Every finding on record at Edgewood Health & Rehabilitation

Based on observation, interview and facility policy review, the facility failed to maintain dining room furniture in a safe/clean/comfortable/homelike environment for two (2) of four (4) days of survey. Findings include:Record review of the facility policy review of the facility policy titled Safe and Homelike Environment, dated 7/2025, revealed, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility . does not pose a safety risk Policy Explanation and Compliance Guidelines: 9.e. Report any furniture in disrepair to Maintenance promptly .During an observation on 7/20/2026 at 10:46 AM, two damaged chairs were on the left side of the main dining room near the front of the room. One chair had missing screws in the padded armrest component. The component moved freely back and forth, exposing rough metal hardware at the end of the chair arm. The second chair had no padded component on the left armrest. Rough metal hardware was exposed at the end of the chair arm.On 7/21/2026 at 9:55 AM, during an observation and interview observed a third chair on the right side of the main dining room near the front of the room. The chair had no padded component on the left armrest, leaving rough metal hardware exposed at the end of the chair arm. The Activity Director verified that the chair was missing the padded armrest component and that the exposed, rough metal could create a safety and injury hazard for residents. The Activity Director removed the chair from use and provided it to maintenance staff.During an interview on 7/22/2026 at 2:16 PM, the Maintenance Director stated that he and the Nursing Home Administrator (NHA) had planned to replace the dining room chairs, but replacement had not occurred. The Maintenance Director stated that he knew about the chair with the loose armrest component but did not know about the two chairs with missing armrest components. He confirmed that no maintenance ticket or log entry had been completed for the damaged chairs. The Maintenance Director further confirmed that exposed rough metal could create a safety hazard and that the loose armrest component could pinch a resident's arm.During an interview on 7/22/2026 at 2:45 PM, the NHA stated that the facility was in the process of obtaining new dining room chairs. The NHA confirmed that chairs with missing or damaged padded armrest components presented a potential safety hazard to residents.

Based on record review, facility policy review, and interview, the facility failed to immediately protect one (1) of three (3) resident reviewed for an allegation of abuse. Resident #62. Findings include:Record review of the facility policy Abuse Policy and Procedures, dated 1/24/2022, revealed, Each resident of this facility has the right to be free from verbal, sexual, physical and mental abuse, involuntary seclusion, corporal punishment, neglect and/or misappropriation of resident property. The facility will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of funds occur .Record review of the facility investigation dated 7/22/26 revealed that on the morning of July 20, 2026, Resident #62 was receiving a shower when Licensed Practical Nurse (LPN) #7 and LPN #8 both heard Resident #62 hollering and both went into the shower room and witnessed Certified Nursing Assistant (CNA) #5 striking Resident #62 with a towel. On 7/20/2026 at 4:03 PM, Resident #62 was observed seated in a wheelchair at the nurses' station. The resident was oriented to person only.During an interview on 7/21/2026 at 3:43 PM, LPN #7 stated that she and LPN #8 were at the nurses' station when they heard yelling from the 300 Hall. Both nurses went to room [ROOM NUMBER] and observed CNA #5 providing shower care to Resident #62. Resident #62 was seated on a shower chair, screaming, and attempting to grab CNA #5's right arm. LPN#7 stated that CNA #5 took the towel she was using to bathe the resident and struck the resident twice. LPN#7 stated that the nurses initially left the doorway to notify Registered Nurse (RN) #3.During an interview on 7/21/2026 at 4:00 PM, LPN #8 stated that she and LPN#7 heard yelling and went to room [ROOM NUMBER]. LPN#8 stated that Resident #62 became combative during shower care. CNA #5 stepped backward, swung a towel at the resident twice, and struck the resident's left arm twice. LPN #8 stated that she went to notify RN #3.During an interview on 7/21/2026 at 4:08 PM, RN #3 stated that LPN #8 reported that the nurses had witnessed CNA #5 hit Resident #62. RN #3 stated that she sent CNA #5 home, notified the Director of Nursing (DON), completed an incident report, performed a body audit, and completed a pain assessment.During a telephone interview on 7/22/2026 at 9:33 AM, CNA #5 stated that Resident #62 became combative, screamed, hit her, grabbed the shower hose, and bent it. CNA #5 denied hitting the resident and stated that she stepped backward and removed the hose from the resident.During a second telephone interview on 7/22/2026 at 10:48 AM, CNA #5 stated that she remained alone with Resident #62 after the incident and dried the resident. CNA #5 stated that LPN #7 briefly entered the room, asked the resident if she was okay, and left the resident alone with her. CNA #5 stated that RN #3 entered the room while she was preparing to dress the resident.During an interview on 7/22/2026 at 3:44 PM, the DON stated that RN #3 notified her of the alleged incident. The DON stated that LPN #7 reported witnessing CNA #5 hit Resident #62 with a towel, while LPN#8 reported that CNA #5 was observed making contact with the towel with the resident's left arm. The DON stated that she was initially informed that staff had immediately removed CNA#5 from the resident.During a follow-up interview on 7/22/2026 at 4:03 PM, LPN #8 stated that CNA #5 raised the towel and that she heard a sound consistent with the resident being struck, although her viewing angle prevented her from seeing the second contact. LPN #7 confirmed that both nurses stepped away from the doorway and lost visual contact with Resident #62 and CNA #5. She stated that one of the nurses should have remained with the resident until RN#3 arrived. LPN #8 stated that she returned approximately five minutes later.During an interview on 7/22/2026 at 4:24 PM, RN #3 stated that she was notified of the incident while LPN #7 was outside on the porch. RN #3 stated that approximately five minutes passed before she entered the room. When she entered, Resident #62 remained alone with CNA #5. RN #3 stated that she performed a body audit and did not identify signs or symptoms of injury.During a telephone interview on 7/22/2026 at 4:40 PM, LPN #8 confirmed that she witnessed CNA #5 strike Resident #62. LPN #8 stated that she and LPN #7 stepped away from the doorway to discuss what they had witnessed and lost visual contact with the resident and CNA #5 for approximately five minutes. LPN #8 confirmed that they should not have left Resident #62 alone with CNA #5.During an interview on 7/23/2026 at 2:17 PM, the DON stated that she had not been informed that the licensed nurses left Resident #62 alone with CNA #5 after witnessing the alleged abuse. The DON confirmed that the nurses should have immediately separated CNA #5 from the resident. She stated that leaving the resident with the alleged perpetrator placed the resident at risk for further abuse and that the facility's policy required removal of the alleged perpetrator.A record review of LPN #7's written statement revealed that she and LPN #8 heard Resident #62 screaming in room [ROOM NUMBER]. LPN #7 documented that Resident #62 was swatting at CNA #5 and that CNA #5 struck the resident with a towel twice. She documented that she could not see additional contact because of her viewing angle.A record review of LPN #8's written statement revealed that the resident was being combative during the shower and that CNA #5 was observed stepping back and making contact with towel with resident's left arm.A record review of CNA#5's written statement revealed that Resident #62 screamed, grabbed the shower hose, and bent it during shower care. CNA #5 denied striking or hitting the resident.A record review of Resident #62's admission Record revealed an admission date of 11/28/2023 and diagnoses that included severe unspecified dementia without other behavioral disturbance and unspecified Alzheimer's disease.A record review of Resident #62's Minimum Data Set assessment, with an Assessment Reference Date of 4/24/2026, revealed a Brief Interview for Mental Status score of 99, indicating the resident interview was not completed.A record review of Resident #62's body audit, dated 7/20/2026, revealed no visible signs of injury.A record review of Resident #62's pain assessment, dated 7/20/2026, revealed no pain was identified.

Based on record review, interviews, and facility policy review, the facility failed to complete the discharge Minimum Data Set (MDS) in accordance with the Center for Medicare and Medicaid Services (CMS) guidelines for one (1) of (22) sampled residents. Resident #104.Findings include: Record review of the facility policy, Minimum Data Set (MDS) assessment dated 05/2006, revealed, It is the policy of this facility to follow the Resident Assessment Instrument (RAI) process as set for by Centers for Medicare and Medicaid Services (CMS) protocol . On 7/23/26 at 10:27 AM, during an interview, MDS Nurse #1, explained that the discharge MDS was never initiated or completed, acknowledging that it should have been done. Furthermore, she pointed out that completing the discharge assessment is crucial to ensure that the resident's status is accurately reported to CMS. MDS Nurse #2, revealed that it was her responsibility to complete the discharge MDS for Resident #104 but failed to do so. She acknowledged that she should have initiated the assessment on March 13, 2026, the day after Resident #104 discharged . Furthermore, she stated it should have been submitted to CMS on March 18, 2026, to ensure timely submission. She pointed out that accurate and timely submission is needed to ensure correct information is reported to CMS.Review of the facility's, admission record revealed the facility admitted Resident #104 on 2/17/26 with diagnoses including Chronic Kidney Disease, Stage 4, Severe.Record review of the MDS with an Assessment Reference Date (ARD) of 10/21/22 revealed Resident #104 had a Brief Interview for Mental Status (BIMS) score of 11 indicating the resident had moderate cognitive impairment.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the resident's use of an indwelling suprapubic catheter and colostomy for one (1) of (22) sampled residents. Resident #22. Findings include:Record review of the facility's Minimum Data Set (MDS) Assessment policy dated 05/2006, revealed, It is the policy of this facility to follow the Resident Assessment Instrument (RAI) process as set for by Centers for Medicare and Medicaid Services (CMS) protocol .On 7/20/2026 at 1:56 PM, Resident #22 was observed in bed with a colostomy intact to the abdomen and a suprapubic catheter draining yellow urine into a catheter collection bag.During an interview on 7/21/2026, the Registered Nurse (RN)/ Minimum Data Set (MDS) nurse reviewed Resident #22's Quarterly MDS assessment with an Assessment Reference Date (ARD) of 4/15/2026. The MDS nurse stated, Oh, I forgot to put her suprapubic catheter and colostomy on there. The MDS nurse confirmed that the assessment did not accurately reflect Resident #22's status but would be corrected and resubmitted.A record review of Resident #22's Medication Review Report with active orders as of 7/21/26 revealed orders dated 3/6/26 for suprapubic catheter care and suprapubic catheter changes. An order was dated 1/27/26 indicated the resident had a colostomy.A record review of Resident #22's Quarterly MDS assessment, with an Assessment Reference Date (ARD) of 4/15/2026, revealed in Section H0100A the Appliance section was coded as none of the above indicating the resident did not have an indwelling catheter or ostomy.

Based on observation, interview, facility policy review, and record review, the facility failed to store medications properly for one (1) of five (5) residents observed for medication administration. (Resident # 32) Findings include:Record review of the facility policy, Medication Storage in The Facility revised 2018 revealed, Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy, personnel, or staff members lawfully authorized to administer medications.An interview at 11:59 AM on 7/22/26, with Licensed Practical Nurse (LPN) #3 revealed she was taking care of Resident # 32 on 7/3/26. She stated that she wasn't thinking like a nurse when she was called away to take care of another resident who had fallen. She stated she left without grabbing the medications and was gone about 15 minutes. During that time, Resident #32's daughter came and identified the medications left at the beside and notified the Registered Nurse (RN) Supervisor. LPN#3 noted that issues with leaving medications at the bedside could be that residents won't take them as in this case, missing a dose of medication, or another resident could come and take them and have a reaction. LPN #3 confirmed that an in-service was done on medication administration and professionalism on 7/15/26 which she signed and also noted that since then, herself and LPN #2 have switched out residents and nurses, so LPN # 3 does not take care of Resident # 32 anymore.An interview with RN #3 at 12:08 PM on 7/22/26, revealed she was the supervisor present on 7/3/26. On that day, she noted that the daughter of Resident # 32 came to get her and when she got into the resident's room there were two pills in a medication cup sitting on the resident's bedside table, that were not taken by the resident. RN #3 stated that the resident's daughter was concerned because she thought the resident wasn't taking her medication.An interview with the Director of Nursing (DON) at 12:20 PM on 7/22/26, revealed she was not present on the day of the incident, but had started an investigation. During the investigation it was identified that LPN #3 had left medications at the bedside of Resident #32. The DON noted that this is dangerous as medications being left out could either not be taken by the resident or kept until later and double dosed or you could see another resident come in the room and take them by mistake and lead to a reaction.On 7/22/26 at 12:28 PM, during an interview the Minimum Data Set (MDS) nurse/ LPN #1 stated she was in her office on the date of the incident, and the Social Worker brought the daughter of Resident # 32 to her office. She stated Resident #32's daughter was complaining that LPN #3 left medications at the bedside without making sure the resident took them. The MDS nurse/LPN#1 stated she updated her care plan that day to address these concerns and then switched out the nurses in charge of caring for Resident #32 to prevent any future issues. She noted that residents' meds are not supposed to be left at bedside. She stated the resident may not take their medications, or another resident could also have come in and taken the medications.An interview with Resident #32's daughter on 7/22/26 at 3:35 PM, revealed she was in the facility visiting her mother on 7/3/26 and came to the bedside and saw medicines left in a medicine cup that her mother had not taken. She was unsure of how long these medications were left on her table and noted that when she asked the nurse about these meds, the nurse tried to give them to the resident, but by then it was well past the time for them to be administered.Record review of the admission Record revealed Resident #32 was admitted on [DATE] with diagnoses that included seizures.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/5/26 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7 which indicated moderate cognitive deficits.Validated Compliance :SA validated through staff interviews, record review, and facility policy review, the facility began an immediate investigation when the grievance was filed regarding medications left at bedside.SA interviewed LPN #3 to determine that she underwent an in-service pertaining to the grievance involving medication administration on 7/5/26. SA interviewed LPN #2 to confirm she has been taking care of the resident since the incident instead of LPN #3 and she noted that she hasn't seen any meds left at bedside in the room. An interview with the resident's daughter revealed she has not had this issue since then either.An interview with the Administrator at 11:31 AM on 7/23/26 revealed the facility handled the complaint of medications left on Resident #32's bedside table by LPN #3 by performing a one on one in- service and policy reading with the nurse regarding medication administration as well as the DON making rounds in the room along with the Social Worker and RN #3 to check for medications being left on bedside. He noted that it is his expectation that medications be administered per policy.An interview with the DON at 11:33 AM on 7/23/26 revealed she completed an in-service, policy review and write up for LPN #3 along with performing rounds herself into the room to check for unattended medications and having ancillary staff in this case, RN#3 and the Social Worker to round on the room to also check. She noted it is her expectation that nurses follow policy when administering medications.An interview with RN #2 on 7/23/26 at 12:02 PM revealed she makes rounds each shift to check for unattended medications at the bedside and has not seen any since this incident occurred and noted that she would investigate if this happened while also notifying the DON.An interview with the Social Worker at 12:10 PM on 7/23/26 revealed she makes daily rounds since the incident occurred to check on residents on the 300 Hall. She also noted that she checks for medications being left at bedside and has not ever witnessed this.The SA also made observations throughout survey on 7/20/26, 7/21/26, 7/22/26 and 7/23/26 and did not observe any medications on bedside table of the resident. A review of facility in-service record revealed LPN #3 was in-serviced on 7/5/26 regarding medication administration policy.A review of facility's grievance log dated 7/3/26 revealed a grievance was made by Resident # 32's daughter regarding medication administration.The facility returned to substantial compliance on 7/5/26 after completing its investigation, educating and disciplining LPN #3, revising Resident #32's care plan, reassigning the resident's medication administration, and implementing monitoring rounds. The facility sustained compliance through the survey ending on 7/23/26.

Based on observation, interview record review and facility policy review, the facility failed to follow infection prevention practices during medication administration for one (1) of five (5) residents observed. Resident #103. Findings Include:Record review of the facility policy Infection Prevention and Control Program with a revision date of 5/26 revealed, Policy: This facility has established and maintains 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 as per accepted national standards and guidelines . During an observation on 7/22/26 at 8:01 AM, observed Licensed Practical Nurse (LPN) #2 administer medications to Resident# 103. During the observation, LPN#2 was observed placing medications and a box of Fluticasone 50 mcg and a box of Budesonide on the resident's bedside table without first disinfecting the surface or using a barrier. After administering the medications LPN #2 placed the two medication boxes containing the resident's nasal spray (Fluticasone) and Inhaler (Budesonide) in the cart, allowing the boxes to come in contact with other resident medications. During an interview at 8:07 AM on 7/22/26, LPN #2 confirmed she should have used a barrier or disinfected the table prior to placing the medications on the table. She noted that infection could possibly spread to other medications due to the possible contact of sputum or mucus from the resident's handling an inhaler and nasal spray which could spread respiratory infection to other residents.During an interview at 2:49 PM, on 7/22/26 with the Director of Nursing (DON) revealed the nurse should have used a barrier to prevent the medications from touching the bedside table and disinfected the bedside table prior to placing the medications on the table to avoid spreading infection to other residents when the medication containers touched other resident's medications in the medication cart.During an interview on 7/23/26 at 10:30 AM, the facility's Infection Preventionist (IP) confirmed that LPN #2 should have disinfected the table with a disinfectant wipe before placing items on the bedside table. She noted that the facility also has medication barriers that nurses can use to prevent cross contamination during administration. She also mentioned that during this instance, the nurse could have also disinfected the medication containers before placing them in the medication cart and failure to do any of these actions resulted in a greater risk to spread infection to other residents.Record review of Resident # 103's admission Record revealed the resident was admitted on [DATE] with diagnoses that included Other cerebral infarction due to occlusion or stenosis of small artery.Record review of Resident # 103's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/16/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.Record review of Resident #103's Order Summary Report with active orders as of 7/22/26 revealed an order dated 6/14/23 for Fluticasone Proplonate nasal suspension and an order dated 6/27/26 for Budesonide-Formoterol Fumerate Inhalation Aerosol.A record review of the Medication Administration Record for July 2026 revealed Fluticasone nasal suspension and Budesonide were both given on 7/22/26 during the 8:00 AM medication observation.

