Every finding on record at Crestway Nursing & Rehabilitation

Based on observation, interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 1 (Cook A) of 11 dietary staff reviewed for qualified dietary staff, in that: The facility failed to ensure [NAME] A had a current had Food Handler Certificate. This failure could place residents who ate food from the facility's kitchen at risk of not having their nutritional needs met and place them at risk for food born illnesses.Findings included: Record review of [NAME] A's food handler certificate revealed [NAME] A completed the Learn2Serve Food Handler Training Course through 360 Training. The certificate reflected a completion date of 04/15/2023 and an expiration date of 04/14/2026. Record review of a list of staff, dated 04/29/26, revealed [NAME] A was listed as an employee who worked in the kitchen and was hired on 1/14/26. During an interview on 04/29/26 at 2:30 p.m. the Administrator stated she would check to see if they had another food handler's certificate for [NAME] A because the current one was expired. During an interview on 04/29/26 at 3:00 p.m. the Dietary Manager stated [NAME] A was on the schedule for that afternoon and was instructed to complete his food handlers prior to returning to duty. The Dietary Manager stated he was new and had not noticed [NAME] A's food handler's certificate had expired. During an observation and record review on 4/30/26 at 9:00 a.m. the Administrator produced a food handler for [NAME] A that revealed [NAME] A successfully completed the required prerequisite program for Food Handler through The Always Food Safe Company. The certificate reflected a completion date of 04/22/2026 and indicated the certification was valid through 04/22/2029. Record review of [NAME] A's food handler's certificate through online database verification revealed [NAME] A successfully completed the required prerequisite program for Food Handler through The Always Food Safe Company. The certificate reflected a completion date of 04/29/2026 and indicated the certification was valid through 04/29/2029. During a follow-up interview, on 04/30/26, at 9:20 a.m. the Administrator stated she was unsure why the dates were different on the food handler's certificate that was given as the updated version for [NAME] A and was unsure why the date was different from the online verification that reflected, he completed the certificate on 4/29/26 instead of 4/22/26. Record review of the facility's policy titled Nutrition Services Personnel Guidelines, revised 01/01/2026, revealed under section IV, Dietary Employees should have food handlers permits in accordance with local, state, and federal regulations within 30 days of hire.

Based on record reviews and interviews, the facility failed to notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of five residents reviewed for notification of changes. The facility failed to notify Resident #1's family when she expired (died) on [DATE]. This failure could result in the resident's family/RP not being aware of the resident's condition. The findings included: Record review of Resident #1's face sheet dated [DATE] revealed an [AGE] year-old female, admitted on [DATE] and readmitted on [DATE] with diagnoses which included displaced fracture of seventh cervical vertebra, subsequent encounter for fracture with routine healing (a break in the small bones of the neck that was healing), hypertension (elevated blood pressure) and anxiety disorder. The face sheet indicated Resident #1 was discharged on [DATE] (location not specified). Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMs score of 3 which indicated a severe cognitive impairment with partial to substantial assistance required for ADL. Record review of Resident #1's discharge MDS assessment dated [DATE] revealed the resident died in the facility on [DATE]. Record review of Resident #1''s General Progress Note dated [DATE] revealed facility staff conducted CPR on the resident until EMS arrived and took over. Time of death was called at 12:02 p.m. ([DATE]) and police arrived to assess scene. Record review of Resident #1's General Progress Note dated [DATE] by the DON indicated the physician was notified of local police arrival (at the facility) and ongoing investigation. Nursing staff instructed by police to not speak with residents, enter room or contact families. During an interview on [DATE] at 1:05 p.m., the ADON stated police conducted an investigation of the death of Resident #1 because another resident saw Resident #1 fall to the floor and thought he saw her roommate hitting her with a croc (a type of foam shoe) or a purse. The ADON stated the facility had conducted an investigation and no other residents or staff heard or saw anything. She stated because the police were involved in the death investigation, they (police) told them (facility staff) that they were not allowed to notify the family of Resident #1 of her death. She stated the police told the management in a group. She stated she was in the office, as well as the DON and Administrator. The ADON stated because they had been told not to tell the family due to the investigation, the family was not notified of Resident #1's death. She stated on [DATE] the family called to check on Resident #1. The ADON stated she took the call and confirmed she died but was not able to offer any other details. She stated she gave the family the phone number of the police officer and told them to call the police for additional information. The ADON stated the family was very upset about it. During an interview on [DATE] at 1:54 p.m., the DON stated on [DATE], she received a call that Resident #1 had fallen, and as they were getting her back in bed, she coded. She stated another resident approached EMS personnel as they were attempting to resuscitate the resident and stated he saw another resident hit her with a shoe. The DON stated this resulted in a police investigation. She stated the results of the investigation after an autopsy was complete was that Resident #1 died as a result of a clot in her lungs. Attempted interview on [DATE] at 2:45 p.m. with the family of Resident #1. No return call was received. During an interview on [DATE] at 3:41 p.m., the local police department investigator stated he told the facility staff they were not to notify Resident #1's family of her death due to the investigation. He stated sternly, it was the local law enforcement responsibility to notify next of kin, not the facilities. During an interview on [DATE] at 4:07 p.m., the DON stated they had asked the police officer if they were okay to notify the family of Resident #1 of her death. She stated the police officer told her, the ADON and Administrator who were all in the office together no. The DON stated he said, don't notify family. The DON stated the police officer stated they would get the medical examiner report first because it was a crime scene and they needed to talk (interview) the family first. The DON stated she did not specifically notify the police officer of their requirements to notify the family of a change of condition. She stated during the investigation itself, facility policy had come up because the police officer originally told them they could not investigate. The DON stated she told the police officer it was their policy to investigate, and he had replied that the police were doing the investigation. The DON stated after the police left the facility conducted their own investigation. The DON stated their policy stated family should be notified timely. She stated she as well as other facility staff wanted to notify them right then and there. She stated they wanted to make sure the important things were completed. She stated because she was unable to do it, she documented it in Resident #1's medical record. During an interview on [DATE] at 4:15 p.m., the Administrator stated an investigator with the local police department told them not to notify family because it was a crime scene and next of kin had to identify the body for the medical examiner. The Administrator stated yesterday ([DATE]), the family called and was frustrated they had received a call from the medical examiner's office to notify them of the death. The Administrator stated she gave the family the name and phone number of the investigator and told them they would need to reach out to the investigator for information. The Administrator stated she did not tell the investigator their facility policy required notification of the family because he firmly told them it was a crime scene, and this is how it goes. The Administrator stated she wanted to notify the family and staff had asked the police if they could. She stated the investigator reiterated to the facility as a team; they could not notify the family. During an interview on [DATE] at 4:31 p.m., the Administrator stated she did not reach out to the Ombudsman, HHSC Program Management or the Medical Director for advice. She stated they discussed the death and police involvement with the Medical Director but not specifically the law enforcement request to not notify. Record review of the facilities policy Change of Condition Notification policy, last revised 06/2020 revealed: Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. II. The Facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition cause by, but not limited to: A. An injury/accident B. A significant change in the resident's physical, cognitive, behavioral or functional status. V. Family Notification: A. The licensed Nurse will notify the resident, the resident's responsible party, or the family/surrogate decision-makers of any changes in the resident's condition as soon as possible.

Based on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 6 residents out of 18 residents (Resident #3, Resident #4, Resident #8, Resident #7, Resident #11, and Resident #55) whose records were reviewed for assessments. 1. The nursing facility did not identify siderails were used as a restraint for Resident #32. The nursing facility did not identify siderails were used as a restraint for Resident #43. The nursing facility did not identify siderails were used as a restraint for Resident #74. The nursing facility did not identify siderails were used as a restraint for Resident #85. Resident #11's quarterly MDS, dated [DATE], inaccurately revealed the resident was receiving hospice care. 6. Resident #55's quarterly MDS, dated [DATE], inaccurately revealed the resident did not have surgical wound. This deficient practice could affect any resident and could result in the inaccurate status of the residents. The findings were: 1. Review of Resident #3's face sheet, dated 7/18/25, revealed he was admitted to the facility on [DATE] with diagnoses including Dementia in other diseases classified, severe and Acute and chronic respiratory failure with hypoxia[JM1] (low levels of oxygen in the body tissues). Review of Resident #3's annual MDS assessment, dated 5/9/25, revealed his BIMS score was 3 indicative of severe cognitive impairment and he had impaired range of motion on both lower extremities. Further review revealed the use of side rails was not identified as a restraint. Review of Resident #3's CP, revised 6/23/25, revealed he required total assistance by 1-2 persons with mobility. Further review revealed Resident #3 had established contractures of bilateral lower and upper extremities due to impaired mobility (upon admission). Review of Resident #3's ADL flowsheet from 7/4/25 to 7/17/25: Self-performance: How resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture revealed he required extensive assistance on a couple of days and total assistance on most days. Review of Resident #3’s consolidated physician orders for July 2025 revealed a side rail order “MAY HAVE 1/4 SIDE RAILS UP AS NEEDED FOR ENABLER Phone Active 05/19/2025.” Observation on 07/16/2025 at 10:16 AM revealed Resident #3 was lying in bed with padded 1/4 side rails on both sides of the bed. The side rails were up and locked and he also had mittens on both hands. Interview on 07/17/25 at 2:05 PM with LVN I revealed Resident #3 was totally dependent on staff for all ADL's and was not able to use the side rails for mobility especially since he wore mittens on both hands. She stated the side rails kept Resident #3 from pulling on his trachea which he would often do if he did not have mittens on. LVN I stated the side rails were used for safety because he would move throughout the bed and was a fall risk. She further stated the side rails kept him from falling out of bed. Interview on 07/17/25 at 2:10 PM with CNA H and CNA E revealed Resident #3 did not use the side rails for mobility. They stated the side rails kept him from falling out of bed because he would move all around his bed. Interview on 07/18/25 at 10:08 AM with the DON revealed Resident #3 was totally dependent on staff for all ADL's and did not use the side rails for mobility. She stated the side rails were used for safety to prevent falls since they were implemented. She stated they were in fact used as restraints.[JM2] [DG3] The DON stated the facility had flagged for restraints, but they did not have an MDS staff to update the MDS assessment. The DON stated it was necessary for the MDS assessment to adequately represent the resident's needs and overall status; otherwise, the result could be that the resident did not receive the necessary care and services as needed. 2. Review of Resident #4's face sheet, dated 7/18/25, revealed he was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (stroke), undifferentiated Schizophrenia and Generalized Anxiety. Review of Resident #4's annual MDS assessment, dated 5/7/25, revealed his BIMS score was 3 indicative of severe cognitive impairment and he had impaired range of motion on both upper and lower extremities. Further review revealed the use of side rails were not identified as restraint use. Review of Resident #4's CP revised on 7/5/25 revealed he required assistance with ADL's due to respiratory failure, muscle wasting and atrophy, unspecified lack of coordination, CVA, cognitive deficit. One of the interventions included Resident #3 required 2- person assistance with bed mobility. Review of Resident #4’s consolidated physician orders revealed an order for side rails, “MAY HAVE 1/4 SIDE RAILS UP AS NEEDED FOR ENABLER Phone Active 04/30/2025.” Observation on 07/16/2025 at 10:33 AM revealed Resident #4 lying in bed asleep, bed was in the low position with padded 1/4 side rails up and locked on both sides. There were mats on the floor on both sides of the bed, wedge bolsters towards the foot of the bed along both sides of the mattress and there was a pillow between the side rail and left shoulder. Resident #4 had socks on both hands. Interview on 07/17/25 at 2:05 PM with LVN I revealed Resident #4 was totally dependent on staff for all ADL's and did not use the side rails for mobility. She stated he was not able to use the side rails for mobility especially since he wore mittens or gloves on both hands. She stated the side rails kept Resident #4 from pulling on his trachea which he would often do if he did not have mittens or gloves on. LVN I stated the side rails were used for safety because he would move throughout the bed and was a fall risk. She further stated the side rails kept him from falling out of bed. Interview on 07/17/25 at 2:10 PM with CNA H and CNA E revealed Resident #4 did not use the side rails for mobility. They stated the side rails kept him from falling out of bed because he would move all around his bed. Interview on 07/18/25 at 10:08 AM with the DON revealed Resident #4 was totally dependent on staff for all ADL's and did not use the side rails for mobility. She stated the side rails were used for safety to prevent falls since they were implemented. She stated they were in fact used as restraints. The DON stated the facility had flagged for restraints, but they did not have an MDS staff to update the MDS assessment. The DON stated it was necessary for the MDS assessment to adequately represent the resident's needs and overall status; otherwise, the result could be that the resident did not receive the necessary care and services as needed. 3. Review of Resident #7's face sheet, dated 7/18/25, revealed she was admitted to the facility on [DATE] with diagnoses including Diffuse traumatic brain injury (happens when a sudden, external, physical assault damages the brain) and contracture joint. Review of Resident #7's MDS assessment, dated 5/30/25, revealed her BIMS score was 6 indicative of severe cognitive impairment. Resident had impaired range of motion on both upper and lower extremities and was dependent on staff for all ADL care including bed mobility. Interview on 07/17/25 at 2:05 PM with LVN I revealed Resident #7 was totally dependent on staff for all ADL's and was not able to use the side rails for mobility because both her hands were contracted. LVN stated the siderails were used for safety to ensure she did not fall out of bed. Observation on 07/16/2025 at 10:46 AM revealed Resident #7 lying in bed asleep with HOB up about 30 degrees. Resident #7's had contractures on both wrists/hands and ¼ side rails were up and locked on both sides of the bed. Interview on 07/17/25 at 2:10 PM with CNA H and CNA E revealed Resident #7 was not able to use the side rails for mobility because of the contractures on her hands. They stated the side rails were used for safety to prevent falls. Interview on 07/18/25 at 10:08 AM with the DON revealed Resident #7 was totally dependent on staff for all ADL's and did not use the side rails for mobility. She stated the side rails were used for safety to prevent falls since they were implemented. She stated they were in fact used as restraints. The DON stated the facility had flagged for restraints, but they did not have an MDS staff to update the MDS assessment. The DON stated it was necessary for the MDS assessment to adequately represent the resident's needs and overall status; otherwise, the result could be that the resident did not receive the necessary care and services as needed. 4. Review of Resident #8's face sheet, dated 7/18/25, revealed she was admitted to the facility on [DATE] with diagnosis to include Anoxic Brain Damage. Review of Resident #8's quarterly MDS assessment, dated, 6/28/25 revealed her BIMS score was coded as severe cognitive impairment and she had impaired range of motion on both upper extremities. Further review revealed the use of side rails were identified as restraint “used less than daily”. Review of Resident #8's CP revised on revealed she required total assistance with ADL's due to Anoxic Brain Injury. One of the interventions included Resident #8 required total assistance by 2- persons with bed mobility. Observation and attempted interview on 07/16/25 at 9:52 AM revealed Resident #8 was lying in bed with 1/4 side rails up and locked on both sides of the bed. Resident #8 had contractures on both wrists/hands. Resident #8 would move her eyes when spoken to but was non-verbal. Interview on 07/17/25 at 2:05 PM with LVN I revealed Resident #8 was totally dependent on staff for all ADL's and was not able to use the side rails for mobility because she had contractures on both hands. LVN I stated the siderails were used daily for safety to ensure Resident #8 did not fall out of bed. Interview on 07/17/25 at 2:10 PM with CNA H and CNA E revealed Resident #4 did not use the side rails daily for mobility because she had contractures on both hands. They stated the side rails were used for safety so that she did not fall out of bed. Interview on 07/18/25 at 10:08 AM with the DON revealed Resident #8 was totally dependent on staff for all ADL's and did not use the side rails for mobility. She stated the side rails were used for safety to prevent falls since they were implemented. She stated they were in fact used as restraints. The DON stated the facility had flagged for restraints, but they did not have an MDS staff to update the MDS assessment. The DON stated it was necessary for the MDS assessment to adequately represent the resident's needs and overall status; otherwise, the result could be that the resident did not receive the necessary care and services as needed. 5. Record review of Resident #11's face sheet, dated 07/18/2025, revealed the resident was [AGE] years old male and admitted to the facility on [DATE] with diagnoses of open-angle glaucoma (increased pressure inside eyes, potentially optic nerve damage and vision loss), type 2 diabetes mellitus (the body has trouble controlling blood sugar and using it for energy), cerebral infarction (area of brain tissue that dies as a result of localized low oxygen due to cessation of blood flow), chronic kidney disease-stage 3 (kidneys are less able to filter water and fluid out of the body), and hemiplegia and hemiparesis (weakness on one side of your body). Record review of Resident #11’s quarterly MDS, dated [DATE], revealed the resident's BIMS score was 14 out of 15, which indicated the resident's cognitive was intact, and in Section O (Special Treatment), it was coded that Resident #11 was receiving hospice care. However, the answer regarding “Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months?) was coded “No,” instead of “Yes” in Section J (Health Conditions). Record review of Resident #11's comprehensive care plan, dated 02/28/2025, revealed The resident received hospice care related to chronic kidney disease - For intervention: coordinate care with hospice care and hospice care program as ordered. Record review of Resident #11’s Physician Certification of Terminal Illness, dated 02/28/2025, revealed hospice physician said, “I certify that I am a physician licensed in the State of Texas or a physician on duty with the United State military and that the recipient identified above is terminally ill with a medical prognosis of six months or less to live if the illness runs its normal course.” Interview on 07/18/2025 at 8:42 a.m. with DON stated because Resident #11 was receiving hospice are, Yes should have been coded to the answer regarding “Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months?) of the resident's quarterly MDS, dated [DATE], instead of No. DON said it was mistake, coding accurately was a MDS nurse's responsibility, and inaccurate MDS assessment might affect improper care to Resident #11. Further interview with DON said the facility did not have MDS nurse, so the company MDS nurse was helping, but the nurse was on vacation at this time. 6. Record review of Resident #55's face sheet, dated 07/18/2025, revealed the resident was [AGE] years old male and admitted to the facility originally on 11/14/2024 and re-admitted on [DATE] with diagnoses of dry eye syndrome bilateral lacrimal glands (inflammation of the tear-shaped gland), fatty liver (fat builds up in the liver), paraplegia (loss of muscle function in the lower half of the body), hypertension (high blood pressure), and dysuria (the sensation of pain or burning when urination). Record review of Resident #55’s quarterly MDS, dated [DATE], revealed the resident's BIMS score was 13 out of 15, which indicated the resident's cognitive was intact, and in Section M (Skin Conditions), the resident’s surgical wound was coded “No.” Record review of Resident #55's comprehensive care plan, dated 05/15/2025, revealed the resident has current surgical wound that require treatment to his left groin. For intervention – Treatment per medical doctor’s orders. Record review of Resident #55’s physician order, dated 06/26/2025, revealed “wound care: Clean left groin post-surgical wound with ¼ strength Dakins, pat dry, apply calcium alginate, dry dressing daily and as needed.” Record review of Resident #55’s weekly sin assessment, dated 05/12/2025, revealed the resident had post-surgical wound of the left groin with no signs of infection. Interview on 07/18/2025 at 9:00 a.m. with Resident #55 refused interview with the surveyor, and the surveyor to observe his wound and wound care. Interview on 07/18/2025 at 9:21 a.m. with DON stated Resident #55 was receiving wound care currently because the resident had post-surgical wound to his groin, so the resident MDS, dated [DATE] regarding the resident’s surgical wound was coded “No” was inaccurate. It should have been coded “Yes.” DON said it was mistake, coding accurately was a MDS nurse's responsibility, and inaccurate MDS assessment might affect improper care to Resident #55. Further interview with DON said the facility did not have MDS nurse, so the company MDS nurse was helping, but the nurse was on vacation at this time. Record review of the facility policy, titled Resident Assessment, revised 03/2022, revealed . 7. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent that included measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs for 3 of 6 Residents (Resident #3, Resident #4 and Resident #7) whose Care Plans were reviewed. The facility failed to recognize Resident #3 used 1/4 side rails as a restraint and failed to implement interventions to ensure his safety.The facility failed to include Resident #4 used 1/4 side rails while in bed, that they were used as a restraint and failed to develop/implement interventions to ensure his safety.The facility failed to develop and implement interventions related to the fact Resident #7 had contractures on both wrists/hands and she used side rails while in bed. These failures could place residents at risk for not getting their medical, physical, and psychosocial needs met and not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings were:Review of Resident #3's face sheet, dated 7/18/25, revealed he was admitted to the facility on [DATE] with diagnoses including Dementia (loss of cognitive functioning it interferes with a person's daily life and activities) in other diseases classified, severe and Acute and chronic respiratory failure with hypoxia (low oxygen levels). Review of Resident #3's annual MDS assessment, dated 5/9/25, revealed his BIMS score was 3 of 10 indicative of severe cognitive impairment and he had impaired range of motion on both lower extremities. Review of Resident #3's CP, completed on 6/23/25, revealed he required total assistance by 1-2 persons with mobility, he had established contractures of bilateral lower and upper extremities due to impaired mobility (upon admission). Further review revealed he used side rails for positioning while in bed. The CP did not identify the side rails were used as a restraint. Review of Resident #3's consolidated physician orders for July 2025 revealed a side rail order MAY HAVE 1/4 SIDE RAILS UP AS NEEDED FOR ENABLER Phone Active 05/19/2025. Observation on 07/16/2025 at 10:16 AM revealed Resident #3 was lying in bed with padded 1/4 side rails on both sides of the bed. The side rails were up and locked and he also had mittens on both hands. Interview on 07/17/25 at 2:05 PM with LVN I revealed Resident #3 was totally dependent on staff for all ADLs. LVN I stated the side rails were used for safety because he would move throughout the bed and was a fall risk. She further stated the side rails kept him from falling out of bed. Interview on 07/17/25 at 2:10 PM with CNA H and CNA E revealed Resident #3 used side rails to keep him from falling out of bed because he would move all around his bed. Interview on 07/18/25 at 10:08 AM with the DON revealed Resident #3 was totally dependent on staff for all ADLs. She stated the side rails were used for safety to prevent falls since they were implemented. She stated they were in fact used as restraints. The DON stated the facility had flagged for restraints, but they did not have an MDS Coordinator who also completed Care Plans. She stated the unit mangers/ADON's were responsible to ensure they were compliant. The DON stated the use of side rails should be identified as restraint use along with implementation of interventions in the CP. She stated this was necessary so that staff was aware to monitor the resident's safety and report any adverse effects. Otherwise, it could result in the resident being injured. 2. Review of Resident #4's face sheet, dated 7/18/25, revealed he was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (stroke), undifferentiated Schizophrenia (serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) and Generalized Anxiety. Review of Resident #4's annual MDS assessment, dated 5/7/25, revealed his BIMS score was 3 of 10 indicative of severe cognitive impairment and he had impaired range of motion on both upper and lower extremities. Review of Resident #4's CP completed on 7/5/25 revealed it did not address the use of bilateral 1/4 side rails while in bed and that they were used as a restraint. Review of Resident #4's consolidated physician orders revealed an order for side rails, MAY HAVE 1/4 SIDE RAILS UP AS NEEDED FOR ENABLER Phone Active 04/30/2025. Observation on 07/16/2025 at 10:33 AM revealed Resident #4 lying in bed asleep, bed was in the low position with padded 1/4 side rails up and locked on both sides. Interview on 07/17/25 at 2:05 PM with LVN I revealed Resident #4 was totally dependent on staff for all ADLs. LVN I stated the side rails were used for safety because he would move throughout the bed and was a fall risk. She further stated the side rails kept him from falling out of bed. Interview on 07/17/25 at 2:10 PM with CNA H and CNA E revealed Resident #4 used side rails to keep him from falling out of bed because he would move all around his bed. Interview on 07/18/25 at 10:08 AM with the DON revealed Resident #4 used the side rails for safety, to prevent falls. She stated the side rails were used for safety to prevent falls since they were implemented. She stated they were in fact used as restraints. The DON stated the facility had flagged for restraints, but they did not have an MDS Coordinator who also completed Care Plans. She stated the unit mangers/ADON's were responsible to ensure they were compliant. The DON stated the use of side rails should be identified as restraint use along with implementation of interventions in the CP. She stated this was necessary so that staff was aware to monitor the resident's safety and report any adverse effects. Otherwise, it could result in the resident being injured. 3. Review of Resident #7's face sheet, dated 7/18/25, revealed she was admitted to the facility on [DATE] with diagnoses including Diffuse traumatic brain injury (occurs when a sudden violent blow or jolt to the head causes damage to the brain) and contracture of the joint. Review of Resident #7's MDS assessment, dated 5/30/25, revealed her BIMS score was 6 of 10 indicative of severe cognitive impairment. Resident had impaired range of motion on both upper and lower extremities and was dependent on staff for all ADL care including bed mobility. Review of Resident #7's CP completed on 6/17/25 revealed she required assistance with all ADLs including bed mobility by 2 staff. The CP did not address or implement interventions related to the fact Resident #7 had contractures on both wrists/hands and she used side rails while in bed. Observation on 07/16/2025 at 10:46 AM revealed Resident #7 lying in bed asleep with HOB up about 30 degrees. Resident #7's had contractures on both wrists/hands and 1/4 side rails were up and locked on both sides of the bed. Interview on 07/17/25 at 2:05 PM with LVN I revealed Resident #7 had contractures on both wrists/hands and was totally dependent on staff for all ADLs. LVN I stated the siderails were used for safety and to ensure she did not fall out of bed. Interview on 07/17/25 at 2:10 PM with CNA H and CNA E revealed Resident #7 had contractures on her hands. They stated the side rails were used for safety to prevent falls. Interview on 07/18/25 at 10:08 AM with the DON revealed Resident #7 was totally dependent on staff for all ADL's related to having contractures on both wrists/hands. She stated the side rails were used for safety to prevent falls since they were implemented. She stated they were in fact used as restraints. The DON stated the facility had flagged for restraints, but they did not have an MDS Coordinator who also completed Care Plans. She stated the unit mangers/ADON's were responsible to ensure they were compliant. The DON stated the use of side rails should be identified as restraint use along with implementation of interventions in the CP. She stated this was necessary so that staff was aware to monitor the resident's safety and report any adverse effects. Otherwise, it could result in the resident being injured. Review of a facility policy, revised March 2022 read in relevant part, a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 3 of 9 Residents (Residents #1, Resident #2 and Resident #7) whose records were reviewed for oxygen use.Nursing staff failed to ensure Resident #1's oxygen concentrator was equipped with 2 filters while in use.Nursing staff failed to ensure Resident #2's oxygen concentrator was equipped with 2 filters while in use.Nursing staff failed to ensure Resident #7's oxygen concentrator was equipped with 2 filters while in use.This deficient practice could affect any respiratory on oxygen therapy and could contribute to respiratory distress, infections, pneumonia and an overall decline in their physical condition.The findings were: 1. Review of Resident #1's face sheet, dated 7/17/25, revealed he was admitted to the facility on [DATE] with diagnosis including Acute and Chronic respiratory failure respiratory failure (lungs have a hard time loading your blood with oxygen or removing carbon dioxide) with hypoxia (low levels of oxygen in your body tissues). Review of Resident 1's admission MDS assessment, dated 3/8/25, revealed his BIMS score was 11 of 15 reflective of moderate cognitive impairment, he received continuous oxygen therapy, tracheostomy care and had an invasive mechanical ventilator. Review of Resident #1's Care Plan dated 6/11/25 revealed he had ineffective breathing pattern related to inability to sustain spontaneous ventilation in which I require a mechanical ventilator. Some of the interventions included Maintain O2 setting at rate to maintain saturations above 90% and oxygen and rate per MD orders. Observation on 7/15/25 at 12:55 PM revealed Resident #1 was lying in bed asleep with a tracheostomy and ventilator in place. Resident #1 was receiving continuous oxygen at 3 liters per minute. Further observation revealed Resident #1's oxygen concentrator did not have filters, it was designed to have a filter on both sides of the concentrator. Resident #1 did not wake up to the call of his name. 2. Review of Resident #2's face sheet, dated 7/17/25, revealed he was admitted to the facility on [DATE] with diagnosis including Respiratory Failure (lungs have a hard time loading your blood with oxygen or removing carbon dioxide) with unspecified hypoxia (low levels of oxygen in your body tissues). Review of Resident #2's quarterly MDS assessment, dated 5/9/25, revealed his BIMS score was 12 of 15 reflective of moderate cognitive impairment and he received continuous oxygen therapy and used a non-invasive mechanical ventilator (BI pap, breathing machine). Review of Resident #2's CP, dated 7/5/25, revealed he received oxygen via nasal canula at times. Interventions included Administer O2 Per MD orders, Change Nasal Cannula and tubing per facility policy. Review of Resident #2's consolidated physician orders for July 2025 revealed an order for the use of the BiPap but not for the oxygen. Observation and interview on 7/15/25 at 12:45 PM revealed Resident #2 lying in bed receiving 02 via nasal cannula at 2 liters per hour. The oxygen concentrator did not have filters. The oxygen concentrator was designed to have a filter on both sides of the concentrator. Interview with Resident #2 stated he received oxygen for shortness of breath. 3. Review of Resident #7's face sheet, dated 7/17/25, revealed he was admitted to the facility on [DATE] with diagnosis including Acute and Chronic respiratory failure respiratory failure (lungs have a hard time loading your blood with oxygen or removing carbon dioxide) unspecified whether with hypoxia (low levels of oxygen in your body tissues) or Hypercapnia (elevated levels of carbon dioxide in the blood). Review of Resident 7's 5-day MDS assessment, dated 6/21/25, revealed his BIMS score had not been determined, he received continuous oxygen therapy, tracheostomy care and had an invasive mechanical ventilator. Review of Resident #7's Care Plan dated 7/14/25 revealed he had impaired cognition related to anoxic brain injury (brain damage due to loss of oxygen), history of cardiac arrest, he had ineffective breathing pattern related to inability to sustain spontaneous ventilation in which I require a mechanical ventilator. Some of the interventions included Maintain O2 setting at rate to maintain saturations above 90% and oxygen and rate per MD orders. Review of Resident #7's consolidated orders for July 2025 did not reveal an order for oxygen therapy. Observation on 7/15/25 at 12:50 PM revealed Resident #7 was lying in bed asleep with a tracheostomy and ventilator in place. Resident #7 was receiving continuous oxygen at 3 liters per minute. Further observation revealed Resident #1's oxygen concentrator did not have filters, it was designed to have a filter on both sides of the concentrator. Resident #7 did not wake up to the call of his name. Interview on 7/15/25 at 1:20 PM with LVN F revealed Resident 1#'s, Resident #2's and Resident #7s oxygen concentrator did not have filters. She stated the concentrators should have the filters to prevent debris from getting into the concentrator which could cause respiratory problems for the residents whose respiratory systems were already compromised. LVN F stated breathing in contaminated air could cause an infection or pneumonia. LVN F stated the assigned RT for the hall was responsible for changing out the filters/ensuring the filters were in place and had not seen him on the hall. She stated all nursing staff was responsible for ensuring the oxygen concentrators were equipped with filters. Interview on 07/15/2025 at 2:15 PM with RT G revealed he was assigned to the 300 hall on this date, 7/15/25. He stated today was the day to change out the filters on the oxygen concentrators. He stated he was in the process of changing them out when a new admission on 400 came in and he went to assist his co-worker to set up the tracheostomy equipment. RT G stated that it took longer than he expected. He stated he did not let the nurse know he was leaving the hall or that he was in the process of changing out the filter on the 300 hall. Interview on7/18/25 at 6:14 PM with the DON revealed the facility had MD standing PRN orders for oxygen use between 0 to 5 liters per min. The DON stated all oxygen concentrators should be equipped with a filter or filters. She stated the RT for the hall was responsible for ensuring the filters were changed out and in place. She stated if the RT was in the process of changing out the filters, she expected the RT to complete the task before moving onto another task. The DON further stated the RT should let the charge nurse know when leaving the hall if in the middle of replacing the filters because any nursing staff could also replace the filters. The DON stated leaving the oxygen concentrators unequipped with the filters could result in the resident suffering from respiratory distress, infections or pneumonia. The DON stated she would provide a copy of the standing orders and a policy on oxygen therapy. A policy for oxygen therapy and standing orders for PRN oxygen therapy were requested and was not received by the end of the survey on 7/18/25 at 11:30 PM.

