Every finding on record at Evergreen Woods

Based on observations, review of facility policy, and interviews, the facility failed to prepare and serve food in a sanitary manner due to the lack of a hair restraint. The findings include: Observation in the kitchen on 8/29/25 at 9:30 AM with the Executive Chef, identified Dietary Aide #1 preparing cold sandwiches for lunch service later that day without the benefit of wearing a beard restraint. Interview with Dietary Aide #1 on 8/29/25 at 9:30 AM identified he was unsure if the facility had beard restraints for staff with facial hair but was pretty sure they didn't. Additionally, Dietary Aide #1 was unaware of the requirement to wear a beard restraint during food preparation and service.Interview with the Executive Chef on 8/29/25 at 9:40 AM identified she was unaware of the staff's requirement to wear beard nets for food preparation and service. The Executive Chef indicated that she believed she did have beard restraints available for staff, but if not, she would order them immediately. Review of the facility's Food Preparation and Service policy of Food Service/Distribution identified that Food and nutrition services staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.

Based on interviews, review of clinical records, facility documentation, and facility policy for 1 of 2 sampled residents, (Resident #51) reviewed for abuse, the facility staff failed to ensure treatment in a dignified manner. The findings include:Resident #51's diagnoses included acute systolic (congestive) heart failure, impingement syndrome and pain of the right shoulder, and venous stasis dermatitis with blistering.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #51 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, required partial/moderate assistance for toileting hygiene, and supervision or touching assistance for transfers.The Resident Care Plan (RCP) dated 8/28/2025 identified Activities of Daily Living (ADL) self-care deficits related to impaired mobility. Interventions included providing encouragement/supervision and allow adequate time to complete tasks.Interview with Resident #51 on 8/29/2025 at 11:03 AM identified that sometime between 11:00 PM on 8/28/2025 and 1:00 AM on 8/29/2025 he/she rang the call bell to ask for assistance with toileting. The resident indicated that the bathroom floor may have been wet making him/her afraid of falling, so he/she requested Nurse Aid (NA) #1 check the floor prior to going. NA #1 responded with I am not maintenance; it is not my job. NA #1 further stated, your aide is on break, (NA #3) they will be back in an hour, smiled, and left the room. Resident #51 indicated this agitated and upset him/her. Resident #51 identified that NA #3 came and assisted him/her 10 minutes later. Resident #51 indicated it had been his/her intention to notify the Director of Nursing (DNS), but this was the first time he/she was reporting the incident to anyone. Review of Resident #51's NA care card (how to provide care) identified he/she required the assistance of 1 staff for mobility and ADLs. Interview with NA #1 on 9/3/2025 at 6:24 AM identified she worked on 8/28/2025 from 11:00 PM to 8/29/2025 at 7:00 AM and although Resident #51 was not on her assignment, she answered the resident's call light, as NA #3 was on break. NA #1 identified that Resident #51 asked to go to the bathroom and asked if she could see if the floor was clean. NA #1 stated the bathroom appeared clean, but she told the resident that if he/she thought it wasn't clean then he/she should call maintenance. NA #1 stated that Resident #51 was aggravated with her for saying that, so she left the room without providing any assistance to allow the resident to calm down. After informing Resident #51's assigned aide, NA #3, they both went to assist the resident. On arrival Resident #51 told NA #1 to get out of the room. NA #1 stated she went back to the room about 30 minutes later to apologize and stated that I didn't mean to treat someone like that. NA #1 appeared to become upset during the surveyor interview, left the interview, and the facility. Interview on 9/3/2025 at 7:07 AM with Licensed Practical Nurse (LPN) #1 identified she, was made aware by NA #2 on 8/29/25 of an incident that occurred on the night shift the previous night which began on 8/28/25 (see F600). NA #2 had not worked on 8/28/25 but was told by Resident #51 on 8/29/25 about an incident with NA #1 during which he/she had requested NA #1 check the bathroom floor for wetness and take him/her to the bathroom. NA #2 indicated Resident #51 went on to state NA #1 replied it was not her job to check the floor, she could not help him/her out of bed due to his/her size, she would call NA #3 to assist and then turned and left the room. Following notification, both she and the Nurse Supervisor, Registered Nurse (RN) #2 immediately went to speak to the resident. Resident #51 stated he/she informed NA #1 of the need to use the bathroom, requested the floor be checked, and that she responded it was not her job to check the floor, she could not help him/her out of bed due to his/her size, she would call NA #3 to assist, and then turned and left the room. Resident #51 indicated he/she felt embarrassed and hurt by what NA #1 had said. LPN #1 stated that if she had been aware of the incident when it happened the previous night she worked (8/28/2025), she would have immediately reported the incident to the nurse supervisor. Interview with NA #2 on 9/3/2025 at 7:53 AM identified Resident #51 described an incident that had occurred on the night shift the previous night which began on 8/28/25 into 8/29/25 when he/she had asked NA #1 for help going to the bathroom and how NA #1 had told him/her that he/she was too heavy, looked out the door and said look, there goes your aide and nurse on break. They can't help you and walked away with a smile on her face. NA #2 identified that after leaving the Resident #51's room, she immediately notified LPN #1 and RN #2 about Resident #51's bathroom encounter with NA #1, and both nurses went to speak with the resident.Interview with DNS on 9/3/2025 at 9:43 AM identified RN #3 made him aware, on 9/1/25, of NA #1's statements regarding toileting that occurred on the night shift beginning on 8/28/2025 into 8/29/25 the morning of 9/1/2025. Interview with RN #3 on 9/3/2025 at 10:00 AM identified she worked during the day shift on 8/29/25. When she went to provide care, Resident #51 made her aware of his/her request for assistance with help to the bathroom. Resident #51 stated NA #1 did not want to help him, his/her assigned aide was on break, and he/she didn't want to get anyone in trouble. RN #3 reported the incident to the DNS on 8/29/2025 during the day (not on 9/1/25 as described by the DNS) but was unsure of the time, and although she knew she should have, she failed to document the incident in the clinical record. Interview with the DNS on 9/3/2025 at 9:43 AM identified he was made aware of Resident #51's treatment of requesting the bathroom on 9/1/25. Interview with the Administrator on 9/3/2025 at 10:24 AM identified that she was never made aware the bathroom incident until interviewed by the surveyor. Interview with NA #3 on 9/3/2025 at 2:10 PM identified that she worked during the night shift on 8/28/2025 from 11:00 PM to 8/29/25 at 7:00 AM. NA #3 identified that she was on break when Resident #51 had an incident with NA #1. NA #3 stated NA #1 had come to the staff break room, sometime towards the end of her break between 3:00 AM to 4:00 AM and told her that she had residents waiting for her help. NA #3 stated that she immediately went to assist Resident #51 and that was when the resident informed her that he/she requested NA #1 was asked to check and take him/her to the bathroom. Resident #51 stated to her that NA #1 refused to check the bathroom and replied to him/her I'm not maintenance. You will have to wait for your aide, and that will be in the next hour or so NA #1 then stopped in the doorway and she smirked at me. NA #3 indicated by the time she arrived at Resident #51's room, the resident indicated he/she had taken a chance and used the bathroom alone because he/she did not want to risk having NA #1 back in the room. Review of the Resident Rights policy dated 2021, in part, identified that the resident has the right to a dignified existence and to be treated with respect, kindness, and dignity.

Based on review of the clinical record, facility documentation, policy, and interviews for 1 of 2 sampled residents, (Resident #51) reviewed for abuse, the facility failed to report an allegation of abuse to the State Agency (SA) within the required time frame. The findings include:Resident #51's diagnoses included acute systolic (congestive) heart failure, impingement syndrome of the right shoulder, pain in the right shoulder, and venous stasis dermatitis with blistering.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #51 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, required partial/moderate assistance for toileting hygiene, and supervision or touching assistance for transfers.The Resident Care Plan (RCP) dated 8/28/2025 identified Resident #51 was at risk for pain related to impaired mobility. Interventions included to manage or reduce side effects associated with pharmacological therapy, such as promoting adequate bowel and bladder function. Additionally, the RCP identified Activities of Daily Living (ADL) self-care deficits related to impaired mobility. Interventions included provide encouragement/supervision and allow adequate time to complete tasks.Interview with NA #2 on 9/3/2025 at 7:53 AM identified an incident with NA #1 occurring on 8/29/2025 into 8/30/2025 at approximately 11:45 PM. Resident #51 was sitting on the side of the bed, legs dangling, and she and NA #1 were assisting him/her to lie down. Resident #51 had open wounds on his/her lower legs covered by bandages. NA #1 grabbed the resident's bandaged legs and pulled upward in a rough/forceful manner. Resident #51 began screaming that NA #1 was hurting him/her and for her to stop. She indicated that NA #1 replied that you are a pretty big guy and make my back hurt. Resident #51 responded I can't help that; I need the help. NA #2 stated that NA #1 did not stop moving Resident #51's legs or remove her hands, despite being screamed at, until Resident #51's legs were fully placed on the mattress. Wanting to get Resident #51 centered on the bed, she asked NA #1 to help boost the resident up with her, but NA #1 grabbed Resident #51 by both upper arms/shoulders and pushed him/her to the middle of the bed. Resident #51 again began screaming stating please don't touch me, what is wrong with you, you are hurting me again. NA #2 stated that she told NA #1 to let go of the resident, due to his/her response and that Resident #51 told NA #1 not to touch him/her anymore. NA #1 then left the room. Resident #51 told NA #2 that he/she didn't want NA #1 to care for him/her anymore because she was rough with care. Resident #51 stated that NA #1 was always complaining about his/her weight and consistently spoke rudely. In addition, NA #2 identified that after leaving Resident #51's room, she immediately notified LPN #1 and RN #2 and both LPN #1 and RN #2 left to speak with Resident #51.An interview with LPN #1 on 9/3/25 at 8:12 AM indicated NA #2 made her aware on 8/29/25 into 8/30/25, that she witnessed Resident #51 receive rough treatment by NA #1 as well as another incident that occurred on the previous night 8/28/25 into 8/29/25 (see F550). Additionally, LPN #1 indicated NA #2 reported to her in the presence of Registered Nurse (RN) #2 that Resident #51 was screaming from pain due to the rough care he/she received by NA #1 during a transfer. NA #2 stated that NA #1 had grabbed the resident by his/her legs and shoulders in a rough manner. On interviewing Resident #51 LPN#1 identified that Resident #51 stated he/she was uncomfortable with NA #1 performing care. LPN #1 identified that she and RN #2 determined NA #1 would not provide care to Resident #51 going forward and that the DNS would be notified of the mistreatment. Additionally, LPN #1 identified that she failed to document the incident in Resident #51 electronic health record.Interview with RN #2 (nurse supervisor) on 9/3/2025 at 9:19 AM identified she was made aware of the 8/29/2025 incident by NA #2 during the night shift on 8/29/25 to 8/30/25. NA #2 indicated that NA #1 had grabbed Resident #51's legs and shoulders causing him/her to scream in pain. RN #2 identified that she did not start an incident report, did not notify the oncoming shift, and did not report the incident to the DNS but should have. RN #2 indicated that she was working a double shift (16 hours) and was exhausted, but it was her responsibility per the facility practice, to start an incident report, and make the appropriate notifications.Interview with DNS on 9/3/2025 at 9:43 AM identified when allegations of abuse occur, the incident should be reported immediately, a report should be sent to the State Agency, suspension initiated for the alleged staff member until the investigation was complete, and that the DNS and Administrator were responsible. The DNS identified he was not made aware of Resident #51's allegation of rough treatment by NA #1 until being interviewed by the surveyor.Interview with the Administrator on 9/3/2025 at 10:24 AM identified that she was never made aware of the incident until interviewed by the surveyor. The facility has a no tolerance policy for abuse and staff were to report allegations immediately, including to the State Agency, Department of Social Services (DSS), and the staff member accused of abuse was to be suspended during the investigation. The Administrator indicated that it was the responsibility of the DNS or Administrator to report abuse, and she should have been notified. Additionally, the Administrator stated she would report the allegation to the State Agency and suspend NA #1 until the investigation was complete.Subsequent to surveyor inquiry, on 9/3/25 at 2:00 PM, the facility Report the incidents to the State Agency.Review of the facility's Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating policy dated 9/2022 directed, in part, that if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and other officials. The administrator or the individual making the allegation immediately reports their findings to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility, the local/state ombudsman, the resident's representative, adult protective services, law enforcement officials, the resident's attending physician and the facility medical director. Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury

Based on interviews, review of clinical records, review of documentation and facility policy for 1 of 2 residents, (Resident #51) reviewed for abuse, the facility failed to thoroughly investigate allegations of staff to resident abuse. The findings include: Number of residents sampled: 2Number of residents cited: 1Resident #51's diagnoses included acute systolic (congestive) heart failure, impingement syndrome of the right shoulder, pain in the right shoulder, and venous stasis dermatitis with blistering.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #51 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, required partial/moderate assistance for toileting hygiene, and supervision or touching assistance for transfers.The Resident Care Plan (RCP) dated 8/28/2025 identified Resident #51 was at risk for pain related to impaired mobility. Interventions included to manage or reduce side effects associated with pharmacological therapy, such as promoting adequate bowel and bladder function. Additionally, the RCP identified Activities of Daily Living (ADL) self-care deficits related to impaired mobility. Interventions included provide encouragement/supervision and allow adequate time to complete tasks.An Interview with NA #2 on 9/3/2025 at 7:53 AM identified an incident with NA #1 occurring on 8/29/2025 into 8/30/2025 at approximately 11:45 PM. Resident #51 was sitting on the side of the bed, legs dangling, and she and NA #1 were assisting him/her to lie down. Resident #51 had open wounds on his/her lower legs covered by bandages. NA #1 grabbed the resident's bandaged legs and pulled upward in a rough/forceful manner. Resident #51 began screaming that NA #1 was hurting him/her and for her to stop. She indicated that NA #1 replied that you are a pretty big guy and make my back hurt. Resident #51 responded I can't help that; I need the help. NA #2 stated that NA #1 did not stop moving Resident #51's legs or remove her hands, despite being screamed at, until Resident #51's legs were fully placed on the mattress. Wanting to get Resident #51 centered on the bed, she asked NA #1 to help boost the resident up with her, but NA #1 grabbed Resident #51 by both upper arms/shoulders and pushed him/her to the middle of the bed. Resident #51 again began screaming stating please don't touch me, what is wrong with you, you are hurting me again. NA #2 stated that she told NA #1 to let go of the resident, due to his/her response and that Resident #51 told NA #1 not to touch him/her anymore. NA #1 then left the room. Resident #51 told NA #2 that he/she didn't want NA #1 to care for him/her anymore because she was rough with care. Resident #51 stated that NA #1 was always complaining about his/her weight and consistently spoke rudely. In addition, NA #2 identified that after leaving Resident #51's room, she immediately notified LPN #1 and RN #2 and both LPN #1 and RN #2 left to speak with Resident #51.An interview with LPN #1 on 9/3/25 at 8:12 AM indicated NA #2 made her aware on 8/29/25 into 8/30/25, that he/she witnessed Resident #51 receive rough treatment by NA #1 as well as another incident that occurred on the previous night 8/28/25 into 8/29/25 (see F550). Additionally, LPN #1 indicated NA #2 reported to her in the presence of Registered Nurse (RN) #2 that Resident #51 was screaming from pain due to the rough care he/she received by NA #1 during a transfer. NA #2 stated that NA #1 had grabbed the resident by his/her legs and shoulders in a rough manner. On interviewing Resident #51 LPN#1 identified that Resident #51 stated he/she was uncomfortable with NA #1 performing care. LPN #1 identified that she and RN #2 determined NA #1 would not provide care to Resident #51 going forward and that the DNS would be notified of the mistreatment. Additionally, LPN #1 identified that she failed to document the incident in Resident #51 electronic health record.Interview with RN #2 (nurse supervisor) on 9/3/2025 at 9:19 AM identified she was made aware of the 8/29/2025 incident by NA #2 during the night shift on 8/29/25 to 8/30/25. NA #2 indicated that NA #1 had grabbed Resident #51's legs and shoulders causing him/her to scream in pain. RN #2 identified that she did not start an incident report, did not notify the oncoming shift, did not start an investigation, and did not report the incident to the DNS but should have. RN #2 indicated that she was working a double shift (16 hours) and was exhausted, but it was her responsibility per the facility practice, start an investigation and notify the appropriate staff. Interview with DNS on 9/3/2025 at 9:43 AM identified that when allegations of abuse occur, the incident should be reported immediately, an investigation should commence, and a suspension initiated for the alleged staff member until the investigation was complete. The DNS identified he was not made aware of Resident #51's allegation of rough treatment by NA #1 until being interviewed by the surveyor.Interview with the Administrator on 9/3/2025 at 10:24 AM identified that she was never made aware of the incident until interviewed by the surveyor. The facility has a no tolerance policy for abuse and staff were to report allegations immediately, begin an investigation and the staff member accused of abuse was to be suspended during the investigation. The Administrator indicated she should have been notified of the allegation. Additionally, the Administrator stated she would initiate an investigation and suspend NA #1 until the investigation was complete.Subsequent to surveyor inquiry, on 9/3/25 at 2:00 PM, the facility began an investigation. Review of the facility's Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating policy dated 9/2022 directed, in part, that if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and other officials. The administrator or the individual making the allegation immediately reports their findings to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility, the local/state ombudsman, the resident's representative, adult protective services, law enforcement officials, the resident's attending physician and the facility medical director. Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury

Based on observations, review of clinical records, facility documentation, facility policy, and interviews for 1 of 3 sampled residents (Resident #29) reviewed for pressure ulcers, the facility failed to ensure signage was posted for a resident on Enhanced Barrier Precautions (EBP) and failed to perform hand washing/hand sanitization during wound care. Based on observations, interviews, clinical record and policy reviews, and facility documentation for 2 of 3 sampled residents, (Resident #13 and #29) reviewed for pressure ulcers and for the only sampled resident (Resident #20) reviewed for intravenous administration, the facility failed to ensure standards of infection control were maintained. The findings included: 1. Resident #13's diagnoses included an unstageable pressure ulcer of the sacral region, muscle weakness, and abnormalities of gait and mobility. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 had a Brief Interview of Mental Status (BIMS) score of 2 indicating severe cognitive impairment and was dependent on staff for personal hygiene, and dressing. The Resident Care Plan dated 6/18/25 identified Resident #13 had an unstageable pressure ulcer on the coccyx. Interventions included providing wound care per the physician order and notifying the physician if the current wound treatment was not effective. A physician's order dated 8/24/25 directed to cleanse the wound with Dakin's solution 0.25%, apply skin prep to the peri-wound, apply Xeroform (wound dressing that keeps the wound moist) over the exposed bone in the wound bed, lightly pack wound with Aquacel Ag (wound dressing that helps prevent infections) and cover with a dry clean dressing daily or as needed due to soiling, saturation, or accidental removal. Observation of Resident #13's wound care with Registered Nurse (RN) Supervisor #1 and Licensed Practical Nurse (LPN) #1 on 9/2/25 at 10:07 AM identified RN #1 performed hand hygiene, applied new gloves and cleaned the wound with normal saline soaked gauze. After cleaning the wound, without the benefit of changing her gloves or sanitizing her hands, RN #1 dried the area with gauze and proceeded to pack the clean wound with Xeroform. Again, without the benefit of changing her gloves or hand sanitizing she packed the wound with Aquacel Ag. RN #1 applied skin prep to Resident #13's peri wound and applied a dry clean dressing over the wound with the same gloves used to originally cleanse the wound. Interview with RN #1 on 9/2/25 at 1:47 PM identified it was facility policy to change gloves after cleaning a wound, identifying she should have performed hand hygiene and changed her gloves, but could not identify why she did not. Interview with the Infection Prevention RN on 9/2/25 at 2:01 PM identified it was facility policy to change gloves when going from dirty to clean during wound care, which included changing gloves after cleaning a wound and prior to packing the wound and placing a clean dressing. A review of the Procedure for Clean Dressing Technique directed to cleanse the wound as ordered, observe the wound for size, color, drainage, appearance then remove gloves, then wash/sanitize hands and apply clean gloves. 2. Resident #20's diagnoses included osteomyelitis, cellulitis, and hypertension. A physician's order dated 8/21/25 directed Enhanced Barrier Precautions (EBP) every shift. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 had a Brief Interview of Mental Status (BIMS) score of 14 indicating cognition was intact. Additionally, the MDS identified Resident #20 required set-up/cleaning assistance from staff for eating, and substantial/maximal assistance for transfers and toileting. The Resident Care plan dated 8/27/25 identified Resident #20 was at risk for complications of infection related to a diagnosis of a right foot wound infection. Interventions included maintaining universal precautions and additional precautions as indicated. A review of the facility's Enhanced Barrier Precautions list identified Resident #20 was on precautions due to his/her wound and intravenous therapy. Observation of Resident #20's room on 9/2/25 at 1:00 PM identified EBP signage posted outside the room. Observation of Licensed Practical Nurse (LPN) #2 on 9/2/25 at 1:00 PM identified she performed hand hygiene, applied gloves, entered Resident #20's room and administered intravenous (IV) medication via a peripherally inserted central catheter/midline located in the right arm without the benefit of placing a gown. Interview with LPN #2 on 9/2/25 at 1:06 PM identified Resident #20 was on EBP due to his/her wound and when the wound was accessed was the only time Personal Protective Equipment (PPE) would have to be placed. Although she could not identify if PPE had to be worn when hanging/administering an IV medication, a review of the EBP signage posted outside Resident #20's room directed providers, and staff must wear gloves and a gown when performing high contact activities such as device care or use: central lines. LPN # 2 identified Resident #20's peripherally inserted central catheter/midline was a central line and she should have worn a gown and gloves when hanging/administering the IV medication, but she did not realize this was necessary because she only worked at the facility 2 days per week. Interview with Registered Nurse (RN) Supervisor #1 on 9/2/25 1:47 PM identified the facility policy on EBP was to wear a gown and gloves with any high contact activities for residents with wounds, urinary catheters, gastrostomy tubes, and IVs. Further a gown and gloves should have been worn by LPN #2 when she was hanging/administering an IV medication to Resident #20. Interview with Infection Prevention RN on 9/2/25 at 2:01 PM identified the facility policy on EBP was to don gloves and a gown anytime staff was to touch a resident, which included hanging/administering an IV medication. 3. Resident #29's diagnoses included fracture around internal prosthetic right hip muscle weakness, and cognitive communication deficit. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #29 had a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment, was dependent for personal hygiene, rolling left and right, and chair/bed-to-chair transfers, and had a stage 2 pressure ulcer. The Resident Care Plan (RCP) in effect on 9/2/25 identified Resident #29 had a stage 2 pressure ulcer. Interventions included use of a pressure reducing mattress, and to turn/reposition the resident. The RCP failed to include the use of Enhanced Barrier Precautions (EBP). A. Observations on 9/2/2025 at 10:30 AM and on 9/3/2025 at 9:20 AM failed to identify EBP signage posted or any Protective Personal Equipment (PPE) (gowns/gloves) outside of Resident #29's room. Interview on 9/3/2025 at 9:28 AM with the Assistant Director of Nursing Services (ADNS) (the Infection Prevention Nurse) identified that the facility policy was to place residents who had a stage 2 pressure ulcer on EBP. The ADNS indicated that he was responsible to place residents on EBP, but he had mistakenly been placing residents on EBP based on the size of their wound. The ADNS indicated that both a sign and PPE should have been located outside of Resident #29's room. Interview with the Director of Nursing Services (DNS) on 9/4/2025 at 10:06 AM identified that the ADNS was responsible for placing residents on EBP and that an EBP sign should have been located outside of Resident #29's room per the facility policy. The DNS further indicated that Resident #29 should have immediately been placed on EBP on 8/21/2025 when a stage 2 pressure ulcer was noted to be present. B. Observation and interview with Licensed Practical Nurse (LPN) #1 on 9/2/2025 at 10:30 AM during the provision of Resident #29's wound care identified, that despite having EBP signage and available PPE outside of the resident's room, LPN #1 failed to place a gown prior to performing wound care. Additionally, LPN #1 failed to perform hand hygiene prior to wound care and during wound care when gloves were changed. She stated she should have but the hand sanitizer was located on the opposite side of Resident #29's room not near the gloves and she had forgotten. Interview on 9/2/2025 at 11:54 AM with the ADNS (the Infection Prevention nurse) identified that before glove placement, upon glove changes, after wound care LPN #1 should have sanitized her hands. Further he identified that staff were last in-serviced (educated) on hand hygiene in November 2024 and LPN #1 was aware that hand hygiene should have been performed with Resident #29 wound care. Interview on 9/2/2025 at 12:01 PM with the DNS identified that LPN #1 failed to follow the facility policy during Resident #29's wound care when she did not perform hand hygiene before placing gloves prior to wound care, when changing gloves, and that she should have had hand sanitizer near her during wound care. The DNS was unable to explain why LPN #1 did not follow facility policy and use proper hand hygiene during the wound care of Resident #29. Review of the Enhanced Barrier Precautions Policy directed in part that EBP precautions apply when a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical device and does not have excretions or secretions that cannot be covered. Signage should be posted on the door or wall outside a resident's room indicating the type of precautions and personal protection equipment (PPE) to use. Examples of high contact resident care activities requiring the use of gown and gloves for EBP's include dressing, bathing/showering, providing hygiene or grooming, changing briefs/toileting, transferring, providing bed mobility, changing linens, prolonged high contact with items in the resident's room, with resident equipment, or with resident's clothing or skin, device care or use ( central line, urinary catheter, feeding tube, tracheostomy, etc.), and wound care. Review of the facility's Handwashing/Hand Hygiene Policy identified, in part, that hand hygiene should be performed before performing an aseptic task and immediately after glove removal.

Based on a tour of the Dietary Department, review of facility policy, and staff interview, the facility failed to ensure expired food was discarded. The findings included: During the initial tour of the Dietary Department on [DATE] at 11:30 AM with the Executive Chef, the following was identified in dry storage: a. one 32-ounce box of baking soda with an expiration date of [DATE]. b. four 28-ounce bags of refried pinto beans with an expiration date of [DATE]. c. five 10-ounce boxes of Couscous with an expiration date of [DATE]. Interview with the Director of Food Services on [DATE] at 10:30 AM identified that the Closing Manager was responsible to check for expiration dates daily and to discard expired food. Further, the Director of Food Service was unable to explain the reason expired food remained in the dry storage area, but stated it may have been due to the kitchen being short staffed. Subsequent to surveyor inquiry, the expired items were discarded. Review of the Dining Department policy (undated) directed, in part, that the executive Chef or their designee will monitor and assure that all food products are not outside of their expiration date. All expired food will be discarded immediately.

Based on clinical record review, observations, facility policy, and interviews for 1 of 3 sampled residents (Resident #339) reviewed for dignity, the facility failed to ensure a urinary privacy bag was utilized. The findings include: Resident #339's diagnosis included heart failure, diabetes, acute respiratory failure, and chronic kidney disease. The Resident Care Plan dated 12/13/23 identified Resident #339 required an indwelling Foley catheter. Interventions included providing privacy bags to the indwelling Foley catheter, empty catheter bag, and keep catheter insertion area clean. An Admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #339 had intact cognition, had no impairment with upper/lower extremity range of motion and was independent with eating. The MDS further identified Resident #339 required set up assistance with oral hygiene, partial/moderate assistance with lower body dressing and personal/toilet hygiene. Additionally, the MDS identified Resident #339 had an indwelling catheter in place. Observation on 12/18/23 at 1:05 PM identified Resident #339 was sitting in a wheelchair and was being transported out of his/her room by the Rehab Director. Resident #339 was further observed to have a urinary collection bag secured to the wheelchair, which contained a large amount of yellow fluid inside without the benefit of being covered with a privacy covering. Interview with the Rehab Director on 12/18/23 at 1:05 PM identified that she was taking Resident #339 to attend a nursing meeting, was unsure of the policy of providing a urinary bag cover and could not find a privacy bag. Interview with the DNS on 12/21/23 at 12:10 PM identified the policy was located in the dignity policy and also identified the physician's order was for the bag to be covered. The DNS further identified that anyone can place a privacy bag on and the expectation was that all residents have a privacy bag always placed. The facility policy identified demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents: for example: helping the resident to keep urinary catheter bags covered.

Based on staff interview, clinical record review, facility documentation, and review of facility policy for 1 of 3 sampled residents (Resident #31) reviewed for accidents, the facility failed to revise the Resident Care Plan (RCP) to include interventions for fall prevention following Resident #31 falling. The findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses that included sequelae of cerebral infarction, unsteadiness on feet, and dementia. Nursing notes dated 9/6/23 identified that Resident #31 was admitted to the facility following hospitalization for a left hip fracture related to a fall from home. A Resident Care Plan (RCP) dated 9/6/23 identified Resident #31 was at risks for falls. Interventions included gentle reminders for Resident #31 to use the call light if needing to get out of bed or chair, reminding Resident #31 to call for assistance prior to moving bed-to-chair and chair-to bed, frequent checks to decrease chance of falling, footwear fitting properly, having non-skid soles, placing call bell within easy reach, keeping areas free of obstructions to reduce risks of falls or injury, and responding promptly to calls for assistance to use the toilet. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 was severely cognitively impaired and required extensive assistance of one staff person for locomotion on the unit, dressing, toileting, and personal hygiene. Resident #31 required limited assistance of two staff for transferring. Additionally, the MDS identified Resident #31 had a history of falls over the past 6 months and had a fall within the last month prior to admission to the facility. Nursing notes dated 9/16/23 at 3:50 PM reflected Resident #31 was out of bed in his/her wheelchair most of the day on 9/16/23, with episodes of confusion and yelling and screaming during the day, and many attempts to stand from his/her wheelchair unassisted. Redirection, distraction and 1 to 1 supervision was needed for Resident #31 to calm and sit down. A facility Incident Report dated 10/8/23 at 8:13 PM identified Resident #31 had an unwitnessed fall on 10/8/23 fall at 8:13 PM. Resident #31 was found sitting on a floor mat on the side of his/her bed, with non-skid socks on, with the bed in the lowest position. Nursing staff assessed Resident #31 for injury and the physician and family were also notified. The disposition noted on the Incident Report was for Resident #31 to be offered toileting prior to hours of sleep (HS). A facility Incident Report dated 11/23/23 at 6:30 PM identified Resident #31 had a witnessed fall on 11/23/23 at 6:30 PM. Resident #31 was observed sitting in his\her wheelchair in the hallway and slid out of the wheelchair onto his/her buttocks on the floor. A staff member present near Resident #31 tried to prevent the fall. Nursing staff assessed Resident #31. The physician and family were also notified. Resident #31 was transferred back to his/her wheelchair after being assessed. The disposition noted on the Incident Report was to add dycem or larger piece if there already to prevent sliding in chair. A facility Incident Report dated 11/23/23 at 9:05 PM identified Resident #31 had a witnessed fall on 11/23/23 at 9:05 PM. Resident #31 was observed walking out of his/her room without a walker and fell in the hallway. Nursing staff assessed Resident #31 and placed at the nurses' station with staff to ensure safety. The physician and family were also notified. The disposition noted on the Incident Report was to remind Resident #31 of needing walker, and possibly signage with pictures to remind Resident #31, if needed. A facility Incident Report dated 11/25/23 at 5:50 AM identified Resident #31 was observed to have lower left leg swelling after a fall on 11/23/23. Resident #31 was assessed by nursing and the foot and ankle were elevated. The physician and family were notified. The disposition noted on the Incident Report was to refer to the fall prevention interventions identified from Resident #31's falls on 11/23/23. A facility Incident Report dated 12/15/23 at 7:50 PM identified Resident #31 had an unwitnessed fall on 12/15/23 at 7:50 PM. Resident #31 was observed on the floor in his/her room crawling toward the door. Resident #31 fell out of bed and onto the floor mat next to the bed. The bed was observed by staff to be positioned at the lowest level. Nursing assessed Resident #31 for injury. The physician and family were notified. Resident #31 was transferred to wheelchair for redirection and placed on 1 to 1 supervision until Resident #31 was calm. The disposition noted on the Incident Report was for the resident to remain in the facility. A facility Incident Report dated 12/15/23 at 11:00 PM identified Resident #31 had a witnessed fall on 12/15/23 at 11:00 PM. Resident #31 was observed standing up from the wheelchair while at the nurses' station and hitting his/her head against the railing of the desk upon falling to the floor. Nursing assessed Resident #31 and the physician and family were notified. The disposition noted on the Incident Report identified for Resident #31 to be encouraged to stay with the nurse while at the nurses' station. A facility Incident Report dated 12/18/23 at 8:40 PM identified Resident #31 had an unwitnessed fall. Resident #31 was observed by staff attempting to scoot him/herself towards the hallway while on the floor of his/her room. The bed was in the lowest position possible and fall mats were in place. Nursing assessed Resident #31 for injury. The physician and family were also notified. The disposition noted on the Incident Report identified staff was to offer to keep Resident #31 out of bed until stating his/she was ready for bed. Interview and clinical record review with the Director of Nursing Services (DNS) on 12/21/23 at 1:45 PM identified that the facility failed to ensure that the RCP for falls was updated to include fall prevention interventions following resident falls occurring on 10/8/23, 11/23/23, 12/15/23, and 12/18/23. The DNS identified the MDS Coordinator was responsible for completing the care plan updates, however, the MDS Coordinator was currently out from work. The DNS indicated being able to put in simple interventions into a care plan while the MDS Coordinator was out from work. Additionally, interview with the DNS on 12/21/23 at 1:45 PM identified the facility policy was for the Interdisciplinary Team to develop fall prevention interventions, which were based upon the disposition identified on the facility Incident Report following a fall. The DNS indicated that fall prevention interventions identified on the facility Incident Reports, dated 10/8/23, 11/23/23, 12/15/23, and 12/18/23, may not have been included in the RCP but were put into place and were communicated to the care team verbally by the supervisor. However, the DNS further indicated that it would be expected to see interventions added to the RCP after a resident had a fall. Review of facility Care Planning policy identified assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team reviews and updates the care plan, including when the resident has been readmitted to facility from a hospital stay.

Based on record review, staff interview and review of facility policy for 1 of 2 residents (Resident #36) reviewed for hospitalization , the facility failed to document the events of Resident #36's transfer to the hospital including an assessment by a Registered Nurse (RN) per professional standards. The findings include: Resident #36 was admitted to the facility on [DATE] with diagnoses that included a lumbar fracture, hypertension and respiratory failure. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #36 had intact cognition and required extensive assistance of 2 for bed mobility and transfers. The MDS further identified Resident #36 required extensive assistance of 1 for toilet use and dressing. Additionally, the MDS identified Resident #36 required limited assistance of 1 for personal hygiene. Nursing notes dated 8/18/23 at 6:40 AM and written by Licensed Practical Nurse (LPN) #1 identified Resident #36 was alert and oriented, tolerated medication well, complained of abdominal and back pain, abdomen was soft to touch, bowel sounds active in all 4 quadrants. Nursing notes by LPN #1 further identified Resident #36 stated I can't deal with this pain anymore, nothing helps. Additionally, LPN #1's note identified Resident #36 had no signs of cardiac distress and remained in bed for the duration of the shift. An Inter-Agency Patient Referral Report (no author/credential of author identified) dated 8/18/23 (from the facility to the Emergency Department) identified Resident #36 had increased back/abdominal pain, negative bowel sounds and a past medical history of ilius. A physician progress note dated 9/1/23 identified Resident #36 was readmitted after being hospitalized from 8/18/23 to 8/31/23 due to a diagnosis of colonic fecal stasis with gaseous distension and non-specific ileus. Interview and record review with the DNS on 2:12 PM failed to identify documentation/nursing notes either electronically or in the paper chart that a Registered Nurse (RN) assessment had been completed subsequent to Resident #36 complaints of not being able to deal with this pain anymore on 8/18/23. Additionally, the DNS was unable to locate nursing notes either electronically or in the paper chart that reflect the events at the time Resident #36 was transferred to the hospital (physician/family being notified, time of transfer, Resident #36's response to the transfer, etc). The DNS also identified she would have expected an RN assessment be documented due to Resident #36's complaints of pain. Interview and record review with the ADNS on 12/22/23 at 9:30 AM identified that she was working on 8/18/23 as the ADNS when Resident #36 was transferred to the hospital, and although she assessed Resident #36 prior to contacting the physician, she did not document the assessment. Furthermore, the ADNS identified that she should have documented an assessment and write a nursing note regarding Resident #36's transfer to the hospital, but did not due to being busy. Additionally, the ADNS identified that the other licensed staff working on 8/18/23 were either agency nurses or nurses that no longer work at the facility. Facility policy regarding Charting and Documentation (revised July 2017) identified all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. According to [NAME], Nursing 2022, The Peer-Reviewed Journal, a rule of documentation is to follow the nursing process completely. The nursing process requires assessment, diagnosis (nursing), planning, implementation and evaluation. This process must be reflected in the documentation of interactions with the patient during care.

Based on observations, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #13) reviewed for positioning, the facility failed to follow physician orders related to pressure reduction. The findings include: Resident #13's diagnoses included arteriosclerosis heart disease, fracture to the right femur, and acute kidney failure. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was moderately cognitively impaired, dependent with lower body dressing, and required maximum assistance with bed mobility. Additionally, the MDS identified Resident #13 was at risk for pressure ulcers/injuries. The Resident Care Plan dated 10/26/23 identified a risk for alteration in skin integrity related to limited range in motion. Interventions included using pillows, pads, or wedges to reduce pressure on heels and pressure points, and to turn/reposition. A physician's order dated 10/26/23 directed Resident #13 to have heel boots and heels elevated while in bed. Observation of Resident #13 on 12/20/23 at 11:45 AM identified him/her asleep in bed, on top of the covers without the benefit of heel elevation or heel boots. No off-loading equipment was observed around Resident #13. Observation of Resident #13 on 12/20/23 at 12:14 PM and again at 1:34 PM identified him/her in bed, on top of the covers without the benefit of heel boots or heel elevation. No off-loading equipment was observed around Resident #13. Review of nursing progress and RCP from 12/1/23 through 12/20/23 failed to indicate Resident #13 was non-complaint with wearing heel boots or keeping heels elevated. Interview with the ADNS on 12/20/23 at 1:43 PM indicated Nurse Aides (NA) and nurses were responsible to ensure that when Resident #13 was in bed, heel boots were in place and that heels were elevated off the mattress. The ADNS identified that according to the physician's order, Resident #13 should have had his/her heels elevated as well as had his/her heel boots in place. The ADNS was unaware of the reason physician's orders were not being followed. Additionally, the ADNS was only able to locate 1 heel boot in Resident #13's room. Interview with Resident #13 on 12/20/23 at 1:46 PM indicated he/she had never worn heel boots. Interview and review of the clinical record, with Registered Nurse (RN) #1 on 12/20/23 at 1:59 PM identified although Resident #13 would kick off his/her boots, RN #1 was unsure if this was the reason Resident #13 did not currently have his/her heels elevated or heel boots in place. RN#1 indicated that therapy and the NAs were responsible for placing Resident #13's heel boots on and could not explain the reason Resident #13 had only 1 boot in his/her room. Interview with NA #1 on 12/20/23 at 1:59 PM indicated Resident #13 was non-compliant with treatment and this information had been reported to the charge nurses. Interview with DNS on 12/20/23 at 2:05 PM failed to identify the reason Resident #13 did not currently have his/her heels elevated or heel boots in place as ordered by the physician. The DNS indicated Resident #13 was non-compliant with treatment due to behavioral issues, however, the facility had failed to identify documentation of the refusals or if this was why heels were not elevated or heel boots were not in place. Subsequent to surveyor inquiry, observation on 12/20/23 at 2:24 PM identified Resident #13 tolerating heel boots, which were noted to be in place. Facility Prevention of Pressure Injuries indicated to reposition all residents with or at risk of pressure injuries and to review and select medical devices with consideration to the ability to minimize tissue damage.

Based on clinical record review, review of facility policy, and interviews for 1 of 3 sampled residents (Resident #339) reviewed for pressure ulcers, the facility failed to ensure a positioning device was appropriately applied. The findings include: Resident #339's diagnoses included heart failure, diabetes, chronic kidney failure, and acute respiratory failure. Resident #339's care plan dated 12/13/23 identified he/she was at risk for alteration in skin integrity related to impaired mobility, age, and cardiac disease. Intervention directed use pillow, pads, or wedges to reduce pressure on heels and pressure points, turn and reposition, and to apply moisture barrier. An Admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #339 had intact cognition, had no impairment with upper/lower extremity range of motion and was independent with eating. The MDS further identified Resident #339 required set up assistance with oral hygiene, partial/moderate assistance with lower body dressing and personal/toilet hygiene. Additionally, the MDS identified Resident #339 had a stage 2 pressure ulcer to coccyx. A physician's order dated 12/13/23 directed a pressure reducing device for the bed, alternating air pressure mattress on bed to promote healing and provide comfort. A Dietician note dated 12/18/23 identified that Resident #339 on 12/15/23 Resident #339's weight was 121.9 pounds (lbs). Observations on 12/18/23 at 10:15 AM identified Resident #339 in bed, lying on his/her side. The setting for the alternating air mattress was set a 8 (a setting of 7-8 was a setting for a resident's weight of 300 lbs to 350 lbs). Observation on 12/19/23 at 10:15 AM identified Resident #339 was in bed, lying on his/her side, the alternating air pressure mattress was set at 8. Observation on 12/20/23 at 12:35 PM identified Resident #339 in bed lying on his/her side with the alternating air pressure mattress set at 8. Interview on 12/20/23 at 2:15 PM with the vendor for alternating air pressure mattress' identified that there was a range tag on the resident's bed and the mattress would be set up according to the range which was by weight. Interview and observation with the ADNS on 12/20/23 at 2:35 PM stated that the alternating air pressure mattress was set according to the resident's weight, observation done with ADNS who checked the setting of Resident's #339 alternating air pressure mattress and she stated that it was set at 8 which was too firm, and it should be down to 4. She denied knowing Resident #339 weight and knowing if there was a policy regarding the alternating air pressure mattress. She provided a copy of the operating, maintenance and troubleshooting card that identified settings for the bed that are specific according to the resident's weight. Review of the facility's Prevention of Pressure Ulcers/Injuries policy identified that the staff are responsible for the redistributing support surfaces are to promote comfort for all residents, prevent skin break down, promote circulation, and provide pressure relief or reduction. Subsequent to surveyor observation on 12/21/23 at 10:30 AM, Resident #339's alternating air pressure mattress was set at 2 which was the setting for a resident who weighs between 85-140 pounds per the operating, maintenance and troubleshooting card.

Based on staff interview, clinical record review, facility documentation, and review of facility policy for 1 of 3 sampled residents (Resident #31) reviewed for accidents, the facility failed to ensure fall risk assessments were completed after resident falls. The findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses that included sequelae of cerebral infarction, other abnormalities of gait and mobility, and dementia. An admission Fall Risk assessment dated [DATE] identified Resident #31 ambulated with difficulty due to problems that included unsteady gait and required the use of assisted devices for ambulation. Furthermore, it was indicated that Resident #31 had a history of falls within the last 90 days and was at higher risk for falls. A Resident Care Plan (RCP) dated 9/6/23 identified Resident #31 was at risks for falls. Interventions included gentle reminders for Resident #31 to use the call light if needing to get of bed or chair, reminding Resident #31 to call for assistance prior to moving bed-to-chair and chair-to bed, frequent checks to decrease chance of falling, footwear fitting properly, having non-skid soles, placing call bell within easy reach, keeping areas free of obstructions to reduce risks of falls or injury, and responding promptly to calls for assistance to use the toilet. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 was severely cognitively impaired and required extensive assistance of one staff person for locomotion on the unit, dressing, toilet use, and personal hygiene. Resident #31 required limited assistance of two staff for transferring. Additionally, it was identified Resident #31 had a history of falls over the past 6 months and had a fall within the last month prior to admission to the facility. A Fall Risk assessment dated [DATE] identified that Resident #31 ambulated with difficulty due to problems that included unsteady gait and required the use of assisted devices for ambulation. Further, it was indicated that Resident #31 had a history of falls within the last 90 days and had a total fall risk evaluation score of 14, which indicated that Resident #31 was at higher risk for falls. Record review of facility Incident Report documentation indicated Resident #31 had falls while at the facility on 9/16/23, 9/23/23, 10/8/23, 11/15/23, 11/23/23, 12/15/23, and 12/18/23 but failed to complete a Fall Risk assessment after the falls. Interview with the DNS on 12/21/23 at 12:18 PM identified the facility policy was for a Fall Risk Assessments to be completed on admission and following falls, as part of the fall process. The DNS also indicated that fall risk assessments were scheduled to be completed routinely every 6 months for long term residents and that the next fall risk assessment for Resident #31 was scheduled for 3/4/24. Clinical record review (review of the electronic record) with the DNS on 12/21/23 at 1:41 PM identified that the facility failed to complete Fall Risk assessments for Resident #31 following Resident #31's falls at the facility and indicated that if a Fall Risk assessment was completed it would be located in the electronic medical record (EMR). Interview with the DNS on 12/21/23 at 1:43 PM identified that the facility failed to complete fall risk assessments following Resident #31's falls at the facility on 9/16/23, 9/23/23, 10/8/23, 11/15/23, 12/15/23, and 12/18/23 in accordance with facility policy and procedures. The DNS identified that the person responsible for completing a fall risk assessment was the nurse that completes the assessment of the resident following a fall. The DNS identified that a fall risk assessment should be done after every resident fall. The DNS indicated being unsure as to the reason fall risk assessments were not completed following Resident #31's falls at the facility on 9/16/23, 9/23/23, 10/8/23, 11/15/23, 11/23/23, 12/15/23, and 12/18/23. Review of the Fall Risk Assessment policy identified that nursing staff and the physician review a resident's history of falls and fall risk factors upon admission. Additionally, the policy identified that staff and the attending physical will collaborate to identify and address fall risk factors and interventions to try to minimize the consequences of fall risks factors for residents. Further, the Interdisciplinary Team, in conjunction with the attending physician, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information.

Based on observation, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #339) reviewed for glucose (blood sugar) testing, the facility failed to appropriate disinfect the area prior to testing and failed to ensure proper hand hygiene. In the laundry room, the facility failed to ensure that the clean laundry was maintained appropriately. The findings include: 1. Resident #339's diagnoses included diabetes, heart attack, and kidney disease. An admission physician's order dated 12/14/23 directed to obtain a blood sugar level with breakfast, lunch, and dinner to calculate how many units of insulin to administer. The Admission Resident Care Plan dated 12/18/2023 identified Resident #339 was at risk for complications related to diabetes (high and low blood sugar irregularities). Interventions included monitoring glucose levels. The admission Minimum Data Set assessment dated [DATE] identified Resident #339 was cognitively intact and required set up assistance with oral hygiene and partial assistance with personal hygiene. Observation of LPN #2 on 12/21/23 at 12:04 PM identified that she had obtained the glucose monitoring device and an alcohol wipe from the medication cart. LPN #2 explained the procedure to Resident #339, wiped Resident #339's left middle finger with the alcohol wipe, then dried the area with a facial tissue. Using a lancet (a single-use needle type device) she obtained a drop of blood from the resident's finger. LPN #2 removed her glove and placed a new pair of gloves without the benefit of first washing or sanitizing her hands. Interview with LPN #2 on 12/21/23 at 12:09 PM identified that it was not the facility policy to wipe the disinfected testing area with a tissue prior obtaining the blood and that the tissue had contaminated the disinfected area. Additionally, LPN #2 indicated that the facility policy was to wash/sanitize her hands after glove removal and prior to placing a new, clean glove. LPN #2 was unable to identify why she had wiped Resident #339's disinfected area with a tissue, or why she had not followed the facility policy for hand washing/sanitizing when gloves were removed or prior to new glove placement. Interview with the DNS on 12/21/23 at 12:37 PM identified the process for disinfecting a resident's finger for blood glucose sampling did not include wiping the area with a tissue, but that a disinfected area should be left to air dry or be dried with sterile gauze. Interview with the ADNS on 12/21/23 at 12:38 PM identified that, according to the facility policy, LPN #2 should have performed hand hygiene after removing gloves and prior to placing on a new glove. Review of the facility policy, Blood Sampling - Capillary Finger Sticks, dated 2014, directed, in part, to clean the testing area with an alcohol swab. Review of the Personal Protective Equipment Using Gloves policy dated 2010 directed, in part, to wash hands after discarding gloves. 2. Observation in the laundry room with Laundry Attendant #1 on 12/22/23 at 11:40 AM identified the following: a. On the wall facing the clean laundry folding table, a fan was noted to have a significant amount of gray material clinging to the fan guard. The fan was blowing directly on clean linen being folded by Laundry Attendant #1. b. A floor fan located to the side of the clean laundry folding table was noted to have a significant amount of gray material clinging to the fan guard. The fan was blowing directly on clean linen being folded by Laundry Attendant #1. Interview with Laundry Attendant #1 on 12/22/23 at 11:50 AM identified that the substance on the fan guards was lint from the dryer. Laundry Attendant #1 indicated that both fans required cleaning and should not have been blowing onto the clean linen. Laundry Attendant #1 identified that she had thought the wall fan was off. Additionally, she noted that the Maintenance Department was responsible for cleaning the wall fan and she should have notified them of the need for cleaning. Although the Maintenance Department was responsible for the wall fan, the floor fan was noted to have a large build-up of lint, and she was responsible for cleaning this fan but had not noticed the build-up. Interview and observation with the Administrator on 12:22/23 at 11:53 AM identified that both fans had a large build-up of debris, required cleaning, and should not have been blowing directly on the area where clean linen was being folded. Although requested a policy on fan cleanliness was not received. 50095

Based on review of facility records, interviews, and facility policy for 1 of 3 Nurse Aides reviewed for training, (NA #2), the facility failed to ensure sufficient hours of education per the regulation. The findings include: Review of facility records on 12/22/23 at 10:48 AM indicated that NA #2 was hired March 2023, however, required trainings were all signed on 12/21/23 (during the ongoing survey). Interview with ADNS on 12/22/23 at 11:45 AM indicated staff were expected to complete all the mandatory required trainings upon hire. The ADNS identified that NA #2's required trainings were not signed until 12/21/23 (9 months post hire) due to NA #2 not being up to date. The ADNS stated that Human Resources, the DNS, and she were responsible to ensure staff completed their mandatory training requirements on hire. Review of facility documentation identified that NA #2 had worked a total of 125 hours between 11/26/23 and 12/7/23, prior to signing off on the required training. Attempts to interview NA #2 were unsuccessful. The facility In-service Training, Nurse Aide policy indicated that required trainings were communication, resident rights and facility responsibilities, abuse, neglect and exploitation of residents, quality assurance and performance improvement (QAPI), infection control, compliance and ethics, and behavioral health.

Based on observations, facility policy review and staff interviews for one of one medication rooms and two of two medication carts, reviewed for medication storage, the facility failed to ensure medications were not accessible to non-licensed persons. The findings include: An observation on 10/26/2021 at 3:10 PM identified the medication room door was open wide and was held open by a wedge-type of magnetic door holder under the bottom of the door. Additional observation identified no licensed staff were in the medication room or within view of the medication room. Further, located inside the unattended medication room were two medication carts that were both observed to be unlocked. Additional observation identified Resident #15 sitting in a wheelchair inside the nursing station next to the open medication room door. NA #1 and NA #2 were reviewing documentation in the corner at the far end of the nursing station, and they were not within view of the open medication door. During an interview with LPN #1 on 10/26/2021 at 3:20 PM, LPN #1 indicated that she left the area and went to grab something, and the open medication door slipped her mind. Further, LPN #1 indicated that Resident #15 was sitting inside the nursing station when she left the area with the medication room door open, and the medication carts unlocked. She indicated that the medication carts should have been locked and she should have ensured the medication room door was closed and locked. Interview and observation with the Administrator on 10/26/2021 at 3:23 PM confirmed the medication room door was left open and identified that there were medications and biologicals stored inside the unattended, unlocked medication room and medication carts. The Administrator indicated that the medication carts should have been locked and the medication room door should have been closed securely and locked. Interview with the DNS on 10/27/2021 at 10:00 AM identified the medication room door and carts should have been locked when not within view of the licensed staff to prevent unauthorized access. The DNS further identified Resident #15 had severely impaired cognition and was able to propel his/her wheelchair independently. Subsequent to surveyor inquiry, the wedge-type magnetic door holder that allowed the medication room door to be propped open was removed. Review of the facility Storage of Medication Policy and Procedure, dated 9/2018, directed in part that the medication supply shall be accessible only to licensure nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The Policy further directed that medication rooms, cabinets, and supplies should remain locked when not in use or attended by persons with authorized access.

Based on clinical record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure a resident was free from mistreatment. The findings include: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Care Plan (RCP) dated 5/13/2021 identified an alteration in mobility, and a problem of depression. Interventions directed to use wheelchair, observe for sadness, agitation, anxiety, fearfulness and changes in condition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented, used a wheelchair, required extensive assistance of one person with bed mobility, transfers, dressing and toilet use, and did not walk. The facility reportable event form dated 7/3/2021 at 2:20 PM identified Resident #1 was alert and oriented, and reported to the charge nurse on that on 7/1/2021 NA #1 and NA #2 called him/her a liar. Resident #1's statement described the incident and further explained that when he/she attempted to leave the room, and NA #1 and #2 pushed his/her wheelchair to prevent Resident #1 from leaving the room. After NA #1 and #2 left the room, Resident #1 reported the incident to LPN #1. Resident #1's statement further indicated that on 7/2/2021 (the day after the incident on 7/1/2021) during the evening shift, NA #1 and NA #2 were mean and rough to him/her. Resident #1 indicated he/she had a TV pillow speaker in his/her hands when NA #1 and #2 entered the room, tried to take the pillow speaker from his/her hands and Resident #1 indicated that there was a struggle for the speaker. The report identified that NA #1 and #2 were suspended and an investigation was initiated. The facility summary identified NA #1 and #2's employment was terminated on 7/7/2021. During an interview with NA #1 on 7/19/2021 at 11 AM she indicated that she and NA #2 were advocating for Resident #1's roommate because Resident #1 wanted to turn off the television. She further indicated that they told Resident #1 not to turn off the TV and that they did not call Resident #1 a liar. NA #1 further indicated that she and NA #2 would often enter Resident #1's room together in case Resident #1 had behaviors (angry or yells). She denied that she or NA #2 had a physical struggle with Resident #1 regarding use of the pillow speaker. Interview with Resident #1 on 7/19/2021 at 11:30 AM identified he/she did not wish to repeat the details of the allegation. Resident #1 indicated that he/she had discussed the incidents with the Administrator, the Administrator investigated the incidents and he/she did not want to discuss it further. During an interview with NA #2 on 7/19/2021 at 12:30 PM, NA #2 denied that she called Resident #1 a liar, prevented Resident #1 from exiting his/her room, and did not have a physical struggle with Resident #1 regarding the TV pillow speaker. Additionally, NA #2 identified that she and NA #1 often work together to provide care for Resident #1's roommate. Interview and review of facility documentation with the Administrator on 7/19/2021 at 11:50 AM identified that the facility substantiated the allegation of abuse and NA #1 and #2's employment was terminated on 7/7/2021. The facility undated Abuse Prevention Program Policy directed in part, that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation and this includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal mental, sexual or physical abuse. Review of the facility undated Residents Rights Policy dated identified in part that employees shall treat all residents with kindness, respect and dignity.

Based on interviews, facility documentation review, and facility policy review, for one of five employees (NA #2) reviewed for abuse training, the facility failed to implement the abuse policy and ensure staff received annual abuse prevention training. The findings include: Review of NA #2's employee file identified NA #2 was hired on 8/3/2018 and abuse training entitled Preventing, Recognizing and Reporting abuse was completed on 8/14/2018. Additional review of the file failed to identify any additional abuse education was provided after 8/14/2018. Interview with the ADNS on 7/19/2021 at 2:16 PM identified that although all staff were required to complete abuse prevention training annually NA #2's last abuse prevention training was on 8/14/2018. She further identified that during the 2020 pandemic she was unable to track employee training, and NA #2 should have received the training during 2019. Review if the Nurse Aide Job Description identified an essential job function included participating and attending all in-service and training programs. Review of the undated Abuse Prevention Program Policy, directed in part, that staff required training and orientation programs that included abuse prevention, identification, reporting stress management, and handling verbally aggressive patient behavior.

Based on clinical record review, review of facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure staff reported an allegation of abuse timely. The findings included: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Care Plan (RCP) dated 5/13/2021 identified an alteration in mobility, and a problem of depression. Interventions directed to use wheelchair, observe for sadness, agitation, anxiety, fearfulness and changes in condition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented, used a wheelchair, required extensive assistance of one person with bed mobility, transfers, dressing and toilet use, and did not walk. The facility reportable event form dated 7/3/2021 at 2:20 PM identified Resident #1 reported to the charge nurse on that on 7/1/2021 NA #1 and NA #2 called him/her a liar. Resident #1 attempted to leave the room, and NA #1 and #2 pushed his/her wheelchair to prevent Resident #1 from leaving the room. After NA #1 and #2 left the room, Resident #1 reported the incident to LPN #1. The report further indicated that on 7/2/2021 during the evening shift, NA #1 and NA #2 were mean and rough. Resident #1 indicated he/she had a TV pillow speaker in his/her hands when NA #1 and #2 entered the room, tried to take the pillow speaker from Resident #1's hands and Resident #1 indicated that there was a struggle for the speaker. The report identified that NA #1 and #2 were suspended and an investigation was initiated. Interview with LPN #1 on 7/19/2021 at 12:15 PM identified that on the evening of 7/1/2021 (two days prior to the date on the facility incident report) Resident #1 reported to her that NA #1 and NA #2 were mean to him/her, NA #1 called Resident #1 a [NAME], and accused him/her of turning off his/her roommate ' s television. Additionally, LPN #1 informed Resident #1 it was his/her right to file a complaint and Resident #1 could notify the social worker of his/her concerns the following day. LPN #1 did not report Resident #1's allegation to the nursing supervisor and she did not speak to NA #1 or NA #2 to determine what had happened. Further, LPN #1 indicated that she did not know why she did not report Resident #1's allegation. She identified that she should have reported the allegation to the nursing supervisor when she was notified of the incident, and she should have written a statement regarding Resident #1's complaint. Review of the time punch details for NA #1 and NA #2 identified both employees worked during the 3-11 shift on 7/1 and 7/2/2021. Interview and facility documentation review with the Administrator on 7/19/2021 at 2 PM identified that although the allegation of abuse was reported to LPN #1 on 7/1/2021, LPN #1 did not report the allegation to the nursing supervisor. The Administrator indicated that LPN #1 should have reported the allegation to the nursing supervisor immediately and the supervisor would have notified the Administrator. She further indicated that if she had known of the allegation, she would have removed NA #1 and #2 from the schedule pending the outcome of the investigation (they would not have worked on 7/2/2021). Review of the undated Abuse Prevention Program Policy, directed in part, that all reports of resident abuse, neglect mistreatment will be promptly reported. The Policy further directed any alleged violation of abuse, neglect, or mistreatment will be reported immediately.

Based on clinical record review, facility documentation review, and staff interviews for one of two residents (Resident #1) reviewed for abuse the facility failed to ensure a resident assessment was completed timely by a registered nurse after an allegation of abuse. The findings included: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Care Plan (RCP) dated 5/13/2021 identified an alteration in mobility, and a problem of depression. Interventions directed to use wheelchair, observe for sadness, agitation, anxiety, fearfulness, and changes in condition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented, used a wheelchair, required extensive assistance of one person with bed mobility, transfers, dressing and toilet use, and did not walk. The facility reportable event form dated 7/3/2021 at 2:20 PM identified Resident #1 reported to the charge nurse on that on 7/1/2021 NA #1 and NA #2 called him/her a liar. Resident #1 attempted to leave the room, and NA #1 and #2 pushed his/her wheelchair to prevent Resident #1 from leaving the room. After NA #1 and #2 left the room, Resident #1 reported the incident to LPN #1. The report further indicated that on 7/2/2021 during the evening shift, NA #1 and NA #2 were mean and rough. Resident #1 indicated he/she had the TV pillow speaker in his/her hands when NA #1 and #2 entered the room, tried to take the pillow speaker from Resident #1's hands and Resident #1 indicated that there was a struggle for the speaker. The report identified that NA #1 and #2 were suspended and an investigation was initiated. Review of the clinical record failed to identify a resident assessment was completed for any potential injuries after Resident #1's allegation of mistreatment. Interview with the Nursing Supervisor (RN #1) on 7/19/2021 at 12:10 PM identified that on 7/3/2021 Resident #1 reported that on 7/1/2021 NA #1 and NA #2 called him/her a liar, prevented Resident #1 from leaving his/her room to report the incident to the nurse by pushing Resident #1's wheelchair into his/her room. Additionally, Resident #1 reported that on 7/2/2021 NA #1 and NA #2 were mean and rough, and grabbed a pillow speaker out of his/her hands. RN #1 indicated she did not complete a physical assessment because Resident #1 did not complain of any injury, Resident #1 did not ask for RN #1 to check anything, and although Resident #1 reported NA #1 and NA #2 were mean and rough, and grabbed the speaker out of Resident #1's hands, she indicated that she was not aware of a physical struggle. RN #1 identified she was not sure if she was supposed to complete an assessment and document it in the medical record; she indicated that The Administrator told her to write a statement on a piece of paper and leave it in the Administrator ' s mailbox. Interview, clinical record review and facility documentation review with the ADNS on 7/19/2021 identified she would not expect RN #1 to conduct and document an assessment after an allegation of mistreatment if Resident #1 did not complain of any injuries. Interview, clinical record review and facility documentation review with the Administrator on 7/19/2021 at 11:50 AM identified that although she identified physical abuse was reported by Resident #1, she would not have expected RN #1 to complete an assessment of Resident #1 after the allegation of mistreatment because Resident #1 did not report any physical injury. The undated facility Abuse and Neglect Policy directed in part, that the nurse would assess the individual and document related findings. The Policy further directed that assessment data included an injury assessment, pain assessment, current behavior, vital signs, and behaviors.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #6), reviewed for accidents, the facility failed to notify the resident representative of an incident. The findings include: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change MDS dated [DATE] identified Resident #6 had severely impaired cognition and was totally dependent on the assistance of 2 people for personal hygiene. A physician's orders [REDACTED]. A nursing progress note dated 6/7/19 at 12:42 PM (a late entry note for 6/6/19) identified when the nurse aides were cutting Resident #6's fingernails, Resident #6 made a sudden movement and obtained a 1 cm by 0.3 cm wide wound on his/her left middle fingertip. The care plan dated 6/7/19 identified Resident #6's fingertip was cut when his/her nails were clipped. Interventions included provide a treatment to the fingertip as directed in the physician's orders [REDACTED]. Interview with the DNS on 6/13/19 at 9:15 AM identified she was unable to find documentation that identified Resident #6's representative was notified of the injury to the resident's finger. Interview on 6/13/19 at 10:35 AM with RN #1 identified she should have notified Resident # 6's representative of the resident's injury but forgot. A review of the facility's change in a resident's status policy identified a nurse will notify the resident's representative when the resident is involved in any accident that results in an injury.

Based on clinical record review and interview for three of six sampled residents reviewed for pressure ulcers (R#51, #62, #86) the facility failed to thoroughly assess pressure sores upon discovery and/or at least weekly, and/or failed to treat pressure sores in accordance with standards of care/current literature/manufacturer's directions, and/or failed to ensure that future pressure sores were prevented, and/or failed to ensure that only properly trained, licensed nurse's applied wound treatments. The findings included: 1. Resident #51 was admitted to facility on 06/02/16 with [DIAGNOSES REDACTED]. Nursing admission assessment dated [DATE] identified the presence of a red stage (1) one pressure sore located on the resident's coccyx without the benefit of measurements. physician's orders [REDACTED]. An interim resident care plan (RCP) dated 06/04/16 identfied a potential for skin breakdown related to impaired mobility, incontinence, and compromised nutritional intake. Interventions included turn and reposition every (2) two hours, check skin during care, encourage adequate nutrition and hydration, and to provide supplement as directed. An admission MDS assessment dated [DATE] identified the resident had no cognitive impairment, required extensive assistance with bed mobility and transfers, was incontinent, and had a stage two (2) pressure ulcer. Wound assessment dated [DATE] identified a stage (1) one open pressure area on the coccyx that measured 3.0 cm x 2.0 cm. that was noted as healed as of 6/16/16. A wound assessment dated [DATE] identified a new stage (2) two pressure area located between the buttocks that measured 1.0 cm x 1.0 cm. Physician orders [REDACTED]. Physician orders [REDACTED]. The pressure sore was documented as healed on 7/26/16. Nurse's notes dated 8/13/16 at 11:38 AM identified that R#51 complained of coccyx pain and that a pressure area was noted. The wound assessment dated [DATE] identfied a stage (2) two pressure ulcer located on R#51's coccyx that measured 2.0 cm x 1.5 cm. The document further identified the color of wound bed was red and that the resident was experiencing pain from the wound. Physician orders [REDACTED]. RCP dated 8/15/16 directed to provide treatment to coccyx per orders and observe for [DIAGNOSES REDACTED], drainage, increased size and depth. physician's orders [REDACTED].#51) an alternating air mattress to promote healing, prevention, and provide comfort. Interview with the ADNS (with DNS present) on 8/24/16 at 9:21 AM indicated that Selan cream can be applied to open (stage 2 ) pressure areas and did not require a protective dressing. S/he further indicated that Licensed staff provide the treatment once a shift and the nurse aides re-apply (to open wounds) after providing incontinent care. Interview with RN#2 on 08/25/16 at 10:02 AM indicated that the Selan treatment was applied by the license nurse every shift and was also re-applied by the nurse aides when they provided the resident incontinent care. In addition, review of A guide for using Selan products identified in-part that the product was used to treat and prevent perineal skin problems due to repeated exposure to heavy incontinence, to maintain skin integrity and to treat stage one (1) pressure ulcers. No where in the manufacturer's information did they recommend using the product on open wounds. 2. Resident #62's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified that the resident had short and long term memory problems and required extensive assistance with bed mobility, transfers, dressing and toilet use. The RCP dated 7/29/16 identified a stage one pressure sore of the buttocks and coccyx. Interventions included to turn and re-position every two hours and as needed when in bed, check skin integrity during care, and update MD as needed. Review of the initial nursing skin integrity documentation dated 7/29/16 identified a new stage one pressure sore on the buttocks, peri-wound normal, no drainage, area reddened and diffuse. Measurement of the area was not available as the description size was left blank. Weekly skin integrity documentation dated 8/5/16 identified a stage one pressure area to the buttocks and coccyx, that was diffuse, the area was estimated to be approximately 5 cm x 5 cm, wound bed red and purple and the area was identified as improved. Weekly skin integrity documentation dated 8/12/16 identified a rash to the coccyx and buttocks, and deep tissue injury (DTI) was checked as present. The assessment lacked measurements. On 8/19/16, wound assessment identified coccyx and buttock pressure wound but lacked appropriate staging (previously as stage one, then DTI), and measurements. Observation of Resident #62's treatment with LPN #2 on 8/24/16 at 9:25 AM identified a blanchable pink inner area, nickel sized, skin was noted to be peeling around the peri-wound. The wound was cleansed with soap and water, followed by the application of Selan cream. LPN#2 identified that although he/she felt the wound was measurable, he/she identified that he/she felt the area was diffuse so we just say diffuse. Interview and review of facility documentation with RN#1 on 8/24/16 at 12:45 PM identified that the facility policy for a stage one pressure ulcer was to measure the area. RN#1 identified that when the wound was measured on 8/5/16 it was probably more easily delineated that's why it was approximated to be 5 cm x 5 cm. On 8/12/15 when the area was noted to be more rashy, and a DTI, it was probably a misinterpretation. RN#1 identified that although the same staff generally perform the weekly measurements and would be able to identify an improvement or decline, they are not documenting what is needed, that the staff should fill out the skin integrity forms completely including measurements and that he/she was unable to explain why the area was not measured and/or that the skin integrity sheets were not completely documented. 3. Resident #86's [DIAGNOSES REDACTED]. The admission evaluation form dated 8/17/16 identified a slightly red area on the coccyx. The admission interim care plan dated 8/17/16 identified potential for skin breakdown, related to impaired mobility with interventions to check skin integrity during care, and treatment per order. The physician's orders [REDACTED]. The initial nursing skin integrity documentation dated 8/17/16 identified a stage 2 pressure ulcer of the coccyx which measured 2 x 1 cm, superficial depth, red / pink in color with no drainage. The weekly nursing skin integrity documentation form dated 8/24/16 identified a stage 1 pressure ulcer measuring 1 x 1 cm and that the wound was improved. Interview and review of facility policy with NA#1 identified that the Nurses Aides can apply Selan cream after the resident is incontinent, that he/she was assigned to and used the Selan cream the week before on Resident #86, but that only the licensed nursing staff applies the Selan AF cream. Interview with RN#1 on 8/25/16 at 11:19 AM identified that he/she was not aware that the manufacturer only recommended Selan for a stage one pressure ulcer. Additionally, although the licensed staff observes stage two pressure ulcers every shift, the nurses aides apply the Selan cream to stage two pressure ulcers when it is ordered for a stage two pressure ulcer and after incontinence has occurred.

Based on observations, clinical record review, review of facility documentation, and interviews for three of four sampled resident reviewed for accidents (Resident # 15, # 26, # 38) the facility failed to ensure an effective wanderguard system and/or failed to ensure adequate supervision to prevent an accident, and/or monitor and/or document the functionality of specialty mattress. The findings include: 1. Resident # 15 ' s [DIAGNOSES REDACTED]. The MDS dated [DATE] identified the resident had severe cognitive impairment, and required extensive assistance with ADLs. physician's order [REDACTED]. The RCP dated 9/16/16 identified a potential for elopement related to cognitive impairment. Interventions included checking the placement and functioning of the wander guard per facility policy. Nurse ' s notes dated 9/23/15 identified that at 10:50 AM, the resident was found lying in a supine position on the pavement in the facility ' s parking lot. The resident ' s wheel chair was observed tipped on its side. The resident was not moved until emergency help arrived and the resident was transferred to the ED for evaluation. The ED report dated 9/23/15 identified a closed fracture of the scaphoid bone of the right wrist and a closed displaced fracture of the surgical neck of the right humerus. Interview, review of the clinical record, review of the facility ' s investigation on 8/23/16 at 1:15 PM with the DNS identified there were two wander guard sensors on the unit located near the unit doors and one located just after the unit doors in the facility ' s foyer hallway. The DNS indicated that approximately ten minutes prior to finding the resident outside, the resident was noted with exit seeking behaviors and set off the first wander guard sensor while attempting to leave the unit. The resident was returned to the common area. Further interview with the DNS identified although the front entrance doors lock when the wander guard is activated, the wander guard failed to activate and the resident was able to leave the facility through the front entrance. Additionally, there was not a staff member present at the front entrance reception desk at the time allowing the resident to leave the facility unnoticed. Prior to the incident the nursing staff checked the placement of the wander guard transmitters every shift to ensure they were appropriately attached to the residents and the maintenance department checked the function weekly. Interview and observation of the two wander guard wall sensors 8/23/16 at 1:30 with the Director of Maintenance identified the wander guard alarm would not sound if the resident passed through too far to the left of the first sensor and/or too far right of the second sensor because the activation fields did not extend to the entire width of the hallway. The resident could have passed through both sensors without activating the alarms. Further interview and review of Wander Guard Testing documentation identified the maintenance department did function checks of the wander guard transmitters located on the residents on 9/4/15, 9/11/15, and 9/18/15. Although the Director of Maintenance indicated that the wall units were checked for function, the facility failed to provide documentation that the wall sensors were checked for function. Subsequently to the incident on 9/23/15 the facility installed additional wall sensors to increase the activation field. And changed the facility ' s policy and now directed the nursing staff to check the function of the wander guard transmitters three times a week and the maintenance department checks the wall sensors daily. 2. Resident # 26 ' s [DIAGNOSES REDACTED]. The annual MDS dated [DATE] identified that R#26 was severely cognitively impaired, and totally dependent on 2 staff members for bed mobility and transfers. Resident Care Plan (RCP) dated 8/12/16 identified that R#26 had alteration in mobility and required mechanical lift and assistance of staff with transfers. Interventions directed to assist R#26 with bed mobility, turn and reposition every 2 hours and prn while in bed, observe for complications of impaired mobility: further decreased range of motion, pressure sores and transfers with mechanical lift and staff assistance to adapted wheelchair. The nurse ' s note dated 7/26/16 at 7:59 a.m. identified that R#26 was found on the floor by Nurse and NA staff after they heard a crash during report. He/she was found on the floor lying on the left side with his/her head on the base of the overhead table. He/she was alert with usual mentation. Laceration to her/his scalp. MD was notified and directed staff to transport to Emergency Department. Review of the facility Reportable Event documentation dated 7/26/16 identified that upon investigation, the alternating air pressure (reducing) mattress controls reported low pressure at the time of the fall. The report indicated that the mattress would be replaced with one with bolstered sides. Observation and Interview with RN#1 8/25/16 at 12 p.m. identified that R# 26's air mattress pump was set on #4 for 150-195 pounds, which consequently was identified by RN#1 to be inaccurate. According to RN#1, settings are weight based and the last weight dated 8/4/16 was 116.4 pounds. RN#1 also indicated that air pressure/mattress settings should identified in the Kardex but the facility did not have specific guidelines for checking the functionality of the air mattresses. In an interview and clinical record review with RN#1 on 8/25/16 at 12:30 p.m. noted that Procare (specialty bed supplier/maintenance Company) came to evaluate the bed after the fall but did not provide any written report on the results of their evaluation. RN#1 noted that the company indicated that the bed was not broken at the time of the fall. RN#1 was unable to provide documentation that the bed settings and / or functioning were being monitored at the time of the fall. Interview with NA#2 on 8/25/16 at 11 a.m. noted that s/he heard a crash and went running into R#26 ' s room and found R#26 on the ground on her/his left side with her/his head on the metal portion of the tray stand. NA#2 reported that he/she saw the bed deflated on the left side when he/she arrived in room. The facility did not provide an air pressure mattress maintenance policy and did not currently have one per confirmation by DNS on 8/25/16. 3. Resident #38's [DIAGNOSES REDACTED]. The RCP dated 6/30/16 identified a risk for falls. Interventions directed motion sensor as directed, chair alarms per orders, and to keep resident in view. Physician orders [REDACTED]. The clinical record identified R #38 had experienced 10 falls from 4/5/16 through 7/24/16. The Reportable Event form dated 7/24/16 identified R #38 attempted to transfer self from the bath room and fell to the floor hitting his/her head on the door jam sustaining a small abrasion to his/her mid back. The facility investigation identified NA #3 assisted R #38 to the bathroom, left R #38 alone unattended in the bathroom, and the resident attempted to transfer and fell to the floor. Subsequently NA #3 received education not to leave residents unattended in the bathroom if they require assistance for transfers or standing. Interview and review of the reportable event with the DNS on 8/25/16 at 11:00 AM identified NA #3 assisted R #38 to the bathroom and left R #38 unattended. The DNS indicated education was provided to NA #3 to educate him/her when residents need assistance for transfers and/or standing they should be attended to at all times while in the bathroom.

Based on clinical record reviews, staff interviews, review of facility documentation and review of facility policy and procedure for two of five residents reviewed for accidents (Resident # 51, 58), the facility failed to follow the residents plan of care for safe transfers resulting in injuries. The findings include: 1. Resident #51's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified that the resident required extensive assistance with ADL's, was unable to ambulate, was dependent on staff for locomotion on and/or off unit and utilized a wheel chair as a mobility device. The care plan (RCP) dated 8/5/13 identified an alteration in mobility due to the resident being unable to stand and ambulate, utilizing a mechanical lift and assist of two (2) staff for transfers. Interventions included to transfer the resident utilizing a mechanical device and staff assistance, as ordered. physician's orders [REDACTED]. Nurse's notes dated 9/13/13 at 5:45 PM identified that the resident was stood up and verbalized "I can't do it ". Nurse's notes dated 9/13/13 timed at 8:00 PM identified that R#51 complained of discomfort in his/her right knee. Nurse's notes dated 9/15/13 timed at 6:00 PM identified that R#51 received an x-ray of right lower extremity that identified a recent fracture involving the right proximal tibia with no displacement. Facility documentation dated 9/16/13 identified that R#51 was not transferred following the plan of care. Interview with the Assistant Director of Nursing (ADNS) on 5/28/14 at 8:34 AM indicated that although R#51 was non-ambulatory and should have been transferred via a Sara (mechanical lift) at the time of the incident, NA#1 and NA#2 had stood the resident, not utilizing a mechanical lift. NA #1 and NA#2 received disciplinary actions and staff were re-educated. Facility mechanical lifts policy procedure identified in part that the purpose of utilizing a mechanical lift was to provide a means of transferring a resident safely that is unable to stand or transfer. 2. Resident #58's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident had severely impaired cognition, no mood or behaviors were exhibited, and required extensive assistance of two for bed mobility, transfers, and toilet use. A care plan dated 3/19/14 identified an alteration in mobility. Interventions included to transfer with the assistance of two staff members. Physician orders [REDACTED]. Physician orders [REDACTED]. Facility documentation/report dated 5/21/14 at 10:30 AM identified that while NA #3 was assisting R#58 to stand in the shower room, the resident's knees buckled and the resident was lowered to the floor sustaining a skin tear on the left forearm. Interview with NA #3 on 5/28/14 at 11:00 AM identified while attempting to transfer R #58 to the shower chair on 5/21/14, R #58's knees buckled and the resident was lowered to the floor. NA #3 knew the resident required the assistance of two for transfers but thought he/she could transfer the resident without the help of another staff member. Interview with the ADNS on 5/28/14 at 11:10 AM indicated when a resident has a fall, or is noted with a bruise and/or skin tear the charge nurse on the unit will initiate a facility report, notify the responsible party, the physician and start an investigation. When the report is completed it is then reviewed by the DNS for follow up to identify what the causative factors were and to determine what interventions should be implemented based on the conclusion of the investigation. The ADNS identified that NA # 3 received a Performance Counseling in-service dated 5/26/14 for failure to follow the residents plan of care related to transfer status.