Based on policy review, record review and interviews, the facility failed to ensure the residents' right to be free from abuse and failed to protect Resident #1 from abusive and degrading treatment by Certified Nurse Aide (CNA) #1 and CNA #2 during the provision of care on the evening of 2/10/26. The abusive conduct included the use of disparaging, derogatory, and humiliating language and intimidation toward Resident #1 while the resident requested assistance and complained of pain during care for one (1) of four (4) sampled residents. Resident #1.The State Agency (SA) identified Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 2/26/26. The IJ began on 2/14/26, when the facility failed to protect residents from abuse, failed to report alleged abuse timely, failed to promptly investigate allegations of abuse, and Administration failed to implement and enforce the facility's abuse policies.The facility's failure to report, protect, and investigate abuse placed all residents residing in the facility at risk in a situation likely to cause serious injury, serious harm, serious impairment, or death.On 2/26/26 at 4:05 PM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the IJ templates.IJ and SQC existed at:42 CFR(s) 483.12(a)(1) - Abuse and Neglect (F600) - Scope and Severity (S/S) - JThe facility submitted an acceptable Removal Plan on 2/27/26 in which the facility alleged all corrective actions to remove the IJ and SQC were completed on 2/27/26, and the IJ was removed as of 2/28/26. Therefore, the scope and severitywere lowered from a J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Included:Record review of the facility policy titled, Abuse Policy and Procedure dated 1/24/22 revealed Each resident of this facility has the right to be free from verbal, sexual, physical and mental abuse.1. Verbal abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability.4. Mental abuse' includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation.Residents are not to be subjected to abuse by anyone. This includes, but is not limited to, facility staff . Record review of the Facility Investigation dated 2/19/26 revealed that on 2/14/26 at approximately 8:40 AM the Resident Representative (RR) for Resident #1 reported an allegation of abuse to the Registered Nurse (RN) Supervisor (RN #2). RN #2 notified the Director of Nurses (DON) of the allegation by telephone at approximately 8:50 AM on 2/14/26. The DON notified the Administrator at 9:01 AM on 2/14/26. The Investigation Timeline revealed that on the evening of 2/10/26 after the evening meal on Unit A Resident #1 was verbally abused by CNA #1 and CNA # 2 who used disparaging, demeaning and derogatory language and deliberate actions to intimidate Resident #1 during provision of care.Record reviews of the timesheets for 2/05/26 through 2/18/26 revealed CNA #1 was on duty at the facility on the evening shift (3:00 PM through 11:00 PM) on 2/10/26.Record review of the timesheets for 2/05/26 through 2/16/26 revealed CNA #2 was on duty at the facility on the evening shift (3:00 PM through 11:00 PM) on 2/10/26, 2/11/26, 2/12/26 and 2/16/26.Record review of the Assignment Sheet 3-11 GROUP 9 dated 2/10/26 revealed CNA #1 was assigned to work with residents in rooms that included Resident #1's room on the evening shift on 2/10/26 and had been assigned to CNA #1 to provide care.On 2/25/26 at 4:30 PM, during an interview with RN #1 revealed that she was notified of an allegation of the verbal abuse of Resident #1 on 2/14/26 at approximately 8:45 AM by RN #2 who told her Resident #1's RR had voiced a complaint of verbal abuse by staff with audio recording. RN #1 said with Resident #1 and her RR in the resident's room, she listened to the recording but could not identify the voices in the audio. She confirmed that the RR for Resident #1 said that she recognized the voice of CNA #2 but did not know the CNA's name and described her as a big, female with short braids and that #2 was the only staff that matched the description. She stated neither the Director of Nurses (DON) nor the Administrator came to the facility on 2/14/26 and that no interviews were conducted 2/14/26. She reported the only intervention initiated on 2/14/26 was the relocation of Resident #1 to Unit B upon request of the RR. RN #1 described Resident #1 as frail and confirmed that the resident was admitted by the facility following a fall, right hip fracture and surgery and needed assistance for activities of daily living (ADLs). RN #1 added regardless of documented functional abilities if asked for assistance the staff should provide requested assistance in a respectful manner. She stated that she listened to the recording on the morning of 2/10/26 and was shocked any staff spoke to any resident in such a cruel, degrading manner.On 2/25/26 at 12:37 PM, during an interview the DON revealed that on 2/14/26 at approximately 8:50 AM she was notified by RN #2 that Resident #1's RR reported an allegation of abuse with audio recording of the incident that was awful. She was unable to provide any interventions to protect residents from further abuse initiated on 2/14/26 or 2/15/26. She stated she reported the allegation to SA on 2/16/26 and began training and interviews with staff, including a 10:30 AM interview with CNA #2 who confirmed she was in the room on 2/10/26 during the incident with CNA#1. She stated she contacted the RR for Resident #1 for the first time on 2/16/26 at 11:00 AM for interview and requested the recording which was received at 11:16 AM. She said that she and the Lead CNA Supervisor listened to the recording, and the Lead CNA Supervisor recognized the voices of Resident #1 and CNA #1 and CNA #2. She confirmed that the recording contained verbal abuse of Resident #1 and stated It was awful. If I could have had them (CNA #1 and CNA #2) arrested, I would have. The DON said that CNA #1 was scheduled to work 2/15/26 but did not report and her last day of employment was 2/10/26 and CNA #2 was on duty 2/11/26 evening shift and 2/16/26 day shift (7:00 AM to 3:00 PM) and clocked out at 11:16 AM on 2/16/26 after CNA #2 confirmed that one of the voices on the recording was hers. She and CNA #2 were working on Unit A on the evening of 2/10/26, entered the room of Resident #1, who was assigned to CNA #1, witnessed CNA #2 having a bad attitude towards the resident and that she was present in the resident's room throughout the incident and not think that she had done anything wrong because she said I didn't curse her (the resident) but was guilty by association. The DON said she informed CNA #2 that her employment at the facility was terminated for verbal abuse of a resident due to the way she spoke to Resident #1 on the evening of 2/10/26 and failure to report abuse.During an interview with the Administrator on 2/26/26 at 10:17 AM, revealed he had been notified by the DON on 2/14/26 at 9:00 AM via telephone that the RR for Resident #1 had reported an allegation of verbal abuse at approximately 8:40 AM. He said the DON was responsible for the investigation and the outcome was that the facility substantiated the allegation of verbal abuse of Resident #1 and resulted in the termination of the employment of CNA#1 and CNA #2 on 2/16/26 for verbal abuse of a resident. On 2/26/26 at 12:45 PM, during an interview CNA #3 confirmed that she was in the room of Resident #1 on the evening of 2/10/26 with Resident #1, CNA #1, CNA #2 and CNA #4 overheard CNA #1 speak the exact words presented as evidence of verbal abuse in an audio recording by the RR. She stated that she only heard the first part of the interaction that she did not perceive as abusive at the time and left the room, closed the door and did not report the interaction.On 2/26/26 at 12:55 PM during an interview CNA #4 confirmed that she was in the room of Resident #1 on the evening of 2/10/26 with Resident #1, CNA #1, CNA #2 and CNA #3 and overheard CNA #1 repeatedly tell Resident #1 to get up and that she was not handicapped and observed the resident attempt to stand without success. She stated that she only heard the first part of the interaction that she did not perceive as abusive at the time and she and CNA #3 left the room, and she did not report the interaction.On 2/26/26 at 1:40 PM, during an interview with the Lead CNA Supervisor revealed that on 2/16/26 at approximately 11:16 AM, she received a recording from the RR for Resident #1 who reported that Resident #1 made the recording. The Lead CNA Supervisor confirmed that the Facility had accepted the recording as evidence of abuse of Resident #1 and had identified the voices on the recording as Resident #1, CNA #1 and CNA #2. She stated that she had listened to the recording and considered the things that both CNA #1 and CNA #2 said and the way they said them were abusive, derogatory and demeaning and said in a malicious manner. She confirmed that based on the recording the resident had requested help repeatedly and was scorned, criticized, and insulted by CNA #1 and CNA #2. She confirmed that Resident #1's concerns were dismissed and her complaints of discomfort and pain were ignored or as well as her complaint that they treated her rough.On 3/02/26 at 11:58 AM, during a telephone interview with RN #2 revealed she was the RN Supervisor on Unit A on the morning of 2/14/26. She reported that the RR for Resident #1 reported verbal abuse of Resident #1 at approximately 8:40 AM and she had notified the DON by telephone at approximately 8:50 AM. She said she listened to a recording presented by the RR of Resident #1 which she described as demeaning, degrading making fun of her (Resident #1), laughing at her, insulting her and intimidating her and she heard the elder cry, scream, complain of pain and beg them to quit. She said she was not aware of any interventions to protect residents from further abuse or investigate the allegation on 2/14/26. She confirmed the resident could be heard on the recording crying, screaming, complaining about 'rough' treatment and asking the CNAs to 'quit' and that both CNA s responded by mocking and laughing at the resident, and described the recording as shocking and terrible.Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 11/04/25 and the resident had diagnoses of encounter for other orthopedic aftercare, fracture of right femur, and dementia.Record review of the Quarterly Minimum Data Set (MDS) for Resident #1 with an Assessment Reference Date (ARD) of 2/6/26 revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Section GG revealed Resident #1 required a wheelchair for mobility and partial/moderate assistance for dressing, to roll from lying on back to left and right side, and to transfer to and from a bed to a chair.Record review of the KARDEX for Resident #1 revealed care instructions included SAFETY.Provide assistance as needed for ADL's (activities of daily living). Provide assistance as needed for transfers & ambulation.Transferring: Requires 1 person stand pivot Weight bearing as tolerated for transfers. Caution with right hip due to surgery. Dressing: Resident requires 1 person assistance with upper and lower body dressing. Resident Care: Anticipate and meet my needs per physical/non-verbal indicators of discomfort/distress.The facility submitted an acceptable Removal Plan on 2/27/26, and the IJ was removed on 2/28/26. Removal PlanThe facility took the following actions to address the citations and prevent any additional residents from suffering an adverse outcome. On 2/14/2026, the facility's administration was notified of an allegation of abuse from Resident #1's Resident Representative (RR) concerning an audio recording at approximately 9:00 AM. The Resident Representative (RR) stated that she believed the incident happened on 2/11/2026. Later investigation would reveal incident occurred on 2/10/2026. After Director of Nursing (DON) and Facility Administrator were notified by Registered Nurse (RN) #1 and Registered Nurse (RN) #2, the facility's administration failed to report the allegation of abuse within the two-hour time frame to the proper organizations. The facility also did not begin a formal investigation until the following day, Sunday February 15, 2026. Although the resident was moved to a different unit in the building, The facility failed to immediately implement protective measures, and staff alleged to be involved continued to provide resident care through 2/16/26. Resident #1 was still at risk for continued abuse. The actions of the facility's administration put Resident #1 at risk for continued abuse as well as the other residents of the facility at risk for potential abuse. The facility failed to ensure all residents were free from abuse after being notified on 2/14/26 at approximately 9:00 AM of an allegation of verbal abuse supported by an audio recording validated by facility administration capturing staff cursing at Resident #1 while the resident was heard screaming.The State Agency (SA) notified the facility of (IJ) Immediate Jeopardy and provided the IJ templates to the facility on 2/26/27 at 4:05 PMCorrective Actions:On 2/14/2026 Resident #1 was moved at approximately 10:00 AM from Unit A to Unit B at the request of the family after discussion with Registered Nurse #1 . On 2/15/2026 at approximately 9:00 AM , the Director of Nursing interviewed Resident #1 regarding the allegations of alleged abuse, and she denied any such happenings. On 2/15/2026 at approximately 9:00 AM, the Director of Nursing(DON) assessed the resident for any physical or emotional effects.On 2/16/2026, Psychosocial support began at approximately 11:15 AM and was conducted for 72 hours by the Social Services Director (SSD). Resident #1 was referred to the Psychiatric Nurse Practitioner for evaluation on 2/18/2026 at approximately 1:46 PM. The Director of Nursing (DON), Staff Development, and Lead CNA (Certified Nursing Assistant) provided education with all staff regarding the Facility Abuse Policy and Procedures beginning on 2/16/2026 at approximately 11:00 PM.A Corporate Nurse conducted an in-service with Director of Nursing (DON) and Facility Administrator regarding Abuse Allegations, investigations and proper reporting timeliness on 2/27/2026 at 8:00 AM. CNA #1 that was identified was a no show on 2/15/2026 and 2/16/2026 and had not worked since 2/10/26. CNA #1 was contacted multiple times on 2/16/2026 beginning at approximately 11:30am to be terminated but did not return phone calls. CNA #2 was terminated upon review of the recording on 2/16/2026 at 11:16 AM, due to her voice being recognized using aggressive language. All staff will be educated on Abuse Policy and Procedure as well as the timeline for reporting and investigation of allegations of abuse beginning on 2/16/2026 at approximately 12:00 PM by Director of Nursing (DON), Staff Development Nurse, Lead CNA and RN Supervisor. No staff will be allowed to work until in-serviced.A Corporate Nurse conducted an in-service with Director of Nursing (DON) and Facility Administrator regarding Abuse Allegations, investigations and proper reporting timeliness on 2/27/2026 at 8:00 AM. AD HOC Quality Assurance (QA) meeting held on 2/27/2026 at 8:30 AM to review plan for removal of Immediate Jeopardy (IJ) tag. Policy was reviewed with no changes. Attendees for QA included: Director of Nursing, Medical Director, Administrator, Corporate Nurse, Business Office Manager, Social Services Director, MDS Nurses, Medical Records Nurses, Registered Nurse Supervisors, Activity Director, Therapy Director, Housekeeping Director, Lead CNA, Staff Development Nurse, Infection Control Nurse and Wound Nurse.The facility alleges all corrective actions were completed on 2/27/2026 and the IJ removed on 2/28/2026.Validation:The SA validated the Removal Plan on 3/2/26 and determined the IJ was removed on 2/28/26 prior to exit on 3/2/26.

Based on policy review, record review and interviews, the facility failed to report an allegation of verbal abuse of a resident within the required timeframe of two (2) hours after the allegation was reported to facility staff. The allegation was reported to the facility on 2/14/26 at approximately 8:40 AM but was not reported to the State Agency until 2/16/26 at 11:30 AM. This was for one (1) of four (4) sampled residents. Resident #1.This failure resulted in Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 02/14/26 and placed Resident #1 and all other residents in a situation that was likely to cause serious harm, serious impairment, serious injury or death.The IJ and SQC existed at:CFR 483.12(c)(1)(4) Reporting of Alleged ViolationsScope and Severity (S/S) JThe SA notified the facility Administrator of the Immediate Jeopardy on 02/26/26 at 4:05 PM and provided the IJ template.The facility submitted an acceptable removal plan on 02/27/26 in which the facility alleged all corrective actions were completed on 02/27/26 and the IJ was removed on 02/28/26. The scope and severitywere lowered from a J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings included:Record review of the facility policy titled, Abuse Policy and Procedure dated 1/24/22 revealed . Any alleged incident REPORTED must be investigated and REPORTED to the state within 2 hours of knowledge of such alleged incident. In addition, a written report must be submitted by Registered Nurse within 72 hours.Record review of the Facility Investigation dated 2/19/26 revealed that on 2/14/26 at approximately 8:40 AM the Resident Representative (RR) for Resident #1 reported an allegation of abuse to the Registered Nurse (RN) Supervisor (RN #2). RN #2 notified the Director of Nurses (DON) of the allegation by telephone at approximately 8:50 AM on 2/14/26 via telephone. The DON notified the Administrator at 9:01 AM on 2/14/26. The allegation of abuse was initially reported to the State Agency (SA) on 2/16/26 at 11:30 AM and the final investigative findings were submitted to SA on 2/19/26.During an interview on 2/25/26 at 12:37 PM, the DON revealed on 2/14/26 at approximately 8:50 AM she was notified by RN #2 of an allegation of abuse of Resident #1 by the resident's RR along with a request to speak with the Administrator. The DON notified the Administrator of the allegation by telephone at approximately 9:01 AM. The DON said she notified SA on 2/16/26 at 11:30 AM.During a telephone interview on 2/26/26 at 9:33 AM, the RR for Resident #1 revealed she had reported an allegation of verbal abuse of Resident #1 on 2/14/26 at approximately 8:40 AM to RN #1 and provided access of the recording to RN #1 and RN #2 and requested to speak to someone in Administration.During an interview on 2/26/26 at 10:30 AM, the Administrator revealed he had been notified by the DON on 2/14/26 at 9:00 AM via telephone that the RR for Resident #1 had reported an allegation of verbal abuse at approximately 8:40 AM. He said that the DON reported the allegation to SA on 2/16/26 at 11:30 AM. The Administrator confirmed the facility failed to report allegations of abuse within required timeframe according to state and federal requirements.During a telephone interview on 3/02/26 at 11:58 AM, RN #2 revealed she was the RN Supervisor on Unit A on the morning of 2/14/26. She stated the RR for Resident #1 reported verbal abuse of Resident #1 at approximately 8:40 AM on 2/14/26 and she had notified the DON by telephone at approximately 8:50 AM.The facility submitted an acceptable Removal Plan on 2/27/26, and the IJ was removed on 2/28/26.Removal PlanThe facility took the following actions to address the citations and prevent any additional residents from suffering an adverse outcome. On 2/14/2026, the facility's administration was notified of an allegation of abuse from Resident #1's Resident Representative (RR) concerning an audio recording at approximately 9:00 AM. The Resident Representative (RR) stated that she believed the incident happened on 2/11/2026. Later investigation would reveal incident occurred on 2/10/2026. After Director of Nursing (DON) and Facility Administrator were notified by Registered Nurse (RN) #1 and Registered Nurse (RN) #2, the facility's administration failed to report the allegation of abuse within the two-hour time frame to the proper organizations. The facility also did not begin a formal investigation until the following day, Sunday February 15, 2026. Although the resident was moved to a different unit in the building, The facility failed to immediately implement protective measures, and staff alleged to be involved continued to provide resident care through 2/16/26. Resident #1 was still at risk for continued abuse. The actions of the facility's administration put Resident #1 at risk for continued abuse as well as the other residents of the facility at risk for potential abuse. The facility failed to ensure all residents were free from abuse after being notified on 2/14/26 at approximately 9:00 AM of an allegation of verbal abuse supported by an audio recording validated by facility administration capturing staff cursing at Resident #1 while the resident was heard screaming.The State Agency (SA) notified the facility of (IJ) Immediate Jeopardy and provided the IJ templates to the facility on 2/26/27 at 4:05 PMCorrective Actions:On 2/14/2026 Resident #1 was moved at approximately 10:00 AM from Unit A to Unit B at the request of the family after discussion with Registered Nurse #1 . On 2/15/2026 at approximately 9:00 AM , the Director of Nursing interviewed Resident #1 regarding the allegations of alleged abuse, and she denied any such happenings. On 2/15/2026 at approximately 9:00 AM, the Director of Nursing(DON) assessed the resident for any physical or emotional effects.On 2/16/2026, Psychosocial support began at approximately 11:15 AM and was conducted for 72 hours by the Social Services Director (SSD). Resident #1 was referred to the Psychiatric Nurse Practitioner for evaluation on 2/18/2026 at approximately 1:46 PM. The Director of Nursing (DON), Staff Development, and Lead CNA (Certified Nursing Assistant) provided education with all staff regarding the Facility Abuse Policy and Procedures beginning on 2/16/2026 at approximately 11:00 PM.A Corporate Nurse conducted an in-service with Director of Nursing (DON) and Facility Administrator regarding Abuse Allegations, investigations and proper reporting timeliness on 2/27/2026 at 8:00 AM. CNA #1 that was identified was a no show on 2/15/2026 and 2/16/2026 and had not worked since 2/10/26. CNA #1 was contacted multiple times on 2/16/2026 beginning at approximately 11:30am to be terminated but did not return phone calls. CNA #2 was terminated upon review of the recording on 2/16/2026 at 11:16 AM, due to her voice being recognized using aggressive language. All staff will be educated on Abuse Policy and Procedure as well as the timeline for reporting and investigation of allegations of abuse beginning on 2/16/2026 at approximately 12:00 PM by Director of Nursing (DON), Staff Development Nurse, Lead CNA and RN Supervisor. No staff will be allowed to work until in-serviced.A Corporate Nurse conducted an in-service with Director of Nursing (DON) and Facility Administrator regarding Abuse Allegations, investigations and proper reporting timeliness on 2/27/2026 at 8:00 AM. AD HOC Quality Assurance (QA) meeting held on 2/27/2026 at 8:30 AM to review plan for removal of Immediate Jeopardy (IJ) tag. Policy was reviewed with no changes. Attendees for QA included: Director of Nursing, Medical Director, Administrator, Corporate Nurse, Business Office Manager, Social Services Director, MDS Nurses, Medical Records Nurses, Registered Nurse Supervisors, Activity Director, Therapy Director, Housekeeping Director, Lead CNA, Staff Development Nurse, Infection Control Nurse and Wound Nurse.The facility alleges all corrective actions were completed on 2/27/2026 and the IJ removed on 2/28/2026.Validation:The SA validated the Removal Plan on 3/2/26 and determined the IJ was removed on 2/28/26 prior to exit on 3/2/26.

