Every finding on record at Cleveland Pines

Based on observations, record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to ensure resident's toenails were trimmed and podiatry services were arranged for 3 of 7 residents reviewed for foot care (Resident #15, Resident #90, and Resident #24). The findings included: 1. Resident #15 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included traumatic brain injury and contractures to bilateral upper and lower extremities. Review of revised care plan dated 6/15/25 revealed Resident #15 was care planned for activities of daily living (ADL) self-care performance deficits related to her disease process. Resident #15 was dependent on staff for all ADL care. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was severely cognitively impaired and had been assessed as requiring total care assistance from staff with all ADL care. Resident #15 was also coded as having no refusals with care. Review of Resident #15's weekly nursing assessments from 1/14/25 through 09/22/2025 revealed no notation that her toenails were long and thick and needed trimmed. Review of the facility's podiatry clinic schedule for 08/25/25, revealed Resident #15 was not seen by the podiatrist. Review of the facility's podiatry clinic schedule for 09/25/25 revealed Resident #15 was not scheduled to see the podiatrist. There were no consultation reports or notations in Resident #15's Electronic Medical Record (EMR) that she had been referred to or seen by a podiatrist since her admission to the facility. An observation of Resident #15's left foot was conducted on 09/24/25 at 4:05 PM. Resident #15's toes revealed thick, long toenails. Resident #15's left great toenail was thick and raised away from skin and left second toenail was black at bottom of nail. An interview was conducted with Nurse #1 on 09/24/2025 at 5:05 PM. Nurse #1 routinely cared for Resident #15 during the 3:00 to 11:00 PM shift. Nurse #1 stated that she could not recall the condition of Resident #15's toenails or if she had ever told anyone about her needing toenail care. Nurse #1 further explained that usually when she saw a resident who required more toenail care then she felt comfortable providing she would tell Social Worker (SW) #1 who would add the resident to the podiatry list. Nurse #1 further explained that if a resident's toenails were bad enough, they would arrange some type of emergency visit. An interview was conducted with NA #2 on 09/25/2025 at 10:35 AM. NA #2 stated that she had noticed Resident #15's toenails being a little long and very thick, but she could not remember if she had reported that to anyone or not. An interview was conducted with the Nurse Practitioner (NP) on 09/25/25 at 1:34 PM. The NP stated that she was not aware of the condition of Resident #15's toenails but given her disease process and contractures to her lower extremities she could see how her toenails may require podiatry services. She revealed the nurses were supposed to complete weekly skin and nail assessments on each resident and if a resident had nail issues that required podiatry services they were supposed to notify SW #1 to have their name added to the podiatry list. An interview was conducted with the Director of Nursing (DON) on 09/25/2025 at 5:56 PM. The DON stated that nursing staff discussed nail care and toenail care daily during the nursing huddles. The DON further explained that she was not aware of any issues with Resident #15's toenail care. The DON also stated that podiatry clinic was held frequently and SW #1 scheduled residents for the podiatry clinic. The DON also stated that sometimes we don't follow up like we should, and some things fall through the cracks. An interview was conducted with Social Worker #1 on 09/26/2025 at 4:07 PM. SW #1 stated that she handled the podiatry clinic, and the podiatry clinic was held every other month or every month depending on how many residents needed to be seen. SW #1 further explained that the last podiatry clinic was held 08/25/2025 and the next podiatry clinic was scheduled for 09/26/2025. SW #1 stated that Resident #15 was not seen during the August podiatry clinic and was not scheduled to be seen on 09/26/2025 and to her knowledge a referral had never been made to add Resident #15 to the podiatry clinic list. An interview was conducted with the Administrator on 09/26/2025 at 5:31 PM. The Administrator stated that she understood the concerns with Resident #15's toenails. The Administrator stated that nursing staff should observe resident's toenails when they complete their skin assessments. 2. Resident #90 was admitted to the facility on [DATE] with diagnoses which included left above the knee amputation, hypertension, and peripheral vascular disease (PVD). Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 was moderately cognitively impaired and had been assessed as requiring partial staff assistance with eating, mobility, and personal hygiene, substantial staff assistance with dressing, and was dependent on staff assistance for showering, toileting, and transfers. Resident #90 was also coded as having no refusals with care and impairment on one side. Review of revised care plan dated 8/01/25 revealed Resident #90 was care planned for activities of daily living (ADL) self-care performance deficits related to his disease process and amputation. The goals included staff assistance in all aspects of daily care to ensure all needs were met. Interventions included staff to provide grooming and personal hygiene. Review of Resident #90's weekly nursing assessments from 1/14/25 through 09/22/2025 revealed no notation that his toenails were long and thick and needed trimmed. Review of the facility's podiatry clinic schedule for 08/25/25, revealed Resident #90 was not seen by the podiatrist. Review of the facility's podiatry clinic schedule for 09/25/25 revealed Resident #90 was not scheduled to see the podiatrist. There were no consultation reports or notations in Resident #90's Electronic Medical Record (EMR) that she had been referred to or seen by a podiatrist since her admission to the facility. An observation of Resident #90's left foot was conducted on 09/24/25 at 5:05 PM. Resident #90's toes revealed thick, long toenails. Resident #90's right great toenail was thick and curling inward towards his skin. An interview and observation were conducted with Nurse #1 on 09/24/2025 at 5:05 PM. Nurse #1 routinely cared for Resident #90 during the 3:00 to 11:00 PM shift. After an observation of Resident #90's toenails on his right foot, Nurse #1 stated that Resident #90's toenails were too long and thick, and she would not feel comfortable trimming them. She revealed Resident #90 should have been seen by a podiatrist but could not recall if she had ever told anyone or referred him for podiatry services. Nurse #1 further explained that usually when she saw a resident who required more toenail care then she felt comfortable providing she would tell social worker (SW) #1 who would add the resident to the podiatry list. Nurse #1 further explained that if a resident's toenails were bad enough, they would arrange some type of emergency visit. An interview was conducted with NA #2 on 09/25/2025 at 10:35 AM. NA #2 stated that she had noticed Resident #90's toenails on his right foot being a little long and very thick, but she could not remember if she had reported that to anyone or not. An interview was conducted with the Nurse Practitioner (NP) on 09/25/25 at 1:34 PM. The NP stated that she was aware of the condition of Resident #90's toenails on his right foot. She revealed she had previously been asked to assist nursing staff with trimming Resident #90's toenails but due to them being so thick she was not able to trim them well. The NP stated she assumed Resident #90 had been referred to the podiatry clinic due to the thickness of his toenails and the facility not having the tools to assist with keeping his toenails trimmed. She revealed nursing staff were supposed to complete weekly skin and nail assessments on each resident and if a resident had nail issues that required podiatry services, they were supposed to notify SW #1 to have their name added to the podiatry list. An interview was conducted with the Director of Nursing (DON) on 09/25/2025 at 5:56 PM. The DON stated that nursing staff discussed nail care and toenail care daily during the nursing huddles. The DON further explained that she was not aware of any issues with Resident #90's toenail care. The DON also stated that podiatry clinic was held frequently and SW #1 scheduled residents for the podiatry clinic. The DON also stated that sometimes we don't follow up like we should, and some things fall through the cracks. An interview was conducted with Social Worker #1 on 09/26/2025 at 4:07 PM. SW #1 stated that she handled the podiatry clinic, and the podiatry clinic was held every other month or every month depending on how many residents needed to be seen. SW #1 further explained that the last podiatry clinic was held 08/25/2025 and the next podiatry clinic was scheduled for 09/26/2025. SW #1 stated that Resident #90 was not seen during the August podiatry clinic and was not scheduled to be seen on 09/26/2025 and to her knowledge a referral had never been made to add Resident #90 to the podiatry clinic list. An interview was conducted with the Administrator on 09/26/2025 at 5:31 PM. The Administrator stated that she understood the concerns with Resident #90's toenails. The Administrator stated that nursing staff should observe resident's toenails when they complete their skin assessments. 3. Resident #24 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included peripheral artery disease (PAD) and a left below the knee amputation (BKA). Resident #24's care plan dated 01/31/2025 revealed Resident #24 was care planned for activities of daily living (ADL) self-care performance deficits related to her disease processes and amputation. The care plan revealed Resident #24 was dependent on staff for putting on and taking off footwear. Resident #24 required maximal assistance with toileting, bathing, and dressing, moderate assistant with bed mobility and was dependent for transfers. Review of Resident #24's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was cognitively intact. The MDS also revealed Resident #24 required maximal assistance with toileting, bathing, and dressing, moderate assistant with bed mobility and was dependent for transfers. The MDS revealed Resident #24 had no rejections of care. Review of Resident #24's weekly nursing assessments from 12/04/2024 through 09/22/2025 revealed no notation that her toenails were long and thick and needed trimmed. Review of the facility's podiatry clinic schedule for 08/25/2025, revealed Resident #24 was not seen by the podiatrist. Review of the facility's podiatry clinic schedule for 09/25/2025 revealed Resident #24 was not scheduled to see the podiatrist. There were no consultation reports or notations in Resident #24's Electronic Medical Record (EMR) that she had been seen by a podiatrist. An observation of Resident #24's right foot was conducted on 09/23/2025 at 1:24 PM. Resident #24's toes revealed thick, long toenails. Resident #24's right great toenail was starting to curl inward into her skin. An interview was conducted with Resident #24 on 09/23/2025 at 1:26 PM. Resident #24 stated that she was no longer able to care for her toenails and that her toes on her right foot looked nasty and she would like to have them trimmed. An interview and observation of Resident #24's right foot was conducted with the Wound Nurse on 09/23/2025 at 1:50 PM. The Wound Nurse stated that she tried to file Resident #24's toenails several days ago but she did not attempt to cut or trim them because of her PAD. The Wound Nurse also stated that she was not sure if Resident #24 was followed by the podiatrist, but it would be best if she was seen by the podiatrist due to Resident #24's severe circulation problems. An interview was conducted with Social Worker #1 on 09/24/2025 at 3:41 PM. SW #1 stated that she handled the podiatry clinic, and the podiatry clinic was held every other month or every month depending on how many residents needed to be seen. SW #1 further explained that the last podiatry clinic was held 08/25/2025 and the next podiatry clinic was scheduled for 09/26/2025. SW #1 stated that Resident #24 was not seen during the August podiatry clinic and was not scheduled to be seen on 09/26/2025. SW #1 stated that she thought Resident #24 had been scheduled for podiatry services in May 2025, but Resident #24 had refused to see the podiatrist. SW #1 also stated that she kept a podiatry log in order to keep up with the residents who needed to be seen, had refused to be seen, and residents who were seen by the podiatrist. SW #1 also revealed that she was unsure if a follow up was made with Resident #24 to get her reschedule for podiatry services. SW #1 stated that the nursing staff would let her know if a resident needed to be added to the podiatry schedule. An interview was conducted with NA #1 on 09/25/2025 at 8:53 AM. NA #1 stated that he had noticed Resident #24's toenails being a little long and very thick, but he could not remember if he had reported that to anyone or not. An interview was conducted with Nurse #1 on 09/25/2025 at 4:07 PM. Nurse #1 routinely cared for Resident #24 during the 3:00 to 11:00 PM shift. Nurse #1 stated that Resident #24's toenails were long and very thick but to be honest, I don't remember if I told anyone about Resident #24's toenails. Nurse #1 further explained that she usually told SW #1, and SW#1 would add the resident to the podiatry list. Nurse #1 further explained that if a resident's toenails were bad enough, they would arrange some type of emergency visit. An interview was conducted with the Director of Nursing (DON) on 09/25/2025 at 5:56 PM. The DON stated that nursing staff discussed nail care and toenail care daily during the nursing huddles. The DON further explained that Resident #24 had refused podiatry care in the past, but she was not sure if any follow up occurred. The DON also stated that podiatry clinic was held frequently and SW #1 scheduled residents for the podiatry clinic. The DON also stated that sometimes we don't follow up like we should, and some things fall through the cracks. An interview was conducted with the Nurse Practitioner (NP) on 09/26/2025 at 11:54 AM. The NP stated that Resident #24 had severe circulatory issues, and the staff should not attempt to provide any type of toenail care for her. The NP stated that Resident #24's toenails should be cared for by the podiatrist. An interview was conducted with the Administrator on 09/26/2025 at 5:31 PM. The Administrator stated that she understood the concerns with Resident #24's toenails. The Administrator stated that nursing staff should observe resident's toenails when they completed their skin assessments.

