Every finding on record at Farwell Care and Rehabilitation Center

Based on interviews and record reviews, the facility failed to thoroughly investigate and document allegations of abuse, neglect, and misappropriation of property for 7 of 7 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7).The facility failed to thoroughly investigate and document evidence of five reported allegations of abuse, neglect, and misappropriation of propertyThis failure could result in residents to experience continued abuse or neglect and decreased quality of life.Findings Included:Resident #1Record review of Resident #1's face sheet, dated 07/23/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included unspecified dementia (showing signs of cognitive decline), cognitive communication deficit (disruption of mental process essential for communication), need for assistance with personal care, and muscle weakness. Record review of Resident #1's quarterly MDS, dated [DATE], section C, revealed a BIMS score of 00, indicating severe cognitive impairment. Record review of Resident #1's care plan, revised on 04/17/2026, revealed a focus of skin tears related to fragile skin, medication effects, or impaired mobility, which require gentle care and protection to prevent further injury. Record review of Resident #1's progress note, dated 07/14/2026, authored by DON, provided the following information: 1250 (12:50 PM)- Notified by staff that [Resident #1] had experienced a skin tear that was bleeding through pant leg on right lateral lower extremity 1255 (12:55 PM)- DON went to resident room with charge nurse LVN D, wound care nurse LVN E, and CNA F to assess the wound lower extremity had a one inch by one-inch square place of skin that had been pulled back exposing tissue and fat underneath. Fat was observed and minimal loss was observed. LVN E placed a clean gauze saturated in wound cleaner to the area. LVN D wrapped the leg with gauze. This RN observed the wheelchair where the leg had been scratched up against and observed the metal area on leg pedals where the wound had occurred. Physical therapy had been consulted for a change in wheelchair or padding prevent further incident occurrence. 1300- [FNP], notified by ADON 1305 (1:05 )- [Resident #1 family member] was notified by ADON. [Resident #1 family member] requested [Resident #1] be taken to [name of local hospital]. Maint G from maintenance called [hospital ER]. 1310- Messaged department heads to make aware of the situation. 1410- Met with ADM to discuss plan of action to prevent future occurrences and to assess further need for [Resident #1] assist during. Will continue to monitor resident upon discharge from the [name of local hospital]. Resident #2Record review of Resident #2's face sheet, dated 07/23/2026, revealed a 61-year- old male admitted to the facility on [DATE] with a readmit on 11/17/2025. Resident #2's diagnoses included acute ischemic heart disease (sudden, severe reduction of blood flow to the heart), diabetes (insulin resistance and high blood sugar levels), heart failure, and need for assistance with personal care. Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 09, indicating moderate cognitive impairment. Record review of Resident #2's care plan, revised on 03/25/2026, revealed a focus of diagnosis of schizophrenia (mental disorder that affects how a person thinks, feels, and believes), which may include delusions, hallucinations, disorganized thinking, or flat affect, placing Resident #2 at risk for impaired communication, safety concerns, and taking medications as prescribed. Resident #2 had a focus, initiated on 06/23/2026, on involvement in a resident-to-resident altercation, sustaining emotional and/or physical injury risk. Resident may exhibit fear, anxiety, or behavioral changes related to the event. Care plan revealed an additional focus, dated 06/18/2026, that stated roommate became agitated and cussing and threw a cup with water at him striking him in the face. Resident sustained an approximately 1cm x 1cm laceration to the chin. Record review of Resident #2's progress note, dated 06/18/2026, authored by LVN H, stated that [Resident #2] was lying in bed after lunch when roommate became agitated and cussing and threw a cup with water at him striking him in the face. Resident sustained approximately 1cm x 1cm laceration to chin. No other injuries noted. Resident #3Record review of Resident #3's face sheet, dated 07/23/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3's diagnoses included unspecified dementia (showing signs of cognitive decline), anxiety disorder (temporary excessive worry or unease), Type 2 diabetes (insulin resistance and high blood sugar levels), and Epilepsy (seizures). Record review of Resident #3's MDS, dated [DATE], revealed a BIMS score of 13 (intact cognition) in section C. Section GG, GG1030, revealed resident required partial/moderate assistance with shower/bathe self and putting on/taking off footwear, supervision or touching assistance with oral hygiene, toileting hygiene, upper body dressing, lower body dressing, and personal hygiene, and setup or clean-up assistance with eating. Section GG1070, mobility, revealed partial/maximal assistance with lying to sitting on side of bed, and supervision or touching assistance with rolling left and right, sit to lying, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, walking 10 feet, walking 50 feet with two turns, and walking 150 feet. Resident #3 was coded as not using a wheelchair. Record review of Resident #3's care plan revealed a focused area, revised on 03/28/2026, of Resident #3 demonstrated wandering and/or exit-seeking behavior, placing self at risk for elopement or injury. Resident #3 has a focus area, revised on 04/30/2026, where resident exhibited episodes of making false accusations (e.g. claiming theft, abuse, or mistreatment without evidence), which may affect relationships with staff and peers and indicated underlying psychosocial or cognitive concerns such as calling 911. Record review of Resident #3's progress note, dated 06/18/2026, authored by ADON, stated Resident #3 was hit in the chest by roommate, no safety awareness and does not like having a roommate. ADM was notified of the situation, video was observed, police and family were notified. Record review of Resident #3's progress note, dated 06/18/2026, authored by ADON, stated a body assessment was completed on Resident #3 and no red areas or discoloration noted. Resident #4Record review of Resident #4's face sheet, dated 07/23/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4's diagnoses included other specified noninfective gastroenteritis and colitis (inflammatory conditions of the digestive tract), excoriation disorder (skin-picking), muscle weakness, and need for personal care. Record review of Resident #4's discharge MDS, dated [DATE], revealed a BIMS score of 13 (cognitively intact) under section C. Section GG, GG1030 revealed resident required supervision or touch assist with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene, and setup or clean-up assistance with eating. Section GG0170 revealed Resident #4 needed supervision or touching assistance with all mobility performance. Record review of Resident #4's care plan revealed a focus, initiated 06/02/2026 and revised on 07/08/2026, of resident requiring varying levels of staff assistance for ADLs placing Resident #4 at risk for decreased independence, impaired dignity, and functional decline. A focused goal initiated 06/02/2026 and revised on 07/08/2026, revealed Resident #4 had the potential for pressure injury development related to limited mobility, incontinence, poor nutrition, fragile skin, impaired sensation, recent surgery or prolonged bed rest with wound noted on the right upper buttocks area. Record review of Resident #4's progress note, dated 06/10/2026, authored by ADON, stated family was writing a grievance statement about an aide they felt like was too rough, and too hurried when resident was showered. Will send the aide to ADM to visit with the aide. Record review of Resident #4's progress note, dated 06/10/2026, authored by ADON, stated spoke with other shower aide and requested to provide Resident #4 showers. Record review of Resident #4's progress note, dated 06/10/2026, authored by DON, revealed ACTD provided grievance report to DON regarding an incident that occurred earlier in the day. Resident #4 reported that aide was being too rough during her shower and being dismissive of the resident's discomfort. DON sent the aide home due to issue with resident complaint and unprofessional behavior with resident. Resident #5Record review of Resident #5's face sheet, dated 07/23/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5's diagnoses include cerebral infarction (stroke), age related cognitive decline (normal, gradual changes in thinking abilities after age [AGE]), muscle weakness, cognitive communication deficit (disruption of mental process essential for communication), and reduced mobility. Record review of Resident #5's annual MDS, dated [DATE], revealed in section C, a BIMS score of 11 (moderate cognitive impairment). Section GG, GG0130, revealed Resident #5 was dependent on toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene, substantial/maximal assistance with upper body dressing, supervision or touching assistance with oral hygiene, and setup or clean-up assistance with eating. Section GG1070 revealed Resident #5 was dependent on toilet transfer and tub/shower transfer, substantial/maximal assistance with rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer. Resident #5 was coded he used a wheelchair. Resident #6Record review of Resident #6's face sheet, dated 07/23/2026, revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #6's diagnoses included unspecified dementia (showing signs of cognitive decline), anxiety (temporary excessive worry), Alzheimer's Disease (progressive neurodegenerative disorder), and major depressive disorder (persistent feelings of sadness). Record review of Resident #6's discharge MDS, completed on 06/23/2026, section C, revealed a BIMS score of 02 (severe cognitive impairment). Section GG, GG0130, revealed he needed supervision or touching assistance with oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, and putting on/ taking off footwear. Resident #6 was coded as needing set up or clean-up assistance with eating. Section GG1070 revealed Resident #6 required supervision or touching assistance with rolling left to right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer. Resident #6 was coded with using a manual wheelchair. Record review of Resident #6's care plan, initiated on 09/27/2025, had a focus of involvement in a resident-to-resident altercation, sustaining emotional and/or physical injury risk. Resident may exhibit fear, anxiety, or behavioral changes related to the event. Resident #6 had a focus, dated 11/20/2026, of exhibiting verbal outbursts characterized by yelling, cursing, or aggressive speech, often in response to perceived frustration, confusion, or unmet needs. Record review of Resident #6's care plan revealed a focus, initiated and revised on 06/23/2026, of Resident #6 exhibited physically aggressive behaviors such as hitting, pushing, or kicking, typically in response to perceived threats, confusion, or frustration. Record review of Resident #6 progress report, dated 06/18/2026, authored by DON, revealed DON spoke with Resident #5 about throwing the cup. Resident #6 was advised behavior was not okay and not to harm other residents. Record review of Resident #6's progress note, dated 06/18/2026, authored by ADON, revealed a referral was made to [name of behavioral health hospital] and family contacted about finding alternate placement for Resident #6. Record review of Resident #6's progress note, dated 06/18/2026, authored by ADON, stated resident threw a cup at his roommate, hit roommate in the chin and there is now an abrasion. Record review of Resident #6's progress note, dated 06/18/2026, authored by ADON, stated that Resident #6 was moved to another room. Resident #7Record review of Resident #7's face sheet, dated 07/23/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7's diagnoses included type 2 diabetes (insulin resistance and high blood sugar levels), age related cognitive decline (normal, gradual changes in thinking abilities after age [AGE]), need for assistance with personal care, and polyneuropathy (nerve disease caused by damage to many nerves). Record review of Resident #7's quarterly MDS, dated [DATE], revealed a BIMS score of 13 (cognitively intact) under section C. Section GG, GG0130, revealed resident needed substantial/maximal assistance with toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. Resident #7 was coded as needing supervision or touching assistance for oral hygiene and setup or clean-up assistance with eating. Records review of Resident #7's care plan, focus dated 12/14/2025 and revised on 12/24/2025, documented resident had impaired cognitive function/dementia or impaired thought processes r/t impaired decision-making, short-term memory loss. Focus, dated and revised on 02/05/2026, revealed a history of trauma or post-traumatic stress disorder, which may impact emotional well-being, daily functioning, and response to care. Record review of Resident #7's progress note, dated 06/09/2026, authored by ADON, stated LVN D reported Resident #7's wheelchair was taken and resident was reporting missing money. Record review of Resident #7's progress note, dated 06/10/2026, authored by ADON, stated ADM talked to Resident #7 and facility will provide a lock box. Record review of Resident #7's progress note, dated 06/10/2026, authored by ADM, stated ADM had spoken with Resident #7 and delivered a lock box. ADM noted that the facility would reimburse Resident #7 for the money lost. Record review of 3613-A (Provider Investigation Report), reported on 06/10/2026, revealed victim was Resident #4 and perpetrator was CNA C. Form 3613-A revealed the perpetrator denied the allegation of being too rough with Resident #4 and result was inconclusive. Section Provider Response stated that CNA C was sent home before her shift ended and marked as do not return in the agency application. CNA C was interviewed who denied the allegation. Interview with Resident #4 was attached, not dated, and Resident #4 provided their account of the events that happened as well as was advised another aide would be the staff providing showers. Three individual progress notes, dated 06/10/2026, authored by ADON, provided with investigation packet along with completed in-services. Record review of 3613-A (Provider Investigation Report), reported on 06/18/2026, revealed an incident for Resident #3 and Resident #5. Resident #5 was noted as the perpetrator. Description of allegation was Resident #5 struck Resident #3 in the chest. LVN H completed a head-to-toe assessment on 06/18/2026 with no injuries, redness, swelling, or bruising noted. Provider response indicated that Resident #5 was moved to an empty room and local police were notified. Report indicated police spoke with Resident #5 about incident. Report stated that Resident #5 admitted to striking Resident #3. HSK I was listed as a witness and provided a written witness statement, dated 06/18/2026 attached to the report. In- services related to the incident were provided. Record Review of 3613-A (Provider Investigation Report), reported on 06/17/2026, revealed an incident for Resident #2 and Resident #7 of resident/patient/client abuse. The 3613-A revealed Resident #7 was the alleged perpetrator and the incident occurred in C Hall. 3613-A indicated that HSK I was a witness to the incident and provided a written statement from HSK I, dated 06/18/2026. LVN H assessed injuries. In-services related to the incident were provided. Record review of 3613-A (Provider Investigation Report), dated 06/17/2026, revealed an incident involving Resident #7. CNA A and CNA B were listed as alleged perpetrators who denied the allegations of taking Resident #7's money. The 3613-A indicated the alleged perpetrators were identified by facility camera. Investigation summary reported that CNA A and CNA B were interviewed and taken off the schedule. Record review of the footage indicated the wheelchair was removed from Resident #7's room but does not state by whom. The report noted that alleged perpetrators were in the shower room for more than 10 minutes with the door closed. After 10 minutes, the alleged perpetrators brought Resident #7's wheelchair out of the room and the bag was repositioned. The sheriff was notified. The investigation is noted to be inconclusive. Provider Action Taken Post-Investigation stated the following: Many people (residents and staff) had access to the resident's room during the night of 06/08/2026. Since she has no camera in her room and there is no camera in the shower room, we could not determine who removed the cash from the resident's bag. We reimbursed the resident and gave her a lock box with a key/lanyard to keep in her room. Report contained one written statement by CNA J who reported the allegation. Record review of 3613-A (Provider Investigation Report), reported on 07/14/2026, revealed an allegation with Resident #1 and CNA F. Description of allegation indicated when CNA F was transferring Resident #1 to bed, blood was noted on pant leg and was reported to unknown nurse. No witnesses were noted in the investigation. Skin assessment was completed by LVN E. Provider response indicated CNA F completed transfer training on 07/14/2026. 3613-A provided a written statement, dated 07/14/2026, attached to report indicating injury was noted when blood was seen on Resident #1's leg when supporting for transfer. CNA F stated she went and told charge nurse (no name provided) about injury. In-service on abuse/neglect/exploitation provided, dated 07/14/2026, revealed CNA F had not completed training. Record review of Resident Rights, dated 07/14/2026, did not indicate CNA F had completed training. Retraining for Proper Transfer was completed by CNA F on 07/14/2026. In an interview on 07/23/2026 at 11:07 AM, Resident #3 stated an incident did occur with Resident #5. Resident #3 stated Resident #5 hit him, but he was not scared and didn't get hurt. In an interview on 07/23/2026 at 11:11 AM, Resident #2 stated he had a roommate before, but he was mean and aggressive. Resident #2 denied his old roommate had done anything to him. In an interview on 07/23/2026 at 11:23 AM, DON stated CNA C was not allowed back to the facility. DON stated it was CNA C's first time working and multiple residents stated she was rough with them in the shower. CNA C was asked to leave within 5-6 hours and asked [name of agency] for CNA C to not return to the facility. In an interview on 07/23/2026 at 3:27 PM, COTA stated she heard someone talking about the incident between Resident #4 and CNA C but didn't know about facts. COTA stated she heard that CNA C was rude to Resident #4. COTA stated she did not know of any additional complaints. COTA stated a negative outcome of not following abuse, neglect, and exploitation policy could be bruising, emotionally damaged, financially damaged, emotional or physical. In an interview on 07/23/2026 at 3:56 PM, CNA B stated via phone interview that she was not contacted or interviewed regarding the incident on 07/14/2026. CNA B stated the facility did not make her aware that she was suspended and she was not in-serviced prior to returning. CNA B stated a negative outcome of not following abuse, neglect, and exploitation policy or thoroughly investigating allegations was it wouldn't be good. In an interview on 07/23/2026 at 4:05 PM, CNA A stated no one called to get any information regarding the incident with Resident #7. CNA A stated a negative outcome of not following abuse, neglect, and exploitation policy or thoroughly investigating allegations was death. In an interview on 07/23/2026 at 4:18 PM, LVN D stated she did report the incident of Resident #4's injury on 07/14/2026 to the DON. LVN D stated she did not write a statement regarding the incident on 07/14/2026. LVN D stated a negative outcome of not following abuse, neglect, and exploitation policy or thoroughly investigating allegations was it could happen again or keep happening. It can put the resident in danger. In an interview on 07/23/2026 at 4:27 PM, CNA F stated she was present for the incidents including Resident #1, Resident #2, Resident #3, Resident #5, and Resident #6. CNA F stated she was not interviewed nor wrote a statement for the incidents that occurred with Resident #2 and Resident #6 or incident with Resident #3 and Resident #5. CNA F stated her last in-service for abuse, neglect, and exploitation was a little before May 15th which is when she graduated. CNA F stated a negative outcome of not following the abuse, neglect, and exploitation policy would be the residents could be in danger or could be hurt. Residents could be mentally and physically abused. It's going to affect them and how they act. In an interview on 07/23/2026 at 5:16 PM, CNA C stated she had only worked at the facility once and it was a couple of months back. CNA C stated she assisted on the hall that was across from therapy. CNA C stated she assisted with personal care, passing trays, daily tasks, showers, making beds, and feeding. CNA C stated she did not have any residents who stated she was hurting them or any residents that were guarded. CNA C stated that the ADM stated someone complained that CNA C was being too rough but other than that, no other complaints were voiced. CNA C stated that she was not made aware of a male resident making a complaint. CNA C stated she was told to switch out with one of the other staff and CNA C was removed from Resident #4's room. CNA C stated she did not go home early and she worked a full shift. CNA C stated she was not advised she was being relieved of her duties and to go home. CNA C stated she was not contacted for an interview and has not heard anything else regarding the situation. CNA C stated she does not remember who the other staff was she switched with. In an interview on 07/23/2026 at 5:45 PM, the DON and ADM were asked about timecards for CNA C. The DON and ADM stated that CNA C was asked to leave and not put on the schedule until investigated. In an interview on 07/23/2026 at 5:53 PM, COP stated he had received approximately two incidents with Resident #2 and Resident #5 as well as Resident #7. He stated he had received them around the same time but was unable to find the date. COP stated he was unable to investigate misappropriation of property at this time due to additional cases he has been working on but he did speak with Resident #5 regarding the incident of resident-on-resident abuse. In an interview on 07/23/2026 at 6:30 PM, ADM reviewed 3613-As submitted. ADM stated that alleged perpetrator (CNA F) for Resident #1 was not trained on abuse, neglect, and exploitation prior to returning to the facility. ADM stated according to policy, staff members were to be suspended. ADM confirmed that CNA F was not suspended but was retrained the same day the incident occurred. Resident #2 and Resident #6 were roommates at the time and Resident #2 got hit in the face. Resident #6 was advised on hitting other residents. ADM stated she did not interview Resident #6 but did have a conversation about behavior. ADM stated that Resident #3 and Resident #5 were roommates at the time of the incident. ADM stated Resident #5 hit Resident #3 in the chest. ADM stated she does not have documentations of the interviews with the residents but had one interview with HSK I. ADM stated she found out about the incident on July 10th, 2026, but the incident was reported on July 9th, 2026. ADM stated she looked at footage of the facility cameras. ADM stated she does not remember who reported the incident to her. ADM stated the DON did speak to CNA A and CNA B but both denied it when she spoke with them on the phone. ADM stated COP spoke with Resident #7. ADM stated that as of right now, she does not have documentation of the interviews. ADM stated a negative outcome of not following the policy could be someone could get hurt or could be exploited. In an interview on 07/23/2026 at 7:15 PM, the DON stated after the incident with Resident #1 occurred, the Resident was sent out to the hospital. The DON stated they asked for CNA F to stay and be retrained on proper and safe transfers. DON stated she believes that CNA F continued to provide care after Resident #7 returned from the hospital. DON stated if she felt there was any malicious intent, the facility would have suspended CNA F. DON stated a call was made to corporate to obtain guidance. DON stated CNA F wrote a statement. DON stated a progress note was done but nurses and wound nurse did not write a statement. DON stated Resident #4 reported the issue with CNA C to the nurse and speech therapist. DON stated that ADM was already made aware of the situation by LVN D. DON stated she did not have any documented interviews with any residents, staff, or alleged perpetrators. DON stated CNA C went home at noon because DON had seen her in the dining room. DON reviewed time sheet for CNA C and stated she worked a full shift and did not clock out of the facility until 6:05 PM. DON stated she told LVN D multiple times that CNA C needed to leave. DON stated she should have gone to send CNA C home when she was in the dining room. DON stated that if CNA C was still in the building, it could have placed residents in harm's way. DON stated she did speak with two residents regarding the care of CNA C, but she did not have any documented interviews. DON stated she doesn't feel protocol was followed. DON stated Resident #2 and Resident #6 were separated and no interviews were documented. DON stated she believes the ADM completed a thorough investigation for the incident involving Resident #2 and Resident #6. DON stated Resident #5 was upset he had a roommate. Resident #2 stated Resident #5 did not hit him. DON stated they did speak with CNA's as to what happened. DON stated no interviews or witness statements were documented. DON stated she was notified that Resident #7 was missing money. DON stated they did watch the camera and suspended the CNA's. DON stated there were no written or documented statements. DON stated she does not believe that CNA B has been retrained prior to returning to work. DON stated a negative outcome of not following the abuse, neglect and exploitation policy is the abuse can continue and the perpetrator could think they are getting away with it. Record review of timecard, dated 06/10/2026, revealed CNA C start time for shift at 06:53 AM and an end time of 6:05 PM on 06/10/2026 for a total of 10 hours and 42 minutes. Record review of Abuse, Neglect and Exploitation policy, dated 2024, stated under heading Policy Explanation and Compliance Guidelines, 1., C. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention. 3. The facility will provide ongoing oversight and supervision of staff to ensure that its policies are implemented as written. Under heading II. Employee Training B. Existing staff will receive annual education through planned in-services and as needed. Under heading V. Investigations of Alleged Abuse, Neglect and Exploitation: A- An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B- written procedures for investigations include: 1. Identifying staff responsible for the investigation, 4. Identifying and interviewing all involved person, including the alleged victim, alleged perpetrator, witnesses, and other who might have knowledge of the allegations, and 6. Providing complete and thorough documentation of the investigation. Under heading VI. Protection of Resident: the facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse during and after the investigations. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation. D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. Record review of Abuse, Neglect, and Exploitation policy, dated 07/14/2026, stated under heading V. Investigation of Alleged Abuse, Neglect, and Exploitation, section B, 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 6. Providing complete and through documentation of the investigation. Under section VI. Protection of Resident, item A: Responding immediately to protect the alleged victim and integrity of the investigation (each time abuse is involved, suspected employee(s) will be suspended pending investigation.

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for respiratory care. The facility failed to store Resident #1's nasal cannula properly. This failure could place resident at risk for complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition.Findings include: Record review of the clinical record for Resident #1 revealed an [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include Parkinson's (a disorder of the central nervous system that affects movements toinclude tremors), acute respiratory failure (occurs when the lungs cannot adequately pull oxygen into the blood or remove carbon dioxide from the body), obstructive sleep apnea (a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and heart failure (a chronic condition in which the heart dose not pump blood as well as it should). Record review of Resident #1's clinical record revealed he had been in the facility for 4 days and an MDS was not due to be completed. Record review of Resident #1's clinical record revealed a baseline care plan with admission date of 05/15/2026 listing him for the use of oxygen therapy. During an observation and attempted interview on 05/19/2026 at 07:58 AM Resident #1 was in his room in his bed. Observed was his O2 concentrator that was on, but his nasal cannula was on the floor next to the head of his bed beside the O2 concentrator. When asked about the nasal cannula Resident #1 reported something about him being under his house. He was unable to give an intelligible answer. During an observation on 05/19/2026 at 09:00 AM Resident #1 was in his wheelchair outside his room. Resident #1's nasal cannula was on the floor in his room in the same position as noted on 05/19/2026 at 07:58 AM. During an observation on 05/19/2026 at 10:00 AM Resident #1 was in his wheelchair in the hallway by the physical therapy department. Resident #1's nasal cannula was on the floor in his room in the same position as noted on 05/19/2026 at 07:58 AM. During an observation on 05/19/2026 at 10:55 AM Resident #1 was in his wheelchair with a staff member taking him to the dining room. Resident #1's nasal cannula was on the floor in his room in the same position as noted on 05/19/2026 at 07:58 AM. During an interview on 05/19/2026 at 10:57 AM LVN A (the nurse responsible for Resident #1 this shift) LVN A reported staff should round every 2 hours or as needed, and all staff including the nurse's and CNAs should do rounds. LVN A entered Resident #1's room and reported his oxygen tubing should not be on the floor, this was an infection control issue, and the resident could get germs. LVN A was not sure who was responsible for completing the training for staff since she only started last Thursday. During an interview on 05/19/2026 at 11:02 AM CNA B (the CNA responsible for Resident #1 this shift) reported she constantly walks back and forth down the hallway and checks every room all the time. CNA B reported she will check every resident for their oxygen, but she is not allowed to touch the oxygen. She entered Resident #1's room and reported she would turn on the oxygen button and put the nasal cannula on the resident. When asked if she would use the current cannula (that was on the floor) CNA B stated yes and when asked if the cannula on the floor was an issue she stated, No it's not an issue if it's on the floor. When asked if she had been trained on oxygen safety and care CNA B stated, It's only my second day and CNA C is my instructor. During an interview on 05/19/2026 at 11:09 AM the DON reported the CNA staff are to do rounds every two hours and the nursing staff are to do rounds at the opposite hours. The DON noticed the nasal cannula on Resident #1's floor and reported it was an issue and should have been addressed to prevent infection control issues. During an interview on 05/09/2026 at 12:00 PM CNA C (the trainer for CNA B) reported she was on light duty at this time and was being utilized as a trainer. CNA C reported CNA B had been working for 2 days and she had not had much time to work with CNA B. CNA C reported staff are expected to do rounds every two hours and a resident's nasal cannula cannot be on the floor. That if the nasal cannula was found on the floor it should be changed for a new one. If a staff member were to use a nasal cannula that had been on the floor, then that was a violation of infection control. CNA C reported the DON has completed training with all the staff on oxygen bottle safety. During an interview on 05/19/2026 at 11:48 AM the Administrator reported the facility did not have a policy that was specific for storing the nasal cannula and tubing off the floor. That it was generally understood. Record review of the facility provided policy titled Oxygen Safety undated, revealed the following:Policy: It is the policy of this facility to provide a safe environment for residents, staff, and the public. Policy Explanation and Compliance Guidelines:Safety of the responsibility of staff.7. Accessories - a. Accessories, i.e. cannulas/tubing, are to be stored when not in use. Cannulas and tubing should be stored in clean zip lock bags that are accessible to the residents.

Based on observation, interview, and record review, the facility failed to ensure that the residents' environment remained as free from accident hazards as was possible; and that each resident received adequate supervision to prevent accident hazards for one resident (Resident #1) of 5 residents observed for accident hazards. -Resident #1 had an oxygen bottle/cylinder left unsecured in his room. This failure could lead to injuries such as bruising, skin tears, fractures, and feelings of fear and isolation. Findings include: Record review of the clinical record for Resident #1 revealed an [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include Parkinson's (a disorder of the central nervous system that affects movements toinclude tremors), acute respiratory failure (occurs when the lungs cannot adequately pull oxygen into the blood or remove carbon dioxide from the body), obstructive sleep apnea (a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and heart failure (a chronic condition in which the heart dose not pump blood as well as it should). Record review of Resident #1's clinical record revealed he had been in the facility for 4 days and an MDS assessment was not due to be completed. Record review of Resident #1's clinical record revealed a baseline care plan with admission date of 05/15/2026 listing him for the use of oxygen therapy. During an observation and attempted interview on 05/19/2026 at 07:58 AM Resident #1 was in his room in his bed. Observed was an oxygen bottle leaning against his dresser and the wall in the corner of his room that was unsecured with a nasal cannula attached to it. When asked about the oxygen bottle Resident #1 reported something about him being under his house. He was unable to give an intelligible answer. During an observation on 05/19/2026 at 09:00 AM Resident #1 was in his wheelchair outside his room. The oxygen bottle was unsecured leaning against his dresser and the wall in the corner of his room. During an observation on 05/19/2026 at 10:00 AM Resident #1 was in his wheelchair in the hallway by the physical therapy department. The oxygen bottle was unsecured leaning against his dresser and the wall in the corner of his room. During an observation on 05/19/2026 at 10:55 AM Resident #1 was in his wheelchair with a staff member taking him to the dining room. The oxygen bottle was unsecured leaning against his dresser and the wall in the corner of his room. During an interview on 05/19/2026 at 10:57 AM LVN A (the nurse responsible for Resident #1 this shift) reported staff should round every 2 hours or as needed, and all staff including the nurse and CNAs should do rounds. LVN A entered Resident #1's room, noted the oxygen bottle leaning against the dresser and wall in the corner of his room, and reported the oxygen bottle was not secured and could explode. LVN A was not sure who was responsible for completing the training for staff since she only started last Thursday. During an interview on 05/19/2026 at 11:02 AM CNA B (the CNA responsible for Resident #1 this shift) reported she constantly walks back and forth down the hallway and checks every room all the time. CNA B reported she will check every resident for their oxygen, but she is not allowed to touch the oxygen. When made aware of the unsecure oxygen bottle in the room CNA B stated, I don't know if that is a problem. I don't know if that bottle is his or not. When asked if she had been trained on oxygen safety and care CNA B stated, It's only my second day and CNA C is my instructor. During an interview on 05/19/2026 at 11:09 AM the DON reported the CNA staff are to do rounds every two hours and the nursing staff are to do rounds at the opposite hours. The DON entered Resident #1's room and noticed the unsecure oxygen bottle and stated, that is a problem. That bottle is supposed to be secured on the back of a wheelchair or in a small cart. That is like a loaded bomb. I just gave an in-service on that. During an interview on 05/09/2026 at 12:00 PM CNA C (the trainer for CNA B) reported she was on light duty at this time and was being utilized as a trainer. CNA C reported CNA B had only been working for 2 days and she had not had much time to work with CNA B. CNA C reported staff are expected to do rounds every two hours. CNA C reported an oxygen bottle should be stored in a place that was secure and if that bottle was not stored correctly it could get dropped and break. CNA C reported the DON has completed training with all the staff on oxygen bottle safety. Record review of the facility provided policy titled Oxygen Safety undated, revealed the following:Policy: It is the policy of this facility to provide a safe environment for residents, staff, and the public. Policy Explanation and Compliance Guidelines:Safety of the responsibility of staff.4. Oxygen storage - c. Cylinders will be properly chained or supported in racks or other fastening (i.e. sturdy portable cars, approved stands) to secure all cylinders from falling, whether connected, unconnected, full, or empty.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. report an allegation of abuse to the State Survey Agency within 2 hours of the allegation for 2 of 5 residents (Resident #1 and Resident #2).The facility failed to report an incident of abuse, dated 03/27/2026, between Resident #1 and Resident #2.This deficient practice could place residents at risk of continued and/or unrecognized abuse, neglect, or exploitation.Findings Included:Resident #1Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility originally on 07/18/2025 with a readmission of 04/10/2026. Diagnoses included but are not limited to dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance (decline in cognitive function with behaviors), weakness (lacking strength), reduced mobility (decreased ability to move freely), and major depressive disorder (mood disorder with persistent feelings of sadness). Record review of Resident #1's discharge MDS assessment, dated 03/30/2026, did not reveal a BIMS score.Record review of Resident #1's care plan, dated 01/30/2026, revealed Resident #1's focused goals of Resident exhibits behavior or trying to assist other residents such as pushing another resident in their wheelchair.Resident exhibits physically aggressive behaviors such as hitting, pushing, or kicking, or throwing things typically in response to perceived threats, confusion, or frustration.Resident exhibits verbal outbursts characterized by yelling, cursing, or aggressive speech, often in response to perceived frustration, confusion, or unmet needs.Resident receives cognitive-enhancing medication for dementia.Record review of Resident #1's progress note, dated 03/27/2026 at 11:45 AM, revealed a report regarding resident behavior grabbing the arm of another resident and causing a bruise.Resident #2Record review of Resident #2's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses include but are not limited to chronic obstructive pulmonary disease (lung disease that makes it difficult to breathe), anxiety disorder (feelings of panic, fear, dread, restlessness, irritability, and difficulty concentrating), hypertensive heart disease with heart failure (heart is unable to pump enough blood to meet the body's needs), and muscle weakness (muscle unable to exert force or perform normal movements). Resident #2 is on hospice.Record review of Resident #2 MDS, dated [DATE], revealed a BIMS score of 11, indicating moderate impairment in thinking and memory.Record review of Resident #2 care plan, dated 03/24/2026, revealed focused goals of Resident experiences excessive worry, nervousness, or unease, which may interfere with daily functioning and quality of life.Resident is prescribed antianxiety medication for management of anxiety, placing them at risk for sedation, falls, cognitive changes, and medication side effects.The resident has impaired cognitive function and impaired thought processes.Record review of Resident #2's progress notes on 04/22/2026 did not reveal documentation related to the incident on 03/27/2026. In an interview and observation on 04/22/2026 at 2:37 PM, the ADM displayed the footage on her computer of the altercation on 03/27/2026 between Resident #1 and Resident #2. The footage revealed that Resident #2 was seated in her wheelchair on the north side of the entrance door, and Resident #2 was seated in a chair on the south side of the lobby. The video timestamp revealed the incident happened at 11:49 AM. An unknown individual approached the door and pulled the door handle. The individual was unable to enter the facility. Resident #1 stood from the chair and walked to where Resident #2 was located and placed both hands on Resident #2's wheelchair handles. Resident #1 moved Resident #2 backwards, away from the door. Resident #2 attempted to push Resident #1 away from her wheelchair with her left arm. The video timestamp of 11:50:45 AM showed Resident #2 reaching back, in a hitting motion with her right forearm, and contacting Resident #1's right forearm 3 times. The video timestamp at 11:51 AM showed Resident #1 letting go of Resident #1's wheelchair in the lobby and returning to the chair on the south side of the lobby. The ADM stated she did not witness the incident between Resident #1 and Resident #2, but it was reported to her by Resident #2. The ADM stated based on the information that Resident #2 provided, she felt it wasn't reportable. In an interview 04/22/2026 at 2:06 PM, the ADON stated she documented the incident of Resident #1 grabbing Resident #2's arm when trying to move her away from the front door on 03/27/2026 in Resident #1's progress notes. The ADON stated the incident happened at the front entrance of the facility. The ADON reported that she did not feel the incident was reportable because it wasn't intentional.In an interview on 04/22/2026 at 2:25 PM, the DON stated she did not witness the altercation between Resident #1 and Resident #2 on 03/27/2026. The altercation was reported to her; however, she could not recall who reported the altercation to her. The DON stated she felt the facility should have reported the incident. The DON stated that a negative outcome of not reporting would be residents wouldn't feel safe. She stated they should be able to feel they are well taken care of. In a follow up interview on 04/22/2026 at 4:23 PM, the ADON stated that she did not watch the video, and was not told what was on the video. The ADON stated that a resident hitting another resident was a reportable incident. In an interview on 04/22/2026 at 4:29 PM, the MA stated that he viewed the video and confirmed he observed Resident #2 strike Resident #1. The MA confirmed he documented what he observed in the video on 03/27/2026 and provided it to the ADM. The MA stated he emailed the video to the ADM on 03/30/2026. The MA stated that a negative outcome of not reporting abuse or neglect could be an injury that was overlooked.In an interview on 04/22/2026 at 4:38 PM, the ADM stated that a resident hitting another resident was reportable. The ADM stated the incident should be reported within 2 hours. The ADM stated a negative outcome was Resident #1 could try to hit someone else. The ADM stated an incident involving a resident hitting another resident would be considered reportable and should be reported within two hours. The ADM also stated a negative outcome for failing to report such incidents could be residents engaging in additional altercations. Record review of the facility's policy of Abuse, Neglect, and Exploitation, dated 2024, revealed under subheading Definitions revealed, Abuse means the willful and infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations.Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated, and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Under heading of The components of the facility abuse prohibition plan are discussed herein:, under [NAME] numeral VII- Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: A. Immediately, but not later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 15 (Resident #1, #4, #14, #27, #38, and Resident #57) Residents reviewed for infection control, in that:-RN D failed to perform hand hygiene or glove change before or after preparation of glucometer, glucose check, preparation of the medication, and the administration of Insulin for Resident #1.-RN D failed to perform hand hygiene before administering medication to Resident #4 via g-tube.-RN D failed to perform hand hygiene or glove change before or after preparation of glucometer, glucose check, preparation of the medication, and the administration of Insulin for Resident #14.-MA E failed to perform hand hygiene or don gloves to administer eye drop medication to Resident #27.-RN D failed to perform hand hygiene or glove change before or after preparation of glucometer, glucose check, preparation of the medication, and the administration of Insulin for Resident #38.-RN D failed to clean glucometer before or after glucose check for Resident #38.-RN D failed to ensure surface of bedside table was clean to place glucometer on in Resident #57's room.-RN D failed to perform hand hygiene or glove change in between treatments of Resident #14 and Resident #1These failures had the potential to affect residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases.Findings Included:During an observation on 12/14/2025 at 7:07 PM RN D did not perform hand hygiene before the start of the medication administration via g-tube for Resident #4. During an observation on 12/14/2025 at 7:17 PM RN D did not perform hand hygiene before donning one glove. RN D stated that the gloves were too big, took off glove, and placed it (glove) back in the box with the other XL gloves. RN D did not clean glucometer machine before starting with the blood sugar check for Resident #38. RN D left Resident #38's room with same gloves that she performed glucose check with and started to prepare medication for Resident #38. No hand hygiene or glove change was performed. RN D then returned to Resident #38's room to administer insulin with the same gloves that she performed all previous tasks with. Once procedures were completed RN D removed gloves but did not perform hand hygiene. During an observation on 12/14/2025 at 7:23 PM RN D did not perform hand hygiene before the preparation of the glucometer, or the performance of the glucose check for Resident #57. RN D took glucometer, lancet, and alcohol wipe into the room and placed the equipment on Resident #57's bedside table, which was dirty from an unidentified spilled liquid. RN D then performed glucose check for Resident #57. RN D left Resident #57's room with no hand hygiene and removed her gloves in the hallway at her medication cart. No hand hygiene was performed before the preparation of Resident #57's insulin. RN D attempted to put gloves on and when the gloves that RN D pulled from the box would not go on her hands, RN D proceeded to wipe her hands on her scrubs and then place her hands in clean gloves. No hand hygiene was performed before or after the administration of the insulin to Resident #57. During an observation on 12/14/2025 at 7:32 PM RN D did not perform hand hygiene or glove changes before or after performing a glucose check, the preparation of Resident #14's insulin, or administration of Insulin to Resident #14. RN D did not remove gloves or perform hand hygiene and then proceeded to prepare the glucometer machine for Resident #1 with the same gloves that she just used for treatment of Resident #14. During an observation on 12/14/2025 at 7:42 PM RN D prepared glucometer, performed glucose check, and performed the administration of Resident #1's insulin with the same gloves that she used with Resident #14, and no hand hygiene or glove changes were performed. During an interview on 12/14/2025 at 7:48 PM RN D stated the negative outcome for not performing hand hygiene or glove changes could lead to infection control issues. During an observation on 12/14/2025 at 7:57 PM MA E performed medication administration of eye drops to Resident #27 and MA E did not perform hand hygiene or don gloves before administering eye drops to Resident #27. During an interview on 12/14/2025 at 7:59 PM MA E was asked why hand hygiene and gloves were not used when eye drops were administered to Resident #27. MA E stated, I don't know, you just make me nervous. MA E stated not performing hand hygiene or donning gloves could lead to increased risk for infection. During an interview on 12/16/2025 at 10:13 AM CN stated not performing hand hygiene or glove changes at the appropriate times could lead to infection for the residents. During an interview on 12/16/2025 at 1:35 PM I-DON stated by not performing hand hygiene it could lead to increased risk for infections. Record review of policy titled, Provision of Quality Care, dated 09/01/2023, revealed the following: .Policy Explanation and Compliance Guidelines: 1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.4. Qualified persons will provide the care and treatment in accordance with professional standards of practice,5. To ensure persons are qualified, .oversight to ensure ongoing employee competency and education regarding areas of employee weaknesses.6. Policies and procedures will reflect current professional standards of practice. a. All employees are responsible for following established policies and procedures. Record review of policy title, Medication Administration via Enteral Tube, dated 09/01/2023, revealed the following: .g. Perform hand hygiene and apply gloves. Record review of policy titled, Medication Administration, dated 09/01/2023, revealed the following: . Policy Explanation and Compliance Guidelines: .4. Wash hands prior to administering medication per facility protocol and product.19. Wash hands using facility protocol and product. Record review of policy title, Hand hygiene, dated 09/01/2023, revealed the following: Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table.Hand Hygiene Table: .Between resident contactsAfter handling contaminated objectsBefore performing invasive proceduresBefore applying and after removing personal protective equipment (PPE), including glovesBefore preparing or handling medications.Before performing resident care procedures.After handling items potentially contaminated with blood, body fluids, secretions, or excretions

