stated the left hand looked good, and the right hand had contractions to two fingers (pinky and ring finger) and it was very tight. While Director of Rehab was assessing her hands, Resident #64 stated that her fingers had been that way for a long time. Director of Rehab asked Resident #64 if she would be okay with OT assessing her to see if they could do something with her fingers to help them open some and she stated they could try. Director of Rehab stated that Resident #64's contracture was due to a progression of her arthritis and had not seen anything in her records about the contracture. She reported that Therapy does not update Care Plans and that any updates are usually discussed in the treatment meetings. Interview with Rehab Therapy Assistant CC on 3/6/25 at 9:09am revealed that Resident #64's fingers on her right hand were contracted but that it hurt the resident to do anything with those two fingers. She stated while Resident #64 was in therapy they tried a warm press, but she couldn't tolerate it due to pain. She hadn't tried a splint because Resident #64 would not allow it. She stated therapy was concerned that working with those fingers would affect the other functional fingers. She stated that any recommendation in therapy would be provided to the nurses, and they would have to ensure that the recommendations were followed. Interview with MDS Coordinator DD on 3/6/25 at 4:44pm revealed the Care Plan is updated as needed after every morning meeting. Nurses have the ability to put some acute information in the Care Plans directly and some of the sections of the Care Plan were updated automatically when MDS was completed. Another individual that could update the Care Plans was the social worker. In regard to Resident #59 having had the air mattress as an intervention in her Care Plan and not using it due to her preference, that intervention should have been removed. Regarding Resident #64's contracture, it should have been listed in the Care Plan. She stated she would go in there and correct these two items. Review of Facility's policy, Care Plans, Comprehensive, dated reviewed December 2024, reflected .A Comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .1. The Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident 8. The comprehensive, person centered care plan will: .Describe the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental and psychosocial well-being; C. Describe services would otherwise be provided for the above, but are not provided due to the residents exercising his or her rights, including the right to refuse treatment .G. incorporate identified problem areas; .J. reflect the resident's expressed wishes regarding care and treatment goals .L. Identify the professional services that are responsible for each element of care M. Aid in preventing or reducing decline in the resident's functional status and/or functional levels N. enhance the optimal functioning of the resident by focusing on a rehabilitative program and O. reflect currently recognized standards of practice for problem areas and conditions .13. Assessment of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . 50910

Based on observations, interviews, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to ensure food items in the facility refrigerator were dated or labeled. 2. The facility failed to ensure that food items in the refrigerator were not expired. 3. The facility failed to ensure that all canned goods in dry storage were not dented and separated from the other canned goods. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination. Findings Included: Observation of refrigerator 1 and 2 and interview with Dietary Manager on [DATE] revealed: At 9:19am 3 trays of approximately 36, 8oz clear plastic cups with various brown, beige, and red liquids with no label of what they were, or date served. The Dietary Manager stated the beige liquids were nectar liquid, the brown were tea, and the red were juice. He stated they had just served them in preparation for lunch. At 9:21am a 5lb unopened block of sliced American and Swiss cheese with a received date of [DATE] and manufacture used by date of [DATE]. The Dietary Manager confirmed that it was expired and stated he would throw it away. The risk to the resident if served expired food was that they could be given a compromised product and could affect the residents' health. Observation of dry storage and interview with the Dietary Manager on [DATE] revealed: At 9:32am an unopened 15oz can of [NAME] Taco Fiesta Black Beans, with a ,d+[DATE] of the can dented on the bottom seal. The Dietary Manager stated he would throw it away due to the dent. Interview with the Dietary Manager on [DATE] at 9:35 revealed when they received their shipments, they wrote a received date on the item and put them away. Once items were opened, they wrote a used by date. On condiments and seasonings, they wrote opened date and discard them on the manufacturers best by date. They discarded opened products based on the shelf life of the food and manufactures best buy dates. The dented cans would be removed from dry goods area, placed in his office for a refund request from the manufacture and discarded Interview with Dietary Aide U on [DATE] at 3:01pm revealed that dietary aides and cooks were responsible for labeling food in the refrigerators. Interview with [NAME] T on [DATE] at 3:03pm revealed that dietary aides were responsible for labeling liquids in refrigerators such as juices, milk, and tea when served. The cooks were responsible for labeling food in refrigerators, freezer, and dry goods area. When items were received, they wrote the date received and date opened on items, the 2nd was the discard date. The second date could also be the open date on items such as seasonings and condiments. The risk to the resident for not labeling items and dating them correctly could result in the resident getting sick from the food provided. Review of facility Policy and Procedure Manual Chapter 3: Food Production and Food Safety dated 2023 revealed .Procedure 12. Leftover food should be stored in covered containers or wrapped in carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2022 Federal Food Code .13. Refrigerated food storage: .f. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers will be consumed by their use by dates, or frozen (where applicable) or discarded . Review of the Food and Drug Administration Food Code, dated 2022, reflected, XXX,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food ,d+[DATE].11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety Review of Food and Drug Administrative Food Code, dated 2022, reflected, .Chapter 3. Food Condition ,d+[DATE].11 Safe, Unadulterated, and Honestly Presented The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.

Based on interview and record review, the facility failed to act promptly upon the grievances of the resident group concerning issues of resident care and life in the facility and demonstrate their response and rationale for such response for 4 (11/19/2024, 12/10/2024, 01/07/2025, and 02/12/2025) of 4 Resident Council Meetings, in that: 1. Concerns voiced during the monthly Resident Council Meetings were not addressed following meetings held on 11/19/2024, 12/10/2024, 01/07/2025, and 02/12/2025. 2. The Resident Council members were not notified regarding facility action taken to address and resolve concerns voiced in prior Resident Council Meetings during the next monthly meetings held on 12/10/2024, 01/07/2025, and 02/12/2025. These failures placed the residents at risk for a decreased quality of life and a decreased feeling of well-being within their living environment. The findings included: Review of the Resident Council Meeting Minutes revealed the following: 11/19/2024- 8 residents attended, and the Activity Director was present. The documented open concerns included residents left in bed and missing activities, concerns regarding staffing, nails not being cut, and call light wait times. New business was regarding long wait times for call lights, medications, and agency aides not being responsive to resident. 12/10/2024- 6 residents attended, and the Activity Director was present. The documented open concerns were the same as the 11/19/2024 meeting. New business included: Administration- still not getting a solution about ongoing issues 01/07/2025- 7 residents attended with open business of the same concerns from the 11/19/24 meeting. New business included concerns with internet service, aides turning the call lights off and not coming back to assist residents and customer service concerns. 02/12/2025- 5 residents attended with open business of concerns regarding wait times for medications, staff wearing earbuds and customer service concerns. New business included missed medications on the weekends, aides talking on the phone in the resident bathrooms, and cold food. Review of the Grievance Log Reports from October 2024 to March 2025 for the Resident Council revealed a total of 11 grievance reports had been completed following Resident Council meetings. In a confidential group interview on 03/05/25 residents said the facility had not provided them a response regarding their concerns noted during resident council meetings and they wanted a written update regarding their previous concerns from each department that they had concerns in. In an interview on 03/06/25 at 3:56 PM with the Activity Director she said she is present for all resident council meetings, took notes for the residents, and turned in grievances into the appropriate department and gave a copy to the Administrator. She stated that the Resident Council President asked for a written action plan from each department, and she verbally informed the Administrator. She stated she was not aware if resident council received a response to their concerns. She stated that it was important for resident council to have a response to their concerns because it was their right to receive a response and know how the problem will be resolved. In an interview on 03/06/25 at 4:22 PM with the Administrator she said she was responsible for grievances, was aware of the Resident Council concerns, and stated she had addressed each grievance . She stated that the grievances were filed with the departments responsible; some of the concerns from resident council did not name a specific resident impacted so she noted what was done regarding the grievance on the grievance. She stated in-services with staff included call light response, CNA responsibilities including to not wear earbuds and providing incontinent care every 2 hours. She stated the facility reviewed staffing, increased staff and reduced using agency staffing. She stated that she only attended the Resident Council meetings when invited and had not spoken to the entire council about the concerns that were addressed and only spoke with the Resident Council President. She stated that communicating responses to the Resident Council was important because it was a resident rights issue, and residents have the right to be heard and treated with dignity. In an interview on 03/06/25 at 4:44 PM with the Resident Council President she stated Resident Council meetings were held monthly and the Activity Director wrote the meeting minutes. She stated that concerns were conveyed to the Administrator, and they had not been told of the outcome of their concerns. She stated that they could tell there were some improvements but there were still the same concerns. She stated that in the previous Resident Council meeting they asked for a written response from each department and had not heard a response yet. She stated that she understood that sometimes solutions took longer to fix but not getting a response was the biggest problem. Record review of the facility's grievance policy titled, Grievances/Complaints, Filing, dated revised December 2023, reflected .Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances . The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative .All grievances, complaints or recommendations stemming from resident or family groups concerning is-sues of resident care in the facility will be considered. Actions on such issues will be responded to verbally, including a rationale for the response . The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems .

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for three of five residents (Resident #98, Resident #34, and Resident #79) reviewed for catheter and incontinence care. 1. The facility failed to ensure CNA G and CNA H provided Resident #98 timely and appropriate perineal care after an incontinent episode when they failed to check and change the resident from 06:00 a.m. to 10:25 a.m. and failed to change the surface of the peri-wipes with each stroke on 03/04/25. 2. The facility failed to ensure Resident #34, who was being treated for a urinary tract infection, was provided timely incontinence care during the 06:00 p.m. to 06:00 AM shift 03/03/25 to 03/04/25. 3. The facility failed to ensure CNA N and CNA O maintained the foley catheter drainage bag below Resident #79's bladder while they transferred the resident with a mechanical lift on 03/05/25. These failures could place residents at risk for not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infections. Findings included: 1. Record review of Resident #98's Admission MDS assessment, dated 02/07/25, reflected a [AGE] year-old male with an admitted [DATE]. He had a BIMS of 15, which indicated he was cognitively intact. Resident #98 required substantial/maximum assist with toileting hygiene. He was occasional incontinent of bladder and frequently incontinent of bowel. Resident #98 had diagnoses which included renal insufficiency (poor function of the kidneys), diabetes, cancer, cellulitis (bacterial infection of the skin). Record review of Resident #98's care plan with a revision date of 02/17/25 reflected, I have an ADL Self-Care performance deficit related to disease and debility .Interventions Toilet use: I require extensive assistance of 1 staff participation to use toilet . In an observation on 03/04/25 at 10:25 a.m. CNA H and CNA G entered Resident # 98's room and asked the resident if he needed changing and he said yes. Both staff put on gloves without performing hand hygiene. CNA H pulled out a packet of peri-wipes and a clean brief from the chest of drawers and uncovered the resident revealing he had brown rings noted on the bed pad. CNA H unfasted the resident's brief revealing it was saturated in urine. CNA H took a peri-wipe and wiped across the resident's pubic area and up and down his penis shaft with several wipes without changing the surface of the wipes. She pushed the saturated brief down toward the residents' buttocks and the staff rolled him onto his side. CNA H then removed the soiled brief and urine-soaked bed pad and threw them on the floor. CNA H then wiped the resident's buttocks front to back without changing the surface of the wipe and then with the same soiled gloves placed a clean brief under the resident. CNA G removed her gloves, left the room without performing hand hygiene and returned with a clean bed pad. CNA G put on clean gloves without performing hand hygiene. CNA H placed the clean bed pad under the resident and then applied barrier cream with the same soiled gloves and wiped the excess onto the clean brief. Both staff members rolled the resident back onto his back and refastened the brief. In an interview with Resident #98 on 03/04/25 at 10:32 a.m. he stated he was last changed yesterday evening but could not remember the time. In an interview on 03/04/25 at 11:45 a.m. with CNA H and CNA G both stated they were supposed to change gloves and perform hand hygiene when they go from dirty before going to clean. CNA H stated she knew she was supposed to change the surface of the wipes each time and was not supposed to throw dirty linen in the floor. She stated she was frustrated since they had found a few residents this morning with brown ringed bed linens. CNA H and CNA G both stated the risk of untimely incontinent care and failing to perform it correctly was urinary tract infections and skin issues. In a follow up interview with CNA H on 03/05/25 at 08:56 a.m. she stated Resident #98 was not her assigned Resident on 03/04/25, but stated she went with CNA G to assist her with turning him. She stated they start making their rounds as soon as they come on shift at 06:00 a.m. She stated there was really no excuse why they were getting in there as late as they were for his first check and change. In a follow up interview on 03/05/25 at 09:35 a.m. with CNA G she stated the reason she was so late getting into Resident #98's room on 03/04/25 was because she was doing a shower on another resident that therapy was wanting up and taken to therapy. She stated he used a urinal usually, but stated he told her he woke up and had been incontinent in his sleep. In an interview on 03/06/25 at 01:50 p.m. with CNA P she stated she worked the 6pm to 6 am shift on 03/03/25-03/04/25. She stated she did not have Resident #98. In an interview on 03/06/25 at 01:55 p.m. with CNA Q she stated she worked on 03/03/25 from 6 pm to 6 am on 03/04/25. She stated she had Resident #98. She stated he had not gone to bed until around 11 p.m. She stated she asked if he needed changing and he told her no. She stated he used a urinal. She stated she helped take his pants and socks off and his brief was dry. She stated she checked on him around 4 a.m. and asked if he needed changing and he told her no. She stated he would usually call them if he needed assistance. 2. Record review of Resident #34's Admission MDS assessment, dated 02/11/25, reflected an [AGE] year-old female with an admitted [DATE]. She had a BIMS of 12, which indicated she was moderately cognitively impaired. Resident #34 required moderate to substantial/maximum assist with ADLs. She was frequently incontinent of bladder and bowel. Resident #34 had diagnoses which included urinary tract infection, cerebral vascular accident (stroke), Parkinson's disease (disorder of the central nervous system that affects movement) and overactive bladder. Record review of Resident #34's care plan dated 02/05/25 reflected, I have a urinary tract infection .Interventions .Check at least every 2 hours for incontinence. Wash, rinse and dry soiled areas In an interview on 03/04/25 at 11:45 a.m. with CNA H she stated Resident #34 was soaked through her brief and bed pad and it had already started to brown ring when she made her first rounds on her around 08:00 a.m. on 03/04/25. CNA H stated the risk of untimely incontinent care and failing to perform it correctly was urinary tract infections and skin issues. In an interview and observation on 03/04/25 at 02:22 p.m. with Resident # 34 and her family member, the family member was attempting to put the bucket under the potty chair. The family member stated they had to help Resident #34 to the potty chair to prevent her from having an accident. The family member stated it sometimes takes a while before anyone comes to help. The family member stated Resident #34 had a bad night last night. Resident #34 stated she could not get any help. She stated she had put on her call light, and no one came. She stated she called her family member and told them she was sitting in pee and needed to go to bed. The family member stated they called the facility at 7:20 p.m. last night (03/03/25) and asked them to please go and help Resident #34. The family member stated the person who answered the phone stated, yes her call light was on. Resident #34 stated they finally came and put her to bed. She stated she had been sitting in pee forever and was soaked. She stated they came in sometime in the middle of the night to change her but could not remember what time that was. She stated this morning (03/04/25) she was soaked from her head to her toe. She stated the CNAs got her cleaned up this morning. In observation and interview on 03/05/25 at 08:10 a.m. Resident # 34 was observed sitting up in bed finishing breakfast. She stated she had a little better night last night but stated she woke up around 3 am soaked in urine. She stated she called for help, and they did come in and change her. She stated no one had been in yet this morning to change her. She stated she was not sure if she was wet or not. In an observation 03/05/25 at 8:15 a.m. CNA L and CNA K entered Resident #34's room to provide incontinence care. Both staff washed their hands, put on gowns and gloves. CNA L unfastened Resident #34's brief revealing a very red area to her perineal area and down her groin. Resident #34 stated it did not hurt or burn. Resident #34 had thick white paste over the entire area. CNA L wiped numerous times to remove the cream, changing out the wipe with each stroke, but had to resort to soap and water to completely remove the paste. Resident's brief was wet but not saturated. ADON F was alerted to come and observe the resident's skin condition. ADON F stated she would reach out to the doctor. CNAs continued with peri care and rolled the resident onto her side. Residents' buttocks were not as red, and no skin breakdown was observed. Staff completed the incontinence care and applied a clean brief. In an interview on 03/05/25 at 08:55 a.m. with CNA H she stated she was assigned Resident # 34 on 03/04/25 on the 6 a.m. to 6 p.m. shift. She stated when she went to check her after breakfast her entire bed, the pad, the sheet everything was wet. She stated her peri area, down her groin and part of her butt were severely red. She stated she took the resident to the shower and pasted her up with zinc oxide. She stated she was not that red the day before. In an interview with CNAs K and L on 03/05/25 at 11:35 a.m. both stated this was their first shift back. Both stated they had not seen Resident #34 with that much redness before. Both stated they did not have any issues with finding residents saturated at shift change. In an interview on 03/06/25 at 01:50 p.m. with CNA P she stated she worked the 6pm to 6 am shift on 03/03/25-03/04/25. She stated she did not have Resident #34. She stated she was assigned to the hall that Resident #34 was on, but she was not allowed to go in her room. She stated the ADON told her last week do not go in her room. She stated she was not sure why the resident did not prefer her. In an interview on 03/06/25 at 01:55 p.m. with CNA Q she stated she worked on 03/03/25 from 6 pm to 6 am on 03/04/25. She stated she remembered being told that Resident # 34's family had called wanting her to be put to bed on the evening of 03/03/25. She stated it was not her hall, but then CNA P told her she could not go into Resident #34's room. She stated she went in and helped her get to bed. She stated she was very wet. She stated she did not know she was assigned to her that night until the call from the Resident's family member and the other aide told her she could not go in the room. She stated after that she went and checked her around 1:30 a.m. and she was soaked. She stated the next time she checked her was around 4:30 am and she was soaked again and had to have a complete bed change. She stated the residents who required incontinent care she tries to do as close to shift change since breakfast comes out about an hour after shift change. She stated she had only taken care of this resident a couple of time. She stated she does not recall if Resident #34 was red, since she does not turn the bright light on to change them during the night shift. In an interview with the DON on 03/06/25 at 02:50 p.m. she stated any resident who was incontinent of bowel and bladder needed to be checked for incontinence every 2 hours and changed as needed. She stated staff were to clean the peri area including penis and scrotum for male residents then move toward the buttocks and change the wipes with each stroke. She stated by not providing accurate incontinent care it placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. 3. Record review of Resident #79's 5-day Medicare MDS assessment, dated 01/18/25, reflected an [AGE] year-old male with an admitted [DATE]. Resident #79 had a BIMS of 15 which indicated he was cognitively intact. He required moderate assistance for ADL care and had a foley catheter and colostomy (opening in the abdominal wall to divert fecal matter from the colon directly onto the skin) . Active diagnoses included diabetes, morbid obesity, and coronary artery diseases (damage in the heart's major blood vessels). Record review of Resident #79's Physician Order Summary, dated 03/06/25, reflected .Keep urinary drainage bag below the level of the bladder at all times . with a start date of 11/11/24. Record review of Resident #79's care plan, initiated on 11/14/24, reflected, I have indwelling foley catheter .Goal .I will show no s/sx of urinary infection through review date .Interventions .Position catheter bag and tubing below the level of bladder In an observation on 03/05/25 at 12:40 p.m. CNA N and CNA O entered Resident #79's room to transfer him from his wheelchair to the bed with a mechanical lift. CNA N unhooked the urinary drainage bag from the wheelchair and handed it to the resident to lay in his lap over his bladder. Staff lifted the resident from the wheelchair which tipped him backward causing the urine to back up in the tubing. Resident was lowered onto the bed and repositioned while the urinary drainage bag lay on top of his abdomen. CNA N then placed the drainage bag on the bed rail. In an interview with CNA N and CNA O on 03/05/25 at 12:50 p.m. they both stated they had been taught the urinary drainage bag was to be kept below the bladder. They both stated they were not sure how they were supposed to position the drainage bag during a mechanical lift. They stated the risk of having the urinary bag above the bladder was the back flow of urine which would lead to infection. In an interview with the DON on 03/06/25 at 08:50 a.m., she stated the staff were taught to keep the urinary drainage bag below the bladder to ensure proper drainage and prevent urine from backing up into the bladder and the risk of infection. She stated proper placement of the foley catheter bag during a mechanical lift transfer was not part of their current check off skills, and stated they needed to include this. He stated she and the ADONs did the competency checks on all the CNA staff a few months ago. Record Review of CNA O's Nurse Aide Proficiency skills check off dated 12/18/24 reflected she was competent in the care of indwelling catheters which included keeping the drainage below the bladder. Record Review of CNA N's Nurse Aide Proficiency skills check off dated 12/11/24 reflected she was competent in the care of indwelling catheters which included keeping the drainage below the bladder. Record review of the facility's policy titled, Perineal Care, dated December 2024, reflected, Purpose-The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .For male patient .Retract foreskin of the uncircumcised male .Wash and rinse urethral area using a circular motion .continue to wash the perineal area including the penis, scrotum and inner thighs. Do not reuse the same washcloth or water to clean the urethra .Thoroughly rinse perineal area in same order, using fresh water and clean washcloth .Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks .Discard disposable items into designated containers .remove gloves .wash and dry hands . Record review of the facility's policy, Catheter Care, Urinary dated June 2018, reflected, The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 5 of 10 Residents (Resident #56, Resident #49, Resident # 98, Resident #155, and Resident #34) and 2 of 4 medication carts (nurses cart Hall A) reviewed for pharmacy services. 1. The facility failed to ensure the Nurses Cart Hall did not have unsecured medication containers for Resident#56, and Resident#49. 2. The facility failed to ensure Resident #155 and Resident #34's anti-fungal powder and were stored properly. 3. The facility failed to ensure Resident #34, and Resident #98's Systane eye drops (lubricating drops for dry eye) were stored properly. 4. The facility failed to ensure Resident #34 did not have her AM dose of tums left on the bedside table on 03/05/25. These failures could place residents at risk of medication misuse, not receiving physician ordered medications which could result in non-therapeutic treatments or injuries and ineffective treatment with the use of expired medications. Findings Included: 1. Observation and record review on 03/04/25 at 09:34 a.m. of nurses' cart Hall A, with RN C revealed: - the blister pack for Resident #56's hydrocodone acetaminophen 5-325 mg tablet (controlled medication used for pain) had 1 blister seal broken, the pill still inside the broken blister, and taped. - the blister pack for Resident #49's hydrocodone acetaminophen 10-325 mg tablet (controlled medication used for pain) had 1 blister seal broken, the pill still inside the broken blister, and taped. Interview on 03/04/25 at 09:57 a.m., RN C stated the count was done at shift change and the count was correct. She stated she did not check the blister packs during the count. She stated she was unaware when the blister pack seal was broken, and she was not aware of who might have damaged the blister pack. She stated the risk to the residents would be a potential for drug diversion. She stated the nurses were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated when a broken seal was observed, she would report it to the DON. Interview on 03/06/25 at 09:44 a.m., the DON stated she expected if a blister pack medication seal was broken the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk would be potential for drug diversion and infection control issue. She stated nurses were responsible for checking the medication blister packs for broken seals, and expiration date during the count on the change of shifts. The DON stated the ADONs, and the DON were supposed to check the carts weekly. The DON further stated the pharmacist did random checks monthly of the medication carts for monitoring. The DON stated the ADONs, and the DON were supposed to do random checks of the medication carts for monitoring. 2. Record review of Resident #155's face sheet dated 03/06/25 reflected a [AGE] year-old-female with an admitted [DATE]. Diagnosis included cellulitis (bacterial infection of the skin). Record review of a Physician order summary sheet dated 03/04/25 did not reflect an order for antifungal powder. An observation on 03/04/25 at 11:25 a.m. revealed CNA G and CNA H providing incontinence care to Resident #155. After completion of incontinence care, CNA H retrieved a bottle of antifungal powder from the Resident's bedside chest of drawers and applied antifungal powder to the resident's stomach flap and groin area. CNA H then returned the bottle of antifungal powder to the chest of drawers. 3. Record review of Resident #98's face sheet dated 03/06/25 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included cellulitis (bacterial infection of the skin) and chronic kidney disease. Record review of Resident #98's Physician order summary report dated 03/03/25 did not reflect an order for Systane eye drops. In an observation and interview on 03/04/25 at 10:15 a.m. with Resident #98 revealed a bottle Systane eye drops on his overbed table. Resident #98 stated he brought them with him to the facility and used them occasionally for his dry eyes. In an observation on 03/06/25 at 08:40 a.m. Resident # 98 still had Systane eye drops at bedside on top of a chest of drawers. 4. Record review of Resident #34's face sheet dated 03/06/25 reflected an [AGE] year-old female with an admitted [DATE]. Diagnosis included urinary tract infection. Record review of Resident #34's Physician orders summary sheet dated 03/06/25 reflected, Calcium Carbonate Oral Tablet 600 MG (Calcium Carbonate) Give 1 tablet by mouth in the morning .(TUMS). With a start date of 02/23/25. There were no orders for Systane eye drops or antifungal powder. In an observation and interview on 03/05/25 at 08:10 a.m. revealed Resident #34 sitting up in bed finishing breakfast. A bottle of Systane eye drops and a bottle of antifungal powder were observed on the bedside table. Resident #34 stated the eye drops were hers that she brought from home and the facility staff had brought in the powder. An observation on 03/05/25 at 8:15 a.m. revealed CNA K and CNA L entered Resident # 34's room to provide incontinence care. A white pill approximately the size of a dime and a bottle of Systane eye drops were observed on the Resident's bedside table. CNA L asked the resident if this was her Tums and Resident #34 stated yes, she had not taken it yet this morning. CNA L stated it looked wet, like the resident had put it in her mouth and took it out. CNA L told resident she was going to throw it away. Resident stated OK. CNA L continued to provide incontinence care and once completed, retrieved a bottle of antifungal cream from the resident chest of drawers, and applied it to the resident's buttocks and perineal area. In an interview with CNA H on 03/05/25 at 08:55 a.m. she stated they had access to the antifungal powder in a cabinet behind the nurse's station and they just get it when they need it. In an interview on 03/05/25 at 10:30 a.m. with the DON she stated antifungal powder was considered a medication and should not be at bedside. She stated the antifungal powder was used to treat a condition or as preventive but stated the CNAs did not have the knowledge to make the determination of when to use it. She stated that would be a nursing judgement. She stated they would do a sweep and pull all the antifungal and determine which residents required the antifungal powder. She stated it should be stored in the nursing supply room not the CNA supply rooms. In an interview on 03/05/25 at 11:35 a.m. with CNA K she stated anytime she had needed antifungal powder she would ask the nurse for it. She stated in the past when she had requested it from LVN S, he would tell her the resident had to have a need for it, that they just could not put on without a need. She stated she had seen several residents with antifungal powder in their rooms, but stated she did not use it. In an interview with CNA L on 03/05/25 at 11:32 a.m. she stated she was new to the facility. She stated she had always seen antifungal powder locked up with the nurse's cart in her previous employment and they would have to get it from the nurses. She stated she had seen antifungal powder in the resident's room here, so she assumed it was OK to use. In an interview with LVN R on 03/06/25 at 08:15 a.m. she stated Systane eye drops should not be in Resident # 34's room. She stated she did not have an order for eye drops and she was not aware she had eye drops in her room. She stated the resident's family brought the resident a lot of things from home. She stated she removed the eye drops and reached out to the doctor for an order. In an interview with MA BB on 03/06/25 at 08:25 a.m. she stated she was the assigned MA yesterday (03/05/25) and today (03/06/25) for Resident # 34. She stated she had taken the resident her morning meds on 03/05/25 and the resident had pulled the Tums out of the cup of pills and laid it on the bedside table. She stated the resident would frequently do that and she stated she would tell the resident she had to watch her take it, but the resident would insist on taking it later. She stated she usually threw it away and would come back later and give it to her if she wanted it, but stated she just left it on the table on 03/05/25. She stated she knew she was not to leave medications at the bedside. She stated she had not noticed the Systane eye drops in Resident #34 or Resident #98's rooms. She stated neither one of them had an order for eye drops. She stated eye drops were not supposed to be at bedside. In an interview on 03/06/25 at 08:45 a.m. with LVN S he stated antifungal powder was kept in the nursing supply closet he thought. He stated it should not be used unless there was a specific reason for it. He stated everywhere he had worked it was not kept at bedside and the CNAs would request it from the nurses. He stated the nurses needed to know if there was an issue that required the use of antifungal powder so they could assess the area and make sure the CNAs were using it properly. He stated Systane eye drops should not be in the resident's room. He stated he was not aware Resident # 98 had eye drops in his room. He stated the risk of having medications at bedside was another resident could wander in, take something that could hurt them, and or the resident may take a medication that could interact with medications the facility was giving the resident. In a follow up interview with the DON on 03/06/25 at 08:50 a.m. she stated going forward they were going to review all of their barrier products and determine which products the CNAs had access to. She stated they had swept the building and removed all the antifungal powders and were assessing which residents required the use of this of this medication. She stated the eye drops were not to be kept in the resident room. She stated any medication, over the counter or prescription had to have an order and record of administration. She stated this ensured accurate medication administration, review for interactions and to ensure the residents were provided what was ordered by the physician. Record review of the facility policy Storage of medication, dated December 2024, revealed The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding are to prevent the possibility of mixing medications of several residents . 47690

