Every finding on record at Cedars Health Center

Based on observation, resident, staff, and family interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for personal hygiene and grooming for five (5) of 28 sampled residents. Resident #4, #10, #34, #60, and #92 Findings Include: Review of the facility policy titled Comprehensive Care Plans unrevised, revealed under, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan Resident #4 Record review of Resident #4's Care Plan Report revealed that he needed assistance with ADL's (Activities of Daily Living) related to recent hospitalization for left femur fracture, total hip arthroplasty d/t autoimmune encephalitis, falls, episodes of confusion. He has weakness and requires staff assistance with dressing, bathing, personal hygiene and transfers, w/c for mobility. An observation of Resident #4 and interview with the resident's sister-in-law at the bedside on 11/17/25 at 11:00 AM revealed the resident was lying in bed and had approximately one-eighth (1/8) inch gray, facial hair. Resident 4's sister-in-law stated he likes to be clean-shaven. An interview on 11/19/25 at 2:00 PM with Certified Nursing Assistant (CNA) #3 and observation of Resident #4, CNA #3 confirmed his face was not shaved, and his hair on his face was long. On 11/20/25 at 9:00 AM, the Assistant Director of Nursing (ADON), stated that the care plan should be implemented for all residents. And, that the expectation is for the staff to follow the care plans, if Resident #4 was supposed to have a shaven face and didn't, the care plan was not followed. Record review of Resident #4's demographic information revealed that the facility admitted Resident #4 on 9/25/2025 with a medical diagnosis that included Encephalitis. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/2025 revealed under Section C that Resident #4's Brief Interview for Mental Status (BIMS) was 2 and her cognitive skills for daily decision making were severely impaired. An interview on 11/20/25 at 9:00 AM with Assistant Director of Nursing (ADON), revealed that the purpose of the care plan was to develop a plan of individualized care for an elder/resident's specific need. She revealed that the care plan included personal hygiene needs including removal of facial hair. ADON agreed that since Resident # 4's facial hair was not removed, his care plan was not followed. Resident #10 Record review of Resident #10's Care Plan Report revealed that he had an ADL self-care deficit related to recent hospitalization for cardiac arrest . His interventions included, Bathing/Showering: Check nail length and trim and clean on bath day and as necessary . Observations on 11/18/25 at 8:20 AM and at 1:28 PM revealed Resident #10's fingernails were approximately one-half of an inch long and had brown substance underneath on both hands. An interview on 11/18/25 at 1:30 PM with Resident #10, revealed that he had his shower yesterday and stated, They don't offer to do my fingernails while I'm in the shower. He also revealed that his fingernails needed to be cleaned and trimmed. During an observation and interview on 11/18/25 at 1:35 PM with CNA #1, she confirmed that Resident #10 had long fingernails with a brown substance underneath. She revealed that Resident #10's scheduled shower days were Mondays, Wednesdays, and Fridays and his fingernails should have been taken care of yesterday Record review of Resident #10's admission Record revealed the facility admitted the resident on 07/15/25 and that he had diagnoses that included Other Reduced Mobility, Need for Assistance with Personal Care, and Other Retention of Urine. Record review of Resident #10's MDS with an ARD of 10/14/25 revealed a BIMS Score of 10 which indicated that he had moderate cognitive deficits. An interview on 11/19/25 at 3:00 PM with the Director of Nursing (DON), revealed that the purpose of the care plan was to develop care specific to each resident so that the staff members knew how to care for the individualized needs of the residents. She revealed that the care plan included personal hygiene needs including fingernail care and removal of facial hair on men and ladies. The DON agreed a care plan was not followed if the residents' ADL needs were not completed. Resident #34 Record review of Resident #34's Care Plan Report revealed under, Focus: The elder has an ADL (activities of daily living) self-care deficit r/t (related to) activity intolerance. Elder requires staff assistance with dressing, bathing, personal hygiene, transfers. During an observation of Resident #34 on 11/17/2025 at 11:39 AM it revealed her sitting in the front lobby with long gray facial hair present on her chin, the sides of her face, and above her lip measuring approximately one-half (1/2) inches in length. On 11/18/25 at 1:10 PM, during an interview with Resident #34, she revealed she did not like to have facial hair. An observation and interview with CNA #6 on 11/18/25 at 1:15 PM confirmed Resident #34 had long gray facial hair. An interview with the MDS Nurse on 11/20/25 at 8:40 AM revealed that staff were aware of the residents' care planned interventions related to ADLs because it triggered them to see and sign off under the task section of the electronic medical record (EMR). She stated it was common sense for female facial hair to be removed during bathing. She confirmed the care plan was not followed for personal hygiene for Resident #34. Record review of the admission Record revealed the facility admitted Resident #34 on 4/15/25 with a medical diagnosis that included Atherosclerosis of Aorta. Record review of the MDS with an ARD of 10/14/25 revealed under section C, a BIMS summary score of 15, which indicated Resident #34 was cognitively intact. Resident #60 Record review of Resident #60's Care Plan Report revealed that she needed assistance with ADL's related to activity intolerance, fatigue, MS (Multiple Sclerosis), Dementia. Observations on 11/17/25 at 12:17 PM and on 11/18/25 at 8:15 AM revealed that Resident #60 had a patch of about 10 - 12 facial hairs on her right and left upper corner of her lip. The facial hairs were approximately three-fourths to one inch long. An interview on 11/17/25 at 12:20 PM with Resident #60 revealed that facial hair was very unattractive and stated, I don't like it. She revealed that the staff never offered to remove her facial hair and she would like it to be gone. An observation and interview on 11/17/25 at 1:40 PM with CNA #2 confirmed that Resident #60 had patches of gray hairs to her right and left corner of her mouth. revealed that Resident #60's scheduled showers were on night shift on Tuesdays, Thursdays, and Saturdays and that should have been taken off. Record review of Resident #60's admission Record revealed the facility admitted the resident on 06/01/24 and that she had diagnoses that included Unspecified Dementia and Primary Progressive Multiple Sclerosis. Record review of Resident #60's MDS with an ARD of 10/28/25 revealed a BIMS Score of 10 which indicated that she had moderate cognitive deficits. Resident #92 Record review of Resident #92's Care Plan Report revealed under, Focus: Elder needs assist with ADL's (activities of daily living) related to Alzheimer's dementia, weakness, activity intolerance. Also revealed under, Interventions: Elder requires assistance of 1 (one) person with bed mobility, transfers, toileting, bathing, personal hygiene. An observation of Resident #92 on 11/17/25 at 11:35 AM revealed she was sitting in her wheelchair in the front lobby area and her fingernails on both hands were long and dirty. Her nails measured approximately 3/4 (three-quarters) of an inch in length past the fingertips with a thick black substance underneath the thumb and index nails. She also had 4 to 5 long gray hairs observed on her chin measuring approximately one-half (1/2) inch in length. On 11/18/25 at 1:20 PM, during an observation and interview with CNA #6, she confirmed Resident #92 had long dirty nails and facial hair to her chin. An interview with the MDS Nurse on 11/20/25 at 8:40 AM revealed nail care and female facial hair would be addressed as part of personal hygiene during bathing and routine care. She confirmed Resident #92's care plan was not followed for personal hygiene. Record review of the admission Record revealed the facility admitted Resident #92 on 11/03/22 with medical diagnosis that included Alzheimer's Disease. Record review of the MDS with an ARD of 8/19/25 revealed under section C, a BIMS summary score of 3, which indicated Resident #92 was severely cognitively impaired.

Based on observation, staff, resident, and resident representative interview, record review, and facility policy review, the facility failed to provide nail care (Resident#10 and Resident #92), and shaving (Resident#4, Resident #34, Resident #60 and Resident #92) for five (5) of 28 sampled residents. Resident #4, #10, #34, #60, and #92Findings Include: Review of the facility policy titled Activities of Daily Living unrevised, revealed under, Policy Explanation and Compliance Guidelines: . 2. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #4 During an observation on 11/17/25 at 11:00 AM it was revealed that Resident #4 was lying in bed unshaved. His facial hair was approximately one-eighth (1/8) inch long and gray. Resident 4's sister-in-law was present at the bedside. During an interview with Resident #4's sister-in-law on 11/17/25 at 11:05 AM, she stated that he likes to be clean shaved. On 11/19/25 at 2:00 PM Certified Nursing Assistant (CNA) #3 was interviewed regarding Resident #4's facial hair. She stated he gets his shower and shaves on the night shift and he normally doesn't refuse care. She confirmed his face was not shaved, and his hair on his face was long. On 11/20/25 at 9:00 AM, the Assistant Director of Nursing (ADON), stated that it was her expectation for the staff to shave Resident #4. She went on to say the he was supposed to have a shaven face and didn't. Record review of Resident #4's demographic information revealed that the facility admitted Resident #4 on 9/25/2025 with a medical diagnosis that included Encephalitis. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/2025 revealed under Section C that Resident #4's Brief Interview for Mental Status (BIMS) was 2 and his cognitive skills for daily decision making were severely impaired. Resident #10 An observation on 11/18/25 at 8:20 AM and again at 1:28 PM, revealed Resident #10 lying in bed in his room with his fingernails approximately one-half of an inch long past the fingertips with a brown substance underneath. An interview on 11/18/25 at 1:30 PM with Resident #10 admitted that his fingernails needed trimmed and cleaned. He stated that he had a shower yesterday, but no one offered to take care of his nails. On 11/18/25 at 1:35 PM CNA #1 was interviewed while observing Resident #10 and confirmed that his fingernails were long and dirty. She admitted they needed trimming and had a brown substance underneath that needed to be removed. Resident #10 had long fingernails with brown substance underneath. She revealed that Resident #10's scheduled shower days were Mondays, Wednesdays, and Fridays and his fingernails should have been done yesterday. She stated that with his nails like they were he could scratch himself or someone else. An interview on 11/18/25 at 2:45 PM with the Registered Nurse (RN) Supervisor confirmed that nail care was supposed to be completed during a Resident's shower time. She revealed that by leaving Resident #10's fingernails long and dirty, it could cause him to scratch himself which could lead to sores on his body, or he could hurt someone else. She stated, We expect them (residents) to feel good and look good. Record review of Resident #10's admission Record revealed the facility admitted the resident on 07/15/25 and that he had diagnoses that included Other Reduced Mobility, Need for Assistance with Personal Care, and Other Retention of Urine. Record review of Resident #10's MDS with an ARD of 10/14/25 revealed under Section C a BIMS Score of 10 which indicated that he had moderate cognitive deficits. Resident #34 On 11/17/25O at 11:39AM Resident #34 was observed sitting in the front room of the facility with visible gray hair on her face. The facial hair was approximately one half (1/2) of an inch long on her chin, sides of her face and above her lip. During an interview on 11/18/25 at 1:10 PM Resident #34 stated that some girl was supposed to have shaved her face last week, but she told me she could not find a razor. The resident admitted that she did not like to have facial hair. An observation and interview on 11/18/25 at 1:15 PM with CNA #6 confirmed that Resident #34 needed to be shaved. She revealed the aides were responsible for shaving facial hair during the resident's bath or whenever it needed to be done. She stated that the 3-11 shift was responsible for doing the bath and stated, But anybody could do it. Record review of Resident #34's ADL Task for November 2025 revealed, ADL- Bathing as scheduled on Mon (Monday), Wed (Wednesday), [NAME] (Friday) 2pm-10pm initialed as done on 11/17/25. An interview with RN #1 on 11/18/25 at 1:28 PM revealed the aides were responsible for shaving the residents as part of hygiene during bathing. RN #1 acknowledged she was responsible for ensuring that the aides provided the care. Record review of the admission Record revealed the facility admitted Resident #34 on 4/15/25 with a medical diagnosis that included Atherosclerosis of Aorta. Record review of MDS with an ARD of 10/14/25 revealed under section C, a BIMS summary score of 15, which indicated Resident #34 was cognitively intact. Resident #60 Observations on 11/17/25 at 12:17 PM and on 11/18/25 at 8:15 AM revealed that Resident #60 had two patches of about 10 - 12 facial hairs on her right and left upper corner of her lip. The facial hairs were approximately three-fourths to one inch long. An interview on 11/17/25 at 12:20 PM with Resident #60 revealed that facial hair was very unattractive and stated, I don't like it. She revealed that the staff never offered to remove her facial hair and she would like it to be gone. An observation and interview on 11/17/25 at 1:40 PM with CNA #2 confirmed that Resident #60 had patches of gray hair on her upper lip area. She admitted that the resident's scheduled showers were on night shift on Tuesdays, Thursdays, and Saturdays. She stated, I don't like facial hair so I pluck mine, and Her's should have been taken off. An interview on 11/18/25 at 2:35 PM with the RN Supervisor revealed that she expected the CNAs to shave facial hair on men and ladies, shampoo their hair if they wanted it, and trim, clean and file fingernails if needed during their scheduled shower time. She stated, No woman wants to be seen like that. She also revealed that she expected the residents to look and feel good about themselves Record review of Resident #60's admission Record revealed the facility admitted the resident on 06/01/24 and that she had diagnoses that included Unspecified Dementia and Primary Progressive Multiple Sclerosis. Record review of Resident #60's MDS with an ARD of 10/28/25 revealed a BIMS Score of 10 which indicated that she had mild cognitive deficits. Resident #92 Resident #92 was observed on 11/17/25 at 11:35 sitting in the front lobby with fingernails that were approximately three fourths (3/4) of an inch long past the tips of her fingers with a thick brown substance under her thumb and index nails. She also had 4 to 5 long gray hairs observed on her chin measuring approximately one-half (1/2) inch in length. An interview with CNA #6 on 11/18/25 at 1:20 PM confirmed Resident #92 had long dirty nails and facial hair to her chin. She stated the aides were responsible for ensuring the nail care and facial hair was addressed with bathing. CNA #6 explained that Resident #92 gets a bath on 3-11 shift and stated it should be addressed during that time or anytime that it was noted. She confirmed the resident could get bacteria under the nails and scratch herself. Record review of Resident #92's ADL Task for November 2025 revealed, ADL- Bathing- give bed bath or shower every Monday, Wednesday, and Friday & (and) as needed initialed as done on 11/17/25. An observation and interview with RN #1 on 11/18/25 at 1:31 PM revealed the aides were responsible for nail care including cutting and cleaning and removing facial hair as part of personal hygiene during bathing. RN #1 acknowledged she was responsible for making sure that the care was provided. She revealed Resident #92 could scratch herself and cause skin concerns. An interview with the Administrator (ADM) on 11/18/25 at 2:10 PM revealed her expectations were for the nail care and facial hair to be addressed with bathing or anytime it was needed. Record review of the admission Record revealed the facility admitted Resident #92 on 11/03/22 with medical diagnosis that included Alzheimer's Disease. Record review of the MDS with an ARD of 8/19/25 revealed under section C, a BIMS summary score of 3, which indicated Resident #92 was severely cognitively impaired.

Based on observation, staff interview, record review, and facility policy review, the facility failed to monitor refrigerated medications for proper temperature control to ensure safe medication storage for one (1) of 11 medication refrigerators in facility. Rehabilitation Unit refrigerator Findings include: Record review of the facility policy titled, Storage of Medication Requiring Refrigeration, dated 4/2025 revealed, It is the policy of this facility to assure proper and safe storage of medications requiring refrigeration and to prevent the potential alteration of medication by exposure to improper temperature controls. Refrigerators used for the storage of medications and biologicals: e. Temperature should be maintained between 36 - 46 degrees F (Fahrenheit). f. Temperature to be monitored daily to ensure proper temperature control and documented on the temperature log with the date, time, and signature of person performing the check clearly written. During an observation of the medication storage room in the rehabilitation/therapy area of the facility, it was noted that the temperature log was incomplete for multiple days in the month of November. The review of the Medication Refrigerator Temp Logs dated November 2025 revealed the temperature was not monitored and documented on 11/1/25, 11/2/25, 11/4/25, 11/5/25, 11/7/25, 11/8/25, 11/9/25, 11/10/25, 11/11/25, 11/13/25, 11/17/25, and 11/19/25. An interview on 11/19/25 at 10:40 AM with Licensed Practical Nurse (LPN) #2 revealed the temperature checks of the medication refrigerators were scheduled to be monitored each night shift. During an interview on 11/19/25 at 10:45 AM, the Director of Nursing (DON) confirmed the facility failed to monitor and document the refrigerated medication temperatures which could alter the effectiveness of the medication. She then revealed that it was her expectation for each medication refrigerator's temperature to be monitored and documented each night shift to ensure the medications were stored properly in the appropriate temperature medication. An interview with the Administrator (ADM) on 11/19/25 at 1:55 PM confirmed that the facility failed to ensure proper and safe medication storage by the failure to monitor and document medication refrigerator temperatures. She stated that it was the facility's policy to ensure medications, including refrigerated medications, were stored properly. She acknowledged that medication effectiveness could be altered by inappropriate storage

Based on observation, staff interview, and facility policy review, the facility failed to maintain a wheelchair in a clean and sanitary manner for one (1) of seven (7) residents using mobility devices in house 600. Resident #92 Findings Include: Review of the facility policy titled Safe and Homelike Environment unrevised, revealed under, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. An observation of Resident #92 on 11/17/25 at 11:35 AM revealed she was sitting in her wheelchair in the front lobby area. The lower wheelchair frame and left wheel were covered in an orange-colored dried substance. An observation and interview with Certified Nurse Aide (CNA) #6 on 11/18/25 at 1:15 PM confirmed Resident #92's wheelchair was dirty and covered in a dried substance that she thought was food. She stated it was everybody's responsibility to ensure the resident equipment was clean. An interview with the Administrator (ADM) on 11/18/25 at 2:10 PM revealed her expectations were for staff to ensure the resident equipment was kept clean to provide a sanitary environment. Record review of the admission Record revealed the facility admitted Resident #92 on 11/03/22 with medical diagnosis that included Alzheimer's Disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/19/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 3, which indicated Resident #92 was severely cognitively impaired

Based on facility policy review, record review and interviews, the facility failed to ensure a resident's right to be free from neglect for one (1) of four (4) sampled residents, Resident #1.On 10/14/25 at approximately 10:16 AM, after returning to the facility from an appointment the facility abandoned Resident #1 on the facility's transport van. Resident #1 was left alone and unattended on the facility transport van for approximately two hours. At 12:15 PM, the facility staff located Resident #1 still strapped in the facility transport van. This resulted in Resident #1 missing her hydration, care and expressing a fear that she was anxious, and thought she would die.The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) at Past Non-Compliance (PNC). The SA determined the IJ began on 10/14/25 when the facility abandoned Resident #1 on the facility transport van and was removed on 10/15/25 when the facility put measures in place to protect all residents from further abuse and neglect. The facility's neglect to provide ordered care and services placed Resident #1 and other residents who use the facility transport van for transfers in a situation that could likely lead to serious injury, harm, impairment or death.The IJ and SQC existed at: 42 CFR 483.12(a)(1) Freedom from Abuse, Neglect, and Exploitation - F600, Scope and Severity J PNC. The SA notified the facility's Administrator of the IJ and SQC at PNC on 10/22/25 and provided the Administrator with the IJ template.Based on the facility's implementation of corrective actions on 10/14/25, the SA determined the IJ and SQC to be PNC and the IJ was removed on 10/15/25, prior to the SA entrance into the facility on [DATE].Findings include:Record review of facility policy titled, Abuse, Neglect, and Exploitation dated 3/15/24, revealed, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. 'Neglect' means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.During an interview with Resident #1's representative on 10/21/25 at 12:40 PM, it was revealed that the resident was transported to and from an appointment by the facility's Transportation Aide (TA). Resident #1 left the facility around 7:45 AM and around 10:00 AM she was secured in the bus to be taken back to the facility. The resident's representative went to the facility to have lunch with the resident, and the facility staff could not locate her. The TA was notified, and she reported that she had brought the resident back earlier that morning then she realized that she had been left on the bus. When the resident returned to the room, she was soaking wet, hot, thirsty, face was puffy and was extremely weak and tired. She revealed that the resident told her she was scared and thought she was going to have to spend the night on the bus and was even concerned that she would not survive the incident. The representative acknowledged that this incident caused the resident emotional distress, and she was now afraid to be transported in the facility's bus. An interview with Resident #1 on 10/20/25 at 1:30 PM, revealed she was left alone on the bus after a doctor's appointment. When they arrived at the facility, the driver got out of the bus and went into the building. The resident was hoping someone would come back to get her, but it was a long time before they returned. Resident #1 stated, I had no water and no phone, and I just sat there in that heat . The sun was shining and beating down, and I was hot and so thirsty for water and air. She stated she kept praying, Lord, it's just my time to die. I don't see no way out and nobody knows I'm here. I can't walk and I don't have a phone to call for help. She stated that being in the bus for so long made me sick and upset and I had to settle myself down and nothing like that had ever happened in my life. During the interview, the resident was in her wheelchair in her room and was pleasant and could articulate with her account of the event that occurred. During a phone interview on 10/21/25 at 4:07 PM, the Transportation Aide (TA) revealed she took Resident #1 to the hospital for a test and returned to pick her up to take her back to the facility around 10:00 AM. She returned to the facility, parked the bus, got out, and went inside the building. Around lunch time, Certified Nursing Assistant (CNA) #1 called her to ask about Resident #1 and she informed her that she had brought her back earlier that morning. She then realized that she did not remember returning the resident to her room, so she went to the bus and found the resident positioned where she had been secured. The resident was alert and said she was hot, but okay and was glad she came to assist her off the bus. She and CNA #1 got the resident out of the bus and back to her room. She acknowledged she had a lot on her mind, and she failed to ensure the resident was cared for appropriately and taken off the bus and returned safely to her room inside the facility. She stated she had been in-serviced on abuse and neglect, but she was uncertain when that was. During a phone interview with Certified Nursing Assistant (CNA) #2 on 10/20/25 at 4:22 PM, it was revealed that when the resident was returned to her room, she was tired and weak and scared and shaken up. She said her mouth was dry and she drank some water. Her pants were soaking wet from where she had urinated on herself.A phone interview with CNA #3 on 10/20/25 at 4:27 PM, revealed when the resident returned to her room, she looked tired and the areas around her eyes were red and puffy, and her blood pressure was slightly elevated. She stated the resident said she was scared when she was left on the bus and was happy to see everybody's faces.During an interview on 10/21/25 at 11:30 AM, CNA #4 revealed at lunch time around noon on 10/14/25, Resident #1's representative asked her where the resident was. They looked in therapy, resident's room, and other rooms and could not locate her. They contacted the TA and was told that the resident was brought back earlier. Shortly after that, the TA brought the bus to the door. She was panicked and said, Oh my God, she's been on the bus for hours! The resident kept telling the staff, Baby, I'm so glad to see y'all. The representative was in the room and very upset and the resident told her representative that it was upsetting and frightening, but I'm alive! During an interview on 10/21/25 at 2:45 PM, the Director of Nursing (DON) revealed it was her expectation that the bus be checked each time it was parked to ensure that no residents were left on the bus. She acknowledged that a vulnerable resident being left in a closed bus in the heat could lead to harmful health consequences and even death. She confirmed the facility neglected a resident's needs when they failed to provide appropriate care when the resident was left alone on a closed bus for approximately two (2) hours with no care or supervision.A phone interview with CNA #1 on 10/22/25 at 10:56 AM, revealed on 10/14/25 around 12:00 PM, Resident #1's representative was looking for the resident, so the staff started searching for her. The TA was contacted, and she stated she had returned the resident earlier that morning. The staff continued to search for the resident. The TA then came to the door with the resident and said she had been left on the bus. The resident was taken to her room to get cleaned up and assessed. She revealed the resident was alert, but her hands were swollen, her eyes were red, her face was puffy, and she looked very tired. She stated the resident told her she was okay now that she was found and told the staff, I'm so glad to see your faces!. During an interview on 10/22/25 at 8:55 AM, the Administrator in Training (AIT) acknowledged that Resident #1 was in a closed bus on a sunny day with an outside temperature approximately 82 degrees for a two (2) hour time frame. He stated that this incident had the potential for severe health complications for this vulnerable resident. He acknowledged his expectation was for each resident to receive their needed care. He confirmed the facility neglected to meet Resident #1's care and safety needs when they failed to ensure she was removed from the bus and placed into the safety of her room in the facility. Phone interviews with the Administrator on 10/21/25 at 2:06 PM and 10/22/25 at 10:02 AM revealed it was her expectation that each resident receive appropriate care. She confirmed the facility neglected to provide the necessary care for an approximate two (2) hour time frame while Resident #1 was left in a facility bus, alone, unattended, with no supervision. It was a sunny day with the temperature approximately 79-82 degrees. She acknowledged that this incident could have had a devastating outcome for this vulnerable resident. She also acknowledged that annual training for abuse and neglect was necessary for all staff members, and it was her responsibility to ensure the Transportation Aide was current with her training. She confirmed that the facility failed to in-service TA on abuse and neglect since her last in-service in May 2024. On 10/22/25 at 2:20 PM, a phone interview with the Medical Doctor revealed he was notified of the incident involving Resident #1 being left on the bus for approximately two hours. He came to the facility to evaluate the resident and gave orders for frequent vital sign monitoring and for lab work. Oral hydration was encouraged. He stated he could not understand how this could happen to a resident and said she was fortunate that she was found as soon as she was, otherwise, the outcome could have been devastating. He revealed with the resident's comorbidities and health status, the potential for serious complications was present. He also revealed that he wanted the resident to be evaluated by a cardiologist for her heart condition, but due to this incident, she was frightened to go on the bus. He stated that both the resident and the resident's representative requested that the appointment be postponed until the resident returns home. Review of timeanddate.com weather review revealed on 10/14/25 at 12:00 PM the outside temperature range was from 79 - 82 degrees and sunny in the town where facility was located. Record review of Transportation Aide's most recent acknowledgment of abuse and neglect training was signed on 5/29/24.Record review of the Corrective Action Form for Transportation Aide dated 10/14/25 revealed Disciplinary Suspension due to Violation of company rules of conduct and Improper conduct. Record review of HR (Human Resources) Action Form dated 10/17/25 revealed the Transportation Aide's reason to take off payroll was Voluntary Resignation. Record review of Transportation Aide's statement revealed, On Oct. 14, 2025, I picked up (proper name of Resident #1 removed) from (proper name of hospital removed). I loaded her in the back of the bus, strapped her down and started back to (proper name of facility removed) to unload her. As I was almost to (proper name of facility removed) I got a phone call from (proper name removed) (activities lady) inquiring if she could use one of the busses to take (proper name of a resident) to the bank that day. I was telling her we needed to put new bus in the shop and I would have to check to see if other bus was going to be available. She also was wanting to know if she was scheduled to use the new bus Friday. I already had 2 emails from people wanting to use the bus. My thought was on trying to figure this bus thing out. I parked the bus went into my office and was checking my appointment schedule for the busses. I didn't realize I hadn't unloaded (proper name of Resident #1 removed) until (proper name of CNA #1 removed) called me. I went to the bus where (proper name of Resident #1 removed) was. Asked if she was OK and if she was hot. She replied, 'I thought y'all had forgot me, but I am OK'. I then took her to (proper name of facility's building removed) and unloaded her. Record review of Progress Note for Resident #1 on 10/14/25 revealed, During post incident assessment of elder, elders skin visualized with no redness, rashes, bruising or open areas noted. Skin warm and dry to touch and intact throughout. Skin turgor good, color appropriate to ethnicity. Resident denies any pain or discomfort. Elder has edema to BLE (bilateral lower extremities) and swelling to right hand, which is baseline for elder.Record review of Medical Doctor's progress note with encounter date of 10/14/25 revealed, Notified around 12:30 PM today that patient had an appointment today. She was transported back to (proper name of facility removed) but was left in the van for 1 to 2 hours. Patient seen and examined . Family members present. Patient notes generalized weakness but denied other symptoms. Family member states she looked drenched when they saw her earlier. She did not eat breakfast or lunch. She has not had much to drink. On exam, she is sitting in her recliner. Lungs CTAB (clear to auscultation bilaterally). No increased work of breathing. On room air. Will encourage oral hydration. Patient had AKI (Acute Kidney Injury) on CKD (chronic kidney disease) with recent hospitalization; creatinine has been down trending. With this event, will recheck BMP (Basic Metabolic Panel) today. Will check vital signs every 30 minutes and space if normal. If tomorrow, vital signs are normal, will resume routine vital checks.Record review of admission Record revealed the facility admitted Resident #1 on 9/10/25 with diagnoses of Paroxysmal Atrial Fibrillation and Chronic Kidney Disease. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/17/25 revealed a Brief Interview for Mental Status (BIMS) of 10 which indicated a moderate cognitive impairment.The SA validated on 10/22/25 that the facility had put measures in place to remove the immediacy of the event and had immediately acted to protect Resident #1 and all other residents in the facility. The facility had an emergency Quality Assurance (QA) meeting, began in-services with all staff, completed a health assessment and monitoring for Resident #1, notified reporting officials of the incident and continued to monitor through their QA program. The Director of Nursing and Assistant Director of Nursing will utilize End-of-Route Witness Audit Form to monitor both the vehicle walk-throughs and the completion of the End-of-Route Two-Person Checklist. Monitoring will occur daily for two weeks, then three times per week for the following two weeks, weekly for the next four weeks, and monthly thereafter. All measures were completed or began on 10/14/25 and the SA confirmed the plan of corrections that were put in place and found that the facility was PNC as of 10/15/25, prior to the SA entrance into the facility on [DATE].