Based on policy review, record review, and interviews, the facility failed to thoroughly investigate an allegation of abuse in a timely manner to prevent further potential abuse. The facility failed to initiate a prompt and thorough investigation after an allegation of verbal abuse of Resident #1 was reported on 2/14/26. The facility did not immediately interview staff or residents, did not initiate protective interventions, and delayed investigative actions until 2/16/26. This deficient practice affected one (1) of three (3) reviewed incidents with documented indications of possible abuse. Resident #1.The facility's failure to initiate a timely investigation and implement protective measures created the likelihood of continued abuse of Resident #1 and other residents and placed them in a situation that was likely to cause serious harm, serious injury, serious impairment or death. Staff confirmed that the allegation involved demeaning and abusive language toward Resident #1, yet no interviews, resident assessments, or protective interventions were implemented on 2/14/26 when the allegation was first reported. This failure placed Resident #1 and other residents at risk for continued abuse.This failure resulted in Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 02/14/26.The IJ and SQC existed at:CFR 483.12(c)(2) Investigation of Alleged ViolationsScope and Severity (S/S) JThe SA notified the facility Administrator of the IJ and SQC on 02/26/26 and provided the IJ template at 4:05 PM.The facility submitted an acceptable removal plan on 02/27/26 in which the facility alleged all corrective actions were completed on 02/27/26 and the IJ was removed on 02/28/26. The scope and severitywere lowered from a J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings included:Record review of the facility policy titled, Abuse Policy and Procedure dated 1/24/22 revealed .The facility will IDENTIFY, correct, intervene in situations in which abuse, neglect and/or misappropriation of funds occur.The facility will thoroughly INVESTIGATE all alleged violations under the direct supervision of the Administrator. The facility will take all necessary steps to prevent further potential abuse while the investigation is in progress. Any employee of the facility suspected of abuse or neglect will be suspended pending investigation until the facility investigation is complete. During and after the investigation, the resident(s) will be PROTECTED from harm through frequent supervision and reassurance by staff. Record review of the Facility Investigation dated 2/19/26 revealed that on 2/14/26 at approximately 8:40 AM the Resident Representative (RR) for Resident #1 reported an allegation of abuse to the Registered Nurse (RN) Supervisor (RN #2). RN #2 notified the Director of Nurses (DON) of the allegation by telephone at approximately 8:50 AM on 2/14/26 via telephone. The DON notified the Administrator at 9:01 AM on 2/14/26. The DON reported to the facility on 2/15/26 and interviewed Resident #1 and attempted to locate the audio recording on the resident's cell phone without success.In an interview on 2/25/26 at 12:37 PM, the DON revealed on 2/14/26 at approximately 8:40 AM she was notified by RN #2 of an allegation of abuse of Resident #1 by the resident's RR along with a request to speak with the Administrator and that the Administrator be notified of the allegation by telephone at approximately 9:01 AM. The DON said she had instructed RN #1 to follow up on 2/14/26 at approximately 10:00 AM and was not aware of any interviews of other residents or staff on 2/14/26. She said RN #1 and RN #2 had told her that they had heard an audio recording that the RR for Resident #1 played for them that indicated verbal abuse. The DON said that on 2/15/26 she reported to the facility on 2/15/26 at approximately 10:00 AM and conducted one interview with Resident #1 and tried to locate the recording on the resident's cell phone without success and did not contact the RR for Resident #1 or conduct any other interviews. The DON said that on 2/16/26 she contacted the RR for Resident #1 and obtained the audio recording and interviewed staff. She reported that interviews of residents were delegated to the Social Services Director (SSD). She described how on 2/16/26 she was able to ascertain the date of the incident was 2/10/26 and that CNA #2 was present during the incident and that at approximately 11:00 AM on 2/16/26 she spoke with the RR for Resident #1, for the first time since notification, by telephone and heard the description that matched CNA #2. The RR provided the audio recording at 11:16 AM she and the Lead CNA Supervisor listened to the recording and the Lead CNA Supervisor positively identified voices on the recording as those of Resident #1, CNA #1 and CNA#2.In an interview on 2/25/26 at 4:30 PM, RN #1 revealed that on 2/14/26 RN #2 notified her at approximately 8:40 AM of an allegation of verbal abuse of Resident #1 brought forth by the resident's RR. She confirmed that the RR was present and requested to speak with the Administrator. RN #1 said that the RR had an audio recording made by Resident #1 on either 2/10/26 or 2/11/26. She said she listened to the recording, played by the RR, on the morning of 2/14/26 and that she was able to identify the voice of Resident #1, but unable to recognize the voices of the two (2) staff members. She stated that she had spoken with the Director of Nurses' (DON) and that they had discussed the RR's requests and the DON instructed her to transfer Resident #1 to Unit B and that there were no further instructions provided. She stated that the DON nor the Administrator came to the facility on 2/14/26. She said she had not conducted any interviews, assessed any residents or placed any interventions in place to protect residents on 2/14/26. RN #1 confirmed that she considered the way Resident #1 was spoken to by staff on the recording as abusive.In a telephone interview on 2/26/26 at 9:33 AM, the RR for Resident #1 said that the resident had voiced complaints of rough treatment by staff, which she had not reported. The RR said she visited Resident #1 on 2/11/26 and while looking at the resident's cellular telephone (cell phone) noticed that the resident had recordings and forwarded the recordings to her own cell phone, listened to them on 2/13/26 at approximately 10:30 PM and heard verbal abuse of Resident #1 which she described as mean, demeaning. She said she reported an allegation of verbal abuse of Resident #1 on 2/14/26 at approximately 8:40 AM to Registered Nurse (RN) #1 and provided access of the recording to RN #1 and RN #2 and requested to speak to someone in Administration. She stated that on 2/16/26 the DON had telephoned her at approximately 11:00 AM and she reported to the DON that she recognized the voice of CNA #2, whose name she did not know, but provided description. She said on 2/16/26 the DON requested she send the recording to staff, which she did at approximately 11:15 AM. In an interview on 2/26/26 at 10:30 AM, the Administrator revealed he had been notified by the DON on 2/14/26 at 9:00 AM via telephone that the RR for Resident #1 had reported an allegation of verbal abuse at approximately 8:40 AM. He said that he had delegated responsibility for investigating the allegation to the DON. He confirmed that he was unaware of any staff interviews conducted to investigate the allegation prior to 2/16/26. He stated that the results of failure to thoroughly investigate an allegation of abuse could include continued abuse of residents. In an interview on 2/26/26 at 12:35 PM, the Lead CNA Supervisor revealed that she was notified of the allegation of verbal abuse of Resident #1 on 2/16/26 at approximately 8:00 AM by the DON. She described her involvement in the investigation as receipt and review of a recording provided by the RR for Resident #1 at approximately 11:16 AM on 2/16/26, during which she was able to identify the voices of Resident #1, CNA #1 and CNA #2.In an interview on 2/27/26 at 12:50 PM, the Social Services Director (SSD) revealed she interviewed four (4) residents (only on the 400 Hall) on 2/19/26 as part of the investigation into the verbal abuse of Resident #1. She stated that the results of failure to thoroughly investigate an allegation of abuse could include continued abuse of residents.In an interview on 3/02/26 at 11:58 AM, during a telephone interview with RN #2 revealed she was the RN Supervisor on Unit A on the morning of 2/14/26 and the RR for Resident #1 reported verbal abuse of Resident #1 at approximately 8:40 AM on 2/14/26. She stated she had notified the DON by telephone at approximately 8:50 AM. She said she was unaware of any interviews or physical assessments of other residents for complaints or signs or symptoms of abuse conducted on 2/14/26. She confirmed she had listened to the recording provided by the RR of Resident #1 and considered the interaction abusive toward the resident.The facility submitted an acceptable Removal Plan on 2/27/26, and the IJ was removed on 2/28/26.Removal PlanThe facility took the following actions to address the citations and prevent any additional residents from suffering an adverse outcome. On 2/14/2026, the facility's administration was notified of an allegation of abuse from Resident #1's Resident Representative (RR) concerning an audio recording at approximately 9:00 AM. The Resident Representative (RR) stated that she believed the incident happened on 2/11/2026. Later investigation would reveal incident occurred on 2/10/2026. After Director of Nursing (DON) and Facility Administrator were notified by Registered Nurse (RN) #1 and Registered Nurse (RN) #2, the facility's administration failed to report the allegation of abuse within the two-hour time frame to the proper organizations. The facility also did not begin a formal investigation until the following day, Sunday February 15, 2026. Although the resident was moved to a different unit in the building, The facility failed to immediately implement protective measures, and staff alleged to be involved continued to provide resident care through 2/16/26. Resident #1 was still at risk for continued abuse. The actions of the facility's administration put Resident #1 at risk for continued abuse as well as the other residents of the facility at risk for potential abuse. The facility failed to ensure all residents were free from abuse after being notified on 2/14/26 at approximately 9:00 AM of an allegation of verbal abuse supported by an audio recording validated by facility administration capturing staff cursing at Resident #1 while the resident was heard screaming.The State Agency (SA) notified the facility of (IJ) Immediate Jeopardy and provided the IJ templates to the facility on 2/26/27 at 4:05 PMCorrective Actions:On 2/14/2026 Resident #1 was moved at approximately 10:00 AM from Unit A to Unit B at the request of the family after discussion with Registered Nurse #1 . On 2/15/2026 at approximately 9:00 AM , the Director of Nursing interviewed Resident #1 regarding the allegations of alleged abuse, and she denied any such happenings. On 2/15/2026 at approximately 9:00 AM, the Director of Nursing(DON) assessed the resident for any physical or emotional effects.On 2/16/2026, Psychosocial support began at approximately 11:15 AM and was conducted for 72 hours by the Social Services Director (SSD). Resident #1 was referred to the Psychiatric Nurse Practitioner for evaluation on 2/18/2026 at approximately 1:46 PM. The Director of Nursing (DON), Staff Development, and Lead CNA (Certified Nursing Assistant) provided education with all staff regarding the Facility Abuse Policy and Procedures beginning on 2/16/2026 at approximately 11:00 PM.A Corporate Nurse conducted an in-service with Director of Nursing (DON) and Facility Administrator regarding Abuse Allegations, investigations and proper reporting timeliness on 2/27/2026 at 8:00 AM. CNA #1 that was identified was a no show on 2/15/2026 and 2/16/2026 and had not worked since 2/10/26. CNA #1 was contacted multiple times on 2/16/2026 beginning at approximately 11:30am to be terminated but did not return phone calls. CNA #2 was terminated upon review of the recording on 2/16/2026 at 11:16 AM, due to her voice being recognized using aggressive language. All staff will be educated on Abuse Policy and Procedure as well as the timeline for reporting and investigation of allegations of abuse beginning on 2/16/2026 at approximately 12:00 PM by Director of Nursing (DON), Staff Development Nurse, Lead CNA and RN Supervisor. No staff will be allowed to work until in-serviced.A Corporate Nurse conducted an in-service with Director of Nursing (DON) and Facility Administrator regarding Abuse Allegations, investigations and proper reporting timeliness on 2/27/2026 at 8:00 AM. AD HOC Quality Assurance (QA) meeting held on 2/27/2026 at 8:30 AM to review plan for removal of Immediate Jeopardy (IJ) tag. Policy was reviewed with no changes. Attendees for QA included: Director of Nursing, Medical Director, Administrator, Corporate Nurse, Business Office Manager, Social Services Director, MDS Nurses, Medical Records Nurses, Registered Nurse Supervisors, Activity Director, Therapy Director, Housekeeping Director, Lead CNA, Staff Development Nurse, Infection Control Nurse and Wound Nurse.The facility alleges all corrective actions were completed on 2/27/2026 and the IJ removed on 2/28/2026.Validation:The SA validated the Removal Plan on 3/2/26 and determined the IJ was removed on 2/28/26 prior to exit on 3/2/26.

Based on policy review, record review, and interviews, the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure administrative leadership implemented timely actions to respond to and manage an allegation of verbal abuse involving Resident #1. The Administrator was notified of the allegation on 2/14/26 at approximately 9:00 AM but failed to ensure the allegation was reported within required timeframes, failed to ensure the alleged perpetrator was immediately removed from resident contact, and failed to ensure a prompt investigation was initiated. This deficient practice affected one (1) of four (4) sampled residents. Resident #1.The facility's failure to provide effective administrative oversight resulted in delays in reporting the allegation to the State Agency (SA) and delays in initiating investigative actions. The alleged perpetrator, Certified Nurse Aide (CNA) # 2, continued to work in the facility after the allegation was reported on 2/14/26 and remained on duty until approximately 11:16 AM on 2/16/26 when employment was terminated. Staff confirmed that neither the Administrator nor the Director of Nurses (DON) reported to the facility on 2/14/26 to initiate investigative actions and that no staff interviews were conducted on that date. The only intervention implemented on 2/14/26 was relocating Resident #1 to another unit at the request of the Resident Representative (RR).The facility's failure to implement effective administrative leadership and ensure timely response to allegations of abuse prevented prompt protection of residents and delayed regulatory reporting and investigation. This failure placed Resident #1 and other residents at risk for continued abuse and harm.The IJ began on 2/14/26, when the facility failed to protect residents from abuse, failed to report alleged abuse timely, failed to promptly investigate allegations of abuse, and Administration failed to implement and enforce the facility's abuse policies.The IJ existed at:CFR 483.70 Administration-Scope and Severity (S/S) JThe SA notified the facility Administrator of the Immediate Jeopardy on 02/26/26 and provided the IJ template at 4:05 PM.The facility submitted an acceptable removal plan on 02/27/26 in which the facility alleged all corrective actions were completed on 02/27/26 and the IJ was removed on 02/28/26. The scope and severitywere lowered from a J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings included:Record review of statement by the Administrator dated 3/02/26 revealed that the facility does not have an Administration Policy.Record review of the facility's Administrator Job Description (undated) revealed the document included ADMINISTRATOR JOB DESCRIPTION.Leads, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents.Responds and resolves complaints and concerns when necessary.Ensures resident incidents and concerns that rise to a reportable event such as alleged abuse, neglect, mistreatment, misappropriation, etc. are reported to the correct entity within the stated regulatory requirement. Record review of the facility policy titled Abuse Policy and Procedure dated 1/24/22 revealed the policy required that residents be free from verbal, physical, mental, and sexual abuse and that allegations of abuse are to be reported and investigated in accordance with regulatory requirements. Record review of the facility investigation dated 2/19/26 revealed that on 2/14/26 at approximately 8:40 AM the Resident Representative (RR) for Resident #1 reported an allegation of verbal abuse with an audio recording to the Registered Nurse (RN) Supervisor (RN #2). RN #2 notified the Director of Nurses (DON) at approximately 8:50 AM and the DON notified the Administrator at approximately 9:01 AM on 2/14/26. Record review of staff schedules revealed that CNA#2, an alleged perpetrator, continued to work in the facility after the allegation was reported on 2/14/26 and worked on 2/16/26 until approximately 11:16 AM when employment was terminated. During an interview on 2/25/26 at 12:37 PM, the DON confirmed the allegation was not reported to the SA until 2/16/26 and that staff interviews did not begin until 2/16/26. During an interview on 2/25/26 at 4:30 PM, RN #1 confirmed that neither the Administrator nor the DON came to the facility on 2/14/26 and that no staff interviews were conducted on that date. RN #1 confirmed the only intervention implemented on 2/14/26 was relocating Resident #1 to another unit at the request of the RR. During an interview on 2/26/26 at 10:17 AM, the Administrator confirmed he had been notified of the allegation of verbal abuse on 2/14/26 at approximately 9:00 AM. He confirmed that he was aware of state and federal regulatory timeframes for reporting allegations of abuse. The facility submitted an acceptable Removal Plan on 2/27/26, and the IJ was removed on 2/28/26.Removal PlanThe facility took the following actions to address the citations and prevent any additional residents from suffering an adverse outcome. On 2/14/2026, the facility's administration was notified of an allegation of abuse from Resident #1's Resident Representative (RR) concerning an audio recording at approximately 9:00 AM. The Resident Representative (RR) stated that she believed the incident happened on 2/11/2026. Later investigation would reveal incident occurred on 2/10/2026. After Director of Nursing (DON) and Facility Administrator were notified by Registered Nurse (RN) #1 and Registered Nurse (RN) #2, the facility's administration failed to report the allegation of abuse within the two-hour time frame to the proper organizations. The facility also did not begin a formal investigation until the following day, Sunday February 15, 2026. Although the resident was moved to a different unit in the building, The facility failed to immediately implement protective measures, and staff alleged to be involved continued to provide resident care through 2/16/26. Resident #1 was still at risk for continued abuse. The actions of the facility's administration put Resident #1 at risk for continued abuse as well as the other residents of the facility at risk for potential abuse. The facility failed to ensure all residents were free from abuse after being notified on 2/14/26 at approximately 9:00 AM of an allegation of verbal abuse supported by an audio recording validated by facility administration capturing staff cursing at Resident #1 while the resident was heard screaming.The State Agency (SA) notified the facility of (IJ) Immediate Jeopardy and provided the IJ templates to the facility on 2/26/27 at 4:05 PMCorrective Actions:On 2/14/2026 Resident #1 was moved at approximately 10:00 AM from Unit A to Unit B at the request of the family after discussion with Registered Nurse #1 . On 2/15/2026 at approximately 9:00 AM , the Director of Nursing interviewed Resident #1 regarding the allegations of alleged abuse, and she denied any such happenings. On 2/15/2026 at approximately 9:00 AM, the Director of Nursing(DON) assessed the resident for any physical or emotional effects.On 2/16/2026, Psychosocial support began at approximately 11:15 AM and was conducted for 72 hours by the Social Services Director (SSD). Resident #1 was referred to the Psychiatric Nurse Practitioner for evaluation on 2/18/2026 at approximately 1:46 PM. The Director of Nursing (DON), Staff Development, and Lead CNA (Certified Nursing Assistant) provided education with all staff regarding the Facility Abuse Policy and Procedures beginning on 2/16/2026 at approximately 11:00 PM.A Corporate Nurse conducted an in-service with Director of Nursing (DON) and Facility Administrator regarding Abuse Allegations, investigations and proper reporting timeliness on 2/27/2026 at 8:00 AM. CNA #1 that was identified was a no show on 2/15/2026 and 2/16/2026 and had not worked since 2/10/26. CNA #1 was contacted multiple times on 2/16/2026 beginning at approximately 11:30am to be terminated but did not return phone calls. CNA #2 was terminated upon review of the recording on 2/16/2026 at 11:16 AM, due to her voice being recognized using aggressive language. All staff will be educated on Abuse Policy and Procedure as well as the timeline for reporting and investigation of allegations of abuse beginning on 2/16/2026 at approximately 12:00 PM by Director of Nursing (DON), Staff Development Nurse, Lead CNA and RN Supervisor. No staff will be allowed to work until in-serviced.A Corporate Nurse conducted an in-service with Director of Nursing (DON) and Facility Administrator regarding Abuse Allegations, investigations and proper reporting timeliness on 2/27/2026 at 8:00 AM. AD HOC Quality Assurance (QA) meeting held on 2/27/2026 at 8:30 AM to review plan for removal of Immediate Jeopardy (IJ) tag. Policy was reviewed with no changes. Attendees for QA included: Director of Nursing, Medical Director, Administrator, Corporate Nurse, Business Office Manager, Social Services Director, MDS Nurses, Medical Records Nurses, Registered Nurse Supervisors, Activity Director, Therapy Director, Housekeeping Director, Lead CNA, Staff Development Nurse, Infection Control Nurse and Wound Nurse.The facility alleges all corrective actions were completed on 2/27/2026 and the IJ removed on 2/28/2026.Validation:The SA validated the Removal Plan on 3/2/26 and determined the IJ was removed on 2/28/26 prior to exit on 3/2/26.

Based on observations, interviews, record review and facility policy review the facility failed to provide assistance with turning and repositioning per standards of care for two (2) of nine (9) sampled residents who required assistance with activities of daily living (ADL) and repositioning. Resident #1 and Resident #2. Findings include: Record review of the facility policy titled ADL CARE POLICY dated 8/23 (August 2023) revealed, It is the policy of this facility to provide appropriate treatment and services in relation to ADL care to residents to ensure all ADL needs are met on a daily basis, while attaining or maintaining the residence of highest, practicable, physical, mental and social well-being.Resident #1On 1/12/26 at 9:30 AM observation revealed Resident #1 was resting in bed on her back with head of bed elevated. She had a family member (niece) seated in a chair next to her bed.On 1/12/26 at 2:00 PM, during an interview the family member that was sitting with Resident #1 revealed she had not left the resident's room since she arrived and Resident #1 had not been turned or repositioned since she arrived prior to 9:30 AM.On 1/12/26 at 2:56 PM, during an interview Certified Nursing Assistant (CNA) #2 confirmed she was assigned to the care of Resident #1 on the 7:00 AM through 3:00 PM shift on 1/12/26. She confirmed that she had turned/repositioned Resident #1 one time on 1/12/26 prior to 9:30 AM and that was the only time. She stated she was familiar with the care instructions for Resident #1 and that she was supposed to be turned/repositioned every two hours while in bed.Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 7/21/24 with diagnoses that included cerebral infarction (stroke) and dysphagia.Record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/12/25 revealed Resident #1 rarely/never understood and had severely impaired cognitive skills for daily decision making. Section GG revealed the facility assessed Resident #1 for being dependent for bed mobility (the ability to roll from lying on back to left and right side and return to lying on back on the bed). Resident #2On 1/12/26 at 11:15 AM, observation and interview with Resident #2 revealed he was lying on his back in his bed. Resident #2 was alert and oriented to person, place and time and reported that both of his legs were uncomfortable and that he needed to be repositioned and had not been assisted to turn or reposition since approximately 5:00 AM when a male CNA turned him onto his back.On 1/12/26 at 11:22 AM, observation and interview revealed CNA #1 entered the room of Resident #2 and repositioned him in bed onto his left side with foam wedge for positioning. CNA #1 stated that it was the first time she had turned/repositioned Resident #2 on 1/12/26.On 1/12/25 at 3:22 PM, during an interview CNA #1 revealed Resident #2 required repositioning every two (2) hours and she had no idea when the last time he was turned on the morning on 1/12/26 before 11:22 AM. She stated Resident #2 was alert and oriented.On 1/12/26 at 3:30 PM, during an interview the Registered Nurse (RN) Supervisor revealed he arrived at the facility at approximately 6:43 AM and was not aware that Resident #2 had not been turned or repositioned during the 7:00 AM through 3:00 PM shift on 1/12/26 until 11:22 AM and added he had assumed everything had been taken care of. He stated he had been responsible for Resident #1's care and Resident #2's care until approximately noon on 1/12/26. He stated that he had not had a chance to check on Resident #2 on 1/12/26. He stated that he felt the postponement of care of Resident #1 and Resident #2 was lack of communication. He stated he was not aware that Resident #1 was not turned/repositioned for approximately five (5) hours on 1/12/26. He said he had training for turning/repositioning residents in bed and would have gladly provided care if he had known the CNAs were overwhelmed or needed assistance for resident ADLs. He stated, I can't make excuses, I just wish staff would have told me. He stated possible complications for dependent residents not being turned/repositioned routinely every two hours included discomfort and damage to skin integrity.On 1/12/26 at 4:45 PM, during an interview the Administrator revealed he expected the nurses and the RN Supervisors to supervise the care of the residents and that all residents receive care according to their abilities and needs.On 1/13/26 at 4:00 PM, during an interview the Director of Nurses (DON) stated she expected direct care staff to provide residents with assistance to turn/reposition in bed as needed every two hours and as needed or requested in order to avoid complications that included discomfort and damage to skin integrity.Record review of the admission Record for Resident #2 revealed the facility admitted the resident on 12/16/25 with diagnoses that included congestive heart failure and cervical region spondylosis with myelopathy.

