Every finding on record at Eagle Crest Rapid Recovery

Based on interview, and record review, the facility failed to ensure resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 7 residents (Resident #1) reviewed for abuse. The facility failed to ensure CNA A did not verbally and emotionally abuse Resident #1 when speaking rudely to Resident #1 on 02/24/2026. The facility failed to ensure Resident #1's resident's right to be treated with dignity and respect on 02/18/2026, when CNA A spoke rudely to Resident #1. This failure could place residents at risk of abuse, and mental anguish and fearfulness. The noncompliance was identified as past noncompliance (PNC) and began on 02/18/2024 and ended on 02/23/2026. The facility corrected the noncompliance before the investigation began on 04/02/2026 at 08:30 a.m. The findings were: Record review of Resident #1's face sheet dated 04/02/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included Alzheimer's disease (a progressive, irreversible neurodegenerative disorder and the most common cause of dementia), atrial fibrillation (heart rhythm disorder causing rapid, irregular heartbeats (arrhythmia) due to disorganized electrical signals in the heart's upper chambers), transient cerebral ischemic attack (a temporary blockage of blood flow to the brain that causes stroke-like symptoms-such as sudden weakness, numbness, or confusion), generalized anxiety (excessive, and uncontrollable worry about daily events), disorder, major depressive disorder, single episode, mild, dementia (brain disorders causing cognitive decline-memory loss, confusion, and behavioral changes that interfere with daily life), moderate, without behavioral disturbance (aggression, defiance, or impulsivity), psychotic disturbance (a severe mental condition characterized by a loss of contact with reality), mood disturbance (persistent, and dysfunctional emotional states), pressure ulcer of right buttock (localized injury to skin and tissue caused by prolonged pressure), irritant contact dermatitis (chronic, skin inflammation causing itchy, dry, rash-prone skin) due to other agent, muscle wasting (loss of muscle tissue) and atrophy (muscle shrinking), difficulty walking, pain, muscle weakness, dysphagia (difficulty swallowing), and cognitive communication deficit (difficulty communicating, listening, speaking, reading and writing). Record review of Resident #1's Comprehensive MDS, dated [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 02 which indicated the resident had severe impaired mental cognition. Record review of Resident #1's progress note dated 02/18/2026 at 10:40 a.m., reflected MD ordered to administer Donepezil HCl (used to treat dementia associated with Alzheimer's disease by improving cognition) oral tablet 10 mg give 1 tablet by mouth one time a day related to unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident physical aggressive with LVN A, hitting LVN A's face and pulling LVN A's hair while assisting CNA A with transfer. Record review of Resident #1's progress note dated 02/18/2026 at 10:50 a.m., reflected a behavior note of Resident #1 refusing all a.m. medications. While assisting resident with transfer, resident became physical aggressive hitting both CNA A and LVN A in the face and pulling LVN A's hair while being transferred from bed to wheelchair with redirection attempts being unsuccessful. Created By RN. Record review of Resident #1's progress note dated 02/23/2026 at 04:34 p.m., reflected a skin/wound assessment was conducted with resident in wheelchair as she was content and approachable at that time. No evidence of any skin alteration or discoloration to arms, leg, face/head, back, hands or feet. Further assessments to be conducted when resident when resident is in bed. Created by RN. Record review of Resident #1's progress note dated 02/25/2026 at 12:38 a.m., reflected an outpatient psychiatry evaluation for generalized anxiety disorder, other specified persistent mood disorders, dementia, severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder, single episode, mild. Created by Psychiatry NP. Record review of audio/video on 04/02/2026 at 12:00 p.m., of a video recording dated 02/18/2026, reflected Resident #1's privacy curtain pulled obstructing the view of CNA A and LVN A providing the resident patient care. The audio captured reflected, CNA A saying, You do not hit anyone in the face then the words, Ugly, ugly, ugly, addressing the resident's hitting. The audio then recorded the resident screaming and then hearing CNA A saying, You do not do that, again referring to the resident hitting CNA A. In an interview on 04/02/2026 at 11:05 a.m., with the ADM and the DON, the ADM stated that on 02/20/2026 he received a complaint based on video footage captured on 02/18/2026, showing CNA A and LVN A transferring Resident #1 from wheelchair to bed. ADM stated Resident #1 required 2-persons assist with transfers. The ADM stated Resident #1 had a personal video/audio recording camera in her room. The DON stated Resident #1's bed was nearest the door and the recording device sat on a chest near the resident's bed. The DON stated once the staff completed the resident's transfer from wheelchair to bed, the video/audio captured LVN A leaving the room and CNA A left inside the room and audio captured CNA A saying Ugly, ugly, ugly to the resident. The DON stated the RP informed her that the words ugly, ugly, ugly, represented hurtful words for the resident because the resident had a past history of being called ugly as a child and caused an emotional reaction in the resident. The DON stated that regardless, no one should say that to any resident. The DON stated that the resident had metal implanted in various locations in her body resulting in pain during transfer. The DON stated that she completed a face-to-face assessment on Resident #1 after seeing the video and she did not find any visual signs of bruises or abuse and her wound care nurse completed the assessment notes in the resident's clinical record. The DON stated she spoke with both CNA A and LVN A and explained they could not reprimand or chastise residents. The DON stated it was her expectation that when working with residents, staff need to be gentle, patient, and explain what was about to happen to residents, and give residents time when residents become agitated. The DON stated that CNA A was terminated as a result of the incident and LVN A submitted her 2-week notice to end employment prior to the incident resulting in neither staff being employed with the facility any longer. In an interview on 04/02/2026 at 01:18 p.m., the RP stated she placed signage on Resident #1's door informing all staff to be careful when moving the resident, because the resident had lots of metal in her body and when moving her caused pain. The RP stated that she had placed a video recording camera in the resident's room just prior to this incident after the resident told her that that CNA A had told the resident to stop being difficult during a clothing change. She stated that incident was reported to the ADM and the DON. The RP stated that the resident had a diagnosis of Alzheimer's and was not being difficult. She stated in the morning of 02/18/2026 the audio video in the resident's room captured CNA A calling the resident's behavior ugly. She stated the words stayed in the resident's mind because when she came to visit the resident that same day, the resident was crying and saying, I am not ugly, and she had to tell the resident, You are not ugly,. She stated as a child the resident was called ugly and caused the resident to have body shaming image of herself throughout her life. She stated the word ugly caused the resident to become emotional. In an interview on 04/02/2026 at 03:47 p.m., MD stated he had not been contacted on or after 02/18/2026 regarding Resident #1's allegation of abuse. He stated that it had been his expectation that he would be contacted to address any adverse effects from the incident. In an interview on 04/02/2026 at 03:58 p.m., CNA A stated on 02/20/2026, the ADM and the DON asked her to write a statement explaining what occurred during patent care with Resident #1 on 02/18/2026, because the DON stated a report was received, that CNA A had told Resident #1 to shut up. She stated on 02/18/2026, she asked LVN A to assist with incontinent care for Resident #1, put the resident to bed, and then checked on the resident every 2-hours thereafter. She stated after writing the statement and speaking to the ADM and the DON, she voluntarily resigned. She stated the ADM and the DON asked her to sign resignation forms, but she refused to sign because she had not told the resident to shut up. In an interview on 04/02/2026 at 04:18 p.m., the DON stated that it was agreed that the facility would have a standard of care meeting with Resident #1's RP every Wednesday at 12:00 p.m., relating to difficulties with staff being unable to administer resident's medications which could have been contributing to the resident's agitation and behaviors. In an interview on 04/02/2026 at 04:46 p.m., the NP stated she assessed Resident #1 on 02/23/2026 after an abuse allegation was made on 02/18/2026. The NP stated she had not been informed that staff had commented to the resident her or her behavior was ugly or that the resident had issues with the use of ugly from childhood. She stated she would address the resident's feelings in the coming visit. The NP stated that the residents had anxiety, memory issues, and issues wanting to eat. The NP stated that Resident #1 had behaviors of lashing out physically towards staff when feeling scared or having difficulties remembering people, places, and events thought out the day. She stated it was her expectation to be informed of the specifics of abuse allegations and behavior issues to know how to specifically address resident's behavior concerns. In an interview on 04/02/2026 at 5:36 p.m., the ADM stated that CNA A was suspended on 02/20/2026 and after an investigation determined to terminate CNA A. the ADM stated that LVN A was suspended on 02/23/2026 but resigned on the same day. He stated it had been his expectation that both staff were to follow protocol. He stated that the facility performed training in-services an ANE and resident rights quarterly and more often as needed. He stated it was recommended that NP be made aware of Resident #1's behaviors for medication adjustment as needed. He stated he was the facility's abuse coordinator. The following evidence was completed by the facility to correct the noncompliance prior to the investigation: Record review of LVN A's two-week notice dated 02/18/2026, reflected, LVN A would end her full-time employment to PRN effective 03/05/2026. Record review of training in-service dated 02/20/2026, reflected the DON provided an ANE training covering Residents are to be free from any form of Abuse. Speak to residents with a respectfully, professional, and compassionate tone. Staff are to provide excellent customer service to residents and families. Suspected abuse, neglect, or exploitation should be immediately reported to the Abuse Coordinator, ADM. CNA A and LVN A signed off acknowledging receipt of training. Record review of disciplinary action form dated 02/20/2026, reflected CNA A received a customer service offense after an allegation of inappropriate workplace conduct specifically alleged emotional abuse. A complaint was received reporting behavior described as demeaning, intimidating, and/or verbally harmful in nature. CNA A was suspended pending investigation. Record review of LVN A's incident statement dated 02/23/2026 reflected, on 02/18/2026, while assisting CNA A transfer Resident #1 from bed to wheelchair, the resident became physically combative, hitting LVN A in the face three times, and the resident used her nails to dig into both LVN A and CNA A's arms while attempting to reposition for the transfer. The resident was instructed not to hit staff. Multiple times to redirect resident's aggressive behavior, all redirection attempts were unsuccessful. Resident transferred safely, with no complaints of pain/discomfort voiced during transfer. After transfer LVN A exited the room leaving Resident #1 with CNA A. Record review of disciplinary action form dated 02/23/2026, reflected LVN A received a customer service offense after an allegation of inappropriate workplace conduct specifically alleged emotional abuse. A complaint was received reporting behavior described as demeaning, intimidating, and/or verbally harmful in nature. LVN A was suspended pending investigation. Record review of 7 of the facility's undated resident safe survey reflected 7 of 7 residents who were cared for by CNA A and LVN A felt safe within the facility, taken care of, and felt they were treated well. Record review of LVN A's background reflected the facility performed a criminal background check on 09/02/2025 finding no concerns for hiring. Record review of CNA A's background reflected the facility performed a criminal background check on 10/24/2025 finding no concerns for hiring. Record review of the facility's undated policy, titled: Abuse Prevention Program. Purpose: Protect the residents in this facility from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual. Record review of the facility's undated policy, titled: Policy: Resident Rights. Purpose: To ensure that resident rights are respected, protected, and promoted. To inform residents of their rights and provide an environment in which such rights can be exercised. Procedure: Residents do not leave their individual personalities or basic human rights behind when they move to a long-term care facility. This facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life and recognizes each resident's individuality and holistic preferences. This facility must provide a notice of rights and services to the resident prior to or upon admission and during the residents' stay. The information must be presented both orally and in writing in the language and in the manner the resident understands.

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change for 1 of 3 residents (Resident #1) reviewed for notification of changes. The facility failed to notify MD of Resident #1 abuse allegation. This failure placed residents at risk for potential injuries, pain, and hospitalization. Findings included:Record review of Resident #1's face sheet dated 04/02/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included Alzheimer's disease (a progressive, irreversible neurodegenerative disorder and the most common cause of dementia), generalized anxiety (excessive, and uncontrollable worry about daily events) disorder, major depressive disorder (severe sadness, low energy, and loss of interest in activities (anhedonia) lasting at least two weeks), single episode, mild, dementia (brain disorders causing cognitive decline-memory loss, confusion, and behavioral changes that interfere with daily life), moderate, without behavioral disturbance (aggression, defiance, or impulsivity), and psychotic disturbance (loss of contact with reality, involving symptoms like hallucinations), and mood disturbance (persistent, and dysfunctional emotional states). Record review of Resident #1's Comprehensive MDS, dated [DATE], reflected the resident had a BIMS score of 02 that indicated the resident had severe impaired mental cognition. Record review of Resident #1's progress note dated 02/18/2026 at 10:40 a.m., reflected the resident had physical aggressive towards LVN A, hitting LVN A in face and pulling nurse's hair while assisting CNA A with transfer. The MD ordered Donepezil HCl (used to treat dementia associated with Alzheimer's disease by improving cognition) oral Tablet 10 mg give 1 tablet by mouth one time a day related to dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Created by LVN A. Record review of Resident #1's progress note/behavior note dated 02/18/2026 at 10:50 a.m., reflected a of Resident #1 refused all a.m. medications. While assisting resident with transfer, resident became physically aggressive hitting CNA A and LVN A in the face and pulling LVN A's hair while the staff attempted to transfer the resident from the bed to wheelchair. Staff redirection of resident's physical aggression was attempted but unsuccessful. Created By RN. Record review of Resident #1's progress note dated 02/23/2026 at 04:34 p.m., reflected resident received a skin/wound assessment by RN. The resident was content and approachable. RN found no evidence of any skin alteration or discoloration to arms, leg, face/head, back, hands or feet. RN to conduct further assessments when resident was transferred to bed. Record review of Resident #1's progress note dated 02/25/2026 at 12:38 a.m., reflected psychiatry NP evaluated Resident #1 for generalized anxiety disorder, other specified persistent mood disorders, dementia, severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder, single episode, mild. Record review of Resident #1's audio/video recording on 04/02/2026 at 12:00 p.m., reflected, on 02/18/2026, CNA A said, You do not hit anyone in the face. Ugly, ugly, ugly, referring the resident's behavior of hitting the staff in the face. Audio recording noted Resident #1 screaming and then CNA A saying, You do not do that as to reference the resident hitting staff. In an interview on 04/02/2026 at 11:05 a.m., with the ADM and the DON, the ADM stated on 02/18/2026 LVN A was asked by CNA A to assisted with Resident #1's bed to wheelchair transfer. The ADM stated after viewing an audio/video recording from a camera in the resident's room, he determined that after the transfer and LVN A leaving the room, CNA A said Ugly, ugly, ugly to the resident. The DON stated due to a past history of the resident being called ugly was a child, the resident found CNA A's ugly, ugly, ugly represented words hurtful. The DON stated she completed a face-to-face assessment on the resident after the incident and found no visual signs of bruises or abuse. The DON stated that reprimanding and chastising residents was explained unacceptable to CNA A and LVN A. The DON stated it was her expectation that when working with residents, staff would act gentle, patient, and explain to the residents what care was to be performed, giving residents time when residents become agitated. The DON stated CNA A was terminated as a result of the incident and LVN A resigned on 02/23/2026. In an interview on 04/02/2026 at 01:18 p.m., the RP stated Resident #1 had pain when moved due to metal in various locations of the resident's body. She stated on 02/18/2026, audio/video from the resident's camera captured CNA A calling the resident ugly. The RP stated when she came to visit the resident that same day, the resident was crying and saying, I am not ugly, and she had to tell the resident, no she was not ugly. The RP stated she placed signage on the resident's door informing staff to be careful when moving the resident. In an interview on 04/02/2026 at 03:47 p.m., the MD stated that it had been his expectation to avoid adverse effects from ANE Resident #1's abuse allegation should have been reported to him immediately for him to address immediately, The MD stated he was not aware of Resident #1's 02/18/2026 allegation of abuse. In an interview on 04/02/2026 at 03:58 p.m., CNA A stated on 02/20/2026, the ADM and the DON asked her provide a written statement of events that took place while providing Resident #1 patient care on 02/18/2026. She stated that the DON stated a report was received, where CNA A was overheard telling Resident #1 to shut up. She stated she explained to the ADM and the DON that on 02/18/2026, LVN A assisted her with providing incontinent care for Resident #1, and then later in the day, transferred the resident to bed, and then checked on the resident every 2-hours throughout the shift. She stated after the statement was written, she voluntarily resigned from her position with the facility. She stated the ADM and the DON requested she sign a resignation form, which she refused because she had not told the resident to shut up. In an interview on 04/02/2026 at 04:46 p.m., the NP stated Resident #1 had anxiety, memory issues, and issues with not wanting to eat. The NP stated the resident could become mean towards others when scared from not remembering what has happened in a day. NP stated on 02/23/2026, she assessed Resident #1 related to an abuse allegation made on 02/18/2026. The NP stated she was not aware that staff had commented to the resident her or her behavior was ugly or that the resident had issues with the use the word ugly from childhood. She stated it was her expectation to be informed of the specifics of abuse allegations and behavior issues to know how to specifically assess and treat the resident's behavior. In an interview on 04/02/2026 at 5:36 p.m., the ADM stated he was the facility's abuse coordinator. He stated CNA A and LVN A were suspended on 02/20/2026 after being made aware of Resident #1 abuse allegation. He stated his expectation was hat CNA A and LVN A followed ANE protocol. He stated after the investigation it was determined to terminate CNA A and LVN A resigned on 02/23/2026. He stated that the facility performed training in-services an ANE quarterly and more often as needed. He stated it was recommended that NP be made aware of Resident #1's behaviors for medication adjustment as needed. Record review of LVN A's two-week notice dated 02/18/2026, reflected LVN A ended her full-time employment to provide PRN effective 03/05/2026. Record review of training in-service dated 02/20/2026, reflected the DON provided an ANE training on residents are to be free from any form of abuse, and speak to residents with a respectfully, professional, and compassionate tone, and staff were to provide excellent customer service to residents and families. Suspected abuse, neglect, or exploitation should be immediately reported to the Abuse Coordinator, the ADM. CNA A and LVN A signed off acknowledging receipt of training. Record review of disciplinary action form dated 02/20/2026, reflected CNA A's customer service offense relating to an allegation of inappropriate workplace conduct specifically alleged emotional abuse. CNA A was suspended pending investigation from a complaint reporting behavior described as demeaning, intimidating, and/or verbally harmful in nature. Record review of LVN A's incident statement dated 02/23/2026 reflected, on 02/18/2026, while LVN A assisted CNA A with Resident #1's bed to wheelchair transfer, the resident became physically combative. Resident#1 hit LVN A in the face three times and dug her nails into both LVN A and CNA A's arms during repositioning. The staff attempted multiple times to redirect Resident #1's aggressive behavior, unsuccessfully. No complaints of pain/discomfort voiced during transfer and resident transferred safely. LVN A exited the room leaving CNA A in the room with Resident #1. Record review of the facility's undated policy titled: Condition Change of the Resident (Observing, recording and reporting). Purpose: Observe, record and report any condition change to the physician so proper treatment can be implemented.

Based on observation, interview, and record review the facility failed to ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain for 1 (Resident #1) of 5 residents reviewed for incontinence. CNA A did not provide incontinent care for Resident # 1 for over 4 hours.CNA A did not clean Resident #1 in the right direction (front to back) instead, CNA A cleaned Resident #1 from back to front during incontinent care. This failure could place residents at risk for infection and impaired skin integrity.Findings: Record review of Resident #1's face sheet dated 02/19/26 revealed a [AGE] year-old female admitted to the facility on [DATE] and again on 02/07/26. Resident #1's diagnoses included the following: repeated falls, cognitive communication deficit, aphasia (a language disorder caused by brain damage that impairs the ability to speak, understand, read, or write) following cerebral infarction (lack of blood flow and oxygen to the brain), hemiplegia (total or partial paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting the right dominant side, and severe sepsis (a life threatening medical emergency caused by the body's response to an infection).Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 4, indicating that Resident #1's cognition was severely impaired. Section GG-Functional abilities revealed that Resident #1 was dependent on toileting hygiene. Section H-Bladder and Bowel revealed that Resident #1 was always incontinent of bladder and bowel.Record review of Resident #1's Comprehensive Care Plan dated 08/16/23 and revised 01/25/26 reflected that resident was being care planned for bladder and bowel incontinence r/t impaired mobility. An intervention included check and change as required for incontinence. Observation at 2:22PM on 02/19/26 of incontinent care for Resident #1by CNA A with the assistance of CNA B. When staff removed Resident #1's brief, there was a strong odor of urine. Resident #1's brief was heavily soiled with urine. Resident skin was intact with no redness or skin rash. When staff repositioned Resident #1 to her right side, CNA A began to clean resident back and forward with the same disposable washcloth before changing for a new one. When CNA A reached for a new disposable washcloth, she continued to clean resident buttocks in the same fashion. Interview on 02/19/26 at 2:37PM with CNA A said she had been working at the facility since December 2025. CNA A said she had been a CNA going on 8 (eight) years. CNA A said the last time she had provided incontinent care for Resident #1 was at 10: 00AM. CNA A said she usually provided incontinent care for the Resident #1 every 2 (two) hours. CNA A said she was assisting residents in the Dining room with meals. CNA A said when residents are not provided with incontinent care every 2 hours, it place resident at risk for urinary tract infections and bed sores. CNA A said when she was done with assisting in the Dining room, she went on break and told the nurse. CNA A said there were 2 other CNA's that were also working in the hall. CNA A said she did not check Resident #1 for incontinent care prior to going on break. CNA A did not answer when asked why she did not check Resident #1 for incontinent care prior to going on break. CNA A said she did not know who was supposed to relieve her when on break and that she just told the nurse. Interview on 02/19/26 at 2:54PM with RN C said she worked at the facility on a PRN basis for 3 months and had been a nurse for 7 years. RN C said she did not recall CNA A telling her that she was going on break. RN C said she did not know what CNA was covering for CNA A when she was on break. Interview on 02/19/26 at 3:48PM with DON said residents should be checked for incontinent care every 2 hours. The DON said if this was not done, it placed the residents at risk for skin breakdown, urinary tract infections, and moisture associated dermatitis (skin irritation, red dry itch rash). The DON said it was the duty of the nurse in charge on the unit that was supposed to ensure that residents were being provided with incontinent care in a timely manner. The DON said whenever the CNA's go on break, they should be notifying the other CNA (s) on the hall as well as the charge nurse. The DON said prior to the CNA going on break, the CNA should be checking residents assigned to ensure that their needs are being met including incontinent care. The DON said the facility did not have a policy on female incontinence but could provide training for female incontinence. Record review of the facility training form (not dated) on peri-care for female incontinence reflected in part: .Wash genital area, moving from front to back . Record review of the facility policy on Incontinence Care revised October 2018 reflected in part: .Basic responsibility .License Nurse, Certified Nursing Assistant.Purpose is to keep skin clean, dry, free of irritation and odor.prevent skin breakdown.prevent infection.

Based on observation, interview, and record review the facility failed to provide necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 (Resident #1) of 5 residents reviewed for personal hygiene. CNA A did not provide incontinent care for Resident # 1 for over 4 hours. This failure could place residents at risk for infection and impaired skin integrity.Findings: Record review of Resident #1's face sheet dated 02/19/26 revealed a [AGE] year-old female admitted to the facility on [DATE] and again on 02/07/26. Resident #1's diagnoses included the following: repeated falls, cognitive communication deficit, aphasia (a language disorder caused by brain damage that impairs the ability to speak, understand, read, or write) following cerebral infarction (lack of blood flow and oxygen to the brain), hemiplegia (total or partial paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting the right dominant side, and severe sepsis (a life threatening medical emergency caused by the body's response to an infection). Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 4, indicating that Resident #1's cognition was severely impaired. Section GG-Functional abilities revealed that Resident #1 was dependent on toileting hygiene. Section H-Bladder and Bowel revealed that Resident #1 was always incontinent of bladder and bowel. Record review of Resident #1's Comprehensive Care Plan dated 08/16/23 and revised 01/25/26 reflected that resident was being care planned for bladder and bowel incontinence r/t impaired mobility. An intervention included check and change as required for incontinence. Observation at 2:22PM on 02/19/26 of incontinent care for Resident #1by CNA A with the assistance of CNA B. When staff removed Resident #1's brief, there was a strong odor of urine. Resident #1's brief was heavily soiled with urine. Resident skin was intact with no redness or skin rash. Interview on 02/19/26 at 2:37PM with CNA A said she had been working at the facility since December 2025. CNA A said she had been a CNA going on 8 (eight) years. CNA A said the last time she had provided incontinent care for Resident #1 was at 10: 00AM. CNA A said she usually provided incontinent care for the Resident #1 every 2 (two) hours. CNA A said she was assisting residents in the Dining room with meals. CNA A said when residents are not provided with incontinent care every 2 hours, it place resident at risk for urinary tract infections and bed sores. CNA A said when she was done with assisting in the Dining room, she went on break and told the nurse. CNA A said there were 2 other CNA's that were also working in the hall. CNA A said she did not check Resident #1 for incontinent care prior to going on break. CNA A did not answer when asked why she did not check Resident #1 for incontinent care prior to going on break. CNA A said she did not know who was supposed to relieve her when on break and that she just told the nurse. Interview on 02/19/26 at 2:54PM with RN C said she worked at the facility on a PRN basis for 3 months and had been a nurse for 7 years. RN C said she did not recall CNA A telling her that she was going on break. RN C said she did not know what CNA was covering for CNA A when she was on break. Interview on 02/19/26 at 3:48PM with DON said residents should be checked for incontinent care every 2 hours. The DON said if this was not done, it placed the residents at risk for skin breakdown, urinary tract infections, and moisture associated dermatitis (skin irritation, red dry itch rash). The DON said it was the duty of the nurse in charge on the unit that was supposed to ensure that residents were being provided with incontinent care in a timely manner. The DON said whenever the CNA's go on break, they should be notifying the other CNA (s) on the hall as well as the charge nurse. The DON said prior to the CNA going on break, the CNA should be checking residents assigned to ensure that their needs are being met including incontinent care. The DON said the facility did not have a policy on female incontinence but could provide training for female incontinence. Record review of the facility training form (not dated) on peri-care for female incontinence reflected in part: .Wash genital area, moving from front to back . Record review of the facility policy on Incontinence Care revised October 2018 reflected in part: .Basic responsibility .License Nurse, Certified Nursing Assistant.Purpose is to keep skin clean, dry, free of irritation and odor.prevent skin breakdown.prevent infection.

Based on interviews and record reviews, the facility did not ensure that the resident's requests, refusals, discontinuations, and advance directives were honored for 1 of 1 (CR#1) resident's DNR. LVN A provided CPR to CR #1 prior to determining if the resident had advanced directives in place resulting in CR #1 receiving life-saving intervention from LVN A and then emergency responders. Emergency responders did restore CR #1's pulse and CR#1 was transported to the hospital where CR#1 expired. The noncompliance was identified as Past Non-Compliance. The IJ began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began. This deficient practice could place residents at risk of harm and injury due to inadequate care.Findings include:Review of CR #1's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Cerebral infraction, Muscle weakness, Hyperlipidemia, Type 2 diabetes without complications, Quadriplegia, acute posthemorrhagic Anemia, and Hypotension. Record Review of CR #1's Care Plan dated [DATE] revealed he was care planned for DNR. Intervention dated [DATE] required staff to check resident file for DNR before calling a code. Review of CR #1's progress note dated [DATE] shows that the following entry was made by RN B. During routine rounding, the nurse observed the resident gasping for air, sweating profusely, and then becoming unresponsive. A code was called, life-saving measures were initiated, and 911 was contacted. Upon EMS arrival, life-saving efforts were transferred to them, and the Do Not Resuscitate (DNR) documentation was subsequently located and confirmed as active. At that point, EMS successfully restored the resident's pulse and blood pressure, and the resident was transported to the hospital. The Nurse Practitioner (NP) was notified and informed about the events. The responsible party (RP) was also contacted and made aware of the situation, including the life-saving measures performed before the DNR was retrieved. The RP expressed understanding and requested the address of the hospital's emergency room where the resident was taken. Record review on [DATE] at 12:00p.m. of facilities in-service documents reflected that on [DATE], the facility conducted an audit of its long-term care and skilled nursing units. The purpose of the audit was to review the list of residents with Do Not Resuscitate (DNR) orders. This list was compiled by the facility's social worker, and the Assistant Director of Nursing (ADON) is responsible for checking it daily for accuracy.In an interview with the ADON On [DATE] at 12:22p.m. she stated that on [DATE], the facility created two binders to expedite the identification of residents with a DNR. The binders were placed on the crash carts and at the nurses' station.Record review on [DATE] at 12:24 p.m. reflected that on [DATE], the facility conducted an in-service training for nursing staff. The training focused on the importance of checking all patients' code status before initiating any life-saving measures. If a Do Not Resuscitate (DNR) order is in place, cardiopulmonary resuscitation (CPR) should not be initiated, as this would contradict the selected end-of-life measures and orders.In an interview on [DATE] at 11:50 a.m., the Administrator stated that, before CPR was performed on CR #1, it was essential to verify the patient's code status. He noted that LVN A's failure to check CR #1's code status violated policy and required the initiation of life-saving measures for CR #1.In an interview on [DATE] at 12:25 p.m., the ADON stated that, before LVN A called a code and initiated Life-Saving Measures on CR #1, the DNR status should have been verified. She indicated that LVN A's failure to check CR #1's DNR status constituted a violation of policy.An unsuccessful attempt was made to contact LVN A on [DATE], at 12:26 p.m., at 10:30 a.m. on [DATE] and 1:00pm on [DATE]. In an interview on [DATE] at 12:55 p.m., LVN B stated that she believed LVN A had already confirmed the code status for CR #1. LVN B mentioned that, per their policy, anyone who calls a code is responsible for verifying the DNR status before initiating the code. LVN B stated that she had been in-serviced to check a resident's code status before initiating life-saving measures. In an interview on [DATE] at 1:17 p.m., with LVN C, she stated that she had received training on /[DATE] to check a resident's code status before initiating life-saving measures. She mentioned that the training emphasized checking the DNR binder on the crash carts, as it was faster than looking it up in the PCC system.In an interview on [DATE] at 2:30 p.m., with CNA A, she stated that she had been trained to check a resident's DNR status. She explained that a book located on the crash carts indicated whether a resident had a DNR. Additionally, she mentioned that the facility offers CPR classes for all CNAs.In an interview on [DATE] at 2:35 p.m., with CNA B, she stated that she had been trained to check a resident's DNR status.In an interview on [DATE] at 2:40 p.m., with CNA C, she stated that she had been trained to check a resident's DNR status.In an interview on [DATE], at 2:45 p.m., with CNA C, she stated that she had been trained to check a resident's DNR status.In a phone interview on [DATE], at 3:30 p.m., with the Regional Director of Nursing for facilities, she stated that on [DATE], she instructed the facility to create a binder to help staff easily identify which residents have a DNR order.Record review of the facility's DNR policy (undated) on [DATE] at 4:00 p.m., revealed that, before any life-saving measures are taken, staff must first determine whether the resident has a DNR in place.Record review of the facility provider report dated o[DATE] reflected that CR#1 received life-saving measures during a medical episode despite having a DNR in place. The nurse on duty failed to comply with CR#1's DNR by calling a code and initiating life-saving measures.measures. If a Do Not Resuscitate (DNR) order is in place, cardiopulmonary resuscitation (CPR) should not be initiated, as this would contradict the selected end-of-life measures and orders.In an interview with the administrator on [DATE], the facility management team suspended LVN A and LVN B because of providing Life Saving Measures to CR #1. CR #1 had a DNR in place, and the nurses failed to confirm the DNR before performing CPR. In an interview on [DATE] at 3:25 p.m., the Medical Director stated that he did participate in a QAPI regarding DNR. He also stated that the negative outcome of not checking for a code status could be unnecessary trauma to the resident's body. In an interview with the facility administrator on [DATE], at 3:25 p.m., the facility held a Quality Assurance and Performance Improvement (QAPI) meeting. The Medical Director confirmed his participation in discussions regarding Do Not Resuscitate (DNR) orders during this meeting.Record review of facility in-service dated [DATE], reflected that the facility held a CPR course that was open to all staff. The course also covered the facility policy on when to initiate and when not to initiate Life-Saving Measures. Record review of LVN_A disciplinary form dated 01 /23/26, the facility management terminated LVN A for failing to verify whether CR #1 had a DNR before calling code and EMS.The noncompliance was identified as Past Non-Compliance. The IJ began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began.