Based on staff, and resident, caregiver, and responsible party interviews, record review, and facility policy review the facility failed to accurately complete an elopement assessment and identify risks to prevent an unsupervised resident from exiting the facility door for one (1) of three (3) residents reviewed for elopement and wandering. Resident #1. Findings Include: Review of the facility policy, Accidents and Interventions dated 05/05/19 revealed, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s) . An interview on 05/05/25 at 8:45 AM with Administrator (ADM), revealed that on 04/26/25, they had a resident to propel himself in his wheelchair outside the facility through an automated sliding door. She revealed that Resident #1 had been at the facility less than a week, he had limited mobility, and there had been no indications that he was an elopement risk. ADM revealed that on 04/26/25 at 7:20 PM, two resident assistants brought Resident #1 from the Assisted Living side, over to the 700 hall of the rehabilitation unit where he resided. She revealed that the resident assistants informed staff that Resident #1 was outside the automatic doors in his wheelchair. ADM revealed that they thought he belonged in the assisted living department and assisted him back into the building. ADM revealed that she arrived at the facility, reviewed the video surveillance, and determined that Resident #1 exited the front of the building through the automatic sliding glass doors and he was assisted back into the assisted living area of the building. An interview on 05/05/25 at 9:20 AM with ADM, revealed that Resident #1 had an elopement risk evaluation completed on admission and had a risk of zero for wandering and elopement documented. She revealed that when a resident's cognition was not good, they had to go by what the family said and the family had not told them that he had elopement risks. An observation and interview with the resident sitter on 05/05/25 at 9:40 AM, revealed Resident #1 sitting in his room in his manual wheelchair with his private caregiver sitting beside him. Resident #1 had a wander guard bracelet intact to his right arm. The caregiver revealed that was now sitting with Resident #1 during the day. She revealed that this behavior wasn't new for him, that at home, he would go outside during the night. A phone interview on 05/05/25 at 10:25 AM with Resident #1's Responsible Party (RP), revealed that he had dementia, he was confused a lot, and he lived with her prior to coming to the facility. She revealed that Resident #1 fell on [DATE] at her house, broke his hip, had surgery and from the hospital, he admitted to the facility for therapy. She revealed that he had been there for four or five days when he got out of the facility. Resident #1's RP confirmed that he had wandered at home, he got out of the house at night, and they had to put alarms on all of the outside doors and they put cameras up. Resident #1's RP revealed that she signed his admission paperwork when he was admitted to the facility and she said the staff never asked her if he wandered or if he had ever gotten out of the house. Resident #1's RP confirmed that she didn't think he would go anywhere because he had a broken hip and was in a wheelchair and she never said anything to the facility. An interview on 05/05/25 at 11:10 AM with Registered Nurse (RN) #1, revealed that she completed all the admission assessments and evaluations during the admission process including the Elopement Evaluation. She revealed that if the resident was not able to give a good history or answer questions appropriately, she asked the family. RN #1 revealed that Resident #1 was confused, and she spoke with the RP about his history of wandering. RN #1 revealed that the RP didn't verbalize any issues or concerns with Resident #1 at that time, and that she usually asked in a more casual way about their behaviors at home and confirmed that she did not directly ask the question that was on the Elopement Assessment Form, Does the Resident have a history of elopement or an attempted elopement while at home? She revealed that she tried to make the admission process more personable with the family and she asked general questions. RN #1 revealed that during Resident #1's Elopement Risk Assessment, there was nothing said that would indicate that the resident had a history of wandering or elopement. RN #1 revealed that she would make sure and clarify from now on, so the question would be answered properly to ensure the safety of the residents. A phone interview on 05/05/25 at 4:12 PM, a phone with Registered Nurse Clinical Coordinator (RNCC), revealed that she received a phone call from the hall nurse on 04/26/25 that Resident #1 had gotten out of the facility unsupervised. She revealed that she came to the facility and checked him out. She revealed that he was very confused but was not hurt. She revealed that she called Resident #1's daughter, and she told her that he had been obsessed with locked doors at home prior to coming there and RNCC revealed that she did not verbalize that he had these wandering behaviors before. Record review of Resident #1's Admission Elopement Evaluation dated 04/21/25 revealed the question, Does the Resident have a history of elopement or an attempted elopement while at home and the answer No was marked. Record review of Resident #1's Admission Record revealed an admitted [DATE] and that he had diagnoses that included Displaced Intertrochanteric Fracture of Right Femur and Dementia. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/28/25 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 06 which indicated that he had severe cognitive deficits.

Based on observation, staff and resident interview, record review and facility policy review, the facility failed to ensure a resident's wheelchair was in good repair for one (1) of 26 residents reviewed during survey. Resident #236 Findings Include: Review of facility policy titled, Safe and Homelike Environment date implemented 1/2024, revealed under the Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belonging to the extent possible. This includes ensuring the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk . An interview and observation on 08/05/24 at 2:20 PM, with Resident #236 revealed she was complaining of her wheelchair arm on the right side being messed up and bothering her. She stated that she had told the nurse twice, but no one has done anything. This observation revealed that the leather covering for the resident's right wheelchair arm rest was missing about three (3) to four (4) inches back from the front, exposing foam and metal that was rough to the touch in places. An observation and interview on 08/05/24 at 2:32 PM, with Certified Nurse Assistant (CNA) #1 confirmed that Resident #236's right wheelchair arm was torn. She stated she had not heard the resident complain. She stated that they could notify maintenance. The State Agency (SA) observed CNA #1 place a call to maintenance and reported Resident #236 needed a new wheelchair immediately. An interview on 08/06/24 at 10:09 AM with the Director of Therapy confirmed that Resident #236's right wheelchair arm torn, exposing foam and the metal was rough to the touch in places. She stated that the therapist had told her that the resident refused to have her wheelchair replaced, but wanted the arm fixed, but had failed to document any of that information. She admitted that the therapist should have documented something about the condition of the wheelchair. She stated that the therapist needed to make sure they are documenting issues like this because we want to be sure and provide the elders with all that they need. An interview with Occupational Therapy (OT) on 08/06/24 at 11:41 AM, confirmed that she noticed when she picked the resident up for therapy on 6/6/24 that her personal wheelchairs overall condition was not good but does not recall specifically noticing the condition of the right arm rest. She revealed she talked with the resident about getting a new wheelchair, but the resident declined. She admits that she never documented anything and confirmed that today the resident complained of her right wheelchair arm and noticed the armrest was in bad condition. An interview on 8/7/24 at 9:45 AM with the Administrator confirmed that the Resident #236's wheelchair arm should have been repaired. She revealed that her expectation was that staff would document that the resident and family had been spoken with about getting a new chair, plus we have plenty of wheelchairs here, it could have been replaced. Record review of Resident #236's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Muscle Weakness.

Based on staff interview, record review, and facility policy review, the facility failed to accurately submit information into the Minimum Data Set (MDS) assessment system for one (1) of 26 residents sampled. Resident #34 Findings include: Record review of facility policy titled, Conducting an Accurate Resident Assessment, dated October 2023, revealed, .The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) . Record review of Center for Medicare and Medicaid Services (CMS)'s Resident Assessment Instrument (RAI) dated October 2023 revealed, Insulin is a medication used to treat diabetes mellitus (DM). Steps for Assessment: 1. Review the resident's medication administration records for the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Determine if the resident received insulin injections during the look-back period. 3. Determine if the physician . changed the resident's insulin orders during the look-back period. 4. Count the number of days insulin injections were received and/or insulin orders changed Record review of Resident #34's Order Review History Report for May 2024 revealed no order for Insulin. Review revealed an order for Ozempic dated 9/29/23 to be given every seven (7) days. Record review of Resident #34's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/31/24, Section N - Medications, revealed one (1) insulin injection was received during the last seven (7) days or since admission/entry or reentry if less than 7 days. During an interview on 8/7/24 at 9:55 AM, the Registered Nurse MDS Coordinator revealed that due to her misunderstanding, she entered Ozempic as an insulin and since it is not an insulin, it should not have been coded as one. She stated this was an error on her part and this led to inaccurate information being submitted into the MDS system. She confirmed she entered that Resident #34 was receiving insulin when she was not, therefore, the MDS was submitted inaccurately. During an interview on 8/7/24 at 10:05 AM, the Administrator confirmed that Ozempic was not an insulin and it should not have been coded as an insulin on the MDS assessment. She confirmed the MDS assessment represents each resident's status at the time of the assessment and the facility failed to accurately complete the MDS assessment for this resident. Record review of Resident #34's Admission Record revealed the facility admitted the resident initially on 10/16/17. Resident #34 has current diagnoses that included Type 2 diabetes mellitus and Dementia. Record review of MDS with Assessment Reference Date (ARD) of 5/31/24 revealed a Brief Interview for Mental Status (BIMS) of 5 indicating the resident has severe cognitive impairment.

Based on observation, staff interviews, record review, and facility policy review the facility failed to prevent the possibility of the spread of infection as evidenced by failing to ensure Enhanced Barrier Precautions were followed during a resident care treatment for one (1) of four (4) resident care treatments observed. Resident #85. Findings Included: Record review of the facility policy Gastrostomy Site Care dated 05/2023 revealed Policy: It is the policy of the facility to perform gastrostomy site care as ordered and per current standard of practice. Policy Explanation and Compliance Guidelines .10. Apply any other PPE (Personal Protective Equipment) as needed to protect self from any exposure to infectious material and to comply with any isolation precautions ordered . Record review of the undated facility policy titled, Enhanced Barrier Precautions revealed .Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities 4. High-contact resident care activities include .g. Device care or use: . urinary catheters, feeding tubes An observation on 08/06/24 at 11:00 AM, of Resident #85's Percutaneous Endoscopic Gastrostomy (PEG) tube care revealed an Enhanced Barrier Precaution sign on the inside of the door. Licensed Practical Nurse (LPN) #1 entered Resident #85's room, washed her hands, applied gloves and failed to apply a protective gown prior to beginning care. An interview on 08/06/24 at 11:20 AM with LPN #1 revealed that she should have put on a gown before providing Resident #85's PEG tube care to help prevent the spread of germs. She revealed that enhanced barrier precautions were put in place to protect the nurse and to protect the resident from the spread of infection and she stated, I knew to do it, I was just nervous. LPN #1 revealed that they followed enhanced barrier precautions when providing care to anyone with a foley catheter, PEG tube, or open wounds. An interview on 08/07/24 at 9:45 AM with Registered Nurse, Infection Preventionist revealed that LPN #1 should have worn gloves and a gown while providing PEG tube care as part of the enhanced barrier precautions. She revealed residents with open wounds and those with indwelling devices such as PEG tubes were placed on enhanced barrier precautions to protect the resident and the staff member and to help prevent the possible spread of infection. RN Infection Preventionist revealed that bacteria could be passed from the resident to staff on their uniforms and infection could be transmitted to other residents without protective gowns in use. An interview on 08/07/24 at 9:55 AM, with the Director of Nursing (DON), revealed residents with open wounds, foley catheters and PEG tubes were placed on enhanced barrier precautions to prevent the spread of infection. She agreed that LPN #1 should have worn a gown and gloves when providing PEG tube care for Resident #85 to prevent the spread of potential infection. Record review of Resident #85's Order Summary Report revealed an order dated 04/01/24, Elder to remain on enhanced barrier precautions with care at all times d/t (due to) presence of PEG tube and Foley catheter. Record review of Resident #85's Admission Record revealed an admitted [DATE] and had diagnoses that included Dysphagia and Encounter for Attention to Gastrostomy.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for a resident that required the use of Enhanced Barrier Precautions (EBP) (Resident #85) and assistance with Activities of Daily Living (ADL's) (Resident #106) for two (2) of twenty-six care plans reviewed. Resident #85 and #106 Findings Include: Record review of the facility policy titled Comprehensive Care Plans dated 10/2022 revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #85 Record review of Resident #85's Care Plan revealed Focus: The resident requires tube feeding r/t (related to) Dysphagia .Interventions .Elder to remain on enhanced barrier precautions with care at all times d/t (due to) presence of PEG (Percutaneous Endoscopic Gastrostomy) tube and Foley catheter . During an observation on 08/06/24 at 11:00 AM, of Resident #85's PEG tube care revealed an Enhanced Barrier Precaution sign on the inside of his door. Licensed Practical Nurse (LPN) #1 entered Resident #85's room, washed her hands, applied gloves and failed to apply a protective gown. During an interview on 08/06/24 at 11:20 AM, Licensed Practical Nurse (LPN) #1 revealed that she should have put on a gown before she provided Resident #85's PEG tube care to help prevent the spread of germs. She revealed that Enhanced Barrier Precautions were put in place to protect the nurse and to protect the resident from the spread of infection and she stated, I knew to do it, I was just nervous. LPN #1 revealed that residents with foley catheters, PEG tubes or open wounds were placed on enhanced barrier precautions. During an interview on 08/07/24 at 9:45 AM, Registered Nurse (RN) Infection Preventionist, revealed that LPN #1 should have worn gloves and a gown while providing PEG tube care as part of the enhanced barrier precautions. She revealed that residents with open wounds and those with indwelling devices such as PEG tubes were placed on Enhanced Barrier Precautions to protect the resident and the staff member to help prevent the spread of germs and possible infection. During an interview on 08/07/24 at 1:30 PM, RN Minimum Data Set (MDS) Coordinator, revealed that the purpose of the comprehensive care plan was to outline each resident's plan of care and what individualized care was needed and provided. She agreed that LPN #1 failed to follow the care plan when she did not wear a gown while she provided Resident #85's PEG Tube care. Record review of Resident #85's Order Summary Report revealed an order dated 04/01/24, Elder to remain on enhanced barrier precautions with care at all times d/t (due to) presence of PEG tube and Foley catheter. Record review of Resident #85's Admission Record revealed an admitted [DATE] and had diagnoses that included Dysphagia and Encounter for Attention to Gastrostomy. Resident #106 Record review of the Care Plan with a date initiated of 12/23/22, for Resident #106 revealed Focus: Resident needs assist with ADL's (activities of daily living) . Interventions: Assist with adl's as needed . During an observation of Resident #106 on 8/5/2024 at 12:09 PM revealed, he was lying in bed, alert with confusion. The resident was unkempt, with his hair unbrushed and greasy on the edges. Gray facial hair observed on his face and above his lip, measuring approximately one fourth (1/4) inch in length. Long fingernails observed on both hands measuring approximately three-eights (3/8) inch in length. During an observation and interview with Licensed Practical Nurse (LPN) # 2 on 8/6/2024 at 10:35 AM, confirmed Resident #106 was unkempt, had long nails and needed to be shaved. During an interview with the Minimum Data Set (MDS) Coordinator on 8/7/2024 at 1:40 PM, revealed the purpose of the care plan was to provide an outline for resident care. She confirmed the activity of daily living (ADL) care plan was not followed for Resident #106. Review of the Admission Record revealed the facility admitted Resident #106 on 12/23/2022 with medical diagnoses that included Unspecified dementia. 47874

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide the necessary assistance with activities of daily living (ADLs) for a resident dependent on staff for bathing, shaving, and nail care for one (1) of 26 residents sampled. Resident #106 Findings Include: Record review of the facility policy titled Activities of Daily Living dated 10/2023 revealed Policy . Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care . An observation of Resident #106 on 8/5/2024 at 12:09 PM revealed, he was lying in bed, alert with confusion. The resident was unkept, with his hair unbrushed and greasy on the edges. Gray facial hair was observed on his face and above his lip, measuring approximately one fourth (1/4) inch in length. Long fingernails were observed on both hands measuring approximately three-eights (3/8) inch in length. An observation and interview with Certified Nurse Aide (CNA) # 2 on 8/6/2024 at 10:25 AM revealed, Resident # 106 was scheduled to get his shower on Monday, Wednesday, and Friday on the 3-11 shift. She explained that the resident should have gotten a shower last night and stated, He does not look like he was showered. CNA #2 revealed the aides were responsible for shaving the male residents with showers and cutting their nails if the resident was not a diabetic. She confirmed Resident #106 needed shaving, and his nails needed to be cut. CNA #2 revealed the resident could scratch himself and cause injury. An observation and interview with Licensed Practical Nurse (LPN) # 2 on 8/6/2024 at 10:35 AM, confirmed Resident #106 was unkempt, had long nails and needed to be shaved. She revealed the resident was not a diabetic, so the aides were responsible for cutting his nails when needed. Record review of the Kardex for Resident #106 revealed .Bathing: ADL -Bathing as ordered . An interview with the Director of Nursing (DON) on 8/7/2024 at 1:35 PM, revealed with Resident #106's ADL care, her expectations were for the aides to include nail care (cleaning, cutting, and filing) and shaving on designated shower day. Review of the Admission Record revealed the facility admitted Resident #106 on 12/23/2022 with medical diagnoses that included Unspecified dementia

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the medication error rate was less than five (5) % (percent) for two (2) of 28 medication opportunities involving Resident #84. Medication error rate was 7.14%. Findings Include: Review of the facility policy titled Medication Administration dated 1/2024 revealed Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines: 10. Ensure that the six rights of medication administration are followed .c. Right dosage . An observation of medication pass, with Licensed Practical Nurse (LPN) #3 on 8/7/2024 at 8:09 AM, revealed she prepared and administered MiraLax 17 grams one capful mixed in water to Resident #84. She then handed the resident a bottle of Flonase (Fluticasone Propionate) nasal spray, in which he administered one spray to each nostril. Record review of Resident #84's August 2024 Medication Administration Record (MAR) revealed an order dated 11/1/2022, Fluticasone Propionate Suspension (Allergies) 50 MCG (micrograms)/ACT (actuation) 2 (two) spray in each nostril one time a day related to Allergic Rhinitis. Also revealed an order dated 4/29/2024, MiraLax Oral Powder (stool softener) 17 GM (grams)/scoop give 34 gram orally two times a day for constipation in 240 ml (milliliters) of liquid. An interview on 8/7/2024 at 8:16 AM with LPN #3, confirmed she did not administer Resident #84's MiraLax and Flonase according to the physician order. She stated the resident liked to give his own nasal spray, but she should have instructed him to give the two sprays instead of one. She explained that she overlooked that the resident was supposed to have 34 grams of MiraLax, and she should have given two capfuls. LPN #3 stated, I just missed it. She revealed not getting the entire dosage of MiraLax could cause constipation. An interview on 8/7/2024 at 10:10 AM, with the Director of Nursing (DON), confirmed Resident #84's physician orders were not followed. She revealed her expectations were for the nurses to view the Medication Administration Record (MAR) and ensure they were giving the correct ordered dose before administration. Record review of the Admission Record revealed the facility admitted Resident #84 on 12/20/2023 with medical diagnoses that included Allergic Rhinitis and Constipation.