Based on observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 12 Residents (Resident #98, Resident #155, Resident #49, Resident #79, and Resident #2) observed for infection control. 1. The facility failed to ensure CNA H and CNA G used the required PPE for Resident #98, who was on enhanced barrier precautions due to her venous access device, while providing incontinence care, failed to change gloves and perform hand hygiene during incontinence care and after, and failed to properly handle soiled linens. 2. The facility failed to ensure CNA H and CNA G change gloves and perform hand hygiene during incontinence care to Resident #155 on 03/04/25. 3. The facility failed to ensure CNA M changed her gloves and performed hand hygiene during incontinence care to Resident #49 on 03/05/25. 4. The facility failed to ensure LVN R performed hand hygiene while providing wound care to Resident #79 on 03/05/25. 5.The facility failed to ensure CNA A performed hand hygiene during incontinent care for Resident #2. 6. CNA A failed to perform hand hygiene between food tray delivery and feeding in the dining area on 03/04/25 during meal services and failed to prevent potential food contamination when she handled a resident's bread with bare hands. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. In an observation and interview on 03/04/25 at 10:15 a.m. Resident #98 had a sign posted outside of his door which indicated enhanced barrier precautions. In an interview with Resident #98, he stated he had been at the facility for about 3 weeks due to issues with his kidneys. He stated he had an access line in his upper right chest. Observed a dressing over a Central Venous line in his upper right chest. In an observation on 03/04/25 at 10:25 a.m. CNA H and CNA G entered Resident # 98's room and asked the resident if he needed changing and he said yes. Both staff put on gloves without performing hand hygiene and did not put on a gown. CNA H pulled out a packet of peri-wipes and a clean brief from the chest of drawers and uncovered the resident revealing he had brown rings noted on the bed pad. CNA H unfasted the resident's brief revealing it was saturated in urine. CNA H took a peri-wipe and wiped across the resident pubic area and up and down his penis shaft with several wipes without changing the surface of the wipes. She pushed the saturated brief down toward the residents' buttocks and the staff rolled him onto his side. CNA H then removed the soiled brief and urine-soaked bed pad and threw them on the floor. CNA H then wiped the residents buttock front to back without changing the surface of the wipe and then with same soiled gloves placed clean brief under the resident. CNA G removed her gloves, left room without performing hand hygiene and returned with a clean bed pad. CNA G put on clean gloves without performing hand hygiene. CNA H placed the clean bed pad under the resident and then applied barrier cream with the same soiled gloves and wiped the excess onto the clean brief. Both staff members rolled the resident back onto his back and refastened the brief. Both staff removed their gloves, gathered up the dirty linens and trash and left the room without performing hand hygiene. 2. In an observation on 03/04/25 at 11:25 a.m. CNA G and CNA H entered Resident #155's room. CNA H stated therapy wanted Resident #155 up and in therapy. Both staff gowned up, washed hands, and put on gloves. CNA H unfastened the resident's brief and wiped across pubic area, down each groin. Rolled resident to her side. CNA G wiped residents' buttocks downward, then changed and wiped from front to back. With the same soiled gloves, placed a clean brief under the resident and then applied barrier cream to her buttocks. While rolling resident back onto her back, the resident stated she was having a bowel movement. The staff rolled her back on her side revealing she had a watery stool. CNA H reached over the resident and wiped the resident from front to back, removed the soiled brief, and with same soiled gloves placed a clean brief under the resident. The staff rolled the resident back onto her back, and CNA H retrieved a bottle of antifungal powder from the bedside chest and applied powder to her stomach flap and groin area, still wearing soiled gloves. Both staff fastened the brief. CNA H then changed her gloves but did not perform hand hygiene. Both staff rolled the resident to place the mechanical sling under her and transferred her to her wheelchair. CNA H pushed the resident to the doorway, removed her gown and gloves, and then retrieved a pair of socks for the resident. CNA H put the resident socks on her and then washed her hands. CNA G finished making the bed, then removed her PPE, and gathered the soiled linen and trash, removed her PPE, and washed her hands. In an interview on 03/04/25 at 11:45 a.m. with CNA H and CNA G both stated they were supposed to change gloves and perform hand hygiene when they go from dirty before going to clean. CNA H stated she knew she was supposed to change the surface of the wipes each time and was not supposed to throw dirty linen on the floor. Both staff stated they looked at the signage on the door to determine what type of precaution to determine what PPE needed to be worn. They stated they just forgot to put the gown on in Resident #98's room. Both stated they had received infection control training on the enhanced barrier precautions and hand hygiene and stated the risk of not following the proper protocol was the spread of germs and infections. 3. In an observation on 03/05/25 at 11:45 a.m. during wound care observation with ADON I and CNA M, both staff entered Resident #49's room, put on gown, washed their hands, and put on gloves. ADON I rolled the resident on her side and opened the brief, revealing she had a large soft bowel movement that had oozed up under the wound dressing. ADON I stated they would have to clean her first. ADON I removed the old wound care dressing and wiped away most of the excess bowel movement. ADON I stated she was going to swap places and let CNA M complete the incontinence care. CNA M moved to the opposite of the bed and proceeded to wipe the resident's anal area and buttocks with several wipes, changing the wipes each time. CNA M then removed the soiled brief and placed a clean brief under the resident with soiled gloves. Then she and ADON I rolled the resident onto her back and CNA M wiped down the vagina vault with soiled gloves. CNA M then removed her gloves and re-gloved without performing hand hygiene. ADON I removed her gloves and washed her hands. CNA M entered residents closet to retrieve a clean draw sheet and placed it under the resident. ADON I the performed wound care with no issues of infection control. Both staff removed their PPE and washed their hands. In an interview with CNA M on 03/05/25 at 12:10 p.m. she stated she was supposed change her gloves and perform hand washing when going from dirty to clean. She stated she should have cleaned the resident's front and then rolled her back over to complete the care. She stated the risk was infection control and cross contamination. 4. During a wound care observation on 03/05/25 at 01:15 p.m. revealed LVN R entered Resident #79's room to provide wound care to his right and left shin, right foot, and left testicular groin. LVN R put on a gown, washed her hands, and put on gloves. On each wound LVN R changed her gloves after cleaning the wounds but did not perform hand hygiene before re-gloving. In an interview on 03/05/25 at 01:35 p.m. with LVN R she stated she was supposed to perform hand hygiene after every glove change. She stated the risk was cross contamination and spread of infection. 5. Observation on 03/05/25 at 9:58 a.m. revealed CNA A entered Resident#2's room to perform incontinence care. CNA A washed her hands, donned gloves. CNA A uncovered Resident#2 and unfastened the resident's brief. CNA A cleaned Resident#2's front area using one wipe per stroke, front to back. CNA A changed gloves without performing hand hygiene, turned Resident#2 to her right side. Resident#2 had a bowel movement. CNA A cleaned the resident's buttocks area using one wipe per stroke, front to back, folded the brief, rolled the under pad over the brief, and pushed both under the resident. CNA A changed gloves without performing hand hygiene, put barrier cream on the resident's buttocks area. CNA A changed gloves without performing hand hygiene. CNA A retrieved a clean pad and brief put them under the resident, and turned her on to her left side, removed the under pad with the dirty brief inside it. CNA A turned resident to her back and finished putting the brief on her. CNA A removed gloves and washed her hands. Interview on 03/05/2025 at 10:26 a.m. CNA A stated the hand sanitizer burns her skin, and she could not use it, but she kept her hands form touching anything. CNA A further stated it was hard to keep going to the bathroom to wash her hands every time she removed the gloves. CNA A declined to answer the question about the risk to the resident. CNA A stated she received training on infection control and resident care two months ago during her orientation. 6. Observation of CNA A in the dining area on 03/04/25 at 12:21 PM revealed 26 residents waiting for their food tray. CNA A assisted with passing trays out and setting up food for the residents. When the food cart arrived, CNA A carried a tray to a resident, took the dinner roll out of the plastic bag with her bare hands, and put it on the resident's plate. She then went back to the cart picked up another tray, took the dinner roll out of the plastic bag with her bare hands, and placed in on another resident's plate. She went back to the food cart a 3rd time, got a tray, took it to a resident, placed it on the table, took the dinner roll out of the plastic bag, and placed it on the resident's plate. CNA A then washed her hands and waited for more trays to be put on the cart. CNA A, touched her clothes, put her hands on her hips, pulled her pants up while waiting, and then got a food tray from the cart, took the bread out of the plastic bag with her hands, and placed it on the resident's plate. She went to the cart and grabbed another tray and placed it on the table in front of a resident. CNA A then went to a resident who already had a tray, moved the resident's tray to a different area on the table, moved the resident in his wheelchair where his food tray was at, sat next to him, and fed him his food. She continued to feed him until he was done and pushed him in his wheelchair back to his room. Interview with CNA A on 3/4/25 at 1:08pm revealed her task was to deliver food trays to the residents in the dining area and set their food up as needed. She acknowledged that that she had not washed or sanitized her hands after delivering every tray. She stated the hand sanitizer was irritating to her skin, so she preferred to wash her hands instead. She stated the requirement was, she should be washing or sanitizing her hands between every tray delivery. The risk to residents for not washing hands would be the possibility of cross contamination that could result in them getting sick. She indicated if you touched your clothes, surfaces, or body parts after washing or sanitizing then you should wash/sanitize again to avoid cross contamination. Interview with CNA V on 3/5/25 at 11:08am revealed CNAs should have washed their hands before they begun passing trays and hand wash or sanitize between each tray delivery to prevent the spread of germs. Interview with CNA M on 3/5/25 at 11:42am revealed CNAs should wash their hands before they started passing out trays and wash hands or sanitize after each tray was delivered to prevent the spread of germs. Interview with CNA W on 3/5/25 at 12:08pm revealed when passing food trays, she would wash her hands before touching the trays, take a tray to a resident, tell them what's on the tray, set the food up, if necessary, then hand sanitize before getting another tray for infection control. Interview on 03/06/25 at 07:35 AM ADON E, revealed she expected CNAs to change gloves and perform hand hygiene before putting on the clean gloves. She stated if CNA A could not use the alcohol-based hands sanitizer she would like her to wash her hands. She stated she just find out that CNA A was allergic to the hand sanitizer and asked her to use proper hand hygiene when taking care of the residents. The ADON E stated the risk to residents was infection control, and cross contamination. Interview on 03/06/2025 at 09:49 AM with the DON, revealed she expected staff to change gloves and wash their hands before care, when they went from dirty to clean, and after care was completed. She stated enhanced barrier precautions were noted on each resident who required extra PPE and expected the staff to always follow it. She stated the risk to residents was developing infection. Interview with ADON E on 3/6/25 at 9:51am revealed her expectation for hand hygiene for staff passing out trays was for them to hand wash or hand sanitize every 3rd tray, unless hands become soiled, or they touched a resident's belongings or their own belongings. Interview with the DON on 3/6/25 at 12:18pm revealed that staff should have used sanitizer on their hands between delivery of every tray. The risk of not sanitizing or washing hands between delivery of trays was cross contamination of the next tray. Record review of the facility's policy, Enhanced Barrier precautions, dated December 2024, reflected, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug resistance organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with Standard Precautions and expand the use of PPE, to donning gown and glove use during high contact resident care activities that provide opportunities for transfer of MDROs to staff hand and clothing Enhanced Barrier Precautions include following practices .hand hygiene .gloves .Eye protection, face Shields .gowns . Record review of the Facility's policy Handwashing/Hand Hygiene revised August 2015 .Policy Interpretation and Implementation .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .b. before and after direct contact with residents .g. Before handling clean or soiled dressing, gauze pad .H. Before moving from a contaminated body site to a clean body site during resident care .k. After handling used dressing. Contaminated equipment .l. after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident .m. After removing gloves .o. before and after eating or handling food; p. before and after assisting a resident with meals .Hand hygiene is the final step after removing and disposing of personal protective equipment .The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .

Based on observations, interviews, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 2 residents (Resident #155) reviewed for peripheral intravenous care. The facility failed to ensure Residents #155's PICC line dressing was changed per the physician's order. This failure placed residents at risk of developing an infection. Findings included: Record review of Resident #155's Face sheet dated 03/06/25 reflected a [AGE] year-old-femle with an admitted [DATE]. Diagnosis included cellulitis (bacterial infection of the skin). Record review of Resident #155's Admission MDS assessment dated [DATE] reflected a BIMS score of 15 indicating no cognitive impairment. The MDS further revealed Section O: Special Treatments, Procedures, and Programs the resident was receiving IV medications. Record review of Resident #155's Baseline care plan dated 02/21/25 reflected, Reason for admission: Resident had a hospital stay with sepsis, bilateral extremity cellulitis, fall with fracture right ankle- she is toe touching weight bearing as tolerated right leg. IV therapy .Initial goals based on admission orders: Resident would like to have skilled nursing with therapy to improve her overall status and return to prior living condition .Physician Orders: IV orders-MIDLINE Left upper arm . Record review of Resident #155's Physician order summary dated 03/04/25 reflected, Change PICC/Midline dressing using sterile techniques every 7 days and PRN, every day shift every 7 days. With an order date of 02/24/25 and a start date of 02/27/25. Record review of Resident #155's February 2025 MAR/TAR revealed the PICC line dressing was changed on 02/27/25 by ADON I. Review of Resident #155's March 2025 MAR/TAR revealed the PICC line dressing change was due again on 03/06/25. Observation on 03/04/25 at 11:20 a.m. with Resident # 155 revealed she had a PICC line in her left upper arm covered with a transparent dressing. The transparent dressing was dated 02/21/25. No redness, drainage or swelling were observed, and the resident denied any pain at the site of insertion. The Resident stated the PICC line was put in at the hospital right before they sent her to the facility on [DATE]. She stated nobody had changed the dressing since she had been there. She stated she thought she got her last doses of antibiotics yesterday. She stated she was on antibiotics for cellulitis. An observation was made 03/04/25 at 01:45 p.m. of Resident #155's PICC line with ADON I who verified the PICC line dressing was dated 02/21/25 and was past due to be changed. In an interview with ADON I on 03/04/25 at 1:46 p.m. revealed it was her initial on the MAR/TAR on 02/27/25 which indicated the dressing was changed on 02/27/25. ADON I stated she must have signed off on the wrong resident, stating she had not changed Resident #155's PICC line dressing on the 02/27/25. She stated she would make sure the dressing was changed today. She stated the risk of signing off the dressing had been completed, when it had not, put the resident at risk of infection due to the insertion site since the dressing did not get changed within the 7 days as ordered. Interview on 03/05/25 at 08:40 a.m. with ADON F revealed any resident who entered the facility with a PICC line needed to have orders in place for changing the dressing within 7 days or PRN if it became soiled or dislodged. She stated the admission nurse was responsible for putting in the orders, and then she checked behind them. She stated Resident # 155 admitted on Friday (02/21/25). She stated when she reviewed the orders on Monday (02/24/25), she saw the order for dressing changes had been left off, so she obtained the order that day and scheduled the dressing change for 02/27/25 which was 7 days from the initial application of the dressing. She stated the nurses were flushing the line each day before and after administration of medication and should be checking the condition of the dressing which would include looking at the date. She stated even if someone accidently signed it off in the record as completed, someone should have noticed it was past due to be changed. She stated the risk of not changing the dressing within the specified time frame was infection. Interview on 03/06/25 at 08:50 a.m. with the DON revealed her expectation was for nurses to be checking the PICC lines every shift, flush before and after medication and to change the dressing every 7 days and as needed if soiled. The DON stated the PICC line dressing should be dated. She stated the nurses were responsible for changing and dating the dressings. The DON stated it was the ADON and her responsibility to ensure PICC line dressings were being changed and dated. The DON stated the potential risk of not following physician orders was that it could lead to an infection. Record review of the facility policy Central Venous Catheter Dressing Changes dated December 2024, reflected, The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressing Change transparent semi-permeable membrane dressing at least every 5-7 days and PRN (when wet, soiled, or not intact) The following information should be recorded in the resident's medical record .Date and time dressing was changed .

Based on observation, interview and record review, the facility failed to notify the resident representative and consult with the resident's physician, when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for one (Resident #15) of five residents. The facility failed to notify Resident #15's physician and resident representative of a bruise to her left hand and dime-sized wound on her right underarm This failure could place residents at risk of a delay in medical intervention and a decline in health. Findings included: Review of Resident #15's Admission MDS Assessment, dated 1/2/25, reflected she was an [AGE] year-old female with an admitted [DATE]. Resident #15 was severely cognitively impaired, and her BIMS score was unable to be determined. She had impairments to lower extremities on both sides and required extensive one-person assistance with ADLs. Resident had an indwelling catheter and had the following active diagnoses: Anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin), wound infection, Non-Alzheimer's Dementia and Paraplegia (paralysis that affects both legs). Review of Resident #15's care plan dated 9/11/24 reflected there is a risk for pressure ulcers and the interventions included: Assess/record/monitor wound healing weekly, assess and document status of wound and healing progress, inform me/family/caregivers of any new area of skin breakdown, obtain and monitor lab/diagnostic work as ordered, report results to MD and follow up as indicated and seen by Wound Care Doctor weekly. Review of Resident #15's order summary printed 3/6/25 reflected, . Weekly Skin Assessment needs to be completed. Weekly, every day shift every Tue for Weekly Skin Documentation . with a start date of 09/12/24. Review of Resident #15's February and March 2025 nurse's notes did not reflect any documentation about the oval 2 inch bruise to her right hand or the dime sized wound to right underarm or notification to the family or physician of it. Review of incident reports for December 2024 to March 2025 did not reflect any documentation about an incident that resulted in injury to Resident #15's right hand or right under arm before 3/4/25. There were no incident reports for Resident #15. Observation and interview of Resident #15 in her bedroom on 03/04/25 at 02:28 PM reflected resident had a purple oval bruise that was approximately two inches on her right hand by her pinky finger and a dime sized scabbed circular wound on her right underarm. Resident #15 stated she did not know what the bruise or mark was from. Observation of Resident #15 on 3/5/25 at 10:46am reflected that Resident #15 had a bruise to her right hand and the small circular scab to her right underarm. Interview of CNA V on 3/5/25 at 11:16am reflected that she provided care to Resident #15 every 2 hours. She stated that the cut on her under arm was from an incident in which her and another CNA were changing her, and her skin tore when they turned her. She was unable to provide the specific date of the incident but stated it was some time last year and the incident was documented. She stated that she believed the bruise on her hand was due to them drawing blood recently. Record review of incident logs for December 2024 through March 2025 did not indicate any incidents related to Resident #15. Interview with CNA M on 3/5/25 at 11:32am reflected that Resident #15 mark on her hand looked like a bruise but had been there a couple of weeks. She believed it may have been caused when they drew blood. Interview with CNA W on 3/5/25 at 12:08pm revealed that she was unaware of any other bruises or the mark on Resident #15's underarm. Interview and observation of Resident #15 and ADON I on 3/6/25 at 8:19am reflected that Resident #15 had a dressing on the wound on her right under arm. Treatment Nurse removed the dressing on the wound and stated she was not aware of that wound. The bandage had blood and the wound had clear pink fluid. The wound was circular and the size of a dime. She stated she would look into what happened and who put the dressing on the wound. ADON I asked Resident #15 what happened and Resident #15 was unable to say. Resident #15 had a the bruise on her right hand. ADON I stated she was unaware of the bruise on Resident #15's hand. Resident #15 was unable to state what happened or when she got the bruise. Interview with RN X on 3/6/25 at 8:41am revealed that she was unaware of a skin tear/wound on Resident #15's right upper arm or bruise to her right hand. She stated she had not put the dressing on it yesterday and didn't see it. She stated that the night shift must have put on the dressing, but she was not notified of it at shift change. She did not know of a bruise to her hand either. She stated now that she knew she would get the measurements and initiate the incident protocol. She would get with staff to find who found the wound and covered it. She would notify ADON, DON, doctor and responsible party of her wound. Interview with ADON E on 3/6/25 at 9:28am revealed that Resident #15 should have had a weekly skin assessment due to having skin integrity issues. The nurses were responsible for completing the weekly skin assessments. When a new wound was found they would call the doctor and notify the ADON I, since she was the Treatment Nurse. When a new wound was found there should be a risk management assessment for change in skin condition completed. The risk to the resident if a wound was not assessed properly was that the resident would not be able to get treatment and further deteriorate. Staff also needed to follow the care plan to ensure that skin-maintained integrity and interventions were done as ordered. Interview with RN Y (night nurse) on 3/6/25 at 1:19pm revealed she had worked Resident #15's hall on 3/5/25 on the night shift but was not assigned to her. She was training a new RN Z and Resident #15 was assigned to her. She was not informed of any wounds or bruises on Resident #15 during her shift and didn't know who had put the dressing on her wound. She stated she last worked with Resident #15 on Thursday or Friday of last week and did not recall seeing any bruises or new wounds. She stated that the new RN Z had not alerted her of any skin issues or new wounds on Resident #15. Attempted interview with RN Z on 3/6/25 at 1:34pm but there was no answer on her phone and a voicemail was left to call back. No call back received. Interview with DON on 3/6/25 at 12:02pm revealed that she had not been notified of Resident #15's wound or bruise on her right side. She stated that the expectation for when an injury or wound was found that the nurse notified the doctor and followed up with recommendations. The nurse would also notify her, the Administrator, and the responsible party for the resident. She stated once she was notified, she would have to do an investigation to rule out abuse or neglect and see what happened. She stated that she was unable to provide proof that the Resident's family or doctor had been notified of the bruise or abrasion since she had not been notified of it and it was the first time she heard of it. Interview with Executive Director on 3/6/25 at 1:46pm revealed that she had just been informed about the wound on Resident #15 in the last hour. She stated that she was not notified of the bruise or abrasion on 3/5/25 and therefore no one else had been notified. She stated that whoever had found the abrasion would have needed to do an incident report and triggering the different necessary tasks and time frames. The tasks would have included notification to doctor and responsible party and completed necessary assessments. She stated they would have needed to contact the physician to get an order to cover the wound. She stated in instances where possible injuries and abrasions are found an incident report must be completed and a list of other tasks to be completed to include notifications to relative, doctors, and assessments would have been triggered. At the time of the interview there had been no incident report completed or notifications to the doctor or the patient representative. Once the incident report was completed, she would investigate to determine the origin of the bruise and abrasion. Once they find the origin or are unable to find the origin she would follow the provider letter on reportable incidents. The risk to the resident of not having the appropriate notifications done is that there would have been a failure to put interventions in place timely. Interview with Resident #15's responsible party on 3/6/25 at 2:10 pm revealed that she had not been notified of Resident #15's new wound or bruise until a few minutes before the surveyor called. She stated that she was looking through the videos to see if she could see when Resident #15 got the bruise . She stated that she saw Resident #15 on Monday and didn't notice it, and she was looking at video footage from Monday evening to Tuesday morning . Review of facility's policy Change in a Resident's Condition or Status revised May 2017 reflected Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): a. accident or incident involving the resident; b, discovery of injuries of an unknown source;,,,4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. There is a significant change in the resident's physical, mental, or psychosocial status; . Review of facility's policy Pressure Ulcers/Skin Breakdown - Clinical Protocol reviewed December 2024 reflected under treatment/management 1. The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents if indicated for type of skin alteration. 2. The physician will help identify medical interventions related to wound management .