Based on observations, record reviews, and Nurse Practitioner and staff interviews, the facility failed to review risks and benefit of side rails use with the resident or resident representative prior to installation, failed to obtain informed consent, and failed to accurately assess 5 of 8 severely cognitively impaired residents for the use of bilateral half side rails on their beds (Resident #3, Resident #9, and Resident #15, Resident #39, Resident #35). Findings included: 1. Resident #3 was readmitted to the facility on [DATE] with diagnoses which included bilateral above knee amputation, cerebrovascular accident (stroke), tonic-clonic seizure disorder, chronic anticoagulation, and altered mental status. Resident #3's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired, unable to make her needs known and staff had to anticipate her needs daily. The assessment also revealed she required extensive assistance of 2 staff members for bed mobility, and she was on a turning and repositioning program. Resident #3 was not coded for side rails. Review of Resident #3's care plan dated 09/04/25 revealed a focus area for activities of daily living (ADL) deficits related to altered mental status, atrial fibrillation, and stroke with hemiplegia (paralysis on one side of body). The goal was for the resident to have all Activities of Daily Living needs met through staff to keep her safe, clean and appropriately dressed. Review of Resident #3's medical record revealed the resident did not have consent for the use of bed rails. Further review of Resident #3's medical record revealed no documentation of risks and benefits of side rail use. Review of Resident #3's physician orders revealed no order for bilateral half or quarter side rails to bed to assist in bed mobility. Review of Resident #3's medical record revealed she had side rail assessments completed on: - 3/21/25 completed by Unit Manager (UM #1) - side rails – does the assist rail restrict voluntary movement– no; at risk for going over/under assist rail- no; reason for device use- bed controls on upper rail to assist resident with manipulating physical environment; family member name- family of Resident #3; family reason for side rail-sense of security; medical symptoms- seizure disorder; were the risks and benefits explained to the resident and/or family-yes; will the side rail assist the resident in being transferred-yes; will the side rails assist the resident in bed mobility-yes; Care Area Assessment used to determine need for side rails-no; identify all the contributes to the resident's need to use assist rails-weakness, pain, balance deficit, knees buckle; assist rail type-quarter length; alternative to assist rails-n/a; resident understands the use and operation of assist rails- yes; resident successfully demonstrated the use of side rails-yes. - 04/8/25 completed by Nurse #2 - side rails – does the assist rail restrict voluntary movement– no; at risk for going over/under assist rail- no; reason for device use- sense of security; family member name- n/a; family reason for side rail-n/a; medical symptoms- weakness; were the risks and benefits explained to the resident and/or family-yes; will the side rail assist the resident in being transferred-yes; will the side rails assist the resident in bed mobility-yes; Care Area Assessment used to determine need for side rails-yes; identify all the contributes to the resident's need to use assist rails-weakness, awareness of safety, balance deficit; assist rail type-half length; alternative to assist rails-none; resident understands the use and operation of assist [NAME]- yes; resident successfully demonstrated the use of side rails-yes. An interview on 9/25/25 at 3:32 PM with Nurse #2 who frequently cared for Resident #3 revealed Resident #3 was dependent with all care, she did not make purposeful movements, and she would not have been able to reach and pull herself in the bed if you asked her. Nurse #2 reported side rail assessments were done with a form that was checked off on the computer. She stated that if the resident could not communicate, we just check the boxes based on the last assessment. She reported she did not go into the room and actually assess if the resident could use the side rails. Nurse #2 reported the side rails kept the residents from rolling off the bed when NAs were performing care. She stated everyone here had bed rails, they came with the bed. - 07/01/25 completed by Unit Manager (UM) #2 - side rails – does the assist rail restrict voluntary movement– no; at risk for going over/under assist rail- no; reason for device use- sense of security; family member name- self; family reason for side rail-security; medical symptoms- weakness; were the risks and benefits explained to the resident and/or family-yes; will the side rail assist the resident in being transferred-yes; will the side rails assist the resident in bed mobility-yes; Care Area Assessment used to determine need for side rails-no; identify all the contributes to the resident's need to use assist rails-weakness, pain, balance deficit; assist rail type-quarter length; alternative to assist rails-none; resident understands the use and operation of assist [NAME]- yes; resident successfully demonstrated the use of side rails-yes. An interview with UM #2 on 09/26/25 at 11:15 AM revealed that side rail assessments were done on all residents on admission and quarterly. She reported that all beds came with side rails on them and there was a standing order for side rail assessments but not for the actual side rail. UM #2 stated when she completed the assessment she assessed for safety, and if the resident could hold the rail but reported the rails were ultimately there for security, for example, if rolling the resident from side to side the side rails were there to stop the resident from falling out of bed. She reported that the facility did not have signed consents for side rails. She reported when doing the assessments, if she answered yes to understanding, it was the family she was speaking about. She reported she guessed she didn't completely understand how to do the assessments for side rails. She stated she assumed if the staff could put the resident's hand on the rail and it stayed there then the resident was ok to have the side rail. Observation of Resident #3 on 09/23/25 at 9:45 AM revealed her lying in bed in her room with side rails up on either side of her bed. The side rails were gray metal that extended from the head of the bed to halfway down the bed. The resident was asleep in bed; bilaterally contracted hands were noted. Observation of Resident #3 on 09/24/25 at 8:45 AM revealed her lying in bed in her room with half side rails up on either side of her bed. The side rails were gray metal that extended from the head of the bed to halfway down the bed. The resident was asleep in bed; bilaterally contracted hands were noted. Observation of patient care for Resident #3 on 09/24/25 at 10:15 AM revealed Resident #3 lying in bed in her room with her side rails up on either side of her bed. Two nurse aides assisted in care for this resident. The resident was observed to have bilateral above knee amputations and bilateral hand contracture. No voluntary movement was observed during care. Turning of the resident side to side required both nurse aides. The resident did not participate in her care. She was unable to make eye contact with nurses' aides and unable to make her needs known. An interview on 09/24/25 at 10:15 AM with Nurse Aide (NA) #2 who was frequently assigned to Resident #3 revealed Resident #3 was unable to participate in any of her care. She reported she had been unable to participate in her care since she came back to the facility on [DATE]. She reported that Resident #3 could sometimes smile and would often scream out if she is in pain but was otherwise nonverbal. She reported she rarely made eye contact any more. An interview with Nurse #6, on 9/26/25 11:58 AM revealed she had not been trained to do side rail assessments. She reported she just knew how to do them from her old job but had always been told if the residents couldn't use the rails, they shouldn't have them. She stated all the residents at this facility had them because they came with the beds. She reported she felt like it was a sense of security for the staff to keep the residents from rolling off the bed. She reported she did the assessment when she was prompted to by the computer software and used the information from the prior assessment. Nurse #6 indicated she shouldn't be using the prior assessment's information for the new assessment but that is what everyone did. An interview on 09/24/25 at 10:45 AM with the Nurse Practitioner (NP) revealed all residents got side rails at admission. She reported that the side rails helped the staff with providing care and for bed mobility. She stated she had never signed an order for side rails but there was a standing order for side rail assessments on all residents, and she believed that was completed on admission and then quarterly, because it was protocol. She reported everyone who was admitted had side rails on their bed because she didn't think the side rails could be removed. She stated if the resident was not moving then the side rail was just going to be there, it did not matter if they could use it or not. Resident #3's side rails were on her bed because they help staff provide care and they couldn't be removed. Resident #3 was not able to use the side rails. An interview with Director of Nursing (DON) on 09/25/25 at 6:04 PM revealed Resident #3 was a bilateral above knee amputee and had contractures in both her hands. She was total care since she returned from the hospital on [DATE]. DON stated she would have expected the nurses to actually assess the resident to determine if the side rails were beneficial, not just check boxes. She reported there were not signed orders or consents for bed rails. An interview with the Administrator on 09/26/25 at 4:50 PM indicated she realized when it was called to her attention during the annual survey that bed rail assessments and use was not being executed correctly and there was an opportunity to improve. 2. Resident #9 was admitted to the facility on [DATE] with diagnoses which included senile degeneration of brain, Parkinson's disease, dementia, and schizophrenia. Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #9 was severely cognitively impaired, and dependent with all activities of daily living. Resident #9 was not coded for side rails on her MDS. Review of Resident #9's medical record revealed the resident did not have a consent for the use of bed rails. Further review of Resident #9's medical record revealed no documentation of risks and benefits of side rail use. Review of Resident #9's physician orders dated 09/25/25 revealed no order for bilateral half side rails. Review of Resident #9's care plan 03/08/25 revealed a focus area for activities of daily living (ADL) deficits related to dementia, Parkinson's disease and Chronic obstructive pulmonary disease (COPD). The goal was for the resident to have all Activities of Daily Living needs met through staff to keep her safe, clean and appropriately dressed. Review of Resident #9's medical record revealed she had only two side rail assessments completed on: - 05/06/25 completed by Nurse #7- side rails - does the assist rail restrict voluntary movement-no; is resident at risk for going over/under the assist rail-no; why is the use of assist rails being considered- sense of security; family member-self; family reason for side rail- sense of security; medical symptoms-weakness; were risks and benefits explained to the resident and/or family-yes; will side rails assist the resident in bed mobility-yes; did the facility use a care area assessment to determine the need for side rails-yes; will side rails assist the resident in transfers- yes; additional reasons why the assist rails assist the resident-yes; assist rail assistance details-assist with mobility; Identify all the contributes to the resident's need to use assist rails-awareness of safety needs, balance deficit, weakness; assist rail type-quarter length; alternative to rails-no; resident understands the use and operation of assist rails-yes; resident height and weight operation of assist rails-yes; resident successfully demonstrated the use of side rails-yes; use of assist rails can be eliminated or reduced-no; elimination of reduction of assist rails details-not applicable. - 08/04/25 completed by UM #2- side rails – does the assist rail restrict voluntary movement-no; is resident at risk for going over/under the assist rail-no; why is the use of assist rails being considered- sense of security; family member-self; family reason for side rail- sense of security; medical symptoms-weakness; were risks and benefits explained to the resident and/or family-yes; will side rails assist the resident in bed mobility-yes; did the facility use a care area assessment to determine the need for side rails-yes; will side rails assist the resident in transfers- yes; additional reasons why the assist rails assist the resident-yes; assist rail assistance details-assist with mobility; Identify all the contributes to the resident's need to use assist rails-awareness of safety needs, balance deficit, weakness; assist rail type-quarter length; alternative to rails-no; resident understands the use and operation of assist rails-yes; resident height and weight operation of assist rails-yes; resident successfully demonstrated the use of side rails-yes; use of assist rails can be eliminated or reduced-no; elimination of reduction of assist rails details-not applicable. An interview with Unit Manager (UM) #2 on 09/26/25 at 11:15 AM revealed that side rail assessments were done on all residents on admission and quarterly. She reported that all beds came with side rails on them and there was a standing order for side rail assessments but not for the actual side rail. UM #2 stated when she completed the assessment she assessed for safety, and if the resident could hold the rail but reports the rails were ultimately there for security, for example, if rolling the resident the side rails were there to stop the resident from falling out of bed. She reported that the facility did not have signed consents for side rails. She reported when doing the assessments, if she answered yes to understanding, it was the family that she was speaking about. She reported she guessed she didn't completely understand how to do the assessments for side rails. She stated she assumed if the staff could put the resident's hand on the rail and it stayed there then the resident was ok to have the side rail. An interview on 09/24/25 at 10:15 AM with Nurse Aide (NA) #2 who was frequently assigned to Resident #9 revealed Resident #9 was unable to participate in any of her care. She reported she had been unable to participate after a decline earlier in the year. She reported that Resident #9 had also been nonverbal since admission but had recently started singing occasionally. NA #2 reported Resident #9 was not able to follow directions and NA #2 had not seen Resident #9 use the side rails since her decline earlier this year. Observation of Resident #9 on 09/24/25 at 10:33 AM revealed her lying in bed in her room with side rails up on either side of her bed. The rails were gray metal that extended from the head of the bed to halfway down the bed. The resident was alert but unable to communicate, she had her left leg thrown off the bed over her right leg, her right leg was bent and pressing on the side of the bed rail. An interview on 9/25/25 at 3:32 PM with Nurse #2 who frequently cared for Resident #9 revealed Resident #9 was dependent with all care. Nurse #2 reported side rail assessments were done with a form that was checked off on the computer. She stated that if the resident could not communicate, staff just checked the boxes based on the last assessment. She reported she did not go into the room and actually assess if the resident could use the side rails. Nurse #2 reported the side rails kept the residents from rolling off the bed when the NAs were performing care. She stated everyone here had bed rails, they came with the bed. An interview with Nurse #6, on 9/26/25 11:58 AM revealed she had not been trained to do side rail assessments. She reported she just knew how to do them from her old job but had always been told if the residents couldn't use the rails, they shouldn't have them. She stated all the residents at this facility had them because they came with the beds. She reported she felt like it was a sense of security for the staff to keep the residents from rolling off the bed. She reported she did the assessment when she was prompted to by the computer software and used the information from the prior assessment. Nurse #6 indicated she shouldn't be using the prior assessment's information for the new assessment but that is what everyone did. An interview on 09/24/25 at 10:45 AM with the Nurse Practitioner (NP) revealed all residents got side rails at admission. She reported that the side rails helped the staff with providing care and for bed mobility. She stated she had never signed an order for side rails but there was a standing order for side rail assessments on all residents, and she believed that was completed on admission and then quarterly, because it was protocol. She reported everyone who was admitted had side rails on their bed because she didn't think the side rails could be removed. She stated, if the resident was not moving then the side rail was just going to be there, it did not matter if they could use it or not. Resident #9's side rails were on her bed because they helped staff provide care and they couldn't be removed. Resident #9 was not able to use them. Observation of Resident #9 on 09/25/25 at 8:15 AM revealed her lying in bed in her room with side rails up on either side of her bed. The resident was asleep. An interview with Director of Nursing (DON) on 09/25/25 at 6:04 PM revealed Resident #9 had Parkinson's and dementia and was dependent with all care since a decline around the first of the year. DON stated she would have expected the nurses to actually assess the resident to determine if the side rail was beneficial, not just check boxes. She reported there were not signed orders or informed consent for bed rails. An interview with the Administrator on 09/26/25 at 4:50 PM indicated she realized when it was called to her attention during the annual survey that bed rail assessments and use was not being executed correctly and there was an opportunity to improve. 3. Resident #15 was admitted to the facility on [DATE] with a readmission on [DATE]. Diagnoses that included traumatic brain injury, tracheostomy (surgical procedure to provide opening in windpipe to provide airway for breathing), bilateral contractures (restricted joint mobility) of upper and lower extremities, and gastrostomy tube (a tube surgically placed in the stomach to provide nutrition, hydration, and medications). Review of revised care plan dated 6/15/25 revealed Resident #15 was care planned for activities of daily living (ADL) deficits related to disease processes. Resident #15 was dependent on staff for all ADL care, bed mobility, transfers, and upper side rails used for assistance with bed mobility. The care plan also revealed Resident #15 had impaired physical mobility and decreased range of motion related to her bilateral contractions of her upper and lower extremities. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was rarely/never understood and was severely cognitively impaired. Resident #15 was dependent on staff for all ADL care, bed mobility, and transfers. In addition, the assessment indicated bed rails were not used under Restraints and Alarms. Resident #15's Electronic Medical Record (EMR) revealed Resident #15's side rail assessments were completed on 1/14/25, 4/14/25, and 7/13/25. The side rail assessments included the following: 1. Does the Assist Rail Restrict Voluntary Movement? No 2. Is Resident at Risk for Going Over/Under the Assist Rail? No 3. Why is the use of assist rail being considered? Sense of security 4. Family Member Name? No Answer 5. Family Reason for Side Rail? No Answer 6. Medical Symptoms? No Answer 7. Were the Risk/Benefits explained to Resident/Family? Yes 8. Will Side Rail assist the Resident in bed mobility? Yes 9. Did Facility use a Care Area Assessment to determine the need for side rails? No 10. Will side rails assist with transfers? Yes 11. Additional Reasons why the Assist Rails assist the resident? No 12. Assist Rail Assistance Details? N/A 13. Identify all the contributes to the Resident's need to use Assist Rails? Weakness/ Pain 14. Assist Rail Type? Quarter Rail 15. Alternative to Assist Rail? None 16. Resident understand the use and operation of assist rail? None 17. Resident height/weight considered in the use of side rail? No 18. Resident successfully demonstrated the use of side rails? Yes 19. Use of Assist Rails can be eliminated or reduced? No 20. Elimination or Reduction of Assist Rail details? Not applicable An interview on 09/26/2025 at 11:58 AM with Nurse #6 who frequently took care of Resident #15 and completed Resident #15's side rails assessments. She stated Resident #15 had involuntary muscle spasms sometimes but could not move voluntarily and had bilateral contractures of the upper and lower extremities. Nurse #6 further explained that Resident #15 could not use her side rails for anything including positioning or bed mobility and was dependent on staff for all care needs. Nurse #6 further stated that Resident #15 was safer with the side rails up so she would not fall out of bed, and the side rails also helped the nursing assistants because it kept Resident #15 from rolling out of bed during care. Nurse #6 also revealed that the facility does not have physician orders for side rails, side rails are just standard practice, and all the beds in the facility have side rails. An observation was conducted of Resident #15 on 9/22/25 at 11:45 AM. Resident #15 was observed lying in bed in her room with side rails that extended from the head of the bed to the middle of the bed. The side rails were up on the right and left side of her bed. The side rails were of metal construction. Resident #15's legs and arms were contracted; she was non-verbal and did not respond when asked questions. An additional observation of Resident #15 was conducted on 9/23/25 at 2:45 PM. Resident #35 was lying in bed in her room with her side rails up on both sides of her bed. Resident #15's legs and arms were contracted; she was non-verbal and unable to answer any questions or follow any directions. Observation of Resident #15 on 9/24/25 at 4:05 PM revealed her lying in bed in her room with side rails up on both sides of her bed. Resident #15 legs and arms were contracted; she was non-verbal and unable to answer any questions or follow any directions. An interview on 09/25/2025 at 1:34 PM with the Nurse Practitioner (NP) about side rails revealed that any resident who was admitted was assessed for side rails. The side rails helped with repositioning and were used for mobility. The NP further explained that for dependent residents, the side rails helped the staff provide resident care. The NP revealed the facility did not have side rails orders and all the beds have side rails, and the bed rails were not removable. The NP stated that she had not seen a bed in the facility without side rails. The NP further stated that all residents in the facility had side rails on their beds. An observation was conducted on 9/25/25 at 3:55 PM. Resident #15 was lying in bed in her room with her side rails up on both sides of her bed. An interview was conducted with the Director of Nursing (DON) on 09/25/2025 at 5:56 PM. The DON stated the nurses reported the side rails helped the aides and prevented Resident #15 from falling out of bed during care. Resident #15 was total care and dependent on staff for all care needs. The DON stated that she was not sure if the facility obtained side rail consents and she was unsure if there were physician orders for bed rails, but the nursing staff did complete quarterly side rail assessments on all residents in the facility. An interview was conducted with the Administrator on 09/26/2025 at 5:22 PM. The Administrator stated that the facility had an opportunity for improvement related to side rails assessments and the use of side rails. She declined to discuss side rail usage or specific resident information regarding side rails. 4. Resident #39 was admitted to the facility on [DATE] with diagnoses which included respiratory failure with tracheostomy status, left upper extremity contracture, aphasia, and quadriplegia. Review of Resident #39's Care Area Assessment (CAA) summaries dated 05/01/25 revealed no CAA summary addressing the use of bed rails. Review of a Side Rail assessment dated [DATE] completed by Nurse #2 revealed the following: 1. Does the assist rail restrict voluntary movement? No. 2. Is resident at risk for going over/under the assist rail? No. 3. Why is the use of assist rail(s) being considered? Bed controls on upper rail. 4. Family member name? None. 5. Family reason for side rails? Bed controllers. 6. Medical symptoms? Weakness. 7. Were the risks and benefits explained to the Resident and/or family? Yes. 8. Will side rails assist the resident in bed mobility? No. 9. Did the facility use a Care Area Assessment to determine the need for side rails? Yes. 10. Will side rail(s) assist the Resident in transfers? No. 11. Additional reasons why the assist rail(s) assist the Resident? No. 12. Assist rail assistance details? Help with mobility. 13. Identify the contributes to the Resident's need to use assist rails. Unable to support trunk in upright position. 14. Assist rail type? Quarter length. 15. Alternative to assist rails? Not applicable An interview was conducted on 09/25/25 at 3:27 PM with Nurse #2. Nurse #2 explained she had completed the Side Rail Assessment for Resident #39 and the side rail assessments were to be completed every 3 to 6 months. The nurse stated the electronic medical record (EMR) alerted staff of when the Side Rail Assessment was due to be completed. Nurse #2 stated if a resident was able to talk, she would go in the room and talk with them to complete their Side Rail Assessment but said if they were unable to talk, like Resident #39, she checked off the assessment based on the answers provided on the last assessment completed. Regarding the answer Nurse #2 provided for question #12 in the Side Rail Assessment, Assist rail assistance details? Help with mobility, Nurse #2 stated she guessed she meant it would help the Nurse Aides (NAs) because it would keep Resident #39 from rolling off the bed, out of the bed, and the side rails, keep her in the bed. Nurse #2 stated Resident #39 did not move at all on her own and was unable to provide any additional information regarding how the side rail benefited Resident #39. Nurse #2 further stated the side rails came standard with all the beds at the facility but said she had worked at other facilities that didn't have bed rails and said they had to have a specific order for side rails. Review of Resident #39's physician orders dated 09/01/25 revealed no orders for bed rails. Review of Resident #39's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was rarely/never understood and the brief interview for mental status (a cognitive screening tool used to assess a resident's memory and orientation) (BIMS) assessment was unable to be conducted. Resident #39's cognitive skills for daily decision making were severely impaired and Resident #39 was dependent on staff to anticipate and provide activities of daily living (ADL). The assessment also revealed she required extensive assistance of 2 staff members for bed mobility and she was on a turning and repositioning program. In addition, the assessment indicated bed rails were not used under Restraints and Alarms. Review of Resident #39's care plan dated 09/04/25 revealed no care plan for the use of bed rails. Observation of Resident #39 on 09/22/25 at 11:31 AM revealed her lying in bed in her room with side rails that extended from the head of the bed to the middle of the bed. The side rails were up on the right and left side of her bed. The side rails were of metal construction and Resident #39 was non-verbal and did not respond when asked questions. Observation of Resident #39 on 09/23/25 at 9:26 AM revealed her lying in bed in her room with her side rails up on the right and left sides of her bed. The resident was turned onto her left side with her head of bed elevated and had earphones on and was watching a program on her electronic tablet attached to the top of her bed rail. Observation of Resident #39 on 09/24/25 at 2:41 PM revealed her lying in bed in her room with the side rails up on the right and left sides of her bed. The resident was turned onto her left side with her head of bed elevated and had earphones on and was watching a program on her electronic tablet attached to the top of her bed rail. An interview on 09/25/25 with Nurse Aide (NA) #1 revealed Resident #39 was total care and unable to do anything for herself and unable to ask for assistance with care. NA #1 stated Resident #39 was non-verbal and only able to blink to some simple yes/no questions. NA #1 further stated she provided total care for Resident #39 which included feeding, changing, bathing, and positioning her in bed. NA #1 stated Resident #39 could not move on her own and was unable to use the side rails for mobility due to her contracture and not being able to move her upper or lower extremities on her own. An interview on 09/25/25 at 2:51 PM with Nurse #7 revealed she usually took care of Resident #39 and said sometimes she could get a response from the resident by the resident blinking her eyes to simple yes/no questions and sometimes she didn't respond at all. Nurse #4 stated Resident #39 was non-verbal, required total care and could not move at all on her own and could not use her side rails to help move herself in the bed. An interview on 09/26/25 at 3:30 PM with the Nurse Practitioner (NP) about side rails revealed that any resident who was admitted to the facility was assessed for side rails, the side rails helped with repositioning and were used for mobility. The NP stated that for dependent residents, the side rails helped the staff provide resident care. The

