Every finding on record at Foothills Rehabilitation Center

Based on clinical record reviews, interviews, facility documentation and policy review, the facility failed to ensure the rights of four residents (#19, #144, #146 and #167) to be free from abuse and neglect by other residents and staff. The universe was 25. The deficient practice resulted in actual harm and placed other residents at risk for further abuse, ongoing harm, and serious adverse outcomes. Findings include:Regarding Resident #167 -Resident #167 was admitted to the facility on [DATE] with diagnoses that included persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage without loss of consciousness, and Crohn's disease. Review of the admission Minimum Data Set (MDS), dated [DATE], did not assess Resident #167's cognitive status. The same MDS also noted that Resident #167's functional status for bathing was total dependence and required 1-person physical assist. The care plan indicated dated December 6, 2022 revealed the resident required total assist for all Activities of Daily Living (ADLs) which included bathing; was at risk for falling related to weakness; and, transfers using a Hoyer lift. The goal was that the resident will remain free from injury. Interventions included frequent checks by staff while in bed; to observe frequently and place in supervised area when out of bed; and, when utilizing Hoyer lift, resident will transfer safely with 2 staff. The Quarterly MDS assessment dated [DATE], indicated that a staff assessment for mental status was completed. It was noted that Resident #167's cognitive skills for daily decision making was severely impaired. The MDS also revealed that Resident #167's functional status for bathing was total dependence and required 2-person physical assist. The assessment also included that the resident had 1 fall with injury since admission or prior assessment. The care plan dated July 20, 2023 included that the resident had behavioral symptom of placing self on the floor. Intervention included to assess whether the behavior endangers the resident and/or others; maintain a calm environment and approach to the resident; redirect as necessary and notify provider if behaviors interfere with orsignificantly impact residents care; and, provide consistent staff as much as possible.A Monthly Summary form, dated August 29, 2023, indicated the resident was totally dependent for bathing and required one-person physical assist. The quarterly MDS assessment dated [DATE], indicated that staff assessed Resident #167's cognitive skills for daily decision making as severely impaired. It was also noted that his functional status for bathing was total dependence and required 2-persons physical assist. The assessment also included that the resident had 2 falls with no injury and 2 falls with injury since admission or prior assessment. The Monthly Summary form, dated October 5, 2023, indicated Resident #167 was total dependence for bathing and required two+ persons physical assist. The nursing progress note dated November 19, 2023 revealed resident was alert and oriented x2 and required maximum assistance with ADLs The Monthly Summary form dated November 23, 2023, indicated Resident #167 was total dependence for bathing and required two+ persons physical assist. The nursing note dated November 23, 2023 included that the resident was alert, non-verbal, responded to simple commands and at times can track staff with eyes, was totally dependent for all ADLs was often very restless in bed and can be found sideways in bed. According to the documentation, resident had bilateral floor mats for safety. The progress note dated November 29, 2023, at 11:26 A.M. created by Registered Nurse (RN/Staff #138) noted that Resident #167 was restless and had pushed the rail on the gurney while a Certified Nurse Assistant (CNA) had turned to throw away a razor. It also noted that the resident had fallen from the gurney and sustained an abrasion to the left side of his head and a hematoma on the right side of his head. It further noted that bleeding was noted in his mouth but staff was unable to determine the cause of the bleeding. The documentation also included that Resident #167 was sent to the emergency room per the physician's order for evaluation. The physician note dated November 29, 2023 included that the resident had a fall and head injury; and, to transfer the resident to acute care hospital. The undated [NAME] Fall Form included that the resident fell from the gurney on November 29, 2023; and that, the resident was sent to the hospital for evaluation and treatment. The progress note dated November 30, 2023 at 1:10 P.M revealed the Interdisciplinary Team (IDT) reviewed the incident and indicated that it was crucial to note that the resident was at a high risk for falls due to his history of falling, subdural hemorrhage, schizoaffective disorder, encephalopathy, persistent vegetative state (PVS), Crohn's disease, slowness and poor responsiveness, as well as muscle wasting. Interventions in place included, but were not limited to, sending the resident to the emergency room for a CT scan. The documentation also included that it was imperative to re-evaluate the resident upon his return from the hospital. The social service note dated December 1, 2023 included that social service spoke with a case manager and discussed the resident's fall and that the resident went to the hospital and had surgery for brain bleed. The fall care plan was revised on December 8, 2023 to include that the resident had an actual fall in the shower on November 29, 2023. The ADLs care plan was revised on December 20, 2023 by the Director of Nursing (DON/Staff #7) to include requiring 2-person assist with showers. It was noted that the start date for the updated intervention was December 11, 2023. There was no evidence that the care plan was revised to include 2-person assist for bathing was identified prior to December 20, 2023. Review of the facility's 5-day investigation report, for the alleged incident, revealed there was one CNA present with Resident #167 when he fell during a shower on November 29, 2023. It also noted that the CNA was following the resident's care plan. An interview with a registered nurse (RN/staff #150) was conducted on March 27, 2026 at 10:01 a.m. The RN stated that CNAs were supposed to check on the resident, turn/reposition and change the resident at least every 2 hours. She said that residents were transferred by using a Hoyer which required 2 persons; and that, staff cannot use Hoyer if there was only one staff transferring the resident. A telephonic interview was conducted with CNA (staff #1) on March 28, 2026 at 7:37 A.M. The CNA stated that she know if the resident was a 2-person assist if there was a green sticker next to their name on the name card outside of their room. Staff #1 said she remembered Resident #167 and she was with Resident #167 in the shower room and showers was just completed when Resident #167 jerked and crossed his legs which then went over the railing on the gurney that resulted in resident falling. The CNA stated that she then opened the shower room door and yelled for help from the nurses; and that, Resident #167 went to the hospital after the fall. The CNA further stated that she was by herself with Resident #167 in the shower room because at the time of the fall, Resident #167 was a 1-person assist. She said that after the fall, the resident then became a 2-person assist. In an interview with a CNA (staff #131) conducted on March 28, 2026 at 7:58 a.m., the CNA said that all residents lifted for any transfers or when providing baths using the Hoyer required 2-person to operate. An interview was conducted on March 28, 2026 at 8:23 A.M. with the MDS/Care Plan Coordinator/Licensed Practical Nurse (Staff #59). Staff #59 explained that the MDS is created upon admission and is updated if there is a change in condition or if a quarterly review is due. She further explained that once the MDS assessment is completed, the comprehensive care plan is triggered with information obtained from the MDS assessments. She added that she and another MDS staff person also create and update the care plans after completion of the MDS. Staff #59 reviewed Resident #167's June 2, 2023 MDS assessment and shared that he was total dependence for bathing and required 2-person assist. Staff #59 reviewed Resident #167's September 2, 2023 MDS assessment and shared that he was total dependence for bathing and required 2-person assist as well. Staff #59 also reviewed Resident #167's comprehensive care plan and shared that it was noted he was a total assist for all ADLs however, it did not specifically say that he was a 2-person assist for bathing. She further shared that she did not know why the care plan did not reflect that the resident was a 2-person assist for bathing. An interview was conducted on March 28, 2026 at 8:41 A.M. with the Director of Nursing (DON/Staff #7). Staff #7 shared that abuse and neglect training is provided to staff on an annual basis and as needed to provide re-education. When asked whether providing a 1-person assist to a resident assessed as requiring a 2-person assist for bathing, resulting in a fall, would constitute neglect, she shared that it would be if the care plan indicated the resident was a 2-person assist and only 1-person assist was done. When asked if not updating the care plan to reflect the MDS assessment as neglect, Staff #7 shared that it would be because the MDS did not link to the care plan so it was not adequately implemented. She further shared that this could lead to residents sustaining an injury because something happened to them due to not getting the proper care. Staff reviewed the September 2, 2023 MDS for Resident #167 and shared that he was total dependence and required 2-person assist for bathing. When reviewing the care plan for Resident #167, she shared that it identified that Resident #167 was a 2-person assist with showers starting December 11, 2023. She further shared that there was no information, regarding bathing with 2-person assist, in the care plan prior to December 11, 2023. Staff #7 explained that the care plan should have reflected that the resident was a 2-person assist prior to that date and confirmed that the care plan did not match the information in Resident #167's MDS. An interview with CNA (Staff #156) was conducted on March 28, 2026 at 11:04 A.M. Staff #156 revealed that neglect occurs when staff fail to meet residents' needs. Staff #156 shared she receives abuse and neglect training during monthly in-services and annual in-depth sessions. When asked whether providing a 1-person assist to a resident assessed as requiring a 2-person assist for bathing, resulting in a fall, would constitute neglect, she confirmed that it would, as the resident did not receive the required level of assistance An interview was conducted on March 28, 2026 at 11:13 A.M. with Licensed Practical Nurse (LPN/Staff #120) who stated that neglect occurs when pain medications were given without a proper pain assessment or when cares were not being provided to the resident. She said providing a 1-person assist to a resident assessed to require a 2-person assist for bathing and resulting in a fall, would constitute neglect. She said that the resident is a 2-person assist because the resident moves a lot; and, if a resident was a 2-person assist, then there must be 2 people helping the resident. The LPN further stated that neglecting the residents could result in injury, skin damage, residents could be emotionally affected and they could lose their trust in staff to keep them safe. Regarding Resident #146 and Resident #145 -Resident #146 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (brain dysfunction due to chemical imbalances), Schizoaffective disorder, and Bi-polar disorder. Review of the quarterly MDS, dated [DATE], indicated that Resident #146 had a BIMS score of 11 indicating moderate cognitive impairment. The same MDS also noted Resident #146 exhibited behavioral symptoms not directed towards others. Review of the Progress Notes, in the clinical record, revealed there were no entries related to an alleged incident of abuse.-Resident #145 was admitted to the facility on [DATE] with diagnoses that included hemiplegia, unspecified affecting unspecified side (paralysis or weakness affecting one side of the body); anoxic brain damage; Schizoaffective disorder; Bio-polar disorder; and generalized anxiety disorder. Review of the quarterly MDS, dated [DATE] revealed that Resident #145 had a BIMS score of 06 indicating severe cognitive impairment. The same MDS also noted that Resident #145 had other behavioral symptoms not directed towards others. Review of the Care Plan, implemented on January 20, 2022 and revised on March 26, 2023, revealed Resident #145 was taking psychotropic medications related to her Bipolar disorder diagnosis. Interventions included assessing if the resident's behavioral symptoms presented a danger to herself and others and to intervene as needed. It was also noted that her behavior and response to medication was to be monitored as well. A review of the progress notes, revealed she was exhibiting behaviors such as using profanity towards staff, refusing cares, attempting to physically injure staff when personal cares are being provided and crying throughout the day. A Progress Note, dated February 21, 2023 noted that Resident #145 had started Risperdal (anti-psychotic). Additional review of the Progress Notes found no documentation regarding an alleged incident of abuse. Further review of the clinical record did not find evidence that a skin assessment was conducted on February 7, 2023 however, an assessment was completed on February 9, 2023 and it was noted that there were no skin issues. Review of a complaint, submitted via the SA's complaint portal, alleged that Residents #146 and #145 were witnessed having a verbal altercation and then one Resident struck the other Resident. Review of the 5-day investigation report, conducted by the facility, revealed that Resident #145 had struck Resident #146 on the arm after a verbal altercation. It also noted that the altercation was witnessed by LPN/Staff #76. The investigative report revealed that interviews were conducted with both residents, post-incident. The report noted that Resident #146 was attempting to get away from Resident #145 so she wouldn't get into trouble. Resident #146 was noted saying that Resident #145 had hit her in the arm before Staff were able to redirect Resident #145. The same investigative report also indicated that Resident #145 was interviewed and was clear on what had taken place. However, she did indicate that she will hit Resident #146 if she finds her (Resident #146) in her space. An interview was conducted on March 26, 2026 at 7:48 A.M. with Staff #17. Staff #17 shared that abuse is when someone harms a resident physically, emotionally and financially. She also shared that she receives training on abuse once a year. Staff #17 recalled working with both Residents #145 and #146. She described Resident #145 as someone who was paralyzed on one side and would sometimes become upset and explode out of the blue. Staff #17 further shared that Resident #145 would try to hit other residents when she was upset. She also explained that because Resident #145 was sometimes hard to understand, when she spoke, she would often get frustrated because staff couldn't understand her and she wouldn't get things the way she wanted them. Regarding, Resident #146, Staff #17 explained that she used to hit herself and would threaten to hit other residents but never did. Staff #17 recalled Residents #145 and #146 having verbal altercations but did not recall them being physical with each other. Staff #17 was read her statement that she provided to the facility during their investigation. The statement indicated that she was working the floor on February 7, 2023 around 2:20 P.M. and was assisting another resident when she had heard Resident #146 screaming for help. It also noted that she did not witness the incident take place. Staff #17 indicated that she still stood by that statement she had provided at the time of the facility's investigation. An interview was conducted on March 26, 2026 at 8:00 A.M. with CNA/Staff #22. Staff #22 recalled both Resident #145 and #146. She described Resident as someone who would get upset when she didn't get what she wanted. She would also get impatient. Staff #22 shared that management had provided training to staff on how to redirect Resident #145 and anticipate when she might hit other residents so they could redirect her. She also shared that Resident #145 had never hit another resident. Staff #22 recalled Resident #146 as someone who was angry with other residents and had tried to hit them however, she couldn't recall if Resident #146 had actually hit anyone. Staff #22 was read her statement that she provided to the facility during their investigation. The statement indicated that Staff #22 was working on February 7, 2023 and was providing cares to a resident around 2:15 P.M. It also noted that she did not witness the incident in the day room. Staff #22 added that she recalled both residents were arguing and she had helped separate them but did not see either residents hit each other. An interview was conducted on March 26, 2026 at 8:23 A.M. with LPN/Staff #76. Staff #76 recalled being in the day room of the unit when Resident #145 and #146 were too close to each other and had started yelling at each other. She indicated that she had separated both residents but didn't think they physically touched each other. Staff #76 shared that Resident #146 tended to be very behavioral was okay as long as no one triggered her. She further shared that Resident #146 was always supervised and she had her own room due to not doing well with roommates. Staff #76 was read her statement that she provided to the facility during their investigation. The statement indicated that she had witnessed Resident #145 yelling, cursing, and moving towards Resident #146 in her wheelchair. It further indicated that Resident #145 had hit Resident #146 once before Staff #76 had separated them. Staff #76 shared that she stood by the statement that she had provided to the facility. She also shared that Resident #146 had no injuries and added that she did not document that she had done a skin check on the resident regarding there not being any injuries. She added that she should have documented everything that she did in the clinical chart. Staff #76 shared that if residents are abused, they are at risk of being injured and could be impacted emotionally and mentally. An interview was conducted on March 28, 2026 at 2:01 P.M. with DON/Staff #7. Staff #7 recalled Resident #145 being in the behavioral unit and that she would hit people. She also recalled Resident #146 and described her as being in the behavioral unit as well. She further shared that Resident #146 would swear, yell, and would seek attention by putting herself on the floor. Staff #7 couldn't recall if both residents had an altercation with each other so she read her copy of the facility's investigation. She shared that both residents had gotten into an altercation and there were no injuries sustained. Staff #7 shared that they try to keep residents, who might have issues with other residents, separate. She further shared that they also involve psychiatrists and have them evaluate residents as well. Regarding Resident #19 -Resident #19 was admitted to the facility on [DATE] with diagnoses that included Dysphagia following cerebral infarction, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Aphasia following cerebral infarction, Type 2 diabetes mellitus with diabetic neuropathy, Cerebrovascular disease. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #19 scored a 9 for the Brief Interview for Mental Status (BIMS) which indicated she had moderate impairment. Care plan dated May 22, 2023 included resident required dependent assist for all ADL's to include bathing, grooming, hygiene, toileting, bed mobility, and dressing. Also, the resident required extensive assistance with meals, and was a two person assist with Hoyer lift. A progress note dated July 24, 2023 at 5:30 p.m. stated a CNA reported to Staff # 321 that Resident #19 needed a splint for her right hand and wrist. The resident was crying in pain when the CNA attempted to move the wrist. The resident also had blood on her lower right lip. An order dated July 24, 2023 10:03 p.m. was for Resident #19 to be transferred to an acute hospital emergency room (ER) for a CT scan of the head and X-rays of the right wrist and right leg. Hospital (ER) report dated July 24, 2023 stated, the resident was nonverbal [AGE] year-old presented to the ER with right wrist pain. There is some swelling and tenderness without any evidence of erythema or warmth and there are no open wounds have a low suspicion for septic joint. Per EMS report, the injury was from staff moving her. She has also been pointing to her leg and complaining of pain there as well. The facility initial report to the State Agency dated July 24, 2023 7:25 p.m. said a resident was hurt by a tall man and had pain the right hand. Further information received stated the resident was sent out to the emergency room for X-rays. The facility 5-day report revealed that Resident #19 complained of right-hand pain, and also said that a tall guy hurt her. The resident was transported to the hospital because of right arm swelling. The report also revealed a CNA was suspended pending an investigation, and that he was the only CNA working with the resident that matched the description. The reported had an interview with the CNA and he said a nurse asked him to lay the resident down. The CNA changed the bedding and he used a gait belt to transfer the resident back to her bed. The 5-day report was concluded with the facility investigation being inconclusive because, the X-ray and CT were done and it was not a clear diagnosis if the resident has a fracture or not. The resident has a new diagnosis of decrease mineralization to the bone. She also has a new diagnosis of osteoarthritis to hand. Review of the personnel file of the alleged CNA (staff #325) revealed that a report dated July 25, 2023 and an attached corrective action form that indicated that Staff #325 was terminated for failure to follow safety rules and unsatisfactory job performance. An interview with a registered nurse (RN, Staff #138) was conducted on March 26, 2026, at 2:43 p.m. The RN stated that any allegation of abuse is reported to the Administrator or the Director of Nursing (DON#7), who then has two hours to report the incident to the State Agency (SA). She further stated that upon receiving an allegation of abuse, she ensures the involved residents are safe, gathers details by speaking with both residents, documents the information, and reports the incident to the DON. On March 27, 2026 at 10:15 a.m. and interview was conducted with the legal guardian of Resident #19. The legal guardian said that Resident #19 would shook her head 'no' when asked if there were any concerns with facility staff; would shook her head 'yes' when asked if she felt safe; and would communicate with staff by mumbling and the use of a word board The legal guardian said there was an issue about a year after Resident #19 was admitted to the facility; and that, during a transfer Resident #19 sustained a fracture her right wrist. The guardian stated that he did not know the specifics of what happened but was told by the facility that it was not the facility's fault. An interview was conducted on March 27, 2026 1:35 p.m. with DON, she said the 5-day report was sent to the SA on July 31, 2023. DON said the initial facility investigation was the CNA reported that he changed the sheets on the bed and used a gait belt to transfer the resident back into bad. The residents brief was changed and he left the room. The facility investigation revealed the resident began crying during a care procedure. a staff member was called to the resident's room for a complaint of pain. The DON said the resident was sent to the ER for x-ray and evaluation. She said the final facility investigation was determined to be inconclusive due to: X-ray and CT were done and it was not a clear diagnosis if the resident has a fracture or not. She said the resident was diagnosed at the hospital with a diagnosis of decrease mineralization to the bone and a new diagnosis of osteoarthritis to hand. The DON said Resident #19 did not go to an optional MRI. Resident #19 was given a splint and started physical therapy when she returned to the facility. An interview was conducted on March 27, 2026 at 3:45 p.m. with Staff #170. Staff #170 stated she remembered the incident and was working. She was called to the room by a Respiratory Therapist (RT) to help assess a resident. She said Resident #19 had dried blood on her mouth and was holding her right hand. The resident had very limited speech but through the use of a speech board Staff #170 was trying to find out what happened and who caused the injury. Resident #19 identified the staff as a male. Resident #19 said that day there was only one male CNA and all other staff was female. She said the Resident #19 was bed bound and would be a two-person Hoyer lift assist. On March 27, 2026 at 4:20 p.m. an interview with Administrator was conducted. She said the incident happened before her employment began. The Administrator said all reports of abuse are investigated fully, but she did not know the specifics of this incident. She said she was pretty sure that Staff #325 wa terminated because of the incident. An interview was conducted on March 28, 2026 at 7:52 a.m. with Staff #110. She said, every room in the 600 hall every resident was a two person assist which is designated by an orange dot outside the room. Linen changes are conducted using two people, one on each side of the bed, if keeping the resident in bed. The process is to gown up, carefully roll the resident from one side to the other side removing the dirty linen. The process is reversed putting the clean linen on. During this careful attention is paid to making sure the trach line is not tangled. Once done the can call an RT if needed. She said nurses can be a second person. If there a visible sign or complaint of injury it to be investigated as an abuse and the floor nurse, DON and Administrator must be notified. An interview was conducted on March 28, 2026, at 10:08 a.m. with a licensed practical nurse (LPN/staff #51) who stated that any allegation of abuse, such as reports of a resident being hit by staff or another resident, was immediately reported to the Administrator, and an investigation was initiated. Regarding Incident between Resident #144 (alleged victim) and Resident #85 (alleged perpetrator) -Resident #144 was admitted on [DATE] with diagnoses of acute and chronic respiratory failure, schizoaffective disorder bipolar type and PTSD (post-traumatic stress disorder. The care plan revised on December 6, 2022 included that the resident required placement on secured unit secondary to psych diagnosis, poor safety awareness, and/or history of substance abuse, which resulted in resident exhibiting behaviors that could potentially place resident or others at risk; had impaired decision making related to long history of mental illness; had difficulty understanding others related to anxiety, schizoaffective bipolar disorder and PTSD; and, had exhibited verbally abusive behavioral symptoms (others were threatened, screamed at, cursed at). Interventions included setting expectations and limits, calming resident if signs of distress develop during the decision-making process (feeling overwhelmed, fatigue, agitation, restlessness, withdrawal), facing the resident when speaking, using a calm tone of voice, speaking clearly and adjusting tone as needed, avoiding over-stimulation (e.g., noise, crowding, other physically aggressive residents), encouraging resident not to block the entry of the dayroom, redirecting resident when he has episodes of aggressive behavior, taking resident to his room and provide 1:1 redirection, assessing whether the behavior endangers the resident and/or others, and intervening if necessary. The nursing note dated January 20, 2023 included the resident had exhibited exit-seeking behavior; and that, the resident attempted to exit from the unit multiple times, was redirected with some improvement noted. The nursing monthly summary note dated January 26, 2023, indicates that the resident was alert to self but intermittently confused, frequently refused care, exhibited exit-seeking behavior by attempting to leave the unit, and persistently requested fluids. A nursing note dated February 6, 2023 included that at 5:30 a.m., Resident #144 self-propelled his wheelchair in the hallway and approached another resident (#85) who was in a wheelchair and was looking out the window by the double doors from behind. The documentation included that the other resident (#85) then turned his upper body around and struck the left side of the upper chest of Resident #144 who then struck the other resident (#85) back with a closed fist. According to the documentation, a certified nurse assistant (CNA/staff #171) was present, saw the incident and immediately separated Resident #144 and the other resident (#85). The documentation included that Resident #144 had slight redness noted to his left upper chest. -Resident #85 was admitted on [DATE] with diagnoses of Schizoaffective disorder, personality disorder, anxiety and major depressive disorder. The care plan dated May 28, 2021 included resident exhibited behaviors such as yelling out profanities, argued with self, hit hand into other hand in a threatening manner even when he was alone in the room. Interventions included increasing sessions with counselor and distracting the resident with things he likes. The care plan dated June 28, 2022 included that resident was on 2:1 for cares related to false accusations and safety. Interventions included 2:1 for all cares, redirection as needed and offering phone and outdoor time. The care plan revised on October 10, 2022 included resident exhibited verbally inappropriate behavioral symptoms towards peers. Interventions included to allow distance in seating other residents around resident #85, to avoid over-stimulation/reducing external stimuli (e.g., noise, crowding, other physically aggressive residents), to provide 1:1 sessions with resident with every disruptive blow up, to remove resident from group activities when behavior is unacceptable, to redirect /divert resident's behavior by engaging with topics that interest him, to redirect from others when behaviors increase, and, when resident becomes verbally abusive or disruptive, move resident to a quiet, calm environment. The behavior notes dated February 2 and 3, 2023 included that the resident was spitting on towels and trash cans, making negative statements toward staff, exhibiting exit-seeking behavior, and repeatedly yelling, cursing, and throwing items throughout the shift. According to the documentation, staff attempted redirection and education, which were only briefly effective. Additional interventions—including distraction, offering food and fluids, and modifying the environment—were implemented; however, these measures did not result in change in the resident's behavior. The nursing note dated February 3, 2023 revealed Resident #85 continued to propel his wheelchair around the unit talking to people who were not there, had loud