Based on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living (ADL) to maintain good grooming and personal hygiene for 2 (Resident #2, Resident #204) of 6 residents reviewed for ADLs. The facility failed to ensure Resident #2 had her fingernails cleaned and trimmed. The facility failed to ensure Resident #204 had showers as care planed three times a week, and as needed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: 1.Record review of Resident #2's quarterly MDS assessment, dated 02/11/25, reflected an [AGE] year-old female who was initially admitted to the facility on [DATE], and readmitted on [DATE]. She had a BIMS score of 09/15, which indicated her cognition was moderately impaired. Resident #2 required substantial/maximum assist with ADLs. Resident #2 had diagnoses which included multiple sclerosis (a chronic, autoimmune disease that affects the central nervous system [brain and spinal cord]), dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), and depression. Record review of Resident #2's care plan, with an onset date of 12/15/24, reflected focus. I have an ADL Self Care Performance Deficit r/t weakness, MS, arthritis. Goal. I will improve current level of function in ADLs through the review date. Intervention. Encourage me to participate to the fullest extent possible with each interaction . An observation on 03/04/25 at 10:37 AM, revealed Resident #2 was laying in her bed. The nails on both hands were approximately 0.3 centimeters in length extending from the tip of her fingers and dirty underneath the nails and around the nail beds. Resident #2 was unable to answer questions related to her fingernail's status. In an interview on 03/05/25 at 09:58 AM, with CNA A she said she was assigned to Resident #2. She stated that most ADLs such as hair trimming and nail clipping were completed during shower times. She revealed that since Resident #2 was not a Diabetic resident, CNAs were responsible for clipping and cleaning her nails. CNA A stated that fingernail clipping should be done weekly or as needed and the risk of not cleaning/ trimming fingernails could be increased risk of infection. 2.Review of Resident #204's Quarterly MDS assessment dated [DATE] reflected Resident #204 was a [AGE] year-old female with initial admitted to the facility on [DATE], and readmission on 02/27/25. Her diagnoses included cerebrovascular accident (Occurs when blood flow to the brain is interrupted, leading to brain cell death and potential neurological damage.), hemiplegia (paralysis of one side of the body) or hemiparesis (weakness on one side of the body), She had a BIMS score of 12/15, which indicated her cognition was moderately impaired. Further review revealed Resident #204 was dependent on staff for shower/bath. Review of Resident #204's Comprehensive Care Plan, dated 02/27/25, reflected the following: focus. I have an ADL Self Care Performance Deficit r/t developmental social disorders, disease, and debility. Goal. I will maintain current level of function .Personal Hygiene through the review date. Interventions/Task BATHING: I am totally dependent on staff to provide a bath M, W, F and as necessary . Record review of Resident #204's document dated 03/06/2025 titled Task: Bath MWF 6pm-6am changed bed linen revealed Resident #204 received one shower in the lock back 14 days period on 03/06/25 at 02:49 PM , meaning she did not receive a shower on 02/28/25; 03/03/25 and 03/05/25. An observation on 03/04/25 at 11:01 AM, revealed Resident #204 was laying in her bed, wearing a black T-shirt with a V-neck opening. Her visible skin was oily and flaky. Resident #204 stated the last time she had a shower was a week ago during her stay in the hospital. In an interview on 03/06/25 at 06:41 AM, with RN B she said she was assigned to Resident #204 as charge nurse. She stated she did not know that Resident #204 did not receive a shower since she came back from the hospital on 02/27/25. She stated residents were supposed to get showers three times a week, and as needed. She stated CNA s were responsible to give residents showers, clean, and trim their fingernails if the resident was not diabetic. RN B stated CNAs were supposed to let the charge nurse know if the resident refused a shower and the documentation of the shower task. RN B stated the charge nurses were responsible to make sure the CNAs were giving residents their showers timely and cleaning their fingernails. RN B stated the risk to residents was improper hygiene, and possible development of infection if there were any open wounds. In an interview with the DON on 03/06/25 at 09:44 AM, she said her expectation was that residents' showers, unless they ask for specific schedule, should be at least three time a week unless the resident refused. DON stated residents' fingernails should be cleaned and trimmed during the shower days, and as needed. DON stated it was the responsibility of CNAs to give residents shower on time weekly, and the charge nurses in the hall should follow up on residents' ADLs/proper hygiene daily. She stated the risk to residents was development of infection, and loss of dignity . Record review of the facility policy titled Care of Fingernails/Toenails revised December 2024 reflected: Purpose. The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .General Guidelines. 1.Nail care includes daily cleaning and regular trimming. Record review of the facility policy titled Shower/Tub Bath revised December 2024 reflected: Purpose. The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin Documentation. the following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual (s) who assisted the resident with the shower/tub bath.

Based on interviews and record review, the facility failed to ensure each resident had the right to be free from abuse for 1 (Resident #1) of 5 residents reviewed for abuse. The facility failed to ensure a safe environment free from abuse for Resident #1 when CNA A entered his room and cut and stabbed him multiple times which caused him to sustained stab wounds to his right neck, left chest, and left arm on [DATE]. The noncompliance was identified as PNC. The IJ was from [DATE] to [DATE]. The facility had corrected the noncompliance before the survey began. This failure caused serious injury resulting in hospitalization and placed the resident at risk of death. Findings included: Review of Resident #1's undated face sheet reflected the resident was a [AGE] year-old male that was admitted to the facility on [DATE]. The diagnoses included unspecified nondisplaced fracture of second cervical vertebra (neck fracture); age-related osteoporosis without current pathological fracture (reduced bone mass); depression (mood disorder); unspecified sequelae of other cerebrovascular disease (affect blood flow and the blood vessels in the brain); polyneuropathy (nerve damage); dysphagia (difficulty swallowing); chronic obstructive pulmonary disease (lung disease); muscle wasting and atrophy (wasting or thinning of muscle mass); and malignant neoplasm of prostate (prostate cancer). Review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating he was cognitively intact. In Section E (Behavior) it stated that Resident #1 did not exhibit physical, nor verbal behavioral symptoms directed towards others. In Section GG (Functional Abilities and Goals) it stated Resident #1 required substantial/maximal assistance with his personal hygiene and toileting hygiene. Review of Resident #1's undated Care Plan, revealed Resident #1 was on anticoagulant therapy related to CAD (coronary artery disease). His goal was to be free from discomfort or adverse reactions related to anticoagulant use with interventions in place to monitor for bruising, significant or sudden changes in vital status and avoid activities that could result in injury. It also revealed Resident #1 is on oxygen therapy related to COPD (lung disease). His goal was to have no signs or symptoms of poor oxygen absorption with interventions in place to monitor for signs and symptoms of respiratory distress, increased heart rate and atelectasis (a collapse of the whole lung or an area of the lung). Further review revealed he was care planned for chest pain related to angina. His goal was to be pain free as evidenced by verbalization of comfort with interventions in place to encourage Resident #1 to avoid activities which increase the risk for chest pain. Review of Resident #1's Progress Notes on EHR revealed a progress note written by LVN A with an effective date of [DATE] at 07:52 am that revealed at approximately 4:45 am, this nurse entered Resident #1's room in response to a CNA questioning why another CNA had come back to work so early. Upon entering the room, I asked CNA A and she said she had just come in early to help I said thank you and walked back out of the room. The CNAs in the hall said that wasn't true and that she had a knife. I rushed back into the room, while CNA A ran out. I saw Resident #1 and he was bleeding profusely from his chest and the right side of his neck. I yelled for help and found a clean pillowcase and applied it to his neck. I ran back out Resident 1's door and yelled for help and to stop CNA A, to call 911 and get me more help, clean towels and to get other nurses. Myself and CNA C continued to apply pressure to Resident 1's wounds. The largest wound being across his throat on the right side to up around his ear to the right jaw. Resident #1's other wounds were a slashing type wound to his left forearm and a stabbing type wound to his left chest area with multiple wounds to his arms or hands. We continued to hold pressure until EMS arrived and Resident #1 was transported to the hospital. Record review of the hospital paperwork provider notes dated [DATE] with a hospital admission time of 07:09 am revealed Resident #1 was admitted for multiple stab wounds. A [AGE] year-old gentleman transferred as a trauma level 1 after sustaining stab wounds to his right neck, left chest and left arm at the skilled nursing facility. He is alert and awake with significant bleeding from his right neck. Pressure is being held to slow the hemorrhage. He states that he does take Plavix. All 12 systems negative other than mentioned above. The Assessment/Plan listed: Stab wound of neck (S11.91XA): Will proceed emergently to the operating room for a wound exploration washout and closure. Multiple stab sounds (T07.XXXA): Left chest wound does not appear to have penetrated the thorax as chest x-ray and ultrasound do not show any pneumothorax or pericardial effusion. During an interview on [DATE] at 4:40 pm with PD #1, she stated she cannot provide an update now as it was an ongoing investigation. PD #1 confirmed CNA A had been arrested and was in jail. During an interview on [DATE] at 04:49 pm with the MD, he stated he did not know CNA A. The MD stated Resident #1 got along with everyone and was lovable. The MD stated Resident #1 was 95yo and healthy for his age. The MD stated when Resident #1 first admitted to the facility in 2022, he had a fracture of the vertebrae. The MD said other than that, Resident #1 was doing well for his age. The MD stated he visited Resident #1 in the hospital, and he was doing great. During an interview on [DATE] at 5:00 pm with Resident #2 (Resident #1's roommate), he stated he was doing okay. Resident #2 stated the incident did not affect him as he was sleeping. Resident #2 stated he cannot understand how he slept through everything. Resident #2 stated when he woke up, the room was full of police and he asked, What did I do? Resident #2 stated he and Resident #1 were like brothers, and they loved each other. Resident #2 stated the Lord kept him asleep because he would have gotten up and jumped in and probably would have gotten hurt. During an interview on [DATE] at 05:05 pm with the MTD, he stated he changed all the door codes internally. The MTD stated whenever there was an incident, or a termination, they change the door codes. The MTD stated he goes to every keypad and wipe all the memory and a new randomly generated code was created. The MTD stated unfortunately there was no printout to provide. The MTD stated the system prompts you for each step, but it does not generate a record. The MTD stated you would have to videotape him going through the process of changing the codes. The MTD stated he was in-serviced on Abuse and Neglect and Emergency Preparedness on [DATE]. The MTD stated he was instructed you always report any concerns to the Abuse Coordinator. The MTD stated for the Emergency Preparedness in-service, they went over the different color codes and identifiable signs. The MTD stated he does not recall