Based on record review, and interviews with resident, facility staff, and the Nurse Practitioner (NP), the facility failed to protect the resident's right to be free from resident-to-resident abuse. On 02/25/25 while providing care to another resident, Nurse Aide (NA) #2 heard a resident yelling get away from me, when she opened the door, she saw Resident #79 kicking Resident #9. NA #2 heard and saw Resident #79 yelling get away from me. Resident #9 was attempting to back up. Resident #79 was alert and oriented and had a history of being combative with staff. Resident #9 was severely cognitively impaired and had a history of wandering. A reasonable person would expect to be free from abuse in their own home and could experience fear, anxiety, and depressed mood. The deficient practice occurred for 1 of 3 residents reviewed for abuse (Resident #9). The findings included:Resident #9 was admitted to the facility on [DATE] with diagnoses which included senile degeneration of brain, Parkinson's disease, dementia, and schizophrenia.Review of Resident #9's care plan 03/08/25 revealed a focus area for activities of daily living (ADL) deficits related to dementia, Parkinson's disease and Chronic obstructive pulmonary disease (COPD). The goal was for the resident to have all activities of daily living needs met through staff to keep her safe, clean and appropriately dressed.Review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was severely cognitively impaired, and dependent with all activities of daily living. Resident #79 was admitted to the facility on [DATE] with diagnosis to include depression, anemia, and heart failure. Review of Resident #79's care plan dated 03/09/25 revealed a focus area for Resident #79 for a behavior problem of being physically aggressive at times with a goal to demonstrate appropriate positive social interactions with the facility.Resident #79 quarterly MDS assessment 6/2/25 revealed Resident #79 was cognitively intact. An interview on 9/25/25 at 2:15 PM with NA #2 revealed on 2/25/25 she was in a room providing care to another resident, behind closed doors, when she heard yelling outside the door. She reported she opened the door and saw Resident #79 kicking Resident #9 and yelling get away from me. NA #2 stated Resident #9 was trying to back up but was slow moving, she was also non-verbal except during rare occasions where she sings. NA#2 reported she immediately separated the two residents and notified the Unit Manager. NA #2 stated that she was not aware of Resident #9 ever being aggressive towards anyone but would grab the rail or any obstacle to help propel herself down the hall, even if it was another resident's wheelchair. NA #2 reported that Resident #9 did not have the mental compacity to understand that grabbing other's property was not appropriate. A second interview with NA #2 on 9/26/25 at 12:31 PM revealed she saw Resident #79 make contact several times with Resident #9's lower legs. Resident #9 was trying to back away but she was a slow mover. NA #2 reported Resident #79 usually wore gray slip-on type shoes with a medium-hard bottom. Resident #9 was nonverbal, but she was grimacing while the incident was happening. An interview on 09/25/25 at 2:05 PM with Unit Manager (UM) #1 indicated she had been made aware of the altercation between Resident #9 and Resident #79 by NA #2 on 2/25/25. NA #2 reported to her that she overheard Resident #9 and Resident #79 yelling, opened the door of the room she was in and saw Resident #79 kicking Resident #9. UM #1 reported she assessed Resident #9, and she didn't remember any injuries. She reported Resident #9 was nonverbal and unable to communicate her feelings, but UM #1 felt that being kicked by someone would have hurt or at least made her feel scared, especially since she was unable to make her feelings known. UM #1 reported Resident #79 was alert and oriented and had been verbally and physically aggressive towards staff in the past. UM #1 reported she had scars on her left arm from Resident #79 attacking her. An interview with Social Worker (SW) #2 on 9/25/25 at 4:02 PM revealed the incident was reported to her by UM #1. SW #2 stated that it was reported to her that both Resident #9 and Resident #79 were in the hallway when Resident #9 got too close to Resident #79 and Resident #79 was seen kicking Resident #9. SW #2 reported NA #2 was close by and separated them immediately. SW #2 indicated she was notified the same day the incident occurred, and she and SW #1 spoke with Resident #79 and asked her what happened. SW #2 indicated that she didn't remember what Resident #79 said but both social workers let Resident #79 know to ask for help instead of acting out in those situations. SW #2 reported to her knowledge neither resident had a history of acting out. She stated she would report any incident to DON or Administrator. SW #2 reported she thought she was told by a NA there was no physical contact made. Interview with SW #1 on 9/25/25 at 4:20 PM revealed she remembered Resident #9 was rolling down 200 hall and got too close to Resident #79, who started shuffling her feet, a NA saw Resident #79 shuffling her feet at Resident #9 and separated them. An interview with Resident #79 on 9/26/25 at 1:10 PM revealed she remembered the lady who goes up and down the hall in her wheelchair all the time. She reported when she was over on the other hall, she got right up on top of me. She stated, I yelled at her and told her to move, she wouldn't and so I kicked her and she was kicking me back, one of the aides come out and moved us away from one another. Resident #79 reported she kicked the resident several times and she was just defending herself because she would not get away from her. An interview on 09/24/25 at 10:45 AM with the NP indicated she could not remember who reported the incident to her. She stated Resident #9 was up in a wheelchair and went to Resident #79's room. Resident #9 grabbed Resident #79, and Resident #79 hit Resident #9, and Resident #9 hit Resident #79 back. NP stated that neither resident had any injuries that she recalled and neither had any prior history of being aggressive towards other residents. She reported Resident #9 would grab other residents to propel herself down the hall. An interview with the Administrator on 9/26/25 at 4:50 PM revealed the day this incident occurred Resident #79 had been agitated. The Administrator stated a NA, who she thought was NA #2, but couldn't remember for sure, reported to her that Resident #79 and Resident #9 did not make contact. The Administrator stated she was told the kicking between the residents was just the word used, as they did not make contact. The Administrator reported her social workers talked to Resident #79 about kicking and that it wasn't appropriate. The Administrator stated, We don't have abuse in this building.