Based on clinical record review, observations, interviews, and review of the facility's policy and procedures the facility failed to ensure their policy was implemented and followed related to abuse/neglect and abuse investigation for Residents #19, #56, #139, #144, #149, #167 and #174. The universe was 25. The deficient practice could result in failure to recognize, respond and take appropriate action to prevent residents from continued abuse and neglect and risk for ongoing harm, exploitation and serious adverse outcomes.Findings include:Regarding Resident #167 -Resident #167 was admitted to the facility on [DATE] with diagnoses that included persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage without loss of consciousness, and Crohn's disease. Review of the admission MDS, dated [DATE], did not assess Resident #167's cognitive status. The same MDS also noted that Resident #167's functional status for bathing was total dependence and required 1-person physical assist. Review of the Quarterly MDS, dated [DATE], indicated that a staff assessment for mental status was completed. It was noted that Resident #167's cognitive skills for daily decision making was severely impaired. The MDS also revealed that Resident #167's functional status for bathing was total dependence and required 2-persons physical assist. Review of a Monthly Summary form, dated August 29, 2023, indicated Resident #167 was total dependence for bathing and required 1-person physical assist. An additional review of a Quarterly MDS, dated [DATE], indicated that staff assessed Resident #167's cognitive skills for daily decision making as severely impaired. It was also noted that his functional status for bathing was total dependence and required 2-persons physical assist. Review of a Monthly Summary form, dated October 5, 2023, indicated Resident #167 was total dependence for bathing and required 2-persons physical assist. Review of a Monthly Summary form, dated November 23, 2023, indicated Resident #167 was total dependence for bathing and required 2-persons physical assist. Review of Resident #167's Progress Notes revealed an entry, dated November 29, 2023, at 11:26 A.M. created by Registered Nurse (RN/Staff #138). It was noted that Resident #167 was restless and had pushed the rail on the gurney when a Certified Nurse Assistant (CNA) had turned to throw away a razor. It also noted that the resident had fallen from the gurney and sustained an abrasion to the left side of his head and a hematoma on the right side of his head. It further noted that bleeding was noted to be in his mouth but staff was unable to determine the cause of the bleeding. The Progress Note also indicated that Resident #167 was sent to the emergency room per the physician's order for evaluation. Additional review of the Progress Note revealed an entry, dated November 30, 2023 at 1:10 P.M. The entry noted that the Interdisciplinary Team (IDT) reviewed the incident and indicated that the resident was a high risk for falls due to his medical conditions. Review of Resident #167's Care Plan indicated that Resident #167 required total assist for all Activities of Daily Living (ADLs) which included bathing. The care plan further indicated that this was initiated on December 6, 2022. The Care Plan also revealed that interventions were revised on December 20, 2023 by the Director of Nursing (DON/Staff #7) to include requiring 2-person assist with showers. It was noted that the start date for the updated intervention was December 11, 2023. There was no evidence, in the Care Plan, that 2-person assist for bathing was identified prior to December 20, 2023. Review of the facility's 5-day investigation report, for the alleged incident, revealed there was one CNA present with Resident #167 when he fell during a shower on November 29, 2023. Review of the facility's incident reports for Resident #167 revealed an undated Lancaster fall form that indicated he fell from the gurney and was sent to the hospital for evaluation and treatment. A telephonic interview was conducted with CNA/Staff #1 on March 28, 2026 at 7:37 A.M. Staff #1 shared that she identifies if the resident is a 2-person assist if they have a green sticker next to their name on the name card outside of their room. Staff #1 indicated that she remembered Resident #167. She shared that he was in the shower room with her and they had just completed the showering cares. Staff #1 further shared Resident #167 then jerked his legs, crossed them, and his legs went over the railing on the gurney and he fell. Staff #1 explained she then opened the shower room door and yelled for help from the Nurses. Staff #1 recalled Resident #167 going to the hospital after the fall. Staff #1 also shared that she was by herself with him in the shower room due to him being a 1-person assist at the time of the fall. She added that after the fall, he then became a 2-person physical assist. An interview was conducted on March 28, 2026 at 11:13 A.M. with Licensed Practical Nurse (LPN/Staff #120. Staff #120 revealed that neglect occurs when pain medications are given without a proper pain assessment or when cares are not being provided to the resident. She shared she receives abuse and neglect training often during monthly in-services. When asked whether providing a 1-person assist to a resident assessed as requiring a 2-person assist for bathing, resulting in a fall, would constitute neglect, she confirmed that it would, as the resident is a 2-person assist because the resident moves a lot. Staff #1 gave an example of a staff being on one side of the resident while washing them, the resident can move towards the other side of the gurney, fall and get hurt. She further explained that if a resident is a 2-person assist, then there must be 2 people helping the resident. Staff #1 shared that neglecting the residents could result in injury, skin damage, residents could be emotionally affected and they could lose their trust in staff to keep them safe. An interview was conducted on March 28, 2026 at 8:23 A.M. with the MDS/Care Plan Coordinator/Licensed Practical Nurse (Staff #59). Staff #59 explained that the MDS is created upon admission and is updated if there is a change in condition or if a quarterly review is due. She further explained that once the MDS assessment is completed, the comprehensive care plan is triggered with information obtained from the MDS assessments. She added that she and another MDS staff person also create and update the care plans after completion of the MDS. Staff #59 reviewed Resident #167's June 2, 2023 MDS assessment and shared that he was total dependence for bathing and required 2-person assist. Staff #59 reviewed Resident #167's September 2, 2023 MDS assessment and shared that he was total dependence for bathing and required 2-person assist as well. Staff #59 also reviewed Resident #167's comprehensive care plan and shared that it was noted he was a total assist for all ADLs however, it did not specifically say that he was a 2-person assist for bathing. She further shared that she did not know why the care plan did not reflect that the resident was a 2-person assist for bathing. An interview was conducted on March 28, 2026 at 8:41 A.M. with DON/Staff #7. Staff #7 shared that abuse and neglect training is provided to staff on an annual basis and as needed to provide re-education. When asked whether providing a 1-person assist to a resident assessed as requiring a 2-person assist for bathing, resulting in a fall, would constitute neglect, she shared that it would be if the care plan indicated the resident was a 2-person assist and only 1-person assist was done. When asked if not updating the care plan to reflect the MDS assessment as neglect, Staff #7 shared that it would be because the MDS did not link to the care plan so it was not adequately implemented. She further shared that this could lead to residents sustaining an injury because something happened to them due to not getting the proper care. Staff reviewed the September 2, 2023 MDS for Resident #167 and shared that he was total dependence and required 2-person assist for bathing. When reviewing the care plan for Resident #167, she shared that it identified that Resident #167 was a 2-person assist with showers starting December 11, 2023. She further shared that there was no information, regarding bathing with 2-person assist, in the care plan prior to December 11, 2023. Staff #7 explained that the care plan should have reflected that the resident was a 2-person assist prior to that date and confirmed that the care plan did not match the information in Resident #167's MDS. An interview was conducted on March 28, 2026 at 9:16 A.M. with the Administrator (Staff #116). She reviewed Resident #167's June 2, 2023 MDS assessment and shared that he was total dependent for bathing and required 2-person support indicating 2 people were to help him. Staff #116 reviewed Resident #167's September 2, 2023 MDS assessment and shared that he was total dependent for bathing and required 2-person assist. Staff #116 explained that in November 2023, based off of her interview with staff, a CNA had taken Resident #167 to the shower on a gurney. The CNA had stated that the resident had jerked or seized and fell off the gurney. She further explained that the fall had taken place in the shower. Staff #116 shared that there was one CNA providing bathing assistance to Resident #167 at the time of the incident. However, she added, that based off the information in the MDS, Resident #167 was supposed to have two people helping him. Staff #116 indicated that this did not meet her expectations and the risk of not providing adequate support, identified in the MDS assessments, can cause harm to the residents. Regarding Resident #174 -Resident #174 was admitted on [DATE] and discharged on February 14, 2024 with diagnosis including acute/ chronic respiratory failure with hypoxia and hypercapnia, muscle weakness, Parkinson's disease, chronic obstructive pulmonary disease, obstructive sleep apnea, morbid obesity, transient ischemic attack, hypoventilation syndrome, atrial fibrillation, chronic systolic congestive heart failure, aneurysm of other specified arteries, anemia, sick sinus syndrome, dyspnea, asthma, gastroparesis, osteoarthritis-right knee and shoulder, chronic kidney disease-stage 2, dependence on supplemental oxygen, hypertension, cardiac pacemaker, localized edema, hypotension and hyperlipidemia. A review of the 5-day MDS (minimum data set) dated November 15, 2023 revealed a BIMS (brief interview of mental status) score of 8, indicating moderate cognitive impairment. A review of the careplan noted that the resident had a focus area of impaired skin integrity due to impaired mobility. Interventions included that the resident is to receive supplements per orders, that chartable tasks to include the CNA (certified nursing assistant) tasks are to be documented and signed off in the electronic health record, dressings are to be changed as ordered, pressure ulcers are to be assessed, pain is to be assessed, skin inspections are to be conducted, areas is to be kept clean and dry, incontinence care is to be provided after each episode, friction is to be reduced by use of lubricants, moisture barrier is to be applied and that the resident is to be turned and repositioned every 2- 4 hours. A review of the facility 5-day investigation revealed that the investigative report was submitted on November 27, 2023. The allegation made by the complainant included that resident #174 had not been repositioned and subsequently developed blisters in the rectal area. The report documented that the allegation was made on November 19, 2023, which was noted to have been a weekend, via voicemail, but the report did not reveal whose voicemail message it had been left on. The report further noted that the voicemail was retrieved on Monday November 20, 2023 at which time notifications and investigation ensued. The investigative report revealed no evidence that staff, resident or complainant had been interviewed regarding the alleged incident. An interview was conducted on March 28, 2026 at 8:46 AM with staff #19, Nurse Manager. Staff #19 stated that resident care is the number one priority and that if there are concerns that call for an investigation, policy is followed to ensure a thorough investigation. She stated that the policy outlines the investigative process. Staff #19 further stated that the risk for not following policy could include not having a complete and accurate investigation of the allegation. An interview was conducted on March 28, 2026 at 2:28 PM with staff #7, DON (Director of Nursing). Staff #7 stated that a 5-day investigation needs to be thorough, documenting what happened. Staff #7 stated that first steps included removing the alleged perpetrator from the schedule, and then to investigate by interviewing staff and residents. The DON further stated that interviews, per policy, are always required on an investigation to ensure it is thorough. Staff #7 stated that she did not interview anyone for this investigation, because she went on the unit and saw the process and as a result knew the cause. She further stated that that she felt that there was no need to identify any specific staff member regarding a potential lapse as multiple staff members had been providing care to the resident. Staff # 7 stated that per the facility policy, interviews need to be conducted for a thorough investigation. An interview was conducted on march 28, 2026 at 2:57 PM with staff #116 Administrator. Staff #116 stated that her expectation is that investigations are thoroughly investigated, per policy, which includes interviews with staff and with everyone who may have been involved, witnessed the above incident and or was present to make sure that everything makes sense regarding the investigation. Staff #116 stated that the risk for not conducting a thorough investigation would include the inability to come to an accurate conclusion. Regarding Resident #19 -Resident #19 was admitted to the facility on [DATE] with diagnoses that included Dysphagia following cerebral infarction, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Aphasia following cerebral infarction, Type 2 diabetes mellitus with diabetic neuropathy, Cerebrovascular disease. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #19 scored a 9 for the Brief Interview for Mental Status (BIMS) which indicated she had moderate impairment. Care plan dated May 22, 2023 included resident required dependent assist for all ADL's to include bathing, grooming, hygiene, toileting, bed mobility, and dressing. Also, the resident required extensive assistance with meals, and was a two person assist with Hoyer lift. A progress note dated July 24, 2023 at 5:30 p.m. stated a CNA reported to Staff # 321 that Resident #19 needed a splint for her right hand and wrist. The resident was crying in pain when the CNA attempted to move the wrist. The resident also had blood on her lower right lip. An order dated July 24, 2023 10:03 p.m. was for Resident #19 to be transferred to an acute hospital emergency room (ER) for a CT scan of the head and X-rays of the right wrist and right leg. Hospital (ER) report dated July 24, 2023 stated, the resident was nonverbal [AGE] year-old presented to the ER with right wrist pain. There is some swelling and tenderness without any evidence of erythema or warmth and there are no open wounds have a low suspicion for septic joint. Per EMS report, the injury was from staff moving her. She has also been pointing to her leg and complaining of pain there as well. The facility initial report to the State Agency dated July 24, 2023 7:25 p.m. revealed a resident was hurt by a tall man and had pain the right hand; and that, the resident was sent out to the emergency room for X-rays. The facility 5-day report revealed that Resident #19 complained of right-hand pain, and also said that a tall guy hurt her. The resident was transported to the hospital because of right arm swelling. The report also revealed a CNA (staff #325) was suspended pending an investigation, and that he was the only CNA working with the resident that matched the description. The reported had an interview with the CNA and he said a nurse asked him to lay the resident down. The CNA changed the bedding and he used a gait belt to transfer the resident back to her bed. The 5-day report was concluded with the facility investigation being inconclusive because, the X-ray and CT were done and it was not a clear diagnosis if the resident has a fracture or not. The resident has a new diagnosis of decrease mineralization to the bone. She also has a new diagnosis of osteoarthritis to hand. Further review of the facility investigation revealed that the facility did not interview the resident's family, other resident's to whom the alleged CBA provided care; and, the facility did not interview family/guardian or responsible party of the roommate of Resident #19 who was identified in their report as in a vegetated state and non-interviewable Review of the personnel file of the alleged CNA (staff #325) revealed that a report dated July 25, 2023 and an attached corrective action form that indicated that Staff #325 was terminated for failure to follow safety rules and unsatisfactory job performance. An interview with a registered nurse (RN, Staff #138) was conducted on March 26, 2026, at 2:43 p.m. The RN stated that any allegation of abuse is reported to the Administrator or the Director of Nursing (DON#7), who then had two hours to report the incident to the State Agency (SA). She further stated that upon receiving an allegation of abuse, she would ensure the involved residents were safe, would gather details by speaking with both residents, would document the information, and would report the incident to the DON. On March 27, 2026 at 10:15 a.m. and interview was conducted with the legal guardian of Resident #19. The legal guardian said that Resident #19 would shook her head 'no' when asked if there were any concerns with facility staff; would shook her head 'yes' when asked if she felt safe; and would communicate with staff by mumbling and the use of a word board The legal guardian said there was an issue about a year after Resident #19 was admitted to the facility; and that, during a transfer Resident #19 sustained a fracture her right wrist. The guardian stated that he did not know the specifics of what happened but was told by the facility that it was not the facility's fault. An interview was conducted on March 28, 2026, at 10:08 a.m. with a licensed practical nurse (LPN/staff #51) who stated that any allegation of abuse, such as reports of a resident being hit by staff or another resident, was immediately reported to the Administrator, and an investigation was initiated. An interview was conducted on March 27, 2026 at 3:45 p.m. with Staff #170 who said that she remembered and was working at the time of the incident with Resident #19. She was called to the room by a Respiratory Therapist (RT) to help assess Resident #19 who had dried blood on her mouth and was holding her right hand. The resident had very limited speech but through the use of a speech board, Resident #19 identified the staff as a male. Staff #170 said that there was only one male CNA (staff #325) and all other staff was female that day. She said the Resident #19 was bed bound and would be a two-person Hoyer lift assist. An interview was conducted on March 28, 2026 at 7:52 a.m. with Staff #110. She said, every room in the 600 hall every resident was a two person assist which is designated by an orange dot outside the room. Linen changes are conducted using two people, one on each side of the bed, if keeping the resident in bed. The process is to gown up, carefully roll the resident from one side to the other side removing the dirty linen. The process is reversed putting the clean linen on. During this careful attention is paid to making sure the trach line is not tangled. Once done the can call an RT if needed. She said nurses can be a second person. If there a visible sign or complaint of injury it to be investigated as an abuse and the floor nurse, DON and Administrator must be notified. In an interview conducted on March 27, 2026 1:35 p.m. with DON, she said the 5-day report was sent to the SA on July 31, 2023. DON said said the initial facility investigation was the CNA reported that he changed the sheets on the bed and used a gait belt to transfer the resident back into bad. The residents brief was changed and he left the room. The facility investigation revealed the resident began crying during a care procedure. a staff member was called to the resident's room for a complaint of pain. The DON said the resident was sent to the ER for x-ray and evaluation. She said the final facility investigation was determined to be inconclusive due to: X-ray and CT were done and it was not a clear diagnosis if the resident has a fracture or not. She said the resident was diagnosed at the hospital with a diagnosis of decrease mineralization to the bone and a new diagnosis of osteoarthritis to hand. The DON said Resident #19 did not go to an optional MRI. Resident #19 was given a splint and started physical therapy when she returned to the facility. On March 27, 2026 at 4:20 p.m. an interview with Administrator was conducted. She said the incident happened before her employment began. The Administrator said all reports of abuse are investigated fully, but she did not know the specifics of this incident. She said she was pretty sure that Staff #325 was terminated because of the incident. Regarding Resident #56: -Resident #56 was admitted on [DATE] with diagnoses of anoxic brain damage, contracture of muscle, dysphagia, and muscle wasting and atrophy The care plan revised on August 8, 2022 included resident was completely incontinent of bowel and bladder. Interventions included to provide incontinence care after each incontinent episode and report signs of skin breakdown or perianal excoriation. The nursing note dated August 8, 2022 included the resident required 1-2 person maximum assist with ADLs (activities of daily living) and had been turned and repositioned every 2-4 hours. A nursing note dated August 10, 2022 revealed resident was incontinent for bowel and bladder, required total assist for all ADLs, was turned and repositioned every 2-4 hors, and was on LAL (low air loss) mattress for skin maintenance. The nursing note dated August 13, 2022 revealed the resident was unable to make needs known, unable to follow simple commands and was incontinent of bowel and bladder with use of pads and brief with sufficient amount of urine output throughout the shift. Review of a nursing notes dated August 21 and 28, 2022 included the resident was incontinent of bowel and bladder with use of pads and brief with sufficient amount of urine output throughout the shift. The nursing note dated August 28, 2022 included a report was received from the night nurse that there was edema noted to the posterior tip of the resident's penis. The documentation included that the provider was notified; and that, the provider saw the resident and ordered nystatin (topical antifungal) as treatment. The physician progress note dated August 28, 2022 revealed that the resident had penile edema, without discharge. Treatment included application of nystatin daily and to check CBC (complete blood count) in the morning. Review of systems included that the resident had no leg edema. The nursing notes dated August 29 and August 31, 2022 revealed the resident was alert but was unable to make needs known, was incontinent for bowel and bladder, required total assistance with ADLs and continued to have swelling on the dorsal side of glans penis with no drainage or redness noted. The facility 5-day investigation submitted on August 30, 2022 revealed that on August 29, 2022, the DON (Director of Nursing) received a message from resident's family that the resident had been abused because the resident's son's penis was swollen. Further review of the investigation found no evidence that interviews were conducted with witnesses, staff who cared for the resident, the staff member identified as responsible, or other residents cared for by that staff member. There was also no review of the events leading up to the incident. The care plan dated August 31, 2022 included the resident had potential for infection and/or skin breakdown related to being uncircumcised. Interventions included conducting skin check no less than 2 x weekly and PRN (as needed); and when providing care, ensure that the foreskin of the penis was retracted to adequately clean the penile area and to let resident know what you are doing and why. An interview with a registered nurse (RN/staff #150) was conducted on March 27, 2026 at 3:38 p.m. The RN stated that resident #56 was non-verbal, had a trach, was on ventilator and had a gastrostomy tube. She stated that she could not recall any incident of the resident having swollen penis. In an interview with the respiratory therapy director (RTD/staff #170) conducted on March 27, 2026 at 3:52 p.m., the RTD stated that she had not seen or heard any reports that the resident had a swollen penis; and that, this was beyond her scope of practice. During an interview with the Director of Nursing (DON/staff #7) conducted on March 28, 2026 at 2:28 p.m., the DON stated that she received a call from the resident's family of an allegation of abuse. However, she stated that she did not interview any staff or residents because when she went to see Resident #56, she saw it and knew what the cause of the swelling of the resident's penis. She further stated that she did not feel the need to identify one person as everyone was involved in the resident's care. However, the DON stated that per their policy on abuse, she needs to conduct interviews during the investigation. Regarding Resident #144 and Resident #85: -Resident #144 was admitted on [DATE] with diagnoses of acute and chronic respiratory failure, schizoaffective disorder bipolar type and PTSD (post-traumatic stress disorder. A care plan dated February 20, 2020 included resident had difficulty understanding others related to anxiety, schizoaffective bipolar disorder and PTSD; had impulse control as evidenced by physical and verbal aggression towards staff and peer and had exhibited verbally abusive behavioral symptoms (others were threatened, screamed at, cursed at). Interventions included speaking clearly/adjusting tone/repeating phrases as needed; asking resident to repeat what has been said to confirm the message was understood; if resident had an increase in behavior and is unable to be redirected, he may lose his next cigarette break, approaching resident in a calm, empathetic manner; removing resident from stimuli, if resident refuses, to attempt to remove stimuli near resident0, avoiding over-stimulation (e.g., noise, crowding, other physically aggressive residents); redirecting the resident when he has episodes of aggressive behavior; taking the resident to his room and provide 1:1redirection; and, assessing whether the behavior endangers the resident and/or others and intervening if necessary. The care plan dated December 23, 2020 included resident required placement on secured unit secondary to psych diagnosis, poor safety awareness, and/or history of substance abuse, which results in resident exhibiting behaviors that could potentially place resident or others at risk. The nursing note dated January 20, 2023 included the resident had exhibited exit-seeking behavior; and that, the resident attempted to exit from the unit multiple times, was redirected with some improvement noted. A nursing note dated February 6, 2023 included that at 5:30 a.m., Resident #144 self-propelled his wheelchair in the hallway and approached another resident (#85) who was in a wheelchair and was looking out the window by the double doors from behind. The documentation included that the other resident (#85) then turned his upper body around and struck the left side of the upper chest of Resident #144 who then struck the other resident (#85) back with a closed fist. According to the documentation, a certified nurse assistant (CNA/staff #171) was present, saw the incident and immediately separated Resident #144 and the other resident (#85). The documentation included that Resident #144 had slight redness noted to his left upper chest. -Resident #85 was admitted on [DATE] with diagnoses of Schizoaffective disorder, personality disorder, anxiety and major depressive disorder. The care plan dated May 28, 2021 included resident exhibited behaviors such as yelling out profanities, argued with self, hit hand into other hand in a threatening manner even when he was alone in the room. Interventions included increasing sessions with counselor and distracting the resident with things he likes. The care plan dated June 28, 2022 included that resident was on 2:1 for cares related to false accusations and safety. Interventions included 2:1 for all cares, redirection as needed and offering phone and outdoor time. The behavior note dated February 3, 2023 included resident had exhibited behaviors all morning, yelling and cursing at staff, talking to people who were not present, hitting self in head, throwing cups/water, and throwing medications in trash can. Per the documentation, multiple attempts were made to redirect, offer of food, fluids, snack, and was given choices on how he would like his medications as well as and attempted to provide a change in environment. However, all attempts were unsuccessful; and, the PRN (as needed) medications for anxiety was administered with minimal effect noted. The nursing note dated February 3, 2023 revealed Resident #85 continued to propel his wheelchair around the unit talking to people who were not there, had loud outbursts, periodic yelling at staff, was cursing, and hitting self in head. The documentation also included that the resident had active delusions and hallucinations stating that he lost 319 pounds in the past 6 months and maybe he can eat a piece of white bread to keep from dying. Per the documentation, the resident received his PRN medication but with minimal effect; and, staff continued to provide NPI (non-pharmacological interventions) to assist with de-escalation of his behaviors. A nursing note dated February 6, 2023 at 5:30 a.m., Resident #85 was sitting in his wheelchair looking out the window on the double door when another resident (#144) in a wheelchair approached Resident #85 from behind. The documentation included that Resident #85 then turned his upper body and struck the other resident (#144 on the left upper chest with his forearm According to the documentation, the other resident (#144) then struck Resident #85 with a closed fist in the center of his back. According to the documentation, a certified nurse assistant (CNA/staff #171) was present, saw the incident and immediately separated Resident #85 and the other resident (#144); and that, Resident #85 did not have any injuries noted. The initial self-report dated February 6, 2023 included that Resident #85 had an altercation with Resident #144. Per the documentation, Resident #85 was at the doorway and Resident #144 came to the doorway too; and that, Resident #85 turned around and hit Resident #144. The undated facility