ever seeing CNA A. The MTD stated he believed the facility was taking the necessary precautions. The MTD stated the facility changed all the door codes, the facility was in the process of hiring off-duty law enforcement as security (right now they have staff volunteers) to man the front desk after hours, they have implemented only using the front entrance, they were reassuring families, residents and staff, and they were completing in-services with everyone. The MTD stated the facility was putting a new system in place for when visitors come after hours there was going to be a camera involved. The MTD stated the facility was also having someone certified by the State to come out and teach Emergency and Disaster training. The MTD stated he does not have to confirm if he was on the schedule, just staff. The MTD stated he believed the facility was doing everything in their power to comfort everyone and prevent abuse from happening again. The MTD stated he spoke with the Chaplain briefly, but he was doing okay. During an interview on [DATE] at 05:10 pm with the DON, she stated she was informed by LVN A that on [DATE] at approximately 11:45 PM, CNA A entered the facility and walked to the long-term care side, looked at the staffing book and then left the facility. The DON stated staff working initially believed when CNA A returned to the facility around 04:45 am, she had returned to clock out and was trying to steal time as she was not scheduled to work. The DON further stated CNA B saw CNA A enter the facility dressed in black scrubs and gave the impression she was there to help. The DON stated CNA C informed LVN A that CNA A was in the building and went into Resident #1's room. The DON stated LVN A said the first time she entered the room, CNA A said, patient care, so she exited the room. She stated CNA B went into the room to inform CNA A that she had already provided care and that was when she saw a knife and LVN A was alerted again. The DON stated as LVN A was going back into Resident #1's room, CNA A was hastily leaving out of the room and exited the facility. LVN A noticed Resident #1 bleeding and started first aide and called out for help. The DON stated 911 was called and alerted a suspicious person in the building and a resident had been stabbed. The DON stated staff provided CNA A's address to law enforcement and they located and arrested her later in the day. The DON stated they had video footage that they turned over to law enforcement showing CNA A entering and leaving the facility both times and entering and exiting the resident's room. The DON stated CNA A had been arrested and the facility had already completed (medical director was notified; wellness checks on all residents; changed all door codes to the facility; started in-services on Emergency Response and Abuse, Neglect and Exploitation; secured an Active Shooter Training for families, residents, and staff for [DATE]; implemented 24-hour around the clock management for the foreseeable future; in the process of getting off-duty cops to use after-hours as security for the foreseeable future for reassurance; had a Psychologist here today to meet with any family, residents, and staff; a Chaplain was here to speak with the roommate, residents, and staff; all families were notified of the incident via the Communication Blast; completed Safe Surveys with residents and had all management on the floor making rounds ensuring wellness; reviewed/modified current policies as applicable to ensure appropriate procedures are in place to prevent harm/potential harm; held an Ad Hoc QAPI meeting to discuss the incident and plan of correction moving forward). During an interview on [DATE] at 08:48 pm with FAM A, she stated Resident #1 lost a lot of blood and the doctor said they need to stabilize his blood pressure. FAM A stated CNA A sliced across Resident #1's neck from the right side and then sliced his chest. FAM A stated Resident #1 also had some defensive wounds on his left arm. FAM A stated LVN A probably saved Resident #1's life. FAM A stated LVN A walked into Resident #1's room as CNA A was exiting the room. FAM A stated she only allows Resident #1 to keep $5 on him to tip the hairdresser. FAM A stated Resident #1 does not keep anything of value in his room. FAM A stated she knows a lot of employees at the facility, and they were wonderful people. FAM A stated the staff loves Resident #1 and he loves them. FAM A stated she has never had any issues with the facility. FAM A stated Resident #1 admitted to the facility for rehabilitation in 2022, and they were so pleased with the facility, they transferred him to the long-term care side. FAM A stated Resident #1 was strong for someone that is about to turn 96-years-old, and he wants to return to the facility. During an interview on [DATE] at 11:15 am, Resident #3 stated she was okay. Resident #3 stated staff conducted a questionnaire about feeling safe. Resident #3 stated she does not need to speak with a counselor or a Priest. During an interview on [DATE] at 11:30 am, Resident #4 stated she felt safe at the facility and was not afraid of anyone. Resident #4 stated no one has threatened or harmed her. Resident #4 stated she answered some questions about feeling safe. Resident #4 stated she was satisfied with her care. During an interview on [DATE] at 11:45 am, Resident #5 stated she felt safe at the facility and was not afraid of anyone. Resident #5 stated no one has threatened or harmed her. Resident #5 stated she completed a questionnaire about safety. Resident #5 stated the staff take good care of her and she was satisfied here. During an interview on [DATE] at 12:00 pm, the [NAME] stated he was at the facility to encourage and support people through their workday. The Chaplain stated he has let everyone know they can call him privately to speak freely. The Chaplain stated he has been administering to the staff since 5:00 am. The Chaplain stated he hates to see tragedy and it was so sad. The Chaplain stated it was a blessing that a facility was so quick to invite them in to minister. The Chaplain stated for him, he does not push a faith-based answer to anyone, and he has been telling them there were 3 ways he can encourage them: listen for as long as they need, he can share if he has a similar life experience, or they can allow him to offer a faith-based approach. The Chaplain stated he believes it creates opportunity for processing and healing to know the facility was making space regardless of what they need or just his presence. During an interview on [DATE] at 12:20 pm, CNA B stated CNA A normally worked during her shift from 10:00 pm until 06:00 am. CNA B stated CNA A arrived at the facility the first time after their shift started around 11:45 pm. CNA B stated she told CNA A she was not on the schedule tonight, but jokingly said You can stay, and I will go home. CNA B stated she saw CNA A walk towards the exit and did not see her anymore. CNA B stated around 04:30 am she was completing her last round. CNA B stated she was in a different resident's room and CNA A poked her head in and asked her if she was okay. CNA B stated she thought to herself, I guess she did not leave. CNA B stated she proceeded to walk out of the room, and she saw CNA A enter Resident #1's room. CNA B stated she saw 2 other CNAs on the hall, and they asked her why CNA A was at the facility. CNA B stated they thought CNA A was trying to steal time and hiding in rooms until 6AM. CNA B stated she sent CNA D in the room, and CNA A said she was providing care. CNA B said she responded, I already changed him. CNA B stated she walked to Resident #1's room and as soon as she opened the door, she saw CNA A with a hunter's knife with a black blade (about the length of her forearm). CNA B stated CNA A said, Get back. CNA B stated as she was closing the door, she saw CNA A put the knife in a cover and place it inside of her scrubs. CNA B stated as soon as she closed the door, she told the other two CNAs, and one of the CNAs ran and told LVN A. CNA B stated LVN A went to enter the room and CNA A was coming out. LVN A asked CNA A for her name, and CNA A just kept walking and exited the building. LVN A went back into the room to check on the residents and she started screaming for help. CNA B stated when she first saw CNA A with the knife, CNA A was standing in front of the resident, so she did not see that she had harmed him. CNA B stated the police arrived and searched the entire facility and looked in all the rooms. CNA B stated she has not returned to work. CNA B stated she was informed they have changed the locks and the codes and when she returns to work, she will have to complete some in-services. CNA B stated she never thought anything negative about CNA A. CNA B stated CNA A was a bit stand-offish and did not talk a lot. CNA B stated when she and CNA A worked on the same hall, she would have to start a conversation with CNA A. CNA B stated CNA A never gave her a vibe as though she would hurt a resident. During an interview on [DATE] at 12:40 pm with LVN B, she stated the day of the incident, she was told a staff member entered the facility and attacked a resident. LVN B stated Resident #1 was stable, but critical. LVN B stated CNA A trained during one of her shifts when she was the Charge Nurse and everything appeared to be normal this day and she had no concerns for CNA A. LVN B stated since the incident, they have completed in-services on Emergency Preparedness and Abuse and Neglect. LVN B stated they went over what to do in the event of an active shooter or an emergency. LVN B stated they read the policy and addressed any questions. LVN B stated you do not engage with the perpetrator; you notify the police. LVN B stated they have had in-services on it in the past. LVN B stated she did not learn anything new, and it was more of a refresher. LVN B stated from the incident itself, she was more vigilant of the behavior of others. LVN B stated they also discussed what constitutes ANE and what to do if you witness it. LVN B said you must remove the resident from the area and ensure their safety. LVN B stated you must assess the resident and make proper notifications. LVN B said this was also a refresher due to being in the medical field for [AGE] years. LVN B stated the IADM checked on her to see how she was doing and if she had any questions. LVN B stated the DON checked in with all staff and informed them the Chaplain would be at the facility to speak with them if needed. LVN B stated both VPs walked throughout the facility checking on residents as well. LVN B stated they were now only allowed to enter and exit via the front doors and only Management were in possession of the door codes. LVN B stated she does not know if anything could have been done different. LVN B stated the AP was a staff member. LVN B stated LVN A took control of the situation and did what needed to be done. LVN B stated the Resident #1 could have died if it was not for LVN A's rapid response. During an interview on [DATE] at 12:55 pm with the SW, she stated they were using Angel Rounds to check in with residents to complete assessments and make any referrals. The SW said the Chaplain left cards to give to anyone in need. The SW stated if they had residents that were feeling overwhelmed or concerned, they will be referred to the PNP. The SW stated they were more aware of the incident and the effects it has on the residents so they can make appropriate referrals. The SW stated they will continue to assess residents and staff due to signs and symptoms may show up later and to be aware that they can develop stressors once the details settle in more. The SW stated Resident #1 was on her Angel Rounds list. The SW stated he was alert and very pleasant. The SW stated he was always out and about. The SW stated Resident #1 loved to do crafts and would pass key chain crosses that he made out to staff and other residents. The SW stated Resident #1 would even teach the other residents how to make things. The SW stated she had never seen Resident #1 have an outburst. The SW stated this incident was never going to make sense to a normal rational person. The SW stated she does not believe the why will ever be a sufficient answer. The SW stated the Resident could have died , and more than one resident or staff could have been hurt. During an interview on [DATE] at 1:10 pm with LVN C, he stated he does not recall ever working with CNA A. LVN C stated he was not informed a lot of details about the incident. LVN C said he just heard a CNA attacked a resident and the resident was sent out. LVN C stated on [DATE], he completed in-services on