Every finding on record at Compere NH Inc

Based on Residents' Rights review, record review and interviews the facility failed to prohibit the use of physical restraint to unnecessarily inhibit freedom of movement for one (1) of five (5) sampled residents. Resident #1. Findings Included:Record review of the facility document titled, Resident Rights Updated 4/04/25 revealed the document stated, Employees shall treat all residents with kindness, respect, and dignity .Record review of the facility policy titled, PHYSICAL RESTRAINT dated 2/20/2012 revealed the policy stated, Restrains shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully, and only with the informed consent from the resident, physician and/or responsible party.Physical restrains shall not be used to limit resident mobility.Record review of the Incident Report dated 7/18/26 prepared by Licensed Practical Nurse (LPN) #1 revealed Resident #1 was in bed with sheet tied to each side rail.Record review of the Final Investigation Report-Alleged Unauthorized Physical Restraint dated 7/21/26 revealed that, On the morning of July 18, 2026, at approximately 7:00 AM Registered Nurse (RN) # 1 working the cart.observed (Resident #1) restrained in her bed with a flat sheet secured from one side rail to the opposite side rail across her torso . According to record review of the Facility Investigation and an interview with the Administrator on 2/27/26 at 11:50 AM and with the Director of Nurses (DON) on 2/27/26 at 2:20 PM Registered Nurse (RN) #1 and LPN #1 removed the sheet immediately, assessed Resident #1 and noted no injury or distress, the licensed nurses then provided instruction to all nursing staff on duty regarding the use of unauthorized restraints and initiated an investigation. The Administrator reported the incident to SA within the required state and federal timeframe along with the final report. The DON initiated a mandatory In-Service Training regarding Residents Rights and Restraints for all nursing staff on 7/18/26 documented on In-Service Training Record with attached sign-in sheet dated 7/18/26. The DON initiated an audit of one hundred percent (100%) of residents and ensured that no restraints had been applied to any other residents in the facility and documented observations on Restraints Audit dated 7/18/26. The DON instituted monitoring of residents for three months documented on Restraints Monitoring record dated 7/18/26 through 7/27/26 to ensure that no unauthorized restraints were in use for any resident. The facility held an ad hoc Quality Assurance (QA) meeting on 7/27/26 documented on Quality Assurance Committee Meeting Agenda with attached sign-in sheet.On 7/29/26 at 11:33 AM, telephone interview with Certified Nursing Assistant (CNA) #1 revealed that the (CNA) had worked the nightshift on 7/17/26 and Resident #1 had been awake throughout the night, and the nursing staff supervised her to prevent her from getting up because she had had several recent falls. CNA #1 revealed that at approximately 4:30 AM she and CNA #1 had assisted Resident #1 to transfer from Geri recliner into bed and she had taken a flat sheet and folded it and tied each end to a quarter side rail on the left and right over and across the torso of Resident #1, whom she reported went to sleep and was resting quietly in bed with the bed in the lowest position. She confirmed that she had tied the sheet across the bed to protect the resident and remind her not to get out of bed if she awoke while the aides were conducting rounds and in the rooms of other residents.Record review of the written statement dated 7/20/26 and signed by Nursing Assistant (NA) #1 revealed she stated, I stated that it was a restraint.I regret I didn't go to the other hall and let the other nurse know what transpired or asked for her to watch Resident, now I know that was an option . Record review of the written statement dated 7/18/26 and signed by RN #1 revealed she stated, Upon arrival to my shift at 7 a.m. I rounded Unit B and observed a flat sheet tied across (Resident #1) abdomen from (left) side rail to (right) side rail . The statement revealed she and LPN #1 immediately removed the sheet and assessed the resident and noted no injuries.Record review of the Individual Employee Timecard for CNA #1 revealed she clocked in for duty on 7/17/26 at 11:01 PM and clocked out at 7:03 AM the following morning. Record review of the Personnel Action for CNA #1 dated 7/18/26 and signed by the Administrator revealed that the resident was separated due to Failure to obey orders, Improper conduct, Violation of company rules, Carelessness and Oter and Remarks included, staff restrained resident using sheet and tied it to both siderails.Record review of the Notice of Termination for CNA #1 dated 7/20/26 and signed by the Administrator revealed that the CNA's employment at the facility was involuntarily terminated due to rule violation related to unauthorized use of a physical restraint of a resident and resident rights.On 7/27/26 at 11:50 AM, interview with the Administrator revealed that the facility had policies to ensure staff upheld the resident rights of each resident and prohibited the use of unauthorized restraints. She stated that the use of unauthorized restraints to prohibit the movement of a resident was strictly prohibited and encroached on the rights of the resident. She confirmed that in-service training was provided for all staff regarding resident rights and the employment of CNA #1 was terminated because her actions violated the rights of Resident #1 and facility policy.On 7/27/26 at 2:20 PM, an interview with the DON revealed that the facility had strict policy regarding the use of restraints and that the use of unauthorized restraints was not tolerated and was considered an action that would result in immediate termination of employment. She confirmed that Resident #1 had a personalized care plan with interventions to address her need for supervision and assistance while in and out of bed to provide for her safety and prevent falls that did not include restraints of any type. She confirmed the resident did not have a physician's order for any restraint. The DON confirmed that Resident #1 was out of the facility and admitted to an acute care facility at the time of the survey due to change of condition not related to the 7/18/26 incident. Record review of the admission Record for Resident #1 revealed the facility admitted her on 7/21/25 and she had diagnoses of dementia, hypertension and anxiety.Record review of the Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) 7/06/26 for Resident #1Revealed the facility assessed the resident had no Brief Interview for Mental Status (BIMS) score and documentation which indicated severely impaired cognitive skills for daily decision making and that the resident was dependent for bed mobility, surface-to-surface transfers and all activities of daily living.On 7/27/26 SA validated through record review of the Facility Investigation dated 7/18/26 and an interview with the Administrator on 7/27/26 at 11:50 AM and with the Director of Nurses (DON) on 7/27/26 at 2:20 PM that on 7/18/26 at approximately 7:00 AM RN #1 and LPN #1 removed the sheet immediately, assessed Resident #1 and noted no injury or distress, the licensed nurses then provided instruction to all nursing staff on duty regarding the use of unauthorized restraints and initiated an investigation. The Administrator reported the incident to SA within the required state and federal timeframe along with the final report according to record review of SA records. SA validated through record review of the Facility Investigation dated 7/18/26 and In-Service Training Records dated 7/18/26 and an interview with the Administrator on 7/27/26 at 11:50 AM and with the Director of Nurses (DON) on 7/27/26 at 2:20 PM that the DON initiated a mandatory In-Service Training regarding Residents Rights and Restraints for all nursing staff on 7/18/26 documented on In-Service Training Record with attached sign-in sheet dated 7/18/26. The SA validated through record review of the Facility Investigation dated 7/18/26 and Restraints Audit Record dated 7/18/26 an interview with the Administrator on 7/27/26 at 11:50 AM and with the Director of Nurses (DON) on 7/27/26 at 2:20 PM that the DON initiated an audit of one hundred percent (100%) of residents and ensured that no restraints had been applied to any other residents in the facility and documented observations on Restraints Audit dated 7/18/26. SA validated through record review of the Facility Investigation dated 7/18/26 and Restraint Monitory records and an interview with the Administrator on 7/27/26 at 11:50 AM and with the Director of Nurses (DON) on 7/27/26 at 2:20 PM that The DON instituted monitoring of residents for three months documented on Restraints Monitoring record dated 7/18/26 through 7/27/26 to ensure that no unauthorized restraints were in use for any resident. SA validated through record review of the Facility Investigation dated 7/18/26 and Quality Assurance Committee Meeting Agenda with attached sign-in sheet dated 7/27/26 and an interview with the Administrator on 7/27/26 at 11:50 AM and with the Director of Nurses (DON) on 7/27/26 at 2:20 PM that the facility held an ad hoc Quality Assurance (QA) meeting on 7/27/26 documented on Quality Assurance Committee Meeting Agenda with attached sign-in sheet.

Based on interviews, record review, and resident rights document review the facility failed to ensure residents were informed of available alternate meal choices, limiting their ability to make informed choices regarding their dining preferences for one (1) of (1) residents interviewed regarding meal options. (Resident #46).Findings include:A record review of the facility booklet titled Matter of Rights (undated), page 5, revealed the following statement: .You have the right to live and receive care in a residential setting that is homelike .During an interview on 6/8/26 at 11:00 AM, Resident #46 stated she would like alternate meal choices but was unaware any alternatives were available. The resident stated she believed she had to eat whatever meal was served.During an interview on 6/9/26 at 2:00 PM, the Dietary Manager explained that the daily menu and alternate meal options should be displayed on hallway televisions and on channel two of resident room televisions. During a joint review with the State Agency, the hallway television failed to display alternate meal choices. A subsequent review of a resident room television revealed channel two also failed to display alternate meal selections. The Dietary Manager acknowledged the omission and stated alternate meal choices should be displayed with the daily menu.During a follow up interview on 6/11/26 at 9:31 AM, the Dietary Manager stated residents have a right to food choices, should be able to select alternative meals, and should know what those selections are daily. The Dietary Manager acknowledged alternate menu options had not been consistently communicated to residents.During an interview on 6/11/26 at 10:42 AM, Certified Nursing Assistant #1 stated dietary staff do not verbally communicate alternate meal options to nursing staff. She stated staff rely on the menu information displayed on resident televisions to inform residents of available meal choices.During an interview on 6/11/26 at 10:53 AM, the Administrator stated alternate meal options should be clearly posted because food choices are important to resident comfort and quality of life. The Administrator acknowledged residents should be able to see available menu options so they are aware of their choices.A record review of Resident #46's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes without Complications and Primary Generalized Osteoarthritis.A record review of Resident #46's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/12/26 revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident was moderately cognitively impaired.

Based on observation and interview, the facility failed to ensure resident alternative menus were posted and met the resident's preferences for one (1) of (1) residents interviewed regarding menus. (Resident #46). Findings include: A review of the facility's [NAME] of Rights booklet, undated, on page 5, revealed .You have the right to live and receive care in a residential setting that is homelike .On 06/08/2026 at 11:00 AM, during an interview, Resident #46 expressed a desire for alternate meals. The resident noted that she was unaware of any alternative options and believed she had to eat whatever was served to her.On 6/9/26 at 2:00 PM, an interview was conducted with the Dietary Manager while reviewing the facility's menu televisions. The manager explained that the daily menu, along with alternate options, should be displayed on the Hallway television and on channel two in resident bedrooms. However, upon joint review with the State Agency (SA), the manager acknowledged that the hallway television failed to display any alternate meal choices. A subsequent check of a random resident's bedroom television confirmed that channel two also omitted the alternate choices. The manager stated he was unaware of this omission and noted that alternates should be displayed alongside the main meal choices.On 6/11/26 at 9:31 AM, in a follow-up interview, the Dietary Manager informed the SA that residents have a right to food choices, should be able to choose different food selections, and should know what those selections are on a daily basis. The manager acknowledged that, previously, alternative menu options had not been consistently communicated to the residents.On 6/11/26 at 10:42 AM, in an interview with Certified Nursing Assistant (CNA) #1, she revealed that they are not verbally inform by the dietary department of resident of meal options. She added that staff relies on what is posted on the televisions to inform residents of their menu choices.On 6/11/26 at 10:53 AM, the Administrator emphasized that since food and activities provide essential comfort to the residents, alternate menu options must be clearly posted. The Administrator acknowledged it is important that menus are visible, so residents are aware of their rights and choices.A record review of Resident #46's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes without Complications and Primary Generalized Osteoarthritis.A record review of Resident #46's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/12/26 revealed a Brief Interview for Mental Status (BIMS) score of (10), indicating the resident is moderately cognitively impaired.

Based on observation, staff interviews, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety related to food items not dated, expired foods, and moisture in the dry bins for one (1) of two (2) kitchen observations.Findings include:A review of the facility's policy, Food Service Operational Standards for Purchasing, Cooking and Storage Originated: 9/04, Policy: The facility stores.food under sanitary conditions to prevent the spread of food borne illness.8. Cooling and storing.g. Label and store foods with the date and time.to indicate when to discard.On 06/08/2026 at 10:13 AM, during an initial observation and tour of the kitchen and interview revealed in the refrigerator : one (1) opened 1/2-gallon fat free butter milk with Best if used by date 5/31/26, (1) opened bag of lettuce containing visible brown and wilted lettuce in the bag with a written-on date of 6/3/26 with no indication of what the date meant, a pan of nine (9) peeled, pre-boiled eggs with no date. An observation of the dry bins revealed the flour bin with blotches of moisture in the flour. An interview with the Dietary Manager (DM) revealed he was made aware of the expired food, undated food and moisture in the flour bin at the time of this tour. The DM stated that although he expects everyone to be aware of expired foods, undated foods and keeping the dry bins items dry, he is ultimately responsible for maintaining food quality standards in the kitchen. The DM explained that the hazard of having expired foods, undated foods in the kitchen and moisture in the dry bins is bacterial growth. The DM stated that he will have his staff make a daily walk through to make sure prepared foods are dated and expired foods are discarded. The DM noted that he will instruct the staff to keep the dry bin lid closed to prevent moisture from getting in.On 06/11/2026 at 10:09 AM, during an interview with the Administrator she expressed understanding at the report of undated food, expired food and moisture in the flour bin. The Administrator explained that the DM is responsible for maintaining food quality in the kitchen. The Administrator stated that resident's' could potentially be food poisoned from expired foods or bacteria growth from moisture in the dry bins. The Administrator stated that she will have the DM make rounds daily to maintain food quality. The Administrator reported that she will have the DM report to her and sign off on his rounds three (3) times a week.

Based on observation, staff interview, record review, and facility policy review, the facility failed to maintain food quality in accordance with professional standards for food safety related to overly ripe produce, exposed foods, undated and unlabeled foods, and expired foods and unsanitary meal preparation for two (2) of three (3) days of survey. Findings included: A review of the facility's policy titled, Food Storage Labeling, dated 3/24, revealed, .The facility will ensure the safety and quality of food by following good storage and labeling procedures .Procedure .2. All food items that are not in their original containers must be labeled with the common name of the food and the use by date. 3. Foods that are prepared and stored for later service must be labeled and dated .8. Rotation a . iv. Foods stored in storage units will be surveyed routinely to identify and discard foods that have passed its manufacturer use-by date or expiration date .10. Product Placement Food is stored in containers .that are .tightly sealed or covered and labeled . On 6/30/25 at 10:06 AM, during an observation and interview in the kitchen with the Certified Dietary Manager (CDM), in Refrigerator #1 there were two (2) beverage cups with sippy lids attached, containing a clear liquid and a brown liquid, without date labels or identifying information. The CDM identified them as thickened water and thickened tea. Refrigerator #2 contained two (2) unopened bags of chopped cabbage showing browning and liquefaction with manufacturer use-by dates of 6/22/25 and 6/24/25. Freezer #2 contained one personal-sized bowl of food covered with plastic wrap, lacking a label or date, and the CDM could not identify its contents. In the pantry, 19 overly ripe bananas with open skins and five (5) bottles of dry seasoning with open lids were observed. The CDM acknowledged the presence of expired, undated, and exposed food items and stated he was responsible for food quality and safety. He reported he conducts regular in-services on food safety and planned to begin making daily rounds to ensure compliance. On 7/1/25 at 11:17 AM, during an observation and interviews with the CDM, [NAME] #1, and [NAME] #2, [NAME] #1 was observed preparing food trays while placing the scoop for pureed bread flat into the food, with the scoop handle touching the food item and then repeatedly using it. During this process, [NAME] #1 asked [NAME] #2-who was actively washing pots in the three-compartment sink-to use a towel to wipe a spill on a resident's plate. The plate was then placed on the food cart. [NAME] #2 acknowledged she used a soapy towel from the dishwashing area and confirmed that dish soap is a chemical. [NAME] #1 acknowledged the entire scoop, including the scoop handle, was touching the food while preparing meals. She also confirmed she had asked [NAME] #2 to wipe a plate with a soapy towel, which was inappropriate. She affirmed her responsibility for food prep sanitation. The CDM acknowledged observing both infractions and stated he would conduct additional in-service training on food safety, noting that he typically oversees tray preparation to ensure food handling standards are met. On 7/2/25 at 9:08 AM, during an interview with the Administrator, he acknowledged he was made aware of the issues involving undated and unlabeled food, overly ripe and expired produce, and the unsanitary practices observed. He stated that the CDM is responsible for kitchen sanitation and food quality and noted his own expectation is for food safety to be maintained.

Based on interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) to reflect residents' assessments for anticoagulant and hypnotic medications for six (6) of eighteen (18) MDS assessments reviewed, Resident #5, Resident #14, Resident #21, Resident #38, Resident #44, and Resident #53. Findings included: A review of the facility's policy titled MDS Assessments, dated 5/2006, revealed, . It is the policy of this facility to follow the RAI (Resident Assessment Instrument) process as set forth by CMS (Centers for Medicare and Medicaid Services) protocol . The facility will follow direction per federal and state guidelines for resident assessment protocol and will refer to the MDS RAI manual. A review of the RAI Manual 3.0 Version 1.19.1, dated October 2024, revealed, . N0415: High-Risk Drug Classes: . N0415D1. Hypnotic: Check if a hypnotic medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) . N0415D2. Hypnotic: Check if there is an indication noted for all hypnotic medications taken by the resident any time during the observation period . N0415E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken . N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days) . Do not code antiplatelet medications such as aspirin . A record review of the Drugs.com package insert for Temazepam (Restoril), updated 3/19/25, revealed the drug classification is Benzodiazepines and indicated that Temazepam is a benzodiazepine hypnotic agent . A record review of the Drugs.com package insert for clopidogrel bisulfa (Plavix), updated 6/12/25, revealed the drug classification is Platelet aggregation inhibitors . A record review of the Drugs.com package insert for aspirin, updated 3/1/24, revealed the drug classification is Platelet aggregation inhibitors . Resident #5 A record review of Resident #5's admission Record revealed the facility admitted the resident on 4/26/22 with diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction. A record review of Resident #5's Quarterly MDS with an Assessment Reference Date (ARD) of 6/5/25 revealed Section N0415 indicated the resident received an anticoagulant medication and no antiplatelet medications during the seven-day look-back period. A record review of Resident #5's Order Summary Report with active orders as of 5/1/25 and 6/1/25 revealed no orders for anticoagulant medications. Physician's orders included Plavix (dated 4/26/22) and Aspirin (dated 9/18/24). A record review of the Medication Administration Records (MARs) for May and June 2025 revealed no anticoagulant medications were administered, however, antiplatelet medications were administered. Resident #14 A record review of Resident #14's admission Record revealed the facility admitted the resident on 1/7/25 with diagnoses including Congestive Heart Failure. A record review of Resident #14's Quarterly MDS with an ARD of 4/11/25 revealed Section N0415 indicated the resident received an anticoagulant medication during the seven-day look-back period and did not receive an antiplatelet. A record review of the Order Summary Report with active orders as of 4/1/25 revealed an order dated 1/7/25 for Plavix. There were no anticoagulant medications listed. A record review of the MAR for April 2025 revealed Plavix was administered daily and there were no anticoagulant medications administered. Resident #21 A record review of Resident #21's admission Record revealed the facility admitted the resident on 4/2/25 with diagnoses including Cerebral Infarction. A record review of the admission MDS with an ARD of 4/8/25 revealed Section N0415 indicated the resident received an anticoagulant medication during the seven-day look-back period. Antiplatelet was not marked as administered. A record review of the Order Summary Report with active orders as of 4/2/25 revealed there were no orders for anticoagulant medications, however, there were physician's orders dated 4/2/25 for Aspirin and Clopidogrel Bisulfate. A record review of the MAR for April 2025 revealed there were no anticoagulant medications administered, and Clopidogrel Bisulfate was administered. Resident #38 A record review of Resident #38's admission Record revealed the facility admitted the resident on 1/10/24 with diagnoses including Cerebrovascular Disease and Insomnia. A record review of the Quarterly MDS with an ARD of 6/26/25 revealed Section N0415 indicated the resident received an anticoagulant medication, however, there was no indication that the resident received an antiplatelet or a hypnotic medication during the seven day look back period. A record review of the Order Summary Report with active orders as of 6/1/25 revealed there were physician's orders for Aspirin (dated 1/10/24) and Restoril (Temazepam) (dated 4/8/25). There were no orders for anticoagulant medications. A record review of the MAR for June 2025 revealed there was no anticoagulant administered, but antiplatelet and hypnotic medications were administered. Resident #44 A record review of Resident #44's admission Record revealed the facility admitted the resident on 6/9/25 with diagnoses including Peripheral Vascular Disease. A record review of the admission MDS with an ARD of 6/16/25 revealed Section N0415 indicated the resident received an anticoagulant medication and did not receive an antiplatelet medication during the seven-day look-back period. A record review of the Order Summary Report with active orders as of 6/9/25 revealed there were no physician orders for anticoagulant medications, but there were orders for Clopidogrel Bisulfate (dated 6/9/25). A record review of the MAR for June 2025 revealed no anticoagulant medications were administered; however, an antiplatelet medication was administered. Resident #53 A record review of Resident #53's admission Record revealed the facility admitted the resident on 3/7/25 with a diagnosis of Cerebral Infarction. A record review of the Quarterly MDS with an ARD of 6/10/25 revealed Section N0415 indicated the resident received an anticoagulant medication during the seven-day look-back period and did not receive an antiplatelet medication. A record review of the Order Summary Report with active orders as of 6/1/25 revealed there were no anticoagulant medications ordered, however there was a physician's order for Plavix (dated 3/7/25). A record review of the MAR for June 2025 revealed there were no anticoagulant medications administered; however, an antiplatelet medication was administered. On 7/2/25 at 10:29 AM, during an interview with Registered Nurse (RN) #1, she explained that different staff members complete each section of the MDS, but she completes Section N for medications. She stated that information is gathered by reviewing residents' medical records. RN #1 confirmed Plavix and Aspirin are classified as antiplatelet medications and Restoril is classified as a hypnotic. After reviewing the MDS and physician orders for Residents #5, #14, #21, #38, #44, and #53, she confirmed the MDS assessments were coded in error. She stated that while staff are responsible for the accuracy of their own sections, she reviews assessments before submission and acknowledges these errors. On 7/2/25 at 10:45 AM, during interviews with the Director of Nursing (DON) and Administrator, both confirmed they were made aware of the inaccurate MDS coding. They acknowledged the facility does not have a triple-check system for accuracy but stated their expectation is for staff to code the MDS accurately to reflect each resident's clinical status.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good grooming and personal hygiene for one (1) of eighteen (18) sampled residents, Resident #34. Findings include: A review of the facility's policy titled Resident Rights, undated, revealed, . Residents' rights, policies, and procedures shall insure that each resident admitted to the center . 9. Is treated with consideration, respect, and full recognition of his dignity and individuality, . in care of his personal needs . On 6/30/25 at 10:55 AM, Resident #34 was observed to have noticeable long, white hairs on her chin. During the initial interview, she shared that she would like them shaved but mentioned it had not been done in quite some time. On 7/1/25 at 11:01 AM, in a follow-up observation and interview, Resident #34 still had long gray hair on her chin. The resident expressed that she wished to have it removed and shared that her Certified Nurse Aide (CNA) had not offered to assist with grooming during the earlier care visit. On 7/1/25 at 11:19 AM, during an interview with CNA #1, she confirmed she was currently assigned to Resident #34 and acknowledged seeing the gray hair on the resident's chin. She stated she would return to take care of it. CNA #1 explained that when helping female residents with their ADLs, it is important to include trimming facial hair to help maintain their dignity. On 7/1/25 at 1:46 PM, during an interview with the Director of Nursing (DON), she stated it is the CNA's responsibility to trim their assigned residents' facial hair when providing ADL care. She added that when CNA #1 saw Resident #34 had hair on her face, she should have trimmed it immediately. A record review of Resident #34's admission Record revealed the facility admitted her on 7/25/23 with diagnoses including Muscle Weakness and Unspecified Lack of Coordination. A record review of Resident #34's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/8/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident's cognition was moderately impaired.

Based on observation, interviews, record review, and facility policy review, the facility failed to honor residents' rights or choices, as evidenced by the resident having to remain in her room despite her request to get up and interact with other residents for one (1) of fifteen (15) sampled residents. Resident #13 Findings include: Record review of the fcility's Resident Rights dated 4/2012, revealed, . Residents' rights, policies, and procedures shall insure that each resident admitted to the center . 5. Is encouraged and assisted throughout the resident period of stay .9. Is treated with consideration, respect, and full recognition of his dignity and individuality .12.May .participate in activities .at his discretion . On 1/08/24 at 12:42 PM, during an observation and interview of Resident #13 revealed the resident was lying in bed with her head elevated watching television. In the interview, the resident stated that she wishes she could get out of her room every day, but staff do not get her up as often as she would like. On 1/9/24 at 8:54 AM, in an interview with Certified Nursing Assistant (CNA) #1, while in the room with Resident #13, she stated that she gets the resident out of her room every other day. CNA #1 stated that today is her shower day therefore, she will be up to attend bingo, which is good because the resident enjoyed playing bingo. CNA #1 confirmed that the resident has no physical constraints that would prohibit her from getting up daily. On 1/9/24 at 9:03 AM, during an interview with Resident #13, she stated that CNA #1 was lying. She says they do not take her out of her room every other day. She claims she wants to get up daily, but they rarely do that and that they only occasionally take her to play bingo. Resident #13 said she wants to get up daily and go to Bingo whenever they have it. On 1/9/24 at 9:34 AM, in an interview with Registered Nurse (RN) #1, she stated that CNAs must get all residents out of their rooms daily unless their acuity level forbids it. As a result, there is no need for a written system to determine if a person wishes to get up or refuses. She stated that she believed the CNA and that if they could not get a resident up, the resident had refused to do so. She added that, based on what she knows, all residents who want to leave their rooms on a daily basis are doing so. On 1/10/24 at 9:04 AM, in an interview with the Activities Director (AD), she stated that there is no resident get-up list or any other documented procedure in place to notify staff of residents who wish to get up on a daily basis. She stated that after her rounds with the residents, she notifies the CNAs of the residents who had indicated that they want to get up for activities. The AD stated that she does not recall and is unsure whether Resident #13 requested to be out of her room daily. On 1/10/24 at 11:57 AM, in an interview with Resident #13's daughter, she indicated that she frequently saw her mother in bed while other residents were up and out of their rooms during her visits. She revealed she had asked the CNA assigned to her mother, Why is my mother in bed? She stated the CNA informed her that her mother could only get up every other day, and today was not that day. The daughter said she did not like that response but assumed it was how things were done at the facility. On 1/10/24, at 12:31 PM, in an interview with the Director of Nursing (DON), she indicated that all residents are permitted to leave their rooms on a daily basis. If a resident refuses to get up, CNAs should report it to the nurse, who should document it in their progress notes. She further stated that regardless of whether the Resident is completely dependent, they should be free to leave their rooms daily, unless the Resident declines. She says denying residents the freedom to get up and out of their rooms violates their rights. On 1/11/24 at 12:52 PM, in an interview with the Administrator, he indicated his expectation of staff is to daily check with the residents and ask in an assumptive tone, Let's get you up today! He added that when staff refuses the request of the resident to get up, it violates their rights. A record review of the Admission Record revealed the facility admitted Resident #13 on 4/30/21. Her diagnoses included Cerebral Aneurysm, Epilepsy, Type 2 Diabetes, and Hypertension. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/09/23, revealed a Brief Interview for Mental Status (BIMS) score of 6, indicating the resident had severe cognitive impairment. However, the interview with the daughter corroborates the resident's account of being left in bed and the resident not being gotten up as she desired.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure the shower room was at a comfortable temperature while providing showers for three (3) of fifteen (15) sampled residents. Residents #8, #9, and #23. Findings Include: A record review of the facility policy titled, Resident Rights, dated 4/2012, revealed, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity . Policy Interpretation and Implementation .3. Our facility will make every effort to assist each resident .is always treated with respect, kindness, and dignity .9. Is treated with consideration .in treatment and in care for his personal needs . Resident #8 Observation on 1/8/23 at 1:00 PM, revealed Resident #8 lying in bed with the head of her bed elevated. The resident was alert and oriented, and able to make her needs known. During an interview with Resident #8 on 1/8/23 at 1:15 PM, revealed she doesn't go to the shower because it's cold in there. Resident #8 said the staff told her the heater does not work in the shower room. Resident #8 said she feels better when she gets a shower, but it's too cold to bathe without heat. The resident said she had talked to the Certified Nursing Assistance (CNA) that assists her with a shower about the room being cold. During an interview on 1/8/23 at 6:15 PM, with Resident #8's daughter, she stated that her mother complains, as well as other residents, that the shower room is cold during their showers. The daughter also said her mother complains that the facility does not dry her hair after shampooing it. The daughter said the facility towel dries the resident's head, which could cause her to get sick. The daughter said she has discussed her complaints with several staff members. A record review of the Admission Record for Resident #8 revealed the resident was admitted to the facility on [DATE], with diagnoses that included Anemia, Essential (Primary) Hypertension, and Chronic Systolic (Congestive) Heart Failure. A record review of the MDS (Minimum Data Set), with an Assessment Reference Date (ARD) 1/5/24, revealed a Brief Interview for Mental Status of 12, which indicated the resident had moderate cognitive impairment. Resident #9 On 1/9/23 at 10:00 AM, the State Agency (SA) observed Resident #9 taking a shower. The resident was shivering during the shower. The shower room did not have any heat blowing during her shower. CNA #1 bathed the resident, using warm water, then dried the resident and put clean clothes on her. The resident shivered during the whole process. During an interview on 1/9/23 at 10:45 AM, with Resident #9, she confirmed the shower room was cold. The resident said she likes to be clean, but she doesn't like the room being cold. The resident revealed she doesn't complain because she needs her showers. Resident #9 stated the shower room is always cold and she is concerned she might get sick from being so cold, however, she added, I just take a chance. During an interview on 1/9/23 at 2:00 PM, CNA #1 revealed she wasn't cold in the shower room because she was working and had not noticed that Resident #9 was shivering and had not complained about being cold. CNA #1 said the heater inside the shower room has not worked since she began employment at the facility. CNA #1 said she had turned the main heater on earlier this morning, but somebody must have turned it off. CNA #1 also stated she towel dried the resident's hair because the shower room does not have an electrical plug and it is the responsibility of the floor CNA to blow dry the resident's hair. A record Review of Resident #9's Admission Record revealed the facility admitted the resident to the facility on [DATE], with diagnoses that included Diabetes Mellitus, Hypertension, Hemiplegia, and Hemiparesis. A record review of the Quarterly Minimum Data Set (MDS), with Assessment Reference Date (ARD) 12/22/23, revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Resident #23 On 1/9/23 at 11:00 AM, the State Agency (SA) observed Resident #23 taking a shower. The resident was shivering during the shower. The shower room did not have any heat blowing during her shower. CNA #2 bathed the resident, using warm water, then dried the resident and put clean clothes on her. The resident shivered during the whole process. The State Agency (SA) asked Resident #23 if she was cold while in the shower. The resident stated, Yes, it's cold in here. During an interview on 1/9/23 at 11:45 AM, Resident #23 confirmed she was cold during her shower. The resident said it is always cold. Resident #23 revealed the staff told her the heater does not work. The resident also said the staff does not dry her hair. She said her head is only dried with a towel. She commented she is cold most of the day because her hair is wet, however, she doesn't complain because she doesn't want to cause problems with the staff. During an interview on 1/9/23 at 2:30 PM, CNA #2 confirmed Resident #23 said she was cold. CNA #2 also said the heater in the shower room has not worked for over a year, however, she thought the main heating unit for the shower was on. CNA #2 stated she didn't realize it was cold in the shower room. A record review the Admission Record for Resident #23 revealed the facility admitted the resident to the facility on [DATE], with diagnoses that included Diabetes Mellitus, Hypertension, and Chronic Kidney Disease. A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 11/17/23, revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. During an interview on 1/9/23 at 2:45 PM, with the Maintenance Director, he confirmed the heater was not on. The Maintenance Director confirmed he turned on the thermostat that is located outside of the shower room on the wall, after the State Agency (SA) inquired about the heat. The Maintenance Director revealed that thermostat only regulates the shower room and the storage room and does not regulate the temperature in the hallway or at the nurse's station. The Maintenance Director also confirmed he had not realized that the knob on the electric heater located in the shower room was broken, but that it has now been replaced. During an interview on 1/9/23 at 3:00 PM, with the Director of Nursing (DON), she stated she did not know the staff were showering the residents without turning on the heater. The DON confirmed the residents could get sick without heat. The DON said the staff will be in-serviced today on making sure the heater is on and that the residents' hair is dried when they are showered. An interview with the Administrator on 1/9/23 at 3:30 PM, revealed he unaware the staff were not using the heater in the shower and that the electric heater located inside the shower room was not working. The Administrator stated the staff know how to regulate the heater by turning regulating the thermostat in the hallway outside the shower door.

Based on record review, interviews, and facility policy review, the facility failed to ensure PRN (as needed) psychotropic medications were discontinued or limited to a 14 day duration without adequate clinical rationale for continued use for one (1) of five (5) residents reviewed for unnecessary medications. Resident #42 Findings include: A record review of the facility's policy Monitoring of Antipsychotic Medication Therapy with revised date 06/2015 revealed . It is the policy of this facility to monitor the effectiveness and side effects for any resident that is taking an antipsychotic medication . The Pharmacy consultant will review these meds monthly and make dose reduction recommendations as indicated per CMS (Center for Medicare and Medicaid Services) guidelines. These recommendations will be forwarded to the physicians for their response within 7 days . Record review of a statement on facility letterhead dated 1/12/24 and signed by the Administrator revealed, (Proper Name) Nursing Home does not have a specific policy that sites the 14 day rule for the new guidelines on Monitoring of Antipsychotic Medications Therapy. We do however follow the federal guidelines on the 14 day psychotropic rule . A record review of Resident #42's Admission Record, revealed the facility admitted the resident on 09/01/2023, with an original admitted [DATE]. Resident #42 was admitted with diagnoses that included Unspecified Psychosis Not Due to A Substance or Known Physiological Condition, Anxiety, Unspecified, and Insomnia, Unspecified. Diagnoses of Unspecified Dementia, Unspecified Severity, With Other Behavioral Disturbance, and Paranoid Schizophrenia was added after the original admitted . A record review of Resident #42's Order Summary Report, with active orders as of 01/11/2024, revealed orders for Klonopin Tablet 0.5 MG (milligrams) (Clonazepam) Give 0.5 mg by mouth every 8 (eight) hours as needed for agitation, with order date and start date of 03/18/2022. A record review of Resident #42's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/2023, revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Further review of the MDS revealed that in the look back period, the resident had no behavioral symptoms and had received antipsychotic and antianxiety medications. A record review of Resident #42's Pharmaceutical Consultant Report (PCSA) Psychoactive Gradual Dose Reduction, dated 07/26/2023 revealed the Nurse Practitioner's (NP) signature and date of 10/02/2023 revealed . This resident is prescribed the following psychotic medications: . 3. Klonopin 0.5 mg QD (every day), 0.5 mg Q8H (every eight hours) PRN (as needed) . Clinical Rationale for continuance . mood instability .multiple GPU (Geripsych Unit) stays . The document has no duration time or stop date for the PRN Klonopin 0.5 mg. A record review of the facility's Interdisciplinary Team Psychotropic Dashboard December 2023 revealed Resident #42 had an order for Klonopin 0.5 mg Q8H prn with no mention of duration of the medication. A record review of Resident #42's MAR for 11/01/2023 - 11/30/2023 revealed that resident received three (3) doses of Klonopin 0.5 mg for agitation but no documented behaviors. A record review of Resident #42's MAR for 12/01/2023 - 12/31/2023 revealed that resident received seven (7) doses of Klonopin 0.5 mg for agitation. Documented behaviors of agitation and yelling for resident on 12/14/2023, 12/15/2023, and 12/16/2023. A record review of Resident #42's Medication Administration Record (MAR) for 01/01/2024 - 01/31/2024 revealed no doses of Klonopin 0.5 mg PRN were given and resident had no behavioral issues. On 01/10/2024 at 2:15 PM, during an interview with Licensed Practical Nurse (LPN) #2, she explained Resident #42 used to have behaviors and would yell out and holler and has been in and out of Geri-psych several times, but her medications have been working and the resident has been much calmer and cooperative. LPN #2 revealed it has been a while since Resident #42 has had any problems with behaviors and has not had any PRN medications for behaviors. LPN #2 further revealed that Resident #42 is very cooperative with medication and care and never refuses. At 2:35 PM on 1/10/24, during an interview with Certified Nurse Aide (CNA) #2, she explained Resident #42 is confused at times, but cooperative with care and has never refused care. On 1/11/24 at 10:09 AM, during an interview with the Director of Nursing (DON), she explained she has been reviewing all residents' records regarding the psychotropic medications and is aware of 14-day period and has interacted with the facility's Advanced Registered Nurse Practitioner (APRN) to discontinue all PRN medications if possible or to have a stop date. The DON stated that Resident #42 has been seeing behavioral health services and has been out to Geri-psych in the past and is doing much better since her last visit. She stated Resident #42 currently has not had any recent behaviors and has adjusted to the medications. She confirmed the resident continues to have an order for Klonopin 0.5 mg Q 8 hours PRN. The DON mentioned that the pharmacy consultant is aware of the regulations because she informed her via an email at an earlier date. On 1/11/23 at 12:00 PM, during a phone interview with the facility's APRN, she explained she understood if a psychotropic medication was used as PRN and still needed after the 14-day period all that was needed was a rationale why but was not aware there was to be a duration of time or stop date for the PRN medication. At 12:20 PM on 1/11/23, during an interview with the facility's Pharmacy Consultant, she explained she is aware of the of the time limit duration for PRN psychotropic medications and informs the facility of the regulations on a monthly basis. She explained she has asked for a stop date monthly when she continues to see a medication with no duration or stop date. She stated the facility has access to her monthly recommendations. The Pharmacy Consultant revealed that she would expect the facility to follow her expectations. On 1/11/24 at 12:52 PM, during an interview with the Administrator, he explained he expected the APRN to know the regulations or requirements for psychotropic medications and to follow the requirements for all residents. He would expect the facility, including the pharmacist consultant, to follow all CMS guidelines to provide appropriate care for all residents.

Based on interviews, record review, and facility policy review, the facility failed to notify the Resident Representative (RR) in writing the reason for a transfer to an acute care hospital for one (1) of one (1) sampled residents for hospitalization s. Resident #35 Findings include: Record review of the facility's Transfers and Documentation policy with a revised date of 11/2017, revealed . E. Documentation- . The documentation for all discharges and transfers, must include, as a minimum, and as they may apply: 1. The reason(s) for the discharge or transfer. 2. That an appropriate notice was provided to the resident and/or resident representative . On 07/18/22 at 01:45 PM, during an interview with the Director of Nursing (DON), she explained Resident #35 is currently in the hospital and is on bed hold with plans to return to the facility. Resident #35's son was at the facility when she was transferred to the hospital and was aware of the transfer. The Social Worker is responsible for mailing transfer and bed hold letters to the family. On 07/18/22 at 02:50 PM, during a phone interview with Resident #35's son, who is the RR, he explained his mother has been in the hospital since 6/24/2022 and plans to return to the facility. He reported he did not receive a letter regarding the hospitalization transfer but did talk on the phone with the Social Worker regarding bed hold. A record review of Resident #35's Admission Record revealed the facility initially admitted her on 02/08/2013 and she was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #35's Physicians Orders dated 6/24/22, revealed .To (Proper Name of Physician and Nurse Practitioner) Transport resident via (Proper Name of Transport Service) to (Proper Name of Acute Care Hospital) for further evaluation . Record review of the Notice of Hospital Transfer/Therapeutic Leave for Medicaid-Eligible Residents letter revealed (Proper Name of Resident #35) .Notice is hereby given Resident Representative that (Proper Name of Resident #35) transferred to (Proper Name of Acute Hospital) at 10:00 PM on 6/24/22 . A record review of Resident #35's (Proper Name of Acute Care Hospital) Hospitalist Daily Progress Note revealed Resident #35 . admitted [DATE] . On 07/18/22 at 03:05 PM, during an interview with the DON, she explained the current notification to the RR is a letter mailed for bed hold and hospital transfer/therapeutic leave. She confirmed this letter does not include the reason for the transfer and she did not know that the reason for transfer was required to be included on the notification letter. On 07/18/22 at 03:30 PM, during an interview with the Corporate Nurse, she explained the facility does not have a hospital transfer letter explaining in writing the reason the resident was transferred to the hospital and the facility did not mail a hospital transfer letter to Resident #35's RR detailing the reason for the transfer. On 07/19/22 at 09:30 AM, during an interview with the facility's Social Worker, she explained she was not aware the letter mailed to Resident #35's RR should have included the reason for transfer. She confirmed she had only mailed bed hold letters to the RR's and she had not mailed any notifications of transfers that included the reason for the transfer. On 07/19/22 at 09:45 AM, during an interview with the Administrator, he explained he was not aware the resident transfer letters mailed to the RR's must include the reason for the transfer.

Based on interviews, record review and facility policy review the facility failed to conduct a Level I Pre-Admission Screening prior to the resident's admission to the facility to determine if the resident has a mental, intellectual disorder, or related condition for five (5) of 17 sampled residents. Resident # 3, Resident #5, Resident #12, Resident #22, and Resident #25 Findings include: A review of the facility's policy PASRR (Pre-Admission Screen and Resident Review), revised 2012, revealed, It is the policy of this facility to do the Pre-Admission Screening process .All persons requiring nursing facility level of care must have a PAS completed for admission to a Medicaid certified nursing facility . Resident #3 A record review of Resident #3's clinical record revealed no Pre-Admission Screening (PAS) had been completed. A record review of the Admission Record for Resident #3 revealed the facility admitted her on 7/29/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/14/22 revealed a Brief Interview for Mental Status (BIMS) score of seven (7) which indicated Resident #3 had severe cognitive impairment. Resident #5 A record review of Resident #5's clinical record revealed no PAS had been completed. A record review of Resident #5's Admission Record revealed the facility admitted her on 4/23/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Quarterly MDS with an ARD of 4/08/22 revealed Resident #5 had a BIMS score of 15 which indicated she is cognitively intact. Resident #12 A record review of Resident #12's clinical record revealed no PAS had been completed. A record review of Resident #12's Admission Record revealed the facility admitted her on 5/19/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Quarterly MDS with an ARD of 4/22/22 revealed Resident #12 had a BIMS score of 00, which indicated she had severe cognitive impairment. Resident #22 A record review of Resident #22's clinical record revealed no PAS had been completed. A record review of the Admission Record for Resident #22 revealed an original admitted [DATE] and a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Comprehensive MDS with an ARD of 5/20/22 revealed a BIMS score of 15, which indicated Resident #22 is cognitively intact. Resident #25 Record review of Resident #25's clinical record revealed no PAS had been completed Record review of the Admission Record for Resident #25 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly MDS with an ARD of 5/31/22 revealed a BIMS score of 15, which indicated Resident #25 is cognitively intact. On 7/18/22 at 12:12 PM, in an interview with the Director of Nursing (DON), she confirmed the Pre-Admission Screenings (PAS) for Resident #3, Resident #5, Resident #12, Resident #22, and Resident #25 were not completed. She stated the Social Worker (SW) is responsible for making sure it is completed upon admission, but she is responsible for ensuring they are completed. She confirmed the PAS should have been completed before the residents were admitted to the facility to make sure that the facility could meet the needs of the residents. On 7/18/22 at 2:10 PM, in an interview with the SW, she stated that she is responsible for making sure the PAS is completed for the residents and it is her responsibility to make sure it is done. On 7/18/22 at 3:01 PM, in an interview with the Administrator, he stated that it is the responsibility of himself and the SW to complete the PAS. He stated that it is a team effort, and the DON is responsible for conducting a final check of the records to make sure everything is completed. He stated a PAS is completed for residents to make sure that the facility can provide for the resident's needs, and a PAS should have been completed prior to the residents' admission to the facility.

Based on staff interview, record interview, and facility statement, the facility failed to accurately code the Minimum Data Set (MDS) related to a [DIAGNOSES REDACTED].#47. Findings include: Review of the facility'S statement, dated 2/27/20 and signed by the Director of Nursing, revealed the facility followed the Resident Assessment Instrument (RAI) Manual for all MDS assessments. Review of the RAI Manual Version 3.0 Chapter 2 revealed the RAI process was the basis for an accurate resident assessment. Review of Resident #47's Pharmaceutical Consultant Report, signed 1/13/20, revealed the resident's provider added the [DIAGNOSES REDACTED]. Review of Resident #47's Significant Change in Status MDS Assessment with an Assessment Reference Date (ARD) of 1/22/20, revealed the [DIAGNOSES REDACTED]. An interview on 2/27/20 at 2:00 PM, with the MDS Nurse, Licensed Practical Nurse (LPN) #1, revealed the issue was related to the [DIAGNOSES REDACTED]. LPN #1 stated she would have a copy of that order to make changes to her assessment. She confirmed the [DIAGNOSES REDACTED]. An interview on 2/27/20 at 2:25 PM with the Director of Nursing confirmed, the [DIAGNOSES REDACTED]. The facility's Face Sheet revealed, the facility admitted Resident #47 on 1/11/19.

Based on record review, staff interview, and facility policy review, the facility failed to refer a resident for a Level II screening related to a new psychiatric [DIAGNOSES REDACTED].#47. Findings include: Review of the facility's Pre-Admission Screening and Resident Review (PASARR) policy, with a revision date of 2012, did not indicate a referral for a Level II Screening after a new psychiatric [DIAGNOSES REDACTED]. Review of the Ascend Provider Manual, revised on 7/3/13, revealed, when a resident experience a significant change in status, a PASARR Level II Change in Status Request Form must be completed by the provider and faxed to Ascend. Review of Resident #47's Pharmaceutical Consultant Report, dated 1/13/20, revealed the resident's provider added the [DIAGNOSES REDACTED]. Review of Resident #47's Significant Change in Status, Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 1/22/20, revealed the [DIAGNOSES REDACTED]. An interview on 2/27/20 at 2:25 PM with the Director of Nursing (DON) confirmed the [DIAGNOSES REDACTED]. The DON stated the [DIAGNOSES REDACTED]. Review of Resident #47's Admission Record revealed the facility admitted Resident #47 on 1/11/19.

Based on staff interview, record review, facility job description, and a facility statement, the facility failed to employ a qualified professional related to the Dietary Manager position for one (1) of (1) certified dietary manager positions. Findings include: Review of the facility's Food Service Manager job description, not dated, revealed the education for the position was a high school diploma/dietary manger certification required. The qualifications revealed it must be either a Dietary Assistant, Certified Dietary Manager, or a Registered Dietician. On 2/26/20 at 5:28 PM an interview with the Dietary Manager revealed he had not gone through the class for certification but was working with the dietician. The Dietary Manager stated he did have the Serve Safe Certification. He stated he had started working as the dietary manager about a year ago. The Dietary Manager also stated, he needed to take the test but just had not taken it yet. A review of the facility statement, dated 2/27/20, and signed by the Administrator, revealed the Dietary Manager was hired by the facility as a Cook on 4/17/17; and, was promoted to his current position on 1/18/18. On 2/27/20 at 9:44 AM an interview with the Administrator revealed she had completed interviews with certified dietary managers, but she currently did not have one that was certified on staff. The Administrator stated she, had been at the facility for about six (6) months.

Based on record review, interview, and policy/procedure review, the facility failed to implement comprehensive care plans for two (2) of six (6) sampled residents, as evidenced by not following the resident's care plan to administer the correct medication. Resident #1 was administered [MEDICATION NAME] instead of [MEDICATION NAME], as ordered per Medical Doctor (MD), and Resident #6 was administered Augumentin, instead of [MEDICATION NAME], as ordered per MD. Findings include: Review of the facility's Following the Care Plan Policy, dated 2011, revealed: It is the policy of this facility to follow a written and approved care plan for each resident. All employees will follow the written care plan that is developed in order to assure the residents needs are met. Resident #1 Review of Resident #1's care plan, dated 9/19/19, revealed the resident had a care plan for [MEDICATION NAME] 75 milligrams (mg) every morning (AM) and every night (HS). Resident #1 also had a care plan for depression, to Give antidepressant medications ordered by physician. Review of Resident #1's physician's orders [REDACTED]. An interview with the Director of Nursing (DON), on 11/24/19 at 12:30 PM, revealed she received a phone call from the dispensing pharmacy saying they were unable to read the order for Resident #1. She stated the pharmacy sent [MEDICATION NAME] 75 mg instead of the [MEDICATION NAME], which was ordered. The DON stated Licensed Practical Nurse (LPN) #1 administered [MEDICATION NAME] 75 mg, instead of [MEDICATION NAME] 75 mg, to Resident #1 on Friday, 9/20/19 at 9:00 AM. The DON stated the medication error was discovered by Medical Records/LPN #2, as she was checking newly delivered medications against the physician's orders [REDACTED]. Further interview with the DON, on 9/26/19 at 9:45 AM, revealed she would consider the care plan was not followed, if the medicine was not administered per orders/care plan. The DON confirmed Resident #1 did not have any adverse effects from receiving the wrong medication. Interview with LPN #1, on 11/26/19 at 10:16 AM, revealed she mistakenly gave Resident #1 the wrong medication, [MEDICATION NAME] instead of [MEDICATION NAME]. LPN #1 confirmed the care plan was not followed, by not giving Resident #1 the medication ordered by the physician. LPN #1 stated Resident #1 was monitored and did not react differently to the medication error. Resident #6 Review of Resident #6's care plan, dated 8/20/19, for [MEDICAL CONDITION], revealed to Give medications as ordered. Record review revealed Resident #6 had physician's orders [REDACTED]. Interview with the DON on 11/25/19 at 3:00 PM, revealed Resident #6 had a medication error on 10/1/19, when [MEDICATION NAME] 875 mg was given instead of [MEDICATION NAME] 875 mg by LPN #3. The DON stated Resident #6 was assessed, with no ill effects noted, from the one-time dose. The DON stated the error occurred when LPN #3 went to the Emergency Drug Kit (EDK) to get the dose of [MEDICATION NAME] 875 mg and saw [MEDICATION NAME] 875 mg, which had [MEDICATION NAME] 875 mg in the contents of the medication. She stated LPN #3 did not realize there was another medication in [MEDICATION NAME]. Interview with the DON, on 11/26/19, from 9:45 AM to 10:45 AM, revealed the care plan was not followed for Resident #6, because the right medication was not administered. Attempts to contact LPN #3 on 11/26/19, were unsuccessful.

Based on record review, interview, and policy/procedure review, the facility failed to deliver services that met professional standards for following the physician's orders [REDACTED]. Resident #1 was administered [MEDICATION NAME], instead of [MEDICATION NAME], as ordered per physician's orders [REDACTED]. Findings include: Review of the facility's Medication Administrator for Oral Medications policy, dated 2008, revealed, BEFORE ADMINISTRATION: Know and perform the triple-check 5-rights of medication administration system: Right Medication, Dose, Time, Route and Person. Review of the facility's Preparation for Medication Administration policy, undated, revealed, prior to administration, the medication and dose on the Medication Administration Record (MAR) is compared with the medication label. If the label and MAR are different, the physician's orders [REDACTED]. Medications are administered in accordance with written orders of the attending physician. Resident #1 Record review of the physician's orders [REDACTED].#1 had an order for [REDACTED]. Resident #1 had no order for [MEDICATION NAME]. Resident #1's record review revealed, Resident #1 was admitted to the facility, on 2/27/17, with the following Diagnoses: [REDACTED]. During an interview, on 11/24/19 at 12:30 PM, the Director of Nursing (DON) stated, Resident #1 received [MEDICATION NAME] 75 mg instead of [MEDICATION NAME], as prescribed by the physician on 9/20/19 at 9:00 AM, by Licensed Practical Nurse (LPN) #1. The DON stated she received a phone call from the dispensing pharmacy saying they were unable to read the order, and she read the order to the pharmacist. However, the Pharmacy sent [MEDICATION NAME] 50 mg tablets with directions to give one and one-half (1 1/2) tablets every AM and every PM. The medication error was discovered by the Medical Records Nurse/LPN #2, as she checked medications against the physician's orders [REDACTED]. The DON stated Resident #1 received only one (1) dose of the [MEDICATION NAME], and there were no changes noted in Resident #1's activity or behavior. Further interview with the DON, on 11/26/19, from 9:45 AM to 10:45 AM, revealed the order for [MEDICATION NAME] was on the MAR correctly, but the medication in the med cart was [MEDICATION NAME]; they were both 75 mg, but according to the five (5) rights, this was not the right medication for Resident #1. Interview with LPN #1, on 11/26/19 at 10:16 AM, revealed she had been trained on following the physician's orders [REDACTED].#1 stated on the morning of 9/20/19, she administered [MEDICATION NAME] to Resident #1, instead of [MEDICATION NAME] as ordered. She stated, It was the wrong medicine and I don't know what was on my mind. She stated the medication error was noticed by LPN #2 when she checked to see if new medications had been delivered. LPN #1 stated Resident #1 only had one (1) dose and did not act any differently throughout the shift. During an interview, on 11/25/19 at 2:40 PM, LPN #2 stated on 9/20/19, at approximately 9:15 AM, she went to the medication cart to verify a new medication order ([MEDICATION NAME]) for Resident #1. She stated when she compared the medication, MAR and physician's orders [REDACTED].#1; however, Resident #1 had no order for [MEDICATION NAME]. LPN #2 stated she verified with LPN #1, Resident #1 had received 75 mg of [MEDICATION NAME], instead of the [MEDICATION NAME], as ordered by the physician. LPN #2 stated she reported this medication error to the DON. LPN #2 stated nurses are in-serviced and trained on following physician's orders [REDACTED]. Review of a Licensed Nurses Orientation Checklist, dated 7/18/19, revealed LPN #1 was trained on Pharmacy Policies and Procedures, including the Administration System. Resident #6 Record review revealed Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Medication error report, completed by the DON on 10/2/19, revealed LPN #3 gave [MEDICATION NAME] ([MEDICATION NAME] and Clavulanate) 875 mg, instead of [MEDICATION NAME] 875 mg. The report documented there were no noted effects of the error made on the resident. Review of the physician's orders [REDACTED].#6 was ordered [MEDICATION NAME] 875 mg once daily for 10 days, related to a Chronic Leg Ulcer. Interview with the DON, on 11/25/19 at 3:00 PM, revealed Resident #6 received [MEDICATION NAME] 875 mg on 10/1/19, instead of [MEDICATION NAME] 875 mg as ordered, administered by LPN #3. The DON stated this occurred when LPN #3 retrieved the [MEDICATION NAME], instead of [MEDICATION NAME] from the Emergency Drug Kit (EDK). The DON stated Resident #6 received one (1) dose of the [MEDICATION NAME], prior to the medication error discovery by LPN #2, as she was checking for new physician's orders [REDACTED].#6 was assessed with [REDACTED]. The DON stated the five (5) rights of medication administration were not followed, because Resident #6 did not receive the right medication, per physician order. Review of the Internet website Drugs.com, revealed [MEDICATION NAME] 875 mg has [MEDICATION NAME] 875 mg and Clavulanate Potassium 125 mg. Clavulanate Potassium 125 mg is a form of Clavulanic Acid, which is similar to [MEDICATION NAME] (PCN). It fights bacteria and is often resistant to PCN and other antibiotics. Attempts to contact LPN #3, on 11/26/19, were unsuccessful. During an interview, on 11/26/19 at 1:45 PM, the Staff Development Nurse stated she would consider not following the physician's orders [REDACTED]. She stated the five (5) rights of medication administration included the right route, the right dose, the right person, the right time, and the right medication. She stated during orientation, the five (5) rights are reviewed and each nurse takes a test after completion of the review. Review of a Licensed Nurses Orientation Checklist, dated 11/6/16, revealed LPN #3 was trained on Pharmacy Policies and Procedures, including the Administration System.

Based on record review, interview, and policy/procedure review, the facility failed to ensure pharmacy services were provided for accurate dispensing and administration of medications, for two (2) of six (6) sampled residents. This was evidenced by, Resident #1 was dispensed and administered [MEDICATION NAME] instead of [MEDICATION NAME], and Resident #6 was dispensed and administered Augumentin instead of [MEDICATION NAME]. Findings include: Review of the facility's PREPARATION FOR MEDICATION ADMINISTRATION policy, undated, revealed: Prior to administration, the medication and dosage schedule on the resident's Medication Administration Record (MAR) is compared with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in direction, or if there is any other reason to question the dosage or directions, the physician's orders [REDACTED]. Medications are administered in accordance with the written orders of the attending physician. Resident #1 Record review revealed Resident #1 was admitted to the facility, on 2/27/17, with the following Diagnoses: [REDACTED]. Review of Resident #1's physician orders, dated 9/19/19, revealed an order for [REDACTED]. This was an increase from 75 mg daily. Resident #1 had no order for [MEDICATION NAME]. Review of the Medication Error Report, dated 9/20/19, revealed Licensed Practical Nurse (LPN) #1 administered [MEDICATION NAME] 75 milligrams (mg) to Resident #1, instead of [MEDICATION NAME] 75 mg, as ordered. The report documented the reason for the medication error was not looking at the MAR closely. The report documented no adverse effects were noted for the resident. Review of the medication card for Resident #1, dated 9/19/19, revealed a label for Quetiapine ([MEDICATION NAME]) 50 mg tab, with one and one-half (1 1/2) tab per each dose for a total of 42 tablets dispensed. One (1) dose had been punched out of the card. During an interview, on 11/24/19 at 12:30 PM, the Director of Nursing (DON) stated the pharmacy dispensed [MEDICATION NAME] 75 mg, instead of [MEDICATION NAME] 75 mg to Resident #1 on 9/19/19. The DON stated she read the order to the pharmacist, after receiving a call, and confirmed to the pharmacist, the order was [MEDICATION NAME]. The DON stated Resident #1 was administered one (1) dose of [MEDICATION NAME] on the morning of 9/20/19, during the AM medication pass, by LPN #1. The DON stated the physician was notified, the resident monitored and assessed, with no adverse effects noted. During an interview, on 11/26/19 at 10:16 AM, LPN #1 stated she administered the [MEDICATION NAME] to Resident #1, instead of the [MEDICATION NAME]. She stated both medications were 75 mg. LPN #1 stated, the [MEDICATION NAME] was not on the MAR and she did not know what she was thinking when she gave the wrong medication. She stated she had been trained on medication administration, which included checking the orders and the MAR. LPN #1 stated Resident #1 acted no differently, related to the medication error. An interview with LPN #2, on 11/25/19 at 2:40 PM, revealed she phoned the pharmacy, when she discovered [MEDICATION NAME] was dispensed, instead of [MEDICATION NAME] for Resident #1, and was told a new pharmacist input the order for [MEDICATION NAME], instead of [MEDICATION NAME], and sent the medication to the facility. She stated LPN #1 confirmed Resident #1 had received one (1) dose of [MEDICATION NAME]. LPN #2 stated she reported the error to the DON. LPN #2 stated they are trained to check the orders on paper, against the computer orders and medications in the card, to ensure all match. LPN #2 stated there was no order for [MEDICATION NAME], nor was it on the MAR for Resident #1. Review of a Licensed Nurses Orientation Checklist, dated 7/18/19, revealed LPN #1 was trained on Pharmacy Policies and Procedures, including the Administration System. Resident #6 Record review revealed Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #6's physician orders, dated 10/1/19, revealed an order for [REDACTED]. Record review of the Medication Error Report, dated 10/2/19, revealed LPN #3 administered [MEDICATION NAME] ([MEDICATION NAME] and Clavulanate) 875 mg, instead of [MEDICATION NAME] 875 mg. (that dose was not in the E. Kit; dose of [MEDICATION NAME] in E. Kit was 200 mg) The report also noted there were no adverse effects for the resident. During an interview, on 11/25/19 at 3:00 PM, the DON confirmed Resident #6 was administered the wrong medication on 10/1/19; when [MEDICATION NAME] 875 mg was given, instead of [MEDICATION NAME] 875 mg, by LPN #3. The DON stated Resident #6 was assessed and noted with no ill effects from the one time dose. The DON stated LPN #3 retrieved the [MEDICATION NAME] from the Emergency Drug Kit (EDK), instead of the [MEDICATION NAME]. The DON stated both were 875 mg, and LPN #3 did not realize there was another medication in [MEDICATION NAME]. The DON stated not getting the right medication could be significant; however, [MEDICATION NAME] and [MEDICATION NAME] are basically the same medication, with the same side effects. The DON stated this was still a med error, due to LPN #3 not giving the right medication. Attempts were made to contact LPN #3, which were unsuccessful, on 11/26/19. Review of a Licensed Nurses Orientation Checklist, dated 11/6/16, revealed LPN #3 was trained on Pharmacy Policies and Procedures, including the Administration System.

Based on interview, record review, facility policy review, and facility investigation review, the facility failed to protect Resident #1 from verbal abuse, when Licensed Practical Nurse (LPN) #1 threatened to whip the resident. This affected one (1) of four (4) residents reviewed for abuse. Findings include: The facility policy titled, Abuse Policy and Procedure, dated 8/2015, noted that abuse is defined as the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm. In an interview on 3/22/19 at 9:30 AM, Resident #1 stated that she walked out to the Nurses Station and asked for a new wafer for her [MEDICAL CONDITION] bag when the nurse, LPN #1, stated that it stunk. Resident #1 stated to LPN #1 that it was either put on perfume or smell like pooh pooh. Resident #1 stated LPN #1 stated that even the ice maker was giving her a headache. Resident #1 stated that is when LPN #1 stated, I don't care about my job or this facility but I will whip your smart ass. Resident #1 stated that LPN #1 just came unglued on her. Resident #1 confirmed RN #1 escorted her to her room and talked to her. RN #1 stated, I have been scared to death because I'm afraid her and her husband will come in and shoot me. Resident #1 also stated LPN #1 Slung her chair back when she jumped on me. Resident #1 stated she was looking for a new place right now because she no longer feels safe at the facility. In a phone interview with RN #1, on 3/22/19 at 11:40 AM, she stated there was an incident on 12/30/18, when Resident #1 and LPN #1 got into an argument regarding Resident #1 spraying perfume because of her [MEDICAL CONDITION] bag smelling. RN #1 stated as the argument progressed, LPN #1 told Resident #1, If you don't get out of my face, I'm going to whoop your ass. At that time, RN #1 stated she intervened and escorted Resident #1 back to her room out of harm's way and reassured her and calmed her down. RN #1 stated the Director of Nursing (DON) was notified and LPN #1 was sent home. RN #1 confirmed the interaction from LPN #1 to Resident #1 was a threat and verbal abuse. In a phone interview with LPN #1 on 3/22/19 at 1:30 PM, LPN #1 confirmed and interaction with Resident #1 when Resident #1 was saying she would do this and she would do that but denied being verbally abusive to the resident. LPN #1 stated she had been terminated by the Administrator because she was seen arguing with Resident #1 on the tape. LPN #1 denied saying to Resident #1 that she was going to whoop her ass. Interview with the facility Administrator on 3/22/19 at 12:05 PM, revealed the facility notified the State Board of Nursing for Verbal Abuse by LPN #1 to Resident #1 and stated the facility substantiated verbal abuse during the facility investigation. In an interview with a Social Services representative on 3/22/19 at 10:50 AM, revealed psychosocial counseling was added for Resident #1 after the event with the nurse, and the verbal abuse after Resident #1 agreed to be seen. Interview with the DON on 3/22/19 at 2:30 PM, confirmed the State Board of Nursing had been notified regarding the verbal abuse by LPN #1 with Resident #1. The DON confirmed LPN #1 had been educated on abuse and neglect when hired and was terminated after the investigation was completed. Record review revealed LPN #1 signed acknowledgement of the facility's policy on Preventing Resident Abuse and the Vulnerable Adult Act on 11/6/18. Record review of the Notice of Termination for LPN #1 was documented as involuntary for verbal abuse toward a resident on 1/3/19 and effective on 1/3/19. On 1/8/19, the facility self-reported the allegation of verbal abuse of Resident #1 on 12/30/18, by Licensed Practical Nurse (LPN) #1. During the investigation it was reported by Registered Nurse (RN) #1 that LPN #1 was heard telling Resident #1, If you don't get out of my face, I'm going to whoop your ass. The facility's investigation revealed the verbal abuse was substantiated, LPN #1 was terminated, reported to the State Board of Nursing, and was reported to all necessary State Agencies. The facility admitted Resident #1 on 8/28/18, with the [DIAGNOSES REDACTED]. In a record review of Resident #1's Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 2/8/19, revealed his Brief Interview for Mental Status (BIMS) score was 15, which indicated she was cognitively intact.

Based on interview, record review, facility policy review and the facility's investigative review, the facility failed to follow the plan of care for Resident #1, to interact with the resident (pleasantly) as much as possible due to a [DIAGNOSES REDACTED]. Findings include: The facility's policy, Following the Care Plan Policy, dated 1/2011, stated, It is the Policy of this facility to follow a written and approved care plan for each resident. All employees will be trained upon hire and be required to follow the care plan. In review of the Care Plan, with a target date of 2/25/19, revealed Resident #1 has a focus for the use of anti-psychotic medications related to the [DIAGNOSES REDACTED]. (The indication would be to have pleasant interactions, not abusive interactions, due to the resident's anxiety). Another intervention included in the resident's care plan was to offer support, encourage resident to vent frustrations and fears, related to anxiety. In an interview on 3/22/19 at 9:30 AM, Resident #1 revealed that she walked to the Nurses Station and asked for a new wafer for her [MEDICAL CONDITION] bag, when the nurse (LPN #1) stated that it stunk. Resident #1 said she stated to LPN #1 that it was either put on perfume or smell like pooh pooh. Resident #1 stated then LPN #1 said that even the ice maker was giving her a headache. Resident #1 said that is when LPN #1 stated, I don't care about my job or this facility but I will whip your smart ass. Resident #1 said that LPN #1 just came unglued on her. Resident #1 confirmed RN #1 escorted her to her room and talked to her. Resident #1 also stated LPN #1 Slung her chair back when she jumped on me. Resident #1 stated she was looking for a new place right now because she no longer feels safe at the facility. In a phone interview on 3/22/19 at 11:40 AM, RN #1 stated on 12/30/18, there was incident when Resident #1 and LPN #1 got into an argument regarding Resident #1 spraying perfume because of her [MEDICAL CONDITION] bag smelling. RN #1 stated LPN #1 told Resident #1, If you don't get out of my face, I'm going to whoop your ass. RN #1 stated she intervened and escorted Resident #1 back to her room out of harm's way and reassured her and calmed her down. RN #1 stated the Director of Nursing (DON) was notified and LPN #1 was sent home. RN #1 confirmed the interaction from LPN #1 to Resident #1 was abuse. On 3/22/19 at 1:30 PM in a phone interview with LPN #1, she confirmed an interaction with Resident #1 saying Resident #1 said she would do this and she would do that but LPN #1 denied being verbally abusive to the resident. LPN #1 stated she had been terminated by the Administrator because she was seen arguing with Resident #1 on the tape. LPN #1 denied that she told Resident #1 that she was going to whoop her ass. In an interview on 3/22/19 at 12:05 PM, the facility Administrator revealed the facility notified the State Board of Nursing for Verbal Abuse by LPN #1 to Resident #1 and stated the facility substantiated verbal abuse during the facility investigation. In an interview on 3/22/19 at 10:50 AM with Social Service, stated psychosocial counseling was added for Resident #1's care plan after the event with the nurse, as well as verbal abuse. In a record review of the Notice of Termination for LPN #1, documentation included involuntary termination for verbal abuse toward a resident on 1/3/19, and effective on 1/3/19. The facility admitted Resident #1 on 8/28/18, with the [DIAGNOSES REDACTED]. In a record review of Resident #1's Quarterly Minimum Data Set (MDS) with the Assessment Reference Date of 2/8/19, revealed his Brief Interview for Mental Status (BIMS) score was 15, which indicated she was cognitively intact.

Based on the observation, interview, record review and policy review, the facility failed to ensure that residents were free from neglect for one (1) of five (5) residents reviewed, Resident #1, as evidenced by a Certified Nursing Assistant (CNA) transferred the resident, who was assessed and care planned for a mechanical lift and two (2) person assistance,by herself, resulting in an injury which required six (6) stitches. Findings include: Review of the facility's Abuse Policy and Procedure,dated 8/2015, included: Neglect means the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the facility's Modified Lift policy, dated 8/2015, revealed each resident upon admission to the facility is assessed for transfers and determined if they require the use of a lift. If they do, the type and size of sling is required. All mechanical lifts require a minimum of two (2) persons for transfer. Each employee will be trained upon hire and annually on use of a lift device. Review of the facility's face sheet revealed, the facility admitted Resident #1 on 11/13/12, with a readmission on 9/23/16. Resident #1's [DIAGNOSES REDACTED]. Review of the Minimum Data Set with a Reference Date of 4/26/18, revealed Resident #1 had a Brief Interview of Mental Status score of 7, indicating the resident had a severe cognitive deficit. Review of Resident #1's transfer assessment, dated 4/26/18, revealed Resident #1 required the use of a mechanical lift with the assistance of two (2) persons. Review of Resident #1's care plan/Kardex and plan of care, initiated 9/16/16, revealed Resident #1 required the used of a mechanical lift with a size medium sling and the assistance of two (2) persons for transfers. Review of the facility's investigative report for an incident involving Resident #1, revealed CNA #1 had transferred the resident on 4/28/18 around 4:18 PM to be weighed, and during the transfer, the resident's ankle was bumped against the wheelchair footrest and the resident sustained [REDACTED]. The resident was transferred to the local hospital, where follow up revealed there was an old [MEDICAL CONDITION], and the resident returned with six (6) sutures to the left ankle. The report revealed that the individual CNA was in-serviced regarding safety marques and facility protocols. Included in the investigative report was a hand written document, signed by CNA #1, dated 4/28/18. The document read, I (named CNA #1) was getting (Resident #1) up on Saturday (MONTH) 28, (YEAR), to go and get her weight. As I was getting (Resident #1) up out of her bed, I proceeded to put her in her wheelchair which was aligned with her bed. As I proceeded to put her in her wheelchair her left swollen ankle which was already swollen, bumped the side of her wheelchair which caused her to get a skin tear on her left ankle. Review of a report of a portable left ankle X-ray for Resident #1, performed 4/28/18, revealed findings of a healing oblique [MEDICAL CONDITION] tibia displaced about 1.5 centimeters (cm) with bony callus formation. There is soft tissue swelling, moderate [MEDICAL CONDITION] changes and generalized osteopenia. Fracture is not clearly demonstrated on 1/1/17. LPN #1 notified the Medical Doctor (MD) and received orders to send Resident #1 to Emergency Department at the hospital. Review of emergency room and Radiology reports from the (Local) hospital on [DATE], revealed Resident #1 arrived status [REDACTED]. Radiological results revealed evidence of a prior fracture without acute injury. Further Emergency Department treatment required suture closure of a four (4) centimeter (cm) laceration of the left ankle, requiring six (6) sutures, and two (2) grams of the [MEDICATION NAME] well as [MEDICATION NAME] for pain. Observation and Interview on 5/19/18 at 12:45 PM, revealed Registered Nurse (RN) #1 relayed information of a recent incident pertaining to Resident #1. She recalled Certified Nursing Assistant (CNA) #1 came to her and asked her to come see Resident #1, whom CNA #1 had just transferred, resulting in an injury to the resident's left ankle, which was bleeding. RN #1 stated that Resident #1 was on [MEDICATION NAME] and the injured area was bleeding freely. She applied pressure until the bleeding subsided. She then cleaned the area with Normal Saline and closed it with steri-strips. RN #1 stated that Resident #1's ankle appeared swollen and angry. RN #1 confirmed CNA #1 had transferred the resident by herself. RN #1 stated she phoned the Nurse Practitioner and received an order for [REDACTED].#1 worked a double day/evening shift that day and received the X-ray results that evening which mentioned a fracture. RN #1 said the attending Physician was notified and Resident #1 was sent to the hospital emergency room for evaluation. RN #1 stated Resident #1 returned to the facility the next day, Sunday 4/13/18 about 1:30 PM, with sutures of the external left ankle. Attempts were made to interview CNA #1 on 5/19/18 at 1:25 PM and again on 5/20/18 at 1:45 PM, without success. Review of CNA #1's training records revealed she had been trained on neglect and the no lift policy and following the Kardex/Care plan on 10/18/17. Review of an individual training report, dated 4/28/18, revealed the CNA had in-service on review of the lift policy, Kardex use, seek assistance when needed, never transfer a resident alone, and to use two (2) people for transfers. This was signed by CNA #1 and the Director of Nursing. Review of a personnel action form, dated 5/17/18, revealed CNA #1 was terminated for not following the lift protocol for Resident #1, who received an injury, as well as not following the protocol for lifting another resident, without injury. Observation on 5/19/18 at 1:30 PM, revealed CNA #2 exposed Resident #1's left ankle and revealed a well healing wound with a very small area of scabbing. [MEDICAL CONDITION] was noted. When asked about transfers of residents, CNA #2 explained all lifting required a minimum of two (2) persons. Never to transfer a resident alone. Interview with CNA #3, on 5/19/18 at 1:35 PM, revealed the facility is totally a no lift facility, staff are never to transfer a resident alone, they must always use a lift. Observation and interview with LPN #3 on 5/19/18 at 1:44 PM, revealed a resident can be a stand and pivot, but any lifting required a mechanical lift with a minimum of two (2) staff members for the safety of the resident and the staff members. Observation of the storage room revealed two (2) total lifts and two (2) sit to stand lifts, the battery packs explaining how they are changed out each shift, and the coding system attached to each lift to ensure staff members always have easy access to the type of transfer/lift to be used on residents as well as the color coded slings hanging on the walls, with the color indicating the size. During an interview on 5/19/18 at 2:00 PM, the DON stated that the incident and injury to Resident #1's ankle occurred on 4/28/18. The DON stated that CNA #1 was involved in transferring Resident #1 improperly without a lift and alone, and was allowed to continue to work on that day after she (DON) provided a one on one (1:1) in-service training related to taking care of residents. Further interview with the DON on 5/20/18 at 1:25 PM, revealed when she talked to CNA #1 on Saturday 4/28/18, the CNA said she could not get anyone to help her at the time of the incident. The DON stated she again advised CNA #1, she must have help and pulled the Kardex and showed her the instructions and reminded her this is a NO Lift Facility. The DON stated that CNA #1 said she was sorry. The DON stated CNA #1 was terminated on 5/17/18, as a result of not following the policy for transfer.

Based on observation, interview and record review, the facility failed to ensure staff followed the plan of care for one (1) of five (5) resident records reviewed for care plans, Resident #1. Findings include: Review of the Care Plan Policy, dated 1/2011, revealed: It is the policy of this facility to follow a written and approved care plan for each resident. All employees will follow the written care plan that is developed in order to assure the resident's needs are met. Review of Resident #1's Comprehensive Care Plane, initiated 1/14/14, included interventions that Resident #1 used the total lift for transfer with a medium sized regular sling and was dependent on two (2) staff for transfers. Review of Resident #1's most recent transfer assessment, dated 4/26/18, revealed Resident #1 required the use of a mechanical lift with the assistance of two (2) persons. Review of the facility's investigative report for an incident involving Resident #1, revealed CNA #1, on 4/28/18 around 4:18 PM, attempted to transfer and weigh the resident. The report revealed CNA #1 failed to follow facility policy by transferring Resident #1 alone, without assistance and without a lift, resulting in an injury to the resident's left ankle which required an emergency room visit requiring six (6) sutures to the left ankle. The facility's internal investigation included an interview by the DON of CNA #1 with her saying that she knew better than to transfer a resident alone and without a lift and she was sorry. The DON held a one-on-one training on the date of the occurrence, 4/28/18, and followed up with more training on 4/30/18 related to transferring with the lift and assistance. CNA #1 was ultimately terminated on 5/17/18 for not following policy. Interview with the DON on 5/20/18 at 2:00 PM, revealed her conclusion of the investigation revealed CNA #1 had failed to follow facility policy and care plan related to transferring residents. She stated they were a no-lift facility with a minimum of two (2) persons for transferring a resident. Review of CNA #1's personnel file revealed she was hired on 10/18/17, for the role of Certified Nursing Assistant which entails and was trained for basic care of all resident needs and the proper use of equipment and devices while caring for residents. Review of the facility's face sheet revealed, the facility admitted the resident originally on 11/13/12, with the most recent admission date of [DATE]. Resident #1's [DIAGNOSES REDACTED]. Review of the Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 4/26/18, revealed Resident #1 has a Brief Interview of Mental Status (BIMS) scored of 10, indicating the resident had moderate mental impairment.