Based on interviews and record review the facility failed to ensure accurate labeling of medication for one (1) of three (3) medication carts. The 400 Hall Medication Cart. Findings include:Record review of the facility policy titled, Medical SUPPLY STORAGE POLICY dated 3/2011 (March 2011) revealed the policy did not address storage of one medication in another's package.Record review of the MEDICATION ERROR REPORT signed by the DON and dated 12/29/25 revealed, .Individual Restasis vial were inside of nebulizer box.family reported wrong vial was brought into the room .On 1/12/26 at 4:45 PM, during an interview the Administrator revealed he expected the nurses to maintain accurate storage of medications in a manner that would provide for safe administration of medications. He stated that storing one medication in the box of a different medication could lead to administration of the wrong medication and cause complications for the resident.On 1/12/26 at 5:00 PM, during an interview the Director of Nurses (DON) confirmed that on 12/29/25 she had been notified by Resident #1's family that a nurse entered the resident's room with an incorrect medication vial for a nebulizer treatment. The DON said she immediately investigated and discovered multiple vials of Restasis eye drops in the Albuterol Sulfate Inhalation Solution package labeled with the name of Resident #1. She stated she removed the incorrect vials of Restasis eye drops and completed an audit of all medications to ensure there were no other incorrectly stored medications on any of the medication carts. She stated that storing one medication in the box of a different medication could lead to administration of the wrong medication and cause complications for the resident.On 1/13/26 at 1:00 PM, during an interview with the Resident Representative for Resident #1, she reported that on 12/29/25 a nurse entered the resident's room with a vial and announced that she was going to administer a nebulizer treatment due to the resident's congestion but that it was obviously not the correct medication and she pointed this out to the nurse and the nurse left the room and did not put the medication into the nebulizer unit. Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 7/21/24 with diagnoses that included cerebral infarction (stroke) and dysphagia.Record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/12/25 revealed Resident #1 was rarely/never understood and had severely impaired cognitive skills for daily decision making.

Based on interview, record review, and facility policy review the facility failed to ensure that the comprehensive person-centered care plan was implemented for one (1) of four (4) sampled residents (Resident #1).Findings included:Record review of the facility policy titled, Care Plans-Comprehensive dated 10/2016 revealed .Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s). Record review of the Care Plan Report for Resident #1 revealed Focus: Resident requires assistance with ADL's (activities of daily living) r/t (related to) muscle weakness/QUATDRIPLEGIA/PARESIS.Interventions.Requires the use of the total mechanical lift X 2 (with two) nursing staff members.Record review of the Care Plan Report date initiated 12/6/23 and revised on 10/20/25, revealed Focus: Resident is at risk for falls and fall related injuries. Interventions. Provide assistance as needed for transfers. 10/17/25 Resident returned from Hospital with X-ray results showing Acute displaced fracture of the left anterolateral rib 9.Record review of the Lift (Determination for Resident Lift/Transfer Assistance for Resident #1 dated 9/23/25 revealed the facility assessed that the resident was dependent for surface-to-surface transfers, and that conditions likely to affect transfer techniques included colostomy, contractures/spasms, paralysis and pressure ulcers and that the resident required two (2) staff and a total mechanical lift with a medium sling. Record review of the Progress Notes for Resident #1 dated 10/17/25 revealed nursing staff documented that the resident was observed on the floor of his room with the transfer sling beneath him, the mechanical lift over him, and his Geri-recliner on its side at the door of the room, was transferred to local hospital and returned to the facility with diagnosis of right rib fracture.Record review of the Incident Report dated 10/17/25 revealed Resident #1 was observed on the floor with the Geri-recliner lying on its side at the door and the resident reported he hit his head, and he was transported to local hospital for evaluation and treatment.Record review of the facility investigation dated 10/21/25 revealed that on 10/17/25 during a bed to Geri-recliner transfer CNA #1 attempted to transfer the resident without assistance and did not lock the Geri-recliner with resulted in a fall and an acute fracture of the left anterolateral rib#9. The resident has as needed pain meds, Oxycodone 5 milligrams by mouth every six hours and Tylenol 325 milligrams by mouth every four hours as needed for pain.Record review of the local hospital Emergency Medicine Attending Physician note dated 10/17/25 revealed documentation that Resident #1 had a mechanical fall from a Hoyer lift and assessment included radiographic imaging which indicated left rib fx (fracture).On 10/28/25 at 2:51 PM, during an interview the Director of Nurses (DON) confirmed that the facility had reported the fall of Resident #1 during a transfer using a full body mechanical lift which resulted in a fractured rib. The DON confirmed that all CNAs had access to and were expected to refer as needed to the computer software available on facility kiosk regarding resident care instructions including for surface-to-surface transfers. On 10/28/25 at 4:00 PM, during an interview Resident #1 stated that on 10/17/25 at approximately 10:40 AM, CNA #1 was using a full body mechanical lift to transfer him from his bed to a Geri-recliner in his room with CNA#2 in attendance. He stated that CNA#2 was in the room but did actively participate in the procedure and that the lift and the Geri-recliner turned over and he landed on the floor.On 10/28/25 at 5:00 PM, during an interview the Minimum Data Set (MDS) Nurse confirmed that she had contributed to the development of the care plan for Resident #1 and that his care plan on 10/17/25 had interventions in place which directed that two (2) nursing staff provide assistance with mechanical lift for surface-to-surface transfers. She confirmed that all CNA's had access via computer software on facility kiosk to the Tasks for each resident that pulled care information from the residents' care plans. She confirmed that the facility provided in-service training which included the responsibility of nursing staff to follow each residents' care plan and included that all surface-to-surface transfers required the participation of (2) staff members. On 10/29/25 at 10:10 AM, during an interview CNA #7 stated that the facility provided training for the transfers with and without mechanical lifts, including instructions that all transfers with lifts required two nursing staff. She confirmed that resident care instructions for all residents were available to CNAs in the software on the facility kiosk. On 10/29/25 at 11:33 AM during a telephone interview CNA #1 revealed she went to assist CNA #2 to transfer Resident #1 from his bed to his Geri-recliner on 10/17/25 and that she (CNA #1) attempted to transfer the resident without the assistance of CNA #2. She stated that she had not waited for CNA #2 to begin the procedure and that after the resident was secured in the sling she had lifted him from the bed, moved him over the Geri-recliner and was pulling the resident using the handlebar straps on the back of the sling to position the resident correctly over the recliner and the resident's back made contact with the back of the recliner, which caused the Geri-recliner to tilt backwards and strike the lift and then the lift and recliner both fell over and the resident landed on the floor at the end of his bed. She stated that Resident #1 was hollering in pain and reported his head hurt. She stated that she and CNA #2 moved the Geri-recliner out of the way and CNA #2 summoned the nurse. She confirmed that the wheels of the Geri-recliner were not locked, and the base of the lift was not open. She confirmed that her employment at the facility had been terminated on 10/17/25 for failure to follow policy for transfers with mechanical lifts.On 10/29/25 at 12:20 PM, during a telephone interview CNA #2 revealed she was assigned to the care of Resident #1 on 10/17/25 and she was providing incontinent care for the resident's roommate at the time that CNA #1 entered the room and proceeded to perform a bed to Geri-recliner transfer with a full body mechanical lift without assistance. She stated that she had summoned CNA#1 for assistance for the transfer of Resident #1 because it was against facility policy to perform transfers with mechanical lifts by only one (1) CNA .She stated that she was concentrated on the procedure she was involved with the roommate when CNA#1 entered the room and did not observed the entire transfer, but she did observe CNA #1 attempting to operate the mechanical lift. CNA #1 was directing the resident in the sling, and she said she saw the resident bump into the back of the Geri-recliner and the recliner tilt backwards and it struck the lift which resulted in the Geri-recliner and the lift falling over and the resident landed on the floor. She stated that she immediately went to Resident #1 and assisted CNA #1 to move the lift then summoned assistance to the resident's room. She stated that Resident #1 reported head pain immediately following the incident. She confirmed that her employment at the facility had been terminated on 10/17/25 for failure to follow policy for transfers with mechanical lifts. On 10/29/25 at 1:23 PM, an interview with the Company Representative for the company that provided facility lifts revealed he was at the facility to conduct in-person In-Service Training with demonstration of safe practices for the use of full body mechanical lifts to nursing staff. He stated that the base of the lift should be open during surface-to-surface transfers, and the chair or Geri-recliner wheel locks should be locked. He stated that the lifts were designed for in-home use and that facility staff were required to follow facility policy for transfers and lift use.On 10/29/25 at 4:55 PM, during an interview the DON stated she had no idea why CNA #1 attempted to transfer Resident #1 using a mechanical lift without assistance of a second staff member. She stated that the facility provided in-service training and policy review for all nursing staff during orientation and at least annually using videos and demonstration and that all CNA s were required to complete the training and participate in a competency check-off to determine safe transfer skills, including always having (2) staff for all transfers with mechanical lifts.Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 12/06/23 and the resident had diagnoses of acute respiratory failure with hypoxia, lack of coordination and osteoporosis.Record review of the Optional State Assessment (OSA) Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 9/23/25 for Resident #1 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Section GG indicated the resident was dependent for mobility and transfers.

Based on interview, record review, and facility policy review, the facility failed to ensure adequate supervision and the implementation of safety interventions to prevent accidents for two (2) of four (4) sampled residents (Resident #1 and Resident #2)Findings included:Record review of the facility policy titled, MODIFIED LIFTING POLICY with a revision date of September 2025 revealed .Use of a mechanical lift requires two (2) nursing assistants or nurses to perform the procedure each time that it is used.Record review of the facility policy titled, TRANSPORT OUT OF FACILITY dated 7/2008 (July 2008) revealed the policy did not address requirements, training for qualifications for staff who performed transportation of residents. Resident #1Record review of the Lift Determination for Resident Lift/Transfer Assistance for Resident #1 dated 9/23/25 revealed the facility assessed that the resident was dependent for surface-to-surface transfers, and that conditions likely to affect transfer techniques included colostomy, contractures/spasms, paralysis and pressure ulcers and that the resident required two (2) staff and a total mechanical lift with a medium sling. Record review of the Progress Notes for Resident #1 dated 10/17/25 revealed nursing staff documented that the resident was observed on the floor of his room with the transfer sling beneath him, the mechanical lift over him, and his Geri-recliner on its side at the door of the room, was transferred to local hospital and returned to the facility with diagnosis of right rib fracture.Record review of the Incident Report dated 10/17/25 revealed Resident #1 was observed on the floor with the Geri-recliner lying on its side at the door and the resident reported he hit his head and he was transported to local hospital for evaluation and treatment.Record review of the facility investigation dated 10/21/25 revealed that on 10/17/25 during a bed to Geri-recliner transfer CNA #1 attempted to transfer the resident without assistance and did not lock the Geri-recliner with resulted in a fall and an acute fracture of the left anterolateral rib#9. The resident has as needed pain meds, Oxycodone 5 milligrams by mouth every six hours and Tylenol 325 milligrams by mouth every four hours as needed for pain.Record review of the Emergency Medicine Attending Physician note dated 10/17/25 revealed documentation that Resident #1 had a mechanical fall from a Hoyer lift and assessment included radiographic imaging which indicated left rib fx (fracture).During an interview on 10/28/25 at 2:51 PM, the Director of Nurses (DON) confirmed that the facility had reported the fall of Resident #1 during a transfer using a full body mechanical lift which resulted in a fractured rib. The DON confirmed that all CNAs had access to and were expected to refer as needed to the computer software available on facility kiosk regarding resident care instructions including for surface-to-surface transfers. She stated that both CNA#1 and CNA #2 had their employment at the facility terminated because of the incident for failure to follow facility policy for transfer of a dependent resident using a full body mechanical lift. During an interview on 10/28/25 at 4:00 PM, Resident #1 stated that on 10/17/25 at approximately 10:40 AM, CNA #1 was using a full body mechanical lift to transfer him from his bed to a Geri-recliner in his room with CNA#2 in attendance. He stated that CNA#2 was in the room but did actively participate in the procedure and that the lift and the Geri-recliner turned over and he landed on the floor.During a telephone interview on 10/29/25 at 11:33 AM, CNA #1 revealed she went to assist CNA #2 to transfer Resident #1 from his bed to his Geri-recliner on 10/17/25 and that she (CNA #1) attempted to transfer the resident without the assistance of CNA #2. She stated that she had not waited for CNA #2 to begin the procedure and that after the resident was secured in the sling she had lifted him from the bed, moved him over the Geri-recliner and was pulling the resident using the handlebar straps on the back of the sling to position the resident correctly over the recliner and the resident's back made contact with the back of the recliner, which caused the Geri-recliner to tilt backwards and strike the lift and then the lift and recliner both fell over and the resident landed on the floor at the end of his bed. She stated that Resident #1 was hollering in pain and reported his head hurt. She stated that she and CNA #2 moved the Geri-recliner out of the way and CNA #2 summoned the nurse. She confirmed that the wheels of the Geri-recliner were not locked, and the base of the lift was not open. She confirmed that her employment at the facility had been terminated on 10/17/25 for failure to follow policy for transfers with mechanical lifts. During a telephone interview on 10/29/25 at 12:20 PM, CNA #2 revealed she was assigned to the care of Resident #1 on 10/17/25 and she was providing incontinent care for the resident's roommate at the time that CNA #1 entered the room and proceeded to perform a bed to Geri-recliner transfer with a full body mechanical lift without assistance. She stated that she had summoned CNA#1 for assistance for the transfer of Resident #1 because it was against facility policy to perform transfers with mechanical lifts by only one (1) CNA .She stated that she was concentrated on the procedure she was involved with the roommate when CNA#1 entered the room and did not observed the entire transfer, but she did observe CNA #1 attempting to operate the mechanical lift. CNA #1 was directing the resident in the sling, and she said she saw the resident bump into the back of the Geri-recliner and the recliner tilt backwards and it struck the lift which resulted in the Geri-recliner and the lift falling over and the resident landed on the floor. She stated that she immediately went to Resident #1 and assisted CNA #1 to move the lift then summoned assistance to the resident's room. She stated that Resident #1 reported head pain immediately following the incident. She confirmed that her employment at the facility had been terminated on 10/17/25 for failure to follow policy for transfers with mechanical lifts. During an interview on 10/29/25 at 4:55 PM, the DON stated she had no idea why CNA #1 attempted to transfer Resident #1 using a mechanical lift without assistance of a second staff member. She stated that the facility provided in-service training and policy review for all nursing staff during orientation and at least annually using videos and demonstration and that all CNA s were required to complete the training and participate in a competency check-off to determine safe transfer skills, including always having (2) staff for all transfers with mechanical lifts.Record review of the personnel file for CNA #1 revealed a PERSONNEL ACTION form dated 10/17/25 which revealed CNA#1's employment at the facility was terminated due to violation of company rules and defective and improper work for failure to follow company policy regarding the proper use of a mechanical lift during a resident transfer resulting in the resident falling. You performed he transfer without a second person. The personnel file included training for the use of mechanical lifts which specified all transfers with mechanical lifts required two (2) staff members.Record review of the personnel file for CNA#2 revealed a PERSONNEL ACTION form dated 10/17/25 which revealed CNA #2's employment at the facility was terminated due to violation of company rules for failure to follow company policy regarding the proper use of a mechanical lift during a resident transfer resulting in in the resident falling. The personnel file included training for the use of mechanical lifts which specified all transfers with mechanical lifts required two (2) staff members.Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 12/06/23 and the resident had diagnoses of acute respiratory failure with hypoxia, lack of coordination and osteoporosis.Record review of the Optional State Assessment (OSA) Minimum Data Set (MDS) with Assessment Reference Date (ARD) 9/23/25 for Resident #1 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The MDS review revealed the facility assessed the resident with impairment of one upper extremity (arm) and both lower extremities (legs), was not able to walk, and was dependent for transfers.Resident #2:Record review of the Incident Report for Resident #2 dated 10/22/25 revealed Licensed Practical Nurse (LPN) #1 documented, STAFF REPORTED THAT WHILE THE RESIDENT WAS SITTING IN THE WHEELCHAIR IN THE VAN, (FACILITY TRANSPORTATION) THE WHEELCHAIR MOVED BACK AND TILTED.STAFF ASSISTED RESIDENT AND PLACED WHEELCHAIR IN A STABLE POSITION.On 10/28/25 at 3:10 PM, during a telephone interview, the Resident Representative (RR) for Resident #2 confirmed that facility staff had notified her that Resident #2 had an incident on the facility van as he was being transported back to the facility from a local hospital and that the wheelchair moved and tilted. She stated that she was not sure if the wheelchair turned completely over based on the report provided by facility staff but confirmed that Resident #2 told her that the wheelchair had fallen over backwards onto the floor of the facility van.On 10/28/25 at 4:25 PM, during an interview Licensed Practical Nurse (LPN) #1 revealed she was working on the 3:00 PM through 11:00 PM shift on 10/22/25 when a local hospital had notified the facility that Resident #2, at the hospital for evaluation, was ready to be released and returned to the facility. She said that when CNA #3 and CNA#4 returned the resident to his room following unloading him from the facility van following transport from the hospital, they reported that the wheelchair had moved back and tilted when they were at a red light. She said that the CNAs stated that the resident had not come out of the wheelchair or been on the floor of the van. She stated that she evaluated the resident immediately and noted no injury and the resident denied pain or discomfort related to the incident. She confirmed that she had notified the resident's RR and his primary healthcare provider, with no new orders noted, and she had notified the Director of Nurses (DON) and had completed an incident report. She clarified statement in the incident report, Resident did not fall by saying that she had not considered the incident a fall because the resident did not come out of the wheelchair. On 10/28/25 at 4:40 PM, during an interview Resident #2 reported that on 10/22/25 he had been transferred to a local hospital emergency department due to unstable vital signs. He stated that following the evaluation he had been released and CNA#3 and CNA#4 arrived at the hospital in the facility van to transport him back to the facility. He stated that during the transport his wheelchair turned over backwards and landed on its back on the floor of the van. He said the CNAs immediately assisted him, still in his wheelchair back into an upright position and continued the transport to the facility. He stated that the nurse had conducted an evaluation, and he had not been injured by the fall. He said that he could not see how the CNAs secured the wheelchair when they had loaded him into the van at the hospital and did not know how or why the wheelchair turned over.On 10/29/25 at 1:44 PM, during an interview CNA #3 stated that she had performed transportation for residents at a different facility where she worked prior to her employment at the facility. She stated that the securement system in the facility van was a lot like the one she had been trained to use at her previous employment. She stated that she had not received any formal training with demonstration and return demonstration or competency checkoff for the operation of the facility van, van lift or resident securement system. She stated that she thought she had the wheelchair secured correctly on 10/22/25 but confirmed that during a stop at a red light she observed in the rear-view mirror Resident #2's wheelchair turned over backwards and landed on the van floor.On 10/29/25 at 2:10 PM, during an interview CNA #4 stated that she and CNA #3 were instructed by the facility DON to pick up Resident #2 from a local hospital to return him to the facility. She stated that she observed Resident #2 turn over backwards with the back of the wheelchair landing on the floor of the van during the transport. She stated that she was riding along for accompaniment and resident supervision. She stated that she was not sure if CNA #3 secured the resident in the facility van appropriately or not and that she had not received any training for the safe use of the securement system on or prior to 10/22/25. She stated that Resident #2 had not complained of pain and did not have any obvious injury or change of level of consciousness. She confirmed that the resident did not leave the wheelchair during the fall. On 10/29/25 at 4:55 PM, during an interview the DON stated she had gone outside with CNA#3 and CNA #4 on 10/22/25 to ensure they were able to provide safe transportation for return of Resident #2 to the facility and verbally explained safe operation of the resident securement system in the van but had not taken a wheelchair, provided a demonstration or required a return demonstration by either CNA to ensure they were able to safely secure Resident #2 in his wheelchair in the van.On 10/29/25 at 5:00 PM, during an interview, the Administrator stated that he expected all staff to have adequate training to perform procedures within their scope of practice in a safe manner that provided a safe environment for all residents. The Administrator stated that transportation services should be provided by staff well trained in the use of safety precautions for the facility van, lift and resident securement system. He confirmed that adequate training included demonstration of competency.Record review of the admission Record for Resident #2 revealed the facility admitted the resident on 7/20/2020 and the resident had diagnoses of acute kidney failure, cognitive communication deficit, vascular dementia and muscle weakness.Record review of the Quarterly MDS with ARD 9/30/25 for Resident #2 revealed the resident had a BIMS score of 7, which indicated severe cognitive impairment. MDS review revealed the resident required setup/clean-up assistance for surface-to-surface transfers and to walk 50 feet and used a wheelchair for mobility.

Based on observation, staff interviews, record review, and facility policy review the facility failed to ensure staff who perform resident transportation possessed and demonstrated the competencies necessary to carry out their responsibilities safely one (1) of four (4) residents dependent on the facility for transportation, Resident #2. Findings included:Record review of the facility policy titled, TRANSPORT OUT OF FACILITY dated 7/2008 (July 2008) revealed the policy did not address requirements, training for qualifications for staff who performed transportation of residents. Record review of the Incident Report for Resident #2 dated 10/22/25 revealed LPN #1 documented, STAFF REPORTED THAT WHILE THE RESIDENT WAS SITTING IN THE WHEELCHAIR IN THE VAN, (FACILITY TRANSPORTATION) THE WHEELCHAIR MOVED BACK AND TILTED.STAFF ASSISTED REISDENT AND PLACED WHEELCHAIR IN A STABLE POSITION. At 3:10 PM on 10/28/25, during a telephone interview, the Resident Representative (RR) for Resident #2 revealed she confirmed that facility staff had notified her that Resident #2 had an incident on the facility van as he was being transported back to the facility from a local hospital and that the wheelchair moved and tilted. She stated that she was not sure if the wheelchair turned completely over based on the report provided by facility staff but confirmed that Resident #2 told her that the wheelchair had fallen over backwards onto the floor of the facility van.At 4:25 PM on 10/28/25, during an interview Licensed Practical Nurse (LPN) #1 revealed she was working on the 3:00 PM through 11:00 PM shift on 10/22/25 when a local hospital had notified the facility that Resident #2, at the hospital for evaluation, was ready to be released and returned to the facility. She said that when Certified Nursing Assistant (CNA) #3 and CNA #4 returned the resident to his room following unloading him from the facility van following transport from the hospital, they reported that the wheelchair had moved back and tilted when they were at a red light. She said that the CNAs stated that the resident had not come out of the wheelchair or been on the floor of the van. She stated that she evaluated the resident immediately and noted no injury and the resident denied pain or discomfort related to the incident. She confirmed that she had notified the resident's RR and his primary healthcare provider, with no new orders noted, and she had notified the Director of Nurses (DON) and had completed an incident report. She clarified statement in the incident report, Resident did not fall by saying that she had not considered the incident a fall because the resident did not come out of the wheelchair. At 4:40 Pm on 10/28/25, during an interview Resident #2 reported that on 10/22/25 he had been transferred to a local hospital emergency department due to unstable vital sign. He stated that following the evaluation he had been released, and CNA #3 and CNA#4 arrived at the hospital in the facility van to transport him back to the facility. He stated that during the transport his wheelchair turned over backwards and landed on its back on the floor of the van. He said the CNAs immediately assisted him, still in his wheelchair back in an upright position and continued the transport to the facility. He stated that the nurse had conducted an evaluation, and he had not been injured by the fall. He said that he could not see how the CNAs secured the wheelchair when they had loaded him into the van at the hospital and did not know how or why the wheelchair turned over.At 1:44 PM on 10/29/25, during an interview CNA #3 stated that she had performed transportation for residents at a different facility where she worked prior to her employment at the facility and said that the securement system in the facility van was a lot like the one she had been trained to use at her previous employment. She stated that she had not received any formal training with demonstration and return demonstration or competency checkoff for the operation of the facility van, van lift or resident securement system. She stated that she thought she had the wheelchair secured correctly but confirmed that during a stop at a red light she observed in the rear-view mirror Resident #2's wheelchair turned over backwards and landed on the van floor. CNA#3 stated she had not received any training for the safe use of the securement system on or prior to 10/22/25.At 2:10 PM on 10/29/25, during an interview CNA #4 stated that she went with CNA #3 to pick up Resident #2 from a local hospital to return him to the facility. She stated that she observed Resident #2 turn over backwards with the back of the wheelchair landing on the floor of the van during the transport. She stated that she was riding along for accompaniment and supervision of the resident. She stated that she was not sure if CNA #3 secured the resident in the facility van appropriately or not and that she had not received any training for the safe use of the securement system on or prior to 10/22/25. She stated that Resident #2 had not complained of pain and did not have any obvious injury or change of level of consciousness. She confirmed that the resident did not leave the wheelchair during the fall. At 4:30 PM on 10/29/25, observation and interview revealed CNA #6 demonstrated use of the facility van lift and securement system. CNA #6 stated that she had received training from the former Maintenance Supervisor and was required to participate in competency checkoffs and return demonstrations of the safe operation of the van, lift and securement system. She demonstrated how if the wheelchair was secured properly by four metal hooks attacked to the floor of the van with a seatbelt applied across the chest of the resident, the chair would not fall over or move. She stated that she had not been on duty when the hospital called for the facility to provide transportation to return the resident to the facility.At 4:45 PM on 10/29/25, during an interview the Maintenance Supervisor revealed that 10/29/25 was his first day in the position. He confirmed that he had received training for the use of the facility van and its lift and resident securement system. He stated he was aware that it would be his responsibility to provide one-on-one training with required return demonstration for any staff designated to operate the facility van and transport residents, but he had not done so yet.At 4:55 PM on 10/29/25, during an interview the DON stated she had gone outside with CNA #3 and CNA #4 on 10/22/25 to ensure they were able to provide safe transportation for return of Resident #2 to the facility and verbally explained safe operation of the resident securement system in the van but had not taken a wheelchair or provided a demonstration or required a return demonstration by either CNA to ensure they were able to safely secure Resident #2 in his wheelchair in the van.At 5:00 PM on10/29/25, during an interview, the Administrator stated that he expected all staff to have adequate training to perform procedures within their scope of practice in a safe manner that provided a safe environment for all residents. The Administrator stated that transportation services should be provided by staff well trained in the use and safety precautions for the facility van, lift and resident securement system. He confirmed that adequate training included competency check-off with demonstration.Record review of the personnel files for CNA #3 and CNA #4 revealed no documentation of training specific to the operation of the facility van, or its lift or securement system for residents in wheelchairs.Record review of the admission Record for Resident #2 revealed the facility admitted the resident on 7/20/2020 and the resident had diagnoses of acute kidney failure, cognitive communication deficit, vascular dementia and muscle weakness.Record review of the Quarterly MDS with an ARD of 9/30/25 for Resident #2 revealed the resident had a BIMS score of 7, which indicated severe cognitive impairment. Section GG revealed the resident required setup/clean-up assistance for surface-to-surface transfers and to walk 50 feet and used a wheelchair for mobility.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide adequate supervision and ensure environmental safety to prevent Resident #1, a vulnerable resident, from exiting the facility unnoticed and unsupervised for one (1) of three (3) residents reviewed. Resident #1 On 6/10/25, Resident #1, who had a Brief Interview for Mental Status (BIMS) score of seven (7), was let out of the building by a lawn service worker. She exited the facility in her wheelchair unnoticed and was last seen inside the facility at 11:05 AM. She was found at 11:08 AM by a visitor walking into the facility in the facility's parking lot, approximately 145 feet from the front door of the building. The facility's failure to provide supervision and ensure environmental safety put Resident #1 and other vulnerable residents at risk for serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 6/10/25, when Resident #1 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 6/17/25 at 2:30 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 6/11/25, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed as of 6/12/25 prior to the SA's entrance on 6/16/25. Findings include: A review of the facility's policy Accidents and Supervision, revised 4/3/25 revealed, Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision .to prevent accidents .Policy Explanation and Guidelines .5. Supervision - Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents . Record review of the Final Investigation revealed, .On 6/10/2025 DON (Director of Nursing) was informed by Social Services Director that she was informed by a visitor that (Resident #1) was outside in facility parking lot, in wheelchair. Social Services Director and MDS (Minimum Data Set) nurse went outside and resident was seated up in wheelchair in parking lot of facility .Staff reviewed the camera system and noted door was held open to allow resident to exit facility by lawn service vendor staff who was exiting the facility after providing lawn services to inner courtyard .Investigation revealed resident was 145 feet from the front door, weather conditions for 6/10/2025 .was as follows, at 10:00 AM the temperature was 80 degrees, cloud cover was at 37%, and humidity was 74%, wind speed was 4.3 westerly winds . Record review of the local conditions revealed on 6/10/25 at 10:00 AM to 11:00 AM was 80 degrees, cloud cover was at 37%, and humidity was 74%. A record review of a statement by the Lawn Care Vendor revealed, .Our employee had been inside performing routine lawn maintenance at the inner courtyard. While he was waiting to be let out of the front door .a resident in a wheelchair came up behind him and followed him outside . A record review of the admission Record revealed the facility admitted Resident #1 on 5/19/2016 with current diagnoses including Heart Failure and Vascular Dementia. A record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 4/15/2025 revealed Resident #1 had a BIMS score of 07, which indicated her cognition was severely impaired. Further review of Section E revealed Resident #1 did not exhibit any wandering behaviors. A record review of the Wandering Elopement Assessment, dated 4/15/25, revealed Resident #1 scored 1.0 which indicated Category of Low Risk for Wandering. On 6/16/25 at 4:00 PM, during an interview with the Administrator and Director of Nursing (DON), they confirmed that on 6/10/25 at approximately 11:05 AM, a lawn care worker opened and held the facility's front door, allowing Resident #1 to exit unsupervised. The resident was found approximately 145 feet from the entrance, sitting in her wheelchair in the parking lot. A review of the facility's surveillance video revealed the resident was outside without supervision for approximately three (3) minutes. The Administrator and DON stated Resident #1 was not care planned as an elopement risk and had not exhibited elopement behaviors prior to the incident. They acknowledged that signage was posted on the inner door instructing individuals not to allow residents to exit. However, they reported that the lawn care worker involved did not speak or read English and was unable to interpret the posted warning. Following the elopement, the facility conducted a head count of all residents. On 6/16/25 at 4:15 PM, during an interview with Licensed Practical Nurse (LPN) #1, she explained that on 6/10/25, she heard the Social Worker call her name and ask for assistance retrieving a resident who was outside. LPN #1 stated that she and the Social Worker immediately ran outside and found Resident #1 sitting in her wheelchair facing the facility entrance, approximately 145 feet from the front door. She stated the resident did not appear to be in any distress, and the weather was overcast, with no rain and mild temperatures. LPN #1 reported that they brought the resident back inside right away and notified the Director of Nursing (DON) and the Administrator. She stated the resident was assessed, and the resident's Resident Representative (RR) and medical provider were notified. On 6/16/25 at 4:30 PM, during an interview with the Social Services Director, she explained that on 6/10/25, a resident's family member informed her that a resident was outside in a wheelchair. She stated she immediately called out to LPN #1, and they both ran outside, where they found Resident #1 in her wheelchair. On 6/17/25 at 9:00 AM, during a review of the facility's surveillance video, a lawn maintenance worker opened and held the front door of the facility, allowing Resident #1 to exit unattended. The video revealed that Resident #1 was outside the facility, unsupervised, for approximately three (3) minutes. The resident was observed wearing a long-sleeved T-shirt, blue jeans, and tennis shoes. There was no rain at the time, and the resident was located in the facility's parking lot. On 6/17/25 at 9:15 AM, during a phone interview with the lawn care manager, he confirmed that one of his crew members held the front door open, allowing Resident #1 to exit the facility. The manager explained that the crew member does not speak or read English and was therefore unable to read the signage posted on the door instructing that residents are not permitted to exit unaccompanied. The facility submitted a corrective action plan as follows: On 6/10/2025 at 11:02 AM, Resident #1 exited the facility unsupervised through the front door, which was held open by a lawn service vendor employee who could not read or speak English to understand the sign posted on the door. This incident represented an Immediate Jeopardy (IJ) situation. The Administrator was presented with an IJ template by the State Agency (SA) on 6/17/2025 at 2:30 PM. On 6/10/2025 at 11:04 AM, a visiting guest leaving the facility notified staff that a resident was outside in front of the facility. Licensed Practical Nurse (LPN) #1 and the Director of Social Services immediately exited the building and assisted Resident #1 back inside. On 6/10/2025 at 11:05 AM, LPN #1 notified the Administrator and the Director of Nursing (DON). On 6/10/2025 at 11:15 AM, an investigation was initiated by LPN #1. A body audit was completed for Resident #1, and no injuries were noted. The resident was placed on hourly observations. On 6/10/2025 at 11:30 AM, the Administrator completed a head count and bed checks. All other residents were accounted for. On 6/10/2025 at 11:40 AM, the Administrator reviewed video camera footage. The footage confirmed that at 11:02 AM, a lawn service vendor exited through the front door and held the door open, allowing Resident #1 to exit the facility. On 6/10/2025 at 11:45 AM, the Administrator notified the facility's Medical Director of the incident. On 6/10/2025 at 11:45 AM, maintenance staff checked all doors for proper functioning and locking. All doors were secured, locked, and functioning properly. On 6/10/2025, the Administrator added signs to the facility's front door in Spanish to coincide with the existing signs in English, which instruct visitors not to allow residents to exit without staff present. On 6/10/2025 at 1:10 PM, the Director of Nursing notified the State Department of Health Complaint Line as well as the Attorney General's Office of Resident #1's elopement. On 6/10/2025 at 2:00 PM, Resident #1's care plan was reviewed and updated by the Minimum Data Set (MDS) nurses. A complete audit was performed by MDS on all residents identified as at risk or exhibiting wandering/elopement behaviors. On 6/11/2025 at 8:00 AM, the Director of Nursing and the Administrator initiated in-service education for staff. Topics included: Door release and observation, Elopement or missing resident policy, Procedures for identifying and responding to elopement, Post-elopement protocols. Staff will not be allowed to work until all Inservice education has been completed. On 6/11/2025, Code [NAME] drills were held by maintenance staff and the administrator during the 7 AM-3 PM and 3 PM-11 PM shifts as part of the in-service training on wandering risk and elopement procedures. On 6/11/2025 at 9:00 AM, maintenance staff re-checked all doors and locks to validate appropriate functioning. All locks were confirmed secure and operational. On 6/11/2025 at 10:00 AM, an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director, Administrator, DON, Social Services Director, MDS (LPN) #1, Infection Preventionist, and RN Unit Managers. The QAPI Committee made the following recommendations: Continue staff in-service training on wandering risk, elopement procedures, and door lock protocols. Maintain hourly observation of Resident #1, as updated on the care plan dated 6/10/2025, indefinitely. No new recommendations were made following the 6/10/2025 audit of residents at risk for elopement. No other residents were identified as high risk at this time. The Administrator and Social Services reviewed the Elopement Binder on 6/10/2025. Resident #1 was added, and their face sheet and photo were included. The Administrator, DON, and Staff Development Coordinator will monitor compliance. The Wandering Resident and Elopement Policy and Procedure was reviewed on 6/11/2025; no revisions were recommended. Implement in-house maintenance staff to manage the facility's inner courtyards effective 6/11/2025. Conclusion: Based on the corrective actions taken and completed on 6/11/25, the facility alleges that Immediate Jeopardy was removed as of 6/12/25. Validation: The SA validated on 6/19/25, through interview and record review, that corrective actions to remove the Immediate Jeopardy were completed on 6/11/25, and the IJ was removed as of 6/12/25, prior to the SA's entrance on 6/16/25.

Complaint: MS #29210 Based on record review, interview, and facility policy review, the facility failed to develop and revise a comprehensive care plan in accordance with physician orders and professional standards for one (1) of three (3) residents reviewed for respiratory equipment (Resident #2). Specifically, the facility failed to update the resident's care plan to reflect a new physician order dated 1/31/25 for an auto-adjusting -(continuous positive airway pressure) C-Pap at 8-18 cm (centimeter) of H20 (water), with modem setup, and the interdisciplinary team did not review or implement updated interventions related to the resident's new therapy. Findings included: A review of the facility's Care Plans-Comprehensive, revised on 10/2016, revealed, .An individualized (person centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident medical, nursing, mental and psychological needs is developed for each resident . A record review of the admission Record revealed the facility admitted Resident #2 on 7/20/2020 with current diagnoses including bipolar disorder. Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/4/25 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 09, which indicated he is moderately impaired. A record review of the physician prescription revealed, on 1/31/2025 Auto-C-Pap at 8-18 cm of H2O. with Modem set up. A record review of the facility's statement dated 6/19/25, and signed by the Administrator revealed, the facility failed to enter the C-Pap 1/31/25 order from physician and care plan was not created or updated to reflect the new order. A record review of Resident #2 facility progress note revealed, on 5/30/25 resident was fitted for and received his C-Pap machine on 5/28/25. A record review of the Comprehensive Care Plan revealed, on 7/20/2020 the resident had a C-Pap at 4 (four) cm and has not been updated to reflect the new order C-Pap at 8-18 cm of H2O, with Modem set up. On 6/16/25 at 4:00 PM, during an interview with Licensed Practical Nurse (LPN)/MDS Coordinator #1, she confirmed that Resident #2's comprehensive care plan was not updated to reflect the new CPAP prescription ordered on 1/31/25. She confirmed that comprehensive care plans are essential to ensure residents receive individualized and coordinated care. New physician orders should be reflected in the plan. On 6/18/25 at 12:38 PM, during an interview with the Director of Nurses (DON), she confirmed that the physician's order the new C-Pap machine dated 1/31/25 was not incorporated into the resident's care plan. She revealed that all new physician orders should be reflected in the care plan to guide staff in providing the appropriate care. This one was missed. On 6/18/25 at 1:00 PM, during an interview with the Administrator, she acknowledged that the interdisciplinary (IDT) team did not review or revise Resident #2's care plan in response to the 1/31/25 physician order the new C-Pap machine. The Administrator confirmed there is no documentation that the IDT met or reviewed the care plan related to the new C-Pap order.

Complaint MS #29210 Based on record review, interview, and facility policy review, the facility failed to ensure services were provided and documented according to professional standards for one (1) of three (3) sampled residents receiving individual Continuous Positive Airway Pressure (C-Pap). Resident #2. Specifically, the facility failed to follow and transcribe a physician's order dated 1/31/25 for a new C-Pap machine, until 5/28/25. Findings included: A review of the facility's policy titled, Transcribing Physician Orders, revised 2/27/2012, revealed, .It is the policy of this facility to transcribe and follow the attending physicians orders as written with order clarification obtained when needed . Resident #2 A record review of the admission Record revealed the facility admitted Resident #2 on 7/20/2020 with current diagnoses including bipolar disorder. Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/4/25 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 09, which indicated he is moderately impaired. A record review of the physician prescription revealed, on 1/31/2025 Auto-(continuous positive airway pressure) C-Pap at 8-18 (centimeter) cm of (water) (H2O), with Modem set up. A record review of the facility's statement dated 6/19/25, and signed by the Administrator revealed, the facility failed to enter the C-Pap 1/31/25 order from physician. A record review of Resident #2 facility progress note revealed, on 5/30/25 resident was fitted for and received his C-Pap machine on 5/28/25. On 6/18/25 at 12:38 PM, during an interview with the Director of Nurses (DON) confirmed that on 1/31/25 following the resident sleep study examination, his physician recommended the resident have a new C-Pap with mask. On 2/6/25 the DON supplied the Administrator with quotes on renting the C-Pap quotes and or purchase of a new machine. On 5/26/25 she received authorization from the Administrator to rent the new C-Pap for Resident #2 and it was supplied to the resident on 5/28/25. On 6/18/25 at 1:00 PM, during an interview with the Administrator confirmed that she received new orders from the DON for Resident #2 to have a new C-Pap machine on 1/31/25. Following she received several quotes from the DON that she gave authorization for the C-Pap on 5/26/25 to the DON. During a phone interview on 6/18/25 at 4:00 PM, the Nurse Practitioner (NP) confirmed that Resident #2 was ordered a new C-Pap by his pulmonologist on 1/31/25, following his sleep study. The importance of receiving a new C-Pap for maintaining optimal therapy effectiveness and ensuring hygiene during that time C-Pap machines and components can degrade leading to reduced airflow.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from abuse for two (2) of seven (7) sampled residents reviewed, Resident #1 and Resident #2. Findings include: Record review of the facility policy titled Preventing Resident Abuse, with a revision date of 8/16/2016, revealed .1. The facility's goal is to achieve and maintain an abuse-free environment .3. Residents have the right to be free from all forms of abuse. Abuse includes conduct that causes or has the potential to cause the resident to experience humiliation, fear, shame, agitation, or degradation. Resident #1 Record review of the facility's Final Investigation dated 2/22/25-2/23/25 revealed the facility's documentation stated that on 2/24/25, the roommate of Resident #1 (Resident #6) reported to the Director of Nursing (DON) and Social Services Director (SSD) that on the night of 2/22/25 or early morning of 2/23/25, she heard Resident #1 say, Stop hitting me, while Certified Nurse Aide (CNA) #1 was rendering care. Resident #6 provided a written statement that read: Saturday midnight shift 11-7 the CNA came in the room around 1:00 AM to change (Resident #1's) brief when I heard a lot of touching, and I heard (Proper name of Resident #1) say, Stop, you hurting me and I heard a pop on her body. Resident #1 scream loud Stop hitting me! and the CNA said, ' You stop hitting me. Record review of the facility's Final Investigation with the date of incident as 3/13/2025 revealed an allegation of verbal abuse by CNA #2. Resident #1's roommate (Resident #6) provided an audio recording-obtained with permission from Resident #1's Responsible Party (RP)-as evidence of inappropriate speech and verbal abuse. The investigation revealed that CNA #2 made belittling, mocking, and profane remarks to Resident #1 during care. Specific comments recorded included the CNA referring to the resident's alopecia by saying, You got a few strands in the back. CNA #2 commented, Look at your feet, how they are overlapping, and You have hair on your chin. She stated, You probably didn't whip your kids ass, but you're up here trying to whip ours. When the resident said she was going out on pass with her daughter, the CNA replied, Well, I want to see that. When discussing the resident's previous work, CNA #2 said, Oh, I couldn't have worked there. I would have been a dead nigga. She remarked, Once an adult and twice a child. When the resident said, That hurts, the CNA said, I bet it didn't hurt when that man was down there. When the resident mentioned her breast, the CNA said, I don't like women. I like men. I don't lick and lap. On 3/18/25 at 11:25 AM, an interview with the SSD revealed she was made aware of the abuse allegation involving Resident #1 and CNA #1 on 2/24/25 at approximately 12:00 PM, as reported by Resident #6. The SSD confirmed the allegation included hearing a pop and Resident #1 screaming out during care. She stated she was informed of the abuse allegation involving Resident #2 on the same day by the resident's RP. Additionally, the SSD reported she learned of the verbal abuse allegation against CNA #2 during a meeting with Resident #1's RP on 3/3/25, concerning abuse that occurred in January and February 2025. On 3/18/25 at 10:50 AM, during observation and interview, Resident #1 was resting in bed, alert and oriented to self, but unable to recall any incidents of abuse or mistreatment. On 3/18/25 at 11:54 AM, during an interview with Resident #6, she confirmed that she had reported both the physical abuse by CNA #1 and verbal abuse by CNA #2. She described the 2/22/25 incident involving CNA #1, confirming that she heard Resident #1 say, Stop hitting me, followed by a pop and Resident #1 screaming. She also described CNA #2 as a bully who used cruel language during care and stated she had helped facilitate the recordings with RP permission due to Resident #1's memory impairment. On 3/18/25 at 12:03 PM, an interview with the Medical Director revealed he had been made aware of the allegations by the Administrator. He stated that both a Nurse Practitioner (NP) and a contract psychiatric NP had assessed the residents, and neither required hospitalization or medical intervention. He reported no change in either resident's condition since the incidents. On 3/20/25 at 2:52 PM, during a telephone interview, the Resident Representative for Resident #1 reported she had heard the audio recording shared by Resident #6 and described CNA #2's language as disrespectful and humiliating. She stated the CNA sounded like a bully and that the language used was degrading, including references to the resident's appearance and sexually inappropriate remarks. Record review of the Admission Record for Resident #1 revealed the resident was admitted on [DATE] with diagnoses that included Unspecified dementia, Brain disorder, and Hypertension. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/14/25 revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Resident #2 Record review of the facility's Final Investigation dated 2/23/25 revealed that Resident #2 reported to the DON that CNA #1 had struck her on the hands during care. The incident occurred on the 11:00 PM-7:00 AM shift. Resident #2 stated that CNA #1 was assisting her to turn in bed and that she was holding onto a positioner. When she didn't release her grip, CNA #1 struck her on the knuckles and repeated, Let go. Resident #2 said she told the CNA, Give me time. I'm [AGE] years old. The facility's investigation revealed CNA #1 had been assigned to Resident #2 and had documented care for that shift. On 3/18/25 at 1:00 PM, during observation and interview, Resident #2 recalled that CNA #1 struck her knuckles during care on 2/23/25, while she was holding a positioner. She said the CNA told her to let go, then struck her, prompting her to respond, Give me time. I'm [AGE] years old. On 3/19/25 at 11:00 AM, the Administrator confirmed that both CNA #1 and CNA #2 had been suspended immediately after their respective allegations and that both were terminated based on the facility's investigations. On 3/20/25 at 1:48 PM, an interview with the DON revealed she was notified of the abuse allegations involving Resident #1 and Resident #2 on 2/24/25. She confirmed CNA #1 was not on duty at the time but was immediately suspended. She stated the roommate of Resident #1 described hearing the resident scream out, Stop hitting me! and hearing CNA #1 respond, You stop hitting me! The DON confirmed CNA #1's employment was terminated, and the incident was reported to the State Agency (SA) certification division.The DON reported she was made aware of the verbal abuse allegation against CNA #2 on 3/13/25. She confirmed CNA #2 was immediately suspended. The resident's RP had shared recordings of the abuse, and Resident #6 confirmed that CNA #2 made mocking and inappropriate comments during care. The DON stated she had previously corrected CNA #2 for making inappropriate remarks about another staff member. Following investigation, CNA #2's employment was terminated, and she was also reported to the SA certification division. Record review of the Admission Record for Resident #2 revealed the resident was admitted on [DATE] with diagnoses that included Atrial fibrillation, Congestive heart failure, and Hypertension. Record review of the Annual MDS with an ARD of 3/4/25 revealed a BIMS score of 10, indicating moderate cognitive impairment. On 3/19/25 at 2:46 PM, during a telephone interview, CNA #2 confirmed familiarity with Residents #1 and #4 and admitted making the statement about that man down there, though she claimed she was quoting someone else. She confirmed her suspension and termination. On 3/20/25 at 2:42 PM, the SA attempted to contact CNA #1 by telephone and text but was unsuccessful.

Based on observation, interview, record review, and facility policy review, the facility failed to implement care plan interventions on the Activities of Daily Living (ADL) care plan for Resident #7 when the resident's drink was left unopened, her cereal was served dry, and her utensils were placed out of reach during the evening meal on 3/20/25 for one (1) of seven (7) sampled residents reviewed. Resident #7. Findings include: Record review of the Care Plan dated 7/07/24 for Resident #7 revealed a focus of Resident requires assistance with ADLs related to muscle weakness and diagnosis of Alzheimer's Disease .Interventions .Provide assistance as needed for ADLs .Resident able to feed self with tray set-up but does require nursing staff to assist with feeding at times due to visual impairment On 3/20/25 at 5:30 PM, during a dining observation and interview, Resident #7 and her roommate were alone in their room. Resident #7 was sitting in bed with her supper tray on her over-the-bed table. She had her soda can unopened in her hand, and her utensils were out of reach on the opposite side of the tray. Resident #7 confirmed that she wanted to eat and drink but could not open the can and did not know where her utensils were. Licensed Practical Nurse (LPN) #3 and the Director of Nursing (DON) arrived and confirmed that the drink should have been opened and the utensils placed within reach during tray set-up as part of meal assistance. On 3/20/25 at 4:40 PM, during an interview with the DON and Administrator, both confirmed that ADL assistance for eating included opening containers and ensuring that residents could reach utensils at the time of tray set-up. They confirmed that care plans were essential for appropriate care and staff were expected to follow them. Record review of the Admission Record for Resident #7 revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Glaucoma, Muscle weakness, and Diabetes.

Based on interviews, record review, and facility policy review, the facility failed to notify the Physician or the Resident Representative (RR) when a resident experienced pain to her right knee after a resident transfer which resulted in a femoral fracture that was diagnosed the following day for one (1) of ten (10) sampled residents that require a mechanical lift for transfers. (Resident #5) Findings Include: A review of the facility's policy Resident Change in Condition revised 2016, revealed, .It is the policy of this facility to promptly notify the resident, his or her attending physician, and the resident representative (RR) of changes in the resident's condition .Procedure 1. The Charge Nurse will notify the resident's attending physician when: a. The resident is involved in any accident or incident that results in an injury .b. There is a significant change in the resident's physical, mental or psychosocial status .g. Deemed necessary or appropriate in the best interest of the resident. 2. Unless otherwise instructed by the resident, the charge nurse will notify the resident representative when: a. The resident is involved in any accident or incident that results in an injury .b. There is a significant change in the resident's physical, mental, or psychosocial status . A record review of the facility's investigation summary dated 7/6/24 and a follow up investigation dated 7/11/24 as reported to the State Agency revealed that on the morning of 7/3/24, Resident #5 complained of right leg pain to the nurse and her daughter via phone. The daughter called the nurse and requested an X-ray of her right leg at this time. The X-ray was completed, and the results came back in the early morning hours of 7/4/24. The interviews conducted included two (2) Certified Nursing Aides (CNAs) involved in transferring Resident #5 from the chair to the bed, the cart nurse, and the resident's roommate. The CNAs stated that upon attempting to transfer Resident #5 from the chair to the bed that afternoon, the lift battery was dead, rendering them unable to lift Resident #5 out of the chair. While the nurse was fetching the battery, Resident #5 began sliding out of the chair. To prevent her from falling, one CNA reclined the back of the chair. Then, one CNA grabbed the two handles at the top of the lift pad and the other grabbed the bottom two handles of the lift pad. The resident yelled out during the transfer. The sitter was in the room at the time of the transfer, she stated that she heard the resident yell out and the resident's knee was on the bed, but her foot was on the floor. During an interview on 7/30/24 at 10:20 AM, Licensed Practical Nurse (LPN #3) confirmed the incident occurred on 7/2/24 at approximately 2:15 PM when CNA #3 asked for assistance with transferring Resident #5 using a mechanical lift. LPN #3 explained she got another battery for the lift, but that battery was also not charged, so she unhooked the resident from the Hoyer and went to get another lift. When she returned with another lift, CNA #3 and CNA #4 informed her the resident had to be manually transferred to the bed because she had started sliding from the wheelchair. On 7/2/24, LPN #3 assessed the resident. CNA #3 reported that Resident #5 was moaning and pointing at her leg. LPN #3 confirmed the sitter also told her at that time Resident #5 was complaining of pain because the CNAs had manually transferred her. She admitted she did not notify the Unit Manager, Medical Director, DON, or Resident Representative (RR) about Resident #5's complaint of knee pain after the manual transfer. During an interview on 7/30/24 at 10:50 AM, CNA #3 admitted she did not notify LPN #3 that Resident #5 had screamed or yelled out in pain during the manual transfer. In an interview on 7/30/24 at 11:20 AM, CNA #4 also confirmed she did not notify LPN #3 that Resident #5 screamed or yelled out in pain during the manual transfer. On 8/1/24 at 11:00 AM, during an interview with the DON, she confirmed the physician, DON, and RR should have been notified of Resident #5's incident on 7/2/24 and resident yelling out in pain at the time of the transfer. She emphasized that it was the facility's policy to notify the Unit Manager, Medical Director, DON, and RR of any changes in residents' conditions and expected the nursing staff to adhere to this policy. On 8/1/24 at 2:17 PM, in an interview with the Administrator, he confirmed that on 7/2/24, the facility did not follow the facility's policy regarding notification of a change in a resident's condition. He stated that he expected the facility staff to comply with the policy and notify the physician and RR. A record review of the Admission Record revealed the facility admitted Resident #5 on 3/2/2018 and she had current diagnoses including Hemiplegia, and Hemiparesis following Cerebral Infarction. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 5/17/24 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact.

Based on interviews, record review, and facility policy review, the facility failed to implement care plan approaches or interventions related to pain when Resident #5 yelled out in pain during a transfer for one (1) of 23 residents reviewed for care plans. (Resident #5) Findings Include: A review of the facility's Following the Care Plan Policy, dated 1/2011, revealed, .It is the Policy of this facility to follow a written and approved care plan for each resident. All employees will be .required to follow the care plan. Procedure .All employees will follow the written care plan that is developed in order to assure the residents needs are met. A record review of the Comprehensive Care Plan with an initiation date of 6/2/23 revealed Focus: Resident is at risk for pain .Interventions initiated on 6/2/2023 .Document type, location and severity of pain .Give medications as ordered . A record review of the facility's investigation summary dated 7/6/24 and a follow up investigation dated 7/11/24 as reported to the State Agency revealed that on the morning of 7/3/24, Resident #5 complained of right leg pain to the nurse and her daughter via phone. The daughter called the nurse and requested an X-ray of her right leg at this time. The X-ray was completed, and the results came back in the early morning hours of 7/4/24. The physician was notified of the results and gave an order for Resident #5 to be sent out for further examination. At approximately 4:37 PM on 7/4/24, the Registered Nurse (RN) Supervisor called the receiving facility to check on Resident #5 and was informed that she was being admitted with a fracture. The Certified Nursing Assistants (CNAs) stated that upon attempting to transfer Resident #5 from the chair to the bed that afternoon .the resident yelled out. The sitter who was in the room, stated that the resident's knee was on the bed, but her foot was on the floor. A record review of the local hospital orthopedic Consult Orders, dated 07/05/24, revealed, .Subjective .right distal periprosthetic femur fracture .A Hoyer lift is used for transfers. Patient had a fall during the transfer and was found to have a right distal femur fracture. She was admitted to the hospitalist for her medical care and orthopedics was consulted for fracture care. Objective: Right lower extremity: Moderate swelling about the fracture site . A record review of the electronic Medication Administration Record (eMAR) for July 2024 revealed an order dated 09/08/20 for Tramadol 50 milligrams (mg) Give 1 tablet by mouth every six (6) hours as needed (PRN) for moderate or severe pain. There was no documentation Resident #5 received any pain medication on 7/2/24, the day the incident occurred. Resident #5 received a routine Duragesic patch for pain on 7/3/24, which was the day following the manual transfer incident in which Resident #5 had screamed out in pain. In an interview on 07/30/24 at 10:20 AM, with Licensed Practical Nurse (LPN) #3, she confirmed on 7/2/24 at approximately 2:15 PM, Resident #5 was manually transferred from her wheelchair to her bed. Shortly after, CNA #3 reported to the nurse that Resident #5 was complaining of pain. LPN #3 confirmed she failed to administer any pain medication to Resident #5 on 07/02/24 when she complained of pain. In an interview with the Director of Nursing (DON) on 8/1/24 at 11:00 AM, she confirmed care plan interventions were not implemented regarding pain when LPN #3 failed to administer the as needed pain medication that was ordered for Resident #5 and did not report the pain to the oncoming nurse. The DON explained that care plans were in place for the staff to use to take care of the residents, and she expected the staff at the facility to follow care plan interventions on the residents. During an interview on 8/1/24 at 2:17 PM, the Administrator confirmed the staff failed to follow the care plan by not administering pain medication and documenting the pain to Resident #5. She expected the staff to follow the care plan. A record review of the Admission Record revealed the facility admitted Resident #5 on 2/24/2023, and she had current diagnoses including Age-related Osteoporosis, Hemiplegia, and Hemiparesis following Cerebral Infarction.

Based on record review, interviews, and facility policy review, the facility failed to ensure a resident was free of accidents and/or hazards when facility staff were aware a resident who was care planned for a mechanical lift was sliding from a wheelchair and the staff detached the lift pad from the mechanical lift, causing the resident to further slide and be manually transferred which resulted in a right femur fracture for one (1) of ten (10) sampled residents that required transfers via mechanical lift. (Resident #5) Findings Include: A review of the facility's Responsibility for Accident/Incident Report Policy dated [DATE] revealed, .It is the policy of this facility for all Incidents and Accidents involving resident's to be investigated immediately upon knowledge of the incident. Procedure .Procedure .They are to document on the proper forms and notify the Administrator and/or DON (Director of Nursing) immediately when there is an injury . A record review of the facility's investigation summary dated [DATE] and a follow up investigation dated [DATE] as reported to the State Agency revealed that on the morning of [DATE], Resident #5 complained of right leg pain to the nurse and her daughter via phone. The daughter called the nurse and requested an X-ray of her right leg at this time. The X-ray was completed, and the results came back in the early morning hours of [DATE]. The physician was notified of the results and gave an order for Resident #5 to be sent out for further examination. At approximately 4:37 PM on [DATE], the Registered Nurse (RN) Supervisor called the receiving facility to check on Resident #5 and was informed that she was being admitted with a fracture. The Administrator and Director of Nursing (DON) were notified at approximately 4:58 PM on [DATE], and a verbal report was made to the State Agency (SA). An investigation was initiated immediately. The interviews conducted included two (2) Certified Nursing Aides (CNAs) involved in transferring Resident #5 from the chair to the bed, the cart nurse, and the resident's roommate. The CNAs stated that upon attempting to transfer Resident #5 from the chair to the bed that afternoon, they connected the lift to the lift pad while she was in the chair. However, the lift battery was dead, rendering them unable to lift Resident #5 out of the chair. The nurse went to retrieve a new battery to re-attempt the transfer. While the nurse was fetching the battery, Resident #5 began sliding out of the chair. To prevent her from falling, one CNA reclined the back of the chair. Then one CNA grabbed the two handles at the top of the lift pad and the other grabbed the bottom two handles of the lift pad. Securing the lift pad at both top and bottom, they were able to slide Resident #5 from the chair to the bed safely. The CNA stated that they slid her over in her bed without incident. The sitter was in the room at the time of the transfer but was sitting on the other side in a chair next to the door with the curtain closed. The sitter stated she saw them lift her but then went back to watching her phone. When she heard the resident yell out, she looked up from her phone to check on the resident. She stated that the resident's knee was on the bed, but her foot was on the floor. A record review of the local hospital orthopedic Consult Orders, dated [DATE], revealed, .Subjective .right distal periprosthetic femur fracture .A Hoyer lift is used for transfers. Patient had a fall during the transfer and was found to have a right distal femur fracture. She was admitted to the hospitalist for her medical care orthopedics was consulted for fracture care. Objective: Right lower extremity: Moderate swelling about the fracture site . A record review of the Lift (Determination for Resident Lift/Transfer Assistance), dated [DATE], for Resident #5, revealed .A. Resident's Level of Assistance .Dependent - Resident requires more than 50 % assistance by staff, or is unpredictable in the amount of assistance offered .B. Can the Resident bear weight? . NO .C. Does the Resident have upper extremity strength to support his/her weight during the transfer .NO .G .1. Equipment used to transfer to and from .total lift . During an interview with Resident #5's daughter on [DATE] at 10:39 AM, she said she received a phone call from the sitter on [DATE] at approximately 8:02 AM, stating that her mother was moaning, groaning, and crying, and that her right knee was hurting. The sitter informed her that the staff transferred the resident on [DATE] at approximately 2:15 PM without using a Hoyer (type of mechanical lift). The daughter explained the sitter informed her that the nurse and the CNA attempted to transfer the resident via the Hoyer when the battery for the Hoyer failed. The nurse went to get another battery. The two CNAs transferred the resident by lifting the Hoyer pad manually. The daughter stated that the sitter heard a loud scream and looked over and noticed her mother's foot was on the floor. The daughter stated that she called the facility and asked for an X-ray. During an interview with the sitter on [DATE] at 10:50 AM, she stated on [DATE] at approximately 2:15 PM, she was sitting across the room with her chair facing the resident's bed. The sitter stated the roommate's privacy curtain was closed, but Resident #5 did not have a privacy curtain on her side. The sitter explained CNA #3 and LPN #3 were attempting to transfer Resident #5 via the Hoyer, however, the battery did not allow them to lift the resident. The nurse left to go and get another battery. CNA #4 entered the room along with the nurse and they attempted to use another battery, but that battery also did not work. CNA #4 stated, We can transfer the resident without using the Hoyer. LPN #3 replied, No, we're going to do the right thing. I know there's another battery around here. LPN #3 exited the room with the Hoyer lift. The sitter stated she was looking down at her phone when she heard Resident #5 scream. She looked up and noticed Resident #5's knee was on the bed and her foot was on the floor. The sitter asked CNA #3 and CNA #4 how the resident's foot got on the floor, but neither CNA responded. The nurse returned with a Hoyer lift and both CNAs informed her the resident was already transferred to the bed. The sitter stated that Resident #5 complained of her right knee hurting her at that time and she notified CNA #3. The sitter stated she left the facility at approximately 3:00 PM. During an interview on [DATE] at 10:20 AM with Licensed Practical Nurse (LPN #3), she said the incident occurred on [DATE] when CNA #3 asked for assistance with a lift for Resident #5. LPN #3 explained that the battery for the lift died and she left the room to get a battery. When she returned to the room, CNA #4 had entered the room and suggested they lift Resident #5 manually by the lift straps because the battery still did not work. LPN #3 insisted to both CNAs that they are going to do this right and she and CNA #3 unhooked the lift pad from the Hoyer lift. LPN #3 left the room with the Hoyer lift. LPN #3 explained that once she returned with a new Hoyer lift, both CNAs told her the resident was sliding and they manually transferred the resident to the bed. LPN #3 stated that she assessed the resident after CNA #3 informed her Resident #5 was moaning and pointing at her leg. The nurse said she did not know the resident screamed during the transfer because the CNAs did not tell her. The nurse admitted she did not investigate to see if anything occurred during the transfer and did not report it to the unit manager or DON. During an interview and observation on [DATE] at 10:50 AM, CNA #3 revealed Resident #5 was sitting in her wheelchair on a lift pad and she started to slide. Therefore, she and LPN #3 hooked all four straps of the lift pad to the mechanical lift, but the battery went out. After trying a different battery, she and LPN #3 unhooked the resident from the lift pad and the nurse went to get another lift. CNA #3 stated Resident #5 started to slide out of the wheelchair and she and CNA #4, manually lifted the resident from the chair to the bed. CNA #3 confirmed the resident screamed when they transferred her and admitted she did not tell the nurse the resident screamed because she moaned all the time. CNA #3 stated that she informed the nurse the resident complained of pain shortly after the transfer. CNA #3 and LPN #3 completed a demonstration of the incident, and CNA #3 explained Resident #5's lift pad straps should have stayed strapped onto the first Hoyer and a fresh battery should have been used. CNA #3 stated Resident #5 would not have slid out of the chair if the lift pad had been secured to the Hoyer and they should have waited for a new battery. An interview with CNA #4 on [DATE] at 11:20 AM, revealed she was asked by CNA #3 to assist her with transferring Resident #5 to her bed via Hoyer. CNA #4 stated that she was taking care of another resident, so LPN #3 was going to assist with the transfer. CNA #4 went to Resident #5's room when she finished and the nurse left the room to get a new battery, but it did not work. Therefore, LPN #3 removed the Hoyer lift from the resident's room to get another one. Resident #5 started to slide out of the wheelchair, so she tilted the wheelchair backward, but the resident continued to slide. CNA #4 stated they used the sling/lift pad to transfer the resident to the bed. CNA #4 stated she grabbed the top of the resident and CNA #3 transferred the resident's legs to the bed. CNA #4 confirmed she did not tell anybody the resident screamed during the transfer because she thought CNA #3 said something because it was her resident, and the resident frequently complained of pain when you touched her. CNA #4 confirmed the resident would not have slid out of the chair if the lift pad she was in had been connected to the Hoyer and they should have waited for a charged battery. During an interview with LPN #6 on [DATE] at 12:00 PM, she stated she was administering medication to Resident #5 on the morning of [DATE] when Resident #5 began crying, stating that her right knee hurt. LPN #6 said she looked at Resident #5's knee and did not see any swelling at that time. She called the Nurse Practitioner (NP) and received an order for an X-ray on [DATE] at 9:30 AM. LPN #6 stated she called the daughter and explained the resident was complaining of right knee pain and that the NP had ordered a mobile X-ray. LPN #6 revealed the X-ray team came later that afternoon, and the results came in during the morning hours the next day ([DATE]). In an interview with the DON on [DATE] at 11:00 AM, she stated that she did not know about the incident regarding Resident #5 being transferred without a mechanical lift until [DATE]. The DON stated the facility called her explaining Resident #5 had a femur fracture and she came to the facility to investigate the event. The DON said that she interviewed the sitter and was told the CNAs transferred the resident manually and that she had been looking down at her phone and heard the resident cry out and when she looked up and saw the resident's foot on the floor. The DON explained she was told the resident started sliding while sitting in her wheelchair and LPN #3 and CNA #4 attempted to transfer her via the Hoyer lift when the battery would not work. The DON stated LPN #3 also said she went to get a battery and when she returned, the CNAs had already transferred the resident to the bed. The DON explained that LPN#3 said she did not know the resident was in any distress. The DON stated she was unaware that the staff removed the lift pad straps from the mechanical lift and that LPN#3 removed the lift from the room to get another one. The DON also stated that she was not aware Resident #5 had screamed during the transfer until she was conducting the investigation. The DON explained LPN #3 and CNA #3 should have left the lift pad straps secured to the Hoyer lift until a charged battery was found. All the staff were trained on the no-lift policy, in which the staff are not allowed to manually lift residents who are required to be transferred with a mechanical lift. During an interview on [DATE] at 2:17 PM, the Administrator stated she was aware of the incident with Resident #5 and was told two (2) CNAs and an LPN were in the room with the resident when the battery in the Hoyer lift died . LPN #3 left the room and CNA #3 and CNA #4 manually transferred Resident #5 from the wheelchair to the bed because she was sliding. The CNAs told her that it would be easier to lift Resident #5 than to let her slide out of the chair onto the floor. The Administrator stated this facility has a no-lift policy, and everyone had been in-serviced A record review of the Admission Record revealed the facility admitted Resident #5 on [DATE] and she had current diagnoses including Age-related Osteoporosis, Hemiplegia, and Hemiparesis following Cerebral Infarction. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #5 had a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact.

Based on interviews, record review, and facility policy review, the facility failed to ensure pain management was provided to a resident who complained of pain after a manual transfer from her wheelchair to the bed and was subsequently diagnosed with a femoral fracture for one (1) of 23 residents reviewed for pain, Resident #5. Findings Include: A record review of the facility's policy Pain Assessment/Management revised 09/10, revealed, It is the policy of this facility to provide guidelines in the identification and treatment of the residents at risk of acute and chronic pain. Each resident's pain will be assessed in an approach designed to increase comfort and promote dignity through administering alternative interventions or medications .pain will be assessed and recorded on the medication administration record. The nurse will document the type of nonverbal or verbal pain the resident is experiencing when documenting the reason the medication is being given. The nurse will also document the intensity of the pain each time a PRN pain medication is given using the rating scale . A record review of the facility's investigation summary dated 7/6/24 and a follow up investigation dated 7/11/24 as reported to the State Agency revealed that on the morning of 7/3/24, Resident #5 complained of right leg pain to the nurse and her daughter via phone. The daughter called the nurse and requested an X-ray of her right leg at this time. The X-ray was completed, and the results came back in the early morning hours of 7/4/24. The physician was notified of the results and gave an order for Resident #5 to be sent out for further examination. At approximately 4:37 PM on 7/4/24, the Registered Nurse (RN) Supervisor called the receiving facility to check on Resident #5 and was informed that she was being admitted with a fracture. The CNAs stated that upon attempting to transfer Resident #5 from the chair to the bed on 7/2/24, they connected the lift to the lift pad while she was in the chair. However, the lift battery was dead, rendering them unable to lift Resident #5 out of the chair. The nurse went to retrieve a new battery to re-attempt the transfer. While the nurse was fetching the battery, Resident #5 began sliding out of the chair. To prevent her from falling, one CNA reclined the back of the chair. Then one CNA grabbed the two handles at the top of the lift pad and the other grabbed the bottom two handles of the lift pad. Securing the lift pad at both top and bottom, they were able to slide Resident #5 from the chair to the bed. When she heard the resident yell out, she looked up from her phone to check on the resident. She stated that the resident's knee was on the bed, but her foot was on the floor. A record review of the electronic Medication Administration Record (eMAR) for July 2024 revealed an order dated 09/08/20 for Tramadol 50 milligrams (mg) Give 1 tablet by mouth every six (6) hours as needed (PRN) for moderate or severe pain. There was no documentation Resident #5 received any pain medication on 7/2/24, the day the incident occurred. Resident #5 received a routine Duragesic patch for pain on 7/3/24, which was the day following the manual transfer incident in which Resident #5 had screamed out in pain. During an interview on 07/30/24 at 10:20 AM, with Licensed Practical Nurse (LPN) #3, she confirmed on 7/2/24 at approximately at 2:15 PM, Resident #5 was manually transferred from her wheelchair to her bed. Shortly after, CNA #3 reported that Resident #5 was complaining of pain. LPN #3 confirmed she failed to administer any pain medication to Resident #5 on 07/02/24 when she complained about pain. In an interview with the Director of Nursing (DON) on 08/01/24 at 11:00 AM, she confirmed the LPN#3 failed to follow the pain policy by not administering pain medication when Resident #5 complained of pain. During an interview on 08/01/24 at 2:17 PM, the Administrator confirmed that on 07/02/24, the facility did not follow the pain policy and should have medicated Resident #5 for pain. She expected the staff to follow the policy and procedures of the facility. A record review of the Admission Record revealed the facility admitted Resident #5 on 2/24/2023, and she had current diagnoses including Age-related Osteoporosis, Hemiplegia, and Hemiparesis following Cerebral Infarction. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 05/17/24 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact.

Based on record review, staff interviews and facility policy review, the facility failed to ensure a care plan was implemented to prevent a resident's access to a medication cart, when a resident, without supervision, opened an unlocked medication cart and drank Lactulose liquid for one (1) of nine (9) sampled residents. Resident #1 The facility's failure to implement care plan interventions placed this resident and other cognitively impaired residents at risk, in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 6/4/24, when Resident #1 opened an unlocked and unattended medication cart and took a bottle of Lactulose and drank from the bottle. The facility Administrator was notified of the IJ on 6/20/24 at 4:25 PM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 6/21/24, in which they alleged all corrective actions to remove the IJ were completed on 6/21/24 and the IJ removed on 6/22/24. The SA validated the Removal Plan on 6/24/24 and determined that the IJ was removed on 6/22/24, prior to exit. Therefore, the scope and severity for CFR 483.21 (b) (1) Comprehensive Care Plans was lowered to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's policy titled, Care Plans - Comprehensive, dated 10/2016, revealed, An individualized (person centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . Record review of the facility's policy titles, Following the Care Plan Policy, dated 1/2011, revealed, It is the Policy of this facility to follow a written and approved care plan for each resident. All employees will be trained upon hire and be required to follow the care plan . All employees will follow the written care plan that is developed in order to assure the residents needs are men. Record review of the Care Plan for Resident #1 with an initiation date of 3/14/22 revealed Focus: At risk for self-harm R/T (related to) removing edible and inedible items from med cart and placing in mouth Interventions: .Keep all medication carts locked and clean on top without any harmful items resting on top. Resident #1 also had a Care Plan created on 1/13/2020 Focus .Moderate cognitive impairment noted with impaired communication ability .Goal: Staff will supervise and cue resident if possible . Record review of the Incident Report dated 6/04/24, revealed Incident Description .At approximately 5:30 PM, resident opened cart and took a bottle of Lactulose and proceeded to drink from the bottle Estimated 60 cc (cubic centimeters) was drank .Immediate Action Taken: Took bottle away from resident .Contacted Poison Control .Contacted NP (Nurse Practitioner) . During an interview on 6/17/24 at 12:00 PM, Licensed Practical Nurse (LPN) #1 confirmed that she was assigned to the care of Resident #1 on 6/04/24 from 7:00 AM through 7:00 PM. She stated that she was aware of previous incidents when the resident accessed unsecured liquids, not intended for consumption and consumed them. The nurse confirmed she observed Resident #1 seated in his wheelchair next to the cart with a medication cart drawer open and an open bottle of Lactulose in his hand with the bottle up to his mouth. LPN #1 stated that she was not aware of care plan interventions for Resident #1 related to his cognitive impairment/impaired communication or risk for self-harm. During an interview on 6/18/24 at 1:18 PM, the Director of Nurses (DON) she stated that limited communication ability, wandering behaviors and cognitive limitations were risk factors for accidents for Resident #1, which were addressed in the resident's care plan. She stated that following care plans for all residents are very important and she expected nursing staff to follow all residents' care plans to meet the needs of each resident. During an interview on 6/18/24 at 3:35 PM, the Administrator revealed that she was made aware of the incident in which Resident #1 obtained medication from an unattended, unlocked medication cart by the DON on the morning of 6/05/24. She stated that she was familiar with Resident #1 and the resident's history of rummaging and drinking inappropriate substances. She stated that she considered following care plans for all residents very important. The Administrator stated that she expected the resident's individualized care plans to be followed and that it was important and that the purpose of having them was to provide instructions for care of each resident. During an interview on 6/20/24 at 3:10 PM, with the Minimum Data Set (MDS)/Nurse #2, she confirmed that the Care Plan for Resident #2 was updated on 6/12/24. She stated that she frequently updated care plans as needed and that it was very important for care plans and the resident care instructions in the Kardex of Point Click Care (PCC) software to be followed. She stated that all nurses had access to all resident care plans via PCC. She explained that the Kardex pulled information directly from the care plan and that all Certified Nurse Aides (CNAs) had access to the Kardex information detailing each resident's care needs. During an interview on 6/20/24 at 3:35 PM, with MDS Nurse #1, she confirmed that she updated the Care Plan for Resident #2 on 6/06/24 and on 6/12/24. She stated that she frequently updated care plans as needed and that it was very important for care plans and the resident care instructions in the Kardex of Point Click Care (PCC) software to be followed for the of care of each resident. The facility submitted the following acceptable Removal Plan on 6/21/24: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. The care plan is being followed for Resident #1. Resident #1 is having one on one supervision at all times which began on 6/20/24 at 5:00pm. A nurse was assigned to the dementia unit each shift for increased supervision for cognitively impaired residents who reside there. This additional nurse began on 6/20/24 at 11:00pm. Resident #1 has been assessed for injuries with no adverse effects noted. Resident Representative attempted to be notified by phone at time of incident with no success. Several phone attempts were followed up by facility with no success. Letter mailed to resident representative on 6/21/24 for notification of incident. The Director of Nursing (DON), Staff Development, Administrator and Registered Nurse (RN) Supervisors provided education to staff whom are directly involved in passing medication and responsible for medication carts which began on 6/20/24 at 5:30pm. An emphasis was placed on ensuring all carts in the facility are always locked when not in attendance. In-service also including following the care plan for Resident #1. In-service is ongoing and continues until all nurses are educated prior to working their shift. There is a designated nurse assigned to the dementia unit each shift to increase supervision of cognitively impaired residents. The extra nurse began working at 11:00pm on 6/20/24. The Director of Nursing (DON), Staff Development, Administrator and Registered Nurse (RN) Supervisors provided education on the one on one supervision on Resident #1 beginning on 6/20/24 at 5:00pm. This in-service is ongoing and will continue until all nursing staff have been in-serviced prior to working their scheduled shift. The Minimum Data Set (MDS) nurse updated the care plan and Kardex to reflect the need for one on one supervision on 6/21/24. Behavior monitoring has been ongoing with this resident but was updated on 6/21/24 to include the behavior of rummaging. The DON or Staff Development Nurse has assigned a staff member each shift to make rounds every 30 minutes to check that all carts in the facility are locked. These rounds began on 6/20/24 at 5:30pm. The Director of Nursing, Staff Development Nurse or Registered Nurse Supervisor are assigned to audit the one on one supervision sheets on a daily basis for compliance with one on one supervision of Resident #1 beginning on 6/21/24. AD HOC Quality Assurance (QA) meeting held on 6/21/24 at 9:00am to review plans for removal of Immediate Jeopardy (IJ) tag. The facility alleges that the immediacy has been removed as of 6/22/2024. Validation: The State Agency (SA) validation of the Removal Plan was made on-site during the Complaint Investigation CI #25376 through record review and interviews on 6/24/24. The SA determined that all corrective actions were completed on 6/21/24 and the IJ was removed on 6/22/24.

Based on observation, staff interviews, record review and facility policy review the facility failed to provide an environment free from accident/hazards and supervision, as evidenced by leaving a medication cart unlocked and unattended, allowing a resident to remove and ingest a medication from the cart for one (1) of nine (9) sampled residents. Resident #1 The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 6/4/24, when Resident #1 opened an unlocked and unattended medication cart and took a bottle of Lactulose and drank from the bottle. The facility's failure to ensure the resident was protected from accident/hazards placed this resident and other residents at risk and in a situation likely to cause serious injury, serious harm, serious impairment or death. The facility Administrator was notified of the IJ and SQC on 6/20/24 at 4:25 PM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 6/21/24, in which they alleged all corrective actions to remove the IJ were completed, and the IJ was removed on 6/22/24. The SA validated the Removal Plan on 6/24/24 and determined that the IJ was removed on 6/22/24, prior to exit. Therefore, the scope and severity for CFR 483.25(d)(2)-Accidents was lowered to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy titled, .Medication Storage in the Facility, revised January 2018, revealed, Medications and biologicals are stored safely, securely, and properly .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication .Procedures: .B . Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access . Record review of the Incident Report dated 6/04/24, revealed Incident Description: .At approximately 5:30 PM, resident opened cart and took a bottle of Lactulose and proceeded to drink from the bottle Estimated 60 cc (cubic centimeters) was drank .Immediate Action Taken: Took bottle away from resident .Contacted Poison Control .Contacted NP (Nurse Practitioner) . On 6/17/24 at 12:00 PM, an interview with LPN #1 revealed that she was familiar with Resident #1 and his care. She confirmed that she was assigned to the care of Resident #1 on 6/04/24 from 7:00 AM through 7:00 PM. She stated that she was aware of previous incidents when the resident accessed unsecured liquids not intended for consumption and consumed them. She stated that drugs or other therapeutic agents should be stored in the secure medication rooms or medication carts, which should be always locked. LPN #1 stated that Resident #1's risk factors for accidents included his behaviors of getting into carts and drinking anything he can get a hold of. LPN #1 stated that at approximately 5:30 PM, she was standing at her med cart cleaning it and stepped into the medication room and didn't realize the push-in locking mechanism on the medication cart had not engaged. She stated that upon exiting the medication room she observed Resident #1 seated in his wheelchair next to the cart with a medication cart drawer open and an open bottle of Lactulose in his hand with the bottle up to his mouth. She stated she immediately retrieved the bottle from the resident. She stated the cause of the incident was that she accidentally left the medication cart unlocked and unattended. On 6/18/24 at 1:18 PM, an interview with the Director of Nurses (DON) revealed that she became aware of the 6/04/24 incident, involving Resident #1, on 6/04/24 at approximately 6:05 PM, when she was notified by telephone by LPN #1. She said LPN #1 told her that she had gone to the medication room and upon exiting the medication room, she observed Resident #1 with a bottle of lactulose up to his lips. The DON stated she instructed LPN #1 to contact poison control, the primary healthcare provider Nurse Practitioner (NP) #1 and the resident's Resident Representative (RR) and to monitor the resident. She stated that limited communication ability, wandering behaviors and cognitive limitations were risk factors for accidents for Resident #1. She stated that the cause of the incident was the resident's mentality. She stated that following the incident, Certified Nurse Aides (CNAs) and nurses did hourly rounds to monitor and assess the resident for seventy-two (72) hours and focused on ensuring the resident displayed no adverse reactions including nausea or diarrhea. On 6/18/24 at 3:35 PM, an interview with the Administrator revealed that she was made aware of the incident in which Resident #1 obtained medication from an unattended, unlocked medication cart by the Director of Nurses (DON) on 6/05/24. She stated that medications carts should be kept locked when unattended to provide safety for all residents. She stated that she was familiar with Resident #1 and the resident's history of rummaging and drinking inappropriate substances. On 6/20/24 at 12:05 PM, during an observation and interview with LPN #2 of the medication cart for the 800 Hall revealed that the drawer where the bottles of Lactulose were stored also contained bottles of liquid Valproic Acid, Colace, Iron Supplement, and Tussin Cough Syrup. Additionally, the drawer contained boxes of Zofran, Fosamax, Immodium and Tylenol tablets. All liquid medications in the drawer had child resistant screw on lids, including the Lactulose containers. She stated that she was familiar with Resident #1 and his care and that he was independent with mobility and able to propel his wheelchair throughout the facility, without assistance, using his legs. She stated that Resident #1 had behaviors of wandering and taking items from carts and drinking them or putting them into his mouth. She stated that Resident #1 required supervision and redirection when he was up in his wheelchair to ensure he did not get anything that he should not put into his mouth. LPN #2 stated that medication carts should always be locked and should never be left unattended for the safety of all residents. On 6/26/24 at 11:30 AM, the facility Medical Director returned a telephone call post exit from the facility. During the telephone interview, he stated that he had been made aware of the 6/04/24 incident involving Resident #1. The Medical Director stated that it was an unfortunate incident that should not have happened. He stated that he was not overly concerned about the resident's consumption of Lactulose, a laxative. He stated that he had continued to follow the care of Resident #1 following the incident and that the resident had no adverse effects. The Medical Director stated that concerns related to the incident included that Resident #1 had gained access to other significant medications, as well as the Lactulose. Record review of the Admission Record for Resident #1 revealed the facility admitted the resident on 6/24/05. The resident had diagnoses that included Dementia with Behavioral Disturbance, Impulse Disorder, Psychotic Disorder with Hallucinations due to Known Physiological Condition, and Personal History of Traumatic Brain Injury (TBI). Record review of the Quarterly Minimum Data Set (MDS), with Assessment Reference Date of 4/12/24, for Resident #1 revealed the resident had no Brief Interview for Mental Status (BIMS) score, as the interview was not conducted. Section C was coded to indicate that the resident is rarely/never understood, therefore the BIMS should not be conducted. Further review of the MDS documented that the resident had a memory problem and modified independence with cognitive skills for daily decision making. Review of the MDS also revealed that Resident #1 used a wheelchair and required no assistance for mobility. The facility submitted the following acceptable Removal Plan on 6/21/24: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. The care plan is being followed for Resident #1. Resident #1 is having one on one supervision at all times which began on 6/20/24 at 5:00pm. A nurse was assigned to the dementia unit each shift for increased supervision for cognitively impaired residents who reside there. This additional nurse began on 6/20/24 at 11:00pm. Resident #1 has been assessed for injuries with no adverse effects noted. Resident Representative attempted to be notified by phone at time of incident with no success. Several phone attempts were followed up by facility with no success. Letter mailed to resident representative on 6/21/24 for notification of incident. The Director of Nursing (DON), Staff Development, Administrator and Registered Nurse (RN) Supervisors provided education to staff whom are directly involved in passing medication and responsible for medication carts which began on 6/20/24 at 5:30pm. An emphasis was placed on ensuring all carts in the facility are always locked when not in attendance. In-service also including following the care plan for Resident #1. In-service is ongoing and continues until all nurses are educated prior to working their shift. There is a designated nurse assigned to the dementia unit each shift to increase supervision of cognitively impaired residents. The extra nurse began working at 11:00pm on 6/20/24. The Director of Nursing (DON), Staff Development, Administrator and Registered Nurse (RN) Supervisors provided education on the one on one supervision on Resident #1 beginning on 6/20/24 at 5:00pm. This in-service is ongoing and will continue until all nursing staff have been in-serviced prior to working their scheduled shift. The Minimum Data Set (MDS) nurse updated the care plan and Kardex to reflect the need for one on one supervision on 6/21/24. Behavior monitoring has been ongoing with this resident but was updated on 6/21/24 to include the behavior of rummaging. The DON or Staff Development Nurse has assigned a staff member each shift to make rounds every 30 minutes to check that all carts in the facility are locked. These rounds began on 6/20/24 at 5:30pm. The Director of Nursing, Staff Development Nurse or Registered Nurse Supervisor are assigned to audit the one on one supervision sheets on a daily basis for compliance with one on one supervision of Resident #1 beginning on 6/21/24. AD HOC Quality Assurance (QA) meeting held on 6/21/24 at 9:00am to review plans for removal of Immediate Jeopardy (IJ) tag. The facility alleges that the immediacy has been removed as of 6/22/2024. Validation: The State Agency (SA) validation of the Removal Plan was made on-site during the Complaint Investigation (CI) MS #25376 through record review and interviews on 6/24/24. The SA determined that all corrective actions were completed on 6/21/24 and the IJ was removed on 6/22/24.