Based on observation, interview, and record review; it was determined the facility failed to ensure each resident was provided with the right to have personal privacy during medical treatments, for 4 (Residents #1, #4, #14, and Resident #38) of 15 residents reviewed for privacy. -RN D failed to knock or announce herself upon entering Resident #4's room or provide privacy before administering medication via peg-tub.-RN D failed to knock or announce herself upon entering Resident #38's room or provide privacy before administering an injectable medication. -RN D failed to knock or announce herself upon entering Resident #14's room or provide privacy before administering an injectable medication. -RN D failed to knock or announce herself upon entering Resident #1's room or provide privacy before administering and injectable medication. -RN A and CNA F failed to knock or announce themselves upon entering Resident #38's room or provide privacy during wound care. These failures could place residents at risk of feeling shame or embarrassment, lowered self-esteem, and a lack of a dignified existence. Findings Included:Resident #1Record review of Resident #1's clinical record revealed Resident #1 was a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified (a condition where the body either doesn't make enough insulin or the body's cells don't respond properly to insulin, leading to elevated blood sugar levels (hyperglycemia), heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), schizoaffective disorder, bipolar type (a serious mental illness combining symptoms of schizophrenia (hallucinations, delusions) with mood swings from bipolar disorder (mania/hypomania and depression) ), bipolar disorder, current episode mixed, severe, without psychotic features (intense mood swings (manic/hypomanic and depressive) cause significant impairment in life, but without hallucinations or delusions), delusional disorders, (a mental health condition where a person has persistent, false beliefs (delusions) that aren't based in reality), major depressive disorder, single episode, unspecified (a serious mood illness causing persistent sadness, loss of interest (anhedonia), fatigue, and impaired daily functioning), intermittent explosive disorder (a mental health condition marked by sudden, impulsive, and disproportionate aggressive outbursts, including yelling, physical fights, or property damage, often preceded by tension and followed by regret). Record review of Resident #1's most recent MDS assessment, dated 10/03/2025, indicated Resident #1 had a BIMS of 06, indicated severe cognitive impairment and a functionality of maximal assistance required with showering/bathing, lower body dressing, and putting on/taking off footwear. Partial/moderate assistance was required with toileting, upper body dressing, and personal hygiene. Resident #1 required supervision with oral hygiene and setup or clean-up assistance with eating. Resident #4Record review of Resident #4's clinical record revealed Resident #4 was a [AGE] year-old female, who was admitted to the facility on [DATE] with diagnoses including epilepsy, unspecified, intractable, with status epilepticus (a severe, hard-to-treat epilepsy where seizures are prolonged or occur in clusters), major depressive disorder, recurrent severe without psychotic features (describes repeated episodes of significant depression where a person experiences core depressive symptoms (sad mood, loss of pleasure, fatigue, sleep/appetite changes, concentration issues, worthlessness) but does not experience delusions or hallucinations (psychotic features), remaining grounded in reality despite severe symptoms), type 2 diabetes mellitus without complications (a condition where the body either doesn't make enough insulin or the body's cells don't respond properly to insulin, leading to elevated blood sugar levels (hyperglycemia), functional quadriplegia (a state of complete inability to move all four limbs, not from a spinal cord injury, but from severe underlying frailty or disability), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (refers to a clinical presentation where cognitive decline (memory, thinking) occurs without the common neuropsychiatric symptoms like agitation, depression, hallucinations, or worry), other symptoms and signs involving cognitive functions and awareness (memory lapses, difficulty concentrating, trouble with decision-making, impaired understanding, language issues (like finding words), attention deficits, confusion, altered perception (difficulty recognizing people/places), poor judgment, slowed thinking, disorientation, and changes in behavior or mood). Record review of Resident #4's most recent MDS assessment, dated 10/31/2025, indicated Resident #4 had a BIMS of 00, indicated severe cognitive impairment and a functionality of total dependency in all care areas. Resident #14Record review of Resident #14's clinical record revealed Resident #14 was a [AGE] year-old male, who was admitted to the facility on 01//17/2025 with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified (a condition where the body either doesn't make enough insulin or the body's cells don't respond properly to insulin, leading to elevated blood sugar levels (hyperglycemia), heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), schizoaffective disorder, bipolar type (a serious mental illness combining symptoms of schizophrenia (hallucinations, delusions) with mood swings from bipolar disorder (mania/hypomania and depression)), mild cognitive impairment of uncertain or unknown etiology (noticeable memory or thinking problems that are more than normal aging but don't significantly disrupt daily life). Record review of Resident #14's most recent MDS assessment, dated 11/05/2025, indicated Resident #14 had a BIMS of 03, indicated severe cognitive impairment and a functionality of total dependency with toileting, shower/bathing, lower body dressing, putting on/taking off footwear, and persona hygiene. Maximal assistance was required for upper body dressing, and set-up or clean-up assistance with eating and oral hygiene. Resident #38Record review of Resident #38's clinical record revealed Resident #38 was a [AGE] year-old female, who was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified (a condition where the body either doesn't make enough insulin or the body's cells don't respond properly to insulin, leading to elevated blood sugar levels (hyperglycemia), heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), metabolic encephalopathy(brain dysfunction from a chemical imbalance, often due to malfunctioning organs (liver, kidneys, etc.) or severe illness, causing confusion, memory issues, personality changes, and in severe cases, coma or seizures), dysphagia, oropharyngeal phase (difficulty swallowing food or liquids), cognitive communication deficit (difficulty talking or understanding due to impaired thinking skills like attention, memory, organization, or problem-solving, often from brain injury (TBI, stroke) or neurological conditions (dementia)), acute kidney failure, unspecified (the sudden loss of kidney function, where kidneys rapidly can't filter waste and balance fluids, causing toxins to build up, often diagnosed by elevated creatinine/BUN in blood tests, and treated by managing the underlying cause, fluids, electrolytes, and sometimes dialysis)Record review of Resident #38's most recent MDS assessment, dated 12/02/2025, indicated Resident #38 had a BIMS of 12, indicated moderate cognitive impairment and a functionality of maximal assistance being required for toileting, shower/bathing, lower body dressing, and putting on/taking off footwear. Supervision or touching assistance was required for oral hygiene, upper body dressing, and personal hygiene, and setup or clean-up assistance with eating. During an observation on 12/14/2025 at 7:07 PM revealed RN D did not announce herself or knock before entering Resident #4's room and did not shut door to Resident #4's room, privacy was not provided to Resident #4 during medication administration via Resident #4's peg-tube.During an observation on 12/14/2025 at 7:17 PM revealed RN D did not announce herself or knock on door of Resident #38's room when RN performed blood glucose check and insulin administration. RN did shut door or pull privacy curtain before the start of procedure for Resident #38 during either procedure. During an observation on 12/14/2025 at 7:32 PM revealed RN D did not announce herself or knock on door of Resident 14's room when RN performed blood glucose check and insulin administration. RN did not shut door or pull privacy curtain to provide privacy to Resident #14 during either procedure. During an observation on 12/14/2025 at 7:42 PM revealed RN D did not announce herself or knock on door of Resident #1's room when RN performed blood glucose check and insulin administration. RN did not shut door or pull privacy curtain to provide privacy to Resident #1 during either procedure. During an interview on 12/14/2025 at 7:48 PM RN D stated the negative outcome for not knocking or announcing oneself or providing privacy during a treatment would be lack of privacy for the residents. During an observation on 12/16/2025 at 10:43 AM revealed RN A and CNA F did not knock or announce themselves before entering Resident #38's room to perform wound care. Neither RN or CNA shut door or pull privacy curtain to provided privacy for Resident #38 before or during wound care treatment. During an interview on 12/16/2025 at 11:25 AM RN A stated the negative outcome for not knocking or announcing herself to the resident or providing privacy during treatment could embarrass the resident. During an interview on 12/16/2025 at 11:30 AM CNA F stated the negative outcome for not knocking or announcing himself to the resident was that it would be invading the resident privacy. During an interview on 12/16/2025 at 1:35 PM I-DON stated that a negative outcome of not knocking or announcing oneself is an invasion of the resident's privacy.During an interview on 2/16/2025 at 12:03 PM CN stated that by not knocking on the door to a resident's room before entering is a dignity and privacy issue, the resident could be changing clothes. The staff is not respecting the resident's dignity, and like I said if they were changing clothes, it could embarrass the residents. Record review of policy titled, Residents Rights, dated 09/01/2023, revealed the following: .Policy Explanation and Compliance Guidelines: .11. The facility will ensure that all direct care and indirect care staff members, including contractors and volunteers are educated in the rights of residents and the responsibility of the facility to properly care for its residents.Privacy and confidentiality. The resident has a right to persona privacy and confidentiality of his or her personal and medical records.a. Personal privacy includes accommodations, medical treatment, . Record review of policy titled, Provision of Quality Care, dated 09/01/2023, revealed the following: .Policy Explanation and Compliance Guidelines: 1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.4. Qualified persons will provide the care and treatment in accordance with professional standards of practice, .6. Policies and procedures will reflect current professional standards of practice. a. All employees are responsible for following established policies and procedures. Record review of policy titled, Training Requirements, dated 09/01/2023, revealed the following: .6. Training content includes, at a minimum: b. Resident rights and facility responsibilities for caring of resident. Record review of policy title, Medication Administration via Enteral Tube, dated 09/01/2023, revealed the following: .11. Procedure: .d. Provide privacy by pulling the privacy curtain or closing the door to a private room. Record review of policy titled, Medication Administration, dated 09/01/2023, revealed the following: .Policy Explanation and Compliance Guidelines: .5. Knock or announce presence.7. Provide Privacy .

Based on observation, interview, and record review, the facility failed to have nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident for 1 (RN D) of 5 staff reviewed for nursing services. -RN D failed to knock or announce herself upon entering Resident #4's room or provide privacy before administering medication via g-tub.-RN D failed to check placement of g-tube for Resident #4 before administering medication via g-tube. -RN D failed to perform hand hygiene before administering medication to Resident #4 via g-tube. -RN D failed to knock or announce herself upon entering Resident #38's room or provide privacy before performing glucose check and the administration of an injectable medication. -RN D failed to perform hand hygiene or glove change before or after preparation of glucometer, glucose check, preparation of the medication, and the administration of Insulin for Resident #38.-RN D failed to store medications in accordance with professional standards for Resident #38. RN D left insulin on top of medication cart unattended in the hallway. -RN D failed to perform hand hygiene before or after the preparation of the glucometer, glucose check, preparation of the medication, and the administration of Insulin for Resident #57. -RN D failed to ensure surface of bedside table was clean to place glucometer on in Resident #57's room. -RN D failed to perform hand hygiene after Resident #57's glucose check and removed her gloves in the hallway at her medication cart. -RN D failed to knock or announce herself upon entering Resident #14's room or provide privacy before performing glucose check and the administration of an injectable medication. -RN D failed to perform hand hygiene or glove change before or after preparation of glucometer, glucose check, preparation of the medication, and the administration of Insulin for Resident #14.-RN D failed to perform hand hygiene or glove change in between treatments of Resident #14 and Resident #1. -RN D failed to knock or announce herself upon entering Resident #1's room or provide privacy before performing glucose check and the administration of an injectable medication. -RN D failed to perform hand hygiene or glove change before or after preparation of glucometer, glucose check, preparation of the medication, and the administration of Insulin for Resident #1. These failures could place residents at risk of feeling shame or embarrassment, lowered self-esteem, and a lack of a dignified existence. These failures could also place residents are risk for lack of drug efficacy, and adverse reactions, as well as exposing them to care that could lead to the spread of viral infections, secondary infections, communicable diseases. Findings Included:Resident #1Record review of Resident #1's clinical record revealed Resident #1 was a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified (a condition where the body either doesn't make enough insulin or the body's cells don't respond properly to insulin, leading to elevated blood sugar levels (hyperglycemia).Record review of Resident #1's most recent MDS assessment, dated 10/03/2025, indicated Resident #1 had a BIMS of 06, which indicated severe cognitive impairment.Resident #4Record review of Resident #4's clinical record revealed Resident #4 was a [AGE] year-old female, who was admitted to the facility on [DATE] with diagnoses including epilepsy, unspecified, intractable, with status epilepticus (a severe, hard-to-treat epilepsy where seizures are prolonged or occur in clusters), type 2 diabetes mellitus without complications (a condition where the body either doesn't make enough insulin or the body's cells don't respond properly to insulin, leading to elevated blood sugar levels (hyperglycemia), functional quadriplegia (a state of complete inability to move all four limbs, not from a spinal cord injury, but from severe underlying frailty or disability), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (refers to a clinical presentation where cognitive decline (memory, thinking) occurs without the common neuropsychiatric symptoms like agitation, depression, hallucinations, or worry), other symptoms and signs involving cognitive functions and awareness (memory lapses, difficulty concentrating, trouble with decision-making, impaired understanding, language issues (like finding words), attention deficits, confusion, altered perception (difficulty recognizing people/places), poor judgment, slowed thinking, disorientation, and changes in behavior or mood). Record review of Resident #4's most recent MDS assessment, dated 10/31/2025, indicated Resident #4 had a BIMS of 00, which indicated severe cognitive impairment. Resident #14Record review of Resident #14's clinical record revealed Resident #14 was a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified (a condition where the body either doesn't make enough insulin or the body's cells don't respond properly to insulin, leading to elevated blood sugar levels (hyperglycemia), heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), schizoaffective disorder, bipolar type (a serious mental illness combining symptoms of schizophrenia (hallucinations, delusions) with mood swings from bipolar disorder (mania/hypomania and depression)), mild cognitive impairment of uncertain or unknown etiology (noticeable memory or thinking problems that are more than normal aging but don't significantly disrupt daily life). Record review of Resident #14's most recent MDS assessment, dated 11/05/2025, indicated Resident #14 had a BIMS of 03, which indicated severe cognitive impairment. Resident #38Record review of Resident #38's clinical record revealed Resident #38 was a [AGE] year-old female, who was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified (a condition where the body either doesn't make enough insulin or the body's cells don't respond properly to insulin, leading to elevated blood sugar levels (hyperglycemia). Record review of Resident #38's most recent MDS assessment, dated 12/02/2025, indicated Resident #38 had a BIMS of 12, which indicated moderate cognitive impairment. Resident #57 Record review of Resident #57's clinical record revealed Resident #57 was a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified (a condition where the body either doesn't make enough insulin or the body's cells don't respond properly to insulin, leading to elevated blood sugar levels (hyperglycemia). Record review of Resident #57's MDS assessment was not completed due to admission to the facility on [DATE]. During an observation on 12/14/2025 at 7:07 PM RN D did not announce herself or knock before entering Resident #4's room and did not provide privacy to Resident #4 during medication administration via Resident #4's g-tube. RN D did not perform hand hygiene before the start of the medication administration via g-tube for Resident #4 and did not verify of placement of g-tube before medications administration. During an observation on 12/14/2025 at 7:17 PM RN D did not announce herself or knock on door of Resident #38's room when RN performed blood glucose check and insulin administration. RN did not provide privacy to Resident #38 during either one of these procedures. RN D did not perform hand hygiene before donning one glove. RN D stated that the gloves were too big, took off glove, and placed it back in the box with the other XL gloves. RN D did not clean glucometer machine before starting with the blood sugar check for Resident #38. RN D then removed Resident #38's Insulin pen from medication cart and placed it on the top of the cart and left the medication on top of the medication cart to go into Resident #38's room to perform Resident #38's glucose check. RN D left Resident #38's room with same gloves that she performed glucose check with and started to prepare medication for Resident #38. No hand hygiene or glove change was performed. RN D then returned to Resident #38's room to administer insulin with the same gloves that she performed all previous tasks with. Once procedures were completed RN D never performed hand hygiene. During an observation on 12/14/2025 at 7:23 PM RN D did not perform hand hygiene before the preparation of the glucometer, or the performance of the glucose check for Resident #57. RN D took glucometer, lancet, and alcohol wipe into the room and placed the equipment on Resident #57's bedside table, which was dirty from an unidentified spilled liquid. RN D then performed glucose check for Resident #57. RN D left Resident #57's room with no hand hygiene and removed her gloves in the hallway at her medication cart. No hand hygiene was performed before the preparation of Resident #57's insulin. RN D attempted to put gloves on and when the gloves that RN D pulled from the box would not go on her hands, RN D proceeded to wipe her hands on her scrubs and then place her hands in clean gloves. No hand hygiene was performed before or after the administration of the insulin to Resident #57. During an observation on 12/14/2025 at 7:32 PM RN D did not announce herself or knock on door of Resident #14's room when RN D performed the glucose check and insulin administration. No privacy was provided during either procedure. RN D did not perform hand hygiene or glove changes before or after performing a glucose check, before or after the preparation of Resident #14's insulin, or administration of Insulin to Resident #14. RN D did not remove gloves or perform hand hygiene and then proceeded to prepare the glucometer machine for another resident with the same gloves that she just used for treatment of Resident #14. During an observation on 12/14/2025 at 7:42 PM RN D did not announce herself or knock on door of Resident #1's room when RN performed blood glucose check and insulin administration and no privacy was provided during either procedure. RN D prepared glucometer, performed glucose check, and performed the administration of Resident #1's insulin with the same gloves that she used with Resident #14, and no hand hygiene or glove changes were ever performed. During an interview on 12/14/2025 at 7:48 PM RN D stated the negative outcome for not knocking or announcing oneself or providing privacy during a treatment would be lack of privacy for the residents. RN D stated performing hand hygiene or glove changes could lead to infection control issues. During a phone interview on 12/16/2025 at 9:43 AM RN D was asked why placement of Resident 4's g-tube was not checked before the administration of medication. RN D stated that the medication was running and that the nurse on the previous shift performed that check. RN D was asked if she could verify that the previous nurse actually did check the placement and she stated that she trusted them to do that. RN D was asked if there was a negative outcome for not checking the placement of the g-tube before the administration of a medication. RN D stated, I don't think so, because it was running. RN D was asked if the g-tube could be dislodged during resident care like a brief change or bed change and RN D stated that it is a possibility. RN D was asked what the facility's policy stated, RN D stated I'm sorry I don't know. RN D stated a negative outcome could possibly be the feeding could get into the resident's gut and not her stomach. During an interview on 12/16/2025 at 10:03 AM I-DON was asked if g-tube placement is verified every time before using. I-DON stated that I do. I-DON stated the negative outcome for not checking placement of g-tube before administering medications, was it (food or medications) wouldn't be going in the right spot. During an interview on 12/16/2025 at 10:13 AM CN stated a negative outcome for not checking placement of a g-tube was if the g-tube had slipped out of the GI tract the tube could be lodged in the wrong area. CN stated a negative outcome was for not performing hand hygiene or glove changes at the appropriate times could lead to infection for the residents. CN also stated nursing staff not having the skill set or the competencies to take care of the residents was very concerning for resident's care and well-being. During an interview on 12/16/2025 at 12:03 PM CN stated not knocking on the door to a resident's room or announcing oneself before entering was a dignity and privacy issue, CN stated the resident could be changing clothes. The staff is not respecting the resident's dignity, and like I said if they are changing clothes, it could embarrass the residents. CN stated a negative outcome for not performing hand hygiene was the spread of infection to other residents within the building. During an interview on 12/16/2025 at 1:35 PM I-DON stated not performing hand hygiene could lead to increased risk for infections, and not knocking or announcing oneself is an invasion of their (the residents) privacy. I-DON stated a negative outcome of not locking up medication was that any resident could take the medication I-DON stated not having a nurse with the appropriate skill set or competencies could lead to an increase in infection or even giving the wrong medication to the wrong patients. Record review of policy titled, Residents Rights, dated 09/01/2023, revealed the following: .Policy Explanation and Compliance Guidelines: .11. The facility will ensure that all direct care and indirect care staff members, including contractors and volunteers are educated in the rights of residents and the responsibility of the facility to properly care for its residents.Privacy and confidentiality. The resident has a right to persona privacy and confidentiality of his or her personal and medical records.a. Personal privacy includes accommodations, medical treatment, . Record review of policy titled, Provision of Quality Care, dated 09/01/2023, revealed the following: .Policy Explanation and Compliance Guidelines: 1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.4. Qualified persons will provide the care and treatment in accordance with professional standards of practice,5. To ensure persons are qualified, .oversight to ensure ongoing employee competency and education regarding areas of employee weaknesses.6. Policies and procedures will reflect current professional standards of practice. a. All employees are responsible for following established policies and procedures. Record review of policy titled, Training Requirements, dated 09/01/2023, revealed the following: Policy Explanation and Compliance Guidelines: .3. Competencies and skill sets for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers must be consistent with there expected roles. 4. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program. 5. Training requirements should be met prior to staff and volunteers independently providing services to resident, annually, and as necessary based on the facility assessment. 6. Training content includes, at a minimum: .b. Resident rights and facility responsibilities for caring of resident. Record review of policy title, Medication Administration via Enteral Tube, dated 09/01/2023, revealed the following: .11. Procedure: .d. Provide privacy by pulling the privacy curtain or closing the door to a private room.g. Perform hand hygiene and apply gloves. h. enteral tube placement must be verified prior to administering any fluids or medication. Record review of policy titled, Medication Administration, dated 09/01/2023, revealed the following: . Policy Explanation and Compliance Guidelines: .4. Wash hands prior to administering medication per facility protocol and product.5. Knock or announce presence.7. Provide Privacy .19. Wash hands using facility protocol and product. Record review of policy title, Hand hygiene, dated 09/01/2023, revealed the following: Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table.Hand Hygiene Table: .Between resident contactsAfter handling contaminated objectsBefore performing invasive proceduresBefore applying and after removing personal protective equipment (PPE), including glovesBefore preparing or handling medications.Before performing resident care procedures.After handling items potentially contaminated with blood, body fluids, secretions, or excretions.

Based on observation, interview, and record review the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 (Resident #7) of 5 residents reviewed for unnecessary drugs.The facility failed to ensure a gradual dose reduction of Resident #7's four psychotropic medications was attempted or contraindicated from May 2024 to December 2025.This failure could lead to residents being overmedicated.Findings Included:Record review of Resident #7's admission record dated 12/16/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), schizoaffective disorder bipolar type (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), major depressive disorder recurrent (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and generalized anxiety disorder (inability to control constant worrying).Record review of Resident #7's quarterly MDS completed on 11/20/25 revealed a BIMS score of 5 which indicated severely impaired cognition. Section N - Medications revealed Resident #7 was coded for antipsychotic, antidepressant, and antianxiety medications. Question N0450A indicated Resident #7 had been receiving antipsychotic medications on a routine basis. Gradual dose reduction questions N0450B-N0450E were blank.Record review of Resident #7's care plan completed on 11/24/25 revealed she received antidepressant, antianxiety, and antipsychotic medications. One of the interventions listed was, Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly.Record review of Resident #7's physician's order summary report dated 12/16/25 revealed the following orders with corresponding start dates:08/24/24 Abilify Oral Tablet 2 MG (Aripiprazole) Give 2 mg by mouth at bedtime for schizo-effective disorder related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE .05/27/23 busPIRone HCl Oral Tablet 7.5 MG (Buspirone HCl) Give 1 tablet by mouth at bedtime related to GENERALIZED ANXIETY DISORDER .08/23/24 Mirtazapine Oral Tablet 7.5 MG (Mirtazapine) Give 1 tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE .05/27/23 PARoxetine HCl Oral Tablet 40 MG (Paroxetine HCl) Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE .Record review of the facility's Drug Regimen Review book revealed no mention of gradual dose reductions for any of the medications listed for Resident #7.During an observation and interview on 12/14/25 at 12:19 PM Resident #7 was seated at a table in the dining room. She stated she had depression, but it was not bad.During an interview and record review on 12/16/25 at 03:58 PM CN provided documentation of gradual dose reduction recommendations on the four medications listed for Resident #7 from May of 2024. He stated but he had not found any others gradual dose reduction recommendations and did not know where else to look for more recent gradual dose reductions.During an interview on 12/16/25 at 04:08 PM RN A stated a resident could be negatively affected by not having a gradual dose reduction for psychotropic medications because the medication might become less effective against their symptoms, they could have withdraw symptoms, or their symptoms might worsen.During an interview on 12/16/25 at 04:11 PM I-DON stated she was not sure how often a gradual dose reduction should be considered for psychotropic medications. She stated that was a good question for CN. I-DON stated a possible negative outcome for a resident not receiving a gradual dose reduction was if you can get them (residents) off of it (psychotropic medication), that is great.During an interview on 12/16/25 at 04:15 PM CN stated the facility was responsible for ensuring a gradual dose reduction was considered for every resident receiving psychotropic medications at least yearly. He stated a possible negative outcome of not addressing gradual dose reductions was, It could be that we are medicating a resident who doesn't need to be medicated.During an interview on 12/16/25 at 04:19 PM Pharm stated gradual dose reductions for psychotropic medications should be addressed at least quarterly. She stated in her personal opinion there was no negative outcome to a resident if that was not done because she believed psychotropic medications should very rarely be reduced in dose because it could result in unwanted withdraw symptoms and exacerbation of the original symptoms.Record review of facility policy titled Unnecessary Drugs and dated 11/2/2025 revealed the following: . It is the facility's policy that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs. The policy did not address gradual dose reduction for psychotropic medications.

Based on observation, interview, and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition to state designated authority for level II resident review upon a significant change in status assessment for 1 (Resident #6) of 15 residents reviewed for PASRR.The facility failed to refer Resident #6 to state designated authority for a PASRR Evaluation due to his diagnosis of PTSD.This failure could place residents at risk of not receiving necessary services or of being harmed by residents who have not been screened properly for placement in a nursing home setting.Findings Included:Record review of Resident #6's admission record dated 12/14/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified psychosis not due to a substance or know physiological condition (mental health disorder characterized by a loss of touch with reality where the exact cause cannot be identified), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), and post-traumatic stress disorder chronic (mental health condition caused by a traumatic event that affects your ability to function normally).Record review of Resident #6's quarterly MDS completed on 11/05/25 revealed a BIMS score of 7 which indicated severely impaired cognition. Section I Active Diagnoses revealed Resident #6 was coded as having PTSD.Record review of Resident #6's care plan completed on 10/15/25 revealed he was care planned for experiencing excessive worry, nervousness or unease which may interfere with daily functioning and quality of life. Resident has history of trauma or post-traumatic stress disorder (PTSD), which may impact emotional well-being, daily functioning, and response to care. Resident has PTSD related to past traumatic experiences, evidenced by anxiety, hypervigilance, sleep disturbance, and verbalized intrusive memories.Record review of Resident #6's PASRR Level 1 Screening revealed it was completed by the MDS Coordinator of his previous facility on 08/20/25. Resident #6 was coded as having no mental illness.Record review of Resident #6's EHR under the miscellaneous tab revealed no other PASRRs.During an observation and attempted interview on 12/14/25 at 12:14 PM Resident #6 was seated at a table in the dining room. He did not have any food in front of him, and he was making chewing motions with his mouth. He did not respond to questions but did nod when asked if he was [name of Resident #6].During an observation and interview on 12/15/25 at 11:52 AM Resident #6 was seated at a table in the dining room. He did not have any food on the table yet. He nodded when asked if staff were taking good of him and nodded again when asked if he was okay. When asked about triggers for his PTSD he looked into the middle distance and began to make chewing motions with his mouth.During an observation and interview on 12/15/25 at 03:59 PM Resident #6 was seated in his wheelchair in the common area. AD interpreted for the surveyor and asked him if he was willing to answer some questions. He looked past us into the middle distance and began making chewing motions with his mouth. AD stated, Oh wow! He is not going to talk. He usually talks a lot. I bet it is because he doesn't recognize you (surveyor).During an interview on 12/16/25 at 11:05 AM RN A stated she did not know what a PASRR was.During an interview on 12/16/25 at 11:36 AM I-DON stated she was unsure who was responsible for ensuring residents with a qualifying diagnosis were referred for a PASRR Evaluation. She stated, I usually just get them (the evaluations) sent to me. I-DON stated there was probably a negative outcome if a resident with a qualifying diagnosis was not referred for a PASRR evaluation, but she was unable to specify what the negative outcome might be.During an interview on 12/16/25 at 11:53 AM CN stated a resident who had a qualifying diagnosis and was not referred for a PASRR Evaluation would be in danger of not receiving necessary treatment.During an interview on 12/16/25 at 12:04 PM ADM stated she was responsible for ensuring residents with qualifying diagnoses were referred for a PASRR Evaluation. She stated she was unaware Resident #6 had a diagnosis of PTSD.Record review of facility policy titled Resident Assessment - Coordination with PASARR Program and dated 11/2/2025 revealed the following: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.

Based on observation, interview, and record review the facility failed, in accordance with State and Federal laws, to store all drugs and biologicals in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions for 2 (Resident #38 and Resident #41) of 15 residents, 1 (treatment cart) of 1 treatment cart reviewed for medication storage. -RN D failed to place Resident #38's Insulin back into treatment cart before going into Resident #38's room to perform a glucose test. This failure could place residents at risk of taking medications that do not belong to them or receiving the wrong dosage of medication, which could lead to adverse reactions, increased exacerbation of disease processes, and hospitalization.Findings Included:Resident #38Record review of Resident #38's clinical record revealed Resident #38 was a [AGE] year-old female, who was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified (a condition where the body either doesn't make enough insulin or the body's cells don't respond properly to insulin, leading to elevated blood sugar levels (hyperglycemia). Record review of Resident #38's most recent MDS assessment, dated 12/02/2025, indicated Resident #38 had a BIMS of 12, indicated moderate cognitive impairment and a functionality of maximal assistance being required for toileting, shower/bathing, lower body dressing, and putting on/taking off footwear. Supervision or touching assistance was required for oral hygiene, upper body dressing, and personal hygiene, and setup or clean-up assistance with eating. During an observation on 12/14/2025 at 7:17 PM RN D removed Insulin pen for Resident #38 from treatment cart and placed it on the top of the cart and left the medication unattended to go into Resident #38's room to perform her glucose check. During an interview on 12/14/2025 at 7:48 PM RN D stated a negative outcome for medication not being placed back in the medication/treatment cart was I guess someone could take it. During an interview on 12/15/2025 at 2:17 PM I-DON stated not locking up medications could lead to another resident taking medications that do not belong to them. I-DON stated that it was her (I-DON) and the charge nurses' responsibility to ensure that orders are updated in the system when a new/change in order is received. I-DON stated she was unaware that medication packets and MARS were not matching. I-DON was asked what a negative outcome was for the instructions on the medications and orders for medication not matching, I-DON stated, I just never thought about it.During an interview on 12/16/2025 at 10:13 AM CN stated that a negative outcome for not locking up medications was that residents could get a hold of a medication that was not theirs. CN stated that it was the nurse that takes the new/changed orders responsibility to place it (new/changed orders) into the MAR. CN stated it is the responsibility of the nurse who took the order to go into the medication cart and place a change of order sticker on the bubble pack for the medication. CN stated that a negative outcome for not following the correct order and following a bubble pack that had not been updated or had the sticker to indicate a change of order, was the resident could get the wrong dosage of medication.Record review of facility provided policy titled, Medication Administration, dated 09/01/2023, revealed the following: .Policy Explanation and Compliance Guidelines: .10. Ensure that the six rights of medication administration are followed:a. Right residentb. Right drugc. Right dosaged. Right routee. Right timef. Right documentation11. Review MAR to identify medication to be administered. 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.