Based on staff interviews, Resident Representative (RR) interview, record review and facility policy review, the facility failed to ensure that one (1) of five (5) sampled residents were protected from physical abuse. Resident #1. Findings included: Record review of the Abuse, Neglect, and Exploitation facility policy dated 03/15/2024, revealed under Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. On 07/01/24 at 10:00 AM, a brief interview with the Administrator revealed that she reported an incident involving a Certified Nursing Assistant (CNA) who aggressively transferred a resident from the bed to her wheelchair and it was recorded on the ring camera that had been placed in the resident's room by her family. On 07/01/24 at 10:15 AM, an interview with the Administrator (ADM) revealed that on the morning of 05/26/24, Resident #1's Resident Representative (RR) sent a snippet of a video that was recorded on the ring camera to the CNA Supervisor. The ADM revealed that Resident #1's RR felt like the employee was rough with her. ADM said that she viewed the video which showed that CNA #1 was transferring Resident #1 from the bed to the wheelchair, and Resident #1 leaned back resisting care and let go of the rail. The ADM revealed that Resident #1 then stated Ain't nobody worth a damn and CNA #1 roughly grabbed Resident #1 under her arm pits and did a quick transfer into the wheelchair. The ADM stated, It made me cringe. ADM revealed that they suspended CNA #1 pending investigation and because of the aggressive handling, she terminated her. ADM revealed that they did a full body audit on Resident #1 and found some bruising under her left armpit and some scattered bruising on both arms that were now healed. She revealed that Resident #1 had Dementia, required more assistance, and needed the staff to be patient with her, allow her more time and not get in a hurry. ADM confirmed that this transfer was too aggressive and stated, I'm just sick over it. ADM revealed that she called CNA #1 in to watch the video and write a statement and CNA #1 reported that Resident #1 had been more resistant to getting up and said she should have left her in bed. ADM revealed that CNA #1 also told her that when Resident #1 let go of the transfer bar, she made the instant decision to transfer her quickly to the wheelchair. The ADM stated that CNA #1 was remorseful and revealed that she had no idea until after watching the video as to how quickly she transferred Resident #1. ADM revealed that CNA #1 did not intentionally harm Resident #1, but a bruise was found under her left armpit and scattered bruising on bilateral arms. ADM revealed that she terminated CNA #1 on 05/29/24 because of the incident. On 07/01/24 at 11:55 AM, an interview with Director of Nursing (DON), revealed that she watched the video a couple times and was shocked and saddened that this incident happened with one of their residents. She revealed that it broke her heart to think that they had someone working with these residents who had no compassion. DON revealed that the staff knew that the family was not able to be there often to see Resident #1 and they had a video camera in her room so they could see her. She stated that Resident #1's family trusted them to take care of her and they let them down. She stated, I hate this happened. On 07/01/24 at 12:15 PM, an interview with CNA Supervisor, revealed that on Saturday morning, May 26, 2024, Resident #1's RR sent her a video that showed that CNA #1 entered the room of Resident #1, dressed her, and was aggressive with her during transfer from the bed to her wheelchair. CNA Supervisor revealed that she saw and heard on video that Resident #1 said that no one was worth a damn around there and then CNA #1 moved quickly and did a swift transfer. CNA Supervisor revealed that CNA #1 should have managed her time better to avoid being in a hurry, should have allowed Resident #1 more time to transfer or she should have waited on someone to help with the transfer. On 07/01/24 at 12:50 PM, a phone interview with Resident #1's RR revealed that she had a ring camera placed in her sister's room and she watched how the staff treated her. She revealed that on the camera footage on 05/26/24, she observed CNA #1 enter the room to get her up and dressed at 5:30 AM, and stated, She practically grabbed her up and throwed her into the wheelchair. RR revealed CNA #1 did not have any patience with her and seemed to be in a hurry and stated, I hope she hasn't treated anyone else like this. Resident #1's RR revealed that she reported this to CNA Supervisor and that CNA #1 had been fired. The State Agency (SA) had attempted to contact CNA #1 several times throughout the investigation and on 07/03/24 at 8:27 AM, CNA #1 returned the phone call. The interview with CNA #1, revealed that she worked at the facility on an As Needed basis and had another full-time job. She revealed that she hadn't worked in two weeks prior to the incident with Resident #1. CNA #1 revealed that on the morning of 05/26/24, she entered Resident #1's room, cleaned her up and dressed her, and when she was ready to transfer her, Resident #1 would not budge. She revealed that prior to this day, Resident #1 would follow commands and help during the transfers. CNA #1 revealed that she was already pressed for time and decided to swiftly transfer her to her wheelchair. CNA #1 revealed the Administrator called her back in to watch the video and she confirmed that it looked like a rough transfer but that was never her intention. She revealed that she normally asked for help with residents, but the nurse wasn't there, and she stated, So I hurried and picked her up, put her in the chair before either of us got hurt. CNA #1 revealed this was a mistake on her end and that she should have left Resident #1 in the bed until she could get help with the transfer because safety should always come first. Record review of CNA #1's Timesheet revealed that she clocked in on 05/25/24 at 10:57 PM and clocked out on 05/26/24 at 7:16 AM and this was the last date that she worked. Record review of CNA #1's written Statement revealed that she had bacon in the oven and had gone into Resident #1's room to get her up and noticed that she was a little more irritable than normal. CNA #1 revealed that when she went to put her shirt on, she leaned back with hesitation. CNA #1 revealed that she pulled resident towards her preparing to pivot, realized Resident #1 had let go of the rail and then took the opportunity to move very quickly to prevent from hurting the resident and herself during the transfer. CNA #1 included in her statement an apology and stated that this was not the appropriate way to transfer a resident. Record review of the Offense/Incident Report completed by the Police Department on 05/28/24 revealed that an officer was dispatched to the facility in regards to a patient being mistreated by an employee. ADM reported to the officer that the ring camera from Resident #1's room was able to record the whole incident. In the video you see CNA #1 aggressively grabbing under Resident #1's arms to the extent that it left noticeable bruising under Resident #1's arms. Officer was able to watch the video of CNA #1 aggressively picking up Resident #1 and in a throwing motion placed her from the bed to the wheelchair. Record review of Resident #1's Progress Note dated 05/26/24, revealed that Resident #1's RR observed on camera in her sister's room in the early morning that she was transferred in an aggressive manner from CNA #1 and she did not want this CNA to take care of her sister anymore. Record review of Resident #1's Progress Note dated 05/27/24 revealed that she had noted a bruise to her left armpit and scattered bruising to her bilateral arms. Record review of Resident #1's Admission Record revealed an admitted [DATE] and she had diagnoses that included Alzheimer's Disease and Vascular Dementia. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 05/10/2024 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 03 which indicated that she had severe cognitive deficits. Record review of Resident #1's Weekly Nursing Note and Skin Audit form dated 05/27/24 revealed that a bruise was noted to left armpit and scattered bruising to bilateral arms.

Based on staff interview, record review and facility policy review the facility failed to ensure that a Certified Nurse Assistant (CNA) maintained an up-to-date certification for one (1) of 115 certifications reviewed. Finding include: Review of the facility policy titled, License Verification, dated ,d+[DATE] revealed all personnel that require a license or certification shall be verified through the appropriate issuing agency. The Human Resources Director, or designee, is responsible for maintaining and ensuring the validity and current status of individual certification/licensure. Any licensed /certified employee is responsible for submitting verification of licensure/certification renewal to Human Resources prior to expiration. Record review of the Certified Nursing Assistant (CNA) certifications revealed CNA #1 did not have an up-to-date certification on file. A copy of the certification revealed it expired on [DATE]. An interview on [DATE] at 11:15 AM, with the Administrator (ADM) confirmed the CNA #1's certification was not up to date in the employee folder and the CNA had been working at the facility since her certification had expired. She stated she works full time ,d+[DATE] shift in one of the Greenhouses. She stated there had been no issues reported regarding the care given by CNA #1. The ADM stated a double check of licenses and certifications should be done with a spread sheet of up-to-date employees from their payroll system. The ADM confirmed that CNA #1 would not be working as a certified nursing assistant until her certification was renewed. An interview on [DATE] at 11:20 AM with the Human Resources Manager revealed she was responsible for keeping track of the CNA certifications. She stated that she goes by her binder, but CNA #1's certification was not in the binder and that she does not do a double check using a list of employees. Record review of CNA #1's certification from the Mississippi Nurse Aide Registry revealed Status-Inactive and an Expiration Date [DATE]. Record review of CNA #1's payroll information revealed she had worked five days from [DATE], through [DATE].

Based on observation, staff and resident interview, and record review the facility failed to provide a resident with an appropriately sized wheelchair for one (1) of 32 residents reviewed. Resident #107 Findings include: Record review of a typed statement dated April 12, 2023 and signed by the Administrator revealed We do not have a policy on Wheelchair Sizing. There is a protocol that therapy follows but not a written policy. An observation on 04/11/23 at 4:45 PM, revealed Resident #107 sitting in her wheelchair in the dayroom, complaining that her wheelchair was too big for her, and she has told people, but they think it is fine. This observation revealed there was 2-4 inches of space on the seat on either side of the resident between her hips and the wheelchair arms. Her arms were stretched over the arms of the wheelchair with only her fingers reaching the self-propel wheels and she was using her tiptoes to push her wheelchair. This observation revealed she was not able to put her feet flat on the floor unless she scooted to the front edge of the wheelchair seat. An interview on 4/12/23 at 2:30 PM, with the Rehabilitation (Rehab) Director revealed that new admissions are provided a wheelchair and that the resident is evaluated on the same day of admission or the next day to make sure the wheelchair size is correct. She stated that the resident's wheelchair should allow the resident's feet to sit flat on the floor while sitting in the wheelchair and should have 1-2 inches of space between the resident's side of hip and the arm of the chair. An interview on 4/12/23 at 3:40 PM, with the Rehab Director confirmed that Resident #107's wheelchair was too big for her body size. She confirmed that she went and evaluated the chair size and determined that the chair was an 18 inch and the resident needed a 16-inch chair and needs some of the height taken off, so that the resident's feet can be flat to the floor. She stated that with the resident's wheelchair being too big could cause the self-propelling of the wheelchair not to be easy and she then stated that we want it to be easy for them. An interview on 4/12/23 at 4:30 PM, with the Administrator confirmed that Resident #107 should not have had a wheelchair that was too big for her. She revealed that she does not understand why one of the Registered Nurses RN's or Shabazz's (Certified Nursing Assistants) had not already mentioned it to someone. Record review of Resident #107's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Muscle Weakness. Record review of Resident #107's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/13/23 revealed in Section C a Brief Interview for Mental Status of 05, which indicates the resident is severely cognitively impaired and in Section G that the resident uses a wheelchair.

Based on observation, staff interview and facility policy review the facility failed to change gloves during wound care while going from a dirty site to a clean site and failed to perform hand hygiene between glove changes for one (1) of four (4) residents observed during wound care. Resident #3 Findings include: Review of Facility Policy dated 10/2022 on Clean Dressing Change revealed, Policy: It is the policy of this facility to provide wound care in a manner to decrease the potential for infection and/or cross-contamination . Policy Explanation and Compliance Guidelines: . 9. Loosen the tape and remove the existing dressing. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wounds as ordered, taking care not to contaminate other skin surfaces or other surfaces of the wound Pat dry with gauze .14. Wash hands and put on clean gloves. 15. Apply topical ointments or creams and dress the wound as ordered . On 04/13/23 at 9:05 AM, observation of wound care to Resident # 3's abdomen performed by Registered Nurse (RN) #2 revealed this RN donned clean gloves, cleaned wound with wound cleanser, patted dry with 4x4s, applied Opticell AG, and covered with bordered dressing. RN#2 failed to perform hand hygiene and change gloves after cleaning the wound bed. RN #2 used the same gloves to clean the wound bed and to apply the Opticell AG and wound dressing. On 04/13/23 at 9:15 AM, an interview with RN#2 revealed that she realized that she had forgotten to wash her hands and change gloves after cleaning the wound. She confirmed that she knew she was supposed to wash her hands and change her gloves after cleaning the wound bed and before applying the wound treatment and dressing. RN#2 stated, I paused a minute during the wound care when I remembered; but it was too late. RN#2 revealed that not changing gloves after cleaning the wound bed and before applying the wound treatment and dressing could cause germs to spread and it could contaminate the wound and cause an infection. On 04/13/23 at 10:00 AM, an interview with the Director of Nursing (DON) revealed it was in their policy to wash hands and change gloves between cleaning a wound and applying treatment and dressing to the wound bed. The DON revealed that not washing hands nor changing gloves could cause contamination and infection. On 04/13/23 at 10:10 AM, an interview with the Administrator revealed it was their policy to wash hands and change gloves during wound care. She confirmed that not washing hands and changing gloves after cleaning the wound bed and prior to applying the treatment and dressing to the wound could cause contamination. Record review of Resident #3's Admission Record documented admitted [DATE] with the following diagnoses to include: Essential Hypertension, unspecified, Morbid Obesity due to excess calories, Cerebral Palsy, unspecified, and Ventral Hernia without obstruction or gangrene. Record Review of Resident #3's Minimum Data Set Section C with Assessment Reference Date of 02/13/2023, documented his Brief Interview for Mental Status (BIMS) Score of 15 which indicated that Resident #3 was cognitively intact.

Based on observation, staff interview, record review, and facility policy review the facility failed to promote and maintain the dignity of a resident as evidenced by a urinary catheter bag with no privacy bag for one (1) of four (4) residents reviewed with a urinary catheter. Resident #115 Findings Include: Record review of the facility policy titled, Promoting/Maintaining Resident Dignity with a revision date of 10/2022 revealed Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality 12. Maintain resident privacy . Record review of a typed statement dated April 12, 2023 and signed by the Administrator revealed We do not have a specific policy on covering catheter bags. An observation on 04/11/23 at 3:48 PM, revealed Resident #115 sitting in the day room of the (Proper name) building on the sofa with his urinary catheter bag hanging off the front of the sofa with no cover over the urine bag that was full of urine. An interview on 4/12/23 at 12:05 PM, with the Director of Nurses (DON) confirmed that residents with urine catheter bags should have a privacy bag covering their urine catheter bag for the resident's dignity. She revealed that the facility has blue privacy bags, and the staff are aware they should always put a privacy bag over the urine catheter bag based on an understood policy. An interview on 4/12/23 at 3:15 PM, with the Administrator confirmed that it is an understood policy that urine catheter bags should be covered with a privacy bag regarding dignity for the resident. Record review of Resident #115's Order Summary Report revealed an order dated 3/15/23, Indwelling Foley catheter in place due to neurogenic bladder . Record review of Resident #115's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Retention of urine and Vascular dementia, unspecified severity. Record review of Resident #115's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/21/23 revealed in Section H that the resident has an indwelling catheter and in Section C a Brief Interview for Mental Status (BIMS) score of 05, which indicated the resident is severely cognitively impaired.

Based on staff, residents,and family interviews, record review and facility policy review the facility failed to provide services for Speech Therapy as ordered by the physician for six (6) of 27 residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5, Resident #12, Resident #13, Resident #14, Resident #15 and Resident #16. Findings include: Review of therapy department policies and procedures titled Administrative Policy and Procedure with a revision date of 8/1/16 revealed, Subject Billing for Therapy Services Procedure .Policy .Billing shall be made only for services provided .Billing for therapy services will be in compliance with Medicare guidelines or other applicable payer (insurance) guidelines. Procedure Charges will be generated for therapy services that are treatment related, patient specific, medically necessary, under orders of a qualified provider, and documented in the medical record on the day the treatment is delivered . Review of the therapy policy titled Therapy Orders Policy with effective date of 7/15/2018, revealed Policy A therapy order from a physician/nonphysician practitioner is required for all therapy services .Procedure .5. Daily schedules will be turned into the Rehab Director daily for filing into binder .7. Rehab Directors will ensure schedules are completed by therapists and filed into the binders per self or designee. 8. Regional Managers will conduct audits of schedule binder and adherence to policy and procedure .c. Patients time in treatment 1. The time the patient is involved in hands-on or directly supervised treatment by the therapists. 2. Treatment time should be calculated from the time the patient begins the first treatment activity to the time the patient finishes the last skilled intervention, and no further assessment is required by the therapist . On 09/29/2022 at 9:27 AM, an interview with the Director of Therapy Services (DTS) revealed that she assisted with the investigation related to a facility reported incident of a complaint that a resident had not received Speech therapy in a few days. The Therapy department is part of the facility as a contracted therapy service. A complaint by a resident of not receiving Speech Therapy in a few days led to the Social Service Department contacting the therapy department and the DTS initiated an investigation that led to the discovery of six (6) residents not receiving speech therapy as ordered, after interviewing all the residents that Speech Therapist (ST) #1 was assigned. During the investigation the DTS determined that falsification of time and documentation by Speech Therapist #1 (ST #1) and the charges for the services that the 6 residents did not receive were backed out and they were not billed. The dates in question that the speech therapy services were not received were 1/18/2022, 1/19/2022 and 1/20/2022. When the DTS interviewed ST#1, she did not say anything, she just signed the paper. ST#1 was terminated. As part of the plan of correction the DTS had the residents who had not received speech services as ordered reassessed to ensure no harm and speech therapy was provided as ordered. The DTS initiated in-services for all the therapy department that included a review of the therapy's Administrative Policy and Procedure : Therapy Orders Policy, Billing for Therapy Services, Billing for Therapy Procedure, and all of the therapy department staff completed an on line in-service titled Fraud , Waste, and Abuse that included objectives to define healthcare fraud and abuse, identify methods to Prevent fraud and abuse, identify methods the Federal Government uses to detect fraud and abuse, and to understand how to report fraud and abuse. As part of the plan of correction to ensure there is no repeat of this type of incident the DTS has initiated every week she selects a random day to audit of shift enter and exit times, which is how therapy clocks in and out and look at all the codes to ensure the times and scheduled visits match, she also randomly interviews residents that are scheduled for treatment across Physical Therapy, Occupational Therapy and Speech Therapy and she maintains a log of the audits. On 03/29/2022 at 9:44 AM an interview with Licensed Physical Therapist #2 (LPT) confirmed that she had been interviewed by the DTS concerning therapy on Resident #5 on 1/18/22 and that she did not co-treat with ST #1 on that date. On 03/29/2022 at 9:46 AM, an interview with Occupational Therapist #3(OT) confirmed that she was interviewed during the investigation of ST #1 and that she did report that she did not co-treat with members of Speech Therapy on 01/18/22 or 01/19/22. On 03/29/2022 at 9:56 AM, an interview with Physical Therapist #4 (PT) confirmed that she was interviewed by the DTS related to co-treating with ST #1 during the week in question, but she could not recall the exact dates. She confirmed that she had not co-treated with ST #1 during the month of January 2022. On 03/29/2022 at 10:00 AM, an interview with Physical Therapy Assistant #5 (PTA) confirmed that she was interviewed during the investigation of ST #1 and that she did not co-treat during the days in question. On 03/29/2022 at 10:10 AM, an interview with Certified Occupational Therapy Assistant #6 (COTA) confirmed that she was interviewed by the DTS during the investigation of ST #1 but denied co-treating with ST #1. She went on to say that she could not recall ever co-treating with ST #1. On 03/29/2022 at 10:20 AM, an interview with the Administrator (ADM) revealed that in January of 2022 the Social Worker discovered that Resident #5 had not received Speech Therapy in a couple days. She sent an inquiry to the DTS asking to confirm if the resident was receiving ordered treatments. That led to the DTS looking into the Speech Therapy scheduled treatment where she discovered there were overlapping treatment times between the speech therapist and other therapies. The DTS initiated an investigation and informed the ADM of the findings. The ADM phoned the reportable incident to the hot line, she reported it to the Attorney General's Office, State Agency, and she had Human Resources to assist her in reporting the incident to the Speech Therapy Licensure. Speech Therapy Licensure was present at the facility the first of March to do their investigation. The ADM reported that she called in another Speech Therapist and utilized their other Speech Therapist to re-assess the residents who were discovered to not have received all their Speech Therapy and provide treatment as ordered by the physician. The ADM and the Director of Nursing (DON) interviewed all the residents that were assigned to ST #1 and confirmed it was six (6) residents who had not received ST. Resident #5, #12, #13, #14, #15, and #16. The ADM reported that she carried the incident to the Quality Assurance meeting and discussed the incident and the Plan of Correction, and that the DTS performed the in-services for the therapy department and that the DTS is keeping a weekly log of her audits to ensure this does not reoccur. The Compliance Officer for the Therapy company has scheduled to come to the facility on [DATE] through April 20, 2022 to do extensive reviews and in-services for the Therapy department. The ADM reported that on 03/11/2022, she and the Executive Director had a Zoom meeting with the Therapy Consultant to review the Plan of Care and voiced there had been no other issues. The facility investigation found that there was a total of six (6) residents #5, #12, #13, #14, #15 and #16 that were assigned to ST #1 with scheduled visits during the time of question. Therapy performed an audit of the six residents that did not receive services and the services were either not billed or the billing removed prior to submission. At the conclusion of the facility investigation the ADM could not substantiate misappropriation of funds as any missed visits were removed from billing and the residents received no charge for services they did not receive. On 03/29/2022 at 2:28 PM, a phone interview with the son of Resident # 5 revealed that over all they were very pleased with the care his mother received while at the facility, he recalls a young dark-haired woman in her 30's worked with his mother while at the facility but could not recall her name. He stated that his mother has continued with therapy on home health since her return home and was continuing to improve. SA validated through record review and interviews on 03/29/22 that the facility held a Quality Assurance meeting and documented through a sign-in sheet for January 2022 and it revealed that the facility had implemented an investigation and were developing and monitoring a plan to ensure that services were received as ordered. SA validated through record review and interviews with staff on 03/29/22 that facility in-services for reviewing Administrative Policy and Procedure: Therapy Orders Policy, Billing for Therapy Services, Billing for Therapy Procedure, and all of the therapy department staff completed an online in-service titled Fraud , Waste, and Abuse that included objectives to define healthcare fraud and abuse, identify methods to Prevent fraud and abuse, Identify methods the Federal Government uses to detect fraud and abuse, and to understand how to report fraud and abuse, confirmed that the therapy department had been in-serviced at 100% of staff participation. SA validated through record review of the facility investigation of ST#1's schedule dated 1/17/2022 through 1/25/2022 revealed that on 01/17/2022 that conflicting times for speech therapy (ST) 8:52 AM to 9:34 AM with Licensed Physical Therapy #2 (LPT)/Occupational Therapy #3 (OT) for 8:35 AM to 9:35 AM for Resident #5, with Resident #13 being out of the facility until 11:16 AM with ST time of 9:50 AM to 10:30 AM, Resident #14 ST time of 11:07 AM to 11:57 AM conflicting with PTA#5/COTA#6's time as 11:07 AM to 11:57 AM and Resident #5 with conflicting ST time for Resident #5 on 01/19/2022 from ST 11:08 AM -11:52 AM and PT#4/OT#3 of 11:04 AM to 11:54 AM. The review revealed that the treatment billing for these encounters for ST had been removed as of 01/25/22. SA validated through record review that the facility investigation revealed that ST #1 received a Notice of Disciplinary Action dated 01/21/2022 that listed the following counseling had taken place, Violation of Company Policy, State Practice Act Violation, Late Documentation, and Falsification of Records. The summary of the violation revealed that a patient and family complained to social services of receiving no speech therapy on 1/17/2022 and 1/18/2022. Referring back to daily schedules that are required to be turned in daily revealed the ST times conflicted with the PT/OT time and that ST #1's labor log does not match the time she was actually seen at the facility. SA validated through further record review of facility investigation revealed that a summary of corrective action plan for ST #1 was termination due to misconduct, falsification of hours worked, and fraudulent charges. These violations against company policy as well as the state practice acts. Charges will need to be removed for these dates as the service was not provided. Dated and signed by ST #1 and DTS on 01/25/2022. SA validated through record review that the facility reported ST #1 to the licensure board on 01/31/22 for a State Practice Act Violation. The SA validated through observations, record review, staff and resident interviews that the facility provided all corrective actions and was at Past Non Compliance (PNC) status as of 01/31/22 when they completed all of their mandated federal reporting and investigation requirements prior to the SA entrance on 03/24/22.