Based on observation, interview and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment, to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of the bed rails for ? of 6 Residents (Resident #3, Resident #4, Resident #7 and Resident #8) whose records were reviewed for restraints. The facility failed to identify the use of bilateral use of side rails as a restraint and failed to ensure Resident #3's safety since his admission date of 05/02/2025. The facility failed to identify the use of bilateral use of side rails as a restraint and failed to ensure Resident #4's safety since his admission date of 8/10/22.The facility failed to identify the use of bilateral use of side rails as a restraint and failed to ensure Resident #7's safety since his admission date of 7/18/25. The facility failed to identify the use of bilateral use of side rails as a daily restraint and failed to ensure Resident #8's safety since his admission date of 6/7/23.This deficient practice could affect any resident using side rails and could result in serious avoidable accidents. The findings included: Review of Resident #3's face sheet, dated 7/18/25, revealed he was admitted to the facility on [DATE] with diagnoses including Dementia in other diseases classified ((loss of cognitive functioning it interferes with a person's daily life and activities), severe and Acute and chronic respiratory failure with hypoxia (low oxygen levels). Review of Resident #3's annual MDS assessment, dated 5/9/25, revealed his BIMS score was 3 indicative of severe cognitive impairment, and he had impaired range of motion on both lower extremities. Further review revealed the use of side rails was not identified as restraint use. Review of Resident #3's CP, revised 6/23/25, revealed he required total assistance by 1-2 persons with mobility. Further review revealed Resident #3 had established contractures of bilateral lower and upper extremities due to impaired mobility (upon admission). Review of Resident #3's consolidated physician orders for July 2025 revealed a side rail order MAY HAVE 1/4 SIDE RAILS UP AS NEEDED FOR ENABLER Phone Active 05/19/2025. Review of Resident #3's ADL flowsheet from 7/4/25 to 7/17/25: Self-performance: How resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture revealed he required extensive assistance on a couple of days and total assistance on most days. Review of Resident #3's assessments did not reveal a restraint assessment or consent for the use of side rail. Observation on 07/16/2025 at 10:16 AM revealed Resident #3 was lying in bed with padded 1/4 side rails on both sides of the bed. The side rails were up and locked and he also had mittens on both hands. Interview on 07/17/25 at 2:05 PM with LVN I revealed Resident #3 was totally dependent on staff for all ADL's and was not able to use the side rails for mobility especially since he wore mittens on both hands. She stated the side rails kept Resident #3 from pulling on his trachea which he would often do if he did not have mittens on. LVN I stated the side rails were used for safety because he would move throughout the bed and was a fall risk. She further stated the side rails kept him from falling out of bed. Interview on 07/17/25 at 2:10 PM with CNA H and CNA E revealed Resident #3 did not use the side rails for mobility. They stated the side rails kept him from falling out of bed because he would move all around his bed. Interview on 07/18/25 at 10:08 AM with the DON revealed Resident #3 was totally dependent on staff for all ADL's and did not use the side rails for mobility. She stated the side rails were used for safety to prevent falls so in fact they were used as restraints. The DON stated she was not aware of alternatives being used prior to installing the side rails. She stated an assessment, a consent including discussing the risks and benefits were not obtained for the use of side rails. The DON stated following these measures were important to ensure the safety of the resident and not taking these measures could result in the resident being injured. 2. Review of Resident #4's face sheet, dated 7/18/25, revealed he was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (stroke), undifferentiated Schizophrenia (serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) and Generalized Anxiety. Review of Resident #4's annual MDS assessment, dated 5/7/25, revealed his BIMS score was 3 of 10 indicative of severe cognitive impairment and he had impaired range of motion on both upper and lower extremities. Further review revealed the use of side rails were not identified as restraint use. Review of Resident #4's CP revised on 7/5/25 revealed he required assistance with ADL's due to respiratory failure, muscle wasting and atrophy, unspecified lack of coordination, CVA, cognitive deficit. One of the interventions included Resident #3 required 2- person assistance with bed mobility. Review of Resident #4's consolidated physician orders revealed an order for side rails, MAY HAVE 1/4 SIDE RAILS UP AS NEEDED FOR ENABLER Phone Active 04/30/2025. Review of Resident #4's assessments did not reveal a restraint assessment or consent for the use of side rail.Observation on 07/16/2025 at 10:33 AM revealed Resident #4 lying in bed asleep, bed was in the low position with padded 1/4 side rails up and locked on both sides. There were mats on the floor on both sides of the bed, wedge bolsters towards the foot of the bed along both sides of the mattress and there was a pillow between the side rail and left shoulder. Resident #4 had socks on both hands. Interview on 07/17/25 at 2:05 PM with LVN I revealed Resident #4 was totally dependent on staff for all ADL's and did not use the side rails for mobility. She stated he was not able to use the side rails for mobility especially since he wore mittens or gloves on both hands. She stated the side rails kept Resident #4 from pulling on his trachea which he would often do if he did not have mittens or gloves on. LVN I stated the side rails were used for safety because he would move throughout the bed and was a fall risk. She further stated the side rails kept him from falling out of bed. Interview on 07/17/25 at 2:10 PM with CNA H and CNA E revealed Resident #4 did not use the side rails for mobility. They stated the side rails kept him from falling out of bed because he would move all around his bed. Interview on 07/18/25 at 10:08 AM with the DON revealed Resident #4 was totally dependent on staff for all ADL's and did not use the side rails for mobility. She stated the side rails were used for safety to prevent falls so in fact they were used as restraints. The DON stated she was not aware of alternatives being used prior to installing the side rails. She stated an assessment, a consent including discussing the risks and benefits were not obtained for the use of side rails. The DON stated following these measures were important to ensure the safety of the resident and not taking these measures could result in the resident being injured. 3. Review of Resident #7's face sheet, dated 7/18/25, revealed she was admitted to the facility on [DATE] with diagnoses including Diffuse traumatic brain injury (occurs when a sudden violent blow or jolt to the head causes damage to the brain) and contracture of the joint. Review of Resident #7's MDS assessment, dated 5/30/25, revealed her BIMS score was 6 of 10 indicative of severe cognitive impairment. Resident had impaired range of motion on both upper and lower extremities and was dependent on staff for all ADL care including bed mobility. Review of Resident #7's assessments did not reveal a restraint assessment or consent for the use of side rail. Observation on 07/16/2025 at 10:46 AM revealed Resident #7 lying in bed asleep with HOB up about 30 degrees. Resident #7's had contractures on both wrists/hands and 1/4 side rails were up and locked on both sides of the bed. Interview on 07/17/25 at 2:05 PM with LVN I revealed Resident #7 was totally dependent on staff for all ADL's and was not able to use the side rails for mobility because both her hands were contracted. LVN I stated the siderails were used for safety to ensure she did not fall out of bed. Interview on 07/17/25 at 2:10 PM with CNA H and CNA E revealed Resident #7 was not able to use the side rails for mobility because of the contractures on her hands. They stated the side rails were used for safety to prevent falls. Interview on 07/18/25 at 10:08 AM with the DON revealed Resident #7 was totally dependent on staff for all ADL's and did not use the side rails for mobility. She stated the side rails were used for safety to prevent falls so in fact they were used as restraints. The DON stated she was not aware of alternatives being used prior to installing the side rails. She stated an assessment, a consent including discussing the risks and benefits were not obtained for the use of side rails. The DON stated following these measures were important to ensure the safety of the resident and not taking these measures could result in the resident being injured. 4. Review of Resident #8's face sheet, dated 7/18/25, revealed she was admitted to the facility on [DATE] with diagnosis to include Anoxic Brain Damage (damage to the brain due to a lack of oxygen supply). Review of Resident #8's quarterly MDS assessment, dated 6/28/25, revealed her BIMS score was severe cognitive impairment and she had impaired range of motion on both upper extremities. Further review revealed the use of side rails were not identified as daily restraint use. Review of Resident #8's CP completed on revealed she required total assistance with ADL's due to Anoxic Brain Injury. One of the interventions included Resident #8 required total assistance by 2- persons with bed mobility. Review of Resident #8's assessments did not reveal a restraint assessment or consent for the use of side rails as a restraint. Observation and attempted interview on 07/16/25 at 9:52 AM revealed Resident #8 was lying in bed with 1/4 side rails up and locked on both sides of the bed. Resident #8 had contractures on both wrists/hands. Resident #8 would move her eyes when spoken to but was non-verbal. Interview on 07/17/25 at 2:05 PM with LVN I revealed Resident #8 was totally dependent on staff for all ADL's and was not able to use the side rails for mobility because she had contractures on both hands. LVN I stated the siderails were used daily for safety to ensure Resident #8 did not fall out of bed. Interview on 07/17/25 at 2:10 PM with CNA H and CNA E revealed Resident #4 did not use the side rails for mobility because she had contractures on both hands. They stated the side rails were used daily for safety so that she did not fall out of bed. Interview on 07/18/25 at 10:08 AM with the DON revealed Resident #8 was totally dependent on staff for all ADL's and did not use the side rails for mobility. She stated the side rails were used daily for safety to prevent falls so in fact they were used as restraints. The DON stated she was not aware of alternatives being used prior to installing the side rails. She stated an assessment, a consent including discussing the risks and benefits were not obtained for the use of side rails. The DON stated following these measures were important to ensure the safety of the resident and not taking these.