Based on observation, interview, and record review the facility failed to, in accordance with professional standards and practices, maintain medical records on each resident that are accurately documented for 3 (Resident #6, Resident #36, and Resident #41) of 15 residents reviewed for accuracy of medical records.1. The facility failed to ensure Resident #6's EHR did not contain NP progress notes for a female resident with his same last name.2. The facility failed to ensure the nurse checking boxes in Resident #36's TAR was providing the treatment being checked off.3. Facility failed to ensure Resident #41's medication bubble pack for her Carbidopa-Levodopa 25mg-100mg's instructions for dosing matched Resident #41's current medication orders.These failures could place residents at risk of not receiving necessary and accurate care/treatment due to inaccurate medical records.Findings Included:1. Record review of Resident #6's admission record dated 12/14/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified psychosis not due to a substance or know physiological condition (mental health disorder characterized by a loss of touch with reality where the exact cause cannot be identified), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), and post-traumatic stress disorder chronic (mental health condition caused by a traumatic event that affects your ability to function normally).Record review of Resident #6's quarterly MDS completed on 11/05/25 revealed a BIMS score of 7 which indicated severely impaired cognition.Record review of Resident #6's care plan revealed it was completed on 10/15/25.Record review of Resident #6's NP progress notes in the miscellaneous tab of his EHR revealed a progress note dated 01/24/25 for a female resident with the same last name as Resident #6.During an interview on 12/16/25 at 11:05 AM RN A stated if a resident's medical record was not accurate, We might miss something that is potentially going wrong with them, for instance, if they get a new diagnosis.During an interview on 12/16/25 at 11:36 AM I-DON stated Resident #6's EHR should not contain any other resident's progress notes. She stated inaccurate medical records could negatively impact a resident's care.During an interview on 12/16/25 at 11:53 AM CN stated a possible negative outcome to residents of inaccurate medical records was, We could be treating the resident wrong if the records are inaccurate. Not treating them for what they really need to be treated for.During an interview on 12/16/25 at 12:04 PM ADM stated resident records needed to be accurate for the residents to receive accurate care.2. Record review of Resident #36's admission record dated 12/14/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic systolic heart failure (a lifelong condition that affects the left ventricle. It occurs when the heart muscle is weak and the ventricle can't contract normally. Symptoms include shortness of breath, fatigue, leg swelling, and increased risk of arrhythmias and organ failure), diastolic heart failure (a condition in which the heart can no longer pump enough blood to the rest of the body), and chronic kidney disease (condition characterized by gradual loss of kidney function over time).Record review of Resident #36's care plan completed 09/29/25 revealed she was at risk for fluid overload and needed some assistance with ADLs. The care plan did not mention TED hose.Record review of Resident #36's quarterly MDS with ARD of 10/24/25 revealed a BIMS score of 14 which indicated intact cognition.Record review of Resident #36's physician's orders dated 12/15/25 revealed the following order with corresponding start date:11/13/25 [NAME] Hose for compression, elevate legs for edema (swelling). one time a day Use ted hose daily.During an observation and interview on 12/14/25 at 3:30 PM Resident #36 stated she did not have any TED hose on and revealed her legs. She stated she had not been aware she was supposed to wear TED hose. She stated she did not have any TED hose and stated she was not able to bend over to put the hose on. Resident #36 stated the aides would have to help her put the TED hose on. She stated if she had some TED hose she would wear them.During an observation and interview on 12/15/25 at 11:05 AM Resident #36 was observed in her room with no TED hose on. Resident #36 stated she had no TED hose on.During an interview on 12/15/25 at 11:10 AM CNA B stated she had cared for Resident #36 for the past week and stated Resident #36 did everything for herself. When asked if Resident #36 had any orders for TED Hose, CNA B stated Resident #36 did not have any orders for TED Hose. When asked if she was aware of an order for TED hose for Resident #36, she said she had not been aware of the order. She stated she had never put the TED hose on Resident #36. She stated she did not know what the care plan said and had not looked at it.During an interview on 12/15/25 at 11:20 AM Resident #36's family member stated she had taken Resident #36 to the cardiologist last month and the cardiologist wrote the order for the TED hose. She stated the Cardiologist stated it would be good for Resident #36 to wear. The family member stated she brought the order back and gave it to the facility staff in the front office. The family member stated she had made visits to the facility several times a week and she had not seen Resident#36 wearing any TED hose. The family member stated she cleaned and straightened Resident #36 drawers every week and she had not seen any TED hose in her drawer.During an interview and record review on 12/15/25 at 2:55 PM I-DON reviewed the TAR and stated the initials on the November and December TAR for Resident #36 were hers. When asked if she had passed meds or done any ADL care for Resident #36 in the past month, she stated she had not. When asked if she had been aware there was an order for Resident #36 to wear TED hose daily, she stated she had not known of the order for TED hose. Review of the TAR with I-DON revealed the TED hose boxes had been checked as completed by her. I-DON stated, Oh shit. I-DON then stated she must have clicked the wrong box by mistake. I-DON stated Resident #36 did not have any TED hose in the facility. She stated the facility had to order the TED hose and the facility had not ordered the hose yet. I-DON stated Resident #36 had edema all the time and she was encouraged to put her legs up in her recliner. I-DON stated the nurse providing care was responsible for filling out the MAR and TAR. I-DON stated she reviewed the TAR for the residents at the end of the day and had gone through the TAR and clicked the boxes to complete tasks as she went. She stated she had not let the agency staff document on the MAR or TAR. She stated the consequences for checking boxes on the TAR without providing the service would be inaccurate records and poor care for the residents. During an interview on 12/15/25 at 03:00 PM RN A stated she had not done any med pass for Resident # 36 and had not assisted her with any ADLs or dressing. She stated she had not been aware of Resident # 36 having an order to wear TED hose. She stated she had not seen her wearing TED hose. She stated she did not know if she had any TED hose or not. When asked if she had completed the TAR documenting Resident #36 had worn TED hose, she stated she had just clicked the boxes. She stated with the agency staffing she had just clicked the boxes herself instead of relying on agency staff to do it. She stated the consequences for not following physician orders for this resident would be the resident being vulnerable to having deep vein thrombosis. She stated other consequences would be inaccurate records.During an interview on 12/16/25 at 11:00 AM the CN stated the policy for the TAR would be the same as policies for the MAR.During an interview on 12/16/25 at 11:36 AM I-DON stated the nurse providing the care was the one who should check the box for the care on the TAR in the resident's EHR. She stated a possible negative outcome of her and the charge nurse checking the box for Resident #36's TED hose, but not applying the TED hose was Resident #36 might not get treatment.During an interview on 12/16/25 at 11:53 AM CN stated the nurse providing the care or treatment was the one who should be checking the box for that care or treatment on the TAR in the resident's EHR. He stated he was not aware the I-DON and charge nurse were checking boxes for Resident #36's TED hose on the TAR in the EHR but not applying the TED hose. He stated a possible negative outcome to residents of this practice was, They (nurses) could not really be doing the treatment they should be doing.During an interview on 12/16/25 at 12:04 PM ADM stated the nurse providing the care or treatment was the one who should be checking the box for that care or treatment on the TAR in the resident's EHR. She stated she was not aware the I-DON and charge nurse were checking boxes on the TAR in the EHR for Resident #36's TED hose but not applying the TED hose. She stated a possible negative outcome for residents of that practice was, They (residents) might not be getting the treatment at all.3. Record review of Resident #41's admission record dated 12/15/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinsonism (conditions that affect the ability to move and live independently).Record review of Resident #41's admission MDS completed 10/03/25 revealed a BIMS of 15 which indicated intact cognition.Record review of Resident #41's care plan completed 10/15/25 revealed the following: Resident has Parkinson?s [sic] disease, resulting in tremors (rhythmic movement of a body part that is out of your control), muscle rigidity (increased resistance to passive movement), bradykinesia (slow movement), and postural instability (inability to maintain equilibrium), placing them at risk for falls, aspiration (something other than air enters the airways), decreased mobility, medication side effects, and impaired ability to perform ADLs. Resident will maintain safe mobility and nutritional intake, demonstrate adherence to medication regimen, and remain free from falls or aspiration during the next 30 days. Administer Parkinson?s [sic] medications on a strict schedule to optimize mobility and reduce symptoms fluctuations.Record review of Resident #41's physicians orders, dated 12/15/2025 revealed the following: Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa) Give 1 tablet by mouth three times a day related to PARKINSONISM, UNSPECIFIED (G20.C) give 12, 17, and 2100 dailyRecord review of Resident #41's medication administration record, dated 12/15/2025 revealed that Resident #41 was getting Carbidopa-Levodopa Oral Tablet 25-100 MG three times a day as ordered.During an observation on 12/14/2025 at 8:18 PM the bubble pack for Resident #41 revealed instructions Take one tablet by mouth four times daily Carbidopa-Levodopa Oral Tablet 25-100 MGDuring an interview on 12/14/2025 at 8:18 PM MA E was asked why there was a discrepancy between the bubble pack and the order on the MAR. MA E stated it (the bubble pack) had always been like that and that she (MA E) had let the supervisor know, but nothing was changed. MA E stated that the negative outcome for this discrepancy was that it could have a negative outcome for the resident.During an observation on 12/15/2025 at 11:05 AM the bubble pack for Resident #41 revealed instructions Take one tablet by mouth four times daily Carbidopa-Levodopa Oral Tablet 25-100 MGDuring an interview on 12/15/2025 at 11:05 AM MA H stated that they (MA's) question the label all the time. MA H stated that a negative outcome for this discrepancy was it could possibly be harmful to the resident.During an interview on 12/15/2025 at 2:17 PM I-DON stated it was her (I-DON) and the charge nurses' responsibility to ensure that orders are updated in the system when a new/change in order is received. I-DON stated she was unaware that medication packets and MARS were not matching. When asked what a negative outcome was for the instructions on the medications and orders for medication not matching, she stated, I just never thought about it.During an interview on 12/16/2025 at 10:13 AM CN stated that it was the responsibility of the nurse who took the new/changed orders to put said orders into the MAR. He stated it was the responsibility of the nurse who took the order to go into the medication cart and place a change of order sticker on the bubble pack for the medication. CN stated that a negative outcome for bubble pack that had not been updated was, the resident could get the wrong dosage of medication.During an interview on 12/16/25 at 11:02 AM CNA J stated a resident could be negatively impacted if their medical records were inaccurate because, We (staff) might not know what we need to know, like what they (residents) like and don't like.During an interview on 12/16/25 at 11:05 AM RN A stated she had been notified by MAs that some medications cards had instructions/signatures that did not match the physician's order. She stated residents could get the wrong dosage of their medication if MAs were not paying attention.During an interview on 12/16/25 at 11:36 AM I-DON stated she had noticed some medication cards with instructions that did not match physician orders. She stated when staff called her attention to that she placed a sticker over the instructions on the medication card that said, Refer to Orders and called the pharmacy for a correction. I-DON stated a possible negative outcome of medication cards with inaccurate instructions was that the resident could be over or under medicated.During an interview on 12/16/25 at 11:41 AM MA K, when asked if she had noticed any instructions/signatures on medication cards not matching physician's orders, stated, We catch that a lot. She stated in that situation she followed the MAR and the physician's order, not the medication card.During an interview on 12/16/25 at 11:53 AM CN stated a resident could be negatively impacted by medication card instructions not matching physician's orders. He stated, We do have one example where originally it (administration of the medication) was 4 times a day and they (physician) changed the order, so [the resident] could get more (of the medication) than ordered.During an interview on 12/16/25 at 12:04 PM ADM stated she had no knowledge of medication card instructions not matching physician's orders. She stated a possible negative outcome to residents was, The wrong schedule or wrong dosage could be followed.Record Review of facility policy titled Medication Administration and dated 11/2/25 revealed the following: Medications are administered by licensed nurses or other staff . as ordered by the physician and in accordance with professional standards of practice.10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation 11. Review MAR to identify medication to be administered. 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, for, dose, route, and time. 17. Administer medication as ordered. 20. Sign MAR after administered.Record review of facility policy titled Documentation in Medical Record and dated 11/2/2025 revealed the following: . Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. Principles of documentation include, but are not limited to: a. Documentation shall be factual, objective, and resident centered. i. False information shall not be documented. ii. Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided. b. Documentation shall be accurate .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure walk in cooler items were properly stored, labeled, and dated.2. The facility failed to ensure proper hot holding procedures were practiced. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings Included:Observation of the walk-in cooler on 12/14/25 at 10:17 am revealed 2 trays of cake pops on the top shelf of the cooler rack. One of the 2 trays was sitting directly under a pipe with a frozen water icicle hanging from the pipe. Both trays of cake pops had not been covered, labeled or dated. In an observation and interview on 12/4/25 at 10:20 am, [NAME] H stated she had already pureed the foods for lunch and pointed to the steam table. She stated she had pureed the foods at 10:00 am and had put the foods on the steam table then. She stated there were 4 residents with pureed diets. She stated the lunch service would start at 12 PM and room trays were plated first. She stated plating food for the dining room would start after room trays were plated. She stated the residents with pureed diets were served at the end of the meal service and they ate in the dining room. An observation of the foods on the steam table revealed all pureed foods were on the steam table. In an observation on 12/14/25 at 11:00 am the pureed foods were seen on the steam table. [NAME] H stated food service would start at 12: 00 pm. In an observation on 12/14/25 at 12:00 pm the pureed food items were on the steam table and had not been served. In an observation on 12/14/25 at 12:30 pm the pureed foods were on the steam table and had not been served yet. In an observation on 12/14/25 at 12:40 pm the pureed meals were served at the end of the service. In an observation on 12/14/25 at 3:33 pm, 2 trays of cake pops on the top shelf inside the cooler. One of the 2 trays of cake pops had been sitting directly under a pipe with a frozen water icicle hanging from the pipe. The 2 trays of cake pops had not been covered, labeled or dated. In an interview on 12/15/25 at 2:46 pm, the RD stated foods should not be prepared and put on the serving line until it was time to serve foods. She stated she was not aware the staff had placed pureed food on the steam table hours before meal service. She stated all staff should be covering, labeling and dating all foods. She stated she had been in the facility at least monthly and had trained the kitchen staff in their kitchen duties. She stated having food on the serving line for so long could compromise foods in palatability, consistency and nutritive value. She stated issues in the kitchen could cause food borne illness. In an interview on 12/16/25 at 3:00 pm, the DM stated the RD had told her not to put the foods on the serving line so early. She stated the foods are not usually put on the serving line that early. She stated the cake pops should have been covered, labeled and dated. She stated she had thrown out the cake pops. She stated the consequences of not covering labeling and dating the cake pops would be cross contamination for the residents. She stated she expected all staff to label and date all food items when used and stored. She stated if foods were not properly wrapped up or labeled and dated this could cause food contamination and sickness to residents. The DM stated she trained the kitchen staff, and she had been trained by the dietician in labeling and dating as well as meal service. Record Review of the facility policy and procedure, dated 12/1/11, titled Food Holding and Service documented:3. Food is placed on steam table no more than 30 minutes prior to meal service Record Review of the facility policy and procedure, dated 12/1/11, titled Food Storage documented: Food is stored and protected from overhead pipes and other contamination. All refrigerated foods are dated, labeled and tightly sealed, including leftovers, using clean covered containers that are approved for food. Record Review of the 2012 facility policy and procedure, titled Post Production Checklist documented Food placed on steam table no sooner than 30 minutes prior to service.

Based on observation, interview and record review, the facility failed to prepare food by methods that conserve nutritive value, flavor, and appearance for 3 (pureed bread, pureed vegetables, and pureed meat) of 5 pureed food items reviewed for meal service.A. The dietary staff did not follow recipes for preparing the pureed bread for the lunch meal on 12/14/25 and 12/15/25 which altered the flavor of the bread. B. Foods from the test tray were not prepared by methods that conserve flavor. These failures could place any resident who consumes food prepared and served by dietary services at risk for dissatisfaction with the food and possible resulting nutrition deficit. Findings Included:In an observation and interview on 12/14/25 at 10:20 am, [NAME] H stated she had already pureed the foods for lunch and pointed to the steam table. She stated she had pureed the foods at 10:00 am and had used leftover sweet potatoes from the day before in the bread. She stated she always used leftover foods to puree bread. She stated she regularly used leftover cake, fruit and sweet potatoes to puree bread. She stated there were 4 residents with pureed diets. In an observation and interview on 12/14/25 at 1:00 pm, test trays were sampled. The pureed test tray consisted of pureed beef roast, mashed potatoes, mixed vegetables, a dinner roll and pineapple cake. The pureed bread was thick in texture extremely sweet and did not taste like bread. The bread tasted like sweet potatoes. The beef roast was very bland and needed salt. The pureed vegetables were unidentifiable and tasted sweet. [NAME] H stated she pureed the bread with sweet potatoes as she thought the residents would eat it better. In an observation and interview on 12/15/25 at 10:30 am [NAME] H stated she had already pureed the bread with baked apples. [NAME] H stated the baked apples were being used for the noon dessert today. This writer tasted the pureed bread. The bread was thick in consistency like glue and stuck to the mouth and the spoon. The bread tasted like apple pie. [NAME] H tasted the bread and stated the bread tasted good like apple pie. In an interview on 12/15/25 at 2:46 pm, the RD stated foods should not be prepared with leftover foods like sweet potatoes or fruit and bread should have been pureed with a liquid like milk. She stated she was not aware the staff had done that. She stated all staff should be following the preprinted recipes for purees. She stated you should not put anything in a puree that was not listed as an approved liquid because it would change the texture and someone could be allergic to a food. She further stated the food would not taste right. She stated she had been in the facility at least monthly and had trained the kitchen staff in their kitchen duties. She stated having foods pureed with other foods like sweet potatoes could compromise foods in palatability, consistency and nutritive value. During an interview on 12/16/25 at 3:00 pm, the DM stated the RD had spoken to her about pureeing foods with sweet potatoes and apples. She stated the RD told her not to do that anymore. The DM stated she had no recipes for pureed bread and no policies for pureed foods. She stated the cooks use the handout titled Pureed Food Guidelines to prepare purees. The DM said milk was the normal liquid added to pureed bread. The DM stated many breads did not normally puree very well with milk. She said she found the residents on pureed diets had eaten better if the foods were sweet. The DM stated she trained the kitchen staff, and she had been trained by the dietician in meal preparation and following recipes. Record Review of the undated handout titled Pureed Foods Guidelines revealed: Add appropriate liquid (ex: broth, milk) if needed, to assist with pureeing. Pureed food should not be sticky. Pureed food should fall off the spoon in a single spoonful when tilted and continue to hold shape on a plate. Examples of liquids to use for bread- milk

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Unidentified Resident) of 13 who was observed for medication administration. -MA C prepared medication for 3 separate unidentified residents and was carrying 3 medication cups around dining room administering medications. -Facility failed to ensure Resident #41's medication bubble pack for her Carbidopa-Levodopa 25mg-100mg's instructions for dosing matched Resident #41's current medication orders. These failures could place residents at risk for receiving medications that do not belong to them; which could result in adverse reactions to medication, deterioration in their health, exacerbation of their disease process, and/or hospitalization. Resident #41Record review of Resident #41's clinical record revealed Resident #41 was a [AGE] year-old female, who was admitted to the facility on [DATE] with diagnoses including parkinsonism, unspecified (a broad medical term for a group of neurological conditions causing similar movement problems, primarily bradykinesia (slowness of movement), muscle rigidity (stiffness), and tremor (shaking), along with balance issues).Record review of Resident #41's most recent MDS assessment, dated 10/03/2025, indicated Resident #41 had a BIMS of 15, indicated no cognitive impairment and a functionality of total dependency was required for toileting, shower/bathing, lower body dressing, personal hygiene, and putting on/taking off footwear. Partial/moderate assistance was required for upper body dressing, and supervision or touching assistance was required for oral hygiene and eating.Record review of Resident #41's physicians orders, dated 12/15/2025 revealed the following: Carbidopa-Levodopa Oral Tablet 25-100 MG(Carbidopa-Levodopa) Give 1 tablet by mouth threetimes a day related to PARKINSONISM,UNSPECIFIED (G20.C) give 12:00pm, 5:00pm, and 9:00pm daily Record review of Resident #41's medication administration record, dated 12/15/2025 revealed that Resident #41 was getting Carbidopa-Levodopa Oral Tablet 25-100 MG three times a day as ordered. During an observation on 12/14/2025 at 11:48 AM MA C carried 3 medication cups into the dining room. MA C walked over to unidentified Resident and gave one of the cups of medication to Unidentified Resident in the dining room. Unidentified resident consumed the medication that was in what appeared to be pudding in the medication cup. MA C left the dining room with the remaining 2 medication cups. During an interview on 12/14/2025 at 11:58 AM MA C was asked if there were medications in the medication cups and if they were for 3 different residents. MA C stated that they were. MA C was asked how she knew who the medications belonged to, and MA C stated that she had written the names of the residents on the medication cups. During an observation of medication pass on 12/14/2025 at 8:18 PM the bubble pack for Resident #41 revealed instructions Take one tablet by mouth four times daily Carbidopa-Levodopa Oral Tablet 25-100 MG During an interview on 12/14/2025 at 8:18 PM MA E was asked why there was a discrepancy between the bubble pack and the order on the MAR. MA E stated it (the bubble pack) had always been like that and that she (MA E) had let the supervisor know, but nothing was changed. MA E stated that the negative outcome for this discrepancy was that it could have a negative outcome for the resident. During an observation of medication pass on 12/15/2025 at 11:05 AM the bubble pack for Resident #41 revealed instructions Take one tablet by mouth four times daily Carbidopa-Levodopa Oral Tablet 25-100 MG During an interview on 12/15/2025 at 11:05 AM MA H stated that they (MA's) question the label all the time. MA H stated that this discrepancy was it could possibly be harmful to the resident. During an interview on 12/15/2025 at 2:17 PM I-DON stated not locking up medications could lead to another resident taking medications that do not belong to them. I-DON stated that it was her (I-DON) and the charge nurses' responsibility to ensure that orders are updated in the system when a new/change in order is received. I-DON stated she was unaware that medication packets and MARS were not matching. I-DON was asked what a negative outcome was for the instructions on the medications and orders for medication not matching, I-DON stated, I just never thought about it. During an interview on 12/16/2025 at 10:03 AM I-DON stated it is not standard practice to pre-prep medications before medication that is due. I-DON stated preparing medications and then carrying more than one resident medication at a time could lead to the wrong resident getting the wrong medication. During an interview on 12/16/2025 at 10:13 AM CN stated preparing multiple residents' medications and then distributing them all at the same time, could lead to the wrong medication being given to the wrong resident. CN stated that it was the nurse that takes the new/changed orders responsibility to place it (new/changed orders) into the MAR. CN stated it is the responsibility of the nurse who took the order to go into the medication cart and place a change of order sticker on the bubble pack for the medication. CN stated that a negative outcome for not following the correct order and following a bubble pack that had not been updated or had the sticker to indicate a change of order, was the resident could get the wrong dosage of medication. During an interview on 12/16/2025 at 2:51 PM MA C stated that she had prepared and dispensed medications as was observed on 12/14/2025 in the past. MA C stated preparing and administering medications for more than 1 resident at a time, could lead to the wrong medication being given to the wrong resident. Record review of facility provided policy titled, Medication Administration, dated 09/01/2023, revealed the following: .Policy Explanation and Compliance Guidelines: .10. Ensure that the six rights of medication administration are followed:a. Right residentb. Right drugc. Right dosaged. Right routee. Right timef. Right documentation11. Review MAR to identify medication to be administered.12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.

Based on observation, interview, and record review, the facility failed to ensure residents who were trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 (Resident #6) of 15 residents reviewed for trauma-informed care.The facility did not ensure Resident #6 had a trauma screening that identified possible triggers when Resident #6 had a history of trauma. This failure could put residents at an increased risk for severe psychological distress due to re-traumatization. Findings Included: Record review of Resident #6's admission record dated 12/14/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified psychosis not due to a substance or know physiological condition (mental health disorder characterized by a loss of touch with reality where the exact cause cannot be identified), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), and post-traumatic stress disorder chronic (mental health condition caused by a traumatic event that affects your ability to function normally).Record review of Resident #6's quarterly MDS completed on 11/05/25 revealed a BIMS score of 7 which indicated severely impaired cognition. Section I Active Diagnoses revealed Resident #6 was coded as having PTSD.Record review of Resident #6's care plan completed on 10/15/25 revealed he was care planned for experiencing excessive worry, nervousness or unease which may interfere with daily functioning and quality of life. Resident has history of trauma or post-traumatic stress disorder (PTSD), which may impact emotional well-being, daily functioning, and response to care. Resident has PTSD related to past traumatic experiences, evidenced by anxiety, hypervigilance, sleep disturbance, and verbalized intrusive memories. Interventions listed were initiated on 08/25/25 and included, but were not limited to, the following: Assess resident's trauma history and triggers (as they are willing to disclose), emotional responses, and coping strategies Develop an individualized care approach that avoids known triggers and incorporates resident-preferred coping mechanisms (e.g., calming music, quiet time, grounding techniques). Ensure all staff are educated on trauma-informed care principles and specific resident considerations to promote a safe, respectful care environment. Monitor for signs of re-traumatization (e.g., agitation, nightmares, avoidance behaviors) and report patterns to the interdisciplinary team for care plan adjustment. Assess resident for PTSD symptoms daily (anxiety, flashbacks, nightmares, triggers). Document resident's identified triggers and preferred calming strategies in care plan.Record review of Resident #6's EHR assessments tab revealed a Brief Trauma Questionnaire completed on 08/21/25 by the previous DON.Record review of Resident #6's Brief Trauma Questionnaire revealed it was completed on 08/21/25 by his resident representative and the following questions were answered yes for Resident #6: Event 1: Have you ever served in a war zone, or have you ever served in a noncombat job that exposed you to war-related casualties? If the event happened, did you think your life was in danger or you might be seriously injured? If the event happened, were you seriously injured? Event 4: Have you ever had a life-threatening illness such as cancer, heart attack, leukemia, AIDS, multiple sclerosis, etc? If the event happened did you think your life was in danger? Event 8: Have you ever been in any other situation in which you were seriously injured, or have you ever been in any other situation in which you feared you might be seriously injured or killed? If the event happened, were you seriously injured? Event 9: Has a close family member or friend died violently, for example, in a serious car crash, mugging, or attack? Event 10: Have you ever witnessed a situation in which someone was seriously injured or killed, or have you ever witnessed a situation in which you feared someone would be seriously injured or killed? Note: Do not answer yes for any event if you have already reported it in questions 1-9.The bottom of the Brief Trauma Questionnaire form had the following information:K1. Are any of the above answered - YES1. YesK2. If the answer to any of the above is yes - insert the date and time for the IDT meeting regarding interventions and plan of care09/10/2025 10:00 (AM)During an observation and attempted interview on 12/14/25 at 12:14 PM Resident #6 was seated at a table in the dining room. He did not have any food in front of him, and he was making chewing motions with his mouth. He did not respond to questions but did nod when asked if he was [name of Resident #6].During an observation and interview on 12/15/25 at 11:52 AM Resident #6 was seated at a table in the dining room. He did not have any food on the table yet. He nodded when asked if staff were taking good of him and nodded again when asked if he was okay. When asked about triggers for his PTSD he looked into the middle distance and began to make chewing motions with his mouth.During an interview on 12/15/25 at 02:00 PM I-DON stated Resident #6 was his own emergency contact. When asked who the resident representative was who filled out his trauma screening, she stated it was probably her (I-DON). She stated, I don't speak Cuban.but we were translating back and forth.During an interview on 12/15/25 at 02:30 PM RN A stated she had worked for the facility for 3.5 months and had not received training on providing trauma-informed care for Resident #6 in regard to his PTSD diagnosis. She stated, I keep my eye on him and if he is crying, I get someone to interpret for me. I make sure he is comfortable. She stated that Resident #6 said his legs hurt when she asked him why he was crying. She stated she did not know what any of Resident #6's triggers were.During an interview on 12/15/25 at 02:33 PM CNA I stated she had been working in the facility for a month and had not received training on providing trauma-informed care for Resident #6 regarding his PTSD diagnosis.During an interview on 12/15/25 at 02:41 PM CNA G stated she had worked for the facility for 31 years and was trained all the time on how to care for Resident #6 in regard to his PTSD diagnosis. She could not provide details of the training except to mention that Resident #6 could get upset and/or angry easily.During an interview on 12/15/25 at 02:51 PM I-DON stated regarding Resident #6, We just monitor him, if he gets anxious, we remove him from the situation he is in. We let him decide and guide us on what we need to do. Sometimes he just needs quiet. She stated she had seen him be triggered by Westerns on TV. She stated she did not know if it was the gunfire or what it was that triggered Resident #6. I-DON stated once he was triggered, he might need to be put to bed for 15 or 20 minutes to calm him down. I-DON stated Resident #6's voice would raise an [NAME] to two if he was triggered. She stated she did not know any details of Resident #6's trauma.During an interview on 12/15/25 at 03:41 PM ADM stated she had no evidence of the IDT meeting mentioned on the bottom of Resident #6's Brief Trauma Questionnaire having taken place.During an observation and interview on 12/15/25 at 03:59 PM Resident #6 was seated in his wheelchair in the common area. AD interpreted for the surveyor and asked him if he was willing to answer some questions. He looked past us into the middle distance and began making chewing motions with his mouth. AD stated, Oh wow. He is not going to talk. He usually talks a lot. I bet it is because he doesn't recognize you (surveyor).During an interview on 12/16/25 at 11:02 AM CNA J stated she had received training on how to approach Resident #6 if he was cranky. She stated he has mood swings. CNA J stated, If you speak Spanish to him, he is a little better towards you. She stated speaking Spanish to Resident #6 helped calm him if he was upset. CNA J stated she did not know what any of Resident #6's triggers were. She stated, Sometime he will just start crying. Sometimes he says it is because he is hurting. CNA J stated a possible negative outcome of not having trauma-informed care was staff would not know how to take care of and approach Resident #6.During an interview on 12/16/25 at 11:05 AM RN A stated she did not know what any of Resident #6's triggers were. She stated, I think it just randomly happens. When he gets upset there is usually a reason for it like another resident is making him mad. I think that if you get too close to his personal space that causes him to trigger. She stated a possible negative outcome of not providing trauma-informed care for Resident #6 was, He might lash out. He seems like he is hyperaware of everything that is going on. He is always looking around.During an interview on 12/16/25 at 11:29 AM CNA B stated she had not received training on providing trauma-informed care for Resident #6 in light of his PTSD diagnosis. She stated, I didn't know about that. I thought it (his behavior) was because he is always hurting. She stated she had noticed moving too quick triggered Resident #6.During an interview on 12/16/25 at 11:36 AM I-DON stated she had not received training on providing trauma-informed care for Resident #6 and she had not trained staff on providing trauma-informed care for him. She stated, We pretty much let him lead us which way he wants to go.During an interview on 12/16/25 at 11:41 AM MA K stated she had not received training on providing trauma-informed care for Resident #6. She stated she did not know what any of Resident #6's triggers were.During an interview on 12/16/25 at 11:53 AM CN stated it was the responsibility of the IDT to ensure a resident with a history of trauma received trauma-informed care. He stated if a facility did not have a social worker (as was the case for this facility at the time of survey) the responsibility fell on I-DON and ADM. CN stated he had not trained staff on providing trauma-informed care for Resident #6. He stated he did not know what any of Resident #6's triggers were. CN stated, To be honest, I did not realize he had PTSD. He stated a resident with a history of trauma could be negatively affected if the facility did not provide trauma-informed care. CN stated, That that trigger them we may inadvertently do and not know. We could put him too close to another resident who yells a lot and that might trigger him. We have to look out for his triggers and try to protect him from those.During an interview on 12/16/25 at 12:04 PM ADM, when asked if staff had been trained to provide trauma-informed care for Resident #6, stated, As far as I know we have trained them on his aggressive behaviors but I don't know about PTSD specifically because I was not even aware he has PTSD so I didn't check up on them (trainings). She stated she did not know what any of Resident #6's triggers were. She stated a resident with a history of trauma could probably be negatively impacted if staff did not provide trauma-informed care. ADM stated, It might cause them to have even more trauma.Record review of facility policy titled Trauma Informed Care and dated 11/2/2025 revealed the following: . It is the policy of this facility to provide care and services which in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preference, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. 'Trauma' results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental physical, social, emotional, or spiritual well-being. Common sources of trauma may include, but are not limited to: . f. War . i. Traumatic life events (death of a loved one, personal illness, etc.) 'Trauma-Informed Care' is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. The facility will work to facilitate the principles of trauma informed care which include: a. Safety - Ensuring residents have a sense of emotional and physical safety. b. Trustworthiness and transparency - Efforts to establish a relationship based on trust, and clear and open communication between staff and the resident. c. Peer support and mutual self-help - If practicable, assist the resident in locating and arranging to attend support groups. d. Collaboration - an emphasis on partnering between residents and/or his or her representative, an all staff and disciplines involved in the resident's care in developing the plan of care. The facility will use a multi-pronged approach in identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event as well as screening and assessment tools . The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals . to develop and implement individualized care plan interventions. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. While most triggers are highly individualized, some common triggers may include, but are not limited to: a. Experiencing a lack of privacy or confinement in a crowded or small space. b. Exposure to loud noises, or bright/flashing lights. d. Sounds, smells, and physical touch. Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. These interventions will also recognize the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery. In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident, and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident.