Based on observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental, and mental and psychosocial needs that were identified in the comprehensive assessment for 6 of 7 residents (Residents #4, #41, #30, #1 #37 and #62) reviewed for care plans. 1. The facility failed to develop and implement a plan of care that addressed the prevention of facility acquired pressure ulcers/injury . 2. The facility failed to develop a plan of care for the continuous use of heel protectors for Residents #4, #41, #1 and #37 who developed facility acquired pressure ulcers/injuries to their feet. 3. The facility failed to develop a plan of care for the continuous use of a special pillow for Resident #30, who developed a pressure ulcer on the leg. 4. The facility failed to develop a care plan to address Resident #62's significant weight loss. An Immediate Jeopardy (IJ) situation was identified on 08/08/25. The IJ template was provided to the Interim Administrator on 08/08/25 at 4:24 PM. While the IJ was removed on 08/11/25 at 5:51 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place residents at risk of not getting their needs met and hospitalization. Findings include: Resident #4Record review of Resident #4's Braden scale for predicting pressure ulcers risk evaluation dated 06/24/25 revealed his score was 14 indicating moderate risk.Record review of Resident #4's undated care plan revealed: Focus - Resident #4 had a pressure injury stage 4 to the right medial heel, 6/26/25. Goal - Resident #4 will have intact skin, free of redness, blisters or discoloration by review date, target date 10/09/25. Interventions included - administer treatments as ordered and monitor for effectiveness, low air loss mattress for pressure reducing measures. Further review of the care plan revealed the interventions did not include heel protector boots (specifically designed for wound care to help prevent heel pressure ulcers by keeping the heel elevated and off the bed surface).Record review of Resident #4's May 2025 Task Care Record revealed, Resident #4 was scheduled for turning/reposition every 2 hours (12 times a day); the task was not completed 12 times a day.Record review of Resident #4's June 2025 Task Care Record revealed, Resident #4 was scheduled for turning/reposition every 2 hours (12 times a day); the task was not completed 12 times a day.Record review of Resident #4's July 2025 Task Care Record revealed, Resident #4 was scheduled for turning/reposition every 2 hours (12 times a day) from 07/01/25 to 07/20/25; the task was not completed 12 times a day. On 07/20/25 the task was changed so the resident was only turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #4's Progress Notes from 01/2025 to 07/2025 revealed, a new in-house unstageable pressure ulcer on the right heal was first identified on 06/26/25.Record review of Resident #4's Wound Care Note 07/02/25, Skin: Stage 4 pressure injury observed on the posterior heel of the lower extremity. Adherent dark firm eschar (describing dead, black, leather-like tissue that is tightly bound to the base of a deep wound. It is a form of necrosis, or tissue death, often associated with severe injury or poor blood supply) present in the affected area. Marked tenderness noted. Callusing skin observed in the surrounding area. WOUND ASSESSMENT:Wound: 1Status: NewLocation: Right Medial HeelPrimary Etiology: Pressure InjurySeverity: Stage 4Size: 2.3 cm x 2.5 cm x 1 cm. Actual area is 5.75 cm2. Actual volume is 5.75 cm3Wound Base: [NAME] escharPeriwound: CallusExudate: NoneWound Odor: NoneWound Pain at Rest: 2Record review of Resident #4's Skin Monitoring: Comprehensive CNA Shower Review from 07/2025 to 09/2025 revealed, he had no marked areas of concern (bruising, skin tears, rashes, dryness, lesions, bed sores, blisters, scratches, abnormal color, abnormal skin, or hardened skin) on: - 07/01/25, 07/03/25, 7/08/25, 07/10/25, 07/12/25, 07/17/25, 07/19/25, 07/22/25, 07/24/25, 7/26/25, 07/29/25, 07/31/25, 08/02/25, 08/05/25, 08/07/25, 08/09/25, 8/12/25, 08/14/25, 8/16/25, 08/19/25, 08/21/25, 08/26/25, 08/30/25, 09/04/25, 09/06/25, 09/09/25, 09/11/25, 09/13/25.Record review of Resident #4's Skin Issues form, effective date 07/30/25 and evaluated by the Wound Care Nurse revealed a stage 4 pressure ulcer/injury to the right heel, in-house acquired, new onset and heel suspension/protection device was listed as additional care.Record review of the facility weekly pressure report dated 08/01/25 revealed Resident #4's stage 4 pressure ulcer to the right heel was in-house acquired and identified on 06/26/25.Record review of Resident #4's August 2025 Task Care Record revealed, Resident #4 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #4's order summary report dated 08/07/25 revealed an active order for pressure injury stage 4 to the right medial heel: cleanse with wound cleanser, pat dry, apply Santyl, skin prep to peri wound and silicone bordered foam dressing daily and as needed every day shift for wound care, dated 08/07/25; low air loss mattress for pressure reducing measures every shift, dated 07/20/25. Further review revealed no orders for heel protector boots.Record review of Resident #4's Kardex (automated storage systems) as of 8/08/25 revealed Monitors included: monitor pressure relieving mattress, pressure relieving pad for the chair as well as turn and reposition. Further review of the Kardex revealed it did not include monitoring for heel protectors. Record review of Resident #4's September 2025 Task Care Record revealed, Resident #4 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each dayRecord review of the facility Podiatry Service list dated 09/09/25 revealed, Resident #4 had not received podiatry services. In an interview and observation of wound care on 08/07/25 at 11:00 AM, Resident #4 was lying on his back on a low air loss mattress, alert and watching television. Resident #4 had no heel protector boots on his feet; the soft boots were on the floor in a corner of the room. Resident #4 said the wound on his right foot hurt and that it was an 8 out of 10 on the pain scale. He stated he had the wound a long time and did not know how he got it. The wound to the right heel was round, pink in the center with white edges and surrounding skin was intact. He was in no distress and tolerated the wound care. The Wound Care Nurse applied the soft heel protector boots to both feet.In an interview on 08/07/25 at 11:30 AM, CNA N stated Resident #4 was supposed to have boots on to help protect his heels from injuries while in bed and while up in the wheelchair. CNA N stated Resident #4 would get agitated, either kick them off his feet or ask to have them removed. CNA N stated she did not notify the charge nurse that he did not have them on in the morning because she was distracted and forgot. CNA N stated usually she would chart whether the boots were on or if the resident refused in the task list under ADLs. Record review of Resident #4's Behavior Progress notes, printed on 08/07/25, revealed no documentation regarding refusal to keep heel protector boots on his feet. An observation on 08/05/25 at 09:18 AM revealed, Resident #4 in bed. The resident kept rubbing his right heel against his left shin and said he had a wound on his right heel that he received wound care for. The resident did not have boots on, just a pair of non-slip socks. A pair of Prevalon heel protection boots (soft boots used to prevent the development of heel pressure ulcer) was observed in the corner of the resident's room, under a bedside table and behind a wheelchair. Resident #41Record review of Resident #41's Braden scale for predicting pressure ulcers risk evaluation on 07/04/25 revealed a score of 12, which indicated high risk.Record review of Resident #41's quarterly MDS dated [DATE] revealed severe impaired cognitive skills for daily decision making. She was coded for functional limitations in range of motion to both sides of upper and lower extremities. Resident #41 was dependent on staff for all ADLs. Resident #41 had a feeding tube for receiving nutrition. Resident #41 was at risk of developing pressure ulcers and no pressure ulcers were listed. Resident #41 had pressure reducing devices for the chair and the bed.Record review of Resident #41's undated care plan revealed: Focus - Resident #41 had stage 3 pressure ulcer to the left medial great toe, 8/1/25. Goal - Resident #41 will remain free from infection through the review date, target date 09/29/25. Interventions included - low air loss mattress, monitoring for changes in skin status and daily observations of skin. Interventions did not include the application of bilateral heel boots every shift. Focus - Resident #41 had stage 3 pressure ulcer to the left medial forefoot, 8/1/25. Goal - Resident #41 will remain free from infection through the review date, target date 9/29/25. Interventions included - low air loss mattress, monitoring for changes in skin status and daily observations of skin. Interventions did not include the application of bilateral heel boots every shift. Further review of Resident #41's care plan revealed there was no plan for Resident #41's risk for developing pressure ulcers and interventions to help prevent pressure ulcers/injuries.Record review of Resident #41's Progress Notes 07/08/25 through 08/08/25 revealed,- 08/01/2025 05:07 PM signed by the Wound Care Nurse: Wound care nurse was notified by charge nurse that the resident has new wounds. Upon assessment resident was found to have two new wounds to the left medial forefoot and left medial great toe. Wounds were cleansed and treated with basic first aid. Wound care MD was notified, awaiting orders.- 08/01/2025 05:10 PM signed by the Wound Care Nurse: Left 1 st toe: Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house. Wound is new.Record review of Resident #41's July 2025 Task Care Record revealed, Resident #41 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #41's August 2025 Task Care Record revealed, Resident #41 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each dayRecord review of Resident #41's skin issues evaluation form effective 08/01/25, by the Wound Care Nurse, revealed a new issue, in-house acquired stage 3 pressure ulcer to the upper surface of the left great toe.Record review of Resident #41's Hospice visit note report date 08/06/25 revealed, Resident #41 had one stage 2 pressure ulcer. On the left medial foot, she had a stage 3. That was 3cm x 2cm x0 centimeters. There was no granulation tissue. The edges were distinct, the shape was round, there was no drainage, 50% to 75% in necrotic slough (dead or dying tissue that appears stringy, soft and yellowish that blocks healing or increases risk of infection, no tunneling (tunnel from surface of wound into deeper tissue). Wound care was not provided on that visit.Record review of Resident #41's 08/06/25 follow up wound evaluation note by the NP revealed the resident had a new wound to the left foot: an unstageable pressure injury on the left great toe, another injury located on the plantar surface of the foot below the great toe that had black eschar tissue (dead tissue) and an unstageable pressure injury to the left lateral foot. Further review of the evaluation revealed preventative measures: continue offloading techniques.Record review of Resident #41's order summary report printed on 08/07/25 revealed an active order for low air loss mattress dated 07/20/25, an order for nurse to ensure bilateral heel boots were in place every shift for DTI dated 07/26/25; an order for daily wound care orders for an unstageable left lateral foot pressure injury, dated 08/07/25; a wound care order three times a week for an unstageable left lower great toe pressure injury, dated 08/07/25. Resident #41 had an active order for Hospice services, dated 07/03/25.Record review of Resident #41's September 2025 Task Care Record revealed,- Resident #41 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.An observation on 08/05/25 at 09:21 AM revealed, Resident #41 lying in bed with both legs contracted and pulled up while receiving continuous feeding via her G-tube (tube that goes into the stomach to provide feedings or medication). The resident was non-responsive to the surveyor and she had heel protection and cushions in place. Resident #30Record review of Resident #30's face sheet dated 08/07/25 revealed an [AGE] year-old admitted to the facility on [DATE] with diagnoses to include dementia, stroke, anxiety, right wrist contracture, chronic pain and palliative care.Record review of Resident #30's Braden scale for predicting pressure ulcers risk evaluation on 06/05/25 revealed a score of 14, which indicated moderate risk. Record review of Resident #30's quarterly MDS dated [DATE] revealed severe impaired cognitive skills for daily decision making. She was coded for functional limitations in range of motion to upper and lower extremities. Resident #30 was dependent on staff for all ADLs. Resident #30 had one stage 4 pressure ulcer that was present upon admission.Record review of Resident #30's undated care plan revealed: Focus - Resident #30 had a stage 4 pressure ulcer to the right medial calf, 3/4/25. Goal - Resident #30's right medial calf will be healed. Interventions included: place resident's pressure reducing device/product on bed/chair. Further review of the intervention did not specify the pillow between the legs.Record review of Resident #1's Skin Monitoring: Comprehensive CNA Shower Review revealed, he had no marked areas of concern (bruising, skin tears, rashes, dryness, lesions, bed sores, blisters, scratches, abnormal color, abnormal skin, or hardened skin) on: 03/25, 6/02/25, 06/04/25, 06/06/25, 06/09/25, 06/11/25, 06/13/25, 06/16/25, 06/18/25, 06/20/25, 06/23/25, 06/25/25, 06/27/25, 06/30/25, 07/02/25, 04/04/25, 07/07/25, 07/09/25, 07/11/25, 07/14/25, 07/18/25, 07/21/25, 07/23/25, 07/25/25, 07/28/25, 07/30/25, 08/01/25, 08/04/25, 08/06/25, 08/08/25, 08/11/25, 08/13/25, 08/15/25, 08/18/25, 08/20/25, 08/22/25, 08/25/25, 08/27/25, 08/29/25, 09/03/25 08, 05/25, 09/05/25, 9/12/25.Record review of Resident #30's February 2025 Task Care Record revealed, Resident #30 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #30's March 2025 Task Care Record revealed, Resident #30 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #30's April 2025 Task Care Record revealed, Resident #30 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #30's May 2025 Task Care Record revealed, Resident #30 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #30's June 2025 Task Care Record revealed, Resident #30 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #30's July 2025 Task Care Record revealed, Resident #30 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #30's August 2025 Task Care Record revealed, Resident #30 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of the facility weekly pressure report dated 08/01/25 revealed Resident #30's stage 4 pressure ulcer to the right medial calf was in-house acquired and identified on 03/04/25.Record review of Resident #30's order summary report printed on 08/06/25 revealed an active order to cleanse the DTI (deep tissue injury) to the right medial calf with dermal wound cleanser, pat dry, apply medihoney, cover with border dressing as needed for compromised dressing, dated 03/06/25; an order for Low air loss mattress for pressure reducing measures every shift, dated 07/20/25; an order for Nurses to ensure pillow between legs for pressure reduction as tolerated ever shift, dated 07/20/25; an order for: Stage 4 right lower medial leg pressure injury: cleanse with wound cleanser. Pat dry, apply Adaptec (non-adherent wound dressing), allograft skin graft (tissue transferred from one person to another) and silicone bordered foam dressing every 5 days and as needed for wound care, date ordered 08/07/25.Record review of Resident #30's follow up wound evaluation notes, date of service was 07/16/25, written by the Wound Care Physician, revealed the evaluation was of the stage 4 ulceration on the right lower extremity around knee joint, follow up for the skin graft application (cellular based tissue product). Preventative measures included to continue with offloading techniques.Record review of Resident #30's September 2025 Task Care Record revealed, Resident #30 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.An observation on 08/05/25 at 09:27 AM revealed, Resident #30 sleeping in bed with legs contracted. There was no pressure relieving pillow between her legs.Observation and interview of wound care for Resident #30 on 08/06/25 at 3:30 PM by the NP and Wound Care Nurse revealed Resident #30 had severe contractures of the lower extremities. There was a rolled-up bed linen between the resident's knees. Resident #30 had an open area, pink in color to the right medial shin, the surrounding skin was intact. The measurements per NP were: Length 2.7cm, Width 2.0cm, Depth 0.2cm. Wound Care Nurse stated the resident was supposed to have a donut pillow placed between the knees. Resident #30 denied pain during the procedure. Low air loss mattress was in place and heel protectors were replaced after the procedure.In an interview and observation on 08/10/25 at 10:45 AM, Resident #31 who was the roommate of Resident #30 stated the aides were not trained on the use of the special pillow, especially during evening and night shift. Resident #31 stated on one occasion the nursing staff stated the pillow was not doing any good and removed the pillow. Resident #31 did not know the name of the nursing staff. Resident #31 stated overall nursing staff were inconsistent when applying the pillow even though there was a sign above the bed with instructions. The sign read: Do not remove pillow from between Resident #30's legs, middle needs to be positioned under wound. Call Wound Care Nurse with any questions. Resident #1Record review of Resident #1's face sheet dated 08/07/25 revealed an [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE] with diagnoses to include cancer of the tongue and of the throat; Hemiplegia (one side paralysis or severe loss of strength on one side) following a stroke; high blood pressure, irregular often rapid heartbeat, and muscle wasting.Record review of Resident #1's Braden scale for predicting pressure ulcers risk evaluation on 05/22/25 revealed a score of 15 indicating he was at risk.Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 13 out of 15 indicating intact cognition. He required substantial/maximum assistance with bed mobility. Resident #1 had one unstageable pressure ulcer. Skin and ulcer treatment: pressure reducing device for the chair, pressure reducing device for the bed, pressure ulcer/injury care and application of dressings to the feet. Resident #1 had a feeding tube to receive nutrition.Record review of Resident #1's undated care plan revealed: Focus - Resident #1 had an unstageable pressure ulcer to the left heel 7/23/25. Goal - Resident #1 will remain free of infection. Interventions included - monitor for changes in skin status and notify physician, refer resident to wound specialist, resident needs to float heels on pillow, resident needs weekly evaluation of wound healing. Further review of the care plan revealed no specific intervention to apply heel protector boots.Record review of Resident #1's July 2025 Task Care Record revealed, Resident #1 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #1's August 2025 Task Care Record revealed, Resident #1 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #1's Skin Monitoring: Comprehensive CNA Shower Review revealed, he had no marked areas of concern (bruising, skin tears, rashes, dryness, lesions, bed sores, blisters, scratches, abnormal color, abnormal skin, or hardened skin) on:- 06/17/25, 07/18/25, 07/28/25, 08/01/25,08/06/25, 08/08/25, 08/11/25, 08/17/25, 07/05/25,- On 08/12/25 he was marked with a skin tear in the inguinal region (where the thigh meets the torso) and sacrum (triangular area below the spine)- On 08/14/25 he was marked with a skin tear on the sacrum.Record review of the facility's weekly pressure report dated 08/01/25 revealed Resident # had an unstageable pressure ulcer to the left heel that was acquired in house and identified on 07/23/25.Record review of Resident #1's wound assessment report for 07/30/25 written by the wound care MD revealed the stage 4 pressure injury to the left posterior heel was acquired in house on 07/23/25.Record review of Resident #1's order summary report printed on 08/06/25 revealed active order to cleanse unstageable pressure injury to the left heel with normal saline, pat dry, apply Santyl to the would bed, cover with silicone border dressing every day shift for wound care, start date was 07/25/25; an active order to check placement of pressure reduction mattress every shift for preventative measures, dated 07/16/25; an active order to check pressure reduction device to the wheelchair every shift for preventative measures. Further review of the order summary report revealed there was no order for heel protector boots.Record review of Resident #1's follow up wound evaluation noted, date of service 08/06/25, by the Wound Care NP revealed the assessment included unstageable pressure ulcer of the left heel and the plan was to continue offloading boots for pressure relief. Resident #37Record review of Resident #37's face sheet dated 8/05/25 revealed a [AGE] year-old admitted to the facility on [DATE], initially admitted on [DATE] and originally admitted on [DATE]. Diagnoses included Guillain-Barre syndrome (a rare condition in which the immune system attacks the nerves causing weakness, numbness or paralysis), heart attack, Quadriplegia (condition characterized by partial or complete paralysis of all four limbs and torso), and dementia.Record review of Resident #37's annual MDS dated [DATE] revealed a BIMS score of 13 out of 15 indicating intact cognition, impairment on both sides of upper and lower extremities and required substantial/maximal assistance for bed mobility. Section M-Skin Conditions revealed Resident #37 was at risk of developing pressure ulcers/injuries and did not have any unhealed pressure ulcers/injuries.Record review of Resident 37's Braden scale for predicting pressure ulcers risk evaluation on 07/04/25 revealed a score of 12 indicating high risk.Record review of Resident #37's undated Care Plan Report revealed: Focus - Resident #37 has actual pressure ulcer development r/t impaired mobility and incontinence. Right heel, 5/7/25. Revision was made on 07/01/25. Goal - The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Target date was 08/25/25. Interventions included - Administer treatments as ordered and monitor for effectiveness, follow facility policies/protocols for the prevention/treatment of skin breakdown, monitor/document/report PRN any changes in skin status, weekly skin assessments. Record review of Resident #37's Skin Monitoring: Comprehensive CNA Shower Review revealed, he had no marked areas of concern (bruising, skin tears, rashes, dryness, lesions, bed sores, blisters, scratches, abnormal color, abnormal skin, or hardened skin) on: 6/03/25, 06/05/25, 06/05/25, 06/10/25, OHH 6/12/25, 06/14/25, Both 6/17/25, 06/19/25, 06/21/25, 06/24/25, 06/26/25, 06/28/25, 07/01/25, 07/03/25, 07/05/25, 07/08/25, 07/10/25, 07/12/25, 07/12/25, 07/19/25, 07/15/25, 07/17/25, 07/19/25 07/22/25, 07/24/25, 07/26/25, 07/29/25, 07/31/25, 08/02/25, 08/05/25, 08/07/25, 08/09/25, 08/12/25, 08/14/25, 08/21/25, 08/26/25, 09/02/25, 09/04/25, 09/09/25.Record review of Resident #37's May 2025 Task Care Record revealed, Resident #37 was scheduled for turning/reposition every 2 hours (12 times a day); the task was not completed 12 times a day.Record review of Resident #37's Progress Notes 04/01/25 to 08/08/25 revealed, the first time Resident #37's wound was observed on 05/07/25.- 05/07/2025 09:46 AM: The Change In Condition/s reported on this CIC Evaluation are/were: Change in skin color or condition.Record review of Resident #37's Wound Assessment Report dated 05/07/25 revealed,Location: Right HeelEtiology: Bullae (large blister containing serous fluid), Pressure InjuryStage/Severity: Deep Tissue InjuryAcquired in House: YesDate Wound Acquired: 05/07/2025In Remission: NoWound Status: NewRecord review of Resident #37's June 2025 Task Care Record revealed, Resident #37 was scheduled for turning/reposition every 2 hours (12 times a day); the task was not completed 12 times a day.Record review of Resident #37's July 2025 Task Care Record revealed, Resident #37 was scheduled for turning/reposition every 2 hours (12 times a day) from 07/01/25 to 07/20/25; the task was not completed 12 times a day. On 07/20/25 the task was changed so the resident was only turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #37's August 2025 Task Care Record revealed, Resident #37 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of the facility weekly pressure report dated on 08/01/25 revealed Resident #37 had a stage 4 pressure ulcer to the right heel that was acquired in house and identified on 05/07/25.Record review of Resident #37's physician order summary report dated 08/06/25 revealed an order for the stage 4 pressure injury (a deep wound that exposes underlying muscle, tendon, cartilage or bone) to the right heel: cleanse with wound cleanser, pat dry, apply Santyl and calcium alginate with silver and cover with border foam dressing every day shift and as needed, dated 08/05/25; an order for low air loss mattress for pressure reducing measures every shift, dated 07/20/25.Record review of Resident #37's follow up wound evaluation note dated 08/06/25 by the wound care NP revealed the recommended treatment included air boots while in bed.Record review of Resident #37's September 2025 Task Care Record revealed, Resident #37 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day Observation and interview of wound care for Resident #37 on 08/07/25 at 10:00 AM, by the Wound Care Nurse and the Physical Therapist revealed the resident had two large circular red spots to the right heel with light colored edges and the surrounding skin was pinkish red in color. The Wound Care Nurse stated the wound was originally one large wound. The Physical Therapist performed the ultramist wound therapy (a painless, non-contact treatment that uses low-frequency ultrasound energy and a saline mist to promote healing in chronic and difficult-to-heal wounds) which took approximately 3 minutes, then the wound care nurse completed the wound care without incident. In an interview on 08/06/25 at 9:45 AM, the Wound Care Nurse stated there have been issues with heel boots not being applied when supposed to particularly with Resident #41 and Resident #30. The Wound Care Nurse stated the orders for the boots were in the MAR, but she would find that the residents would not have the boots on. The Wound Care Nurse stated the CNAs would immediately place the heel protectors on the residents when the wound care nurse was seen rounding. The Wound Care Nurse stated Resident #30 had a special pillow for between her knees because of the wound on the leg and that the pillow went missing. The Wound care nurse stated in services included heel protectors were conducted with the CNAs but the issue continued, the heel protectors were still not being applied when they were supposed to and that there was a failure in the system.In an interview on 08/06/25 at 11:42 AM, the DON stated pressure relieving boots for Resident #4 was supposed to be in the physician orders and in the MAR/TAR but the electronic health records would not populate when she checked. The DON stated areas more prone to developing pressure ulcers would be over bony prominences and treatment to help reduce pressure ulcers would be turning, repositioning, checking skin frequently as well as weekly skin checks. The DON stated orders for prophylactic heel protection would be devices like heel boots and wedges to float heels. The DON stated she started working at the facility 2 months ago and just learned the facility had a lot of in-house acquired heel ulcers, was investigating and the plan was to do in-services on skin issues effective immediately. In an interview on 08/06/25 at 4:00 PM, the DON stated the wound care nurse was responsible to ensure all the Wound Care MD recommendations and orders were followed. In an interview on 08/08/25 at 7:30 AM, the ADON stated the purpose of the heel protectors was to protect the resident's skin integrity, reduce pressure and protect bony prominences for any resident who was in bed all the time. The ADON stated the physician orders heel protectors, and any nurse can enter the order into PCC, then the information for heel protectors should also be in the Kardex. The ADON stated heel protectors should be used whenever the resident lays down or up in a chair and that the nurses were ultimately responsible to ensure they were being used. The ADON stated the expectation was that the CNAs notify the nurses if heel protectors continuously fall off and for repeated resident refusals. The ADON denied seeing any issues with heel protectors not being used as ordered.In an interview on 08/08/25 at 8:10 AM, the Wound Care Nurse stated there were certain CNAs who ensured heel protectors were in place, but other aides were inconsistent. The Wound Care Nurse stated the purpose of the heel protector boots was to prevent pressure injuries, infection or new injuries from developing especially with the hospice residents, the residents who were contracted, those who prefer to stay in bed and those less mobile in bed. The Wound Care Nurse stated Resident #41 developed new injurie[TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 5 of 7 (Residents #4, #41, #30, #1 and #37) residents reviewed for pressure ulcers.- The facility failed to turn and reposition Resident #4 every 2 hours and failed to identify skin issues during CNA skin monitoring during showers and nurse skin assessments. Resident #4 developed an in-house stage 4 pressure to his heel without any previously documented skin concern. - The facility failed to ensure Resident #4's low-air-loss mattress was in use as ordered by his physician. - The facility failed to turn and reposition Resident #41 every 2 hours and failed to identify skin issues during CNA skin monitoring during showers and nurse skin assessments. Resident #4 developed an in-house stage 3 pressure to the upper surface of the left great toe and foot without any previously documented skin concern. - The facility failed to ensure Resident #41's low-air-loss mattress was not covered by a fitted sheet that could restrict the pressure relieving function of the mattress and cause pressure points that increased pressure to the resident. - The facility failed to turn and reposition Resident #30 every 2 hours and failed to identify skin issues during CNA skin monitoring during showers and nurse skin assessments. Resident #30 developed an in-house stage 3 pressure to her calf without any previously documented skin concern.- The facility failed to ensure Resident #30's ordered donut pillow was in place which resulted in deterioration of the resident's pressure ulcer to her leg.- The facility failed to turn and reposition Resident #1 every 2 hours and failed to identify skin issues during CNA skin monitoring during showers and nurse skin assessments. Resident #1 developed an in-house stage 4 pressure to his left heal without any previously documented skin concern.- The facility failed to turn and reposition Resident #37 every 2 hours and failed to identify skin issues during CNA skin monitoring during showers and nurse skin assessments. Resident #1 developed an in-house stage 4 pressure to his left heal without any previously documented skin concern. The visit was reopened on 08/08/25. The IJ template was provided to the Interim Administrator on 08/08/25 at 4:24 PM. While the IJ was removed on 08/11/25 at 5:51 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition, pain, and/or the need for hospitalization and prolonged treatment.Findings include: Resident #4Record review of Resident #4's face sheet dated 08/07/25 revealed a [AGE] year-old admitted to the facility on [DATE] with the diagnoses to include Hemiplegia (one sided paralysis or severe loss of strength on one side) following a stroke, Diabetes, high blood pressure, mental disorder and muscle weakness.Record review of Resident #4's quarterly MDS dated [DATE] revealed a BIMS score of 5 out of 15 indicating severe impaired cognition. He required substantial/maximum assistance with bed mobility. Resident #4 was at risk of developing pressure/ulcers/injuries and did not have any unhealed pressure ulcers. Resident #4 had pressure reducing device for the bed and for the chair.Record review of Resident #4's Braden scale for predicting pressure ulcers risk evaluation dated 06/24/25 revealed his score was 14 indicating moderate risk.Record review of Resident #4's undated care plan revealed: Focus - Resident #4 had a pressure injury stage 4 to the right medial heel, 6/26/25. Goal - Resident #4 will have intact skin, free of redness, blisters or discoloration by review date, target date 10/09/25. Interventions included - administer treatments as ordered and monitor for effectiveness, low air loss mattress for pressure reducing measures. Further review of the care plan revealed the interventions did not include heel protector boots (specifically designed for wound care to help prevent heel pressure ulcers by keeping the heel elevated and off the bed surface).Record review of Resident #4's May 2025 Task Care Record revealed, Resident #4 was scheduled for turning/reposition every 2 hours (12 times a day); the task was not completed 12 times a day.Record review of Resident #4's June 2025 Task Care Record revealed, Resident #4 was scheduled for turning/reposition every 2 hours (12 times a day); the task was not completed 12 times a day.Record review of Resident #4's July 2025 Task Care Record revealed, Resident #4 was scheduled for turning/reposition every 2 hours (12 times a day) from 07/01/25 to 07/20/25; the task was not completed 12 times a day. On 07/20/25 the task was changed so the resident was only turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #4's Progress Notes from 01/2025 to 07/2025 revealed, a new in-house unstageable pressure ulcer on the right heal was first identified on 06/26/25.Record review of Resident #4's Wound Care Note 07/02/25, Skin: Stage 4 pressure injury observed on the posterior heel of the lower extremity. Adherent dark firm eschar (describing dead, black, leather-like tissue that is tightly bound to the base of a deep wound. It is a form of necrosis, or tissue death, often associated with severe injury or poor blood supply) present in the affected area. Marked tenderness noted. Callusing skin observed in the surrounding area. WOUND ASSESSMENT:Wound: 1Status: NewLocation: Right Medial HeelPrimary Etiology: Pressure InjurySeverity: Stage 4Size: 2.3 cm x 2.5 cm x 1 cm. Actual area is 5.75 cm2. Actual volume is 5.75 cm3Wound Base: [NAME] escharPeriwound: CallusExudate: NoneWound Odor: NoneWound Pain at Rest: 2Record review of Resident #4's Skin Monitoring: Comprehensive CNA Shower Review from 07/2025 to 09/2025 revealed, he had no marked areas of concern (bruising, skin tears, rashes, dryness, lesions, bed sores, blisters, scratches, abnormal color, abnormal skin, or hardened skin) on: - 07/01/25, 07/03/25, 7/08/25, 07/10/25, 07/12/25, 07/17/25, 07/19/25, 07/22/25, 07/24/25, 7/26/25, 07/29/25, 07/31/25, 08/02/25, 08/05/25, 08/07/25, 08/09/25, 8/12/25, 08/14/25, 8/16/25, 08/19/25, 08/21/25, 08/26/25, 08/30/25, 09/04/25, 09/06/25, 09/09/25, 09/11/25, 09/13/25.Record review of Resident #4's Skin Issues form, effective date 07/30/25 and evaluated by the Wound Care Nurse revealed a stage 4 pressure ulcer/injury to the right heel, in-house acquired, new onset and heel suspension/protection device was listed as additional care.Record review of the facility weekly pressure report dated 08/01/25 revealed Resident #4's stage 4 pressure ulcer to the right heel was in-house acquired and identified on 06/26/25.Record review of Resident #4's August 2025 Task Care Record revealed, Resident #4 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #4's order summary report dated 08/07/25 revealed an active order for pressure injury stage 4 to the right medial heel: cleanse with wound cleanser, pat dry, apply Santyl, skin prep to peri wound and silicone bordered foam dressing daily and as needed every day shift for wound care, dated 08/07/25; low air loss mattress for pressure reducing measures every shift, dated 07/20/25. Further review revealed no orders for heel protector boots.Record review of Resident #4's Kardex (automated storage systems) as of 8/08/25 revealed Monitors included: monitor pressure relieving mattress, pressure relieving pad for the chair as well as turn and reposition. Further review of the Kardex revealed it did not include monitoring for heel protectors. Record review of Resident #4's September 2025 Task Care Record revealed, Resident #4 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day In an interview and observation of wound care on 08/07/25 at 11:00 AM, Resident #4 was lying on his back on a low air loss mattress, alert and watching television. Resident #4 had no heel protector boots on his feet; the soft boots were on the floor in a corner of the room. Resident #4 said the wound on his right foot hurt and that it was an 8 out of 10 on the pain scale. He stated he had the wound a long time and did not know how he got it. The wound to the right heel was round, pink in the center with white edges and surrounding skin was intact. He was in no distress and tolerated the wound care. The Wound Care Nurse applied the soft heel protector boots to both feet.In an interview on 08/07/25 at 11:30 AM, CNA N stated Resident #4 was supposed to have boots on to help protect his heels from injuries while in bed and while up in the wheelchair. CNA N stated Resident #4 would get agitated, either kick them off his feet or ask to have them removed. CNA N stated she did not notify the charge nurse that he did not have them on in the morning because she was distracted and forgot. CNA N stated usually she would chart whether the boots were on or if the resident refused in the task list under ADLs. An observation on 08/05/25 at 09:18 AM revealed, Resident #4 in bed. The resident kept rubbing his right heel against his left shin and said he had a wound on his right heel that he received wound care for. The resident did not have boots on, just a pair of non-slip socks. A pair of Prevalon heel protection boots (soft boots used to prevent the development of heel pressure ulcer) was observed in the corner of the resident's room, under a bedside table and behind a wheelchair. Resident #41Record review of Resident #41's face sheet dated 08/07/25 revealed an [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE] with the diagnoses to include Senile Degeneration (a progressive deterioration of the brain tissue and function that occurs with aging), high blood pressure, COPD (chronic obstructive pulmonary disease) (a lung condition caused by damage to the airway), lack of coordination, muscle weakness, reduced mobility, and dementia.Record review of Resident #41's Braden scale for predicting pressure ulcers risk evaluation on 07/04/25 revealed a score of 12, which indicated high risk.Record review of Resident #41's quarterly MDS dated [DATE] revealed severe impaired cognitive skills for daily decision making. She was coded for functional limitations in range of motion to both sides of upper and lower extremities. Resident #41 was dependent on staff for all ADLs. Resident #41 had a feeding tube for receiving nutrition. Resident #41 was at risk of developing pressure ulcers and no pressure ulcers were listed. Resident #41 had pressure reducing devices for the chair and the bed.Record review of Resident #41's undated care plan revealed: Focus - Resident #41 had stage 3 pressure ulcer to the left medial great toe, 8/1/25. Goal - Resident #41 will remain free from infection through the review date, target date 09/29/25. Interventions included - low air loss mattress, monitoring for changes in skin status and daily observations of skin. Interventions did not include the application of bilateral heel boots every shift. Focus - Resident #41 had stage 3 pressure ulcer to the left medial forefoot, 8/1/25. Goal - Resident #41 will remain free from infection through the review date, target date 9/29/25. Interventions included - low air loss mattress, monitoring for changes in skin status and daily observations of skin. Interventions did not include the application of bilateral heel boots every shift. Further review of Resident #41's care plan revealed there was no plan for Resident #41's risk for developing pressure ulcers and interventions to help prevent pressure ulcers/injuries.Record review of Resident #41's Progress Notes 07/08/25 through 08/08/25 revealed,- 08/01/2025 05:07 PM signed by the Wound Care Nurse: Wound care nurse was notified by charge nurse that the resident has new wounds. Upon assessment resident was found to have two new wounds to the left medial forefoot and left medial great toe. Wounds were cleansed and treated with basic first aid. Wound care MD was notified, awaiting orders.- 08/01/2025 05:10 PM signed by the Wound Care Nurse: Left 1 st toe: Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house. Wound is new.Record review of Resident #41's July 2025 Task Care Record revealed, Resident #41 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #41's August 2025 Task Care Record revealed, Resident #41 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each dayRecord review of Resident #41's skin issues evaluation form effective 08/01/25, by the Wound Care Nurse, revealed a new issue, in-house acquired stage 3 pressure ulcer to the upper surface of the left great toe.Record review of Resident #41's Hospice visit note report date 08/06/25 revealed, Resident #41 had one stage 2 pressure ulcer. On the left medial foot, she had a stage 3. That was 3cm x 2cm x0 centimeters. There was no granulation tissue. The edges were distinct, the shape was round, there was no drainage, 50% to 75% in necrotic slough (dead or dying tissue that appears stringy, soft and yellowish that blocks healing or increases risk of infection, no tunneling (tunnel from surface of wound into deeper tissue). Wound care was not provided on that visit.Record review of Resident #41's 08/06/25 follow up wound evaluation note by the NP revealed the resident had a new wound to the left foot: an unstageable pressure injury on the left great toe, another injury located on the plantar surface of the foot below the great toe that had black eschar tissue (dead tissue) and an unstageable pressure injury to the left lateral foot. Further review of the evaluation revealed preventative measures: continue offloading techniques.Record review of Resident #41's order summary report printed on 08/07/25 revealed an active order for low air loss mattress dated 07/20/25, an order for nurse to ensure bilateral heel boots were in place every shift for DTI dated 07/26/25; an order for daily wound care orders for an unstageable left lateral foot pressure injury, dated 08/07/25; a wound care order three times a week for an unstageable left lower great toe pressure injury, dated 08/07/25. Resident #41 had an active order for Hospice services, dated 07/03/25.Record review of Resident #41's September 2025 Task Care Record revealed,- Resident #41 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.An observation on 08/05/25 at 09:21 AM revealed, Resident #41 lying in bed with both legs contracted and pulled up while receiving continuous feeding via her G-tube (tube that goes into the stomach to provide feedings or medication). The resident was non-responsive to the surveyor and she had heel protection and cushions in place. Resident #30Record review of Resident #30's face sheet dated 08/07/25 revealed an [AGE] year-old admitted to the facility on [DATE] with diagnoses to include dementia, stroke, anxiety, right wrist contracture, chronic pain and palliative care.Record review of Resident #30's Braden scale for predicting pressure ulcers risk evaluation on 06/05/25 revealed a score of 14, which indicated moderate risk. Record review of Resident #30's quarterly MDS dated [DATE] revealed severe impaired cognitive skills for daily decision making. She was coded for functional limitations in range of motion to upper and lower extremities. Resident #30 was dependent on staff for all ADLs. Resident #30 had one stage 4 pressure ulcer that was present upon admission.Record review of Resident #30's undated care plan revealed: Focus - Resident #30 had a stage 4 pressure ulcer to the right medial calf, 3/4/25. Goal - Resident #30's right medial calf will be healed. Interventions included: place resident's pressure reducing device/product on bed/chair. Further review of the intervention did not specify the pillow between the legs.Record review of Resident #1's Skin Monitoring: Comprehensive CNA Shower Review revealed, he had no marked areas of concern (bruising, skin tears, rashes, dryness, lesions, bed sores, blisters, scratches, abnormal color, abnormal skin, or hardened skin) on: 03/25, 6/02/25, 06/04/25, 06/06/25, 06/09/25, 06/11/25, 06/13/25, 06/16/25, 06/18/25, 06/20/25, 06/23/25, 06/25/25, 06/27/25, 06/30/25, 07/02/25, 04/04/25, 07/07/25, 07/09/25, 07/11/25, 07/14/25, 07/18/25, 07/21/25, 07/23/25, 07/25/25, 07/28/25, 07/30/25, 08/01/25, 08/04/25, 08/06/25, 08/08/25, 08/11/25, 08/13/25, 08/15/25, 08/18/25, 08/20/25, 08/22/25, 08/25/25, 08/27/25, 08/29/25, 09/03/25 08, 05/25, 09/05/25, 9/12/25.Record review of Resident #30's February 2025 Task Care Record revealed, Resident #30 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #30's March 2025 Task Care Record revealed, Resident #30 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #30's April 2025 Task Care Record revealed, Resident #30 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #30's May 2025 Task Care Record revealed, Resident #30 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #30's June 2025 Task Care Record revealed, Resident #30 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #30's July 2025 Task Care Record revealed, Resident #30 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #30's August 2025 Task Care Record revealed, Resident #30 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of the facility weekly pressure report dated 08/01/25 revealed Resident #30's stage 4 pressure ulcer to the right medial calf was in-house acquired and identified on 03/04/25.Record review of Resident #30's order summary report printed on 08/06/25 revealed an active order to cleanse the DTI (deep tissue injury) to the right medial calf with dermal wound cleanser, pat dry, apply medihoney, cover with border dressing as needed for compromised dressing, dated 03/06/25; an order for Low air loss mattress for pressure reducing measures every shift, dated 07/20/25; an order for Nurses to ensure pillow between legs for pressure reduction as tolerated ever shift, dated 07/20/25; an order for: Stage 4 right lower medial leg pressure injury: cleanse with wound cleanser. Pat dry, apply Adaptec (non-adherent wound dressing), allograft skin graft (tissue transferred from one person to another) and silicone bordered foam dressing every 5 days and as needed for wound care, date ordered 08/07/25.Record review of Resident #30's follow up wound evaluation notes, date of service was 07/16/25, written by the Wound Care Physician, revealed the evaluation was of the stage 4 ulceration on the right lower extremity around knee joint, follow up for the skin graft application (cellular based tissue product). Preventative measures included to continue with offloading techniques.Record review of Resident #30's September 2025 Task Care Record revealed, Resident #30 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.An observation on 08/05/25 at 09:27 AM revealed, Resident #30 sleeping in bed with legs contracted. There was no pressure relieving pillow between her legs.Observation and interview of wound care for Resident #30 on 08/06/25 at 3:30 PM by the NP and Wound Care Nurse revealed Resident #30 had severe contractures of the lower extremities. There was a rolled-up bed linen between the resident's knees. Resident #30 had an open area, pink in color to the right medial shin, the surrounding skin was intact. The measurements per NP were: Length 2.7cm, Width 2.0cm, Depth 0.2cm. Wound Care Nurse stated the resident was supposed to have a donut pillow placed between the knees. Resident #30 denied pain during the procedure. Low air loss mattress was in place and heel protectors were replaced after the procedure.In an interview and observation on 08/10/25 at 10:45 AM, Resident #31 who was the roommate of Resident #30 stated the aides were not trained on the use of the special pillow, especially during evening and night shift. Resident #31 stated on one occasion the nursing staff stated the pillow was not doing any good and removed the pillow. Resident #31 did not know the name of the nursing staff. Resident #31 stated overall nursing staff were inconsistent when applying the pillow even though there was a sign above the bed with instructions. The sign read: Do not remove pillow from between Resident #30's legs, middle needs to be positioned under wound. Call Wound Care Nurse with any questions. Resident #1Record review of Resident #1's face sheet dated 08/07/25 revealed an [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE] with diagnoses to include cancer of the tongue and of the throat; Hemiplegia (one side paralysis or severe loss of strength on one side) following a stroke; high blood pressure, irregular often rapid heartbeat, and muscle wasting.Record review of Resident #1's Braden scale for predicting pressure ulcers risk evaluation on 05/22/25 revealed a score of 15 indicating he was at risk.Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 13 out of 15 indicating intact cognition. He required substantial/maximum assistance with bed mobility. Resident #1 had one unstageable pressure ulcer. Skin and ulcer treatment: pressure reducing device for the chair, pressure reducing device for the bed, pressure ulcer/injury care and application of dressings to the feet. Resident #1 had a feeding tube to receive nutrition.Record review of Resident #1's undated care plan revealed: Focus - Resident #1 had an unstageable pressure ulcer to the left heel 7/23/25. Goal - Resident #1 will remain free of infection. Interventions included - monitor for changes in skin status and notify physician, refer resident to wound specialist, resident needs to float heels on pillow, resident needs weekly evaluation of wound healing. Further review of the care plan revealed no specific intervention to apply heel protector boots.Record review of Resident #1's July 2025 Task Care Record revealed, Resident #1 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #1's August 2025 Task Care Record revealed, Resident #1 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #1's Skin Monitoring: Comprehensive CNA Shower Review revealed, he had no marked areas of concern (bruising, skin tears, rashes, dryness, lesions, bed sores, blisters, scratches, abnormal color, abnormal skin, or hardened skin) on:- 06/17/25, 07/18/25, 07/28/25, 08/01/25,08/06/25, 08/08/25, 08/11/25, 08/17/25, 07/05/25,- On 08/12/25 he was marked with a skin tear in the inguinal region (where the thigh meets the torso) and sacrum (triangular area below the spine)- On 08/14/25 he was marked with a skin tear on the sacrum.Record review of the facility's weekly pressure report dated 08/01/25 revealed Resident # had an unstageable pressure ulcer to the left heel that was acquired in house and identified on 07/23/25.Record review of Resident #1's wound assessment report for 07/30/25 written by the wound care MD revealed the stage 4 pressure injury to the left posterior heel was acquired in house on 07/23/25.Record review of Resident #1's order summary report printed on 08/06/25 revealed active order to cleanse unstageable pressure injury to the left heel with normal saline, pat dry, apply Santyl to the would bed, cover with silicone border dressing every day shift for wound care, start date was 07/25/25; an active order to check placement of pressure reduction mattress every shift for preventative measures, dated 07/16/25; an active order to check pressure reduction device to the wheelchair every shift for preventative measures. Further review of the order summary report revealed there was no order for heel protector boots.Record review of Resident #1's follow up wound evaluation noted, date of service 08/06/25, by the Wound Care NP revealed the assessment included unstageable pressure ulcer of the left heel and the plan was to continue offloading boots for pressure relief. Resident #37Record review of Resident #37's face sheet dated 8/05/25 revealed a [AGE] year-old admitted to the facility on [DATE], initially admitted on [DATE] and originally admitted on [DATE]. Diagnoses included Guillain-Barre syndrome (a rare condition in which the immune system attacks the nerves causing weakness, numbness or paralysis), heart attack, Quadriplegia (condition characterized by partial or complete paralysis of all four limbs and torso), and dementia.Record review of Resident #37's annual MDS dated [DATE] revealed a BIMS score of 13 out of 15 indicating intact cognition, impairment on both sides of upper and lower extremities and required substantial/maximal assistance for bed mobility. Section M-Skin Conditions revealed Resident #37 was at risk of developing pressure ulcers/injuries and did not have any unhealed pressure ulcers/injuries.Record review of Resident 37's Braden scale for predicting pressure ulcers risk evaluation on 07/04/25 revealed a score of 12 indicating high risk.Record review of Resident #37's undated Care Plan Report revealed: Focus - Resident #37 has actual pressure ulcer development r/t impaired mobility and incontinence. Right heel, 5/7/25. Revision was made on 07/01/25. Goal - The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Target date was 08/25/25. Interventions included - Administer treatments as ordered and monitor for effectiveness, follow facility policies/protocols for the prevention/treatment of skin breakdown, monitor/document/report PRN any changes in skin status, weekly skin assessments. Record review of Resident #37's Skin Monitoring: Comprehensive CNA Shower Review revealed, he had no marked areas of concern (bruising, skin tears, rashes, dryness, lesions, bed sores, blisters, scratches, abnormal color, abnormal skin, or hardened skin) on: 6/03/25, 06/05/25, 06/05/25, 06/10/25, OHH 6/12/25, 06/14/25, Both 6/17/25, 06/19/25, 06/21/25, 06/24/25, 06/26/25, 06/28/25, 07/01/25, 07/03/25, 07/05/25, 07/08/25, 07/10/25, 07/12/25, 07/12/25, 07/19/25, 07/15/25, 07/17/25, 07/19/25 07/22/25, 07/24/25, 07/26/25, 07/29/25, 07/31/25, 08/02/25, 08/05/25, 08/07/25, 08/09/25, 08/12/25, 08/14/25, 08/21/25, 08/26/25, 09/02/25, 09/04/25, 09/09/25.Record review of Resident #37's May 2025 Task Care Record revealed, Resident #37 was scheduled for turning/reposition every 2 hours (12 times a day); the task was not completed 12 times a day.Record review of Resident #37's Progress Notes 04/01/25 to 08/08/25 revealed, the first time Resident #37's wound was observed on 05/07/25.- 05/07/2025 09:46 AM: The Change In Condition/s reported on this CIC Evaluation are/were: Change in skin color or condition.Record review of Resident #37's Wound Assessment Report dated 05/07/25 revealed,Location: Right HeelEtiology: Bullae (large blister containing serous fluid), Pressure InjuryStage/Severity: Deep Tissue InjuryAcquired in House: YesDate Wound Acquired: 05/07/2025In Remission: NoWound Status: NewRecord review of Resident #37's June 2025 Task Care Record revealed, Resident #37 was scheduled for turning/reposition every 2 hours (12 times a day); the task was not completed 12 times a day.Record review of Resident #37's July 2025 Task Care Record revealed, Resident #37 was scheduled for turning/reposition every 2 hours (12 times a day) from 07/01/25 to 07/20/25; the task was not completed 12 times a day. On 07/20/25 the task was changed so the resident was only turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of Resident #37's August 2025 Task Care Record revealed, Resident #37 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day.Record review of the facility weekly pressure report dated on 08/01/25 revealed Resident #37 had a stage 4 pressure ulcer to the right heel that was acquired in house and identified on 05/07/25.Record review of Resident #37's physician order summary report dated 08/06/25 revealed an order for the stage 4 pressure injury (a deep wound that exposes underlying muscle, tendon, cartilage or bone) to the right heel: cleanse with wound cleanser, pat dry, apply Santyl and calcium alginate with silver and cover with border foam dressing every day shift and as needed, dated 08/05/25; an order for low air loss mattress for pressure reducing measures every shift, dated 07/20/25.Record review of Resident #37's follow up wound evaluation note dated 08/06/25 by the wound care NP revealed the recommended treatment included air boots while in bed.Record review of Resident #37's September 2025 Task Care Record revealed, Resident #37 was only scheduled to be turned/repositioned every shift (three times a day). The task was completed and signed for no more than 3 times each day Observation and interview of wound care for Resident #37 on 08/07/25 at 10:00 AM, by the Wound Care Nurse and the Physical Therapist revealed the resident had two large circular red spots to the right heel with light colored edges and the surrounding skin was pinkish red in color. The Wound Care Nurse stated the wound was originally one large wound. The Physical Therapist performed the ultramist wound therapy (a painless, non-contact treatment that uses low-frequency ultrasound energy and a saline mist to promote healing in chronic and difficult-to-heal wounds) which took approximately 3 minutes, then the wound care nurse completed the wound care without incident. In an observation and interview on 09/16/25 at 03:00 PM, Resident #37 lying in bed with pressure relieving boots on. She said her pressure ulcer on her heel started off as a blister and at the time she did not use pressure relieving boots. Resident #37 said she only started wearing the boots after she developed her pressure ulcer. In an interview on 08/06/25 at 9:45 AM, the Wound Care Nurse stated there have been issues with heel boots not being applied when supposed to particularly with Resident #41 and Resident #30. The Wound Care Nurse stated the orders for the boots were in the MAR, but she would find that the residents would not have the boots on. The Wound Care Nurse stated the CNAs would immediately place the heel protectors on the residents when the wound care nurse was seen rounding. The Wound Care

Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 8 residents (Resident #82) reviewed for pain management. - The facility failed to continuously assess Resident #82's pain for more than 24 hours after her admission on [DATE]. This failure could place residents at risk for decreased quality of life, uncontrolled, irretractable pain, and hospitalization. Findings Include: Record review of Resident #82's Face Sheet, dated 08/06/25, revealed an [AGE] year-old female, admitted to the facility from a private home for hospice-respite services, with diagnoses of: Alzheimer's Disease, protein-calorie malnutrition. Record review of Resident #82's Admin Census revealed, she admitted to the facility on [DATE] at 1:16 PM. Record review of Resident #82's Entry MDS dated [DATE] revealed, Resident #82 entered from hospice. Record review of Resident #82's Baseline Care Plan, signed by LVN J on 08/05/25, revealed, comments- Resident #82 was confused and blind. Medications Resident #82 was taking: opioids was not documented/selected. Medical conditions; does resident need terminal care was documented as NO. Record review of Resident #82's Clinical admission documentation, dated 08/05/25 at 09:04 PM, revealed, the resident arrived on a stretcher with no family/support person in attendance. The resident's baseline neurological information was unknown, she had highly impaired hearing, had chronic disorganized thinking, severe cognitive impairment, and mood was pleasant, and no unwanted behaviors witnessed was marked as 'not met.' Under special care: the options of hospice, respite and palliative care were not selected. Under pain; indicators of pain was marked as none. Mouth or facial pain, discomfort or difficulty with chewing was not assessed. Under the clinical care plan section, pain was blank. Vocal complaints of pain was not assessed. The following clinical suggestions were left blank/unchecked: Evaluate for factors that aggravate the pain (position, activity, etc.); Evaluate the side effects of pain medication(s); Administer pain medication as ordered - monitor effectiveness; Administer pain medication as ordered - monitor effectiveness; Evaluate for pain and discomfort. Record review of Resident #82's Order Summary Report dated 08/06/25 revealed:- Admit to facility under the care of the Medical Director for hospice or respite care. With a start date of 08/05/25.- Morphine 20 mg/5ml: give 0.5 ml by mouth every 1 hours as needed for SOB/pain. With a start date of 08/05/25.- Monitor pain and record per scale. Use the 0-10 Pain Scale or PAINAD Scale. Document vital signs,interventions, and outcomes, in the progress notes as needed. Use non-pharmacological pain interventionsas needed. NOTIFY PHYSICIAN IF PAIN IS NOT CONTROLLED. every shift. With a start date of 08/06/25.- Monitor for Decreased Respiratory rate, Drowsy, Change in Cognition, Pain control effectiveness, constipation, nausea, vomiting, or itching every shift. If any of these occur notify MD immediately.She had no other orders for any pain medication and no pain monitoring orders active on the day she admitted [DATE]. Record review of Resident #82's August MAR printed on 08/06/25 at 04:21 PM revealed,- Resident #82 had not received her morphine since admission.- on 08/06/25 LVN M had monitored the resident for pain but there was no documented pain scale. Record review of Resident #82's Pain Level: Weights & Vitals records on 08/06/25 at 04:22 PM revealed, the facility had not assessed or recorded any pain levels for Resident #82. Record review of Resident #82's Progress Notes printed on 08/06/25 at 04:25 PM revealed;- 08/05/25 at 08:19 PM signed by LVN J: Upon arrival, the resident presented with agitation, which was consistent with her baseline behavior. Obtaining vital signs was challenging, and the resident refused a full skin assessment.- 08/05/25 at 08:46 PM signed by LVN J: Resident not cooperative with transfers. Resident is not cooperative with repositioning.- 08/05/25 at 09:02 PM signed by LVN J: Behaviors: Repetitive: Chronic. Disruptive: Chronic. Resident has frequent delusions (e.g., suspicions, verbal disruption) that are harmful to self or others or limits participation in activities. Resident has behavior (i.e., combativeness, verbal disruptions) that is harmful to self or others or limits participation in activities. Resident has anxiety or nervousness that impairs his/her quality of life or limits participation in activities. Medication Evaluation: Non-pharmacologic approaches have been used prior to prescribing the medication. Medication improved some of the resident's above symptoms.- 08/05/25 at 09:04 PM signed by LVN J: Mental Status: Resident was disorganized in thinking. Oriented to person.Disorganized thinking: Chronic. Level of cognitive impairment: Severe impairment (affecting all areas of judgement).- 08/06/25 at 07:42 PM signed by LVN G: staff in room to obtain vital signs when patient became agitated and upset and told staff to get the hell out.-08/07/25 at 09:00 AM signed by LVN S: Hospice was called regarding resident's behavior, and this nurse was told that one of the nurses would call her ASAP after getting an order from the MD for ABH cream for agitation and anxiety. Response still pending.- 08/07/25 at 01:05 PM signed by the DON: Resident observed in bed, hollering out at staff as they attempted to assist and resident observed saying don't touch me.-08/07/25 at 02:00 PM signed by LVN S: Resident was able to eat most of her dinner. she has been calm. there was no screaming and hollering at all and there was much more cooperation from her. Record review of Resident #82's Pain Assessments revealed, a pain assessment was completed on 08/06/25 at 05:49 PM by the Unit Manager. Resident #82 was unable to answer any questions about her pain frequency, the effect of pain on her function. The resident's numeric rating of pain was documented as 0 but the verbal descriptor scale was documented as not assessed. Staff documented Resident #82 had no indicators of pain or possible pain, and the pain management section that documented non-medication and medication management of pain was left blank. The final comment read: Resident denies pain at this time. Record review of Resident #82's POC Response History dated 08/06/25 at 07:25 PM revealed; there was no documentation of any assessment of pain. No data was found for Question 1: Resident Complained of Pain with answer options of Yes, No, Resident not available, Resident Refused and Not Applicable. In an observation and interview on 08/06/25 at 02:13 PM, inspection of the 200 Hall Nurse Cart with LVN M revealed:- a clear Ziploc bag with text that read loose [Resident #82] return to family; give to DON, loose narcotics no label that contained 12 prefilled 1 ml syringes with 0.5 ml of blue liquid labeled Morphine 20 mg/5ml. The syringe labels did not contain pharmacy information, prescriber information, resident information or directions for use.- Resident #82 had no control sheets for any medications including the morphine syringesLVN M said the prefilled syringes arrived with Resident #82, but they could not be used. She said the medication could not be used because they did not have the appropriate labeling so their contents could not be verified. LVN M said she had no other morphine available for Resident #82 and she had not administered any morphine to Resident #82 during her shift. In an interview on 08/06/25 at 03:15 PM, the DON said LVN J received the medications for Resident #82. She said the medication was not appropriately labeled so they could not be used. In an interview on 08/06/25 at 04:30 PM, the surveyor notified the DON that Resident #82 had not received any pain medication since admission and nursing staff reported they had no pain medication available for the resident. In an interview on 08/06/25 at 04:40 PM, LVN M said Resident #82 had not reported pain but she was agitated. She said she had checked on Resident #82 only 3 times during her shift that started at 6 AM. She said Resident #82 was only oriented to herself but she could press the call bell and the resident had not pressed it to report pain. LVN M said she had not done any specific pain monitoring for Resident #82. An observation on 08/06/25 at 04:43 PM revealed, Resident #82 in her room screaming out for a family member. The resident continuously bit the bed remote and the cord to the bed remote. She screamed saying give me my clothes that she stole. Do you know where some of my things are, I am fitting to call [the police department]. I assume she stole my clothes. The resident called people trash and said she was going to bop the shit out of someone and said she wanted to fight staff. Resident #82 continued to scream you're stupid that's what's wrong with you, you're dumb, she then calmed down and said I don't feel good someone try to take my pulse, I feel bad while biting her hand. In an interview on 08/06/25 at 04:43 PM, CNA AP said Resident #82 had been combative since admission on [DATE]. The resident was combative when providing incontinent care. The resident was calm when she slept but when she was awake, she was fidgeting and trying to get out of bed. In an interview on 08/06/25 at 05:00 PM, LVN M said earlier she talked to the resident and she calmed down and laid back down but no one told her the resident was biting herself and attempting to hit staff. An observation on 08/06/25 at 05:05 PM revealed, LVN M talking to Resident #82 in the resident's room. LVN M asked Resident #82 if she wanted to drink and the resident said well, thank you darling. Resident #82 began screaming and said, Get that stuff off me, in my eye or nose she did not want it and it tastes awful and asked for a family member. LVN M asked Resident #82 who for a family member was and Resident #82 responded a good friend but get out of my face. Resident #82 said I don't feel good today I feel kind of bad, she continued to ask for a family member and said, I am going to lay back down, I don't feel good, I am tired. Resident #82's behaviors continued until 05:22 PM, as she shouted and insulted staff. Resident #82 said I don't feel good, that hurts, I don't feel so good. In an interview on 08/06/25 at 05:40 PM, the DON said Resident #82's hospice provider had not delivered the resident's pain medication and she requested it be ordered stat so at this moment Resident #82 had no medications available for pain management. She said she notified the Medical Director, who said he could not prescribe anything for Resident #82 since her initial medications were prescribed by hospice The DON said at this moment the facility could only use non-pharmacological methods like massage/repositioning and distraction if Resident #82 reported pain, so she notified the hospice medical director to call in a stat order for Resident #82's pain medications. She said based on the records she reviewed the nursing staff called the hospice provider to notify them they could not accept the medication and while Resident #82 had orders to receive morphine in the system there was none at hand at the time. The DON said she could attempt to get an alternative pain medication in the interim but she had not done so because she had just learned Resident #82 did not have any pain medication on hand. The DON said she did not know the frequency Resident #82 received pain medications in the past but due to the fact the resident had every 1-hour prn pain medication, nursing staff should check on the resident every 1 hour and document in the EMR. She said failure to adequately manage a resident's pain could result in withdrawal symptoms of nervousness, headaches, and nausea. The DON said with Resident #82's use of prn morphine the resident should have had orders for pain monitor and she said the facility needs to round on [Resident #82] often. An observation on 08/07/25 at 08:33 AM revealed, Resident #82 screamed at staff with the room door closed and a staff member later identified as CNA AE was heard responding to the resident. Resident #82 said I don't want bacon, are you that dumb, if you don't have any food with some food in it. If you throw one more piece of food in my face shut up. Is that clear if not the next piece is going to be in your face. I don't want Bacon, eggs, grits is there nothing else to eat. CNA AE said bacon, eggs and grits was for breakfast when Resident #82 said Can I get a piece of bread to make a sandwich, this is pathetic I want something to eat. I asked you a question, shut up, I wanna see what you are going to tell me. Resident #82 then asked, is the bacon the bacon, eggs the only thing you got? to which CNA AE said yes. The resident then screamed If you put one more thing in my mouth, I am going to slap you. If this falls in my lap, I am going to slap you in your face. Is there anything I can eat except that crap you showed me? to which CNA AE said, that's all we have. Resident #82 said I am trying to think of something I can eat, are you sure that's the only thing to which CNA AE said, yes mam, that's all we have. Resident #82 said Tell you a secret, bacon, eggs and grits are not what I want for breakfast lunch or dinner. CNA AE told Resident #82 that she would leave, and Resident #82 responded Is there anything else for dinner, you don't know a damn thing. Resident #82 said I there anything else for dinner, you don't know a damn thing. She said something inaudible and then die before asking for lunch meat, to which CNA AE said there was no lunch meat and lunch was at 12:00. In an interview on 08/07/25 at 08:45 AM, CNA AL said Resident #82 was very aggressive. He said when the resident admitted she tried to hit staff and said staff should Kill yourself and called people a piece of shit when they tried to weigh her in the mechanical lift ( a device used to transfer individuals with limited mobility). As the surveyor interviewed CNA AL, Resident #82 was heard screaming I don't feel good do you have anything to eat, mam mam, is there anyone in the house that has a brain. You are just downright dumb. CNA AL said he had not received any special instructions or directives on how to provide care to Resident #82. He just knew, in his professional experience, to make sure the resident's bed was in low position since the resident moved around in her bed and to keep the door open. Resident #82 was heard screaming y'all are dumb assess and CNA AE came out of the resident's room. An observation and interview on 08/07/25 at 08:49 AM revealed, Resident #82's breakfast tray. Her cup of orange juice was full and her bacon eggs and grits looked untouched. CNA AE said the resident was combative, while she was trying to assist her with breakfast and threw food at her. She said Resident #82 only ate 1 piece of bread, some grapes. In an interview on 08/07/25 at 08:52 AM, LVN S said Resident #82 had behaviors all morning and they were unable to treat her with her PRN medications because the resident refused medications. In an interview on 08/07/25 at 10:12 AM, the Medical Director said hospice was expected to provide all medications for hospice residents. He said if a resident admitted with inappropriately labeled medications nursing staff were supposed to rectify the issue while reconciling the medication. He said he was ok with the facility using Resident #82's inappropriately labeled medication and that's on hospice. In regard to ordering alternative medications in the interim when hospice medications were not available, the Medical Director said since it was a hospice resident, hospice had the responsibility for taking care of their patient. He said failure to have appropriate medications for hospice residents would place them at risk for pain, anxiety, and restlessness. The Medical Director said an opioid tolerant patient could experience withdrawal symptoms which included: tachycardia (fast heart rate), and increased agitation. He said when he assessed the resident she was resting comfortably. The Medical Director said facility staff had not notified him that the resident was yelling, screaming and threatening staff upon admission. He said if a hospice resident displayed those symptoms, the facility must call the hospice provider so they can address the behaviors. The Medical director said he expected residents with behaviors be seen immediately and medication administered to address the behaviors but he was not notified about the behaviors or the unavailable medication. He said he would intervene if hospice was not responding to the facility's requests and he wanted hospice to step up their game in regard to medication availability. The Medical director said he was notified yesterday of Resident #82's behaviors, and he would expect hospice to provide a response to reported behaviors or unavailable medications within 1-2 hours and facility to contact him within an 8-hour shift if hospice had not responded. When the Medical Director was asked at what point he would intervene, since Resident #82 had not had medications since admission, he would not provide an answer. The Medical Director said he had not been notified that Resident #82 was refusing her medications and failure to treat behaviors could place residents at risk for increased discomfort and escalating behaviors. An observation on 08/07/25 at 10:43 AM revealed, Resident #82 in bed screaming is anybody here. The DON was observed and heard on the phone at the nursing station talking to the hospice provider. She said Resident #82 had been at the facility since the 5th and asked if anyone was coming to see the resident. The DON said the resident had behaviors and hospice needed to come to the facility to complete an evaluation. In an interview on 08/07/25 at 11:22 AM, LVN J said he admitted Resident #82 around 6 PM on 08/05/25. He said the resident arrived at the facility unaccompanied via EMS transport but the hospice staff came in to tuck Resident #82 in. He said Resident #82's medications were found in her personal items in a dirty plastic bag with a pressed sealed, the medications were not appropriately labeled so they could not be used. LVN J said a medication had to have the resident's name, and strength. He said Resident #82's medications were mixed with red and green so he could not confirm what it was. He said he notified and showed the hospice staff the inappropriately labeled medication on the day Resident #82 admitted and the hospice nurse said she would take care of it. LVN J did not report Resident #82 experiencing any pain at admission. In an interview on 08/07/25 at 11:39 AM, the DON said Resident #82's Morphine came in at 1:30 AM on 08/07/25 (36 hours after the resident admitted ). She said the information was just communicated to her and did not require documentation in the resident's chart. An observation and interview on 08/07/25 at 12:26 PM, the Hospice Nurse was talking to Resident #82 in the resident's room. The Hospice Nurse said she provided care to Resident #82 prior to the resident's admission to the facility. She said the resident was doing pretty good but she had a bad headache this morning. The Hospice Nurse said she did not tuck the resident in when she arrived and this was the first time she saw the resident since she admitted to the facility. She reviewed Resident #82's orders on her cellphone and said Resident #82's Morphine was ordered for prn every 1 hour, but the resident did not always receive pain medication.In an interview on 08/11/25 at 02:01 PM, the DON said failures with Resident #82's medications started with the hospice providers failure to provide appropriate medication. She said the facility has since educated their contracted hospice providers on the medication expectations and if a medication was unavailable nursing staff must immediately notify the doctor to get an alternative treatment that could be pulled from the automated dispensing system. She said the facility completed audits to ensure all residents had their pain medications, had appropriate pain monitoring orders, and ensured pain monitoring reflected the residents needs depending on how frequently the medication was administered. The DON said the facility completed audits to ensure all residents had their medications, trained staff on documentation of behaviors and the clinical management team will continue to audit the 24-hour report to ensure all identified behaviors are addressed. Record review of the undated facility policy titled Pain Management with no revision date revealed, Purpose: Ensure that residents receive pain management in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. Procedure: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. Pain management is based on the comprehensive assessment of a resident. In order to help a resident attain or maintain his or her highest practicable level of well-being and to prevent or manage pain, the facility, to the extent possible: 1. Recognizes when the resident is experiencing pain and identifies circumstances when pain can be anticipated. Medication regimens for residents receiving end of life, palliative or hospice care may include opioids alone or combining opioids and benzodiazepines. Their use must be consistent with accepted standards of practice for this specialty of care. Pharmacological as well as non-pharmacological interventions will be implemented in accordance with the comprehensive resident assessment. These interventions will be included in the resident's plan of care. Record review of the facility policy titled admission Order with no revision date revealed, Policy: admission Orders Purpose: Ensure each resident receives necessary care and services upon admission. Procedure: At the time each resident is admitted , this facility must have physician orders for the resident's immediate care. Physician orders for immediate care are those written and/or verbal orders this facility's staff need to provide essential care to the resident, consistent with the resident's mental and physical status upon admission to the facility. These orders should, at a minimum, include dietary, medications (if necessary) and routine care to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and ensure it had a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and that drug records were in order and an account of all controlled drugs was maintained and periodically reconciled for 1 of 3 (200 Hall Medication Cart) medication carts and 5 of 8 residents (Resident #49, Resident #69, Resident #71, Resident #75 and Resident #82) reviewed for pharmacy services. - The facility failed to acquire medications hospice residents and residents admitted for respite care (a short term stay in a nursing facility that provides temporary relief for caregivers of individuals needing assistance, allowing them to take a break from their caregiving duties) immediately after admission which resulted in: Resident #82 not having morphine available at admission and not having her ABH gel (a topical containing Alprazolam/Benadryl/Haldol that is applied to the wrist used to treat behaviors) leaving the resident with uncontrolled behaviors, unable to eat and combative with staff.- The facility failed to have a system in place to log and track ABH gel (lorazepam/Benadryl/Haldol) and Morphine received for Resident #82 on 08/05/25.- The facility failed to ensure the 200 Hall Nursing Cart did not contain expired Insulin for administration to Resident #69.- The facility failed to ensure nursing staff administered pre-prandial (before a meal) insulin to Resident #2, Resident #8, Resident #19, and Resident #65 safely by administering it more than 30 minutes before scheduled meals. These failures could place residents at risk for misappropriation of controlled substances, uncontrolled pain, uncontrolled behaviors and hospitalization. Findings include: Record review of the facility In-service/Education Sheet dated 01/08/25 revealed, Subject- Ordering Medication. When ordering medication, we only order medications for long-term residents who are not hospice. Any resident on hospice service that need medication. Hospice should be notified and called to fill those RX. Any respite residents should come in with their own medication. We DO NOT order medication for hospice or respite residents. IF YOU HAVE ANY QUESTIONS/CONCERNS PLEASE REACH OUT TO THE UNIT MANAGER. Record review of Resident #82's Face Sheet, dated 08/06/25, revealed an [AGE] year-old female, admitted to the facility from a private home for hospice-respite services, with diagnoses of: Alzheimer's Disease, protein-calorie malnutrition. Record review of Resident #82's Admin Census revealed, she admitted to the facility on [DATE] at 1:16 PM. Record review of Resident #82's Entry MDS dated [DATE] revealed, Resident #82 entered from hospice. Record review of Resident #82's Baseline Care Plan, signed by LVN J on 08/05/25, revealed, comments- Resident #82 was confused and blind. Medications Resident #82 was taking: opioids was not documented/selected. Medical conditions; does resident need terminal care was documented as NO. Record review of Resident #82's Clinical admission documentation, dated 08/05/25 at 09:04 PM, revealed, the resident arrived on a stretcher with no family/support person in attendance. The resident's baseline neurological information was unknown, she had highly impaired hearing, had chronic disorganized thinking, severe cognitive impairment, and mood was pleasant, and no unwanted behaviors witnessed was marked as 'not met.' Under special care: the options of hospice, respite and palliative care were not selected. Under pain; indicators of pain was marked as none. Mouth or facial pain, discomfort or difficulty with chewing was not assessed. Under the clinical care plan section, pain was blank. Vocal complaints of pain was not assessed. The following clinical suggestions were left blank/unchecked: Evaluate for factors that aggravate the pain (position, activity, etc.); Evaluate the side effects of pain medication(s); Administer pain medication as ordered - monitor effectiveness; Evaluate for pain and discomfort. Record review of Resident #82's Progress Notes printed on 08/06/25 at 04:25 PM revealed;- 08/05/25 at 08:19 PM signed by LVN J: Upon arrival, the resident presented with agitation, which was consistent with her baseline behavior. Obtaining vital signs was challenging, and the resident refused a full skin assessment.- 08/05/25 at 08:46 PM signed by LVN J: Resident not cooperative with transfers. Resident is not cooperative with repositioning.- 08/05/25 at 09:02 PM signed by LVN J: Behaviors: Repetitive: Chronic. Disruptive: Chronic. Resident has frequent delusions (e.g., suspicions, verbal disruption) that are harmful to self or others or limits participation in activities. Resident has behavior (i.e., combativeness, verbal disruptions) that is harmful to self or others or limits participation in activities. Resident has anxiety or nervousness that impairs his/her quality of life or limits participation in activities. Medication Evaluation: Non-pharmacologic approaches have been used prior to prescribing the medication. Medication improved some of the resident's above symptoms.- 08/05/25 at 09:04 PM signed by LVN J: Mental Status: Resident was disorganized in thinking. Oriented to person.Disorganized thinking: Chronic. Level of cognitive impairment: Severe impairment (affecting all areas of judgement).- 08/06/25 at 07:42 PM signed by LVN G: staff in room to obtain vital signs when patient became agitated and upset and told staff to get the hell out.-08/07/25 at 09:00 AM signed by LVN S: Hospice was called regarding resident's behavior, and this nurse was told that one of the nurses would call her ASAP after getting an order from the MD for ABH cream for agitation and anxiety. Response still pending.- 08/07/25 at 01:05 PM signed by the DON: Resident observed in bed, hollering out at staff as they attempted to assist and resident observed saying don't touch me.-08/07/25 at 02:00 PM signed by LVN S: Resident was able to eat most of her dinner. she has been calm. there was no screaming and hollering at all and there was much more cooperation from her. Record review of Resident #82's Order Summary Report dated 08/06/25 revealed,- Admit under the care of the [Medical Director] for hospice or respite care with a start date of 08/05/25.- Escitalopram 10 mg: give 1 tablet by mouth one time a day for depression with a start date of 08/05/25.- Mirtazapine 15 mg: give 1 tablet by mouth at bedtime for depression with a start date of 08/05/25.- Lorazepam 1 mg: give 1 tablet by mouth every 2 hours as needed for anxiety/agitation with a start date of 08/05/25.- ABH Gel 1mg/25mg/1mg/mL gel: apply 1 ml to inner wrist every 6 hours prn severe agitation with a start date of 08/05/25.- Morphine 20 mg/5ml: give 0.5 ml by mouth every 1 hours as needed for SOB/pain. With a start date of 08/05/25. In an observation and interview on 08/06/25 at 02:13 PM, inspection of the 200 Hall Nurse Cart with LVN M revealed:- a clear Ziploc bag with text that read loose [Resident #82] return to family; give to DON, loose narcotics no label that contained 12 prefilled 1 ml syringes with 0.5 ml of blue liquid labeled Morphine 20 mg/5ml. The syringe labels did not contain pharmacy information, prescriber information, resident information or directions for use.- Resident #82 had no control sheets for any medications including the morphine syringesLVN M said the prefilled syringes arrived with Resident #82, but they could not be used. She said the medication could not be used because they did not have the appropriate labeling so their contents could not be verified. LVN M said she had no other morphine available for Resident #82 and she had not administered any morphine to Resident #82 during her shift. In an interview on 08/06/25 at 03:15 PM, the DON said LVN J received the medications for Resident #82. She said the medication was not appropriately labeled so they could not be used. In an interview on 08/06/25 at 04:30 PM, the surveyor notified the DON that Resident #82 had not received any pain medication since admission and nursing staff reported they had no pain medication available for the resident. In an interview on 08/06/25 at 04:40 PM, LVN M said Resident #82 had not reported pain but she was agitated. She said she had checked on Resident #82 only 3 times during her shift that started at 6 AM. She said Resident #82 was only oriented to herself but she could press the call bell and the resident had not pressed it to report pain. LVN M said she had not done any specific pain monitoring for Resident #82. An observation on 08/06/25 at 04:43 PM revealed Resident #82 in her room screaming out for a family member. The resident continuously bit the bed remote and the cord to the bed remote. She screamed saying give me my clothes that she stole. Do you know where some of my things are, I am fitting to call [the police department]. I assume she stole my clothes. The resident called people trash and said she was going to bop the shit out of someone and said she wanted to fight staff. Resident #82 continued to scream you're stupid that's what's wrong with you, you're dumb. She then calmed down and said, I don't feel good someone try to take my pulse, I feel bad while biting her hand. In an interview on 08/06/25 at 04:43 PM, CNA AP said Resident #82 had been combative since admission on [DATE]. The resident was combative when providing incontinent care. The resident was calm when she slept but when she was awake, she was fidgeting and trying to get out of bed. In an interview on 08/06/25 at 05:00 PM, LVN M said earlier she talked to the resident and she calmed down and laid back down but no one told her the resident was biting herself and attempting to hit staff. An observation on 08/06/25 at 05:05 PM revealed. LVN M talking to Resident #82 in the resident's room. LVN M asked Resident #82 if she wanted to drink and the resident said well, thank you darling. Resident #82 began screaming and said, Get that stuff off me, in my eye or nose she did not want it and it tastes awful and asked for . LVN M asked Resident #82 who was and Resident #82 responded a good friend but get out of my face. Resident #82 said I don't feel good today I feel kind of bad, she continued to ask for a family member and said, I am going to lay back down, I don't feel good, I am tired. A staff member attempted to put a pillowcase on her pillow and Resident #82 snatched at it, tugging at it before the staff member released the pillow and the resident said, you better shut up, you ain't got nothing but yourself. LVN M retrieved Lorazepam and attempted to administer it to Resident #82 and the resident said get out of my face, I want you all to get out of my house or I will call the police. Need a brain in your head. LVN M was unable to administer the medication and walked towards her nursing cart and then Resident #82 said Need a brain in your head, I don't feel feel good, I feel real sick. LVN M hid the Lorazepam in pudding and administered the medication to Resident #82 who then said, I don't like you; I don't want you here. I know how you are; you are a liar. Resident #82's behaviors continued until 05:22 PM, as she shouted and insulted staff. Resident #82 said I don't feel good, that hurts, I don't feel so good. In an interview on 08/06/25 at 05:40 PM, the DON said Resident #82's hospice provider had not delivered the resident's pain medication and she requested it be ordered stat so at this moment Resident #82 had no medications available for pain management. She said she notified the Medical Director, who said he could not prescribe anything for Resident #82 since her initial medications were prescribed by hospice The DON said at this moment the facility could only use non-pharmacological methods like massage/repositioning and distraction if Resident #82 reported pain, so she notified the hospice medical director to call in a stat order for Resident #82's pain medications. She said based on the records she reviewed the nursing staff called the hospice provider to notify them they could not accept the medication and while Resident #82 had orders to receive morphine in the system there was none at hand at the time. The DON said she could attempt to get an alternative pain medication in the interim but she had not done so because she had just learned Resident #82 did not have any pain medication on hand. The DON said she did not know the frequency Resident #82 received pain medications in the past but due to the fact the resident had every 1-hour prn pain medication, nursing staff should check on the resident every 1 hour and document in the EMR. She said failure to adequately manage a resident's pain could result in withdrawal symptoms of nervousness, headaches, and nausea. The DON said with Resident #82's use of prn morphine the resident should have had orders for pain monitor and she said the facility needs to round on [Resident #82] often. An observation on 08/07/25 at 08:33 AM revealed, Resident #82 screamed at staff with the room door closed and a staff member later identified as CNA AE was heard responding to the resident. Resident #82 said I don't want bacon, are you that dumb, if you don't have any food with some food in it. If you throw one more piece of food in my face shut up. Is that clear if not the next piece is going to be in your face. I don't want Bacon, eggs, grits is there nothing else to eat. CNA AE said bacon, eggs and grits was for breakfast when Resident #82 said Can I get a piece of bread to make a sandwich, this is pathetic I want something to eat. I asked you a question, shut up, I wanna see what you are going to tell me. Resident #82 then asked, is the bacon the bacon, eggs the only thing you got? to which CNA AE said yes. The resident then screamed If you put one more thing in my mouth, I am going to slap you. If this falls in my lap, I am going to slap you in your face. Is there anything I can eat except that crap you showed me? to which CNA AE said, that's all we have. Resident #82 said I am trying to think of something I can eat, are you sure that's the only thing to which CNA AE said, yes mam, that's all we have. Resident #82 said Tell you a secret, bacon, eggs and grits are not what I want for breakfast lunch or dinner. CNA AE told Resident #82 that she would leave, and Resident #82 responded Is there anything else for dinner, you don't know a damn thing. Resident #82 said I there anything else for dinner, you don't know a damn thing. She said something inaudible and then die before asking for lunch meat, to which CNA AE said there was no lunch meat and lunch was at 12:00. In an interview on 08/07/25 at 08:45 AM, CNA AL said Resident #82 was very aggressive. He said when the resident admitted she tried to hit staff and said staff should Kill yourself and called people a piece of shit when they tried to weigh her in the mechanical lift ( a device used to transfer individuals with limited mobility). As the surveyor interviewed CNA AL, Resident #82 was heard screaming I don't feel good do you have anything to eat, mam mam, is there anyone in the house that has a brain. You are just downright dumb. CNA AL said he had not received any special instructions or directives on how to provide care to Resident #82. He just knew, in his professional experience, to make sure the resident's bed was in low position since the resident moved around in her bed and to keep the door open. Resident #82 was heard screaming y'all are dumb assess and CNA AE came out of the resident's room. An observation and interview on 08/07/25 at 08:49 AM revealed, Resident #82's breakfast tray. Her cup of orange juice was full and her bacon eggs and grits looked untouched. CNA AE said the resident was combative, while she was trying to assist her with breakfast and threw food at her. She said Resident #82 only ate 1 piece of bread, some grapes. In an interview on 08/07/25 at 08:52 AM, LVN S said Resident #82 had behaviors all morning and they were unable to treat her with her PRN medications because the resident refused medications. In an interview on 08/07/25 at 10:12 AM, the Medical Director said hospice was expected to provide all medications for hospice residents. He said if a resident admitted with inappropriately labeled medications nursing staff were supposed to rectify the issue while reconciling the medication. He said he was ok with the facility using Resident #82's inappropriately labeled medication and that's on hospice. In regard to ordering alternative medications in the interim when hospice medications were not available, the Medical Director said since it was a hospice resident, hospice had the responsibility for taking care of their patient. He said failure to have appropriate medications for hospice residents would place them at risk for pain, anxiety, and restlessness. The Medical Director said an opioid tolerant patient could experience withdrawal symptoms which included: tachycardia (fast heart rate), and increased agitation. He said when he assessed the resident she was resting comfortably. The Medical Director said facility staff had not notified him that the resident was yelling, screaming and threatening staff upon admission. He said if a hospice resident displayed those symptoms, the facility must call the hospice provider so they can address the behaviors. The Medical director said he expected residents with behaviors be seen immediately and medication administered to address the behaviors but he was not notified about the behaviors or the unavailable medication. He said he would intervene if hospice was not responding to the facility's requests and he wanted hospice to step up their game in regard to medication availability. The Medical director said he was notified yesterday of Resident #82's behaviors, and he would expect hospice to provide a response to reported behaviors or unavailable medications within 1-2 hours and facility to contact him within an 8-hour shift if hospice had not responded. When the Medical Director was asked at what point he would intervene, since Resident #82 had not had medications since admission, he would not provide an answer. The Medical Director said he had not been notified that Resident #82 was refusing her medications and failure to treat behaviors could place residents at risk for increased discomfort and escalating behaviors. An observation on 08/07/25 at 10:43 AM revealed, Resident #82 in bed screaming is anybody here. The DON was observed and heard on the phone at the nursing station talking to the hospice provider. She said Resident #82 had been at the facility since the 5th and asked if anyone was coming to see the resident. The DON said the resident had behaviors and hospice needed to come to the facility to complete an evaluation. In an interview on 08/07/25 at 10:47 AM, LVN S said she called the hospice provider to see if they could bring Resident #82's ABH gel and the resident really needed it. She said the facility currently had nothing in place to prevent/treat Resident #82's behaviors and the only medication she could administer was morphine because it was a liquid. An observation on 08/07/25 at 10:49 AM revealed, VP A and CNA AL in Resident #82's room. Resident #82 said I called about 5 to 8 times for help. VP A asked what Resident #82 needed and the resident said, a potty, I got to TT, got to real bad, oh man that hurts. Resident #82 said, I gotta go real bad, it takes forever for someone to come. She had to go bad but no one was here. Oh, that hurts. VP A instructed CNA AL to go to therapy to get a wheelchair to take Resident #82 to the restroom. At 10:53 AM, CNA AL returned to Resident #82's room with a wheelchair and informed the resident she got a wheelchair to take her to the restroom to which Resident #82 said thank you. In an interview on 08/07/25 at 11:22 AM, LVN J said he admitted Resident #82 around 6 PM on 08/05/25. He said the resident arrived at the facility unaccompanied via EMS transport but the hospice staff came in to tuck Resident #82 in. He said Resident #82's medications were found in her personal items in a dirty plastic bag with a press zipper, and the medications were not appropriately labeled so they could not be used. LVN J said a medication had to have the resident's name, strength and Resident #82's medications appeared to be mixed fluids that were red and green so he could not confirm what it was. He said he notified and showed the hospice staff of the inappropriately labeled medication on the day Resident #82 admitted and the hospice nurse said she would take care of it. LVN J said when the resident arrived, she displayed behaviors, she would tell people they were stupid or say, I love you and he did not remember if he administered her any medications for behaviors but if he did it should be recorded in the resident's chart. LVN J said he worked the morning shift when Resident #82 admitted to the facility, and he was not notified about the resident refusing meals or being difficult. He said he did not remember anything serious being brought to his attention' and there was nothing serious that he had to take any immediate action for in regard to Resident #82. In an interview on 08/07/25 at 11:39 AM, the DON said Resident #82's Morphine came in at 1:30 AM on 08/07/25 (36 hours after the resident admitted ). She said the information was just communicated to her and did not require documentation in the resident's chart. An observation and interview on 08/07/25 at 12:26 PM, revealed the Hospice Nurse talking to Resident #82 in the resident's room. The Hospice Nurse said she provided care to Resident #82 prior to the resident's admission to the facility. She said the resident was doing pretty good but she had a bad headache this morning. The Hospice Nurse said she did not tuck the resident in when she arrived and this was the first time she saw the resident since she admitted to the facility. She reviewed Resident #82's orders on her cellphone and said Resident #82's Morphine was ordered for prn every 1 hour, but it was prn so the resident did not always receive pain medication. She said the resident liked to be left alone and the resident did not eat this morning because she did not care about the food. The Hospice Nurse said Resident #82 liked fast food, snacks, and sodas. She called Resident #82's family on the phone and asked them to bring the resident some snacks. The Hospice Nurse said the facility needed ABH gel on hand to be able to provide care to Resident #82, she said she had not seen the resident since she admitted on [DATE]. In an interview on 08/07/25 at 12:52 PM, the Hospice Nurse said sometimes Resident #82 will take her lorazepam but ABH gel was needed when Resident #82 became combative or when she refused her Lorazepam. She said she was not notified until this morning that the resident had behaviors and the facility did not have ABH gel. The Hospice Nurse said she received notification from her office at 09:49 AM this morning that the resident had behaviors, and there was an emergency need for the resident's ABH gel so she put in a stat order. She said the facility needs to notify the hospice provider as soon as possible when a resident had behaviors or needed medications. In an interview at 08/07/25 at 02:46 PM, LVB S said the facility received only 6 doses of ABH gel today, 08/07/25, at 1 PM. Record review of the facility policy Acceptance of medications on Admission with no revision date revealed, Purpose: Establish uniform guidelines for acceptance of medications upon admission of a resident to the facility. Procedure: 1. Medications (e.g., drugs, sedatives, narcotics, medicated lotions, ointments, etc.) brought by or with the resident upon admission to the facility may not be used after admission unless the contents of the container have been examined and positively identified by the pharmacy/pharmacist or the resident's attending physician. 4. Medications which are accepted, but do not meet the facility's labeling requirements, must be returned to the pharmacy for proper labeling prior to administration. 5. If there is any doubt concerning the identity of a medication, the staff/charge nurse must contact the resident's attending physician and/or facility pharmacist 7. Medications not accepted by the facility must be returned to the resident's representative or destroyed in accordance with the facility's established procedures. 8. The staff/charge nurse will be responsible for documenting the results of the facility's decision to accept or reject medications brought by the resident upon admission. Record review of the facility policy titled admission Order with no revision date revealed, Policy: admission OrdersPurpose: Ensure each resident receives necessary care and services upon admission. Procedure: At the time each resident is admitted , this facility must have physician orders for the resident's immediate care. Physician orders for immediate care are those written and/or verbal orders this facility's staff need to provide essential care to the resident, consistent with the resident's mental and physical status upon admission to the facility. These orders should, at a minimum, include dietary, medications (if necessary) androutine care to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. In an interview on 08/11/25 at 02:01 PM, the DON said failures with Resident #82's medications started with the hospice providers failure to provide appropriate medication. She said the facility has since educated their contracted hospice providers on the medication expectations and if a medication was unavailable nursing staff must immediately notify the doctor to get an alternative treatment that could be pulled from the automated dispensing system. She said the facility completed audits to ensure all residents had their pain medications, had appropriate pain monitoring orders, and ensured pain monitoring reflected the residents needs depending on how frequently the medication was administered. The DON said the facility completed audits to ensure all residents had their medications, trained staff on documentation of behaviors and the clinical management team will continue to audit the 24-hour report to ensure all identified behaviors are addressed. 200 Hall Nursing CartRecord review of Resident #69's Face Sheet dated 08/11/25 revealed, a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included: hemiplegia and hemiparesis (weakness and paralysis) following cerebral infarction, Type 2 Diabetes Mellitus (DM), high blood pressure, and muscle weakness. Record review of Resident #69's Quarterly MDS dated [DATE] revealed severely impaired cognition as indicated by a BIMS score of 07 out of 15. The indication of use of insulin injections was noted. Record review of Resident #69's undated Care Plan revealed, Focus - Has Diabetes Mellitus and at risk for complications. Intervention: Diabetes medication as ordered by doctor. Monitor/document for side effects andeffectiveness. Record review of Resident #69's physician orders dated 08/11/25 revealed order dated 02/08/25 for Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 10 unit subcutaneously after meals for DM II hold if missing a meal or fasting otherwise DO NOT hold without an order.In an observation and interview on 08/06/25 at 02:13 PM, inspection of the 200 Hall Nurse Cart with LVN M revealed:- An expired open and in-use 10 ml vial of HumaLOG Insulin with an open date of 07/01/25.- a clear plastic bag with text that read loose [Resident #82] return to family; give to DON, loose narcotics no label that contained 12 prefilled 1 ml syringes with 0.5 ml of blue liquid labeled Morphine 20 mg/5ml. The syringe labels did not contain pharmacy information, prescriber information, resident information, or directions for use.- Resident #82 had no control sheets for any medications including the morphine syringes.LVN M said nursing staff are expected to check their carts daily as used for expired and inappropriately labeled medication. She said insulin vials are labeled with the date opened in order to track their expiration date. LVN M said the vial of insulin was opened on 07/01/25 and it was expired because insulin is only good for 28 days after opening. She said after expiration, insulin can lose its potency or become contaminated placing residents at risk of uncontrolled blood sugars or infections if used so they must be discarded. LVN M said she had administered Resident #69 insulin from that vial after the calculated expiration date of 07/28/25. LVN M said the inappropriately labeled prefilled syringes arrived with Resident #82, but they could not be used. She said the medication could not be used because they did not have the appropriate labeling so their contents could not be verified. LVN M said there were no control log sheets for the medications because it could not be used and they were to be returned to the family. She said normally when the facility received controlled medications nursing staff logged in the medication and documented use as well as disposal to prevent misappropriation. LVN M said since there was no record of the receipt of the medication there was no way to confirm how many syringes arrived with the resident or to track if the contents of the Ziploc were stolen. In an interview on 08/06/25 at 03:15 PM, the DON said LVN J received the medications for Resident #82. She said the medicationwas not appropriately labeled so they could not be used. She said when nursing staff received controlled substances 2 nurses were supposed to complete a count and then fill out and sign a narcotic log prior to placing the medication in the locked drawer to prevent diversion and to establish the count. She said failure to log controlled substances could place residents at risk of unauthorized access which could result in allergies, safety issues and misappropriation. The DON said nursing staff are expected to check their carts daily as used for expired or inappropriately labeled medication. She said multidose containers including insulin should be labeled with the date opened in order to track the expiration date. She said most insulin expire after 28 days and they can become contaminated or have decreased potency placing residents at risk for infection and hyperglycemia if used. Resident #49 Record review of Resident #49's Face Sheet dated 08/11/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included: Heart failure, Type 2 Diabetes Mellitus (DM), high blood pressure, and muscle weakness. Record review of Resident #49's Quarterly MDS dated [DATE] revealed cognitively intact as indicated by a BIMS score of 14 out of 15. The indication of use of insulin injections was noted. Record review of Resident #49's undated Care Plan revealed, Focus - Has Diabetes Mellitus and is at risk for complications. Intervention: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Record review of Resident #49's physician orders dated 08/11/25 revealed order date of 05/01/2025 for NovoLOG Flexpen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Aspart) Inject 8 units subcutaneously at bedtime for DM 2 HOLD FOR BS LESS THAN 150. Additionally, order date 04/30/2025 for NovoLOG Injection Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 0 - 149 = 0 units; 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 10 unit 10 units and call MD, subcutaneously before meals for DM. Review of Resident #49's MAR Location of Administrator Report revealed, Resident #49's sliding scale insulin was scheduled for 06:00 AM (1.5 hours before the scheduled breakfast); 11:30 AM and 04:30 PM- 07/05/25 Resident #49 received his insulin Aspart scheduled for 06:00 AM at 05:04 AM.- 07/10/25 Resident #49 received his insulin Aspart scheduled for 06:00 AM at 05:25 AM.- 07/13/25 Resident #49 received his insulin Aspart scheduled for 06:00 A

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 9%, based on 3 errors out of 32 opportunities, which involved 2 of 7 residents (Resident #48 and Resident #56) and 1 of 3 staff (LVN M) reviewed for medication errors.- LVN M failed to accurately administer medication to Resident #48 by crushing extended release Mucinex (a medication used for phlegm and congestion).- LVN M failed to accurately administer medications to Resident #56 by failing to administer the resident's Lexapro 5 mg (used to treat depression) and attempting to administer 10 ml of seizure medication (Levetiracetam) instead of 7.5 ml as ordered by the resident's physician.These failures could place all residents receiving medication at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.Findings include:Resident #56Record review of Resident #56's Face Sheet dated 08/06/25 revealed, a [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses which included: brain damage, type 2 diabetes, epilepsy (a brain condition in which abnormal electrical activity in the brain causes recurring seizures), MDD, difficulty swallowing, protein-calorie malnutrition (malnutrition caused by insufficient protein and calories), quadriplegia (full body paralysis) and gastrostomy status (a tube placed in the stomach through a hole in the abdomen Record review of Resident #56's Annual MDS dated [DATE] revealed, short- and long-term memory problems, severely impaired cognitive skills for daily decision making, total dependence for all ADLs, aphasia (brain damage that affects the person's ability to communicate), feeding tube while a resident, received 51% or more of his intake via tube feeding and 501 ml per day or more via tube feeding.Record review of Resident #56's undated Care Plan revealed, Focus: may require tube feeding r/t dysphagia; intervention- the resident is dependent with tube feeding and water flushes. PPE required for high resident contact care activities. Focus: history of seizure disorders r/t anoxic (complete lack of oxygen) brain injury. Risk of infection- EBP at all time; interventions: Staff is to wear PPE's for all contact with resident as long as the resident is on EBP precautions, for things such as dressing, changing linens, transfers, providing hygiene, wound care, device care (or use), bathing or showering, changing briefs or assisting with toileting.Record review of Resident #56's Order Summary Report dated 08/06/25 revealed, - Bolus: ISOSOURCE 1.5 administer 1 can six times a day.- Check for residual. Hold feeding and notify MD if residual >150 mL every shift.- Flush tube with 30mL before and after feeding, Every shift.- Flush tube with 30mL before and after meds. Every shift.- Allopurinol Tablet 100 MG: Give 1 tablet by mouth two times a day for Gout. - Carvedilol Oral Tablet 3.125 MG: Give 1 tablet via PEG-Tube two times a day for hypertension; hold for SBP less 110 &or HR less than 60.- Entresto Oral Tablet 24-26 MG (Sacubitril-Valsartan) : Give 1 tablet via PEG-Tube two times a day for Hypertension; hold for SBP less than 110 &or HR 60.- Levetiracetam Oral Solution 100 MG/ML: Give 7.5 ml via PEG-Tube two times a day for seizure.- Lexapro Oral Tablet 5 MG (Escitalopram Oxalate) : Give 1 tablet via PEG-Tube one time a day for Depression. - Memantine HCl Oral Tablet 10 MG: Give 1 tablet via PEG-Tube two times a day for dementia.- Tramadol HCl Oral Tablet 50 MG: Give 1 tablet via PEG-Tube two times a day for Pain.- Valproic Acid Oral Solution 250 MG/5ML: Give 5 ml via PEG-Tube two times a day for seizure. Record review of Resident #56's August 2025 MAR revealed, LVN M did not administer Resident #56's Escitalopram 5 mg scheduled on 08/09/25 at 09:00 AM. An observation on 08/09/25 at 09:52 AM revealed, LVN M preparing medication for administration for Resident #56. She popped out 1 tablet of: Entresto, Memantine, Carvedilol, Allopurinol and Tramadol into individual medication cups; and poured out 5 ml of Valproic Acid and 10 ml of Levetiracetam. LVN M checked all drawers in her cart that contained blister packed medication but could not locate Resident #56's Lexapro so she proceeded without the medication. At 09:56 AM, she crushed each medication separately and returned them to their individual medication cups and at 10:00 LVN M she entered into Resident #56's room with all the medications. Resident #56 was observed to be non-verbal.; He displayed an exaggerated smile intermittently and some nonverbal sounds. She dissolved each medication with 10-15 ml of water and mixed each with individual spoons. At 10:07 AM, she drew 30 ml of warm water into a syringe, connected it to Resident #56's G-tube port and pushed all 30 mL of water. Right after LVN M withdrew her first liquid medication and attempted to start administering the resident's medication, the surveyor stopped her and asked her to verify the volume of Levetiracetam she was going to administer. LVN M confirmed the volume was 10 ml instead of 7.5 ml and she wasted approximately 2.5 mL into the trash. LVN M then administered all 7 medications to Resident #56 by pushing them through the syringe with approximately a 10-15 ml of water flush in between each medication. In an interview on 08/09/25 at 03:15 PM, the DON said nursing staff are expected to check orders prior to administering medications and they must ensure the medications are the appropriate formulation that can be crushed. Resident #48Record review of the Resident #48's Face Sheet dated 08/06/25 revealed, a 75pyear-old male, who admitted to the facility on [DATE], with diagnoses including diagnosis which included: stage 4 pressure ulcer to the hip, left sided weakness and paralysis, and end stage renal disease.Record review of Resident #48's undated Care Plan revealed, Special Instructions: Crush Medications. Focus: acid reflux and risk for complications; interventions- give medications as ordered.Record review of Resident #48's Order Summary revealed, Guaifenesin ER Tablet Extended Release 12 Hour600 MG Give 1 tablet by mouth every 12 hours for congestion with start date of 08/05/25.An observation on 08/06/25 at 08:32 AM revealed, LVN M preparing for medication administration to Resident #48. She retrieved a Guaifenesin ER 600 mg (Mucinex) pill and crushed it along with 4 other solid form medications, mixed them in pudding and administered it to resident #48.In an interview on 08/09/25 at 02:23 PM, LVN M said she had not administered Resident #56's Lexapro because the pharmacy had not delivered the medication. She said she had access to the automated dispensing system; but she had not checked if it contained Lexapro and she did not know if it usually did. LVN M said nursing staff were expected to check the automated dispensing system when a medication was not available because failure to administer medications as ordered could place residents at risk for untreated health conditions and worsening of symptoms. She said ER medications could not be crushed because crushing these formulations would impact how the medication was absorbed.Record review of LVN M's Competency Assessment: Medication Administration dated 06/03/25 revealed, LVN M was deemed competent and was assessed for the right drug, right dose.Record review of the facility policy titled Medication Administration, General, with no revision date revealed, purpose: Safely and accurately administer physician-ordered medication to each resident. 5. Remember the six (6) Rs of correct medication administration: a. Right Resident; b. Right Drug; c. Right Dose: Verify against MAR, Check the medical record for the physician's order if unsure. d. Right Dosage Form, Verify against the MAR; e. Right Time; f. Right Route. Only crush medications as ordered. The consulting pharmacy will provide a Do Not Crush list of medications. Consult a pharmacist before crushing medications if unsure. Some medications that are never to be crushed include: a. Enteric-coated medications; b. Sustained or extended-release tablets; c. Sublingual or buccal tablets; d. Effervescent tablets.Record review of the facility policy titled Medication Error, undated, with no revision date revealed, Definitions: Medication Error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with: 1. The prescriber's order; 2. Manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological or 3. Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various [NAME] Healthcare(R) 203 Operational Guidelines: Long-Term Care practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils.

Based on observation, interview, and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 8 resident (Resident #26 and Resident #62) reviewed for accuracy of assessments. - The facility failed to ensure Resident #26's admission MDS, dated [DATE], accurately reflected the residents use of opioid pain medication, Oxycodone,. - The facility failed to ensure Resident #62's Annual MDS, dated [DATE], accurately reflected the residents significant weight loss of 12.7% over a 6-month period from 01/15/25 to 07/08/25 dated. These failures could place residents at risk of inaccurate assessments, which could compromise their plan of care . Findings include: Resident #62 Record review of Resident #62's face sheet, dated 08/10/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #62 had diagnoses which included: seizures, anxiety disorder, hypertension (high blood pressure) and alcohol dependence with alcohol induced persisting dementia. Record review of Resident #62's Annual MDS, dated [DATE], revealed intact cognition as indicated by a BIMS score of 14 out of 15, non-traumatic brain disfunction, non-Alzheimer's dementia. Resident #11 did not have weight loss of 5% of more in the last month or loss of 10% or more in the last 6 months. Record review of Resident #62's, undated, Care Plan revealed, Focus: impaired cognitive function/impaired thought process; Interventions- Administer medications as ordered. Focus- use of antipsychotic medication and at risk for complications. Interventions- monitor/report PRN adverse reactions to antipsychotic therapy; appetite loss & weight loss. There were no focus areas addressing any dietary or weight loss concerns for Resident #62. Record review of Resident #62's weights records revealed:- 01/14/25 at 03:38 PM- 129 lbs.- 07/08/25 at 02:14 PM- 112.6 lbs. Record review of Resident #62's Nutrition/Dietary Notes revealed,- 05/02/25 at 02:03 PM: RD note for weight change. CBW: 115 lbs. Current BMI: 22.5 (slightly under desired range for age). Weight trends: -2.2% x30 days, -7.3% x90 days, -10.9% x180 days. Ordered diet is adequate. Charted meal intake mostly 76-100% with/ a few refusals noted. Although no significant weight change has occurred x30 day, nutritional intervention may be beneficial at this time to prevent continued weight loss/promote weight stability. Ordered diet: Regular, Regular texture, thin consistencyRec: fortified food w/ all meals Goals: adequate PO intake, CBW +/- 5% x30 days. RD to monitor.- 07/09/25 at 03:23 PM: RD note for weight change. CBW: 112.6#. Current BMI: 21.3 (slightly under desired range for age).Weight trends: -1.7% x30 days, -4.1% x90 days, -12.7% x180 days. Ordered diet is adequate. Charted meal intake varies meal to meal, Resident able to make food preferences. Ordered diet: Regular, Regular texture, thin consistency. Goals: adequate PO intake, CBW +/- 5% x30 days RD to monitor.- 08/06/25 at 05:47 PM- Weight Review: CBW: 110 lbs. 61 Current BMI: 20.8 (slightly under desired range for age).Weight trends: -2.5% x30 days, -4.3% x90 days, -11.3% x180 days. Ordered diet: Regular, Regular texture, thin consistency. Charted meal intake varies meal to meal 26-76% depending on meal, Resident able to make food preferences known. Due to weight trends, and highly particular eating habits, RD rec order pre-albumin level x 1 to evaluate recent nutrition status. Res with history of significant weight loss, with non sig weight loss x 90/180 days. Note res has previously desired weight loss but now she is considering borderline underweight for age. RD will continue to monitor. An observation and interview on 08/05/25 at 09:21 AM revealed Resident #62 well groomed, well dressed in no immediate distress. She said the facility provided her sufficient food, her diet was appropriate and she had no issues or concerns. Resident #62 appeared thin but was in good spirits. Resident # 26 Record review of Resident #26's face sheet, dated 08/05/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #26 had diagnoses which included: fracture of the right forearm, person injured in traffic collision and orthopedic (having to do with bones, joints, ligaments, tendons and muscles) aftercare. Record review of Resident #26's admission MDS, dated [DATE], revealed intact cognition as indicated by a BIMS score of 14 out of 15, upper extremity (shoulder, elbow, wrist, hand) functional limitation in range of motion, and other fracture. Under the pain assessment interview, Resident #26 reported: the presence of pain occasionally, with pain occasionally impacting her sleep, pain rarely or not at all interfering with her therapy activities and her day-to-day activities; and her pain intensity was a 02 out of 10. Under pain management, Resident #26 was coded no for: received scheduled pain medication regimen; no for received PRN pain medications or was offered and declined; and received non-medication intervention for pain. Record review of Resident #26's, undated, Care Plan revealed Focus: risk for pain related to recent fracture; Goal- resident will not have an interruption in normal activities due to pain through the review date; intervention- administer analgesic (drug to relieve pain) as per orders, monitor/record pain characteristics per shift and as needed. Record review of Resident #26's Order Summary Report, dated 08/10/25, revealed, - Acetaminophen 500 mg: give 2 tablets by mouth every 8 hours as needed for pain with order start date of 07/15/25- Oxycodone 5 mg: Give 1 tablet by mouth every 6 hours as needed for severe pain for 3 days 7-10 pain scale with order state of 07/15/25 and end date of 07/18/25.- Oxycodone 5 mg: Give 1 tablet by moth every 6 hours for severe pain with order start date of 07/16/25. - Oxycodone 5 mg: Give 1 tablet by mouth every 12 hours for severe pain with order start date of 07/17/25. - Lidocaine 5% patch: apply to lower back and right shoulder topically for lower back pain and right shoulder pain order start date 07/24/25.- Oxycodone 5 mg: Give 1 tablet by mouth every 8 hours as needed for pain with order start date of 08/01/25. Record review of Resident #26's Progress Notes revealed,07/17/25 signed by the NP, - Resident #26's reported pain was adequately controlled; she is currently on oxycodone 5 mg every 12 hours. Patient currently has cast in place with minor swelling noted in fingers.Neurologically intact. Pain is adequately controlled with oxycodone 5 mg every 12 hours. Will continue current pain management regimen and wound care. Record review of Resident #26's July- August MAR revealed, -Resident #26 received scheduled and PRN oxycodone in July and PRN oxycodone in August. -Resident #26 was administered Lidocaine 5% Lidocaine patches to her back in July and August An observation and interview on 08/05/25 at 09:45 AM revealed Resident #26 lying in bed with a cast covered with a band aid wrap on her right lower arm. The resident said she broke her arm in a car accident, and she received scheduled pain medication, but it stopped when she was feeling better, and starting receiving PRN pain medication when she started experiencing pain again. Resident #26 reported her pain was controlled by her current pain regimen and she took her pain medications to get ahead of the pain. An observation on 08/06/25 at 08:15 AM revealed, LVN M applied a Lidocaine 5% patch to Resident #26 as ordered. In an interview on 08/11/25 at 07:37 AM, the MDS Nurse said she was the MDS coordinator for 2 years and she was responsible for completing MDS and Care Planning for the facility. She said the MDS was an assessment completed in collaboration with other facility staff that addressed the diagnosis, medications and treatments of a resident. The MDS nurse said she was responsible for the accuracy of the MDS, and no other staff verified the contents of the MDS after her. She said an inaccurate MDS placed residents at risk of the facility not having a true representation of the residents and the resident's needs not being met. In an interview on 08/11/25 at 01:13 PM, after reviewing Resident #62's MDS the MDS Nurse said the resident's MDS was inaccurate and significant weight loss should have coded in Resident #62's care plan. She said Resident #26 was administered pain medications scheduled and PRN in July prior to the completion of her MDS so her MDS should have been coded for received pain medications. She could not provide a reason Resident #26 and Resident #62's MDSs were inaccurate. Record review of the facility's policy titled Resident Assessment with no revision date revealed, .Procedure: This facility conducts initially and periodically a comprehensive, accurate,standardized reproducible assessment of each resident's functional capacity. The comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, uses the resident assessment instrument (RAI) specified by CMS.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3of 5 residents (Residents #37, Resident #48 and Resident #56) reviewed for infection control practices.-PT E failed to follow proper infection control and hand hygiene after providing wound care to Resident #37. - -PT E failed to perform hand hygiene prior to leaving the resident's room.-CNA N failed to follow proper infection control practices by washing hands in the clean utility room after handling dirty trash bags.- LVN M failed to wear the appropriate PPE when administering medications via G-tube to Resident #56. - LVN M failed to administer medications to Resident #48 and Resident #56 without touching the medication with her hands.Findings included:Resident #37Record review of Resident #37's face sheet dated 8/05/25 revealed a [AGE] year-old admitted to the facility on [DATE], initially admitted on [DATE] and originally admitted on [DATE]. Diagnoses included Guillain-Barre syndrome (a rare condition in which the immune system attacks the nerves causing weakness, numbness, or paralysis), heart attack, Quadriplegia (condition characterized by partial or complete paralysis of all four limbs and torso), and dementia.Record review of Resident #37's annual MDS dated [DATE] revealed a BIMS score of 13 out of 15 indicating intact cognition, impairment on both sides of upper and lower extremities and required substantial/maximal assistance for bed mobility. Section M-Skin Conditions revealed Resident #37 was at risk of developing pressure ulcers/injuries and did not have any unhealed pressure ulcers/injuries.Record review of Resident #37's physician order summary report dated 08/06/25 revealed and order for the stage 4 pressure injury (a deep wound that exposes underlying muscle, tendon, cartilage or bone) to the right heel: cleanse with wound cleanser, pat dry, apply Santyl and calcium alginate with silver and cover with border foam dressing every day shift and as needed. Dated 08/05/25.Record review of Resident #37's undated Care Plan Report revealed: Focus - Resident #37 has actual pressure ulcer development r/t impaired mobility and incontinence. Right heel, 5/7/25. Revision was made on 07/01/25. Goal - The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Target date was 08/25/25. Interventions - Administer treatments as ordered and monitor for effectiveness: Responsible position LVN, RN. Follow facility policies/protocols for the prevention/treatment of skin breakdown: CNA, LVN, RN. Monitor/document/report PRN any changes in skin status: Weekly skin assessment: CNA, LVN, RN. Further review revealed Ultra mist therapy (a cutting-edge debridement ultrasound used in wound care) was not included in the interventions.Record review of Resident #37's Skin Issues form effective date 07/30/25 and evaluated by the Wound Care Nurse revealed, modality used was Ultrasound Mist and heel suspension/protection device was listed as additional care.Observation of wound care on 08/07/25 at 10:00 AM, PT E and Wound Care Nurse performed hand hygiene, put on gowns and gloves and entered Resident #37's room. PT E completed the Ultra mist procedure on Resident #37's stage 4 pressure ulcer wound to the right heel. Wound Care Nurse completed the wound care to Resident #37's right heel. PT E removed used gown and gloves, placed them into trash bag then securing the bag. PT E stepped out of the room, walked down the hallway to the dirty utility room and put the trash bag into the bin. PT E walked across the hallway and washed hands in the clean utility room.In an interview on 08/07/25 at 10:30 AM, PT E was asked why did she wash hands in the clean utility room and not in Resident #37's room prior to leaving, PT E stated that she had to make sure the used Ultra Mist tubing that had hard plastic pieces was taken to the dirty utility room right away and that the clean utility room door was open so she used that sink to wash hands. PT E stated she should not have done that because infection could be spread that way and instead, she should have sanitized hands prior to leaving the resident room first.During an observation and interview on 08/07/25 at 11:30 AM, CNA N walked to the dirty utility room with trash bags then walked across the hall touched the keypad and door handle of the clean utility room and washed hands in the sink of the clean utility room. CNA N stated she would use the clean utility room to wash hands all the time and no one ever said anything about it. When asked the question what could go wrong, CNA N stated bacteria could be transferred from the dirty utility room to the clean utility room and then possibly to the residents. CNA N stated she should have used hand sanitizer when coming out of the dirty utility room instead of using the clean utility room sink.In an interview on 08/07/25 at 4:00 PM, the DON stated the expectation after completing resident care and before leaving the resident room was for staff to hand wash or hand sanitize and after exposure to any bodily fluids the staff must use hand soap and water. The DON stated it was important to do so to alleviate the spread of germs for infection control. The DON stated staff should not use the clean utility room sink to wash hands after resident care and at minimum perform hand sanitization then go to the rest room or staff employee room to wash hands. Record review of the undated facility policy for Hand Hygiene, Operational Guidelines: Long-Term Care read in part: Purpose: Handwashing will be regarded by this facility as the single most important means of preventing the spread of infection. Procedure: 1. Staff will follow the facility's established hand hygiene procedures to prevent the spread of infection and disease to other staff, residents and visitors. 2. Hands should be washed.under the following conditions.d. After having direct contact with the resident.h. After handling used dressings, contaminated equipment, etc. i. After contact with.non-intact skin.m. After removing gloves.Resident #56Record review of Resident #56's Face Sheet dated 08/06/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: brain damage, type 2 diabetes, epilepsy (a brain condition in which abnormal electrical activity in the brain causes recurring seizures), MDD, difficulty swallowing, protein-calorie malnutrition (malnutrition caused by insufficient protein and calories), quadriplegia (full body paralysis) and gastrostomy status.Record review of Resident #56's Annual MDS dated [DATE] revealed, short- & long-term memory problems, severely impaired cognitive skills for daily decision making, total dependence for all ADLs, aphasia (brain damage that affects the person's ability to communicate), feeding tube while a resident, received 51% or more of his intake via tube feeding and 501 ml per day or more via tube feeding.Record review of Resident #56's undated Care Plan revealed, Focus: may require tube feeding r/t dysphagia; intervention- the resident is dependent with tube feeding and water flushes. PPE required for high resident contact care activities. Focus: history of seizure disorders r/t anoxic (complete lack of oxygen) brain injury. Risk of infection- EBP at all time; interventions: Staff is to wear PPE's for all contact with resident as long as the resident is on EBP precautions, for things such as dressing, changing linens, transfers, providing hygiene, wound care, device care (or use), bathing or showering, changing briefs or assisting with toileting.Record review of Resident #56's Order Summary Report dated 08/06/25 revealed, - Allopurinol Tablet 100 MG: Give 1 tablet by mouth two times a day for Gout. - Carvedilol Oral Tablet 3.125 MG: Give 1 tablet via PEG-Tube two times a day for hypertension; hold for SBP less 110 &or HR less than 60.- Entresto Oral Tablet 24-26 MG (Sacubitril-Valsartan) : Give 1 tablet via PEG-Tube two times a day for Hypertension; hold for SBP less than 110 &or HR 60.- Levetiracetam Oral Solution 100 MG/ML: Give 7.5 ml via PEG-Tube two times a day for seizure.- Lexapro Oral Tablet 5 MG (Escitalopram Oxalate) : Give 1 tablet via PEG-Tube one time a day for Depression. - Memantine HCl Oral Tablet 10 MG: Give 1 tablet via PEG-Tube two times a day for dementia.- Tramadol HCl Oral Tablet 50 MG: Give 1 tablet via PEG-Tube two times a day for Pain.- Valproic Acid Oral Solution 250 MG/5ML: Give 5 ml via PEG-Tube two times a day for seizure. An observation on 08/09/25 at 09:52 AM revealed, LVN M preparing medication for administration for Resident #56. She popped out 1 tablet of: Entresto, Memantine, Carvedilol, Allopurinol and Tramadol into individual medication cups; and poured out 5 ml of Valproic Acid and 10 ml of Levetiracetam. LVN M touched the tramadol pill with her hands as she placed it in the cup. At 09:56 AM, she crushed each medication separately and returned them to their individual medication cups and at 10:00 LVN M she entered into Resident #56's room with all the medications. She did not wear a gown when she entered the residents room or through the medication administration process. She dissolved each medication with 10-15 ml of water and mixed each with individual spoons and then wore gloves. At 10:07 AM, she drew 30 ml of warm water into a syringe, connected it to Resident #56's G-tube port and pushed all 30 mL of water. Right after LVN M withdrew her first liquid medication and attempted to start administering the resident's medication, the surveyor stopped her and asked her to verify the volume of Levetiracetam she was going to administer. LVN M confirmed the volume was 10 ml instead of 7.5 ml and she wasted approximately 2.5 mL into the trash. LVN M then administered all 7 medications to Resident #56 by pushing them through the syringe with approximately a 10-15 ml of water flush in between each medication. Resident #48Record review of the Resident #48's Face Sheet dated 08/06/25 revealed, a 75pyear-old male who admitted to the facility on [DATE] with diagnosis which included: stage 4 pressure ulcer to the hip, left sided weakness and paralysis, and end stage renal disease.Record review of Resident #48's undated Care Plan revealed, Special Instructions: Crush Medications. Focus: acid reflux and risk for complications; interventions- give medications as ordered.Record review of Resident #48's Order Summary revealed, Cholecalciferol Oral Capsule 50 MCG (2000 UT)(Vitamin D3) Give 1 capsule by mouth one time a day for supplement.An observation on 08/06/25 at 08:32 AM revealed, LVN M preparing for medication administration to Resident #48. She retrieved a caplet of Cholecalciferol touching it with her bare hands and placed it in a medication cup and administered it along with 5 crushed solid form medications and 1 emptied capsule mixed in pudding and administered it to resident #48.Record review of LVN M's Competency Assessment: Medication Administration dated 06/03/25 revealed, LVN M was deemed competent. Record review of the facility policy titled Enhanced Barrier Precautions , PURPOSE: Prevent the spread of novel or targeted multidrug-resistant organisms (MDROs). Enhanced Barrier Precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.High-contact resident care activities include device care or use of a device: central line, urinary catheter, feeding tube, tracheostomy/ventilator. Enhanced Barrier Precautions apply to: All residents with any of the following. Wounds and/or indwelling medical devices (i.e., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. Procedure: 1. Perform hand hygiene with ABHR before entering the resident room. 2. Wear gloves and a gown when providing high-contact resident care activities (see General Information).

Based on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors for 4 of 11 residents (Residents #2, #8, #19, and #65) reviewed for significant medication errors. - The facility failed to ensure nursing staff administered pre-prandial (before a meal) insulin to Resident #2, Resident #8, Resident #19, and Resident #65 safely by administering it more than 30 minutes before meals. This failure could place residents at risk of uncontrolled blood sugars, hypoglycemia (low blood sugars), hyperglycemia (high blood sugars) and worsening of diabetes. Findings included: Record review of the facility provided Schedule of Mealtimes with no revision date revealed:- Breakfast - Dining Room: 8:00 - 8:30; Hallway: 7:30 - 8:00.- Lunch - Dining Room: 12:00 - 12:30; Hallway: 11:30 - 12:00.- Dinner - Dining Room: 5:30 - 6:00; Hallway: 5:00 - 5:30. Record review of the American Diabetes Association: Glycemic Goals and Hypoglycemia- Standards of Care in Diabetes 2025 revealed, Blood sugars were in range when between 70- 180 mg/dL; level 1 hyperglycemia (181- 250 mg/ dL); Level 2 hyperglycemia (greater than 250 mg/dL)TIR 70-180 mg/dL; Goal of greater than 50 Percent of time in range.TAR >250 mg/dL; Goal of less than 10 Percent of time in level 2 hyperglycemia.TAR 181-250 mg; Goal of less than 50 Percent of time in level 1 hyperglycemia. In an interview and observation on 08/06/25 at 07:20 AM, LVN K said she had already administered insulin to her residents, including sliding scale insulins that must be administered before meals. The surveyor observed at the time of the interview breakfast was not yet served in the halls or in the dining room. In an interview an observation on 08/06/25 at 07:22 AM, LVN C said she had already administered insulin to her residents, including sliding scale insulins that must be administered before meals. She said she administered her morning insulins at approximately 6:45 AM, since they were scheduled at 7:00 AM. The surveyor observed at the time of the interview breakfast was not yet served in the halls or in the dining room and LVN C said breakfast was normally served at 08:00 AM. In an interview and observation on 08/06/25 at 07:25 AM, LVN M said she had already administered insulin to her residents including sliding scale insulins that must be administered before meals. The surveyor observed at the time of the interview breakfast was not yet served in the halls or in the dining room. Observations on 08/06/25 revealed- 07:34 AM: no breakfast on halls or in the dining area.- 07:45 AM: no breakfast on halls or in the dining area- 07:50 AM: no breakfast on halls or in the dining area.- 07:55 AM: no breakfast on halls or in the dining area.- 08:00 AM: no breakfast on halls or in the dining area.- 08:09 AM: no breakfast on halls or in the dining area- 08:15 AM: no breakfast on halls or in the dining area- 08:35 AM: no breakfast on 100, 200, 300, and 400 Halls, staff passed breakfast on 800, 500, 600 & 700 halls and breakfast served in the dining room.- 08:35 AM: Nursing staff passing breakfast on the 800 hall. In an interview on 08/06/25 at 11:26 AM, the Medical Director said pre-prandial/short acting insulin should be served 15-30 minutes before meals to adjust blood sugar for anticipated meals. He said administration of short acting insulin could place residents at risk for hypoglycemia (low blood sugar). In an interview on 08/06/25 at 11:42 AM, the DON said nursing staff were expected to wait until meal trays were on the halls and trays are being passed before administering insulin. She said the facility had insulin scheduled for 07:00 AM while breakfast was scheduled for 07:30- 08:00 AM. She said pre-prandial (before meals) insulin should be administered within 15 minutes of meals in order to prevent anticipated hyperglycemia (high blood sugar) associated with meals and to prevent hypoglycemia if insulin was administered too early before meals. The DON said she did not know when the facility staff administered insulin but she was unaware breakfast was not served until past 08:15 am. She said it was absolutely not appropriate for insulin to be administered an hour or more before a meal. The DON said breakfast was late that morning because one of the dietary staff did not show up for work. She said snacks were served after meals and at bedtime and facility residents did not receive any stacks between 6 AM and breakfast. Resident #2 Record review of Resident #2's Face Sheet dated 08/11/25 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including: Type 2 Diabetes Mellitus (DM), high blood pressure, blindness, generalized anxiety disorder, and muscle weakness. Record review of Resident #2's Quarterly MDS dated [DATE] revealed severely impaired cognition as indicated by a BIMS score of 01 out of 15. The indication of use of insulin injections was noted. Record review of Resident #2's undated Care Plan revealed, Focus - Has Diabetes Mellitus. Intervention: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Record review of Resident #2's physician orders dated 08/11/25 revealed order date of 04/01/2025 for Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 200 = 0 units;201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units GREATER THAN 400 = 10 UNITS & CALL MD & LAB AS ORDERED, subcutaneously with meals for ANTIDIABETICS. Record review of Resident #2's MAR Location of Administration Report revealed:- on 08/06/25 LVN C administered Resident #2's Insulin Lispro at 07:17 AM. Resident #8 Record review of Resident #8's Face Sheet dated 08/11/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including: Type 2 DM with hyperglycemia, Atherosclerotic Heart Disease (a buildup of plaque in blood vessels that can cause a heart attack, chest pain and stroke), high blood pressure, and end stage renal disease on dialysis. Record review of Resident #8's Quarterly MDS dated [DATE] revealed moderately impaired cognition as indicated by a BIMS score of 12 out of 15. The indication of use of insulin injections was noted. Record review of Resident #8's undated Care Plan revealed, Focus - Has Diabetes Mellitus and is at risk for complications. Intervention: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Record review of Resident #8's physician orders dated 08/11/25 revealed order date of 03/21/2025 for Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units 401 +/= Give 12 units BS > Give 12 units and notify MD, subcutaneously before meals and at bedtime. Review of Resident #8's MAR revealed:- the resident's sliding scale insulin was scheduled for 07:00 AM, 11:00 AM 04:00 PM (1 hr. before dinner) and 08:00 PM- on 07/20/25 Resident #8 was administered his Humalog at 06:49 AM by LVN T Record review of Resident #8's blood sugar levels from 07/01/25 to 08/06/25 revealed, the resident had no recorded episodes of hypoglycemia (blood sugars under 70). He spent greater than 50% of time within the goal ADA range of 70-180. Resident #19 Record review of Resident #19's Face Sheet dated 08/11/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included: Alzheimer's Disease, Type 2 Diabetes Mellitus (DM), high blood pressure, and muscle wasting and atrophy. Record review of Resident #19's Quarterly MDS dated [DATE] revealed severely impaired cognition as indicated by a BIMS score of 03 out of 15. The indication of use of insulin injections was noted. Record review of Resident #19's undated Care Plan revealed, Focus - Has Diabetes Mellitus and is at risk for complications. Intervention: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Record review of Resident #19's physician orders dated 08/11/25 revealed order date of 03/21/2025 for Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units 401 +/= Give 12 units BS > Give 12 units and notify MD, subcutaneously before meals and at bedtime. Review of Resident #19's MAR Location Administration Report revealed, the resident's insulin lispro was scheduled for 07:00 AM, 11:00 AM, 4:00 PM (1 hr before dinner) and 08:00 PM.- on 08/07/25 Resident #19 was administered his 11:00 AM dose of insulin at 01:07 PM. Record review of Resident #19's blood sugar levels from 07/01/25 to 08/06/25 revealed, the resident had no recorded episodes of hypoglycemia (blood sugars under 70). He spent greater than 50% of time within the goal ADA range of 70-180. Resident #65 Record review of Resident #65's Face Sheet dated 08/11/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis which included: Aphasia (inability to speak) following cerebral infarction, Type 2 Diabetes Mellitus (DM), high blood pressure, unspecified psychosis, and muscle weakness. Record review of Resident #65's Quarterly MDS dated [DATE] revealed severely impaired cognition as indicated by a BIMS score of 02 out of 15. The indication of use of insulin injections was noted. Record review of Resident #65's undated Care Plan revealed, Focus - Has Diabetes Mellitus and is at risk for complications. Intervention: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Record review of Resident #65's physician orders dated 08/11/25 revealed order date of 07/23/2025 for Insulin Glargine Solution 100 UNIT/ML Inject 23 unit subcutaneously at bedtime for diabetes. Additionally, dated 07/01/2025 Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 4 unit subcutaneously before meals for DM and dated 06/04/25 Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8 units; 350 - 399 = 10 units, subcutaneously before meals and at bedtime for DMII inject subcutaneously per order. Review of Resident #65's MAR Location of Administrator Report revealed, Resident #65's sliding scale insulin was scheduled for 07:00 AM, 11:00 AM and 04:00 PM (1 hr. before dinner) in June.- 06/05/25 Resident #65 received his Insulin Lispro scheduled for 04:00 PM at 03:23 PM.- 06/06/25 Resident #65 received his Insulin Lispro scheduled for 11:00 PM at 10:47 AM.- 06/10/25 Resident #65 received his Insulin Lispro scheduled for 07:00 AM at 09:22 AM.- 06/13/25 Resident #65 received his Insulin Lispro scheduled for 07:00 AM at 06:44 AM.- 06/15/25 Resident #65 received his Insulin Lispro scheduled for 04:00 PM at 03:39 PM.- 06/20/25 Resident #65 received his Insulin Lispro scheduled for 07:00 AM at 06:29 AM.- 06/23/25 Resident #65 received his Insulin Lispro scheduled for 07:00 AM at 06:48 AM.- 06/25/25 Resident #65 received his Insulin Lispro scheduled for 04:00 PM at 03:52 PM. Review of Resident #65's MAR Location of Administrator Report revealed, Resident #65's sliding scale insulin was scheduled for 06:00 AM ( 1 1/2 hrs before scheduled breakfast), 11:00 AM and 04:00 PM (1 hr. before dinner) in JULY.- 07/03/25 Resident #65 received his Insulin Lispro scheduled for 06:00 AM at 06:47 AM.- 07/04/25 Resident #65 received his Insulin Lispro scheduled for 04:00 PM at 04:15 PM- 07/04/25 Resident #65 received his Insulin Lispro scheduled for 04:00 PM at 04:06 PM- 07/05/25 Resident #65 received his Insulin Lispro scheduled for 06:00 AM at 06:14 AM.- 07/05/25 Resident #65 received his Insulin Lispro scheduled for 04:00 PM at 04:16 PM- 07/06/25 Resident #65 received his Insulin Lispro scheduled for 06:00 AM at 06:11 AM.- 07/09/25 Resident #65 received his Insulin Lispro scheduled for 06:00 AM at 06:48 AM.- 07/10/25 Resident #65 received his Insulin Lispro scheduled for 06:00 AM at 06:20 AM.- 07/11/25 Resident #65 received his Insulin Lispro scheduled for 06:00 AM at 06:00 AM.- 07/12/25 Resident #65 received his Insulin Lispro scheduled for 06:00 AM at 06:54 AM.- 07/17/25 Resident #65 received his Insulin Lispro scheduled for 06:00 AM at 05:43 AM.- 07/20/25 Resident #65 received his Insulin Lispro scheduled for 06:00 AM at 06:39 AM. Review of Resident #65's MAR Location of Administrator Report revealed, the resident received Insulin Lispro at:- 08/01/25 at 04:23 PM- 08/02/25 at 04:18 PM- 08/05/25 at 06:49 AM.- 08/05/25 at 04:09 PM- 08/06/25 at 06:32 AM. Record review of Insulin Lispro (HumaLOG) Highlights of Prescribing Information revised 03/2013 revealed, HUMALOG is a rapid-acting insulin. You should take HUMALOG within fifteen minutes before eating or right after eating a meal.Record review of Insulin Aspart Highlights of Prescribing Information revised 02/2023 revealed, How should I take Insulin Aspart?: Insulin Aspart starts acting fast. You should eat a meal within 5 to 10 minutes after you take your dose of Insulin Aspart. Record review of FIASP Highlights of Prescribing Information revised 06/2023 revealed, How should I take FIASP?: FIASP(R) starts acting fast. You should take your dose of FIASP(R) at the beginning of the meal or within 20 minutes after starting a meal. Record review of the facility policy Medication Administration, General with no revision date revealed, no instructions on the administration of insulin. Record review of the facility policy titled Pharmacy Services with no revision dated revealed, Procedure- the facility must. 3. Employ or obtain services of a licensed pharmacist who. b- establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation. Record review of the Highlights of Prescribing Information for HumaLOG revealed, when in use (opened) 10 mL vials of HumaLOG are to be used within 28 days when stored in the refrigerator or at room temperature.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, the expiration date when applicable and stored all drugs and biologicals in locked compartments and under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 3 medication carts ( 500/600/700 Hall Medication aide Cart, 200 Hall Nursing Care) and 1 of 1 (500/600 Hall Med Room) Medication Rooms reviewed for medication storage. - The facility failed to ensure the 500/600/700 Hall Medication Aide Cart did not contain open multidose liquid supplements with no open date and loose pills.- The facility failed to ensure medication in the 500/600 Hall Med Room were stored under proper temperature controls- The facility failed to ensure the 200 Hall Med Cart did not contain supplements stored outside of proper temperature controls and controlled medication without proper pharmacy labeling. These failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings include: 500/600 Hall Med Room In an observation and interview on 08/06/25 at 12:40 PM, inspection of the 500/600 Hall Med Room Cart with LVN K revealed,- The medication refrigerator with no thermometer or device to determine the temperature. The fridge contained varied containers of Insulin, eye drops, vaccinations and TB test. - The refrigerator temperature log had not been signed on 08/05/25 and 08/06/25. All previous temperatures were checked during the night shift between 01:00 AM and 04:00 AM. LVN K said the medication refrigerator was supposed to have a thermometer sitting on the shelf but she did not know what happened to it. She said the night shift was responsible for checking the temperature and documenting it on the log. 500/600/700 Med Aide Cart In an observation and interview on 08/06/25 at 02:03 PM, inspection of the 500/600/700 Hall Med Aide Cart with CMA F revealed,- an open and in use bottle of Pro-stat protein supplement with no open date with manufacturer instructions that read Discard 3 months after opening.- 2nd drawer with 11 lose pills of assorted colors and sizes.CMA F said nursing staff are expected to check their carts daily as used for loose pills and inappropriately labeled medications. She said multidose containers must be labeled with the date opened in order to track the expiration date. CMA F said she did not know the beyond use date for the bottle of pro-stat so it could not be used because if expired it could cause residents GI upset.In an observation and interview on 08/06/25 at 02:13 PM, inspection of the 200 Hall Nurse Cart with LVN M revealed:An open and in-use bottle of acidophilus probiotic at room temperature with manufacturer instructions to Refrigerate after opening.- a clear plastic bag with text that read loose [Resident #82] return to family; give to DON, loose narcotics no label that contained 12 prefilled 1 ml syringes with 0.5 ml of blue liquid labeled Morphine 20 mg/5ml. The syringe labels did not contain pharmacy information; prescriber information, resident information or directions for use. LVN M said nursing staff were expected to check their carts daily as used for storage temperature and inappropriately labeled medication. She said the bottle of acidophilus (a probiotic) was supposed to be stored in the fridge because leaving it at room temperature could impact the potency. LVN M said the inappropriately labeled prefilled syringes arrived with Resident #82, but they could not be used. She said all medication was is supposed to have the pharmacy labeling which identified the resident, the drug, provider, dose and instructions for use. LVN M said inappropriately labeled medications could place residents at risk of adverse drug events, and side effects.In an interview on 08/06/25 at 03:15 PM, the DON said nursing staff were expected to check their carts daily as used for inappropriately labeled/packaged, expired medications, and medications stored out of manufacturer recommended temperatures daily as used and nursing management completed audits on Mondays. She said all medications were expected to be in their blister packs with pharmacy labeling, not lose to prevent a medication error or loss of inventory. She said multidose containers like pro-stat, should be labeled with the open date to track the expiration date, because if administered residents could become sick. The DON said all medications must be stored at the correct temperature and the night shift nurses were expected to check the temperature of the med room Fridge daily and document it on the log. She said without the thermometer, staff were unable to ensure that medications were stored at the correct temperature so they must me discarded immediately. The DON said medication stored in an uncontrolled or inappropriate temperature environment can become damaged and if administered can result in damage or infection to residents.Record review of the facility policy titled Storage of Medications with no revision date revealed, Policy: Storage of Medications. Purpose: Ensure that medications are stored in a safe, secure, and orderly manner. Procedure: 1. Medications are stored in the containers in which they are received. Transfer between containers is performed only by the dispensing pharmacy. 2. Drug containers having soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels are returned to the pharmacy for proper labeling before storing. 3. No discontinued, outdated, or deteriorated medications are to be used for use in this facility. All such medications are destroyed according to facility policy. 8. Medications requiring refrigeration must be stored in the refrigerator located in the drug room at the nurse's station. Medications must be stored separately from food and must be properly labeled. Proper temperature in the refrigerator must be maintained in accordance with manufacturer specification and national guidelines. 11. Multi-dose vials that have been opened or accessed should be dated and discarded within 28 days of opening/initial access unless the manufacturer specifies a shorter or longer date.Record review of the facility policy titled Labeling Medications with no revision date revealed, Purpose: Ensure that all medications maintained in the facility are properly labeled in accordance with current state and federal guidelines. Procedure: General Guidelines: 1. Drug labels must be legible at all times. 2. Any drug label that is soiled, incomplete, illegible, worn or makeshift must be returned and replaced by the dispensing pharmacy, not merely covered over. 3. Labels for individual drug containers must include: a. Resident's name. b. Prescribing physician's name. c. Name, address, and telephone number of dispensing pharmacy. d. Name, strength, and quantity of the drug. e. Prescription number. f. Date drug was dispensed. g. Appropriate accessory and cautionary statements. h. Expiration date. i. Directions for use. j. Remaining refills. 7. Containers that are soiled, cracked or without secure closures will not be used.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 8 residents (Resident #43) reviewed for ADL care. The facility failed to provide nail care to Resident #43, leaving the resident with fingernails approximately 1/2 inch longer than the nail bed and his toenails were long with some curling around the tip of his toes. Findings include: Record review of Resident #43's face sheet, dated 08/11/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #43 had diagnoses which included weakness & paralysis after a stroke, high cholesterol, muscle weakness and muscle wasting. Record review of Resident #43's Quarterly MDS, dated [DATE], revealed moderately impaired cognition as indicated by a BIMS score of 09 out of 15, no behavioral symptoms, no rejection of care, and supervision or touching assistance with personal hygiene. Record review of Resident #43's, undated, Care Plan revealed, Focus: Resident #43 has an ADL self-care performance deficit related to hemiplegia (paralysis on one side of the body), intervention: personal hygiene with 1 person assistance. Record review of Resident #43's POC Response History, dated 08/11/25, revealed in the last 30 days the resident had not received any manicures and had not refused any manicures. Record review of Resident #43's Progress Notes from 10/30/24 to 08/06/25 revealed, no documented refusal of nail care.In an observation and interview on 08/05/25 at 09:15 AM, Resident #43 was observed in bed with long fingernails. He said he preferred his fingernails short and had no problem with his nails being cut.An observation on 08/06/25 at 08:05 AM revealed Resident #43 lying in bed as the resident was administered oral medications. The DON and a staff nurse interrupted medication administration to assess Resident #43 and then the DON began to cut the residents nails. His nails were approximately 1/2 inches beyond the nail bed on his right hand except for his 3rd finger, which was short, Resident #43's left fingernails were all greater than 1/2 inch beyond his nail bed. Resident #43's toenails were overgrown, his 2nd to 4th toenails curled around the tip of his toes, his big toes were 1/4 to 1/2 inch beyond the nail bed. Only Resident #43's smallest toenails were at normal length. In an interview on 08/11/25 at 03:36 PM, the DON said nursing staff were expected to provide ADL care to residents which included personal hygiene and nail care. She said CNAs and Nurses were responsible for performing nail care to residents without diabetes. She said failure to provide nail care and maintaining nails at a short length placed residents at risk for infection, skin breakdown and injury if their nails snagged. The DON said the resident was known to be verbally aggressive, but she did not know of any issues with nail care. She said prior to her cutting the resident's nails on 08/06/25 she did not know Resident #43 had not received nail care. Record review of the facility's, undated, policy Bath, Bed revealed, purpose: Cleanse, refresh and soothe the resident Stimulate circulation; Inspect the body. Supplies/Equipment: Orange stick for nail care, if used by the facility. Procedure: 22. Care of fingernails and toenails is part of the bath. Be certain nails are clean. If toenails are difficult to cut, inform the charge nurse. 23. Check care plan for specifics regarding nail care, i.e., podiatrist or licensed nurse may need to do this.

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 of 1 Resident (Resident #56) reviewed for enteral nutrition.- LVN M failed to administer medications and enteral feed safely to Resident #56 by: initiating medication administration without first checking for G-tube (a tube inserted through the abdominal wall into the stomach for the administration of medication and food) placement,; administering a bolus feed immediately following medication administration of 7 medications,; and forcefully pushing medication and the bolus feed through a connected syringe instead of gravity.These failures could place residents at risk of injuries, and hospitalization.Findings include:Record review of Resident #56's Face Sheet dated 08/06/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: brain damage, type 2 diabetes, epilepsy ( a brain condition in which abnormal electrical activity in the brain causes recurring seizures), MDD, difficulty swallowing, protein-calorie malnutrition (malnutrition caused by insufficient protein and calories), quadriplegia (full body paralysis) and gastrostomy status. Record review of Resident #56's Annual MDS dated [DATE] revealed, short- & long-term memory problems, severely impaired cognitive skills for daily decision making, total dependence for all ADLs, aphasia (brain damage that affects the person's ability to communicate), feeding tube while a resident, received 51% or more of his intake via tube feeding and 501 ml per day or more via tube feeding.Record review of Resident #56's undated Care Plan revealed, Focus: may require tube feeding r/t dysphagia; intervention- the resident is dependent with tube feeding and water flushes. PPE required for high resident contact care activities. Focus: history of seizure disorders r/t anoxic (complete lack of oxygen) brain injury. Risk of infection- EBP at all times; interventions: Staff is to wear PPE's for all contact with resident as long as the resident is on EBP precautions, for things such as dressing, changing linens, transfers, providing hygiene, wound care, device care (or use), bathing or showering, changing briefs or assisting with toileting.Record review of Resident #56's Order Summary Report dated 08/06/25 revealed, - Bolus: ISOSOURCE 1.5 administer 1 can six times a day.- Check for residual. Hold feeding and notify MD if residual greater than 150 mL every shift.- Flush tube with 30mL before and after feeding, Every shift.- Flush tube with 30mL before and after meds. Every shift.- Allopurinol Tablet 100 MG: Give 1 tablet by mouth two times a day for Gout. - Carvedilol Oral Tablet 3.125 MG: Give 1 tablet via PEG-Tube two times a day for hypertension; hold for SBP less 110 &or HR less than 60.- Entresto Oral Tablet 24-26 MG (Sacubitril-Valsartan) : Give 1 tablet via PEG-Tube two times a day for Hypertension; hold for SBP less than 110 &or HR 60.- Levetiracetam Oral Solution 100 MG/ML: Give 7.5 ml via PEG-Tube two times a day for seizure.- Lexapro Oral Tablet 5 MG (Escitalopram Oxalate) : Give 1 tablet via PEG-Tube one time a day for Depression. - Memantine HCl Oral Tablet 10 MG: Give 1 tablet via PEG-Tube two times a day for dementia.- Tramadol HCl Oral Tablet 50 MG: Give 1 tablet via PEG-Tube two times a day for Pain.- Valproic Acid Oral Solution 250 MG/5ML: Give 5 ml via PEG-Tube two times a day for seizure.Record review of Resident #56's August 2025 MAR revealed, LVN M did not administer Resident #56's Escitalopram 5 mg scheduled on 08/09/25 at 09:00 AM.An observation on 08/07/25 at 09:52 AM revealed, LVN M preparing medication for administration for Resident #56. She popped out 1 tablet of: Entresto, Memantine, Carvedilol, Allopurinol and Tramadol into individual medication cups; and poured out 5 ml of Valproic Acid and 10 ml of Levetiracetam. At 09:56 AM, she crushed each medication separately and returned them to their individual medication cups and at 10:00 AM LVN M she entered into Resident #56's room with all the medications. Resident #56 was observed to be non-verbal. He displayed an exaggerated smile intermittently and some nonverbal sounds. She dissolved each medication with 10-15 ml of water and mixed each with individual spoons. At 10:07 AM, she drew 30 ml of warm water into a syringe, connected it to Resident #56's G-tube port and pushed all 30 mL of water. LVN M did not check for placement of Resident #56's G-tube with auscultation (listening to sounds) or by checking residual (the amount of feed that can be withdrawn from the feeding tube that is used to determine stomach fullness) prior to pushing 30 ml of feed, and Resident #56 started making sounds following the 30 mL of fluid. LVN M then administered all 7 medications to Resident #56 by pushing them through the syringe with approximately a 10-15 ml of water flush in between each medication. After administering the medications, LVN M then administered enteral feeding Isosource with the syringe. After the first 30 mL of enteral feed, Resident #56 became visibly agitated, his non-verbal sounds increased in volume, his exaggerated grins increased in frequency, his eyes bulged as they darted between LVN M and the surveyor, and he began to bite his fingers. Resident #56's bulging eyes appeared to be intentionally done and accompanied his exaggerated smile. The Surveyor interrupted the enteral feed and asked LVN M how she could determine if Resident #56 suffered any discomfort from the enteral feed and expressed concern about the increased volume of his non-verbal sounds, his biting of his fingers as well as bulging of his eyes. LVN M said the behaviors the surveyor observed were the resident's baseline and he knew how to communicate, so she knew he did not have discomfort. Resident #56's non-verbal volumes, biting of his finger, bulging, and darting eyes between LVN M and the surveyor subsided but did not stop and the nurse continued the enteral feed. LVN M did not administer approximately 30 ml of the enteral feed to Resident #56. When asked, she said she did not complete the total feed because since administered with the medications it might have been too much fluid for the resident at once and not because the surveyor expressed concern over Resident #56's non-verbal ques. Due to the resident's inability to communicate, the surveyors lack of knowledge of the resident and the decreased volume and frequency of behaviors expressed by Resident #56 at the end of the g-tube administration, the surveyor was unable to determine if the resident experienced any discomfort.In an interview on 08/08/25 at 02:23 PM, LVN M said prior to administering medication via G-tube nursing staff were expected to check for placement with auscultation by injecting 10 cc of air into the tube and listening for sounds. She said she did not check for placement prior to administration of medications and enteral feed to Resident #56 because she checked placement in the morning. She said staff check for placement to ensure that the tube is in the right place (stomach) because if it is not in the stomach the fluid administered could enter the wrong place causing irritation and inflammation. LVN M said the use of gravity vs. syringe for administration depended on the type of the tube and she could not administer medications via gravity for Resident #56 because of the type of tube he had. She said Resident #56's G-tube was too small to administer medications via gravity, so it had to be pushed slowly with the syringe. LVN M said G-tube administration should be performed via gravity because pushing via the syringe can cause the resident to throw up, damage the tubing or cause the resident internal damage. LVN M said during G-tube administration nursing staff are expected to observe the resident for any signs of discomfort. She said she was monitoring Resident #56's facial expressions for pain and she did not observe any.In an interview on 08/9/25 at 03:15 PM, the DON said prior to administering medication or feeding via a resident's G-tube nursing staff must first check for placement by checking the residual (the amount of feed that can be withdrawn from the feeding tube that is was used to determine stomach fullness) because failure to check for placement could result in the liquid being administered into the wrong area if the tube was not in the stomach, resulting in injury and infection. She said medications and feed should be administered via gravity and not through a syringe push because gravity delivers the medication to the stomach at a steady flow to prevent GI spasms. The DON said forceful pushing through the syringe could place residents at risk for cause injury to the GI system and damage to the tube. The DON said medication and bolus feeds were not to be completed concurrently because there was a risk of the medication being diluted. She said when monitoring a resident during G-tube administration, nursing staff should be monitoring the resident's face for the appearance of nauseousness or grimacing that could indicate pain.Record review of LVN M's Competency Assessment: G-tube Medication Administration, dated 06/03/25, revealed; 12- Check G-tube placement( instill about 10 ml of air and listen for sound- ensure syringe is dated); 13- check for residual (know residual volume- if greater than 10 ml, stop, hold medications and feeding and notify. If the resident is receiving bolus feedings consider the amount of medication and fluid to be instilled. The feeding may need to be at a different time than the medication administration to avoid overload. LVN M was deemed competent for G-tube medication administration.Record review of the facility policy titled Enteral Nutritional Therapy, (Tube Feeding), with no revision date revealed, also known as: Gastrostomy (G-tube) tube feeding, Percutaneous endoscopic gastrostomy (PEG) tube feeding, Bolus tube feeding, Assisted nutrition and hydration. Purpose: Provide liquid nutrition through a tube, inserted into the stomach; . Administer medications directly into the stomach. Procedure: 3. Remove plug from end of feeding tube check position of tube and attach barrel of syringe to end of tubing. 4. Check position of tube by: a. Listening for breath sounds at end of tube or place end of tube in a glass of water below water level to be sure no bubbles appear from nasogastric tube. b. Checking the length of tube for proper position for gastric or jejunostomy tubes. 5. Holding the barrel of the syringe at or below the level of the stomach, pour prescribed amount of water into the syringe (bolus feeding). 6. Administer the amount of feeding to be given by holding the syringe 12 to 14 inches above the level of the stomach. Allow the feeding to flow into the stomach very slowly (bolus feeding). 7. Follow the feeding with the prescribed amount of water and administer in the same manner. Monitoring and care of the feeding tube: 1. Check gastric resident volume (GRV) is no longer recommended for individuals that are alert and able to report symptoms that indicate a feeding is well tolerated. GRV checking may be appropriate for individuals unable to report symptoms such as bloating, nausea or abdominal pain. 2. Verify that the tube is functioning properly and is properly positioned before beginning any feeding as well as before administering any medications.

Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 8 residents (Resident #25) reviewed for quality of care. - The facility failed to provide wound care to Resident #26 on 08/03/25. This failure could place residents at risk of worsening of wounds, infection and pain. Findings include:Record review of Resident #26's face sheet, dated 08/05/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #26 had diagnoses which included: fracture of the right forearm, person injured in traffic collision and orthopedic (having to do with bones, joints, ligaments, tendons and muscles) aftercare. Record review of Resident #26's admission MDS, dated [DATE], revealed intact cognition as indicated by a BIMS score of 14 out of 15, upper extremity (shoulder, elbow, wrist, hand) functional limitation in range of motion, and other fracture. Under the pain assessment documented, Resident #26 reported: the presence of pain occasionally, with pain occasionally impacting her sleep, pain rarely or not at all interfering with her therapy activities and her day-to-day activities; and her pain intensity was a 02 out of 10. Under pain management, Resident #26 was coded no for: received scheduled pain medication regimen; no for received PRN pain medications or was offered and declined; and received non-medication intervention for pain.Record review of Resident #26's, undated, Care Plan revealed Focus: risk for pain related to recent fracture; Goal- resident will not have an interruption in normal activities due to pain through the review date; intervention- administer analgesic (drug to relieve pain) as per orders, monitor/record pain characteristics per shift and as needed.Record review of Resident #26's Order Summary Report revealed the following:- Cleanse surgical incision to the right inferior forearm with dermal wound cleanser, pat dry, apply Adaptec wound bed, wrap with kerlix, apply splint, wrap with ace bandage every day shift every other day for wound care -Start Date- 08/01/25- Cleanse laceration to the right medial first digit with dermal wound cleanser, pat dry, apply Adaptec every day shift every other day for wound care -Start Date- 08/01/2025 0600- Cleanse surgical incision to the right inferior forearm with dermal wound cleanser, pat dry, apply Adaptec wound bed, wrap with kerlix, apply splint, wrap with ace bandage every day shift every other day for wound care-start Date- 08/01/2025 0600Record review of Resident #26's August 2025 MAR printed on 08/05/25 at 12:28 PM revealed the following: - Resident #26 was scheduled to receive wound care on 08/01/25, 08/03/25 and 08/05/25.- On 08/03/25, LVN M documented Resident #26 did not receive wound care to her right arm but she was assessed on the morning and evening shift for: pain, placement of her pressure reduction mattress, her pressure reduction device on her wheelchair, signs and symptoms of bleeding due to blood thinner administration, adverse reactions associated with opioid medication use, edema (fluid buildup in the legs) and her vitals were checked. Record review of Resident #26's Progress Notes, dated 08/05/25 at 12:34 PM, revealed the following: - On 08/03/25 at 05:01 PM signed by LVN M: Patient out on pass with family unable to perform wound care.- On 08/03/25 at 09:31 PM signed by LVN M: patient out on pass with family unable to perform wound care.- On 08/03/25 at 08:57 PM signed by LVN G- Resident received a skilled evaluation.There was no documentation of the resident going out on a day pass, when the resident left or returned, or documentation of refusal of wound care.An observation and interview on 08/05/25 at 09:45 AM revealed Resident #26 lying in bed with a cast covered with a band aid wrap on her right lower arm. The resident said she broke her arm in a car accident. and she had not received wound care over the weekend because the facility did not provide wound care on the weekend. She said she was supposed to receive wound care every other day and the last time she received wound care was on Friday (08/01/25). Resident #26 said she did not have any pain or discomfort due to the missed wound care.In an interview on 08/08/25 at 01:42 PM, the Wound Care Nurse said she was responsible for wound care Monday through Friday and floor nurses did wound care on the weekend. She said when a resident was out on a pass, nursing staff were expected to perform wound care prior to the resident leaving and if they were unable to, wound care must be completed immediately after the resident returned to the facility. The Wound Care Nurse said she did not know Resident #26 did not receive wound care on Sunday and she was not notified.In an interview on 08/11/25 at 02:44 PM, the DON said if a resident was going out on a pass, nursing staff should have provided care prior to the resident leaving the facility or when they returned and wound care should not be missed until the next session. She said Resident #26 did not go out for the entire day so her care should have been moved to the next shift. The DON said failure to receive wound care could place residents at risk for infection and worsening of the wound.Record review of the facility's, undated, policy titled Quality of Care revealed, Purpose: Ensure identification and provision of needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental and psychosocial needs. Procedure: Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with evidence-based criteria, professional standards of practice, the comprehensive person-centered care plan and resident choices.

Based on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care that met professional standards of quality of care for one of 8 residents (Resident #82) reviewed for base line care plans. The facility failed to develop and implement a baseline plan of care that addressed Resident #82 who admitted to the facility for 5 days of respite care ( a short term stay in a nursing facility that provides temporary relief for caregivers of individuals needing assistance, allowing them to take a break from their caregiving duties) needs for the administration of morphine for her pain, and behaviors that became so severe she required administration of ABH gel. This failure could place residents at risk of not having their individual, medical, functional, and psychosocial needs identified, and services provided which could cause a physical or psychosocial decline in health. Findings Include: Record review of Resident #82's face sheet, dated 08/06/25, revealed an [AGE] year-old female who was admitted to the facility with Alzheimer's Disease and protein-calorie malnutrition. She admitted to the facility from a private home for hospice-respite services. Record review of Resident #82's Admin Census revealed, she admitted to the facility on [DATE] at 01:16 PM. Record review of Resident #82's Entry MDS, dated [DATE], revealed Resident #82 entered from hospice. Record review of Resident #82's Baseline Care Plan, signed by LVN J on 08/05/25, revealed Vision and Hearing: Vision and Hearing impaired. There was no documented active diagnoses contributing to admission; no initial admission goals and under comments- Resident #82 was confused and blind. Medications Resident #82 was taking: psychotropic medications documented but opioids were not documented. Medical conditions; does resident need terminal care was documented as no. Under Social Services; Mental health needs and behavioral concerns were blank and no further comments were documented. The baseline care plan did not include any goals or interventions for any of the areas documented. Record review of Resident #82's Clinical admission documentation, dated 08/05/25 at 09:04 PM, revealed the resident arrived on a stretcher with no family/support person in attendance. The resident's baseline neurological information was unknown, she had highly impaired hearing, had chronic disorganized thinking, severe cognitive impairment, and mood was pleasant, no unwanted behaviors witnessed was marked as 'not met.' No options were selected for mood (cheerful, pleasant, anxious, tearful, flat effect or agitated); anxious, agitated, behavior(s) present (yes, no); disruptive (new, chronic); refuses care (new chronic), resists care (new, chronic) and there was no mood & behavior note. Under special care: the options of hospice, respite and palliative care were not selected. The entire 'care planning section' that included a focus, goal and intervention for behavior management was blank and unselected. Record review of Resident #82's Pain Level: Weights & Vitals records, on 08/06/25 at 04:22 PM, revealed the facility had not assessed or record any pain levels for Resident #82. Record review of Resident #82's Order Summary Report, dated 08/06/25, revealed,- Admit under the care of the [Medical Director] for hospice or respite care.- Escitalopram 10 mg: give 1 tablet by mouth one time a day for depression.- Mirtazapine 15 mg: give 1 tablet by mouth at bedtime for depression.- Lorazepam 1 mg: give 1 tablet by mouth every 2 hours as needed for anxiety/agitation.- ABH Gel 1mg/25mg/1mg/mL gel: apply 1 ml to inner wrist every 6 hours PRN severe agitation. - Morphine 20 mg/5ml: give 0.5 ml by mouth every 1 hours as needed for SOB/pain. An observation on 08/06/25 at 04:43 PM revealed, Resident #82 in her room screaming out. The resident continuously bit the bed remote and the cord to the bed remote. She screamed saying give me my clothes that she stole. Do you know where some of my things are, I am fitting to call [the police department]. I assume she stole my clothes. The resident called people trash and said she was going to bop the shit out of someone and said she wanted to fight staff. Resident #82 continued to scream you're stupid that's what's wrong with you, you're dumb, she would then calm down and said I don't feel good someone try to take my pulse, I feel bad while biting her hand. In an interview on 08/06/25 at 04:43 PM with CNA AP, Resident #82 had been combative since admission on [DATE]. The resident was combative when providing incontinence care. The resident was calm when she slept but when she was awake, she was fidgeting and trying to get out of bed. In an interview on 08/06/25 at 05:00 PM, LVN M said earlier she talked to the resident, and she calmed down and laid back down but no one told her the resident was biting herself and attempting to hit staff. An observation on 08/06/25 at 05:05 PM revealed LVN M talking to Resident #82 in the resident's room. LVN M asked Resident #82 if she wanted to drink and the resident said well, thank you darling. Resident #82 began screaming and said, Get that stuff off me, in my eye or nose she did not want it and it tastes awful and asked for. LVN M asked Resident #82 who was and Resident #82 responded a good friend but get out of my face. Resident #82 said I don't feel good today I feel kind of bad, she continued to ask for and said, I am going to lay back down, I don't feel good, I am tired. A staff member attempted to put a pillowcase on her pillow and Resident #82 snatched at it, tugging at it before the staff member released the pillow and the resident said, you better shut up, you ain't got nothing but yourself. LVN M retrieved Lorazepam and attempted to administer it to Resident #82 and when the resident said get out of my face, I want you all to get out of my house or I will call the police. Need a brain in your head. LVN M was unable to administer the medication and walked towards her nursing cart and then Resident #82 said Need a brain in your head, I don't feel good, I feel real sick. LVN M hid the Lorazepam in pudding and administered the medication to Resident #82 who then said, I don't like you; I don't want you here. I know how you are; you are a liar. Resident #82's behaviors continued until 05:22 PM, as she shouted and insulted staff. Resident #82 said I don't feel good, that hurts, I don't feel so good. An observation on 08/07/25 at 08:33 AM revealed, Resident #82 screamed at staff with the room door closed and a staff member later identified as CNA AE was heard responding to the resident. Resident #82 said I don't want bacon, are you that dumb, if you don't have any food with some food in it. If you throw one more piece of food in my face shut up. Is that clear if not the next piece is going to be in your face. I don't want Bacon, eggs, grits is there nothing else to eat. CNA AE said bacon, eggs and grits was for breakfast when Resident #82 said Can I get a piece of bread to make a sandwich, this is pathetic I want something to eat. I asked you a question, shut up, I wanna see what you are going to tell me. Resident #82 then asked, is the bacon, eggs the only thing you got? to which CNA AE said yes. The resident then screamed If you put one more thing in my mouth, I am going to slap you. If this falls in my lap, I am going to slap you in your face. Is there anything I can eat except that crap you showed me? to which CNA AE said, that's all we have. Resident #82 said I am trying to think of something I can eat, are you sure that's the only thing to which CNA AE said, yes mam, that's all we have. Resident #82 said Tell you a secret, bacon, eggs and grits are not what I want for breakfast lunch or dinner. CNA AE told Resident #82 that she would leave, and Resident #82 responded Is there anything else for dinner, you don't know a damn thing. Resident #82 said Is there anything else for dinner, you don't know a damn thing. She said something inaudible and then die before asking for lunch meat, to which CNA AE said there was no lunch meat and lunch was at 12:00. In an observation and interview on 08/07/25 at 08:45 AM, CNA AL said Resident #82 was very aggressive. He said when the resident admitted she tried to hit staff and said staff should Kill yourself and called people a piece of shit when they tried to weigh her in the Hoyer lift (a device used to transfer individuals with limited mobility). CNA AL said Resident #82 had selective hearing and came with mitts in her back and they could have been some kind of restraint. As the state surveyor interviewed CNA AL, Resident #82 was heard screaming I don't feel good do you have anything to eat, mam mam, is there anyone in the house that has a brain. You are just downright dumb. CNA AL said he had not received any special instructions or directives on how to provide care to Resident #82. He just knew, in his professional experience, to make sure the resident's bed was in the low position since the resident moved around in her bed and to keep the door open. Resident #82 was heard screaming y'all are dumb asses CNA AE came out of the resident's room. CNA AE said the resident was combative, while she was trying to assist her with breakfast and threw food at her. In an interview on 08/07/25 at 08:52 AM, LVN S said Resident #82 had behaviors all morning and they were unable to treat her with her PRN medications because the resident refused medications. An observation on 08/07/25 at 10:43 AM revealed Resident #82 in bed screaming is anybody here. The DON was observed and heard on the phone at the nursing station talking to the hospice provider. She said Resident #82 was at the facility since the 5th and asked if anyone was coming to see the resident. The DON said the resident had behaviors and hospice needed to come to the facility to complete an evaluation. In an interview on 08/07/25 at 10:47 AM, LVN S said she called the hospice provider to see if they could bring Resident #82's ABH gel and the resident really needed it. She said the facility currently had nothing in place to prevent/treat Resident #82's behaviors and the only medication she could administer was morphine because it was a liquid. An observation on 08/07/25 at 10:49 AM revealed, VP A and CNA AL in Resident #82's room. Resident #82 said 1 called about 5 to 8 times for help. VP A asked what Resident #82 needed and the resident said, a potty, I got to TT, got to real bad, oh man that hurts. Resident #82 said I gotta go real bad, it takes forever for someone to come. She had to go bad, but no one was here. Oh, that hurts. VP A instructed CNA AL to go to therapy to get a wheelchair to take Resident #82 to the restroom. At 10:53 AM, CNA AL returned to Resident #82's room with a wheelchair and informed the resident she got a wheelchair to take her to the restroom to which Resident #82 said thank you. In an interview at 08/07/25 at 02:46 PM, LVN S said the facility received only 6 doses of ABH gel today, 08/07/25 at 1 PM.In an interview on 08/11/25 at 02:44 PM, VP A said the baseline care plan was opened by the admitting nurse, and then the IDT team completed it. She said the baseline care plan should be completed within 48 hours of admission, and it should address the immediate needs of the system addressing the major systems. VP A said the facility did not accurately capture Resident #82's use of opioid pain medication or her behaviors in the baseline care plan. She said an inaccurate baseline care plan placed resident's at risk of things being missed.Record review of the facility's, undated, policy Baseline Care Plan/Summary revealed, Purpose: Promote continuity of care and communication among staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission. Also, to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the Baseline Care Plan. A Baseline Care Plan for each resident will be developed within 48 hours of the resident's admission to this facility. The Baseline Care Plan will be based on information available from the transferring provider as well as discussions with the resident/representative. It will include interim approaches for meeting the resident's immediate needs and will reflect changes to approaches, as necessary, that occur before the development of the comprehensive care plan. 2. This Baseline Care Plan will include, but not limited to this information needed to care for the resident: a. Initial goals based on admission orders; b. Instruction needed to provide effective and person-centered care that meets professional standards of quality care; c. Resident's immediate health and safety needs; d. Physician orders.

Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there was a significant change in condition in the resident's physical, mental, or psychosocial status and a need to alter treatment significantly for 1 of 8 residents (Resident #11) reviewed for notification of changes. The facility failed to notify the physician of Resident #11's reported chest pain and SOB which resulted in the discontinuation of her PT session on 08/08/25. This failure could place residents at risk of delayed identification and treatment of undiagnosed illnesses, hospitalization, pain, and suffering. Findings include: Record review of Resident #11's Face Sheet, dated 08/08/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #11 had diagnoses which included: osteoarthritis (breakdown of cartilage and bone in a joint), lack of coordination, irregular heartbeat, hypertension (high blood pressure), anemia (condition were blood doesn't carry enough oxygen to the rest of the body) and back fracture. Her diagnosis did not include hypotension (low blood pressure), orthostatic hypotension (a sudden drop in blood pressure when standing up from a sitting or lying down position), or heart failure. Record review of Resident #11's Quarterly MDS, dated [DATE], revealed intact cognition as indicated by a BIMS score of 15 out of 15, no lower or upper extremity functional limitations in range of motion, maximum assistance needed to: roll left and right, move from sitting to lying and lying to sitting on the side of the bed, to move from sit to stand, and transfer from a bed to a chair. Resident #11's primary reason for admission was her orthopedic condition (having to do with bones, joints, ligaments, tendons and muscles), and she had anemia and hypertension. Resident #1's MDS did not include orthostatic hypotension or heart failure. Record review of Resident #11's, undated, Care Plan revealed Focus initiated on 04/10/25: chronic heart failure and at risk for complications; Goal- resident will have clear lung sounds, heart rate and rhythm within normal limits; Interventions- give cardiac medications as ordered, monitory vital signs every shift and notify MD of significant abnormalities. Monitor/document/report PRN s/sx of congestive heart failure: SOB upon exertion; weakness and/or fatigue, increased heart rate, lethargy (a state of persistent tiredness, lack of energy and sluggishness), and disorientation. Focus initiated on 04/10/25: hypotension and at risk for complications. Record review of Resident #11's Physician's Orders revealed,- Discontinued Midodrine 2.5 mg: give 1 tablet by mouth two times a day for hypotension, hold for SBP greater than 130. Written on 03/20/25. - Ivabradine 5 mg: give 1 tablet by mouth two times a day for chronic heart failure dated 04/05/25.- Active Midodrine 5mg: give 1 tablet by moth every 8 hours for hypotension hold for BP more than 160. Written on 08/06/25. Record review of Resident #11's Vitals: Blood Pressure, Weights and Vitals Summary, dated 08/08/25 at 02:55 PM, revealed, 08/08/25 at 08:10 AM- 100/51 mmHg taken on the right arm while resident was lying, with alert of Diastolic Low of 60 exceeded.08/07/25 at 07:05 PM- 91/55 mmHg taken on the right arm while resident was lying, with alert of Diastolic Low of 60 exceeded.08/07/25 at 05:03 PM- 103/65 mmHg, taken on the right arm while resident was lying.08/07/25 at 08:15 AM- 98/64 mmHg, taken on the right arm while resident was lying.08/06/25 at 08:19 PM- 102/63 mmHg, taken on the right arm while resident was lying.08/06/25 at 04:08 PM- 91/56 mmHg, taken on the right arm while resident was lying.08/06/25 at 08:38 AM- 111/73 mmHg, taken on the right arm while resident was lying.08/05/25 at 08:24 PM- 113/68 mmHg, taken on the right arm while resident was lying.08/04/25 at 08:52 AM- 102/66 mmHg, taken on the right arm while resident was lying.08/04/25 at 09:38 AM- 102/63 mmHg, taken on the right arm while resident was lying.08/03/25 at 07:57 PM- 95/63 mmHg, taken on the right arm while resident was lying.08/03/25 at 10:37 AM- 128/63 mmHg, taken on the right arm while resident was lying.08/02/25 at 07:09 PM- 108/66 mmHg, taken on the right arm while resident was lying. Record review of Resident #11's Progress Notes, dated 08/08/25 at 02:53 PM, revealed;- 08/06/25 at 11:25 AM, signed by the Medical Director- Chief Complaint- follow up orthostatic hypotension. Resident #11 was seen this morning. Patient and therapy staff report that patient continues to have orthostatic hypotensive episodes. Her blood pressure drops precipitously with change of position from lying/sitting in bed to seated upright in a chair or standing. Patient becomes very lightheaded. She is currently on midodrine 2.5 mg twice a day for management of her hypotension. We will increase midodrine to 5 mg every eight hours. Assessment and Plan- Orthostatic hypotension: Patient continues to have orthostatic hypotensive episodes with position changes from lying/sitting to upright position, causing lightheadedness. Currently on Midodrine 2.5 mg twice daily. Will increase Midodrine to 5 mg every eight hours to better manage blood pressure fluctuations. Hold parameters remain in place for SBP - 130.- 08/06/25 at 11:29 PM signed by LVN G- new order to d/c Midodrine 2.5 mg increase to 5 mg every eight hours hold for SBP greater than 160- 08/07/25 at 04:18 PM signed by the Wound Care Nurse- Resident refused wound care stating that she is too dizzy. Charge nurse notified.- 08/07/25 at 11:27 PM signed by LVN G- night 2/3 after new order to d/c Midodrine 2.5 mg increase to 5 mg every eight hours hold for SBP greater than 160. No adverse reactions noted.- 08/08/25- there were no notes from LVN J. Record review of Resident #11's PT: Treatment Encounter Notes, completed by PT E, revealed;- 08/05/25: PT assessed vitals pre-treatment: 101/62 and HR = 78bpm. PT aced wrapped legs to increase bp. PTassessed vitals sitting EOB: 92/64 and HR = 74bpm. PT transferred Resident #11 with stand pivot with max assistance-dependence and attempted to take Bp, but machine reported error. Resident #11 reported severe dizziness, so PT transferred resident to bed dependent and sit to supine with moderate assistance. PT assessed vitals: 78/54 and HR = 84bpm. PT and floor nurse scooted Resident #11 to HOB. PT assessed vitals post-treatment: 109/62 and 42bpm. Response to treatment: Pt. reports dizziness with stand pivot transfer. Barriers Impacting Treatment: orthostatic hypotension. Consultation Note: PT notified floor nurse LVN J about s/s of orthostatic hypotension.-08/08/25: PT assessed vitals: Bp = 96/62 and HR = 88bpm. PT wrapped both legs with ace wrap to improve bp. PTsupervised Resident #11 perform long sitting to EOB sitting. PT assessed vitals: Bp = 105/72 and HR = 115bpm. PT stretched resident 3x30sec . to improve ROM. PT assessed vitals after 10 min . sitting EOB: Bp = 107/53 and HR = 48bpm. Resident #11 reports not feeling right. Resident reports having chest pain and SOB, so PT instructed resident to perform EOB sitting to long sitting with moderate assistance. PT notifies floor nurse LVN J. PT assessed vitals: O2 = 93-95%, HR dropped from 94 to 84 to 70 on pulse oximeter then went back up; RR = 29; Bp = 106/83. Floor nurse LVN J came to give pt. medicine for chestpains, but pt. reported it resolved. Response to Session Interventions: Pt. passively and actively participates with skilled interventions until chest pains and SOB reported, then session was stopped and floor nurse LVN J was notified immediately. Barriers Impacting Treatment: pt. reported chest pains and SOB. Treatment Modifications to Overcome Barriers: session discontinued. Consultation Note: PT reported to floor nurse that pt. reports chest pain and SOB. Floor nurse LVN J came to give pt. medicine for chest pains, but pt. reported it resolved. In an interview on 08/08/25 at 03:05 PM, LVN J said Resident #11 normally suffered from hypotension. He said earlier Resident #11 told therapy she was not feeling well, but she was ok when he checked on her. He said the facility did not have an alert value set to notify the physician when a resident had low blood pressure, and Resident #11's orders only set to hold her Midodrine for SBP over 160. LVN J said he did not have to notify the doctor because the resident was not symptomatic when he checked on her. LVN J said nursing staff were expected to notify the physician when there was anything abnormal, and if Resident #11 was symptomatic he would call the doctor. He said if a resident had an abnormal value of symptomatic, nursing staff were expected to document a change of condition in the residents chart and notify the physician. LVN J said Resident #11 was ok when he checked on her and he knew his patient. In an observation and interview on 08/08/25 at 03:20 PM, PT E said she completed PT with Resident #11 earlier in the day. She said at the beginning of their session that day the resident said she was not feeling well, and she was shaky, so she checked her blood pressure. PT E said Resident #11 had been dealing with orthostatic hypotension and in today's session the resident kept saying she just doesn't feel like herself. After 10 minutes of sitting Resident #11 said she did not feel good and even though the resident usually reported dizziness, today Resident #11 said her chest hurt and she had trouble breathing. PT E said in response to Resident #11's complaint of chest pain and SOB she set the resident back in bed because this complaints of chest pain and difficulty breathing was new. She said she checked Resident #11's vitals: her oxygenation was fluctuating; she had a high respiration rate and high heart rate. PT E said she notified LVN J of the resident's complaints and when LVN J entered to administer medication to Resident #11, the resident said she was no longer having chest pain and medication was not administered. PT E said due to the resident's complaints of chest pain and difficulty breathing she notified Resident #11 that she had to discontinue therapy. Record review of PT E's PT Notes for Resident #11 dated 08/08/25 revealed, Observation of PT E's notes for Resident #11 revealed handwritten notes that read: pain 0/0 and BP of 96/62 pretreatment, The notes included multiple blood pressure and heart rate readings recorded over the treatment session. In an interview on 08/08/25 at 03:36 PM, the Medical Director said Resident #11 suffered from hypotension and he saw the resident earlier in the week. He said the resident did not get out of bed much but when she did, she reported lightheadedness. The Medical Director said after evaluating the resident, he increased her Midodrine to 5 mg every 8 hours. He said Resident #11's blood pressure ran low frequently with the SBP sometimes in the 90s, but he would not have immediate concerns unless the resident was showing signs and symptoms of low blood pressure. The Medical Director said, facility staff had not notified him Resident #11 experienced chest pain and SOB and notification should have been sent to the NP and himself because Resident #11's symptoms indicated possible syncope (a temporary loss of consciousness caused by a brief reduction in blood flow to the brain). In an interview on 08/08/25 at 03:44 PM, the NP said Resident #11 usually did not have complaints but she was aware the resident suffered from orthostatic hypertension. The NP said she was not notified by facility staff that Resident #11 experienced chest pain and SOB and she should have been notified since such symptoms were changes of condition. In an interview on 08/08/25 at 03:51 PM, the DON said if a resident suffered from SOB or chest pain the MD must be notified and it be documented as a change of condition in the resident's chart. An observation and interview on 08/08/25 at 04:08 PM revealed, Resident #11 appeared to be in no immediate distress. Resident #11 said earlier, during therapy, she was sitting on the side of the bed and felt a sharp pain in her chest and her breathing became heavy/short so PT E laid her back in bed and she started feeling better. Resident #11 said LVN J came in and offered her some medication, but she felt better so she did not take it and that was that. She said LVN J had not checked on her since then and no one else had checked on her since LVN J offered her medication. Resident #11 said she was always dizzy during therapy but the chest pain is something new, she had dizziness at home and did not know she had orthostatic hypotension, and she fainted. She said even though she did not break anything when she fainted that was why she was at the facility. Record review of the facility Notification Manual' revealed, immediate notification should be the NP and if you cannot reach the NP; then call: the Medical Director. Symptom or sign: Chest pain, pressure and tightness; immediate: new abrupt onset, unrelieved by medications or accompanied by sweating, change in vital signs or new EKG changes. Non-Immediate- relieved by antacids or nitroglycerin, without other symptoms, but recurring more often than usual. Record review of the facility's, undated, policy titled Condition change of Resident revealed, Purpose: observe, record and report any condition change to the physician so proper treatment can be implemented. 3. Assess the resident and notify the attending physician of the resident's condition. Compare the resident's current condition to his/her prior level of function. 4. 6. Notify resident's responsible party. 7. Monitor resident's condition frequently until stable. 8. Document assessment observations in medical record. Record review of the facility's, undated, policy titled Notification of Change revealed, Purpose: Ensure resident and/or resident representative notification of specific changes during the resident's stay in the facility. Procedure: 1. The facility must immediately inform the resident, consult with the resident's physician, and notify, consistent with his/her authority, the resident representative(s) when there is; A significant change in the resident's physical, mental or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications).

Based on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. - The facility failed to update and post the daily nursing staffing information on Saturday 06/28/25, Sunday 06/29/25, Monday 06/30/25 and at the beginning of the 1st shift on 07/01/25. The last revision was made on 06/27/25. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include:An observation on 07/01/25 at 07:51 to 08:00AM revealed, the facility Daily Nurse Staffing Report posting on the top of a pony wall located in front of the receptionist desk that read Date: 06-27-25. The posting indicated the facility had three shifts, 1st, 2nd, and 3rd, but the time the shift began and ended for RNs, LVNs and CMAs was not included; only Nursing Assistants were indicated as working 6AM-2 PM (1st shift), 2 PM-10 PM (2nd shift), 10PM-6AM (3rd shift). The posting indicated the number of staff scheduled for each category: 1st shift: RN-1, LVN-3, CMA-1, Nursing Assistant-6; 2nd Shift: RN-0, LVN-3, CMA-1, Nursing Assistant-6; 3rd shift: Nursing Assistant-4. The posting did not have the total number of hours worked for their direct care licensed and unlicensed nursing staff. In an interview on 07/02/25 at 12:29 PM, the DON said she started working in the facility in May of 2025. She said the Staffing Coordinator was responsible for the nursing staffing posting, the posting was put up in the morning, and it should include the facility name, census, and direct care staffing numbers. She said she did not know who was responsible for updating the posting on the weekends and when the staffing coordinator did not work but she would find out. The DON said the purpose of the posting was to notify families of the number and type of direct care nursing staff were in the building so they know what services could be provided. She said failure to update the nursing staffing posting would leave families unaware of what direct care nursing staff were working on that day. The DON said she did not know what time the posting had to be updated but she assumed it was during business hours. In an interview on 07/07/25 at 11:37 AM, the Administrator said the Staffing Coordinator was responsible for the facility daily nursing posting and it should contain the facility name, date, census, and the number of each type of staff. She said the staff shifts are varied with nurses working 12-hour shifts at 6AM-6PM & 6PM-6AM; CNAs- 8 hours, Med Aides 12 hours either 7-7 or 8-8. The Administrator said the Staffing Coordinator's schedule was Monday through Friday typically 8AM-5 PM with little variation in hours depending on the facility's needs and some varied weekend shifts. She said on the weekends when the Staffing Coordinator was not available the MOD was responsible for the nursing posting, and the MOD (department heads such as SW, Medical Records, HR, Dietary Manager etc.) worked rotating weekends. The administrator said she did not know why the posting was not updated over the weekend and on Monday (06/28/25, 06/29/25, 06/30/25), but the posting was not yet updated on Tuesday (07/01/25) because the surveyors arrived at the facility before the staffing coordinator did. She said the purpose of the staffing posting was to show the ratio of staff to residents and failure to update it timely could result in visitors being unaware of the number of staff available in the building. In an interview on 07/07/25 at 11:49 AM, the Staffing Coordinator said she was responsible for the facility nursing posting and her scheduled hours were Monday- Friday 8 AM to 5 PM or sometimes 6 PM. She said the purpose of the posting was to inform anyone who enters the building of the number of the direct care staff, and it should be updated in the morning around 8 AM. The Staffing Coordinator said on days she does not work, the staff member who worked as the receptionist was responsible for updating the nursing posting. She said she worked over the weekend of 06/28/25 -06/29/25 as a CNA on the floor and in her regular position as the Staffing Coordinator on 06/30/25 and she could not remember any issues that arose that prevented her from updating the nursing posting on those days. The Staffing Coordinator said over the weekend she must have just forgotten because she was working as a CNA but did not have a reason for Monday, she said it was just a mistake. She said failure to update the nursing staffing posting could result in visitors/residents being unaware of the staff present in the building during a particular shift. Record review of the facility policy Nursing Staffing information with no revision date revealed, Purpose: Make nurse staffing information readily available in a readable format to residents and visitors at any given time. Procedure: Data RequirementsThe facility must post the following information daily: 1. Facility name; 2. The current date; 3. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: a. Registered nurses; b. Licensed practical nurses or licensed vocational nurses (as defined under State law); c. Certified nurse aides4. Resident census. Posting Requirements: 1. The facility must post the nurse staffing data as specified above daily at the beginning of each shift. 2. Date must be posted as follows: a. Clear and readable format. b. In a prominent place readily accessible to residents, staff, and visitors.

Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 5 residents (Resident #1) reviewed for pain management, in that; Resident #1 experienced pain after a fall on 10/06/2023 and the pain was not reported to the NP until 10/09/2023. The facility failed to contacted the NP or Physician after the fall when Resident #1's pain level increased to a level 9, resulting in an increase PRN pain medications. These failures affected one resident who was placed at risk of pain, bruising, and increased use of PRN pain medication. An Immediate Jeopardy (IJ) was identified on 10/09/2023 at 6:35 PM. The IJ template was provided to the facility on [DATE] at (6:35PM. While the IJ was removed on 10/12/2023 at 3:40 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure placed residents at risk of injury and pain. Findings include: In an interview with RP on 10/07/2023 at 12:40PM, he stated he did not witness the incident that occurred with Resident #1 on 10/06/2023. He stated his Resident #1 called and informed him that one of the loops that hooked onto the Hoyer lift broke and Resident #1 fell . He stated Resident #1 was not sent to the hospital. He stated he spoke to the facility administrator, and he was informed that the facility has to go through a process when an incident happens, the process was not provided. He stated a little mesh on the harness sling tore and they gently lowered her to the ground. He stated Resident #1 informed him she fell out of the harness and it was not gently lowered to the ground. He stated Resident #1 informed him that she landed on her left side. In an interview on 10/07/2023 at 2:13PM with Resident #1, the resident stated she had a fall during a Hoyer (Mechanical) lift transfer on 10/06/2023. The resident stated the mesh part of the sling tore during the transfer and she fell to the floor. The resident stated she was about waist high, 3 feet from the floor. The resident stated she landed on her left side, and she did not hit her head. The resident stated she had pain in her left buttocks and upper left shoulder. The resident stated she was not sent to the hospital and x rays were not done after the fall. The resident complained of pain and stated she was on a scheduled pain medication as well as an as needed pain medication. Resident #1 stated. during the interview and stated she was now fearful of doing Hoyer lift transfers. Record review of Resident #1 EMR on 10/07/2023, revealed on she was admitted to the facility on [DATE] with diagnoses including Encephalopathy (brain disease), Sepsis, Muscle Weakness, Cognitive Communication, Stenosis (Pressure on spinal cord), Morbid Obesity, Record review of Resident #1 EMR revealed on 09/01/23 she weighed 251lbs. Record review of Resident #1's and the MDS dated [DATE], revealed the resident was a 2 person assist with transfers and a BIMS score of 12 (indicating the resident's cognition was intact). Record review of Resident #1's care plan dated 08/07/2023 revealed the resident was care planned for the use of a Hoyer lift . In an interview on 10/07/2023 at 3:08PM with CNA-A, she stated she went into to assist CNA-B with a Hoyer lift transfer for Resident #1 because it was the residents shower time. She stated during the transfer the sling ripped and the resident had a fall. She stated the resident complained of pain on her left leg near her calf. She stated she thinks the sling may have been thrown away because it was broken. In an interview on 10/07/2023 at 3:18PM with CNA-B, CNA-B stated she and CNA-A placed the resident on the Hoyer sling and in the process of pivoting the resident over to the wheelchair, the mesh part of the sling tore resulting in the resident falling to the floor. CNA-B stated the resident began crying and complained of pain in her left shoulder. She stated the resident was assessed by the nurses. CNA-B stated she inspected the sling prior to the transfers and it looked okay. In an interview on 10/07/2023 at 3:32PM with RN, she was at the nursing station and at about 3:30 PM CNA-A informed her that she needed assistance in a room, she stated she was informed the Hoyer lift tore. She stated when she entered the room the resident was sitting on her buttocks and the Hoyer lift was to the side. She stated the resident was upset and hysterical, there was no bruising or bleeding or trauma to the skin. She stated the resident did not hit her head. She stated she assessed her pain level and she received pain PRN medication which the resident already had a prescription for. She stated she called the NP and she was informed to monitor the resident. She stated the resident was not sent out the hospital and X ray were not ordered. She stated the residents PRN medications were increased due to her pain. In an interview on 10/07/2023 at 4:00PM with DON, she stated the resident was not sent to the hospital or for X ray because they were informed to Monitor the resident. She stated the Hoyer slings does come in different sizes, but she was not sure of exactly what the sizes were. The DON stated the staff were trained to identify which size sling to choose when doing a Hoyer Lift transfers but there was not any evidence of training for staff regarding choosing the correct sling for the correct weight provided . Record review of Resident #1 EHR on 10/07/2023 revealed, there was no orders for X rays. Record review of the residents Pain Levels on 10/09/2023 revealed she had pain level of 9 on 10/6, 10/07, 10/08, the resident was given her PRN pain medication when she complained of pain. Record review of Resident #1 EHR on 10/09/2023 revealed, a new order per NP of 2 view X ray of the left leg. In an interview with Resident #1 on 10/09/2023 at 5:05PM, she stated she was still in pain at a level 8 and she reported she had just received her PRN pain medication and thought it may have been working. She stated she had a bruise on the back of her left shoulder. The residents bruised was observed to be dark purple circular bruise about the size of a grape fruit. She stated she was informed that she would be getting x rays completed that evening but they had not been completed at the time of the interview. In an interview with the NP on 10/09/2023 at 5:37PM, he stated the facility contacted him on 10/06/2023 to inform him that Resident #1 had a fall during a Hoyer lift transfer. He stated he informed the staff to do neurological checks on the resident and notify the provider if there was any significant change. He stated he was off over the weekend, so he was unsure if the facility reached out to any of the on-call staff. He stated the facility reached out to him again today and informed him the resident was complaining of pain in her left lower extremities. He stated he ordered x-rays for the resident. In an interview with the Administrator on 10/09/2023 at 5:51PM, she stated she was working the 10/06/2023, the incident occurred. She stated the RP came to her and stated he wanted to file a incident. She stated she did not know what was going on at the time but the DON and ADON had tried contacting her via phone on 10/06/2023, but she missed the call. She stated the DON informed her that it was not a hard fall, that the resident went down slowly. She stated the aides got the nurse immediately to assess the resident. She stated she immediately in-serviced the staff. She stated the RP seemed to be calm at that point. She stated the incident occurred the evening of 10/06/2023. She stated the resident was not sent out to the hospital because the NP was contacted, and they were informed to monitor the resident. She stated they did order x-rays from what she understood; she stated she thought x rays were ordered today (10/09/2023). She stated the incident was not reported to HHSC because she did not see it at the time as a reportable. She stated she investigated the incident immediately and there was no injury due to the Hoyer or the sling at the time. She stated the Hoyer slings did come in different sizes. She stated when she heard of the incident, she immediately knew that the training would be done. She stated she did not know what size sling was used for the resident. She stated the housekeepers should be looking at the Hoyer slings when they are doing laundry. Record review of X-Rays results dated 10/09/2023 revealed the resident did not sustain any fractures. On 10/09/2023 at 6:35 PM. the Administrator was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 10/12/2023 8:43 AM. The POR revealed: IV. What corrective actions have been implemented for the identified residents? The following action items were implemented. d. The physician notified, immediately on 10/6/23 at 3:30pm, of the resident's condition and x-ray ordered on 10/09/23. e. Resident assessed immediately, no redness or bruising, and no abnormalities. f. Follow -up documentation on fall every shift completed. g. Social Services set up psychosocial appointments to address and help with the resident having any feelings of fear of not being safe while Hoyer lifted. h. Files for all residents using mechanical lifts were audited on 10/7/2023 and no other accidents were identified as 10/11/2023. V. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? g. Licensed nurses will be in-serviced to ensure they are aware to notify Physician of any changes following an incident for 72 hours on 10/9/2023. VI. How will the system be monitored to ensure compliance? a. DON/ Designee will follow up daily on incidents and changes of conditions log to ensure proper documentation is in place to include NP and Physician notifications. A 24-hour review and incident review log will be used to audit notifications etc. b. This audit will be reported for the following 3 months in QAPI. c. Management will actively monitor for any subsequent or related complaints and addressing those as they arrive. Quality Assurance: An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 10/10/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan. IJ monitoring included: Record review revealed the RN completed her mechanical lift sling training on 10/06/2023, transfer training and competency check on 10/10/23 and she signed off on the nurse training regarding notification of change of conditions. In an interview with RN on 10/12/2023 at 2:27PM, she stated, although she had never had to conduct a mechanical lift transfer on any of the residents while she worked here in the facility, she was trained on safe mechanical lift transfers, which included to always have to have two people, to inspect the mechanical lift and sling, and to ensure the right size sling was being used. She stated in the case of any injury, she would instantly notify the family, DON and the resident's physician. She stated she would call the nurse practitioner/physician to report any changes in condition observed following an injury for up to 72 hrs. Record review on revealed the LVN completed her mechanical lift sling training on 10/06/2023, transfer training and competency check on 10/10/23 and she signed off on the nurse training regarding notification of change of conditions. In a phone interview with the LVN on 10/12/2023 at 3:10PM she stated she was trained on how to use the mechanical lift and on notifications after change of conditions. She stated she would monitor a resident up to 72 hours following an incident to ensure there was no change of condition, and if there was a change, she would report to the NP or the physician. She said she was tested on how to use the mechanical lift but never had to perform a transfer on the floor. She stated generally two people were needed for the transfer, one person was needed to control the mechanical and the other was there to stabilize the patient from bed to chair or chair to bed. She stated she checked the battery level, sling condition for lack of rips, tears or frays, and the sling size using the posted weight to sling size reference guide. Record review on 10/12/2023 revealed the DON kept a running log on any resident injuries that occurred in the facility. In an interview with the DON on 10/12 2023 at 3:25PM, she stated staff were to check battery to ensure it was fully charged, check the sling for any tears or rips and loops were intact, and for the right size. She stated the staff were to make sure two people performed a mechanical lift transfer, positioning the resident not too high or not too low and to make the lift was locked upon decent. She stated for falls or injuries, nurses were to notify the NP, DON and family, do a pain and fall assessment as well as a skin assessment by the wound care nurse (for every fall). She stated they were to document up to 72 hours on any changes of condition or if the resident remained stable. She stated only one resident on her log so far had experienced an injury with change of condition and the resident was still discharged at the hospital until further notice. An Immediate Jeopardy (IJ) was identified on 10/09/2023 at 6:35 PM. The IJ template was provided to the facility on [DATE] at (6:35PM. While the IJ was removed on 10/12/2023 at 3:40 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to properly inspect the Hoyer Lift slings, resulting in it tearing and causing the resident to have a fall and sustain a bruise to her left shoulder. Resident #1's fall caused pain at a level 9. -The facility failed to properly train the staff on how to report concerns and determine properly Hoyer sling sizes. An Immediate Jeopardy (IJ) was identified on 10/09/2023 at 6:35 PM. The IJ template was provided to the facility on [DATE] at (6:35PM. While the IJ was removed on 10/12/2023 at 3:40 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure placed residents at risk of serious injury and pain. Findings include: Record review of Resident #1 EMR on 10/07/2023, revealed on -she was admitted to the facility on [DATE] with diagnoses including Encephalopathy (brain disease), Sepsis, Muscle Weakness, Cognitive Communication, Stenosis (Pressure on spinal cord), Morbid Obesity, Record review of Resident #1 EMR revealed on 09/01/23 she weighed 251lbs. Record review of Resident #1's MDS dated [DATE], revealed the resident was a 2 person assist with transfers and a BIMS score of 12 (indicating the resident's cognition was intact). Record review of Resident #1's care plan dated 08/07/2023 revealed the resident was care planned for the use of a Hoyer lift. Record review of Resident #1's EMR on 10/07/2023 revealed, there was no orders for x rays. Record review of the residents Pain Levels on 10/09/2023 revealed she had pain level of 9 on 10/6, 10/07, 10/08, the resident was given her PRN pain medication when she complained of pain. Record review of Resident #1 EHR on 10/09/2023 revealed, a new order per NP of 2 view x ray of the left leg. In an interview on 10/07/2023 at 2:13PM with Resident #1, the resident stated she had a fall during a(Mechanical) lift transfer on 10/06/2023. The resident stated the mesh part of the sling tore during the transfer and she fell to the floor. The resident stated she was about waist high, 3 feet from the floor. The resident stated she landed on her left side, and she did not hit her head. The resident stated she had pain in her left buttock and upper left shoulder. The resident stated she was not sent to the hospital and x rays were not done after the fall. The resident complained of pain and stated she was on a scheduled pain medication as well as an as needed pain medication. Resident #1 stated she was now fearful of doing Hoyer lift transfers. In an interview on 10/07/2023 at 2:56PM with the DON, she stated Resident #1 had a witnessed fall on 10/06/2023 during a Hoyer lift transfer. She stated the resident was assessed by the RN and the NP was notified. She stated the resident complained of pain to her left. She stated the resident was given pain medication. She stated the resident was already on a scheduled pain medication and an as needed pain medication. She stated the resident was not sent to the hospital or for x ray because they were informed to monitor the resident. The DON stated the incident was not reported to HHSC because it was a witnessed fall. She stated the Hoyer slings did come in different sizes but she was not sure of exactly what the sizes were. The DON stated the staff were trained to identify which size sling to choose when doing a Hoyer Lift transfers but there was not any evidence of training for staff regarding choosing the correct sling for the correct weight provided In an interview on 10/07/2023 at 3:00PM with the Maintenance Supervisor, he stated he was not responsible for checking the slings for the Hoyer lifts. He stated the laundry department usually checked the slings while completing laundry. In an interview on 10/07/2023 at 3:08PM with CNA-A, she stated on 10/06/2023, she went into to assist CNA-B with a Hoyer lift transfer for Resident #1 because it was the resident's shower time. She stated they strapped the resident into the Hoyer sling/lift and they were lifting her and the mesh on the sling broke. She stated the resident was about waist level when she fell from the Hoyer lift. She stated once the resident fell , they assessed the resident and did not move her, and CNA-B called for the RN to assess her. She stated the person who started the transfer usually checked the straps to make sure it is not broken. She stated the sling was kind of old looking when she saw it. She stated the resident complained of pain on her left leg near her calf. She stated they got another sling and put the resident back on it and got her back up. She stated she thinks the sling may have been thrown away because it was broken. She stated she was last trained on Hoyer lifts about a month ago. She stated there had not been any training since the incident occurred. She stated she was not sure if the slings came in different sizes. She stated she did not know which sling to choose when doing a Hoyer lift because she thought they were all the same. She stated she only knew that some of them look different. She stated when she did a Hoyer lift transfer, she get whichever sling was available when she goes into the laundry room. She stated the risk of getting the wrong size sling when doing a transfer was someone could fall out of the sling. In an interview on 10/07/2023 at 3:18PM with CNA-B, she stated on 10/06/2023 she and CNA-A were in the process of transferring Resident #1 to her wheelchair when the incident occurred . CNA-B stated she and CNA-A placed the resident in the Hoyer sling and in the process of pivoting the resident over to the wheelchair, the mesh part of the sling tore resulting in the resident falling to the floor. CNA-B stated the resident was about waist high when she had the fall. CNA-B stated the resident landed on her left side hitting her left leg, left buttock and left shoulder, and stated she did not hit her head. CNA-B stated the resident began crying and complained of pain to her left shoulder. She stated the resident was assessed by the RN. CNA-B was asked how to determine the size of the sling needed for the residents and she stated the facility had different style slings and stated she thought all the slings were one size. She stated she accessed the sling prior to the transfer, and it did not appear to be torn or ripped. She stated the resident was assessed by the nurses. CNA-B stated she inspected the sling prior to the transfers and it looked okay. In an interview on 10/07/2023 at 3:32PM with the RN, she stated she was at the nursing station and at about 3:30 PM CNA-A informed her that she needed assistance in a room; she stated she was informed the Hoyer lift sling tore. She stated when she entered the room, Resident #1 was sitting on her buttocks and the Hoyer lift was to the side. She stated she observed the Hoyer lift sling, and it was hooked correctly. She stated the resident was alert and oriented. She stated she accessed the resident and on the resident was upset and hysterical, there was no bruising or bleeding or trauma to the skin. She stated the resident did not hit her head. She stated another Hoyer lift sling was retrieved and the resident was transferred back into bed. She stated she assessed her pain level, and she received pain PRN medication which the resident already had a prescription for. She informed the DON a soon as the incident occurred. She stated she called the NP and she was informed to monitor the resident. She stated the resident was not sent out the hospital and an x ray was not ordered. She stated she was going to call the RP, but he had already arrived to the facility and he was yelling and upset. She stated the slings came in different sizes. She stated there should be a weight on the label when doing a Hoyer lift transfer. She stated she did not see the weight on the sling at the time of the incident, but she did observe a rip in the sling. In an observation of Hoyer lift slings (2 were available in the laundry room) on 10/07/2023 at 3:53PM, revealed the weight requirements on the slings were not legible. Some of the tags were torn and some of the weight requirements were not visible at all. In an interview with Resident #1 on 10/09/2023 at 5:05PM, she stated she was still in pain at a level 8 and she reported she had just received her PRN pain medication and thought it may have been working. She stated she had a bruise on the back of her left shoulder. The residents bruised was observed to be dark purple circular bruise about the size of a grape fruit. She stated she was informed that she would be getting x rays completed that evening but they had not been completed at the time of the interview. Record review of X-Rays results dated 10/09/2023 revealed the resident did not sustain any fractures. Record review of Safe Lifting and Movement of Residents Policy revised July 2017, reflected .Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices All equipment design and use will meet or exceed guidelines and regulations concerning resident safety and the use of restraints Safe lifting and movement of residents is part of an overall facility employee health and safety and injury-prevention strategies; Involves employees in identifying problem areas and implementing workplace safety and injury prevention strategies . Continually evaluates the effectiveness of workplace safety and injury-prevention strategies On 10/09/2023 at 6:35 PM. the Administrator was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 10/12/2023 8:43 AM. The POR revealed: . I. What corrective actions have been implemented for the identified residents? The following action items were implemented. a. The physician notified, immediately on 10/6/23 at 3:30pm. b. The Hoyer sling was removed immediately and disposed of. c. Visual inspection of all Hoyer lift slings inventoried and completed through 10/10/2023. No other concerns were identified in terms of residents; 1 sling was properly labeled on 10/11/2023. II. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? a. An in-service was initiated with direct care staff on 10-9-2023 by the Director of Nursing and Therapy designee, on Hoyer lift transfer training. b. An in-service was initiated with housekeeping and laundry staff on 10-9-2023 by the Housekeeping Supervisor, on Hoyer lift sling laundry care and factors that reduce the life of the sling. c. Another additional training was initiated to all direct care staff on 10/10/2023 to also include and highlight details of Hoyer slings sizing, colors, and proper use by demonstration. d. Staff completed a competency checklist on Hoyer Lift transfer Training with return demonstration on 10/10/2023. e. New hires will have transfer training to include Hoyer lift with therapy. f. DON/designee to perform daily random audits to ensure staff are using Hoyer lifts properly and Hoyer slings are in good condition. III. How will the system be monitored to ensure compliance? a. DON/Therapy/designee will perform random audits weekly to ensure staff are using Hoyer lifts properly and Hoyer slings are in good condition, and proper size and will be documented on a log. As an inspection routine, the log will capture the staff member and the observer, the condition of lift and sling, and proper use. Also, will highlight if staff member needs more training. So far this week there have been no similar resident occurrences or findings. b. Housekeeping will continue to monitor the condition and wear and tear of slings, also if sling needs to be replaced via a daily log. If observer sees that sling is deemed not usable, the observer will bring sling to DON or Administrator. Quality Assurance: An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 10/10/2023 with the Medical Director. The Medical Director has reviewed and agrees with this plan. IJ monitoring included: Record review of staff competency checks revealed 69 competency checks were completed including for CNA-B and CNA-A. Record review of Mechanical lift: How to Use a Patient Lifter Transfer Guide revealed the sling size for weight ranges were included in the guide. Record review revealed the facility had policies on of Falls and Fall Risk management, Safe Lifting and Movement of Residents. Record review revealed in-services on [Mechanical] Lift Transfer trainings were conducted by the therapy department on 10/10/23 for all direct care staff. Record review revealed the facility had a policy on Sling Laundry Care dated 10/09/23 and was signed off by staff in the laundry department. In an interview with the OT on 10/12/2023 at 12:27PM, she revealed she helped train staff on how to perform a transfer of a resident by mechanical lift and what steps to follow to ensure the transfer was safe. She stated staff were to ensure the sling was free of rips or tears and to make sure the sling fit the resident they were transferring. She stated the weight/sling size guide could be found in the shower rooms and guidebook. She stated she also trained staff on how to transfer their resident from bed to wheelchair and wheelchair to bed. In an interview with the Laundry Supervisor on 10/12/2023 at 12:45PM, she stated she was to collect and wash dirty slings with no bleach or hot water. She stated slings were to be air-dried and inspected for damage to the sling hooks and/or net material, such as tears, holes, fraying, and illegible labels. She stated if damaged slings were to be identified, she would give them to the Administrator or DON to have them replaced. Record review of the Log for Daily Mechanical Sling Check reflected one of one sling was replaced on 10/11/2023 and one of 13 slings were replaced on 10/12/2023. In an interview with the Laundry Aide on 10/12/2023 at 12:57PM, she stated she washed slings separately from other linens with no bleach and only cold water. She stated she dried the slings without heat and checked if it was good for use and not broken. Record review revealed the ST completed his transfer training and competency check on 10/10/23. In an interview with the ST on 10/12/2023 at 1:02 PM, he stated to know the appropriate size of sling to use on a resident, he checked the patient's weight in the EHR and referenced the weight to sling size guide. He stated to perform a safe transfer by mechanical lift, he needed to conduct the transfer with another staff member to guide the resident as he maneuvered the mechanical lift. Record review revealed CNA-C completed her transfer training and competency check on 10/10/23. In an interview with CNA-C on 10/12/2023 at 1:17PM, she stated prior to transferring a resident using the mechanical lift, she checked for holes, rips, tears, and ensured the sling straps were intact and were the right size for the person. She stated she would refer to the label on the sling to determine the appropriate size of sling to use on the resident. Record review revealed CNA-D completed her mechanical lift sling training on 10/06/2023 and her transfer training and competency check on 10/10/23. In an interview with CNA-D on 10/12/2023 at 1:30 PM, she stated she was trained by the therapy department on how to use a mechanical lift. She stated prior to transferring a resident by mechanical lift, she checked to make sure the right size was being used, the hook and sling material were in good condition and the battery was fully charged. She would make sure to get help from another aide for the transfer. She stated if there was an injury, she would report to the nurse. Record review revealed CNA-E completed her mechanical lift sling training on 10/06/2023 and her transfer training and competency check on 10/10/23. In an interview with CNA-E on 1012/2023 at 1:44PM, she stated that prior to transferring a resident using a mechanical lift, she would check the battery, check the sling for rips and holes and for the right size based on the posted sling color codes on the guide located at the desk and linen closets. She stated the codes informed her on which color to use based on resident's weight. If the sling was not legible or if there were any issues, she would notify the nurse and the DON about it. Record review revealed CNA-F and CNA-G completed their transfer training and competency checks on 10/10/23. Observations of mechanical lift transfer of Resident #2 on 10/12/2023 at 2:18PM, by CNA-F and CNA-G revealed a safe transfer of Resident #2 from the Geri-chair to her bed and the sling was in good condition, appropriate sling size, and coordination of loops . CNA-G operated the lift machine while CNA-F guided the resident. Record review revealed the RN revealed she completed her mechanical lift sling training on 10/06/2023, transfer training and competency check on 10/10/23 and she signed off on the nurse training regarding notification of change of conditions. In an interview with RN on 10/12/2023 at 2:27PM, she stated, although she had never had to conduct a mechanical lift transfer on any of the residents while she worked at the facility, she was trained on safe mechanical lift transfers, which included to always have two people, to inspect the mechanical lift and sling, and to ensure the right size sling was being used. She stated in the case of any injury, she would instantly notify the family, the DON and the resident's physician. She stated she would call the nurse practitioner/physician to report any changes in condition observed following an injury for up to 72 hrs. Record review revealed CNA-B completed her mechanical lift sling training on 10/06/2023 and her transfer training and competency check on 10/10/23. In an interview with CNA-B on 10/12/2023 at 2:40PM, she stated for mechanical lift transfers she would ensure the battery was fully charged, made she had a second staff to the spot the resident, she would check the sling for holes, rips, frays, tears or wear. She stated the linen closet and book at the nursing station had the guides for weight sling size she could reference prior to transferring residents. Record review revealed CNA-H completed her mechanical lift sling training on 10/06/2023 and her transfer training and competency check on 10/10/23. In an interview with CNA-H on 10/12/2023 at 2:52PM, she stated for mechanical lift transfers, she needed two staff to conduct a safe transfer with one person guiding the patient and the other person maneuvering the mechanical lift. She stated she checked to ensure the battery was charged, checked for tears or rips in the slings, and if the appropriate size was being used depending on the resident's weight. Record review revealed CNA-I completed her mechanical lift training and competency check on 10/10/23. In an interview with CNA-I on 10/12/2023 at 3:02PM, she stated two people were needed to conduct a mechanical lift transfer and she had to check to ensure the sling was in good condition with no loose strings, tears, the appropriate size for the resident was used, and the battery needed to be fully charged,. She stated if the tag on a sling was illegible, then she would not use it but instead report it to her charge nurse. Record review revealed LVN completed her mechanical lift sling training on 10/06/2023, transfer training and competency check on 10/10/23 and she signed off on the nurse training regarding notification of change of conditions. In a phone interview with LVN on 10/12/2023 at 3:10 she stated she was trained on how to use the mechanical lift and on notifications after change of conditions. She stated she would monitor a resident up to 72 hours following an incident to ensure there was no change of condition, and if there was a change, she would report to the NP or the physician. She said she was tested on how to use the mechanical lift but never had to perform a transfer on the floor. She stated generally two people were needed for the transfer, one person was needed to control the mechanical lift and the other was there to stabilize the resident from bed to chair or chair to bed. She stated she checked the battery level, sling condition for lack of rips, tears or frays, and the sling size using the posted weight to sling size reference guide. Record review revealed the DON kept a running log on any resident injuries that occurred in the facility. In an interview with the DON on 10/12 2023 at 3:25PM, she stated staff were to check battery to ensure it was fully charged, check the sling for any tears or rips and loops were intact, and for the right size. She stated the staff were to make sure two people performed a mechanical lift transfer, positioned the resident not too high or not too low and to make sure the lift was locked upon descent. She stated for falls or injuries, nurses were to notify the NP, the DON and family, do a pain and fall assessment as well as a skin assessment by the wound care nurse (for every fall). She stated they were to document up to 72 hours on any changes of condition or if the resident remained stable. An Immediate Jeopardy (IJ) was identified on 10/09/2023 at 6:35 PM. The IJ template was provided to the facility on [DATE] at (6:35PM. While the IJ was removed on 10/12/2023 at 3:40 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on interview and record review, the facility failed to ensure 1 of 9 residents(Cr#3) care plan was followed in that: The facility failed to ensure CR#3's care plan was followed to allow two staff to provide ADL care. This failure could place residents who required 2 staff for ADLs at risk for injury, discomfort, and decreased quality of care. Findings included: CR#3 Record review of CR#3 admission face sheet record revealed CR#3 was an 87 -year- old female who was admitted to the facility on [DATE]. Her diagnoses included morbid obesity due to excessive calories (overweight), type 2 diabetes, muscle weakness, cognitive communication deficit (problems communicating), congestive heart failure, peripheral vascular disease (blood circulation disorder), current use of anticoagulant (blood thinner) and antithrombotic/antiplanets ( drugs used to reduce the formation of blood clots), acute or chronic essential primary hypertension (high blood pressure), iron deficiency anemia, gastro esophageal reflux disease (black flow of stomach acid form to stomach to the mouth), and bronchitis (inflammation of the lining of the tubes that carry air to and from the lungs Record review or quarterly MDS assessment, dated 7/22/2022, indicated CR #3 could made herself understood and had impaired vision. CR#3's BIMS score was 11 indicating she was moderately impaired aware. She required extensive assistance of 1 staff for all ADLs, including bed mobility, dressing, and hygiene. For toileting and bathing, she was total care with one person assisted and total care for transfer with two persons assisting. She was incontinent of bowel and bladder. Record review of CR#3's care plan, dated 10/8/2022, revealed the resident required extensive assistance of 2 staff for bed mobility, dressing, toilet use, hygiene, and bathing. Record review of CR#3's care plan, dated 08/12/2022, indicated the resident was a fall risk due to gait balance and the interventions was to anticipate and meet the resident needs. Follow facility's fall protocol. Record review of the nurse's notes dated 8/12/2022 at 2:48 pm, documented CR#3 was found face down on the floor in her room. Certified Nurse Aide said she was changing her diaper and she asked her to roll to the other side and she, by mistake, rolled to the floor. Patient sustained injury: redness noted on bilateral knees, hematoma by the right wrist, left hand abrasion, skin tear to forehead, bruise by the forearm. Record review of nursing notes dated 8/12/2022 by LVN A indicated CR #3 was transferred to the hospital by ambulance. In an interview with LVN A on 1/3/2023 at 12:12 pm, she said that she was called to the room of CR#3 and saw her face down on the floor. She said she immediately assessed CR#3 and the resident said she said she was in pain, and she gave her pain medication. She said she called 911, the doctor and family, and CR#3 was sent to the emergency room . She said CR#3 sustained injuries to bilateral knees, hematoma by the right wrist, left hand abrasion, skin tear to forehead, bruise by the forearm. Further interview with LVN A revealed CR#3 was a two- person assist with ADLs but CR#3 could also assist with turning. In an interview with CNA B on 01/03/2023 at 12:34 pm revealed that she was providing incontinent care and asked CR#3 to assist her by rolling to her side and she rolled and fell out of the bed and hit the floor, she said she did not know what happened that day because she usually assists her when she provides incontinent care for her. She said CR#3 was a two person assist with incontinent care, but she could follow direction and she could do her by herself. She said she always provide care by herself, but she needed two persons help to get her out of bed. Record review of nursing notes dated 8/12/2022 by LVN A indicated CR #3 was transferred to the hospital by ambulance. During an interview on 01/10/2022 at 2:40 pm with MDS Coordinator, LVN H, she said CR #3 required 2 staff assistance for transfer. She said the resident was able to follow commands and she could assist with turning. She said the resident was a big lady and should be a two persons transfer for safety. During an interview on 01/10/2022 at 2:53 pm with MA E, she said CR #3 required 2 staff assistance. She said the resident was alert and oriented and was able to follow commands and she could assist with turning, when care was given. She said the resident was able to assist by holding to the rail when care was given. During an interview on 1/04/2023 at 3:45 p.m., the DON said she was not working at the facility when the incident took place. She said CR#3's MDS assessment was one person assist for ADL's but did not know why the care plan had two persons assisted for ADL's. She said, they were going to review the care plans and re-assess residents and make the necessary adjustments. Further interview regarding staff training regarding CR#3's fall she said she was going to look for documentation regarding in-service for CR#3 fall. Record review of the facility's documentation regarding in-service on falls, presented to the survey team for review, CNA B was included in the training. Record review of the facility's Care Plan policy dated August 2006 read in part . Policy Statement: The care plan shall be used in developing the resident's daily care routine and will be available to staff personnel who have responsibility for proving care or services to the resident.

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (CR #1) of four residents reviewed for accidents, hazards, and supervision. -CNA E and CNA G improperly transferred CR # 1 in a mechanical lift resulting in the resident falling 3 to 4 feet and hitting her head on a dresser and fracturing both legs. This failure affected 1 discharged resident and placed 2 other residents on the 600 hall at risk for injury due to improper mechanical lift transfer. Findings include: Intake #: 6; 2 Record review of CR # 1's medical file revealed she was an [AGE] year old female that was admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. CR # 1 discharged to the hospital on [DATE]. Record review of CR # 1's Annual MDS assessment dated [DATE] revealed her BIMS was 99 indicating severe cognitive impairment. She required extensive two-person assistance with bed mobility and dressing and was totally dependent with two-person assistance for transfers. She was always incontinent of bladder and frequently incontinent of bowel. She had no range of motion impairment to her upper or lower extremities. She was 60 inches tall and weighed 159 pounds. Record review of CR # 1's Care Plan dated [DATE] revealed a care plan for problem: Impaired mobility requiring total assist for transfers and wheelchair mobility secondary to left sided [MEDICAL CONDITION] from cardiovascular accident. Interventions included Hoyer lift with at least 2 person assist with transfers. Record review of the facility's report to HHSC on [DATE] read, DON received a call by the nurse on duty that the resident had fallen off the hoyer lift during transfer procedure from the bed to wheelchair. She had slipped out on the side of the sling while hanging on the hoyer lift. According to both of the CNAs during the transfer that the resident just slipped out of the side of the sling. resident sustained [REDACTED]. (Family member) was in the room during the incident. Resident was taken to the ER for further evaluation. The report read that CNAs were suspended and in-services on mechanical lift transfers and abuse/neglect were started. An attached email from the DON to HHSC dated [DATE] read that the hospital had confirmed to them that CR # 1 sustained a bilateral tibial fracture and a laceration to the left side of her head. Record review of hospital records for CR # 1 revealed she was admitted to the hospital on [DATE] for Bilateral Tibial Fracture (Fracture of both sides of the body in the shinbone). Review of the hospital History and Physical dated [DATE] revealed, The patient is an [AGE] year old woman with history of dementia, history [MEDICAL CONDITION] debility, history of hypertension, who presents after falling in the nursing home. She was being lifted by a Hoyer lift and fell about 4 feet in the air. Her (family member) who was at bedside witnessed the fall. The patient hit her head and slammed into a wall. There was no loss of consciousness. No behavioral changes. The patient had a wound to her scalp and her wound to her left elbow and she has been noted to be in pain .Right knee x-ray with 3 views shows possible proximal tibial fracture. Left knee, 3 views, shows mildly displaced proximal tibial fracture. Head CT shows no acute intracranial abnormalities, no [MEDICAL CONDITION]. Record review of a Witness Statement Form regarding incident dated [DATE] for CR #1 from CNA E read, I was not the CNA assigned to take care of this resident. I was asked by the assigned CNA to help get this resident out of bed for dinner. When I walked into the room, the hoyer lift was already there. I helped get the hoyer sling underneath the resident. I hooked the right side of the sling onto the lift, and the other CNA hooked the left side of the sling to the lift. This sling does not crisscross under the legs. That sling has longer sides that go under the legs. This sling had hooks that clip onto the hoyer, and they have different colors. The colors are used depending on the height and/or weight of the resident. (I then asked how she would know which color hook to use, CNA was unable to definitively answer. She explained that it is based on the fit and comfort of the resident.) The (family member) was in the room. She was standing on the side of the bed that is closest to the door. While we were transferring the resident into her wheelchair, she had her arms crisscrossed across her chest. The chair was at the bottom of the bed. I was operating the controls on the hoyer lift. When we first hooked her onto the lift, the legs of the left (sic) were closed and under the bed. When we turned her around, lifting her off the bed, I opened the legs of the lift to make it easier to move. The other CNA was holding the sling, directing it. There is a piece on the back you can hold onto that makes it easier to direct the resident. The resident slid and fell to the left side. She was straight in the sling when we first moved her. She wasn't leaning at all. She was in the right position. When the resident slid, she came out of the sling on her left side. She hit the left side of her head on the bedside commode. She was bleeding from what looked like right behind her left ear. (Family member) went to the door to get the nurse. I never moved the resident. She was laying on her left side when the nurse came into the room to assess her. This statement was signed by RN A on [DATE] and read that the statement was taken via the telephone. Record review of a Witness Statement Form from CNA G regarding CR # 1 read, I was the CNA assigned to take care of this resident. Myself and another CNA were using the hoyer lift to get this resident up for dinner. We hooked the sling up to the hoyer lift. I attached the right side of the sling, the other CNA hooked the left side of the sling. There are different colors on the hooks. I'm not sure why there are different colors, but I usually just communicate with whoever is helping me. That way we're using the same color hook. I felt like I was just following what I had seen during orientation on the floor. We moved the roommate's bed over to make sure there was plenty of room to move the hoyer lift. The other CNA was using the controls for the hoyer while I was guiding the resident. Her head was near me, and her feet were facing the top of the bed. When we lifted her up, I reached around to grab the wheelchair. It happened so fast. The resident tilted and slid out of the sling. She fell on to the floor. She hit against the wall, and fell sideways, hitting the left side of her head on the chest of drawers. I had the wheelchair at the foot of the bed because the hoyer lift has really long legs. It's difficult to keep the wheelchair near it. The resident's (family member) was in the room during the transfer. She went to the door to get the nurse the same time the nurse was coming in the door. I noticed the resident's head was bleeding, so I was trying to support it while I was waiting for the nurse to check her out. There was no bedside commode in the room. This statement was signed by RN A on [DATE] and read that the statement was taken via the telephone. Record review of a Witness Statement Form from LVN F read, I was the charge nurse assigned to this resident. I heard I (sic) loud noise coming from the 600 hallway. I assumed it was from 601 because I knew the CNAs were getting her up for dinner. I knew this because I saw the resident's daughter coming down the hall earlier, and I know she likes her mother up for meals. At that time, I asked the CNA at the desk if she knew whether (CR # 1) was up. She told me that they were getting her up right now. When I walked into the room, the (family member) was coming out to get me. I observed the resident laying on the floor on her back. Her head was at the foot of the bed near the dresser, and her feet were facing the top of the bed. I could see that she was bleeding from near her head. I crouched down to determine where the blood was coming from and realized I didn't have any gloves on. I ran to the bathroom, washed my hands quickly, and grabbed the box of gloves. I was putting on gloves as I was kneeling back down. I saw a laceration behind her left ear. I couldn't tell exactly how big it was. The CNAs told me that they were trying to transfer into the wheelchair when she slid out of the sling. She hit the left side of her head on the dresser and landed on her legs. I got up and asked the other charge nurse to call 911, so that she could be transferred to ER due to the bleeding from her head. The (family member) was also requesting she be transferred. I didn't notice anything different with her legs at that time. They are slightly contracted and don't straighten out. I didn't see where the wheelchair was while I was in the room, as I was taking care of the resident. I did notice that the resident's bed was in the normal position, and the roommates bed was pushed out of the way. She was transferred to (hospital) for observation, accompanied by her daughter. This statement was signed by RN A on [DATE]. Record review of a Witness Statement Form signed by LPN C on [DATE] revealed, I was working on (Rehab) over the weekend. I was holding the on-call phone. I received a call from DON @ 5:03 PM on Sunday (MONTH) 12th, (YEAR) that this resident had fallen. She asked me to go and investigate the situation, as she had received a message that the resident had fallen and was being transferred to hospital. I walked over to (LTC) and observed resident on the stretcher with EMTs present. Resident's (family member) was present and visibly upset. I walked into the room to see what happened. I observed the bed approximately 4 ½ feet off the ground, and the wheelchair was facing the window. I went to assess the hoyer. The hoyer pad was still attached to the hoyer lift. The straps in the front did not match. They were purple and green. The straps on the bottom were purple, and they were not criss-crossed. In an interview with a family member over the telephone on [DATE] at 4:54 PM she stated she was in the room while CR # 1 was being transferred from the bed to the wheelchair in the mechanical lift by two CNAs. She stated CNA G was doing all of the work while the other CNA, CNA E, was just standing by watching. She stated they had an old sling which looked way too small for CR # 1. She stated they lifted her up very, very high, and then the sling tilted and CR # 1 slid out and fell from the lift and her head hit a dresser and then she landed on the floor. She stated there was a lot of blood. She stated EMS came and took her to the ER. She stated CR # 1 never lost consciousness. She stated CR # 1 remained hospitalized and they had done two CT scans and didn't find anything. She stated CR # 1 legs were both fractured from the knees down. She stated the resident had not walked in years. In an interview with the DON on [DATE] at 9:38 AM she stated the mechanical lift sling has ties on it to place the lift hooks on and the ties are color coded. She stated they need to ensure they are hooking up each corner of the sling on the same color tie or the sling will be unbalanced and tilt. The DON stated when they transferred CR # 1, The CNA hooked it up wrong. She stated they had hooked the sling up to different color hoops on each end. The DON further stated she was told by the nurse that was on duty that day that the sling was up very, very high - almost to the ceiling. In an interview with the Unit Manager LVN R on [DATE] at 10:54 AM she stated she talked to the family member who was there when CR # 1 fell the next day on [DATE]. She stated she told her she was standing in the doorway of the room when she fell . She stated one of the CNAs was operating the lift and the other one was standing by. She stated she said when they got ready to turn the lift she went flying out of it. She said they had her up in the air and one CNA was operating the lift and the other just standing there on standby. Interview with CNA G on [DATE] at 10:16 AM, she stated they were getting CR # 1 up for dinner around 4:00 PM on [DATE]. She stated they put the sling under her on the bed. She stated CNA E was maneuvering the mechanical lift. She stated the CNA E did have CR # 1 up real high because her legs are contracted and bent downward, so they have to lift her very high to make sure her legs are above the bed and she does not get hurt. CNA G stated when you close the legs on the lift, it moves them closer, tight together. She stated you have to close the legs on the lift before you slide it under the bed. There's a button to open or close the legs. Then when you pull the lift it out from under the bed, you have to open the legs in order to push the wheelchair in between them to let the resident down into it. She stated when CNA E pulled the lift out from under the bed, she went around the bed and she reached around to grab her wheelchair and when she looked back she saw the sling tilt sideways and CR # 1 slid out of the side and fell . CNA G stated, I didn't make it to her wheelchair. She stated she was not holding onto the resident when it happened because she had turned around to get the wheelchair to move it under the lift. In an interview with CNA E on [DATE] at 11:59 AM she stated CNA G called her to help her transfer CR #1 on [DATE]. She stated when she arrived in the room the sling was in the chair and the mechanical lift was already in the room. She stated she helped CNA G to turn the resident to put the sling under her. CNA E stated she operated the controls on the mechanical lift. She stated they had to put CR # 1 a little higher due to her legs were contracted and she couldn't straighten them. She stated when she turned the lift around CNA G put the wheelchair under it, between the legs of the lift and CNA G was behind the resident and when she started to lower the lift, the resident fell . She stated she did not know what happened, it happened so fast. She stated she could not see what the other CNA was doing behind the resident when it happened. She stated CNA G was helping turn her and was holding onto her when they first lifted her up. But, when it happened she could not see if CNA G was touching the resident or not. She stated there was a strap under the sling to hold onto to control the resident's movement. She stated she could not say if the other CNA was holding onto the strap on the sling or not. CNA E stated the wheelchair had already been placed under the mechanical lift when CR #1 fell . Observation & Interview on [DATE] at 1:47 PM of the sling that the DON stated was used when CR #1 fell from the mechanical lift revealed it was dark blue and appeared large enough to transfer a large person. It had tie hoops on each corner at different levels in three colors, blue, green, and purple. In interview with the DON at this time she stated they go by weight and the blue ties were for a small person, the green ties were for a medium weight person, and the purple ties were for a larger person. She stated it was very important the hooks on the lift were all on the same color tie, but when they transferred CR #1 they were hooked on purple and green not all on the same color. She stated the mechanical lift was not hooked up right. Observation & Interview on [DATE] at 1:56pm of CR #1's room with the DON revealed her bed was by the window and a roommate's bed was near the door to the room. A dresser belonging to the roommate was against the opposite wall between the two beds. The DON stated CR #1 hit her head on that dresser. In an interview with the ADON on [DATE] at 1:59 PM, he stated that he came down to the facility after the accident on [DATE] to reenact what happened. He stated LPN C went to the room with him. He stated LPN C laid down on the bed and he had CNA E and CNA G show him how they put CR #1 in the sling with LPN C acting as the resident. He stated they did not crisscross the ends over the legs at the bottom of the sling the way they were supposed to. He stated this helps hold the resident tightly in the sling. He stated when they began lifting LPN C up she started to slide, so he had them put her back down. He stated they had hooked up a different color at the top than at the bottom of the sling. The ADON stated in regard to the mechanical lift and how to hook up the sling correctly they basically didn't know it. He further stated the way it seemed to him that they didn't take it seriously. Observation of CR # 1 on [DATE] at 2:58 PM in the hospital with the family member present revealed she was lying on her back covered up with both legs stretched out straight and casts on both legs from the feet to over the top of her knees. She had a cap covering her head. Resident # 1 was awake off and on and tried to speak and converse, but was not interviewable. A pint of blood was hung and was infusing. In interview with the family member at this time [DATE] at 2:58 PM she stated they were going to cut the cast away over CR # 1's left knee to look at it and find out why it was bleeding. She stated the resident had a laceration on her head and also had a cut on her left elbow. The family member stated CR # 1's legs were never contracted. She stated that was not true. She stated what happened was that when she arrived in the room the two CNA's were cleaning CR # 1 and the tall one (CNA E) was bent over holding the resident on her side while the other CNA was cleaning her and she complained that it was hurting her back. The family member said she then suggested they should lift the bed up higher so they could clean her easier. She stated the bed was in a low position. She stated the CNAs then did raise the bed up high to finish cleaning her. She stated when they started transferring her in the mechanical lift they did not lower the bed back down before lifting the resident up in the sling. The family member stated that's why the bed was up so high. In a telephone interview with LVN F over the telephone on [DATE] at 5:13 PM, she verified the mechanical lift was up very high, almost to the ceiling when she was in the room after the accident on [DATE]. She stated the reason she noticed it was because after CR # 1 left for the hospital CNA E was trying to remove the mechanical lift from the room and it was up so high that she couldn't get it through the doorway. She told CNA E she would have to move the mechanical lift down to get it through the door. She stated she told her she hoped she did not have it up so high while they had the resident in it. She stated CNA E responded that she put it up high to transfer the resident because she's so tall. Record review of CNA E's personnel file revealed her date of hire was [DATE]. Her CNA certification was verified and expired on [DATE]. EMR and Criminal Background Checks were ran on [DATE] and there were no barriers to employment. CNA E was terminated on [DATE] for Gross Negligence and Conduct endangering life, safety, or health of residents. A Nursing Assistant Skills Review Checklist was initialed as completed by CNA E and RN B on [DATE]. Included in the checklist was Transfers: Body mechanics, bed to chair, pivot turn, mechanical lift, use of gait belt. Record review of CNA G's personnel file revealed her date of hire was [DATE]. EMR and Criminal Background Checks were ran on [DATE]. Her CNA certification was verified and expired on [DATE]. CNA G was terminated on [DATE] for Gross Negligence and Conduct endangering life, safety, or health of residents. An Employee Orientation Check was initialed by the CNA on [DATE] and included the nursing department area Lifting/Moving Residents. In an interview with CNA A on [DATE] at 11:34 AM she stated she received training on using the mechanical lift durng orientation when she first started working in the facility eight months ago. In an interview with CNA B on [DATE] at 2:06 PM she stated RN B trained her on transferring with the mechanical lift. She stated she was always taught to crisscross the sling. In an interview with CNA F on [DATE] at 2:13 PM she stated when she first started working in the facility eight months ago RN B showed her how to use the sit to stand lift, the gait belt, and the mechanical lift. She stated they always crisscross the sling at the bottom. In an interview with CNA C on [DATE] at 2:38 PM she stated when she first started in (MONTH) (YEAR) she was trained on the mechanical lift and the sit to stand by RN B. She stated she shadowed someone using the hoyer with RN B. In an interview with CNA D on [DATE] at 2:55 PM she stated she worked mostly in the therapy department and the ADON trained her on how to transfer with the mechanical lift. She stated she had worked in the facility four months. In a second interview over the telephone with CNA E on [DATE] at 1:11 PM she stated that when she started working in the facility they put her with someone and she followed them for two days. She stated they didn't use the mechanical lift while she was shadowing them. She stated they did not give her any training on using the mechanical lift in this facility. She stated she was taught how to transfer with the mechanical lift during her CNA training. She stated she had been a CNA for about 1 ½ years. She stated she received training also on the mechanical lift at the previous facility she worked at before. She stated she followed the rule of always having another person helping you when using the mechanical lift. She stated they were not crisscrossing the sling with that type of sling. She then stated one of the CNAs taught her how to use the mechanical lift in this facility. She stated she heard that since this accident they are having them all crisscross the bottom of the sling, but they were not doing that before on that sling. She stated no one told them that before. She stated the dark blue sling is the one they used with CR # 1 on [DATE]. Record review of the in-services conducted revealed an in-service titled Transfer training, ADLs was conducted on [DATE] with 14 staff who signed as having attended. CNA G attended this in-service. CNA E's name was not listed on this in-service. In an interview conducted with the Director of Rehab on [DATE] at 1:36 PM she stated they assist the facility with mechanical lift training with the CNAs. She stated they watch a video and they give them handouts which explain how to use the mechanical lift. She stated they also do a competency skills checkoff. She stated they do a sign in sheet which goes to the facility. She stated she does not keep any copies of the sign in sheets. She stated she works for a different company in Rehab and she has no control over the facility's paperwork. She stated she provides the training, but the paperwork goes to them. She stated the facility sends new CNAs to them for transfer training and to the best of her knowledge they have done the mechanical lift training with all of the CNAs. Record review of the facility's policy titled Safe Lifting and Movement of Residents, Revised (MONTH) 2013, revealed, In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents .Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents .Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices .Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. According to the list provided by the DON there were three residents who required mechanical lift transfers on the 600 hall.

Based on observation, interview and record review, the facility failed to ensure that each resident received the adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (Resident #1 and #5) reviewed for neglect. - The facility failed to ensure the welfare of Resident #1 when providing toileting needs. Resident #1 was assessed as requiring extensive assistance from two staff for toileting. CNA B toileted Resident #1 by herself and while exiting the bathroom Resident #1 sustained a head injury hematoma and was sent to the ER. - The facility failed to ensure and promote the welfare of Resident #5 when providing routine care. Resident #5 was assessed as requiring total assistance from one staff for Bathing. CNA L left Resident #5 unattended in the shower. Resident #5 fell to the floor and sustained two fractures to the right knee. This failure affected 2 residents and placed all 34 additional residents at risk of infection, pain, harm or decreased quality of life due to lack of supervision. Findings include: Intake # 1 Resident #1 Record review of Resident# 1's face sheet revealed admitted [DATE] and re-admission date of [DATE] and [AGE] years of age. Further review of the face sheet noted Resident# 1 [DIAGNOSES REDACTED]. Record review of Resident#1 MDS with ARD 7/15/18 revealed: - understood and usually understands others and had clear speech - severely impaired cognitively for decision making, BIMS Score of 3 - extensive assistance/1 person physically assist for bed mobility, transfers, dressing and personal hygiene - limited assistance/1 person physically assist for eating - extensive assistance/2 person physically assist for toilet use - Activity did not occur for bathing - balance: moving from seated to standing 2= not steady only able to stabilize with staff assistance - balance: walking (with assistive device if used) 2= not steady only able to stabilize with staff assistance - balance: turning around while walking 2= not steady only able to stabilize with staff assistance - Balance: moving on and off toilet 2= not steady only able to stabilize with staff assistance - always incontinent of bladder and frequently incontinent of bowel Care plan dated 6/25/18 revealed Problem/Need Resident #1's family express unrealistic expectations, wants one on one care provider. Approaches Welfare of resident will be the main focus in providing routine/prn care, Family will be educated/made aware of consequences of not following medical recommendations for resident. Care plan dated 6/25/18 revealed Problem/Need Resident #1 is unable to perform ADL's independently, requires min to mod assistance from staff. Approaches Assist with dressing, grooming, and hygiene at level required and encourage participation. Allow resident choices when providing ADL care. Care plan dated 6/25/18 revealed Problem/Need Resident #1 is at risk for falls as evidenced by poor safety awareness and resident requiring min to mod assist X1 for transfers/ambulation attempts with rolling walker. Approaches Assist resident with all mobility needs as indicated during all shifts to decrease fall risks. Undated Care plan Problem/Need Resident #1 is on restorative nursing program to improve/maintain ambulation related to poor balance, vision deficit, strength, endurance and safety training. Resident will be free of falls or injury with ambulation and transfers. Approaches Ask how resident is doing, and observe closely for dizziness, unsteady gait, impaired balance or fatigue during ambulation. Record review of Resident #1's care plan revealed there was no documentation in Resident #1's Care plan as to how much ADL support of physical assistance from direct care staff is required to assist Resident #1 in areas of ADL care. (Bathing, dressing, grooming, Personal hygiene/oral care, and Toileting). Observation of Resident #1 on 7/25/18 at 10:15 am revealed she was sitting in a chair with a table in front of her while watching TV. Resident #1 had a quarter size raised area to the left side of her forehead and a dime size scabbed area above the raised area. Observation of the resident's bathroom area revealed that upon coming out of the bathroom the door is hinged on the right side and closes on the left. Record review of Resident #1's incident report dated 7/16/18 revealed in part: reported to supervisor Yes, date/Time; 7/16/18 1:30pm Narrative of incident and description of injuries: Patient coming out restroom with Aide in front when she heard patient say aaaahhh, patient sat down in chair when Aide noticed hematoma to left side forehead., notified Nurse immediately. Ice applied. Hematoma to left side forehead. Immediate Actions Taken: Applied Ice, notified MD, new order sent to Methodist Willowbrook for evaluation 7/16/18 2:16pm. Record Review of Resident #1's CNA Daily Care Guide printed 7/26/18 revealed in part: - one person assist for Transfers, dressing, and eating -two person assist for toileting -activity did not occur for bathing Record review of Resident #1's Daily Care Guide revealed there was no documentation in Resident #1's CNA Daily Care Guide as to how much ADL self-performance is required/needed from Resident or how much ADL support of physical assistance from direct care staff is required to assist Resident #1 in areas of ADL care. (Bathing, grooming, Personal hygiene/oral care, and Bed Mobility). Record Review of Resident #1's CNA Documentation Form ADL Assistance and Support dated (MONTH) (YEAR) revealed in part: Toilet use Time, 6/2 one person assist initialed for dates 7/1, 7/2, 7/3, 7/4, 7/6, 7/8,7/9, 7/10, 7/11, 7/12, 7/13, 7/16, 7/18, 7/20, 7/21, 7/22, 7/23, 7/25, also for the 2-10 shift initialed 7/1, 7/2, 7/3, 7/5, 7/6, 7/8,7/9, 7/10, 7/11, 7/12, 7/14, 7/15, 7/19, 7/21, 7/22, 7/23, and 7/25. Record Review of Resident #1's Nursing Departmental Notes dated 7/16/18 at 3:07pm revealed in part: Patient coming out of restroom with Aide in front when she heard patient say aaaahhhh, patient sat down in chair when aide noticed large hematoma to left side forehead., Patient states she doesn't know what happened. Record Review of Resident #1's Hospital Records After Visit Summary printed date 7/17/18 at 2:14pm revealed in part: Your Medications have changed STOP taking aspirin 81mg [MEDICATION NAME] coated tablet, [DIAGNOSES REDACTED].#1's hospital records revealed CT results updated 7/16/18 at 9:02pm in part: Findings 1. Small acute subdural hematoma over the lateral cerebral convexity on the left side and large scalp contusion in the frontal temporal region on the left side are again noted. Impression: Slightly extensive subdural hemorrhage on the left side compared with the prior study. Record Review of Resident #1's Nursing Departmental Notes dated 7/17/18 at 8:30pm revealed in part: Patient came back from the hospital at 8:30pm on 7/17/18 , she has [MEDICAL CONDITION] and bruising on the left side of her face at her cheek. Eyes bruised bilaterally, she has a small red area on top of the left side of her head, discontinue aspirin due to brain bleed and allow adequate rest. Interview on 7/26/18 at 3:00pm with CNA B, she said she was the CNA that had assisted Resident #1 to the bathroom. She stated that she was alone with resident #1 and helped clean her up in the bathroom. She was walking in front of the resident walking out of the bathroom to get her chair ready. CNA B said she heard the resident say ouch and she asked her what was wrong, and Resident #1 said the room was closing in on her. CNA B said she did not notice the area on the resident's head was raised until the resident sat down in the chair. CNA B stated that she thinks the resident hit her head on the door frame and not the door but did not witness the accident and told the nurse LVN W. CNA B stated that she was not aware that Resident #1 required 2 person assist for toileting. Interview with ADON on 7/26/18 at 6:30pm revealed he was aware of Resident #1's incident. ADON stated that it was a unwitnessed incident but the CNA could tell what happened, the facility investigated and decided it was not reportable to HHSC. ADON stated Resident #1 sustained a Hematoma to the left of her head. ADON stated when in-servicing on Abuse, Neglect and Exploitation the facility policy and procedure along with the HHSC is the reference information. Resident #5 Record review of Resident# 5's face sheet revealed admitted [DATE] and re-admission date of [DATE] and [AGE] years of age. Further review of the face sheet noted Resident# 5's [DIAGNOSES REDACTED]. Record review of Resident# 5's MDS with ARD 6/11/18 revealed: - understood and understands others and had unclear speech - cognitively intact for decision making, BIMS Score of 15 - extensive assistance/1 person physically assist for bed mobility and toilet use - extensive assistance/2 person physically assist for transfers - limited assistance/1 person physically assist for dressing and personal hygiene - supervision/set-up physically assist for eating - total dependence/1 person physically assist for bathing - frequently incontinent of bladder and incontinent of bowel - balance: moving from seated to standing 2= not steady only able to stabilize with staff assistance - balance: moving on and off toilet 2= not steady only able to stabilize with staff assistance - balance: moving surface to surface 2= not steady only able to stabilize with staff assistance Record review of Resident #5's care plan dated 6/21/18 revealed in part: Problem/Need, Consistent refusal of safety precautions. Approaches Discuss with resident implications of not complying with therapeutic regime. Record review of care plan dated 6/21/18 revealed Resident #5 is at risk for trauma related to poor bone density, requires max assist with transfers, poor safety awareness. Approaches Observe resident during rounds on all shifts for changes indicating possible injury occurrence Assist resident with positioning needs as indicated during all shifts to decrease fall related fracture risks. Record review of care plan dated 6/2/18 revealed Resident #5 is at risk for falls as evidenced by poor safety awareness, history of falls and resident requiring extensive assist per resident request sit to stand with 1-2 assist for transfers. Approaches: Observe resident during rounds on all shifts for changes in status indicating increased fall risk for an actual fall occurrence and assist resident as indicated Provide resident education on fall reduction tips and observe resident during rounds on all shifts for compliance. Sit to stand with transfers. Record review of care plan dated 6/2/18 revelaed Resident #5 has a Self-Care Deficit Dressing/grooming/bathing as evidence by resident requiring extensive assist for dressing/grooming and bathing needs per resident. She is a sit to stand for transfers. Approaches: Observe resident during rounds on all shifts for dressing/grooming/bathing needs and assist resident as indicated. Shower/bathe resident per schedule and as indicated to meet hygiene care needs. Record review of care plan dated 6/21/18 revealed Resident #5 is at risk for disuse syndrome as evidence by fluctuations in decline in functional status and decreased mobility to extremities times 4. Record review of care plan dated 6/2/18 revealed Resident #5 has had an actual fall with injury due to unsteady gait, poor safety awareness, non-compliance with call light system and history of falls. Resident #5 will not sustain a major injury as a result of any falls through the next review date 9/21/18. Approaches: Monitor resident when moving about room/facility. Ongoing reinforcement and education on the risk of unassisted transfers, ambulation, and non-compliance with safety measures. Record review of care plan dated 7/24/18, revealed Resident #5 is at risk for falls. 7/24/18 fall with injury. Approaches: Remind Resident to ask for assistance for all ambulation. Monitor for changes in Resident's condition that may warrant increased supervision/assistance and notify the physician 7/24/18 sent to ER. Record review of Resident #5's Nursing note dated 7/24/18 at 4:49pm revealed in part: 7:40am this nurse was called to shower room on the unit, responded immediately, found resident lying onto her right side, stated I fell , my knees and my body is hurting .Immediately assessed by Nurse Practitioner, who found that Resident right knee was swollen and painful to touch. Record Review of Resident #5's CNA Daily Care Guide printed 7/26/18 revealed in part: -one person assist for bathing, dressing and toileting -two person assist for Transfers Record review of Resident #5's CNA Dialy Care Guide revealed there was no documentation for how much ADL self-performance is required/needed from Resident in the ADL care areas of (Bathing, toileting, grooming, transferring, Personal hygiene/oral care, and Bed Mobility) or how much ADL support of physical assistance from direct care staff is required to assist Resident #5 in areas of ADL care. (grooming, Personal hygiene/oral care, and Bed Mobility). Record Review of Resident #5's CNA Documentation Form ADL Assistance and Support dated (MONTH) (YEAR) revealed in part: Bathing, 6/2 shift, 1/1 supervision and set-up assist initialed for dates 7/3, 7/7. Indicating resident self-performance was supervision oversight, encouragement or cueing and setup help only. Record Review of Resident #5's Incident report print dated 7/26/18 revealed in part: Incident Type: Fall Unwitnessed Date/Time: 7/24/18 7:40am Type of Injury: Fracture Location: Shower Room Equipment: Shower chair - wheeled Activity at time: To/frm shower-alone Incident Level: Non-Witnessed Narrative of Incident and description of injuries: Nurse was called to shower room, found Resident lying on her right side on the floor, complaining of generalized body pain including her knees Nurse Practitioner, who was on the Unit, assessed Resident, finding Resident right knee swollen and painful to touch. Swollen right knee. Resident Condition at Time of Incident medical risk factors possibly related to incident: Fall History, [MEDICAL CONDITION], Incontinency, B&B Urgency and Tremors/[MEDICAL CONDITION]. Record Review of Resident #5's physician progress notes [REDACTED]. MA stepped out when heard patient scream. Per nurse patient was found on the floor prone, screaming of pain to bilateral knees, lower back and right side of her head. 911 was called to send the patient to Hospital to be evaluated. Physical Exam: General female laying on the shower floor prone, post fall in acute discomfort, awaiting on EMS to arrive, not moving patient to avoid further injury. Pain to bilateral knees, lower back and right temporal area 10/10. Record Review of the facility's ProviderInvestigation Report sent to HHSC revealed in part: Date & Time Submitted: (MONTH) 24, (YEAR) at 11:50am Report Submitted by DON, Date & Time facility first learned of the incident 7/24/18 at 8:00am. Report Details: The Resident was being showered by CNA. Resident asked the CNA to go to her room to grab her phone because she forgot it. CNA left the shower room, & resident slid out of her shower chair onto the floor. Resident has a fractured left knee. Extent of injuries: ER staff reports resident is being admitted to hospital for fracture of left knee. Description of in-service training: Abuse & Neglect In-service initiated. Record review of Resident #5's right knee x-ray report dated 7/24/18 revealed Impression: 1. There is mild displaced fracture traversing the distal femoral metaphysis. 2. There is an appearance concerning for subtle [MEDICAL CONDITION] tibial plateau. Record review of Resident #5's Right Lower extremity CT report dated 7/24/18 revealed Impression: 1. Mildly comminuted, impacted distal femoral metaphyseal fracture. Attemps were made to contact CNA L for an interview, but CNA L did not return calls from surveyor prior to exit. Record review of the witness statement signed by CNA L on 7/24/18 revealed she was the CNA taking care of resident. She and another CNA transferred the Resident using the sit to stand lift placing the resident in the shower chair and CNA L wheeled the resident from her room to the shower room. CNA documented in her statement that while she was showering the resident at approximately 7:20am, resident asked her to go to her room to get her cell phone. CNA told her No. We can get it later and that resident stated I always shower by myself. I've been doing it for years. CNA stated she left the resident there and went back to the resident's room to get the phone because she was insisting so no one would steal it and when she was on the way back with the phone she heard the resident shouting. She opened the door and the resident was on the floor she got the nurse right away the NP was there also who assessed her and she was transferred to the hospital after that. In an interview on 7/26/18 at 5:30pm with DON, she revealed the incident dated 7/16/18 with Resident #1 head hematoma was not reported to HHSC because the facility knew what happened, DON was not aware that Resident #1 was a 2 person assist for toileting. DON stated Resident #5's incident was reported because the CNA left the resident alone in the shower and should not have. DON stated that the CNA's are expected to use the CNA Care guide on the computer to find information on how to provide care for their assigned resident. DON also stated that the information in the Care Guide should accurately reflect the current Care plan and MDS for the Resident. Record review of Facility Abuse Prevention Policy revised 11/2016 revealed in part: Purpose: To ensure that the facility will do all that it can within its control to prohibit abuse, neglect, involuntary seclusion, and misappropriation of property for all customers. Neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. III. Prevention: Actions to prevent abuse, neglect, adverse events, mistreatment/exploitation, and misappropriation of property. c. Identifying, correcting and intervening in situations in which abuse, sexual abuse mistreatment/exploitation, adverse event, neglect and/or misappropriation of resident property is more likely to occur. f. Nursing staffing and communication tools identifying resident specific needs will be available daily and adjusted as needed. IV. Identification: Staff will identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse or neglect, including resident-to-resident abuse. Staff will also report in accordance with Facility Abuse Policy. Protection during Investigation The Administrator, or designee, shall ensure that the following persons are notified immediately of the allegation of abuse an that an investigation is underway: State Agencies, within required timeframes, as required by state and local law. The Facility 672 dated 7/25/18 revealed 100 census.

Based on observation, interview and record review, the facility failed to prohibit and prevent neglect of residents for 1 of 6 residents (Resident #1) reviewed for neglect. -The facility failed to train CNA B in the use of mechanical lifting devices. -Then the facility failed to train CNA B on how to access resident's information to determine the required type of assistance required for transfer for each resident. -CNA B failed to transfer Resident #1 in accordance with her plan of care when using a mechanical lift. CNA B transferred Resident #1 alone and Resident #1 sustained a puncture wound to her left upper inner arm during transfer and had to receive 5 sutures in the emergency room . These failures affected one resident and could affect the remaining 24 residents who required the assistance of two staff members and a mechanical lift for transfers by placing them at risk for injury. Findings included: Intake # 1 Record review of Resident #1's Face Sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's admission MDS assessment, dated 07/28/17 revealed Resident #1 had moderately impaired cognition with a BIMS score of 11 out of a possible 15. She required extensive assistance of two person physical assistance for bed mobility, transfer and walk in corridor and extensive assistance of one person physical assist for locomotion, dressing, toilet use and personal hygiene. Record review of Resident #1's Comprehensive Plan of Care, dated 07/21/17, revealed in part; -Problem/need: ADL deficit: Resident #1 is unable to perform ADL's independently, requires extensive assistance form staff secondary to impaired cognition, weakness, and/or physical limitations. -Approaches: Transfer with 2 person assist with mechanical lift. Record review of the facility's Provider Investigation Report, dated 08/10/17, revealed on 08/10/17, while Resident #1 was being showered while in the Sit-to-Stand (mechanical lift) and the wheelchair behind Resident #1, Resident #1 abruptly sat down and threw her body weight into the wheelchair causing a puncture (wound) to the left under arm. Provider action taken post-investigation: Resident #1 educated. In-service on transferring. Equipment checked for issues/malfunctions, none noted. Order received for Keflex (antibiotic) as pre-cautionary measures. Stitches clean and in place. Padded arms on Sit-to-Stand (mechanical lift). Record review of a hand written document dated 8/10/2017 and signed by CNA B revealed in part; I was showering Resident #1 and used the Sit-to-Stand (mechanical) lift for assistance. I showered Resident #1, dried her and got her dressed. I used the Sit -to-Stand (mechanical) lift again to assist me with Resident #1. I informed Resident #1 that we were going to sit now that I was going to lower the machine. I started lowering the machine but Resident #1 sat down into her chair before the machine (mechanical lift) was lowered all the way. When Resident #1 sat down, I realized that her arm was stuck inside the tip of the machine. Resident #1 was already sitting. I then ran out for help. The nurse and DON immediately came in for help. Resident #1 was anxious to sit down which caused her arm to be jammed . Record review of Resident #1 Incident Report dated 8/10/2017 at 4:01 p.m. revealed in part; -Incident type: Skin tear - deep puncture. -Location: Shower room -Equipment: Lift - motorized -Activity at time: To/from shower-assist -Narrative of incident and description of injuries: Called into the shower by involved CNA. Observed that Resident #1 left bottom part of the excess skin had been punctured by the loop that holds the sling in it. Safely removed skin from the lift. Puncture wound to left arm underneath that has excess skin. -Immediate actions taken: Applied pressure dressing. Call emergency room and gave report. -24 hour Follow-up: Alert, oriented x2. Punctured the left arm excess skin. Resident #1 had 5 stitches. Record review of the incident investigation report signed by the DON dated 8/10/2017 at 4:01 p.m. revealed in part; This writer went into the shower to see Resident #1 sitting in the wheelchair with the Sit-to-Stand sling still attached to the left side. The Hoyer lift was locked and legs spread on the Sit-to-Stand lift. CNA stated that she was helping to put Resident #1 back into the wheelchair when Resident #1 felt the back of the wheelchair and she decided to sit down before the Sit-to-Stand was all the way down causing a puncture to left under arm of the excess skin. The loop of the Hoyer lift was not sharp. The excess skin was removed and dressing applied. Resident #1 was sent to the hospital for 5 stitches to the left arm. Record review of a hand written document dated 8/10/2017 at 4:40 p.m. and signed by LVN C revealed in part: I was called by CNA B who said 'come here for a minute, Resident #1's skin is in between the Hoyer lift'. I went to the bathroom and saw Resident #1 sitting on her wheelchair holding on to the Hoyer lift. Saw a puncture to the skin with a non-sharp part of the Hoyer lift. Removed the skin from the lift (mechanical) immediately and applied a pressure dressing. DON present at this time Record review of Resident #1's departmental/nurses notes dated 8/10/2017 at 6:00 p.m. and signed by LVN C revealed in part Skin puncture to left upper arm during transfer in the shower. Pressure dressing applied, ER called. At approx 6:45 p.m. Resident #1 was transferred to the hospital Record review of Resident #1's Hospital emergency room report dated 8/10/2017 at 7:24 p.m. revealed in part; Chief complaint: Laceration. Initial comments: This is a [AGE] year old female with past medical history of [REDACTED]. There is a 3 cm laceration with extravasation of fat tissue to the medial aspect of the left upper extremity. Bleeding is controlled. Pain is 6 from a scale of 0-10. -Additional instructions: Tetanus shot today. -Laceration/wound repair: Left upper extremity linear horizontal, laceration, 3.0 c.m. in length, into the subcutaneous tissue. Wound was closed with 5 sutures. Record review of Resident #1's Wound Assessment report dated 8/11/2017 revealed in part; -New wound identified 8/10/2017 to Left Upper arm bottom. -Wound type: Puncture. -Cause: Accident/other trauma. -Measurements: 7.0x0.2 c.m. (Length x Width) -Current weight: 239.80 lbs. -Notes: Resident #1 sustained injury during transfer. Sent to emergency room and returned to facility with 5 sutures. Record review of Resident #1's MD orders revealed orders in part; -8/11/2017 Keflex (antibiotic) 500 mg capsule by mouth every 12 hours for 7 days. -8/11/2017 Observe left upper arm sutured area for signs of infection. Keep area clean and dry. -8/17/2017 Remove sutures from left upper arm on 8/21/2017. Record review of a document with title Employee Education and Counseling dated 8/11/2017 and signed by CNA B and Unit Manager/In-service Coordinator revealed in part: Topic: Safe Lifting and Movement of Residents. Lifting Machine, using a Portable. Further record review revealed attached policy and procedure with title Lifting Machine, Using a Portable revised December 2013 that read in part Purpose: The purpose of this procedure is to help lift residents using a manual lifting device. General Guidelines: Two (2) nursing assistants are required to perform this procedure. In an observation and interview on 8/22/2017 at 10:11 a.m. with Resident #1, she stated that she did not remember anything related to any incidents in the facility. Resident #1 stated that she remembered using the standing Hoyer lift device in the facility but did not recall any incidents. Further interview and observation revealed that Resident #1 had a clean and intact 4x4 dressing to her left upper inner arm. Resident #1 stated she did not know why she had the dressing to her left upper inner arm. In a phone interview on 8/22/2017 at 12:10 p.m. with CNA B, she stated that she was the CNA caring for Resident #1 on the day of the incident. CNA B further said On that day, I was already finished giving the shower to Resident #1 and I was going to transfer her to her chair. Resident #1 was on the standing lift and I had the wheelchair behind the standing lift. As I was lowering down the machine, Resident #1 sat down in her wheelchair before the machine was all the way down. I was watching as the machine was going down and then I saw that Resident #1's skin went under the machine. Her left hand was holding the machine and the extra skin on her left upper inner arm somehow got inside the metal part between the strap and the Hoyer lift hook. I went out of the hallway, I called the ADON. The DON and LVN C also came when I called them. I thought we were going to need to call 911 but LVN C was able to remove the skin from the hook where the skin got trapped. I was alone assisting Resident #1. Resident #1 is able to stand but she got inpatient and sat down before the machine was all the way down. Resident #1 required 1 to 2 people assistance for transferring. I believe you can use one person when using the Sit-to-Stand lift machine. They just trained us and they told us to use two people when using the Sit-to-Stand lift machine just in case. Further interview at that time, CNA B stated that she had not received any training in the facility on how to use the standing Sit-to-Stand Hoyer lift machine involved in the incident with Resident #1 prior to the incident. CNA B said she had been working in the facility since April 2017. When asked how she knew what type of assistance is needed for each resident during transferring, CNA B responded There is no information available about Resident #1 and there is no information about any of the residents most of the time. Nurses don't give you report on the care of the residents. You figure it out on your own. The Administrator said communication was 1 way, I don't know what she meant by that. We don't get report on the residents. You have to ask the residents. For Resident #1 I knew she needed 1 person for transferring but sometimes you need 2 people with her. All depends on how Resident #1 feels. In an observation on 8/22/2017 at 1:07 p.m. revealed that CNA D transferred Resident #1 from her wheelchair to her bed. CNA D first placed a FWW (front wheel walker) in front of the wheelchair of Resident #1. He then assisted Resident #1 up by pulling her up by the gait belt around her waist. CNA D then instructed Resident #1 to give small steps until she was in front of her bed and then assisted her to sit in the bed. CNA D further assisted Resident #1 to put her feet up. In an interview on 8/22/2017 at 1:15 p.m. with CNA D, he stated that female CNA's were still using the standing Hoyer lift for Resident #1 and then said Resident #1 required a lot of help to get her up from a sitting position. I am a man and I am strong and can do it. But for female CNA's working with her, they are still using the Hoyer standing lift. You saw how much help I gave to Resident #1 to help her get up. Resident #1 is big person and sometimes she does not help much. In an interview on 8/22/2017 at 1:18 p.m. with the ADON and CNA Staff Coordinator, the ADON stated that staff were still using the Sit-to-Stand machine on Resident #1. ADON then said that on the day of the incident, he believed that Resident #1 dropped herself down to the chair during the transfer. At that time, CNA Staff Coordinator stated Resident #1 probably had her arms on the front middle handle instead of on the handles on the side. In an interview on 8/22/2017 at 1:26 p.m. with the DON, she stated that Resident #1 required one person assistance for transferring using the Sit-to-Stand lift at the time of the incident. DON then said as of today Resident #1 required one person assistance using the FWW for transferring. That's what her care plan reads. Our policy and procedure also says that one person can use the standing mechanical lift. Requested Resident #1's care plan and policy and procedure to use the Sit-to-Stand mechanical lift. In a second interview with the ADON on 8/22/2017 at 2:45 p.m. he stated that the CNA Staff Coordinator was responsible for training the new CNA's and checking their Skills check during orientation. He then said that CNA's were able to find information about each of the residents on the ADL book. Requested to review the ADL book. Further interview at that time, the ADON asked the CNA Staff Coordinator for the ADL book and the CNA Staff Coordinator stated that the facility did not have a ADL book for information related to resident care. CNA Staff Coordinator then said that nursing staff was supposed to give report to the oncoming nursing staff to inform about the care of the residents. Continued interview on 8/22/2017 at 2:50 p.m. with CNA Staff Coordinator, when asked if CNA B had any training on using the Sit-to-Stand mechanical lift, the CNA Staff Coordinator said as she flipped thru some papers on her office the Standing lift can be used by one staff person only if the resident can help. Resident #1 required a one person assist for transfer but varies, there are some days that she needs 2 person for transfers because she would buckle. Sometime Resident #1 is tired and does not want to help. CNA Staff Coordinator then said that she could not find any training for CNA B for the use of the Sit-to Stand mechanical lift prior to the incident and then said I don't have the Skill check list. I don't know if CNA B gave it to the HR Coordinator. Further interview at that time, she stated that she was in charge of training new CNA's and provide them with the Skill check list. She then said that once the new CNA's were done with the Skill check list, they were supposed to give the completed Skill check list to the HR Coordinator. CNA Staff Coordinator said that new CNA's had 90 days to have the Skill check list completed and signed. She then said that she did not know who was supposed to make sure new CNA's returned their Skill check list back. When asked who was supposed to verify their skills, the CNA Staff Coordinator said that the CNA's training the new CNA's were supposed to verify and sign the Skill check form. CNA Staff Coordinator then said she was going to go to the HR office to check if the Skill check list for CNA B was there. In an interview on 8/22/2017 at 3:02 p.m. with the HR Coordinator, she stated that she did not have the completed Skill check list documents. She said that the In-service Coordinator was the one responsible of keeping the completed Skill check list. In an interview on 8/22/2017 at 3:05 p.m. with Unit Manager/In-service Coordinator, she stated that she was responsible to maintain all completed Skill check documents in a binder for all CNA's. When asked about CNA B skill check list and documentation that CNA B was trained on using a mechanical lift prior to the incident with Resident #1, the Unit Manager/In-service Coordinator flipped thru binders in her office. Further observation and interview on 8/22/2017 at 3:13 p.m. the Unit Manager/In-service Coordinator said that she could not find CNA B's Skill check list or training documentation. Unit Manager/In-service Coordinator said she was responsible to make sure all new CNA's had their Skill check list completed and did not know why CNA B's documents were not filed completed. In a phone interview on 8/22/2017 at 3:32 p.m. with LVN C, she stated that on the day of the incident with Resident #1, the CNA assigned for Resident #1 called her and told her to come and see Resident #1 and then said I saw Resident #1, she had a puncture wound. The hook of the mechanical lift was inside of Resident #1's skin. I took the skin out and it was mostly on the fat tissue on the skin to her left upper inner arm. Resident #1 was in the shower room. She was sitting down on her wheelchair. She was being transferred with the Standing lift. Resident #1 was holding the bar on top of the Standing lift with the left arm. The part of the skin under her left arm was probably dangling and got punctured with the hook that holds the straps of the Standing lift. Resident #1 required 2 person assistance for transfers. LVN C further said that she did not know who gave report to CNA's regarding the care of residents and then said CNA's can figure it out when caring for the residents. In an interview on 8/22/2017 at 4:05 p.m. with the DON, she stated that the nursing staff can access information regarding residents' care on the computer thru smart charting. She said that smart charting was a system where the information about the residents came from the care plan of the residents. DON said that the nurses were supposed to know how to access in the computer the smart charting and that the ADON and the CNA Staff Coordinator were supposed to know as well. DON continued saying that she was new in the facility and that the Unit Manager/In-service Coordinator was new in the position and that the Unit Manager/In-service Coordinator was trying to do two things at once because the other Unit Manager had resigned and then said We are trying to get an In-service Coordinator to keep track of all the Skill checks of the nursing staff. In an interview on 8/22/2017 at 4:45 p.m. with the ADON, he stated that he knew about the computer system where staff could find information regarding residents' care needs. Further interview and observation revealed that ADON looked into the computer and said he was going to find the information regarding Resident #1's ADL assistance required. ADON then said while looking at the computer According with the schedule care monitor Resident #1 requires 2 persons assistance for transfers. This system gets the information from the care plan of the residents. We will start today training all nursing staff on this system so everybody knows how to access it and finds information about each of the residents regarding their care and assistance needed. In an interview on 8/22/2017 at 5:15 p.m. with the Administrator, she stated that the In-service Coordinator was responsible of the entire process of the Skill check list of CNA's and that the In-service Coordinator was in charge of getting the new CNA's on board. She further said that all nursing supervisors were trained by the Corporate nurse on the computer system and that they should had known where to find information regarding the care of the residents and that the nursing supervisors were responsible to train the rest of the nursing staff. Record review of the employee file for CNA B revealed a hire date of 4/18/2017. Further record review revealed no Skill check list on her file or training on the use of mechanical lifting devices prior to 8/10/2017. Record review of the facility abuse prevention policy last revised 11/2016 revealed in part; The facility will do all that it can within its control to prohibit neglect. Neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Record review of the facility policy and procedure with title Care Plan last revised August 2007 revealed in part; .Our facility develops a comprehensive care plan for each residents that includes measurable objectives and timetable to meet the resident's medical, nursing needs . Record review of the facility policy and procedure with title Safe Lifting and Movement of Residents last revised December 2013 revealed in part; In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 3.- Staff will document resident transferring and lifting needs in the care plan. 4.- Staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices. 6.- Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques . Record review of the policy and procedure with title Lifting Machine, Using a Portable revised December 2013 that read in part Purpose: The purpose of this procedure is to help lift residents using a manual lifting device. General Guidelines: Two (2) nursing assistants are required to perform this procedure. The DON provided a list of 25 residents who required the assistance of a mechanical lift for transfers.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents, for one (Resident #1) of six residents reviewed for accidents. -The facility failed to train CNA B in the use of mechanical lifting devices. -Then the facility failed to train CNA B on how to access resident's information to determine the required type of assistance required for transfer for each resident. -CNA B failed to transfer Resident #1 in accordance with her plan of care when using a mechanical lift. CNA B transferred Resident #1 alone and Resident #1 sustained a puncture wound to her left upper inner arm during transfer and had to receive 5 sutures in the emergency room . These failures affected one resident and could affect the remaining 24 residents who required the assistance of two staff members and a mechanical lift for transfers by placing them at risk for injury. Findings included: Intake # 1 Record review of Resident #1's Face Sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's admission MDS assessment, dated 07/28/17 revealed Resident #1 had moderately impaired cognition with a BIMS score of 11 out of a possible 15. She required extensive assistance of two person physical assistance for bed mobility, transfer and walk in corridor and extensive assistance of one person physical assist for locomotion, dressing, toilet use and personal hygiene. Record review of Resident #1's Comprehensive Plan of Care, dated 07/21/17, revealed in part; -Problem/need: ADL deficit: Resident #1 is unable to perform ADL's independently, requires extensive assistance form staff secondary to impaired cognition, weakness, and/or physical limitations. -Approaches: Transfer with 2 person assist with mechanical lift. Record review of the facility's Provider Investigation Report, dated 08/10/17, revealed on 08/10/17, while Resident #1 was being showered while in the Sit-to-Stand (mechanical lift) and the wheelchair behind Resident #1, Resident #1 abruptly sat down and threw her body weight into the wheelchair causing a puncture (wound) to the left under arm. Provider action taken post-investigation: Resident #1 educated. In-service on transferring. Equipment checked for issues/malfunctions, none noted. Order received for Keflex (antibiotic) as pre-cautionary measures. Stitches clean and in place. Padded arms on Sit-to-Stand (mechanical lift). Record review of a hand written document dated 8/10/2017 and signed by CNA B revealed in part; I was showering Resident #1 and used the Sit-to-Stand (mechanical) lift for assistance. I showered Resident #1, dried her and got her dressed. I used the Sit -to-Stand (mechanical) lift again to assist me with Resident #1. I informed Resident #1 that we were going to sit now that I was going to lower the machine. I started lowering the machine but Resident #1 sat down into her chair before the machine (mechanical lift) was lowered all the way. When Resident #1 sat down, I realized that her arm was stuck inside the tip of the machine. Resident #1 was already sitting. I then ran out for help. The nurse and DON immediately came in for help. Resident #1 was anxious to sit down which caused her arm to be jammed . Record review of Resident #1 Incident Report dated 8/10/2017 at 4:01 p.m. revealed in part; -Incident type: Skin tear - deep puncture. -Location: Shower room -Equipment: Lift - motorized -Activity at time: To/from shower-assist -Narrative of incident and description of injuries: Called into the shower by involved CNA. Observed that Resident #1 left bottom part of the excess skin had been punctured by the loop that holds the sling in it. Safely removed skin from the lift. Puncture wound to left arm underneath that has excess skin. -Immediate actions taken: Applied pressure dressing. Call emergency room and gave report. -24 hour Follow-up: Alert, oriented x2. Punctured the left arm excess skin. Resident #1 had 5 stitches. Record review of the incident investigation report signed by the DON dated 8/10/2017 at 4:01 p.m. revealed in part; This writer went into the shower to see Resident #1 sitting in the wheelchair with the Sit-to-Stand sling still attached to the left side. The Hoyer lift was locked and legs spread on the Sit-to-Stand lift. CNA stated that she was helping to put Resident #1 back into the wheelchair when Resident #1 felt the back of the wheelchair and she decided to sit down before the Sit-to-Stand was all the way down causing a puncture to left under arm of the excess skin. The loop of the Hoyer lift was not sharp. The excess skin was removed and dressing applied. Resident #1 was sent to the hospital for 5 stitches to the left arm. Record review of a hand written document dated 8/10/2017 at 4:40 p.m. and signed by LVN C revealed in part: I was called by CNA B who said 'come here for a minute, Resident #1's skin is in between the Hoyer lift'. I went to the bathroom and saw Resident #1 sitting on her wheelchair holding on to the Hoyer lift. Saw a puncture to the skin with a non-sharp part of the Hoyer lift. Removed the skin from the lift (mechanical) immediately and applied a pressure dressing. DON present at this time Record review of Resident #1's departmental/nurses notes dated 8/10/2017 at 6:00 p.m. and signed by LVN C revealed in part Skin puncture to left upper arm during transfer in the shower. Pressure dressing applied, ER called. At approx 6:45 p.m. Resident #1 was transferred to the hospital Record review of Resident #1's Hospital emergency room report dated 8/10/2017 at 7:24 p.m. revealed in part; Chief complaint: Laceration. Initial comments: This is a [AGE] year old female with past medical history of [REDACTED]. There is a 3 cm laceration with extravasation of fat tissue to the medial aspect of the left upper extremity. Bleeding is controlled. Pain is 6 from a scale of 0-10. -Additional instructions: Tetanus shot today. -Laceration/wound repair: Left upper extremity linear horizontal, laceration, 3.0 c.m. in length, into the subcutaneous tissue. Wound was closed with 5 sutures. Record review of Resident #1's Wound Assessment report dated 8/11/2017 revealed in part; -New wound identified 8/10/2017 to Left Upper arm bottom. -Wound type: Puncture. -Cause: Accident/other trauma. -Measurements: 7.0x0.2 c.m. (Length x Width) -Current weight: 239.80 lbs. -Notes: Resident #1 sustained injury during transfer. Sent to emergency room and returned to facility with 5 sutures. Record review of Resident #1's MD orders revealed orders in part; -8/11/2017 Keflex (antibiotic) 500 mg capsule by mouth every 12 hours for 7 days. -8/11/2017 Observe left upper arm sutured area for signs of infection. Keep area clean and dry. -8/17/2017 Remove sutures from left upper arm on 8/21/2017. Record review of a document with title Employee Education and Counseling dated 8/11/2017 and signed by CNA B and Unit Manager/In-service Coordinator revealed in part: Topic: Safe Lifting and Movement of Residents. Lifting Machine, using a Portable. Further record review revealed attached policy and procedure with title Lifting Machine, Using a Portable revised December 2013 that read in part Purpose: The purpose of this procedure is to help lift residents using a manual lifting device. General Guidelines: Two (2) nursing assistants are required to perform this procedure. In an observation and interview on 8/22/2017 at 10:11 a.m. with Resident #1, she stated that she did not remember anything related to any incidents in the facility. Resident #1 stated that she remembered using the standing Hoyer lift device in the facility but did not recall any incidents. Further interview and observation revealed that Resident #1 had a clean and intact 4x4 dressing to her left upper inner arm. Resident #1 stated she did not know why she had the dressing to her left upper inner arm. In a phone interview on 8/22/2017 at 12:10 p.m. with CNA B, she stated that she was the CNA caring for Resident #1 on the day of the incident. CNA B further said On that day, I was already finished giving the shower to Resident #1 and I was going to transfer her to her chair. Resident #1 was on the standing lift and I had the wheelchair behind the standing lift. As I was lowering down the machine, Resident #1 sat down in her wheelchair before the machine was all the way down. I was watching as the machine was going down and then I saw that Resident #1's skin went under the machine. Her left hand was holding the machine and the extra skin on her left upper inner arm somehow got inside the metal part between the strap and the Hoyer lift hook. I went out of the hallway, I called the ADON. The DON and LVN C also came when I called them. I thought we were going to need to call 911 but LVN C was able to remove the skin from the hook where the skin got trapped. I was alone assisting Resident #1. Resident #1 is able to stand but she got inpatient and sat down before the machine was all the way down. Resident #1 required 1 to 2 people assistance for transferring. I believe you can use one person when using the Sit-to-Stand lift machine. They just trained us and they told us to use two people when using the Sit-to-Stand lift machine just in case. Further interview at that time, CNA B stated that she had not received any training in the facility on how to use the standing Sit-to-Stand Hoyer lift machine involved in the incident with Resident #1 prior to the incident. CNA B said she had been working in the facility since April 2017. When asked how she knew what type of assistance is needed for each resident during transferring, CNA B responded There is no information available about Resident #1 and there is no information about any of the residents most of the time. Nurses don't give you report on the care of the residents. You figure it out on your own. The Administrator said communication was 1 way, I don't know what she meant by that. We don't get report on the residents. You have to ask the residents. For Resident #1 I knew she needed 1 person for transferring but sometimes you need 2 people with her. All depends on how Resident #1 feels. In an observation on 8/22/2017 at 1:07 p.m. revealed that CNA D transferred Resident #1 from her wheelchair to her bed. CNA D first placed a FWW (front wheel walker) in front of the wheelchair of Resident #1. He then assisted Resident #1 up by pulling her up by the gait belt around her waist. CNA D then instructed Resident #1 to give small steps until she was in front of her bed and then assisted her to sit in the bed. CNA D further assisted Resident #1 to put her feet up. In an interview on 8/22/2017 at 1:15 p.m. with CNA D, he stated that female CNA's were still using the standing Hoyer lift for Resident #1 and then said Resident #1 required a lot of help to get her up from a sitting position. I am a man and I am strong and can do it. But for female CNA's working with her, they are still using the Hoyer standing lift. You saw how much help I gave to Resident #1 to help her get up. Resident #1 is big person and sometimes she does not help much. In an interview on 8/22/2017 at 1:18 p.m. with the ADON and CNA Staff Coordinator, the ADON stated that staff were still using the Sit-to-Stand machine on Resident #1. ADON then said that on the day of the incident, he believed that Resident #1 dropped herself down to the chair during the transfer. At that time, CNA Staff Coordinator stated Resident #1 probably had her arms on the front middle handle instead of on the handles on the side. In an interview on 8/22/2017 at 1:26 p.m. with the DON, she stated that Resident #1 required one person assistance for transferring using the Sit-to-Stand lift at the time of the incident. DON then said as of today Resident #1 required one person assistance using the FWW for transferring. That's what her care plan reads. Our policy and procedure also says that one person can use the standing mechanical lift. Requested Resident #1's care plan and policy and procedure to use the Sit-to-Stand mechanical lift. In a second interview with the ADON on 8/22/2017 at 2:45 p.m. he stated that the CNA Staff Coordinator was responsible for training the new CNA's and checking their Skills check during orientation. He then said that CNA's were able to find information about each of the residents on the ADL book. Requested to review the ADL book. Further interview at that time, the ADON asked the CNA Staff Coordinator for the ADL book and the CNA Staff Coordinator stated that the facility did not have a ADL book for information related to resident care. CNA Staff Coordinator then said that nursing staff was supposed to give report to the oncoming nursing staff to inform about the care of the residents. Continued interview on 8/22/2017 at 2:50 p.m. with CNA Staff Coordinator, when asked if CNA B had any training on using the Sit-to-Stand mechanical lift, the CNA Staff Coordinator said as she flipped thru some papers on her office the Standing lift can be used by one staff person only if the resident can help. Resident #1 required a one person assist for transfer but varies, there are some days that she needs 2 person for transfers because she would buckle. Sometime Resident #1 is tired and does not want to help. CNA Staff Coordinator then said that she could not find any training for CNA B for the use of the Sit-to Stand mechanical lift prior to the incident and then said I don't have the Skill check list. I don't know if CNA B gave it to the HR Coordinator. Further interview at that time, she stated that she was in charge of training new CNA's and provide them with the Skill check list. She then said that once the new CNA's were done with the Skill check list, they were supposed to give the completed Skill check list to the HR Coordinator. CNA Staff Coordinator said that new CNA's had 90 days to have the Skill check list completed and signed. She then said that she did not know who was supposed to make sure new CNA's returned their Skill check list back. When asked who was supposed to verify their skills, the CNA Staff Coordinator said that the CNA's training the new CNA's were supposed to verify and sign the Skill check form. CNA Staff Coordinator then said she was going to go to the HR office to check if the Skill check list for CNA B was there. In an interview on 8/22/2017 at 3:02 p.m. with the HR Coordinator, she stated that she did not have the completed Skill check list documents. She said that the In-service Coordinator was the one responsible of keeping the completed Skill check list. In an interview on 8/22/2017 at 3:05 p.m. with Unit Manager/In-service Coordinator, she stated that she was responsible to maintain all completed Skill check documents in a binder for all CNA's. When asked about CNA B skill check list and documentation that CNA B was trained on using a mechanical lift prior to the incident with Resident #1, the Unit Manager/In-service Coordinator flipped thru binders in her office. Further observation and interview on 8/22/2017 at 3:13 p.m. the Unit Manager/In-service Coordinator said that she could not find CNA B's Skill check list or training documentation. Unit Manager/In-service Coordinator said she was responsible to make sure all new CNA's had their Skill check list completed and did not know why CNA B's documents were not filed completed. In a phone interview on 8/22/2017 at 3:32 p.m. with LVN C, she stated that on the day of the incident with Resident #1, the CNA assigned for Resident #1 called her and told her to come and see Resident #1 and then said I saw Resident #1, she had a puncture wound. The hook of the mechanical lift was inside of Resident #1's skin. I took the skin out and it was mostly on the fat tissue on the skin to her left upper inner arm. Resident #1 was in the shower room. She was sitting down on her wheelchair. She was being transferred with the Standing lift. Resident #1 was holding the bar on top of the Standing lift with the left arm. The part of the skin under her left arm was probably dangling and got punctured with the hook that holds the straps of the Standing lift. Resident #1 required 2 person assistance for transfers. LVN C further said that she did not know who gave report to CNA's regarding the care of residents and then said CNA's can figure it out when caring for the residents. In an interview on 8/22/2017 at 4:05 p.m. with the DON, she stated that the nursing staff can access information regarding residents' care on the computer thru smart charting. She said that smart charting was a system where the information about the residents came from the care plan of the residents. DON said that the nurses were supposed to know how to access in the computer the smart charting and that the ADON and the CNA Staff Coordinator were supposed to know as well. DON continued saying that she was new in the facility and that the Unit Manager/In-service Coordinator was new in the position and that the Unit Manager/In-service Coordinator was trying to do two things at once because the other Unit Manager had resigned and then said We are trying to get an In-service Coordinator to keep track of all the Skill checks of the nursing staff. In an interview on 8/22/2017 at 4:45 p.m. with the ADON, he stated that he knew about the computer system where staff could find information regarding residents' care needs. Further interview and observation revealed that ADON looked into the computer and said he was going to find the information regarding Resident #1's ADL assistance required. ADON then said while looking at the computer According with the schedule care monitor Resident #1 requires 2 persons assistance for transfers. This system gets the information from the care plan of the residents. We will start today training all nursing staff on this system so everybody knows how to access it and finds information about each of the residents regarding their care and assistance needed. In an interview on 8/22/2017 at 5:15 p.m. with the Administrator, she stated that the In-service Coordinator was responsible of the entire process of the Skill check list of CNA's and that the In-service Coordinator was in charge of getting the new CNA's on board. She further said that all nursing supervisors were trained by the Corporate nurse on the computer system and that they should had known where to find information regarding the care of the residents and that the nursing supervisors were responsible to train the rest of the nursing staff. Record review of the employee file for CNA B revealed a hire date of 4/18/2017. Further record review revealed no Skill check list on her file or training on the use of mechanical lifting devices prior to 8/10/2017. Record review of the facility abuse prevention policy last revised 11/2016 revealed in part; The facility will do all that it can within its control to prohibit neglect. Neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Record review of the facility policy and procedure with title Care Plan last revised August 2007 revealed in part; .Our facility develops a comprehensive care plan for each residents that includes measurable objectives and timetable to meet the resident's medical, nursing needs . Record review of the facility policy and procedure with title Safe Lifting and Movement of Residents last revised December 2013 revealed in part; In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 3.- Staff will document resident transferring and lifting needs in the care plan. 4.- Staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices. 6.- Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques . Record review of the policy and procedure with title Lifting Machine, Using a Portable revised December 2013 that read in part Purpose: The purpose of this procedure is to help lift residents using a manual lifting device. General Guidelines: Two (2) nursing assistants are required to perform this procedure. The DON provided a list of 25 residents who required the assistance of a mechanical lift for transfers.

Based on interview and record review, the facility failed to ensure adequate supervision and assistance devices were provided to prevent an accident for 1 of 5 residents reviewed for accidents and supervision. (Resident #1) The facility did not properly secure Resident #1's wheelchair during a van transport. The wheelchair moved causing Resident #1 to lean up against the wheelchair ramp gate, injuring Resident #1's right ear, right shoulder and right clavicle. This failure placed 33 residents who were dependent on a wheelchair at risk of injury. Findings included: Record review of Resident#1's face sheet revealed initial admitted [DATE] and re-admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. Record Review of Resident#1's Care plan dated 5/13 and revised 3/6/17 for ADL Deficit revealed in part - Problem/Need: Resident#1 is un able to perform ADL's independently, requires Extensive/Total assistance (of 2 people) . secondary to impaired cognition, weakness, and physical limitations-R sided paresis 3/6/17 Hoyer lift for transfers. Approaches: Hoyer lift for transfers. -Problem/Need: (Resident#1) is at risk for falls r/t incontinence, decreased mobility, psych med usage, HX falls Approaches: 7/6/17- Van drivers in-serviced on proper locking/seatbelt securing when transporting Record review of Resident #1's medical record, Progress note dated 7/12/17 revealed in part . History of Present Illness: Fracture of unspecified part of left clavicle, subsequent encounter for fracture with routine healing-Improving Treatment: F/U with ortho Flaccid [DIAGNOSES REDACTED] affecting right dominant side Clinical notes: Right side [DIAGNOSES REDACTED] Wheel Chair bound Fall Precautions at all times Observation of Resident #1 on 7/18/17 at 9:20 a.m. during initial tour revealed he was fully dressed, sitting in his high-back wheelchair in his room watching TV. while waiting for his morning medications. Resident #1 had an sling on his right arm and one foot rest on his wheel chair, the right foot. Resident #1 speech was impaired and did not recall the incident. Record review of Incident Investigation dated 7/6/17 at 12:00 p.m. revealed Resident was coming back from apt. the van driver was turning the corner when the Resident upper body repositioned into the ramp gate. Resident got abrasion to right ear. Right shoulder has dislocation. Right shoulder and left wrist has bruise on it. X-ray was done stat notified family, MD, and DON. Resident has sling to help with dislocation of the right shoulder. Record review of Post-Incident Actions dated 7/6/17 at 12:00 p.m. revealed section 'narrative of incident' read in part .Writer informed via Van driver/facility transportation of residents w/c tilting during transportation to facility. During this time resident hit guard rail in facility van causing abrasions to right ear/scalp, bruising to right shoulder. Record review of resident incident follow-up report dated 7/6/17 at 12:00 p.m.revealed section '24 Hour Follow-up' read in part . Right ear has skin abrasion, bruised on right shoulder and left wrist dislocation of right shoulder. Record review of Resident #1's nurses notes date 7/6/17 at 2:43 p.m. revealed Writer informed via Van Driver, facility transporter of residents w/c tilting causing him to hit guard rail in van. Resident noted with abrasions to right earlobe and right lateral scalp. Bruising noted to right shoulder with decreased ROM noted, pain 3/10. Record Review of Resident #1's Wound Assessment report dated 7/6/17 notes revealed Resident skin assessed to find discoloration purple/green tint to right shoulder, left wrist area, left hand between thumb and 1st finger, and right hand. Resident new skin tear to right ear measuring 0.5 X 0.5 cm. Record review of Resident #1's Imaging Report from Hospital B, dated 7/7/17, revealed he had a displaced clavical, and the acromioclavicular joint appeared disrupted. Findings are suggestive of an underlying acromioclavicular joint injury. Interview on 7/18/16 at 11:30 a.m., the Van Driver said before he transported Resident #1 the morning of 7/6/17, he loaded Resident #1, secured chest and lap seat belt, and straps to the wheelchair wheels. He said he did the same procedure of strapping the resident in the w/c before returning to the facility and when he made a left turn, Resident #1 shifted his body to the right and fell into the w/c ramp gate. The Van Driver stated that he used the resident's pants to straighten him up in the w/c and that the seatbelts and straps were in place and the wheelchair did not turn over or move. He stated that he had On-the-Job training when initially hired in January of 2016 but has not been trained about the van, lift and securing of wheelchairs until after the alleged incident of 7/6/17. He could not recall the specifics of that training. Interview with the Maintenance Director said four safety straps should be used to assure wheelchairs do not move while transporting residents. He stated that on 7/6/17 he assessed Resident #1's wheelchair after the incident and found that if the right side brake on the wheelchair was loose slightly, that if you applied to much pressure to the brake it would allow the wheelchair to still move. The Maintenance Director stated that he tighten both sides of Resident #1's wheel chair that day after the incident. Interview with DON on 7/18/17 at 1:30 p.m. revealed she initially interviewed the Van driver on 7/6/17 after the incident happened and Van driver said he had lifted resident #1 from his wheelchair, placed him on the floor of the w/c van repositioned the wheelchair because the w/c was tilted and then picked Resident #1 off the floor and straightened him back in the w/c. DON said the Van Driver had not been trained or in-serviced on how to transfer or move/reposition Residents in the wheelchair until after the alleged incident of 7/6/17. DON revealed her expectation is for the Van Drivers to not move the Residents if accident in the van and for the Van Driver to call 911 immediately. The DON said Resident #1 was sent for an emergency evaluation on 7/6/17 with open area to his right ear and decreased ROM to his right arm and later returned to the facility with the right arm in a sling due to dislocation. The DON said she thought Resident #1 sustained the injury during transport, but she really didn't know. During an interview on 7/18/17 at 11:00 a.m., the administrator said she was out of town when the incident happened. She stated the Van Driver was not oriented and checked off on the use of the van, w/c lift or properly securing of w/c in the van until after the alleged incident of 7/6/17. Follow-up interview with Van Driver while Administrator present on 7/18/17 at 2:45 p.m. he said he removed the resident from the wheelchair and placed him on the floor and straightened the wheel chair because the chair was tilted. Van driver stated that he had picked Resident #1 from the floor by placing his arms under the resident's arms because he was dead weight. Administrator stated that the Van Driver will be placed off Van duty until re-trained and the facility will be using an outside source until Van Driver is re-trained. In-service training dated 7/12/17 revealed DVD Video presentation on operation by mobility services. Record review of an undated Wheelchair transportation safety checklist initialed by the Van Driver dated 7/6/17 read in part Before loading resident, visually check equipment for properly working conditions .Instruct the operator to restrict personnel movement near the lift to reduce the risk of being injured from the lift platform .Set both wheelchair brakes and fasten safely restraints before raising the lift to the level of entry into the van. Record review of Van Driver's employee file revealed date of hire as 1/6/16. Further review of the employee file revealed a Job Description-Concierge (Van Driver) acknowledged and signed by Van Driver 1/6/16. The document read in part Reports to Executive Director and Director of Nursing .Job Summary . This person is responsible for the safe transport of residents and family members to and from their destinations Safety and Sanitation .4. Observes safety needs of residents as indicated in care plan .7. Reports all hazardous conditions and equipment to supervisor immediately. A list provided by the DON on 7/18/17 indicated 33 residents were dependent on a wheelchair.

Based on observation, interview and record review, the facility failed to ensure residents were free from neglect for 1 of 5 residents reviewed for neglect (Resident #1) in that: --The facility did not properly secure Resident #1's wheelchair during a van transport. The wheelchair moved causing Resident #1 to lean up against the wheelchair ramp gate, injuring Resident #1's right ear, right shoulder and right clavicle. This failure affected 1 resident and placed an additional 32 residents who were dependent on a wheelchair at risk of neglect, physical harm, mental harm, injury, and hospitalization . Findings included: Record review of Resident#1's face sheet revealed initial admitted [DATE] and re-admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. Record Review of Resident#1's Care plan dated 5/13 and revised 3/6/17 for ADL Deficit revealed in part - Problem/Need: Resident#1 is un able to perform ADL's independently, requires Extensive/Total assistance (of 2 people) . secondary to impaired cognition, weakness, and physical limitations-R sided paresis 3/6/17 Hoyer lift for transfers. Approaches: Hoyer lift for transfers. -Problem/Need: (Resident#1) is at risk for falls r/t incontinence, decreased mobility, psych med usage, HX falls Approaches: 7/6/17- Van drivers in-serviced on proper locking/seatbelt securing when transporting Record review of Resident #1's medical record, Progress note dated 7/12/17 revealed in part . History of Present Illness: Fracture of unspecified part of left clavicle, subsequent encounter for fracture with routine healing-Improving Treatment: F/U with ortho Flaccid [MEDICAL CONDITION] affecting right dominant side Clinical notes: Right side [MEDICAL CONDITION] Wheel Chair bound Fall Precautions at all times Observation of Resident #1 on 7/18/17 at 9:20 a.m. during initial tour revealed he was fully dressed, sitting in his high-back wheelchair in his room watching TV. while waiting for his morning medications. Resident #1 had an sling on his right arm and one foot rest on his wheel chair, the right foot. Resident #1 speech was impaired and did not recall the incident. Record review of Incident Investigation dated 7/6/17 at 12:00 p.m. revealed Resident was coming back from apt. the van driver was turning the corner when the Resident upper body repositioned into the ramp gate. Resident got abrasion to right ear. Right shoulder has dislocation. Right shoulder and left wrist has bruise on it. X-ray was done stat notified family, MD, and DON. Resident has sling to help with dislocation of the right shoulder. Record review of Post-Incident Actions dated 7/6/17 at 12:00 p.m. revealed section 'narrative of incident' read in part .Writer informed via Van driver/facility transportation of residents w/c tilting during transportation to facility. During this time resident hit guard rail in facility van causing abrasions to right ear/scalp, bruising to right shoulder. Record review of resident incident follow-up report dated 7/6/17 at 12:00 p.m.revealed section '24 Hour Follow-up' read in part . Right ear has skin abrasion, bruised on right shoulder and left wrist dislocation of right shoulder. Record review of Resident #1's nurses notes date 7/6/17 at 2:43 p.m. revealed Writer informed via Van Driver, facility transporter of residents w/c tilting causing him to hit guard rail in van. Resident noted with abrasions to right earlobe and right lateral scalp. Bruising noted to right shoulder with decreased ROM noted, pain 3/10. Record Review of Resident #1's Wound Assessment report dated 7/6/17 notes revealed Resident skin assessed to find discoloration purple/green tint to right shoulder, left wrist area, left hand between thumb and 1st finger, and right hand. Resident new skin tear to right ear measuring 0.5 X 0.5 cm. Record review of Resident #1's Imaging Report from Hospital B, dated 7/7/17, revealed he had a displaced clavical, and the acromioclavicular joint appeared disrupted. Findings are suggestive of an underlying acromioclavicular joint injury. Interview on 7/18/16 at 11:30 a.m., the Van Driver said before he transported Resident #1 the morning of 7/6/17, he loaded Resident #1, secured chest and lap seat belt, and straps to the wheelchair wheels. He said he did the same procedure of strapping the resident in the w/c before returning to the facility and when he made a left turn, Resident #1 shifted his body to the right and fell into the w/c ramp gate. The Van Driver stated that he used the resident's pants to straighten him up in the w/c and that the seatbelts and straps were in place and the wheelchair did not turn over or move. He stated that he had On-the-Job training when initially hired in January of 2016 but has not been trained about the van, lift and securing of wheelchairs until after the alleged incident of 7/6/17. He could not recall the specifics of that training. Interview with the Maintenance Director said four safety straps should be used to assure wheelchairs do not move while transporting residents. He stated that on 7/6/17 he assessed Resident #1's wheelchair after the incident and found that if the right side brake on the wheelchair was loose slightly, that if you applied to much pressure to the brake it would allow the wheelchair to still move. The Maintenance Director stated that he tighten both sides of Resident #1's wheel chair that day after the incident. Interview with DON on 7/18/17 at 1:30 p.m. revealed she initially interviewed the Van driver on 7/6/17 after the incident happened and Van driver said he had lifted resident #1 from his wheelchair, placed him on the floor of the w/c van repositioned the wheelchair because the w/c was tilted and then picked Resident #1 off the floor and straightened him back in the w/c. DON said the Van Driver had not been trained or in-serviced on how to transfer or move/reposition Residents in the wheelchair until after the alleged incident of 7/6/17. DON revealed her expectation is for the Van Drivers to not move the Residents if accident in the van and for the Van Driver to call 911 immediately. The DON said Resident #1 was sent for an emergency evaluation on 7/6/17 with open area to his right ear and decreased ROM to his right arm and later returned to the facility with the right arm in a sling due to dislocation. The DON said she thought Resident #1 sustained the injury during transport, but she really didn't know. During an interview on 7/18/17 at 11:00 a.m., the administrator said she was out of town when the incident happened. She stated the Van Driver was not oriented and checked off on the use of the van, w/c lift or properly securing of w/c in the van until after the alleged incident of 7/6/17. Follow-up interview with Van Driver while Administrator present on 7/18/17 at 2:45 p.m. he said he removed the resident from the wheelchair and placed him on the floor and straightened the wheel chair because the chair was tilted. Van driver stated that he had picked Resident #1 from the floor by placing his arms under the resident's arms because he was dead weight. Administrator stated that the Van Driver will be placed off Van duty until re-trained and the facility will be using an outside source until Van Driver is re-trained. In-service training dated 7/12/17 revealed DVD Video presentation on operation by mobility services. Record review of an undated Wheelchair transportation safety checklist initialed by the Van Driver dated 7/6/17 read in part Before loading resident, visually check equipment for properly working conditions .Instruct the operator to restrict personnel movement near the lift to reduce the risk of being injured from the lift platform .Set both wheelchair brakes and fasten safely restraints before raising the lift to the level of entry into the van. Record review of Van Driver's employee file revealed date of hire as 1/6/16. Further review of the employee file revealed a Job Description-Concierge (Van Driver) acknowledged and signed by Van Driver 1/6/16. The document read in part Reports to Executive Director and Director of Nursing .Job Summary . This person is responsible for the safe transport of residents and family members to and from their destinations Safety and Sanitation .4. Observes safety needs of residents as indicated in care plan .7. Reports all hazardous conditions and equipment to supervisor immediately. A list provided by the DON on 7/18/17 indicated 33 residents were dependent on a wheelchair.

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable for one of three residents (Resident #63) reviewed for pressure ulcers. The facility failed to prevent the development of pressure sores for Resident #63 who developed a stage IV pressure sore on the left heel and an unstageable pressure sore on the right heel and was diagnosed with [REDACTED]. This failure affected one resident and had the potential to affect the remaining 53 residents in the NStep rehabilitation wing, and placed them at risk for unnecessary pain, infection, and a decline in the residents health and well being. Findings include: Resident #63 Record review of Resident #63's face sheet (undated) revealed that he was an [AGE] year old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #63's Admission MDS (Minimum Data Set) dated 9/7/16 revealed that he was understood and usually understood others. His BIMS (Brief Interview for Mental Status) was 15, indicating no cognitive impairment. His functional status revealed he was extensive-one person assist for bed mobility, locomotion, dressing, toileting, and personal hygiene, and total dependence-one person assist for bathing. Active [DIAGNOSES REDACTED]. This document revealed that he received pain medication on an as needed basis. He reported occasional pain. This document revealed that he was not at risk for a pressure ulcer and that he did not have a stage 1 or higher pressure ulcer. He did not receive any antibiotics . This document also revealed he received 5 days of physical therapy and 3 days of occupational therapy. Record review of Resident #63's Significant Change MDS dated [DATE] revealed that he usually understood others and was usually understood. His Brief Interview for Mental Status revealed a score of 1, indicating severe cognitive impairment. His functional status revealed he was an extensive assist, with need for two persons for; bed mobility, transfers, toilet use, and bathing. He was an extensive assist with needing one person for locomotion, dressing, and personal hygiene. His active [DIAGNOSES REDACTED]. It further revealed he was on a scheduled pain medication regimen. Resident #63 was unable to be interviewed for presence of pain. Staff pain assessment was facial expressions. Pain was observed to be present for 3 to 4 days. This document revealed that he did not have pressure ulcers on prior assessment. He had a Stage 4 pressure ulcer that measured 7 cm in length, 7 cm in width, and 2 cm in depth. Record review of Resident #63's Skin assessment dated [DATE] noted Incision to left hip, skin tears to both buttocks, and skin turgor was firm. This document revealed the resident had no pressure sores on admission. Record review of Resident #63's Braden Risk Assessment Report dated 8/31/16 revealed that he was a moderate risk for development of pressure ulcers. He was bedfast with limited mobility. Record review of Resident #63's Care Plan dated 9/7/16 revealed that he was not identified or care planned for being at risk for a pressure ulcer, or interventions to avoid development of pressure sores. In an interview on 10/5/16 at 6:30 a.m. with the MDS LVN , she stated that they look at the nurses notes, braden scale, and weekly wound reports. She also stated that on the admission MDS we should have put that Resident #63 was at risk for pressure ulcer. She confirmed Resident #63 did not have a care plan for being at risk for pressure ulcer. Record review of LVN #23's (who was terminated) statement dated 9/27/16, he stated that approximately 1-2 weeks ago during a busy 6 pm - 6 am shift, CNA #53 called him into resident #63's room because he had blood stains at the foot of his bed on the left side. Upon assessment he noted a small blister on his left heel that appeared to have ruptured. He stated in his statement that he cleaned the area with normal saline and applied an protective dressing. He wrote it on the 24 hour report about the blister and for it to be reported to the wound care nurse for evaluation and treatment when she came in on the oncoming shift. In an interview on 10/5/16 at 1:32 with ADON #3, he stated that when 24 hour reports are written the unit managers look at them, we looked for LVN #23's 24 hour report and were unable to find it. The 24 hour reports that are written the night before are discussed the next day at the 9 a.m meeting. He further stated that care plans are supposed to identify at risk residents for pressure ulcers and include interventions i.e., food intake, protein, turning and position every two hours and upload the heels. Record review of the facility's Wound Assessment Report dated 9/22/16 revealed: -Right heel 2.50 cm x 3.50 cm x 0, unstageable, due to eschar. Record review of the facility's Wound Assessment Report dated 9/26/16 revealed: -Left heel 7 cm x 7 cm x 0 cm. Stage 4. Record Review of Resident #63's wound care consult report dated 10/3/16 revealed : -Right heel wound measured 5 cm x 5 cm x 0, unstageable. -Left heel wound measured 7cm x 7 cm x 2 cm, stage 4. Record review of Resident #63's MRI dated 10/5/16 of the left lower joint revealed that he developed Calcaneal osteomelitis, (a severe infection of the bone, bone marrow, and surrounding tissue). In an interview on 10/5/2016 at 4:00pm, the DON said Resident #63 developed a wound on his heel after he was in bed most of the time. He said they started doing skin assessments on all residents who were at risk for wound development and found a bandage on Resident #63 ' s heel. He said he interviewed a CNA who said she found a fluid filled blister a few days ago (somewhere between 3-5 days) and reported it to the nurse on duty. He said he interviewed the nurse who claimed he put it on the 24-hour report. He said he checked the report and there was no note of the wound. He said they terminated the nurse for not reporting the wound. He said ever since then, he has monitored the wound closely. Facility provided their Pressure Ulcer Treatment policy and not the Pressure Ulcer Prevention Policy as requested. The facility's resident roster revealed that there were 54 residents in the NStep unit.

Based on observation, interview and record review, the facility failed to provide necessary care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for 1 resident of 19 residents (Resident #63) reviewed for quality of care. LVN #39 failed to assess and treat Resident #63 for pain during wound care when the resident was grimacing and complaining of severe pain. This failure affected one resident and had the potential to affect 73 residents who were on a pain management program and place them at risk for uncontrolled pain, depression, and a decline in health. Findings include: Record review of Resident #63's face sheet (undated) revealed that he was an [AGE] year old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #63's Admission MDS (Minimum Data Set) dated 9/7/16 revealed that he was understood and usually understood others. His BIMS (Brief Interview for Mental Status) was 15, indicating no cognitive impairment. His functional status revealed he was extensive-one person assist for bed mobility, locomotion, dressing, toileting, and personal hygiene, and total dependence-one person assist for bathing. Active [DIAGNOSES REDACTED]. This document revealed that he received pain medication on an as needed basis. He reported occasional pain. This document revealed that he was not at risk for a pressure ulcer and that he did not have a stage 1 or higher pressure ulcer. He did not receive any antibiotics . This document also revealed he received 5 days of physical therapy and 3 days of occupational therapy. Record review of Resident #63's Significant Change MDS dated [DATE] revealed that he usually understood others and was usually understood. His Brief Interview for Mental Status revealed a score of 1, indicating severe cognitive impairment. His functional status revealed he was an extensive assist, with need for two persons for; bed mobility, transfers, toilet use, and bathing. He was an extensive assist with needing one person for locomotion, dressing, and personal hygiene. His active [DIAGNOSES REDACTED]. It further revealed he was on a scheduled pain medication regimen. Resident #63 was unable to be interviewed for presence of pain. Staff pain assessment was facial expressions. Pain was observed to be present for 3 to 4 days. This document revealed that he did not have pressure ulcers on prior assessment. He had a Stage 4 pressure ulcer that measured 7 cm in length, 7 cm in width, and 2 cm in depth. Record Review of Resident # 63's care plan revealed that he was care planned for pain on 9/7/16, and revealed a goal that resident will verbalize relief of pain with a pain scale of 3 or less, and interventions included to monitor for prn use (care plan does not say prn use of what) and assess for routine dosing. Care plan was not updated as a result of the significant change MDS. Record review of Resident #63's consolidated Physicians Orders dated October 2016 revealed a PRN (as needed ) order for [MEDICATION NAME] 5-325 tablet, give one by mouth every 4 hours as needed for pain, and to do a pain assessment every shift using 0-10 pain scale: Assessment 1-3 = mild pain 4-6 = moderate pain 7-10 = severe pain If pain is reported , what intervention was taken: 0= none per resident's choice 1= reposition 2= massage 3= gentle range of motion 4= hot or cold pack 5= tens unit 6= prn pain medication Record Review of the physicians orders dated 9/26/16 revealed to cleanse Right heel (Stage 3) with normal saline, pat dry, apply Santyl with Calcium Alginate and dry dressing daily. And to cleanse Left heel (Stage 4) with normal saline, pat dry, apply Santyl with Calcium Alginate and dry dressing daily. Record review of Resident #63's TARS (Treatment Administration Record) dated 10/1/16-10/31/16 revealed that he had moderate pain on October 3rd (level 6), and severe pain on October 4th (level 7) and 5th with a (level 8). Documented Interventions were prn pain medication given on October 3-5th. Record review of Resident #63's MARS ( Medication Administration Record) dated 10/1/16 - 10/31/16 revealed that he received prn pain medication on October 1, 2016 at 7:10 a.m, and not again till October 5th, 2016. On October 5th at 6:20 a.m. Resident #63 received two tablets of [MEDICATION NAME] 5/325 for pain in his feet. Observation and interview on 10/5/16 at 11:50 a.m. of Resident #63's wound care treatment by LVN #39, who began with the right heel, revealed a blackened open heel. At 12:05 p.m. LVN # 39 removed outer dressing to left heel, the heel had a strong odor, drainage copious, yellow, tinged with red streaks. Wound covered entire heel, approx 7cm X 7 cm X 2 cm. During application of Santyl, Resident # 63 was moaning, and gripping his left leg. When LVN #39 was asked when the resident last received pain medication, she stated it was at 9 am and he can get it every 6 hours. LVN #39 asked the resident if he was okay, he just moaned. During application of the calcium alginate to wound bed, resident was grimacing, and moaning, grabbing his leg lifting his upper body half way off the bed, gripping his thigh. Once Resident #63's leg was placed back on the off-loading pillow, he fell back on the bed with face in repose, no grimacing or groaning. Procedure completed at 12:20 p.m. In an interview with LVN #39 on 10/5/16 at 12:26 p.m., she stated that the day got away from her when it was revealed that Resident last received pain meditation at 6:20 a.m. She said, I should have stopped and got an order for [REDACTED]. In an interview on 10/7/16 at 12:00 p.m. with ADON #3, he confirmed that Resident #63 had moderate to severe pain on October 3rd and 4th 2016, and did not receive any pain medication. He further stated that residents should receive pain medication 30 minutes prior to wound care. In an interview on 10/5/2016 at 3:45pm, LVN #24 said before wound care, Resident #63 received one dose of [MEDICATION NAME] at 6:20am. She said she assisted with wound care to Resident #63 ' s heels around 12:00pm. She said she was holding his leg up off of the bed to allow the wound care nurse access to the wound. She said when they started on Resident #63 ' s right heel, he tried to help her hold his leg up. She said the wound care nurse asked if he was okay, and she heard him say, yes ma ' am. She said towards the end of the treatment, Resident #63 was grimacing and got shaky. She said he never moaned or called out. She said his pain was no more than usual. She said he was not able to express his pain on a scale of 1-10, so they used non-verbal cues to assess pain. She said she would rate his pain at a 6, but after noticing the extent of the wound, she would assess his pain at an 8. She said if his medication was administered closer to his wound care, it probably would have helped his pain. In an interview on 10/5/2016 at 3:55pm, LVN #39, the wound care nurse, said she performed wound care with Resident #63 a little while before 12:00pm. She said Resident #63 is pleasantly confused. She said during wound care, Resident #63 usually appeared to be in pain, and would cry out, moan, move his leg side to side. She said today, while cleaning his right heel, he was calling out and moaning moderately. She said she asked him if he was okay, and he said, yes, ma ' am. She said he was holding his leg up because he was helping the other nurse. She said she did not see him with facial grimacing, but said she did not see his face that much while treating the wound. She said she would rate his pain at an 8 on a scale of 1-10. She said they usually give pain medications within 1 hour of treatment, but said time got away from me. In an interview on 10/6/2016 at 8:15am, the DON said he watched wound care that morning with Resident #63. He said he was in a lot of pain and they had to stop. He said he asked if they should keep going and Resident #63 said yes. He said pain was subjective and it was hard to say what the resident can and cannot tolerate. Record Review of the facility's Pain Assessment and Management policy dated 2001 and revised on October 2010 revealed in part; Recognizing pain: Observe the resident for physiologic and behavioral (non-verbal ) signs of pain. a. verbal expressions such as groaning, crying, screaming; b. facial expressions such as grimacing, frowning , clenching of the jaw. Ask the resident if he/she is experiencing pain, be aware that the resident may avoid the term ' Pain ' . Review the Medication Administration Record [REDACTED]. Record Review of the facility's Pressure Ulcer Treatment policy dated 2001 and revised on October 2010, revealed that one of the interventions was Pain Control. Step #3 in the procedure was to assess the resident ' s level of pain and provide [MEDICATION NAME], as ordered before wound care. According to the CMS Form 672, there were 73 residents on a pain management program.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one of four residents (Resident #2) reviewed for care and services provided. - The facility failed to assess and manage Resident #2's pain during care when she was found an open area. Staff continued to provide care even after Resident #2 told them she was in pain and the wound care nurse squeezed Resident #2's open area causing the resident to scream in pain. -The facility staff failed to provide timely assistance to the bathroom and appropriate incontinent care to Resident #2. This failure affected one resident and placed the other 32 residents who were receiving preventive skin care at risk of not receiving adequate assessments, medical care, pain and decline in their physical, mental and psychosocial health and self esteem. Findings include: Review of Resident #2's face sheet revealed she was a [AGE] year old female who was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Significant change MDS assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment. She required extensive assistance for bed mobility, transfers, dressing and personal hygiene. She required limited assistance for toilet use, was occasionally incontinent of bowel and had an Indwelling catheter. Resident #2 was identified at risk to developing pressure ulcers and did not have a pressure ulcer. Record review of Resident #2's Care Plan revealed in part: Problem onset: 11/2/2015 -Potential for skin breakdown related to frequent episodes of bowel incontinence, immobility . Goal: (Resident #2) will maintain skin integrity and be clean and dry for next 90 days. Approaches: Monitor skin daily with care, assist resident to reposition frequently, assist resident to bathroom if indicated, offer frequently. Notify MD and family of any noted changes. -(Resident #2) is at risk for pressure ulcers due to incontinence and immobility. Goal: (Resident #2) will remain free of skin breakdown. Approaches: (Resident #2) needs daily observation of skin with routine care. Record review of Resident #2's skin report dated 6/7/2016 revealed that her skin was intact. Observation and interview on 6/15/2016 at 9:35 a.m. revealed that Resident #2 was heard from the nursing station screaming loudly for help to go to the bathroom. Resident #2 was in her room seated on her chair screaming help, help. It has been over an hour, I am hurting, I want to have a bowel movement, help me to go to the bathroom. At that time, Resident #2 went out of her room to the nursing station and started screaming at the nursing staff who were at the nursing station, that she wanted to be helped to the bathroom and that she needed to have a bowel movement. MA A then wheeled Resident #2 back to her room and to the bathroom and said (Resident #2) usually has a sitter. I don't know much about her. I will wait for her aide. Resident #2 continued screaming loudly I need to get to the toilet, help me. I really need to go. I had been waiting too long already, help me. Observation and interview on 6/15/2016 at 9:45 a.m. revealed C.N.A. B came to Resident #2's bathroom and said (Resident #2) wants to have a bowel movement, she wants to go to the bathroom. She has a foley catheter, but she want to use the toilet to have a bowel movement. C.N.A. B further said that she was taking care of another resident and that she came to assist Resident #2 as soon as she could. Further observation at that time, while C.N.A. B removed Resident #2's brief, the brief was noted soiled with bowel movement. Resident #2's sacral area was reddened and she had a circular open area approx 0.6 x 0.6 c.m to her left upper buttocks. The open area had approx. 50% yellow slough in the middle and the surrounding site was reddened. Resident #2 had bowel movement scattered to her buttocks areas. Her urinary catheter drainage bag was attached to the lower part of her wheelchair. Continued observation at that time while C.N.A. B transferred Resident #2 to the toilet, her urinary catheter tube was not anchored to her body and the urinary catheter tube was stretched and pulled during the transfer. Further observation and interview at that time revealed that Resident #2 said while seated at the toilet That's why I am disgusted with you guys, I had been hollering for help to go to the bathroom for a long time and I was hurting in pain. C.N.A. B then said she had a big bowel movement in the toilet. Further observation during incontinent care at that time revealed that while C.N.A. B assisted Resident #2 up from the toilet to a standing position, Resident #2's urinary catheter tube was stretched and pulled again. Resident #2's sacrum area was still reddened and Resident #2 was complaining of pain to her buttocks areas while C.N.A. B was cleaning her buttocks with disposable wipes. C.N.A. B then placed a brief on Resident #2 after cleaning her buttocks without providing foley catheter care and without cleaning the front perineal area. C.N.A. B did not apply a moisture barrier ointment to Resident #2's sacral area as ordered after incontinent care either. In an interview on 6/15/2016 at 10:20 a.m. with C.N.A. B she stated that she would normally do incontinent care for residents in their bed and that when residents were in their beds, she would clean the front perineal area first, including the urinary catheter tube and then would clean the buttocks areas. When asked about why she did not clean the front perineal area for Resident #2's and urinary catheter care, C.N.A. B stated I can do it later when I put her to bed, it will be after lunch. Observation on 6/15/2016 at 11:10 a.m., Resident #2 said to C.N.A B and C.N.A. D my buttocks hurts so much, can you check for sores there? I feel like I have sores on my buttocks. C.N.A. D then said (Resident #2) wants to go to bed and we will do incontinent care on her as well. Resident #2 was seated on a thin pillow in her wheelchair and she tried to move herself on the wheelchair while complaining of pain to her buttocks area. Observation on 6/15/2016 at 11:12 a.m. during incontinent to Resident #2 revealed that her entire buttocks areas were very reddened including the sacral area and the surrounding open area to her left upper buttocks. The open area to her left upper buttocks was bleeding and while C.N.A C cleaned the buttocks areas, Resident #2 stated that her buttocks were hurting. Observation and interview on 6/15/2016 at 11:17 a.m. after incontinent care, C.N.A. C said she was going to put a skin barrier ointment on Resident #2's buttock areas so they could put her brief on. When asked if Resident #2's buttocks usually had open areas and reddened, C.N.A. C and C.N.A. D both said that they were not sure. They said they had not worked with Resident #2 recently. When asked what they usually do when they see unprotected open areas on the resident's buttocks and reddened areas, C.N.A. C stated We tell the nurse. I can go now and call the wound care nurse. Observation and interview on 6/15/2016 at 11:20 a.m. with the Wound Care Nurse, she stated as she looked at Resident #2's open area to her left buttocks That's not a pressure sore, that is a boil that had opened. At that time, Resident #2 stated to the Wound Care Nurse Have you had a bed sore?. The Wound Care Nurse kept repeating that's not a pressure sore, that's a boil and the yellow part inside is the head of the boil. At that time the Wound Care Nurse squeezed the open area with her right hand fingers and Resident #2 screamed It hurts. The Wound Care Nurse then replied I know it hurts, I will call the MD now, let's put a dressing to the site to protect the area. At that time the Wound Care Nurse measured the open area to Resident #2's left buttocks area and said It measured 0.6 x 0.5 c.m. with a depth of 0.2 c.m. and the yellow part in the middle is 0.2 x 0.3 c.m. The Wound Care Nurse then placed a dressing on Resident #2's left upper buttocks. Further interview at that time with the Wound Care Nurse, she stated that she was not aware of the open area to Resident #2's left buttocks area and that she had assessed Resident #2 the previous week and that she did not have the open area. She further said that C.N.A's were responsible to apply a moisture barrier ointment to Resident #2 sacral area after each incontinent episode. She then said that she was not sure if she had notified C.N.A. B regarding the order to apply moisture barrier ointment to Resident #2 sacral area because she did not know that C.N.A. B was assigned to Resident #2. In an interview on 6/15/2016 at 11:30 a.m. with Unit Manager E, she stated that Resident #2 was currently on antibiotics for urinary tract infection and that she had ESBL in the urine (Extended spectrum beta-lactamase, enzyme produced by bacteria such as Escherichia coli and KIebsiella which are bacteria normally found in the human bowel). She further said as she read the Medication Administration Record [REDACTED]. Further interview with Unit Manager E at that time, she then said that Resident #2 went to see her urologist on 6/13/2016 and had ordered antibiotics for urinary tract infection and that Resident #2 had long history of recurrent urinary tract infections. She further said Resident #2 is supposed to have a leg strap holding her urinary catheter tube in place and the nurses are supposed to check for the leg straps first thing in the morning. In a second interview on 6/15/2016 at 11:55 a.m. with C.N.A. B, she stated that she did not know that Resident #2 needed to have any ointments after incontinent care to her sacral area and that the Wound Care Nurse did not let her know about it. She further said that she did not report the open area to Resident #2's left upper buttocks because when she worked when Resident #2 about one week ago, Resident #2 had a dressing to her left upper buttocks and that she assumed that the Wound Care Nurse was aware of the open area. C.N.A. B then said that when she first saw Resident #2 at around 6:00 a.m., her leg strap that was holding her urinary catheter leg bag was dirty and that she removed and threw the leg strap away and forgot to let the nurse know. In an interview on 6/15/2016 at 3:00 p.m. with Unit Manager E, she stated that C.N.A.'s were supposed to report changes on residents' skin right away to the nurses or the Wound Care Nurse. In an interview on 6/15/2016 at 3:50 p.m. with the DON, she stated that she had just arrived to the facility and that she was new in the facility and had not finished her own training yet. She further said that the Administrator had told her there were some concerns regarding incontinent care and foley catheter care but that she did not know the specifics. The DON then said that the facility was currently providing training to the staff. Record review of the facility policy and procedure Perineal Care revised September 2005 read in part: .The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .The following information should be recorded in the resident's medical record. 3.- Any discharge, bleeding, skin care problems or irritation, complaints of pain or discomfort . Record review of the facility policy and procedure Change in a Resident's Condition or Status revised October 2010 reads in part: Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical condition . Record review of the facility policy and procedure Catheter Care, urinary revised October 2010 revealed in part: .Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. 1.- Review the resident's care plan to assess for any special needs of the resident. 2.- Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thing.) According to the CMS-672 there were 33 residents receiving preventive skin care at the facility.

Based on interview and record review, the facility failed to develop and implement their policy that prohibited mistreatment, neglect, and abuse of two of eight residents (CR# 1 and CR # 3) reviewed for care provided. CR # 3 was admitted to the facility on [DATE] at 11:45 a.m. , with some behaviors. He was not monitored and frequently assessed following a change in condition ,when he was found without oxygen being administered by nasal cannula, and his oxygen saturation was 89%. CR# 3 was found unresponsive on the floor. CR # 3 was pronounced dead at the hospital following transfer by emergency crew. On [DATE], CR # 1 was placed on the floor while two aides attempted to transfer her from bed to a wheelchair that staff was aware was defective. This failure affected two residents, with one who expired and placed 107 residents at risk of injury due to faulty equipment not being removed from resident use and not receiving services needed and /or prompt transfers when a decline and/or a change in their health status was identified which could cause medical decline and death. Intake # 6 and 7 Findings include: CR#3 Record review of CR# 3 face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR#3 ' s nursing admission assessment dated [DATE] revealed a new admission on [DATE] at 11:45 a.m. Vital signs documented were 98 temperature, pulse was 80 , respiration was 20 and diastolic blood pressure 120 (no documented systolic blood pressure). Also documented was the resident had no respiratory related issues and his memory was ok . Record review of CR #3's fall assessment dated [DATE] revealed no fall history, no behaviors, moderately impaired vision, ambulates without problem, not steady but able to stabilize. Fall risk score was 12 (a score of 10 or higher is considered high risk); fall intervention was bed in low position. Record review of CR#3 ' s physician's orders [REDACTED]. Record review of CR#3 ' s nurses notes dated [DATE] at 12:24 p.m., revealed CR# 3 was admitted to facility, "alert and oriented times ,[DATE] , resident was very restless during admission"..., CR# 3 stated "I can ' t breathe. On oxygen at ,[DATE] liters via nasal cannula " . Record review of CR#3 ' s nurses notes dated [DATE] at 1:45 p.m., revealed " ( CR# 3 )had a bowel movement. Aide went to change him but he refused. Started yelling at the staff stating to get out of here , don ' t touch me." 6am to 6pm nurse asked CR# 3 if he can allow the aide to change his dirty brief, CR# 3 stated "no". "Noted feces underneath his fingernails he allowed staff to clean his fingernails. CR# 3 is on contact isolation [MEDICAL CONDITION] of the sputum " . Record review of CR#3 ' s nurses notes dated [DATE] at 5:08 p.m., revealed " while making rounds , noted (CR# 3) on the floor lying on his right side, no pulse noted, supervisor checked pulse and noted no pulse, CPR was initiated , 911 was called and they came in and continued CPR, (CR#3) was transferred to the hospital " . Record review of CR#3 ' s nurses notes revealed addendum dated [DATE] at 11:33 p.m., " late entry [DATE]: (CR# 3) was moved to a single room by himself due to isolation [MEDICAL CONDITION] of sputum, at 1:00 p.m. Aide went to serve CR#3 lunch, at 1.15 p.m. An aide went back into his room to check on him. Aide saw the restorative aide standing at the door and reported the resident threw away his lunch tray and was yelling out "don ' t touch me." Nurse went to resident ' s room to talk to him to allow aides to clean him but he refused and stated "get out of my room, I will hit you with something, I don ' t want then to change me." Nurse waited till 1:30 p.m., and went back to see if (CR#3) had calmed down. He allowed staff to clean his left hand. At 1:56 p.m., aides did their last round and (CR#3) still refused to be put to bed. He was sitting on the right side of his bed. (CR#3) stated "no one should touch me, leave me alone." Nurse then went to document (CR#3 )refused care. At 2:00 p.m., nurse went to check on (CR#3 )with aide. (CR#3) continued to refuse care. He stated " I can ' t breathe". Noticed oxygen nasal cannula was on the floor. Replaced cannula back to his nose. Oxygen saturation was 89% on room air and went up to 99% after oxygen was replaced. Nurse went to document and told aide to go home. At 2:55 p.m., while making rounds noticed (CR#3) was on the floor. Weekend supervisor was on the hall, they came in the room. No pulse felt, I went to look in (CR#3 ' s) chart to see his code status and went back to the room and the DON had started CPR. 911 was called. CPR was continued until EMS arrived and took over and (CR# 3) was transferred out " . Record review of CR#3 ' s nurses notes dated [DATE] at 12:39 p.m., revealed " late entry for [DATE] at approximately 2:55 p.m., I was called to the resident ' s room to respond to a possible code situation. Upon entering the room the resident was found on the floor on his left side facing the bed. I checked for a carotid pulse and respiration . No pulse was palpated, no respiration noted. I was informed that he was a full code status. Resident was positioned on his back and CPR was initiated. I instructed a charge nurse to call 911. CPR was continued until 911 arrival at which time they took over. I noted a skin tear to the resident ' s left cheek, left elbow and an abrasion above the residents left eye brow. The bed was in a low position, there was an oxygen concentrator on and the tubing was found next to the resident but no longer placed via nasal cannula route when resident was found. Resident was transported via 911 and CPR remained in progress " . Interview on [DATE] at 2;15 p.m., the DON said she responded to CR#3 ' s room on the day of the incident. CR#3 was admitted to the facility the same day and was found on the floor unresponsive. She stated CPR was initiated and 911 was called. When 911 came, they took over the resuscitation and transferred the resident to the hospital. The DON further said the facility reported the incident due to the resident just being admitted and the incident occurred few hours later. The DON in response to why it took the charge nurse 55 minutes or longer to check on the CR# 3 after identifying he was restless and had exhibited some behavior including removing his O2 nasal cannula said " I see what you mean but the nurse said she checked on CR#3 " . Several attempts to interview the charge nurse present on the day of incident was not successful as calls were not returned. Record review of the facility investigation report dated [DATE] at 8:45 p.m., revealed at 2:55 p.m., aide found CR#3 on the floor, had no pulse or respiration upon assessment. CPR was initiated, 911 was called and they took over CPR upon arrival to the facility at 3:46 p.m. 911 left facility at 4:00 p.m., and arrived at the hospital at 4:06 p.m. Further review of investigation report revealed in- service was provided to all staff regarding fall prevention program. Record review of witness statement from the weekend supervisor who responded to CR#3 ' s room on the incident date revealed " at bout 2:55 p.m, while sitting with the DON, an aide rushed toward us for emergency. We rushed to the room and observed CR#3 on the floor face down. Both the DON and I turned him face up while another staff rushed for the crash cart, CR#3 ' s chart and 911 was called. I left to get supply needed and when I came back 911 was with CR#3 " . Record review of CR#3 ' s nurses notes dated [DATE] at 7:06 p.m., revealed " CR# 3 ' s son at facility and notified facility CR#3 was deceased . Record review of facility investigation report revealed in-service on fall policy and procedure dated [DATE]. Record review of additional documentations submitted by facility after exit on [DATE] revealed " the charge nurse assigned to CR#3 was provided education on identifying changes of condition on [DATE] (prior to the incident) by the DON. Staff saw the resident at 2 pm and it was less than an hour before next round was made at 2:55 p.m. " There was no evidence indicating CR#3 was monitored after 2 p.m, when he was found without the nasal cannula on and had anoxygen saturation of 89%. CR #3 was not monitored again until 2:55p.m., when he was found on the floor unresponsive. CR # 1 Record review of CR #1 face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1 ' s MDS dated [DATE] revealed her cognition was intact. The resident was dependent on staff for transfers, was wheelchair bound and weighed 179 pounds. Record review of CR# 1 care plan dated [DATE] revealed the resident had ADL care self-deficits with bed mobility, transfers, ambulation, locomotion on/off unit, dressing , eating, toilet use, personal hygiene, and bathing related to late effects of [MEDICAL CONDITION] left sided weakness/[MEDICAL CONDITION] and [MEDICAL CONDITION]. Approach for transfers read - provide two staff extensive assistance with mechanical lift transfer. Record review of CR#1 ' s incident report dated [DATE] revealed at 6:45 a.m., revealed the resident was noted to be sitting upright on the floor mat in her room, in front of the wheelchair. The resident was awake and alert and denied any pain. Two aides were transferring the resident from bed to her wheelchair. As they were placing the resident in the wheelchair the wheelchair rolled backward and the resident was lowered to the floor . Further review of the facility ' s incident report for CR #1 dated [DATE] revealed the intervention following the incident was the wheelchair was replaced. Interview on [DATE] at 9:09 a.m., MA # 1 said she was called to assist CNA#2 to manually transfer CR# 1. She said they attempted to place CR# 1 in the wheelchair but the wheelchair rolled back. MA# 1 said they tried twice without success and had to put the resident on the floor. MA#1 said she did not know CR #1 ' s wheelchair was not locking but was informed after the incident that the wheelchair was faulty. MA# 1 said she did not ensure the wheelchair was locked prior to attempting transfer. Interview on [DATE] at 9:23 a.m., CNA # 2 said MA # 1 was assisting her to manually transfer CR# 1 to her wheelchair but the wheelchair kept rolling backwards. She said they had to put the resident on the floor. CNA# 2 further said she knew CR# 1 ' s wheelchair was not working properly from the previous day because the wheels were not locking. CNA#2 reported she notified the maintenance person at the facility about the wheelchair. CR#1 ' s wheelchair was changed after the incident and CNA#2 said she did not receive any training following the above incident. Interview on [DATE] at 10:37 a.m., the facility Maintenance Director said he was notified of the defective wheelchair after the incident on [DATE]. He said he was not told of the faulty wheelchair prior to the incident. He said the wheelchair brakes did not lock properly which caused the wheelchair to move even when locked. He said he has now fixed the wheelchair. Record review of the facility maintenance log revealed no concerns regarding CR# 1 ' s wheelchair was logged in January, February or [DATE] . Interview on [DATE] at 2:40 p.m., the DON said CR#1 ' s legs gave out during the transfer, and staff had to place her on the floor. The DON said she was not aware CR#1 ' s wheelchair was not working properly prior to the incident. Record review of facility in-services dated [DATE] revealed a training that was on safe transfer with mechanical lift, use of gait belts and locking the wheelchairs before transfer. In-service did not address removing defective devices from residents use. Record review of the facility ' s policy on Abuse prevention program dated [DATE] defined neglect as " failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Facility census dated [DATE] listed 107 residents