Based on interview and record review, the facility failed to ensure each resident's drug regimen be free from unnecessary drugs without adequate indications for its use for 3 of 5 (Resident #3, #61, and #82) residents reviewed for unnecessary medications., in that: 1. The facility failed to monitor the behaviors and side effects of Resident #3's Remeron for depression and Buspirone for anxiety. 2. The facility failed to ensure there was a correct diagnosis for the use of Zyprexa for agitation for Resident #61. 3. Resident #82 received psychoactive medications for which he did not have a documented diagnosis. This failure could lead to residents being prescribed medications without indication and place residents at risk of unnecessary side effects and a decline in overall health. The findings were: The findings included: Record review of Resident #61’s face sheet dated 7/18/2025 revealed a [AGE] year-old male was admitted on [DATE] to the facility with diagnoses that included: dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, end stage renal disease (kidney failure), and hypertension. Record review of Resident #61’s care plan dated 5/28/2025 revealed the resident was care planned for psychotropic medications with GDR interventions; falls due to lack of safety awareness with interventions side rails used as a reminder of edge of bed, staff to assist with transfers, call light in reach. He was not care planned for agitation or anxiety. Record review of Resident #61’s CMDS dated [DATE] he had a BIMS score of 14, indicative of intact cognitive status. Resident #61’s CMDS did not reveal a reason or diagnosis for anti-psychotic medication. Record review of physician orders dated 5/27/2025 revealed orders for: Zyprexa 5mg, 1 tab by mouth daily at bedtime for agitation; and Remeron 15mg 1 tab by mouth daily at bedtime for depression. Record review of Resident #61’s nursing notes for the month of May 2025 through July 2025 revealed no documentation of aggression. Record review of Resident #61's medication review dated 5/28/2025 revealed for albuterol nebulizer solution to be changed from every 2 hours prn to four times daily- every 6 hours and the changing dosage time for tamsulosin to be administered at night and potassium to be added to drug regimen because of low potassium. There was no review of Zyprexa or Remeron. Interview on 07/17/2025 11:19 AM the DON said the MDS Coordinator was on vacation. She looked into the MDS for Resident #61 and she said the resident was admitted on the medications and the doctor kept the medication until he was seen by psych. When he had the order for the eval, the NP that would have done it moved out of state, so they waited for a new person and the eval was done 7/11/2025. The DON said after he was seen by psych, they still had not taken him off the medications. Interview on phone 7/17/2025 at 2:56PM RP of Resident #61 said the resident did have a diagnosis of depression because he had been in and out of the hospital since late December 2024. She said he had never been aggressive with staff or anybody. The RP said he did have episodes of delirium when he first started dialysis because the dialysis, he received was too strong for him and when they realized it was too strong, they gave him a milder dialysis and the delirium stopped. She said she recalled a meeting she had on the phone while she was driving, they went through the medication fast, and they asked for consents for his medication, but she thought it was for his appetite, but he had never been aggressive. She said she lived in [NAME], and she did not come often, but they call her for everything that concerned him. She said she did not want him to take that because he did not have that behavior, and she would call the facility to inform them to stop it. Interview on 07/18/2025 09:13 AM Pharmacy Consultant said the medication Zyprexa was used for agitation and he was doing a report to send to the facility and he would put in a request to stop the medication. He said Zyprexa could be used in conjunction with Remeron for depression. He was informed by the surveyor that it was used for agitation and not depression. He said hospitals would discharge residents on Zyprexa and normally after 90 days if there were no behaviors, it would be discontinued. He said he would ask for GDR for Zyprexa. He was informed that the resident had no diagnosis for agitation. Interview on 7/18/2025 at 7:21PM the DON said there should be a diagnosis for administering psychotropic medication to ensure it was given for the correct reason and correct therapeutic effect. The DON said medications given without a diagnosis could cause adverse reactions or long-term issues. Record review of facility policy titled, “Pharmacy Services- Role of the Provider Pharmacy” revised 4/2019 stated in part, under subsection c. “Help the facility identify comply with its legal and regulatory requirements related to medications and medication management”, f. “Maintain a mediation profile for each patient, that includes all pertinent information, including that which is required by law and regulation”; g. “Screen new medication orders for key parameters, including appropriate indications.” Record review of the facility policy titled “Antipsychotic Medication Use,” revised 07/2022, stated in part “Antipsychotic medications shall generally be used only for the following diagnoses/conditions as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders: schizophrenia, schizoaffective disorder, schizophrenia disorder, delusional disorder, mood disorders (e.g., bipolar disorder, depression with psychotic features, and treatment refractory major depression), psychosis in the absence of dementia, and medical illness with psychotic symptoms and/or treatment-related psychosis or mania.” 1. Record review of Resident #3's face sheet, dated 07/18/2025, revealed the resident was [AGE] years old male and admitted to the facility originally on 05/02/2025, and re-admitted on [DATE] with the diagnosis of anemia (the blood does not have enough healthy red blood cells and hemoglobin), ), type 2 diabetes mellitus (the body has trouble controlling blood sugar and using it for energy), anxiety disorder, depression disorder, hypertension (high blood pressure), and respiratory failure (serious condition that makes it difficult to breathe on your own). Record review of Resident #3's 5-days MDS, dated [DATE]/25, revealed Resident #3's BIMS score was 99 reflecting the resident was unable to interview, dependent to all activities of daily living such as bed mobility, transfer, and personal hygiene, and receiving antianxiety and antidepressant as ordered. Record review of Resident #3’s comprehensive care plan, dated 05/19/2025, revealed “the resident had at risk for side-effects due to use of antidepressant and antianxiety. For intervention – monitor for behaviors manifested and notify medical doctor if medication can be reduced and monitor for side effects.” Record review of Resident #3’s physician orders, dated 05/19/2025, revealed the resident had the orders of “Remeron oral tablet 15 mg Give 0.5 tablet enterally at bedtime for depression and Buspirone oral tablet 15 mg Give one tablet enterally two times a day for anxiety.” Record review of Resident #3's medication administration record, dated from 07/01/2025 to 07/31/2025 revealed the resident was receiving his Remeron oral tablet 15 mg Give 0.5 tablet enterally at bedtime for depression at 8:00 pm and Buspirone oral tablet 15 mg Give one tablet enterally two times a day for anxiety at 8:00 am and 8:00 pm. Further record review of the medication administration record revealed there were no order and scheduled for monitoring Resident #3’s behaviors regarding anxiety and depression and side effects regarding antianxiety and antidepressant. Interview on 07/18/2025 at 7:11 p.m. DON stated Resident #3 was still taking his Remeron for depression at bedtime and buspirone for anxiety two times a day as ordered, but there were no monitoring the resident’s behaviors and side effects regarding antianxiety and antidepressant. The facility nurses should have monitored Resident #3’s behaviors and side effects regarding antianxiety and antidepressant per the facility policy, and it was a mistake and DON's responsibility to make sure following the facility policy to prevent possible unnecessary medications. Record review of Resident #82’s face sheet, dated 07/18/2025, revealed he was admitted on [DATE] with diagnoses including Generalized Anxiety Disorder, Anemia, and Type 2 Diabetes Mellitus. Record review of Resident #82’s admission MDS, dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #82’s care plan, no revision date, revealed, “I have episodes of Anxiety busPIRone HCl hydrOXYzine HCl”; “I am taking OLANZapine for episodes of Agitation”; “I am taking Divalproex Sodium for the treatment for mood”; “At risk for side effects R/T use of psychotropic medication Olanzapine dx: agitation.” Record review of Resident #82’s order summary as of 07/18/2024, revealed, “Divalproex Sodium Oral Tablet Delayed Release 500 MG (Divalproex Sodium) Give 1 tablet by mouth at bedtime for Mood GIVE one 500mg tablet with 250mg tablet to equal 750mg at bedtime”, “Divalproex Sodium Oral Tablet Delayed Release 500 MG (Divalproex Sodium) Give 1 tablet by mouth one time a day for Mood”, “hydrOXYzine HCl Oral Tablet 50 MG (Hydroxyzine HCl) Give 1 tablet by mouth every 8 hours as needed for anxiety for 14 Days”, “traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 0.5 tablet by mouth at bedtime for Depression GIVE 1/2 50MG TAB TO = 25MG”, “Xanax Oral Tablet 0.5 MG (Alprazolam) Give 1 tablet by mouth every 8 hours as needed for ANXIETY for 14 Days”, “ZyPREXA Oral Tablet 2.5 MG (Olanzapine) Give 1 tablet by mouth at bedtime for AGITATION for 7 Days.” Further review of Resident #82’s clinical record as of 07/18/2025, revealed no documentation of the resident having diagnoses of agitation or mood. During an interview with the DON on 07/18/2025 at 7:21 p.m., the DON stated that there should be a diagnosis for administering psychotropic medications to ensure the medication was given for the correct reason. The DON stated that giving medications without a diagnosis could cause adverse reactions or long-term issues for the residents. Record review of the facility policy, Antipsychotic Medication Use, dated July 2022, revealed, Residents will not receive medications that are not clinically indicated to treat a specific condition.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards of food service safety for 1 of 1 kitchen, in that: The dry storage area had 2 boxes of funnel cake mix with an expiration date of 10/31/2024 hand written on the box. The dry storage area had a box of 9 juice cups with spillage and gnats in the box. The dry storage area had 2 containers of sugar with the lids not secured. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 7/15/2025 at 11:24AM in the dry storage area, there were 2 containers with sugar and the tops of the containers were not secured to the containers. There was a box with 9 individual servings of juice cups that had spillage in the box and when the box was moved, approximately 4 gnats flew out of the box. Observed 2 boxes of funnel cake mix with no manufacturer expiration date on the box, but there was a handwritten date on the box of 10/31/2024. Interview on 7/15/2025 at 11:24AM the DM said, When in doubt, throw it out and mumbled an explicit statement under his breath, Fuck! Shit!,when he saw the unsecured containers of sugar. Ther DM said it was important to make sure foods were not expired and to make sure foods were properly stored because contamination or cross contamination could happen and cause food borne illness for the residents. Interview on 7/17/2025 at 1:45PM the RD said it was important to keep food in airtight containers to protect the integrity of the food and to protect it from contamination and cross contamination. She said bugs or debris could contaminate containers that were not sealed properly. The RD said expired food should not be served because it could cause food borne illness to the residents that received food from the kitchen. The RD said an in-service would be done immediately with the kitchen staff. Interview on 7/18/2025 at 3:30PM The DM said it was important to store food properly to prevent food borne illness to the residents. He said food that was expired should not be stored to use because it could cause the residents to become ill and cause food borne illness. Record review of facility policy titled Food Receiving and Storage dated November 2022 stated: Foods shall be received and stored in a manner that complies with safe food handling practices. Under section titled: Dry Food Storage stated: 3. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 (Resident #3, Resident #70) of 18 residents reviewed for infection control practices. 1. CNA-C changed her gloves without sanitizing or washing her hands during emptying Resident #3's colostomy bag on 07/17/2025. 2. RT-J changed her gloves without washing her hands or using hand sanitizer while providing tracheostomy care for Resident #70. 3. LVN-I touched curtains, bed rails with gloves before she administered medication through peg tube for Resident #3. These deficient practices could place residents at risk for cross contamination and infections.Facility Record review of Resident #70’s Care Plan dated 7/4/2025 revealed she required EBP; she was at risk of falls and the family did not want the bed lower because they want her to be in view of the camera; she used oxygen via tracheostomy. Record review of Resident #70’s QMDS dated [DATE] revealed she had a BIMS score of 99 indicative of severe cognitive deficit and unable to interview; peg tube; total dependent on staff for all assistance; oxygen therapy with tracheostomy, and suctioning. Observation on 07/17/2025 at 08:10 AM of medication pass LVN-I donned gloves and then the gown for EBP for Resident #3. With the clean gloves, closed the privacy curtain, touched the bed control and began administering the resident's medications through the peg tube without changing her gloves. Interview on 7/17/2025 at 8:35AM the DON said, “Oh my God. LVN-I should have changed her gloves after touching everything in the room or not wear gloves and wash her hands again before putting clean gloves on and rendering care to the resident”. The DON said RT-J should have either washed her hands or used hand sanitizer before she put on new gloves. The DON said not following infection control policy could cause bacteria and infection to be passed to the residents. Record review of policy titled “Hand Hygiene” not dated stated “Gloves are for protection, not prevention of pathogen transfer. Gloves prevent the transfer of pathogens to your hands, but they can still become contaminated. If gloves become contaminated, they should be removed and replaced”; “If your gloves touch anything outside the designated G-tube care field (e.g. bed rails, clothing, surfaces), remove and discard them immediately, wash your hands, and put on a fresh pair before continuing”; And “Avoid touching clean items or surfaces with potentially contaminated gloves’; “ if gloves are contaminated, change them immediately to prevent the spread of infection”. Record review of policy from CDC titled “Tracheostomy Care” dated 7/2025 stated 4. ‘When cleaning tracheostomy tube site, use aseptic technique and hand hygiene”. No Notes 1. Record review of Resident #3's face sheet, dated 07/18/2025, revealed the resident was [AGE] years old male and admitted to the facility originally on 05/02/2025, and re-admitted on [DATE] with the diagnosis of anemia (the blood does not have enough healthy red blood cells and hemoglobin), ), type 2 diabetes mellitus (the body has trouble controlling blood sugar and using it for energy), anxiety disorder, depression disorder, hypertension (high blood pressure), and respiratory failure (serious condition that makes it difficult to breathe on your own). Record review of Resident #3's 5-days MDS, dated [DATE], revealed Resident #3's BIMS score was 99 reflecting the resident was unable to interview, the resident had colostomy, and dependent to all activities of daily living such as bed mobility, transfer, and personal hygiene, and receiving antianxiety and antidepressant as ordered. Record review of Resident #3’s comprehensive care plan, dated 05/19/2025, revealed “the resident had colostomy. For intervention – staff to provide colostomy care every shift and as needed.” Observation on 07/17/2025 at 2:45 p.m. revealed CNA-C opened Resident #3’s colostomy bag and emptied feces to a plastic bag, then changed gloves without sanitizing or washing CNA-C’s hands. CNA-C cleaned the bag and closed the pouch clamp, then changed gloves without sanitizing or washing CNA-C’s hands. CNA-C removed all equipment and took off her gloves and sanitized her hands before leaving the resident’s room. Interview on 07/17/2025 at 2:55 p.m. CNA-C stated she changed gloves without sanitizing or washing hands after emptying Resident #3’s feces and cleaning the colostomy bag. Further interview with CNA-C said she received hand hygiene training and she said she should have sanitized or washed her hands between changing her gloves to prevent possible infection, especially contacting to body fluid. Interview on 07/18/2025 at 11:40 a.m. DON said CNA-C should have sanitized or washed her hands between changing her gloves to prevent possible infection, especially contacting to body fluid per the facility policy. It was infection control issue.

Based on interview and record review, the facility failed to ensure the resident's right to be informed and make treatment decisions for 2 of 23 residents (Resident# 2 and Resident #82) reviewed, in that: Resident's #2 and #82 did not sign their own consent forms to receive psychoactive medications. This deficient practice could result in residents receiving medications and treatments for which they have not given informed consent. The findings were: Record review of Resident #2's face sheet, dated 07/18/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Other Schizoaffective Disorders, Adjustment Disorder with Anxiety, Type 2 Diabetes Mellitus Without Complications. Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 12 which indicated moderate cognitive impairment. Record review of Resident #2's care plan, no revision date, revealed, At risk for side effects R/T use of psychotropic medication for dx: schizophrenia. Further review revealed, I am at risk for side effects due to use of antidepressant medication r/t dx of depression and I use psychotropic medications -antipsychotic meds -antidepressant meds with an intervention, Staff to acquire consent prior to administering medication. Record review of Resident #2's order summary as of 07/18/2025, revealed Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for MOOD order date 03/21/2025, SEROquel Oral Tablet 400 MG (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime for SCHIZOPHRENIA order date 03/28/2025 and Sertraline HCl Tablet 100 MG Give 2 tablet by mouth one time a day for DEPRESSION 2 tabs to equal 200mg order date 05/05/2025. Record review of Resident #2's clinical record as of 07/18/2025, revealed Psychoactive Medication Therapy Informed Consent Form, dated 01/27/2025, to receive the medication Sertraline for depression which was signed by the resident's representative instead of the resident. Record review of Resident #2's clinical record as of 07/18/2025, revealed Psychoactive Medication Therapy Informed Consent Form, dated 03/21/2025, to receive the medication Xanax for anxiety which was signed by the resident's representative instead of the resident. Record review of Resident #2's clinical record as of 07/18/2025, revealed Psychoactive Medication Therapy Informed Consent Form, dated 03/02/2025, to receive the medication Alprazoiam for anxiety which was signed by the resident's representative instead of the resident. Record review of Resident #2's clinical record as of 07/18/2025, revealed Psychoactive Medication Therapy Informed Consent Form, dated 03/21/2025, to receive the medication Zoloft for depression which was signed by the resident's representative instead of the resident. Record review of Resident #2's clinical record as of 07/18/2025, revealed Psychoactive Medication Therapy Informed Consent Form, dated 03/21/2025, to receive the medication Seroquel for schizophrenia which was signed by the resident's representative instead of the resident. Record review of Resident #82's face sheet, dated 07/18/2025, revealed he was admitted on [DATE] with diagnoses including Generalized Anxiety Disorder, Anemia, and Type 2 Diabetes Mellitus. Record review of Resident #82's admission MDS, dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #82's care plan, no revision date, revealed, I have episodes of Anxiety busPIRone HCl hydrOXYzine HCl; I am taking OLANZapine for episodes of Agitation; I am taking Divalproex Sodium for the treatment for mood; At risk for side effects R/T use of psychotropic medication Olanzapine dx: agitation.Record review of Resident #82's clinical record as of 07/18/2025, revealed Psychoactive Medication Therapy Informed Consent Form, dated 06/24/2025, to receive the medication Divalproex for mood disorder which was signed by the resident's representative instead of the resident. Record review of Resident #82's clinical record as of 07/18/2025, revealed Psychoactive Medication Therapy Informed Consent Form, dated 06/24/2025, to receive the medication Buspirone for anxiety which was signed by the resident's representative instead of the resident. Record review of Resident #82's clinical record as of 07/18/2025, revealed Psychoactive Medication Therapy Informed Consent Form, dated 06/24/2025, to receive the medication Olazapine for agitation which was signed by the resident's representative instead of the resident. Record review of Resident #82's clinical record as of 07/18/2025, revealed Psychoactive Medication Therapy Informed Consent Form, dated 06/24/2025, to receive the medication Hydroxyzine for anxiety which was signed by the resident's representative instead of the resident. Record review of Resident #82's clinical record as of 07/18/2025, revealed Psychoactive Medication Therapy Informed Consent Form, dated 06/24/2025, to receive the medication Xanax for anxiety which was signed by the resident's representative instead of the resident. Record review of Resident #82's clinical record as of 07/18/2025, revealed Psychoactive Medication Therapy Informed Consent Form, dated 06/24/2025, to receive the medication Remeron for depression which was signed by the resident's representative instead of the resident. Record review of Resident #82's clinical record as of 07/18/2025, revealed Psychoactive Medication Therapy Informed Consent Form, dated 06/24/2025, to receive the medication Trazadone for depression related insomnia which was signed by the resident's representative instead of the resident. During an interview with Resident #2 on 07/18/2025 at 6:00 p.m., Resident #2 stated he would like to have the opportunity to make treatment decisions for himself. During an interview with Resident #82 on 07/18/2025 at 6:15 p.m., Resident #82 stated he would like to have the opportunity to make treatment decisions for himself. During an interview with the DON on 07/18/2025 at 6:30 p.m., the DON stated residents should have the opportunity to give consent for themselves. The DON further stated the consents were obtained from the residents' representatives prior to the BIMS scores being obtained and the facility was not yet aware that the residents were able to speak for themselves. Record review of the facility policy, Resident Rights, revised February 2021, revealed, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include.: be informed of and participate in his or her care planning and treatment.

Based on interview and record review the facility failed to refer all residents to PASARR with newly evident or possible serious mental disorder for level II resident review for 1 of 6 Residents (Resident #4) whose records were reviewed for PASARR assessments. The facility failed to refer Resident #4 for PASARR (Preadmission Screening and Resident Review) Level II comprehensive evaluation when Resident #4 was diagnosed with Major Depressive Disorder (causes a persistently low or depressed mood and a loss of interest in activities that you used to enjoy) on 4/1/23 and undifferentiated Schizophrenia (serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) on 2/16/24. This deficient practice could affect residents diagnosed with mental disorders and could result in the residents not receiving the necessary services from PASARR.The findings were:Based on interview and record review the facility failed to refer all residents to PASARR (Preadmission Screening and Review) with newly evident or possible serious mental disorder for level II resident review for 1 of 6 Residents (Resident #4) whose records were reviewed for PASARR assessments. The facility failed to refer Resident #4 for PASARR Level II comprehensive evaluation when Resident #4 was diagnosed with Major Depressive Disorder (causes a persistently low or depressed mood and a loss of interest in activities that you used to enjoy) on 4/1/23 and undifferentiated Schizophrenia (serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) on 2/16/24. This deficient practice could affect residents diagnosed with mental disorders and could result in the residents not receiving the necessary services from PASARR. The findings were: Review of Resident #4's face sheet, dated 7/18/25, revealed he was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder (causes a persistently low or depressed mood and a loss of interest in activities that you used to enjoy) and undifferentiated Schizophrenia (serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) and Generalized Anxiety. Further review revealed Resident #4 did not have a diagnosis of Dementia (loss of cognitive functioning it interferes with a person's daily life and activities). Review of Resident #4's annual MDS assessment, dated 5/7/25, revealed his BIMS score was 3 of 10 indicative of severe cognitive impairment. Further review revealed he had diagnoses including Anxiety, Depression and Schizophrenia (serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior). Review of Resident #4's CP revised on 7/5/25 revealed he used psychotropic medications and was receiving psychological, psychiatry services for visits, and medication management. Review of Resident #4's consolidated physician orders for July 2025 revealed he was receiving Escitalopram Oxalate Oral Tablet 10 MG (Escitalopram Oxalate) Give 1 tablet via PEG-Tube one time a day for DEPRESSION. Start date was 5/01/2025. Review of Resident #4's PASRR Level 1 Screening, dated 8/25/22, revealed he did not meet the criteria for mental illness. Interview on 7/18/25 at 4:45 PM with the DON revealed Resident #4 did not have diagnosis of Dementia and was diagnosed with Major Depressive Disorder and Schizophrenia after being admitted to the facility. The DON stated usually the MDS Coordinator was responsible for referring residents for PASARR services, but that position was vacant. She stated he should have been referred to PASARR for evaluation to determine if he met the criteria for mental illness. The DON stated if he did, he would receive services which could improve his quality of life. Otherwise, he could suffer a decline in mental condition. The DON was asked for a PASARR policy on 7/18/25 at 4:45 PM and did not provide one by the end of the survey on 7/18/25 at 11:30 PM.