Based on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for 1 of 16 residents (Resident #36) reviewed for physician orders for treatments. A. The facility failed to follow physician's orders and apply TED hose as ordered for Resident # 36. (Thrombo-Embolic Deterrent hose which are medical stockings designed to prevent blood clots to the legs). The failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. Findings included: Record review of admission record dated 12/14/25 revealed Resident #36 was an 84-y o female admitted to the facility on [DATE] with diagnoses of heart failure, heart disease, muscle weakness, dementia and chronic kidney disease. Record review of Resident #36's care plan dated 9/29/25 documents resident is sometimes incontinent, was at risk for fluid overload, and needed some assistance with ADLs. Record review of Resident #36's Quarterly MDS dated [DATE] documented a BIMS score of 14 out of 15 which indicates cognition was intact.Record review of Resident #36's active physician's orders dated 12/15/25 revealed an order for TED hose to be used daily with an order start date of 11/13/25. In an observation and interview on 12/14/25 at 3:30 pm, Resident # 36 stated she had not had any TED hose on and revealed her legs. She stated she had not been aware she was supposed to wear TED hose. She stated she had not had any TED hose and stated she was not able to bend over to put the hose on. Resident #36 stated the aides would have to help her put the TED hose on. She stated if she had some TED hose she would wear them. In an observation and interview on 12/15/25 at 11:05 am, Resident #36 had been observed in her room with no TED hose on. Resident #36 stated she had no TED hose on. In an interview on 12/15/25 at 11:10 am, CNA B stated she had cared for Resident #36 for the past week and stated Resident #36 did everything for herself. When asked if Resident #36 had any orders for TED Hose, CNA B stated Resident #36 did not have any orders for TED hose. She stated she had never put the TED hose on Resident #36. She stated she did not know what the care plan said and had not looked at it. In an interview on 12/15/25 at 11:20 am Resident #36's family member stated she had taken Resident #36 to the cardiologist last month and the cardiologist wrote the order for the TED hose. She stated the cardiologist stated it would be good for Resident #36 to wear them. The family member stated she brought the order back and gave it to the facility staff in the front office. The family member stated she had made visits to the facility several times a week and she had not seen Resident#36 wearing any TED hose. The family member stated she cleaned and straightened Resident #36 drawers every week and she had not seen any TED hose in her drawer. In an interview and record review on 12/15/25 at 2:55 pm, the I-DON reviewed the TAR and stated the initials on the November and December TAR for Resident # 36 were hers. When asked if she had passed meds or done any ADL care for Resident # 36 in the past month, she stated she had not. When asked if she had been aware there was an order for Resident # 36 to wear TED hose daily, she stated she had not known of the order for TED hose. Review of the TAR with I-DON revealed the TED hose boxes had been checked as completed by her. I-DON replied, Oh shit. The I-DON then stated she must have clicked the wrong box by mistake. The I-DON stated Resident #36 did not have any TED hose in the facility. She stated the facility had to order the TED hose and the facility had not ordered the hose yet. The I-DON stated Resident #36 had edema all the time and she was encouraged to put her legs up in her recliner. The I-DON stated the nurse providing care was responsible for filling out the MAR and TAR. The I-DON stated she reviewed the TAR for the residents at the end of the day and had gone through the TAR and clicked the boxes to complete tasks as she went. She stated she had not let the agency staff document on the MAR or TAR. She stated the consequences for checking boxes on the TAR without providing service would be inaccurate records and poor care for the residents. In an interview on 12/15/25 at 3:00 pm RN A stated she had not done any med pass for Resident #36 and had not assisted her with any ADLs or dressing. She stated she had not been aware of Resident #36 having an order to wear TED hose. She stated she had not seen her wearing TED hose. She stated she did not know if she had any TED hose or not. When asked if she had completed the TAR documenting Resident #36 had worn TED hose, she stated she had just clicked the boxes. She stated with the agency staffing she had just clicked the boxes herself instead of relying on agency staff to do it. She stated the consequences for not following physician orders for this resident would be the resident being vulnerable to having deep vein thrombosis. She stated other consequences would be inaccurate records. In an interview on 12/16/25 at 11:00 am the CN stated the policy for the TAR would be the same as policies for the MAR. In an interview on 12/16/25 at 11:53 am the CN stated the nurse doing the treatment was responsible for checking the boxes on the TAR. He stated he had not been aware of the I-DON and the charge nurses checking boxes but not providing services. He stated it should have been done by the person providing service. He stated it was never correct to check the boxes without providing services. Record Review of the facility policy dated 11/2/25, titled Medication Administration revealed Medications are administered by licensed nurses or other staff . as ordered by the physician and in accordance with professional standards of practice. 17. Administer medication as ordered.20. Sign MAR after administered.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs for 2 of 15 (Residents #6 and Resident #36) Residents reviewed for care plans.1. Resident #6 had a diagnosis of PTSD, and his care plan was not specific or person-centered regarding his history of trauma and his triggers.2. Resident #36 did not have TED hose care planned had an order for TED hose daily. There was no documentation in the care plan of measurable objectives, interventions, or timeframes for how staff would meet this need.These failures could affect all residents that reside in the facility by not having their needs met and putting them at risk of being inappropriately cared for and/or re-traumatized. Findings included:1. Record review of Resident #6's admission record dated 12/14/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified psychosis not due to a substance or know physiological condition (mental health disorder characterized by a loss of touch with reality where the exact cause cannot be identified), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), and post-traumatic stress disorder chronic (mental health condition caused by a traumatic event that affects your ability to function normally).Record review of Resident #6's quarterly MDS completed on 11/05/25 revealed a BIMS score of 7 which indicated severely impaired cognition. Section I Active Diagnoses revealed Resident #6 was coded as having PTSD.Record review of Resident #6's care plan completed on 10/15/25 revealed he was care planned for experiencing excessive worry, nervousness or unease which may interfere with daily functioning and quality of life. Resident has history of trauma or post-traumatic stress disorder (PTSD), which may impact emotional well-being, daily functioning, and response to care. Resident has PTSD related to past traumatic experiences, evidenced by anxiety, hypervigilance, sleep disturbance, and verbalized intrusive memories. Interventions listed were initiated on 08/25/25 and included, but were not limited to, the following:Assess resident's trauma history and triggers (as they are willing to disclose), emotional responses, and coping strategiesDevelop an individualized care approach that avoids known triggers and incorporates resident-preferred coping mechanisms (e.g., calming music, quiet time, grounding techniques).Ensure all staff are educated on trauma-informed care principles and specific resident considerations to promote a safe, respectful care environment.Monitor for signs of re-traumatization (e.g., agitation, nightmares, avoidance behaviors) and report patterns to the interdisciplinary team for care plan adjustment.Assess resident for PTSD symptoms daily (anxiety, flashbacks, nightmares, triggers).Document resident's identified triggers and preferred calming strategies in care plan.During an observation and attempted interview on 12/14/25 at 12:14 PM Resident #6 was seated at a table in the dining room. He did not have any food in front of him, and he was making chewing motions with his mouth. He did not respond to questions but did nod when asked if he was [name of Resident #6].During an observation and interview on 12/15/25 at 11:52 AM Resident #6 was seated at a table in the dining room. He did not have any food on the table yet. He nodded when asked if staff were taking good of him and nodded again when asked if he was okay. When asked about triggers for his PTSD he looked into the middle distance and began to make chewing motions with his mouth.During an interview on 12/15/25 at 02:30 PM RN A stated she had worked for the facility for 3.5 months and had not received training on providing trauma-informed care for Resident #6 in regard to his PTSD diagnosis. She stated she did not know what any of Resident #6's triggers were.During an interview on 12/15/25 at 02:33 PM CNA I stated she had been working in the facility for a month and had not received training on providing trauma-informed care for Resident #6 regarding his PTSD diagnosis.During an interview on 12/15/25 at 02:41 PM CNA G stated she had worked for the facility for 31 years and was trained all the time on how to care for Resident #6 in regard to his PTSD diagnosis. She could not provide details of the training except to mention that Resident #6 could get upset and/or angry easily.During an interview on 12/15/25 at 02:51 PM, the I-DON stated regarding Resident #6, We just monitor him, if he gets anxious, we remove him from the situation he is in. We let him decide and guide us on what we need to do. Sometimes he just needs quiet. She stated she had seen him be triggered by Westerns 9genre) on TV. She stated she did not know if it was the gunfire or what it was that triggered Resident #6. The I-DON stated once he was triggered, he might need to be put to bed for 15 or 20 minutes to calm him down. The I-DON stated Resident #6's voice would raise an [NAME] to two if he was triggered. She stated she did not know any details of Resident #6's trauma.During an observation and interview on 12/15/25 at 03:59 PM Resident #6 was seated in his wheelchair in the common area. AD interpreted for the surveyor and asked him if he was willing to answer some questions. He looked past us into the middle distance and began making chewing motions with his mouth. AD stated, Oh wow! He is not going to talk. He usually talks a lot. I bet it is because he doesn't recognize you (surveyor).During an interview on 12/16/25 at 11:29 AM CNA B stated she had not received training on providing trauma-informed care for Resident #6 in light of his PTSD diagnosis. She stated, I didn't know about that. I thought it (his behavior) was because he is always hurting. She stated she had noticed moving too quick triggered Resident #6.During an interview on 12/16/25 at 11:36 AM, the I-DON stated she had not received training on providing trauma-informed care for Resident #6 and she had not trained staff on providing trauma-informed care for him. She stated, We pretty much let him lead us which way he wants to go.During an interview on 12/16/25 at 11:41 AM, MA K stated she had not received training on providing trauma-informed care for Resident #6. She stated she did not know what any of Resident #6's triggers were.During an interview on 12/16/25 at 11:53 AM, CN stated it was the responsibility of the IDT to ensure a resident with a history of trauma received trauma-informed care. He stated he had not trained staff on providing trauma-informed care for Resident #6 because he was not aware Resident #6 had a diagnosis of PTSD.During an interview on 12/16/25 at 12:04 PM, the ADM, when asked if staff had been trained to provide trauma-informed care for Resident #6, stated, As far as I know we have trained them on his aggressive behaviors but I don't know about PTSD specifically because I was not even aware he has PTSD so I didn't check up on them (trainings).2. Resident #36Record review of an admission record dated 12/14/25 revealed Resident #36 was an 84-y o female admitted to the facility on [DATE] with diagnoses of heart failure, heart disease, muscle weakness, dementia and chronic kidney disease.Record review of a care plan dated 9/29/25 documents resident was sometimes incontinent, was at risk for fluid overload, and needed some assistance with ADLs. The Care Plan did not reflect any interventions, objectives or goals for TED hose. Record review of a quarterly MDS dated [DATE] documented a BIMS score of 14 out of 15 which indicates cognition was intact.Record review of Resident #36's physician's orders revealed an order for TED hose with a start day of 11/13/25.In an observation and interview on 12/14/25 at 3:30 pm, Resident #36 stated she had not had any TED hose on and revealed her legs. She stated she had not been aware she was supposed to wear TED hose. She stated she was not able to bend over to put the hose on. Resident #36 stated the aides would have to help her put the TED hose on. She stated if she had some TED hose she would wear them.In an observation and interview on 12/15/25 at 11:05 am, Resident #36 had been observed in her room with no TED hose on. Resident #36 stated she had no TED hose on.In an interview on 12/15/25 at 11:10 am, CNA B stated she had cared for Resident #36 for the past week and stated Resident #36 did everything for herself. When asked if Resident #36 had any orders for TED Hose, CNA B stated Resident #36 did not have any orders for TED hose. She stated she had never put TED hose on Resident #36. She stated she did not know what the care plan said and had not looked at it.In an interview on 12/16/25 at 11:05 am, RN A stated she thought the ADON, DON, and charge nurse were responsible for the care plans. She stated a whole team came up with the plan. She stated the care plan should be specific to each person because what worked for some might not work for others.In an interview on 12/16/25 at 11:36 AM the I-DON stated she had been responsible for care plans. She stated she had put them in the EHR and the MDS Coordinator reviewed them. When asked what the consequences of an inaccurate or not person-centered care plans would be she stated As you get to know them you can better get a feel for what they want or need. In an interview on 12/16/25 at 11:53 AM, the CN stated staff responsible for care plans were the interdisciplinary team. He stated that usually the MDS Coordinator would cover everything that came from the MDS. He stated acute care plans for nursing had been done by the ADON and DON, Activities, Dietary, and SW. He stated the consequences of having inaccurate or not person-centered care plans would depend on what had not been care planned. He stated for example, If it was an allergy, we might give them something they are allergic to. If PTSD had not been care planned, we may not be taking care of him as we should be.In an interview on 12/16/25 at 12:04 PM, the ADM stated care plans were in the computer and whoever was doing an admission had been responsible for the care plan. The ADM stated, The DON should check to make sure it was accurate. The care plan meetings were done by the MDS coordinator. The ADM stated the ADON had the task of contacting the families. The ADM stated the MDS coordinator had attended the care plan meetings by teams or phone. The ADM stated the consequences of inaccurate or not person-centered care plans would be residents not getting the care they need.Record Review of the facility policy dated 11/2/25, titled Comprehensive Care Plans revealed:It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished are to maintain the residents' highest practicable physical, mental, and psychosocial well-being.6. The comprehensive care plan will include measurable objectives and timeframes to meet the residents' needs as identified in the residents' comprehensive assessment. Record review of facility policy titled Trauma Informed Care and dated 11/2/2025 revealed the following: . It is the policy of this facility to provide care and services which in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preference, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. d. Collaboration - an emphasis on partnering between residents and/or his or her representative, an all staff and disciplines involved in the resident's care in developing the plan of care. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals . to develop and implement individualized care plan interventions. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan . Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. These interventions will also recognize the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery. In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident.

Based on interview and record review the facility failed to perform a preadmission screening for individuals with a mental disorder and individuals with intellectual disability for 1 (Resident #29) of 15 residents reviewed for preadmission screening.The facility failed to perform a preadmission screening for Resident #29 prior to admission on [DATE].This failure could place residents at risk of not receiving needed services.Findings Included:Record review of Resident #29's admission record dated 12/15/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement), and psychotic disorder with hallucinations due to know physiological condition (mental health condition where the hallucinations are caused by a general medical disorder). Resident #29's admission record noted he arrived to the facility from his home.Record review of Resident #29's quarterly MDS completed 09/15/25 revealed a BIMS score of 3 which indicted severely impaired cognition. Section I - Active Diagnoses revealed he had diagnoses for anxiety disorder and psychotic disorder.Record review of Resident #29's care plan completed on 09/22/25 revealed he was care planned for using antipsychotic, antidepressant, and antianxiety medications.Record review of Resident #29's PASRR Level 1 Screening revealed it was completed on 03/08/25, four days after he was admitted to the facility.During an interview on 12/16/25 at 11:05 AM RN A stated she did not know what a PASRR was.During an interview on 12/16/25 at 11:36 AM I-DON stated she was unsure who was responsible for ensuring residents had a PASRR Level 1 Screening prior to admission. She stated, I usually just get them (PASRRs) sent to me. I-DON stated there was probably a negative outcome if a resident was admitted without a PASRR Level 1 Screening, but she was unable to specify what the negative outcome might be.During an interview on 12/16/25 at 11:53 AM CN stated MDS LVN was responsible for ensuring residents have a PASRR Level 1 Screening prior to admission. He stated if the resident was coming from the community and not from another facility or a hospital the facility would send a staff member to perform a PASRR Level 1 Screening prior to admission. He stated a resident who was admitted without a PASRR Level 1 Screening would be in danger of not receiving necessary treatment.During an interview on 12/16/25 at 12:04 PM ADM stated she was responsible for ensuring residents had a PASRR Level 1 Screening prior to admission. She stated if a resident was admitted without a PASRR Level 1 Screening it was against regulations and they might not get the right services.Record review of facility policy titled Resident Assessment - Coordination with PASARR Program and dated 11/2/2025 revealed the following: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I - initial pre-screening that is completed prior to admission .

Based on interview and record review the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #1) of 15 residents reviewed for advance directives.The facility failed to ensure Resident #1's DNR was dated by the physician, thereby rendering it invalid.This failure could place residents at risk of not having their end-of-life wishes honored. Findings Included:Record review of Resident #1's admission record dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), type 2 diabetes (insufficient production of insulin, causing high blood sugar), and heart failure (heart muscle fails to pump blood as it should). Resident #1's advance directive was listed as DNR.Record review of Resident #1's quarterly MDS completed on [DATE] revealed a BIMS score of 6 which indicated severely impaired cognition.Record review of Resident #1's care plan completed on [DATE] revealed the following: The resident's advance directives are: DNR . The resident's wishes will be honored throughout the review period. Honor the resident's wishes.Record review of Resident #1's OOH-DNR titled, Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order Texas Department of State Health Services revealed Resident #1 and a notary signed the document on [DATE]. The physician signed the document, printed his name, and provided his license number but the line for the physician to date the document was blank.During an interview on [DATE] at 11:05 AM RN A stated everybody was responsible for ensuring residents' advance directives were honored. She stated that a DNR not dated by the physician was not valid. RN A stated an invalid DNR could result in a resident passing without no intervention or opportunity to survive.During an interview on [DATE] at 11:36 AM I-DON stated she and the nurses on the floor were responsible for ensuring a resident's advance directive was honored. She stated she did not know if a DNR undated by the physician was valid or not. I-DON stated an invalid DNR could result in the facility going against their (residents') wishes.During an interview on [DATE] at 11:53 AM CN stated a resident's advance directive started with the social worker and if the facility did not have a social worker, the responsibility to ensure a resident's advance directive was honored fell to the DON. He stated a DNR not dated by the physician was not valid. CN stated a possible negative outcome of a resident having an invalid DNR was, We could be letting someone pass when we should be doing a code on them.During an interview on [DATE] at 12:04 PM ADM stated facility staff were responsible as a team to ensure resident advance directives were honored. She stated during admission it was made clear to residents and their families that if they opted for a DNR it had to be signed by a doctor before it could go into effect. ADM stated a DNR not dated by the physician was not valid. She stated a possible negative outcome of an invalid DNR was that a resident could get CPR and not want it.Record review of facility policy titled Residents' Rights Regarding Treatment and Advance Directives and dated [DATE] revealed the following: .It is the policy of this facility to support and facilitate a resident's right to . formulate advance directives.Record review of a blank Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Texas Department of State Health Services Instructions for Issuing an OOH-DNR Order revealed the following: . The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals.

Based on interviews and record reviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles for 5 of 5 employees (the CNA, the DA, the Hskpr, the LPN and the SW) reviewed for required trainings.The facility failed to ensure Abuse, Neglect and Exploitation Training, Fall Prevention, Restraint Reduction, HIV and Bloodborne Pathogens, Emergency Procedures, and Dementia Training were completed for the CNA, the DA, the Hskpr, the LPN, and the SW upon hire and prior to providing care for or working with residents.This failure could cause a lack of understanding and skill needed to provide adequate care of residents with varying conditions and levels of care. Findings included:Record review of the CNA's employee file on 07/23/2025 at 2:35M reflected no evidence she had been trained in Fall Prevention, Restraint Reduction, HIV and Bloodborne Pathogens, Emergency Procedures or Dementia prior to or on her first day of employment, on 07/08/2025.Record review of the DA's employee file on 07/23/2025 at 2:39PM reflected no evidence he had been trained in Restraint Reduction, HIV and Bloodborne Pathogens, Emergency Procedures or Dementia prior to or on his first day of employment, on 06/16/2025.Record review of the LPN's employee file on 07/23/2025 at 3:07PM reflected no evidence he had been trained on Emergency Procedures prior to or on his first day of employment, on 06/17/2025.Record review of the SW's employee file on 07/23/2025 at 3:12PM reflected no evidence he had been trained in Resident Abuse, Neglect and Exploitation, Fall Prevention, Restraint Reduction, HIV and Bloodborne Pathogens, Emergency Procedures or Dementia prior to or on his first day of employment, on 06/12/2025.Record review of the Hskpr's employee file on 07/23/2025 at 3:17PM reflected no evidence she had been trained on Emergency Procedures prior to or on her first day of employment, on 06/09/2025.An interview with the Administrator and DON on 07/23/2025 at 3:28PM revealed they were both aware of the required trainings that needed to be completed prior to staff providing care for or working with residents. The Administrator stated she was unsure why all trainings had not been completed as they had been assigned to each employee in the facility's online learning portal. She stated it was the responsibility of each staff member to ensure their trainings were completed before starting their duties in the facility. The DON stated there should be a staff member who reviews the trainings prior to and just after the employee's orientation, to ensue everything has been assigned and completed and all training materials were understood, but they have not assigned a staff member to do so. She stated the negative outcome of staff members not being trained prior to working with residents would be a lack of understanding of basic concepts needed to care for and interact with residents in the facility. This surveyor asked for the policy and procedures regarding required trainings at hire, but the Administrator and DON were unable to produce the policy.

Based on interviews, observations and record reviews, the facility failed to ensure that residents are free from neglect for 1 of 6 residents (Resident #1) reviewed for neglect. The facility failed to ensure Resident #1 was assessed after a fall on [DATE] resulting in his head hitting the floor and sustaining a laceration to the right eyebrow/cheek . The facility failed to monitor the resident after the fall and after approximately 3.5 hrs. a change in condition was noted resulting in the resident being transferred to the hospital where he expired due to a brain bleed. This failure could place residents at risk of substandard or delay of care, physical harm, or death. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:20 PM. Although the IJ was removed on [DATE] at 6:00 PM the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. The Plan of removal (POR) of IJ will be included in the findings. Findings included: Record Review of Resident #1's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Dysarthria following Cerebral Infarction (slurred speech after a stroke), muscle weakness, difficulty in walking, and hypothyroidism(overactive thyroid). Record Review of Resident #1's Admission MDS dated [DATE] revealed that Resident #1 had a BIMS (Brief Interview for Mental Status) score of 3 out of 15 which indicated he had severe cognitive impairment. MDS also revealed that Resident #1 required only supervision and set up help only for walking. He required supervision of one staff physical assist for transfer, bed mobility, eating, and toileting. He needed extensive assist of one staff for dressing and hygiene. Record Review of Resident #1's care plan dated [DATE] revealed that Resident #1 was at risk for falls due to dysarthria and CVA (Cerebrovascular accident). He also had a communication problem related to dysarthria and Cerebrovascular accident(stroke). Interventions were to monitor/document for physical/nonverbal indicators of discomfort, or distress and follow up as needed. Monitor/document and report any changes in ability to communicate. Record Review of physician's orders dated [DATE] revealed that Resident #1 was taking Clopidogrel 75 mg one time a day related to Acute Cerebrovascular (obstruction of arteries of the brain) insufficiency. Resident #1 was also taking Aspirin low dose 1 tablet daily for Cerebral Infarction (stroke). Record Review of Resident #1's progress notes dated [DATE] revealed he was a fall risk and had ,d+[DATE] falls in the past three months prior to admission. Record Review of Facility Fall incident Log revealed that Resident #1 had three falls since admission, [DATE], Resident #1 had two falls with no injuries and [DATE] one fall with head injury. Record Review of Resident #1's Neurological Flow sheet dated [DATE] revealed that RN A conducted neuro checks and vitals on Resident #1 from the time of the incident until he was transported to the hospital at 5:45 AM. The flow sheet revealed no pain assessment documentation for Resident #1. Record Review of Fall assessment dated [DATE] at 1:40 AM revealed no documentation of pain assessed at the time of the incident. Record Review of the facility investigation report completed by DON revealed that Resident #1's fall occurred on [DATE] at or about 1:40 AM. The investigation report revealed that the resident was standing in his room at his bedside while CNA B was assisting him in changing his brief. Resident #1 lost his balance falling hitting his head. Resident sustained a 1-inch laceration to the right brow/cheek area and a skin tear to the right wrist. Investigation revealed that the resident had a change of condition at approximately 5:00 AM and was transported to the hospital via ambulance. Resident #1 died at 5:18 PM at the hospital. Record Review of Resident #1's medical record from emergency roiagnom on [DATE] revealed that the transport for the resident was delayed due to resident coughing up large amounts of blood, Resident #1 was placed on a Laryngeal Mask Airway (temporary method to maintain an open airway) Assessment indicated that Resident #1 was in an altered state of consciousness, secondary to a brain hematoma with midline shift.(brain bleed with a shift) Resident #1 expired on [DATE] at 5:18 PM, cause of death was a fall hitting his right skull causing a brain bleed and midline shift of the brain which was fatal. During an interview/observation on [DATE] at 8:45 AM, the ADON stated that a pain assessment should have been completed on Resident #1 and thought that the pain assessment was done on the same document as the Neurological Flow Sheet but wasn't for sure. Because the ADON wasn't for sure, she accessed the facility's EHR to show surveyor where the pain assessment would be documented. The ADON told surveyor that she wasn't sure if she should be showing this to surveyor but then pulled up an anonymous resident that she had completed a pain assessment on in the past to show surveyor where it would be documented. During a telephone interview on [DATE] at 10:58 AM, RN A stated she was called into the room by CNA B on [DATE] at approximately 1:40 AM to assist with Resident #1 as he had fallen. RN A stated she observed Resident #1 on the floor on his right side and a 6-inch diameter pool of blood near the resident. RN A stated she did wound care on his head injury and wrist area. RN A stated she put a dressing on the wound and got the bleeding stopped. RN A stated she started the neuro and vital checks on the resident after she got him into bed. RN A stated that pain assessments are done along with the neuro checks but the resident wasn't complaining of pain. RN A stated she did not contact the physician immediately due to Resident #1 being stable. RN A stated that the physician was notified on or about 5:00 AM when the resident's blood pressure elevated, and he became lethargic and stopped responding. During an interview/observation on [DATE] at 11:05 AM, the DON accessed Resident's #1 fall assessment dated [DATE] via the facility's EHR but could not find where the pain assessments were conducted on Resident #1 after his fall on [DATE]. The DON showed surveyor the fall assessment document and showed where the pain assessment should be documented, but the area was grayed out and nothing was in the assessment about pain. The DON stated that the pain assessment was supposed to be done during neuro/vital check but was not documented so she is not sure if it was completed. During an interview on [DATE] at 11:15 AM, the ADM stated that falls happen and sometimes fall mats don't work as they also could be considered a fall hazard because residents trip over them. The ADM stated he was not familiar with the resident but had seen him walk around the facility with his walker. The ADM was not sure of what assessments were completed on the resident at the time of his fall. Record Review on [DATE] of Abuse, Neglect and Exploitation Policy revised on [DATE] revealed that neglect is the failure of the facility, its employees, or service provers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriate of resident property and exploitation that achieves: Assuring an assessment of the resources needed to provide care to all residents is included in the facility assessment. Record Review on [DATE] of facility policy Head Injury policy revised on [DATE] revealed in part It is the policy of this facility to report potential head injuries to the physician and implement intervention to prevent further injury. Policy explanation and compliance guidelines a. Vital signs b. General condition and appearance c. Neurological evaluation d. Evaluation of the head, eyes, ears, and nose for significant change in vision, hearing, smell or bleeding. e. Any injuries to head, neck, eyes, or face including lacerations, abrasion or bruising. f. Pain assessment. On [DATE] at 4:20 PM the Administrator, DON, and ADON were notified that an Immediate Jeopardy had been identified, IJ templates were provided, and a Plan of Removal was requested. On [DATE] at 9:18 AM the Facility's Plan of Removal was accepted. It was alleged that the facility failed to ensure that Resident #1 was being assessed for pain after a fall that resulted in a head injury that ultimately resulted in death. The facility's plan of Removal stated as follows: Actions to Prevent Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. o The DON implemented disciplinary action with licensed nurse who was aware of significant change but did not report it to the physician. o Additional Relias training was assigned and will be completed by [DATE]. o All Licensed nurses were educated by DON on change of condition and physician notification regulations, as well as facility policy and procedure. o Nurse Aides were educated by the DON on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses. o New hires (licensed nurses and nurse aides) will be educated on change of condition and physician notification regulations, as well as facility policies and procedure, accordingly in orientation human resources/designee. o Notification of Changes Policy reviewed and updated on [DATE]. o The DON implemented a Quality Assurance Performance Improvement (QAPI) performance improvement project (PIP) with the focus on physician notification of significant changes. o The PIP resulted in implementation of daily DON/designee audits of the 24-hr report to monitor for changes in the resident condition. o The DON/designee will also complete chart audits/health documentation assessment as follows: o Three residents weekly for four weeks then; o Two residents weekly for two weeks then; o Two residents a month for two months o Will Review PIP results at monthly QAPI meeting X 90 days Monitoring the plan of Removal Included: During an interview on [DATE] at 12:16 PM, DON stated that RN A will be required to take three trainings before returning to work and was written up. RN A will be required to take Basic injury assessment, Adverse incident management and Preventing, recognizing, and reporting abuse. DON stated that in-services were conducted on [DATE] educating the staff on change of condition, physician notification regulation as well as facility policy and procedures. DON stated that she revised the policy Notification of changes on [DATE] and was attached to the POR. DON said that all staff will be given a paper copy of the revised policy. DON also stated that she implemented a Quality Assurance Performance Improvement (QAPI) which focused on physician notification of significant changes. The Performance Improvement Plan (PIP) resulted in implementing a daily audit to monitor changes in resident conditions. The DON stated she and the ADON will complete the assessment audits and the audits will be documented in their EHR. DON stated that she and the ADON have completed one audit to date. The DON also stated that after she sent the POR, she decided that she would require all licensed nurses would take Adverse Incident Management training as well. During interviews on [DATE] from 12:35 PM to 5:50 PM 47 of 47 staff (1 ADM, 1 DON, 1 ADON, 1 Dietary Manager, 2 Cooks, 4 Dietary Staff, 1 Activity Director, 1 Activity Director Assistant, 1 Social Worker, 5 Housekeepers/Laundry, 1 Maintenance Supervisor, 1 Van driver/maintenance, 1 Housekeeping Assistant, 3 RNs, 7 LVNs, 12 CNAs, 1 CMA, 2 Human resources) members verified that they received training on the new policy Notification of Changes and ANE training on [DATE]. Record Review on [DATE] of new policy Notification of Changes revised on [DATE] revealed in part the facility promptly inform the resident physician where there is a change requiring notification. The policy also stated accidents resulting in an injury, falls involving resident hitting head and on blood thinners send to ER for further evaluation. An Immediate Jeopardy was identified on [DATE] at 4:20 PM. While the Immediate Jeopardy was removed on [DATE] at 6:00 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns.

Based on interview and record review, it was determined the facility failed to immediately inform the physician and resident representative after a significant change in condition for 1 of 6 Residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's Physician and Responsible Party after Resident #1 had a fall with injuries that resulted in a brain hematoma with a midline shift in which Resident died due to fall. The facility failed to notify Resident #1's Physician and Responsible Party after Resident #1 had a fall resulting in his head hitting the floor and sustaining a laceration to the right eyebrow/cheek. This failure could place residents at risk by causing a delay in necessary medical intervention, not allowing physician and families to be aware of any changing conditions and/or death. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:20 PM. While the immediate jeopardy was removed on [DATE] at 6:00 PM, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. Findings include: Record Review of Resident #1's clinical record on revealed he admitted on [DATE], was [AGE] years of age with the following diagnoses: dysarthria following cerebral infarction (slurred speech after a stroke), muscle weakness, difficulty in walking (not elsewhere classified), occlusion and stenosis of bilateral carotid arteries (blocked or narrowing of the large arteries), benign prostatic hyperplasia (prostate gland enlargement) without lower urinary tract symptoms, hypothyroidism (overactive thyroid), hyperlipidemia (high cholesterol), other insomnia, essential (primary) hypertension (high blood pressure). Record review of an admission MDS assessment dated [DATE], documented that Resident #1 had clear speech, was usually understood but had some difficulty communicating some words or finishing thoughts, sometimes understands and able to respond to simple, direct communication only. Brief Interview for Mental Status (BIMS) was a 3 out of 15 indicating he had severely impaired cognition. He required only supervision and set up help only for walking. He required supervision of one staff physical assist for transfer, bed mobility, eating, and toileting. He needed extensive assist of one staff for dressing and hygiene. Record Review of Resident #1's care plan, dated [DATE] revealed he was identified as a fall risk with interventions that include Resident #1's call light is within reach, and ensure the resident is wearing appropriate footwear, the resident needs prompt response to all requests. Record Review of Resident #1's Progress notes dated [DATE], revealed he was a fall risk and has had ,d+[DATE] falls in the past 3 months prior to admission and that his fall risk score is a 10.0 indicating he was high risk. Record Review of Resident # 1's Physician's orders dated [DATE] revealed Resident #1 was taking Clopidogrel 75 MG tablet once a day for Acute Cerebrovascular insufficiency (obstruction of arteries to the brain). Also, on [DATE] revealed Resident was taking Aspirin low dose 81 mg tablet daily for cerebral infarction (stroke). Record Review of Facility Fall Incident Log on [DATE] at 1:50 PM revealed Resident #1 had 3 falls since admission. Resident #1experienced 2 falls on [DATE]rd, without injury and then one on [DATE] with injury to head and wrist. Record Review of the facility's Provider Investigation Report dated [DATE] and revealed Resident #1 had a fall on [DATE] at 1:40 AM when Resident was standing in room by bedside with CNA B assisting to change him, he lost his balance and fell to the floor hitting his head. Resident sustained a laceration approximately 1 inch to right eyebrow/cheek and skin tear to right wrist. Resident was assessed by RN A and Resident was responding in usual manner at time of initial assessment - area was cleansed, and dressing applied to right side of head. Neuro protocol was performed by RN A. CNA B sat outside resident's room to monitor as well. At approximately 5:00 AM resident had a change in condition. Primary Care Physician and EMS were then notified. Patient was taken to Emergency Department where CT results showed a brain hematoma (brain bleed) with midline shift. He was placed on comfort measures at hospital, where he expired later that afternoon. During a phone interview with Resident #1's POA on [DATE] at 11:40 AM, she stated that she was not called when Resident #1 fell and that she didn't get a call from the facility until he was unresponsive which was around 5:00 AM on [DATE]. POA was informed at that time that Resident #1 was being transported to hospital by ambulance for further evaluation. During a phone interview with RN A on [DATE] at 1:20 PM, she stated that Resident #1 fell at 1:40 AM. CNA B was helping to change Resident #1's brief/pull up, standing beside the bed and he lost his balance and fell hitting his head on a bedside table. She stated when she got to his room, he was laying on his right side and a pool of blood was on the floor of about 6 inches in diameter. She stated Resident was responding and helped them get him off the floor and back into bed. She stated she started wound care on his right temple area and his right wrist and got the head injury bleeding stopped and started neuro checks and vitals. Neuro checks were performed every 15 minutes for the first hour after injury, every 30 minutes for the next hour, every hour until his vitals changed. She went on to state that he wasn't complaining of any pain. RN A stated that since she got the bleeding stopped on Resident #1's head injury, she felt it was ok not to call the physician or EMS. Resident #1 remained stable until around 5AM but then his blood pressure went up and he became lethargic and stopped responding. When asked if physician was called immediately after Resident #1's fall, she stated no, he was called around 5:00 AM. When asked why she waited until 5:00 AM to call the physician, she said, You've got a point. In an interview on [DATE] at 2:18 PM with the DON about Resident #1's fall, DON stated that it was at the discretion of RN A about when to call the physician. When asked what medications Resident #1 was taking, since EHR wasn't allowing surveyors to see all aspects of Resident's chart, she went to Resident #1's patient file and showed surveyor that Resident was taking a blood thinner which was the generic brand of Plavix and an Aspirin, each one time per day. During a phone interview with the Resident #1's primary care physician on [DATE] at 2:50 PM he revealed that he was not called about Resident #1's fall on [DATE] until approximately 6AM. He stated that he told RN A to call EMS immediately and get him to the hospital and he then stated that RN A did not follow protocol, that he was to be notified immediately after any fall. He went on to state had he been notified immediately after the fall; he would have sent Resident #1 immediately to the ER for a CT scan of his brain. He stated immediacy could have made a difference in what happened to Resident #1. Record Review of facility policy Head Injury dated [DATE] stated: It is the policy of this facility to report potential head injuries to the physician and implement interventions to prevent further injury. Policy goes on to state that assessment will include: vital signs, general condition and appearance, neurological evaluation - checking for changes in behavior, cognition, dizziness, nausea, physical functioning, slurred speech, Pain assessment. Call 911/EMS and attempt to stabilize the resident's condition if respiratory distress or a hemorrhaging wound occurs. Notify physician and follow order for care: provide information from physical assessment, describe how injury occurred and how situation has been managed so far, report any recent medication changes or use of anticoagulant/antiplatelet medications, any recent lab or diagnostic test results. On [DATE] at 4:20 PM the Administrator, DON, and ADON were notified that an Immediate Jeopardy had been identified, IJ templates were provided, and a Plan of Removal was requested. The Facility's Plan of Removal (as follows) was accepted on [DATE] at 9:18 AM. It is alleged that the facility failed to notify Resident #1's Physician and Responsible Party after resident #1 had a fall with injuries. Facility Plan of Removal states: The DON implemented disciplinary action with licensed nurse who was aware of significant change but did not report it to the physician. Additional Relias training was assigned and will be completed by [DATE]. All Licensed nurses were educated by DON on change of condition and physician notification regulations, as well as facility policy and procedure. Nurse Aides were educated by the DON on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses. New hires (licensed nurses and nurse aides) will be educated on change of condition and physician notification regulations, as well as facility policies and procedure, accordingly in orientation human resources/designee. Notification of Changes Policy reviewed and updated on [DATE]. The DON implemented a Quality Assurance Performance Improvement (QAPI) performance improvement project (PIP) with the focus on physician notification of significant changes. The PIP resulted in implementation of daily DON/designee audits of the 24-hr report to monitor for changes in the resident condition. The DON/designee will also complete chart audits/health documentation assessment as follows: Three residents weekly for four weeks then; Two residents weekly for two weeks then; Two residents a month for two months. Will Review PIP results at monthly QAPI meeting X 90 days. Monitoring of the Plan of Removal Included: In an interview on [DATE] at 12:16 PM, the DON stated that RN A will be required to take three trainings before returning to work and was written up. RN A will be required to take Basic injury assessment, Adverse incident management and preventing, recognizing, and reporting abuse. The DON stated that in-services were conducted on [DATE] educating the staff on change of condition, physician notification regulation as well as facility policy and procedures. The DON stated that she revised the policy Notification of changes on [DATE] and it was attached to the POR. DON said that all staff will be given a paper copy of the revised policy. The DON also stated that she implemented a Quality Assurance Performance Improvement (QAPI) which focused on physician notification of significant changes. The Performance Improvement Plan (PIP) resulted in implementing a daily audit to monitor changes in resident conditions. The DON stated she and the ADON will complete the assessment audits and the audits will be documented in their EHR. The DON stated that she and the ADON have completed one audit to date. The DON also stated that after she sent the POR, she decided that she would require all licensed nurses would take Adverse Incident Management training as well. During interviews with facility staff conducted on [DATE] from 12:35 PM to 5:55PM, 47 of 47 staff (1 Admin, 1 DON, 1 ADON, 1 Dietary Manager, 2 Cooks, 4 Dietary Staff, 1 Activity Director, 1 Activity Director Assistant, 1 Social Worker, 5 Housekeepers/Laundry, 1 Maintenance Supervisor, 1 Van driver/maintenance, 1 Housekeeping Assistant, 3 RNs, 7 LVNs, 12 CNAs, 1 CMA, 2 Human Resources) members verified that they had been in serviced on when to notify physician and family and had received Notification of Changes training and Abuse/neglect training on [DATE]. Record Review on [DATE] of new policy Notification of Changes revised on [DATE] revealed facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Accidents, resulting in injury, where falls involve hitting head and on blood thinners such as Plavix, Eliquis, Xarelto sent to ER for further evaluation. Potential to require Physician intervention. Significant change in resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status including life threatening conditions or clinical complications. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:20PM. While the Immediate Jeopardy was removed on [DATE] at 6:00PM, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns.

Based on interviews and record review, the facility failed to ensure the resident environment remains as free from accidents hazards as is possible, and each resident received adequate supervision and assistance to prevent accidents for 1 of 5 residents (Resident #1) reviewed for transfers. CNA A failed to transfer Resident #1 using a mechanical lift which resulted in Resident #1 receiving a fracture to her right lower femur. This failure placed residents at risk of falls, lacerations, fractures, and even death. Findings included: Record review of Resident #1's clinical record revealed she admitted to the facility on [DATE], was [AGE] years old with the following Diagnoses: [REDACTED]. -An Annual MDS resident assessment, dated 1/12/2020, documented the resident scored 11 of 15 on a mini-mental exam, required extensive assistance by two staff for bed mobility, totally dependent on two staff for transfers, totally dependent on one staff for toileting and bathing, incontinent, 64 inches tall and 186 pounds. Care Plan, last reviewed 11/03/2020 - At risk for falls related to weakness and poor balance - will receive extensive assistance with transfers to reduce the risk of falls. Potential for little activity involvement related to dementia and pain, prefers to be in bed most of the time -X-ray, dated 11/7/2020, documented distal femur comminuted [MEDICAL CONDITION] femur. Underlying advanced [MEDICAL CONDITION]. -Orthopedic Surgery Consult, dated 11/8/20 - has not been out of bed in almost two years. On stretcher cart, on right long-leg splint, difficult to communicate. Had a long discussion with POA given her general condition, patient might not be indicated for surgery in this hospital. Record review of the Provider Investigation Report, dated 11/7/20, related to Resident #1 revealed Resident #1 was sent to the emergency room for evaluation of pain to her right leg. The investigation revealed that Resident #1 became weak and was lowered to the ground while being manually transferred by a nurse aide on 11/4/20. It was clearly stated in the care tracker that the resident was to be transferred with the mechanical lift. The lift was available for use. After the resident was lowered to the ground, the charge nurse was informed of the incident and assisted getting the resident back to bed. The charge nurse failed to complete the report associated with falls, The charge nurse also failed to inform the provider. Response to the incident: 1. Charge Nurse was placed on a three day suspension and will be required to complete education associated with this incident. 2. The CNA was discharged from the facility. The agency that he is associated with has been informed. 3. The DON had conducted interviews with staff to ensure that the mechanical lift is being used with the residents who require it. This was completed 11/9/20 to 11/12/20. 4. The DON has also completed audits of all charts to ensure that the transfer assessment is current and reflects the needs of each resident. Completed on 11/9/20. 5. The DON also completed an audit of all care tracker information to ensure the information provided reflects the accurate needs of the residents. Completed on 11/9/20. 6. The DON and Staff Development Nurse will continue to conduct training with staff related to the reporting of incidents and the use of the mechanical lifts. 7. In-service on care plans, abuse/neglect, fall education, lift transfers and reporting requirements is in progress at this time. Completed 11/1/20 and 11/12/20. 8. The CNA that was working at the time of the incident had received the needed information for care for Resident #1. The CNA did have the ability to access the needed information. Records indicate the CNA has made entries into the care tracker system. The DON had placed a printed copy of the Resident #1's care tracker plan on the unit as well. 9. The Charge Nurse that failed to report the assisted change in position as a fall has been placed on a three day suspension without pay. She also has had immediate education and will also be completing a longer term project in which she will audit and become familiar with the care planning process. Upon her return, she will be placed on probation for weekly meetings with the DON on procedures for one month. Then meetings will be twice per month for 90 days. During an interview on 12/17/20 at 10:00 a.m., the Administrator stated CNA A (agency nurse aide) transferred Resident #1 without using a mechanical lift. The Administrator stated Resident #1 got weak and CNA A had to lower the resident to the floor. The Administrator stated CNA A went and got LVN B to help get Resident #1 off of the floor and into her bed. The Administrator stated it was at that time that LVN B realized that CNA A did not use the mechanical lift to transfer Resident #1. The Administrator stated there was a mechanical lift on the COVID-19 positive unit where Resident #1 was located and CNA A knew Resident #1 was a mechanical lift only. The Administrator stated they immediately terminated CNA A and reported the incident to the agency he worked for. During an interview on 12/17/2020 at 10:40 a.m., the DON stated CNA A was transferring Resident #1 without using a mechanical lift. The DON stated Resident #1 became weak during the transfer and CNA A lowered Resident #1 to the floor. The DON stated Resident #1 had severe [MEDICAL CONDITION] and received a fracture to her leg. The DON stated there was always a mechanical lift available on the COVID-19 unit and clean slings to use with the lift were provided daily and as needed. The DON stated all staff, including agency staff, were trained on using the mechanical before ever working on the floor. During an interview on 12/17/2020 at 11:25 a.m., LVN B stated she was working the day CNA A transferred Resident #1 without the use of a mechanical lift. LVN B stated she was charting on the COVID-19 unit and CNA A was assisting residents. LVN B stated CNA A asked for help to get Resident #1 into bed because the resident had given out during a transfer and had to be lowered to the floor. LVN B stated when she entered Resident #1's room, the resident was lying on her back and she did not say she was in any pain. LVN B stated she assessed Resident #1 and there were no visible injuries so they lifted her and placed her in bed. LVN B stated Resident #1 wanted to be changed so together they changed her brief and that was when Resident #1 started complaining of her right knee hurting. LVN B stated Resident #1 was always in pain because of her arthritis and there was no swelling at that time. LVN B stated two days later, Resident #1's right leg looked bigger that the other and she called to get an x-ray which revealed a fracture. During an interview on 12/17/20 at 11:45 a.m., CNA A stated Resident #1 was trying to self-transfer from her wheelchair to her bed when the incident happened. CNA A stated Resident #1 missed her bed when she was transferring herself and said her knee was going out, so he just lowered her to the floor and then got the nurse to help him put her in bed. CNA A stated the facility considered that a fall but he lowered Resident #1 very gently to the floor. CNA A stated he did not know Resident #1 was a mechanical lift and there was never a mechanical lift or sling on the COVID-19 unit. CNA A stated the nurse assessed Resident #1 and there was no bruising or marks on her. Record review of CNA A's statement, dated 11/9/2020, documented Resident #1 was being transferred from wheelchair to bed and she started to slide down my leg in the middle of the transfer. I helped Resident #1 to the floor safely and then notified the charge nurse. Record review of a policy titled, Lifting, Transfer Policy, and signed by CNA A on 9/29/20, revealed the following: Purpose: To foster safety both for residents and the staff and maintain the resident's functional capabilities to their highest practical level. Procedures: 1. An assessment of lifting and transferring of each resident will be made on admission, when there is significant change off condition and annually thereafter. If the resident's status changes, an update will be made in the care plan and an update will be sent to all nursing staff. 2. All residents that require total assistance (ability to bear less than 50% of his/her weight) with transfers must be lifted by two nursing staff members or an ultra-lift with 2 nursing staff. Record review of a Total Mechanical Lift Competency Checklist, dated 9/29/20, revealed to always refer to the policy & procedures, the individual's care plan and the manufacturer's guidelines. The checklist reflected all yeses where checked off and was signed by CNA A.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for all residents when: -had COVID-19 positive resident and negative resident residing on the same hallway to prevent the spread of COVID-19. -failed to have dedicated staff to care for only COVID-19 positive residents. Staff were going from COVID positive residents to COVID negative residents. -staff were not wearing the proper PPE and were not using hand hygiene when appropriate. - failed to ensure food was delivered to residents without spreading COVID-19 throughout the building. Dietary Staff were going from COVID positive residents to COVID negative residents. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/8/2020 at 3:00 p.m. While the IJ was lowered on 10/11/2020 at 12:30 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. The evidence is as follows: An observation on 10/8/2020 at 9:50 a.m. revealed the facility had hallways like a wagon wheel with all hallways opening up into a rotunda. There was a plastic barrier at the beginning of hall A and C. Since hall A and C had the barriers up, the Investigators initially believed those two hallways were where the COVID-19 positive residents were located. The double doorways to B, E and F hallway were all open with staff walking freely between each hallway. The nurses station was located in between halls D and E with administrative offices being on D hall. (After interviews with staff, it was revealed there were COVID-19 positive residents located on every hallway which made the whole facility COVID-19 positive) An observation on 10/8/2020 at 9:55 a.m. revealed the AD exited C hall wearing only a mask and no other PPE. The entrance to this hall was covered by plastic barrier. (AD should have been wearing a gown, face shield and gloves) An observation on 10/8/2020 at 10:00 a.m. revealed LVN A exited A hall wearing a white cloth lab coat and mask. While walking away from the hall, LVN A removed her contaminated lab coat and laid it across a med cart that was parked across from the nurse's station without sanitizing her hands afterwards. LVN A then walked into the nurses station, opened the swinging door with her contaminated hands, reached for a bottle of hand sanitizer and proceeded to sanitize her hands. (LVN A should have also been wearing a face shield and gloves) An observation on 10/8/2020 at 10:10 a.m., revealed the maintenance man exited A hall, wearing only a mask and no other PPE. At the same time, LA was exiting C hall, with PPE of white cloth lab coat and mask. LA then went to enter E hall, wearing the same PPE. There was not any observation of hand sanitizing after exiting one hall and entering another. (Maintenance man and LA should have been wearing face shields and gloves) An observation on 10/8/2020 at 10:15 a.m. revealed a black two tier multi-use cart, coming from behind the plastic barrier located on A hall, and pushed through the center of the facility into the dining area. An observation on 10/8/2020 at 10:19 a.m. revealed CNA B on B hall coming out of one room and entering another room, wearing the same PPE of white cloth lab coat and a mask. There was no observation of hand sanitizing or PPE removal. This hall had no barrier and the double doors were opened. During an interview on 10/8/2020 at 10:20 a.m., the DON stated A hall and C hall were where their most well residents were and halls B, E and F were the most infected hallways. The DON stated they ran out of room on E hallway for the COVID-19 positive residents because E hall was their hottest zone for COVID-19. The DON stated there were 3 residents on the COVID-19 positive E hall, then they had 2 positive residents on Hall A, 2 positive residents on Hall C, and 1 positive resident on Hall B. During an interview on 10/8/2020 at 10:46 a.m., the Administrator was asked about expectations for donning and doffing PPE and the proper way to enter and exit the hallways with positive COVID-19 patients. The Administrator stated that donning of PPE, for positive COVID-19 patients, should be done outside the room, prior to entering and doffing is to occur outside the room after exiting the room. The Administrator stated that staff who work sister halls with positive COVID-19 patients should enter and exit through the back doors. During an interview on 10/8/2020 at 11:11 am, CNA C, who is responsible for C hall, confirmed there were two positive COVID-19 patients and additional negative patients on the hall that day. CNA C stated she would don a blue disposable gown and gloves prior to entering a positive room, and doff the PPE prior to exiting the room (exposing herself to [MEDICAL CONDITION]). CNA C stated PPE of a white cloth lab coat and gloves were worn when entering and giving care to patients that were negative. CNA C stated that prior to exiting the room, PPE of white coat was hung up on the patient's door. CNA C stated that she enters and exits through the plastic barrier into the center of the facility. During a follow-up interview on 10/8/2020 at 11:17 a.m., the Administrator stated she had one staff for each hallway and did not have enough staff to dedicate staff to care for positive residents only. During an interview on 10/8/2020 at 11:22 a.m., CNA D stated she was responsible for A hall, confirmed there were three positive patients and 10 negative patients on the hall that day. CNA D stated the PPE donned prior to entering a patient's room consists of Blue disposable gown, mask, face shield, gloves and foot protectors and those who are negative PPE consists of white cloth lab coat, mask and gloves. CNA D stated PPE was changed with each positive patient and the same lab coat is used when entering a negative patient's room. CNA D stated when entering and exiting the hall, she will enter through the barrier and exit through the barrier and at end of shift through the barrier and through the facility to the time clock. During an interview on 10/8/2020 at 11:25 a.m., CNA E stated she was responsible for B hall and confirmed all patients were positive on the hall that day. CNA E stated the PPE donned prior to entering a patient's room consists of Blue disposable gown, mask, and gloves. CNA E stated PPE was doffed in the patient's room and placed in a trash bag which was located in the patient's room. CNA E stated when entering and exiting the hall for breaks and end of shift, she would exit through the barrier, through the facility, to the time clock. During an interview on 10/8/2020 at 11:28 a.m., CNA F stated she was responsible for A hall and confirmed four patients were positive and 11 were negative on the hall that day. CNA F stated the PPE donned prior to entering a patient's room consists of Blue disposable gown, mask, and gloves. CNA F stated PPE is doffed in the patient's room and placed in a trash bag, which was located in the patient's room. CNA F stated when entering and exiting the hall for breaks and end of shift, she would exit through the barrier, through the facility, to the time clock. An observation on 10/8/2020 at 11:50 a.m., revealed a black two tiered cart with two layers of white, Styrofoam clam shell boxes, on the top tier, pushed through the plastic barrier on A hall. Staff member waited outside the barrier. An observation on 10/8/2020 at 12:00 p.m., revealed a black two tiered cart come out from behind the plastic barrier on A hall, through the center of the facility, into the dining room. During an interview on 10/8/2020 at 2:37 p.m., the DM stated all meal carts are not to go behind the barrier because they would be considered contaminated. The DM stated staff were to hand the meal boxes to the staff on the other side, to be loaded on a cart of their own. DM also stated that all carts are to be sanitized prior to entering the kitchen. Record Review of the COVID-19 Response for Nursing Facilities, (Version 3.4) (8/12/20) documented the following: 6: To Do's for Nursing Facilities: *For the duration of the state of emergency, all Nursing Facility personnel should wear a facemask while in the facility. Staff who are caring for residents in a building with widespread COVID-19 infection, should wear an N95 respirator and all suggested PPE. *To avoid transmission within facilities, Nursing Facilities should use separate staffing teams for COVID-19 positive residents to the best of their ability, and designate separate facilities or units within a facility to separate residents into three categories: those who are COVID-19 negative, those who are COVID-19 positive, and those with unknown COVID-19 status. *Isolate residents with positive cases. 9.Facility Activities Required for Long Term Care COVID-19 Response Immediate (0-24 hours) *Activate resident isolation/facility cohort plan, including establishing a unit, wing or group of rooms for any positive residents. Attachment 1: Immediate Response Guidelines -Create an isolation wing/unit *identify a separate, well-ventilated area to use as an isolation area. This nursing home area should be an isolated wing, unit, or floor that provides meaningful separation between COVID-19 positive residents and the space where the facility cares for residents who are COVID-19 negative or untested and asymptomatic. A curtain or a moveable screen does not provide meaningful separation. Review of the facility's Novel Coronavirus Prevention and Response, dated 5/20/20, documented the following: l. Residents on the Pink and Red Zones are to have dedicated staff and not to enter other zones, if at all possible. Primary Red/Pink zone will be on E hall exiting the end of the hallway so not to cross into the main area of the facility. Linen, trash and staff is to exit the end of E hall. The Administrator was notified on 10/8/2020 at 3:00 p.m. that an Immediate Jeopardy (IJ) had been identified due to the above failures. A copy of the IJ template was provided to the Administrator. The Plan of Removal, accepted on 10/9/2020 at 11:20 a.m. documented the following: On 10/8/2020 post IJ notification: Residents: Resident # 6 and Resident # 7 were moved from private rooms on A hall and placed together in E hall. These residents were taken out the exit door on A hall and entered the E hall exit door to prevent crossing the lobby area of the facility. Transferred outside of the building at 4:50 p.m. Resident #8 from B hall and Resident #9 from C hall were removed from a private room and placed in E hall together. These residents were taken out of the B and C exit doors and taken to the E hall exit and entered the building to prevent crossing the lobby area of the facility. Transferred outside of the building at 5:15 p.m. Resident #10 was removed from his private room on C hall and placed in a semi-private room on E hall. Resident rooms were cleaned and disinfected and the rooms fogged after the resident was taken to E hall. At 5:25 p.m. E hall now has all positive residents and no positive residents are on any other hallway. Rooms were labeled, changed in the computer system and the 24 hour report sheet updated to reflect the changes in the facility. Staffing is adjusted to having E hall with separate staffing with a nurse and aide for each shift that will not cross over to any other hallway. On 10/9/2020 the remaining 3 residents on C hall will be moved to B hall to help with staffing the facility. This will be used for any new COVID positive residents since E hall is now limited in rooms. All hallway zones were changed to reflect the new hallway standards. Red zone for E hall, yellow zones for all other hallways. In-service was given to all staff of our basic infection control and zones of the hallway staff expectations in which once on E hall, they do not cross off of E hall and they must leave the facility. As per our procedure, meals and breaks may be taken on courtyard but they are not to co-mingle. Trash, linen will be taken out of E hall and back outside to laundry services. All staff is assigned to the COVID unit is not to enter back into the facility and will only exit the E hall exit. The empty resident rooms were fogged and disinfected upon the resident leaving the room by housekeeping staff, to assure a clean environment and the doors were closed. Dietary services were in-serviced by the dietary manager on 10/8/2020 at 4:00 p.m. to explain carts are not to cross barrier walls to avoid cross contamination, and the need for carts to be sanitized upon return to the dining room. Drinking cups were also addressed in the in-service. This was done by 6:00 p.m. on 10/8/2020. To be done: In-service will be conducted on the night shift to assure that the staff are understanding the procedures and the infection control policy, by the MDS nurse who is working night shift to accommodate the new changes. All staff will be in-services by Friday evening that is currently working; we do have some staff that are on vacation or not currently working due to a COVID leave. Those individuals will be in-serviced upon return to the facility by HR and/or their department head. Sign in sheets being given to HR for safe keeping. Therapy staff will be in-serviced once they return to the building on where to don and doff PPE equipment and informed they will be required to check with the charge nurse to assure no new residents which are on services have tested positive. This will be done by the DON and signatures will be obtained to document in-service. In Summary: 1. All residents who have tested positive as of 10/8/2020 are relocated to E hall. 2. All staff who are currently working have been in-serviced, this includes Dept. Heads, Dietary, Housekeeping and Nursing. 3. Rooms have been fogged and disinfected. 4. Room changes have been addressed with rooms being labeled, medications changed in medication carts and in the EMR. 5. Department heads will continue the in-service for their specific procedures in their departments. 6. Staff has been adjusted to accommodate the necessary changes; for COVID residents and non-COVID residents/ recovered COVID residents. 7. C hall will be considered a hall to isolate COVID positive residents if we need extra rooms. 8. In-service will be on-going to assure staff understands the procedures and policies. 9. Dietary carts will be disinfected prior to coming into the building from any COVID positive wing. Monitoring of the facility's plan of removal: An observation on 10/11/2020 at 9:45 a.m. upon entry to the facility, E hall had the plastic barrier up with the double doors closed and all COVID-19 positive residents were residing on the hallway. C hall did not have any residents on that hallway. An observation on 10/11/2020 at 9:50 a.m. revealed housekeeping was cleaning and disinfecting at the nurse station counter tops and commonly touched surfaces. During an interview on 10/11/2020 at 10:15 a.m. CNA D stated she had worked at the facility for six years and they had been recently in-serviced over PPE donning and doffing, infection control and where each person was supposed to be working. CNA D stated she uses hand sanitizer all the time and she only works with negative residents. CNA D stated E hall was where all the positive residents were and she was not to go on that hallway at all. CNA D stated the staff that do work on that hallway leave the hallway out the door at the end of the hallway and doff their PPE outside. During an interview on 10/11/2020 at 10:25 a.m., LVN A stated E hall was the COVID-19 hall. LVN A stated there were no COVID-19 positive residents on any of the other hallways and C hall was left empty for newly admitted residents for quarantine. LVN A stated she had been in-serviced on infection control, PPE donning and doffing and hand washing and using hand sanitizer. LVN A stated all residents that are not on the positive hallway do not have any symptoms at this time and temperatures were taken at the beginning of every shift. LVN A stated no one comes in the facility through E hall and anyone on that hallway exits through the door at the end of the hallway. During an interview on 10/11/2020 at 10:38 a.m., the DON stated all the rooms in the facility and the foyer have been cleaned and fogged. The DON stated all COVID-19 positive residents were moved to hall E and there was a total of 9 positive residents with one resident who was positive was sent to the hospital. The DON stated they cleared off C hall and that will be used for new admits and residents who were returning from the hospital. The DON stated she in-serviced staff on infection control and having separate staffing for positive and negative residents. The DON stated the dietary department also in-serviced staff on the dietary carts not going on the positive hall and then back into the facility without being sanitized. The DON stated in-services were also conducted with the laundry staff and trash collection. The DON stated the girls working on the unit use the phone to communicate any needs that they might have. The DON stated the food was delivered to E hall at the side door and instead of handing the food trays to staff, the food was left on the cart outside the door and staff were called to inform them that the food was delivered. The DON stated she worked with scheduling and they now have dedicated staff for the COVID-19 positive hall. The DON stated staff were working a lot of extra but all shifts are covered. During an interview on 10/11/2020 at 10:50 a.m., HK stated they clean rooms, bathrooms, floors change trash bags, m op and sweep floors and then disinfect everything with a spray or fogger. HK stated the wet time for the disinfectant that they use was 60 seconds and they disinfect everything throughout the day. HK stated they had been in-serviced on infection control and how to properly clean rooms. HK stated they had two HK's working at the facility during the day and he was not working on the positive hallway. HK stated today, the other HK has the positive hall (E) along with F hall. HK stated when he got that assignment, he would first clean F hall and then put on all PPE and go to E hall and clean and then leave the facility out the door at the end of E hall. HK stated he would not be allowed back in the facility until he went home and showered. During an interview on 10/11/2020 at 11:00 a.m., the DA stated when they served food to residents on E hall, they uses all paper products and deliver the food to a cart that's on the patio off of E hall. The DA stated dietary staff place the food trays to the cart on the patio. The DA stated they call the staff working on E hall and tell them to get the meals off of the cart. The DA stated the cart stays on the patio. The DA stated she had been in-serviced over infection control and the meal carts and several other things. During an interview on 10/11/2020 at 11:10 a.m., DW stated she had been in-serviced on infection control, wearing PPE, sanitizing and handwashing. DW stated she knew that everything needs to be clean. During an interview on 10/11/2020 at 11:20 a.m., LA G stated she had only been working at the facility for a month but she knew not to go on E hall. LA G stated the laundry was collected in special bags on that hallway. LA G stated someone else would be better to talk to. During an interview on 10/11/2020 at 11:30 a.m., LA H stated staff bring the dirty laundry off of E hall and set the bags outside. LA H stated staff pick up the laundry from E hall wearing full PPE and take it to the laundry. LA H stated they usually wash dirty laundry from E hall last and then disinfect the washing machine. During an interview on 10/11/2020 at 11:45 a.m., the Maintenance Man stated he was also over the laundry and housekeeping personnel. The Maintenance Man stated personnel on E hall would take the laundry and put it in a bag and set the bag outside the door at the end of E hall. The Maintenance Man stated then laundry personnel would put the dirty laundry in a secondary bag or container to take to the laundry. The Maintenance Man stated when the dirty laundry get to the soiled linen room, all staff are wearing full PPE and they place the soiled linen in the washing machines and that should take care of that. The Maintenance Man stated the washing machines have all the chemicals self-metered from a computer and there was a sanitizer that goes into the rinse cycle. The Maintenance Man stated the all the housekeeping supplies for E hall stays on that hallway. The Maintenance Man stated he had been fogging the whole building every day and the wet time for the disinfectant he uses was 1 minute. In an observation on 10/11/2020 at 12:15 p.m., an employee was cleaning the nurse station with disinfectant wipes. The dining room, activity room, and all sitting areas have been set up to promote social distancing. Observations throughout this investigation revealed staff and residents were properly wearing masks; disinfecting of commonly touched surfaces was observed often and all over the building; areas were set up to promote social distancing and social distancing was being practiced. The Immediate Jeopardy was lifted on 10/11/2020 at 12:30 p.m. The facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interviews and record review, it was determined the facility failed to ensure residents remained free from accidents, hazards, and each resident received adequate supervision and assistance when being transferred for 1 of 7 residents (Resident #1) reviewed for accidents and hazards. CNA B and NA C failed to transfer Resident #1 with the Hoyer lift as required by her care plan, which caused Resident #1 to fall to the floor on her knees. Resident #1's fall resulted in a [MEDICAL CONDITION] femur at the arthroplasty (knee replacement) of the left knee and the right knee's arthroplasty was dislocated with a rod displaced. This fracture and arthroplasty dislocation required Resident #1 to go to the hospital and ultimately have surgery to repair the right knee. An Immediate Jeopardy was identified that existed from 4/14/19 to 4/15/19. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This deficient practice has the potential to affect all residents in the building who require assistance with transfers by 2 staff members using the Hoyer lift by causing resident injuries such as falls, fractures, and even death. The evidence is as follows: Record Review of Resident #1's Face Sheet documented an [AGE] year old female was admitted to the facility on [DATE], with a readmission date of [DATE] (after surgery on the right knee) with the following Diagnoses: [REDACTED]. -Care Plan, dated 1/3/19, documented Resident #1 needs to be lifted mechanically using Mechanical lift with two + person support due to inability to assist in transfers safely. Total assist for transfers and bed mobility. -A significant change in status MDS resident assessment, dated 2/11/19, documented the resident scored 10 of 15 on a mini-mental exam (moderately impaired), totally dependent on two + staff for transfers, locomotion on and off of unit and toileting, totally dependent on one staff for bathing, required extensive assistance of one staff for dressing and personal hygiene, incontinent of bladder and bowel, 66 inches tall and 241 pounds. -Nurses Notes documented the following: -4/14/19 at 3:15 p.m. - asked by RN D to look at resident's legs following fall. Knocked on door and entered resident's room called by name. Resident in very pleasant mood, no pain or discomfort noted. Asked if I could look at her legs, stated yes. Right knee noted that had a pin like raised up just below knee cap, approximately 1 inch high, no skin breakage or bruise noted. When area gentle rubbed, resident denied any pain or discomfort. Gently rubbed left knee denied any pain but then resident turned left foot and a loud pop noted from the left knee area. No bruising or swelling noted to either knee at this time. I informed RN D, yes I think she needs to be transferred for follow up with doctor to see if anything might be broke. (Documented by LVN E) -4/14/19 at 3:21 p.m. - resident was being transferred without hoyer lift by two NAs (One was a CNA). Resident fell to knees, NAs proceeded to put resident to bed before reporting incident. Incident reported to this nurse. Upon assessment, resident was lying in bed and states that both knees were hurting 4 out of 10. Appliance in right knee looked more deformed than normal. Looked as though something was sticking up and trying to poke through skin. Resident did not appear to be in distress. Vitals all within normal limits. Called doctor and orders to send resident to emergency room . Record review on the Incident/Accident Report filled out by RN D, dated 4/14/19, reflected resident was being transferred without lift from chair to bed by two NAs (one was a CNA). Resident fell to knees. Complaints of both knees hurting, right knee appliance deformed. Sent out per doctor's order. Record review of Resident #1's emergency room notes, dated 4/14/19, documented Resident #1 had been ambulatory until recently when she started using a wheelchair predominantly. During a transfer today, the patient fell to her knees. She is intolerant of any range of motion or attempts to use legs due to bilateral knee pain. Left knee is worse than right. Right knee: she exhibits decreased range of motion, deformity, and bony tenderness. Left knee: she exhibits decreased range of motion, tenderness. Bilateral knees have arthroplasty scars. Reviewed left knee images and my preliminary reading is: fracture of distal femur at arthroplasty. Reviewed Right knee images and my preliminary reading is: arthroplasty is dislocated with rod displaced. Facility Nurse's note - dated 4/20/19 at 2:00 p.m. - Report from Hospital received, resident had no complaints of pain today. Resident's knees are not to be bent and must remain in brace for left knee and immobilizer for right knee. Resident has 16 French Foley catheter, no mental status changes since admission to hospital. Resident arrived at facility, via ambulance, resident assisted x4 staff into bed. Clean dry dressings to bilateral knees with ace wrap and brace and immobilizer in place. Resident to be up in Geri chair with legs supported at all times. During an interview on 4/22/19 at 10:05 a.m., the Administrator stated Resident #1 was a Hoyer lift and both CNA B and NA C were terminated. The Administrator stated during the investigation after Resident #1's fall, CNA B said she had transferred Resident #1 before lunch all by herself. The Administrator stated, if you are a new CNA in this facility, when doing a Hoyer lift, you have to have at least one CNA assisting that has alot of experience. The Administrator stated NA C knew Resident #1 was a Hoyer lift and questioned CNA B about the Hoyer lift but proceeded in assisting with the transfer without the Hoyer lift. The Administrator stated CNA B and NA C were holding onto Resident #1's pants and when she fell ; Resident #1's pants ripped. The Administrator stated after Resident #1 fell , CNA B and NA C went and got the Hoyer lift, transferred Resident #1 to her bed and then informed the charge nurse about the fall. During an interview on 4/22/19 at 11:10 a.m., LVN A stated two of her students from her CNA class were involved in the incident. LVN A stated when a resident is a Hoyer lift, two CNAs transfer using the Hoyer lift, never without the lift. LVN A stated staff are to follow what was in the care profile in the computer and what was on it. During an interview on 4/22/19 at 11:32 a.m., Resident #1 stated those two girls (CNA B and NA C) had never transferred her before but both knew she was a Hoyer lift. Resident stated she did not know what happened when she fell to her knees, she just knew she was going down. Resident #1 stated she had surgery on her right knee because she had a previous knee replacement and the fall broke some stuff in there. Record review of LVN A's statement, dated 4/19/19, documented the following: In CNA class, we go over in the book that we only give care that is on the resident's plan of care. I also talk with the students about where to find this information. I then take them to a care tracker (computer in hallway) and log in and show them how to look on the care plan in the computer and then I have them reciprocate the procedure. When you log on to the care tracker and click on a resident, a box pops up telling you that there is new information that they must view to care for a resident. I did explain that they must first look at the plan of care before providing care. I also go over in class, with the help of LVN H, how to properly use a lift and they all attended and actually used the sling without a resident in it to show they properly understand how to use equipment. They are also told in class and on the floor with clinical that they are not to transfer any resident without a licensed CNA and that there always must be two people to complete using a lifting device. Record review of LVN H's statement, dated 4/15/19. documented the following: On 2/28/19, went over the mechanical lifts with LVN A's CNA class. Went over the policy and check off list. I covered all 3 lifts and some safety measures. Forms were signed individually by CNA B and NA C. During an interview on 4/22/19 at 1:00 p.m., CNA B stated they (with NA C) did a two person lift on Resident #1, her pants ripped and she went down on her knees. When asked if she knew Resident #1 was a Hoyer lift, after a very long pause, CNA B stated she slightly remembered Resident #1 was a Hoyer lift but she did not check her profile before providing care and she hadn't worked that hall before. During an interview on 4/22/19 at 1:20 p.m., NA C stated she was working her hall and CNA B asked her to help transfer Resident #1 from her wheelchair to her bed. NA C stated when she entered Resident #1's room, there was not a sling under the resident for the Hoyer lift so she told CNA B that Resident #1 was a Hoyer lift and they needed to get a sling under the resident. NA C stated CNA B said she had seen others transfer Resident #1 with two people. NA C stated they started transferring Resident #1 and she started to slip, her pants ripped and she fell to her knees. NA C said CNA B went to get the Hoyer lift and they transferred Resident #1 to her bed, made her comfortable and then she went and informed the charge nurse about the fall. During an interview on 4/22/19 at 1:45 p.m., LVN E stated she went to Resident #1's room to help RN D assess her legs. LVN E stated both CNA B and NA C were new but both knew Resident #1 was a Hoyer lift. LVN E stated the facility just had a CNA meeting and all staff were told when doing a Hoyer lift, get a CNA with alot of experience to help if they were a new CNA. Record review of a CNA meeting, dated 3/12/19 at 1:30 p.m., documented: need an experienced CNA with a new CNA to use lift together EXAMPLE: Resident #2 and #1 - no new CNAs together with the lift. The sign-in sheet documented CNA B and NA C attended this training. This training was 34 days prior to Resident #1's fall when being transferred incorrectly. During an interview on 4/22/19 at 2:15 p.m., RN D stated CNA B and NA C were lying Resident #1 down after lunch and she was doing paperwork. RN D stated NA C came and told her that Resident #1 had a fall and they (CNA B and NA C) just eased her down to the ground on her knees. RN D stated when she went down the hallway and saw the lift in the hallway and Resident #1 was already in bed, she realized they (CNA B and NA C) did not come and get her while Resident #1 was still on the floor. RN D stated Resident #1's left knee was hurting so she assessed her and all of her vitals were good. RN D stated on Resident #1's right knee, it looked like a pin or bone was trying to pop up out of the skin. RN D stated Resident #1 was not in alot of pain but her right knee did not look right. RN D stated she called the doctor and got an order to send Resident #1 to the hospital. RN D stated she was very upset that CNA B and NA C had gotten Resident #1 up off the floor with the lift and put her to bed before they informed her of the fall. RN D stated that was a very big issue because any time anyone has a fall, don't move them, staff are to get a nurse to assess for any injuries. RN D stated she called the DON and then call Resident #1's daughter. RN D stated she immediately pulled CNA B and NA C off the floor, counseled both of them and wrote both of them up. RN D stated she told them they have to follow everything on the care plan. RN D stated both CNA B and NA C were new and she (RN D) did not realize they were trying to transfer Resident #1 without a Hoyer lift and without an experienced CNA. RN D had CNA B and NA C write out statements and then instructed them to go home. RN D found out later that one of Resident #1's knees had a broken appliance and the other knee had a fracture. RN D stated, If they are going to take short cuts now, how can they ever be trusted again. During an interview on 4/22/19 at 2:45 p.m., LVN F stated she was not here the day Resident #1 fell but everyone knew Resident #1 was a Hoyer lift and she had always been that way. During an interview on 4/22/19 at 2:56 p.m., CNA I stated she had worked at the facility for a long time and if there were any questions about how to care for a resident, staff would look in the care tracker for answers. CNA I stated everyone knew Resident #1 was a Hoyer lift transfer with two staff, That was just common sense. During an interview on 4/22/19 at 3:06 p.m., CNA G stated staff are to look in the care tracker to know how to transfer resident. CNA G stated she was aware Resident #1 was a Hoyer lift as that was very common knowledge. Record review of in-service the facility implemented was: SUBJECT (S): Mechanical Lift DATE CONDUCTED: 4/15/19 starting at 2:19 p.m. All 20 CNAs employed by the facility and all 16 nurses signed in attendance. The In-service regarding Mechanical Lift is as follows: *Safety of the Residents and Staff -- Use critical thinking - Think ahead of what could happen . -always follow the care plan by checking the care tracker for each resident, check before beginning to take care of your residents (things can change overnight) -always report to the charge nurse if you have any questions or have a change in resident's condition and if there is anything different on the care tracker that needs to be brought to charge nurse. Reporting (protecting the resident) -if you see a co-worker making a transfer incorrectly, or lifting a resident incorrectly according to care tracker, you must report the incorrect transfer to protect the resident. -Report to your charge nurse -Reporting is also available anonymously by calling the Corporate Compliance number at [PHONE NUMBER], EXT 302 -You may report directly to the DON, or Administrator Protecting yourself -by questioning a co-worker's actions before the lift takes place, if you know it to be wrong, you are not only protecting the resident but protecting yourself. -DO NOT get in a hurry slow down, Nothing is worth taking a short cut. -The mechanical lifts were also designed to help you protect your back, please take care of yourself by not lifting more than your back can handle DO NOT take chances. Important points to remember -stop and think before you act -some residents are weak, more prone to need assistance -if residents in bed all the time, their muscles can atrophy, their bones may soften -residents have arthritis, may not be able to bear weight -don't jump into a transfer without thinking it out. Mechanical Lifts We have 3 lifts -The older Tollos mechanical lift - holds 500 pounds -The (newest) Relias 600 - Invacare lift - holds 600 pounds -The Manual Hoyer - holds 400 pounds Safety Measures involving the lifts -ALWAYS use 2 trained nursing staff to operate the lifts -Student NAs or new CNAs should always be paired up with a seasoned CNA to transfer using the lifts (example - 1 NA and 1 seasoned CNA or 1 new CNA with one seasoned CNA). Points about the mechanical lifts -Always explain the procedure to the resident -if getting resident out of bed, raise the bed to a good working height and lock bed in place. -be sure the wheelchair or Geri chair is locked before lifting resident to the chairs, or shower chair. -Always have the legs of the lift open when lifting or lowering the resident. -lock the lift during placement of the sling and hooking it up -unlock the lifts when lifting resident or lowering them (the lift needs to gravity balance) -be sure using the correct size sling for the correct size resident (weights are on the resident profile or may ask nurse what the weight of the resident is) ( Most of the slings have the sizes and weights the sling will safely cover on the back of the sling.) -if slings are frayed, have holes in them .do not use! -slings may be left under the resident while in a wheelchair or Geri chair, but not to be left under them while in bed -when placing the sling under the resident, be sure it is placed correctly. It should be centered well, but have enough of sling at the top to protect the neck -do not allow the residents to hold on to the lift bars where slings are hooked, they must keep their arms/hands inside the sling -scope out the slings to be sure as lifting/lowering that they are not getting hung on anything -slings should be thrown in the laundry bin at the end of the day (probably the end of the evening shift) -slings need to be thrown into the laundry if visibly soiled -- if wet. -DO NOT allow a resident to talk you out of using the proper lift, if needed to, tell your charge nurse During interviews with 8 different direct care staff members on 4/22/19 of both day and night shifts, they all stated they had been in serviced on using the Hoyer lift and it was required to have 2 staff members to operate the Hoyer lift when transferring a resident. They also stated that one of the two staff members doing a Hoyer lift was required to be seasoned. During an interview with the Administrator on 4/23/19 at 11:45 a.m., she was notified an Immediate Jeopardy existed from 4/14/19 through 4/15/19 prior to entrance, the facility identified the deficient practice and took the necessary corrective actions.

Based on observation, interview and record review; it was determined the facility failed to immediately consult with the Resident's physician when there was an accident involving the Resident that results in an injury and has the potential for requiring physician intervention for 1 of 8 residents reviewed for notification of changes (Resident #1). RN A incorrectly administered Resident #6's medications to Resident #1, in addition to Resident #1's medications. Resident #6's medications included multiple medications that lower blood pressure. RN A failed to immediately notify the physician, until approximately 1-1.5 hours after the medication error. Resident #1's blood pressure fell to a life-threatening level. Upon notification of the medication error, Resident #1's physician ordered Resident #1 transferred to the local hospital. Resident #1 required intravenous fluids to stabilize her blood pressure, transportation to the hospital via EMS, and admission to the hospital. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility's failure to immediately consult with the Resident's physician when there was an accident involving the Resident that results in an injury and has the potential for requiring physician intervention could place 53 residents requiring oral medication at risk for shallow breathing, [MEDICAL CONDITION], low blood pressure, poor cerebral perfusion, poor blood circulation to other vital organs, peripheral blood clots, deep vein thrombus, [MEDICAL CONDITION] thrombus, coma and death. Findings include: Record review of Resident #1's clinical record revealed: Resident #1 is an [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #1's MDS, dated [DATE], it stated: Resident #1 has impaired vision and hearing; BIMS-12; Depression-3; limited 1 person assist for all bed mobility, transfers, dressing, toileting, ADLs, bathing and hygiene; wheelchair; no upper extremity or lower extremity impairment; always continent of bowel and bladder; occasional complaints of pain requiring medication; and at risk for falls and pressure sores. While reviewing the care plan for Resident #1, dated 11/5/17, it states: Resident #1 has vision, mobility and cognitive impairment, occasional verbal aggression, poor activity involvement, ADL deficit requiring at least 1 person assist, pain, anxiety, depression, bowel and bladder incontinence, at risk for falls, dehydration, dyspnea, weight loss and pressure sores. While reviewing the Nurses' Notes, dated 11/6/17, for Resident #1, it stated: 11/6/17 at 11:25 a.m.: Resident was given another resident's medication this morning. Medication Nurse reported to Charge Nurse and DON. Vital signs were checked about 30 minutes after incident, temperature - 97.1, blood pressure - 111/64, pulse - 70, respirations - 16, oxygen saturation - 95% on Room Air. About 10:45 a.m., Resident became lethargic and pale, slurred speech, rechecked vital temperature - 97.8, blood pressure - 96/54, 60/29, pulse - 51, heart rate - 24, oxygen saturation - 93% Room Air. Doctor notified and received telephone order to send to emergency room for evaluation. Ambulance called, notified daughter, informed her of what happened, and transferred her call to DON. Transferred to emergency room via ambulance about 11:15. - LVN A 11/6/17 at 1:59 p.m.: Resident admitted observation at (hospital) overnight. While reviewing the MAR for Resident #1's morning medication that she received on 11/6/17, it stated: Asprin 81mg by mouth daily [MEDICATION NAME] XL 50mg by mouth daily (medication for treating high blood pressure) [MEDICATION NAME] 10mg by mouth three times daily (medication for treating high blood pressure) Requip 0.25mg (2 tabs) by mouth daily [MEDICATION NAME] 40mg by mouth daily [MEDICATION NAME] 17 grams by mouth daily Calcium/Vitamin D 500mg/200 international units by mouth three times daily Cranberry 450mg (2 tabs) by mouth daily Co-enzyme 100mg (2 capsules) by mouth daily Folic Acid 1mg by mouth daily [MEDICATION NAME] 2.5mg by moth daily [MEDICATION NAME] 5000 units by mouth daily While reviewing the Facility Investigation Report listing Resident #6's morning medications that Resident #1 received on 11/6/17, it stated: [MEDICATION NAME] 30mg by mouth daily (medication for treating depression) [MEDICATION NAME] 600mg by mouth twice daily (medication for treating [MEDICAL CONDITION]) [MEDICATION NAME] 40mg by mouth daily (medication for treating high blood pressure) [MEDICATION NAME] 25mg by mouth daily (medication for treating high blood pressure) [MEDICATION NAME] 100mg by mouth twice daily (medication used for treating [MEDICAL CONDITION]) Calcium/Vitamin D 500mg/125 international units by mouth twice daily [MEDICATION NAME] 1mg by mouth daily (medication for treating [MEDICAL CONDITION]) [MEDICATION NAME]/Levadopa 25mg/100mg by mouth three times daily (medication for treating [MEDICAL CONDITION]) Requip 2mg by mouth daily (medication for treating restless leg syndrome or [MEDICAL CONDITION]) During an interview on 11/15/17 at 9:20 a.m., DON confirmed RN A had come to her a little before morning stand up meeting (starting at 8:30 a.m.) on 11/6/17 and told her she had made a medication error. She confirmed she was informed Resident #1 had received her morning medication and Resident #6's morning medication. She confirmed she instructed RN A to assess the resident, inform the physician, and inform the Resident's family. She confirmed approximately 1 hour later, Resident #1 experienced significantly low blood pressure, was pale and disoriented, and required transfer to the local emergency room . She confirmed the medication was administered incorrectly to the wrong resident. During an interview on 11/15/17 at 11:15 a.m., LVN B confirmed on 11/6/17 about 8:00 a.m., she saw LVN C repeatedly interrupt RN A while she was passing medications. LVN B confirmed after the second interruption, I told (LVN C) to leave her alone because she was passing meds. LVN B confirmed a short time later, RN A informed her of the medication error. LVN B confirmed (RN A) told her that she had given Resident #1 her morning medications in addition to Resident #6's morning medications. LVN B confirmed Resident #1 was brought to the commons area near the nurses' stating to monitor her. LVN B confirmed approximately 1-1.5 hours later, at approximately 10:30 a.m., she looked over at Resident #1, and she was very pale. She confirmed she immediately went to examine Resident #1, and she was very pale, disoriented, lethargic and I couldn't understand her. LVN B was unable to recall Resident #1's blood pressure, but she stated, it was about 60/28. LVN B confirmed Resident #1's low blood pressure was a potentially life-threatening situation. LVN B confirmed she immediately notified the physician and EMS. She confirmed EMS arrived and started intravenous fluids on Resident #1. LVN confirmed EMS transported Resident #1 to the hospital, and she was admitted for observation. During an interview on 11/15/17 at 11:29 a.m., MD 1 confirmed he was informed of the medication error on 11/6/17. He was unable to recall what time he was first notified, but stated, it should be in their notes. He confirmed he was concerned about the potentially life-threatening problems of (Resident #1) receiving her own medication and another resident's medication. He stated, that's why I wanted her sent to the ER. He stated that when he asked how the medication error occurred, he was told the nurse got the names mixed up because they both begin with 'C'. He stated, . that excuse is completely unacceptable. They have to be very mindful of the medications they are giving residents. During an interview on 11/15/17 at 11:50 a.m., LVN C confirmed on 11/6/17 at approximately 8:20 a.m., RN A came to her to tell her Resident #1 did not have a medication that she needed in the cart. She stated, we looked at the MAR, and (RN A) realized she had given the wrong meds to the wrong resident. I told her to tell ADM and DON. During an interview on 11/15/17 at 1:35 p.m., Resident #1 confirmed she remembered when she was given the incorrect medication on 11/6/17. She stated, I don't know what they gave me, but they drugged me up. She confirmed she first noticed it when she attempted to get up from bed. She stated, I kept trying to stand up over and over again, but I had no strength .I couldn't move. She confirmed EMS arrived and started intravenous fluids on her. She confirmed she was taken via EMS to the hospital and was admitted . She confirmed she was very scared, and I thought I was going to die. She confirmed she asked the EMS personnel several times am I alive or dead .am I going to die. During an interview on 11/15/17 at 2:12 p.m., RN A confirmed she made the medication error on 11/6/17 at 8:20 a.m. She stated, I was pulling (Resident #6's) medications, and somehow I thought it was for (Resident #1). She confirmed the MAR indicated [REDACTED]. When asked how she confused the names, she stated, both names begin with ca. RN A stated she was distracted and rushed because LVN C had come to tell her that they still needed to count and order medications at least 4-6 times while she was doing medication pass. RN A confirmed this was her first day on medication cart by herself. She confirmed she had been with someone to supervise her prior to 11/6/17. She confirmed she notified ADM and DON of the medication error at approximately 8:30 a.m. on 11/16/17. She confirmed she was instructed to assess the resident, notify the family and notify the physician. RN A confirmed the physician was not notified until 10:30 a.m. When asked why, she stated, I got busy getting her vital signs, making sure she was okay, and calling the family, I forgot. She confirmed the amount and type of medications Resident #1 received was potentially life-threatening. She confirmed EMS had to start intravenous fluids to stabilize Resident #1's blood pressure, transport her to the hospital, and Resident #1 was admitted to the hospital for observation. During an interview on 11/15/17 at 3:18 p.m., MD 1 confirmed he did not remember what time he was notified. When informed the medication error report said it was 10:30 a.m. (two hours after the medication error was identified by staff), he stated, then that is probably right. He confirmed that had he been notified of the incident earlier he would not have wanted her there. He confirmed he would have transferred her earlier for a higher level of care. During an interview on 11/15/17 at 2:46 p.m., Pharm confirmed she was familiar with the medication error. She confirmed the risks for the amount/type of medication Resident #1 received were: low blood pressure, low heart rate, low respirations, and decreased level of consciousness, lethargy, and disorientation. She confirmed the facility did not notify her that Resident #1 received her morning medication and Resident #6's morning medication. When asked, given that knowledge, could this have been life-threatening, she responded, They saved her life by catching it, monitoring it, and sending her out. She confirmed the medications that lower blood pressure that Resident #1 received were: Resident #1's morning medication: [MEDICATION NAME] 20mg PO BID, [MEDICATION NAME] XL 50 mg PO QD, [MEDICATION NAME] 10 mg PO TID; and Resident #6's morning medication: [MEDICATION NAME] 25mg PO, [MEDICATION NAME] 40 mg PO, and [MEDICATION NAME] 100mg. During an interview on 11/16/17 at 10:32 a.m., ADM confirmed she believed the situation occurred because RN A is a new nurse, and the facility could have done a better job training her. She confirmed she was unaware (LVN C) was rushing (RN A). When she was asked how the medication error occurred, since the EMAR has a picture of the resident and their name on the same page as the medications being pulled for administration, she stated, I'm not sure how that happened. While reviewing the Medication Error Report, dated 11/6/17, for Resident #1, it stated: Date of Error: 11/6/17 Time of Error: 8:20 a.m. Physician Notified on 11/6/17 at 10:30 a.m. DON notified on 11/6/17 at 8:20 a.m. Outcome to Resident: Resident had to be transferred to (the hospital) via EMS Type of Error: wrong resident Reason for Error: failure to identify resident While reviewing the facility's undated policy for Administration of Medication, it stated: Policy A physician order [REDACTED]. Procedures 2. Check Electronic Medication Administration Record [REDACTED] 3. Read each order entirely. 10. Identify resident before administering the drug. While reviewing the facility's undated policy for Medication Errors and Drug Reactions, it stated: Procedure: All medication errors and drug reactions must be promptly reported to the Director of Nursing, attending physician and the pharmacist. 1. A detailed account of the incident must be recorded in the resident's medical record. The documentation should include: a. Time and date of the incident f. Date and time the physician was notified and instructions/orders given. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from 11/6/17 through 11/7/17. The facility took the following actions to correct the non-compliance on 11/6/17: RN A was immediately removed from medication administration duties, remedial one-on-one training regarding the 6 rights of medication administration was provided to RN A, and a policy of a quiet zone while administering medication was initiated, and training for all staff administering medications was begun covering the 6 rights of medication administration, the quiet zone while administering medication, policy training for medication errors, and physician notification. The training for all staff administering medication was completed on 11/7/17. This surveyor confirmed on 11/17/17 that the facility took the following corrective actions to correct the noncompliance: 1) Interviews with all available licensed nurses and medication aides to confirm the additional training regarding medication administration had been performed. 2) Interviews with all available licensed nurses and medication aides to confirm the RN A had not worked the medication cart by herself since 11/6/17. 3) Interviews with all available licensed nurses and medication aides to confirm RN A is being trained on the medication cart and will be receiving additional training regarding medication administration. 4) Interviews with all available licensed nurses and medication aides to confirm the additional measure of implementation of a quiet zone while passing medications, spot checks by administration during medication pass, and documentation training had been performed. Review of the Resident Census, dated 11/15/17, shows documented a census of 53, with 53 residents receiving medications (RN A interview).

Based on observation, interview and record review; it was determined the facility failed to ensure residents were free from neglect for 1 of 8 residents reviewed for neglect (Resident #1). RN A incorrectly administered Resident #6's medications to Resident #1, in addition to Resident #1's medications. Resident #6's medications included multiple medications that lower blood pressure. RN A failed to immediately notify the physician, until approximately 1-1.5 hours after the medication error. Resident #1's blood pressure fell to a life-threatening level. Upon notification of the medication error, Resident #1's physician ordered Resident #1 transferred to the local hospital. Resident #1 required intravenous fluids to stabilize her blood pressure, transportation to the hospital via EMS, and admission to the hospital. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility's failure to ensure residents remain free of neglect could place 53 residents requiring oral medication at risk for shallow breathing, [MEDICAL CONDITION], low blood pressure, poor cerebral perfusion, poor blood circulation to other vital organs, peripheral blood clots, deep vein thrombus, [MEDICAL CONDITION] thrombus, coma and death. Findings include: Record review of Resident #1's clinical record revealed: Resident #1 is an [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #1's MDS, dated [DATE], it stated: Resident #1 has impaired vision and hearing; BIMS-12; Depression-3; limited 1 person assist for all bed mobility, transfers, dressing, toileting, ADLs, bathing and hygiene; wheelchair; no upper extremity or lower extremity impairment; always continent of bowel and bladder; occasional complaints of pain requiring medication; and at risk for falls and pressure sores. While reviewing the care plan for Resident #1, dated 11/5/17, it states: Resident #1 has vision, mobility and cognitive impairment, occasional verbal aggression, poor activity involvement, ADL deficit requiring at least 1 person assist, pain, anxiety, depression, bowel and bladder incontinence, at risk for falls, dehydration, dyspnea, weight loss and pressure sores. While reviewing the Nurses' Notes, dated 11/6/17, for Resident #1, it stated: 11/6/17 at 11:25 a.m.: Resident was given another resident's medication this morning. Medication Nurse reported to Charge Nurse and DON. Vital signs were checked about 30 minutes after incident, temperature - 97.1, blood pressure - 111/64, pulse - 70, respirations - 16, oxygen saturation - 95% on Room Air. About 10:45 a.m., Resident became lethargic and pale, slurred speech, rechecked vital temperature - 97.8, blood pressure - 96/54, 60/29, pulse - 51, heart rate - 24, oxygen saturation - 93% Room Air. Doctor notified and received telephone order to send to emergency room for evaluation. Ambulance called, notified daughter, informed her of what happened, and transferred her call to DON. Transferred to emergency room via ambulance about 11:15. - LVN A 11/6/17 at 1:59 p.m.: Resident admitted observation at (hospital) overnight. While reviewing the MAR for Resident #1's morning medication that she received on 11/6/17, it stated: Asprin 81mg by mouth daily [MEDICATION NAME] XL 50mg by mouth daily (medication for treating high blood pressure) [MEDICATION NAME] 10mg by mouth three times daily (medication for treating high blood pressure) Requip 0.25mg (2 tabs) by mouth daily [MEDICATION NAME] 40mg by mouth daily [MEDICATION NAME] 17 grams by mouth daily Calcium/Vitamin D 500mg/200 international units by mouth three times daily Cranberry 450mg (2 tabs) by mouth daily Co-enzyme 100mg (2 capsules) by mouth daily Folic Acid 1mg by mouth daily [MEDICATION NAME] 2.5mg by moth daily [MEDICATION NAME] 5000 units by mouth daily While reviewing the Facility Investigation Report listing Resident #6's morning medications that Resident #1 received on 11/6/17, it stated: [MEDICATION NAME] 30mg by mouth daily (medication for treating depression) [MEDICATION NAME] 600mg by mouth twice daily (medication for treating [MEDICAL CONDITION]) [MEDICATION NAME] 40mg by mouth daily (medication for treating high blood pressure) [MEDICATION NAME] 25mg by mouth daily (medication for treating high blood pressure) [MEDICATION NAME] 100mg by mouth twice daily (medication used for treating [MEDICAL CONDITION]) Calcium/Vitamin D 500mg/125 international units by mouth twice daily [MEDICATION NAME] 1mg by mouth daily (medication for treating [MEDICAL CONDITION]) [MEDICATION NAME]/Levadopa 25mg/100mg by mouth three times daily (medication for treating [MEDICAL CONDITION]) Requip 2mg by mouth daily (medication for treating restless leg syndrome or [MEDICAL CONDITION]) During an interview on 11/15/17 at 9:20 a.m., DON confirmed RN A had come to her a little before morning stand up meeting (starting at 8:30 a.m.) on 11/6/17 and told her she had made a medication error. She confirmed she was informed Resident #1 had received her morning medication and Resident #6's morning medication. She confirmed she instructed RN A to assess the resident, inform the physician, and inform the Resident's family. She confirmed approximately 1 hour later, Resident #1 experienced significantly low blood pressure, was pale and disoriented, and required transfer to the local emergency room . She confirmed the medication was administered incorrectly to the wrong resident. During an interview on 11/15/17 at 11:15 a.m., LVN B confirmed on 11/6/17 about 8:00 a.m., she saw LVN C repeatedly interrupt RN A while she was passing medications. LVN B confirmed after the second interruption, I told (LVN C) to leave her alone because she was passing meds. LVN B confirmed a short time later, RN A informed her of the medication error. LVN B confirmed (RN A) told her that she had given Resident #1 her morning medications in addition to Resident #6's morning medications. LVN B confirmed Resident #1 was brought to the commons area near the nurses' stating to monitor her. LVN B confirmed approximately 1-1.5 hours later, at approximately 10:30 a.m., she looked over at Resident #1, and she was very pale. She confirmed she immediately went to examine Resident #1, and she was very pale, disoriented, lethargic and I couldn't understand her. LVN B was unable to recall Resident #1's blood pressure, but she stated, it was about 60/28. LVN B confirmed Resident #1's low blood pressure was a potentially life-threatening situation. LVN B confirmed she immediately notified the physician and EMS. She confirmed EMS arrived and started intravenous fluids on Resident #1. LVN confirmed EMS transported Resident #1 to the hospital, and she was admitted for observation. During an interview on 11/15/17 at 11:29 a.m., MD 1 confirmed he was informed of the medication error on 11/6/17. He was unable to recall what time he was first notified, but stated, it should be in their notes. He confirmed he was concerned about the potentially life-threatening problems of (Resident #1) receiving her own medication and another resident's medication. He stated, that's why I wanted her sent to the ER. He stated that when he asked how the medication error occurred, he was told the nurse got the names mixed up because they both begin with 'C'. He stated, . that excuse is completely unacceptable. They have to be very mindful of the medications they are giving residents. During an interview on 11/15/17 at 11:50 a.m., LVN C confirmed on 11/6/17 at approximately 8:20 a.m., RN A came to her to tell her Resident #1 did not have a medication that she needed in the cart. She stated, we looked at the MAR, and (RN A) realized she had given the wrong meds to the wrong resident. I told her to tell ADM and DON. During an interview on 11/15/17 at 1:35 p.m., Resident #1 confirmed she remembered when she was given the incorrect medication on 11/6/17. She stated, I don't know what they gave me, but they drugged me up. She confirmed she first noticed it when she attempted to get up from bed. She stated, I kept trying to stand up over and over again, but I had no strength .I couldn't move. She confirmed EMS arrived and started intravenous fluids on her. She confirmed she was taken via EMS to the hospital and was admitted . She confirmed she was very scared, and I thought I was going to die. She confirmed she asked the EMS personnel several times am I alive or dead .am I going to die. During an interview on 11/15/17 at 2:12 p.m., RN A confirmed she made the medication error on 11/6/17 at 8:20 a.m. She stated, I was pulling (Resident #6's) medications, and somehow I thought it was for (Resident #1). She confirmed the MAR indicated [REDACTED]. When asked how she confused the names, she stated, both names begin with ca. RN A stated she was distracted and rushed because LVN C had come to tell her that they still needed to count and order medications at least 4-6 times while she was doing medication pass. RN A confirmed this was her first day on medication cart by herself. She confirmed she had been with someone to supervise her prior to 11/6/17. She confirmed she notified ADM and DON of the medication error at approximately 8:30 a.m. on 11/16/17. She confirmed she was instructed to assess the resident, notify the family and notify the physician. RN A confirmed the physician was not notified until 10:30 a.m. When asked why, she stated, I got busy getting her vital signs, making sure she was okay, and calling the family, I forgot. She confirmed the amount and type of medications Resident #1 received was potentially life-threatening. She confirmed EMS had to start intravenous fluids to stabilize Resident #1's blood pressure, transport her to the hospital, and Resident #1 was admitted to the hospital for observation. During an interview on 11/15/17 at 3:18 p.m., MD 1 confirmed he did not remember what time he was notified. When informed the medication error report said it was 10:30 a.m. (two hours after the medication error was identified by staff), he stated, then that is probably right. He confirmed that had he been notified of the incident earlier he would not have wanted her there. He confirmed he would have transferred her earlier for a higher level of care. During an interview on 11/15/17 at 2:46 p.m., Pharm confirmed she was familiar with the medication error. She confirmed the risks for the amount/type of medication Resident #1 received were: low blood pressure, low heart rate, low respirations, and decreased level of consciousness, lethargy, and disorientation. She confirmed the facility did not notify her that Resident #1 received her morning medication and Resident #6's morning medication. When asked, given that knowledge, could this have been life-threatening, she responded, They saved her life by catching it, monitoring it, and sending her out. She confirmed the medications that lower blood pressure that Resident #1 received were: Resident #1's morning medication: [MEDICATION NAME] 20mg PO BID, [MEDICATION NAME] XL 50 mg PO QD, [MEDICATION NAME] 10 mg PO TID; and Resident #6's morning medication: [MEDICATION NAME] 25mg PO, [MEDICATION NAME] 40 mg PO, and [MEDICATION NAME] 100mg. During an interview on 11/16/17 at 10:32 a.m., ADM confirmed she believed the situation occurred because RN A is a new nurse, and the facility could have done a better job training her. She confirmed she was unaware (LVN C) was rushing (RN A). When she was asked how the medication error occurred, since the EMAR has a picture of the resident and their name on the same page as the medications being pulled for administration, she stated, I'm not sure how that happened. While reviewing the Medication Error Report, dated 11/6/17, for Resident #1, it stated: Date of Error: 11/6/17 Time of Error: 8:20 a.m. Physician Notified on 11/6/17 at 10:30 a.m. DON notified on 11/6/17 at 8:20 a.m. Outcome to Resident: Resident had to be transferred to (the hospital) via EMS Type of Error: wrong resident Reason for Error: failure to identify resident While reviewing the facility's undated policy for Administration of Medication, it stated: Policy A physician order [REDACTED]. Procedures 2. Check Electronic Medication Administration Record [REDACTED] 3. Read each order entirely. 10. Identify resident before administering the drug. While reviewing the facility's undated policy for Medication Errors and Drug Reactions, it stated: Procedure: All medication errors and drug reactions must be promptly reported to the Director of Nursing, attending physician and the pharmacist. 1. A detailed account of the incident must be recorded in the resident's medical record. The documentation should include: a. Time and date of the incident f. Date and time the physician was notified and instructions/orders given. While reviewing the facility's undated policy for Abuse Prevention Program, it stated: Purpose: Protect the residents in this facility from ., neglect Definitions: Neglect: The depravation of omitted goods or services would cause, among other things, emotional distress. Procedure: 1. The facility is committed to protecting the resident's from abuse, neglect, .by anyone including but not limited to: facility staff, It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from 11/6/17 through 11/7/17. The facility took the following actions to correct the non-compliance on 11/6/17: RN A was immediately removed from medication administration duties, remedial one-on-one training regarding the 6 rights of medication administration was provided to RN A, and a policy of a quiet zone while administering medication was initiated, and training for all staff administering medications was begun covering the 6 rights of medication administration, the quiet zone while administering medication, policy training for medication errors, and physician notification. The training for all staff administering medication was completed on 11/7/17. This surveyor confirmed on 11/17/17 that the facility took the following corrective actions to correct the noncompliance: 1) Interviews with all available licensed nurses and medication aides to confirm the additional training regarding medication administration had been performed. 2) Interviews with all available licensed nurses and medication aides to confirm the RN A had not worked the medication cart by herself since 11/6/17. 3) Interviews with all available licensed nurses and medication aides to confirm RN A is being trained on the medication cart and will be receiving additional training regarding medication administration. 4) Interviews with all available licensed nurses and medication aides to confirm the additional measure of implementation of a quiet zone while passing medications, spot checks by administration during medication pass, and documentation training had been performed. Review of the Resident Census, dated 11/15/17, shows documented a census of 53, with 53 residents receiving medications (RN A interview).

Based on interview and record review; it was determined the facility failed to implement its written policies and procedures that prohibit and prevent neglect for 1 of 6 residents reviewed for neglect (Resident #1). RN A incorrectly administered Resident #6's medications to Resident #1, in addition to Resident #1's medications. Resident #6's medications included multiple medications that lower blood pressure. RN A failed to immediately notify the physician, until approximately 1-1.5 hours after the medication error. Resident #1's blood pressure fell to a life-threatening level. Upon notification of the medication error, Resident #1's physician ordered Resident #1 transferred to the local hospital. Resident #1 required intravenous fluids to stabilize her blood pressure, transportation to the hospital via EMS, and admission to the hospital. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility's failure to implement its written policies and procedures that prohibit and prevent neglect could place 53 residents requiring oral medication at risk for shallow breathing, [MEDICAL CONDITION], low blood pressure, poor cerebral perfusion, poor blood circulation to other vital organs, peripheral blood clots, deep vein thrombus, [MEDICAL CONDITION] thrombus, coma and death. Findings include: While reviewing the facility's undated policy for Abuse Prevention Program, it stated: Purpose: Protect the residents in this facility from ., neglect Definitions: Neglect: The depravation of omitted goods or services would cause, among other things, emotional distress. Procedure: 1. The facility is committed to protecting the resident's from abuse, neglect, .by anyone including but not limited to: facility staff, Record review of Resident #1's clinical record revealed: Resident #1 is an [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #1's MDS, dated [DATE], it stated: Resident #1 has impaired vision and hearing; BIMS-12; Depression-3; limited 1 person assist for all bed mobility, transfers, dressing, toileting, ADLs, bathing and hygiene; wheelchair; no upper extremity or lower extremity impairment; always continent of bowel and bladder; occasional complaints of pain requiring medication; and at risk for falls and pressure sores. While reviewing the care plan for Resident #1, dated 11/5/17, it states: Resident #1 has vision, mobility and cognitive impairment, occasional verbal aggression, poor activity involvement, ADL deficit requiring at least 1 person assist, pain, anxiety, depression, bowel and bladder incontinence, at risk for falls, dehydration, dyspnea, weight loss and pressure sores. While reviewing the Nurses' Notes, dated 11/6/17, for Resident #1, it stated: 11/6/17 at 11:25 a.m.: Resident was given another resident's medication this morning. Medication Nurse reported to Charge Nurse and DON. Vital signs were checked about 30 minutes after incident, temperature - 97.1, blood pressure - 111/64, pulse - 70, respirations - 16, oxygen saturation - 95% on Room Air. About 10:45 a.m., Resident became lethargic and pale, slurred speech, rechecked vital temperature - 97.8, blood pressure - 96/54, 60/29, pulse - 51, heart rate - 24, oxygen saturation - 93% Room Air. Doctor notified and received telephone order to send to emergency room for evaluation. Ambulance called, notified daughter, informed her of what happened, and transferred her call to DON. Transferred to emergency room via ambulance about 11:15. - LVN A 11/6/17 at 1:59 p.m.: Resident admitted observation at (hospital) overnight. While reviewing the MAR for Resident #1's morning medication that she received on 11/6/17, it stated: Asprin 81mg by mouth daily [MEDICATION NAME] XL 50mg by mouth daily (medication for treating high blood pressure) [MEDICATION NAME] 10mg by mouth three times daily (medication for treating high blood pressure) Requip 0.25mg (2 tabs) by mouth daily [MEDICATION NAME] 40mg by mouth daily [MEDICATION NAME] 17 grams by mouth daily Calcium/Vitamin D 500mg/200 international units by mouth three times daily Cranberry 450mg (2 tabs) by mouth daily Co-enzyme 100mg (2 capsules) by mouth daily Folic Acid 1mg by mouth daily [MEDICATION NAME] 2.5mg by moth daily [MEDICATION NAME] 5000 units by mouth daily While reviewing the Facility Investigation Report listing Resident #6's morning medications that Resident #1 received on 11/6/17, it stated: [MEDICATION NAME] 30mg by mouth daily (medication for treating depression) [MEDICATION NAME] 600mg by mouth twice daily (medication for treating [MEDICAL CONDITION]) [MEDICATION NAME] 40mg by mouth daily (medication for treating high blood pressure) [MEDICATION NAME] 25mg by mouth daily (medication for treating high blood pressure) [MEDICATION NAME] 100mg by mouth twice daily (medication used for treating [MEDICAL CONDITION]) Calcium/Vitamin D 500mg/125 international units by mouth twice daily [MEDICATION NAME] 1mg by mouth daily (medication for treating [MEDICAL CONDITION]) [MEDICATION NAME]/Levadopa 25mg/100mg by mouth three times daily (medication for treating [MEDICAL CONDITION]) Requip 2mg by mouth daily (medication for treating restless leg syndrome or [MEDICAL CONDITION]) During an interview on 11/15/17 at 9:20 a.m., DON confirmed RN A had come to her a little before morning stand up meeting (starting at 8:30 a.m.) on 11/6/17 and told her she had made a medication error. She confirmed she was informed Resident #1 had received her morning medication and Resident #6's morning medication. She confirmed she instructed RN A to assess the resident, inform the physician, and inform the Resident's family. She confirmed approximately 1 hour later, Resident #1 experienced significantly low blood pressure, was pale and disoriented, and required transfer to the local emergency room . She confirmed the medication was administered incorrectly to the wrong resident. During an interview on 11/15/17 at 11:15 a.m., LVN B confirmed on 11/6/17 about 8:00 a.m., she saw LVN C repeatedly interrupt RN A while she was passing medications. LVN B confirmed after the second interruption, I told (LVN C) to leave her alone because she was passing meds. LVN B confirmed a short time later, RN A informed her of the medication error. LVN B confirmed (RN A) told her that she had given Resident #1 her morning medications in addition to Resident #6's morning medications. LVN B confirmed Resident #1 was brought to the commons area near the nurses' stating to monitor her. LVN B confirmed approximately 1-1.5 hours later, at approximately 10:30 a.m., she looked over at Resident #1, and she was very pale. She confirmed she immediately went to examine Resident #1, and she was very pale, disoriented, lethargic and I couldn't understand her. LVN B was unable to recall Resident #1's blood pressure, but she stated, it was about 60/28. LVN B confirmed Resident #1's low blood pressure was a potentially life-threatening situation. LVN B confirmed she immediately notified the physician and EMS. She confirmed EMS arrived and started intravenous fluids on Resident #1. LVN confirmed EMS transported Resident #1 to the hospital, and she was admitted for observation. During an interview on 11/15/17 at 11:29 a.m., MD 1 confirmed he was informed of the medication error on 11/6/17. He was unable to recall what time he was first notified, but stated, it should be in their notes. He confirmed he was concerned about the potentially life-threatening problems of (Resident #1) receiving her own medication and another resident's medication. He stated, that's why I wanted her sent to the ER. He stated that when he asked how the medication error occurred, he was told the nurse got the names mixed up because they both begin with 'C'. He stated, . that excuse is completely unacceptable. They have to be very mindful of the medications they are giving residents. During an interview on 11/15/17 at 11:50 a.m., LVN C confirmed on 11/6/17 at approximately 8:20 a.m., RN A came to her to tell her Resident #1 did not have a medication that she needed in the cart. She stated, we looked at the MAR, and (RN A) realized she had given the wrong meds to the wrong resident. I told her to tell ADM and DON. During an interview on 11/15/17 at 1:35 p.m., Resident #1 confirmed she remembered when she was given the incorrect medication on 11/6/17. She stated, I don't know what they gave me, but they drugged me up. She confirmed she first noticed it when she attempted to get up from bed. She stated, I kept trying to stand up over and over again, but I had no strength .I couldn't move. She confirmed EMS arrived and started intravenous fluids on her. She confirmed she was taken via EMS to the hospital and was admitted . She confirmed she was very scared, and I thought I was going to die. She confirmed she asked the EMS personnel several times am I alive or dead .am I going to die. During an interview on 11/15/17 at 2:12 p.m., RN A confirmed she made the medication error on 11/6/17 at 8:20 a.m. She stated, I was pulling (Resident #6's) medications, and somehow I thought it was for (Resident #1). She confirmed the MAR indicated [REDACTED]. When asked how she confused the names, she stated, both names begin with ca. RN A stated she was distracted and rushed because LVN C had come to tell her that they still needed to count and order medications at least 4-6 times while she was doing medication pass. RN A confirmed this was her first day on medication cart by herself. She confirmed she had been with someone to supervise her prior to 11/6/17. She confirmed she notified ADM and DON of the medication error at approximately 8:30 a.m. on 11/16/17. She confirmed she was instructed to assess the resident, notify the family and notify the physician. RN A confirmed the physician was not notified until 10:30 a.m. When asked why, she stated, I got busy getting her vital signs, making sure she was okay, and calling the family, I forgot. She confirmed the amount and type of medications Resident #1 received was potentially life-threatening. She confirmed EMS had to start intravenous fluids to stabilize Resident #1's blood pressure, transport her to the hospital, and Resident #1 was admitted to the hospital for observation. During an interview on 11/15/17 at 3:18 p.m., MD 1 confirmed he did not remember what time he was notified. When informed the medication error report said it was 10:30 a.m. (two hours after the medication error was identified by staff), he stated, then that is probably right. He confirmed that had he been notified of the incident earlier he would not have wanted her there. He confirmed he would have transferred her earlier for a higher level of care. During an interview on 11/15/17 at 2:46 p.m., Pharm confirmed she was familiar with the medication error. She confirmed the risks for the amount/type of medication Resident #1 received were: low blood pressure, low heart rate, low respirations, and decreased level of consciousness, lethargy, and disorientation. She confirmed the facility did not notify her that Resident #1 received her morning medication and Resident #6's morning medication. When asked, given that knowledge, could this have been life-threatening, she responded, They saved her life by catching it, monitoring it, and sending her out. She confirmed the medications that lower blood pressure that Resident #1 received were: Resident #1's morning medication: [MEDICATION NAME] 20mg PO BID, [MEDICATION NAME] XL 50 mg PO QD, [MEDICATION NAME] 10 mg PO TID; and Resident #6's morning medication: [MEDICATION NAME] 25mg PO, [MEDICATION NAME] 40 mg PO, and [MEDICATION NAME] 100mg. During an interview on 11/16/17 at 10:32 a.m., ADM confirmed she believed the Immediate Jeopardy occurred because RN A is a new nurse, and the facility could have done a better job training her. She confirmed she was unaware (LVN C) was rushing (RN A). When she was asked how the medication error occurred, since the EMAR has a picture of the resident and their name on the same page as the medications being pulled for administration, she stated, I'm not sure how that happened. While reviewing the Medication Error Report, dated 11/6/17, for Resident #1, it stated: Date of Error: 11/6/17 Time of Error: 8:20 a.m. Physician Notified on 11/6/17 at 10:30 a.m. DON notified on 11/6/17 at 8:20 a.m. Outcome to Resident: Resident had to be transferred to (the hospital) via EMS Type of Error: wrong resident Reason for Error: failure to identify resident While reviewing the facility's undated policy for Administration of Medication, it stated: Policy A physician order [REDACTED]. Procedures 2. Check Electronic Medication Administration Record [REDACTED] 3. Read each order entirely. 10. Identify resident before administering the drug. While reviewing the facility's undated policy for Medication Errors and Drug Reactions, it stated: Procedure: All medication errors and drug reactions must be promptly reported to the Director of Nursing, attending physician and the pharmacist. 1. A detailed account of the incident must be recorded in the resident's medical record. The documentation should include: a. Time and date of the incident f. Date and time the physician was notified and instructions/orders given. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from 11/6/17 through 11/7/17. The facility took the following actions to correct the non-compliance on 11/6/17: RN A was immediately removed from medication administration duties, remedial one-on-one training regarding the 6 rights of medication administration was provided to RN A, and a policy of a quiet zone while administering medication was initiated, and training for all staff administering medications was begun covering the 6 rights of medication administration, the quiet zone while administering medication, policy training for medication errors, and physician notification. The training for all staff administering medication was completed on 11/7/17. This surveyor confirmed on 11/17/17 that the facility's took the following corrective actions to correct the noncompliance: 1) Interviews with all available licensed nurses and medication aides to confirm the additional training regarding medication administration had been performed. 2) Interviews with all available licensed nurses and medication aides to confirm the RN A had not worked the medication cart by herself since 11/6/17. 3) Interviews with all available licensed nurses and medication aides to confirm RN A is being trained on the medication cart and will be receiving additional training regarding medication administration. 4) Interviews with all available licensed nurses and medication aides to confirm the additional measure of implementation of a quiet zone while passing medications, spot checks by administration during medication pass, and documentation training had been performed. Review of the Resident Census, dated 11/15/17, shows documented a census of 53, with 53 residents receiving medications (RN A interview).