Based on clinical record review, staff interviews, facility documentation and policy reviews, the facility failed to ensure allegations of abuse for 5 of 25 sampled residents (#19, #174, #149, #139 and #56) were thoroughly investigated. The deficient practice could result in failure to recognize, respond and take appropriate action to prevent residents from continued abuse and neglect and risk for ongoing harm, exploitation and serious adverse outcomes.Findings include: -Resident #174 was admitted on [DATE] and discharged on February 14, 2024 with diagnosis including acute/ chronic respiratory failure with hypoxia and hypercapnia, muscle weakness, Parkinson's disease, chronic obstructive pulmonary disease, obstructive sleep apnea, morbid obesity, transient ischemic attack, hypoventilation syndrome, atrial fibrillation, chronic systolic congestive heart failure, aneurysm of other specified arteries, anemia, sick sinus syndrome, dyspnea, asthma, gastroparesis, osteoarthritis-right knee and shoulder, chronic kidney disease-stage 2, dependence on supplemental oxygen, hypertension, cardiac pacemaker, localized edema, hypotension and hyperlipidemia. A review of the 5-day MDS (minimum data set) dated November 15, 2023 revealed a BIMS (brief interview of mental status) score of 8, indicating moderate cognitive impairment. A review of the care plan noted that the resident had a focus area of impaired skin integrity due to impaired mobility. Interventions included that the resident is to receive supplements per orders, that chartable tasks to include the CNA (certified nursing assistant) tasks are to be documented and signed off in the electronic health record, dressings are to be changed as ordered, pressure ulcers are to be assessed, pain is to be assessed, skin inspections are to be conducted, areas is to be kept clean and dry, incontinence care is to be provided after each episode, friction is to be reduced by use of lubricants, moisture barrier is to be applied and that the resident is to be turned and repositioned every 2- 4 hours. A review of the facility 5-day investigation revealed that the investigative report was submitted on November 27, 2023. The report documented that the allegation was made on November 19, 2023, which was noted to have been a weekend, via voicemail, but the report did not reveal whose voicemail message it had been left on. The report further noted that the voicemail was retrieved on Monday November 20, 2023 at which time notifications and investigation ensued. The investigative report revealed no evidence that staff, resident or complainant had been interviewed regarding the alleged incident. The allegation made by the complainant included that resident #174 had not been repositioned and subsequently developed blisters in the rectal area. An interview was conducted on March 28, 2026 at 2:28 PM with staff #7, DON (Director of Nursing). Staff #7 stated that a 5-day investigation needs to be thorough, documenting what happened. Staff #7 stated that first steps included removing the alleged perpetrator from the schedule, and then to investigate by interviewing staff and residents. The DON further stated that interviews are always required on an investigation to ensure it is thorough. Staff #7 stated that she did not interview anyone for this investigation, because she stated that she went there and saw it herself and as a result knew the cause and just proceeded to educate the staff. Ashe further stated that that she felt that there was no need to identify a specific staff member as multiple staff members had been providing care to the resident. Staff # 7 stated that per the facility policy, interviews need to be conducted for a thorough investigation. An interview was conducted on march 28, 2026 at 2:57 PM with staff #116 Administrator. Staff #116 stated that her expectation is that investigations are thoroughly investigated which includes interviews with staff and with everyone who may have been involved, witnessed the above incident and or was present to make sure that everything makes sense regarding the investigation. Staff #116 stated that the risk for not conducting a thorough investigation would include the inability to come to an accurate conclusion. -Resident #19 was admitted to the facility on [DATE] with diagnoses that included Dysphagia following cerebral infarction, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Aphasia following cerebral infarction, Type 2 diabetes mellitus with diabetic neuropathy, Cerebrovascular disease. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #19 scored a 9 for the Brief Interview for Mental Status (BIMS) which indicated she had moderate impairment. A progress note dated July 24, 2023 at 5:30 p.m. stated a CNA reported to Staff # 321 that Resident #19 needed a splint for her right hand and wrist. The resident was crying in pain when the CNA attempted to move the wrist. The resident also had blood on her lower right lip. An order dated July 24, 2023 10:03 p.m. was for Resident #19 to be transferred to an acute hospital emergency room (ER) for a CT scan of the head and X-rays of the right wrist and right leg. Hospital (ER) report dated July 24, 2023 stated, the resident was nonverbal [AGE] year-old presented to the ER with right wrist pain. There is some swelling and tenderness without any evidence of erythema or warmth and there are no open wounds have a low suspicion for septic joint. Per EMS report, the injury was from staff moving her. She has also been pointing to her leg and complaining of pain there as well The facility initial report to the State Agency dated July 24, 2023 7:25 p.m. said a resident was hurt by a tall man and had pain the right hand. Further information received stated the resident was sent out to the emergency room for X-rays. The facility 5-day report was submitted on July 31, 2023 revealed that Resident #19 complained of right-hand pain, and also said that a tall guy hurt her. The resident was transported to the hospital because of right arm swelling. The report also revealed a CNA was suspended pending an investigation, and that he was the only CNA working with the resident that matched the description. The reported had an interview with the CNA and he said a nurse asked him to lay the resident down. The CNA changed the bedding and he used a gait belt to transfer the resident back to her bed. The 5-day report was concluded with the facility investigation being inconclusive because, the X-ray and CT were done and it was not a clear diagnosis if the resident has a fracture or not. The resident has a new diagnosis of decrease mineralization to the bone. She also has a new diagnosis of osteoarthritis to hand. Further review of the facility investigation revealed that the facility did not interview the resident's family, other resident's to whom the alleged CBA provided care; and, the facility did not interview family/guardian or responsible party of the roommate of Resident #19 who was identified in their report as in a vegetated state and non-interviewable. -Resident #56 was admitted on [DATE] with diagnoses of anoxic brain damage, contracture of muscle, dysphagia, and muscle wasting and atrophy. The care plan revised on August 8, 2022 included resident was completely incontinent of bowel and bladder. Interventions included to provide incontinence care after each incontinent episode and report signs of skin breakdown or perianal excoriation. The nursing note dated August 8, 2022 included the resident required 1-2 person maximum assist with ADLs (activities of daily living) and had been turned and repositioned every 2-4 hours. A nursing note dated August 10, 2022 revealed resident was incontinent for bowel and bladder, required total assist for all ADLs, was turned and repositioned every 2-4 hors, and was on LAL (low air loss) mattress for skin maintenance. The nursing note dated August 13, 2022 revealed the resident was unable to make needs known, unable to follow simple commands and was incontinent of bowel and bladder with use of pads and brief with sufficient amount of urine output throughout the shift. Review of a nursing notes dated August 21 and 28, 2022 included the resident was incontinent of bowel and bladder with use of pads and brief with sufficient amount of urine output throughout the shift. The nursing note dated August 28, 2022 included a report was received from the night nurse that there was edema noted to the posterior tip of the resident's penis. The documentation included that the provider was notified; and that, the provider saw the resident and ordered nystatin (topical antifungal) as treatment. The physician progress note dated August 28, 2022 revealed that the resident had penile edema, without discharge. Treatment included application of nystatin daily and to check CBC (complete blood count) in the morning. Review of systems included that the resident had no leg edema. The nursing notes dated August 29 and August 31, 2022 revealed the resident was alert but was unable to make needs known, was incontinent for bowel and bladder, required total assistance with ADLs and continued to have swelling on the dorsal side of glans penis with no drainage or redness noted. The facility 5-day investigation submitted on August 30, 2022 revealed that on August 29, 2022, the DON (Director of Nursing) received a message from resident's family that the resident had been abused because the resident's son's penis was swollen. Further review of the investigation found no evidence that interviews were conducted with witnesses, staff who cared for the resident, the staff member identified as responsible, or other residents cared for by that staff member. There was also no review of the events leading up to the incident. The care plan dated August 31, 2022 included the resident had potential for infection and/or skin breakdown related to being uncircumcised. Interventions included conducting skin check no less than 2 x weekly and PRN (as needed); and when providing care, ensure that the foreskin of the penis was retracted to adequately clean the penile area and to let resident know what you are doing and why. An interview with a registered nurse (RN/staff #150) was conducted on March 27, 2026 at 3:38 p.m. The RN stated that resident #56 was non-verbal, had a trach, was on ventilator and had a gastrostomy tube. She stated that she could not recall any incident of the resident having swollen penis. In an interview with the respiratory therapy director (RTD/staff #170) conducted on March 27, 2026 at 3:52 p.m., the RTD stated that she had not seen or heard any reports that the resident had a swollen penis; and that, this was beyond her scope of practice. During an interview with the Director of Nursing (DON/staff #7) conducted on March 28, 2026 at 2:28 p.m., the DON stated that she received a call from the resident's family of an allegation of abuse. However, she stated that she did not interview any staff or residents because when she went to see Resident #56, she saw it and knew what the cause of the swelling of the resident's penis. She further stated that she did not feel the need to identify one person as everyone was involved in the resident's care. However, the DON stated that per their policy on abuse, she needs to conduct interviews during the investigation. -Resident #149 was admitted on [DATE] with diagnoses of sepsis, delirium and anxiety. The care plan dated November 23, 2022 included that the resident was a 2:1 with care. Intervention included 2 staff present when caring for the resident. Another care plan dated January 17, 2023 revealed the resident chose not to use the call at times instead he yells out for help. Intervention included resident re-education on using the call light instead of yelling for help. The nursing notes dated March 3, 4 and 5, 2023 included resident was alert and oriented x 3, was able to make needs known and 2:1 care maintained throughout the shift. A nursing note dated March 6, 2023 included the resident was alert and oriented x 3-4, used the call light to make needs known and remained on 2:1 for all personal cares. Review of the facility's grievance log revealed that on March 6, 2023, the resident filed a grievance that staff did not wake him up when care was provided. The facility initial report dated March 8, 2023 revealed that the resident alleged being intimidated by the way staff spoke to him in a loud tone regarding his numerous complaints; and, how 2 CNAs can no longer care for him as a result of his complaints. The undated facility investigation included that on March 8, 2023, at about 11:44 a.m., Resident #149 reported feeling intimidated by the way staff spoke to him; and, said that a staff member used a loud tone while discussing his frequent complaints about caregivers, which he said resulted in two caregivers no longer being allowed to care for him. The investigation included an interview with a registered nurse (RN/Staff #32) who reported that he was in the resident's room with a CNA providing care and that any discussion about staff not being allowed to care for the resident was only with CNAs and respiratory therapists, not with the resident. Per the documentation, the RN denied speaking to the resident about this issue and denied raising his voice; and, the RN reported that he did not recall the resident apologizing to him. The documentation also included that the RN reported that during the night shift from March 5 to March 6, 2023, he worked with one CNA because another CNA could not work with the resident; and that, he administered bedtime medications, spoke with the resident, gave PRN medications when needed, and changed the resident's dressing at 1:00 a.m., noting the resident was awake during the treatment. The investigation included interviews of two CNAs (staffs #131 and #182and who worked with the RN (staff #32) when the RN provided care with Resident #149. The documentation included that both CNAs denied witnessing the RN tell the resident anything except that they were to change the resident's brief. Continued review of the facility investigation revealed no evidence that interviews were conducted with other residents to whom the alleged RN provided care or service. -Resident #139 was admitted on on May 21, 2021 with diagnoses of stage 4 CKD (chronic kidney disease, dependence on renal dialysis, anxiety and type 2 diabetes with diabetic neuropathy. A nursing note dated October 20, 2022 included that the resident complained of of chest pain and was sent out to the hospital ER (emergency room). The discharge MDS (Minimum Data Set) assessment dated [DATE] included that the resident had an unplanned with return anticipated discharge to acute hospital on October 20, 2022. The nursing notes dated October 21, 2022 revealed that the resident was back at the facility; and that, the resident was sent back to the hospital because of high blood sugar level. The nursing note dated October 25, 2022 included that the resident arrived back at the facility and reported that she was missing $70 missing from before she left to hospital. A nursing note dated October 26, 2022 revealed that the resident continued to talk about her missing money. Per the documentation, staff conducted a search but was not able to find the missing money. The facility initial self-report dated October 26, 2022 that at approximately 3:30 p.m., the resident stated that she was missing $75.00 and 4 quarters which she left in a Ross bag in her room when she went went back to the acute hospital on October 22, 2022. The facility 5-day investigation dated November 2, 2022 revealed that the facility concluded that the missing money may have been misplaced because the alleged missing money was left in a Ross bag that may have been placed in the trash can in the resident's room. Per the documentation, the resident's missing money was replaced in full on October 26, 2022. The investigation included interviews conducted with 3 CNAs (certified nursing assistants), 2 of which worked on October 26, 2022 the day the resident came back from the hospital and 1 worked on the day the resident was discharged to the hospital on October 25, 2022. However, the facility did not have any interviews with staff who were on shift or took care of the resident on October 20 and 21, 2026; and, there were no evidence that other residents were interviewed as well. An interview with the social services director (SSD/staff #111) was conducted on March 26, 2026 at 1:13 p.m. The SSD stated that if she receives a report that the resident was missing personal items including money or reports of money stolen, she would go talk to the resident and ask permission if she could try to locate it in the resident's room; and if the missing item cannot be found, the facility will try to replace it. She stated that if it was about missing/stolen money and the money was noted in the resident's inventory list, then it will be replaced. However, if the missing/stolen money was not in the inventory list, she will notify the administrator who will then decide whether the missing/stolen money will be replaced or not. The SSD further stated that replacement of missing/or stolen money was on a case to to case basis as it does not happen all the time. Regarding the allegation of the missing money for resident #139, the SSD stated that she would have to look at the records and see if there was a grievance for this allegation and what the resolution was. In an interview with a registered nurse (RN/staff #138) conducted on March 26, 2026 at 2:43 a.m., the RN stated that any allegations of abuse will be reported immediately to the DON/administrator who then has 2 hours to report the incident to SA. She stated that if she receives a report of allegations of abuse, she will ensure that the resident involved was safe and she will talk to the resident to get as much details of the allegation. The RN said that she will then document that she reported the incident to the DON. The RN also said that if the allegation involved a staff, she will report to the DON who will then tell the alleged staff to stop caring for the resident and will be sent home by the DON or Administrator until the investigation was completed During an interview with the DON (staff #7) conducted on March 28, 2026 at 1:16 p.m., the DON stated that any reports of resident's missing item including missing money is reported to the SSD who will then complete a grievance form. She stated that an investigation will be initiated and the incident will reported to the SA (state Agency). She further stated that the incident will be thoroughly investigated and and the facility's report/investigation will be submitted to the SA within the required timeframe. In a later interview conducted on March 28, 2026 at 2:28 p.m., the DON stated that the facility's investigation needs to be thorough to address and identify what happened. She stated the investigation includes removing the involved staff from schedule, interviews with staff and residents to get answers needed for the investigation. The DON said that interviews are always required on an investigation and not having interviews would result in the investigation not being thorough. In a written statement from the administrator dated March 28, 2026, the Administrator wrote that they were not able to locate the investigation or any documents pertaining to the missing money of Resident #139. An interview with the administrator was conducted on March 28, 2026 at 2:57 p.m. The administrator stated that facility investigation was done thoroughly; and that, investigations includes interviews with staff and with everyone to make sure that everything makes sense. She stated that if interviews were missing in the investigations, then it would be hard to come to a conclusion of what have happened, whether incident happened or not, and the investigation was not thorough. The facility policy on Preventing, Reporting and Investigation Abuse and Neglect included that it is their policy that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Facility is committed to protecting residents from abuse by anyone. Abuse prevention program provides guidelines that govern as a minimum identification of occurrences and patterns of potential mistreatment/abuse; protection of residents during abuse investigation; timely and thorough investigations of all reports and allegations of abuse; development of investigative protocols governing reports and allegations of resident ANE, resident-to-resident abuse, exploitation, individual injury; and, reporting and filing of accurate documents relative to incidents of abuse. The policy also included that witness reports will be obtained in writing; and, the individual conducting the investigation, will, as a minimum: Interview the person(s) reporting the incident; Interview any witnesses to the incident; Interview the resident as medically appropriate; Interview staff members (on all shifts) who have had contact with the resident during period of the alleged incident; Interview the resident's roommate; and, Interview other residents to whom the accused employee provides care or services.

Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure a baseline care plan was provided to resident/representative for 3 of 25 sampled residents (#168, #171 and #175). The deficient practice could result in residents not receiving the necessary care and services to meet their assessed needs upon admission.Findings include:-Resident #168 was admitted on [DATE] with diagnoses of acute posthemorrhagic anemia, unsteadiness of feet, difficulty of walking, seizures, and COPD (chronic pulmonary obstructive disease). The nursing note dated October 23, 2023 included that resident arrived from the hospital, was alert and oriented x 4 and was able to make needs known. Per the documentation all consents were signed by the resident. The baseline care plan dated October 23, 2023 included that the meeting was attended by the social services and nutrition staff; and did not indicate the resident or resident representative was part of the creation of the baseline care plan. Per the documentation, initial goals of the resident was to get better and was a full code. However, all the items in the initial goals based on admission orders section were not marked and was not signed and dated by the resident or resident representative. Further, the baseline care plan had a completion date of May 2, 2024 (approximately 7 months after the resident's admission date) and that, it was not completed by a specific staff but was documented as system completed. There was no evidence that the baseline care plan summary was provided to the resident and/or the resident representative. The clinical record revealed that the resident was transferred to the hospital on November 2, 2023 per hematologist request. The nursing note dated November 6, 2023 revealed that resident remained discharged at the hospital. -Resident #175 was admitted on [DATE] with diagnoses of acute kidney failure, contusion of left knee and type 2 diabetes mellitus. The nursing note dated January 23, 2024 included that the resident was alert and oriented x 4 and arrived at the facility via stretcher. Per the documentation, resident had edema to left upper extremities, left knee swollen and bruised from the last fall, had MASD (Moisture-Associated Skin Damage) with redness to gluteal cleft back and front, and had Foley catheter in place for failed voiding trial. The baseline care plan was initiated on January 23, 2024. Significant diagnoses included fall with left knee contusion, rhabdomyolysis and dehydration. Discharge plan was to home with support. Initial goals were to use a walker and get well enough to return home. Per the documentation, care plan participants included the resident/resident representative, social services, DON (director of nursing), nutrition and activities staff. It also included that a copy of the initial care plan was provided to resident/representative on January 23, 2024 at 7:00 p.m. However, the resident/resident representative signature and date section was not signed and dated by either the resident or the resident representative. Further review of the baseline care plan revealed that completion date was July 27, 2024 (approximately 6 months from the date of admission) and was not completed by a specific staff but was documented as system completed. Review of the clinical record revealed that resident was transferred to the hospital on January 28, 2024 because of a low blood sugar. -Resident #171 was admitted on [DATE] with diagnoses of acute & chronic respiratory failure with hypoxia, pneumonia due to pseudomonas, dysphagia, attention to tracheostomy and attention to gastrostomy The nursing note dated April 15, 2025 included that the resident was admitted with a complex medical history including acute and chronic respiratory failure with both hypoxia and hypercapnia, pneumonia due to Pseudomonas, tracheostomy dependence, PEG tube for enteral feeding, dysphagia, ventilator dependence, paraplegia,hypothyroidism, conversion disorder with seizures, paroxysmal atrial fibrillation, generalized anxiety disorder, polyneuropathy, gastroesophageal reflux disease (GERD), delayed physiological development, and a history of COVID-19. The baseline care plan was initiated on April 15, 2025. Significant Diagnoses included acute and chronic respiratory failure, hypoxia, with history of Peg tube and Trach with use of ventilator, developmental delay, Schizophrenia, seizure disorder and quadriplegia. Care Plan participants included resident/resident representative, social services and an RN (registered nurse). It also included that the facility spoke with the public fiduciary and consents were faxed to them. Discharge plan was to remain in the facility at this time and may re-evaluate discharge plan if condition changes or resident chooses to initiate discharge plan. Further, the documentation included that hopes to discharge the resident to a group home. Initial goals of the resident was for physical and occupational therapy and to transition to self independence. The documentation also included that the resident alert and oriented x 1, had a pressure call light and a copy of the initial care plan was provided to resident/representative on April 15, 2025. However, the resident/resident representative signature and date section was not signed and dated by either the resident or the resident representative. There was no evidence found that the copy of the baseline care plan was provided to the resident representative i.e., the public fiduciary. Further review of the baseline care plan revealed that completion date was October 31, 2025 (approximately 6 months from the date of admission) and was not completed by a specific staff but was documented as system completed. The nursing note dated April 15, 2025 included that the resident's public fiduciary was notified of the resident's admission and the staff will fax medication consents to them. The documentation did not include that the baseline care plan such as interim interventions/approaches in place to meet the resident's immediate needs. The social service note dated April 17, 2025 included that social services met had a 48-hour meeting with the resident's public fiduciary who planned for resident's return to the medical group home. The documentation did not include the baseline care plan with interventions/approaches in place to meet resident's needs were discussed with the public fiduciary. In an interview with a nurse manager (staff #19) conducted on March 28, 2026 at 8:46 a.m., the nurse manager stated that when residents are admitted , the receiving nurse starts with a baseline care plan observations and documents the assessment in the clinical record. She stated that the nurse leadership team then conducts a secondary review of the entries and ensure that they are completed and the information were accurate. She stated that there was always a risk if the baseline care plan was not completed timely or accurately; however, resident safety was a priority and the care plan helps to ensure that. An interview was conducted with a licensed practical nurse (LPN/staff #51) on March 28, 2026 at 10:08 a.m. The LPN stated that when there was a new admission, she receives the admission packet about information regarding the resident. She said that when the resident arrives at the facility, she will then conduct head-to-toe assessment and identify the needs of the resident. The LPN said that baseline care plan is initiated with the needs based on the assessment conducted on admissions; and, interventions to address these identified need are put in place. In another interview with the nurse manager (staff #19) conducted on March 28, 2026 at 10:27 a.m., the nurse manager stated that before admission, she reviews the admission packet related to resident's medications, diagnosis codes and would verify with the provider the resident's medications, contact pharmacy to ensure that medications were available for the resident when the resident gets admitted . She stated that a piece of paper containing this information with important notes is provided to the nurse in the unit where the resident will be admitted . She then opens the observations in their electronic record which included assessments for fall, Braden scales, baseline care planning, and any assessment that the nurse had to complete for the admission. She said that baseline care plan is then completed by the nurse within 14 days of the resident admission. She does not know why baseline care plan will be documented as system completed. During an interview with the Director of Nursing (DON/staff #7) conducted on March 28, 2026 at 1:16 p.m., the DON stated that baseline care plan is created in conjunction with the comprehensive care plan; and that, the baseline care plan needs to completed within 48 hours or resident's admission. She said that the social services staff would then meet with the resident within 48 hours of admission and will ask the resident if they wanted copy of the baseline care plan. She stated that the social service staff will then document in the electronic record whether or not the resident or representative received a copy or not. In a later interview with the DON conducted on March 28, 2026 at approximately 3:00 p.m., the DON stated that she checked the clinical record of residents #168, #171 and #175 and found no documentation that the resident or representative was provided with a copy of baseline care plan. Review of the facility's policy on Care Plans included that an individualized comprehensive person centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The resident is informed of his or her rights to participate in his or her treatment, and provided advance notice of care planning conferences. If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process.

Based on observations, staff interviews and review of policies and procedures, the facility failed to ensure that food was labeled and stored in accordance with professional food safety standards. The deficient practices could result in food-borne illnesses.Findings include:An initial kitchen observation was conducted on March 24, 2026 at 8:20 AM with the Dietary Manager (staff #108). There was an open 2-pound package of Hormel deli smoked ham inside a Ziploc bag with no open date on either the original packaging or the Ziploc bag; and, a box of mushrooms labeled with a production date of March 9, 2026 was found in the kitchen refrigerator. The mushrooms in the box were dark brown in color and were 'mushy'. The Dietary Manager stated that the mushrooms were browning and should be going in the trash. A observation of the kitchen freezer was also conducted with the dietary manager (staff #108) on March 24, 2026 at 8:30 AM. In the freezer was an open 64-ounce bag of Frozen Harvest mixed vegetables with no open or use-by date. There was also an open unlabeled and undated bag of cream colored, meat-like textured pieces, which were identified by the Dietary Manager as boneless skinless chicken pieces. The Dietary Manager stated that an open date and label should always be documented on the packaging once the original package has been opened; and that, if the date was not documented, staff would not know when the food item was opened and/or if the food item was still good to use.In an observation of the dry storage area conducted with the dietary manager (staff #108) on March 24, 2026 at 8:35 AM, there were 2 cans of Fancy Pinto Beans, 1 can of 100% canned pumpkin and 2 cans of harvest diced peached that were dented in different areas of the can including the on the seems and the body of the cans and were found in the canned storage section. These cans were not stored in the dented section but rather on the ready for use racks. The Dietary Manager immediately removed all 5 dented cans and stated that these should have not been stored with the for use canned items because of the potential risk could include food-[NAME] illness.During an interview conducted with the Dietary Manager on March 26, 2026 at 7:44 AM, the dietary manager stated that the expectation was that all food items are labeled and dated when stored. She stated that if items were not labeled and dated the risk would be that staff would not know when the items went out of 'code'. She also stated that the walk-in refrigerators was not conducive to fresh-produce because they are too cold and too moist; and, her expectation was that produce was used based on rotation-first in, first out. The dietary manager further stated that she checks produce rotation twice a week and that dietary staff were also expected to check, but sometimes they put it off until later and forget to do it. Further, she stated that there was no risk regarding the mushrooms as they were taken out and would be replaced. Regarding the dented cans, the dietary manager said that her expectation was for staff to recognize this upon delivery; and that, no dented cans should be going on the 'rack' but should instead be stored with the dented cans on the shelf. The facility policy on Proper Labeling/Dating Procedures included that everything in the freezer, thaw box, reach in refrigerators and dry storage needs an open date. Loose bags of vegetables, blueberries, pie shells, etc., must have today's date. Any loose items need to be in a container with an open date.Review of the facility policy on Food Storage included that food items should be stored, thawed and prepared in accordance with good sanitary practice. Dented or bulging cans should be placed on damaged goods shelf and returned for credit.

Based on the clinical record review, observations, interviews, facility documentation, and policy, the facility failed to ensure infection control practices were followed regarding Enhanced Barrier Precautions (EBP) for 3 residents (#82, #42, and #10) The universe is 25. This deficient practice can result in contamination and spread of infection.Findings include:-Resident #82 was admitted to the facility on [DATE] with diagnoses of MRSA (Methicillin resistant Staphylococcus aureus) infection, rash and other nonspecific skin eruption, Zoster without complications and disorder of skin and subcutaneous tissue. The care plan dated March 2, 2026 included resident was at risk for dehydration related to MRSA bacteremia. The nursing note dated March 21, 2026 revealed admission diagnosis of MRSA infection. The wound note dated March 24, 3036 included that the resident had a wound to the breast related to acute generalized exanthematous pustulosis. The facesheet in the clinical record that resident was on EBP related to PICC (Peripherally Inserted Central Catheter), wounds and recent MDRO infections However, during an observation was conducted on March 24,2026 at 1:04 PM, there was no sign posted outside of the resident's room regarding resident being on EBP and any instructions regarding what PPE (personal protective equipment) to wear when providing care. In another observation conducted on March 25, 2026 at 11:45 AM, the outside of the resident's room continued to have no signs posted related to resident being on EBP -Resident #48 was admitted on [DATE] with diagnoses of open wound to the left and right lower leg and Methicillin resistant Staphylococcus aureus infection as the cause of diseases. The admission MDS (minimal data set) assessment dated [DATE] included a a BIMS (Brief Interview for Mental Status) score of 15 indicating that the resident was cognitively intact. Active diagnoses included open wound to the right lower leg, Methicillin resistant Staphylococcus aureus infection. The assessment coded the resident had an infection of the foot. The skilled observation note dated March 22, 2026 revealed an admission diagnoses of open wound to the right and left left lower leg and Methicillin resistant Staphylococcus aureus infection as the cause of diseases. Per the documentation, the resident was alert and oriented to person, place, time and situation; and that, the resident had no adverse reactions to IV (intravenous) antibiotic. Review of the clinical record revealed that Resident #48 was on EBP for open wounds. During an observation conducted on March 26, 2026 at 11:57 AM, there was no sign regarding resident being on EBP posted outside of the resident's room and any instructions regarding what PPE (personal protective equipment) to wear when providing care. -Resident #10 was admitted on [DATE] with diagnoses of type 2 diabetes mellitus with diabetic neuropathy, cystectomy and irradiation cystitis without hematuria. The 5-day MDS assessment dated [DATE] revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. Active diagnoses included BPH (benign prosthetic hyperplasia, neurogenic bladder and obstructive uropathy. The assessment also included that Resident #10 was coded for ostomy. Review of the clinical record revealed the resident was on EBP for urostomy. However, during an observation conducted on March 25, 2026 at 4:17 PM, there was no sign regarding resident being on EBP posted outside of the resident's room and any instructions regarding what PPE (personal protective equipment) to wear when providing care. An interview was conducted on March 25, 2026 at 4:27 PM with Wound Nurse (Staff #36) who stated EBP signs are used for residents with open wounds, catheters and MDRO. Staff #36 stated EBP signs are used to let staff when enhanced barrier precautions are needed. She stated that without signage in front of the applicable rooms, there is a risk for exposing residents to infections, or introducing other bacteria. Staff # 36 stated signage is essential to communicate with staff, when EBP is required, especially staff who do not have access to clinical records. Staff #36 reviewed resident #82 and confirmed that the resident is on EBP but does not have a sign in front of the door. An interview was conducted on March 25, 2026 at 4:22 PM with Respiratory Therapist (RT/staff #113) who stated that EBP signs were used when residents have diagnosis such as MRSA; and that, EBP signs let staff know to wear a gown, mask and wash hands before entering and after leaving the room for direct care. Further, the RT stated that not having EBP signs posted on the resident's room posed a risk for the spread of infection, and passing infections to other residents. In an interview with the registered nurse (RN/staff #90) conducted on March 25, 2026 at 4:37 PM, the RN stated that EBP signs were used for residents who have an IV, foley and wounds; and that, if there were no signs posted when a resident was on EBP was not a good practice it could be dangerous for both staff and resident and could result in the spread of the infection. An interview was conducted with Licensed Practical Nurse (LPN/staff #129) on March 26, 2026 at 10:28 AM. The LPN stated that EBP were used for resident on IV treatment and had open wounds; and that, when a resident was on EBP there would be a sign posted on their door. The LPN also said that EBP signs were posted to make visitors, such as family members, aware of what to do when entering the room of a resident on EBP; and, if the EBP was not followed, there is a risk for spread of bacteria or infection. During an interview with the with the Director of Nursing ( DON/Staff #7) conducted on March 27, 2026 at 11:54 AM, the DON stated that the resident's status related to EBP and/or TBP (transmission-based precautions) was communicated with a banner on the facesheet of clinical records; and, there would be signs about this posted on the resident's room door. She stated that it does not meet her expectation if there were no signs outside the resident's door and the resident was on EBP. The DON further stated that an EBP sign explains to staff/visitor when to wear PPE (Personal Protective Equipment) which was a barrier of infection between patients and employees; and, when PPE was not worn when needed it imposes a risk of infections. The facility's policy titled Isolation- categories of transmission-based precautions revised April 2012 revealed examples of infections requiring Contact Precautions include, but are not limited to: Infections with multi-drug resistant organisms, Heavily draining wounds with non-contained drainage. Signs used to alert staff of contact precautions. The policy further noted that the facility will implement a system to alert staff to the type of precautions the resident requires. It was documented that this facility utilizes the following system for identification of Contact Precautions for staff and visitors: Sign posted on resident room/door See Nurse Before Entering Room. The facility will also ensure that the resident's care plan and care specialist communication system indicates the type of precautions implemented for the resident.

Based on clinical record review, observations, interviews, and review of the facility's policies and procedures, the facility failed to ensure one resident's (#120) advance directive was accurately documented and implemented in accordance with the resident's expressed preference. The universe was 25. The deficient practice could result in the resident's wishes and preferences related to life-sustaining treatment not followed and honored. Findings include:Resident #120 was admitted to the facility on [DATE], discharged on [DATE], and returned to the facility on [DATE]. His diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Morbidity, and Acute Kidney failure, unspecified.Review of the Change in Condition (CIC) Minimum Data Set (MDS), dated [DATE], revealed Resident #120 completed a Brief Interview for Mental Status (BIMS) and scored a 13 which indicated he was cognitively intact.Review of Resident #120's Care Plan revealed it was last reviewed/revised on [DATE]. The Care Plan identified Resident #120's code status as Full Code and noted that the code status would be re-addressed on a quarterly basis or as needed. It also noted that in the event of a cardiac or respiratory arrest, staff are to perform resuscitation measures per facility guidelines.Review of the Physician's orders revealed an order, dated [DATE] indicating Resident #120's Code Status was DNR.Review of Resident #120's Progress Notes, in the clinical chart, revealed an entry, dated [DATE] at 7:51 A.M. The entry noted that Resident #120 was full code. The Progress Note entry was e-signed by the Nurse Practitioner (NP/Staff #201).Further review of the Progress Notes revealed a second entry, dated [DATE] at 8:45 A.M., which noted Resident #120's Code Status as full code. The Progress Note entry was e-signed by NP/Staff #205.Review of Resident #120's clinical record revealed a red DNR warning next to his picture on his profile.A review of the Residents' Code Book at the Nurses' station was conducted on [DATE] at 10:48 A.M. There was no Advance Directive or DNR sheet for Resident #120 in the Code Book.An interview was conducted with Resident #120 on [DATE] at 10:53 A.M. Resident #120 shared that he wanted life saving measures to be taken to save him if necessary and that he did not want to be a DNR.An interview was conducted on [DATE] at 11:02 A.M. with Certified Nursing Assistant (CNA/Staff #69). Staff #69 explained that the Nurses' station has a DNR/DNI (Do Not Intubate) book for each of the units. She further shared that she has not needed to use the book during her shift to determine a resident's code status. However, Staff #69 did share that she did not memorize her residents' code status so she would immediately ask her unit Nurse to find out a resident's code status. Staff #69 further shared that she is certified in Cardiopulmonary Resuscitation (CPR) and she was able to perform this on residents, if necessary.An interview was conducted with CNA/Staff #165 on [DATE] at 11:10 A.M. Staff #165 shared that she would provide CPR to all residents regardless of their code status. She further shared that she did not know how to find out a resident's code status but it was important, to her, to give everyone CPR so they all can have a chance to live.An interview was conducted on [DATE] at 11:17 A.M. with Licensed Practical Nurse (LPN/Staff #120). Staff #120 explained that if a resident was in distress and needed CPR to be performed, the CNAs are certified to perform this. Staff #120 shared that Residents' code status are in their Electronic Health Record (EHR) as well as the Daily Report Sheet which identifies the resident's code status, how they take their medications, the Doctor's name, and any special instructions. She provided an undated Daily Report Sheet and it was observed that Resident #120's code status was listed as DNR. Staff #120 also shared that she mostly works in her current unit and has most of her resident's code status memorized but if there was an emergency situation, she would still look at the Daily Report Sheet and also check the EHR in case something changed. She further shared that there is also a folder containing Residents' code status. However, she added that the information regarding the code status, that is in the folder, is copied and given to emergency personnel when residents are transported to the hospital. Staff #120 explained that Resident #120 was on Hospice until several weeks ago and she was aware that he was thinking of changing his code status to full code but she believed he was still a DNR. She added that she did not know if his code status had changed. Staff #120 reviewed the code status book and shared that she did not see a code status form for Resident #120. She stated that the form should be in the book especially if Resident #120 was a DNR, however if they were full code then they did not need a code status form. An interview was conducted on [DATE] at 12:10 P.M. with the Director of Nursing (DON/Staff #7). Staff #7 confirmed that CNAs are able to provide CPR to residents if necessary. She further shared that all CNAs at the facility are certified in CPR. Staff #7 shared that when a person is admitted to the facility, they are asked what their preferences are related to their Code Status. She further shared that residents are able to change their code status at any time as it is their choice. If a resident were to tell a CNA that they wanted to change their code status, then the CNA needs to tell a Nurse. Staff #7 added that the code status for that resident should be made right away because if they change their mind and something were to happen to the resident, the correct code status needs to be in place. When asked what the code status for Resident #120 was, Staff #7 indicated that he was a DNR. When asked if that information was listed on the care plan for the resident, she reviewed the EHR and shared that the code status was listed as Full Code. She further shared that the information was not accurate. Staff #7 was also asked to review the most recent Progress Note written by the NP. After reviewing the Progress Note, Staff #7 shared that it was noted the resident was Full Code. Staff #7 explained that this was an error because the documentation did not match each other. She further explained that Resident #120 is alert and oriented and is able to make his own decisions. She also shared that this was a risk to the resident because there was a potential for staff to not provide CPR because he is not listed as Full Code which is against his wishes.Review of the facility's policy and procedure, titled Advance Directives, explained that the code status for Residents will be displayed prominently in the medical record/EHR. It also indicated that the care plan for each resident will reflect their treatment preferences including their advance directive. The policy and procedure further indicated that the Interdisciplinary Team will routinely review the residents' advance directives with the resident and/or their representative to ensure their wishes have not changed.

Based on observations, resident interviews, staff interviews, and a review of policies and procedures, the facility failed to ensure a safe homelike environment for residents. This deficient practice had the potential for resident injury and psychosocial harm. Findings include:Resident #39 was admitted on [DATE] with diagnosis including anemia, hypertension, diabetes mellitis, and depressionThe 5-day MDS (minimum data set) with an assessment reference date of December 29, 2025 revealed that the resident had a BIMS score of 15, indicating that the resident was cognitively intact.A review of the facilities work-orders from January 2026 through March 26, 2026 revealed a total of 16 work orders for the entire time span. There was no evidence of a work-order for either the baseboards or the hole in the wall for the 200-hall.An observation was conducted on March 24, 2026 at 9:27 AM past the entrance doors of the 200-hall secured unit. To both sides of the hall, missing sections of baseboards were observed. On the right- hand side past the entrance door, approximately 2.5 feet of roughly 4-inch baseboard was missing entirely and on the left-hand side, approximately 1.5 feet of baseboard was missing. On the left side where the baseboard resumed, the existing baseboard was partially bent forward extending into the hall approximately an inch.An observation was conducted on March 26, 2026 at 9:55 AM, in the dinning/ communal area of the 200- hall. On the back side of the room to the left side of the nurse's station, a visible hole measuring approximately 3 inches (height) by 2.5 inches (width) was observed. The portion of the hole that was not visible was partially covered by a plain beige blank outlet plate cover which was observed to be broken in half. No visible wiring was observed. The bottom end of the broken plate cover revealed jagged edges.An interview was conducted on March 26, 2026 at 9:25 AM with resident #39 who stated that chipping baseboard in her room by the bed had not been an issue, as it was minor, but she didn't like how the baseboards in the hall looked and that it did not make feel 'homey'.An interview was conducted on March 26, 2026 at 9:41 AM with staff #51, LPN (licensed practical nurse). Staff #51 stated that resident in the facility should feel like they are at home. They should have things like their favorite blanket, things they are familiar with, their own belongings and should have the ability to arrange things, within in reason, in their own rooms. Staff #51 stated that the appearance, walls, floors, and ceilings also factored into 'home-like' environment. Staff #51 further stated that cracks in the walls and floors could constitute safety issues and would need to be fixed immediately. She stated that peeling baseboards might have chemical adhesives that could be 'toxic' and should be fixed immediately. She stated that generally if maintenance is notified they respond right away. She stated that she normally works a different hall and is not aware of any maintenance issues that have not been addressed, but stated that if there were issues the risk to the resident, of not addressing the issue, could include depression and not feeling like they belong.An interview was conducted on March 26, 2026 at 9:52 AM with staff #17, CNA (certified nursing assistant). Staff #17 stated that to her, a homelike environment meant that things should be like home and conforming to resident's likes. Staff #17 stated that peeling or entirely missing baseboards in the 200-hall did not look good and would make residents feel as if the building was not being taken care of.An interview was conducted on March 26, 2026 at 9:59 AM with staff #50, LPN. Staff #50 stated that a home-like environment includes a resident's room furnishing and their ability to come out of their room into communal areas. She stated that she did not like the appearance of missing or peeling baseboards. Staff #50 stated that staff have the ability to report issues to the maintenance depart but was not aware of any issues that were currently being worked on in the 200-hall. Staff #50 was directed to the hole in the wall by the nurse's station and stated that she was not aware that it was there. She stated that she observed the outlet plate to be broken and jagged on the bottom edge, with the hole measuring approximately 2 x 4 inches. She stated that the risk to residents could include residents attempting to put their hand in the hole and potentially cutting themselves on the jagged edges of the plate cover.An interview was conducted on March 26, 2026 at 10:24 AM with staff #48, Maintenance Director. Staff #48 stated that the facility generally receives 20 plus work orders daily and the department would prioritize anything with potential resident safety concerns and that there are completed right away. Staff #48 stated that they are in the process of renovating some of the rooms and that some had already been entirely renovated. Staff #48 further stated that he had started renovations approximately 6 months ago on the 200-hall, but that they still had a lot left. He stated that outstanding work orders for the 200 hall included repairs to the main door and hallway painting. He stated that in the 200-hall dining area, just some painting and improvements were needed. When asked about the baseboards, he stated that he was aware and that they would be fixed. When asked about the hole in the wall, staff #48 stated that he was aware that there was a partial plate cover over a hole by the nurse's station on the 200-hall which needed to be replaced. Staff #48 stated that that this issue would qualify as a high priority issue because of the broken plate and because it was a 'lock-down' unit. Staff #48 stated that the issue was reported verbally to him on March 15, 2026. He stated that it should have been fixed by now and that the risk included someone getting cut. When asked he further stated that the 200-hall, currently, does not constitute a home-like environment and stated that additional risks to residents could include resident's feeling bad about their current living situation.An interview was conducted on March 26, 2026 at 11:58 AM with staff #116, Administrator. Staff #116 stated that a homelike environment includes a resident feeling comfortable in their room/ facility and can include having their belongings, hygiene supplies being afforded privacy and even having one plant if they are not on the respiratory unit. If a resident voices concern regarding home-like environment then they are placed on high-priority to ensure that they do feel comfortable in their setting. Staff #116 stated that holes in walls are fixed the minute maintenance finds out about them, but stated that maintenance does need to be made aware of them by staff or residents. Staff #116 stated that one of the challenges that had been encountered was staff not providing written work orders to the maintenance department. The administrator further stated that a hole in the wall with a partial plate cover and jagged edges could potentially cause a skin tear for a resident and that no one likes to see holes in the wall.A review of the facility policy titled Quality of Life-Homelike Environment with a revised date of February 2014 revealed that it's focus was to provide the residents with a safe, clean, comfortable homelike environment.

Based on clinical record review, interviews, facility policy review and the Resident Assessment Instrument, the facility failed to ensure the assessment for one sampled Resident #45. The universe was 25. The deficient practice could result in residents not meeting their needs according to the comprehensive assessment. Findings include:Resident #45 was admitted to the facility on [DATE] with diagnoses that included presence of cardiac pacemaker, morbid (severe) obesity, type 2 diabetes mellitus with other skin complications, type 2 diabetes mellitus with diabetic polyneuropathy and chronic respiratory failure with hypoxia.The face sheet in the electronic medical records revealed Resident #45 was identified as a white female.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] included Resident #45 had a BIMS (Brief Interview for Mental Status) score of 14 which indicated resident was cognitively intact. Section A101 included Resident #45 was white.However, the Prehospital Medical Care Directive dated March 13, 2025 and signed by Resident #45 revealed that the resident's race was documented as black.Despite inconsistencies with documentation related to the resident's race, the continuity of care document with a creation date of March 26, 2026 continued to reveal the resident's race was white.During an interview with resident #45 conducted on March 25, 2026 at 2:12 p.m., Resident #45 identified herself as a black/African American female.An interview was conducted on March 26, 2026 at 10:42 a.m. with the MDS coordinator (staff #107) who stated that upon resident's admission, the interdisciplinary team (IDT) assess the residents related to all aspects of resident care. She said the MDS staff then reviews the diagnoses codes, medications, and functional ability; and, there was a 7 day look back to conduct a review and to look for any discrepancies. The MDS coordinator stated that the MDS assessment was specific for each facility; and, she pulls the information from the documentation that was added by the admissions nurse including the resident's demographics. She said that MDS assessment accuracy was important; and, Resident #45 was black. A review of the clinical record was conducted with the MDS coordinator who stated that the resident's demographics/race in the MDS assessment should have been coded as black/African American.In an interview with the Director of Nursing (DON) conducted on March 26, 2026 2026 at 3:38 p.m., the DON stated that MDS information needs to be accurate because it is used to ensure the facility accurately provides care for the residents. A review of the clinical record was conducted with the DON who stated that the clinical record identified Resident #45 as a white female. She stated that this inaccurate because Resident #45 was black/African American.The facility policy titled Resident Assessments with a revision date of March 2025 included that all persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information.The RAI manual included that the RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents. The goal of the Overview to the Item-by-Item Guide to the MDS is to facilitate the accurate coding of the MDS resident assessment and to provide assessors with the rationale and resources to optimize resident care and outcomes. Standardizing self-reported data collection for race allows for the equal comparison of data across multiple healthcare settings and is an important step in improving quality of care and health outcomes.

Based on clinical record review, interviews, the facility documentation and policy review, the facility failed to ensure the care plan was revised to reflect the assessed need for a two-person assist with bathing for one resident's (#167). The universe was 25. The deficient practice led to staff providing care with only one person assist which resulted in the resident sustaining an injury and being hospitalized .Resident #167 was admitted to the facility on [DATE] with diagnoses that included persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage without loss of consciousness, and Crohn's disease.Review of the admission Minimum Data Set (MDS), dated [DATE], did not assess Resident #167's cognitive status. The same MDS also noted that Resident #167's functional status for bathing was total dependence and required 1-person physical assist.The care plan indicated dated December 6, 2022 revealed the resident required total assist for all Activities of Daily Living (ADLs) which included bathing. The Quarterly MDS assessment dated [DATE], indicated that a staff assessment for mental status was completed. It was noted that Resident #167's cognitive skills for daily decision making was severely impaired. The MDS also revealed that Resident #167's functional status for bathing was total dependence and required 2-person physical assist.A Monthly Summary form, dated August 29, 2023, indicated the resident was totally dependent for bathing and required one-person physical assist. The quarterly MDS assessment dated [DATE], indicated that staff assessed Resident #167's cognitive skills for daily decision making as severely impaired. It was also noted that his functional status for bathing was total dependence and required 2-persons physical assist.The Monthly Summary forms, dated October 5 and November 23, 2023, indicated Resident #167 was total dependence for bathing and required two+ persons physical assist.The progress note dated November 29, 2023, at 11:26 A.M. created by Registered Nurse (RN/Staff #138) noted that Resident #167 was restless and had pushed the rail on the gurney while a Certified Nurse Assistant (CNA) had turned to throw away a razor. It also noted that the resident had fallen from the gurney and sustained an abrasion to the left side of his head and a hematoma on the right side of his head. It further noted that bleeding was noted in his mouth but staff was unable to determine the cause of the bleeding. The documentation also included that Resident #167 was sent to the emergency room per the physician's order for evaluation.The progress note dated November 30, 2023 at 1:10 P.M revealed the Interdisciplinary Team (IDT) reviewed the incident and indicated that the resident was a high risk for falls due to his medical conditions.The ADLs care plan was revised on December 20, 2023 by the Director of Nursing (DON/Staff #7) to include requiring 2-person assist with showers. It was noted that the start date for the updated intervention was December 11, 2023. There was no evidence that the care plan was revised to include 2-person assist for bathing was identified prior to December 20, 2023.Review of the facility's 5-day investigation report, for the alleged incident, revealed there was one CNA present with Resident #167 when he fell during a shower on November 29, 2023. It also noted that the CNA was following the resident's care plan. An interview was conducted on March 28, 2026 at 8:23 A.M. with the MDS/Care Plan Coordinator/Licensed Practical Nurse (Staff #59). Staff #59 explained that the MDS is created upon admission and is updated if there is a change in condition or if a quarterly review is due. She further explained that once the MDS assessment is completed, the comprehensive care plan is triggered with information obtained from the MDS assessments. She added that she and another MDS staff person also create and update the care plans after completion of the MDS. Staff #59 reviewed Resident #167's June 2, 2023 MDS assessment and shared that he was total dependence for bathing and required 2-person assist. Staff #59 reviewed Resident #167's September 2, 2023 MDS assessment and shared that he was total dependence for bathing and required 2-person assist as well. Staff #59 also reviewed Resident #167's comprehensive care plan and shared that it was noted he was a total assist for all ADLs however, it did not specifically say that he was a 2-person assist for bathing. She further shared that she did not know why the care plan did not reflect that the resident was a 2-person assist for bathing.An interview was conducted on March 28, 2026 at 8:41 A.M. with the Director of Nursing (DON/Staff #7). Staff #7 shared that once a resident's needs are assessed, the MDS is reviewed and then the care plan is developed from the information obtained in the MDS. She further shared that the MDS nurse will do the assessments and the care plan development and/or updates. Staff #7 reviewed the June 2, 2023 MDS for Resident #167 and shared that he was total dependence and a 2-person assist for bathing. She also reviewed the September 2, 2023 MDS for Resident #167 and shared that he was total dependence and required 2-person assist for bathing at that time as well. When reviewing the care plan for Resident #167, she shared that it identified that Resident #167 was a 2-person assist with showers starting December 11, 2023. She further shared that there was no information, regarding bathing with 2-person assist, in the care plan prior to December 11, 2023. Staff #7 explained that the care plan should have reflected that the resident was a 2-person assist prior to that date and confirmed that the care plan did not match the information in Resident #167's MDS. Staff #7 explained that if a resident's required supports was not identified on the care plan, there would be a risk of injury to the resident.Review of the facility's policy and procedure titled 'Care Plans - Comprehensive' (last reviewed October 2025) indicated the comprehensive care plan is to be developed to address each resident's medical, nursing, mental, and psychosocial needs. The policy further specified the care plan is to be based on a thorough assessment, including the MDS, and must be developed within seven days of completion of the MDS to reflect the resident's current assessed needs.

Based on clinical record review, interviews, review of the facility's policy and procedures, the facility failed to ensure one resident (#167) was free from unavoidable accidents. The universe was 25. The deficient practice resulted in a resident sustaining a major injury.-Resident #167 was admitted to the facility on [DATE] with diagnoses that included persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage without loss of consciousness, and Crohn's disease.Review of the admission Minimum Data Set (MDS), dated [DATE], did not assess Resident #167's cognitive status. The same MDS also noted that Resident #167's functional status for bathing was total dependence and required 1-person physical assist.The care plan indicated dated December 6, 2022 revealed the resident required total assist for all Activities of Daily Living (ADLs) which included bathing; and, was at risk for falling related to weakness. The goal was that the resident will remain free from injury. Interventions included frequent checks by staff while in bed and to observe frequently and place in supervised area when out of bed.The Quarterly MDS assessment dated [DATE], indicated that a staff assessment for mental status was completed. It was noted that Resident #167's cognitive skills for daily decision making was severely impaired. The MDS also revealed that Resident #167's functional status for bathing was total dependence and required 2-person physical assist. The assessment also included that the resident had 1 fall with injury since admission or prior assessment.The care plan dated July 20, 2023 included that the resident had behavioral symptom of placing self on the floor. Intervention included to assess whether the behavior endangers the resident and/or others; maintain a calm environment and approach to the resident; redirect as necessary and notify provider if behaviors interfere with orsignificantly impact residents care; and, provide consistent staff as much as possible.A Monthly Summary form, dated August 29, 2023, indicated the resident was totally dependent for bathing and required one-person physical assist. The quarterly MDS assessment dated [DATE], indicated that staff assessed Resident #167's cognitive skills for daily decision making as severely impaired. It was also noted that his functional status for bathing was total dependence and required 2-persons physical assist. The assessment also included that the resident had 2 falls with no injury and 2 falls with injury since admission or prior assessment.The Monthly Summary form, dated October 5, 2023, indicated Resident #167 was total dependence for bathing and required two+ persons physical assist.The nursing progress note dated November 19, 2023 revealed resident was alert and oriented x2 and required maximum assistance with ADLsThe Monthly Summary form dated November 23, 2023, indicated Resident #167 was total dependence for bathing and required two+ persons physical assist.The nursing note dated November 23, 2023 included that the resident was alert, non-verbal, responded to simple commands and at times can track staff with eyes, was totally dependent for all ADLs was often very restless in bed and can be found sideways in bed. According to the documentation, resident had bilateral floor mats for safety.The progress note dated November 29, 2023, at 11:26 A.M. created by Registered Nurse (RN/Staff #138) noted that Resident #167 was restless and had pushed the rail on the gurney while a Certified Nurse Assistant (CNA) had turned to throw away a razor. It also noted that the resident had fallen from the gurney and sustained an abrasion to the left side of his head and a hematoma on the right side of his head. It further noted that bleeding was noted in his mouth but staff was unable to determine the cause of the bleeding. The documentation also included that Resident #167 was sent to the emergency room per the physician's order for evaluation.The physician note dated November 29, 2023 included that the resident had a fall and head injury; and, to transfer the resident to acute care hospital.The progress note dated November 30, 2023 at 1:10 P.M revealed the Interdisciplinary Team (IDT) reviewed the incident and indicated that it was crucial to note that the resident was at a high risk for falls due to his history of falling, subdural hemorrhage, schizoaffective disorder, encephalopathy, persistent vegetative state (PVS), Crohn's disease, slowness and poor responsiveness, as well as muscle wasting. Interventions in place included, but were not limited to, sending the resident to the emergency room for a CT scan. The documentation also included that it was imperative to re-evaluate the resident upon his return from the hospital. The social service note dated December 1, 2023 included that social service spoke with a case manager and discussed the resident's fall and that the resident went to the hospital and had surgery for brain bleed. The fall care plan was revised on December 8, 2023 to include that the resident had an actual fall in the shower on November 29, 2023.The ADLs care plan was revised on December 20, 2023 by the Director of Nursing (DON/Staff #7) to include requiring 2-person assist with showers. It was noted that the start date for the updated intervention was December 11, 2023. There was no evidence that the care plan was revised to include 2-person assist for bathing was identified prior to December 20, 2023.Review of the facility's 5-day investigation report, for the alleged incident, revealed there was one CNA present with Resident #167 when he fell during a shower on November 29, 2023. It also noted that the CNA was following the resident's care plan. Review of the facility's incident reports for Resident #167 revealed an undated [NAME] fall form that indicated he fell from the gurney and was sent to the hospital for evaluation and treatment.A telephonic interview was conducted with CNA (staff #1) on March 28, 2026 at 7:37 A.M. The CNA stated that she know if the resident was a 2-person assist if there was a green sticker next to their name on the name card outside of their room. Staff #1 said she remembered Resident #167 and she was with Resident #167 in the shower room and showers was just completed when Resident #167 jerked and crossed his legs which then went over the railing on the gurney that resulted in resident falling. The CNA stated that she then opened the shower room door and yelled for help from the nurses; and that, Resident #167 went to the hospital after the fall. The CNA further stated that she was by herself with Resident #167 in the shower room because at the time of the fall, Resident #167 was a 1-person assist. She said that after the fall, the resident then became a 2-person assist.In an interview with another CNA (staff #13) conducted on March 28, 2026 at 8:22 a.m., she stated that if the resident was a fall risk, the resident are place on fall preventive measures such as low bed and mats on the floor. She stated that every time she checks on the resident, she would check that these interventions are implemented. The CNA said that if the resident continues to fall despite the interventions, she will check the residents more frequently.An interview was conducted on March 28, 2026 at 8:41 A.M. with DON/Staff #7 who said that if the resident's care plan indicated that the resident was a 2-person assist and only 1-person assist was done and resulted in resident falling, then it would be neglect. She also said that not updating the care plan to reflect that the resident was a 2-person assist was also neglect because the MDS did not link to the care plan so it was not adequately implemented. She further stated that this could lead to residents sustaining an injury because something happened to them due to not getting the proper care. During the interview a review of the clinical record was conducted by the DON who stated that the MDS assessment dated [DATE] coded that Resident #167 was totally dependent and required 2-person assist for bathing; however, the DON stated that Resident #167 was identified to require a 2-person assist with showers only starting December 11, 2023. She further stated that there was no information, regarding bathing with 2-person assist, in the care plan prior to December 11, 2023. The DON further stated that the care plan should have reflected that the resident was a 2-person assist prior to December 11, 2023; and, she said that the resident's the care plan did not match the information in Resident #167's MDS.An interview was conducted on March 28, 2026 at 9:16 A.M. with the Administrator (Staff #116) who said that the resident's June 2 and September 2, 2023 MDS assessments showed that Resident #167 was totally dependent for bathing and required 2-person support which mean that 2 people were to help Resident #167 when providing showers/bathing. The administrator said that based on her interview with which she conducted in November 2023, a CNA took Resident #167 to the shower on a gurney; and, the CNA reported that jerked or seized and fell off the gurney. The administrator said that the fall took place in the shower; and that, there was only one CNA providing bathing assistance to Resident #167 at the time of the incident; but, the administrator said that based on the MDS assessment, Resident #167 was supposed to have two people helping him. Further, the administrator said that this did not meet her expectations and the risk of not providing adequate supports, identified in the MDS assessments, can cause harm to the residents.An interview with CNA (Staff #156) was conducted on March 28, 2026 at 11:04 A.M. Staff #156 revealed that neglect occurs when staff fail to meet residents' needs. Staff #156 shared she receives abuse and neglect training during monthly in-services and annual in-depth sessions. When asked whether providing a 1-person assist to a resident assessed as requiring a 2-person assist for bathing, resulting in a fall, would constitute neglect, she confirmed that it would, as the resident did not receive the required level of assistance. An interview was conducted on March 28, 2026 at 11:13 A.M. with Licensed Practical Nurse (LPN/Staff #120) who stated that neglect occurs when pain medications were given without a proper pain assessment or when cares were not being provided to the resident. She said providing a 1-person assist to a resident assessed to require a 2-person assist for bathing and resulting in a fall, would constitute neglect. She said that the resident is a 2-person assist because the resident moves a lot; and, if a resident was a 2-person assist, then there must be 2 people helping the resident. The LPN further stated that neglecting the residents could result in injury, skin damage, residents could be emotionally affected and they could lose their trust in staff to keep them safe.A review of the facility's policy and procedure titled Accidents and Incidents - Investigating and Reporting indicated it was last revised in November 2023. The policy and procedure indicated that all accidents or incidents that take place on the premises will be investigated and reported to the Director of Nursing and Administrator.The facility policy on Fall Risk Assessment included that the nursing staff, in conjunction with the Attending Provider, Consultant Pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls.

Based on observation, interviews, review of clinical record, and facility policy and procedure review, the facility failed to ensure medications were not left at bedside for one of 26 sampled residents (#102). The universe was 124. The deficient practice could result in resident taking the medication outside of the physician ordered parameters resulting in complications such as overdose, negative medication interactions and other residents having unrestricted access to medications.Findings include: Resident #102 was admitted on [DATE] with diagnoses disorganized schizophrenia, age-related osteoporosis, dependence on supplemental oxygen, peripheral vascular disease, obstructive sleep apnea, chronic bronchitis, hereditary and idiopathic neuropathy, and depression. The quarterly MDS (minimum data set) dated March 4, 2026 revealed a BIMS (brief interview of mental status) score of 14, indicating that the resident was cognitively intact. The review of the MDS further revealed no potential indicators of psychosis or behaviors.A review of the physician orders revealed an order for antifungal powder to be applied to the groin area on both sides and to the breast folds. The documented order start date was December 1, 2025 and an initial end date was documented as 'open-ended' and later changed to March 24, 2026.Review of the clinical record revealed no evidence that the resident was assessed and was determined to be safe to self-administer medications.An observation was conducted on March 24, 2026 at 10:30 AM in the room of resident #102. There were two 3-ounce bottles of Thera antifungal powder with an active ingredient of miconazole nitrate 2% on the resident's night table; and that, one bottle was empty and the other bottle was half-empty.An interview was conducted on March 24, 2026 at 10:59 AM with a registered nurse (RN/Staff #143) who stated that a medication was given to the resident and can be administered by mouth, via injection, cream, patches, lotions and powders. The RN stated that residents were not allowed to have medications at the bedside unless there was a current order in place and the resident was care-planned for it. Staff #143 stated the risk for having a medication at bedside could include overdose and another resident coming in and taking the medication.An interview was conducted on March 24, 2026 at 11:04 AM with certified nursing assistant (CNA/Staff #17) who stated that a medication was something prescribed by a doctor but could also include over the counter medications. She stated that tablets can be medications as well as injectables and powders; and that, residents were not allowed to have medications at bedside. Staff #17 stated that she checks for medication in the resident's room each time she provides treatment and if she found medications in the room she would inform the nurse. During the interview, an observation was conducted with the CNA who entered the room of resident #102, saw the 2 bottles of antifungal powder, and then brought the bottles to the RN (staff #20) who then stated that these were medications and that the resident should not have with them at bedside. Staff #20 reviewed the resident's EHR (electronic health record) and stated that there was an order for the antifungal powder but no order for self-administration of the medication. She further stated that there was also no evidence of an assessment for self-administration in the record or that it was care-planned, which she stated it should have been.An interview was conducted on March 26, 2026 at 7:30 AM with the director of nursing (DON/staff #7) who stated that a medication can come in different forms such as tablet, cream, powder or drops; and, it could be administered orally, topically or via injection. She stated that it was important to assess if the resident can self-administer medications appropriately; and, part of the assessment includes a teaching component to ensure resident safety. The DON further stated that an order was required for medication self-administration, a progress note documenting that the resident was able to self-administer medications in the correct manner and, a care plan entry. Regarding resident #102, the DON said that resident #102 reside in the long-term care hall of the facility which also had residents with behaviors. She said that miconazole nitrate was a medication. A review of the clinical record was conducted with the DON who stated that an order for the miconazole medication was in place but there was no order for resident to self-administer it. She also said that the clinical record did not have any self-administration assessment conducted for Resident #102; and that, the resident was not care planned for medication self-administration. The DON stated that not having an assessment or an order for self-administration could pose risk to include misuse or overdose.A review of the facility policy titled Self-Administration of Medications with a revision date of December 2012 revealed that as part of the evaluation of a resident being able to self-administer medications, staff and the practitioner would assess each resident's mental and physical abilities to determine if a resident is capable of self-administering medications. The policy further documented that post assessment, the findings would be documented and that medications must be stored in a safe and secure place, which is not accessible by other residents.

The facility failed to ensure resident #1 was free from avoidable accidents when transferring a resident using a Hoyer lift. This deficient practice placed the resident at risk for serious injury, pain, and further decline.Findings include:Resident #1 was admitted to the facility on [DATE], with diagnoses that include obesity, chronic pain syndrome, and long-term use of anticoagulants. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status score of 14, which indicates she was cognitively intact. A review of the care plan, dated March 19, 2025, indicated that a Hoyer lift with 2 staff will be used to safely transfer the resident, and an identified goal was that the resident would not have an injury related to transfers. A review of the physician's orders, dated March 23, 2025, revealed Resident #1 was to be transferred using a 2-person Hoyer lift. A review of the progress notes in the resident's Electronic Health Record (EHR) revealed a note, dated July 17, 2025, at 6:41 P.M., indicating Resident #1 was in her room with two CNAs who were attempting to transfer the resident from the chair to the bed. The note continues to describe that during the transfer, using the Hoyer lift, the Hoyer lift had tilted to the side, and the resident fell on the floor. The note also indicates that the resident had fallen on her buttocks and lower back and did not hit her head. An interview was conducted with Resident #1 on July 31, 2025, at 12:20 P.M. Resident #1 shared that Certified Nursing Assistant (CNA/Staff #27) and described the second staff member as a CNA who was working a different hall but could not remember her name. Resident #1 further shared that she felt staff were rushed that day, and Staff #27 had told Staff #30 to move the legs on the lift closer together. Resident #1 added that the legs of the Hoyer lift are usually spread apart to balance the Hoyer lift. Resident #1 recalled CNA/Staff #30 saying that it wasn't a good idea, and shortly after that, the Hoyer fell, and she had fallen to the ground. Resident #1 shared that usually when she is transferred, CNAs don't close the legs of the Hoyer until she is over the bed; however, Staff #27 wanted the legs together before she was over the bed so that the Hoyer legs could go under the bed more easily. Resident #1 estimated that she was about 2 feet away from the bed and suspended approximately 4 feet from the ground when the Hoyer had tipped over. Resident #1 also shared that she is still scared about using the Hoyer, so she doesn't get out of bed as often as she used to. She added that she had to get anxiety medications to help calm her. She also expressed that she no longer wanted Staff #27 to transfer her because she was not comfortable with him doing the transfer. A telephonic interview was conducted with Staff #30 on July 31, 2025, at 2:05 P.M. Staff #30 shared that she had received training on using the Hoyer lift 2 weeks after she was hired. Staff #30 shared that she was assigned to work a different hallway when Staff #27 had asked her for help with using a Hoyer lift to transfer Resident #1. They were attempting to move Resident #1 from her motorized chair to her bed when the Hoyer lift was not able to move forward due to a cord on the floor blocking the lift's forward progress. Staff #30 explained that she was working the remote for the Hoyer, and Staff #27 was using his hands to guide the resident in the sling. She continued to explain that once the Hoyer lift was stuck, she noticed that Staff #27 had his foot on the leg of the Hoyer and he was trying to push the Hoyer over the cord. It was at that time that she attempted to tell Staff #27 to wait multiple times. She shared that Staff #27 appeared to be frantic, like he was in a rush to get it done. It looked like he wasn't thinking clearly, and he was not hearing me because he was so focused on moving the Hoyer. Staff #30 then shared that it was at that point when the Hoyer fell over her, and the resident fell to the floor onto her lower back and butt from the maximum height. She also shared that Staff #27 then left the room to get help while Staff #30 was able to push the Hoyer off of herself. An interview was conducted on July 31, 2025, at 3:22 P.M. with Staff #27. He shared that he gets training on using the Hoyer lift annually and whenever there is an incident. He also shared that the last time he received training on the Hoyer lift was the same week the fall took place. Staff #27 explained that it was around 5:00 P.M., and Resident #1 was in her motorized wheelchair when she had expressed wanting to be transferred into bed. Staff #27 shared that he was in a rush that day to get everything done because he was trying to get residents changed before dinner time so they could eat comfortably as the dinner trays were close to being delivered. The other CNAs in the unit were in the dining area assisting residents, and he was in the hallway alone. He then went to another hallway to get assistance from another CNA for the Hoyer transfer. Staff #27 explained that prior to starting the process of transferring a resident, using a Hoyer lift, he ensures the area that the Hoyer lift will be used in is clear and that nothing can get caught is on the floor. He also ensures there's enough room to maneuver the Hoyer. He confirmed that he did this prior to using the Hoyer to transfer Resident #1; however, he shared that there was a tubing (oxygen tube) and electrical cord from Resident #1's roommate on the floor but he thought it was far enough out of the way that it wouldn't interfere with movement of the Hoyer lift. He also said that Staff #30 had told him that she was going to try to move the base legs closer together to fit under the bed. While he and the other CNA were turning Resident #1 towards the bed, the roommate's tubing and electrical cord were in the way, and the wheels of the Hoyer lift got caught in the tubing. He indicated that he was able to dislodge the tubing. Staff #27 explained that he believed the momentum of the sling swinging caused the Hoyer and the resident to fall over. He confirmed that Resident #1 was at the highest point in the Hoyer, due to her bed being high, when she fell. He recalled Resident #1 crying out as she fell, and she had told him that her rear end had hurt where she had landed. Staff #27 left to get a nurse immediately after the fall, and Registered Nurse (RN/Staff #70) assessed the resident and took her vitals. A mobile X-ray was brought in, but it was not able to do the scan because the resident was too big for it. The resident indicated she did not want to go to the hospital because she didn't like hospitals. Staff #27 confirmed that neurochecks were done post-fall. When asked what the risks to the residents were if the Hoyer area was not cleared before transferring residents, Staff #27 indicated that the risk would be that the Hoyer's movement would be impeded, and it would be harder to do tighter turns. The resident could fall and get injured. An interview was conducted on August 1, 2025, with Licensed Practical Nurse (LPN/Staff #93) at 8:25 A.M. Staff #93 explained that before transferring a resident, using a Hoyer lift, she would look at the bed position and the space in the room to ensure there is room to maneuver the Hoyer lift. She would also ensure that the Hoyer is working before starting the transfer and then explain to the resident what she and other staff will be doing. She also shared that she would ensure there are no cords or tubes on the floor because the Hoyer would not be able to go over it, We have to make sure it is out of the way. Staff #93 shared that the risks to the residents if they have a fall from a Hoyer lift would depend on how far the resident was from the ground. If the resident had a higher-level fall, they could have a fracture. An interview was conducted on August 1, 2025, with CNA/Staff #16 at 8:42 A.M. When asked what the process was when transferring a resident using a Hoyer lift, Staff #16 explained the process as follows: She would get a 2nd staff member to assist her and hook up the resident and ensure they are clipped in. Ensure the Hoyer is in position and one staff member is to watch the feet and the body while the other staff person operates the Hoyer lift using the remote and ensures the Hoyer lift is stable for transfer. Make sure everything is out of the way, and make sure cords are out of the way. She explained that the Hoyer lift is not able to go over cords. If you had a resident in there and tried to go over the cord, the resident in the sling would rock back and forth. She shared that a few days before this interview, she was moving a Hoyer lift with no resident in there, and there was a cord on the floor. She indicated that the sling bar was swaying and shared that she could imagine if a resident were in the sling, it would rock even more. She added that she couldn't get the Hoyer lift over the cord, so she had to move the cord out of the way before she could move the Hoyer lift. When asked what the risk to the resident would be if you attempt to push a Hoyer lift over a cord, she indicated that the Hoyer lift would tip over and fall. When asked if the legs of the Hoyer lift could be moved closer together to fit under the resident's bed, Staff #16 shared that it was risky because if the resident was obese, they might tip and fall because the legs would be too close together. She stated that she would use common sense on figuring out how much she is able to close the legs to fit under the bed without sacrificing resident safety. An interview was conducted with the Director of Nursing (DON/Staff #106) on August 1, 2025, at 9:13 A.M. Staff #106 shared that CNAs do trainings on the Hoyer lifts and have a competency test on hire, annually, and if anything happens. When asked what happened to Resident #1, Staff #106 shared that Staff #30 and Staff #27 were transferring the resident from the wheelchair to the bed, and they had put her on the sling. While transferring the resident, the Hoyer tipped. She indicated that she was not sure what caused the Hoyer to topple, but she thought it was because the legs were in the incorrect position, but she didn't know for sure. Staff #106 explained that during the process of transferring a resident, using a Hoyer lift, her expectations were that the staff would ensure the legs of the Hoyer lift were wide enough for the balance of the patient. She also shared that the legs of the Hoyer were to be open and not closed during transfer, or the legs moved closer together when the patient is in the sling, but not yet over the bed. If this were to happen, there would be the risk of the Hoyer lift tipping and the patient falling and having an injury. Staff #106 also shared that nothing should be on the floor because it wouldn't be a flat surface. There would be a bump there, and the Hoyer lift would not be able to go over it. The risk to the resident would be that the Hoyer would lose its balance, and the resident might fall because of the swinging of the sling. Review of the policy titled, Lifting Machine, Using a Mechanical, last revised in July 2024, explains the procedure of using a lifting device. Step 4 of the procedures instructs the reader to Prepare the Environment: - Clear an unobstructed path for the lift machine; ensure there is enough room to pivot; position the lift near the receiving surface; and place the lift at the correct height.

Based on the clinical record review, staff and resident interviews, and facility policies and procedures, the facility failed to protect the resident (#8) rights to be free from physical abuse by another resident (#7). The deficient practice could result in bodily injury and emotional or mental trauma.Findings include:-Regarding Resident # 7:Resident #7 was admitted to the facility on [DATE], with diagnoses that included diffuse traumatic brain injury with loss of consciousness, essential hypertension, hereditary and idiopathic neuropathy, unspecified, intrapartum hemorrhage, unspecified, anxiety disorder, unspecified. The quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS revealed that the resident had no potential indicators of psychosis but exhibited physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing or abusing others sexually), verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others, and rejection of care (e.g., bloodwork, taking medications, ADL assistance), with a frequency of 1 to 3 days. Furthermore, the MDS revealed that the resident wore glasses to improve visual acuity and was usually able to make themselves understood and understand others.The resident's quarterly care plan dated June 12, 2025, revealed that the resident was at risk for elopement related to traumatic brain injury, as evidenced by attempting to leave the building. Interventions included the use of a wander guard, completion of elopement risk assessment, and placement of the resident in supervised areas. Further, the care plan revealed that the resident had the potential to exhibit behavioral symptoms, including refusal of care, cussing at staff, and swatting with arms. The resident was noted to be gaining control of functional abilities and will now swing at staff and family. The care plan revealed that the resident is now able to drag himself out of bed, climb into his wheelchair, and propel out of the room. The resident sometimes dragged himself to the toilet and poured water from the toilet onto himself. The resident had been observed wandering into other residents' rooms and taking items. The related short-term goal identified in the care plan stated that the resident will show no signs or symptoms of negative consequences or outcomes secondary to behaviors. Interventions in the care plan included the use of two staff for all care provided, staff to watch the resident when he is out of bed in common areas, and staff will assess whether behaviors endanger the resident and or others and intervene if necessary. Additional interventions included that staff will convey an attitude of acceptance toward the resident, not alienate or criticize the resident when he is resistant to care, maintain a calm environment, and provide consistent staff as much as possible.A review of the progress note dated July 18, 2025, at 09:54 P.M. revealed notes from the facility's behavioral health team meeting where the resident's behaviors and medications were reviewed. Results of the meeting revealed that the team's psychiatric provider increased the resident's valproic acid to 250 mg TID due to behaviors and review of laboratory results.A review of a progress note dated July 19, 2025, at 10:23 P.M. revealed that the resident was involved in a resident-to-resident altercation after he was noted to wander into another resident's (resident # 8) room and take the other resident's water bottle. Staff returned the water bottle, and resident # 8 witnessed the resident coming out of the room and questioned resident #7 about taking his things. Resident #7 became agitated, began cursing, and while the staff were separating the residents, reached out and made contact, striking him in the arm. No injuries to either resident were reported.An additional review of progress notes of the past 30 days revealed entries noting resistance to care or aggression on June 24, 2025, at 10:53 P.M, June 26, 2026, at 10:36 P.M., June 30, 2025 at 02:56 P.M., July 15, 2025, at 10:18 A.M., July 18, 2025, at 06:25 A.M. All other entries indicated that the resident was cooperative with care.-Regarding Resident #8:Resident # 8 was admitted on [DATE], with diagnoses that included intracranial injury with loss of consciousness of unspecified duration, major depressive disorder, recurrent, anxiety disorder, unspecified.The quarterly MDS dated [DATE], revealed a BIMS score of 13, indicating intact cognition. The PHQ-2 revealed a score of 00, indicating no mood disturbance. Behavioral symptoms identified in the MDS included no presence of delusions, physical symptoms directed towards others, rejection/refusal of care, or wandering.A review of the resident's care plan indicated that placement was required on a secured unit secondary to his psychiatric diagnosis, poor safety awareness, which resulted in the resident exhibiting behaviors that could possibly place the resident or others at risk. A review of the resident's monthly summary progress note dated June 13, 2025, revealed that the resident had mild cognitive and memory impairment and was independent in the majority of activities of daily living, requiring only supervision or set-up assistance. The note further stated that the resident exhibited infrequent behaviors and had effective communication and understanding. review of the resident's progress note dated July 19, 2025, at 10:47 P.M. revealed that the resident was involved in a resident-to-resident altercation. The resident witnessed resident #7 coming out of his room and questioned him about taking his things. Staff attempted to separate the two residents. Resident #7 contacted the resident, hitting him in the arm. Skin assessments were conducted on both residents, which revealed no injury. Notifications were completed, but no further interventions were identified.A review of the resident's progress notes dated July 20, 2025, revealed that the resident had no complaints of pain and that no injury was noted to the resident's arm. The note indicated that the resident was up in the dayroom and spending time in activities. A review of the facility's grievance log for the previous 4 months (from April through July, 2025) revealed that there were no grievances listed for either resident. An interview was conducted with Licensed Practical Nurse (LPN/ Staff #160) on July 21, 2025, at 11:16 A.M. The LPN stated that she is familiar with abuse and defined it as verbal, physical, sexual, confinement, or misappropriation. Staff #160 stated that she receives abuse training at the facility annually and holds Crisis Prevention Institute (CPI) certification. The LPN stated that if staff witness abuse between residents, the first goal is to create safety, separate the residents, call the doctor, family, administrator, and Director of Nursing (DON). When asked about the specific incident, the LPN stated that she remembered the event and was in the day room speaking with a physician on the phone. Upon completing the telephone conversation, she turned around and noticed that resident #7 was no longer in the day room. She stated that she walked into the hallway and observed resident #7 coming out of resident #8's room, carrying some of resident #8's property as he was in his wheelchair. The LPN stated that she took the property from resident #7 and redirected him to return to the day room. She then stated that as they were moving out of resident #8's room, resident #8 returned to the unit and observed the LPN and resident #7 exiting resident #8's room. Staff #160 stated that the residents began cursing at each other, and resident #7 reached out from his wheelchair, leaned across the doorway to the room, and got him on the arm (referring to resident #8). The LPN stated that the residents were separated and assessed for injury, and that no injuries were observed.The LPN stated that resident #7's baseline is that he becomes agitated, but it is more often with staff than with other residents. Mitigation strategies reported by staff #160 included keeping resident #7 on a secure, locked down unit, supervising him, and charting on targeted assessments. The LPN stated that this incident did not meet her expectations and that the risk could be harm to the resident.A follow-up interview was conducted with staff #160 on July 21, 2025, at 2:17 P.M. She stated that day she had called the physician to report a critical lab on another resident. The LPN stated that she believed that other staff were in the shower room, but one was there and the other was taking vital signs in another area. The LPN stated that she was distracted by speaking on the telephone and writing instructions from the provider.A telephone call to interview Certified Nursing Assistant (Staff #73) was placed on July 21, 2025, at 11:30 AM. There was no answer, and a message was left. No return call was received.A telephone message was left on July 21, 2025, at 11:31 A.M. with staff #158, Certified Nursing Assistant (CNA), requesting a call back. The CNA returned the call on July 21, 2025, at 12:25 P.M. and stated that she recalls no events of resident-to-resident abuse on unit and if observed, it would not meet her expectations. The CNA stated that the risk to the resident is that they could be removed from the facility.An interview was conducted with resident #8 on July 21, 2025, at 12:18 P.M. The resident stated that he felt safe at the facility and denied any concerns. Resident #8 stated that he recalled no incidents. An observation of resident #7 was conducted on July 21, 2025, at 12:21 P.M., who was non-interviewable due to unclear verbal responses and ‘fist-bump' gestures.An interview was conducted with Certified Nursing Assistant (CNA), (Staff #122) on July 21, 2025, at 12:38 P.M., who stated that abuse could be physical, verbal, sexual or financial. The CNA stated that she is familiar with resident #7's baseline, stating, 'he can be a handful, so we really need to keep an eye on him. She further stated that resident #7 is now able to propel his manual wheelchair independently and moves quickly, often attempting to wander into other areas, including other residents' rooms. She reported that resident #7 explores other areas looking for things like jackets, games, or anything, really, and other residents get angry. The CNA stated, he doesn't really know what's going on. She stated that he is not on 1:1 status, but he really should be. The CNA reported that this has been reported to the facility administration. The CNA stated that resident-to-resident abuse would not meet her expectations and that the risk to the resident is that they may be harmed or may be moved.An interview was conducted with the Director of Nursing (DON), Staff #14, on July 21, 2025, at 2:15 P.M., who defined abuse as resident-to-resident or staff-to-resident and could include physical or verbal abuse, sexual abuse, or misappropriation. The DON stated that residents on the behavioral unit could be there for many reasons. The DON stated that the residents sign a contract and could be court-ordered are here for many reasons, and all require monitoring to watch the residents. Staff #14 stated that the staffing on unit is consistent with two CNAs and a nurse on every shift, which has an average daily census of 7 to 8 residents. The DON stated that some residents cannot be roomed with other residents. The DON stated that someone is assigned to be observing in the day room, and the other checks on the residents who are in their rooms. The DON stated that someone needs to know where the resident is at all times. Staff #14 stated that in this event, the nurse had to call a doctor, and the resident left while she was on the phone. The DON stated that she had not completed a full debrief on the incident, as it occurred the previous weekend, but advised staff that resident #7 must be monitored closely. Staff #14 reported that staff was assigned to the dining room to observe all staff, but that now, a staff member must observe him at all times. The DON stated that the resident has not been placed on 1:1 observation as she did not wish to set staff up to fail, as they may not be able to provide that level of supervision. The DON stated that when resident #7 arrived at the unit and before the incident, he was in a vegetative state, less independent, and could not participate or cooperate in therapy. However, he has now progressed and demonstrates increased mobility and function. The DON stated that the resident's family is very supportive and has a goal of taking him home. When asked what resident #7's care plan included about monitoring in the common area, she stated that before the incident, someone had to be in the dining room to observe; however, now someone needs to monitor him at all times. The DON stated that observation means that you have to keep your eyes on them at all times. Staff #14 stated that if the telephone call to the provider was not urgent, the staff member could have waited to make the call to the provider. The DON stated that the phone on the unit is behind the desk next to the med cart, which permitted the nurse to face the dining room, but based on the circumstances, she may have had her head down taking orders as she spoke to the provider. The DON stated that this event did not meet her expectations, and the risk of abuse could be injury to the resident. A review of the policy, Preventing, Reporting and Investigating Abuse/Neglect revised July 2023, revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy defined abuse as, The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.

Based on staff interviews, facility documents and the facility policy and procedures, the facility failed to complete a thorough investigation. The deficient practice could result in allegations not being substantiated. Based on staff interviews, facility documents and the facility policy and procedures, the facility failed to complete a thorough investigation. The deficient practice could result in allegations not being substantiated. Findings include: Review of the 5 day investigation dated June 13, 2025 revealed that (Resident #3) reported to (staff #11) that another nurse (staff #42) has verbally abused her and attempted to hit her awhile back. This document included that 3 residents had been interviewed, however, interviews with staff were not included. An interview was conducted on June 25, 2025 at 2:53 P.M. with the Director of Nursing (DON/staff #18) who said when an allegation is made, the facility has to make sure the resident is safe, separate them, suspend the alleged perpetrator, and do a skin check. She said that she would interview staff, interview the resident and interview other residents. The DON said that she was on vacation during this incident. An interview was conducted on June 25, 2025 at 3:00 P.M. with the Administrator (staff #31) who said the facility did interviews with the resident and the case manager did an interview with resident. She said that they do not have interviews with staff. This Administrator said that staff was spoken to but it was not written down. A policy titled Preventing, Reporting and Investigating Abuse/Neglect dated July 2023, all reports shall be promptly and thoroughly investigated by facility management. The individual conducting the investigation will, as a minimum: Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident.

Based on clinical record review, interviews, facility documentation and policy review, the facility failed to ensure a colostomy care order was in place for one resident (#1) in accordance with professional standards of care. The deficient practice could result in residents not receiving the needed services for colostomy care. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, acute respiratory failure, use of a gastrostomy tube, and tracheostomy tube. On April 30, 2025, a review of Resident #1's orders revealed no orders for colostomy care. Review of Resident #1's care plan did not identify him having a colostomy bag or that colostomy care was needed. A review of Resident #1's progress notes revealed a note, Respiratory Vent Note, dated February 16, 2025 at 8:05 PM indicating that Resident #1 had a distended abdomen that was hard to the touch. Review of progress note, dated February 17, 2025 at 2:02 PM, revealed Resident #1 was sent out to an acute care facility for further evaluation. A review of a progress note, dated February 28, 2025 at 7:49 PM, revealed Resident #1 was readmitted to the facility; and that, Resident #1 had a midline incision at abdomen approximated with staples. Colostomy with liquid stool in it. Mother notified of resident's return. A review of the acute care facility's documentation revealed that Resident #1 had a total colectomy with ileostomy on February 18, 2025. A review of the facility's Point of Care Bowel/Bladder Report revealed inconsistencies in the number of times a day the resident was checked -- included several days where Resident #1 was not checked and recorded as 'No Bowel/Bladder Data Recorded': -April 10, 2025 -April 15, 2025 -April 17, 2025 -April 18, 2025 -April 19, 2025 -April 22, 2025 -April 24, 2025 -April 25, 2025 -April 29, 2025 A review of the Medication Administration Record (MAR) for April revealed no order for colostomy care. An interview was conducted with Certified Nursing Assistant (CNA/Staff #54) on May 1, 2025 at 9:34 AM. Staff #54 stated that for residents who have a colostomy bag, they are checked every two hours and then the bag is changed when it is full or when it starts to come off. Staff #54 confirmed that Resident #1 had a colostomy bag. Staff #54 stated that she checks Resident #1 often because his bag does not stick well due to him being hairy in the area of the bag; and that, she had not observed his bag pop or him soiling himself with feces. An interview was conducted on May 1, 2025 at 9:56 AM with Registered Nurse (RN/Staff #91) who stated that colostomy bags are changed as needed depending on how quickly it gets filled. However, the bags are checked every two hours. Staff #91 confirmed that Resident #1 had a colostomy bag. Staff #91 stated that residents do not need an order for colostomy bag, however that they do need an order for colostomy care. Staff #91 was asked to locate an order for colostomy care for Resident #1 and confirmed that she was not able to locate one in the Electronic Health Record (EHR). Staff #91 stated that the risks of not having an order for colostomy care may result in patients not getting checked and the bag wouldn't get changed. She added that this would lead to the resident getting an infection. An interview was conducted on May 1, 2025 at 10:17 AM with the Director of Nursing (DON/Staff #166) who stated that residents' orders for the colostomy bags are often lumped together with orders for colostomy care. Staff #166 was asked to locate an order for colostomy care or a colostomy bag for Resident #1. Staff #166 acknowledged that she was unable to locate one in the EHR. Staff #166 stated that not having an order for the colostomy care did not meet her expectations and that possible risks for not having the order would be the residents not getting the care they needed. She added that this could lead to them getting sick and, something detrimental could happen to the residents. A secondary review of Resident #1's orders revealed an order, dated May 1, 2025 at 10:53 AM, created by staff #166. The order was for Colostomy: Change and care PRN and was instructed to be done every shift and as needed. A review of a policy titled, Medication, Treatment, and Other Orders, last reviewed in January 2025, stated Medications, treatments, and other orders will be consistent with principles of safe and effective order prescribing. Facility staff shall follow physician's orders as prescribed.

Based on observations, staff interviews and review of policies and procedures, the facility failed to ensure that staff followed sanitary guidelines during tray-line and when preparing pureed foods; and failed to ensure that foods within the refrigerator were appropriately labeled and dated. The deficient practices could result in food-borne illnesses. Findings include: An initial kitchen observation was conducted on March 4, 2025 at 8:30 A.M. in conjunction with the dietary manager (Staff #34). During the refrigerator observation it was observed that dough, a package of 4, was not labeled or dated, which was identified by the dietary manager as pizza dough. A plastic bag containing breaded fish and a bag of tortillas were also not labeled or dated. An observation was conducted on March 5, 2025 at 11:38 A.M. for purred food. It was observed that the cook, (Staff #143) had touched the outside of the food ladle with the fingers of her left hand and then proceeded to use the same ladle to obtain more ham and beans to add to the food processor. It was further observed that she touched the rim of the inside container of the food processor with four fingers of her left hand while scrapping down the sides of the container. The dietary manager, staff #34, and cook, staff #143, were informed of the observation and the puree was discarded and a new ladle was obtained. A tray-line observation was conducted on March 5, 2025 at 12:11 P.M. The facility cook (staff #118) was observed placing a her thumb on plates during the tray-line serving process. It was further observed that staff #118 was not wearing gloves while plating. After the plates were pointed out to the dietary manager, staff #34, she stated that the cook, staff #118, had washed her hands. When asked if the bare thumb should be present on a plate on which food is being served to residents she stated that it should not and she addressed the concern with the cook, staff 118. An interview was conducted on March 5, 2025 at 10:56 A.M. with the dietary manager (staff #34). Staff #34 stated that she follows her internal policy for labeling and dating items. She stated that the pizza dough should have been labeled and dated and that the tortillas were out of the box and should also have been labeled and dated. The dietary manager stated that after discussing with staff, the fish had been labeled and dated but because of how it was wrapped the date and label were inside the packaging and not visible on the outside. Staff #34 stated that this did not meet her expectations and that she would be conducting an in-service with kitchen staff. The dietary manager stated that the risk could include staff not knowing when the item arrived or where it came from. An interview was conducted on March 5, 2025 at approximately 11:40 A.M. with the dietary manager, staff #34. The dietary manager stated that she had not observed the hand contact with the ladle or the inside of the food processor during puree, but stated that this would not meet her expectations. She stated that the risk to the residents would include cross-contamination. An interview was conducted on March 5, 2025 at 11:43 A.M. with the dietary aide, (staff #174). The dietary aide stated that all items in the refrigerator have to have an open and a use by date. An interview was conducted on March 5, 2025 at 12:11 P.M. with the facility contracted dietician (staff #179) who was present during tray-line. The dietician stated that it was important to limit contact with the plate and that the risk could include food sliding to the side of the plate where the bare thumb had been in contact with the plate. An interview was conducted on March 5, 2025 at 2:25 P.M. with the administrator (staff #102). The administrator stated that her expectation is that staff label, date and follow the rules regarding temperature control for food storage. The administrator stated that that the risk could be anything, including bacterial growth and that someone could get sick. The administrator further stated that her expectation is that during food service, puree or tray-line, that hands do not come in contact with food being served. She stated that she had given staff a restaurant analogy, when made aware of the finding, and had asked if they wanted someone to put their bare hands on their plate containing food or inside their glass. She stated it was 'gross' and that the risk could include bacterial contamination which could be detrimental to the resident's health and safety and could make them sick. A review of the facility policy entitled food storage with a revision date on March 09, 2020 revealed that all products should be inspected for safety and quality and be dated upon receipt, when opened and when prepared. It further noted that all food items stored need to be labeled and dated. A review of the policy entitled Trayline Setup and Service revised July 2, 2018 revealed under item #12, that food should not be handled with bare hands.

Based on observation, clinical record review, staff interviews and policy review, the facility failed to provide incontinence care for one resident (#2). The deficient practice could result in an increased risk for resident discomfort and or infection. Findings include: Resident #2 was admitted on [DATE] with diagnosis including end stage renal disease, surgical aftercare on the circulatory system, type 2 diabetes with diabetic neuropathy, chronic diastolic congestive heart failure, chronic pain syndrome, and major depressive disorder-recurrent. A review of the admission MDS (minimum data set) dated July, 18, 2023 revealed no noted BIMS (brief interview of mental status) score. A review of the resident's care plan revealed that the resident required a one person assist for all activities of daily living to include toileting and hygiene. The care plan further revealed that the resident had the potential for skin breakdown and pressure related injuries due to the normal aging process and incontinence, further noting that the resident needed staff assistance with bed mobility, transfers and toileting. A review of the skin assessments in the resident's electronic health record revealed no evidence of skin breakdown as related to incontinence care. A review of the facility's 5-day investigation revealed that staff #11 (CNA-certified nursing assistant) and the resident's former roommate (no longer at the facility) observed that staff #190 (CNA) left resident #2 sitting on the side of the bed, while taking the roommate to lunch, during which time resident #2 had been left soiled and not changed. It was further noted that the roommate stated that the staff member had told resident #2 to just sit on the edge of her bed, because her briefs were dirty and then walked out of the room. The facility's investigative report noted that staff #190 did not follow the facility policy and procedure for caring for residents and further noted that the resident felt a little bit abused. The 5-day investigative reported noted no injuries to the resident. A telephone call was placed on December 4, 2024 at 10:50 A.M. to staff #11, transportation coordinator, left message on voicemail. No return call received. An interview was conducted on December 4, 2024 at 11:01 A.M. with resident #2. The resident stated that she recalled that incident where she had been cursed out by the staff member and had been left soiled sitting on the side of the bed. She stated that she had been left soiled, sitting on the side of the bed for about 30 minutes or maybe a bit longer. She further stated that she recalled staff #190 screaming at her but could not recall what she had said. The resident reported no resulting skin breakdown. Resident #2 stated that she felt embarrassed at the time, but feels safe and well-cared for currently. An interview was conducted on December 4, 2024 at 11:05 A.M with a licensed practical nurse (LPNstaff #155). Staff #155 stated that when a resident is soiled, the resident has to be changed right away-generally within a few minutes. She stated that the risk for not changing residents promptly could include skin breakdown. An interview was conducted on December 4, 2024 at 11:10 A.M. with a Certified Nursing Assistant (CNA/staff #10) and another CNA (CNA/staff #88). Staff #88 stated that it generally only takes a few minutes to attend to a resident's call light, and if she was unable to attend to the resident right away, she would alert one of her co-workers to assist. Staff #10 stated that if a resident's incontinence was not addressed promptly, then the risk could be at risk for skin breakdown. Both CNA's stated that the maximum time for call light response is about 10 minutes and that each CNA generally has about 7-8 resident's to care for. Neither reported any staffing concerns. An interview was conducted on December 4, 2024 at 11:16 A.M. with an LPN nursing manager (LPN/staff #69). Staff #69 stated that the expectation is that a resident is changed right away when soiled, to ensure that waste does not remain on the resident's body. Staff #69 stated that this is why aids conduct rounds. Staff #69 further stated that it would not meet his expectations if staff did not attend to a soiled resident right away or ensure that another staff member was able to assist. Staff #69 stated that the risk for a resident remaining soiled for extended periods could include moisture associated skin disease or skin breakdown. A telephone call was placed to former staff #190 (CNA) on December 4, 2024 at 11:25 A.M. A message was left requesting a call back; however, the former staff member did not return the call. An interview was conducted on December 4, 2024 at 11:38 A.M. with the Director of Nursing, (DON/staff #50) and the Administrator (admin/staff #76). When asked if 30 minutes met the DON's expectation for a resident wait time to be changed when soiled, staff #50 stated that 30 minutes was a long time and that her expectation is that staff reach out to other staff to ensure that residents are changed timely. Staff #50 further stated that the risk for a resident being soiled for 45 minutes, as noted in the facility's 5-day investigative report for resident #2, is skin breakdown. A review of the facility policy entitled Perineal Care revised October 2023, revealed that the purpose of the procedure is to ensure cleanliness and comfort to the resident, and prevent infection and skin irritation.

Based on clinical record review, staff and resident interviews, facility records and facility policy the facility failed to ensure that one resident (#1) out of 3 sampled is free from preventable falls. This deficient practice could result in resident injury and mortality. Findings include: Resident #1 was admitted on [DATE] with diagnosis including MS (multiple sclerosis) chronic respiratory failure, tracheostomy, hemiplegia and hemiparesis affecting the right dominant side, chronic pain, muscle weakness, wedge compression fractures, fracture of right tibia, and fracture right fibula. A review of the MDS (minimum data set) dated November 13, 2024 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident was cognitively intact. A review of the resident's care plan revealed that a focus area noting that the resident required the use of a mechanical lift device (Hoyer lift) and a 2-person assist was initiated on December 5, 2023. A review of the progress notes revealed that on November 15, 2024 at 8:00 A.M. that staff was called into the room of resident #1. It was notated that resident #1 was found on the floor face down. Documentation revealed that the fall occurred during a Hoyer lift transfer from the shower gurney back into bed. The resident was noted to be bleeding from the nose and a laceration to the forehead was evident. There was not reported loss of consciousness. Progress notes further revealed that the resident received initial treatment and that notifications transpired. The progress notes further revealed that the resident was complaining of bilateral lower extremity pain. A subsequent progress note entry on November 15, 2024 at 9:00 P.M. revealed that the resident had returned from the hospital via stretcher. It was noted that the right leg below the knee to the toes was splinted, and a laceration to the forehead was observed. A new order of oxycodone 5 milligrams every 4 hours was also noted. A review of the facility 5-day investigation revealed that resident #1 had been sent to the hospital post Hoyer lift fall and returned the same day. It was noted that the resident did not require surgery for the incurred compression fracture of lumbar vertebrae 1 and 3 or the right ankle fracture. The report further revealed that staff #12 CNA (certified nursing assistant) was terminated post incident. The report indicated that the facility reviewed the fall in their quality assurance and performance improvement meeting and that precautionary measures, to include review of documentation for orders and care plans linked to point of care the CNA's to facilitate appropriate transfers were present. It was noted that an in-service was initiated for Hoyer transfer training on November 18, 2024 with an noted completion date of one week, excluding staff that are on vacation. Furthermore, the report indicated that weekly audits would be started and would continue for four months to ensure that staff are following facility protocol regarding Hoyer lift transfers. A review of the in-service training logs revealed a training for Hoyer transfers ranging from November 18, 2024 through November 25, 2024. It was noted that staff #12 participated in previous Hoyer lift transfer training in 2023 and again in 2024. An interview was conducted on November 25, 2024 at 10:32 A.M. with a Certified Nursing Assistant (CNA/staff #34). Staff #34 stated that a Hoyer lift transfer always requires 2 staff members. She stated that as a CNA she has to make sure that the right size sling for the Hoyer lift to accommodate the resident is being utilized. She further stated that she would always advise the resident of what is about to happen and ensure their comfort. Staff #34 stated that there is never a good reason to conduct a Hoyer lift transfer with only one staff person. Staff #34 stated that the risk for not conducting a 2-person Hoyer lift would include not knowing if sling is properly positioned, if it looks right', that the resident could fall and would not feel safe with only one person assisting. An interview was conducted on November 25, 2024 at 10:40 A.M. with a CNA (CNA/staff #18(. Staff #18 stated that she usually works the unit where resident #1 resides. She stated that resident #1 requires a Hoyer lift transfer. She stated that a Hoyer lift transfer is always a 2-person assist, unless the person is on a ventilator, in which case the resident is a 3-person assist. Staff #18 stated that at no time can a resident who is a Hoyer lift be transferred by only one staff member. She stated that she was aware of a Hoyer lift fall that occurred the previous week involving resident #1. Staff #18 stated that she was there the day of the fall, but had not been assisting with the transfer. She stated that she was called, after the resident had fallen and was assessed to help put the resident back into bed. She stated that the resident had sustained ankle and back injuries, as well as scratches to the forehead and leg, but stated that she felt he was recovering well at this time. Staff #18 further stated that resident #1 had a tracheostomy in place but was not on a ventilator, therefore he would require a 2-person assist with the Hoyer lift transfer. She stated that the risk for the resident in not having 2-staff members facilitate the transfer would include not effectively being able to keep an eye on the resident and potential injury. Staff #18 stated that she had just received Hoyer lift training the previous week, but did not recall on which day. An interview was conducted on November 25, 2024 at 10:46 A.M. with resident #1. The resident stated that there was only one staff member assisting him with the Hoyer lift transfer when the fall occurred. He stated that he thought everything was secured on the Hoyer lift. Resident #1 further stated that during the transfer, while he was in the Hoyer lift, the batteries had given out and staff # had to retrieve new batteries. He stated that at the time he was on the Hoyer lift above the shower bed and thought it was about 2 minutes before staff # returned. He stated that when the staff # returned, he asked him if he was ready to proceed. He said once the transfer progressed, he was not sure how it happened but did a backflip out of the Hoyer lift and landed on his face. He stated that he thought his legs hit the side of the Hoyer lift. Resident # stated that his right foot had a fractured ankle and is currently in a sling and that his back is fractured. Resident #1 stated that he does have pain but usually more in the ankle. An interview was conducted on November 25, 2024 at 10:54 A.M. with a Licensed Practical Nurse (LPN/staff #159). Staff #159 stated that a Hoyer lift transfer always requires 2-staff members to assist. She stated that generally one staff member would utilize the remote, while the other would check for proper connection of the sling. She further stated that the benefit of using 2 staff members includes the ability to have extra eyes on the resident while rolling them and properly positioning them. She stated that ultimately it is an issues of safety for the resident. Staff #159 stated that she had received Hoyer transfer training last week but could not recall any prior Hoyer lift trainings. She stated that the risk with a 1-person Hoyer lift transfer is that the staff member may miss a critical element to ensure resident safety. A telephone call was placed on November 25, 2024 at 11:22 A.M. to a Registered Nurse (RN/staff #42). The call went to voicemail and a message was left. Staff #42 was noted to be present on the day of the incident. No return call was received. An interview was conducted on November 25, 2024 at 11:39 with an LPN (LPN/taff #127). Staff #127 stated that Hoyer lift transfer is always a 2-person transfer. She stated that if another CNA is not available a nurse would assist to ensure that there are always 2 people present. She stated that she thought there were quarterly trainings on Hoyer lift transfers. Staff #127 stated that the benefit of requiring the 2-person Hoyer lift transfer is that one person watches the resident while the other is maneuvering the resident into the proper position. She stated that the risk of only one person transferring the resident could include falls. She stated that she had never seen anyone on her hall conducting a one-person Hoyer lift. A telephone call was placed on November 25, 2024 at 11:51 A.M. to a CNA (CNA/staff #12). The call went to voicemail and a message was left requesting a call-back. An interview was conducted on November 25, 2024 at 12:05 P.M. with the Director of Nursing (DON/staff #180) and The Administrator (admin/staff #96). Staff #180 stated that all Hoyer lift transfers require a 2-person assist. Staff #180 stated that staff receive Hoyer lift training upon hire and annually thereafter. She stated that the risk for not conducting a Hoyer lift transfer, as required by facility policy, could result in injury to the resident. She stated that staff #12 was immediately terminated and that all other staff received Hoyer lift training. A return telephone call from a CNA (CNA/staff #12) was received on November 26, 2024 at 9:37 A.M. Staff #12 stated that he recalled the fall involving resident #1. He stated that the resident was Hoyer lift transfer requiring a 2-person assist. Staff #12 stated that he was by himself when he was attempting to get the resident ready for a shower. He stated that he did not ask for assistance from other staff as he thought he could conduct the transfer by himself. He said at one point, the battery on the Hoyer lift had given out and he had to obtain a new battery. Staff #12 stated that at the time he went to replace the battery, the resident was on the shower gurney and not on the Hoyer lift. He stated that once the battery was replaced, he proceeded to transfer the resident with the Hoyer lift. He then stated that 'it all happened so fast, he flipped out of the Hoyer lift and landed on his face' at which time he immediately called for help. Staff #12 stated that he had participated in Hoyer lift training in the past year and was aware that a Hoyer lift transfer required 2-staff members to participate in the transfer. Staff #12 stated that the risk for not having 2-staff present to facilitate the transfer could result in residents, like resident #1, getting hurt. A review of the facility policy entitled Lifting Machine with a copyright date of 2001 revealed that at least 2 nursing assistants are needed to safely move a resident with a mechanical lift. Review of facility guidance entitled Hoyer Lift Transfers revealed that the transfer is with 2-staff members from start to finish and that staff should 'NEVER' transfer with a Hoyer lift by themselves.

Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#62) did not sustain a preventable accident. The sample size was 24. The deficient practice increased the risk for pain, injury and/or hospitalization . Findings include: Resident #62 admitted to the facility on [DATE] with diagnoses including cerebellar stroke syndrome, diverticulosis of the large intestine and a persistent vegetative state. The activities of daily living (ADL) care plan dated 03/11/21 related to bathing, grooming, hygiene, toileting and bed mobility had a goal for the resident not to decline in ADL function. Interventions included 2 staff assistance for bed mobility. Review of the annual Minimum Data Set assessment dated [DATE] revealed the resident's cognition was not assessed and she required total assistance of one to two persons for most ADLs. A nursing progress note dated 01/15/23 at 3:30 a.m. included that the nurse had been called to the resident's room where she was observed on the floor without a brief, and a scant amount of feces noted. The note indicated the Certified Nursing Assistant (CNA) had assisted the resident to the floor from being at the edge of the bed. No injuries were identified. According to the note, two CNAs and the nurse assisted the resident back to bed using a Hoyer lift. The note stated that messages were left for the on-call provider and the resident's case manager. On 01/16/23 at 12:04 p.m. a nursing progress note included that the resident's right foot and ankle were swollen and painful. The provider was notified and an order for foot and ankle x-ray was obtained. Per a nursing progress note dated 01/16/23 at 5:04 p.m. the x-ray result for the resident's right foot was negative for fracture, but the right ankle had an acute bimalleolar fracture. The note indicated that the nurse practitioner, the resident's emergency contact and the case manager were notified. New orders were received for an orthopedic consult and to wrap the ankle with an ACE wrap. Review of a CNA (staff #51) written statement dated 01/23/23 included that she was changing the brief of resident #62. She stated that she positioned the resident on her left side and that her body was on the left side of the bed. The statement indicated that she finished cleaning the resident's bottom, that she was stable and still on the bed. According to the statement, as staff #51 walked to the other side of the bed to get cream for the resident's bottom she saw the resident's legs slip off the bed. She stated that she grabbed the resident's upper body in an attempt to hold her in place, but the resident fell off the bed and landed on her bottom. She stated that she still held her upper body and arm to lay her on the ground. She stated that she laid the resident on her right side and put a pillow under her head, then went to get the nurse. An interview was conducted on 02/15/23 at 1:13 p.m. with a Licensed Practical Nurse (LPN/staff #88). She stated that on the night of 01/15/23, at approximately 3:00 a.m., staff #51 called her to report that the resident was on the floor. She stated that the resident was really petite and didn't move much, and that the resident had an air-based mattress. She stated that staff #51 had told her that she was providing incontinence care to the resident and had positioned her on her left side. She said that staff #51 told her that she had been standing behind the resident on the opposite side of the bed. Staff #51 told her that she noticed that the resident was sliding off the mattress. She stated that staff #51 reported that the resident had landed on the floor on her right side, facing her roommate. Staff #88 reported that the resident had a dry patch of skin on her left thoracic area, but no injury visible to her feet. She stated that she was unable to perform neuro checks because the resident kept slapping her hand away and would not open her eyes. Staff #88 stated that she thought the resident only required one person for incontinence care. On 02/15/23 at 1:30 p.m. an interview was conducted with a CNA (staff #52). She stated that a co-worker had called her into the resident's room to assist her. She stated that her co-worker (staff #51) had told her that as she had turned the resident onto her side the resident's legs went over the side of the bed and her body followed. She stated that the resident had fallen onto the floor. She stated that she told staff #51 to go get the nurse. She stated that staff #51 got the vitals cart and took the resident's vitals, per protocol. She stated that staff #51 brought the Hoyer lift into the room and stated that it didn't work. She stated that she, the nurse and staff #51 loaded the resident onto the Hoyer sling and lifted her back onto the bed. During an interview conducted on 02/16/23 at 7:42 a.m. with a Nurse Assistant (NA/staff #51), she stated that during her rounds on 01/15/23 she was providing incontinence care to resident #62. She stated that she had raised the bed to approximately waist-height (4 feet), as she normally did, so she would not hurt her own back. She stated that the resident had an air mattress, that she was not sure of the name of the device, but that the bottom had a base and the top layer was like a balloon. She stated that during care, she turned the resident onto her left side and cleaned her bottom. She stated that the resident was close to the edge of the bed. She stated that while the resident was on the edge of the mattress, the mattress kind of deflated and squished down on that side, and the air went to the other side. She stated that she was standing on the right side of the bed. She stated that when she had finished cleaning the resident's bottom, she moved to go over to the left side of the bed. She stated that she saw the resident slip over the side. She stated that she was able to grab the resident by her arm and shoulder and hold her before she hit the floor. She stated that she lowered the resident to the floor so she could go get help. She stated that the resident's legs had not been hanging over the side of the mattress, but that she was probably too close to the edge or she would not have fallen over. An interview was conducted on 02/16/23 at 11:07 a.m. with the Director of Nursing (DON/staff #18). She stated that it was her expectation that the CNA Point of Care charting program would explain the needs of the resident and what type of assistance they would need. She stated that she expects the CNA to read the instructions and follow them. She stated that she would anticipate that the CNA would raise the bed for body mechanics purposes, so they won't hurt themselves. She stated that when a resident has an air mattress, the weight shifts, and the resident could potentially slip off the bed. She stated that after the particular incident involving resident #62, they completed an audit of all the residents who require extensive/total assistance who also have air mattresses. She stated that those residents now require 2-person assistance. She stated that she updated the care plans as well, because it was identified as a fall risk and if it happened to one person, it could happen to someone else. The Safe Lifting and Movement of Residents policy, revised February 2021, included that in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Nursing staff, in conjunction with rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessments shall include the resident's mobility and cognitive status.

Based on an observation, clinical record review, interviews, and review of facility documentation and policy, the facility failed to ensure that one of three sampled residents (#9) was provided supervision to prevent accidents that lead to death. The deficient practice could lead to death. Findings include: Resident #9 was admitted on [DATE] with diagnoses that included schizoaffective disorder, delusional disorders and cerebral infarction. A Quarterly Minimum Data Set (MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score was not conducted as the resident is rarely or never understood and a staff assessment for mental status included that the resident had a memory problem and was severely impaired for making decisions regarding the tasks of daily life. This document included that this resident had fluctuating disorganized thinking. This document included that the resident required 1 person assistance and was totally dependent on staff for locomotion on and off the unit and for eating and that this resident required a mechanically altered diet. A care plan dated [DATE] included that the resident has a history of impaired decision making related to cognition impairment, schizophrenia, delusion disorder, & depression disorder. The care plan had interventions including to determine if decisions made the resident endanger the resident or others and intervene if necessary and to provide cues and supervision for decision making. A speech therapy progress and discharge summary date [DATE] included a short-term goal that the patient will safely swallow minced and moist diet utilizing cuing or compensatory strategies from trained staff or caregivers and included that the goal was not met and the resident was not safe for a diet upgrade. A physician's order dated [DATE] included regular diet, puree texture (PU4), thin liquids. A progress note dated [DATE] included Patient had finished eating her lunch and was sitting at a table in the day room with other Patients. This writer was called by another patient sitting with patient and stated the patient was acting funny. Patient was approached and a solid piece of food was noted on her stomach. Patient was not coughing and did not appear to be choking. Patient noted to be very shaky and was offered a drink of water, patient took the water bottle and took a drink she put the water bottle down and was noted to still be shaky. Patient then collapsed in her wheel chair. The Heimlich was done 6 times and there was no response from patient. Help was called and patient was transferred to her bed, she did not respond to being moved and appeared to stop breathing. Patient was not coded due to DNR status. The facility's investigative report received by the State Agency on [DATE] included that the facility had received a call from the medical examiner that the resident had died from choking on food. This document included an interview with resident #16 who stated that she was eating lunch and resident #9 took a quesadilla from her tray and that she had not informed anyone that resident #9 had taken the quesadilla. This document also included an interview with a Registered Nurse (RN/staff #25) which included she was called to the unit and on arrival resident #9 was in bed with no vital signs and that she was informed by a CNA that resident had food in her mouth and they just took some out. This staff member used a spoon to scoop out what she could. -Resident #16 was admitted on [DATE] with diagnoses of schizoaffective disorder bipolar type, vascular dementia with behavioral disturbance and major depressive disorder. An Annual Minimum Data Set (MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. A care plan dated [DATE] included that the resident has a history of impaired decision making related to cognition impairment, schizophrenia, delusion disorder, & depression disorder. The care plan included interventions of determine if decisions made the resident endanger the resident or others and intervene if necessary and to provide cues and supervision for decision making. An Issuance of Letters dated February 27, 2017 included that the Pima County Fiduciary was appointed as guardian for resident #16 who was an adult incapacitated person. A psychiatric therapy appointment note dated [DATE] included that this resident's insight and judgement were poor. An interview was conducted with a Certified Nursing Assistant (CNA/staff #43) on [DATE] at 3:03 PM who said that the lock down unit was for residents with behaviors and dementia. She said that resident #9 had both dementia and behaviors and sometimes she would grab things, or push the table. She said that she would rarely move the wheelchair. She said that the resident would talk nonsense or hit the staff and refuse care. She said that resident was having a good day on the day of the incident and was sitting at the table with the rest of the residents and ate everything. She said that she went to the bathroom and when she came back it was happening and she did not know what was wrong. She said that the nurse was in the dining room with the residents. An interview was conducted with a Licensed Practical Nurse (LPN/staff #28) on [DATE] at 3:12 PM who said that normally resident #9 talked about demons and that sometimes you could talk her down. She said that she was very limited and that she could not move her wheelchair. She said that on the day resident #9 passed away she was alone in the room with residents #9 and #16 just after lunch and that residents #9 and #16 were sitting across from each other. She said that she was charting at the desk when resident #16 told her that resident #9 was acting funny. She checked resident #9 who was shaking and looked like going into manic episode and that a minute after she just collapsed at the wheelchair and that she stopped breathing. She said that resident #9 had food on her stomach and that it looked like a squished cheese sandwich. She said that she thought maybe she was choking and that she was there without any other staff. She said that she started the Heimlich maneuver because she saw food so she did it as a precaution. She said that she brought the resident to the doorway to call for help and that when the CNA's came they put resident #9 to bed and resident #9 had stopped breathing and that she was unable to find a heartbeat. She said that resident #9 did not have any food, but resident #16 had a quesadilla and that a quesadilla could look like a squished cheese sandwich. She said that she did not see how resident #9 could get the food, but that she heard that resident #9 got it from resident #16. She said that resident #16 was very capable of doing things. She said that one of the CNA's was in the bathroom and that she did not know where the other CNA was at. She said that she knew that one of the nurses had told resident #9's family that she choked on a quesadilla but that it could have been a heart attack. A follow up interview was conducted on [DATE] at 4:55 with LPN (staff #28) who said that she knew that 1 CNA was in the restroom and that the other CNA may have told her that she left but that she did not recall. She said that she was the one in the dining room and that she was supervising. She said that she was not able to see what was going on from the nursing station, but she knew about the situation because resident #16 told her. An interview was conducted on [DATE] at 10:11 AM with a CNA (staff #12) who said that the residents on the secure unit require supervision during meal times because some were on a puree diet or needed assistance. She said that the staff are always checking on them. She said that she remembered resident #9 and that she had some behavior problems and was not always cooperative with care. She said that resident #9 could feed herself and move her hands. She said that she would not be able to reach over and grab something off of another person's plate but if someone gave her something she could grab it. She said that resident #16 was on a regular diet and that she was always trying to get people in trouble and was never happy with what the staff did. She said that resident #16 would occasionally exchange words with the other residents, but that she was usually good with them. She said that on [DATE] she was working on that unit and that she picked up all of the trays except resident #16's tray. She said that she left the unit to talk to the staffing person at their desk and that she was on the way back when she heard the panic button. She said she did not think that she told the nurse that she left but that she did not remember. She said that she thought everyone was safe, because there was not another tray except resident #9, and the there was another CNA and the nurse were in the room. She said that normally all of the staff were in the dining room during meals except the person who assists the residents who stay in bed for meals. An interview was conducted with an LPN (staff #10) on [DATE] at 1:43 PM following an observation of the lunch meal who said that he was in the lunch room watching lunch because lunch time is not a medication pass time, and because it is good to have a 3rd or 4th eye because the residents cannot be left alone. He said that this unit is a locked down unit and that the residents have behaviors and risk of aspiration so safety first. An interview was conducted on [DATE] at 2:58 PM with the Director of Rehabilitation (staff #92) who said that resident #9 was referred to speech therapy for dysphagia caused by impaired cognitive inabilities and that someone had requested a diet upgrade. He said that the diet was puree texture with thin liquids on evaluation. He said that the resident had trials of minced moist texture but that the goals were not met and so the resident was kept on a puree texture diet. An interview was conducted on [DATE] at 3:29 PM with the Corporate Resource/Acting Director of Nursing (staff #23) who said that a puree texture diet is recommended after speech therapy has done an evaluation and that it is usually for dysphagia. She checked resident #9's diet order and said that it was regular diet, puree texture with thin liquids. She said that resident #9's cognition would vary day to day on whether resident #9 would be mentally capable of stopping herself from eating something she should not have. She said that she did not think that resident #16 would be capable of stopping herself from giving another resident something she should not eat. She said that resident #16 would voice that she knows, but that she would act on her own volition. She said that a quesadilla was a regular menu item on the day that resident #9 passed away but that she did not know what menu item resident #16 had chosen. She said that it was the facilities' routine was to have supervision. She said that after this incident, the facility educated the staff that residents should not exchange food, that they should be supervised, and how to do an emergency call. A policy titled Safety and Supervision of Residents included resident safety and supervision and assistance to prevent accidents are facility wide priorities. This document included implementing interventions to reduce accident risks and hazards includes implementing interventions when appropriate, and that resident supervision is a core component of the systems approach to safety.

Based on observations, clinical record reviews, staff interviews, documentation from the Centers for Disease Control (CDC), and policies and procedures, the facility failed to maintain an effective infection control program, by failing to ensure that contact precautions were followed for one resident (#17) with active Clostridium Difficile (C-diff). As a result, the Condition of Immediate Jeopardy (IJ) was identified. The facility also failed to ensure that infection control procedures were followed during catheter care. Findings include: On January 13, 2016 at 9:50 a.m., the Condition of Immediate Jeopardy (IJ) was identified. The Administrator, Director of Nursing, and the Clinical Consultant were informed of the facility's failure to implement infection control procedures for one resident (#17), who was on contact precautions for[DIAGNOSES REDACTED]. Observations were conducted of one CNA (certified nursing assistant) who entered this resident's room, without donning a gown or gloves, and exited the room, without washing her hands on multiple occasions. This CNA also removed a water pitcher from the resident's room and took it into a shower room and the water break room. The Administrator presented a plan of correction on January 13, 2016 at 10:23 a.m. The Administrator was informed that the plan of correction needed to include a time frame for completing staff education regarding infection control procedures. The Administrator presented a second plan of correction on January 13, 2016 at 10:39 a.m. The Administrator was informed that the plan of correction needed to address the use of personal protective equipment (PPE) related to contact precautions and that all nursing staff needed to be educated on infection control/contact precautions. The Administrator presented a third plan of correction on January 13, 2016 at 11:19 a.m. The plan of correction was accepted at 11:25 a.m. The plan of correction included staff education on isolation/contact precautions and the use of PPE, disinfecting affected areas, and monitoring. Multiple observations were conducted on January 13 and 14, 2016 of the facility implementing their plan of correction. Multiple staff were interviewed and were knowledgeable of infection control procedures including contact precautions. The Condition of Immediate Jeopardy was abated on January 14, 2016 at 8:15 a.m. -Resident #17 was admitted to the facility on on November 30, 2015, with [DIAGNOSES REDACTED]. Per the nursing notes dated January 5, 2016, the resident was having loose stools. A care plan dated January 5, 2016, identified a problem area related to the resident having loose stools due to[DIAGNOSES REDACTED]. Approaches included the following: -Maintain contact isolation. -Administer antibiotics as ordered. -Monitor lab work as ordered. -Use principles of infection control and universal/standard precautions. A physician's orders [REDACTED]. Review of a laboratory report dated January 7, 2016, revealed the resident was positive for[DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Nursing notes dated January 9 and 10, 2016, documented that the resident continued to have loose stools. A physician's orders [REDACTED]. Per a nursing note dated January 11, 2016, the resident continued on contact isolation for[DIAGNOSES REDACTED]. Nursing notes on January 12 and 13, included the resident continued to have multiple loose stools. An observation was conducted on January 13, 2016, of resident #17's room. Outside the resident's room was a cart with gowns and gloves. Also, there was a red sign taped to the door frame which included that the resident was on isolation precautions. On January 13, 2016 at 8:15 a.m., a CNA was observed in the resident's room, without a gown or gloves on. The CNA was standing by the resident's bed and was handling food and liquids, which were on the bedside table. The CNA was then observed to exit the room carrying the resident's water pitcher and did not wash her hands prior to leaving the room. The CNA then walked down the hallway and opened the shower room door, with the water pitcher in hand and went inside. The CNA exited that room and went back to the resident's room. Once again, the CNA was observed to enter the resident's room, without donning a gown and gloves. The CNA then exited the resident's room for the second time and did not wash her hands. Upon exiting, the CNA was again observed to be carrying the resident's water pitcher. She then walked down the hallway and entered another room that contained an ice chest. She exited that room and then walked back to the resident's room. Again, the CNA was observed to enter the resident's room, without donning a gown and gloves. During part of the above observations, a Licensed Practical Nurse (LPN) was present. The LPN stated that the CNA needed to have a gown and gloves on and that without them,[DIAGNOSES REDACTED] could be transmitted to other residents and staff. The LPN also stated that the resident had loose stools last night. An interview was conducted on January 13, 2016 at 8:30 a.m. with the above CNA. The CNA acknowledged that she had entered the resident's room without applying a gown and gloves and had taken the resident's water pitcher into two different rooms, and then went back into the resident's room without donning a gown or gloves. The CNA also acknowledged that she did not wash her hands when exiting the resident's room. The CNA stated that she knew she was supposed to wear a gown and gloves before entering the resident's room and that she should have washed her hands when leaving the room. Interviews were conducted with the Director of Nursing (DON) and administrative staff on January 13, 2016. The DON stated that proper infection control procedures had not been implemented for resident #17, who was diagnosed with [REDACTED]. The DON stated that for residents on isolation precautions, staff should apply a gown and gloves before entering, and should wash their hands when exiting the room. The DON stated that all infection control measures had to be implemented for residents with[DIAGNOSES REDACTED]. A facility policy on[DIAGNOSES REDACTED] included the following that preventative measures will be taken to prevent the occurrence of[DIAGNOSES REDACTED] among residents and that precautions will be taken while caring for residents with[DIAGNOSES REDACTED] to prevent the transmission of[DIAGNOSES REDACTED] to others. The policy included that[DIAGNOSES REDACTED] will be considered in residents with acute onset of diarrhea (three or more unformed loose stools) or abdominal pain. Steps toward prevention included the following: Frequent handwashing with soap and water by staff and residents, wearing gloves when handling feces or fecally contaminated articles, disinfection of items with potential fecal soiling (e.g. bedpans, commode chairs, bedrails, etc.). In addition, the policy included that residents with diarrhea associated with[DIAGNOSES REDACTED] will be placed on contact precautions. Healthcare workers and visitors will wear gloves and gowns when entering the room of a resident with[DIAGNOSES REDACTED]. Residents with diarrhea and suspected[DIAGNOSES REDACTED] infection will be placed on contact precautions while awaiting laboratory results. When caring for residents with diarrhea or fecal incontinence caused by[DIAGNOSES REDACTED], staff will maintain vigilant hand hygiene. Handwashing with soap and water is superior to alcohol based hand rub for the mechanical removal of[DIAGNOSES REDACTED] spores from hands. Glove use when caring for residents with[DIAGNOSES REDACTED] infection, washing hands with soap and water upon exiting the room of a resident with[DIAGNOSES REDACTED] infection and strict adherence to hand hygiene is considered best practice. Review of the 2007 CDC guidelines regarding[DIAGNOSES REDACTED] revealed that[DIAGNOSES REDACTED] spores are transferred to patients mainly via the hands, who have touched a contaminated surface or item. For prevention of transmission of[DIAGNOSES REDACTED] in healthcare settings, use contact precautions for patients with known or suspected[DIAGNOSES REDACTED]. The guidelines included to use gloves and gowns when entering patients rooms and during care and for all interactions that may involve contact with patient or potentially contaminated areas in the patients environment. -An observation of Foley catheter care was conducted on January 13, 2016 at 8:20 am. During this observation, a CNA (Certified Nursing Assistant) was observed to clean a resident's labia, urethral meatus and Foley catheter tubing. However, the CNA cleansed the Foley catheter tubing in an inward direction toward the insertion site, rather than starting at the insertion site outward. An interview was conducted with the CNA, who agreed that she had wiped the Foley catheter tubing in the wrong direction. The CNA acknowledged that this technique put the resident at risk for a urinary tract infection. An interview was immediately conducted with the Assistant Director of Nursing, who was present during the Foley catheter care. At this time, she agreed that improper technique was implemented during catheter care. She stated that the CNA should have wiped the catheter tubing from the insertion site outward. A facility policy titled, Urinary Catheter Care included The purpose of this procedure is to prevent catheter-associated urinary tract infections. The policy also included the following: 11. Use a clean wipe to cleanse and rinse the catheter from insertion site to approximately four inches outward.

Based on closed clinical record review, staff interviews, facility documentation, Manufacturer's instructions and policy review, the facility failed to ensure that the resident's environment remained free of accident hazards, by failing to ensure one resident (#1) was transferred safely using a mechanical lift. The sample size was three. Findings include: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was in a persistent vegetative state and was totally dependent on two staff for bed mobility and transfers. A care plan included that the resident was at risk for falls with injuries related to the use of a mechanical lift device, and due to respiratory failure with trach and ventilator, seizures, contractures and amputation of the lower limbs. The goal listed was that the resident would have a reduced risk of injury from falls and transfers, with using the hoyer lift. An approach included for staff to utilize the large full body sling for transfers. There were no other interventions related to using a mechanical lift for transfers or the number of staff required to use during transfers. According to the ADL (activities of daily living) care plan, the resident required 2 persons for cares and repositioning. According to the Medication Administration Record (MAR) for [DATE], the resident received coumadin (anticoagulant) 5 to 6 mg daily from [DATE] through 12, and received 7 mg daily from [DATE] through 15, prophylactically for deep vein thrombosis. A nursing note dated [DATE] at 8:45 a.m., included After shower, while transferring resident in full Hoyer sling from shower gurney to bed with three staff members assisting, resident was witnessed (to) fall from the Hoyer lift. Proper Hoyer, proper sling, and proper mechanics were in use. Resident witnessed hitting head on floor from the fall. 911 emergency called and transferred to (name of hospital) . A review of the hospital documentation dated [DATE] revealed .Patient was dropped four feet from a Hoyer lift at nursing home. She fell back first and hit the back of her head, but did change her baseline mental status which is open eyes with flexion contractures of both arms but no response to anything. She is bleeding from the back of her head and has a laceration on the top of her head. Patient can not communicate. EMS (emergency medical service) found her laying back down on the ground and transported her in full spine precautions . A hospital CT (computed tomography) scan of the resident's head dated [DATE] documented .Large right frontoparietal scalp hematoma. Gas bubbles are present within the frontal component. This is consistent with skin laceration .There is no evidence of intracranial hemorrhage . A nursing note dated [DATE] at 4:30 p.m., documented the resident returned from the hospital and had a Kerlix dressing to the scalp, which was intact. The note also included that the resident had a Vaseline gauze dressing beneath and per emergency room notes, they were unable to close wound, top of scalp avulsion . A nursing note dated [DATE] at 8:00 p.m. included that the wound to the top of the scalp appears to be approximately 6 to 8 centimeters (cm) in length by 2 cm wide, and the wound was not approximated. The note included that it was difficult to assess the size, as the hair was not cut in the emergency room and is covering the wound. Also noted was that the depth was unable to be determined and there was clotted blood, which we do not want to disturb to prevent further bleeding. No further bleeding was noted on dressings, post arrival on unit. The fall care plan was revised on [DATE], which included to always use at least 3 staff during transfers and that the resident's body will maintain functional alignment during transfers. Review of a nursing note dated [DATE] at 6:38 p.m. revealed Resident monitored multiple times today for increased swelling to face/head. Ice pack being applied to right side of face on and off all day to assist with swelling. Right eye and cheek were noticed to being slightly swollen and left eye was open with no swelling noticed during earlier part of day. No changes to swelling when checked at 3:00 p.m. At 5:00 p.m. was called to unit to recheck swelling to face. Noticed swelling had doubled in size and was informed of recent emesis .received order to send 911 to have resident reevaluated. According to the facility's investigative report and witness statements, the resident was being transferred on [DATE] at 8:30 a.m. from the shower gurney, using the full hoyer lift, by two CNAs and a Respiratory Therapist, who was assisting with the ventilator. Before they brought the lift in the room, they moved the roommate's commode and chair so they could get the gurney and the hoyer lift in the room. When they started lifting the resident, CNA #1 who was doing the mechanical part of the lift, realized that they had not moved the commode far enough away to be able to pull the lift back to move the resident. At this time, CNA #1 attempted to push the commode with his foot and the lift jerked, and the part holding the sling swung forward and back, and the resident slid out, before CNA #2 could stop her. The resident hit her head on the floor causing a laceration which was approximately 6 cm by 2 cm on the back of the scalp and a hematoma on the top of her scalp, which measured approximately 5 cm by 5 cm. The resident was assessed and transferred to the hospital and then returned the same day. The laceration was not stapled or sutured. The following day ([DATE]), the resident had some emesis and increased swelling to her face and was transferred back to the hospital. The facility's investigative documentation also included that it was identified that the additional items of the roommate that were partially on (resident #1's name) side of the room impeded the transfer making it difficult to position the lift. According to the hospital documentation dated [DATE], the resident presented to the hospital with vomiting that started today. She is in a baseline vegetative state. She was seen here in the emergency department yesterday after being dropped on her head while being transferred to a bed. She has severe edema over her head and the wound was not sutured due to the swelling . Another CT scan of the resident's head dated [DATE] revealed .Massive scalp hematoma, extending inferiority over the face bilaterally. This has increased dramatically since prior CT .no subdural hematoma or parenchymal bleed . Further review of the hospital documentation dated [DATE] revealed the resident had CT scans of the head and neck that did not show any intracranial injury, but did show a focal hematoma. Per the documentation, the resident had a large laceration of the scalp that could not be closed secondary to the large hematoma and was being admitted to the hospital because of being on coumadin and having this massive hematoma as a result of her injury yesterday . Clinical record documentation showed that the resident returned to the facility on [DATE] at 2:00 p.m. A nursing note dated [DATE] included the resident had a laceration to the posterior scalp, bruising to the head and edema. The resident is comatose, non verbal, and non responsive. Per the note, new interventions included to assess transfers with hoyer and increase staff assistance to 3 persons, and will order an amputee sling for use during transfers. Clinical record documentation showed that the resident returned to the facility on [DATE]. The fall care plan was revised on [DATE] and included the following: use 2 nursing staff for transfers with a new type of lift sling, with RT available as needed. Further review of the clinical record revealed a Respiratory Note dated [DATE], which included Called to patient's room for suction by CNA (certified nursing assistant) around 12:00 p.m. Upon arrival patient had a large amount of oral frothy secretions. SPO2 (saturation of peripheral oxygen) was in 40's and HR (heart rate) was in 30's. Patent was taken off vent and bagged at 100%. SPO2 increased to high 90's. After a few minutes SPO2 decreased into the 50's. Patient was taken off vent and bagged at 100%. Unable to maintain patient's SPO2 on 100%. RN (registered nurse) made aware and called 911. Patient was bagged until fire department arrived and took over. A review of the hospital documentation dated [DATE] revealed .presents to the emergency department due to unresponsiveness. Her last known normal was 1:00 a.m. Her baseline is non verbal but she usually can respond to stimuli. She desaturated to 50% at (name of nursing facility). EMS got her to 100% with trach and has been manually suctioning the trach. Her blood pressure was ,[DATE] and her temperature was 100.3. She has an infected three inch laceration on the top of her head. She was recently started on IV (intravenous) antibiotics yesterday and is taking Cipro . The hospital documentation dated [DATE] further included .The ICU (intensive care unit) was called for possible evaluation and then possible admission of a patient status [REDACTED]. Once arrived into the emergency room , the patient had a code arrest with ventricular fibrillation. This was a prolonged code, approximately after 3:00 a.m. continuous until almost 5:00 a.m. The patient has been shocked six times. In the process of this, she has had three episodes of seizures all of them requiring treatment .It has to be mentioned that the patient has undergone a CT head reevaluation which showed a new subarachnoid hemorrhage .There was also a new intraventricular hemorrhage with preexisting large scalp hematoma laceration .This patient may be admitted to the ICU, although at this point I feel that the care at this point would be futile, inhumane, and of no benefit for this patient that is actively dying . Additional hospital documentation dated [DATE] revealed that withdrawal of life support orders were written and the resident expired. An interview was conducted with CNA #1 on [DATE]. The CNA stated that he was assisting CNA #2 transfer the resident from the shower gurney to the bed. He stated that he had to move the roommates commode over to one side. He said a full body sling was under the resident and they began to lift the resident via the hoyer lift, but had to stop as he still could not move. He said that he tried to move the bedside commode with his foot. He stated that CNA #2 then screamed that the resident fell to the floor. He said that he did not know how the resident fell from the sling on the hoyer lift, but the resident was top heavy, because she had bilateral leg amputations. CNA #1 stated that there was no where to move in the room during the transfer, because the room was so cluttered. He said that he did not think the incident would have happened had the room not have been so cluttered. An interview was conducted with CNA #2 on [DATE]. CNA #2 stated that CNA #1 was helping her transfer the resident back to bed from the shower gurney. She said the shower gurney had to be moved so they could access the resident's bed, because there was not a lot of room. She said that she asked CNA #1 to wait so she could move the gurney, but he backed up and started yanking the hoyer like he was fighting with it. Staff member #2 stated that it looked like he was pulling on the hoyer lift to move it. She said the next thing she knew, the resident fell to the ground. CNA #2 said that she believed that it was the jolt of the hoyer, which caused the resident to fall, because all four straps to the full body sling were still attached to the hoyer lift and the resident slid out. An interview was conducted on [DATE], with the RT (respiratory therapist) who was in the room at the time of the incident. The RT stated that he assisted with the transfer only to ensure that the tubing didn't get caught and the ventilator was placed properly. The RT stated that as soon as he turned, the resident was already falling and it happened so quickly that he could not react. The RT stated that the resident slid out of the full body sling. An interview was conducted with the maintenance director on [DATE]. The maintenance director stated that he inspected the hoyer lift after the incident and did not find anything wrong with the lift. The director stated that the only way the hoyer could tip was if it started rocking and that would take a lot of force. An interview was conducted with the ADON (Assistant Director of Nursing) on [DATE]. The ADON stated that the facility reenacted the situation after the incident and had staff transfer her on the full body sling. The ADON stated that when her legs were out flat, the lift felt sturdy, but when she brought her legs up (to assimilate a resident without legs), she felt a bit like she was off pendulum and you could have felt how the incident could have happened. The ADON further stated that no one mentioned that the room was cluttered. An interview was conducted with the DON (Director of Nursing) and corporate nurse on [DATE]. They stated that the resident did not have legs to balance her and she was top heavy. They stated that there may have been some rocking motion when CNA #1 attempted to move the bedside commode. Review of the Manufacturer's instructions for the hoyer lift revealed the following: Clear path for lift: ensure there is space for lift to pivot and move freely to receiving area. A review of the facility's policy regarding Proper Use of a Hoyer Lift revealed .Prepare Environment .Ensure there is space for lift to pivot and move freely to receiving area .

Based on clinical record review, observations, facility documentation, staff and resident interviews, and review of facility policy and procedures, the facility failed to ensure that one resident (#1) on a ventilator received proper care and services, by failing to ensure safety measures were in place. Findings include: Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the closed clinical record revealed the resident was ventilator dependent and was a full code. The resident was alert and oriented times two to three. According to a psychiatric evaluation dated [DATE], the resident reported having anxiety and fear for the past four months related to [MEDICAL CONDITION] failure and care received by staff. A respiratory therapy (RT) note written by RT#1 dated [DATE] at 2:09 p.m., included documentation in the comment section that the resident was up in a Geri chair in the dayroom and the external alarm was "on". A progress note dated [DATE], by RT #2, documented that he was beginning rounds between 3:40 to 3:45 p.m. and walked into the resident's room. The resident was blue with no pulse, but felt warm. The note included he grabbed the code cart and called for help and told the charge RN to call 911. Chest compressions were initiated, the resident was bagged at 15 liters of oxygen, and color returned to the resident. Compressions continued with no pulse, and the resident was suctioned. EMS arrived at approximately 4:00 p.m. and transported the resident to the hospital. Review of the hospital documentation for [DATE], revealed CPR (cardiopulmonary resuscitation) efforts continued once at the hospital, however, were ineffective and the resident was pronounced dead at 4:30 p.m. Review of the facility's investigation revealed that the resident had been in the day room and was brought back to her room at approximately 2:30 p.m. Around 2:45 p.m., the resident and the resident's roommate both put on their call lights. RT was notified as the resident requested to be suctioned, which was done. At that time the resident was alert and oriented and had no distress. Per the investigation, a CNA (certified nursing assistant) reported that at approximately 3 p.m. the resident's call light was still on, so she went in the room and the resident had already been seen by RT and had no further requests. The investigative report further included that at approximately 3:40 p.m., RT#2 (the oncoming RT) approached the resident's room and heard the internal ventilator disconnect alarm and entered the room. The resident was unresponsive and cyanotic. RT #2 also noticed that the ventilator was disconnected on the side of the ventilator at the tubing connection, not at the resident. He immediately replaced the connection at the ventilator and checked for a pulse and found none. He then went out of the room and noticed the outside secondary alarm was not on and reset the alarm and went to get the crash cart. As he was returning to the room, he told the RN to call 911. Additional staff responded and CPR was given. The resident responded by clearing cyanosis, however, when pulses were checked again, there was only a weak thready pulse with compressions. They continued CPR until paramedics arrived at 4 p.m. The resident was transferred to the hospital by paramedics at 4:16 p.m. According to the ventilator internal log for [DATE], the resident was disconnected from the ventilator at 3:37 p.m. on [DATE]. On [DATE] at 11:15 a.m., the RT unit manager demonstrated how the ventilator alarm system operates. She set up a ventilator and showed that when the tubing becomes disconnected from the ventilator, or is not working correctly, an internal alarm sounds. She stated that there is also a back up external alarm system, which is connected to the ventilator. She said the external alarm boxes are outside of the resident rooms and are turned on when a ventilated resident is inside the room. She demonstrated that when it is turned on there is a blinking green light and if the ventilator becomes disconnected or is not working properly, the external alarm also sounds. She further explained that if a resident is out of the room, the external alarm box is turned around, which tells the staff that no residents are in the room that are connected to the ventilator. A phone interview was conducted on [DATE], with RT#1 (day shift). He said that the resident was in the dayroom in a Geri chair and that he had assisted the CNAs in returning the resident to her room. He stated that after they transferred the resident to her bed, he set up the ventilator on the top of the beside dresser and checked the tubing connections to the ventilator, which were secure. He said he then connected the external alarm to the ventilator, but failed to turn on the external alarm, which was outside of the door. He went on to say that he left the facility at 3:15 p.m. and that he and the oncoming RT (#2), did not conduct walking rounds on his residents. A phone interview was conducted on [DATE], with the oncoming evening RT (#2). He said that he was just starting his rounds around 3:40 p.m. on [DATE], when he walked into the resident's room and heard the internal ventilator disconnect alarm going off. He said he discovered that the tubing had become disconnected from the side of the ventilator, and not from the resident's trachea. He stated the resident was sitting up in bed, with her head angled to the side and her facial color was blue. He said he immediately reconnected the ventilator tubing to the vent and then checked for a pulse and did not find one. He stated he left the room and noticed that the external alarm outside of the door was not on so he reset it, and then went to retrieve the code cart. He also said at this same time he told the nurse to call 911. Once he returned with the code cart, CPR was started. He said CPR was done by the RT's and a CNA until the paramedics arrived at 4:00 p.m.. He further stated that at the start of his shift, he had not done walking rounds with the day shift RT (#1) and that the external alarm not being on, would have been caught. An interview was conducted on [DATE] at 12:40 p.m., with the evening RN who had worked a double shift on [DATE]. She stated she observed the resident around 2:45 p.m., and the resident had no complaints. She said about 3:45 p.m., she was exiting the nurses station when RT #2 told her to call 911, which she did. An interview was conducted on [DATE] at 1:15 p.m., with an RT who had worked the other side of the unit on [DATE]. She stated that she always does walking rounds with the oncoming RT at shift change and that it was their policy to do so. She stated that had walking rounds been done that day, the external alarm not being turned on would have been corrected. She further added that on one occasion when she was working with the resident's roommate, resident (#1) disconnected her tubing from her trachea to set off the alarm, in order to get her attention. On [DATE] at 11:05 a.m., an interview was conducted with the roommate of resident #1, who was in the room on [DATE] at the time of the incident. This resident had a trach, but was not connected to a ventilator and was able to speak in a soft tone. She stated that she heard an alarm go off at about shift change, which she thought was around 3:00 to 3:30 p.m. She stated that the alarm did not sound like an IV (intravenous fluids) alarm and she felt it was important. She said when no staff arrived, she put her call light on, but no one answered her call light and the alarm had been going off for quite a few minutes. She stated that she then pounded on her over the bedside table with her dry erase board that she uses to communicate with, but still no one responded. She stated she finally heard the RT staff (#2) enter the room about 10 minutes after the alarm began, and overheard him saying that she did not have a pulse. She said shortly after many people arrived to help revive her roommate, until paramedics arrived at 4:00 p.m. Additional observations were conducted on [DATE], which revealed that outside of each room was a metal bracket, which stored the external ventilator alarm box. The box was approximately five by eight inches in size. When turned on there was a flashing green light that indicated a resident was in the room with the ventilator connected. An observation was also made of the distance between resident #1's room and the RT work station, which was approximately 100 feet. Two others RTs were interviewed on [DATE] at 1:25 p.m. One stated that it is sometimes difficult to hear the internal ventilator disconnect alarm in a room over a resident's television set, but you can hear the external ventilator alarm from the RT station. The other RT stated that if he was in the RT work station, there was no way to hear an internal ventilator alarm down at the end of the unit, where the resident's room had been. An interview was conducted with the RT unit manager on [DATE]. At this time the ventilator log mentioned above was reviewed for [DATE] at 2:09 p.m., when the resident was noted to be up in Geri chair in the day room and the documentation included that the external alarm was on. She said the charting was inaccurate, as there was no way the resident could be connected in the dayroom to the external alarm. The facility's policy and procedure regarding respiratory rounds dated [DATE], included the purpose was to assure that the respiratory residents are monitored and inspected by staff for safety. The policy included that rounds will be done at the beginning and end of each shift to do initial daily assessment and continuous monitoring. The policy also stated that all rounds will be documented in the resident's record and for ventilator residents should include, "All ventilator settings, oxygen liter flow, alarm and equipment functioning properly..." A review of the facility's policy and procedure for remote alarms dated [DATE], documented that remote alarms "alert all licensed staff of potentially life threatening situations with mechanical ventilators, such as accidental disconnection from the resident. It is the responsibility of all licensed staff to answer remote alarms and respond immediately to location of said alarm." The policy further included to turn on remote alarm, check if alarm is functional and monitor for alarm and that when the resident is taken off the ventilator, the alarm will be turned vertical and the alarm will be reversed when not in use.