Abuse and Neglect and Emergency Preparedness. LVN C stated they always had the Emergency Color Codes attached to the back of their ID. LVN C stated the trainings were more of a refresher for him as he used to conduct all the in-servicing at his prior facility. LVN C stated the only difference was the color codes due to the colors not being universal. LVN C stated they discussed the definition of Abuse (physical, emotional, verbal, misappropriation, etc.). LVN C stated they discussed examples and answered questions. LVN C stated staff had to repeat back what they understood. LVN C stated they also discussed proper reporting. LVN C stated they then discussed to always refer to the card on the back of their IDs for any incidents. LVN C stated everything was a refresher for him. LVN C stated Resident #1 could have died . LVN C stated other residents or staff could have been injured. LVN C stated if CNA A had walked up to him, or if anyone that would have seen her in her uniform would not have questioned her. LVN C stated he was unsure of what could have been done different due to not knowing her intentions. During an interview on [DATE] at 1:50 pm with CNA E, she stated she was not working this day. CNA E said they were in-serviced on Abuse and Neglect and Emergency Preparedness on [DATE]. CNA E said they discussed the various types of abuse and how to handle each one. CNA E said if they see something they were to report it immediately to the Charge Nurse and the IADM. CNA E said it was information she already knew. CNA E stated they discussed the different color codes and their purpose. CNA E stated everything was a refresher. CNA E stated CNA A could have hit an artery and Resident #1 could have died . CNA E stated she does not understand why this happened. CNA E said she cannot comprehend it at all. During an interview on [DATE] at 2:30 pm with the IADM, she stated they had an unscheduled CNA that entered the facility with her door code. The IADM stated around 5AM on Thursday, ,d+[DATE], per the video footage CNA A walked down the hall and entered Resident 1's room. The IADM stated she believes CNA A encountered staff, but nothing confrontational. The IADM stated as CNA A entered Resident #1's room, she could be seen on video looking behind her to see if the hall was clear and then shut the door. The IADM stated CNA B opened the door and saw CNA A with a knife. The IADM stated CNA B went and alerted LVN A and as LVN A was entering Resident #1's room, CNA A exited past her and exited the facility. The IADM stated LVN A proceeded to enter the room and observed Resident #1 was bleeding. The IADM stated she received a call at 05:09 am stating Resident #1 had been stabbed by CNA A, he was being attended to and 911 had been called. The IADM stated they have ensured that all doors remain locked and changed all entrance and exit door codes. The IADM stated they were only entering and exiting through the front entrance. The IADM stated for now, only management staff will have the door codes. The IADM stated all employes will have to be logged in at the front desk and they will have to verify they were scheduled to work. The IADM stated they made psychiatric counseling available to all families, residents and staff. The IADM stated they have a contract with a Chaplain group to provide private counseling if needed and the Chaplain met with the Management Team this morning. The IADM stated they completed in-services on Emergency Codes and Preparedness, and Abuse and Neglect on [DATE]. The IADM stated both VPs, herself and the Corporate RN provided all the in-services to management and staff on [DATE]. The IADM stated she was in-serviced by VP B. The IADM stated they also completed Safety Surveys with all Long-Term residents. The IADM stated they have changed Angel Rounds to be conducted several times a day opposed to once a day to ensure the residents are okay. The IADM stated they completed well-checks on all residents to ensure no one else had been injured. The IADM stated they were securing off-duty police officers to work security detail. The IADM stated they were also having Active Shooting/Emergency Training on ,d+[DATE] for families, residents and staff. The IADM stated they have wrecked their brains and cannot think of anything that could have been done differently in this situation. The IADM stated they have Morning Meetings each day and if they see anything escalating, they address it. The IADM stated however, nothing was identified leading up to this incident. The IADM stated there were no concerns for CNA A, and she last worked two nights prior. The IADM stated no residents, family, nor staff ever complained about CNA A. The IADM stated the systems they had in place did not fail them. The IADM stated this was an isolated incident by one of their approved employees. The IADM stated they never had a system where they had only one entrance and had to confirm if they were on the schedule. The IADM stated the only thing they were lacking was the security officer. The IADM stated she believes CNA A entered the facility wanting to do harm and could have done more harm. The IADM stated they could not tell if Resident #1 was targeted or random. The IADM stated CNA A passed several rooms before entering this one. The IADM stated she visited Resident #1 at the hospital, and he asked if he did anything to piss CNA A off. The IADM stated she assured Resident #1 that he had not. The IADM stated Resident #1 said, She sure did beat me. The IADM said Resident #1 wanted to know if he can have his room back. During an interview on [DATE] at 02:55 pm with VP A, she stated they received the notification of the incident, staff called 911 and rendered first aid. VP A stated the police were still at the facility when she arrived at 7:45 AM on [DATE]. VP A stated they had already started Safe Surveys with the Residents to make sure they felt safe and comfortable. VP A stated they were able to have a psychologist and Chaplain Services to meet onsite with family, residents and staff to provide support. VP A stated the MD changed all the door codes. VP A stated for now, only the Department Heads had the door codes. VP A stated they notified the doctor and Resident #1's family. VP A stated the remaining families were notified via their Communication Blast. VP A stated during the Ad Hoc QAPI Meeting with the MD this morning, they looked over their policies and procedures, but did not identify any necessary changes. VP A stated on [DATE], they completed in-services on Abuse and Neglect and How to Respond to Emergencies and Traumatic Incidents. VP A stated she re-educated the DON on Abuse and Neglect and Emergency Response and they all in-serviced staff on the same information. VP A identified how things would look moving forward and were working on obtaining off-duty law enforcement to work as security officers after-hours. VP A stated she does not believe anything could have been done different unless they had a crystal ball to foresee the future. VP A stated she believes policy was followed to the best of the facility's ability. VP A stated Resident #1 could have expired. During an interview on [DATE] at 3:25 pm with VP B, she stated she was notified about the incident by the DON on [DATE] around 5:25 am. VP B stated she was told Resident #1 had been injured by CNA A and transported to the hospital. VP B stated CNA A had fled the facility and the police was present and starting an investigation. VP B said they have ensured all doors were secure and changed the codes. VP B said the front entrance was now always staffed and employees must confirm they were scheduled to work. VP B said they have a daytime receptionist, but now the front entrance will be staffed 24 hours. VP B said they completed a facility sweep to verify the wellness of the residents, completed Safe Surveys and began in-servicing on Abuse and Neglect and Facility Emergency Events (Active Shooter/Incidents). VP B said she has conducted in-services with staff and Administration. VP B stated the in-servicing was on-going and any employee that has not been in-serviced will be in-serviced at the start of their shift. During an interview on [DATE] at 3:40 pm with the PNP, she stated she went to the facility the next day on Friday, ,d+[DATE]. The PNP stated on Thursday, ,d+[DATE] she was called by her employer and was asked to go out to the facility to check in on the staff and the residents to see where she could be of assistance and see if they needed help with anything. The PNP stated her primary reason for coming in on Friday was to assess the residents to see how they were doing emotionally. The PNP stated all the residents she spoke with on Friday were okay. The PNP stated a lot of the feedback she received was a lot of them were asleep and was not aware of the situation until the aftermath. The PNP stated she questioned the residents about how they felt about the situation, if they felt safe, assessed what they knew about the situation and made sure they had accurate information about the incident from what she had been told from staff. The PNP stated she informed the residents about the safety measures that she was informed the facility was currently implementing as well. The PNP stated she did not have any residents that communicated to her not wanting to be at the facility, nor any PTSD-type symptoms. The PNP stated some of the residents were just upset that it happened. The PNP stated Resident #1 was one of her patients. The PNP stated Resident #1 had never voiced any concerns about the facility, nor staff leading up to the incident. The PNP stated Resident #1 was a very well-known resident, and his family was very involved with his care at the facility. The PNP stated Resident #1 was diagnosed with depression and that was why she was seeing him. The PNP stated admission to a nursing home was an adjustment for a lot of the LTC residents. The PNP stated the Residents have gone their entire life living independently on their own to sharing a room with a roommate. The PNP stated Residents must navigate that relationship, being provided care by staff and being away from their families. The PNP restated the victim's family was very involved in his care and they were at the facility quite often. The PNP stated she did not assess any staff or families. The PNP stated the facility Psychologist came in the day of the incident to speak with staff and she also rounded on the residents. The PNP stated they were working with the facility to see how they can provide care for the staff too. The PNP stated some staff informed her that a Chaplain came out to visit with them and the residents too. The PNP stated she believes the facility was handling the situation appropriately. During an interview on [DATE] at 3:55 pm with CNA C, she stated on (Wednesday ([DATE]), CNA A showed up to the facility at 11:44 pm. CNA C stated she works on the skilled side and CNA A works on the long-term care side. CNA C stated you must enter the facility after hours on the skilled side where she works. CNA C stated CNA A walked past them on the skilled side and walked towards long-term care. CNA C stated CNA A was on the long-term care side for about 30 minutes and does not know what she did while down there. CNA C stated CNA A eventually walked back out of the building between 12:30 am and 01:00 am. CNA C stated she then went outside to get her lunch from her family member, and she saw CNA A sitting in her car parked under the awning. CNA C stated she assumed CNA A was on break since they work on different sides of the building. CNA C stated CNA A saw her, but she did not think CNA A was doing anything wrong. CNA C stated she then went back into the facility. CNA C stated later during her shift, she remembered she was in a Resident's room, and she told the Resident it was 4:54 am. CNA C stated when she walked out of the Resident's room, she saw CNA A walking back into the facility. CNA C stated she and CNA D said, CNA A must be stealing time. CNA C stated CNA A had been gone this entire time and came back to change a few people and clock out. CNA C stated her, and CNA D waited a few minutes after CNA A walked down the hall to long-term care, and they decided they would go and catch her. CNA C stated looking back at it, the incident must have occurred while they were waiting outside of the rooms. CNA C stated they never heard any noises. CNA C stated CNA B told them which room CNA A was in, so CNA D knocked on the door and started to walk in and CNA A said, I am changing them. CNA C stated CNA B said Well, if she is in there changing them, I am going to go in a[TRUNCATED]