Based on interviews and record review, the facility failed to review and revise resident care plans after each assessment for 1 of 18 residents (Resident #55) reviewed for care plan revision/timing. The facility failed to ensure Resident #55's care plan addressed changes in his smoking status regarding the resident could keep his cigarettes and lighter because he was very safe smoker after smoking assessment, dated 05/08/2025. This deficient practice could affect residents' care and services and may cause a delay in treatment and/or decline in health. Findings included:Record review of Resident #55's face sheet, dated 07/18/2025, revealed the resident was [AGE] years old male and admitted to the facility originally on 11/14/2024 and re-admitted on [DATE] with diagnoses of dry eye syndrome bilateral lacrimal glands (inflammation of the tear-shaped gland), fatty liver (fat builds up in the liver), paraplegia (loss of muscle function in the lower half of the body), hypertension (high blood pressure), and dysuria (the sensation of pain or burning when urination). Record review of Resident #55's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 13 out of 15, which indicated the resident's cognitive was intact, and the resident required substantial/maximal assistant (Helper does more than half the effort) to chair to bed transfer and sit to stand. Record review of Resident #55's comprehensive care plan, dated 05/15/2025, revealed the resident is a smoker. For interventions - all cigarettes and lighter must be stored in med room and smoking assessment per social worker. Smoking in designated area only. Record review of Resident #55's smoking assessment, dated 05/08/2025, revealed The resident may smoke independently, smoke unsupervised in designated smoking area, and have been informed of smoking policies and procedures - Plan of care should be updated. Attempted interview on 07/18/2025 at 9:00 a.m. with Resident #55 revealed he refused the interview with the surveyor. Interview on 07/18/2025 at 9:21 a.m. with DON stated Resident #55 could keep his cigarettes and disposable lighter per the facility policy because he was safe and independent smoker after the smoking assessment, dated 05/08/2025. The current care plan was incorrect, and it should have been updated and revised after smoking assessment (dated 05/08/2025). The DON stated updating and revising care plan was MDS nurse's responsibility, but the facility did not have MDS nurse, so the company MDS nurse was helping, but the nurse was on vacation at this time. That might cause not updating care plans, and not updating care plan might cause improper care to the resident. Record review of the facility smoking policies, revised 08/2022, revealed . 12. Residents who have independent smoking privileges are permitted to keep cigarettes, electronic-cigarettes, pipes, tobacco, and other smoking items in their possession. Only disposable safety lighters are permitted. All others of lighters, including matches, are prohibited.

Based on observation, interview and record review the facility failed to ensure that residents received proper treatment and good foot health in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 of 1 Resident (Resident #9) whose records were reviewed for assessments. LVN/Treatment Nurse K failed to assess Resident #34's feet during a head-to-toe assessment and did not identify he had significantly long toenails and two ingrown toenails. This deficient practice could affect any resident and could contribute to pain, infections and loss of toes. The findings were:Review of Resident #9's face sheet, dated 7/17/25, revealed he was admitted to the facility on [DATE] with diagnosis including Critical Illness Myopathy (generalized weakness involving the muscles of the extremities, trunk, and respiration that frequently occurs in conjunction with severe illness and is associated with significant morbidity and mortality). Review of Resident #9's admission MDS assessment, dated 4/6/25, revealed his BIMS score was 15 of 15 reflective of not having impaired cognition and he did not have foot problems. Review of Resident #9's CP, dated 7/14/25, revealed he was at risk for skin breakdown and I am at risk for new pressure ulcers due to my impaired mobility and one of the interventions included Weekly Skin Assessment. Notify MD and Family of any skin breakdown or skin problems. Review of Resident #9's admission Nursing Assessment, dated 4/1/25, including an assessment of his feet, did not reveal any skin problems. Interview on 7/17/25 at 1:49 PM of Resident #9 revealed he was lying in bed. Resident #9 stated his feet hurt related to ingrown toenails. Resident's voice was faint and difficult to hear but also communicated with a communication board. Resident #9 stated he let nursing staff know about it since admission and stated he was waiting for staff to address the issue. Interview on 7/17/25 at 4:35 PM with LVN L, charge nurse revealed she was not aware of Resident #9 having any problems with his feet. Observation and interview on 7/17/25 at 5:13 PM with the DON and Resident #9 revealed she assessed Resident #9's feet. The DON stated his feet were scaly and dry and all of his toenails were long. She stated his toenails needed to be cut. The DON stated his left great toenail was significantly long and looked like it was ingrown. His great toenail was approximately 1 inch past his nail bed and there were red spots on the corners of the nail. The DON stated the right toenail on the 4th toe was curled over and under his toe. She stated the right great toenail also appeared to be ingrown. Resident #9 stated his toes hurt when he wore shoes. The DON stated the treatment nurse completed weekly skin assessments and should have seen the condition of his toenails. She stated the CNA's should also be completing any skin problems on Resident's shower sheets. The DON stated the result of Resident #9 not receiving care could lead to skin infections, other ingrown toenails and loss of toes. Interview on 7/18/25 at 9:55 AM with LVN/Treatment Nurse K revealed she had assumed her position about two months ago during May 2025. She stated she was responsible for completing weekly skin assessments on all residents and had completed assessments for Resident #9. She stated she had been focused on developing a system to ensure she completed all resident assessments. LVN K stated she did not remember assessing Resident #9's feet but it was part of the assessment and should have capture the condition of his feet. She stated she had been focused on developing a system to ensure she completed all resident assessments. LVN K stated not assessing Resident #9's delayed care, could cause infections and a decline in his overall physical health. Review of facility policy, Resident Examination and Assessment, revised 2014 read in relevant part, The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. Physical Exam 8. Skin: a. intactness; b. moisture; c. color; d. texture; and presence of bruises, pressure sores, redness, edema, rashes.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #62) reviewed for incontinence care. When CNA-A was providing incontinent care to Resident #62 on 07/17/2025, CNA-A did not clean the resident's suprapubic area (the area of the abdomen located below the umbilical region). This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included:Record review of Resident #62's face sheet, dated 07/18/2025, revealed the resident was a [AGE] year-old female and admitted to the facility originally on 06/06/2025, and re-admitted on [DATE] with the diagnoses of type 2 diabetes mellitus (not control blood sugar in the body), necrotizing fasciitis (serious bacteria infection that destroys tissue under the skin), chronic kidney disease (kidneys are less able to filter water and fluid out of the body), hypertension (high blood pressure), and heart failure (heart cannot pump enough oxygen-rich blood to meet the body's needs). Record review of Resident #62's admission MDS, dated [DATE], revealed the resident's BIMS score was 15 out of 15, which indicated the resident's cognitive function was intact, and the resident had indwelling urinary catheter and frequently incontinent to bowel. Resident #62 was dependent (helper does all of the effort) to sit-to-stand and chair-to-bed transfer, and for toilet transfer, not attempted due to medical condition or safety concerns. Record review of Resident #16's comprehensive care plan, dated 06/12/2025, revealed the resident has a Foley catheter (indwelling urinary catheter). For intervention - staff will clean the catheter every shift or as needed, and incontinent care every 2 hour and as needed for bowel incontinence. Observation on 07/17/2025 at 2:03 p.m. revealed CNA-A opened Resident #62's old and dirty brief and cleaned the resident's catheter, genital area by separating it with hand, and then cleaned the left and right groin area. CNA-A turned the resident to her right side without cleaning the suprapubic area, which the area was folded up with skin. CNA-A cleaned the resident's buttock area, then put a new and clean brief on the resident. Interview on 07/17/2025 at 2:17 p.m. with CNA-A stated she did not clean Resident #62's suprapubic area because she was nervous and forgot to clean the area. CNA-A said she should have opened and cleaned the area when providing peri-care to Resident #62 because the resident's suprapubic area was folded up with skin to prevent possible infection, especially fungus, and had peri-care training around two months ago. Interview on 07/17/2025 at 3:16 p.m. with DON said CNA-A should have opened and cleaned Resident #62's suprapubic area when providing peri-care to the resident because the area was folded up with skin to prevent infection. The DON stated DON had responsibility for monitoring CNA-A by checking off the CNA's skills two months ago. Record review of the facility policy, titled Perineal care, revised 02/2018, revealed The purpose of this procedures are to provide cleanliness and comfort to the resident to prevent infections and skin irritation and to observe the resident's skin condition. wash perineal area, wiping from front to back.

Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #17) of 2 residents reviewed for enteral nutrition. When LVN-B flushed Resident #17's gastrostomy tube with 30 ml of water, LVN-B pushed water inside the barrel of the syringe with a plunger, instead of using gravity. This failure could place residents with gastrostomy tube at risk for complications, aspiration, and pneumonia. Findings included:Record review of Resident #17's face sheet, dated 07/18/2025, revealed the resident was [AGE] years old male, originally admitted on [DATE], and re-admitted to the facility on [DATE] with diagnoses of personal history of covid-19, seizures (sudden burst of electrical activity in the brain), peritonitis (redness and swelling of the lining of the belly or abdomen), hypertension (high blood pressures), and gastro-esophageal reflux disease (the stomach contents leak backward from the stomach into the esophagus). Record review of Resident #17's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment and had a feeding tube. Record review of Resident #17's comprehensive care plan, dated 05/24/2025, revealed the resident was dependent on feeding tube for nutritional needs and at risk for aspiration. For intervention - administer tube feeding as ordered, check for placement prior to feeding and flushed administration, and provide flushed as ordered to maintain hydration and patency of tube. Record review of Resident #17's physician order, dated 01/16/2025, revealed the resident had the order of Flush gastrostomy tube with 30 ml of water before and after medication and 10 ml between medication. Observation on 07/17/2025 at 10:22 a.m. LVN-B checked the placement of Resident #17's gastrostomy tube and residual, then flushed the gastrostomy tube with 30 ml of water by pushing the water inside barrel of syringe with plunger, instead of using gravity. Interview on 07/17/2025 at 10:53 a.m. with LVN-B stated he flushed Resident #17's gastrostomy tube with 30 ml of water by pushing the water inside barrel of syringe with plunger, instead of using gravity. LVN-B said he thought pushing the water for flush was fine because Resident #17 did not have residual. However, LVN-B stated he should have used gravity when flushing Resident #17's gastrostomy tube to prevent possible aspiration and the resident's abdominal discomfort. The nurse said it was mistake. Interview on 07/17/2025 at 3:16 p.m. the DON said LVN-B should have used gravity when flushing Resident #17's gastrostomy tube, instead of pushing a plunger, to prevent possible aspiration and the resident's abdominal discomfort. The DON said if gravity could not be used due to blockage of tube, nurses could push a plunger gently. The facility did not have policy regarding using gravity for tube feeding.

Based on observations, interview, and record reviews, the facility failed to provide pharmaceutical services to administer drugs and biologicals that meet the needs of each resident for 1 of 9 (Cart #1 on 400 hall) medication carts observed for expired medication in that: The facility failed to remove expired medications from medication cart #1 1 bottle of Gentle Lax and 1 bottle of Extra Strength Tylenol 500mg This failure could result in residents decreased health response or misuse of medication.Findings included: Observation on 07/16/2025 at 10:40AM medication cart 1 of 4 for #400 hall revealed 1 bottle of Gentle Lax with an expiration date of 03/2025 and 1 bottle of Acetaminophen 500mg with expiration date of 04/2025. Interview on 7/16/2025 at 10:45AM LVN B said he missed the expiration dates on the medications. He said it would not be safe to give because it could cause an adverse reaction to the resident or it may not be as effective to use for effective results. Interview on 7/16/2025 at 11:10AM the DON said expired medications would not be as effective or not be able to have the therapeutic results for their use or it could cause an adverse reaction. Record review of facility policy titled “Medication Labeling and Storage” dated February 2023 stated under “Medication Storage” 3. “If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these medications. Findings included: Observation on 07/16/2025 at 10:40AM medication cart 1 of 4 for #400 hall revealed 1 bottle of Gentle Lax with an expiration date of 03/2025 and 1 bottle of Acetaminophen 500mg with expiration date of 04/2025. Interview on 7/16/2025 at 10:45AM LVN B said he missed the expiration dates on the medications. He said it would not be safe to give because it could cause an adverse reaction to the resident or it may not be as effective to use for effective results. Interview on 7/16/2025 at 11:10AM the DON said expired medications would not be as effective or not be able to have the therapeutic results for their use or it could cause an adverse reaction. Record review of facility policy titled “Medication Labeling and Storage” dated February 2023 stated under “Medication Storage” 3. “If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these medications.

Based on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #7) out of 18 residents reviewed for medical records. Resident #7's psychiatric doctor added the resident's general anxiety as one of the resident's diagnosis and prescribed diazepam 2 mg three times a day for anxiety, but the facility did not add the new diagnosis to the resident's medical record. This failure placed residents at risk for missed treatment and medications which could result in decline in heal and well-being.Findings included: Record review of Resident #7's face sheet, dated 07/18/2025, revealed the resident was [AGE] years old female and admitted to the facility on [DATE] with diagnosis of abnormal findings in urine, type 2 diabetes mellitus (not control blood sugars in the body), hypertension (high blood pressures), hyperlipidemia (high fat in the body), cystitis (urinary bladder infection), and gastro-esophageal reflux disease (the stomach contents leak backward from the stomach into the esophagus). Further record review of Resident #7's face sheet did not have diagnosis of general anxiety. Record review of Resident #7's 5-days MDS, dated [DATE], revealed the resident's BIMS was 0 out of 15, which indicated the resident had severe cognitive impairment and receiving antianxiety as ordered. Record review of Resident #7's physician order, dated 05/23/2025, revealed the resident had the order of Diazepam oral tablet 2 mg Give one tablet enterally three times a day for anxiety. Record review of Resident #7's medication administration record from 07/01/2025 to 07/31/2025 revealed the resident's Diazepam oral tablet 2 mg Give one tablet enterally three times a day for anxiety was scheduled 7:00 am, 1:00 pm, and 7:00 pm. Record review of Resident #7's psychiatric physician note, dated 05/30/2025, revealed the resident's psychiatric doctor added the resident's general anxiety as one of the resident's diagnoses and currently used diazepam 2 mg three times a day for anxiety. Record review of Resident #7's medical diagnosis list of the resident's electronic medical record revealed there was no diagnoses of general anxiety. Interview on 07/18/2025 at 7:59 p.m. DON stated Resident #7 was receiving Diazepam 2 mg three times a day enterally for the resident's anxiety, and the resident's psychiatric doctor added the diagnoses of general anxiety, but the facility did not update it to the resident's medical record. The resident's medical record was not accurate. Updating medical record was one of MDS nurse's responsibilities, but the facility did not have MDS nurse, and it might cause inaccurate medical record. Inaccurate medical record might cause improper care to the resident. Record review of the facility policy, titled Electronic Medical Records, revised 03/2014, revealed Electronic medical records may be used on lieu of paper records when approved by the Administrator.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 (Resident #16) of 18 residents reviewed for environmental concerns. Resident #16's oxygen cylinder was stored in the resident room, but per the facility policy indicated Do not oxygen cylinder in any resident room or living area. This failure could place residents at risk of a diminished quality of life and respiratory status due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included:Record review of Resident #16's face sheet, dated 07/18/2025, revealed the resident [AGE] years old female, originally admitted to the facility on [DATE], and re-admitted on [DATE] with diagnosis of dysphagia (difficulty of swallowing), chronic pain, encephalopathy (brain damage), hyponatremia (level of sodium in the blood is too low), and personal history of covid-19. Record review of Resident #16's quarterly MDS, dated [DATE], revealed the resident's BIMS was 9 out of 15 indicated the resident had moderate cognitive impairment, required dependent on assist (Helper does ALL of the effort) to chair to bed transfer, and for toilet transfer, not attempted due to medical condition or safety concerns. Record review of Resident #16's comprehensive care plan, dated 06/23/2025, revealed the resident nebulizer breathing treatment ordered due to respiratory failure. For intervention - observe for sign and symptoms of adverse reactions: increased dyspnea (difficulty of breathing). Record review of Resident #16's physician order, dated 07/15/2025, revealed oxygen at 2 to 4 liters per minute via nasal canula to maintain oxygen saturation greater than 90 % and record saturation every shift. Observation on 07/15/2025 at 1:34 p.m. revealed there was one oxygen cylinder found in Resident #16's room, and the cylinder had full oxygen. Interview on 07/15/2025 at 1:34 p.m. LVN-D stated there was one oxygen cylinder found in Resident #16's room, and it should have been stored in the oxygen storage room, instead of resident's room for safety. LVN-D said she did not know how long it was stored in the room and what reason the oxygen cylinder was in Resident #16's room because the resident never use it. Interview on 07/18/2025 at 11:10 a.m. the DON said all oxygen cylinder should have been stored in the oxygen storage room for safety, instead of resident's room. Record review of facility policy, titled Fire Safety and Prevention, revised 05/2017, revealed Oxygen safety: . F. store oxygen cylinders in racks with chains, sturdy portable carts, or approved stands. Never leave oxygen cylinder free-standing. Do not oxygen cylinders in any resident room or living area.