Based on observation, interview and record review; it was determined the facility failed to ensure residents remained free of any significant medication errors for 1 of 8 residents reviewed for mediation errors (Resident #1). RN A incorrectly administered Resident #6's medications to Resident #1, in addition to Resident #1's medications. Resident #6's medications included multiple medications that lower blood pressure. RN A failed to immediately notify the physician, until approximately 1-1.5 hours after the medication error. Resident #1's blood pressure fell to a life-threatening level. Upon notification of the medication error, Resident #1's physician ordered Resident #1 transferred to the local hospital. Resident #1 required intravenous fluids to stabilize her blood pressure, transportation to the hospital via EMS, and admission to the hospital. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility's failure to ensure that residents remained free of any significant medication errors affected one resident and could place 47 additional residents receiving oral medication at risk for shallow breathing, [MEDICAL CONDITION], low blood pressure, poor cerebral perfusion, poor blood circulation to other vital organs, peripheral blood clots, deep vein thrombus, [MEDICAL CONDITION] thrombus, coma and death. Findings include: Record review of Resident #1's clinical record revealed: Resident #1 is an [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #1's MDS, dated [DATE], it stated: Resident #1 has impaired vision and hearing; BIMS-12; Depression-3; limited 1 person assist for all bed mobility, transfers, dressing, toileting, ADLs, bathing and hygiene; wheelchair; no upper extremity or lower extremity impairment; always continent of bowel and bladder; occasional complaints of pain requiring medication; and at risk for falls and pressure sores. While reviewing the care plan for Resident #1, dated 11/5/17, it states: Resident #1 has vision, mobility and cognitive impairment, occasional verbal aggression, poor activity involvement, ADL deficit requiring at least 1 person assist, pain, anxiety, depression, bowel and bladder incontinence, at risk for falls, dehydration, dyspnea, weight loss and pressure sores. While reviewing the Nurses' Notes, dated 11/6/17, for Resident #1, it stated: 11/6/17 at 11:25 a.m.: Resident was given another resident's medication this morning. Medication Nurse reported to Charge Nurse and DON. Vital signs were checked about 30 minutes after incident, temperature - 97.1, blood pressure - 111/64, pulse - 70, respirations - 16, oxygen saturation - 95% on Room Air. About 10:45 a.m., Resident became lethargic and pale, slurred speech, rechecked vital temperature - 97.8, blood pressure - 96/54, 60/29, pulse - 51, heart rate - 24, oxygen saturation - 93% Room Air. Doctor notified and received telephone order to send to emergency room for evaluation. Ambulance called, notified daughter, informed her of what happened, and transferred her call to DON. Transferred to emergency room via ambulance about 11:15. - LVN A 11/6/17 at 1:59 p.m.: Resident admitted observation at (hospital) overnight. While reviewing the MAR for Resident #1's morning medication that she received on 11/6/17, it stated: Asprin 81mg by mouth daily [MEDICATION NAME] XL 50mg by mouth daily (medication for treating high blood pressure) [MEDICATION NAME] 10mg by mouth three times daily (medication for treating high blood pressure) Requip 0.25mg (2 tabs) by mouth daily [MEDICATION NAME] 40mg by mouth daily [MEDICATION NAME] 17 grams by mouth daily Calcium/Vitamin D 500mg/200 international units by mouth three times daily Cranberry 450mg (2 tabs) by mouth daily Co-enzyme 100mg (2 capsules) by mouth daily Folic Acid 1mg by mouth daily [MEDICATION NAME] 2.5mg by moth daily [MEDICATION NAME] 5000 units by mouth daily While reviewing the Facility Investigation Report listing Resident #6's morning medications that Resident #1 received on 11/6/17, it stated: [MEDICATION NAME] 30mg by mouth daily (medication for treating depression) [MEDICATION NAME] 600mg by mouth twice daily (medication for treating [MEDICAL CONDITION]) [MEDICATION NAME] 40mg by mouth daily (medication for treating high blood pressure) [MEDICATION NAME] 25mg by mouth daily (medication for treating high blood pressure) [MEDICATION NAME] 100mg by mouth twice daily (medication used for treating [MEDICAL CONDITION]) Calcium/Vitamin D 500mg/125 international units by mouth twice daily [MEDICATION NAME] 1mg by mouth daily (medication for treating [MEDICAL CONDITION]) [MEDICATION NAME]/Levadopa 25mg/100mg by mouth three times daily (medication for treating [MEDICAL CONDITION]) Requip 2mg by mouth daily (medication for treating restless leg syndrome or [MEDICAL CONDITION]) During an interview on 11/15/17 at 9:20 a.m., DON confirmed RN A had come to her a little before morning stand up meeting (starting at 8:30 a.m.) on 11/6/17 and told her she had made a medication error. She confirmed she was informed Resident #1 had received her morning medication and Resident #6's morning medication. She confirmed she instructed RN A to assess the resident, inform the physician, and inform the Resident's family. She confirmed approximately 1 hour later, Resident #1 experienced significantly low blood pressure, was pale and disoriented, and required transfer to the local emergency room . She confirmed the medication was administered incorrectly to the wrong resident. During an interview on 11/15/17 at 11:15 a.m., LVN B confirmed on 11/6/17 about 8:00 a.m., she saw LVN C repeatedly interrupt RN A while she was passing medications. LVN B confirmed after the second interruption, I told (LVN C) to leave her alone because she was passing meds. LVN B confirmed a short time later, RN A informed her of the medication error. LVN B confirmed (RN A) told her that she had given Resident #1 her morning medications in addition to Resident #6's morning medications. LVN B confirmed Resident #1 was brought to the commons area near the nurses' stating to monitor her. LVN B confirmed approximately 1-1.5 hours later, at approximately 10:30 a.m., she looked over at Resident #1, and she was very pale. She confirmed she immediately went to examine Resident #1, and she was very pale, disoriented, lethargic and I couldn't understand her. LVN B was unable to recall Resident #1's blood pressure, but she stated, it was about 60/28. LVN B confirmed Resident #1's low blood pressure was a potentially life-threatening situation. LVN B confirmed she immediately notified the physician and EMS. She confirmed EMS arrived and started intravenous fluids on Resident #1. LVN confirmed EMS transported Resident #1 to the hospital, and she was admitted for observation. During an interview on 11/15/17 at 11:29 a.m., MD 1 confirmed he was informed of the medication error on 11/6/17. He was unable to recall what time he was first notified, but stated, it should be in their notes. He confirmed he was concerned about the potentially life-threatening problems of (Resident #1) receiving her own medication and another resident's medication. He stated, that's why I wanted her sent to the ER. He stated that when he asked how the medication error occurred, he was told the nurse got the names mixed up because they both begin with 'C'. He stated, . that excuse is completely unacceptable. They have to be very mindful of the medications they are giving residents. During an interview on 11/15/17 at 11:50 a.m., LVN C confirmed on 11/6/17 at approximately 8:20 a.m., RN A came to her to tell her Resident #1 did not have a medication that she needed in the cart. She stated, we looked at the MAR, and (RN A) realized she had given the wrong meds to the wrong resident. I told her to tell ADM and DON. During an interview on 11/15/17 at 1:35 p.m., Resident #1 confirmed she remembered when she was given the incorrect medication on 11/6/17. She stated, I don't know what they gave me, but they drugged me up. She confirmed she first noticed it when she attempted to get up from bed. She stated, I kept trying to stand up over and over again, but I had no strength .I couldn't move. She confirmed EMS arrived and started intravenous fluids on her. She confirmed she was taken via EMS to the hospital and was admitted . She confirmed she was very scared, and I thought I was going to die. She confirmed she asked the EMS personnel several times am I alive or dead .am I going to die. During an interview on 11/15/17 at 2:12 p.m., RN A confirmed she made the medication error on 11/6/17 at 8:20 a.m. She stated, I was pulling (Resident #6's) medications, and somehow I thought it was for (Resident #1). She confirmed the MAR indicated [REDACTED]. When asked how she confused the names, she stated, both names begin with ca. RN A stated she was distracted and rushed because LVN C had come to tell her that they still needed to count and order medications at least 4-6 times while she was doing medication pass. RN A confirmed this was her first day on medication cart by herself. She confirmed she had been with someone to supervise her prior to 11/6/17. She confirmed she notified ADM and DON of the medication error at approximately 8:30 a.m. on 11/16/17. She confirmed she was instructed to assess the resident, notify the family and notify the physician. RN A confirmed the physician was not notified until 10:30 a.m. When asked why, she stated, I got busy getting her vital signs, making sure she was okay, and calling the family, I forgot. She confirmed the amount and type of medications Resident #1 received was potentially life-threatening. She confirmed EMS had to start intravenous fluids to stabilize Resident #1's blood pressure, transport her to the hospital, and Resident #1 was admitted to the hospital for observation. During an interview on 11/15/17 at 3:18 p.m., MD 1 confirmed he did not remember what time he was notified. When informed the medication error report said it was 10:30 a.m. (two hours after the medication error was identified by staff), he stated, then that is probably right. He confirmed that had he been notified of the incident earlier he would not have wanted her there. He confirmed he would have transferred her earlier for a higher level of care. During an interview on 11/15/17 at 2:46 p.m., Pharm confirmed she was familiar with the medication error. She confirmed the risks for the amount/type of medication Resident #1 received were: low blood pressure, low heart rate, low respirations, and decreased level of consciousness, lethargy, and disorientation. She confirmed the facility did not notify her that Resident #1 received her morning medication and Resident #6's morning medication. When asked, given that knowledge, could this have been life-threatening, she responded, They saved her life by catching it, monitoring it, and sending her out. She confirmed the medications that lower blood pressure that Resident #1 received were: Resident #1's morning medication: [MEDICATION NAME] 20mg PO BID, [MEDICATION NAME] XL 50 mg PO QD, [MEDICATION NAME] 10 mg PO TID; and Resident #6's morning medication: [MEDICATION NAME] 25mg PO, [MEDICATION NAME] 40 mg PO, and [MEDICATION NAME] 100mg. During an interview on 11/16/17 at 10:32 a.m., ADM confirmed she believed the situation occurred because RN A is a new nurse, and the facility could have done a better job training her. She confirmed she was unaware (LVN C) was rushing (RN A). When she was asked how the medication error occurred, since the EMAR has a picture of the resident and their name on the same page as the medications being pulled for administration, she stated, I'm not sure how that happened. While reviewing the Medication Error Report, dated 11/6/17, for Resident #1, it stated: Date of Error: 11/6/17 Time of Error: 8:20 a.m. Physician Notified on 11/6/17 at 10:30 a.m. DON notified on 11/6/17 at 8:20 a.m. Outcome to Resident: Resident had to be transferred to (the hospital) via EMS Type of Error: wrong resident Reason for Error: failure to identify resident While reviewing the facility's undated policy for Administration of Medication, it stated: Policy A physician order [REDACTED]. Procedures 2. Check Electronic Medication Administration Record [REDACTED] 3. Read each order entirely. 10. Identify resident before administering the drug. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from 11/6/17 through 11/7/17. The facility took the following actions to correct the non-compliance on 11/6/17: RN A was immediately removed from medication administration duties, remedial one-on-one training regarding the 6 rights of medication administration was provided to RN A, and a policy of a quiet zone while administering medication was initiated, and training for all staff administering medications was begun covering the 6 rights of medication administration, the quiet zone while administering medication, policy training for medication errors, and physician notification. The training for all staff administering medication was completed on 11/7/17. This surveyor confirmed on 11/17/17 that the facility took the following corrective actions to correct the noncompliances: 1) Interviews with all available licensed nurses and medication aides to confirm the additional training regarding medication administration had been performed. 2) Interviews with all available licensed nurses and medication aides to confirm the RN A had not worked the medication cart by herself since 11/6/17. 3) Interviews with all available licensed nurses and medication aides to confirm RN A is being trained on the medication cart and will be receiving additional training regarding medication administration. 4) Interviews with all available licensed nurses and medication aides to confirm the additional measure of implementation of a quiet zone while passing medications, spot checks by administration during medication pass, and documentation training had been performed. Review of the Resident Census, dated 11/15/17, shows documented a census of 53, with 53 residents receiving medications (RN A interview).

Based on record review, observation and interviews, the facility failed to develop and implement their written policies and procedures to prevent neglect for 1 of 12 residents (Resident #1) who sustained injuries during a mechanical sit-to-stand transfer. CNA "A" while lifting Resident #1 by means of a mechanical lift, failed to: - ensure Resident #1 was safely transferred by two staff in accordance with the resident's assessed transfer requirements. - ensure the resident's right paralyzed arm was positioned down in front of the resident's body during the transfer. - ensure the sling was held in position during the transfer. - ensure Resident #1 was safely transferred by two staff in accordance with the resident's assessed and care planned transfer requirements. This failure caused Resident #1 to slide out of the sling resulting in fractures to Resident #1's right arm. On 03/17/14 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 03/19/14, the facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility had not yet in-serviced all direct care staff regarding special considerations for residents with specific medical conditions when using mechanical lifts. This failure placed the remaining 11 residents in the facility that were transferred by means of mechanical lifts, at risk of injury and/or death. The evidence was as follows: 1.) POLICY (undated): Section 11- Safety Policy: Abuse Prevention Program Procedure: A. The facility is committed to protecting residents from abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. B. Actions to be taken to screen, train, prevent and identify abuse: 3. Identification: a. Identification of occurrences and patterns of potential mistreatment/abuse. b. Ongoing review and analysis of abuse/neglect incidents. 4. Prevention: a. Administration Dept. Heads will observe how employees interact with residents. 5. Protection: a. Administration will protect residents during investigations of abuse. 6. Investigation: b. Known incidents review: injuries should be assessed to determine if evidence matches explanation of incident or if further explanation is needed. 2.) POLICY (undated): Lifting, Transfer, and Repositioning Policy Purpose: To foster safety both for residents and the staff and maintain the residents' functional capabilities to their highest practical level. Procedures: 2. All resident(s) that require total assistance with transfers must be lifted by a mechanical lift and repositioned with two nursing staff. 3.) Review of the manufacturer's Operating Instructions for the Sara 2000 mechanical lift, pg. 10, documented: 11. Residents who have suffered a "stroke", who can only hold on with one hand, or residents who cannot hold on at all, may still be lifted by the Sara 2000, but it will be necessary for the attendant, (or a second attendant), to hold the resident's arm/arms down in front of the body during the lift. Additionally, the instructions warned the sling could possibly ride up the back, making it necessary to hold the sling in position when lifting/lowering. 4.) Review of the record of admission (Face Sheet) documented Resident #1 was admitted to the facility on [DATE]. She was [AGE] years of age at the time of the incident. 5.) Review of the annual Minimum Data Set (MDS) resident assessment instrument dated 1/17/14 documented [DIAGNOSES REDACTED]. It documented a cognitive summary score of 2 out of a possible 15, and total dependence on two+ person physical assist for transfers. It documented upper and lower extremity impairment on one side, a height of 61 inches, and a weight of 233 pounds. 6.) Review of the Plan of Care dated January, 2014, documented Resident #1 required mechanical lifts using the Arjo (brand name) "Sara" (sit-to-stand) lift and sling, with extensive to total assistance due to right-sided paralysis. 7.) Review of Interdisciplinary Progress Notes by LVN "B" dated 3/3/14 at 08:53 a.m. documented: Resident (#1) was in Sara lift being transferred from shower chair to wheelchair and Resident let go with right arm and knees buckled. Resident was assisted to floor. Sustained an abrasion to right arm and abrasion to hand. Resident complained of pain to left arm when moved. The fall occurred at 07:30 a.m. NOTE: Review of the Incident/Accident report dated 3/3/14 and the Provider Investigation Report dated 3/4/14 clarified it was in fact Resident #1's left arm and hand that sustained abrasions, and she complained of pain to her right arm. Additionally, due to right-sided paralysis, it was the left hand that released the Sara lift grab handle. Further review of LVN "B's" 3/3/14 Interdisciplinary Progress Notes documented Resident #1 had been transported to a local clinic as a result of the incident, and returned to the facility on [DATE] at 18:16 p.m., with a right proximal humerus fracture. 8.) Review of x-ray reports from Muleshoe Area Medical Center dated 3/3/14 documented the following: HUMERUS 2 VIEW RIGHT- [MEDICAL CONDITION] humeral shaft. SHOULDER 2 VIEW RIGHT- Humeral head and neck fractures. CLAVICAL RIGHT- [MEDICAL CONDITION] humerus. ELBOW AP & LATERAL RIGHT- Foreshortening of the radial neck suspicious for fracture visible on the lateral image. 9.) Review of the FNP report dated 3/3/14, documented under ADDENDUM: On the shoulder, the fracture is more involved than previously thought. There is external internal rotation views and it showed an oblique [MEDICAL CONDITION] metaphysis and [MEDICATION NAME] humeral neck fracture. 10.) Review of the Nurse Aide Meeting/In-Service dated 3/11/14 at 1:30 p.m., documented lift policies and precautions had been reviewed as a result of the incident. 11.) Observation on 3/18/14 at 10:35 a.m., revealed with the Administrator present, CNA "A" reenacted the incident using the Sara lift with the DON assisting as the resident/patient. The reenactment revealed CNA "A" failed to ensure Resident #1's paralyzed right arm was held down in front of the body, and failed to ensure her left arm was held down in front of the body once Resident #1 became weak and released hold of the grab handle. Both of the DON's (patient) arms were observed to be extended outside the sling. Additionally, it was observed CNA"A" failed to ensure the sling was held in position, as the DON (patient) slid out of the sling down to the floor, pulling her arms above her head and down through the inside of the sling, as she was eased to the floor by CNA"A". 12.) During an interview on 3/17/14 at 10:00 a.m., the DON said the incident was determined by the facility to not have been the result of an improper transfer by CNA "A". Rather, the incident occurred due to the fact Resident #1 had right-sided paralysis and had released her left hand from the grab handle due to weakness. 13.) During an interview on 3/17/14 at 10:40 a.m., the facility Administrator stated facility policy allowed for 1-person mechanical lift transfers. 14.) During an interview on 3/17/14 at 12:15 p.m., CNA "C" stated he had never utilized the assistance of a second aide when mechanically transferring Resident #1, as per her plan of care. CNA "C" said he felt comfortable executing 1-person mechanical lift transfers of Resident #1 without assistance from a second aide. 15.) During a telephone interview on 3/17/14 at 1:30 p.m., CNA "A" stated she executed 1-person mechanical lift transfers of Resident #1 multiple times. CNA "A" stated she occasionally utilized staff assistance to perform 2-person mechanical lift transfers; however she usually performed the transfers solo. CNA "A" then said "When you use the mechanical lift, the lift is the second person". During a subsequent interview on 3/18/14 at 1:40 p.m., CNA "A" said it would not have been physically possible for her to have held Resident #1's arms down in front of the body, and have held the sling in place, and have operated the Sara lift by herself without the assistance of a second person. CNA "A" said "It would have taken 2 people to do all that". During a third and final interview on 3/19/14 at 11:25 a.m. CNA "A", when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition, and that would have required the assistance of a second person. 16.) During an interview on 3/17/14 at 2:00 p.m., CNA "D" said all mechanical lifts required 2 people, adding the lift itself was the second person. 17.) During an interview on 3/17/14 at 2:00 p.m. following observation of a mechanical Hoyer (full body) lift transfer with full body sling, Resident #8, when asked whether 1 or 2 staff generally transferred her, replied "It's generally just one". 18.) During an interview on 3/17/14 at 3:10 p.m., the PTA said he had no knowledge regarding the facility policies and procedures for mechanical lift transfers. The PTA said he advised staff to seek assistance of a second staff person if they did not feel comfortable executing mechanical lift transfers by themselves. 19.) During an interview on 3/18/14 at 11:00 a.m., the MDS Coordinator acknowledged she had misinformed staff that a mechanical lift could replace an actual staff person when executing mechanical lift transfers. The MDS Coordinator continued, "that's the way it was before the 3.0 (MDS) came out". 20.) During a telephone interview on 3/18/14 at 1:30 p.m., the FNP revealed Resident #1's injuries occurred as the result of the way her arms came down through the sling when the incident occurred, as the x-ray revealed an angular fracture indicative of a twisting motion. Additionally, the FNP said "I was puzzled as to why they (the facility) transferred her (Resident #1) that way? I think she would have required a 2-person Hoyer (mechanical lift) transfer because she's not really able to stand up due to right-sided hemi paralysis". 21.) During an interview on 3/19/14 at 10:36 a.m., CNA "E" , when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition. 22.) During an interview on 3/19/14 at 10:50 a.m., CNA "F", when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition. 23.) During an interview on 3/19/14 at 11:00 a.m., CNA "G" acknowledged having been instructed during the 3/11/14, 1:30 p.m. in-service (attendance signed by CNA "G"), that a mechanical lift constituted a second person, therefore aides were to code 1-person mechanical lift transfers as 2-person transfers on the ADL Flow Logs. CNA "G" said "A lot of us were confused about this because we learned in school this is not a 2-person transfer." On 3/17/14 at 3:50 p.m., the facility Administrator and DON were notified an Immediate Jeopardy situation had been identified. On 3/18/14 at 2:10 p.m., the facility submitted the following plan of removal: A.) - To correct the lack of training of staff on the policies and mechanics of the Maxi Lift and the Sara Lift, in-services have been conducted with nursing staff effective March 11, 17, and 18, 2014. - All subsequent transfers since the incident have involved two staff. - The training on March 17th and 18th was provided by Debbie Parmer, Director of HR (Human Resources), and included demonstration training by each staff person and reviewing the Lift, Transfer and Repositioning Guidelines for each nursing staff person and the Lift Assessment Tool for those responsible for such task. List of nursing staff involved in this training can be supplied. We will not even consider the lift as a second person in transfer care planning. Ongoing responsibility for this training will reside with the Director of HR. - To correct any discrepancies or uncertainties in every care plan that involves use of a mechanical lift, all such care plans have been reviewed and corrected by nursing supervisors and agreement between completed MDS and resulting Care Plans have been harmonized. Subsequently, all Care Tracker buttons have been lit up that instruct the nursing assistants in the correct method to transfer elders. This is completed as of 3/18/2014 and is available for review. Ongoing responsibility for this system correction will reside with the ADON. - We do not dispute that a deficiency is warranted due to the lack of harmony between the MDS and Care Plan. We have invested immensely in correcting this ASAP (as soon as possible), and believe it will not occur again based on the above plan. B.) Specific actions taken: - In-service was conducted on March 11, 2013 with the CNA staff by the DON. - Policy was rewritten to update the facility changes as evident of Policy lift and transfer. - New assessment forms were created to reflect our policy changes. - Nursing staff was in-serviced on 3/17-3/18 with hands on demonstration of both lifts and reviewing current policy regarding Transfer/Lifts. - 100% of residents were assessed regarding transfers. - Resident profiles were updated to reflect any changes. - Care plans were updated to reflect any changes. - Care plan for (Resident) Patsy Brady has been previously scheduled and will address concerns with family member this week. 24.) Observations of 5 mechanical lift transfers during the course of the investigation on 3/17/14; revealed al mechanical lift transfers were executed by two staff. 25.) Record review on 3/19/14 at 11:45 a.m., revealed in-services had been conducted on 3/17-18/14 regarding transfer safety with regards to mechanical lift transfers. 26.) Record review on 3/19/14 at 12:00 p.m., revealed the plans of care for the 12 sampled residents in the facility who were lifted by mechanical means were updated to accurately to reflect the residents' transfer needs in accordance with their MDS assessments. The facility provided the updated plans of care for sampled Residents #1-12, which correlated with the residents' transfer requirements documented on their comprehensive assessments. 27.) Review of the new, revised copy of the policy titled Lifting, Transfer, and Repositioning, provided on 3/18/14, documented under #5 that 1-person mechanical lifts continued to be facility policy: 5. A lift designation is placed in each resident section of the electronic medical record. The five designations are (independent, one person, one person with a lift, two persons, two persons with a lift). 28.) During an interview on 3/19/14 at 10:36 a.m., CNA "E" , when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition. CNA "E" stated having been retrained the mechanical lift could not be utilized as a second person on 3/18/14. 29.) During an interview on 3/19/14 at 10:50 a.m., CNA "F", when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition. CNA "F" stated having been retrained the mechanical lift could not be utilized as a second person on 3/18/14. 30.) During an interview on 3/19/14 at 11:00 a.m., CNA "G" acknowledged having been instructed during the 3/11/14, 1:30 p.m. in-service (attendance signed by CNA "G"), that a mechanical lift constituted a second person, therefore aides were to code 1-person mechanical lift transfers as 2-person transfers on the ADL Flow Logs. CNA "G" said "A lot of us were confused about this because we learned in school this is not a 2-person transfer." CNA "G" stated having been re-trained on 3/18/14 that the lift could not be considered as a second person during transfers, and could not be coded as such on the Care Tracker system/ADL Flow Log. On 3/19/14 at 1:20 p.m., the Administrator, DON, MDS Coordinator, Business Office Manager and Human Resources Coordinator were advised the IJ was removed. The facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility had not yet in-serviced all direct care staff regarding special considerations for residents with specific medical conditions when using mechanical lifts, and had yet to revise their policy regarding mechanical transfers requiring 2 staff to assist as per MDS guidelines pertaining to 2+ persons assist for transfers. 31.) The facility provided CMS Form 802 dated 3/17/14 identified on the left margin all residents' transfer requirements, and was approved by the DON as accurate on 3/17/14 at 12:50 p.m. for Residents #1-12, as having required mechanical lift transfers.

Based on observation and interviews, the facility failed to implement their policies and procedures to prevent neglect for 1 of 12 residents (Resident #1) who sustained injuries during a mechanical sit-to-stand transfer. CNA "A" while lifting Resident #1 by means of a mechanical lift, failed to: - ensure Resident #1 was safely transferred by two staff in accordance with the resident's assessed transfer requirements. - ensure the resident's right paralyzed arm was positioned down in front of the resident's body during the transfer. - ensure the sling was held in position during the transfer. - ensure Resident #1 was safely transferred by two staff in accordance with the resident's assessed and care planned transfer requirements. This failure caused Resident #1 to slide out of the sling resulting in fractures to Resident #1's right arm. On 03/17/14 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 03/19/14, the facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility had not yet in-serviced all direct care staff regarding special considerations for residents with specific medical conditions when using mechanical lifts. This failure placed the remaining 11 residents in the facility that were transferred by means of mechanical lifts, at risk of injury and/or death. The evidence was as follows: 1.) Review of the record of admission (Face Sheet) documented Resident #1 was admitted to the facility on [DATE]. She was [AGE] years of age at the time of the incident. 2.) Review of the annual Minimum Data Set (MDS) resident assessment instrument dated 1/17/14 documented [DIAGNOSES REDACTED]. It documented a cognitive summary score of 2 out of a possible 15, and total dependence on two+ person physical assist for transfers. It documented upper and lower extremity impairment on one side, a height of 61 inches, and a weight of 233 pounds. 3.) Review of the Plan of Care dated January, 2014, documented Resident #1 required mechanical lifts using the Arjo (brand name) "Sara" (sit-to-stand) lift and sling, with extensive to total assistance due to right-sided paralysis. 4.) Review of Interdisciplinary Progress Notes by LVN "B" dated 3/3/14 at 08:53 a.m. documented: Resident (#1) was in Sara lift being transferred from shower chair to wheelchair and Resident let go with right arm and knees buckled. Resident was assisted to floor. Sustained an abrasion to right arm and abrasion to hand. Resident complained of pain to left arm when moved. The fall occurred at 07:30 a.m. NOTE: Review of the Incident/Accident report dated 3/3/14 and the Provider Investigation Report dated 3/4/14 clarified it was in fact Resident #1's left arm and hand that sustained abrasions, and she complained of pain to her right arm. Additionally, due to right-sided paralysis, it was the left hand that released the Sara lift grab handle. Further review of LVN "B's" 3/3/14 Interdisciplinary Progress Notes documented Resident #1 had been transported to a local clinic as a result of the incident, and returned to the facility on [DATE] at 18:16 p.m., with a right proximal humerus fracture. 5.) Review of x-ray reports from Muleshoe Area Medical Center dated 3/3/14 documented the following: HUMERUS 2 VIEW RIGHT- [MEDICAL CONDITION] humeral shaft. SHOULDER 2 VIEW RIGHT- Humeral head and neck fractures. CLAVICAL RIGHT- [MEDICAL CONDITION] humerus. ELBOW AP & LATERAL RIGHT- Foreshortening of the radial neck suspicious for fracture visible on the lateral image. 6.) Review of the FNP report dated 3/3/14, documented under ADDENDUM: On the shoulder, the fracture is more involved than previously thought. There is external internal rotation views and it showed an oblique [MEDICAL CONDITION] metaphysis and [MEDICATION NAME] humeral neck fracture. 7.) Review of the Nurse Aide Meeting/In-Service dated 3/11/14 at 1:30 p.m., documented lift policies and precautions had been reviewed as a result of the incident. 8.) Observation on 3/18/14 at 10:35 a.m., revealed with the Administrator present, CNA "A" reenacted the incident using the Sara lift with the DON assisting as the resident/patient. The reenactment revealed CNA "A" failed to ensure Resident #1's paralyzed right arm was held down in front of the body, and failed to ensure her left arm was held down in front of the body once Resident #1 became weak and released hold of the grab handle. Both of the DON's (patient) arms were observed to be extended outside the sling. Additionally, it was observed CNA"A" failed to ensure the sling was held in position, as the DON (patient) slid out of the sling down to the floor, pulling her arms above her head and down through the inside of the sling, as she was eased to the floor by CNA"A". 9.) During an interview on 3/17/14 at 10:00 a.m., the DON said the incident was determined by the facility to not have been the result of an improper transfer by CNA "A". Rather, the incident occurred due to the fact Resident #1 had right-sided paralysis and had released her left hand from the grab handle due to weakness. 10.) During an interview on 3/17/14 at 10:40 a.m., the facility Administrator stated facility policy allowed for 1-person mechanical lift transfers. 11.) During an interview on 3/17/14 at 12:15 p.m., CNA "C" stated he had never utilized the assistance of a second aide when mechanically transferring Resident #1, as per her plan of care. CNA "C" said he felt comfortable executing 1-person mechanical lift transfers of Resident #1 without assistance from a second aide. 12.) During a telephone interview on 3/17/14 at 1:30 p.m., CNA "A" stated she executed 1-person mechanical lift transfers of Resident #1 multiple times. CNA "A" stated she occasionally utilized staff assistance to perform 2-person mechanical lift transfers; however she usually performed the transfers solo. CNA "A" then said "When you use the mechanical lift, the lift is the second person". During a subsequent interview on 3/18/14 at 1:40 p.m., CNA "A" said it would not have been physically possible for her to have held Resident #1's arms down in front of the body, and have held the sling in place, and have operated the Sara lift by herself without the assistance of a second person. CNA "A" said "It would have taken 2 people to do all that". During a third and final interview on 3/19/14 at 11:25 a.m. CNA "A", when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition, and that would have required the assistance of a second person. 13.) During an interview on 3/17/14 at 2:00 p.m., CNA "D" said all mechanical lifts required 2 people, adding the lift itself was the second person. 14.) During an interview on 3/17/14 at 2:00 p.m. following observation of a mechanical Hoyer (full body) lift transfer with full body sling, Resident #8, when asked whether 1 or 2 staff generally transferred her, replied "It's generally just one". 15.) During an interview on 3/17/14 at 3:10 p.m., the PTA said he had no knowledge regarding the facility policies and procedures for mechanical lift transfers. The PTA said he advised staff to seek assistance of a second staff person if they did not feel comfortable executing mechanical lift transfers by themselves. 16.) During an interview on 3/18/14 at 11:00 a.m., the MDS Coordinator acknowledged she had misinformed staff that a mechanical lift could replace an actual staff person when executing mechanical lift transfers. The MDS Coordinator continued, "that's the way it was before the 3.0 (MDS) came out". 17.) During a telephone interview on 3/18/14 at 1:30 p.m., the FNP revealed Resident #1's injuries occurred as the result of the way her arms came down through the sling when the incident occurred, as the x-ray revealed an angular fracture indicative of a twisting motion. Additionally, the FNP said "I was puzzled as to why they (the facility) transferred her (Resident #1) that way? I think she would have required a 2-person Hoyer (mechanical lift) transfer because she's not really able to stand up due to right-sided hemi paralysis". 18.) During an interview on 3/19/14 at 10:36 a.m., CNA "E" , when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition. 19.) During an interview on 3/19/14 at 10:50 a.m., CNA "F", when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition. 20.) During an interview on 3/19/14 at 11:00 a.m., CNA "G" acknowledged having been instructed during the 3/11/14, 1:30 p.m. in-service (attendance signed by CNA "G"), that a mechanical lift constituted a second person, therefore aides were to code 1-person mechanical lift transfers as 2-person transfers on the ADL Flow Logs. CNA "G" said "A lot of us were confused about this because we learned in school this is not a 2-person transfer." 21.) POLICY (undated): Section 11- Safety Policy: Abuse Prevention Program Procedure: A. The facility is committed to protecting residents from abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. B. Actions to be taken to screen, train, prevent and identify abuse: 3. Identification: a. Identification of occurrences and patterns of potential mistreatment/abuse. b. Ongoing review and analysis of abuse/neglect incidents. 4. Prevention: a. Administration Dept. Heads will observe how employees interact with residents. 5. Protection: a. Administration will protect residents during investigations of abuse. 6. Investigation: b. Known incidents review: injuries should be assessed to determine if evidence matches explanation of incident or if further explanation is needed. 22.) POLICY (undated): Lifting, Transfer, and Repositioning Policy Purpose: To foster safety both for residents and the staff and maintain the residents' functional capabilities to their highest practical level. Procedures: 2. All resident(s) that require total assistance with transfers must be lifted by a mechanical lift and repositioned with two nursing staff. 23.) Review of the manufacturer's Operating Instructions for the Sara 2000 mechanical lift, pg. 10, documented: 11. Residents who have suffered a "stroke", who can only hold on with one hand, or residents who cannot hold on at all, may still be lifted by the Sara 2000, but it will be necessary for the attendant, (or a second attendant), to hold the resident's arm/arms down in front of the body during the lift. Additionally, the instructions warned the sling could possibly ride up the back, making it necessary to hold the sling in position when lifting/lowering. On 3/17/14 at 3:50 p.m., the facility Administrator and DON were notified an Immediate Jeopardy situation had been identified. On 3/18/14 at 2:10 p.m., the facility submitted the following plan of removal: A.) - To correct the lack of training of staff on the policies and mechanics of the Maxi Lift and the Sara Lift, in-services have been conducted with nursing staff effective March 11, 17, and 18, 2014. - All subsequent transfers since the incident have involved two staff. - The training on March 17th and 18th was provided by Debbie Parmer, Director of HR (Human Resources), and included demonstration training by each staff person and reviewing the Lift, Transfer and Repositioning Guidelines for each nursing staff person and the Lift Assessment Tool for those responsible for such task. List of nursing staff involved in this training can be supplied. We will not even consider the lift as a second person in transfer care planning. Ongoing responsibility for this training will reside with the Director of HR. - To correct any discrepancies or uncertainties in every care plan that involves use of a mechanical lift, all such care plans have been reviewed and corrected by nursing supervisors and agreement between completed MDS and resulting Care Plans have been harmonized. Subsequently, all Care Tracker buttons have been lit up that instruct the nursing assistants in the correct method to transfer elders. This is completed as of 3/18/2014 and is available for review. Ongoing responsibility for this system correction will reside with the ADON. - We do not dispute that a deficiency is warranted due to the lack of harmony between the MDS and Care Plan. We have invested immensely in correcting this ASAP (as soon as possible), and believe it will not occur again based on the above plan. B.) Specific actions taken: - In-service was conducted on March 11, 2013 with the CNA staff by the DON. - Policy was rewritten to update the facility changes as evident of Policy lift and transfer. - New assessment forms were created to reflect our policy changes. - Nursing staff was in-serviced on 3/17-3/18 with hands on demonstration of both lifts and reviewing current policy regarding Transfer/Lifts. - 100% of residents were assessed regarding transfers. - Resident profiles were updated to reflect any changes. - Care plans were updated to reflect any changes. - Care plan for (Resident) Patsy Brady has been previously scheduled and will address concerns with family member this week. 24.) Observations of 5 mechanical lift transfers during the course of the investigation on 3/17/14; revealed al mechanical lift transfers were executed by two staff. 25.) Record review on 3/19/14 at 11:45 a.m., revealed in-services had been conducted on 3/17-18/14 regarding transfer safety with regards to mechanical lift transfers. 26.) Record review on 3/19/14 at 12:00 p.m., revealed the plans of care for the 12 sampled residents in the facility who were lifted by mechanical means were updated to accurately to reflect the residents' transfer needs in accordance with their MDS assessments. The facility provided the updated plans of care for sampled Residents #1-12, which correlated with the residents' transfer requirements documented on their comprehensive assessments. 27.) Review of the new, revised copy of the policy titled Lifting, Transfer, and Repositioning, provided on 3/18/14, documented under #5 that 1-person mechanical lifts continued to be facility policy: 5. A lift designation is placed in each resident section of the electronic medical record. The five designations are (independent, one person, one person with a lift, two persons, two persons with a lift). 28.) During an interview on 3/19/14 at 10:36 a.m., CNA "E" , when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition. CNA "E" stated having been retrained the mechanical lift could not be utilized as a second person on 3/18/14. 29.) During an interview on 3/19/14 at 10:50 a.m., CNA "F", when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition. CNA "F" stated having been retrained the mechanical lift could not be utilized as a second person on 3/18/14. 30.) During an interview on 3/19/14 at 11:00 a.m., CNA "G" acknowledged having been instructed during the 3/11/14, 1:30 p.m. in-service (attendance signed by CNA "G"), that a mechanical lift constituted a second person, therefore aides were to code 1-person mechanical lift transfers as 2-person transfers on the ADL Flow Logs. CNA "G" said "A lot of us were confused about this because we learned in school this is not a 2-person transfer." CNA "G" stated having been re-trained on 3/18/14 that the lift could not be considered as a second person during transfers, and could not be coded as such on the Care Tracker system/ADL Flow Log. On 3/19/14 at 1:20 p.m., the Administrator, DON, MDS Coordinator, Business Office Manager and Human Resources Coordinator were advised the IJ was removed. The facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility had not yet in-serviced all direct care staff regarding special considerations for residents with specific medical conditions when using mechanical lifts, and had yet to revise their policy regarding mechanical transfers requiring 2 staff to assist as per MDS guidelines pertaining to 2+ persons assist for transfers. 31.) The facility provided CMS Form 802 dated 3/17/14 identified on the left margin all residents' transfer requirements, and was approved by the DON as accurate on 3/17/14 at 12:50 p.m. for Residents #1-12, as having required mechanical lift transfers.