Based on record review and staff interviews, the facility failed to complete a thorough investigation of an allegation of resident-to-resident abuse for 1 of 3 residents reviewed for abuse (Residents #9). Findings included: The facility's Prohibit and Prevent Violations of Resident Abuse, Neglect, Misappropriation of Resident Property and Exploitation policy indicated in part, all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/ or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. All resident to resident altercations must be reported in accordance with the regulations to include any willful action that results in physical injury, mental anguish, or pain. Should an incident or suspected incident of resident abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. The following guidelines are used when performing the investigation: - Review 24-hour initial report form- Review the resident's medical record to determine events leading up to the incident- Interview the person reporting the incident.- Interview the resident(s) involved in the allegation- Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition- Interview staff members- Interviews with the resident's roommate, family members and visitors- Review events leading up to the alleged incident Resident #9 was admitted to the facility on [DATE] with diagnoses which included senile degeneration of brain, Parkinson's disease, dementia, and schizophrenia. Resident #79 was admitted to the facility on [DATE] with diagnosis to include depression, anemia, and heart failure. Review of an emailed care event notification (a facility document used to report a care event) dated 9/23/25 read: the Nurse Aide (NA) overheard Resident #79 yelling. She opened the door and saw Resident #79 kicking Resident #9 in the legs telling her to get away. Staff separated them and notified the social worker. No injury noted. Handwritten at the bottom of the email was further information regarding the incident. The handwritten portion read: NA #2 separated residents immediately. Unit Manager (UM) #1 assessed residents, no injuries noted. Provider, Nurse Practitioner (NP) was notified. SW #1 and SW #2 spoke with Resident #79 about behavior and to call staff for assistance. Incident was isolated and did not happen again. The facility did not provide an author of the event care notification. Review of NA #2's handwritten statement on 02/25/25 in the incident folder read: as I was providing care to a resident, I overheard Resident #79 screaming in the hallway! I opened the door and saw Resident #79 kicking Resident #9, telling her to get away! I notified the charge nurse and moved residents! An interview on 9/25/25 at 2:15 PM with NA #2 revealed on 2/25/25 she was in a room providing care to another resident, behind closed doors, when she heard yelling outside the door. She reported she opened the door and saw Resident #79 kicking Resident #9 and yelling get away from me. NA #2 stated Resident #9 was trying to back up but was slow moving, she is also non-verbal except during rare occasions where she sings. NA#2 reported she immediately separated the two residents and notified the unit manager. NA #2 stated that she was not aware of Resident #9 ever being aggressive towards anyone but would grab the rail or any obstacle to help propel herself down the hall, even if it was another resident's wheelchair. NA #2 reported that Resident #9 did not have the mental capacity to understand that grabbing other's property was not appropriate. A second interview with NA #2 on 9/26/25 at 12:31 PM revealed on 2/25/25 she saw Resident #79 make contact several times with Resident #9's lower legs. Resident #9 was trying to back away, but she was a slow mover. NA #2 reported Resident #79 usually wore gray slip-on type shoes with a medium-hard bottom. Resident #9 was nonverbal, but she was grimacing while the incident was happening. NA #2 did not remember telling anyone the residents did not make contact because she saw the incident very clearly. NA#2 stated she reported this to UM #1. Review of a nurses note in Resident #9's medical chart written by UM #1 on 2/25/25 at 2:04 PM read: The NA overheard Resident #79 yelling. She opened the door and saw Resident #79 kicking Resident #9 in the legs telling her to get away. Staff separated them and notified the social worker. No injury noted. I notified the nurse practitioner (NP). Review of a nurse's note in Resident #79's medical chart written by UM #1 on 2/25/25 at 2:22 PM read: The NA overheard Resident #79 yelling. She opened the door and saw Resident #79 kicking Resident #9 in the legs telling her to get away. Staff separated them and notified the social worker. No injury noted. I notified the nurse practitioner (NP). An interview on 09/25/25 at 2:05 PM with Unit Manager (UM) #1 indicated she had been made aware of the altercation between Resident #9 and Resident #79 by NA #2 on 2/25/25. NA #2 reported to her that she overheard Resident #9 and Resident #79 yelling, opened the door of the room she was in and saw Resident #79 kicking Resident #9. UM #1 reported she assessed resident #9 and she didn't remember any injuries. She reported Resident #9 is nonverbal and unable to communicate her feelings, but UM #1 felt that being kicked by someone would have hurt or at least made her feel scared, especially since she was unable to make her feelings known. UM #1 reported she did not complete any further assessments for physical injuries or mental anguish on Resident #9 or Resident #79 after the initial assessment. An interview with Social Worker (SW) #2 on 9/25/25 at 4:02 PM revealed the incident was reported to her by UM #1. SW #2 stated that it was reported to her that both resident #9 and #79 were in the hallway when Resident #9 got too close to Resident #79 and Resident #79 was seen kicking Resident #9. SW #2 reported that NA #2 was close by and separated them immediately. SW #2 reported she was notified the same day the incident occurred, and she and SW #1 spoke with Resident #79 and asked her what happened. SW #2 indicated that she didn't remember what Resident #79 said but both social workers let Resident #79 know to ask for help instead of acting out in those situations. SW #2 reported to her knowledge neither resident had a history of acting out. She stated she would report any incident to Director of Nursing (DON) or Administrator. Review of typed statement signed and dated on 2/25/25 by SW #2 read: SW #2 and SW #1 spoke with resident, Resident #79 about kicking another resident. Resident #79 yelled at social workers that she was in the doorway of her room, and the other resident kicked her and that she just kicked her back. SW explained that it is not appropriate to kick other people and to call staff when she needs help with another resident. A second interview with SW #2 on 9/25/25 at 5:00 PM revealed when asked who she reported the incident to she stated she believed she had reported it to the DON, but she couldn't be sure. She reported she thought she was told by a NA there was no actual physical contact made, but she couldn't remember exactly who told her. SW #2 reported she doesn't remember if she told the administrator or the DON that or not. When SW #2 was asked why the incident was not further investigated, she indicated because it wasn't abuse, no one was injured, they didn't make contact. When asked why, when her statement revealed, Resident #79, who was alert and oriented, admitted to kicking and yelling at Resident #9 to get her away, an investigation was not started. SW #2 could not provide an answer. When asked if it was proven there was no contact between the residents why did she not amend her statement to reflect that she responded, I just didn't, the statements are what they are. When asked if she felt that being kicked or even kicked at while being yelled at in your home could cause mental anguish, SW #2 stated, yes, of course it would. Interview with SW #1 on 9/25/25 at 4:20 PM revealed she thinks she remembered being told by someone that Resident #9 was rolling down 200 hall and got too close to Resident #79, who started shuffling her feet, a NA saw Resident #79 shuffling her feet at Resident #9 and separated them. SW #1indicated she became aware of the incident when SW#2 came to ask her to go see Resident #79 with her. When asked why she felt there was an inconsistency between SW #2's statement and her understanding of what happened, SW #1 said she didn't know. When asked why she felt an investigation did not occur after Resident #79 admitted to kicking Resident #9, SW #1 reported because it wasn't abuse, no injuries were reported. SW #1 indicated she felt as a reasonable person if she were kicked or kicked at while being yelled at in her home it could cause mental anguish. An interview with Resident #79 on 9/26/25 at 1:10 PM revealed she remembered the lady who went up and down the hall in her wheelchair all the time grabbing things. She reported when she was over on the other hall, she got right up on top of me. She stated I yelled at her and told her to move, she wouldn't and so I kicked her and she was kicking me back, one of the aides come out and moved us away from one another. Resident #79 reported she kicked the resident several times and she was just defending herself because Resident #9 would not get away from her. An interview with the Director of Nursing on 9/25/25 at 6:05 PM indicated she had no firsthand knowledge of the allegation. Review of the typed statement signed and dated 02/25/25 by the Administrator read, reported that Resident #79 was sitting in her room and Resident #9 was coming down the hallway. Resident #9 got to close to Resident #79 and Resident #79 started yelling at Resident #9 and kicking her feet at her. There was no contact made and social workers spoke to Resident #79 and told her to call for a staff member in the future if Resident #9 was bothering her because kicking her was not appropriate. Resident #79 is alert and oriented and understands what is being said to her. Review of the investigation folder revealed written statements from NA #2, SW #2, the Administrator, and two nurse's notes written by UM #1. There were no statements from roommates or documentation about the conflicting statements between SW #2, NA#2, the nurses notes and the Administrator. There was no documentation of skin assessments done after the initial assessment to rule out injuries that may have taken longer to reveal themselves, such as bruising. There was also no documentation of any assessments that were carried out on either resident to determine if any mental anguish occurred after the incident An interview with the Administrator on 9/26/25 at 4:50 PM revealed the day this incident occurred Resident #79 had been agitated. The Administrator stated a NA, who she thought was NA #2, but couldn't remember for sure, reported to her that Residents #79 and Resident #9 did not make contact. When the statements from the social worker, nurse aide and the nursing notes were reviewed with the Administrator she reported she understood the kicking between the residents to be just the word used, as the residents did not make contact. The Administrator did not reply with an answer when asked why the statements were not amended to show no contact was made. The Administrator reported she did not interview Resident #79 because the social workers had already talked to her about kicking not being appropriate. When asked why an investigation was not initiated when the Administrator learned that Resident #79 told the social workers that she and Resident #9 had in fact kicked one another she could not provide an answer, she continued to repeat, We do not have abuse in this building. She indicated she did not do an investigation because there was no injury, therefore it was not abuse. The Administrator explained the facility checked the residents when the incident occurred for any physical injury but denied any further assessments of the residents a because abuse did not occur. She also reported the facility did not assess either resident for any mental anguish immediately following the incident or at any time since the incident occurred. She further stated that as a reasonable person, getting kicked or kicked at while being yelled at in her home would cause mental anguish. The Administrator reported she did not believe either of these resident's experienced any mental anguish because it was not reported to her and she continued to state, We don't have abuse in this building.

Based on record review and staff interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II review was completed for residents with new mental health diagnoses for 3 of 4 residents (Resident #9, Resident #43, and Resident #15) reviewed for PASRR.The findings included: 1. Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE] with a readmission on [DATE]. PASRR level I was completed on 9/07/17 prior to admission with a recommendation to resubmit paperwork for PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. The electronic medical record revealed Resident #9 was diagnosed with anxiety disorder on 9/09/17, mood affective disorder on 8/01/23, and schizophrenia on 10/24/24. No PASRR level II was completed. During an interview on 9/26/25 at 5:35 PM with the Administrator, she communicated her understanding that PASRR level II should be completed in a timely manner upon the admission or readmission of a resident with a mental health diagnosis and anytime a resident has had a change of condition or received a new mental health diagnosis. 2. Review of Resident #43's medical record revealed the resident was admitted to the facility on [DATE] with a readmission on [DATE]. PASRR level I was completed on 6/08/23 prior to admission to the facility with a recommendation to resubmit paperwork for PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. The electronic medical record revealed Resident #43 was diagnosed with post-traumatic stress disorder (PTSD) on 7/11/23, bipolar disorder on 1/02/25, and major depressive disorder on 9/07/25. No PASRR level II was completed. An interview on 9/26/25 at 4:07 PM with Social Worker (SW) #1 revealed she was responsible for completing PASRR paperwork for residents. She stated she typically completed paperwork for PASRR level II when residents had a limited level II, and their paperwork required them to be reviewed every 30 or 60 days or had a change in behaviors. SW revealed she was not aware PASRR level II should be completed for residents with mental health diagnosis upon their admission or readmission or when they received a new mental health diagnosis as she was not always made aware of their new diagnosis. SW stated her understanding that based on Resident #43's mental health diagnosis, PASRR level II should have been completed. During an interview on 9/26/25 at 5:35 PM with the Administrator, she communicated her understanding that PASRR level II should be completed in a timely manner upon the admission or readmission of a resident with a mental health diagnosis and anytime a resident has had a change of condition or received a new mental health diagnosis. 3. Review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE] and PASRR level I was completed 1/13/25 prior to admission to the facility with a recommendation to resubmit paperwork for a PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. The electronic medical record revealed Resident #15 was diagnosed with anxiety disorder on 9/03/25. No PASRR level II was completed. An interview on 9/26/25 at 4:07 PM with Social Worker (SW) #1 revealed she was responsible for completing PASRR paperwork for residents. She stated she typically completed paperwork for PASRR level II when residents had a limited level II, and their paperwork required them to be reviewed every 30 or 60 days or had a change in behaviors. SW revealed she was not aware PASRR level II should be completed for residents with mental health diagnosis upon their admission or readmission or when they received a new mental health diagnosis as she was not always made aware of their new diagnosis. SW stated her understanding that based on Resident #15's new mental health diagnosis, PASRR level II should have been completed. During an interview on 9/26/25 at 5:35 PM with the Administrator, she communicated her understanding that PASRR level II should be completed in a timely manner upon the admission or readmission of a resident with a mental health diagnosis and anytime a resident has had a change of condition or received a new mental health diagnosis.

Based on observations, record reviews, and staff interviews, the facility failed to follow their infection control standards and procedures when Nurse #6 failed to sanitize her hands and change her gloves between replacing the new tracheostomy (a surgically created opening in the windpipe through the neck to provide an airway for breathing) ties and neck collar and before cleaning the stoma and outer cannula and applying new disposable inner cannula and when Nurse #7 failed to sanitize her hands and change her gloves after inserting the new inner cannula and before cleaning around the stoma and outer cannula and placing the stoma dressing and new neck collar and ties. The deficient practice occurred for 2 of 2 residents reviewed for respiratory care (Resident #15 and Resident #39).The findings included:1. Resident #15 was admitted to the facility on [DATE] with diagnoses which included respiratory failure and tracheostomy status.Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired and was coded for tracheostomy care.Resident #15's comprehensive care plan revised on 06/15/25 revealed a focus area for being at risk for respiratory complications secondary tracheostomy. Interventions included tracheostomy care as ordered by physician.An observation was conducted on 09/24/25 at 12:44 PM of tracheostomy care being provided to Resident #15 by Nurse #6 and the Infection Preventionist (IP). Nurse #6 was providing tracheostomy care with the assistance of the IP. Nurse #6 and the IP were on either side of Resident #15's bed and had the tracheostomy supplies for care on a towel on the resident's overbed table next to Nurse #6. Nurse #6 and the IP had sanitized their hands and donned their gown and gloves and Nurse #6 began by removing the humidified oxygen trach collar (a piece that sits over the tracheostomy stoma and connects to an oxygen source with humidification to prevent airway drying). Nurse #6 and the IP then removed the ties on either side of the outer cannula (the main body of the tracheostomy tube that is inserted into the trachea to keep it open and serves as the primary structure into which the inner cannula fits) and removed the strap around the resident's neck and discarded it into the trash bag at the foot of the bed. The strap around the neck and ties were visibly soiled. Nurse #6 with the same gloves on proceeded to remove the inner cannula and discarded it in the trash bag at the foot of the bed touching the inside of the trash bag. With the same gloves on, Nurse #6 picked up the packaged inner cannula, opened the package, discarded the package in the trash bag and with the same gloves on inserted the new inner cannula and locked it into place. Nurse #6 replaced the trach collar after changing out the trach collar piece and she and the IP attached it on either side and placed the elastic connection behind the resident's neck. Nurse #6 then gathered her supplies and trash, doffed her gown and gloves, sanitized her hands and left the room. The IP with the same gloves on proceeded to clean the resident's mouth with a mouthwash-soaked oral swab. After completing oral care, the IP doffed her gown and gloves, sanitized her hands and left the room.An interview was conducted on 09/25/25 at 5:30 PM with the Director of Nursing (DON). The DON stated she expected the nurses to follow all infection control procedures when providing tracheostomy care to residents. She further stated Nurse #6 had told her that she had changed her gloves during the procedure.An interview was conducted on 09/26/25 at 11:58 AM with Nurse #6. Nurse #6 stated she felt like the tracheostomy care on Resident #15 had gone really well yesterday. Nurse #6 stated she thought she had sanitized her hands and changed gloves during the trach care but said if she didn't she knew she was supposed to and again said she was pretty sure she had sanitized her hands and changed gloves during the procedure. An interview was conducted on 09/26/25 at 12:30 PM with the Infection Preventionist (IP). The IP stated she was aware Nurse #6 should have changed her gloves during the trach care and said she started to say something to her but was not sure she could do so. She stated Nurse #6 should have doffed her gloves and sanitized her hands after replacing Resident #15's ties and collar and before inserting her disposable inner cannula, especially since the collar around her neck was visibly soiled. The IP also stated she should have sanitized her hands and changed her gloves before providing mouth care to Resident #15.2. Resident #39 was admitted to the facility on [DATE] with diagnoses which included respiratory failure and tracheostomy status. Resident #39's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired and was coded for tracheostomy care.Resident #39's comprehensive care plan revised on 09/04/25 revealed a focus area for being at risk for respiratory complications secondary tracheostomy. Interventions included tracheostomy care as ordered by physician.An observation was conducted on 09/24/25 at 1:18 PM of tracheostomy care being provided to Resident #39 by Nurse #7. Nurse #7 was already in Resident #39's room with her gown and gloves on and was providing the care with the assistance of the IP. Nurse #7 and the IP were on either side of Resident #39's bed and had the tracheostomy supplies for care on a towel on the resident's overbed table next to Nurse #7. Nurse #7 and the IP had sanitized their hands and donned their gown and gloves and Nurse #7 began by removing the humidified oxygen trach collar. Nurse #7 then removed the disposable inner cannula and placed it in the trash bag at the foot of the bed. Nurse #7 picked up the new inner cannula and placed it in the trach and locked it. Nurse #7 with the same gloves on and without sanitizing her hands and donning clean gloves removed the trach dressing around the stoma. Nurse #7 and the IP then removed the ties on either side of the outer cannula and removed the strap around the resident's neck and discarded it into the trash bag at the foot of the bed. The strap around the neck and ties were visibly soiled. Nurse #7 with the same gloves on proceeded to clean around the stoma of the trach, replaced the neck strap and ties around the outer cannula of the trach. Nurse #7 then replaced the trach collar after changing out the trach collar piece and she and the IP attached it on either side and placed the elastic connection behind the resident's neck. Nurse #7 then gathered her supplies and trash, doffed her gown and gloves, sanitized her hands and left the room. The IP with the same gloves on proceeded to clean the resident's mouth with a mouthwash-soaked oral swab. After completing oral care, the IP doffed her gown and gloves, sanitized her hands and left the room.An interview was conducted on 09/25/25 at 2:51 PM with Nurse #7. Nurse #7 stated she felt like the tracheostomy care on Resident #39 could have gone better. Nurse #7 stated she should have sanitized her hands and changed her gloves during the procedure but said she didn't see her extra gloves on the bedside table. Nurse #7 further stated she knew she should have sanitized her hands and changed her gloves during the procedure but said she didn't see another pair of gloves on her field and so she just kept going with the trach care. An interview was conducted on 09/25/25 at 5:30 PM with the Director of Nursing (DON). The DON stated she expected the nurses to follow all infection control procedures when providing tracheostomy care to residents. An interview was conducted on 09/26/25 at 12:30 PM with the Infection Preventionist (IP). The IP stated she was aware Nurse #7 should have changed her gloves during the trach care and said she started to say something to her but was not sure she could do so. She stated Nurse #7 should have doffed her gloves and sanitized her hands after inserting her disposable inner cannula, and before cleaning around the stoma and replacing the ties, neck strap, and trach collar. The IP also stated she should have sanitized her hands and changed her gloves before providing mouth care to Resident #39.