Based on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of his or her personal and medical records for 1 of 6 residents (Resident #4) reviewed for residents' rights. The facility failed to ensure LVN A locked the medication cart computer screen and left an unidentified resident's (Resident #4) information exposed. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons. The findings included: Observation on 6/18/25 at 9:48 a.m. revealed a medication cart was left unlocked and unattended facing the hallway in the 200 hall and the computer screen on top of the medication cart counter was left opened with an Resident # 4's information exposed. Observation and interview on 6/18/25 at 9:49 a.m. revealed LVN A walked out of a resident room from across the hall on the 200 hall and walked up to the unlocked computer screen on top of the medication cart counter exposing an Resident # 4's information. LVN A stated, he had forgotten to lock the computer screen and leaving the computer screen open was a HIPAA violation and could result in an unauthorized person obtaining information from the resident and use their name fraudulently. During an interview on 6/18/25 at 4:13 p.m., the DON stated it was her expectation that staff locked the computer screens because exposed resident information was a HIPAA violation. The DON stated a resident's visible information could be used in the wrong way. Record review of the facility document titled, Resident Rights with revision date December 2016 revealed in part, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .The unauthorized release, access, or disclosure of resident information is prohibited .All .access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA Compliance Officer .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for care plans: The facility failed to ensure Residents #1's comprehensive care plan reflected he received a mechanically altered diet. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services. The findings included: Record review of Resident #1's face sheet dated 6/18/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (cancer) of brain, hemiplegia (paralysis) affecting the left dominant side, and aphasia (language disorder that affects the ability to communicate usually caused by damage to the brain). Record review of Resident #1's most recent admission MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills, was dependent on staff with eating, and required a mechanically altered diet. Record review of Resident #1's Order Summary Report dated 6/18/25 revealed the following: - Regular diet MECHANICAL SOFT texture, REGULAR consistency, Double Portions, Mighty Shake TID. Serve liquid(s) in Adult Sip cup. Assist with Feedings; Encourage dining room feedings, with order date 4/30/25 and no end date. Record review of Resident #1's comprehensive care plan with review date 4/28/25 revealed the resident was at risk for aspiration due to swallowing difficulty and had a diet order for regular diet, pureed texture, with interventions to provide diet as ordered. During an observation on 6/18/25 at 12:11 p.m., Resident #1 was sitting in the dining room waiting on the lunch service. The ADON was observed serving Resident #1 his lunch and the meal ticket revealed the resident was supposed to receive a mechanical soft diet texture with regular consistency fluids, double portions, and a Mighty Shake, which the resident received. During an interview on 6/19/25 at 8:51 a.m., the DON stated Resident #1's care plan should have been updated to reflect the resident received a mechanical soft diet instead of puree. The DON stated the DM was in charge of updating the care plan for Resident #1. During an interview on 6/19/25 at 11:05 a.m., the DM stated he was routinely involved in care plan meetings and concentrated on discussions regarding a resident's diet. The DM stated he had updated Resident #1's meal ticket to reflect the resident received a mechanical soft diet but had never updated a care plan. The DM stated he was aware where to find a care plan but had never been told he needed to make dietary updates on the care plan. During an interview on 6/19/25 at 1:11 p.m., LVN B stated she had received a telephone order from Resident #1's physician on 4/30/25 to change the resident's diet order from puree to mechanical soft. LVN B stated she should have updated the care plan to reflect the diet change because she had taken the order from the physician. LVN B stated, MDS, Nursing, Dietary, Activities can all update the care plan for their specific discipline. LVN B stated the care plan was important because it reflected the type of care the resident should be getting or what needs to be done. During an interview on 6/20/25 at 9:59 a.m., the MDS Coordinator stated she was responsible for auditing resident care plans and was the gatekeeper for ensuring accuracy and updating pertinent information, such as medications, code status, and dietary changes. The MDS Coordinator stated she was not aware if the DM was supposed to update care plans based on his discipline. The MDS Coordinator stated the care plan was important because it painted a picture of the resident and helped staff as a guide to follow on how to take care of a resident. Record review of the facility document titled Care Plans, Comprehensive Person-Centered, with revision date December 2016 revealed in part, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .The care planning process will .Include measurable objectives and timeframes .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 4 residents (Resident #1 and #2) reviewed for accidents and supervision. 1. Resident #1 was transferred without a mechanical lift on 10/25/24 and experienced pain to her right leg/sustained a distal fracture 2. Resident #2 was transferred by a single staff member instead of the required two during a mechanical lift on 09/25/2024 and the mechanical lift tipped over, dropping the resident, and resulting in a bump and laceration to her nose. The noncompliance was identified as PNC. The IJ began on 9/24/2024 and ended on 11/27/2024. The facility had corrected the noncompliance before the investigation began. This deficient practice could place residents at-risk of harm, serious injury, or death. The findings included: 1. Record review of Resident #1's admission record, dated 03/26/25, reflected a [AGE] year-old female initially admitted [DATE] and readmitted [DATE] with diagnoses to include hemiplegia and hemiparesis (paralysis and partial weakness of one side), age-related physical debility, lack of coordination, and acquired absence of left leg below knee. Record review of Resident #1's MDS assessment, dated 10/16/24, reflected Resident #1 was dependent (helper does ALL of the effort) for chair/bed-to-chair transfers and had a BIMS of 15 (indicating she was cognitively intact). Record review of Resident #1's care plan, last reviewed 02/19/25, revealed that mechanical lift transfer was not listed. Resident #1's care plan reflected Transfer: I require supervision, limited to extensive assistance in self-performance with 1-person physical assistance for all transfers. I may require more help on days I feel weak. Record review of Facility Provider Investigation Report, dated 11/12/24, reflected . On 10/25/24 at approx. [8:48 PM] Resident was lowered to ground during transfer from chair to bed by [LVN B] and [CNA A]. [LVN B] reported to DON that during transfer x2 resident became unable to bear weight and was lowered to ground by her and [CNA A]. Resident did not hit head during incident . [Resident #1] not on therapy PT/OT services due to pending insurance claim. [Resident #1] assist x2 with transfers. [Mechanical lift] may be used prn after HD treatments when resident is weaker. Resident stated she did not think she needed [mechanical lift] at this time due to feeling ok after HD and M-F regular staff being present. Record review of Resident #1's nurse's progress note, dated 10/25/24 at 08:48 PM, reflected staff was attempting to assist resident out of bed when due to residents non weight bearing status, more staff was needed to assist resident. Resident was then placed in a sitting position and when more staff arrived she was transferred to a geri chair using the [mechanical lift]. Patient did complain of pain to her right knee due to sitting up with her legs out in front of her. Head to toe assessment performed and resident is injury free and has been medicated with prn norco, md and don notified Record review of Resident #1's October 2024 MAR, accessed on 03/28/25, reflected Resident #1 received HYDROcodone-Acetaminophen Oral Tablet 5-325 MG . for moderate to severe pain from 10/26/24 through 10/29/24. Record review of Resident #1's Tibia/Fibula (two long bones located in lower leg) X-ray, dated 10/26/24, reflected no fracture or dislocation. Record review of Resident #1's November 2024 MAR, accessed on 03/28/25, reflected Resident #1 received HYDROcodone-Acetaminophen Oral Tablet 5-325 MG . for moderate to severe pain 11/04/24-11/07/24, 11/09/24, and 11/11/24. Record review of Resident #1's radiology results report for a knee X-ray, dated 11/11/24, reflected an acute distal femoral diametaphyseal fracture. Record review of Resident #1's hospital documents, dated 11/12/24, reflected orthopedic surgery spoke with patient and recommended no surgical intervention as patient is nonambulatory and has advance osteoporosis has no foot function and recommended nonoperative treatment with immobilizer on the right knee for 4 to 6 weeks with follow-up with orthopedic surgery as an outpatient in 3 weeks for repeat imaging . Interview on 03/28/25 at 10:50AM, CNA A revealed Resident #1 was supposed to be transferred via mechanical lift on 10/25/24, but LVN B decided to transfer resident with 2 people and no mechanical lift. Interview on 03/28/25 at 11:00AM, LVN B revealed Resident #1 was transferred via mechanical lift, however on this day (10/25/24) they did not use the mechanical lift because all of the mechanical lifts were taken. Interview on 03/28/25 at 11:10 AM, Resident #1 revealed she had been transferred via mechanical lift for 3 years and she had told CNA A and LVN B to transfer her via mechanical lift during the incident on 10/25/24. Resident #1 revealed she felt weak during this transfer because she had been to dialysis earlier that day. She revealed she felt scared and upset when the staff did not transfer her via mechanical lift. Interview on 03/28/25 at 11:15AM, the DOR revealed Resident #1 was not seen by physical therapy until after her fall in October (10/25/24) due to insurance coverage so they did not assess how Resident #1 should be transferred. Interview on 03/28/25 at 11:25AM, LVN C and CNA D revealed Resident #1 had been a mechanical transfer since she had been at this facility. 2. Record review of Resident #2's Face Sheet, dated 03/28/2025, reflected a [AGE] year-old female resident initially admitted to the facility on [DATE] with diagnoses of diabetes mellitus (a group of diseases that result in too much sugar in the blood), dementia (a group of thinking and social symptoms that interferes with daily functioning), and quadriplegia (paralysis of all 4 limbs). Record review of Resident #2's Comprehensive Person-Centered Care Plan, undated, reflected I require assistance with my ADL's because I [sic] Diagnosis of: Quadriplegia with interventions to include, Transfer: I require total assistance in self performance with 2 person physical assistance staff support using a mechanical Hoyer lift. Record review of Resident #2's Quarterly MDS Assessment, dated 12/23/2024, reflected that Resident #2 required assistance with chair/bed-to-chair transfer and was Dependent on staff, meaning Helper does ALL the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Record review of the Facility Provider Investigation Report, dated 10/01/2024, reflected, On 9/25/24 at approx. 930 am: Resident was transferred to gerichair from bed via hoyer by [CNA E] for breakfast. [CNA E] states that she transferred the resident to gerichair and as resident was lowered into gerichair hoyer lift tipped over. [CNA E] states she was able to catch resident to assist to floor. [LVN K went] in room and assessed resident. MD notified. Resident noted with abrasion to bridge of nose and head. [RT L and RT M] in room and evaluated, suctioned resident. [LVN K] called EMS to transport resident to ER for further eval. Resident positioned safely on floor until EMS arrived. [LVN K] informed family of incident and transfer for ER. [CNA E] suspended pending investigation. Record review of Resident #2's progress note, dated 09/25/2024 at 2:02 pm, reflected Resident returned from hospital. Abrasion to nose. CT and scans at hospital were negative. Continue neuros. MD notified. No new orders. Record review of Resident #2's Skin Assessment, dated 09/25/2024, reflected that Resident #2 had 1cm x 0.1cm x MD well approximated laceration to bridge of nose. No discernable drainage. No odor. Interview on 03/26/2025 at 11:56 AM, the DON stated that CNA E performed an unauthorized 1-person mechanical lift on Resident #2. The DON stated it is explicitly against policy to perform a 1-person transfer with a mechanical lift, and that any employees who are observed performing a 1-person mechanical lift are terminated. The DON stated that the only injury to Resident #2 was a bump and laceration on her nose, and that tests at the hospital did not reveal further injury. Interview on 03/27/2025 at 3:30 PM, LVN K stated she remembered the incident and was there after the resident had fallen. LVN K stated the only injury observed was the laceration on the residents nose. LVN K stated that after the incident occurred, the Director of Rehabilitation at the facility assisted in ensuring all staff had mechanical lift-trainings and that all staff were observed to ensure they passed competency tests on the use of a mechanical lift. Record review of staff competencies reflected that all nursing staff (CNA's, LVN's, and Respiratory Therapists) had a competency test on mechanical lifts between 09/25/2024 and 10/28/2024. Interview on 03/28/25 at 02:00PM, Maintenance worker J revealed the facility checked mechanical lifts quarterly and they all currently work. The facility implemented the following interventions: Interview with DON on 03/26/2024 at 11;56 AM revealed CNA E was not allowed to return to the facility due to not following facility policy regarding mechanical lifts. The DON further revealed that the mechanical lift had been replaced as a whole to prevent further injuries to residents. Observation on 03/28/25 at 01:45PM revealed there were 5 mechanical lifts in the building in working condition. Record review of Maintenance log 2024 reflected one mechanical lift was broken but fixed on 02/03/25. Record review of in-service training, dated 11/26-27/24, reflected all staff were in serviced on Abuse and Neglect. Record review of in-service training, dated 09/25/24, revealed all staff were trained on abuse neglect policy and procedure, resident assist x (0, 1, 2) status, [mechanical lift] policy and procedure, and reporting and removing of non-functioning equipment. Record review of Nursing Competency Evaluations was completed. Mechanical Lift Transfer competencies were completed between 09/25/2024 and 10/28/2024, with all direct care staff having completed a competency evaluation. Record review on 03/28/2025 of CNA Roster dated 03/28/2025 reflected Resident #1 was a 2 person transfer via mechanical lift. Interview on 03/27/2025 at 10:18 AM, CNA U stated she typically works from 6:00 AM until 2:00 PM, and that mechanical lifts always have to do 2 people. CNA U stated she regularly gets mechanical lift training, and has had one as recently as about a month ago. CNA U stated she has never seen anyone become injured during a mechanical lift, and if she ever saw another staff member doing a mechanical lift by herself she would contact her nurse, ADON, and DON. Interview on 03/27/2025 at 3:30 PM, LVN K stated she typically works from 8:00 AM until 5:00 PM, and the director of rehabilitation had trained staff on mechanical lifts after the incidents. LVN K stated she feels comfortable on how to use a mechanical lift and that training and competencies on mechanical lifts are done frequently. Interview on 03/27/2025 at 6:11 PM, CNA S stated he typically worked 10 PM until 6 AM and he recieved training on how to perform a mechanical lift last month. CNA S stated mechanical lifts must be done with 2 staff members and had never seen a 1 person mechanical lift. Interview on 03/27/2025 at 6:14 PM, CNA T stated they typically work 6:00 AM until 2:00 PM and had a mechanical lift training within the last month and that they have never seen a 1 person mechanical lift, as all mechanical lifts were completed with 2 people. Interview on 03/28/2025 at 8:33 AM, CNA V stated they typically work 2:00 PM until 10:00 PM and had a mechanical lift training last month. CNA V was able to describe the different duties for each person during a mechanical lift, why it was imperative that the mechanical lift was done by 2 people, and that they had never seen a resident become injured during a mechanical lift. Interview on 03/28/25 at 09:30 AM, CNA Z, typically worked 2PM-10PM, revealed she was trained on transferring residents via mechanical lift and knew how to find out if a resident was transferred via mechanical lift, to include following therapy recommendations for residents. Interview on 03/28/25 at 02:15PM LVN C, typically worked 2PM-10PM, revealed she had been trained on how to do mechanical lifts and what residents were transferred via mechanical lifts. Interview on 03/28/2025 at 2:19 PM, CNA X stated she typically worked 6:00 AM until 2:00 PM, but will regularly pick up shifts at other times. CNA X stated that it is explicitly against policy to do a 1 person mechanical lift and that they had never seen a person become injured during a mechanical lift. Interview on 03/28/2025 at 2:22 PM, CNA Y stated that she works as needed and has worked all shifts, but primarily works between 6:00 AM until 2:00 PM, or 2:00 PM until 10:00 PM. CNA Y stated that she has extensive training on mechanical lifts and has been trained by the facility within the last few months. CNA Y stated she had never seen a person do a 1 person mechanical lift transfer at the present facility or at any facility she has worked at. CNA Y stated if she saw a staff member attempting to do a 1 person mechanical lift, she would step in to assist to ensure it became a 2 person mechanical lift transfer, and then report it to the DON. Interview on 03/28/25 on 02:33 PM, RN P revealed he worked all shifts and he was trained on how to use the mechanical lifts properly and knew where to look to identify if a resident required a mechanical lift for transfer. He also got this information from report from the previous nursing staff. Interview on 03/28/25 on 02:37 PM, CNA Q, typically worked 2PM-10PM, revealed she was trained on how to properly transfer residents with mechanical lifts (to include needing 2 people to transfer) and what residents needed to be transferred via mechanical lift. She was trained frequently about mechanical lifts with the last training being last month. Interview on 03/28/25 at 02:38PM, LVN R, typically worked the 8AM to 5PM shift, revealed she knew what residents were to be transferred via mechanical lift by looking at the Kardex or using CNA sheets at the nursing station. LVN R further revealed they needed 2 staff members to transfer residents via mechanical lift and she was trained frequently on using mechanical lifts. Facility policy titled, Safe Lifting and Movement of Residents, revised July 2017, reflected 1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regard the safe lifting and moving of residents . 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis .8. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. 10. Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. Facility policy titled, [Mechanical Lift] Policy, undated, reflected Every [mechanical lift] transfer requires 2 PERSON ASSIST for the safety of the resident and the staff members. The noncompliance was identified as PNC. The IJ began on 09/25/2024 and ended on 11/27/2024. The facility had corrected the noncompliance before the investigation began. The Administrator and the DON were notified on 03/28/2025 at 09:00 PM, a past non-compliance IJ situation had been identified due to the above failure.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #2) of four residents reviewed for abuse. The facility failed to keep Resident #2 free from abuse when CNA A roughly provided bed mobility assistance and incontinent care on 02/11/2025 and 02/13/2025. The noncompliance was identified as past non-compliance IJ. The noncompliance began on 02/15/2025 and ended on 02/19/2025. The facility corrected the non-compliance before the investigation began. This deficient practice could affect any resident and result in emotional and physical abuse. The findings include: Record review of Resident #2's Admission Record, dated 02/20/2025, reflected a [AGE] year-old male. He was initially admitted to the facility on [DATE] and readmitted on [DATE]. He was noted to have a responsible party (RP) identified that was other than himself. Record review of Resident #2's Medical Diagnosis list, undated but accessed on 02/21/2025, reflected Resident #2 had diagnoses which included other specified trisomies and partial trisomies of autosomes (a genetic condition that results in abnormalities of the person's chromosomes which often cause severe physical and intellectual disabilities) and cerebral cysts (a fluid-filled sac in the brain that can be cancerous or noncancerous and may cause headaches, vision problems, or nausea). Record review of Resident #2's Quarterly MDS, signed as completed on 01/29/2025 by the DON, reflected Resident #2 had a BIMS score of 15, which indicated he was cognitively intact. His mood was documented as having never felt lonely or isolated over the last 2 weeks and he did not have any documented behavioral symptoms. He was documented as having had upper extremity (shoulder, elbow, wrist, hand) impairment on one side and lower extremity (hip, knee, ankle, foot) impairment on both sides. He used a wheelchair and was dependent (requiring a helper for all of the effort) for toileting hygiene and lower body dressing. He was always incontinent of urine and bowel. During an observation on 02/19/2025 at 04:30 p.m. revealed 2 pictures, with no date stamp and was submitted by Resident #2's RP on 02/18/2025, the first picture with deep purple bruising noted in multiple sites of upper right arm, ranging from mid upper interior side of right arm to the interior of the elbow. The second picture with deep purple bruising on the right hand, palm side of hand, extending from the little finger and ring finger to the palm of the hand. Source of bruising was not evident from pictures. During an observation on 02/20/2025 at 04:30 p.m. revealed 3 videos, with no date stamp and submitted by Resident #2's RP on 02/18/2025, CNA A was observed changing Resident #2's incontinence brief while in his bed. Due to the same clothing and positioning of CNA A, Resident #2, and Resident #3 visible on the videos, two of the three videos appeared to have been recorded on the same day and to have been recorded back-to-back. On one video, CNA A was observed to roughly grab Resident #2's left foot and with force push his foot against the right side of the bed, causing a visible bend in his foot and a compression of the mattress under his foot, and then she proceeded to grab Resident #2's right wrist, and roughly [NAME] Resident #2 onto his left side using only her handholds of the resident's right wrist and the pad of his left foot. On a separate video, which appeared to have occurred on a separate day, CNA A was observed to flick Resident #2's left leg, from a position of him turned onto his right side with both of his knees together, and then she abruptly pushed his left leg, still bent at the knee to the left side, which resulted in his legs to become fully opened at the hip. Audio on the videos was able to be heard but not sufficiently distinguished. Prior observation of images of Resident #2's bruises was not found to match possible injuries noted during video observation. During an interview on 02/20/2025 at 12:20 p.m., Resident #2's RP stated the videos she submitted were from Tuesday (02/11/2025) and Thursday (02/13/2025) at around 06:30 p.m.