Based on interviews, record review, and facility policy review, the facility failed to timely manage and treat complaints of pain for two (2) of four (4) sampled residents, when the unit the residents resided on did not have a licensed nurse to assess, monitor, or treat complaints of pain from approximately 7:00 PM on 3/22/24 until approximately 1:47 AM on 3/23/24. Residents #2 and #4 Findings Include: Record review of the facility policy titled, Pain Assessment/Management, revised 9/10, revealed, It is the policy of this facility to provide guidelines in the identification and treatment of residents at risk for acute and chronic pain. Each residents pain will be assessed in an approach designed to increase comfort and promote dignity through administering alternative interventions or medications .Staff members providing direct care .will use an interdisciplinary approach observing pain symptoms in the resident and report it to the nurse. If possible, the nurse will discuss with the resident the severity and quality of pain using the pain reference scale. This will be documented on the pain assessment. When a resident demonstrates pain, whether verbally or non-verbally, the nurse is to administer pain med per PRN (as needed) orders . Resident #2 On 4/01/24 at 4:30 PM, an interview with Resident #2 revealed the resident reported that there was not a licensed nurse on the 500 Hall from 7:00 PM on Friday, 3/22/24 until between 1:00 AM and 2:00 AM on Saturday, 3/23/24. Resident #2 stated that she reported all over body pain, which she rated nine (9) on a 0-10 pain scale, to her Certified Nurse Aide (CNA). The resident explained that the CNA told her that there was not a nurse to give her any medicine. The resident stated that she had not been able to go to sleep until she received her medication later that night. Record review of the Order Summary Report, with active orders as of 3/1/24 for Resident #2, revealed a physician order for Norco Tablet 7.5-325 MG (milligrams) (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours for pain as needed for Moderate Pain, with an order date of 12/02/21. There was also an order, dated 1/26/21 to Evaluate pain per pain scale (0-10) every shift PRN. If pain is present document interventions and follow up on effects. Notify MD (Medical Doctor) of persistent pain unrelieved by intervention, every shift. Record review of the Admission Record for Resident #2 revealed the facility admitted the resident on 1/26/21, with diagnoses that included Type 2 diabetes and Peripheral autonomic neuropathy. Record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 3/19/24, for Resident #2, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #4 On 4/03/24 at 11:30 AM, an interview with Resident #4 revealed the resident recalled having had surgery and having surgical related pain on the evening of 3/22/24, that was untreated for several hours. The resident recalled she had been told by the CNA that there was no nurse on their unit to give her any pain medication. The resident stated she was still real sore at the surgical site and rated her pain on the evening of 3/22/24, as 5 to 6 on a 0-10 pain scale. Record review of the Order Summary Report, with active orders as of 3/1/24 for Resident #4, revealed physician orders dated 2/2/24, Evaluate Pain Per Pain Scale (0-10) every shift and as needed and if pain is present document interventions and follow up on effects. Notify MD (Medical Doctor) of persistent pain unrelieved by intervention, every shift, Acetaminophen Oral Tablet 500 MG, give 2 tablets by mouth every 6 hours PRN, Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG, give 2 tablets by mouth every 6 hours PRN, and Tramadol HCL (hydrochloride) Oral Tablet 50 MG, give 1 tablet by mouth every 6 hours PRN. Record review of the Admission Record for Resident #4 revealed that the facility admitted the resident on 2/2/24, with diagnoses that included Encounter for orthopedic aftercare following surgical amputation and Peripheral vascular disease. Record review of the 5 Day MDS with ARD of 2/09/24, for Resident #4, revealed the resident had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. On 4/01/24 at 6:40 PM, an interview with Registered Nurse (RN)#1 revealed that she worked at the facility as the RN Supervisor for the 3:00 PM to 11:00 PM (3-11) shift and that she was responsible for the entire building. RN #1 confirmed that she did not go on the 500 Hall the entire time she was on duty on the evening of 3/22/24. She stated that Licensed Practical Nurse (LPN) #1 counted the narcotics and took the cart for outgoing LPN #2 and that LPN #1 did not request assistance during the shift. On 4/01/24 at 7:00 PM, an interview with LPN #1 revealed that she counted the narcotics with LPN #2 at approximately 6:50 PM on 3/22/24 because she was under the impression that the Float Nurse was coming in to take care of and administer medications to the residents on the 500 Hall. LPN #1 reported that she had been busy with her assigned residents on the 600 and 800 Halls and did not go on the 500 Hall during her shift until LPN #3 arrived at approximately 1:47 AM on 3/23/24. LPN #1 said that at 1:47 AM she and LPN #3 counted the narcotics for the 500 Hall medication cart and LPN #3 assumed responsibility for the residents on 500 Hall. LPN #1 confirmed that she did not provide any supervision or monitoring, including pain monitoring or administration of any medications, for the residents on the 500 Hall. She explained she felt the situation occurred because LPN #4 called-in, the Float Nurse did not show up, the RN Supervisor did not assume responsibility for the 500 Hall, and the On-Call Nurse did not answer calls from the facility. LPN #1 stated that she notified RN #1 at or around 8:00 PM on 3/22/24, that there was no nurse on the 500 Hall. On 4/02/24 at 2:15 PM, an interview with LPN #3, revealed that he was made aware that there was no nurse on the 500 Hall after 7:00 PM on 3/22/24, sometime after midnight on the morning of 3/23/24. He stated he reported to the facility at 1:47 AM, completed a narcotic count with LPN #1 and administered medications to the residents on the 500 Hall. He stated that he was concerned about the report of no nurse on the 500 Hall because Resident #2 can't go to bed without her bedtime medicine. He stated that he had contacted the Nurse Practitioner (NP) and notified her of the delay in delivery of services, with no new orders noted. LPN #3 confirmed that Resident #2 was awake when he reported to work at 1:47 AM. On 4/02/24 at 4:00 PM, during a telephone interview with the NP for Residents #2 and #4, she stated that she expected the physician orders to be followed to provide for each resident's needs. She stated that failure to receive pain assessments and pain medication as prescribed could result in prolonged pain and discomfort and said, I don't want any of my patients to be in pain, that's why I write orders for pain management and said she felt that failure to assess residents for pain and failure to administer prescribed pain management medications was unacceptable. On 4/02/24 at 4:10 PM, a follow-up interview with RN #1 revealed that she stated that she was shocked that a resident could report pain or the need for medication to a CNA that was not communicated to a licensed nurse. She stated that the CNAs should not have told residents that there were no nurses to give them medications or assess them for pain management needs. She stated that the CNAs should have reported resident needs to a nurse and denied having any such requests reported to her on the evening of 3/22/24. On 4/02/24 at 4:20 PM, during an interview CNA #1 confirmed that on 3/22/24 she had worked the 3PM-11PM shift and was assigned to rooms 507-B through 511. CNA #1 reported that no licensed nurse came on to the 500 Hall after 7:00 PM. She stated that Resident #4 reported pain and requested pain medication and I told her the nurse wasn't there yet. I told (LPN #1) and she said she would let the nurse know when they got there. CNA #1 confirmed that LPN #1 did not assess Resident #4 for pain or come to the 500 Hall. On 4/02/24 at 4:30 PM, during an interview CNA #3 reported that she had worked from 3PM-11PM at the facility on 3/22/24 and was assigned to rooms 512 through 520. CNA #3 confirmed that no nurse came to the 500 Hall after 7:00 PM. CNA #3 stated that Resident #2 and other residents requested their medications and she had told them that their nurse had not made it yet. CNA #3 revealed that she had not notified any licensed nurse of the resident's requests. CNA #3 confirmed that some of her assigned residents were still awake when she left the facility at 11:00 PM. On 4/03/24 at 12:11 PM, during an interview the Director of Nurses (DON) confirmed that the facility utilized the (0-10) Pain Scale for pain assessment of residents and that nurses are encouraged to anticipate pain management needs of residents. The DON confirmed that pain interventions were not utilized from 7:00 PM on 3/22/24 through approximately 1:47 AM on 3/23/24, due to a break in staff communication. The DON further confirmed the facility did not have a licensed nurse on the 500 Hall during this time, to monitor and administer medications to the residents on the 500 Hall for approximately six (6) hours and 45 minutes. 7:00 PM on 3/22/24, until approximately 1:47 AM. The DON stated that LPN #1 should have been made aware of resident complaints of pain and requests for medications, as LPN #1 had the keys to the 500 Hall medication cart. She stated that she expected that residents' physician orders to be followed. On 4/03/24 at 1:15 PM, an interview with the Administrator revealed the Administrator was unaware of the staffing issue that occurred on 3/22/24, until inquiries were made regarding the incident by the State Agency on 4/01/24. Record review of the facility MEDICATION PASS TIMES dated 12/01/23, revealed the facility defined scheduled medication administration times for physician orders for HS (bedtime) as 8:00 PM.

Based on interviews, record review and facility policy review, the facility failed to revise a comprehensive care plan regarding interventions to prevent a dependent resident from falling for one (1) of three (3) residents reviewed for falls. Resident #98. Findings include: Review of the facility's policy, titled Care Plans-Comprehensive, dated 10/2016 revealed, An individualized (person centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; b. When desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly . Record review of the Fall Assessment for Resident #98, dated 04/06/23, revealed the resident scored an 18. The score indicated Resident #98 was High Risk for Falls. Record review of the Care Plan for Resident #98 revealed, Total care required with ADL's (Activities of Daily Living) R/T(related to) HX (History) of CVA's (Cerbrovascular Accidents) with hemiplegia of the left non dominant side, date initiated 04/06/23 . Interventions: Requires 1 person total assistance with personal hygiene . Requires 2 person total assistance with bathing . Requires total assistance x(times) 2 (two)staff member for dressing . Total assistance with bed mobility 2 persons assistance . These interventions were initiated after Resident #98's fall. Record review of the Care Plan Resident is at risk for falls and falls related injuries r/t (related to) weakness . initiated 4/6/23 and revised 4/22/23 . The care plan did not have interventions in place to address the number of staff needed to provide incontinent care or bed mobility safely. During an interview on 07/27/23 at 2:00 PM, with Licensed Practical Nurse (LPN) # 6, she revealed she was responsible for completing the residents fall assessment on 4/6/23. LPN #6 confirmed Resident #98's score revealed the resident was High Risk for Falls. LPN #6 also confirmed Resident #98's care plan should have been revised when the significant change Minimum Data Set (MDS) was completed on dated 4/6/23. The LPN explained Resident #98 was also placed on Hospice due to a decline in her health. LPN #6 confirmed Resident #6 was totally dependent on staff and needed two (2) persons assist while providing incontinent care and bed mobility because the resident was a high risk for falls. The LPN also confirmed Resident #98's care plan should have been revised prior to the fall. During a telephone interview on 7/27/23 at 3:00 PM, with the Director of Nursing (DON), she explained she thought Resident #98's care plan said she was a one (1) to two (2) persons assist. The DON said she didn't have access to Resident #98's records at this time and is unable to make a comment. During an interview with the Administrator on 7/27/23 at 3:15 PM, he confirmed Resident #98 was a totally dependent resident and needs two persons to assist. The Administrator said he didn't know why the residents care plan did not address how many staff it takes to safely provide care.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide care in a manner to protect vulnerable residents from falls resulting in injury for one (1) of three (3) residents reviewed for falls. Resident #98 Findings include: Review of the facility's policy, Fall Risk Documentation Policy and Procedure, revised 5/2005 revealed, It is the policy of this facility to evaluate and provide least restrictive intervention when a resident is a risk for falls. Upon Admission, Quarterly, and as needed the Fall Risk documentation form will be completed for each resident. The resident will be scored in eight (8) areas. A total score of these areas will determine at what level of risk the resident is. A score of 10 or greater will place the resident in the High-Risk category. Prevention protocol will be initiated immediately and documented on the care plan. Review of the facility's protocol, Protocol for Residents Who Are at Risk for Falls, revised 5/2001 revealed, 1. Residents identified as being at high risk for fall shall be place on the fall prevention program list. This list should be at each nurse's station where it is easily accessible by all staff. The Director of Nursing (DON) should also keep an updated list. 2. Resident identified as high risk for falls shall be addressed on their ADL's (Activities of Daily Living). All staff should know the designation utilized by the facility through in-service an education. 3. Residents shall be assessed at a minimum for the following: mental status, history of fall, continence, vision, gait/balance, blood pressure, medications, predisposing disease, footwear, and environment. 4. Residents shall be screened by therapy. 5. Care plan shall include all specific interventions appropriate to resident and this information should be accessible to all staff. 6. The nurse's notes shall reflect all steps taken in the assessment process as well as the interventions to prevent falls. 7. Residents shall remain in the Fall Prevention Program until the Fall Risk Assessment no longer indicated high risk or the interdisciplinary care plan team determines that the resident is no longer at risk. 8. If a fall occurs with a resident who has been identified as High Risk, the cause of the fall should be investigated and then referral made to the Fall Management Committee by the criteria in the Fall Management Protocol. Review of the Fall Risk Assessment, with the effective date of 5/13/2023, revealed the resident scored an 18, which placed the resident in the High-Risk category for falls. During an interview on 07/25/23 at 10:11 AM, with Resident #98's daughter, she verbalized concern about her mother falling out of the bed. The resident's daughter said her mother does not move. She doesn't understand how she could have fallen out of the bed. The daughter said the resident was sent to the local hospital and was assessed. Review of Resident #98's, Progress Notes dated 05/23/23 at 10:20 PM, revealed the nurse returned to unit and was informed by another nurse that while Certified Nurse Aide (CNA) #4 was providing peri care to Resident #98, while the CNA turned the resident over in the bed, she reached for the wipes and the resident's top leg slid, causing her to slide out of the bed. The CNA reported that she witnessed that the resident's head bumped the side rail while she was being turned over, and she guided the resident to the floor. The CNA stated that the resident did not hit her head on the ground. It was further documented the resident was assessed and edema was noted to the face, a small laceration was noted above the left eye and a small laceration with a scant amount of blood was noted at the nasal area under the left eye. The Nurse Practitioner (NP) was notified, and an order was received to transfer the resident to the emergency room (ER) at a local hospital for evaluation. On 07/27/23 at 1:00 PM, during a telephone interview with the Director of Nursing (DON), she revealed she was responsible for conducting the investigation of Resident #98's fall. The DON said CNA #4 was providing peri care and as she turned Resident #98 over in the bed, and reached for the wipes, the residents top leg slid, causing her to slide out of the bed to the floor. Reportedly, Resident #98 bumped her head on the side rail. CNA #4 stated she guided the resident to the floor and denied that the resident hit her head on the floor. Resident #98 was noted with edema to face, a small laceration above the left eye and a small laceration, with a scant amount of blood to the nasal area under the left eye. The NP was notified, and an order was received to transfer to the local ER for evaluation. The DON explained prior to the fall, the resident was a one (1) to two (2) persons assist with bed mobility. During an interview on 07/27/23 at 2:00 PM, with Licensed Practical Nurse (LPN) # 6, she revealed she was responsible for completing the fall assessment for Resident #98 on 4/6/23. LPN #6 confirmed the resident's score revealed the resident was High Risk for falls. LPN #6 also confirmed the resident was totally dependent on staff and needed two (2) persons assist while providing peri care and bed mobility because the resident was a high risk for falls. On 7/27/23 at 2:30 PM, during an interview with CNA #4, she confirmed she was providing peri care to Resident #98. CNA #4 said she turned the resident over away from her. The CNA reported that Resident #98 was stiff and slid out of the bed to the floor. CNA #4 also said she was unable to catch the resident because she was on the opposite side of the bed. CNA #4 revealed she thinks the resident hit her head on the bed rail because of the laceration on her nose and her left eye. The CNA said the resident did not hit her head on the floor because she went down feet first. CNA #4 reported the only time they use two (2) CNAs to provide care is with transfers. However, CNA #4 revealed Resident #98 should have two (2) people to provide care because the resident needs total care and is unable to assist. CNA #4 also said the resident has a mattress that is slippery and probably that caused the resident to slide out of the bed. During an interview on 7/27/23 at 3:00 PM, with the Administrator, he confirmed Resident #98 had a fall on May 23, 2023, and needs total assistance with Activities of Daily Living (ADL's). The facility admitted Resident #98 on 12/16/2022, per the Admission Record with the diagnoses that included Osteomyelitis, Muscle Weakness, and Osteoarthritis. The Significant Change Minimum Data Set (MDS), with the Assessment Reference Date (ARD) of 04/06/23, revealed Resident #98's cognition is severely impaired. Section G revealed Resident #98 was totally dependent with one person assist for bed mobility. 47873