Based on staff and facility interviews, record review and facility policy review, the facility failed to protect the residents from misappropriation of funds for ten (10) of 25 residents that resided in two (2) greenhouses. Findings Include: Record review of facility policy titled Abuse, Neglect and Exploitation revealed Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary or permanent, use of resident's belongings or money without the resident's consent. Record review of facility investigation related to drug diversion that was discovered on 08/09/2021, revealed that a random narcotic audit was conducted by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 08/9/2021. The ADON identified an unrecognized witness signature recorded on 08/6/2021 on a controlled substance record. The ADON questioned LPN #2 on 08/10/21 when she returned to work as to who signed the narcotic sheet with her and she was unable to tell the ADON who had signed the record as witness to destroy a narcotic. The ADON thought this was very suspicious that she did not know who had witnessed a narcotic destruction with her the day before and this led to a more detailed audit beginning immediately on 08/10/2021. LPN #2 was relieved of her narcotic keys and immediately suspended pending further investigation. LPN #1 then became under suspicion as also being involved when she suddenly resigned immediately on 08/11/2021. The facility continued to gather interviews and conducted narcotic audits and during their investigation it was revealed a drug diversion had occurred and The Drug Enforcement Administration (DEA) was notified and was at the facility investigating the incident on 08/13/2021. The facility notified the State Agency (SA), the responsible parties (RP), the Medical Director, held a QA meeting, and in-serviced all staff. Record review of the narcotic record revealed that LPN #2 and LPN #1 were the only nurses signing out as needed (PRN) narcotics for Resident #8 and Resident #1. Record review of on campus Pharmacy Packing slips revealed the following: On 05/18/2021 the pharmacy sent Resident #2 90 tablets of [MEDICATION(S)] 10/325 milligrams (mg) tablets that were not logged into narcotic control record as received. On 08/21/21 the pharmacy sent Resident #3 60 [MEDICATION(S)] 5/325 mg tablets with only 30 tablets logged into the narcotic control record as received. On 06/25/21 the pharmacy sent Resident # 9 60 tablets of [MEDICATION(S)] 0.5 mg that was not added to the narcotic control record as received. On 07/29/21 the pharmacy sent Resident # 9 90 tablets of [MEDICATION(S)] 5/325 mg that was not added to the narcotic control record as received. On 06/29/21 the pharmacy sent Resident # 7 30 tablets of [MEDICATION(S)] 0.5 mg that was not added to the narcotic control record as received. On 07/23/21 the pharmacy sent Resident # 7 30 tablets of [MEDICATION(S)] 0.5 mg that was not added to the narcotic control record as received. On 07/22/2021 the pharmacy sent Resident # 6 60 tablets of [MEDICATION(S)] 5.325mg that was not added to the narcotic control record as received. On 07/27/21 the pharmacy sent Resident # 10 42 tablets of [MEDICATION(S)] 0.25 mg that was not added to the narcotic control record as received. On 08/6/2021 the pharmacy sent Resident # 10 42 tablets of [MEDICATION(S)] 0.25 mg that was not added to the narcotic control record as received. On 06/29/21 the pharmacy sent Resident #8 28 tablets of [MEDICATION(S)] 0.5 mg that was not added to the narcotic control record as received. On 08/6/21 the pharmacy sent Resident #8 28 tablets of [MEDICATION(S)] 0.25 mg that was not added to the narcotic control record as received. On 07/27/21 the pharmacy sent Resident #5 90 tablets of [MEDICATION(S)] 5/325 mg and LPN #2 logged in 45 tablets to the narcotic control record that was received instead of the 90 count. On 07/28/21 the pharmacy sent Resident # 4 90 tablets of [MEDICATION(S)] 5/325 mg that was not added to the narcotic control record as received. Record review of a facility in-service dated 08/13/2021 revealed the title Controlled Substances stated that all narcotics are to be logged in and verified by two (2) nurses. This in-service was performed twice that day until all staff had completed the in-services. On 01/24/2022 at 10: 55 AM, an interview with the DON revealed that the ADON noticed a witness signature for wasting a medication on the controlled substance log that she did not recognize and that led to a further investigation during a random narcotic audit. An investigation was initiated for both the Greenhouse #1 and Greenhouse #2 on 08/10/2021. When LPN #1 was questioned about the signature, she was unable to identify the signature. On 01/24/2022 at 1:40 PM, an interview with the DON revealed that the facility worked with the Pharmacy to gather the cost of the medications and reimbursed the funds back to the resident's accounts. The DON reported that all residents were assessed, and families were notified of the occurrence. The facility then contacted the pharmacy for the medication delivery sheets and reconciled them with the narcotic logs and discovered that there were narcotic discrepancies back to May 2021 for the Greenhouse #1 and Greenhouse #2 where LPN #1 and LPN #2 worked. When LPN #2 was questioned by the DON about the unaccounted-for narcotics she exited the room and returned with a pill in a cup voicing she had found the pill loose in the medication cart. The narcotic keys were taken from LPN #2 immediately and she was sent home that day and did not return. LPN #1 was questioned when she returned to work on 08/10/21 and then she abruptly resigned without notice the next day and that's when we really got suspicious of LPN #1 the DON stated. As part of the plan of correction and to prevent this type of occurrence from reoccurring the DON or the ADON conduct random audits of the narcotic logs against the delivery slips that are provided by pharmacy and the facility has put in place that two (2) nurses must receive and sign in all narcotics to the narcotic log when they are delivered from the pharmacy. On 01/25/2022 at 12:07 PM, an interview with Resident # 9 with a Brief Interview for Mental Status (BIMS) score of 15 revealed he had been given his medication on time and had not had any problems. Resident #9 confirmed he had a nurse back last year that did not have his [MEDICATION(S)] in with his medications and when he asked about it, she pulled the [MEDICATION(S)] out of her back pocket, but he could not recall the date and stated that he did not tell anyone that it occurred because he knew what medications he was supposed to take and always looked to make sure they were right. Resident #9 confirmed that the nurse no longer worked here that had done that. Record review of the personnel file for LPN #1 revealed her hire date as 03/5/2021 and her termination date as 08/11/2021. LPN #1 had a criminal background check showing no disqualifying events and was cleared for hire on 03/2/2021, her license was verified expiration date 12/31/2021, and her 3 reference checks were validated with no concerning issues. LPN #1 completed in-service training for Residents Rights and Abuse, Neglect, and Exploitation on 03/5/2021. LPN #1 had a counseling statement dated 08/9/2021 related to failure to complete work on time, but no other concerns. Record review of personnel file for LPN #2 revealed her hire date as 02/25/2022 and her termination date as 08/13/2021. LPN #2 had a criminal background check showing no disqualifying events and was cleared with no felony conviction, her license was verified with an expiration date of 12/31/2021, and her 3 references were validated with no concerning issues. LPN #2 completed in-service training for Residents Rights and Abuse, Neglect, and Exploitation on 02/25/2022. LPN #2 had a counseling statement dated 08/5/2021 related to failure to complete work on time, but no other concerns. Record review of facility In - Service for nurses dated 8/13/2021 revealed an in-service related to medication administration, Abuse, Neglect, Misappropriation of funds, Narcotic diversion, and Exploitation, presented by the DON. Record review of statement as part of facility drug diversion investigation signed by the DON and the ADON revealed that once they had established that on 08/10/2021 a Narcotic diversion had occurred, the nurse was immediately suspended until further investigation. The investigation continued through 08/24/2021. All families of the elders in question were contacted and made aware of the diversion without giving specific details. The residents' physicians were mere made aware of the diversion and investigation. All potential elders affected by this diversion were assessed for potential harm. As part of the performance improvement plan, the ADON and DON began to reconcile controlled substance records. The Pharmacy now sends them monthly controlled records to the DON and ADON and they verify that all those medications were signed in and accounted. The ADON and /or DON will perform random controlled substance reconciliations with the LPN's at least monthly. The nurse receiving the narcotics are to sign then in with a witness for verification purposes. Interview on 02/09/2022 at 10:15 AM, with the former Pharmacy Director, Pharmacy #2, revealed that she was the Director of Pharmacy prior to 08/10/2021 for over [AGE] years. The Pharmacy is located on the grounds of the nursing facility. It is an in-house Pharmacy. Pharmacy #2 currently serves as an as needed (PRN) Pharmacist, since her retirement in September 2021, and works approximately 3 days per week. Pharmacy #2 confirmed that the new Director of Pharmacy, effective 10/6/2021, was Pharmacy #1. Prior to the incident of 08/24/2021 the Pharmacy would obtain the prescription from the physician each month and fill it according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The courier is contracted by the Pharmacy for the delivery of all medications. The courier delivered the medications/narcotics to the houses and a nurse would receive the medications from the courier. The nurse who received the medications/narcotics she/he would sign a receiving slip and give it back to the courier and the courier would retain the receiving slip and turn it in to the Pharmacy upon completed delivery. What happened prior to 08/24/21 was only one nurse signed for the delivery of medications to the houses. More than one card of narcotics for one prescription i.e., 30 pills per card of meds, 45 pills per card of meds, and 60 pills per card, would be delivered. The receiving nurse could or may have signed only one of the cards into the medicine cart, and possibly pocketed the other. Pharmacy #2 stated that, We think that is what may have happened, but no elder (resident) was ever totally out of the medicine. There was medicine to be dispensed to the elder. Pharmacy #2 stated that after she retired, the new Director of Pharmacy, Pharmacy #1, had the medications reviewed and all records audited and he and the billing officer, Pharmacy #3 counted all the medications that were possibly mis-appropriated and refunded their accounts or refunded the facility. Since the incident of 08/24/21, we changed the number of cards to be delivered at one time to only one card of narcotics per elder per prescription. After 08/24/21, there had to be two nurses to sign for the delivery of medications to the houses from the courier. Also, we now send a list weekly to the DON of all the narcotics that were filled for the elders. Then once per month we send a monthly report to the facility Administrator of all narcotics that were filled and delivered to the houses for the elders. Hopefully, this misappropriation of medications/narcotics will not ever to happen again with the new processes that were put in place. Interview on 02/09/2022 at 10:45 AM, with Pharmacy #1 revealed that he began his new role on 10/6/2021. He confirmed that he and Pharmacy #3 sat down together and identified 10 elders from 2 of the 10 houses that had confirmed misappropriated medications/narcotics on 08/24/2022. They reimbursed several hundred dollars in misappropriated medications/narcotics. Pharmacy #1 provided a copy of all the medications that were reimbursed to the 10 identified elders of Greenhouse #1 and Greenhouse #2. All ten (10) elders identified lived in these two houses and none of the other eight houses of elders were affected. Pharmacy #1 confirmed that the pharmacy services for the greenhouses is an in-house facility pharmacy located on the campus of the long-term care facility. He confirmed that they provide all the medications/narcotics for the facility. Interview on 02/09/2022 at 11:05 AM, with Pharmacy #3, revealed that she was the billing officer for the Pharmacy and had worked at the facility since 2011. She confirmed that she and Pharmacy #1, had identified 10 elders that lived in two houses that had misappropriated medications/narcotics. They reimbursed all 10 accounts to the residents and the facility. The reimbursement occurred on the January 2022 billing cycle. She identified that most all the narcotics that were missing were pain medications such as [MEDICATION(S)] and anti-anxiety medications such as [MEDICATION(S)]. Record review of facility medication administration records for the months of May, June, July, and August 2021 for the ten (10) residents affected by the missing drugs revealed it was documented that the residents were administered their medications. Review of the nurses' notes for the 10 affected residents revealed that the residents were assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility investigation titled Narcotic Diversion Investigation 8/10/2021 -8/24/2021 and signed by the DON and ADON confirmed that Residents, # 1, #2,#3, #4, #5, #6, # 7, #8, #9, and #10 were assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/09/2022 at 3:50 PM a phone interview with Pharmacy #4 revealed that he came to the facility two (2) or three (3) times per month to review resident medications, review expiration dates especially for insulin. He reported that he periodically looks at the narcotic count however in his report he does not list that he checks it, he only documents if there is a recommendation or problem. Pharmacy #4 reported that the facility contacted him when they discovered the drug diversion last year and they had already notified the Board of Pharmacy, he felt the new changes in the delivery and monitoring the narcotics the facility had already revised would prevent a future incident from occurring. Pharmacy #4 reported he did a note in his September report that he performed a random narcotic count in Greenhouse #1 and that he had done another in Greenhouse #2. Pharmacy #4 reported that going forward he planned to document on his monthly report the specific house that he will be performing random narcotic checks on during his visits. On 02/09/2022 at 4:10 PM, a phone interview with LPN #4 revealed that prior to the discovery of the drug diversion when we received a delivery from the pharmacy of narcotics if another nurse was present, we would both sign but if not, we would accept the medication with one signature. After the discovery of the missing narcotics, we were in-serviced that going forward there must be two signatures to receive narcotics and that if there was not another nurse in the house, we are to call for another nurse to come to witness receiving medication, usually it will be one of the RN's that will come to assist. LPN #4 also reported that when the nurses reconcile the narcotic logbook, they first count the cards to ensure the correct number of medication cards are accounted for and they count the medications on each card one-by-one. LPN #4 reported that they were also instructed that shift change would always require two signatures when reconciling the narcotic count with the off going nurse and the oncoming nurse. LPN # 4 confirmed that she did remember doing a random narcotic count with Pharmacy #4 after the discovery of the missing drugs, but could not remember the date, but that it was either in September or October of 2021. On 02/09/2022 at 5:30 PM, a phone interview with LPN #5 reported that she works 7 PM to 7 AM shift and that she did work the shift after LPN #2 when she worked at the facility. LPN #5 reported that LPN #2 on two separate occasions had left before LPN #5 got to the medication cart and that she had to call LPN #2 to return to count the narcotics and sign the log. LPN #5 reported she did tell the supervisor but cannot recall which supervisor was working on the two occasions nor can she remember the dates of the occurrences only that she believed it was in the summer of 2021. LPN #5 reported that she never receives narcotic deliveries on 7 PM to 7 AM shift, but now she has been in-serviced on it if she did receive any narcotic deliveries, she would need to sign for those with a witness, requiring 2 signatures and that they were in-serviced to never accept keys to the medication cart before reconciling the narcotics with count and signature, and in-serviced on improving documentation. LPN #5 reported that when the nurse gives a PRN pain medication, she is to chart the pain level of the resident then red lettering pops up to remind the nurse to come back to chart effectiveness of the pain medication, if the medication is not helping, she would notify the RN. Record review of Quality Assurance (QA) attendance sign in sheet revealed 13 staff members including the medical director attended the meeting on 08/26/21. On 02/10/2022 at 9:05 AM, a phone interview with RN #3 supervisor revealed that she is assigned to Greenhouse #1 and Greenhouse #2 and that on occasion she works the carts should a nurse call in. She cannot recall exact dates, but she did follow LPN #1 a few times and the narcotic count was always right, she denies ever seeing anything that would have made her suspicious of a drug diversion until the ADON and DON initiated the investigation in August of 2021. On 02/10/2022 at 1:10 PM, an interview with Resident #8 with a BIMS score of 15 revealed that she could not remember ever having asked for pain medication without receiving it. I would know if something was missing from my little medicine cup, I may not know what they all are, but I know what they are supposed to look like. She denies any issues with medications. On 02/10/2022 at 1:15 PM, an interview with LPN #3 revealed that he was transferred from the rehab section when it closed for renovation to primarily work in Greenhouse #1 and Greenhouse #2. LPN #3 reported he was not working in the houses at the time of the drug diversion, but they had all received lots of in-services since it occurred. LPN #3 reported that Resident #3 does ask for pain medication regularly and that the physician recently changed the PRN schedule where she could get them every 4 hours as needed. Resident #4 has prn pain medication ordered but she usually always gets one in the morning and one in the evening, that is usually all she asks for. Resident # 6 has not asked for any prn pain meds in a while, she just came back from a hospital stay related to kidney stones and pneumonia. Resident #1 has a low BIMS score, but he can still let you know if he is hurting, but he is not one who generally has the need for a lot of pain control. Resident #9 takes all his scheduled medications and all his prn medication every time he can have them, he usually will always look at his meds before taking them. On 02/10/2022 at 1:41 PM, an interview with Resident #2 with a BIMS score of 15 revealed that he had been enjoying activities and had just returned to his room. The resident denied ever needing any medication that he did not get. He denied ever hearing or seeing anything that would be considered abuse or neglect. Resident #2 reported that he is pleased with his care and had no problems getting his medications. Interview on 02/10/2022 at 1:45 PM, with the DON revealed that the policy and procedure for the acceptance of the delivered medications/narcotics prior to 08/24/2021 was dated 11/2017. The DON dated and signed the policy and procedure to confirm the dates that it was in utilized. The policy was not revised but the protocol was changed and updated on 08/13/2021. The DON provided the new protocol with the new protocol date of effectiveness. On 02/10/2022 at 1:47 PM, an interview with Resident #3 with a BIMS score of 9 revealed that she reported that she occasionally would be late getting her medication but did not recall a time that she didn't get it at all. She reported the doctor recently ordered that she could have her prn pain medicine every 4 hours if needed. On 02/10/22 at 2:00 PM the SA attempted to call LPN #1 and LPN #2 with no response. On 02/10/22 the State Agency validated through interviews, record review, facility policy review and observations with residents and staff that the facility had begun an immediate investigation when the suspicious of misappropriation of the resident's medications had occurred. The facility held a QA meeting, gathered interviews, and audited all resident's medication at 100% and reported the incident to all appropriate authorities and terminated the nurses involved and reported the nurses to the Board of Nursing and the Attorney Generals office and MSDH. The SA validated that the facility had taken all necessary measures to be at past non compliance with the deficient practice that occurred on 08/09/21.

Based on resident interview, staff interview, record review and facility policy review, the facility failed to prevent verbal abuse and failed to prevent mental abuse via threats of punishment or deprivation, exploitation of an elder via intimidation and threats, misappropriation of an elder's property without her consent, and involuntary confinement or seclusion via the removal of a resident's property for two (2) of ten (10) residents reviewed for abuse. Residents # 1 and Resident #9. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 01-25-2017, revealed, Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, and involuntary seclusion . Policy Explanation and Compliance Guidelines: 3. Willful means the individual deliberately, not that the individual must have intended to, inflict injury or harm. 7. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation . 9. Involuntary Seclusion refers to the separation of a resident from other residents or from his/her room or confinement to his/her room against the resident's will . 10. Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. 11. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary or permanent, use of the a resident's belongings or money without the resident's consent. Resident #1 Review of Resident #1's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #'1's Minimum Data Sate (MDS) dated [DATE], revealed, she had a Brief Interview of Mental Status (BIMS) of 15, making her interviewable, and cognitively able to answer questions, and she required extensive assistance for her activities of daily living (ADL's) and was always incontinent of bowel and bladder. On 04-30-2021 at 10:40 AM, during an interview with Resident #1 she stated, The nurse came in and sat on the bed and she yelled at me to turn the TV down. It was loud, I will say that. When she sat on the bed, my bed made a popping noise. I asked her if she broke my bed and she said, why would you ask me that, I am not that fat? She screamed at me again to turn down the TV, and I tried but she was sitting in the way. I told her if she would move her fat ass, I could turn it down. She put her finger in my face and told me I was rude and that it wouldn't be tolerated. She reached over to give me my insulin shots, but she did it too high on my ribs and I hollered. She apologized and went to give me my second shot in the same area and it hurt too so I hit her on the arm with the remote. She pried my fingers off the remote. It really hurt my hand. She took the remote from me and put it on the TV stand, and then turned around and unplugged the TV from the wall and told me when you can treat others with respect you can have your remote back and can watch TV. She left out of the room. I would guess it was an hour or better before anyone came back into the room to give me my remote back. I had kinda dozed off, I don't remember if it was an aide or her to be honest. But this is not the first time she has done this. It has happened before with her, not for a while, like several months, but it has happened before. I am worried that she is trying to give me an air bubble sometimes to shut me up. I know I am paranoid sometimes and get excited, but I was told she was working tonight and I'm nervous because I am the reason she has been suspended and missed money. Review of Resident #1's Departmental Notes, dated 04-19-2021 at 10:31 PM, revealed, Elder became upset et (and) very agitated w/ (with) me upon administering medication et insulin to her. Upon entering her room, elder had her TV (television) extremely loud. I asked elder to cut it down. Elder ignored me . as I prepared to administer the insulin, I sat on the edge of her bed to gain betterview. Elder only wants her insulin injections in her left lower abdomen, despite needing to rotate the sites out. Once I sat down elder asked did you break my bed? I replied back, what do you mean? She replied, did you break my bed when you sat down? I replied, no, I'm not that heavy, why would you say that? She replied, seem like you did. I told elder that was really rude of her to say, I haven't done anything to her. Elder's TV was still loud, so I yelled for her to cut it down, elder screaming I am trying to but if you would move your fat ass out infront of my TV, I could. I told elder to keep any rude comments to herself, because its not nice and won't be tolerated. I proceeded to administer the first injection the 57 units of [MEDICATION(S)], Elder proceeded to yell out. I apologized and began to administer her sliding scale of 12 units. As I inject the SS (sliding scale), Elder yelled out again and started hitting me with her remote control. I told her to stop and took the remote control from her. I tried to cut the TV down but the remote stopped working. I turned the TV down manually from the TV itself and told the elder, until her attitude is better the TV will stay off. I removed any objects that the elder could possibly throw or push over and left. Call light within reach. Will cont (continue) to monitor. This note was authored and signed by Licensed Practical Nurse (LPN) #1. On 04-30-2021 at 2: 30 PM, during an interview with the Administrator and Director of Nursing (DON), they both stated they were on the fence with what to do, so they had not let her work since the report and she had continued to be suspended. Both agreed the investigation had holes in it and she back tracked about the reason she removed the remote. One time LPN #1 stated it was to see if it was broken, the other time it was to punish the elder for her behaviors. The State Agency (SA) read the definitions of willful, mental abuse, exploitation, and misappropriation of resident property from the facility's abuse policy, and both agreed what occurred fit all of those categories. On 05-03-2021 at 9:30 AM, during an interview with the Executive Director and Administrator, the SA was informed they the facility had chosen to terminate LPN#1 after her suspension ended and had reported the LPN to the Board of Nursing (BON), based on her documentation of the event, and Resident #1's fear of her caring for her again. On the morning of 05-03-2021, the SA received LPN#1's phone number and attempted to call her for an interview. She did not return my call throughout the duration of the survey. A copy of the written statement from LPN#1 given during her questioning for the facility investigation was provided to the SA. The statement stated, This nurse prepared (formal name) Resident#1's medication . After drawing up the insulin, I entered back into the room and sat on the edge of the bed. Elder looked at me and asked Did you break my bed? I replied No, why would you say that? I'm not that heavy. Elder replied, Oh seems like it. I asked the Elder to hold her left arm up to see the abdomen better. Elder said she couldn't hear me, while trying to turn the TV down. In an elevated voice, I asked the Elder to turn the volume down from 99. Elder replied, I will if you would move your fat ass out of the way! I told the Elder that she would feel a stick, and administered the insulin. Elder yelled out, I apologized and told her I don't mean to hurt her. I started administering the second injection and Elder yelled out again. Before I could apologize, the Elder started hitting me with her TV remote. I removed the remote from the Elder's hands and told her to please not hit staff. I tried to turn the TV down with no luck. The remote was broken. I put the remote on the dresser and unplugged the TV only to get the volume under control. I left the room and asked the Shahbaz to come back in the room with me to see if they could help get the volume down. We plugged the TV back up, and the Shahbaz was able to manually turn the volume down. We left the room with the TV plugged up and the remote near the Elder. The SA looked at a copy of the facility schedule, and neither Shahbaz who worked with LPN #1 that night was on the schedule during the survey. Neither Shahbaz returned a phone call to the SA. Written statements were received from the facility for both Shahbaz. Shahbaz #1's written statement revealed, I remember (formal name) LPN #1 telling me (resident's formal name) Resident #1 hit her with the remote. I don't remember going into her room until the end of the evening to check on her and she was asleep. I think it was the other girl who went in her room several times but I never went in her room the whole time until the end of my shift. Shahbaz #2's written statement revealed, I was in the back and when I came out (formal name) LPN#1 told me (formal name) Resident #1 hit her with the remote. She said she went in and asked her about the situation and (formal name) Resident #1 said she hit her. Resident #1 had the remote in her hand but she couldn't remember if the TV was on or off. Resident #1 wasn't upset she just told her several times throughout the evening she popped that nurse. Neither of the Shahbaz statements indicated they went back into Resident #1's room with LPN#1 to see if they could help get the volume down, or plug the TV back up. Neither Shahbaz talked about going in the room and manually turning the volume down, or leaving the room with the nurse and the TV being plugged up and the remote near the resident A written statement by Social Services, dated 04-23-2021, was provided regarding her interview with Resident #1. The statement revealed, She sat on the bed so hard I though a piece had fallen off. My TV was on and loud. She asked me to turn it down. I realized it was not working because she was blocking the TV. She yelled again for me to turn down the TV. She gave me the shot in my rib area where it hurts, and I hit her in the arm with the remote. She grabbed the remote. She took my fingers off the remote. I heard a pop and it hurt real bad. I think it's fractured. She pointed her finger in my face stating You are not going to do that again. I pointed my finger in her face and told her to get out of my room. She put the remote on the dresser where I could not reach it and unplugged the TV. On 05-04-21 at 11:00 AM, during an interview with Social Services, she stated she went to interview Resident #1 because of a nurses note that was brought to her attention. She asked her about the remote situation, and Resident #1 was in a good mood that day. Elder told her very calmly that the nurse sat on the edge of her bed for an insulin shot, the TV was loud, so the nurse asked her to turn it down. She tried to turn it down, but the nurse's body was in the way. Resident #1 said she cussed her. The nurse gave the insulin shot in her rib cage area and it hurt so she hit her with the remote control. The nurse pried her fingers off the remote and took it from her. LPN #1 unplugged the TV and placed the remote on top of the TV and left the room. Resident #9 Review of Resident #9's Face Sheet revealed, she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's MDS, dated [DATE], revealed, she is moderately hard of hearing, has a BIMS of 15, making her interviewable, required limited assistance of one staff for her adl's, and was frequently incontinent of bowel and bladder. Review of the facility's investigation, dated 01-05-2021 revealed, that on 12-28-2020, Housekeeper #1 was witnessed slinging a pack of diapers and cursing (formal name) Resident #9, and talking to her in a loud and menacing tone. Review of a written statement from the eye witness, Shahbaz #3 revealed, I came back in the building from [NAME] and heard yelling and cursing going on. We saw the cleaner yelling, standing over (formal name) Resident #9. She was slinging a pack of diapers and cursing at (formal name) Resident #9 for accusing her of tampering with her things. Some things that were said were, I don't have to steal out of your p**** a** room, I'm in my right mind, I don't play that sh**. The SA attempted to reach Housekeeper #1, and there was no answer or answering machine to leave a message for a return call. Shahbaz #3 had been terminated for Job Abandonment on 03-12-2021, prior to the survey. A message was left for her, with no return call to the SA. On 04-30-2021 at 3:15 PM, during an interview with the Executive Director, she stated Shahbaz #3 was the one that reported the incident to her. She had no idea why Shahbaz #3 had waited eight (8) days to report it to her. She stated she had interviewed Housekeeper #1 but must not have written it down and put it in the folder. She stated the housekeeper didn't deny screaming at the Elder, but did deny that she cussed her out. When asked by the SA if there were other residents or staff interviewed to see if there was a pattern with the Housekeeper, and she stated, Oh I know that we did, we just must not have written them all down. If there was something that was pertinent we would have made sure to put it in the folder with the investigation. Record review of the Attorney General Report dated 1/5/21 revealed Housekeeper #1 was immediately suspended upon report and will be terminated. On 05-03-2021 at 2:00 PM, during an interview with Resident #9, she stated she remembered that day and the housekeeper yelling at her, but she had not put in her hearing aides that day and didn't know what all she said. She knew that she had something in her hands but didn't remember what it was. She said she talked with the Executive Director because she had been told the housekeeper had been fired and she was afraid it was her fault. She said the Executive Director reassured her, she was not the reason she had to be let go. When asked by the SA if she was fearful or worried about staff being rough with her or using profanity around her she stated, no, I'm not afraid to be here, the staff are good to me, and I'm sorry that young lady got fired.

Based on observation, staff interview, record review and policy review, the facility failed to implement the care plans for two (2) of six (6) residents, Resident #1 and Resident #2, resulting in avoidable injuries to both residents. Certified Nursing Assistant (CNA) #3 failed to follow the care plan for Resident #1 which included approaches for extensive assistance of two (2) persons for bed mobility, toileting, transfers, and for dressing. CNA #3 transferred Resident #1 to the toilet without assistance; left her unassisted and, the resident fell ; and received a [MEDICAL CONDITION] humerus. When the care plan approaches included extensive assistance of two (2) persons for bed mobility, toileting, transfers and dressing. CNA #5 failed to follow the care plan approaches which included the use of a mechanical lift with two (2) persons transferring, and transferred Resident #2 from the wheelchair to the bed without assistance of another person or the mechanical lift as required. Resident #2 received rib fractures during the transfer when the care plan approaches included the use of a mechanical lift with two (2) persons for transferring. Findings include: Resident #1: Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/24/12, revealed that she had short and long term memory problems with mild cognitive deficits. Resident #1 required extensive assistance of two (2) persons for transfer and toileting. Review of Resident #1's Care Plan dated 5/3/12 revealed that assistance was required for activity of daily living (ADL) functions related to general weakness and history of severe [MEDICAL CONDITION] arthritis. Approaches included extensive assistance of two persons for bed mobility, toileting, transfers and dressing. Review of the ADL for December 2012 and January 2013 for Resident #1, (which is used for backup when the electronic charting system is down and correlates to the Daily Care Guide), revealed that extensive assist of two (2) persons was required for bed mobility, toileting, transfer and dressing; two (2) persons or mechanical lift and two (2) persons for transfers; and transfer on and off the commode. Review of a "Resident Incident Report" for Resident #1 dated 1/12/13 at 5:08 p.m., revealed that Resident #1 was taken to the bathroom by CNA #3 and left unattended. The nurse heard a loud noise and scream. Resident #1 was found on the bathroom floor on her left side. Resident #1 had two (2) skin tears to the left inner and outer elbow, egg sized knot to the left side of her head and complained of pain to her left arm/shoulder with a possible fracture. Interview with CNA #4, CNA Guide, on 2/5/13 at 3:09 p.m. revealed that CNA #3 admitted to transferring Resident #1 to the bathroom, leaving her on the toilet unassisted, answered the doorbell and the resident fell from the toilet. CNA #4 stated that when she asked CNA #3 about the incident, that CNA #3 had stated that she knew she wasn't supposed to leave Resident #3 alone and had made a stupid mistake. CNA #4 stated that CNA #3 had been in-serviced on 12/10/12 for transfer/lifts/ and following the care plan and still didn't follow the care plan for Resident #1. Interview with LPN #1 on 2/5/13 at 12:25 p.m. revealed that she was passing medication around 5:00 p.m. by Resident #1's door when Resident #1 turned on her call light. LPN #1 stated that CNA #3 assisted Resident #1 to the toilet with her walker, left the resident on the toilet and came to the medication cart talking. LPN #1 stated that all of the CNAs had been trained on following the care plan and that Resident #1's care plan called for two (2) person assist with transfers, that would include on/off the toilet and someone should stay with the resident. LPN #1 stated that all CNAs should know to stay with the resident but had specifically told CNA #3 not to leave Resident #1 alone because she gets anxious. Interview with the Director of Nursing (DON) on 2/5/12 at 4:10 p.m. revealed that CNA #3 was terminated for not following the care plan for Resident #1. The DON stated that Resident #1 had been assessed and care planned for a two (2) person assist for toileting and CNA #3 had assisted the resident by herself and left her on the toilet unassisted and went to answer the doorbell and the resident fell and sustained a fracture. The DON stated that she didn't know why CNA would write the statement about being in trouble if the state was here unless she knew that she would be in trouble for transferring the resident by herself. The DON stated that CNA #3 had not followed Resident #1's care plan by not getting assistance and for leaving the resident unassisted on the toilet, which is a safety risk. Resident #2 Findings include: Observation and interview with Resident #2 on 2/5/13 at 11:20 a.m. revealed that she was alert and oriented to person, place and time. Resident #2 could not recall the date but stated that the girl (CNA #5) had picked her up without the lift and hurt her ribs. Resident #2 stated that she put her arms around CNA #5's neck and the CNA grabbed around her and then she heard cracking. Resident #2 stated that she didn't start hurting at that time but did later and told the nurse the next day. Further interview with Resident #2 on 2/5/13 at 1:40 p.m., revealed that (she) had real brittle bones and fractures in the past and that she didn't think CNA #5 meant to hurt her when she transferred her to bed but that she did hurt. Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's most recent MDS with an ARD of 11/22/12, revealed that she was cognitively intact with a brief interview for mental status of 15. (13-15 is indicative of no cognitive impairment). Resident #2 required total assistance of two (2) persons for transfers. Review of Resident #2's care plan dated 12/19/07 and updated 6/20/12, revealed that she required assistance with ADLs related to [MEDICAL CONDITION] and Arthritis. Approaches included: utilize two (2) persons and full body sling using mechanical lift for transfers. Review of Resident #2's December and January ADL sheet revealed that a mechanical lift with two (2) persons were to be used during transfers. Review of an Incident Report for Resident #2 dated 1/11/13 at 12:25 p.m. revealed that CNA #5 transferred Resident #2 from the wheelchair to the bed without the lift by herself on 1/9/13 and on 1/10/13 the resident reported to the nurse that she thought her ribs were broken. X-rays were done on 1/10/13 with results reported on 1/11/13 of acute left posterior 9th and 10th rib fractures. Interview with CNA #5 on 2/6/13 at 10:30 a.m., revealed that Resident #2 was ready to go to bed and when transferred she asked the resident to put her arms around her (CNAs) neck and lifted the resident up and put her in the bed. CNA #5 stated that sometimes the lift was used for the resident, but that she had just gotten busy and put Resident #2 in the bed. CNA #5 stated that she was aware that Resident #2 needed two (2) person assist or the use of the lift that it was in the care plan. CNA #5 stated that CNA #6 was standing at the doorway and had gotten the lift to put another resident to bed and did ask if she needed help but told her that she had it. CNA #5 stated that Resident #2 didn't complain of pain at the time of the transfer. CNA #5 stated that she was aware that the care plan was supposed to be followed and that she had been in-serviced to that effect. CNA #5 stated that she had been terminated for not following the care plan for Resident #2. Interview with CNA #6 on 2/5/13 at 11:35 a.m., revealed that she had witnessed the incident of Resident #2 being transferred by CNA #5. CNA #6 stated that CNA #5 had taken Resident #2 to her room to lie down. CNA #6 stated that she asked CNA #5 if she needed any help and CNA #5 replied that she had it. CNA #6 stated that Resident #2 put her arms around CNA #5's neck and was lifted up from the wheelchair to the bed by CNA #5. CNA #6 stated that she had offered to help with the transfer but CNA #5 declined, so she took the lift to transfer another resident. Interview with CNA #4, Guide, on 2/5/13 at 3:09 p.m., revealed that she had spoken with CNA #5 and CNA #6 about the transfer of Resident #2. CNA #4 stated that the lift was right there and CNA #6 was right there to assist and had asked CNA #5 if she needed assistance and CNA #5 chose to lift Resident #5 by herself without the use of the lift or assistance. CNA #4 stated that she reminded CNA #5 of the care plan for Resident #2 which included the use of the lift. CNA #5 replied that she had " kind of been in a hurry " and just put Resident #2 to bed and that the resident had not complained. CNA #4 stated that there had just been recent training to follow the care plan. Interview with RN #A on 2/6/13 at 9:30 a.m. revealed that she spoke with Resident #2 who informed her that CNA #5 had transferred her from the wheelchair to the bed without the lift and she heard a cracking noise. RN #A stated that Resident #2 was care planned to have two (2) persons and the mechanical lift for transfers. Interview with the DON, with the Administrator present, on 2/5/13 at 10:00 a.m., revealed that both CNA #3 and CNA #5 were trained on following the care plans and did not follow them for Resident #1 and Resident #2 and the residents were injured. Review of the facility's policy "Using the Care Plan/Following the Care Plan" with a revised date of August 2006, revealed that all nursing personnel including RN, LPN, and Shabazim (Certified Nursing Assistants) are to follow the resident's care plan. Cross-refer to F-224 for the facility's failure to provide adequate supervision and assistance devices to prevent injuries for Resident #1 and Resident #2 by transferring them inappropriately and both residents received injuries with fractures.

Based on observation, interview and record review, the facility failed to ensure that two (2) of six (6) residents, Resident #1 and Resident #2, received adequate supervision and assistance to prevent avoidable accidents as evidenced by Certified Nursing Assistant (CNA) #3 transferred Resident #1 to the toilet without assistance; left her unassisted and, the resident fell ; and received a fracture of the left humerus. CNA #5 transferred Resident #2 from the wheelchair to the bed without assistance of another person or the mechanical lift as required and Resident #2 received rib fractures during the transfer. Findings included: Resident #1: Observation and interview of Resident #1 on 2/5/13 at 1:00 p.m. revealed that she was in a wheelchair and was alert and oriented to name and place. Resident #1 had no complaint of mistreatment but stated that she did have a broken left arm. Resident #1 stated that the staff usually took her to the bathroom and stayed with her or right outside the door but now they use the lift to get her in bed for toileting. Resident #1 stated that she wore a splint for awhile and took some pain medication for a few days after the incident. Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/24/12, revealed that she had short and long term memory problems with mild cognitive deficits. Resident #1 required extensive assistance of two (2) persons for transfer and toileting and the care plan dated 5/3/12 included approaches for extensive assistance for two persons for bed mobility, toileting, transfers and dressing. Review of a handwritten statement dated 1/12/13 with CNA #3's signature revealed: "I (CNA #3) took (Resident #1) to the bathroom at 5:00 p.m. Had told elders if state was (here) I would get in trouble. Left Elder unattended to go answer the door. Hear elder fall, rushed in room, found elder in bathroom floor". Interview with CNA #3 on 2/6/13 at 9:40 a.m. revealed that she had taken Resident #1 to the bathroom with a walker and left her on the toilet, went to answer the door and the resident fell from the toilet. Interview with CNA #4, CNA Guide, on 2/5/13 at 3:09 p.m. revealed that when she asked CNA #3 about the incident that CNA #3 had stated that she knew she wasn't supposed to leave Resident #3 alone and had made a stupid mistake. Resident #2 Findings include: Observation and interview with Resident #2 on 2/5/13 at 11:20 a.m. revealed that she was alert and oriented to person, place and time. Interview with Resident #2 on 2/5/13 at 1:40 p.m., revealed that (she) had real brittle bones and fractures in the past and that she didn't think CNA #5 meant to hurt her when she transferred her to bed but that she did hurt. Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. Interview with CNA #5 on 2/6/13 at 10:30 a.m., revealed that Resident #2 was ready to go to bed and when transferred she asked the resident to put her arms around her (CNAs) neck and lifted the resident up and put her in the bed. CNA #5 stated that sometimes the lift was used for the resident, but that she had just gotten busy and put Resident #2 in the bed. CNA #5 stated that she was aware that Resident #2 needed two (2) person assist or the use of the lift that it was in the care plan. Cross Refer to F-224 for the facility ' s failure to ensure that two (2) of six (6) residents, Resident #1 and Resident #2, were not neglected.

Based on observation, interview, record review and policy review, the facility failed to ensure that care plans were followed for two (2) of six (6) residents, Resident #1 and Resident #2 as evidenced by Certified Nursing Assistant (CNA) #3 failed to follow the care plan and transferred Resident #1 to the toilet without assistance, left her unassisted and the resident fell and received a [MEDICAL CONDITION] humerus. CNA #5 failed to follow the care plan and transferred Resident #2 from the wheelchair to the bed without assistance of another person or the mechanical lift as required and Resident #2 received rib fractures during the transfer. Findings included: Cross-refer to F224 for the facility's failure to follow the care plan for Resident #1 and Resident #2 by transferring them inappropriately and both residents were injured with fractures.

Part I: CI MS # Based on observation, interview, record review and policy review, the facility failed to ensure that one (1) of eight (8) residents reviewed, Resident (Elder) #3, was not neglected. Resident #3 was deemed a full code status and was found not breathing on [DATE] at 3:45 a.m. The Certified Nursing Assistant (CNA) brought an isolation cart to the room instead of the crash cart, there was not an Ambu-Bag available on the crash cart, and no rescue breathing was performed for approximately five (5) to eight (8) minutes. The crash cart checklist of supplies had not been documented for [DATE]. Resident #3 expired at the facility. The facility's failure to ensure that crash carts were readily available with appropriate supplies, the failure to ensure that staff were knowledgeable of where the crash cart was located, the failure of rescue breathing not performed timely and not performing a check of the supplies for the crash cart every shift was deemed an Immediate Jeopardy (IJ) on [DATE] at 10:20 a.m. The IJ was identified to exist beginning on [DATE] and continued through [DATE]. The Administrator was notified of the IJ on [DATE] at 10:20 a.m. The facility provided a credible Allegation of Compliance (AoC) on [DATE] at 9:20 a.m. Based on the facility's implementation of corrective actions and verification of those corrective actions, the IJ was removed as of [DATE] at 9:20 a.m. and lowered to a "G" level which constitutes actual harm with potential for more than minimal harm. Findings included: Cross refer to F309 for the facility's failure to prevent neglect for Resident #3 by not providing rescue breathing for approximately five (5) to eight (8) minutes as required in the cardio-pulmonary guidelines of compression/breathing ratio of 30:2 and not having the appropriate supplies (Ambu-Bag) available to start resuscitative efforts. The facility submitted the following Allegation of Compliance for the Immediate Jeopardy: "An Immediate jeopardy was identified on [DATE] at 10:05 a.m. for Resident #3 for failure of equipment not available (ambu bag) on crash cart, failure to perform necessary procedures of cardiopulmonary resuscitation (CPR), and staff unaware of location of crash cart. The following steps were taken for these allegations of immediate jeopardy for Elder #3 as follows: 11 /,[DATE] at 2:00 p.m. RN #9 and #10 checked all the crash carts to ensure all equipment present including ambu bags, in-serviced RN's and LPN's on crash carts being stocked appropriately and equipment working and all items in date, inserviced LPN's on documentation of crash carts every shift per licensed nurse on crash cart check list [DATE] at 11:00 p.m. RN #7 in-serviced RN's and LPN's on crash carts being stocked appropriately including ambu bags and equipment working and all items in date, also on documentation of crash cart checklist completed every shift per licensed nurse on crash cart checklist. [DATE] at 9:00 a.m. RN #1 checked the crash carts in Green House (GH) #1, 2 and 3 for all equipment and supplies on crash cart including ambu bag with none noted missing. [DATE] at 8:30 a.m. RN #3 checked the crash carts in GH #4, 5 and 6 for all supplies and equipment including ambu bag with none noted missing. [DATE] at 8:30 a.m. RN #4 checked the crash carts in GH #7 & 8 for all supplies and equipment including ambu bag with none noted missing. [DATE] at 9:00 a.m. RN #5 checked the crash carts in GH #9 & 10 for all supplies and equipment including ambu bag with none noted missing. [DATE] at 9:30 a.m. RN #6 checked the crash carts at Cedars for all supplies and equipment including ambu bag with none noted missing. [DATE] at 10:30 a.m. RN #2 reviewed all elders charts that have expired in the facility since September of 2012 until November of 2012 and found no other elders out of the seven deaths that were a Full Code-all of these elders were Do Not Resuscitate. [DATE] at 2:30 p.m. an inservice was initiated by Clinical Care Coordinators (RN's #,[DATE]) to all nursing personnel including RN's, LPN's and Shabazim(Certified Nursing Assistants). No Nursing staff including RN's, LPN's and Shabazim (Certified Nursing Assistants ) are allowed to work until they are inserviced on the following: 1.) Location of crash cart and equipment, crash cart checklist done each shift per licensed nurse, replacing all supplies immediately on crash cart. 2.) The proper procedure for Cardiopulmonary Resuscitation(CPR) including if no ambu bag or pocket mask available begin mouth to mouth rescue breathing. 3.) Failure to provide necessary services and goods for elders is neglect. [DATE] at 2:30 p.m. the above inservice was initiated:- RN #1 inserviced LPN's and Shabazim for ,[DATE] and ,[DATE] in GH #1, 2 and 3. RN #3 inserviced LPN's and Shabazim for ,[DATE] and ,[DATE] in GH #4, 5, 6. RN #4 inserviced LPN's and Shabazim for ,[DATE] and ,[DATE] in GH #7 & 8. RN #5 inserviced LPN's and Shabazim for ,[DATE] and ,[DATE] in GH #9 & 10. RN #10 inserviced LPN's and Shabazim for ,[DATE] and ,[DATE] at Cedars. [DATE] at 7:00 p.m. the above inservice was initiated- RN #3 inserviced LPN's for 7p-7a in GH ,[DATE]. [DATE] at 11:00 p.m. the above inservice was initiated - RN #6 inserviced LPN's and Shabazim for ,[DATE] at Cedars. RN #10 inserviced Shabazim for ,[DATE] in GH ,[DATE]. [DATE] at 4:00 p.m. an emergency QA meeting was called to address an Immediate Jeopardy due to the following: failure of equipment not available (ambu bag) on crash cart, failure to perform necessary procedures of cardiopulmonary resuscitation(CPR) and staff unaware of crash cart locations. Attendees included: Medical Director, ED, Director of Nursing, Assistant Director of Nursing, and Clinical Care Coordinators (RN #1, 2, 3, 4, 5, 6, 9, 10). Implementation of procedures/Inservices were discussed with no further immediate actions taken." Part II: CI MS # Based on observation, interview, record review and policy review, the facility failed to ensure that one (1) of eight (8) residents reveiwed, Resident #7, was not neglected by failure of a Certified Nursing Assistant (CNA) to perform the necessary transfer of Resident #7 from the wheelchair to the bed without assistance of another staff or the use of a mechanical lift on [DATE]. Resident #7 complained of pain and swelling of the left knee on [DATE] and was identified with a [MEDICAL CONDITION] on [DATE]. The physician was not notified of Resident #7's complaint of pain and swelling until [DATE]. Findings included: Cross refer to F309, Part II, for the facility's failure to transfer Resident #7 appropriately and to notify the physician of Resident #7's complaint of pain and swelling of the left knee on [DATE] when it was initially reported to the nursing staff.

Based on observation, interview, record review and policy review, the facility failed to ensure that two (2) of six (6) residents, Resident #1 and Resident #2, were neglected as evidenced by Certified Nursing Assistant (CNA) #3 failed to follow the care plan and transferred Resident #1 to the toilet without assistance, left her unassisted and the resident fell and received a [MEDICAL CONDITION] humerus. CNA #5 failed to follow the care plan and transferred Resident #2 from the wheelchair to the bed without assistance of another person or the mechanical lift as required and Resident #2 received rib fractures during the transfer. Findings included: Resident #1: Review of a written report to the (Name of State Agency) dated 1/15/13 revealed that on 1/12/13 Resident #1 was assisted by (CNA #3) to the bathroom and left unassisted on the toilet. Observation and interview of Resident #1 on 2/5/13 at 1:00 p.m. revealed that she was in a wheelchair and was alert and oriented to name and place. Resident #1 had no complaint of mistreatment but stated that she did have a broken left arm. Resident #1 stated that the little girl (didn't know her name) had taken her to the bathroom and she thought that she (Certified Nurse Assistant) would help her out and (Resident) tried to get up to go back to her chair and she just hit the floor. Resident #1 stated that the staff usually took her to the bathroom and stayed with her or right outside the door but now they use the lift to get her in bed for toileting. Resident #1 stated that she wore a splint for awhile and took some pain medication for a few days after the incident. Resident #1 had joint deformities and leaned her head to the left and downward and has Kyphosis. Resident #1 stated that she had crippling arthritis and it was hard to do things by herself. Observation of Resident #1 on 2/5/13 at 1:10 p.m. revealed that two (2) Certified Nursing Assistants (CNAs), CNA #1 and CNA #2, transferred the resident using a mechanical lift from the wheelchair to the bed without concerns. Resident #1's left elbow was slightly [MEDICAL CONDITION] with fading bruises noted. Resident #1 had no complaint of pain to the elbow. Both CNA #1 and CNA #2 stated that prior to her fall Resident #1 could ambulate to the bathroom with the assistance of one (1) person and a walker but that it was safer for two (2) assist and someone stayed with her or waited right outside the bathroom door until she was finished. Both CNAs stated that if any resident had to be assisted to the bathroom then someone stayed with them. Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/24/12 revealed that she had short and long term memory problems with mild cognitive deficits. Resident #1 required extensive assistance of two (2) persons for transfer and toileting. Review of Resident #1's Care Plan dated 5/3/12 revealed that assistance was required for activity of daily living (ADL) functions related to general weakness and history of severe [MEDICAL CONDITION] arthritis. Approaches included extensive assistance of two persons for bed mobility, toileting, transfers and dressing. Review of the ADL for December 2012 and January 2013 for Resident #1, (which is used for backup when the electronic charting system is down and correlates to the Daily Care Guide), revealed that extensive assist of two (2) persons was required for bed mobility, toileting, transfer and dressing; two (2) persons or mechanical lift and two (2) persons for transfers; and transfer on and off the commode. Review of a "Resident Incident Report" for Resident #1 dated 1/12/13 at 5:08 p.m., revealed that Resident #1 was taken to the bathroom by CNA #3 and left unattended. The nurse heard a loud noise and scream. Resident #1 was found in the bathroom floor on her left side. Resident #1 had two (2) skin tears to the left inner and outer elbow, egg sized knot to the left side of her head and complained of pain to her left arm/shoulder with a possible fracture. Review of an "Incident Investigation" dated 1/12/13 revealed that Resident #1 had an un-observed fall with head injury, humeral head fracture and two (2) skin tears to the left medial and lateral elbow. The reason: "Shaboz (Certified Nurse Assistant) took pt (patient) to restroom and left unattended". Other contributing factors identified: "dependent upon staff assist, thin fragile, skeletal fragility, Hx (history) of dizziness, and Kyphosis". Review of a handwritten statement dated 1/12/13 with CNA #3's signature revealed: "I (CNA #3) took (Resident #1) to the bathroom at 5:00 p.m. Had told elders if state was (here) I would get in trouble. Left Elder unattended to go answer the door. Hear elder fall rushed in room found elder in bathroom floor". Review of Resident #1's physician's orders [REDACTED]. Review of Resident #1's X-ray report dated 1/12/13 of the upper extremity revealed a comminuted and possibly impacted [MEDICAL CONDITION] humeral head and neck and questionable left-sided rib injuries of the 2nd, 3rd, 6th and 7th ribs of uncertain age. Interview with CNA #3 on 2/6/13 at 9:40 a.m. revealed that she had taken Resident #1 to the bathroom with a walker and left her on the toilet, went to answer the door and the resident fell from the toilet. CNA #3 stated that Resident #1 could ambulate with one (1) person assist and the walker to the bathroom and was able to sit on the toilet without difficulty. CNA #1 stated that she did not recall the nurse telling her to stay with the resident. CNA #1 stated that she shouldn't have left Resident #1 by herself. CNA #3 stated that normally when she assisted Resident #1 to the bathroom that she stayed with her but this was during a meal and when she heard the doorbell she went to answer it. CNA #3 stated that she was aware that she needed to follow the care plan and probably did have in-service about following the care plan. CNA #3 stated that two (2) people transferred Resident #1 from the chair to the bed but that she normally walked to the bathroom with just one (1) person. CNA #1 stated that she did not recall what the care plan actually was for Resident #1's toileting/transfer needs. Interview with CNA #4, CNA Guide, on 2/5/13 at 3:09 p.m. revealed that CNA #3 admitted to transferring Resident #1 to the bathroom, leaving her on the toilet unassisted, answered the doorbell and the resident fell from the toilet. CNA #4 stated that when she asked CNA #3 about the incident, that CNA #3 had stated that she knew she wasn't supposed to leave Resident #3 alone and had made a stupid mistake. CNA #4 stated that CNA #3 had been in-serviced on 12/10/12 for transfer/lifts/ and following the care plan and still didn't follow the care plan for Resident #1. Interview with LPN #1 on 2/5/13 at 12:25 p.m. revealed that she was passing medication around 5:00 p.m. by Resident #1's door when Resident #1 turned on her call light. LPN #1 stated that CNA #3 assisted Resident #1 to the toilet with her walker, left the resident on the toilet and came to the medication cart talking. LPN #1 stated that she instructed CNA #3 not to leave Resident #1 on the toilet by herself because Resident #1 was unsteady and has crippling of her joints and skeletal frame. LPN #1 stated that CNA #3 remarked that Resident #1 would not get up by herself. LPN #1 stated that the doorbell rang and CNA #3 went to answer the door. LPN #1 heard a loud noise and Resident #1 scream. LPN #1 stated that she found Resident #1 lying on the bathroom floor on her left side with skin tears to the left elbow, a knot on her head and complaining of left arm/shoulder pain. LPN #1 stated that she notified the physician and got an order to transfer Resident #1 to the ER. LPN #1 stated that Resident #1 returned later that night with a [DIAGNOSES REDACTED]. LPN #1 stated that the rule of thumb was if a resident needed assistance to the bathroom, then they needed assistance of someone being close by. LPN #1 stated that all of the CNAs had been trained on following the care plan and that Resident #1's care plan called for two (2) person assist with transfers, that would include on/off the toilet and someone should stay with the resident. LPN #1 stated that all CNAs should know to stay with the resident but CNA #3 was specifically told not to leave Resident #1 alone because she gets anxious. Interview with the Director of Nursing (DON) on 2/5/12 at 4:10 p.m. revealed that CNA #3 was terminated for not following the care plan for Resident #1. The DON stated that Resident #1 had been assessed and care planned for a two (2) person assist for toileting and CNA #3 had assisted the resident by herself and left her on the toilet unassisted and went to answer the doorbell and the resident fell and sustained a fracture. The DON stated that she didn't know why CNA would write the statement about being in trouble if state were here unless she knew that she would be in trouble for transferring the resident by herself. The DON stated that CNA #3 had not followed Resident #1's care plan by not getting assistance and for leaving the resident unassisted on the toilet, which is a safety risk. Resident #2: Observation and interview with Resident #2 on 2/5/13 at 11:20 a.m. revealed that she was alert and oriented to person, place and time. Resident #2 could not recall the date but stated that the girl (CNA #5) had picked her up without the lift and hurt her ribs. Resident #2 stated that she put her arms around CNA #5's neck and the CNA grabbed around her and then she heard cracking. Resident #2 stated that she didn't start hurting at that time but did later and told the nurse the next day. Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's most recent MDS with an ARD of 11/22/12 revealed that she was cognitively intact with a brief interview for mental status of 15. (13-15 is indicative of no cognitive impairment). Resident #2 required total assistance of two (2) persons for transfers. Review of Resident #2's care plan dated 12/19/07 and updated 6/20/12 revealed that she required assistance with ADLs related to [MEDICAL CONDITION] and Arthritis. Approaches included: utilize two (2) persons and full body sling using mechanical lift for transfers. Review of Resident #2's December and January ADL sheet revealed that a mechanical lift with two (2) persons were to be used during transfers. Review of an Incident Report for Resident #2 dated 1/11/13 at 12:25 p.m. revealed that CNA #5 transferred Resident #2 from the wheelchair to the bed without the lift by herself on 1/9/13 and on 1/10/13 the resident reported to the nurse that she thought her ribs were broken. X-rays were done on 1/10/13 with results reported on 1/11/13 of acute left posterior 9th and 10th rib fracture. Review of an "Incident Investigation" report dated 1/11/13 revealed that Resident #2 had fractured left ribs and investigation found that resident was transferred from the wheelchair to the bed without the lift. Investigation also determined that another CNA witnessed the event. Review of a handwritten statement signed by CNA #5 on 1/11/13 revealed that she had taken Resident #2 to her room on 1/9/13 to lay her down and had gotten the wheelchair close to the bed and locked the wheels. CNA #5 asked Resident #2 to put her arms around her neck and then CNA #5 lifted Resident #2 out of the chair easily and placed her in the bed. CNA #5 documented that there was only one lift in the house to be used and another CNA (CNA #6) had gotten the lift to use on another resident. Review of a nurse's note dated 1/10/13 at 1:03 p.m. revealed that Resident #2 reported that she thought her ribs were broken. Resident #2 said "yesterday when (CNA #5) was transferring me from the w/c (wheelchair) to the bed she didn't use the lift and when she picked me up I felt my ribs crack" and the resident complained that it hurt when she moved. Review of a Radiology X-ray report dated 1/10/13 revealed that Resident #2 had acute to sub-acute fractures of the left posterior 9th and 10ths ribs. Correlate clinically. There was an old [MEDICAL CONDITION] 5th rib. Review of Resident #2's January 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #2 also used an incentive spirometer every four (4) hours while awake from 1/11/13-2/1/13. Interview on 2/6/13 at 10:30 a.m., with CNA #5, stated that CNA #6 was standing at the doorway and had gotten the lift to put another resident to bed and did ask if she needed help but told her that she had it. CNA #5 stated that Resident #2 didn't complain of pain at the time of the transfer. CNA #5 stated that she was aware that the care plan was supposed to be followed and that she had been in-serviced to that effect. CNA #5 stated that she had been terminated for not following the care plan for Resident #2. Interview with CNA #6 on 2/5/13 at 11:35 a.m. revealed that she had witnessed the incident of Resident #2 being transferred by CNA #5. CNA #6 stated that CNA #5 had taken Resident #2 to her room to lie down. CNA #6 stated that she asked CNA #5 if she needed any help and CNA #5 replied that she had it. CNA #6 stated that Resident #2 put her arms around CNA #5's neck and was lifted up from the wheelchair to the bed by CNA #5. CNA #6 stated that she had offered to help with the transfer but CNA #5 declined, so she took the lift to transfer another resident. CNA #6 stated that she was counseled for not reporting the incident. Interview with CNA #4, Guide, on 2/5/13 at 3:09 p.m. revealed that she had spoken with CNA #5 and CNA #6 about the transfer of Resident #2. CNA #4 stated that the lift was right there and CNA #6 was right there to assist and had asked CNA #5 if she needed assistance and CNA #5 chose to lift Resident #5 by herself without the use of the lift or assistance. CNA #4 stated that she reminded CNA #5 of the care plan for Resident #2 which included the use of the lift. CNA #5 replied that she had kind of been in a hurry and just put Resident #2 to bed and that the resident had not complained. CNA #4 stated that there had just been recent training to follow the care plan. Interview with RN #A on 2/6/13 at 9:30 a.m. revealed that she spoke with Resident #2 who informed her that CNA #5 had transferred her from the wheelchair to the bed without the lift and she heard a cracking noise. RN #A stated that Resident #2 reported that she didn't tell anyone until the next day (1/10/13) about the incident. RN #A stated that x-rays were taken and that Resident #2 did have fractured ribs. RN #A stated that Resident #2 was care planned to have two (2) persons and the mechanical lift for transfers. Interview with the DON, with the Administrator present, on 2/5/13 at 10:00 a.m. revealed that both CNA #3 and CNA #5 was trained on following the care plans and did not follow them for Resident #1 and Resident #2 and the residents were injured. The DON stated that CNA #3 had been told by the nurse not to leave Resident #1 on the toilet by herself and she did anyway and the resident fell and received fractures. The DON stated that CNA #5 admitted to transferring Resident #2 without the lift and knew to use it but stated that she was in a hurry. The DON stated that the appropriate equipment, the lift, was available and other staff was available but CNA #5 chose to lift the resident unassisted and the resident received fractured ribs. The DON and Administrator agreed that both CNAs were negligent in their actions. Review of the facility's policy "Abuse, Neglect, Vulnerable Adult" provided by the DON on 2/6/13 at 2:00 p.m., revealed that negligence was defined as "failure to give assigned care or giving improper care that causes harm". The examples of abuse/neglect included failure to provide appropriate or needed care and not following the care plan. Review of the facility's policy "Using the Care Plan/Following the Care Plan" with a revised date of August 2006, revealed that all nursing personnel including RN, LPN, and Shabazim (Certified Nursing Assistants) are to follow the resident's care plan. Cross-refer to F-323 for the facility's failure to provide adequate supervision and assistance devices to prevent injuries for Resident #1 and Resident #2 by transferring them inappropriately and both residents received injuries with fractures.

CI MS # Based on observation, interview, record review and policy review, the facility failed to ensure that one (1) of eight (8) residents reviewed, Resident (Elder) #3, received the standard of care for Cardio-pulmonary Resuscitation when found not breathing and without a pulse. Resident #3 was deemed a full code status and was found not breathing on [DATE] at 3:45 a.m. The Certified Nursing Assistant (CNA) brought an isolation cart to the room instead of the crash cart, there was not an Ambu-Bag available on the crash cart, and no rescue breathing was performed for approximately five (5) to eight (8) minutes. The crash cart checklist of supplies had not been documented for [DATE]. Resident #3 expired at the facility. The facility's failure to ensure that crash carts were readily available with appropriate supplies, the failure to ensure that staff were knowledgeable of where the crash cart was located, the failure of rescue breathing not performed timely and not performing a check of the supplies for the crash cart every shift was deemed an Immediate Jeopardy (IJ) on [DATE] at 10:20 a.m. The IJ was identified to exist beginning on [DATE] and continued through [DATE]. The Administrator was notified of the IJ on [DATE] at 10:20 a.m. The facility provided a credible Allegation of Compliance (AoC) on [DATE] at 9:20 a.m. Based on the facility's implementation of corrective actions and verification of those corrective actions, the IJ was removed as of [DATE] at 9:20 a.m. and lowered to a "G" level which constitutes actual harm with potential for more than minimal harm. Findings included: Cross refer to F309, Part I, for the facility's failure to perform rescue breathing timely for Resident #3 when found not breathing on [DATE] at 3:45 a.m. The facility submitted the following Allegation of Compliance for the Immediate Jeopardy: "An Immediate jeopardy was identified on [DATE] at 10:05 a.m. for Resident #3 for failure of equipment not available (ambu bag) on crash cart, failure to perform necessary procedures of cardiopulmonary resuscitation (CPR), and staff unaware of location of crash cart. The following steps were taken for these allegations of immediate jeopardy for Resident#3 as follows: 11 /,[DATE] at 2:00 p.m. RN #9 and #10 checked all the crash carts to ensure all equipment present including ambu bags, in-serviced RN's and LPN's on crash carts being stocked appropriately and equipment working and all items in date, inserviced LPN's on documentation of crash carts every shift per licensed nurse on crash cart check list [DATE] at 11:00 p.m. RN #7 in-serviced RN's and LPN's on crash carts being stocked appropriately including ambu bags and equipment working and all items in date, also on documentation of crash cart checklist completed every shift per licensed nurse on crash cart checklist. [DATE] at 9:00 a.m. RN #1 checked the crash carts in GH # 1, 2, 3 for all equipment and supplies on crash cart including ambu bag with none noted missing. [DATE] at 8:30 a.m. RN #3 checked the crash carts in GH #4, 5, 6 for all supplies and equipment including ambu bag with none noted missing. [DATE] at 8:30 a.m. RN #4 checked the crash carts in GH #7 & 8 for all supplies and equipment including ambu bag with none noted missing. [DATE] at 9:00 a.m. RN #5 checked the crash carts in GH # 9 & 10 for all supplies and equipment including ambu bag with none noted missing. [DATE] at 9:30 a.m. RN #6 checked the crash carts at Cedars for all supplies and equipment including ambu bag with none noted missing. [DATE] at 10:30 a.m. RN #2 reviewed all elders charts that have expired in the facility since September of 2012 until November of 2012 and found no other elders out of the seven deaths that were a Full Code-all of these elders were Do Not Resuscitate [DATE] at 2:30 p.m. an inservice was initiated by Clinical Care Coordinators (RN's #,[DATE]) to all nursing personnel including RN's, LPN's and Shabazim(Certified Nursing Assistants). No Nursing staff including RN's, LPN's and Shabazim (Certified Nursing Assistants ) are allowed to work until they are inserviced on the following: 1.) Location of crash cart and equipment, crash cart checklist done each shift per licensed nurse, replacing all supplies immediately on crash cart. 2.) The proper procedure for Cardiopulmonary Resuscitation(CPR) including if no ambu bag or pocket mask available begin mouth to mouth rescue breathing. 3.) Failure to provide necessary services and goods for elders is neglect. [DATE] at 2:30 p.m. the above inservice was initiated:- RN #1 inserviced LPN's and Shabazim for ,[DATE] and ,[DATE] in GH #1, 2 and 3. RN #3 inserviced LPN's and Shabazim for ,[DATE] and ,[DATE] in GH #4, 5, 6. RN #4 inserviced LPN's and Shabazim's for ,[DATE] and ,[DATE] in GH #7 & 8. RN #5 inserviced LPN's and Shabazim for ,[DATE] and ,[DATE] in GH #9 & 10. RN #10 inserviced LPN's and Shabazim for ,[DATE] and ,[DATE] at Cedars. [DATE] at 7:00 p.m. the above inservice was initiated- RN #3 inserviced LPN's for 7p-7a in GH ,[DATE]. [DATE] at 11:00 p.m. the above inservice was initiated - RN #6 inserviced LPN's and Shabazim for ,[DATE] at Cedars. RN # 10 inserviced Shabazim for ,[DATE] in GH ,[DATE]. [DATE] at 4:00 p.m. an emergency QA meeting was called to address an Immediate Jeopardy due to the following: failure of equipment not available (ambu bag) on crash cart, failure to perform necessary procedures of cardiopulmonary resuscitation(CPR) and staff unaware of crash cart locations. Attendees include: Medical Director , ED, Director of Nursing, Assistant Director of Nursing, Clinical Care Coordinators (RN#1, 2, 3, 4, 5, 6, 9, 10). Implementation of procedures/Inservices were discussed with no further immediate actions taken."

Part I: CI MS # Based on observation, interview, record review and policy review, the facility failed to ensure that one (1) of eight (8) residents (also known as elders) reviewed, Resident (Elder) #3, received the necessary care and services to maintain/attain the highest practicable physical well-being. Resident #3 was deemed a full code status which included orders for Cardio-pulmonary Resuscitation (CPR) and was found not breathing on [DATE] at 3:45 a.m. The Certified Nursing Assistant (CNA), also known as Shabazim, brought an isolation cart to the room instead of the crash cart, there was not an Ambu-Bag available on the crash cart, and no rescue breathing was performed for approximately five (5) to eight (8) minutes. The crash cart checklist of supplies had not been documented for [DATE]. Resident #3 expired at the facility. The facility's failure to ensure that crash carts were readily available with appropriate supplies, the failure to ensure that staff were knowledgeable of where the crash cart was located, the failure of rescue breathing not performed timely and not performing a check of the supplies for the crash cart every shift was deemed an Immediate Jeopardy (IJ) on [DATE] at 10:20 a.m. The IJ was identified to exist beginning on [DATE] and continued through [DATE]. The Administrator was notified of the IJ on [DATE] at 10:20 a.m. The facility provided a credible Allegation of Compliance (AoC) on [DATE] at 9:20 a.m. Based on the facility's implementation of corrective actions and verification of those corrective actions, the IJ was removed as of [DATE] at 9:20 a.m. and lowered to a "G" level which constitutes actual harm with potential for more than minimal harm. Findings included: Review of Resident #3's medical record revealed that he was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed that he was cognitively impaired and required extensive to total assistance with activity of daily living. Review of a physician's orders [REDACTED]. Review of a physician's orders [REDACTED].#3 was to be discharged to the funeral home. Review of Resident #3's Nurse's Notes dated [DATE] at 5:35 a.m. revealed the following documentation: " At 03:45 a.m, heard (CNA #1) yell my name. Found her in (Resident #3's) room. She stated he was not breathing. Quickly assessed elder. (CNA #1) and myself felt faint pulse. Immediately retrieved backboard and started chest compressions. Called (RN #7) Supervisor at approx. 3:50 a.m., and then called 911. EMT's arrived at 4:05 a.m. and took over CPR. EMT's continued until 04:25 a.m., when they called (Physician) at (hospital) and obtained an order to stop CPR. Called (physician) and notified her of elder's death. (Physician) stated she would inform elder's attending physician. (RN #7) notified family members and funeral home. EMT's notified coroner. The note was documented by RN #8. Review of a report from the Emergency Medical Services dated [DATE] revealed that the EMT's were dispatched at 03:55 a.m. and arrived at the patient (Resident #3) at 04:06 a.m. The date and time of discontinuing CPR was [DATE] at 04:25 a.m. The primary symptom listed on the report for Resident #3 was Cardiopulmonary Arrest. The Chief Complaint was documented as [MEDICAL CONDITION] x 15 minutes. The report had documentation of the patient being found in full arrest at approximately 0350 a.m. this morning, unknown how long patient had been pulseless prior to staff's discovery. Interview with RN #8 on [DATE] at 9:00 a.m. revealed that she was working in the house when CNA #1 called for her to come to Resident #3's room. RN #8 stated that when she arrived Resident #3 was not breathing and had frothy sputum in his mouth. RN #8 stated that she called 911 and the Supervisor and sent CNA #1 to get the crash cart. RN #8 stated that the CNA came back with the backboard and the isolation cart. RN #8 stated that they placed the backboard under the resident and then went and got the crash cart. RN #8 stated that Resident #3 initially had a weak pulse but was not breathing and upon reassessment there was no pulse. RN #8 stated that she started chest compressions but there wasn't an Ambu Bag on the crash cart. RN #8 stated that when the supervisor (RN #7) arrived that she reported there was no Ambu Bag and RN #7 went to another house to get one. RN #8 stated that when RN #7 returned with the Ambu Bag that breaths were given to the resident. RN #8 stated that it probably took RN #8 two (2) to three (3) minutes to get to the house where Resident #3 was initially after contact and then maybe three (3) to four (4) minutes to get the Ambu Bag back so that breaths could be given. RN #8 stated that rescue breathing was not imitated prior to use of the Ambu Bag but that chest compressions were. RN #8 stated that the EMT's arrived and took over the CPR and called the physician to stop the code. RN #8 stated that she was not aware of the policy to check the crash cart every shift and had not checked for supplies that night prior to the code of Resident #3. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 9:25 a.m. revealed that she nor the DON had been aware that there had not been an Ambu Bag available for Resident #3's code until they received the statement from RN #8 that morning ([DATE]). The ADON stated that each crash cart was supposed to be checked every shift by the supervisor for supplies. Interview with RN #7 on [DATE] at 9:00 p.m. revealed that she had been called to the house by RN #8 that Resident #3 had coded. RN #7 stated that she was initially in the 500 house when she received that call and it took her approximately three (3) minutes to get to the home where Resident #3 was located. RN #8 stated that upon arrival to the house chest compressions had been started but they could not locate the Ambu Bag. RN #7 stated that she called LPN #1 from the 900 house who met her with the Ambu Bag and she went back to Resident #3's room and breathing for the resident was initiated. RN #7 stated that it took approximately two (2) minutes to get the Ambu Bag. RN #7 stated that Resident #3 was still warm but had no pulse or respirations and that CPR was continued by herself and RN #8 and CNA #1 until the EMT's arrived and took over. RN #7 stated that Resident #3 never responded to the CPR and expired. RN #7 stated that a protocol was in place at the time that the house nurse was to check the crash cart every shift for supplies. RN #7 stated that she notified the Director of Nursing and the Supervisor of the need to replace Ambu Bags for both houses that morning after the code for Resident #3. On [DATE] at 12:37 p.m. it was observed to be approximately 78 steps from house 700 to house 900 door to door, which took approximately one (1) minute at a fast pace. Interview with CNA #1 on [DATE] at 9:35 p.m. revealed that she had checked on Resident #3 ([DATE]) around 1:30 a.m. and he was fine, sleeping and breathing, but on the next round he was not breathing. CNA #1 stated that she called for RN #8 who was in the house. CNA #1 stated that she thought Resident #3 had a faint pulse when she touched his hand. CNA #1 stated that she was instructed to go get the crash cart and stated that she got one that had some things on it but wasn't sure it was the right one and went back to get another one. CNA #1 stated that the supervisor went and got the breathing bag because there wasn't one on the cart that they had. CNA #1 stated that she ran and got the backboard and they put it under Resident #3 and RN #8 started chest compressions. CNA #1 stated that they took turns with the compressions but no mouth to mouth breathing was done. CNA #1 stated that she had not had in-service prior about the crash cart but now know where and what it is. CNA #1 stated that she was certified in CPR. Interview and observation with LPN #1 on [DATE] at 6:10 a.m. revealed that she was working in the 900 house one morning ([DATE]) and received a call from RN #7 to meet her at the door with an Ambu Bag. LPN #1 stated that the crash carts were supposed to be checked every shift for supplies. Observation of the checklist for the 1000 house where LPN #1 was working this shift revealed a lot of omissions in documentation of the checklist for the 7a-7p shift. Review of the [DATE] Crash Cart Checklist revealed that the there was no documentation of the crash cart being checked on the 7p-7a shift from [DATE]-[DATE], [DATE]-[DATE], [DATE], [DATE] and [DATE]-[DATE]. There was documentation that the Ambu Bag was present on [DATE] on the 7a-7p shift. Observation and interview with CNA #2 and CNA #3 on [DATE] at 6:40 a.m. at the 200 house revealed that neither CNA was aware of where the crash cart was located for the house. Both CNAs went to several rooms looking for the cart and CNA #3 rummaged through the isolation cart in the supply room and stated that maybe there were some things in that cart. The crash cart was next to the isolation cart. The CNAs were called back to the room as they exited and told that the crash cart was in that room. Observation and interview with LPN #2 on [DATE] at 6:50 a.m. at the 600 house revealed that the crash cart had all supplies with the exception of an oxygen regulator, which had been used the day prior and was to be replaced today. LPN #2 stated that each cart was to be checked each shift for supplies and the supervisor notified if there were missing supplies. Observation of the crash cart checklist revealed that the oxygen regulator had been missing since [DATE] and periodically throughout the month. Review of the crash cart check lists for supplies available revealed the following information for each Green House (GH) and the main unit for [DATE]: 100 GH - completed every shift 200 GH - not completed for 7a-7p shift for [DATE], [DATE], [DATE]; for the 7p-7a shift=[DATE]. 300 GH - completed every shift 400 GH - [DATE] for the 7p-7a shift 500 GH - 7p-7a shift=[DATE], [DATE] and [DATE]. For the 7a-7p shift=[DATE] and [DATE] 600 GH - 7p-7a shift [DATE]. 700 GH - completed every shift 800 GH - completed every shift 900 GH - 7p-7a shift=[DATE], [DATE]; 7a-7p shift=[DATE], [DATE] and [DATE]. 1000 GH - 7p-7a shift=[DATE] and [DATE]. Main House Cedars - No check list available. Interview with the Director of Nursing (DON) on [DATE] at 8:00 a.m. revealed that she knew that the checklists for checking the crash carts were not good and had already done some in-services with the LPNs and RNs about checking every shift for needed supplies and to report to the supervisor. The DON stated that the supervisor can go to the supply rooms and take items to the houses. The DON stated that she didn't know why the Ambu Bag was not available in the 700 house the night that Resident #3 coded. The DON stated that mouth-to-mouth resuscitation should have been initiated to Resident #3. The DON stated that the CNAs should have known where the crash carts were located. Interview with RN #6 on [DATE] at 8:25 a.m. revealed that there had never been a checklist for the crash cart that was in the nursing office (at the main building), that she eyed the cart weekly for supplies. RN #6 stated that staff was supposed to replace what they used. Observation of the crash cart in the nursing office revealed that all necessary equipment was available. Interview with RN #11 on [DATE] at 8:28 a.m. revealed that a check list was not used for the nursing office (main unit) but that they were used at the Houses. RN #11 stated that the supervisors could get any equipment or supplies for the main unit or Houses. Interview with the Medical Director on [DATE] at 4:00 p.m. revealed that he had not been made aware of not having an Ambu Bag available during the code situation for Resident #3 until today ([DATE]). The Medical Director stated that equipment should be available for CPR and that staff should know how to find it. The Medical Director stated that the standards for CPR should be 30 compressions to two (2) breaths and agreed that five (5) to eight (8) minutes could be pertinent without oxygen. The Medical Director stated that he did attend a Quality Assurance (QA) meeting about the incident on this date ([DATE]). Review of the facility's policy and procedure "Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS)" with a revised date of [DATE], revealed: "2. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times." Under the Equipment and Supplies section: "2. Pocket face masks, Ambu bags (,[DATE] L capacity), and/or mouth shields." Under Steps in the Procedure" "6. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2". Review of the facility's policy and procedure for "Crash Cart Checks" with a revised date of [DATE], revealed that the purpose was to monitor proper CPR supplies. The following steps were outlined: "1. Crash carts are to be checked for all supplies at the beginning of every shift by a licensed nurse by crash cart check list. 2. RN Supervisor's have a key for supply room to restock Crash cart if you use the crash cart and/or need to restock the cart. 3. Crash carts are located in laundry room in GH (Greenhouse) 100-GH 400, crash carts are located in supply closet in GH 500-GH 1000. Crash cart a Cedars is located in 500 hall nursing station." Review of the facility's "Abuse Protocol" dated [DATE], revealed: 'It is the policy of this facility to prohibit any form of elder abuse....To assist our facility's staff members in recognizing incidents of abuse, the following definitions of abuse are provided: 7. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." The facility submitted the following Allegation of Compliance for the Immediate Jeopardy: "An Immediate jeopardy was identified on [DATE] at 10:05 a.m. for Elder #3 for failure of equipment not available (Ambu bag) on crash cart, failure to perform necessary procedures of cardiopulmonary resuscitation (CPR), and staff unaware of location of crash cart. The following steps were taken for these allegations of immediate jeopardy for Elder #3 as follows: 11 /,[DATE] at 2:00 p.m. RN #9 and #10 checked all the crash carts to ensure all equipment present including Ambu bags, in-serviced RN's and LPN's on crash carts being stocked appropriately and equipment working and all items in date, inserviced LPN's on documentation of crash carts every shift per licensed nurse on crash cart check list [DATE] at 11:00 p.m. RN #7 in-serviced RN's and LPN's on crash carts being stocked appropriately including ambu bags and equipment working and all items in date, also on documentation of crash cart checklist completed every shift per licensed nurse on crash cart checklist. [DATE] at 9:00 a.m. RN #1 checked the crash carts in GH #1, 2, 3 for all equipment and supplies on crash cart including ambu bag with none noted missing. [DATE] at 8:30 a.m. RN #3 checked the crash carts in GH #4, 5, 6 for all supplies and equipment including ambu bag with none noted missing. [DATE] at 8:30 a.m. RN #4 checked the crash carts in GH #7&8 for all supplies and equipment including ambu bag with none noted missing. [DATE] at 9:00 a.m. RN #5 checked the crash carts in GH #9&10 for all supplies and equipment including ambu bag with none noted missing. [DATE] at 9:30 a.m. RN #6 checked the crash carts at Cedars for all supplies and equipment including ambu bag with none noted missing. [DATE] at 10:30 a.m. RN #2 reviewed all elders charts that have expired in the facility since September of 2012 until November of 2012 and found no other elders out of the seven deaths that were a Full Code-all of these elders were Do Not Resuscitate [DATE] at 2:30 p.m. an inservice was initiated by Clinical Care Coordinators (RN's #,[DATE]) to all nursing personnel including RN's, LPN's and Shabazim(Certified Nursing Assistants). No Nursing staff including RN's, LPN's and Shabazim (Certified Nursing Assistants) are allowed to work until they are inserviced on the following: 1.) Location of crash cart and equipment, crash cart checklist done each shift per licensed nurse, replacing all supplies immediately on crash cart. 2.)The proper procedure for Cardiopulmonary Resuscitation (CPR) including if no ambu bag or pocket mask available begin mouth to mouth rescue breathing. 3.) Failure to provide necessary services and goods for elders is neglect. [DATE] at 2:30 p.m. the above inservice was initiated:- RN #1 inserviced LPN's and Shabazim for ,[DATE] and ,[DATE] in GH #1, 2 and 3. RN #3 inserviced LPN's and Shabazim for ,[DATE] and ,[DATE] in GH #4, 5, 6. RN #4 inserviced LPN's and Shabazim for ,[DATE] and ,[DATE] in GH #7 & 8. RN #5 inserviced LPN's and Shabazim for ,[DATE] and ,[DATE] in GH #9 & 10. RN #10 inserviced LPN's and Shabazim for ,[DATE] and ,[DATE] at Cedars. [DATE] at 7:00 p.m. the above inservice was initiated- RN #3 inserviced LPN's for 7p-7a in GH ,[DATE]. [DATE] at 11:00 p.m. the above inservice was initiated - RN #6 inserviced LPN's and Shabazim for ,[DATE] at Cedars. RN #10 inserviced Shabazim for ,[DATE] in GH ,[DATE]. [DATE] at 4:00 p.m. an emergency QA meeting was called to address an Immediate Jeopardy due to the following: failure of equipment not available (ambu bag) on crash cart, failure to perform necessary procedures of cardiopulmonary resuscitation(CPR) and staff unaware of crash cart locations. Attendees include: Medical Director, ED, Director of Nursing, Assistant Director of Nursing, Clinical Care Coordinators (RN #1, 2, 3, 4, 5, 6, 9, 10). Implementation of procedures/Inservices were discussed with no further immediate actions taken." Part II: CI MS # Based on observation, interview, record review and policy review, the facility failed to ensure that one (1) of eight (8) residents reveiwed, Resident #7, was provided the goods and services to attain/maintain the highest practicable physical well-bing by failure of a Certified Nursing Assistant (CNA) to perform the necessary transfer of Resident #7 from the wheelchair to the bed without assistance of another staff or the use of a mechanical lift on [DATE]. Resident #7 complained of pain and swelling of the left knee on [DATE] and was identified with a [MEDICAL CONDITION] on [DATE]. The physician was not notified of the resident's initial complaint of pain and swelling until [DATE]. Findings included: Resident #7: Review of a written report from the facility dated [DATE], revealed that Resident #7 had a lateral left tibia plateau impacted fracture. Investigation revealed that CNA #4 had transferred Resident #7 on [DATE] without assistance and was terminated for not following the care plan and failure to report the incident. Observation and interview with Resident #7 on [DATE] at 12:50 p.m. revealed that she was sitting in a wheelchair and was alert and confused. CNAs #5 and #6 transferred Resident #7 from the wheelchair to the bed without concerns using the mechanical lift. Both CNAs stated that Resident #7 had always been a two (2) person transfer or one (1) person with the lift, but was safer with two (2) persons because she sometimes got aggressive. Both CNAs stated that Resident #7 now required two (2) persons and the lift for transfers. Resident #7's left knee was slightly swollen and CNA #6 stated that it wasn't nearly as swollen as it had been. Review of Resident #7's medical record revealed that she was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's most recent MDS with an ARD of [DATE], revealed that she had severe cognitive impairment and required total assistance with transfers. Review of Resident #7's care plan dated [DATE] and updated on [DATE] revealed that she required one (1) to two (2) person assist with transfers. (Review of the policy for two person lift transfer (not dated) revealed the standard: Residents who are unable to assist with the transfer, should be moved from a bed/chair by means of a two-person lift, or a mechanical lift device.) Review of a physician's progress note dated [DATE] revealed that Resident #7 required assist of two (2) persons for transfer or a lift. Review of the "ADL (Activity for Daily Living) Documentation" for Resident #7 on [DATE] at 19:00 (7:00 p.m.) revealed that the ceiling lift was not documented as used and that CNA #4 performed the transfer completely because the elder did not help at all (total). There was documentation of "2" for how many people did it take to help the elder get in and out of bed/chair. Review of Departmental Notes dated [DATE] at 12:49 a.m. documented by LPN #2, revealed that Resident #7 moaned and grunted when turned, rubbing her left knee, left knee was slightly swollen, no warmth, tender to touch. Tylenol 325 milligram (mg) was given for knee pain. Review of Departmental Notes dated [DATE] at 4:30 p.m. documented by LPN #3, revealed that it was reported that elder displayed left knee pain on prior shift. Shahbaz stated that elder seemed resistant to them getting her up or touching her knee at approximately 3:45 p.m. Upon inspection, left knee was noted slightly swollen and tender to touch. Slight warmth was noted. Two (2) Tylenol 500 mg was administered due to tenderness in knee. Elder was unable to respond appropriately when asked if her knee was hurting. Review of Departmental Notes dated [DATE] at 12:32 a.m. documented by LPN #2, revealed that Resident #7 complained of knee pain when turned, said "oh" and Tylenol was given with good results. Left knee remains swollen, no warmth, painful when moved. Review of Departmental Notes dated [DATE] at 12:30 p.m. documented by LPN #3, revealed that Resident #7's left knee was noted to be slightly less swollen and had slight warmth to touch, but not as much as the previous day and stated no when asked about pain, but noted that resident only occasionally responds appropriately to questions that are asked. Review of Departmental Notes dated [DATE] at 8:42 a.m. documented by LPN #4, revealed that she had spoken to the physician related to Resident #7's complaint of pain to the left knee and received an order for [REDACTED]. Review of Departmental Notes dated [DATE] at 10:34 a.m. documented by LPN #4, revealed that a new order was obtained to get an x-ray of Resident #7's left knee, that it was reported that the elder may have bumped her knee over the weekend, no incident was reported and elder is complaining of pain to the knee. Left knee is swollen and warm, tender to touch. Elder is not able to straighten the leg and x-ray company to get x-ray. Review of Departmental Notes dated [DATE] at 2:15 p.m. revealed that the results of Resident #7's x-ray of the left knee showed a lateral tibial plateau impaction type fracture with moderate knee joint effusion. Review of the 24 Hour Communication Report, that is documented by the CNAs that document incident and acute issues, dated [DATE] revealed that Resident #7 complained of the left leg hurting bad on the day shift; left knee hurting on the evening shift; and knee some swelling on the night shift. Review of the corresponding 24 Hour Report that is documented by nurses on [DATE] revealed no documentation by the 7a-7p shift nurse at all and on the 7p-7a shift LPN #2 documented that Resident #7 had complaint of knee pain. Review of the 24 Hour Communication Report dated [DATE] revealed that Resident #7's knee was hurting on the day shift and on the night shift there was documentation that the left knee and foot was swollen. Review of the corresponding 24 Hour Report dated [DATE] revealed no documentation by the 7a-7p nurse at all and the 7p-7a nurse documented Resident #7's acu-check only. Review of the 24 Hour Communication Report dated [DATE], revealed that Resident #7's left leg was hurting on day shift; didn't complain about leg on the evening shift and complained of knee sore on the night shift. Review of the corresponding 24 Hour Report dated [DATE] revealed that the 7a-7p nurse documented nothing at all and the 7p-7a nurse documented Resident #7's acu-check only. Review of the 24 Hour Communication Report dated [DATE], revealed that Resident #7 had an x-ray done and her leg is hurt. Review of the corresponding 24 Hour Report dated [DATE] revealed no documentation at all by the 7a-7p nurse and the 7p-7a nurse documented that Resident #7 had a [MEDICAL CONDITION] tibia and x-rays had been done. There was no documented evidence that the physician was notified of Resident #7's complaint of left knee pain, swelling and warmth from the initial complaint on [DATE] until [DATE]. There was documented complaints daily from Resident #7 of pain/pain symptoms and swelling of the left knee from [DATE]-[DATE]. There was no documented assessment of Resident #7's swelling of her left knee by the Registered Nurse from [DATE]-[DATE]. On [DATE] at 9:01 a.m. RN #3 documented that the Responsible Party was aware of the need for an x-ray and was in agreement. Review of a physician's orders [REDACTED].#7 to have [MEDICATION NAME] 10 mg now for fracture, one time dose. Review of the Radiology Report dated [DATE] for Resident #7's left knee revealed an impression: Findings compatible with lateral tibial plateau impaction type fracture with moderate knee joint effusion. Review of Resident #7's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s notes prior to [DATE]. This was a change in status for Resident #7. Interview with the DON on [DATE] at 8:00 a.m. revealed that Resident #7 had complained of knee pain and thought that she had a flare up with [MEDICAL CONDITION]. The DON stated that staff gave her Tylenol and got an order for [REDACTED].#4 had transferred Resident #7 without the use of a lift, in a bear hug, and may have bumped her knee. The DON stated that CNA #4 was suspended and terminated for not following the care plan because Resident #7 required two person assist with transfers or the use of a lift. The DON stated that there was no reason for not using the lift because the GH's all have ceiling tracks for the lift. Interview with CNA #4 on [DATE] at 12:40 p.m. revealed that she had transferred Resident #7 ([DATE]) around ,[DATE]:30 p.m. from the wheelchair to the bed by herself in a bear hug and not with a lift like she was supposed to. CNA #4 stated that she had just gotten into a hurry and didn't do it right. CNA #4 stated that when she stood Resident #7 up that the resident's knees buckled. CNA #4 stated that Resident #7 didn't fall but that her knee may have twisted or bumped against something, she wasn't sure. CNA #4 stated that she didn't report this because there was no complaint of pain at the time of the transfer. CNA #4 stated that when she returned to work the other staff told her of Resident #7's knee hurting. CNA #4 stated that CNA #8, her supervisor, had asked if anything unusual had occurred and that's when it was reported about the transfer by herself. CNA #4 stated that she realized that it was neglect for not following the care plan and had been trained to follow the care plan. CNA #4 stated that there were other staff available and she could have used the lift but was just in a hurry and didn't. Interview with LPN #2 on [DATE] at 10:20 a.m. revealed that she had worked [DATE] and [DATE] on the 7p-7a shift and CNA #4 had reported that while turning Resident #7 she noted the resident's knee was swollen. LPN #2 stated she observed Resident #7's left knee swollen, red and tender to touch and thought that it was arthritis because nothing seemed out of place and gave her Tylenol which eased her. LPN #2 stated that CNA #4 had not reported that she had transferred Resident #7 by herself or any incident/injury. LPN #2 stated that Resident #7 required two (2) person assist for transfers/lift. LPN #2 stated that she passed on the complaint of pain and swelling for Resident #7 to the next shift. LPN #2 stated that the knee was not as swollen on [DATE] but Resident #7 still had some complaint of pain. LPN #2 stated that she had not notified the physician of Resident #7's complaint of pain and swelling of the knee, but that she should have called the physician and gotten an x-ray. Interview with LPN #3 on [DATE] at 10:05 a.m. revealed that she had worked the 7a-7p shift on [DATE] and [DATE]. LPN #3 stated that LPN #2 had notified her of Resident #7's left knee swelling and pain on [DATE] and they had both agreed that it may have been arthritis and gave Resident #7 Tylenol which relieved her. LPN #3 stated that the next day Resident #7's knee was not as swollen, not as warm and the resident didn't complain of pain. LPN #3 stated that there had been no reports of Resident #7 having increased pain or difficulty on [DATE]. LPN #3 stated that she had not notified the Physician or RN Supervisor of Resident #7's pain/swelling because there had been no reports of injury/incident and thought that it was arthritis and gave standing orders of Tylenol. LPN #3 was not sure of the documentation for the 24 Hour report, and stated that she had documented in the nurse's notes. Interview with LPN #4 on [DATE] at 9:45 a.m. revealed that she worked on [DATE] (7a-7p) and had no complaints about Resident #7's knee hurting. LPN #4 stated that on [DATE] the CNAs came to her and said that Resident #7 had a complaint of her knee. LPN #4 stated that she and the RN Supervisor (RN #3), observed Resident #7 with a swollen knee that was kind of warm to touch and when attempting to straighten her leg it appeared painful for Resident #7. LPN #4 stated that she notified the physician and got and order for x-rays. LPN #4 stated that it had been charted over the weekend of Resident #7's pain/swelling but there had been no documentation of the physician being notified. LPN #4 stated that no one had reported anything about Resident #7 on [DATE] and the resident had no complaint with medications. LPN #4 did not recall about the 24 hour report, stated that the CNAs usually come tell her of any concerns. Interview with RN #3 on [DATE] at 12:05 p.m. revealed that no one had reported Resident #7's pain and swelling to the knee to her until [DATE]. RN #3 stated that she was filling in for someone on leave and had only worked [DATE] as the Clinical Care Coordinator for that GH. RN #3 stated that LPN #4 had gotten her to assess Resident #7's knee on [DATE] because it was red/swollen and they'd been treating for arthritis. RN #3 stated that she told LPN #4 to call the physician because it looked worse than arthritis. RN #3 stated that Resident #7's knee was more swollen than the other knee, had no bruising and was warm to touch. RN #3 stated that an x-ray was ordered. Interview with CNA #7 on [DATE] at 12:18 p.m. revealed that Resident #7 had always been a two (2) person transfer for a long time or either one (1) person and the lift. CNA #7 stated that she returned to work on [DATE] and Resident #7 was complaining of

2 Based on observation, staff interview, record review and policy review, the facility failed to implement the care plans for two (2) of six (6) residents, Resident #1 and Resident #2, resulting in avoidable injuries to both residents. Certified Nursing Assistant (CNA) #3 failed to follow the care plan for Resident #1 which included approaches for extensive assistance of two (2) persons for bed mobility, toileting, transfers, and for dressing. CNA #3 transferred Resident #1 to the toilet without assistance; left her unassisted and, the resident fell ; and received a [MEDICAL CONDITION] humerus. When the care plan approaches included extensive assistance of two (2) persons for bed mobility, toileting, transfers and dressing. CNA #5 failed to follow the care plan approaches which included the use of a mechanical lift with two (2) persons transferring, and transferred Resident #2 from the wheelchair to the bed without assistance of another person or the mechanical lift as required. Resident #2 received rib fractures during the transfer when the care plan approaches included the use of a mechanical lift with two (2) persons for transferring. Findings include: Resident #1: Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/24/12, revealed that she had short and long term memory problems with mild cognitive deficits. Resident #1 required extensive assistance of two (2) persons for transfer and toileting. Review of Resident #1's Care Plan dated 5/3/12 revealed that assistance was required for activity of daily living (ADL) functions related to general weakness and history of severe [MEDICAL CONDITION] arthritis. Approaches included extensive assistance of two persons for bed mobility, toileting, transfers and dressing. Review of the ADL for December 2012 and January 2013 for Resident #1, (which is used for backup when the electronic charting system is down and correlates to the Daily Care Guide), revealed that extensive assist of two (2) persons was required for bed mobility, toileting, transfer and dressing; two (2) persons or mechanical lift and two (2) persons for transfers; and transfer on and off the commode. Review of a Resident Incident Report for Resident #1 dated 1/12/13 at 5:08 p.m., revealed that Resident #1 was taken to the bathroom by CNA #3 and left unattended. The nurse heard a loud noise and scream. Resident #1 was found on the bathroom floor on her left side. Resident #1 had two (2) skin tears to the left inner and outer elbow, egg sized knot to the left side of her head and complained of pain to her left arm/shoulder with a possible fracture. Interview with CNA #4, CNA Guide, on 2/5/13 at 3:09 p.m. revealed that CNA #3 admitted to transferring Resident #1 to the bathroom, leaving her on the toilet unassisted, answered the doorbell and the resident fell from the toilet. CNA #4 stated that when she asked CNA #3 about the incident, that CNA #3 had stated that she knew she wasn't supposed to leave Resident #3 alone and had made a stupid mistake. CNA #4 stated that CNA #3 had been in-serviced on 12/10/12 for transfer/lifts/ and following the care plan and still didn't follow the care plan for Resident #1. Interview with LPN #1 on 2/5/13 at 12:25 p.m. revealed that she was passing medication around 5:00 p.m. by Resident #1's door when Resident #1 turned on her call light. LPN #1 stated that CNA #3 assisted Resident #1 to the toilet with her walker, left the resident on the toilet and came to the medication cart talking. LPN #1 stated that all of the CNAs had been trained on following the care plan and that Resident #1's care plan called for two (2) person assist with transfers, that would include on/off the toilet and someone should stay with the resident. LPN #1 stated that all CNAs should know to stay with the resident but had specifically told CNA #3 not to leave Resident #1 alone because she gets anxious. Interview with the Director of Nursing (DON) on 2/5/12 at 4:10 p.m. revealed that CNA #3 was terminated for not following the care plan for Resident #1. The DON stated that Resident #1 had been assessed and care planned for a two (2) person assist for toileting and CNA #3 had assisted the resident by herself and left her on the toilet unassisted and went to answer the doorbell and the resident fell and sustained a fracture. The DON stated that she didn't know why CNA would write the statement about being in trouble if the state was here unless she knew that she would be in trouble for transferring the resident by herself. The DON stated that CNA #3 had not followed Resident #1's care plan by not getting assistance and for leaving the resident unassisted on the toilet, which is a safety risk. Resident #2 Findings include: Observation and interview with Resident #2 on 2/5/13 at 11:20 a.m. revealed that she was alert and oriented to person, place and time. Resident #2 could not recall the date but stated that the girl (CNA #5) had picked her up without the lift and hurt her ribs. Resident #2 stated that she put her arms around CNA #5's neck and the CNA grabbed around her and then she heard cracking. Resident #2 stated that she didn't start hurting at that time but did later and told the nurse the next day. Further interview with Resident #2 on 2/5/13 at 1:40 p.m., revealed that (she) had real brittle bones and fractures in the past and that she didn't think CNA #5 meant to hurt her when she transferred her to bed but that she did hurt. Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's most recent MDS with an ARD of 11/22/12, revealed that she was cognitively intact with a brief interview for mental status of 15. (13-15 is indicative of no cognitive impairment). Resident #2 required total assistance of two (2) persons for transfers. Review of Resident #2's care plan dated 12/19/07 and updated 6/20/12, revealed that she required assistance with ADLs related to [MEDICAL CONDITION] and Arthritis. Approaches included: utilize two (2) persons and full body sling using mechanical lift for transfers. Review of Resident #2's December and January ADL sheet revealed that a mechanical lift with two (2) persons were to be used during transfers. Review of an Incident Report for Resident #2 dated 1/11/13 at 12:25 p.m. revealed that CNA #5 transferred Resident #2 from the wheelchair to the bed without the lift by herself on 1/9/13 and on 1/10/13 the resident reported to the nurse that she thought her ribs were broken. X-rays were done on 1/10/13 with results reported on 1/11/13 of acute left posterior 9th and 10th rib fractures. Interview with CNA #5 on 2/6/13 at 10:30 a.m., revealed that Resident #2 was ready to go to bed and when transferred she asked the resident to put her arms around her (CNAs) neck and lifted the resident up and put her in the bed. CNA #5 stated that sometimes the lift was used for the resident, but that she had just gotten busy and put Resident #2 in the bed. CNA #5 stated that she was aware that Resident #2 needed two (2) person assist or the use of the lift that it was in the care plan. CNA #5 stated that CNA #6 was standing at the doorway and had gotten the lift to put another resident to bed and did ask if she needed help but told her that she had it. CNA #5 stated that Resident #2 didn't complain of pain at the time of the transfer. CNA #5 stated that she was aware that the care plan was supposed to be followed and that she had been in-serviced to that effect. CNA #5 stated that she had been terminated for not following the care plan for Resident #2. Interview with CNA #6 on 2/5/13 at 11:35 a.m., revealed that she had witnessed the incident of Resident #2 being transferred by CNA #5. CNA #6 stated that CNA #5 had taken Resident #2 to her room to lie down. CNA #6 stated that she asked CNA #5 if she needed any help and CNA #5 replied that she had it. CNA #6 stated that Resident #2 put her arms around CNA #5's neck and was lifted up from the wheelchair to the bed by CNA #5. CNA #6 stated that she had offered to help with the transfer but CNA #5 declined, so she took the lift to transfer another resident. Interview with CNA #4, Guide, on 2/5/13 at 3:09 p.m., revealed that she had spoken with CNA #5 and CNA #6 about the transfer of Resident #2. CNA #4 stated that the lift was right there and CNA #6 was right there to assist and had asked CNA #5 if she needed assistance and CNA #5 chose to lift Resident #5 by herself without the use of the lift or assistance. CNA #4 stated that she reminded CNA #5 of the care plan for Resident #2 which included the use of the lift. CNA #5 replied that she had kind of been in a hurry and just put Resident #2 to bed and that the resident had not complained. CNA #4 stated that there had just been recent training to follow the care plan. Interview with RN #A on 2/6/13 at 9:30 a.m. revealed that she spoke with Resident #2 who informed her that CNA #5 had transferred her from the wheelchair to the bed without the lift and she heard a cracking noise. RN #A stated that Resident #2 was care planned to have two (2) persons and the mechanical lift for transfers. Interview with the DON, with the Administrator present, on 2/5/13 at 10:00 a.m., revealed that both CNA #3 and CNA #5 were trained on following the care plans and did not follow them for Resident #1 and Resident #2 and the residents were injured. Review of the facility's policy Using the Care Plan/Following the Care Plan with a revised date of August 2006, revealed that all nursing personnel including RN, LPN, and Shabazim (Certified Nursing Assistants) are to follow the resident's care plan. Cross-refer to F-224 for the facility's failure to provide adequate supervision and assistance devices to prevent injuries for Resident #1 and Resident #2 by transferring them inappropriately and both residents received injuries with fractures.

CI MS # Based on observation, interview, record review and policy review, the facility failed to ensure that one (1) of eight (8) residents reveiwed, Resident #7, was provided the treatment and services to attain/maintain the highest practicable physical well-bing by failure of a Certified Nursing Assistant (CNA) to perform the necessary transfer of Resident #7 from the wheelchair to the bed without assistance of another staff or the use of a mechanical lift on 11/10/12. Resident #7 complained of pain and swelling of the left knee on 11/11/12 and was identified with a [MEDICAL CONDITION] on 11/14/12. The physician was not notified of the resident's initial complaint of pain and swelling until 11/14/12. Findings included: Resident #7: Review of a written report from the facility dated 11/15/12, revealed that Resident #7 had a lateral left tibia plateau impacted fracture. Investigation revealed that CNA #4 had transferred Resident #7 on 11/10/12 without assistance and was terminated for not following the care plan and failure to report the incident. Observation and interview with Resident #7 on 11/26/12 at 12:50 p.m. revealed that she was sitting in a wheelchair and was alert and confused. CNAs #5 and #6 transferred Resident #7 from the wheelchair to the bed without concerns using the mechanical lift. Both CNAs stated that Resident #7 had always been a two (2) person transfer or one (1) person with the lift, but was safer with two (2) persons because she sometimes got aggressive. Both CNAs stated that Resident #7 now required two (2) persons and the lift for transfers. Resident #7's left knee was slightly swollen and CNA #6 stated that it wasn't nearly as swollen as it had been. Review of Resident #7's medical record revealed that she was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's most recent MDS with an ARD of 10/22/12, revealed that she had severe cognitive impairment and required total assistance with transfers. Review of Resident #7's care plan dated 11/23/09 and updated on 8/30/12 revealed that she required one (1) to two (2) person assistance with transfers. (Review of the policy for two person lift transfer (not dated) revealed the standard: Residents who are unable to assist with the transfer, should be moved from a bed/chair by means of a two-person lift, or a mechanical lift device.) Review of a physician's progress note dated 8/25/12 revealed that Resident #7 required assistance of two (2) persons for transfer or a lift. Review of the "ADL (Activity for Daily Living) Documentation" for Resident #7 on 11/10/12 at 19:00 (7:00 p.m.) revealed that the ceiling lift was not documented as used and that CNA #4 performed the transfer completely because the elder did not help at all (total). There was documentation of "2" for how many people did it take to help the elder get in and out of bed/chair. Review of Departmental Notes dated 11/11/12 at 12:49 a.m. documented by LPN #2, revealed that Resident #7 moaned and grunted when turned, rubbing her left knee, left knee was slightly swollen, no warmth, tender to touch. Tylenol 325 milligram (mg) was given for knee pain. Review of Departmental Notes dated 11/11/12 at 4:30 p.m. documented by LPN #3, revealed that it was reported that elder displayed left knee pain on prior shift. Shahbaz stated that elder seemed resistant to them getting her up or touching her knee at approximately 3:45 p.m. Upon inspection, left knee was noted slightly swollen and tender to touch. Slight warmth was noted. Two (2) Tylenol 500 mg was administered due to tenderness in knee. Elder was unable to respond appropriately when asked if her knee was hurting. Review of Departmental Notes dated 11/12/12 at 12:32 a.m. documented by LPN #2, revealed that Resident #7 complained of knee pain when turned, said "oh" and Tylenol was given with good results. Left knee remains swollen, no warmth, painful when moved. Review of Departmental Notes dated 11/12/12 at 12:30 p.m. documented by LPN #3, revealed that Resident #7's left knee was noted to be slightly less swollen and had slight warmth to touch, but not as much as the previous day and stated no when asked about pain, but noted that resident only occasionally responds appropriately to questions that are asked. Review of Departmental Notes dated 11/14/12 at 8:42 a.m. documented by LPN #4, revealed that she had spoken to the physician related to Resident #7's complaint of pain to the left knee and received an order for [REDACTED]. Review of Departmental Notes dated 11/14/12 at 10:34 a.m. documented by LPN #4, revealed that a new order was obtained to get an x-ray of Resident #7's left knee, that it was reported that the elder may have bumped her knee over the weekend, no incident was reported and elder is complaining of pain to the knee. Left knee is swollen and warm, tender to touch. Elder is not able to straighten the leg and x-ray company to get x-ray. Review of Departmental Notes dated 11/14/12 at 2:15 p.m. revealed that the results of Resident #7's x-ray of the left knee showed a lateral tibial plateau impaction type fracture with moderate knee joint effusion. Review of the 24 Hour Communication Report, that is documented by the CNAs that document incident and acute issues, dated 11/11/12 revealed that Resident #7 complained of the left leg hurting bad on the day shift; left knee hurting on the evening shift; and knee some swelling on the night shift. Review of the corresponding 24 Hour Report that is documented by nurses on 11/11/12 revealed no documentation by the 7a-7p shift nurse at all and on the 7p-7a shift LPN #2 documented that Resident #7 had complaint of knee pain. Review of the 24 Hour Communication Report dated 11/12/12 revealed that Resident #7's knee was hurting on the day shift and on the night shift there was documentation that the left knee and foot was swollen. Review of the corresponding 24 Hour Report dated 11/12/12 revealed no documentation by the 7a-7p nurse at all and the 7p-7a nurse documented Resident #7's acu-check only. Review of the 24 Hour Communication Report dated 11/13/12, revealed that Resident #7's left leg was hurting on day shift; didn't complain about leg on the evening shift and complained of knee sore on the night shift. Review of the corresponding 24 Hour Report dated 11/13/12 revealed that the 7a-7p nurse documented nothing at all and the 7p-7a nurse documented Resident #7's acu-check only. Review of the 24 Hour Communication Report dated 11/14/12, revealed that Resident #7 had an x-ray done and her leg is hurt. Review of the corresponding 24 Hour Report dated 11/14/12 revealed no documentation at all by the 7a-7p nurse and the 7p-7a nurse documented that Resident #7 had a [MEDICAL CONDITION] tibia and x-rays had been done. There was no documented evidence that the physician was notified of Resident #7's complaint of left knee pain, swelling and warmth from the initial complaint on 11/11/12 until 11/14/12. There was documented complaints daily from Resident #7 of pain/pain symptoms and swelling of the left knee from 11/11/12-11/14/12. There was no documented assessment of Resident #7's swelling of her left knee by the Registered Nurse from 11/11/12-11/14/12. On 11/14/12 at 9:01 a.m. RN #3 documented that the Responsible Party was aware of the need for an x-ray and was in agreement. Review of a physician's orders [REDACTED].#7 to have [MEDICATION NAME] 10 mg now for fracture, one time dose. Review of the Radiology Report dated 11/14/12 for Resident #7's left knee revealed an impression: Findings compatible with lateral tibial plateau impaction type fracture with moderate knee joint effusion. Review of Resident #7's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s notes prior to 11/11/12. This was a change in status for Resident #7. Interview with the DON on 11/26/12 at 8:00 a.m. revealed that Resident #7 had complained of knee pain and thought that she had a flare up with [MEDICAL CONDITION]. The DON stated that staff gave her Tylenol and got an order for [REDACTED].#4 had transferred Resident #7 without the use of a lift, in a bear hug, and may have bumped her knee. The DON stated that CNA #4 was suspended and terminated for not following the care plan because Resident #7 required two person assist with transfers or the use of a lift. The DON stated that there was no reason for not using the lift because the GH's all have ceiling tracks for the lift. Interview with CNA #4 on 11/26/12 at 12:40 p.m. revealed that she had transferred Resident #7 (11/10/12) around 9-9:30 p.m. from the wheelchair to the bed by herself in a bear hug and not with a lift like she was supposed to. CNA #4 stated that she had just gotten into a hurry and didn't do it right. CNA #4 stated that when she stood Resident #7 up that the resident's knees buckled. CNA #4 stated that Resident #7 didn't fall but that her knee may have twisted or bumped against something, she wasn't sure. CNA #4 stated that she didn't report this because there was no complaint of pain at the time of the transfer. CNA #4 stated that when she returned to work the other staff told her of Resident #7's knee hurting. CNA #4 stated that CNA #8, her supervisor, had asked if anything unusual had occurred and that's when it was reported about the transfer by herself. CNA #4 stated that she realized that it was neglect for not following the care plan and had been trained to follow the care plan. CNA #4 stated that there were other staff available and she could have used the lift but was just in a hurry and didn't. Interview with LPN #2 on 11/27/12 at 10:20 a.m. revealed that she had worked 11/10/11 and 11/11/12 on the 7p-7a shift and CNA #4 had reported that while turning Resident #7 she noted the resident's knee was swollen. LPN #2 stated she observed Resident #7's left knee swollen, red and tender to touch and thought that it was arthritis because nothing seemed out of place and gave her Tylenol which eased her. LPN #2 stated that CNA #4 had not reported that she had transferred Resident #7 by herself or any incident/injury. LPN #2 stated that Resident #7 required two (2) person assist for transfers/lift. LPN #2 stated that she passed on the complaint of pain and swelling for Resident #7 to the next shift. LPN #2 stated that the knee was not as swollen on 11/12/12 but Resident #7 still had some complaint of pain. LPN #2 stated that she had not notified the physician of Resident #7's complaint of pain and swelling of the knee, but that she should have called the physician and gotten an x-ray. Interview with LPN #3 on 11/27/12 at 10:05 a.m. revealed that she had worked the 7a-7p shift on 11/11/12 and 11/12/12. LPN #3 stated that LPN #2 had notified her of Resident #7's left knee swelling and pain on 11/11/12 and they had both agreed that it may have been arthritis and gave Resident #7 Tylenol which relieved her. LPN #3 stated that the next day Resident #7's knee was not as swollen, not as warm and the resident didn't complain of pain. LPN #3 stated that there had been no reports of Resident #7 having increased pain or difficulty on 11/12/12. LPN #3 stated that she had not notified the Physician or RN Supervisor of Resident #7's pain/swelling because there had been no reports of injury/incident and thought that it was arthritis and gave standing orders of Tylenol. LPN #3 was not sure of the documentation for the 24 Hour report, and stated that she had documented in the nurse's notes. Interview with LPN #4 on 11/27/12 at 9:45 a.m. revealed that she worked on 11/13/12 (7a-7p) and had no complaints about Resident #7's knee hurting. LPN #4 stated that on 11/14/12 the CNAs came to her and said that Resident #7 had a complaint of her knee. LPN #4 stated that she and the RN Supervisor (RN #3), observed Resident #7 with a swollen knee that was kind of warm to touch and when attempting to straighten her leg it appeared painful for Resident #7. LPN #4 stated that she notified the physician and got and order for x-rays. LPN #4 stated that it had been charted over the weekend of Resident #7's pain/swelling but there had been no documentation of the physician being notified. LPN #4 stated that no one had reported anything about Resident #7 on 11/13/12 and the resident had no complaint with medications. LPN #4 did not recall about the 24 hour report, stated that the CNAs usually come tell her of any concerns. Interview with RN #3 on 11/27/12 at 12:05 p.m. revealed that no one had reported Resident #7's pain and swelling to the knee to her until 11/14/12. RN #3 stated that she was filling in for someone on leave and had only worked 11/13/12 as the Clinical Care Coordinator for that GH. RN #3 stated that LPN #4 had gotten her to assess Resident #7's knee on 11/14/12 because it was red/swollen and they'd been treating for arthritis. RN #3 stated that she told LPN #4 to call the physician because it looked worse than arthritis. RN #3 stated that Resident #7's knee was more swollen than the other knee, had no bruising and was warm to touch. RN #3 stated that an x-ray was ordered. Interview with CNA #7 on 11/27/12 at 12:18 p.m. revealed that Resident #7 had always been a two (2) person transfer for a long time or either one (1) person and the lift. CNA #7 stated that she returned to work on 11/12/12 and Resident #7 was complaining of pain and her knee was swollen. CNA #7 stated that CNA #4 made a statement that she would take responsibility for it but never said why. CNA #7 stated that they (CNAs) had written on the 24 Hour report about Resident #7's pain and had reported to the nurse's but they had said it was arthritis. CNA #7 stated that Resident #7 didn't usually complain of pain much. Interview with CNA #8, Shabazim Guide, on 11/26/12 at 9:03 a.m. revealed that the CNAs were educated extensively for following the care plan and using the lift for necessary transfers. CNA #8 stated that CNA #4 had reported that she had known better but had transferred Resident #7 by herself with a body/pivot from the wheelchair to the bed. CNA #8 stated that CNA #4 should have used the lift or a two (2) person transfer with Resident #7. CNA #8 stated that Resident #7 had pain and swelling that night after the transfer. CNA #8 stated that the only thing out of the ordinary with Resident #7 after interviewing staff was that CNA #4 had transferred Resident #7 by herself. Interview with the DON on 11/27/12 at 9:25 a.m. revealed that the standard for transfer assistance if a resident requires two (2) person assistance, unless specified otherwise, one (1) person can transfer with the lift or two (2) persons can transfer manually. The DON stated that CNA #4 as well as the other CNAs were all aware of that standard. The DON stated that CNA #4 admitted to transferring Resident #7 by herself and the resident had no other incidents. Interview with the DON on 11/27/12 at 1:15 p.m. revealed that the physician should have been notified of Resident #7's pain/swelling of the knee because it was a change in status. Upon reviewing of the 24 hour communication reports/24 hour reports from 11/11/12-11/14/12, the DON stated that if the day nurse had looked at the 24 hour reports she would have known that there were concerns with Resident #7's knee. The DON stated that Resident #7 had no complaints on 11/10/12 and then after midnight is when LPN #2 documented the first complaint of pain/swelling, therefore deducted after investigation that it had to be related to when CNA #4 transferred her back to bed, whatever may have happened. The DON stated that CNA #4 should not have transferred Resident #7 by herself without the use of the lift or getting the assistance of another person. Review of the facility's policy "Change in a Resident's Condition or Status" with a revised date of April 2007, revealed: "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 policy reads: "1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: d. A significant change in the resident's physical/emotional/mental condition". Review of the policy for two person lift transfer (not dated) revealed the standard: Residents who are unable to assist with the transfer, should be moved from a bed/chair by means of a two-person lift, or a mechanical lift device. Review of the facility's policy "Safe Lifting and Movement of Residents" with a revised date of October 2009, revealed: "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". The policy documented that Manual lifting of residents shall be eliminated when feasible.

2 Based on observation, interview and record review, the facility failed to ensure that two (2) of six (6) residents, Resident #1 and Resident #2, received adequate supervision and assistance to prevent avoidable accidents as evidenced by Certified Nursing Assistant (CNA) #3 transferred Resident #1 to the toilet without assistance; left her unassisted and, the resident fell ; and received a fracture of the left humerus. CNA #5 transferred Resident #2 from the wheelchair to the bed without assistance of another person or the mechanical lift as required and Resident #2 received rib fractures during the transfer. Findings included: Resident #1: Observation and interview of Resident #1 on 2/5/13 at 1:00 p.m. revealed that she was in a wheelchair and was alert and oriented to name and place. Resident #1 had no complaint of mistreatment but stated that she did have a broken left arm. Resident #1 stated that the staff usually took her to the bathroom and stayed with her or right outside the door but now they use the lift to get her in bed for toileting. Resident #1 stated that she wore a splint for awhile and took some pain medication for a few days after the incident. Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/24/12, revealed that she had short and long term memory problems with mild cognitive deficits. Resident #1 required extensive assistance of two (2) persons for transfer and toileting and the care plan dated 5/3/12 included approaches for extensive assistance for two persons for bed mobility, toileting, transfers and dressing. Review of a handwritten statement dated 1/12/13 with CNA #3's signature revealed: I (CNA #3) took (Resident #1) to the bathroom at 5:00 p.m. Had told elders if state was (here) I would get in trouble. Left Elder unattended to go answer the door. Hear elder fall, rushed in room, found elder in bathroom floor. Interview with CNA #3 on 2/6/13 at 9:40 a.m. revealed that she had taken Resident #1 to the bathroom with a walker and left her on the toilet, went to answer the door and the resident fell from the toilet. Interview with CNA #4, CNA Guide, on 2/5/13 at 3:09 p.m. revealed that when she asked CNA #3 about the incident that CNA #3 had stated that she knew she wasn't supposed to leave Resident #3 alone and had made a stupid mistake. Resident #2 Findings include: Observation and interview with Resident #2 on 2/5/13 at 11:20 a.m. revealed that she was alert and oriented to person, place and time. Interview with Resident #2 on 2/5/13 at 1:40 p.m., revealed that (she) had real brittle bones and fractures in the past and that she didn't think CNA #5 meant to hurt her when she transferred her to bed but that she did hurt. Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. Interview with CNA #5 on 2/6/13 at 10:30 a.m., revealed that Resident #2 was ready to go to bed and when transferred she asked the resident to put her arms around her (CNAs) neck and lifted the resident up and put her in the bed. CNA #5 stated that sometimes the lift was used for the resident, but that she had just gotten busy and put Resident #2 in the bed. CNA #5 stated that she was aware that Resident #2 needed two (2) person assist or the use of the lift that it was in the care plan. Cross Refer to F-224 for the facility ' s failure to ensure that two (2) of six (6) residents, Resident #1 and Resident #2, were not neglected.