- 07:30 p.m. She stated she was unable to provide the videos with date and time stamps. She stated she last saw Resident #2 on Monday, 02/10/2025 and he did not have the bruises noted in the pictures at that time. She stated Resident #2 could not provide a lot of information regarding the incident, but he could give her the person's name. He named CNA A. She stated when she asked Resident #2 about the bruises, he mostly replied it happened during his showers, on Tuesdays and Thursdays. She stated the source or cause of the bruising on Resident #2's arm was still unknown. She stated Resident #2 was not aggressive, and he did not like to complain or accuse anyone of hitting him. During an interview on 2/20/25 at 11:40 a.m., the DON revealed that CNA A was terminated. During an observation and interview on 02/21/2025 at 11:07 p.m., revealed Resident #2 was observed to be sitting in his wheelchair in the hallway. His arms were noted to be covered up to his wrist, but light, dark purple bruising was noted on his right hand. Resident #2 stated he was pinched by CNA A in the shower hard and indicated an injury to his upper right arm. He stated the facility staff were nice except for CNA A. He stated, she hurt me, and I don't feel safe with CNA A. When asked about the bruise on his hand, Resident #2 stated he had blood taken last month and pointed toward the area in the facility where bloodwork would have been taken. During an interview on 02/24/2025 at 12:21 p.m., CNA A stated she worked the 2:00 p.m. to 10:00 p.m. shift, Monday to Friday, the week of Valentine's Day (02/10/2025- 02/14/2025). She stated she was assigned to work with the residents on 300-hall for those shifts. She stated Resident #2 was one of her patients for the week of 02/10/2025 to 02/14/2025. She stated after she assisted Resident #2 with a shower on Thursday, 02/13/2025, she put him on his bed to change his brief. She stated Resident #2's behaviors would start when he was taken back to his room following the shower. She stated he could be difficult if you didn't do what he said. She stated, he didn't want to go back into bed, and he didn't want to turn. She stated he tried to hit her, and she had stopped him by putting her arm up to block him. She stated any bruising or scratches he had was not from her. She stated she did see bruising on Resident #2 on Friday, 02/14/2025 but was under the impression they had already been reported. She stated she completed facility training documentation which indicated she was trained on incontinent care, resident rights, and abuse/neglect. She stated she knew the procedures. During an interview on 02/24/2025 at 12:36 p.m., the LSW stated she was familiar with Resident #2, since he had a tendency to come visit her during the day. She stated she had not observed any changes in his behaviors following the incident reported on 02/15/2025. She stated he had not expressed any concerns or fears of other staff members. She stated following the incident, she came into the facility and completed safe surveys with other residents and spoke with Resident #2. She stated no other residents reported concerns during the safe surveys. She stated she completed a trauma assessment on Resident #2 on 02/15/2025. She stated she documented that he reported to have had nightmares because that was the closest way to document on that specific form that he reported to her that the incident still bothered him, but he didn't want to think about it. She stated the nursing department had already started abuse and neglect training with staff by the time of her response to the incident. During an interview on 02/24/2025 at 05:11 p.m., LPN E stated he worked on the 300-hall, Monday to Friday during the 02:00 p.m. to 10:00 p.m. shift. He stated he recalled observing Resident #2's bruises but thought they were due to Resident #2's recent lab draw. He stated Resident #2 was upset with CNA A and CNA A did tell him Resident #2 was aggressive; however, he stated he did not observe Resident #2 having been aggressive. He stated CNA A told him Resident #2 did not want his shower and when he spoke with Resident #2, Resident #2 said he wanted his shower later. LPN E stated CNA A did shower Resident #2 later that shift. LPN E stated when he gave Resident #2 his 08:00 p.m. medications, Resident #2 did not say anything to him. LPN E stated he believed he first saw Resident #2's bruises on Thursday and asked Resident #2 what had happened. He stated Resident #2 reported to him that it was CNA A, but this report occurred after the facility had started an investigation. LPN E did not provide a date for when he observed Resident #2's bruises or a date for when he had a conversation with Resident #2 regarding CNA A. During an interview on 02/24/2025 at 08:47 p.m., LPN F stated she worked double weekends on the 300-hall. She stated the only prior behaviors she observed from Resident #2 was his preference to hang around in the hallways and he liked to talk and be social. She stated she was present at the time CNA B first reported Resident #2's allegation of abuse from another CNA. She stated CNA B told her of Resident #2's allegation and she went to assess and speak with Resident #2. She stated she noted quite a few bruises of differing size that were purple to brownish in color on his arm. She stated Resident #2 initially wouldn't tell her what happened but then he told her the same report he had given CNA B, that CNA A hit him. She stated she was unable to get a straight answer on when the incident occurred, but Resident #2 repeatedly stated it happened on his shower day and CNA A was mean, she hit him, and he was trying to fight back. LPN F stated Resident #2 did not appear to be scared or apprehensive of other CNAs. She stated following her assessment, she identified around 5 scattered bruises on Resident #2's arm and hand and 3 tiny bruises on his abdomen, which she stated Resident #2 identified as resulting from where CNA A pinched him. She identified a bruise on his ear, which Resident #2 stated was where CNA A pinched and pulled his ear. She stated an abuse allegation had to be reported within 2 hours and she immediately reported the allegation to the weekend supervisor, RNJ, who reported it to the administrator, who was the abuse coordinator. She stated the facility staff were in-serviced on abuse that same day she initially reported the allegation. During an interview on 02/24/2025 at 09:16 p.m., CNA B stated he worked weekends and primarily on 300-hall. He stated Resident #2 was typically talkative, happy, and wanted to say hi to everyone. He stated Resident #2 liked to get up in the morning, be in his wheelchair, and go to all the activities. He stated Resident #2 never refused care from him and always wanted his showers. CNA B stated he was the one to initially report Resident #2's allegation of abuse. He stated he noticed the bruising on Resident #2's right arm and even though Resident #2 tended to bruise easily when the facility did bloodwork, he asked Resident #2 what had happened because there were more bruises than normal. He stated Resident #2 replied that CNA A did it. CNA B stated he had never heard Resident #2 have hate towards anyone, but Resident #2 told him he hated CNA A. CNA B stated he noticed the additional bruising on Resident #2's right arm, bicep, ear cartilage, and right hand, but was more concerned about Resident #2 having stated he hated CNA A and she had hit him. CNA B stated following Resident #2 reporting what occurred, he finished Resident #2's shower, got him into his wheelchair, and then reported the allegation to LPN F. He stated following his report to LPN F, he observed LPN F reported the incident to the weekend supervisor and then the report escalated from there. He stated he felt as if the facility responded to the allegation appropriately, they immediately took action, which included having assessed Resident #2. He stated the staff had an in-service on abuse and neglect that same weekend of his initial report. During an interview on 02/25/2025 at 10:43 a.m., the DON stated Resident #2 attended bingo on 02/13/2025, which would have finished up around 03:00 p.m. She stated bingo was not scheduled on the activity calendar at that time, but the residents really loved bingo, so it was held more often. She stated CNA A had documented under Resident #2's Tasks his shower was taken at 02:49 p.m., but CNA A may have documented at that time because she was planning on going to get him for his shower at that time. The DON stated the Task screen was not visible under surveyor EMR access. During an interview on 02/25/2025 at 01:03 p.m., the DON stated the facility process for screening when hiring was human resources completed background, license, and reference checks upon hire and then background and license checks as scheduled. She stated CNA A had not had any noted concerns or complaints for possible abusive behaviors. She stated she was first notified of Resident #2's CNA A abuse allegation by the weekend supervisor. She stated the weekend supervisor had already called Resident #2's RP, his PCP, and taken CNA A's statement. She stated CNA A was put on leave at that time. She stated the weekend supervisor asked Resident #2's RP if she could review the camera footage from Resident #2's room. The DON stated the facility turned in a self-report of the incident and spoke to Resident #2's RP about wanting to do a police report. The DON stated the LSW ended up putting in the police report on Monday, 02/17/2025. The DON stated she came in on Saturday following the incident having been reported to her and the LSW and administrator also became involved in the investigation. The DON stated she believed the incident happened during the Thursday, 02/13/2025, 02:00 p.m. to 10:00 p.m. shift. She stated LPN E had gone into Resident #2's room that night and Resident #2 had told him he was okay. She stated LPN E did not report having had identified any indicators on Thursday night or Friday. She stated Resident #2 was not seen to have bruises on Friday, 02/14/2025 and he seemed fine during the facility Valentine's Day party, which he attended. She stated he did not report bruising or pain at that time. She stated the incident seemed to come back up for Resident #2 on Saturday, 02/15/2025 because it was another of his shower days and he really loved that CNA, CNA B. The DON stated it was her expectation the nurse would get involved when a resident refused a shower, to determine why they refused and to find out if there was a way to alleviate that reason. She stated for when a resident had behaviors, the CNA was supposed to separate themselves from the situation and go inform the nurse. She stated she would expect the nurse to intervene and possibly let her know if she needed to switch staffing assignments or follow up with the resident. The DON stated she did view the camera footage and would say that it was abuse, CNA A was rough with Resident #2. She stated that was not how she would want anyone to be treated. During an interview on 02/25/2025 at 01:31 p.m., the ADMIN stated staff were trained on abuse and neglect upon hire and as needed following every incident. The ADMIN stated she was notified of the incident involving Resident #2 and CNA A on Saturday, 02/15/2025 around 03:00 p.m. to 04:00 p.m. She stated the investigation, and the incident response was a group effort with the DON completing the investigation and interviews, and safe surveys were conducted. She stated with abuse allegations, the staff member would be immediately suspended with the primary goal to protect the resident until the investigation was completed. She stated CNA A had not had any previous complaints and as soon as they were notified of the abuse allegation, CNA A was put on suspension. The ADMIN stated the allegation of abuse was confirmed following their facility investigation and the facility was planning to refer CNA A. She stated Resident #2's RP did decide for a police report to be submitted for this incident. The ADMIN stated following this incident, Resident #2 did not require treatment other than responding to his emotional distress and his request for CNA A to not be back in his room. The ADMIN stated for any reason, if a resident was having behaviors, staff were trained and in-serviced to monitor for resistance to care and to let the nurse know. She stated her expectation was for staff to stop attempting the care and to notify the nurse. They may try to approach at a different time. The ADMIN stated CNA A's care did appear abusive on the camera footage, she [CNA A] was flopping his legs back and forth. The ADMIN stated following viewing of the camera footage it was pretty evident CNA A's behaviors were unprovoked by Resident #2. Record review of Resident #2's Progress Notes reflected the following entries: - Incident Note written by the DON, dated 02/15/2025 at 02:30 p.m., reflected On 2/15/25 Resident verbalized to [CNA B] and [LPN F] that [CNA A] made him leave bingo to take a shower. While in shower [CNA A] pulled his ear and pinched his stomach. Stated he tried to punch and kick her back. Then CNA put resident in bed after he stated he did not want to go to bed. Stated Employee [sic] punched him on arm in room. Resident has camera in room. [Resident #2 RP] notified of allegation and stated she would review footage. Resident with bruising to RUA [right upper arm], L [left] ear and abdomen. [Resident #2's PCP] notified. Skin and pain assessment completed. Employee suspended pending investigation. - Nursing note written by RN K, dated 02/15/2025 at 04:05 p.m. and noted as LATE ENTRY, reflected Resident's [Resident #2's RP] reviewed footage of personal camera that is in resident's room. Footage provided to this nurse by [Resident #2's RP]. 8 videos sent. In clips there are no obvious incidents of staff member hitting resident or of resident being combative. Noted resident pushed over to side, legs allowed to fall to bed instead of supporting through turns during peri care. [Resident #2's RP] states she will come by facility to visit resident tomorrow to see how he is doing. Informed RP resident is in good spirits and not complaining of pain or any other discomfort at this time. Staff continuing to monitor. - Nursing note written by RN K, dated 02/15/2025 at 04:11 p.m. and noted as LATE ENTRY, reflected Resident is up in power chair propelling self-down [sic] hall. Noted smiling and speaking to another resident at nurses [sic] station. No s/s of distress at this time. Will continue to monitor. - Incident Note written by LPN H, dated 02/15/2025 at 09:33 p.m. and noted as LATE ENTRY, reflected Patient presents with no behaviors at this time. Patients' [sic] vitals remain stable and states no pain to Rt arm. Received all nighttime medications. Will continue to monitor for changes. Patient is now in bed asleep. - Incident Note written by LPN H, dated 02/15/2025 at 10:21 p.m., reflected Patient presents with no behaviors at this time. Patients' [sic] vitals remain stable and states no pain to Rt arm. Received all nighttime medications. Will continue to monitor for changes. Patient is now in bed asleep. - Activities Note written by LPN H, dated 02/16/2025 at 05:39 a.m., reflected Patient slept through the night and presented with no behaviors. Vitals remain stable. - Incident Note written by LPN H, dated 02/16/2025 at 06:00 a.m., reflected Patient slept through the night and presented with no behaviors. Vitals remain stable. - Nursing Note written by RN K, dated 02/16/2025 at 03:14 p.m., reflected .Resident in a cheerful mood. No complaints verbalized to me or other staff members at this time. - Nursing Note written by LPN H, dated 02/16/2025 at 08:40 p.m., reflected Patient is in chair engaging in conversation with people. No signs of distress noted. Vitals are stable and no aggressive behavior observed. - Social Services Note written by the LSW, dated 02/18/2025 at 04:40 p.m., reflected This SW met with [officer name and badge number], with [county name] sheriff office. Case #[number documented]. He met with this resident to discuss the incident that occurred between himself and the CNA. [Officer M] also spoke with the DON and me, as well as this resident's [Resident's RP]. The officer is turning over his report to the Detective [sic] and he will follow up, after he reviews the case. - Social Services Note written by the LSW, dated 02/19/2025 at 08:29 a.m., reflected This SW spoke with this resident, about how he was doing and if he was feeling anxious or upset about the situation, that he had with his CNA. He said that he was fine and that he was happy. Record review of Resident #2's Care Plan, dated as last review completed 01/24/2025 and accessed 02/20/2025, reflected the following focuses with interventions: - Resident #2 required assistance with his ADLs because of his cerebral cysts. Interventions included: - Bed Mobility: I require limited to extensive assistance in self performance [sic] with 1 person [sic] physical assistance staff support. - Personal Hygiene: I require supervision, limited assistance in self performance [sic] with 1 person [sic] physical assistance staff support during my personal hygiene. - Toileting: I require limited to extensive assistance in self performance [sic] with 1 person [sic] physical assistance staff support. - Resident #2 is known to become upset very easily when I feel I am in trouble or done something wrong . Interventions included: - Approach in a calm and reassuring manner - Explain care procedures in simple terms - Staff to redirect resident in gentle manner when behaviors are noted. - 2/13/2025 Suspected physical abuse of resident by staff member as evidenced by: Resident report 2/15/25. Interventions included: - Arrange for psych consultation as ordered by primary MD. - Assess/record/report [sic] to MD prn noted s/sx of suspected abuse: Unexplained bruising, bleeding, swelling, other s/sx of trauma Unusual [sic] or unexplained behavioral symptoms (fearfulness, aggressiveness, acting out sexually) [sic] Vaginal bleeding or discharge Penile [sic] discharge Resident [sic], staff or family member reports of abusive behavior. - Discuss with resident/family concerns, fears or issues related to suspected abuse. - Document resident, family or staff member statements concerning the alleged abuse. - Immediately notify regulatory agencies of suspected abuse. Record review of facility investigation file for incident #564291, received 02/20/2025 upon entry for investigation, reflected the following documents: - an Employee Disciplinary Action Form, dated 02/15/2025 for counseling with CNA A. Notation of Decision on document included Suspension and Termination boxes checked with plan of correction written, Employee terminated due to investigation- intake #564261. - a document titled, Self-Reporting Protocol - Abuse and/or Neglect, dated 02/15/2025. The document reflected: - Notifications checked as completed included: abuse coordinator, the DON, Resident RP, Resident PCP, facility Medical Director, local law enforcement, and a report to THHS was completed within specified timeframe, - CNA A was suspended pending investigation on 02/15/2025, - Resident #2 was interviewed, a BIMS was conducted, and a head-to-toe skin assessment was completed on 02/15/2025, - Resident Safe Surveys were conducted, - incident reports in [EMR] were completed, and - abuse/neglect in-servicing was started for all staff. - a printed statement titled [CNA A] 2/15/2025. The statement included On Tuesday [02/11/2025] I did not have any issues with [Resident #2]. On Thursday [02/13/2025] when I was trying to transfer him [Resident #2] to the bed he started hitting everything, scratching his face. His friend from B bed [Resident #3] got up and was peeking through the curtain trying to talk to him and get his attention so I told him to go to the other side of the curtain. He was banging his arm on the rail. That's how he acts when I put him back to bed. I told the nurse he was acting out again. The nurse went in the room but by that time he was settled in bed and calm. I gave him a shower in the shower room and I didn't have any problems, it's when I try to put him in bed. I never hit [Resident #2], I put my arm up to keep him from hitting me. I did notice a healing bruise to his right shoulder area when I changed him. - a printed statement titled 8/15/2025 [Resident #2's] Statement. The statement included I don't like [CNA A] no more. I got mad with [CNA A] because she did not let me play games .I was trying to keep playing the games and [CNA A] don't let me play. She keeps punching me. Look, see? (shows bruising to right upper arm.) I hit [CNA A] and then she hit me on purpose. - Six Resident Safe Surveys, dated 02/15/2025, completed by RN K and the LSW on residents with rooms on 300-hall [hall Resident #2's room was located and CNA A's assigned hall]. All residents noted to select that they felt safe in the facility. - a copy of the self-report for incident #564291, sent by the ADMIN on 02/15/2025 at 03:32 p.m. - a copy of Resident #2's Trauma Informed Care Assessment, dated 02/15/2025 at 03:12 p.m. and signed by the DON. The assessment reflected Resident #2 had experienced an unusually or especially frightening, horrible, or traumatic event and he had nightmares about the event(s), but he did not need to try hard to not think about the event(s), was not on constant guard, did not feel detached from people or activities, or feel guilty or unable to stop blaming himself. - a copy of Resident #2's Pain Evaluation, dated 02/15/2025 at 03:12 p.m. and signed by the DON. The evaluation reflected, Resident #2 denied pain or hurting at any time in the last 5 days. Under Conclusion, NO pain, intervention is not necessary. Re-assess quarterly or with onset of pain. was selected and a documented note, assessment completed due to abuse allegation and bruising noted. Resident states he currently does not have pain. was included under Progress Notes. - a copy of Resident #2's Weekly Skin Assessment Report, dated 02/15/2025 at 03:14 p.m. and signed by the DON. The report reflected Resident #2 had three light yellow bruises on his abdomen, a purple bruise on his left ear, five yellow to purple bruises on his right upper arm. He did not have any open injuries and was not in pain. Resident #2's PCP and RP were noted to have been notified on 02/15/2025. Record review of the facility's document, Inservice Attendance Record, labeled with topic Abuse, Neglect, Self Report, Involuntary Exclusion, received 02/20/2025 but dated 02/25/2025, reflected 82 of 146 staff had completed the training. Of the clinical staff that completed the training, 16 of 34 were CNAs from multiple shifts, 13 of 22 were LPNs from multiple shifts, 2 were weekend RNS of 7 RNs, and 15 of 32 were therapy staff. 45 of the total facility staff were identified as not full-time staff with 10 staff labeled as part-time employees, 32 staff labeled as working PRN (as needed), and 3 staff labeled as LOA (on leave of absence). Record review of the police report, dated as reported 02/18/2025 at 03:24 p.m., reflected Resident #2's RP reported Resident #2 was assaulted by a staff member. The general report noted the officer spoke with the facility LSW, the DON, and Resident #2's RP at the facility. The report noted the officer was advised by his supervisor sergeant to notify the criminal investigation department. Record review of the facility's policy Abuse Prevention Program, dated as revised December 2016, reflected a policy statement which stated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation stated As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff . 4. Implement measures to address factors that may lead to abusive situations, for example: a. Provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation; . The noncompliance was identified as past non-compliance IJ. The noncompliance began on 02/15/2025 and ended on 02/19/2025. The facility corrected the non-compliance before the investigation began.