Based on record reviews and interviews with staff, the facility failed to have effective systems in place for accurate reconciliation of controlled medications and maintaining accurate records of a resident's controlled medication declining count sheet for 1 of 6 residents reviewed for pharmacy services (Resident #46).The findings included:Review of the facility's Controlled Substances Distribution and Control Policy read in part:PROCEDURESD. A separate record will be maintained on each controlled substance in the form of a declining inventory record (Controlled Substance Sign-Out Sheet). Such record will be accurately maintained and will include: 6) The quantity of the controlled substance currently on hand.10) Such records will be reconciled to a physical count of the remaining doses at each shift change by two licensed nurses including the nurse taking charge of these controlled substances 11) Such record will be retained by the facility for a period of not less than three (3) years.Resident #46 was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder.Review of a physician order dated 2/7/2023 last modified on 12/15/2024 read, lorazepam (Ativan) tablet 0.5mg by mouth twice daily.Review of the Controlled substance delivery manifest dated 12/9/2024 revealed receipt of 25 tabs of Ativan 0.5 mg for Resident #46 and was signed by Nurse #1 and Nurse #8.The controlled declining inventory sheet dated 12/9/2024 for Resident #46's Ativan 0.5mg tablets was not available for review, the facility was unable to locate the sheet.Review of the incident report dated 12/17/2024 revealed an event description that read: Resident's card of Ativan is missing. There were 10 tablets left on the card. The narcotic sheet was still in the nurse's book. The incident report indicated the missing tablets belonged to Resident #46.During an interview on 9/25/2025 at 2:20 PM Nurse #2 stated she worked from 7:00 AM to 3:00 PM on 12/17/2024 and thought the card that contained 10 Ativan 0.5mg tablets was present in the locked controlled substance drawer when she counted on the morning of 12/17/2024 and in the afternoon Resident #46's Ativan tablets were not in the drawer. Nurse #2 stated it was toward the end of the shift when she realized the card with Resident #46's 10 Ativan tablets was missing from the locked controlled substance drawer, and the controlled declining countdown sheet was still in the book. Nurse #2 indicated she reported this to the Director of Nursing (DON) and the DON called whoever she needed to call and contacted the pharmacy to see if Resident #46's card that contained 10 Ativan 0.5mg tablets had accidentally been sent back to the pharmacy.Review of Omnicell log dated 12/17/2024 revealed Nurse #3 obtained Ativan 0.5mg for Resident #46 on 12/17/2024 at 9:59 PM.Review of the Medication Administration Record (MAR) for 12/17/2024 revealed Resident #46 received Ativan 0.5mg at 9:30 AM and 9:00 PM.During an interview on 9/26/2025 at 9:00 AM Resident #46 stated she thought she received all her medications because she took a lot. Resident #46 stated she did not have any concerns about her Ativan and did not recall going without her medication. Resident #46 stated she did not remember any of her medications going missing.During an interview on 9/25/2025 at 1:54 PM the Director of Nursing stated on 12/17/2024 it was discovered by Nurse #2 that Resident #46's Ativan 0.5mg card that contained 10 tablets was missing. The DON stated the controlled declining inventory sheet for Resident #46's Ativan 0.5mg was in the controlled declining inventory book on 12/17/2024. The DON stated the controlled declining inventory sheet for Resident #46's Ativan 0.5mg dispensed 12/9/2024 could not be found. The DON stated she knew the controlled declining count sheets were supposed to be maintained for three years and stated it must have been put in the investigation folder that was unable to be located. The DON stated Resident #46's missing 10 Ativan 0.5mg tablets were never found, but she believed it was human error and not misappropriation.Review of Resident #46's pharmacy charges revealed the 25 tablets of Ativan 0.5mg dispensed on 12/17/2024 were provided to Resident #46 at no charge.During an interview on 9/26/2025 at 4:54 PM the Administrator stated she expected the controlled medications to be accurately maintained and for controlled declining inventory sheets to be kept per the policy.

Based on record reviews, facility activity calendars, and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 6 of 8 residents reviewed for activities. (Residents #58, #8, #53, #20, #63, and #16). The residents expressed not being able to leave the facility for almost 2 years made them feel more dependent, sad, depressed, and they missed getting out with the group to shop and socialize with other people. The findings included: A review of the activity calendars for January 2024 through July 2024 revealed activities for inside of the facility or grounds during the week and some activities on the weekends. There were no activities scheduled for outside of the facility and grounds. Review of the Resident Council Meeting minutes for April 2023 through June 2024 revealed the residents requested in July 2023 and August 2023 to go on outings outside the facility. Observation on 07/17/24 at 12:30 PM revealed the facility was located within driving distance to several local and commercial shops, grocery stores, local and commercial coffee shops, fast food and sit-down restaurants. a. Resident #58 was admitted to the facility on [DATE]. An annual MDS assessment dated [DATE] indicated Resident #58 felt it was very important to have activities that that included going outside of the facility and doing things in a group setting. The assessment further indicated that Resident #58 was cognitively intact. An interview was conducted with Resident #58 on 07/17/24 at 10:38 AM during the resident council meeting which revealed there had not been a scheduled group outing outside the facility in almost two years and the resident council had requested one during their monthly meetings and were told it was not possible to go on outings outside the facility because they did not have a van that could transport a group on outings outside the facility. She stated she felt it was important for residents to get outside in the world and socialize with people other than those at the facility because it allowed them some independence and socialization with other people. Resident #58 further stated she would love to go out to eat with a group and go shopping and be able to touch things and be able to pick out her own belongings. She revealed personally being able to do her own shopping and socializing with other people outside of the facility was very important to her and would make her feel more normal and like she still had some independence. Resident #58 further revealed not getting outside the walls of the facility had made her sad and dependent on others for her needs. b. Resident #8 was admitted to the facility on [DATE]. An annual MDS assessment dated [DATE] indicated Resident #8 felt it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated that Resident #8 was cognitively intact. An interview was conducted with Resident #8 on 07/17/24 at 10:36 AM during the resident council meeting which revealed there had not been a scheduled group outing outside the facility in almost two years and the resident council had requested one during their monthly meetings and were told it was not possible to go on outings outside the facility because they did not have a van that could transport a group on outings outside the facility. She stated she felt it was important for residents to get outside the walls of the facility because it allowed them some freedom and independence to socialize with other people outside the facility. Resident #8 stated not being able to go on outings had made her feel depressed and sad because she would like to be able to go out to eat and go shopping and pick out her own belongings. c. Resident #53 was admitted to the facility on ,d+[DATE] and readmitted on [DATE]. An annual MDS assessment dated [DATE] indicated Resident #53 felt it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #53 was cognitively intact. An interview was conducted with Resident #53 on 07/17/24 at 10:40 AM during the resident council meeting which revealed there had not been a scheduled group outing outside the facility in almost two years and the resident council had requested one during their monthly meetings and were told it was not possible to go on outings outside the facility because they did not have a van that could transport a group on outings outside the facility. He stated he felt it was very important for residents to get outside the walls of the facility and be able to socialize with one another and other people outside the facility because it made them feel more normal. Resident #53 stated he had been requesting to go to a particular restaurant for some time but had been told it was not possible because there was no transportation to take residents outside the facility. He revealed he did not care about going shopping but knew that was important to some of the residents but said it was important to him to be able to go out to eat with a group and socialize and not being able to do so made him sad. d. Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE]. An annual MDS assessment dated [DATE] indicated Resident #20 felt it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #20 was cognitively intact. An interview was conducted with Resident #20 on 07/17/24 at 10:32 AM during resident council meeting which revealed there had not been a scheduled group outing outside the facility in almost two years and the resident council had requested one during their monthly meetings and were told by administrative staff they did not have a van to transport residents in for 'fun outings just medical appointments. She agreed with other residents they had been told by the administrator that it was impossible to go on outings outside the facility because there was not a van available for transport of the residents. She agreed with other residents that it was important to go on group outings outside the facility because it allowed the residents some independence, socialization with the group and with people outside of the facility and made them feel more like a normal person and not just a resident stuck in a facility. e. Resident #63 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #63 felt it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated that Resident #63 was cognitively intact. An interview was conducted with Resident #63 on 07/17/24 at 10:30 AM during resident council meeting which revealed there had not been a scheduled group activity outside the facility since her admission and the resident council had requested one during their monthly meetings and were told by administrative staff, they did not have a van to transport residents in for 'fun outings just medical appointments. She agreed she felt group activities outside of the facility were important to residents that were able to go and participate because it allowed them to exercise some independence, socialization with the group and outside world and made them feel more like a normal person. Resident #63 agreed with other residents not being able to leave the facility with residents and participate in group activities outside the facility had sometimes made her feel as though she had lost some of her independence and was having to rely on someone else to do her personal shopping instead of doing it herself. f. Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE]. An annual MDS assessment dated [DATE] indicated Resident #20 felt it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #20 was cognitively intact. An interview was conducted with Resident #20 on 07/17/24 at 10:32 AM during resident council meeting which revealed there had not been a scheduled group outing outside the facility in almost two years and the resident council had requested one during their monthly meetings and were told by administrative staff they did not have a van to transport residents in for 'fun outings just medical appointments. She agreed with other residents they had been told by the administrator that it was impossible to go on outings outside the facility because there was not a van available for transport of the residents. She agreed with other residents it was important to go on group outings outside the facility because it allowed the residents able to go some independence, socialization with the group and with people outside of the facility and made them feel more like a normal person and not just a resident stuck in a facility. g. Resident #16 was admitted to the facility on [DATE]. An admission MDS assessment dated [DATE] indicated Resident #16 felt it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated that Resident #16 was cognitively intact. An interview was conducted with Resident #16 on 07/17/24 at 10:34 AM during the resident council meeting which revealed there had not been a scheduled group outing outside the facility since her admission and the resident council had requested one during their monthly meetings and were told it was impossible because there was not a van that could transport the residents on outings outside of the facility. She stated she thought that had a great activities program at the facility and was pleased with the activities staff and the programs they offered She agreed with other residents it was important to go on group outings outside the facility because it allowed the residents some independence and socialization with outside people and made them feel more like a normal person. Resident #16 further stated she would love to go on outings to restaurants to eat and go shopping but wanted the internal activities to continue as well. An interview was conducted with the Activities Director (AD) on 07/18/24 at 10:49 AM which revealed she was aware the residents wanted to go on group outings and said they brought it up all the time during resident council meetings. She stated she had been told with the van they currently have there is only room for two to three residents at a time, so they were not able to go on group outings. The AD further stated there was only one van driver and when they had taken the residents to the local fair two years ago it had been a long process for the van driver to take two to three at a time and then get everyone back and forth so last year they had brought the residents food from the fair and set up an inhouse carnival with games for them to play. She explained they had popcorn, snow cones, fried Oreos and funnel cakes provided for the residents. The AD further explained residents had requested to go grocery shopping, shopping at Walmart, Dollar General, and requested to go out to eat at one of the local restaurants. She stated she would love to take the residents on outings because she knew it was important to them, but was told they did not have a van to accommodate outings for fun. An interview was conducted with the Administrator on 07/18/24 at 3:22 PM which revealed she was aware the residents wanted to go on group outings and she wanted them to be able to go out on group outings but said the barrier to group outings was their van only being able to accommodate a couple of residents at a time, only having one van driver, and having the staff to send with the residents on outings. She stated that currently their van was only used for transporting residents to medical appointments. The Administrator further stated they had started a Make a Wish program in which residents wanting to do special things would be accommodated but said they had just started it and it would be a single resident wish and not a group event. She explained they had taken residents who needed to bank appointments and attorney appointments but had not done any group outings or fun activities in the van. The Administrator further explained the social workers were available to do shopping for the residents monthly and were able to get what they needed at stores but said she knew it was not the same as the residents being able to go and pick out their own belongings.

Based on record review, and staff interviews, the facility failed to clarify and update the medical records to reflect the desired advance directive for 1 of 1 resident (Resident #64) reviewed for code status. The findings included: Resident #64 was admitted to the facility on [DATE]. A review of Resident #64's paper chart at the nurses' station revealed a paper copy of Resident #64's Medical Orders for Scope of Treatment (MOST) form dated 1/30/24 which indicated to attempt resuscitation with full scope of treatment. The MOST form was signed by Resident #64 and the Nurse Practitioner on 1/30/24. A review of Resident #64's electronic medical record indicated a physician's order dated 3/27/24 for Do Not Attempt Resuscitation (DNAR)/limited scope of treatment. A progress note in Resident #64's medical record dated 3/27/24 by the Medical Director (MD) indicated Resident #64's family wanted to keep her at facility for now and not to send to hospital. (The family) noted that they were aware of decline. (The MD) discussed with multiple family members in room and they wished to have her be Do Not Resuscitate/Do Not Intubate. Resident #64 had a poor long term prognosis. An interview with Nurse #1 on 7/16/24 at 12:20 PM revealed she would refer to Resident #64's paper chart at the nurses' station for her code status. Nurse #1 reviewed the MOST form and stated that Resident #64 was a full code so she would attempt cardiopulmonary resuscitation. After Nurse #1 was prompted to check Resident #64's electronic medical record, she noted that Resident #64's most recent code status order was DNAR. Nurse #1 stated that she was not sure why there was a discrepancy in Resident #64's code status, and said that she would want them to match. Nurse #1 added that if she received a new order from the doctor, she would notify the Unit Coordinator who would give the new code status to the office secretary to get scanned into the electronic medical record and placed in the paper chart. An interview with Unit Coordinator #1 on 7/16/24 at 12:29 PM revealed he didn't know why Resident #64 had conflicting advance directive in her electronic medical record and paper chart. Unit Coordinator #1 stated Resident #64's family might have requested for her code status to be changed. Unit Coordinator #1 shared that the facility's process when there was a change to a resident's advance directive was when they receive an order, the nurse should have a new MOST form signed by the family and the doctor, and then it should be placed in the office secretary's box so it could be filed. Unit Coordinator #1 stated that the advance directives in Resident #64's electronic medical record and paper chart should match. An interview with Unit Coordinator #2 on 7/16/24 at 12:47 PM revealed she remembered when Resident #64 was first admitted to the facility, her family wanted her to be a full code. Unit Coordinator #2 stated that the MD did not fill out a new MOST form when he changed Resident #64's code status to DNAR on 3/27/24. Unit Coordinator #2 confirmed that she acknowledged the 3/27/24 order, but the MD did not tell her about it, and she did not pay much attention to it because it wasn't about her medications. Unit Coordinator #2 stated that she acknowledged a lot of orders each day. Unit Coordinator #2 stated that she thought the MD might have initiated a new MOST form for Resident #64, and she was not aware that he did not. A follow-up interview with UC #1 on 7/16/24 at 12:55 PM revealed he had noticed that some orders got put in the electronic medical records without the nurses knowing about them. He stated that the facility probably needed to have a better process with changing code status especially without the resident going out and coming back from the hospital. An interview with the Director of Nursing (DON) on 7/18/24 at 2:59 PM revealed she found out that the MD spoke with Resident #64's family and they wanted to change her code status, so he put in the order but did not say anything to nursing that he was changing her code status. The DON stated the MD should have went ahead and filled out a new MOST form when he changed Resident #64's code status. The DON further stated that the code status in Resident #64's electronic medical record and paper chart should be the same.

Based on observations, record review, resident, staff, and Nurse Practitioner interview the facility failed to follow physician's order to provide and apply a left resting hand splint to prevent further contracture for 1 of 3 resident reviewed for limited range of motion. (Resident #30) The findings included: Resident #30 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis of left side and muscle weakness. A quarterly Minimum Data Set for Resident #30 dated 6/25/24 revealed the resident was cognitively intact with no refusals or rejection of care and no orthotic use documented. The care plan for Resident #30 updated on 6/25/24 revealed, Resident #30 had an Activities of Daily Living deficit related to physical functioning with weakness status post hemiplegia following a stroke. A review of the nurse practitioner order dated 4/29/24 revealed occupational therapy to evaluate and treat Resident #30 for left hand contracture, current left-hand splint provided would not fit fingers properly. A review of the occupational therapist evaluation note dated 5/06/24 revealed Resident #30 required a left-hand splint to address his contracture. OT evaluated and would place order for new left-hand splint and when received would provide OT services for Resident #30. An observation and interview on 7/15/24 at 10:52 AM revealed Resident #30 sitting up in his wheelchair dressed. The resident's left hand appeared contracted, and he was not wearing a splint. This surveyor asked Resident #30 if he wore a splint on his left hand and he stated no that therapy supposedly ordered a splint for him to wear but it had not come in yet. An observation on 7/16/24 at 3:55 PM revealed Resident #30 was sitting up in his wheelchair dressed in his room. Resident #30 was not wearing his splint. An interview with the Occupational Therapist (OT) on 7/17/24 at 2:30 PM revealed Resident # 30 suffered from a left-hand contracture and did require a splint for his left hand. She stated she placed an order for Resident #30 left-handed splint with the business manager she believed in March 2024 and still had not received the splint. She revealed equipment orders can sometimes take longer depending on the medical equipment company but never more than a month and she should have checked on the equipment prior to now. The OT stated once Resident #30 received his left-handed splint they would begin services to address his range of motion while using his splint. An interview with the business office manager on 7/17/24 at 2:40 PM revealed she received a request from OT on 5/08/24 to order a left side hand splint for Resident #30. She stated she had completed the order at 2:20 PM on 5/08/24 and received confirmation of the order. She revealed therapy had not notified her of the missing equipment and she was not aware the splint had not been received. An interview with the Nurse Practitioner (NP) on 7/18/24 at 1:44 PM revealed she had seen Resident #30 this morning and realized he did not have his left-handed splint and asked for a temporary splint or washcloth for his contraction until his splint come in. She stated although she did not believe Resident #30 to have no actual change since she had ordered the left-handed splint in April, she had expected that he would have the splint and OT would be working with him by now. She revealed Resident #30 should have his left-handed splint and receive treatment for his contracture to assist with keeping it from contracting more. An interview with the Director of Nursing and the Administrator on 7/18/24 at 3:44 PM revealed they were not aware that Resident #30 did not have a left-hand splint as ordered and there should have been follow-up to assure Resident #30 had the correct left-hand splint as ordered and was wearing it as tolerated.

Based on observation, record reviews, and staff interviews, the facility failed to implement their infection control policy for hand hygiene/handwashing, when the Treatment Nurse did not perform hand hygiene according to the facility's policy and procedure when she doffed her gloves after preparing her dressing for the wound and did not sanitize her hands before donning clean gloves to remove the old dressing from the wound for a resident (Resident #4). This occurred for 1 of 1 resident observed for wound care. The findings included: The facility's policy entitled Hand Hygiene last revised on 08/21/23 read in part: The hands are the conduits for almost every transfer of potential pathogens from one patient to another, from contaminated object to a patient, and from a staff member to a patient. Because of this, hand hygiene is the single most important procedure to prevent infection. Washing with soap and water is appropriate when the hands are visibly soiled or contaminated with blood or other body fluids, when exposure to potential spore-forming pathogens is strongly suspected or proven, and after using the restroom. An alcohol-based hand rub is appropriate for decontaminating the hands: Before direct patient contact, putting on gloves, or inserting an invasive device After contact with inanimate objects in the patient's environment After removing gloves Hand sanitizing: Apply alcohol-based hand rub to the palm of one hand and then rub your hands together, covering all surfaces of your hands. Continue rubbing your hands together until all the product has dried. A wound treatment observation was made on 07/17/24 at 2:15 PM on Resident #4 with the Treatment Nurse. The Treatment Nurse gathered her supplies and placed them on the overbed table which she had covered with a clean garbage bag. The Treatment Nurse washed her hands with soap and water, dried them and donned clean gloves. She proceeded to pull up a chair to the bedside of the resident with her gloved hands and sat down in the chair and applied her isolation gown (Resident #4 was on Enhanced Barrier Precautions) after sitting down in the chair. With the same gloves on, the Treatment Nurse began preparing her dressing and applied antimicrobial skin and wound gel to her gauze and cut her bordered gauze dressing to fit the wound. She doffed her gloves and without sanitizing her hands, donned a clean pair of gloves and removed the old dressing from Resident #4's wound. The Treatment Nurse then doffed her gloves, sanitized her hands, donned clean gloves and proceeded to clean the wound with wound cleanser. She doffed her gloves after cleansing the wound, sanitized her hands, and donned clean gloves and applied the wound gel gauze dressing and covered the wound with the bordered gauze dressing. The Treatment Nurse bagged her trash, doffed her gloves, washed her hands with soap and water and discarded her trash and carried her supplies out of the room. An interview on 07/18/24 at 10:38 AM with the Treatment Nurse revealed she thought it was ok to change gloves without sanitizing her hands because she had not yet touched the resident. She stated she remembered sanitizing her hands during the process of the dressing change but said she should sanitize her hands with every change of her gloves. An interview on 07/18/24 at 11:14 AM with the Infection Preventionist (IP) revealed she did handwashing audits on all staff as part of the infection control program. The IP explained that she would have expected the Treatment Nurse to have sanitized her hands after doffing gloves and before donning clean gloves as outlined in their handwashing policy. She stated in addition, someone from corporate comes in twice a month and does random audits on staff for handwashing. The IP further stated she had not watched the Treatment Nurse or audited her during dressing changes and to her knowledge that corporate had not audited her either but said they could add her to their audit to watch her during dressing changes. An interview on 07/18/24 at 3:01 PM with the Director of Nursing (DON) revealed it was her expectation for all staff to follow the handwashing policy and procedure and sanitize their hands with alcohol-based hand rub or wash their hands with soap and water any time they removed their gloves.

Based on observations and staff interviews the facility failed to ensure food preparation knives ready for use were clean. This practice had the potential to affect food served to residents. Findings included: On 3/22/23 at 11:55 AM an observation of the kitchen revealed two food preparation knives ready for use in the knife storage rack contained visible dried debris on the sides of the blades. The cook was present when the observation was made. On 3/22/23 at 12:54 PM the Dietary Manager (DM) stated the knives were assigned to be cleaned by the cook after use and were placed in the knife rack by the cook. The DM said the knives should have been cleaned and stored without dried debris on them and were overlooked before storing them. The cook was interviewed on 3/22/23 at 1:13 PM and stated the cooks were responsible to wash, clean and sanitize the knives after use. He said the knives were checked for cleanliness before placing them into the storage rack for use. The cook said he believed the 2 knives were overlooked when they were cleaned. The Administrator stated on 3/23/23 at 2:14 PM that the knives should have been cleaned prior to storing them in the knife rack.

Based on observation and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions that the committee had previously put into place following the facility's [DATE] recertification survey. The failure related to two deficiencies that were originally cited during the [DATE] recertification survey and was cited on the current recertification and complaint survey of [DATE]. The recited deficiencies were in the areas of infection prevention and control and food safety requirements and store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The continued failure of the facility during two surveys of record in the same area showed a pattern of the facility's inability to sustain an effective Quality Assurance program. The Findings included: This tag is cross referenced to: F-880 Based on observations, record review and staff interviews the facility failed to implement their policy for Infection Prevention when 1 of 1 staff (Nurse Aide #1) failed to put on gloves and a gown before entering a resident's room for 1 of 2 residents on contact precautions (Resident #6). During the recertification survey of [DATE] the facility was cited for F-880. The facility failed to implement the Centers for Disease Control and Prevention (CDC) guidelines for the use of Personal Protective Equipment (PPE) when 1 of 3 staff members (Staff #1) failed to discard her N95 mask and disinfect her goggles after leaving a quarantine room and before going to a non-quarantine room, 1 of 3 staff members (Staff #2) had no eye protection while in the quarantine room, and 1 of 3 staff members (Staff #3) wore a surgical mask and had no eye protection while in a quarantine room. These practices affected 4 of 4 residents reviewed for infection control. These failures occurred during a COVID-19 pandemic. F-812 Based on observations and staff interviews the facility failed to ensure food preparation knives ready for use were clean. This practice had the potential to affect food served to residents. During the recertification survey of [DATE] the facility was cited for F-812. The facility failed to dispose of expired perishable food items in 1 of 1 cooler. Staff drinks were observed to be stored alongside resident food items in the kitchen freezer. The facility also failed to dispose of expired foods and date individual cartons of juice and bottled drinks in 1 of 2 resident nourishment rooms. On [DATE] at 2:32 PM the Administrator was interviewed and explained the incidents were isolated. The infection control incident broke down because the staff was not paying attention. The facility had been focused on infection control for 3 years and had improved infection control procedures with lots of training and staff education. The kitchen knives were overlooked and should have been cleaned. Quality assurance committee met monthly, and the goal was to be and remain in compliance with CMS regulations.

Based on observations, record reviews, and staff interviews, the facility failed to implement their policy for Infection Prevention when 1 of 1 staff (Nurse Aide #1) failed to put on gloves and a gown before entering a resident's room for 1 of 2 residents on contact precautions (Resident #6). The findings included: The facility's policy entitled, Infection Prevention .Contact, Contact Enteric . read in part, Isolation precautions will be used .when standard precautions alone are not adequate to eliminate or minimize occupational exposure to communicable disease .contact precautions are indicated for patients who are known or suspected to be infected with microorganisms that can be transmitted by direct contact with the patient or indirect contact with environmental surfaces .personal protective equipment (PPE) including gloves and gown are worn to enter a patient's room. Perform hand hygiene with soap and water when leaving room. Resident #6 was admitted to the facility on [DATE] with current diagnoses of Clostridioides diffcile (C-diff), a bacterium that causes an infection of the large intestines, and Methicillin-resistant Staphylococcus Aureus (MRSA), a bacteria that can cause serious infections that can lead to sepsis or death. An observation of the 300-hall on 3/20/23 at 12:20pm revealed Resident #6 was on contact precautions and the signage on the door instructed staff to clean their hands before entering the room, put on gloves before entering the room and put on a gown before entering the room. A continuous observation from 12:20pm to 12:22pm revealed NA #1 went into room [ROOM NUMBER] to deliver the lunch tray. NA #1 did not put on gloves or a gown before taking the meal tray into the resident. NA #1 adjusted the bedside table and pulled the curtain while in the resident's room. NA #1 exited the room, cleaned her hands with hand sanitizer and continued down the hall towards the meal cart. An interview on 3/20/23 at 12:22pm with NA #1 revealed she was aware that Resident #6 was on contact precautions. She stated that since she was not handling the resident's urine, she did not need to put on gloves and a gown. She then stated she should have put on gloves and a gown to enter the resident's room when delivering the meal tray. An interview on 3/20/23 at 4:53pm with the Infection Preventionist (IP) revealed that when a resident was on contact precautions, gloves and a gown should be worn when entering the room, regardless of the reason for going into the room. NA #1 should have put on gloves and a gown before entering the resident's room regardless of the reason for going into the room. The IP stated there were plenty of personal protective equipment (PPE) supplies available and the PPE was provided outside the door of room [ROOM NUMBER]. An interview on 3/21/23 at 3:45pm with the Director of Nursing (DON) revealed NA#1 should have put on gloves and a gown before entering room [ROOM NUMBER]. The DON stated there were plenty of PPE supplies available and were provided outside the door of room [ROOM NUMBER]. She further stated staff should don PPE before entering a room with contact precautions regardless of the reason for going into the room. An interview on 3/23/23 at 2:04pm with the Administrator revealed staff have been educated many times about using PPE when entering a room on contact precautions. The Administrator further stated that regardless of the reason, NA#1 should have donned gloves and a gown before she entered room [ROOM NUMBER].

Based on observations, resident and staff interviews and record review the facility failed to ensure the Minimum Data Set (MDS) was accurate for 2 of 3 residents reviewed for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 1.Resident #6 was admitted to the facility on [DATE] with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #6 required limited assistance with activities of daily living (ADL) and was not coded for active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated 03/08/21 revealed Resident #6 had stated to a staff member that he felt like killing himself at times. He was referred to the Psych Physician for a consultation. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A joint interview was conducted with the MDS Nurse on 06/10/21 at 11:43 AM. Resident #6's electronic medical record revealed Resident #6 was taking an antidepressant medication during the assessment period for an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS nurse stated she had just missed coding the active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An interview conducted with the MDS Corporate Consultant on 6/10/21 at 11:50 AM revealed Resident #6 was taking an antidepressant medication for an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview conducted with the Director of Nursing (DON) on 06/10/21 at 4:20 PM revealed Resident #6's MDS should be accurately coded for active diagnosis. An interview conducted with the Administrator on 06/10/21 at 4:45 PM revealed there were errors on Resident #6's MDS and the resident's active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The interview revealed the facility had no recent in-servicing on MDS coding. 2. Resident #43 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #43 required extensive assistance with activities of daily living (ADL) and was not coded for active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A joint interview was conducted with the MDS Nurse and MDS Corporate Consultant on 06/10/21 at 11:50 AM. Review of Resident #43's electronic medical record revealed the resident had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interview further revealed the MDS Cooperate Consultant expected for depression to be coded on Resident #43's MDS. An interview conducted with the MDS Corporate Consultant on 6/10/21 at 2:30 PM revealed Resident #43 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It was further revealed the MDS Cooperate Consultant expected for [CONDITION(S)] to be coded on Resident #43's MDS. An interview conducted with the Director of Nursing (DON) on 06/10/21 at 4:20 PM revealed Resident #43's MDS should be accurately coded for active diagnoses. An interview conducted with the Administrator on 06/10/21 at 4:45 PM revealed there were errors on Resident #43's MDS and the resident's active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Resident #80 was readmitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #80 required extensive assistance with activities of daily living (ADL) and was coded for Hospice care under special treatments, procedures, and programs. A Hospice progress note dated 01/23/21 revealed Resident #80 was discharged from Hospice care in need of no further services. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A joint interview conducted with the MDS Nurse and MDS Corporate Consultant on 06/10/21 at 11:50 AM revealed after review of Resident #80's electronic medical record the resident should have not been coded for Hospice due to being discharged before the last MDS review. An interview conducted with the Director of Nursing (DON) on 06/10/21 at 4:20 PM revealed Resident #80's MDS should have been accurate and should not have been coded with current Hospice care. An interview conducted with the Administrator on 06/10/21 at 4:45 PM revealed Resident #80 should not have been coded for Hospice care due to being discharged before the most current MDS review. 4. Resident # 60 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 60's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident # 60 required extensive assistance of one person for bed mobility, dressing, and personal hygiene. Resident # 60 required extensive assistance of two persons for transfers. The MDS indicated Resident # 60 required use of limb and trunk restraints. A review of Resident # 60's medical record revealed no orders or care plans for restraints. Observations of Resident # 60 on 6/6/2021 at 3:36 PM revealed she had a yellow nameplate outside her door (indicating she was a high fall risk). Resident # 60 was sitting upright with a half lap-tray on the right side of her wheelchair. Her right arm was resting on the tray. Resident # 60 was alert but did not respond appropriately to questions. The resident was observed on 6/9/2021 at 3:28 PM lying on her back in a low bed with a scoop mattress. On 6/10/2021 at 10:30 AM Resident # 60 was sitting upright in her wheelchair using her feet to mobilize in the hallway. The resident was observed to grab the wall and attempt to stand. She was observed to stand almost upright before a staff member redirected her. An interview with Nurse Aide # 1 (NA) on 6/10/2021 at 9:23 AM revealed Resident # 60 was a high fall risk. Interventions to prevent falls included a low bed, a scoop mattress, gripper socks, room close to the nurse's station, and frequent checks. NA # 1 stated she was not aware of the use of any restraints in the facility. An interview with the MDS Nurse # 1 on 6/10/2021 at 11:54 AM revealed Resident # 60 did not utilize restraints. The Nurse stated she clicked on restraints by accident when completing the 4/27/2021 MDS. She stated she made the correction earlier today. An interview with the Safety Nurse (Nurse # 12) on 6/10/2021 at 2:50 PM revealed the facility was restraint-free. She stated residents who were a high falls risk were provided numerous interventions to prevent falls up to, but not including restraints. Interventions included yellow nameplates on resident doors, low beds, gripper socks, wheel locks for wheelchairs, call bells, personal items, sensory items and mobility aids (wheelchairs / walkers) all within reach and traffic paths clear of clutter. The Safety Nurse indicated Resident # 60 had a half lap-tray in place for support due to recent fracture of her right arm. As Resident # 60 can still get up, the lap-tray was not a restraint. The Safety Nurse also informed a neurologist had ordered an abdominal binder for hypotensive episodes, but the binder was only placed around the resident's abdomen and was not used to secure her to the wheelchair. An interview with the Director of Nursing on 6/10/2021 at 4:30 PM revealed the facility did not utilize restraints for any resident. She stated the MDS entry for restraints must have been completed in error. She stated her expectation of the MDS was for it to be coded correctly. An interview with the Facility Administrator on 6/10/2021 at 4:55 PM revealed the facility was restraint-free. She stated the MDS was most likely coded in error. Her expectation of the MDS was that it be coded accurately.

Based on observation and staff interviews, the facility failed to dispose of expired perishable food items in 1 of 1 cooler. Staff drinks were observed to be stored alongside resident food items in the kitchen freezer. The facility also failed to dispose of expired foods and date individual cartons of juice and bottled drinks in 1 of 2 resident nourishment rooms. The findings included: a. An observation of the cooler was made on [DATE] at 10:50 AM with the Dietary Manager (DM). The observation revealed the following: A container of [MEDICATION(S)] salad three-fourths full, with an expiration date of [DATE] written on the container A container of chicken salad, full, with expiration date of [DATE] written on the container b. An observation of a freezer was made on [DATE] at 11:15 AM. The DM was present. The observation revealed the following: Two staff members' drinks were stored alongside food items in a freezer reserved for food for resident consumption. c. An observation of the nourishment room on the 200 hall was completed on [DATE] at 11:25 AM. A staff nurse was present. The observation revealed the following: An intact box of thickened apple juice with use by [DATE] stamped on the box inside the cabinet. A bin of prune juice containers in the refrigerator with no expiration dates on the containers in the refrigerator. 3 bottled drinks with no expiration dates on the bottles in the refrigerator (Available for any resident consumption) 4 containers of vanilla pudding with expiration dates of [DATE]. An interview was conducted with the DM on [DATE] at 11:15 AM. The DM stated the expired items in the cooler should have been disposed of at the end of the shift on the day of expiration. He stated opened items should have had the open date written on the package. The DM stated staff thermoses should not be stored alongside items for resident consumption. An interview with the Director of Nursing on [DATE] at 11:55 AM revealed the nourishment rooms were checked daily by dietary staff. She stated the check included review of expiration dates. She indicated the items must have simply been missed. She stated, all we can do now, is do better. An interview with the Administrator on [DATE] at 4:50 PM revealed the food items in the kitchen cooler should have been discarded on the expiration date, the opened items should have been labeled with an opened date, and the nourishment room items should have been checked more closely and disposed of accordingly. She could not explain why personal mugs were stored in the dedicated resident freezer. She stated the DM was still very new to long-term care and would make sure corrections were made.

Based on record review, observations and staff interviews, the facility failed to implement the Centers for Disease Control and Prevention (CDC) guidelines for the use of Personal Protective Equipment (PPE) when 1 of 3 staff members (Staff #1) failed to discard her N95 mask and disinfect her goggles after leaving a quarantine room and before going to a non-quarantine room, 1 of 3 staff members (Staff #2) had no eye protection while in the quarantine room, and 1 of 3 staff members (Staff #3) wore a surgical mask and had no eye protection while in a quarantine room. These practices affected 4 of 4 residents (Resident #235, Resident #338, Resident #285 and Resident #322) reviewed for infection control. These failures occurred during a COVID-19 pandemic. The findings included: The Centers for Disease Control and Prevention (CDC) guideline entitled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 2/23/21 indicated, in part: *The Personal Protective Equipment (PPE) recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: 1. Respirator - Put on an N95 respirator (or equivalent or higher-level respirator) before entry into the patient room or care area, if not already wearing one as part of extended use strategies to optimize PPE supply. Disposable respirators should be removed and discarded after exiting the patient's room or care area and closing the door unless implementing extended use or re-use. Perform hand hygiene after removing the respirator or facemask. 2. Eye Protection - Put on eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use strategies to optimize PPE supply. Remove eye protection after leaving the patient room or care area, unless implementing extended use. Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use unless following protocols for extended use or re-use. A review of the facility's COVID-19 policy entitled, COVID-19 Resident/Teammate Management - COVID Outbreak Response, revised on 3/2021 indicated the following statements under PPE Enhancement: 1. Respiratory protection should be worn at all times when not eating or drinking in the facility. Eye protection for all patient care. 2. For hallways/neighborhoods with two or more cases, teammates shall wear N95 or equivalent respirator for all resident care for the duration of the outbreak. 3. If the outbreak extends beyond a single hallway/neighborhood, routine N95 use will be expanded as appropriate. The facility did not have a policy regarding PPE use and management for staff members when working in the quarantine hall designated for new admissions and re-admissions. 1. A continuous observation was made of Staff #1 on 6/9/21 from 8:14 AM to 9:08 AM during medication administration. During the observation, a sign for special droplet/contact precautions was on Resident #235's room door. While preparing Resident #235's medications in the hallway, Staff #1 was observed wearing a surgical mask and goggles. As she got ready to enter Resident #235's room, Staff #1 discarded the surgical mask, used hand sanitizer and put on an N95 mask on her face. She proceeded to put on a gown and gloves and entered Resident #235's room to administer her medications. Before leaving the room, Staff #1 removed her gown and gloves and washed her hands in the room sink. Staff #1 exited Resident #235's room and did not discard her N95 mask or disinfect her goggles. At 8:26 AM, Staff #1 entered Resident #338's room who was not on special droplet/contact precautions and asked Resident #338 what she wanted to drink. Staff #1 then proceeded to walk from the 400 hallway and passed through 100 hall to the nourishment room that was located on the 200 hall. After obtaining some juices out of the refrigerator, Staff #1 went back to Resident #338's room to give her medications. At 9:08 AM, Staff #1 entered Resident #285's room who was not on special droplet/contact precautions and asked Resident #285 what he wanted to drink with his medications. An interview conducted with Staff #1 on 6/9/21 at 9:09 AM revealed she forgot and should have discarded her N95 mask when she left Resident #235's room who was on special droplet/contact precautions. Staff #1 confirmed that Resident #235 was currently the only newly admitted resident on the hall who was on special droplet/contact precautions. Staff #1 stated that she had been told to leave her goggles on the whole time she was working and to only clean it between shifts unless it was visibly soiled. An interview with the facility's Infection Preventionist on 6/9/21 at 4:28 PM with the Administrator present revealed Staff #1 should have discarded her N95 mask and sanitized her goggles when she exited Resident #235's room. An interview with the organization's Infection Preventionist (IP) on 6/10/21 at 11:15 AM revealed the facility had been practicing extended use for N95 mask and eye protection. The staff members had been trained not to remove their N95 mask and goggles once they put them on, treat both PPE as part of their face and not to touch their face. The organization's IP stated they felt there was a higher chance of contamination with constantly touching their masks to remove them. She explained that the facility was following the organization's infection control policies and procedures. An interview was conducted on 6/10/21 at 4:26 PM with the Director of Nursing (DON) who stated she did not expect Staff #1 to discard her N95 mask and disinfect her goggles after exiting a room on special droplet/contact precautions because that was not what they were trained to do. The DON stated the facility was following the organization's infection control policies and procedures which included to discard their masks and disinfect their goggles at the end of the day. An interview with the Administrator on 6/10/21 at 4:51 PM revealed she expected Staff #1 to have done what she was trained to do related to PPE use. She added that it was hard to keep up with the CDC guidelines because they kept on changing all the time. 2. An observation was made on 06/09/21 of Staff #2 entering Resident #235's room who was on enhanced droplet contact precautions according to the sign on the resident's door. He entered Resident #235's room at 12:40 PM with an N95 mask on but no goggles or face shield. Resident #235 was admitted to the facility on [DATE], and according to her discharge summary from the hospital, was not vaccinated for COVID-19 and had refused vaccines while hospitalized so the resident was placed on enhanced droplet/contact precautions for 14 days. Staff #2 was observed approximately 2 feet from the resident while obtaining her history and exited the room at 1:21 PM. An interview was conducted on 06/09/21 at 2:59 PM with Staff #2. He revealed he had been involved from the beginning through their Quality Assurance and Process Improvement program with COVID-19. He stated he and the Nurse Practitioner (NP) work closely together in managing the residents at the facility. He further stated they were following the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) guidance for nursing homes in caring for the residents at the facility. He mentioned the hospital organization the facility belonged to had also provided education and guidance to the facility staff on COVID-19. Staff #2 indicated he and the staff at the facility were following the protocols and were wearing all the appropriate Personal Protective Equipment (PPE) when caring for the residents. An interview with the facility's Infection Preventionist (IP) on 06/09/21 at 4:28 PM with the Administrator present, revealed Staff #2 was expected to wear goggles when in resident rooms who were on enhanced contact/droplet precautions. An interview with the organization's IP on 6/10/21 at 11:15 AM revealed the facility was following the organization's infection control policies and procedures. The organization's IP stated Staff #2 was expected to wear goggles while in resident rooms who were on enhanced contact/droplet precautions. 3. Resident #236 was admitted to the facility on [DATE], and according to her discharge summary from the hospital, was not vaccinated for COVID-19 and had refused vaccines while hospitalized so the resident was placed on enhanced droplet/contact precautions for 14 days. On 06/09/21 at 1:29 PM Staff #3 was observed entering Resident #236's room with gown, gloves and surgical mask on but no N95 mask and no goggles or face shield on to deliver the resident a pitcher of water. Staff #3 was observed exiting the room, doffing her gown and gloves. An interview on 06/09/21 at 1:35 PM with Staff #3 revealed she had not paid attention to the sign on the resident's door for enhanced droplet/contact precautions and the need for an N95 when going into the room. She stated she was concentrated on getting the resident some water to drink and had not read the sign before entering the room. Staff #3 stated she had received training regarding wearing the appropriate Personal Protective Equipment (PPE) into the room of a resident on enhanced contact precautions but stated she had failed to put on an N95 mask and goggles prior to going into Resident #236's room. An interview with the facility's Infection Preventionist on 6/9/21 at 4:28 PM with the Administrator present revealed Staff #3 should have donned an N95 mask and goggles prior to going in Resident #236's room and should have discarded the N95 when leaving the room and donned a surgical mask for source control. An interview with the organization's Infection Preventionist (IP) on 6/10/21 at 11:15 AM revealed the facility was following the organization's infection control policies and procedures. The organization's IP stated the staff were expected to wear an N95 and goggles while in resident rooms who were on enhanced contact/droplet precautions. The organization's IP further stated they had been practicing extended use for N95 mask and eye protection.

Based on observations, record reviews, and resident, and staff interviews, the facility failed to provide shaving of chin hairs and nail care to maintain personal hygiene for 2 of 3 dependent residents (Residents #73 and 105) reviewed for activities of daily living (ADL). The findings included: 1. Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #73's most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed she was cognitively intact for daily decision making and revealed she was dependent on 1 staff person for personal hygiene. A review of Resident #73's care plan dated 01/23/19 revealed she had a care plan for activities of daily living (ADL). The care plan stated Resident #73 was at risk for decline in her ability to participate in daily care due to muscle spasms and severe contractures in all her joints. The goals were for Resident #73 to continue to participate in daily care and for staff to complete bathing, grooming, dressing and incontinence care through the next review. The interventions included among others total assistance with all personal hygiene, dressing, toileting and bathing needs. A review of the shower schedule for all residents revealed Resident #73 was scheduled for 2 showers per week on Tuesday and Friday on 1st shift (7:00 AM to 3:00 PM). An observation and interview on 02/25/19 at 11:59 AM with the resident revealed she had visible grey chin hairs that were approximately ¼ inch long. The resident stated she liked for her chin hairs to be trimmed but she could not do it herself. An observation and interview on 02/27/19 at 9:55 AM with the resident revealed she had a bed bath yesterday and stated they had not trimmed her chin hairs after her bath. Resident #73 still had grey chin hairs that were approximately ¼ inch long. An observation and interview on 02/28/19 at 10:57 AM revealed the resident resting in bed and stated she had her bed bath and there were visible powders on her chest and she was dressed in clean matching clothing. Resident #73 stated she did not know why they had not shaved her chin hairs after her bath but stated she would like them trimmed. An interview on 02/28/19 at 11:10 AM with Nurse Aid (NA) #4 revealed she was able to see the chin hairs on Resident #73 and stated she did not think about trimming them after her bath but stated she would trim them now. An observation and interview on 02/28/19 at 3:46 PM with Resident #73 revealed she had her chin hairs shaved and the resident rubbed her chin and stated her chin was so smooth and it felt so good to have it shaved. An interview was conducted on 03/01/19 with the Director of Nursing (DON) and Administrator. The DON stated she would have expected the resident's chin hairs to have been shaved following her bath. The DON stated shaving men and women was a part of their routine hygiene care. 2. Resident #105 was admitted to the facility on [DATE] for short term rehab with [DIAGNOSES REDACTED]. A review of Resident #105's most recent admission Minimum Data Set ((MDS) dated [DATE] revealed he was severely cognitively impaired for daily decision making, had unclear speech and required extensive to total assistance of 1 to 2 staff with all activities of daily living (ADL). A review of Resident #105's care plan dated 12/07/18 revealed he had a care plan for activities of daily living (ADL). The care plan stated Resident #105 was at risk for decline in his ability to participate in daily care due to cognition and difficulty communicating and weakness. The goals were for Resident #105 to continue to participate in daily care and for staff to anticipate needs and complete bathing, grooming, dressing and incontinence care through the next review. The interventions included among others extensive assistance with all personal hygiene, dressing, toileting, and total care with bathing. A review of the shower schedule for all residents revealed Resident #105 was scheduled for 2 showers per week on Monday and Thursday on 1st shift (7:00 AM to 3:00 PM). An observation and interview on 02/25/19 at 9:53 AM revealed Resident #105 lying in bed with tee shirt and brief on. His tube feeding was infusing via pump. The resident was noted to have long fingernails on both hands with nails extending ¼ to ½ inch beyond the end of his fingers. The left index finger was noted to have brown debris under it and the nail according to the resident had been mashed and injured. The resident stated he could not trim his nails and did not like for them to be long. An observation on 02/26/19 at 9:43 AM revealed Resident #105 lying in bed and his nails were still long and extending ¼ to ½ inch beyond his fingertips. The resident stated he had his bath yesterday but they had not trimmed his nails. An observation on 02/28/19 at 9:40 AM revealed Resident #105 was lying in bed with his tube feeding infusing via pump. His sitter was at his bedside and stated the staff usually washed him off about every day and got his dressed. The sitter stated they had washed him up and dressed him but had not cut and cleaned his nails. An interview with Nurse Aid (NA) #5 and Nurse #3 revealed they had not noticed his fingernails or the debris under his index nail on his left hand. NA #5 stated she would clean under his nails and Nurse #3 stated she would trim his nails. NA #5 and Nurse #3 stated his nails should have been cleaned and trimmed after his bath. An interview was conducted on 03/01/19 with the Director of Nursing (DON) and Administrator. The DON stated she would have expected nail care to have been done following his bath/shower. The DON stated nail care was a part of their routine hygiene care.

Based on record review and staff interviews, the facility failed to complete the quarterly Minimum Data Set (MDS) assessment within the required time frame for 1 of 11 sampled residents reviewed for complete quarterly MDS assessments (Resident #4). The findings included: Resident #4's most recent Minimum Data Set (MDS) was a quarterly that was completed on 10/19/18. Review of her computerized medical record revealed that the next MDS which had an assessment reference date (ARD) of 02/07/19 was not completed when reviewed on 02/28/19. An interview with the MDS coordinator was conducted on 02/28/19 at 3:18 PM. The MDS coordinator stated that for the most part, she was able to complete MDS assessments on time, however, she stated Resident #4's assessment was not completed on time. She stated Resident #4's due assessment was triggered late and she has not completed the assessment as of this date. The MDS coordinator stated she has found that the computer system was missing a few residents and not notifying her of due dates, Resident #4 being one of those that was not being triggered on time. She stated that although she identified this as a problem she had not informed anyone in management or corporate of the identified problem. A joint interview with the Director of Nursing and the Administrator on 03/01/19 at 9:29 AM revealed that neither had been informed of any computer issues resulting in MDS assessments not being triggered on time. They stated they expected the MDS assessments to be completed within the required time frames. An interview with the secretary on 03/01/19 at 9:44 AM revealed that she kept a manual schedule of due dates for MDS assessments to assist the MDS coordinator keep track of due dates. She showed her system and noted that Resident #4 was scheduled for the quarterly in (MONTH) 2019 as due but it was scratched off and not done. She was not sure why. She further stated that the computer system did not catch and inform staff that Resident #4's quarterly MDS was due in January. She also stated that she has noticed there was a problem with the computer not triggering required assessments on time but that she has not reported this problem to anyone. She stated she was not sure what happened resulting in Resident #4 not having a quarterly assessment on time.

Based on record review and staff interview, the facility failed to transmit a discharge return anticipated Minimum Data Sets (MDS) assessment in the required time frames for 1 of 4 sampled discharged residents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE]. The admission Minimum Data Set ((MDS) dated [DATE] was completed. She then had a significant change MDS completed on 09/07/18. Review of the computerized record revealed that Resident #1 was discharged with return anticipated on 10/08/18. Resident #1 was never readmitted to the facility and the discharge MDS was noted to be ready for transmission but had not been transmitted as of 02/28/19. An interview with the MDS coordinator was conducted on 02/28/19 at 3:23 PM. The MDS coordinator stated that since (MONTH) (YEAR) she has been without the second MDS staff. She further stated that she has been transmitting assessments about every other day. The MDS coordinator stated that she noticed a couple of days ago that the discharge MDS was still open so fixed it and it was now ready to be sent. She stated the discharge MDS was completed, just not transmitted. A joint interview with the Director of Nursing and the Administrator on 03/01/19 at 9:30 AM revealed they stated they expected the MDS assessments to be transmitted when completed and on time.

Based on observations, record reviews, and staff interviews, the facility failed to utilize the correct lift to transfer 1 of 3 sampled residents resulting in a fractured arm. (Resident #63) The findings included: Resident #63 was admitted to the facility 09/03/08 with [DIAGNOSES REDACTED]. A review of Resident #63's medical record revealed hospice services were initiated 03/25/13 relating to adult failure to thrive and Alzheimer's dementia. A quarterly Minimum Data Set ((MDS) dated [DATE], indicated Resident #63 demonstrated memory loss and unclear speech but was usually understood and usually understood others. The MDS specified the resident's cognition was moderately impaired with poor decision making and required staff cueing and supervision. The MDS described Resident #63 as totally dependent on staff assistance for all care including transfers from bed to chair and did not ambulate during the assessment period. Resident #63's weight was recorded on this MDS as 122 pounds. A care plan dated 08/06/13 identified Resident #63 with a self care deficit related to impaired mobility and memory. The care plan specified the resident had decreased safety awareness. The care plan goal included the resident would receive no injuries from falls. Care plan interventions contained instructions for a mechanical lift for transfers. A review of Resident #63's medication administration records (MAR) dated 09/01/13 through 09/30/13 and 10/01/13 through 10/31/13 was conducted. Physician orders [REDACTED]. Comparing the 09/2013 MAR with the 10/2013 MAR revealed no notable increase in dosages or frequency of pain medication had been administered through 10/21/13. A review was conducted of a "Help-Me" guide for nursing assistants updated 10/08/13. The guide provided instructions to utilize a mechanical lift for transfers for Resident #63. Further review of Resident #63's medical record revealed a nurse's note dated 10/13/13 at 3:25 PM. The note specified a nursing assistant reported the resident had a raised area on the forehead. The nurse documented the resident was up in a high-backed cushioned chair and vital signs and oxygen saturations were within normal limits for this resident. The documentation also included when the resident was asked how this raised area occurred, the resident responded "I don't know." An additional nurse's note dated 10/13/13 at 6:00 PM documented the resident complained of right arm and shoulder pain upon movement. An assessment of the resident revealed slight swelling was noted to the right shoulder and a small abrasion was noted to the right lower leg. The note continued the physician was notified and requested the resident be sent to the hospital for evaluation. A review of Emergency Department (ED) Physician documentation dated 10/13/13 at 7:22 PM was conducted. The ED Physician described Resident #63 as nonambulatory for more than 5 years and required evaluation of a bruise on the forehead and swelling and pain in the right upper arm. The report also noted some abrasions on the back of the resident's lower legs. The resident was further described as unable to turn over in the bed without assistance. Further review of the ED Physician's documentation revealed x-rays of the right arm and shoulder and a computed tomography (CT) of the head were completed. Results of the shoulder and arm x-ray revealed a fracture of the upper right arm and an additional [DIAGNOSES REDACTED]. The CT showed no evidence of trauma to the head. The ED Physician's documentation specified the resident's right arm was placed in a sling with a swath for further support and returned to the facility. No medication changes were ordered. Continued review of Resident #63's medical record revealed a nurse's note dated 10/13/13 at 11:30 PM. The note documented the resident's return to the facility. The note contained information describing the sling was in place. The note documented, after the resident was positioned in the bed, the resident acknowledged she was comfortable and without pain. A review was conducted of a statement provided to the Director of Nursing (DON) by Nursing Assistant (NA) #3 on 10/14/13 after NA #3 was called at 4:30 PM to return to the facility. The statement specified at around 11:30 AM on 10/13/13, NA #3 was returning from her break. She observed NA #2 coming out of Resident #63's room with a sit to stand lift. NA #3 stated NA #2 asked NA #3 what lift was used by Resident #63. She replied the mechanical lift. NA #2 stated she could not find that lift and asked if NA #3 would help her use the sit to stand lift to transfer Resident #63 from her bed to the chair. NA #3 obliged and assisted NA #2 with the transfer using the sit to stand lift. NA #3 stated she did notice a bruise on Resident #63's forehead that contained a small scratch in the middle of the bruise. Other statements from staff members that worked 10/13/13 on Resident #63's unit including NA #2 were reviewed. These statements were dated as obtained on 10/14/13 through 10/15/13. Review of these statements revealed NA #2 was interviewed multiple times on these days. NA #2 provided conflicting information. A handwritten physician's progress note dated 10/18/13 and signed by the Medical Director (MD) was reviewed. The note indicated the MD determined Resident #63's fractured arm was a result of the incorrect lift being utilized for a transfer of the resident from her bed to the chair. An observation of Resident #63 being transferred from bed to chair was conducted on 10/21/13 at 11:59 AM. Nursing Assistant (NA) #1 and Nurse #1 were observed utilizing a mechanical lift for the transfer. The resident was observed with a sling on her right arm that contained a pillow for support. The nursing assistant and nurse placed a sling under the resident's body while the resident was lying in bed. The sling extended from the resident's head to her knees and supported her legs, arms, and torso. The corners of this sling were then attached to bars on the mechanical lift. As the bars were lifted via a motor contained within the lift, the sling cradled the resident's body. The resident's body was raised from the bed and guided by the staff to a chair. The chair was high-backed and contained cushions for support. At no time during the transfer did the resident call out, grimace, or indicate she experienced pain. After being position in the cushioned chair, NA #1 asked the resident if she was comfortable. The resident was observed nodding her head to indicate her answer was yes. An interview with the Administrator was conducted 10/21/13 at 2:53 PM. The Administrator stated she was first notified by facility staff at approximately 5:40 PM on 10/13/13 that Resident #63 was complaining of right arm pain and would be sent to the hospital for evaluation per physician's orders [REDACTED]. The Administrator called the facility at approximately 2:00 AM on 10/14/13 and received a report confirming the resident had returned to the facility and did have a fracture to the right upper arm. The origin of the fracture was unknown. The Administrator stated at that time she notified the police via phone. Around 9:25 AM on 10/14/13 two policemen came to the facility. They informed the Administrator the police would not investigate until the facility investigated and suspected a crime against the elderly had been committed. At 9:41 AM on 10/14/13 a 24 hour report was faxed to the Department of Health Services Regulation. Throughout that day the facility investigation was conducted by the Administrator, Director of Nursing (DON), and Clinical Coordinator. Nurses and nursing assistants were interviewed and statements taken. Residents were also interviewed and no concerns were identified by the residents. On 10/14/12 it was determined NA #2 and NA #3 used an incorrect lift during the transfer of Resident #63 on 10/13/13. Both of these nursing assistants were suspended that day. The Administrator stated due to multiple discrepancies in NA #2's statements she provided explaining how the incident occurred, she was terminated 10/16/13. NA #3 was suspended during the investigation. She was re-educated on the proper transferring of residents and will be monitored for one month to ensure compliance with facility policies. The Administrator stated the conclusion that the sit to stand lift was used was reached by demonstrations of the use of the sit to stand lift. The way the straps fit the arms and the placement of the feet on the base of the lift were consistent with the fracture to the upper arm and abrasions noted on Resident #63's lower legs. The Administrator stated the Medical Director also concluded via demonstration of the sit to stand lift, the fractured upper arm was consistent with the strap on the sit to stand lift pulling under the right arm as the lift raised the resident. The Administrator added the resident was too weak to hold onto the lift handles and hold her back straight without slumping as was required to utilize this lift. The Administrator stated during the investigation, Resident #63's roommate who was deemed interviewable, reported a lot of noise going on behind the curtain on the day of the incident. The Administrator explained NA #2 had reported the noise occurred when she attempted to push the lift close to the resident's bed. The Administrator added the facility concluded this was how the resident had hit her head on the lift and sustained the forehead bruise. Additional interview with the Administrator revealed beginning 10/14/13, education was provided to all clinical staff regarding facility policies concerning resident transfers. Also on this day, the facility staff development nurse began performing nursing assistant competencies which required return demonstrations of utilization of lifts and other nursing assistant tasks. The Administrator stated since this incident occurred the DON and Clinical Supervisor had audited other residents to ensure the correct lift was used. The Help-Me guides were also audited to ensure the correct lift was listed for each resident that required use of a lift for transfers. On 10/17/13 at 12:40 PM, a 5 day report was filed with the Department of Health Services Regulation. The report contained the results of this investigation as previously stated. Additional interviews on 10/21/13 at 3:50 PM with the Administrator and DON revealed re-education of clinical staff was initiated 10/14/13 and monitoring nursing assistants for the selection and use of lifts had begun. The facility plan also included the formation of a new committee called Performance Improvement. This committee will consists of direct care staff that will review all aspects of resident care including proper transfers. The committee will make recommendations as needed to management staff for improvement in systems and techniques. On 10/14/13, the Administrator made the decision to take this incident with the action plan to the next Quality Assessment and Assurance committee meeting this month. Observations, review of facility documentation and interviews with staff during the survey of 10/21/13 revealed the facility had implemented corrective actions. Observations of residents being transferred utilizing mechanical lifts revealed the proper lift was used correctly on 3 sampled residents. Interviews with staff revealed they had been instructed to use the correct lift and 2 staff members were required for each lift. Review of facility documentation revealed monitoring of NAs transferring residents safely with the recommended lift. Facility documentation review also revealed education and return demonstrations of lift operation began on 10/14/13.