Based on observation, record review and interviews, the facility failed to utilize results of the comprehensive assessment to develop and revise plans of care for 5 of 19 residents (#1, 4, 7, 12, and 17) sampled for accuracy of assessments with regards to transfer assistance: - The plans of care for Residents #1, 4 and 7 inaccurately documented requirements for transfer assistance in accordance to the residents' comprehensive assessments. - The plans of care for Residents #12, and 17 failed to document need for transfer assistance. The comprehensive assessments for these residents documented the residents required extensive to total 2+ person assistance for transfers. This failure placed 19 residents who required transfer assistance at risk for injury and decreased physical, mental and psychosocial well-being, and placed all residents at risk of incomplete/inaccurate plans of care not developed in accordance with the comprehensive assessment. On 03/17/14 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 03/19/14, the facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility had not yet in-serviced all direct care staff regarding special considerations for residents with specific medical conditions when using mechanical lifts. This failure placed 19 residents who required transfer assistance at risk for injury and decreased physical, mental and psychosocial well-being, and placed all residents at risk of incomplete/inaccurate plans of care not developed in accordance with the comprehensive assessment. The evidence was as follows: 1) RESIDENT #1: - Review of the record of admission (Face Sheet) documented Resident #1 was admitted to the facility on [DATE]. She was [AGE] years of age at the time of the incident. - Review of the annual Minimum Data Set (MDS) resident assessment instrument dated 1/17/14 documented [DIAGNOSES REDACTED]. It documented a cognitive summary score of 2 out of a possible 15, and total dependence on two+ person physical assist for transfers. It documented upper and lower extremity impairment on one side, a height of 61 inches, and a weight of 233 pounds. - Review of the Plan of Care dated January, 2014, documented Resident #1 required mechanical lifts using the Arjo (brand name) "Sara" (sit-to-stand) lift and sling, with extensive to total assistance due to right-sided paralysis. The plan of care failed to specify Resident #1 required a 2-person assisted lift. Note: The plan of care was updated following the incident to reflect the need for two staff when transferring Resident Brady. 2.) RESIDENT #4: - Observation of Resident #4 on 3/19/14 at 12:50 p.m. revealed a totally dependent resident who required a Geri-chair propelled by staff for mobility. - The record of admission (Face Sheet), documented an admission date of [DATE]. It documented Resident #4 was [AGE] years of age. [DIAGNOSES REDACTED]. - The MDS resident assessment instrument dated 1/25/14 documented Resident #4 was totally dependent on 2+ person physical assist for transfers. - The plan of care dated January, 2014 documented "assist for transfers" (pg. #5 of 8). The plan of care failed to specify the level of assistance required for transfers. 3.) RESIDENT #7: - The record of admission documented an admission date of [DATE]. It documented Resident #7 was [AGE] years of age. [DIAGNOSES REDACTED]. - The MDS resident assessment instrument dated 3/3/14 documented extensive two+ persons physical assist for transfers. - The plan of care dated March, 2014 documented "Transfer resident with assistance of staff x 1". 4.) RESIDENT #12: - The record of admission documented Resident #12 was admitted to the facility on [DATE]. It documented the resident was [AGE] years of age. [DIAGNOSES REDACTED]. - The MDS resident assessment instrument dated 1/31/14 documented extensive two+ persons physical assist for transfers. - The plan of care dated January, 2014 (5 pages), failed to document Resident #12's requirements for transfer assistance. 5.) Resident #17: - The record of admission documented an admission date of [DATE]. It documented Resident #17 was [AGE] years of age. [DIAGNOSES REDACTED]. - The MDS resident assessment instrument dated 12/24/13 documented Resident #17 required extensive two+ persons physical assist for transfers. - The plan of care dated December, 2013 (7 pages) failed to document Resident #17's requirements for transfer assistance. 6.) During an interview on 3/19/14 at 10:36 a.m., CNA "E" reported only having access to residents' plans of care via the facility computerized "Care Tracker" system for documenting ADL assistance. CNA "E" denied having any access to the comprehensive assessment in order to determine residents' transfer requirements. 7.) During an interview on 3/19/14 at 10:50 a.m., CNA "F reported only having access to residents' plans of care via the facility computerized "Care Tracker" system for documenting ADL assistance. CNA "F" denied having any access to the comprehensive assessment in order to determine residents' transfer requirements. 8.) During an interview on 3/19/14 at 11:00 a.m., CNA "G" reported only having access to residents' plans of care via the facility computerized "Care Tracker" system for documenting ADL assistance. CNA "G" denied having any access to the comprehensive assessment in order to determine residents' transfer requirements. On 3/17/14 at 3:50 p.m., the facility Administrator and DON were notified an Immediate Jeopardy situation had been identified. On 3/18/14 at 2:10 p.m., the facility submitted the following plan of removal: A.) - To correct the lack of training of staff on the policies and mechanics of the Maxi Lift and the Sara Lift, in-services have been conducted with nursing staff effective March 11, 17, and 18, 2014. - All subsequent transfers since the incident have involved two staff. - The training on March 17th and 18th was provided by Debbie Parmer, Director of HR (Human Resources), and included demonstration training by each staff person and reviewing the Lift, Transfer and Repositioning Guidelines for each nursing staff person and the Lift Assessment Tool for those responsible for such task. List of nursing staff involved in this training can be supplied. We will not even consider the lift as a second person in transfer care planning. Ongoing responsibility for this training will reside with the Director of HR. - To correct any discrepancies or uncertainties in every care plan that involves use of a mechanical lift, all such care plans have been reviewed and corrected by nursing supervisors and agreement between completed MDS and resulting Care Plans have been harmonized. Subsequently, all Care Tracker buttons have been lit up that instruct the nursing assistants in the correct method to transfer elders. This is completed as of 3/18/2014 and is available for review. Ongoing responsibility for this system correction will reside with the ADON. - We do not dispute that a deficiency is warranted due to the lack of harmony between the MDS and Care Plan. We have invested immensely in correcting this ASAP (as soon as possible), and believe it will not occur again based on the above plan. B.) Specific actions taken: - In-service was conducted on March 11, 2013 with the CNA staff by the DON. - Policy was rewritten to update the facility changes as evident of Policy lift and transfer. - New assessment forms were created to reflect our policy changes. - Nursing staff was in-serviced on 3/17-3/18 with hands on demonstration of both lifts and reviewing current policy regarding Transfer/Lifts. - 100% of residents were assessed regarding transfers. - Resident profiles were updated to reflect any changes. - Care plans were updated to reflect any changes. - Care plan for (Resident) Patsy Brady has been previously scheduled and will address concerns with family member this week. 9.) Observations of 5 mechanical lift transfers during the course of the investigation on 3/17/14; revealed al mechanical lift transfers were executed by two staff. 10.) Record review on 3/19/14 at 11:45 a.m., revealed in-services had been conducted on 3/17-18/14 regarding transfer safety with regards to mechanical lift transfers. 11.) Record review on 3/19/14 at 12:00 p.m., revealed the plans of care for the 12 sampled residents in the facility who were lifted by mechanical means were updated to accurately to reflect the residents' transfer needs in accordance with their MDS assessments. The facility provided the updated plans of care for sampled Residents #1-12, which correlated with the residents' transfer requirements documented on their comprehensive assessments. 12.) Review of the new, revised copy of the policy titled Lifting, Transfer, and Repositioning, provided on 3/18/14, documented under #5 that 1-person mechanical lifts continued to be facility policy: 5. A lift designation is placed in each resident section of the electronic medical record. The five designations are (independent, one person, one person with a lift, two persons, two persons with a lift). 13.) During an interview on 3/19/14 at 10:36 a.m., CNA "E" , when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition. CNA "E" stated having been retrained the mechanical lift could not be utilized as a second person on 3/18/14. 14.) During an interview on 3/19/14 at 10:50 a.m., CNA "F", when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition. CNA "F" stated having been retrained the mechanical lift could not be utilized as a second person on 3/18/14. 15.) During an interview on 3/19/14 at 11:00 a.m., CNA "G" acknowledged having been instructed during the 3/11/14, 1:30 p.m. in-service (attendance signed by CNA "G"), that a mechanical lift constituted a second person, therefore aides were to code 1-person mechanical lift transfers as 2-person transfers on the ADL Flow Logs. CNA "G" said "A lot of us were confused about this because we learned in school this is not a 2-person transfer." CNA "G" stated having been re-trained on 3/18/14 that the lift could not be considered as a second person during transfers, and could not be coded as such on the Care Tracker system/ADL Flow Log. On 3/19/14 at 1:20 p.m., the Administrator, DON, MDS Coordinator, Business Office Manager and Human Resources Coordinator were advised the IJ was removed. The facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility had not yet in-serviced all direct care staff regarding special considerations for residents with specific medical conditions when using mechanical lifts, and had yet to revise their policy regarding mechanical transfers requiring 2 staff to assist as per MDS guidelines pertaining to 2+ persons assist for transfers. 16.) The facility provided CMS Form 802 dated 3/17/14 identified on the left margin all residents' transfer requirements, and was approved by the DON as accurate on 3/17/14 at 12:50 p.m. for Residents #1-12, as having required mechanical lift transfers.

d on record review, observation, interview, 1 of 6 CNAs observed for competency in skills and techniques for transfer assistance, (CNA "A") failed to demonstrate provision of care necessary for Resident #1 as identified in the resident's assessment and described in the plan of care. Failure to ensure nurse aides are competent in skills necessary to care for residents ' needs placed nurse aides at risk of causing injury to residents, and placed residents who required transfer assistance at risk for injury: - CNA "A" while lifting Resident #1 by means of a mechanical lift, failed to ensure Resident #1 was safely transferred by two staff in accordance with the resident's assessed transfer requirements. This failure caused Resident #1 to slide out of the sling resulting in fractures to Resident #1's right arm. On 03/17/14 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 03/19/14, the facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility had not yet in-serviced all direct care staff regarding special considerations for residents with specific medical conditions when using mechanical lifts. This failure placed 19 residents who required transfer assistance at risk for injury and decreased physical, mental and psychosocial well-being. The evidence was as follows: 1.) Review of Resident #1's annual MDS resident assessment instrument dated 1/17/14 documented total dependence on two+ persons physical assist for transfers. It documented upper and lower extremity impairment on one side, and a weight of 233 pounds. 2.) Review Resident #1's plan of care dated January, 2014, documented Resident #1 required mechanical lifts using the Arjo (brand name) "Sara" (sit-to-stand) lift and sling, with extensive to total assistance due to right-sided paralysis. 3.) Review of the manufacturer's Operating Instructions for the Sara 2000 mechanical lift, pg. 10, documented: 11. Residents who have suffered a "stroke", who can only hold on with one hand, or residents who cannot hold on at all, may still be lifted by the Sara 2000, but it will be necessary for the attendant, (or a second attendant), to hold the resident's arm/arms down in front of the body during the lift. Additionally, the instructions warned the sling could possibly ride up the back, making it necessary to hold the sling in position when lifting/lowering. 4.) Review of Provider Investigation Report dated 3/4/14 documented on 3/3/14 Resident #1 sustained injuries to include fractures while being transferred by CNA "A" using the Sara lift. The report documented neglect was unfounded, and that CNA "A" had demonstrated correct use of the Sara lift, and was able to state when the lift would not be used such as if a resident was unable to stand safely. 5.) Review of Resident #1's x-ray reports from Muleshoe Area Medical Center dated 3/3/14 documented the following: HUMERUS 2 VIEW RIGHT- [MEDICAL CONDITION] humeral shaft. SHOULDER 2 VIEW RIGHT- Humeral head and neck fractures. CLAVICAL RIGHT- [MEDICAL CONDITION] humerus. ELBOW AP & LATERAL RIGHT- Foreshortening of the radial neck suspicious for fracture visible on the lateral image. 6.) Observation on 3/18/14 at 10:35 a.m., with the Administrator present, revealed CNA "A" reenacted the 3/3/14 incident using the Sara lift, with the DON assisting as the resident/patient (Resident #1). The reenactment revealed CNA "A" failed to ensure Resident #1's paralyzed right arm was held down in front of the body, and failed to ensure her left arm was held down in front of the body once Resident #1 became weak and released hold of the grab handle. Both of the DON's (patient) arms were observed to be extended outside the sling. Additionally, it was observed CNA"A" failed to ensure the sling was held in position, as the DON (patient) slid out of the sling down to the floor, pulling her arms above her head and down through the inside of the sling, as she was eased to the floor by CNA"A". 7.) During an interview on 3/17/14 at 10:00 a.m., the DON said the incident was determined by the facility to not have been the result of an improper transfer by CNA "A". Rather, the incident occurred due to the fact Resident #1 had right-sided paralysis and had released her left hand from the grab handle due to weakness. 8.) During an interview on 3/17/14 at 10:40 a.m., the facility Administrator stated facility policy allowed for 1-person mechanical lift transfers. 9.) During an interview on 3/17/14 at 12:15 p.m., CNA "C" stated he had never utilized the assistance of a second aide when mechanically transferring Resident #1 with the Sara lift, as per her plan of care. CNA "C" said he felt comfortable executing 1-person mechanical lift transfers of Resident #1 without assistance from a second aide. 10.) During a telephone interview on 3/17/14 at 1:30 p.m., CNA "A" stated she executed 1-person mechanical lift transfers of Resident #1 multiple times. CNA "A" stated she occasionally utilized staff assistance to perform 2-person mechanical lift transfers; however she usually performed the transfers solo. 11.) During an interview on 3/19/14 at 10:36 a.m., CNA "E" , when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition. 12.) During an interview on 3/19/14 at 10:50 a.m., CNA "F", when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition. 13.) Review of the facility provided employee roster dated 3/17/14, documented 32 CNAs. On 3/17/14 at 3:50 p.m., the facility Administrator and DON were notified an Immediate Jeopardy situation had been identified. On 3/18/14 at 2:10 p.m., the facility submitted the following plan of removal: A.) - To correct the lack of training of staff on the policies and mechanics of the Maxi Lift and the Sara Lift, in-services have been conducted with nursing staff effective March 11, 17, and 18, 2014. - All subsequent transfers since the incident have involved two staff. - The training on March 17th and 18th was provided by Debbie Parmer, Director of HR (Human Resources), and included demonstration training by each staff person and reviewing the Lift, Transfer and Repositioning Guidelines for each nursing staff person and the Lift Assessment Tool for those responsible for such task. List of nursing staff involved in this training can be supplied. We will not even consider the lift as a second person in transfer care planning. Ongoing responsibility for this training will reside with the Director of HR. - To correct any discrepancies or uncertainties in every care plan that involves use of a mechanical lift, all such care plans have been reviewed and corrected by nursing supervisors and agreement between completed MDS and resulting Care Plans have been harmonized. Subsequently, all Care Tracker buttons have been lit up that instruct the nursing assistants in the correct method to transfer elders. This is completed as of 3/18/2014 and is available for review. Ongoing responsibility for this system correction will reside with the ADON. - We do not dispute that a deficiency is warranted due to the lack of harmony between the MDS and Care Plan. We have invested immensely in correcting this ASAP (as soon as possible), and believe it will not occur again based on the above plan. B.) Specific actions taken: - In-service was conducted on March 11, 2013 with the CNA staff by the DON. - Policy was rewritten to update the facility changes as evident of Policy lift and transfer. - New assessment forms were created to reflect our policy changes. - Nursing staff was in-serviced on 3/17-3/18 with hands on demonstration of both lifts and reviewing current policy regarding Transfer/Lifts. - 100% of residents were assessed regarding transfers. - Resident profiles were updated to reflect any changes. - Care plans were updated to reflect any changes. - Care plan for (Resident) Patsy Brady has been previously scheduled and will address concerns with family member this week. 14.) Observations of 5 mechanical lift transfers during the course of the investigation on 3/17/14; revealed al mechanical lift transfers were executed by two staff. 15.) Record review on 3/19/14 at 11:45 a.m., revealed in-services had been conducted on 3/17-18/14 regarding transfer safety with regards to mechanical lift transfers. 16.) Record review on 3/19/14 at 12:00 p.m., revealed the plans of care for the 12 sampled residents in the facility who were lifted by mechanical means were updated to accurately to reflect the residents' transfer needs in accordance with their MDS assessments. The facility provided the updated plans of care for sampled Residents #1-12, which correlated with the residents' transfer requirements documented on their comprehensive assessments. 17.) Review of the new, revised copy of the policy titled Lifting, Transfer, and Repositioning, provided on 3/18/14, documented under #5 that 1-person mechanical lifts continued to be facility policy: 5. A lift designation is placed in each resident section of the electronic medical record. The five designations are (independent, one person, one person with a lift, two persons, two persons with a lift). 18.) During an interview on 3/19/14 at 10:36 a.m., CNA "E" , when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition. CNA "E" stated having been retrained the mechanical lift could not be utilized as a second person on 3/18/14. 19.) During an interview on 3/19/14 at 10:50 a.m., CNA "F", when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition. CNA "F" stated having been retrained the mechanical lift could not be utilized as a second person on 3/18/14. 20.) During an interview on 3/19/14 at 11:00 a.m., CNA "G" acknowledged having been instructed during the 3/11/14, 1:30 p.m. in-service (attendance signed by CNA "G"), that a mechanical lift constituted a second person, therefore aides were to code 1-person mechanical lift transfers as 2-person transfers on the ADL Flow Logs. CNA "G" said "A lot of us were confused about this because we learned in school this is not a 2-person transfer." CNA "G" stated having been re-trained on 3/18/14 that the lift could not be considered as a second person during transfers, and could not be coded as such on the Care Tracker system/ADL Flow Log. On 3/19/14 at 1:20 p.m., the Administrator, DON, MDS Coordinator, Business Office Manager and Human Resources Coordinator were advised the IJ was removed. The facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility had not yet in-serviced all direct care staff regarding special considerations for residents with specific medical conditions when using mechanical lifts, and had yet to revise their policy regarding mechanical transfers requiring 2 staff to assist as per MDS guidelines pertaining to 2+ persons assist for transfers. 21.) The facility provided CMS Form 802 dated 3/17/14 identified on the left margin all residents' transfer requirements, and was approved by the DON as accurate on 3/17/14 at 12:50 p.m. for Residents #1-12, as having required mechanical lift transfers.

Based on observation, record review and interviews, the facility failed to ensure 5 of 12 residents (Residents #1, 4, 7, 12, and 17) sampled for accident hazards received adequate supervision and accuracy of care plans with regards to assessed transfer requirements: - CNA "A" while lifting Resident #1 by means of a mechanical lift, failed to ensure Resident #1 was safely transferred by two staff in accordance with the resident's assessed transfer requirements. This failure caused Resident #1 to slide out of the sling resulting in fractures to Resident #1's right arm. - The plans of care for Residents #1,4 and 7 inaccurately documented requirements for transfer assistance in accordance to the residents' comprehensive assessments. - The plans of care for Residents #12, and 17 failed to document need for transfer assistance. The comprehensive assessments for these residents documented the residents required extensive to total 2+ person assistance for transfers. On 03/17/14 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 03/19/14, the facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility had not yet in-serviced all direct care staff regarding special considerations for residents with specific medical conditions when using mechanical lifts. This failure placed 19 residents who required transfer assistance at risk for injury and decreased physical, mental and psychosocial well-being, and placed all residents at risk of incomplete/inaccurate plans of care not developed in accordance with the comprehensive assessment. The evidence was as follows: RESIDENT #1: 1.) Review of the record of admission (Face Sheet) documented Resident #1 was admitted to the facility on [DATE]. She was [AGE] years of age at the time of the incident. 2.) Review of the annual Minimum Data Set (MDS) resident assessment instrument dated 1/17/14 documented [DIAGNOSES REDACTED]. It documented a cognitive summary score of 2 out of a possible 15, and total dependence on two+ person physical assist for transfers. It documented upper and lower extremity impairment on one side, a height of 61 inches, and a weight of 233 pounds. 3.) Review of the Plan of Care dated January, 2014, documented Resident #1 required mechanical lifts using the Arjo (brand name) "Sara" (sit-to-stand) lift and sling, with extensive to total assistance due to right-sided paralysis. The plan of care failed to specify Resident #1 required a 2-person assisted lift. Note: The plan of care was updated following the incident to reflect the need for two staff when transferring Resident Brady. 4.) Review of Interdisciplinary Progress Notes by LVN "B" dated 3/3/14 at 08:53 a.m. documented: Resident (#1) was in Sara lift being transferred from shower chair to wheelchair and Resident let go with right arm and knees buckled. Resident was assisted to floor. Sustained an abrasion to right arm and abrasion to hand. Resident complained of pain to left arm when moved. The fall occurred at 07:30 a.m. NOTE: Review of the Incident/Accident report dated 3/3/14 and the Provider Investigation Report dated 3/4/14 clarified it was in fact Resident #1's left arm and hand that sustained abrasions, and she complained of pain to her right arm. Additionally, due to right-sided paralysis, it was the left hand that released the Sara lift grab handle. Further review of LVN "B's" 3/3/14 Interdisciplinary Progress Notes documented Resident #1 had been transported to a local clinic as a result of the incident, and returned to the facility on [DATE] at 18:16 p.m., with a right proximal humerus fracture. 5.) Review of x-ray reports from Muleshoe Area Medical Center dated 3/3/14 documented the following: HUMERUS 2 VIEW RIGHT- Fracture of the proximal humeral shaft. SHOULDER 2 VIEW RIGHT- Humeral head and neck fractures. CLAVICAL RIGHT- Fracture of the proximal humerus. ELBOW AP & LATERAL RIGHT- Foreshortening of the radial neck suspicious for fracture visible on the lateral image. 6.) Review of the FNP report dated 3/3/14, documented under ADDENDUM: On the shoulder, the fracture is more involved than previously thought. There is external internal rotation views and it showed an oblique fracture of the humeral metaphysis and transverse humeral neck fracture. 7.) Review of the manufacturer's Operating Instructions for the Sara 2000 mechanical lift, pg. 10, documented: 11. Residents who have suffered a "stroke", who can only hold on with one hand, or residents who cannot hold on at all, may still be lifted by the Sara 2000, but it will be necessary for the attendant, (or a second attendant), to hold the resident's arm/arms down in front of the body during the lift. Additionally, the instructions warned the sling could possibly ride up the back, making it necessary to hold the sling in position when lifting/lowering. 8.) Review of the Nurse Aide Meeting/In-Service dated 3/11/14 at 1:30 p.m., documented lift policies and precautions had been reviewed as a result of the incident. 9.) Observation on 3/18/14 at 10:35 a.m., revealed with the Administrator present, CNA "A" reenacted the incident using the Sara lift with the DON assisting as the resident/patient. The reenactment revealed CNA "A" failed to ensure Resident #1's paralyzed right arm was held down in front of the body, and failed to ensure her left arm was held down in front of the body once Resident #1 became weak and released hold of the grab handle. Both of the DON's (patient) arms were observed to be extended outside the sling. Additionally, it was observed CNA"A" failed to ensure the sling was held in position, as the DON (patient) slid out of the sling down to the floor, pulling her arms above her head and down through the inside of the sling, as she was eased to the floor by CNA"A". 10.) During an interview on 3/17/14 at 10:00 a.m., the DON said the incident was determined by the facility to not have been the result of an improper transfer by CNA "A". Rather, the incident occurred due to the fact Resident #1 had right-sided paralysis and had released her left hand from the grab handle due to weakness. 11.) During an interview on 3/17/14 at 10:40 a.m., the facility Administrator stated facility policy allowed for 1-person mechanical lift transfers. 12.) During an interview on 3/17/14 at 12:15 p.m., CNA "C" stated he had never utilized the assistance of a second aide when mechanically transferring Resident #1, as per her plan of care. CNA "C" said he felt comfortable executing 1-person mechanical lift transfers of Resident #1 without assistance from a second aide. 13.) During a telephone interview on 3/17/14 at 1:30 p.m., CNA "A" stated she executed 1-person mechanical lift transfers of Resident #1 multiple times. CNA "A" stated she occasionally utilized staff assistance to perform 2-person mechanical lift transfers; however she usually performed the transfers solo. CNA "A" then said "When you use the mechanical lift, the lift is the second person". During a subsequent interview on 3/18/14 at 1:40 p.m., CNA "A" said it would not have been physically possible for her to have held Resident #1's arms down in front of the body, and have held the sling in place, and have operated the Sara lift by herself without the assistance of a second person. CNA "A" said "It would have taken 2 people to do all that". During a third and final interview on 3/19/14 at 11:25 a.m. CNA "A", when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition, and that would have required the assistance of a second person. 14.) During an interview on 3/17/14 at 2:00 p.m., CNA "D" said all mechanical lifts required 2 people, adding the lift itself was the second person. 15.) During an interview on 3/17/14 at 2:00 p.m. following observation of a mechanical Hoyer (full body) lift transfer with full body sling, Resident #8, when asked whether 1 or 2 staff generally transferred her, replied "It's generally just one". 16.) During an interview on 3/17/14 at 3:10 p.m., the PTA said he had no knowledge regarding the facility policies and procedures for mechanical lift transfers. The PTA said he advised staff to seek assistance of a second staff person if they did not feel comfortable executing mechanical lift transfers by themselves. 17.) During an interview on 3/18/14 at 11:00 a.m., the MDS Coordinator acknowledged she had misinformed staff that a mechanical lift could replace an actual staff person when executing mechanical lift transfers. The MDS Coordinator continued, "that's the way it was before the 3.0 (MDS) came out". 18.) During a telephone interview on 3/18/14 at 1:30 p.m., the FNP revealed Resident #1's injuries occurred as the result of the way her arms came down through the sling when the incident occurred, as the x-ray revealed an angular fracture indicative of a twisting motion. Additionally, the FNP said "I was puzzled as to why they (the facility) transferred her (Resident #1) that way? I think she would have required a 2-person Hoyer (mechanical lift) transfer because she's not really able to stand up due to right-sided hemi paralysis". 19.) During an interview on 3/19/14 at 10:36 a.m., CNA "E" , when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition. 20.) During an interview on 3/19/14 at 10:50 a.m., CNA "F", when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition. 21.) During an interview on 3/19/14 at 11:00 a.m., CNA "G" acknowledged having been instructed during the 3/11/14, 1:30 p.m. in-service (attendance signed by CNA "G"), that a mechanical lift constituted a second person, therefore aides were to code 1-person mechanical lift transfers as 2-person transfers on the ADL Flow Logs. CNA "G" said "A lot of us were confused about this because we learned in school this is not a 2-person transfer." RESIDENT #4: 22.) Observation of Resident #4 on 3/19/14 at 12:50 p.m. revealed a totally dependent resident who required a Geri-chair propelled by staff for mobility. 23.) The record of admission (Face Sheet), documented an admitted 7/6/09. It documented Resident #4 was [AGE] years of age. [DIAGNOSES REDACTED]. 24.) The MDS resident assessment instrument dated 1/25/14 documented Resident #4 was totally dependent on 2+ person physical assist for transfers. 25.) The plan of care dated January, 2014 documented "assist for transfers" (pg. #5 of 8). The plan of care failed to specify the level of assistance required for transfers. RESIDENT #7: 26.) The record of admission documented an admission date of [DATE]. It documented Resident #7 was [AGE] years of age. [DIAGNOSES REDACTED]. 27.) The MDS resident assessment instrument dated 3/3/14 documented extensive two+ persons physical assist for transfers. 28.) The plan of care dated March, 2014 documented "Transfer resident with assistance of staff x 1". RESIDENT #12: 29.) The record of admission documented Resident #12 was admitted to the facility on [DATE]. It documented the resident was [AGE] years of age. [DIAGNOSES REDACTED]. 30.) The MDS resident assessment instrument dated 1/31/14 documented extensive two+ persons physical assist for transfers. 31.) The plan of care dated January, 2014 (5 pages), failed to document Resident #12's requirements for transfer assistance. Resident #17: 32.) The record of admission documented an admission date of [DATE]. It documented Resident #17 was [AGE] years of age. [DIAGNOSES REDACTED]. 33.) The MDS resident assessment instrument dated 12/24/13 documented Resident #17 required extensive two+ persons physical assist for transfers. 34.) The plan of care dated December, 2013 (7 pages) failed to document Resident #17's requirements for transfer assistance. 35) During an interview on 3/19/14 at 10:36 a.m., CNA "E" reported only having access to residents' plans of care via the facility computerized "Care Tracker" system for documenting ADL assistance. CNA "E" denied having any access to the comprehensive assessment in order to determine residents' transfer requirements. 36.) During an interview on 3/19/14 at 10:50 a.m., CNA "F reported only having access to residents' plans of care via the facility computerized "Care Tracker" system for documenting ADL assistance. CNA "F" denied having any access to the comprehensive assessment in order to determine residents' transfer requirements. 37.) During an interview on 3/19/14 at 11:00 a.m., CNA "G" reported only having access to residents' plans of care via the facility computerized "Care Tracker" system for documenting ADL assistance. CNA "G" denied having any access to the comprehensive assessment in order to determine residents' transfer requirements. 38.) 22.) POLICY (undated): Lifting, Transfer, and Repositioning Policy Purpose: To foster safety both for residents and the staff and maintain the residents' functional capabilities to their highest practical level. Procedures: 2. All resident(s) that require total assistance with transfers must be lifted by a mechanical lift and repositioned with two nursing staff. On 3/17/14 at 3:50 p.m., the facility Administrator and DON were notified an Immediate Jeopardy situation had been identified. On 3/18/14 at 2:10 p.m., the facility submitted the following plan of removal: A.) - To correct the lack of training of staff on the policies and mechanics of the Maxi Lift and the Sara Lift, in-services have been conducted with nursing staff effective March 11, 17, and 18, 2014. - All subsequent transfers since the incident have involved two staff. - The training on March 17th and 18th was provided by Debbie Parmer, Director of HR (Human Resources), and included demonstration training by each staff person and reviewing the Lift, Transfer and Repositioning Guidelines for each nursing staff person and the Lift Assessment Tool for those responsible for such task. List of nursing staff involved in this training can be supplied. We will not even consider the lift as a second person in transfer care planning. Ongoing responsibility for this training will reside with the Director of HR. - To correct any discrepancies or uncertainties in every care plan that involves use of a mechanical lift, all such care plans have been reviewed and corrected by nursing supervisors and agreement between completed MDS and resulting Care Plans have been harmonized. Subsequently, all Care Tracker buttons have been lit up that instruct the nursing assistants in the correct method to transfer elders. This is completed as of 3/18/2014 and is available for review. Ongoing responsibility for this system correction will reside with the ADON. - We do not dispute that a deficiency is warranted due to the lack of harmony between the MDS and Care Plan. We have invested immensely in correcting this ASAP (as soon as possible), and believe it will not occur again based on the above plan. B.) Specific actions taken: - In-service was conducted on March 11, 2013 with the CNA staff by the DON. - Policy was rewritten to update the facility changes as evident of Policy lift and transfer. - New assessment forms were created to reflect our policy changes. - Nursing staff was in-serviced on 3/17-3/18 with hands on demonstration of both lifts and reviewing current policy regarding Transfer/Lifts. - 100% of residents were assessed regarding transfers. - Resident profiles were updated to reflect any changes. - Care plans were updated to reflect any changes. - Care plan for (Resident) Patsy Brady has been previously scheduled and will address concerns with family member this week. 39.) Observations of 5 mechanical lift transfers during the course of the investigation on 3/17/14, revealed al mechanical lift transfers were executed by two staff. 40.) Record review on 3/19/14 at 11:45 a.m., revealed in-services had been conducted on 3/17-18/14 regarding transfer safety with regards to mechanical lift transfers. 41.) Record review on 3/19/14 at 12:00 p.m., revealed the plans of care for the 12 sampled residents in the facility who were lifted by mechanical means were updated to accurately to reflect the residents' transfer needs in accordance with their MDS assessments. The facility provided the updated plans of care for sampled Residents #1-12, which correlated with the residents' transfer requirements documented on their comprehensive assessments. 42.) Review of the new, revised copy of the policy titled Lifting, Transfer, and Repositioning, provided on 3/18/14, documented under #5 that 1-person mechanical lifts continued to be facility policy: 5. A lift designation is placed in each resident section of the electronic medical record. The five designations are (independent, one person, one person with a lift, two persons, two persons with a lift). 43.) During an interview on 3/19/14 at 10:36 a.m., CNA "E" , when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition. CNA "E" stated having been retrained the mechanical lift could not be utilized as a second person on 3/18/14. 44.) During an interview on 3/19/14 at 10:50 a.m., CNA "F", when shown the operational handbook for the Sara 2000 mechanical lift, page 10, said she had not been trained by the facility regarding special issues warned about in the handbook that were specific to Resident #1's medical condition. CNA "F" stated having been retrained the mechanical lift could not be utilized as a second person on 3/18/14. 45.) During an interview on 3/19/14 at 11:00 a.m., CNA "G" acknowledged having been instructed during the 3/11/14, 1:30 p.m. in-service (attendance signed by CNA "G"), that a mechanical lift constituted a second person, therefore aides were to code 1-person mechanical lift transfers as 2-person transfers on the ADL Flow Logs. CNA "G" said "A lot of us were confused about this because we learned in school this is not a 2-person transfer." CNA "G" stated having been re-trained on 3/18/14 that the lift could not be considered as a second person during transfers, and could not be coded as such on the Care Tracker system/ADL Flow Log. On 3/19/14 at 1:20 p.m., the Administrator, DON, MDS Coordinator, Business Office Manager and Human Resources Coordinator were advised the IJ was removed. The facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility had not yet in-serviced all direct care staff regarding special considerations for residents with specific medical conditions when using mechanical lifts, and had yet to revise their policy regarding mechanical transfers requiring 2 staff to assist as per MDS guidelines pertaining to 2+ persons assist for transfers. 46.) The facility provided CMS Form 802 dated 3/17/14 identified on the left margin all residents' transfer requirements, and was approved by the DON as accurate on 3/17/14 at 12:50 p.m. for Residents #1-12, as having required mechanical lift transfers.