Based on observations, interviews, and record reviews the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 5 of 79 residents (Resident #5, #7, #10, #11, and #12) reviewed for elopement. 1. Resident #5 was admitted on [DATE] with diagnoses which included dementia and was assessed on 02/26/2024 as a wander risk at 9 out of a possible 11 for high risk. Resident #5 walked out of the facility on 03/16/2024 around 3:00 to 4:00 PM and was discovered 13 miles away on a public street and returned to the facility at 9:40 PM. 2. Residents #7, #10, #11, and #12 have been assessed as at risk for wandering while the facility has a front door which was unlocked and unmonitored from 6:00 AM to 8:00 AM and 5:00 PM to 10:00 PM on Monday through Friday and unlocked and unmonitored from 6:00 AM to 8:00 AM and 7:00 to 10:00 PM on Saturdays and Sundays. The facility receptionist's monitors the front door from 6:00 to 5:00 Monday through Friday and from 6:00 AM to 7:00 PM on Saturdays and Sundays but are unaware of which residents are at risk for wandering and or elopement. An IJ was identified on 04/19/2024. The IJ template was provided to the facility on [DATE] at 02:44 PM. While the IJ was removed on 04/20/2024, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that was not an Immediate Jeopardy due to the facility staff had not been trained on measures to identify and support residents needs for safe outdoor activities. These failures could place residents at risk of harm, severe injury, and possible death to residents who require supervision to prevent elopement. The findings included: 1. A record review of Resident #5's admission record dated 04/18/2024 revealed an admitted [DATE] with diagnoses which included dementia (the loss of cognitive functioning and thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), altered mental status, restlessness and agitation, and noncompliance with medical treatment and regimen. A record review of Resident #5's admission MDS assessment, dated 03/01/2024, revealed Resident #5 was a [AGE] year-old male admitted for long term care with dementia safety needs and assessed with a BIMS score of 09 out of a possible 15 which indicated moderately impaired cognition. Further review revealed Resident #5 was assessed independent for indoor mobility (ambulation): code the resident's need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury. Further review revealed Resident #5 was assessed as Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort when assessed for Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. A record review of Resident #5's base line care plan dated 02/23/2024 revealed Resident #5 was assessed as needing no assistance with locomotion, Locomotion on unit: support provided 0. No setup or physical help from staff. A record review of Resident #5's Wander Risk assessment dated [DATE] revealed LVN D assessed Resident #5 as at Risk to Wander, out of a possible, low risk to wander, at risk to wander, and high risk to wander. During an interview on 04/17/2024 at 9:00 AM the Administrator stated on 03/16/2024 Resident #5 eloped from the facility and was returned the same evening around 9:00 PM. The Administrator stated after the elopement Resident #5 was placed on a 1 to 1 level of supervision and was discharged to another facility with a secured memory care unit. The Administrator stated she reported the incident to the state survey agency and provided in-service education for the staff for elopement protocols and provided a practice drill for elopement protocols. The Administrator stated she was in the process of securing bids to have a secured front door and back door to include a back fenced area. A record review of the facility's investigation report, dated 3/22/2024, revealed Resident #5 eloped from the facility on Saturday 03/16/2024 around 03:00 PM to 4:00 PM and was returned to the facility by Resident #5's POA around 10:00 PM. A record review of Resident #5's nursing progress notes dated 03/16/2024 revealed LVN C documented at 7:23 PM, 1713 (5:13 PM) went to assess resident and obtain vital signs for 2-10 PM shift but resident not in room; looked in dining room where residents are gathering for evening meal; resident not in dining room; searched for resident in all rooms on 100 and 200 hall; unable to locate resident; 1726 (5:26 PM) paged for CODE PINK overhead and informed weekend supervisor; all rooms, closets, shower rooms, storage rooms searched but unable to find resident; searched outside grounds, as well as convenience stores across street and across open field from facility; weekend supervisor notified administrator, DON, and family; placed call to IT (representative) to review camera footage; (Local) Sheriff Office notified and deputy dispatched; 1850 (6:50 PM) administrator called and informed weekend supervisor that resident had been located at (local) ER (emergency room ); informed deputy who left to go make contact with resident at ER; 1950 (7:50 PM) deputy returned to facility and informed this nurse that administrator had been given incorrect information and that resident is not at (local) ER; deputy had notified maintenance director and requested that he return to facility to review camera footage to verify that resident did, in fact, leave premises; informed weekend supervisor who, in turn, informed administrator. A record review of Resident #5's nursing progress notes dated 03/16/2024 revealed LVN C documented at 9:37 PM, 2030 (8:30 PM) Resident #5's POA came to facility to report that resident had called him; resident had left facility on foot and got a ride to an old address, and got the people that live there now to take him to the west side; Resident #5's POA states that he is going to go try and find him in the not so nice place that he's at, and try and get him to come back, I will call y'all when I find him; 2140 (9:40 PM) Resident #5's POA arrived back at facility with resident; resident smiling and laughing; no acute distress noted; denies pain or discomfort; resident will be placed on 1:1 monitoring. During an interview on 04/20/2024 at 4:20 PM LVN C stated she was the charge nurse on 03/16/2024 and recalled she saw Resident #5 around 3:00 PM and then could not locate Resident around 5:00 and announced Code Pink which alerted the staff a Resident was missing. LVN C stated the staff began searching the facility and then searched the immediate neighborhood. LVN C stated she alerted the local police, the doctor, and Resident #5's POA. LVN C stated Resident #5's POA called the facility, around 8:00 PM and reported he had discovered Resident #5 downtown and would return shortly. During an interview on 04/18/2024 at 3:25 PM the DON stated Resident #5 was admitted on [DATE] and assessed as a wander risk due to his diagnoses of dementia and did not have any history of elopements and or verbalizations of ideations for elopement. The DON stated Resident stated the front doors are not locked from 6:00 AM to 10:00 PM and the receptionist monitors the doors from 8:00 to 5:00 PM. The DON stated the 10:00 PM to 6:00 AM nurse locked the front doors at 10:00 PM and unlocked the doors at 6:00 AM. The DON stated on 03/16/2024 at around 5:00 PM LVN C attempted to assess Resident #5 and discovered she could not find him and alerted the weekend Supervisor RN who initiated the elopement protocol. The DON stated the police were alerted and Resident #5's POA was alerted. The DON stated Resident #5's POA called the facility and reported he had discovered Resident #5 had boarded a public bus and traveled to an apartment he used to rent, and the landlord identified Resident #5 and drove Resident #5 to the downtown homeless shelter. The DON stated she and multiple facility staff independently used their vehicles to search the downtown homeless shelter area and Resident #5 was discovered by the homeless shelter and rode back to the facility with Resident #5's POA. During an interview on 04/19/2024 at 12:07 PM Resident #5's POA stated he had met Resident #5 several years ago and recognized Resident #5 had no family and or friends to look after him and so I began to follow his well-being .and became his POA. Resident #5's POA stated over the years Resident #5 was diagnosed with dementia and Resident #5's moments of clarity were becoming less and less. Resident #5's POA stated after Resident #5's recent hospitalization it was determined a safe discharge from the hospital would require long term care at the facility. Resident #5's POA stated on 03/16/2024 early evening he received a call from the facility reporting Resident #5 was missing. Resident #5's POA stated he was immediately concerned and drove to the facility to assist in Resident #5's search. Resident #5's POA stated during his time searching the facility's surrounding area for Resident #5 he recalled Resident #5 had a recollection of his previous address, so he decided to call Resident #5's previous landlord and learned from the previous landlord that Resident #5 had presented at the home and attempted to reside there. Resident #5's POA stated the landlord reported he drove Resident #5 downtown to a local charity and dropped him off. Resident #5's POA asked for specific details of a location and the landlord identified an area by a highway bridge. Resident #5's POA drove to the area and located Resident #5 on a public street by the local charity and a highway bridge. Resident #5's POA stated Resident #5 stated he did not know how he got there and was hungry. Resident #5's POA stated he drove Resident #5 back to the facility to be assessed. Resident #5's POA provided the address to Resident #5's previous address and the area where he found Resident #5. Resident #5's POA stated he learned from Resident #5 that he more than likely rode the bus to his previous address. A record review of the city's public transport system revealed a bus route from the facility to Resident #5's previous residence which ran directly without a need to change buses. Further review revealed the trip required 20 miles in distance, 1.5 hrs. in duration, and a walk of 7/10ths of a mile. 2. A record review of Resident #7's admission record dated 04/19/2024, revealed an admitted [DATE] with diagnoses which included schizophrenia (a serious mental disorder in which people interpret reality abnormally.) A record review of Resident #7's quarterly MDS assessment dated [DATE] revealed Resident #7 was a [AGE] year-old-male admitted from the hospital for long term care with needs for wandering and schizophrenia safety supports and assessed with a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. Further review revealed Resident #7 used a wheelchair. A review of the Functional Abilities and Goals assessment, dated 04/08/2024, revealed Resident #7 was assessed to an ability to use a wheelchair as: Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns .Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity and Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space .Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as Resident completes activity. Assistance may be provided throughout the activity or intermittently. A record review of Resident #7's care plan dated 04/19/2024 revealed, Resident independent with ADLS (Activities of Daily Life). Maintain independence through review date: I may fluctuate on my ADL's Self-Performance score and fluctuate in my ADL. Support score because some days I may need more or less help due to my physical impairment and cognitive impairments .USES WALKER TO AMBULATE TRANSFERS-INDEPENDENT TO LIMITED ASSIST AT TIMES. A record review of Resident #7's Wandering Risk Scale dated 03/22/2024, revealed, Resident #7 was assessed by LVN D as At Risk for Wandering. A record review of Resident #10's admission record dated 04/19/2024 revealed an admitted [DATE] with diagnoses which included dementia (the loss of cognitive functioning and thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) and schizophrenia (a serious mental disorder in which people interpret reality abnormally.) A record review of Resident #10's quarterly MDS assessment dated [DATE] revealed Resident #10 was a [AGE] year-old-male admitted from the hospital for long term care with needs for wandering, dementia and schizophrenia safety supports and assessed with a BIMS score of 9 out of 15 which indicated severe cognitive impairment. A review of the Functional Abilities and Goals assessment, dated 01/22/2024, revealed Resident #10 was assessed with the ability to, Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space with, Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as Resident completes activity. Assistance may be provided throughout the activity or intermittently. A record review of Resident #10's care plan dated 04/19/2024 revealed Resident #10 was at risk for falls related to generalized weakness, impaired cognition, use of psychoactive meds and irregular gait, dementia, poor safety awareness, hearing and visual impairment, psychotropic med use, and prior falls with interventions: Monitor resident every shift or as needed and keep watch .I use a walker . ensure resident's safety at all times and keep watch . I am at risk of injury as I have impaired visual functioning due to Cataracts and macular degeneration A record review of Resident #10's Wandering Risk Scale dated 03/17/2024, revealed, Resident #10 was assessed by LVN D as At Risk for Wandering. A record review of Resident #11's admission record dated 04/19/2024 revealed an admitted [DATE] with diagnoses which included dementia (the loss of cognitive functioning and thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and legal blindness (a person cannot attain 20/200 vision even with prescription eyewear.) A record review of Resident #11's quarterly MDS assessment dated [DATE] revealed Resident #11 was a [AGE] year-old-male admitted from another facility for long term care with needs for wandering, dementia and blindness. Resident #11 was assessed with a BIMS score of 14 out of a possible 15 which indicated intact cognition. A review of the Functional Abilities and Goals assessment, dated 10/24/2023, revealed Resident #11 was assessed with the ability to, Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space with, Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as Resident completes activity. Assistance may be provided throughout the activity or intermittently. Resident #11 had a need for a walker (a device that gives support to maintain balance or stability while walking). A review of the Functional Abilities and Goals assessment, dated 10/24/2023, revealed Resident #11 was assessed with the ability to, Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space with, Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. Assistance may be provided throughout the activity or intermittently. A record review of Resident #11's care plan dated 04/19/2024 revealed, I am at risk of injury as I have impaired visual functioning due to Blindness and cataracts . I am at risk for injuries or falls related to generalized weakness, use of psychoactive meds, dementia, and blindness . I require assistance with Activity Daily living due to due to impaired cognition related to diagnosis of Dementia, generalized weakness, blindness, depression . Pt requires INDEPENDENT WITH TRANSFERS AND LOCOMOTION/AMBULATION AT TIMES NEEDS supervision of one with Transfers, dressing, toileting, and walking in room. A record review of Resident #11's Wandering Risk Scale dated 03/17/2024, revealed, Resident #11 was assessed by LVN D as At Risk for Wandering. A record review of Resident #12's admission record revealed an admitted [DATE] with diagnoses which included dementia (the loss of cognitive functioning and thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), bipolar II disorder (a mental health condition that involves periods of depression and periods of elevated mood), and unspecified psychosis (thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not). A record review of Resident #12's quarterly MDS assessment dated [DATE] revealed Resident #12 was a [AGE] year-old-male admitted from a nursing facility for long term care with support needs for wandering and dementia. Resident #12 was assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. Further review revealed Resident #12 had a need for a walker (a device that gives support to maintain balance or stability while walking). A review of the Functional Abilities and Goals assessment, 12/29/2023, revealed Resident #12 was assessed with the ability to, Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space with, Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. Assistance may be provided throughout the activity or intermittently. A record review of Resident #12's care plan dated 04/19/2024 revealed, I require assistance with activities of daily living due to lack of coordination, abnormal gait, muscle weakness which can impair my performance with mobility tasks (PMHx (past medical history): HTN (high blood pressure), Bipolar d/o (disorder), Neuropathy (nerve pain), Severe mood swing) .Ambulates with a walker .Encourage resident to perform as much of the activity as possible . I use walker for locomotion related to generalized weakness . Provide supervision at all times when resident is able to move around using his Walker . I am at risk for elopement related to wandering risk assessment score .Discuss with resident/family risks of elopement and wandering . A record review of Resident #12's Wandering Risk Scale dated 03/17/2024, revealed, Resident #12 was assessed by LVN D as At Risk for Wandering. During an interview on 04/20/2024 at 2:23 PM LVN D stated she used the facility's electronic program Wander Risk Scale for assessing residents for elopement risks. LVN D stated residents could be assessed as 1. Low risk, 2. at risk for wandering, and 3. high risk to wander. An observation on 04/18/2024 at 4:01 PM revealed Resident #7 use his wheelchair to ambulate out the facility's front automatic sliding front doors. Further observation revealed Resident #7 enjoying the outdoor weather and returning into the facility, several minutes later During an interview on 04/18/2024 at 4:10 PM Receptionist A stated she observed Resident #7 ambulate outside and return inside. Receptionist A stated residents are free to go outside and return when they choose. Receptionist A stated she had no list of residents who could and or could not go outdoors unsupervised. Receptionist A stated she worked from Monday through Friday from 08:00 AM to 5:00 PM and when she arrived the front doors were already opened, and the doors remained open when she left. During an interview on 04/18/2024 at 4:50 PM Receptionist B stated she was the receptionist on the weekends and was on duty from 8:00 AM to 7:00 PM. Receptionist B stated when she arrived the front doors were already opened, and the doors remained open when she left. Receptionist B stated she had worked at the facility 3 years and Resident #5 was new to her, but she was not concerned for his safety because he could walk and make his needs known. Receptionist B stated she had no list of residents who could and or could not go outdoors unsupervised. Receptionist B stated she worked on the day Resident #5 eloped and could not recall the exact time she saw Resident #5 outside of the facility but did recognize the time of day which was after lunch and before dinner . Receptionist B stated she recalled she heard the announcement Code Pink which indicated a Resident was missing and learned Resident #5 was missing. Receptionist B stated she and the staff began a search for Resident #5 to include the immediate neighborhood surrounding the facility. During an interview on 04/20/2024 at 1:55 PM the Director of Rehabilitation stated Residents #7, #10, #11, and #12 were not safe to ambulate out of the facility without supervision due they were all at risk for falls with severe injuries complicated by the various outdoor terrains and their inabilities to cope with those varied terrains. During an interview on 04/19/2024 at 2:40 PM the Administrator and the DON stated Resident #5 was not at risk for wandering due to a lack of elopement history, verbalizations of elopement, and his was alert and oriented to himself, his surroundings, and time. The Administrator and the DON stated Residents #7, #10, #11, and #12 were not at risk for wandering due to a lack of elopement histories, verbalizations of elopement, and were alert and oriented to themselves, their surroundings, and time. A record review of the facility's Elopements policy dated December 2007, revealed, staff shall investigate and report all cases of missing residents . staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or director of nursing. if an employee observes a resident leaving the premises, he or she should: attempt to prevent the departure in a courteous manner; get help from other staff members in the immediate vicinity, if necessary; and instruct another staff member to inform the charge nurse or director of nursing services that a resident has left the premises This was determined to be an Immediate Jeopardy (IJ) on 04/19/24 at 02:44 PM. The facility Administrator and the DON were notified. The Administrator was provided with the IJ template on 4/19/24 at 02:44 PM & a POR was requested. The following Plan of Removal submitted by the facilityApril 19, 2024, at 6:20pm as follows: The facility respectfully submits this plan of removal to abate the allegations of immediate jeopardy identified on April 19, 2024. Facility failed to have current interventions in place to monitor residents who are at risk for wandering out the front door as the front doors are not secured. Resident #5, with a BIMS of 8 and Wandering Risk Assessment score of 9 indicating Resident #5 was at risk to wander. Resident #5 ambulated outside to the facility front patio and from there left the premise to return to his previous home. Inservice completed on 3/17/24 - covering Elopement. Elopement drill completed on 3/21/24. Resident #5 was placed on 1:1 monitoring from the time of his return to the facility on [DATE] until his transfer to a secured unit on 4/5/24. Residents with the potential to be affected by the alleged deficient practice: The Facility immediately completed a 100% re-assessment of all residents' wander risk on 3/18/24. Any residents who were noted at risk for wandering at this time, were reviewed by the IDT Team and found not at risk for elopement . Each residents' care plan was updated to reflect this determination . Staff were in-serviced on Elopement , and an elopement drill was also subsequently completed. Bids were solicited and received for a keypad locking mechanism for the front entrance doors as well as the Hall 200 exit door. The incident was referred to the QAPI committee for review on the next scheduled QAPI meeting. Resident identified to have been affected by the alleged deficient practice: Resident #5 was located and returned to the facility on [DATE]. Resident #5 was assessed for injury with none noted. Resident #5 was interviewed and stated he decided to go visit his previous home to inquire if it would be available for him to return to upon discharge from the Facility. The Facility launched an in-depth investigation to determine how and when Resident #5 left the premises. The Facility interviewed staff and residents to determine the details of Resident #5 leaving Facility property. The Facility interviewed Resident #5 to learn the reason why, and the way, Resident #5 left. Alternate placement was sought for security of Resident #5. The IDT team determined Resident #5 was aware of when he left premises and why (to visit his previous home). The IDT team felt Resident #5 had the potential to attempt to leave the premise again to visit and inquire about his previous home. As such, Resident #5 was placed on 1:1 monitoring in the Facility and alternate placement at a secured facility was obtained. Resident #5 transferred to the secure facility on 4/5/24. Systemic Measures: Receptionist Hours Extended: The Facility immediately extended the hours of Reception at the front entrance of the building. This will include the hours of 6am-8am and 5pm-8pm. Coverage of the front entrance will now include a total daily timeframe of 6am-8pm. The front entrance door will be locked between the hours of 8pm and 6am. Should the Receptionist need to leave the desk, he/she will either call for relief to step-in in his/her absence or lock the front door until returning to duty. Hall 200 Exit Door alarm/lock: The Facility immediately implemented a temporary door alarm that will sound when the door is opened. The bid for the keypad for this exit door was signed by the Administrator and will be placed by (contractor) Engineering on 4/23/24. Wander Risk Binder: The Facility immediately implemented a Wander Risk Binder that includes pictures of the five (5) residents whose Wander Risk Assessment currently scores each at risk for wandering, although all five (5) residents had previously been reviewed by the IDT Team at the time of the incident and deemed not at risk for elopement due to no documented attempts of exit seeking in the past. All five (5) residents' care plans were updated to reflect the wander risk assessment result, and the fact that the resident was not deemed an elopement risk by the IDT Team. The Wander Risk Binder will be placed at the front Receptionist desk and at the nurses' station. The binder will be updated by DON or designee. The binder will be reviewed daily. Locking Log: The Facility immediately implemented a locking log for staff to document the locking and unlocking of the front entrance door. Training: Will be completed by 4/20/24 as follows: a. Initiate staff in-servicing of the Wander Risk Binder located at front Reception and the nurses' station. b. Initiate staff in-servicing of Elopement protocol. c. Initiate staff in-servicing of new door alarm placed on 200 Hall exit door. d. Initiate staff in-servicing on Locking Log. Inservice sign in sheet will be cross reference with employee roster. Quality Assurance Performance Improvement: On 4/19/24 the Quality Assessment and Assurance Committee members to include the Medical Director, Administrator, and Director of Nursing, and the Regional Director of Clinical Services met to review and approve this plan. The Administrator and/or Designee will review the Locking Log daily for 3 months. The Administrator and/or Designee will review the Wander Risk Assessment Binders located at the reception and nurses' station daily for 3 months. The results of the Administrator and/or Designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations during the scheduled meetings for 3 months. The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary. Date of Correction: April 19, 2024 Monitoring of the POR as follows: The facility respectfully submits this plan of removal to abate the allegations of immediate jeopardy identified on April 19, 2024. Plan submitted on April 19, 2024, at 6:20pm. Facility failed to have current interventions in place to monitor residents who are at risk for wandering out the front door as the front doors are not secured. Resident #5, with a BIMS of 8 and Wandering Risk Assessment score of 9 indicating Resident #5 was at risk to wander. Resident #5 ambulated outside to the facility front patio and from there left the premise to return to his previous home. Inservice completed on 3/17/24 - covering Elopement. Elopement drill completed on 3/21/24. Resident #5 was placed on 1:1 monitoring from the time of his return to the facility on [DATE] until his transfer to a secured unit on 4/5/24. Residents with the potential to be affected by the alleged deficient practice: The Facility immediately completed a 100% re-assessment of all residents' wander risk on 3/18/24. Any residents who were noted at risk for wandering at this time were reviewed by the IDT Team and found not at risk for elopement. Each residents' care plan was updated to reflect this determination. Staff were in-serviced on Elopement, and an elopement drill was also subsequently completed. Bids were solicited and received for a keypad locking mechanism for the front entrance doors as well as the Hall 200 exit door. The incident was referred to the QAPI committee for review on the next scheduled QAPI meeting. Resident identified to have been affected by the alleged deficient practice: Resident #5 was located and returned to the facility on [DATE]. Resident #5 was assessed for injury with none noted. Resident #5 was interviewed and stated he decided to go visit his previous home to inquire if it would be available for him to return to upon discharge from the Facility. The Facility launched an in-depth investigation to determine how and when Resident #5 left the premises. The Facility interviewed staff and residents to determine the details of Resident #5 leaving Facility property. The Facility interviewed Resident #5 to learn the reason why, and the way, Resident #5 left. Alternate placement was sought for security of Resident #5. The IDT team determined Resident #5 was aware of when he left premises and why (to visit his previous home). The IDT team felt Resident #5 had the potential to attempt to leave the premise again to visit and inquire about his previous home. As such, Resident #5 was placed on 1:1 monitoring in the Facility and alternate placement at a secured facility was obtained. Resident #5 transferred to the secure facility on 4/5/24. Systemic Measures: Receptionist Hours Extended: The Facility immediately extended the hours of Reception at the front entrance of the building. This will include the hours of 6am-8am and 5pm-8pm. Coverage of the front entrance [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents and hazards. Resident #1 sustained a fall on 12/17/2023 during an attempted transfer when CNA B opted not to follow facility policies and procedures and care plan which require a 2 person physical assist. Resulting is Resident #1 having intense pain requiring PRN medications This failure could place residents requiring assistance with ADLs in danger of injury. Findings included: Record review of Resident #1's electronic facesheet revealed Resident #1 was originally admitted on [DATE] and was [AGE] years of age. Further review revealed Resident #1's diagnoses included: Chronic Respiratory Failure, Anxiety Disorder, Tracheostomya procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck), Epilepsy, and Quadriplegia (paralysis of all four limbs). Record review of Resident #1's MDS (Quarterly), dated 10/9/2023, revealed Resident #1 had a BIMS of 14 (Cognitively Intact). Note-ADLs were disabled for this MDS. Record review of Resident #1's careplan, dated, 10/14/2023, stated, I am being transferred via Hoyer Lift. Goals included, I shall have minimal complications from the use of hoyer lift for transfers. My staff will have no problems/difficulties during hoyer lift transfers. Interventions included, staff will not use the hoyer lift sling or the hoyer lift machine if they detect any issues with either that pose a danger to (Resident #1) and will report these to charge nurse immediately Staff will use a 2 person assist with all hoyer lift transfers. During the transfer process staff will use both hands and place them under (Resident #1) while the resident is in the hoyer lift sling to help guide during the transfer and to provide additional support as a precaution. Record review of Resident #1's progress notes, dated 12/17/2023 at 12:30 PM, written by RN A, stated, Entered (Resident #1's) room to inquire about fall. Noted (Resident #1) resting in bed, head elevated, specialized call light within reach of right cheek. (Resident #1) is alert and oriented and able to make his needs known. Mood is pleasant. Pupils are equal, round and reactive to light and accommodation. Speech is at baseline. Denies nausea, headache or visual changes. VS remain within normal limits with neurological checks per protocol. Although he has decreased sensation to pain due to diagnosis of quadriplegia, he is able to feel pain to neck area and up as well as muscle spasms. States he has had localized sweating episodes that also let him know he when he is in pain. (Resident #1) states he was suctioned by RT and taken off the vent as is routine for him around this time every day to get up to chair. States the sling was placed under him and his aide, (CNA B), placed hoyer machine over him in preparation to transfer. (Resident #1) stated you may want to get two people. When asked what (CNA B) responded says he does not remember but she proceeded with transfer. (Resident #1) recalled chair was not where it usually is, at edge of bed in front of tv, but remained in front of foot of B bed. States he was elevated in hoyer and aide went to raise arm from chair. He started to feel himself slipping slowly. (Resident #1) says I didn't say anything because it happened so fast. My left side was slipping because I had a silky shirt on, and then my body turned in the sling. That's when I slid out.Assessed for pain and (Resident #1) states he is starting to have some pain and tightness to right posterior neck and base of head. Requests help repositioning. T3 administered. During interview (Resident #1's Physician) requests resident to be sent out for evaluation. (Resident #1) hesitant and reluctant but ultimately agrees to be sent to (Hospital Downtown). [sic] Record review of Resident #1's progress notes, dated 12/17/2023 at 3:00 PM, written by RN A, stated, Note Text: Ambulance here to transfer. (Resident #1) placed on vent for tranfer. Speaking valve kept at bedside in green case. IV to right arm flushed and patent. GTube flushed. No reports of pain at this time, just soreness to back of head. T3 effective. Noted some swelling to lower back of head. Quarter size redenned area to top of head, noted while up in stretcher. Cell phone and charger sent with resident, per request. Alert and orient x 4. No change in mental status. All personal items remain in room. [Sic] Observation and interview on 12/27/2023 at 2:59 PM, revealed Resident #1 lying in his bed. Further observation revealed the resident had a tracheostomy affixed to his throat and was bedbound. During an interview at this time, Resident #1 revealed he sustained a fall earlier several weeks prior. When asked how the fall occurred, Resident #1 stated CNA B attempted to transfer the resident via Hoyer Lift. Resident #1 said he informed CNA B that the transfer required 2 people and stated CNA B looked outside the door in an attempt to summon assistance but was unsuccessful. Resident #1 said CNA B proceeded to attempt to transfer Resident #1 by herself. Resident #1 said during the attempt, he fell head-first onto the floor and blacked out. Resident #1 said after he regained consciousness, he experienced intense pain to his head, neck, and shoulder. Telephone interview on 12/28/2023 at 11:15 AM, RN A stated she was the nurse supervisor when Resident #1 sustained the fall. RN A stated CNA B attempted to transfer Resident #1 without assistance which subsequently resulted in Resident #1 falling to the floor. RN A stated she counselled CNA B and sent her home. RN A stated CNA B was evening and had not been back to the facility since the incident. When asked what could have been done differently, RN A stated, Every single Hoyer transfer has to have 2 people, and said the facility's Aide Rosters clearly state which residents require a Hoyer transfer. When asked if Resident #1 sustained any injuries, RN A stated Resident #1 complained of pain to the right posterior neck and was treated with his prn pain medication. RN A further stated Resident #1 has a hard time verbalizing pain because he is a quadriplegic. RN A said Resident #1 returned from the hospital and said, everything was negative, though he continued to complain of pain to his shoulder neck and and was sent to the hospital following the fall. Resident #1 denied currently experiencing pain relative to this incident during the time of this interview. Interview on 12/28/2023 at 11:32 AM, the DON was asked if she was familiar with Resident #1's fall and the DON responded that she was. The DON said CNA B was counselled and had since left to another country. The DON said she would like to sit down with CNA B to discuss whether or not she should be retained for future employment. Interview on 12/28/2023 at 11:47 AM, the Administrator agreed that CNA B violated the facility's hoyer transfer policy. Interview on 12/29/2023 at 3:15 PM, CNA B stated she did not utilize assistance during the transfer of Resident #1 because her colleagues were on a smoke break but was aware Resident #1 required a 2 person physical assist during transfers. CNA B said when she initiated the transfer Resident #1 then sustained a fall. CNA B said she around and saw Resident #1 on the floor and was in shock and yelled for one of the facility's RT's to call for help. Record review of facility policy, titled, Lifting Machine, Using a Mechanical (Revied July 2017), stated, General Guidelines, 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 11 residents (Resident #1 and Resident #2) reviewed for accidents and supervision, in that: 1. Resident #1 was not transferred properly to prevent a fall with injury of left femur fracture. 2. Resident #2 was not provided personal care in a manner to prevent a fall without injury. These failures could place residents who were at risk for falls at risk for avoidable accidents and could result in a decline in physical condition. The non-compliance was identified as past non-compliance. The non-compliance began on 08/09/2023 and ended on 10/24/2023. The facility had corrected the non-compliance before the survey began. The findings included: 1. Record review of Resident #1's face sheet, dated 11/08/2023, revealed Resident #1 was admitted to the facility on [DATE] with an original admitted [DATE] with diagnoses which included: encounter for other orthopedic aftercare, cellulitis of left lower limb, unspecified fracture of left femur, subsequent encounter for closed fracture with routine healing, dementia, history of falling, age-related osteoporosis without current pathological fracture, peripheral vascular disease, nontraumatic intracranial hemorrhage and unspecified atrial fibrillation, unspecified intellectual disabilities and hypertension. Resident review of Resident #1's care plan, with last care plan completed date 07/10/2023 revealed care plan stated Focus: I am at risk for injuries or falls related to generalized weakness, impaired cognition, impaired mobility, related to history of falls .Interventions: staff to provide appropriate level of assistance with ADLs. Record review of Resident #1's Quarterly MDS assessment, dated 07/26/2023, revealed the resident's BIMS score was 6, which indicated severe cognitive impairment. The resident required extensive assistance (staff provide weight bearing support) with two person's physical assistance for bed mobility, and transfers. Record review of Resident #1's fall risk assessment dated [DATE], revealed a total score of 10 or above represents HIGH RISK with Resident #1's score being a 9. Record review of Resident #1's Occupational Therapy Discharge Summary for dates of services 07/17/2023 to 08/08/2023 revealed Patient able to transfer Max assist via stand pivot. Record review of Resident #1's Incident note, dated 08/09/2023, revealed resident was being trans, to bed by the CNA, she got weak and was lower to the floor and into bed, resident suffered a left knee injury (swelling/tenderness), MD informed, x-ray ordered . Record review of Resident #1's Radiology Interpretation, dated 08/09/2023, revealed, Significant Findings, Left Knee X-ray 1-2V: Limited due to underpenetration and body habitus. There is an acute displaced fracture of the partially visualized distal femoral diaphysis. Degenerative changes most sever in the lateral compartment where there is essentially bone-on-bone. Bony demineralization. Soft tissue swelling. Small joint effusion . Impression: Technically limited. Soft tissue swelling and small joint effusion. Acute displaced fracture of the partially visualized distal femoral diaphysis. Record review of Resident #1's care plan, with last care plan start date 08/10/2023, revealed Focus: I have an ADL Self Care Performance Deficit r/t Dx: Osteoporosis. Interventions: TRANSFER: I require 2 staff participation with transfers. Record review of Resident #1's fall risk assessment dated [DATE], revealed a total score of 10 or above represents HIGH RISK with Resident #1's score being an 11. Observation and interview on 11/08/2023 at 5:14 p.m. revealed Resident #1 being transferred to bed by assistance of two CNAs using a mechanical lift. Resident #1 stated staff always have two people to help her with transfers. Resident #1 further stated she had hurt her leg sometime in August, stating when it happened, she sat down real hard, but everyone was wonderful and took great care of her. Resident #1 stated since her hurting her leg the staff use the sling to transfer her. 2. Record review of Resident #2's face sheet, dated 11/09/2023, revealed Resident #2 was admitted to the facility on [DATE] with an original admitted [DATE] with diagnoses which included: dementia, diabetes mellitus due to underlying condition with diabetic neuropathy, malignant neoplasm of unspecified kidney, encephalopathy, hypertension, acute and chronic respiratory failure with hypoxia, and acute kidney failure. Record review of Resident #2's Occupational Therapy Discharge Summary, dated 04/25/2023 - 06/22/2023, revealed, Patient to perform sideline bed mobility at [NAME] to facilitate transfers to W/C, and to off load sactrum to prevent skin break .Discharge 06/22/2023, Patient does not demo any attempts to initiate or participate in bed mob task req'ing Total A to complete. Record review of Resident #2's Quarterly MDS assessment, dated 08/09/2023, revealed Resident #2 with memory problems for both long- and short-term memory. The resident required total dependence (full staff performance every time during entire 7-day period) with two person's physical assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. Resident review of Resident #2's care plan, with last care plan review completed date 08/09/2023 revealed care plan stated, Focus: I require assistance with my ADL's because I Physical Impairment .Intervention: Bed Mobility: I require total assistance in self-performance with 2-person physical assistance staff support. Personal Hygiene: I require total assistance in self-performance with 2-person physical assistance staff support during my personal hygiene. Toileting: I require total assistance in self-performance with 2-person physical assistance staff support. Record review of Resident #2's Incident note, dated 09/18/2023, revealed, While CNA doing patient care, resident had a fall at bedsite . Record review of Resident #2's Activities note, dated 09/18/2023, revealed Daughter called DON regarding concerns with mothers fall from bed. Concerned side rails were not up when incontinent care provided. Spoke with LVN and CNA regarding fall on 10-6 shift. CNA stated that 1/4 side rails were up and resident slid from side of bed to knees on floor during care. CNA stated she was able to guide patient to floor but was unable to catch resident due to being on other side of bed. CNA stated that resident is on air mattress and pushed off mattress with her knees causing resident to slide to floor feet first Record review of Resident #2's Fall Risk Assessment Form, dated 09/18/2023, revealed a total score of 10 or above represents HIGH RISK with Resident #1's score being a 10. Observation 11/09/2023 at 4:00 p.m. Resident #2 observed in her bed with head of bed elevated, bed in lowest position, call light within reach and floor mat at bedside. Interview on 11/09/2023 at 11:35 a.m. the DON revealed after Resident #2's fall she in-serviced the CNA involved with the incident. The DON further stated she updated the CNA resident roster, and more in-services were given. The DON stated the CNA resident roster was updated during morning meetings by herself, and the ADONs, along with during nursing shifts if changes occurred, however the overall updates were the responsibility of the nursing management. The DON further stated when changes were made to the CNA resident roster the old roster was removed and new put in place. Interview on 11/08/2023 at 2:45 p.m. with CNA B stated she had been working for the facility for two weeks and had been orientated to the CNA binder which has the CNA resident roster which gives the staff a great deal of information regarding each resident including how the resident was to be transferred and how many staff it takes to provide care. Interview on 11/08/2023 at 3:00 p.m. with LVN C revealed the CNAs use a resident roster which provides the CNAs information regarding residents and during the beginning of the shift the nurses will talk about changes or updates on residents. LVN C further stated this information was passed on to CNAs. Interview on 11/08/2023 at 3:22 p.m. with CNA D revealed the CNAs use a book the DON had provided the staff which gives them the information regarding residents and their needs. Interview on 11/08/2023 at 3:30 p.m. with CNA E revealed she kept informed of residents needs by using the information sheets provided which list the residents with everything needed and how to care for them. CNA E further stated she would also talk to her nurse regarding any changes that may have occurred. Interview on 11/08/2023 at 4:15 p.m. the DON revealed the CNAs resident roster had been put in place after the first incident with Resident #1 and she had only fine tuned the tool. The DON further stated the CNA resident roster informed staff of level of care regarding transfers, mobility, and personal care. Interview on 11/08/2023 at 4:16 p.m. with the ADON A stated the CNA resident roster which was kept in the CNA binder was initiated after Resident #1's fall. The ADON A stated this was updated by the ADONs and DON upon changes. The ADON stated interventions were put in place and the staff had been in-serviced on the use of the CNA resident roster and it was to also be provided to agency staff when used so they were aware of resident needs. Interview on 11/09/2023 at 9:04 a.m. the DON stated since her and the administrator started, they noticed the facility had been using a great deal of agency staff of which they have decreased this use as they felt facility CNAs take more ownership of the care of the residents. The DON further stated when they would have to use agency staff, they tried to use the same ones to ensure familiarity with residents and their care. Interview on 11/09/2023 at 9:27 a.m. CNA F revealed she would ask other staff if she was not sure of the level of care of a resident and would also use the CNA sheet that would tell her the level of care a resident required. CNA F stated the CNA sheet told her whether she could perform the care by herself or if it required more than one person. Interview on 11/09/2023 at 9:45 a.m. RN G stated to prevent falls she would make sure items were in reach for the resident's use, place bed in low position, if fall mats were ordered use the fall mats, and many times she will place herself close to a resident's room she knew had the risk so she could observe the residents. RN G further stated she would also look at the CNA assignment book for recent updates on level of care. Interview on 11/09/2023 at 4:26 p.m. CNA H revealed the facility had a list of residents with the residents' levels of care, which told staff how many staff members it took to provide care such as mobility, transfers, feeding, personal care and showers. CNA H further stated the list let them know the staff what the resident needed. CNA H stated the ADON updated the list, and the nurses would also update the CNAs of any changes. Interview on 11/09/2023 at 4:45 p.m. CNA I stated she had been working for the facility for a week and there was a CNA binder available to the CNAs and it was easily accessible to the CNAs or staff to look for information regarding the residents. CNA I further stated the binder helped her know the care a resident needed. Record review of In-Service Training Report, dated 08/10/2023, revealed 40 of 73 nursing employees were in-serviced on the topics, stand pivot transfer/squat pivot transfer, gait belt training, education on communicating any concerns with current transfer method to IDT/Rehab screen for safest & most appropriate transfer method, new assignment sheet with transfer method discussed & explained in detail the location & importance in having assignment sheet on them. Record review of In-Service Training Report, dated, 09/14/2023, revealed 21 of 73 nursing employees were in-serviced on the topic, Falls in Older People. Record review of In-Service Training Report, dated, 09/18/2023, revealed, CNA involved in the incident for Resident #2 fall with no injury in-serviced on Educated CNA on asking for assistance with care and using CNA roster/POC to determine how much assistance resident requires. Reviewed safety, bed mobility, fall management with care., provided by the DON. Record review of In-Service sign-sheet, dated 10/24/2023, revealed, 26 of 73 nursing employees were in-serviced on the topic, CNA Roster: Please review CNA/Nurse roster binder located at nurses station daily. Record review of the facility's Falls and Fall Risk, Managing policy, revised March 2018, revealed Policy Statement: Based on previous evaluations, and current data, the staff will identify interventions related to the resident's specific risk and causes to try and to prevent the resident from falling and to try to minimize complications from falling. Record review of the facility's Resident Mobility and Range of Motion policy, revised July 2017, revealed Policy Statement: 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.

Based on interviews and record review, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities for 1 of 9 residents (Resident #1) who was reviewed for enteral feeding tubes in that: Resident #1's G/T feedings were continued without a KUB with [MEDICATION NAME] (contrast media) confirmation of proper placement. As a result, Resident #1 was hospitalized . This deficient practice could place residents who require enteral feedings at risk of not receiving necessary treatment and services to prevent complications and could result in improper placement, pain, mental anguish, infection, or death. Findings included: Record review of Resident #1's clinical resident profile (undated) revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #1 was discharged on [DATE]. Review of Resident #1's baseline care plan dated 11/18/20 indicated Resident #1 was alert and cognitively intact, with an NPO diet with enteral tube feedings to prevent weight loss. No interventions were included on the baseline care plan for G/T care. Record review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's progress notes revealed an entry by LVN E dated 11/26/20 at 11:01 p.m. signed and locked on 12/1/20 at 6:57pm read Resident [DEVICE] noted with bloody leakage from site after evening medications administered. Replaced with 22 Fr. Air bolus with auscultation to confirm placement, aspirated 10cc gastric juice, gtube patent, no sign of leakage. Stoma clean and no SOI (signs of infection). Place STAT order for gtube KUB placement. Record review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's physician's orders [REDACTED]. Directions for one time only. After clicking on the order, the audit details showed the order was created by LVN E on 12/1/20 at 6:06 p.m. Record review of Resident #1's progress notes revealed an entry by LVN F titled Daily skilled Nurses Notes V.2 dated 11/26/20 at 11:31p.m. signed and locked on 11/27/20 at 6:48a.m. documented a second KUB was performed due to G/T leaking a large amount of formula. Further documentation that KUB results reported a gastrostomy tube was over the gastric region and the KUB would need to be repeated with contrast to confirm placement in the stomach. Further documented no [MEDICATION NAME] was available and supervisory nurse (LVN G) assessed Resident #1 for placement via air bolus and auscultation and residual check and the feeding was resumed with no leakage noted. Record review of Resident #1's progress notes revealed an entry by LVN G dated 11/27/20 at 1:07 a.m. signed and locked 12/1/20 at 9:40 p.m. read KUB shows [DEVICE] in stomach; placement has been verified after replacement by 3 nurses, myself, LVN E, and LVN F, using air bolus and aspiration of gastric contents; tube feeding restarted; resident tolerating well with no adverse reactions or distress noted. Record review of KUB report for Resident #1 revealed report date 11/26/20 at 2:06pm. Results: . No foreign body noted [DEVICE] in the stomach with contrast. Conclusion: Nonobstructive bowel gas pattern Record review of KUB report for Resident #1 revealed report date 11/26/20 at 11:39pm . Results: .A gastrostomy tube is over the gastric region. To see if a feeding tube is located inside the stomach, please inject contrast before repeating an X-ray exposure. Conclusion: No evidence of obstruction or significant intraabdominal pathology seen. The findings are unchanged from 26Nov2020 Record review of Resident #1's progress notes revealed an entry by LVN H dated 11/28/20 at 5:31p.m. signed and locked on 11/29/20 at 11:43p.m. read Resident appears to have a decreased level of consciousness. Vs BP 81/50 P149 T97.0 R12 93O2% on 8L.[MEDICAL CONDITION] to BUE and BLE. Bowel sounds active x4 quads. Verified Gtube in place via auscultation, effective. Per MD to be transferred to a hospital. Notified family member and supervisor on shift. 911 call was called for transportation via stretcher. No s/s of distress noted at this time. Record review of Resident #1's physician's orders [REDACTED].@ 57ml/hr x 22hrs/day to run via enteral pump via gtube and provide a total of 1881 kcal (kilocalorie) and 1254 ml. Further review revealed an order with a start date of 11/18/20, discontinued date 11/27/20, revised 11/18/20 read Flush gtube with 40ml water/hour via gtube pump x 22 hours Record review of Resident #1's physician's orders [REDACTED]. Further review revealed an order with a start date of 11/18/20 with no end date, revised 11/18/20 read Flush Gtube with 50 ml of water when pump off or as needed Record review of resident #1's November MAR indicated [REDACTED]. In an interview on 12/1/20 at 5:15pm with the DON, he reported that RN's and LVN's change G/T's at the facility and they are checked off on the training and he ensures they are trained to do it. The DON further reported that no nurse replaces a gastrostomy tube without having the training and having the skill demonstrated and checked off on it. In an interview on 12/2/20 at 9:01a.m. RN J reported resident #1 was treated in the ER for septic shock. RN J further reported a CT scan showed Resident #1's G/T was dislodged in her abdomen and showed fluid in her abdomen. Resident #1 underwent surgery and 5 liters of what appeared to be enteral feeding formula was drained from her abdominal cavity. Resident is currently in the ICU and being treated for [REDACTED]. RN J further confirmed the surgeon documented that [MEDICAL CONDITION] was from the enteral feeding formula that was drained from Resident #1's abdominal cavity. In an interview on 12/2/20 at 12:00pm RN A confirmed she was trained for G/T care and replacement and her skill checked off. RN A reported always getting a KUB with [MEDICATION NAME] to verify placement and reported it was done for every replacement before the G/T could be used. In an interview on 12/2/20 at 12:20 p.m. RN B confirmed being trained on G/T care and replacement. RN B reported every G/T replacement done had to be verified by a KUB with [MEDICATION NAME] before the G/T could be used and feedings and medications are held until verified by KUB report. RN B reported that Resident #1 was discharged to the hospital and they had changed Resident #1's G/T three times in a short amount of time. RN B reported that the first time the G/T had fallen out and she replaced it, and the second time it was leaking tube feeding around it, so she replaced it and both times it was confirmed by KUB with [MEDICATION NAME] that it was in the stomach. In an interview on 12/2/20 at 12:35pm LVN C confirmed being trained on G/T care and replacement but had not replaced a G/T yet because she had not been checked off. LVN C able to describe steps for replacement and reported that a KUB with [MEDICATION NAME] was always done to verify placement before the G/T could be used. In an interview on 12/2/20 at 12:45pm LVN D reported she had been working at the facility about 2 years. LVN D reported that she was trained for G/T care and replacements and she was also checked off on the skill before being able to replace them. LVN D was able to describe the steps for replacement and verification and reported that a KUB with [MEDICATION NAME] was always used to verify tube placement before it could be used. In an interview on 12/2/20 at 3:47pm LVN G reported that she verified tube placement by air bolus and auscultation as ordered and wrote the progress note to reflect that a total of 3 nurses verified placement by air bolus and auscultation before tube feedings were resumed. LVN G reported that the facility was out of [MEDICATION NAME] and the pharmacy was not answering the phone and it was Thanksgiving, so they went with the conclusion from the report that there were no changes as she couldn't let the resident go without feedings or meds all night. In an interview on 12/2/20 at 3:15pm the DON, reported that the nurses continued the feeding for Resident #1 due to the KUB report dated 11/26/20 at 11:39pm conclusion that read the findings are unchanged from 26NOV2020. DON confirmed that the report read Results: .A gastrostomy tube is over the gastric region. To see if a feeding tube is located inside the stomach, please inject contrast before repeating an X-ray exposure. but stated he had no repeat report and the conclusion read no changes. DON further reported it was Thanksgiving and the facility had no [MEDICATION NAME] contrast and the pharmacy did not answer the phone. In an interview on 12/2/20 at 4:00pm LVN E reported that Resident #1's G/T was leaking tube feeding formula around the tube at the stoma site and the G/T was changed and documented. Further reported that she had been trained on G/T replacement and KUB with [MEDICATION NAME] to verify placement but that the pharmacy did not answer, and 3 nurses verified placement by air bolus with auscultation. LVN E further reported that she called the Dr. and notified him of the situation and he gave her an order to resume feedings. LVN E further reported that she documented the Dr. was notified of the last G/T replacement on 11/26/20 and the KUB report without [MEDICATION NAME] in Resident #1's progress notes but could not find it. LVN E reported that it may be in one of her skilled notes. In an interview on 12/3/20 at 10:45 a.m., present were the administrator, DON, and ADON. The ADON reported that facility has [MEDICATION NAME] currently and has 4 to 5 doses on hand. The ADON reported that pharmacy kept track in their system and that the pharmacy would replace the [MEDICATION NAME] as it is used so the facility does not run out. DON reported that there was no specific pharmacy emergency policy for [MEDICATION NAME]. DON reported that the Physician would be called if the facility ran out of [MEDICATION NAME]. In an interview on 12/3/20 at 11:30a.m. RN I reported that she had been trained on G/T replacement and care and had been checked off on the skills checklist. Reported that she assessed Resident #1 with RN B after changing of the resident's G/T on 11/25/20. RN I reported that a KUB with [MEDICATION NAME] was always done after G/T replacement to verify placement before it is used. In a telephone interview on 12/2/20 at 4:58pm the Dr. reported that he gets so many calls and he does not remember the facility contacting him about Resident #1's G/T leaking, the KUB report, or ordering to resume tube feedings but that he honestly could not remember. In an interview on 12/3/20 at 2:25p.m. LVN E reported that Resident#1's G/T was leaking large amounts of tube feeding and confirmed that the tube feeding was leaking around the stoma site and was saturating the resident's gown and bedding. LVN E further reported that she had repositioned the G/T several times to stop the leaking but an hour later the leakage had saturated the resident's gown and bedding again. LVN E reported that Resident #1's stoma site was much larger than the G/T and that the supervising nurse, (LVN G) suggested changing the size to a 22FR G/T from an 18FR and after changing to a 22FR G/T all leakage from the stoma site stopped. LVN E reported that the Dr. was notified, and an order obtained for the 22FR G/T. Review of facility check off training updated 8/23/19 and titled (facility name) subtitled Replacement and Care of Gastrostomy Tube and Stoma Site .11. Order KUB with [MEDICATION NAME] per MD/NP order to verify placement. Confirmed LVN G passed on 5/12/20, LVN F passed on 1/20/20, LVN E passed on 6/15/20, and RN B passed on 9/17/20. Review of facility policy, undated and titled Replacement and Care of the Gastrostomy Tube .Replacement . 11. Order KUB with [MEDICATION NAME] per MD/NP order to verify placement. Documentation and Reporting 1. Document date and time the procedure was done on the EMR. 2. Document how the resident tolerated the procedure. Review of facility policy revised April 2018 and titled Administering Medication through an Enteral Tube . General Guidelines .8. This procedure is contraindicated if the tube is obstructed or improperly positioned, if the resident is vomiting, or if bowel sounds are absent.18. If you suspect improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician.