Every finding on record at George Regional Health & Rehab Center

Based on observation, interview, record review, and facility policy review, the facility failed to procure, store, and maintain food under sanitary conditions by failing to ensure opened food items were properly covered, labeled, dated, and discarded in accordance with facility policy and by failing to remove moldy and deteriorated fresh produce from refrigerated storage, with the potential to affect all residents who received food prepared by the dietary department.Findings include: A review of the facility's policy titled, Food Storage, revealed .Procedure.7.c. Date marking should be visible on all high-risk food to indicate the date .ready-to-eat TCS (time/temperature control for safety) food should be consumed, sold, or discarded.12. Leftover food should be stored in covered containers or wrapped carefully and securely.clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2022 Federal Food Code.13.f. all food should be covered, labeled, and dated, and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates.or discarded.g. All foods should be stored to allow air circulation. On 06/28/2026 at 10:27 AM, during an observation and interview on the initial kitchen tour with the Dietary Manager (DM) #1, the following observations were made: one (1) opened pound cake, dated 06/19/2026, was stored with the food product exposed, was not repackaged or covered, and had not been discarded in accordance with the facility's seven-day policy after opening, Five (5) containers of fresh blueberries with visible mold were stored in a case that restricted adequate air circulation, and (1) one-pound container of strawberries contained visible mold on the fruit. DM #1 observed the above findings and acknowledged the produce was deteriorated. During an interview, DM #1 stated dietary staff were responsible for monitoring opened food items to ensure they were properly covered, labeled, dated, and discarded in accordance with facility policy. She further stated dietary staff were responsible for monitoring fresh produce and removing spoiled items from storage.On 07/01/2026 at 2:36 PM, during a follow-up interview, DM #1 stated all food items were expected to be covered, labeled, dated, and discarded in accordance with facility policy. She stated responsibility for monitoring food storage was shared among dietary staff and acknowledged accountability had not been consistently maintained. She reported plans to provide re-education and monitor staff compliance.On 07/01/2026 at 3:23 PM, during an interview, the Administrator stated the facility expected food items to be properly covered, labeled, dated, stored, and discarded in accordance with facility policy to maintain sanitary conditions and reduce the risk of foodborne illness.A record review of dietary staff in-service records dated 10/28/2025 and 10/31/2025 revealed staff received education regarding foodborne illness prevention, cross-contamination, food storage, and leftover food handling.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure required oxygen cautionary signage was posted for a resident receiving oxygen therapy, affecting one (1) of two (2) residents reviewed for respiratory care. (Resident #12).Findings include:A review of the facility's policy titled, Oxygen Administration, implemented and revised 02/04/2026, revealed, .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences . Policy Explanation and Compliance Guidelines .6. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use .On 06/29/2026 at 10:35 AM, during an observation and interview, Resident #12 was observed lying in bed receiving oxygen via nasal cannula at 2 liters/minute (L/min). The resident stated she was recovering from pneumonia, continued to have a cough, felt weak, and experienced shortness of breath. No oxygen cautionary signage was observed on the resident's door or door frame.On 06/29/2026 at 2:05 PM, during a follow-up observation, Resident #12 remained in bed receiving oxygen via nasal cannula at 2 L/min. No oxygen cautionary signage was observed on the resident's door or door frame.On 06/30/2026 at 9:40 AM, during an observation, Resident #12 was not in the room; however, oxygen remained in use at 2 L/min from the wall outlet. No oxygen cautionary signage was observed on the resident's door or door frame.On 06/30/2026 at 9:55 AM, during an interview, Certified Nurse Aide (CNA) #5 stated Resident #12 had experienced weakness since returning from the hospital following treatment for pneumonia and wore oxygen most of the time while in her room, removing it only when leaving the room.On 06/30/2026 at 10:40 AM, during an interview and observation, Licensed Practical Nurse (LPN) #1 stated Resident #12 had been using oxygen as needed since returning from the hospital with pneumonia. LPN #1 stated residents receiving oxygen should have an oxygen caution sign posted on the door frame to indicate oxygen was in use. During the observation, LPN #1 confirmed no oxygen cautionary signage was present. LPN #1 further stated responsibility for placing the signage was not assigned to a specific staff member.On 06/30/2026 at 4:00 PM, during an interview, the Director of Nursing (DON) confirmed an oxygen cautionary sign should have been posted near the entrance of Resident #12's room, typically on the door frame, to alert staff and visitors that oxygen was in use. The DON stated the purpose of the signage was to promote resident and staff safety and confirmed staff were expected to place the sign whenever oxygen was in use.A record review of Resident #12's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including non-ST elevation myocardial infarction (NSTEMI)(Heart Attack).A record review of Resident #12's Order Summary Report revealed a physician's order for oxygen at 2 L/min via nasal cannula as needed for complaints of dyspnea or oxygen saturation less than 92 percent, with a start date of 06/16/2025.A record review of Resident #12's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/06/2026 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact.

Based on record review, staff interview, and facility policy review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) Level I screenings were completed accurately and residents received appropriate referral for PASRR Level II evaluation in accordance with PASRR requirements, affecting two (2) of (2) residents reviewed for PASRR requirements. (Residents #2 and #8).Findings Include:A review of the facility's policy, Resident Assessment- Coordination with PASARR program with revision date 10/30/25, revealed Policy: the facility coordinates assessments with the preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder (MD), intellectual disability (ID), or related condition receives care and services in the most integrated setting appropriate to their needs.Policy Explanation and Compliance Guidelines.5. a. The facility must screen the individual using the State's Level 1 screening process and refer any resident who has or may have MD, ID, or a related condition to the appropriate state designated authority for Level II PASARR evaluation. Resident #2A record review of the admission Record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus with Unspecified Complications, Major Depressive Disorder, Recurrent, Unspecified, and Schizoaffective Disorder, Depressive Type.A record review of the Order Summary Report for Resident #2 revealed active physician orders for Quetiapine Fumarate 25 mg daily with start date 10/18/24 and Sertraline HCL 50 mg daily with start date 1/30/26.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/29/2026 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Review of Section I revealed a diagnosis of schizophrenia.A record review of Resident #2's clinical record revealed a PASRR Level I assessment was present; however, no PASRR Level II evaluation was located in the medical record. Further review of the Pre-admission Screening (PAS) Application for Long Term Care revealed Section IX, Federal PASRR, was marked No for a diagnosis of major mental illness. Review of the LTSS Mississippi Screening Questionnaire revealed Section I (Medications) contained no documented medications, and Section J (Diagnosis 1) identified Acute Respiratory Failure with Hypoxia as the resident's diagnosis, although the clinical record documented an active diagnosis of schizoaffective disorder.On 6/29/26 at 3:13 PM, an interview with the Director of Nursing (DON) for Resident #2 revealed a PASRR Level II evaluation had not been completed.On 06/30/2026 at 11:27 AM, during an interview, Social Services Director (SS #1) stated a PASRR Level I assessment was completed upon admission. She confirmed a PASRR Level II evaluation had not been completed. She stated a diagnosis change typically prompt a PASRR Level II review and confirmed no PASRR Level II evaluation was in Resident #2's medical record.On 06/30/2026 at 12:44 PM, during an interview with the Director of Nursing (DON), she stated the facility submits PASRR Level I assessments upon admission and relies on the appropriate state designated authority to identify residents requiring a PASRR Level II evaluation. She acknowledged the facility did not follow up when the PASRR Level I assessment was completed incorrectly and did not trigger a PASRR Level II evaluation. After reviewing Resident #2's PASRR Level I assessment, the DON confirmed inaccurate information had been entered in Section I and Section J and acknowledged the inaccurate information could prevent a PASRR Level II evaluation from being initiated. She further stated staff are expected to complete PASRR Level I assessments accurately.Resident #8A record review of Resident #8's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The record revealed a diagnosis of schizoaffective disorder was added on 06/30/2025 following the resident's admission.A record review of the Pre-admission Screening (PAS) Application for Long Term Care for Resident #8 revealed Section IX. Federal PASRR was marked yes for a diagnosis of Alzheimer's/dementia and no for diagnosis of a major mental illness. No documentation was identified showing the updated psychiatric diagnosis of schizoaffective disorder had been submitted to the appropriate state-designated PASRR authority for review.A record review of the Order Summary Report for Resident #8 revealed orders for Aricept Oral Tablet 10 MG (Donepezil Hydrochloride) with a start date 4/28/25 and Zyprexa Oral Tablet 2.5 MG (Olanzapine) with a start date 11/20/25.A record review of the Annual MDS with an ARD of 4/22/2026 for Resident #8 revealed a BIMS score of 11, indicating moderately impaired cognition. Review of Section I revealed a diagnosis of schizophrenia.On 6/30/26 at 1:51 PM, an interview with the Social Services Designee (SS #2) for Resident #8 revealed no significant behavioral concerns had been reported, and no PASRR Level II evaluation had been initiated following the addition of the schizoaffective disorder diagnosis.On 07/01/2026 at 9:16 AM, during an interview with Registered Nurse (RN) #1, she confirmed the diagnosis of schizoaffective disorder documented for Resident #8 on 06/30/2025 should have prompted the facility to submit the updated diagnosis for PASRR review following the resident's admission.On 07/01/2026 at 2:55 PM, during a post-exit interview, the Administrator acknowledged the facility failed to submit the required PASRR referrals for Level II evaluation for Residents #2 and #8. The Administrator stated there was no rebuttal to the findings.

Based on interviews, record review, and facility policy review, the facility failed to resolve and provide follow-up regarding grievances brought forward by the Resident Council related to food quality and cleanliness of resident rooms for six (6) of (12) months of Resident Council meetings reviewed. Findings include:A review of the facility's policy, Resident and Family Grievances, revised 2/1/26 revealed It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal, or fear of discrimination or reprisal. The grievance official would take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. Steps to resolve the grievance may involve forwarding the grievances to the appropriate department manager for follow-up. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the grievance official. Prompt efforts include acknowledgement of complaint/grievance and actively working toward a resolution of that complaint/grievance. The grievance official, or designee, will keep the resident appropriately appraised of progress towards resolution of the grievances. The grievance official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include, at minimum, the date the grievance was received, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions. statement as she was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of grievance, and the date written decision was issued. The facility will make prompt efforts to resolve grievances.A review of the facility's policy, Resident Council Meetings, revised 12/17/25 revealed the facility Shall act upon concerns and recommendation of the Council, make attempts to accommodate recommendations to the extent practical, and communicate its decisions to the Council. The Activity Director, or designated Liaison, shall assist the Resident Council with scheduling of meetings and meeting topics, upon request by the Council.A record review of the Resident Council Meeting Minutes dated January 1, 2026, revealed the breakfast and supper were cold. The chicken breast and chicken legs are not cooked all the way. The fried chicken was cooked hard. The dietary resolution for January was a cook, and a defective base heater was replaced. The staff was in-serviced to temp (check the temperature) of the chicken at the thickest part of the chicken. February 2026, The Residents complained that the resolution for January was not effective because the food continues to be over and undercooked in February 2026. The resolution for February from dietary revealed they have instructed the staff to recommend an alternate from the always available menu, if the residents have concerns about fried food. March 2026, Residents complained they are not getting the correct food that they ordered from always available menu. Example, if they order a ham sandwich, they will receive a hamburger. The dietary resolution is that the residents can choose from the regular menu or the always available menu. May 2026, the residents complained that the resolutions are not effective because the chicken is overcooked and they are not receiving what they ordered from the always available menu. The Dietary manager stated that he talked to the cooks about the cooking time for chicken tenders. June 2026 revealed residents repeatedly voiced concerns regarding food quality, food temperature. The residents stated their complaints have not been resolved because the food is terrible. In the meeting the minutes the residents also expressed concerns about room cleanliness, and housekeeping services March 2026, The housekeeping resolution revealed the resident's rooms will be cleaned and trash taken out daily for April 2026, and June 2026. The residents' state this has not been resolved because the staff do not clean their rooms are take out the trash on weekends. The meeting minutes revealed the same concerns that were discussed during multiple meetings. The records revealed interventions were discussed and corrective actions were implemented, but follow-up with the resident council to see if interventions put in place resolved the issues.On 6/29/26 at 3:00 PM, during an interview with Resident Council members attended by the Administrator, Residents reported they routinely complained during resident council meetings about cold food, poor food quality, and unclean and the rooms. The residents also reported the food was either undercooked or overcooked. Residents provide examples that baked chicken was undercooked and fried chicken was cooked too hard. The residents reported these concerns have been discussed for several months and they were told that if they did not like the meal being served, they could order from the always available menu. The residents further reported that when concerns were brought directly to the Administrator, improvements occurred for a couple of weeks and then conditions returned to the same routine. The residents reported housekeeping staff would clean rooms on the day a complaint was made; however, housekeeping services were not consistently provided on weekends. The residents reported food quality and room cleanliness were worse on weekends. One resident reported requesting soup and receiving a can of soup from the kitchen. Several residents reported garbage cans were overflowing by Monday morning because housekeeping services were not provided on the weekends.On 6/29/26 at 3:15 PM, during an interview with the Activity Director (AD), the AD reported she attended Resident Council meetings and was aware residents had voiced concerns regarding food services and room cleanliness for several months. The AD reported she was unable to provide documentation demonstrating the concerns were resolved. The AD reported she communicated the residents' concerns to the Dietary Director and Housekeeping Director and that residents continued to complain about food quality and room cleanliness. The AD reported concerns were addressed; however, they had not been resolved. The AD further reported she typically read the department heads' responses back to the residents during Resident Council meetings. On 6/30/26 at 09:00 AM, during an interview with the Housekeeping Supervisor, the supervisor acknowledged residents had complained regarding cleanliness of resident rooms. The supervisor reported he believed the concerns had been corrected and focused on the residents who directly complained to him. The supervisor reported he was unaware additional residents continued to have the same concerns. On 6/30/26 at 10:00 AM, during an interview with the Dietary Manager, the Dietary Manager reported he was not aware residents continued to complain about the food. The Dietary Manager reported residents had not complained directly to him in over a year except for one resident who frequently requested menu items that were unavailable. The Dietary Manager reported that residents who did not like the meal being served could order from the always available menu. The Dietary Manager reported he had not attended Resident Council meetings to discuss concerns with residents because he was unaware the concerns continued.On 7/1/16 at 09:00 AM Certified Nursing Assistant (CNA)# 6 explained that the residents have complained about the food being cold and one resident complains they never give him what he orders. If he orders a sandwich with chips. He will get the sandwich and no chips. If he orders two boxes of cereal. He will only get one. CNA #6 also stated that the residents complain about their rooms not being cleaned on the weekends.On 7/1/26 at 9:20AM, interview with CNA #7 explained that the residents have complained about the poor quality of food. The CNA #7 stated the residents complain of not getting what they requested, food is cold (mainly soup) and it's either not done or it's cooked too hard. The residents also complain about their rooms not being cleaned on weekends. The CNA #7 said she thinks the facility does not have enough housekeepers to clean all the rooms. On 7/1/26 at 1:00 PM, during an interview with the Administrator, the Administrator acknowledged the facility was expected to investigate resident grievances, implement corrective actions when indicated, and provide follow-up regarding concerns raised through the Resident Council process. The Administrator confirmed she was aware of the residents complaining about the food and the cleanliness of their rooms. The Administrator said she expected the department heads to resolve the complaints in a timely manner. Record review of Resident council Members:Resident #3A record review of the facility admission record revealed the resident was admitted on [DATE] with a DX of Occlusion and Stenosis of right carotid artery.A record review of residents Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/20/26 revealed a Brief Interview for Mental Status(BIMS) score of 15 which indicated cognitively intact.Resident #8A record review of the facility admission record revealed the resident was admitted on [DATE] with a DX of Hypertension, and pain.A record review of residents' Annual MDS with an ARD of 4/22/26 revealed BIMS score of 11 which indicated cognitively intact. Resident #11A record review of the facility admission record revealed the resident was admitted on [DATE] with a DX of Chronic Embolism and Thrombosis and Hypertension.A record review of resident's Quarterly MDS with an ARD of 4/1/26 revealed BIMS score of 15 which indicated cognitively intact. Resident #16A record review of the facility admission record revealed the resident was admitted on [DATE] with a DX of Chronic Kidney Disease with stage 1through stage 4A record review of residents' Quarterly MDS with an ARD of 5/13/26 revealed BIMS score of 15 which indicated cognitively intact. Resident #23A record review of the facility admission record revealed the resident was admitted on [DATE] with a DX of spastic paraplegia and neurogenic bladder.A record review of residents' admission MDS with an ARD of 4/22/26 revealed BIMS score of 15 which indicated cognitively intact. Resident #24A record review of the facility admission record revealed the resident was admitted on [DATE] with a DX of Atrial FibrillationA record review of residents' Quarterly MDS with an ARD of 6/10/26 revealed BIMS score of 15 which indicated cognitively intact. Resident #33A record review of the facility admission record revealed the resident was admitted on [DATE] with a DX of ParaplegiaA record review of residents' Quarterly MDS with an ARD of 3/25/25 revealed BIMS score of 15 which indicated cognitively intact. Resident #40A record review of the facility admission record revealed the resident was admitted on [DATE] with a DX of Fracture of unspecified part of left clavicle and heart failure.A record review of residents' Quarterly MDS with an ARD of 5/6/26 revealed BIMS score of 14 which indicated cognitively intact. Resident #44 A record review of the facility admission record revealed the resident was admitted on [DATE] with a DX of Chronic Obstructive Pulmonary Disease (COPD).A record review of residents' admission MDS with an ARD of 4/24/26 revealed BIMS score of 15 which indicated cognitively intact. Resident #47 A record review of the facility admission record revealed the resident was admitted on [DATE] with a DX of heart failure and Hypertension.A record review of residents' Quarterly MDS with an ARD of 5/6/26 revealed BIMS score of 15 which indicated cognitively intact.

Based on record review, staff interview, and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the Resident's nutritional status by coding the resident as receiving tube feeding when the resident had no feeding tube, did not receive enteral nutrition during the assessment reference period, and had an active physician order for a regular diet, affecting one (1) of (16) residents reviewed for MDS accuracy. (Resident #24).Findings include:A review of facility's policy titled, MDS 3.0 Completion, with a revised date of 12/17/25, revealed, .Policy.Residents are assessed.to identify care needs.Policy Explanation and Compliance Guidelines.1.conducts.comprehensive, accurate.assessment of each resident's functional capacity. A record review of the admission Record revealed Resident #24 was admitted by the facility on 9/13/24 with diagnoses including Unspecified Atrial Fibrillation. A record review of Resident #24's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/2026 revealed Section K0520, Nutritional Approaches, Item B (Feeding tube [e.g., nasogastric or abdominal (PEG)] while a resident), was coded Yes, indicating the resident received tube feeding during the assessment reference period.A record review of Resident #24's Registered Dietitian (RD) Assessment, with an effective date of 03/10/2026, revealed the resident's current diet order was a regular diet. The effective date of the assessment fell within the MDS assessment reference period for the Quarterly MDS with an ARD of 03/11/2026.A record review of Resident #24's Order Summary Report revealed an active physician's order, dated 09/13/2024, for a regular diet with regular texture and regular/thin liquid consistency. The order remained active during the Quarterly MDS assessment reference period with an ARD of 03/11/2026.A record review of Resident #24's Intake and Output report for the month of March 2026, which included the Quarterly MDS assessment reference period with an ARD of 03/11/2026, revealed the resident consumed meals by mouth, with meal intake documented as the percentage consumed for each meal. The Intake and Output report contained no documentation indicating the resident received enteral nutrition or nutrition administered by feeding tube during the assessment reference period.A record review of Resident #24's clinical record revealed no physician orders, assessments, progress notes, dietary documentation, or other medical record documentation indicating the resident had a feeding tube or received enteral nutrition during the Quarterly MDS assessment reference period with an ARD of 03/11/2026. On 06/30/2026 at 3:47 PM, during an interview with Licensed Practical Nurse (LPN) #2, she stated she was responsible for completing MDS assessments. She reported that medical records, including physician orders, progress notes, therapy documentation, and dietary records, are reviewed to determine the appropriate MDS coding. She confirmed that tube feeding should not have been coded on the Quarterly MDS with an ARD of 03/11/2026. On 07/01/2026 at 12:30 PM, during an interview with the Director of Nursing (DON), she confirmed the MDS with an ARD of 03/11/2026 had been coded incorrectly to indicate the resident had a feeding tube. She stated the resident had never had a feeding tube or received enteral nutrition while residing at the facility. The DON further stated her expectation was that MDS assessments be completed accurately and reflect the resident's actual status during the assessment reference period. On 07/01/26 at 1:18 PM, during an interview with the Administrator, she stated that Resident #24 did not have a feeding tube and had not received enteral nutrition. She confirmed the Quarterly MDS with an ARD 3/11/26 was coded inaccurately. She stated her expectation was that the MDS be completed accurately and reflect the resident's status during the assessment reference period.

Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement individualized comprehensive care plan interventions that addressed residents' assessed needs and physician-prescribed treatment regiments, for three (3) of (16) residents reviewed for comprehensive care planning. (Residents #6, #7, and #55). Findings include: A review of the facility's policy titled, Comprehensive Care Plans revised on 2/1/26, revealed It is the policy of the facility to develop and implement a comprehensive person centered care plan for each resident consistent with residents rights that include measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs and ALL services that are identified in resident's comprehensive assessment to meet professional standards of quality.Policy Explanation and Compliance Guidelines.3. The comprehensive care plan will describe.a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident #6 A record review of Resident #6's Care Plan Report revealed a pain-related focus and interventions that included administration of prescribed pain medication; however, the care plan did not include individualized interventions directing staff how to manage the resident's pain during activities of daily living (ADLs), repositioning, or turning, despite documentation and staff reports that the resident experienced pain during these care activities. On 6/29/26 at 2:29 PM, during an interview with Resident #6, the resident reported experiencing pain during turning, repositioning, movement, and dressing and reported not routinely being offered pain medication prior to bathing or ADL care. On 6/30/26 at 2:30 PM, an interview with Certified Nursing Assistant (CNA #4) for Resident #6 revealed the resident verbalized pain during repositioning, transfers, and ADL care and reported notifying nursing staff when pain was reported. On 6/30/26 at 2:35 PM, an interview with Registered Nurse Charge Nurse (RN #3) for Resident #6 revealed nursing staff received reports of the resident experiencing pain and reported the resident complained of pain during bathing, repositioning, and turning. On 6/30/26 at 3:50 PM, an interview with Minimum Data Set (MDS)/Care Plan and Admissions Nurse (RN #1) for Resident #6 revealed the care plan should include individualized interventions based on MDS findings and nursing input. During review of the care plan, RN #1 confirmed individualized interventions addressing pain during ADLs and repositioning were not included. A record review of the admission Record for Resident #6 revealed the facility admitted the resident on 5/1/2026 with the diagnoses of CHRONIC COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE. A record review of the Order Details for Resident #6 revealed a physician order for Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (milligrams) every eight (8) hours PRN (as needed). A record review of the Annual MDS with an Assessment Reference Date (ARD) of 5/8/2026 for Resident #6 revealed Section J indicated frequent pain and a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired. Resident #7 A record review of Resident #7's Care Plan Report revealed a focus of At risk for injury/falls, r/t (related to) Hemiplegia, Dementia, Epilepsy, Muscle Weakness, and Poor Safety Awareness. Interventions included keeping the resident's call light within reach. The care plan also included a separate focus of At risk for abnormal bleeding related to med (medication) usage, initiated on 07/17/2024. Interventions under this focus directed staff to observe for bruising, nosebleeds, hematuria (blood in the urine), bloody stools, bleeding gums, and petechiae (tiny pinpoint red, purple, or brown spots caused by bleeding under the skin), and to report signs and symptoms of abnormal bleeding to MD (Medical Doctor). On 06/29/2026 at 2:35 PM, during an observation of Resident #7, the resident was lying in bed. The call light was wrapped around the overhead bed light fixture above the head of the bed, placing it beyond the resident's reach. On 06/30/2026 at 11:30 AM, during an interview with RN #2, she stated Resident #7 did not refuse medications or treatments. After reviewing Resident #7's Medication Administration Record (MAR), RN #2 confirmed there was no documentation of monitoring for potential adverse consequences associated with the resident's psychotropic or anticoagulant medications. She further stated there was no designated area on the MAR to document monitoring for potential adverse consequences. On 06/30/2026 at 2:00 PM, during an interview and observation of Resident #7, resident was in the dining room interacting with activities. Resident reported that he wasn't sure what types of medications he is on, but the staff give him his medications daily. On 07/01/2026 at 9:09 AM, during an observation of Resident #7's room while the resident was out of the room, the call light remained wrapped around the overhead bed light fixture in the same inaccessible position observed on the previous two survey days. On 7/1/26 at 9:33 AM, an interview with Certified Nursing Assistant Supervisor (CNA #1) for Resident #7 revealed staff received training on call light placement and resident safety. During the interview, the call light remained in the same inaccessible position observed on the previous survey days. CNA #1 stated the call light should only be temporarily moved out of reach while cleaning the room or making the bed and should otherwise remain within the resident's reach. On 7/1/26 at 3:15 PM, an interview with the Administrator for Residents #6 and #7 revealed expectations were for staff to ensure each resident's comprehensive care plan was individualized and implemented with interventions addressing identified needs, including pain management and safety. A record review of Resident #7's admission Record revealed the facility initially admitted the resident on 7/28/22 with the diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Vascular Dementia, Mild, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, And Other Seizures. A record review of Resident #7's Order Summary Report with active orders as of 6/30/26 revealed physician orders for Duloxetine HCl Enteric Coated Pellets Cap 30 MG (milligram) Give 1 caplet orally one time a day for Pain (dated 07/01/2024), Rexulti Oral Tablet 0.5 MG Give 1 tablet by mouth one time a day for Dementia with agitation (dated 07/29/2025), Trazodone HCl Oral tablet Give 25 mg by mouth at bedtime for Depression/Insomnia (dated 01/26/2026), and Xarelto Oral Tablet 15 MG Give 1 tablet orally one time a day related to Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris (dated 07/01/2024). The resident was receiving an antipsychotic, antidepressant, and anticoagulant, all of which require monitoring for potential adverse consequences. There were no orders for monitoring the side effects of the medications. A record review of Resident #7's Quarterly MDS with an ARD of 04/08/26 revealed a BIMS score of 12, indicating moderately impaired cognition. Section GG revealed impairment on one side. A review of Section N revealed he was administered antipsychotic, antidepressant, and anticoagulant medications. A record review of Resident #7's medical records, including the MAR, revealed there was no documentation that the resident was monitored for the side effects of the medications. Resident #55 A record review of Resident #55's Care Plan Report revealed a focus of At risk for altered level of comfort, r/t (related to) Parkinsons disease. Interventions directed staff to observe for adverse side effects to medications such as increased lethargy, slurred speech, sedation or confusion and notify physician. On 06/30/2026 at11:00 AM, during an interview and observation with Resident #55, resident observed lying in her bed watching television. Resident reported that she is on medications that she doesn't think she needs. She reported that she doesn't know why she is at the facility except for therapy. On 06/30/2026 at 11:50 AM, during an interview with RN #2, she stated Resident #55 had been admitted to the facility approximately two (2) weeks earlier and had adjusted well. She reported that the resident took her medications without difficulty. RN #2 stated she had administered a PRN (as needed) medication on one occasion for increased anxiety after the resident reported seeing men in her bathroom. RN #2 further stated there was no designated place on the MAR to document monitoring for potential adverse consequences of Resident #55's medications. On 06/30/2026 at 3:05 PM, during an interview, the Director of Nursing (DON) stated residents receiving psychotropic medications, anticoagulants, and anti-anxiety medications were expected to be monitored for potential adverse consequences each shift. After reviewing the Medication Administration Records for Residents #7 and #55, the DON confirmed there was no documentation demonstrating monitoring for adverse consequences. The DON stated that if there was no designated place to document medication monitoring, staff were expected to notify management so the issue could be corrected. A record review of Resident #55's admission Record revealed the facility admitted the resident on 06/17/2026 with the diagnoses of Parkinson's Disease Without Dyskinesia, Without Mention of Fluctuations, Anxiety, and Depression. A record review of Resident #55's Order Summary Report with active orders as of 7/1/26 revealed orders for Aripiprazole Oral Tablet 5 mg Give 1 tablet by mouth one time a day related to Anxiety Disorder (dated 6/18/26), Fluoxetine HCL Oral Tablet 40 mg Give 1 capsule by mouth one time a day related to Depression ((dated 6/18/26), Hydroxyzine HCL Oral Tablet 25 mg Give 1 tablet by mouth every 8 hours as needed for anxiety (dated 6/30/26), and Trazadone HCL Oral Tablet 100 mg Give 1 tablet by mouth one time a day related to Insomnia (dated 6/18/26). The resident was receiving an antipsychotic, antidepressants, and anxiolytic medication requiring monitoring for potential adverse consequences. There were no orders identified for monitoring the side effects of the medications. A record review of Resident #55's admission MDS with an ARD of 06/24/2026 revealed in progress with BIMS Score of 12, indicating moderately impaired cognition. A review of Section N revealed she was administered antipsychotic and antidepressant medications. A record review of Resident #55's medical records, including the MAR, revealed there was no documentation that the resident was monitored for the side effects of the medications.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure residents receiving psychotropic and high-risk medications, including anticoagulants, were monitored for potential adverse consequences in accordance with professional standards of practice and facility policy, affecting two (2) of five (5) residents reviewed for unnecessary medications. (Residents #7 and #55).Findings include:A record review of the facility's policy titled, Unnecessary Drugs with revision date of 2/1/26, revealed Policy: It is the facility's policy that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being free from unnecessary drugs . Adverse consequence refers to unwanted, unintended, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. It may include various types of adverse drug reactions and interactions . Policy Explanation and Compliance Guidelines . 3. d. Adequate monitoring for efficacy and adverse consequences; e. Preventing, identifying and responding to adverse consequences . Resident #7A record review of Resident #7's admission Record revealed the facility admitted the resident on 10/03/25 with the diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Vascular Dementia, Mild, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, And Other Seizures. A record review of Resident #7's Order Summary Report with active orders as of 6/30/26 revealed physician orders for Duloxetine HCl Enteric Coated Pellets Cap 30 MG (milligram) Give 1 caplet orally one time a day for Pain (dated 07/01/2024), Rexulti Oral Tablet 0.5 MG Give 1 tablet by mouth one time a day for Dementia with agitation (dated 07/29/2025), Trazodone HCl Oral tablet Give 25 mg by mouth at bedtime for Depression/Insomnia (dated 01/26/2026), and Xarelto Oral Tablet 15 MG Give 1 tablet orally one time a day related to Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris (dated 07/01/2024). The resident was receiving an antipsychotic, antidepressant, and anticoagulant, all of which require monitoring for potential adverse consequences. There were no orders for monitoring the side effects of the medications. A record review of Resident #7's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/26 revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. A review of Section N revealed he was administered antipsychotic, antidepressant, and anticoagulant medications.A record review of Resident #7's medical records, including the Medication Administration Record (MAR), revealed there was no documentation that the resident was monitored for the side effects of the medications.On 06/30/2026 at 11:10 AM, during an interview with Certified Nurse Aide (CNA) #4, she stated Resident #7 became agitated several times per week and, on occasion, used profane language toward staff.On 06/30/2026 at 11:30 AM, during an interview with Registered Nurse (RN) #2, she stated Resident #7 did not refuse medications or treatments. After reviewing Resident #7's MAR, RN #2 confirmed there was no documentation of monitoring for potential adverse consequences associated with the resident's psychotropic or anticoagulant medications. She further stated there was no designated area on the MAR to document monitoring for potential adverse consequences.On 06/30/2026 at 2:00 PM, during an interview and observation of Resident #7, resident was in the dining room interacting with activities. Resident reported that he wasn't sure what types of medications he is on, but the staff give him his medications daily. Resident #55 A record review of Resident #55's admission Record revealed the facility admitted the resident on 06/17/2026 with the diagnoses of Parkinson's Disease Without Dyskinesia, Without Mention of Fluctuations, Anxiety, And Depression. A record review of Resident #55's Order Summary Report with active orders as of 7/1/26 revealed orders for Aripiprazole Oral Tablet 5 mg Give 1 tablet by mouth one time a day related to Anxiety Disorder (dated 6/18/26), Fluoxetine HCL Oral Tablet 40 mg Give 1 capsule by mouth one time a day related to Depression ((dated 6/18/26), Hydroxyzine HCL Oral Tablet 25 mg Give 1 tablet by mouth every 8 hours as needed for anxiety (dated 6/30/26), and Trazadone HCL Oral Tablet 100 mg Give 1 tablet by mouth one time a day related to Insomnia (dated 6/18/26). The resident was receiving an antipsychotic, antidepressants, and anxiolytic medication requiring monitoring for potential adverse consequences.A record review of Resident #55's admission MDS with an ARD of 06/24/2026 revealed in progress with BIMS Score of 12, which indicated moderate cognitive impairment. A review of Section N revealed she was administered antipsychotic and antidepressant medications.A record review of Resident #55's medical records, including the MAR, revealed there was no documentation that the resident was monitored for the side effects of the medications.On 06/30/2026 at11:00 AM, during an interview and observation with Resident #55, resident observed lying in her bed watching television. Resident #55 reported that she is on medications that she doesn't think she needs. She reported that she doesn't know why she is at the facility except for therapy. On 06/30/2026 at 11:30 AM, during an interview with CNA #4, she stated Resident #55 had been admitted to the facility approximately two (2) weeks earlier. She reported the resident was cooperative with care and had not exhibited behavioral concerns. However, she stated the resident experienced increased confusion during the afternoon and evening hours.On 06/30/2026 at 11:50 AM, during an interview with RN #2, she stated Resident #55 had been admitted to the facility approximately (2) weeks earlier and had adjusted well. She reported that the resident took her medications without difficulty. RN #2 stated she had administered a PRN (as needed) medication on one occasion for increased anxiety after the resident reported seeing men in her bathroom. RN #2 further stated there was no designated place on the MAR to document monitoring for potential adverse consequences of Resident #55's medications.On 06/30/2026 at 3:05 PM, during an interview and record review, the Director of Nursing (DON) stated residents receiving psychotropic medications, anticoagulants, and anti-anxiety medications were expected to be monitored for potential adverse consequences each shift. After reviewing the MARs for Residents #7 and #55, the DON confirmed there was no documentation demonstrating monitoring for adverse consequences. The DON stated that if there was no designated place to document medication monitoring, staff were expected to notify management so the issue could be corrected.On 07/01/2026 at 3:23 PM, during an interview with the Administrator, she stated that she expects all staff to document care and duties required for their shift following regulatory requirements.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure the resident environment remained as free of accident hazards as possible by maintaining Resident #7's call light within reach, consistent with the resident's assessed fall risk, left-sided hemiplegia, need for assistance with mobility and toileting, and comprehensive care plan interventions, affecting one (1) of (16) residents reviewed for accident prevention. (Resident #7). Findings include:A review of the facility's policy titled, Call Lights-Accessibility and Timely Response, with revision date 2/1/26 revealed, Staff will ensure the call light is within reach of the resident and secured as needed.A record review of Resident #7's Fall Risk Evaluation dated 4/10/26 identified the resident as being at risk for falls due to balance problem while standing, decreased muscular coordination, and requires use of assistive devices.On 06/29/2026 at 2:35 PM, during an observation of Resident #7, the resident was lying in bed. The call light was wrapped around the overhead bed light fixture above the head of the bed, placing it beyond the resident's reach.On 06/30/2026 at 2:45 PM, during an observation of Resident #7's room while the resident was out of the room, the call light remained wrapped around the overhead bed light fixture above the head of the bed in the same inaccessible position observed on 06/29/2026.On 7/1/26 at 9:05 AM, an interview with Certified Nursing Assistant (CNA) #2 for Resident #7 revealed staff were trained to ensure the resident's call light was within reach, offer hydration, and address resident needs prior to exiting the room.On 07/01/2026 at 9:09 AM, during an observation of Resident #7's room while the resident was out of the room, the call light remained wrapped around the overhead bed light fixture in the same inaccessible position observed on the previous two survey days.On 7/1/26 at 9:19 AM, during an interview with CNA #3, she reported Resident #7 required limited assistance with mobility due to left-sided paralysis, required assistance with transfers and toileting, had an unsteady gait, and was able to communicate needs. She stated staff were expected to ensure the call light and other necessary items remained within the resident's reach before leaving the room.On 7/1/26 at 9:33 AM, an interview with CNA #1 for Resident #7 revealed staff received training on call light placement and resident safety. During the interview, the call light remained in the same inaccessible position observed on the previous survey days. CNA #1 stated the call light should only be temporarily moved out of reach while cleaning the room or making the bed and should otherwise remain within the resident's reach.On 07/01/2026 at 2:56 PM, during an interview, the Administrator stated staff were expected to ensure residents' call lights remained within reach at all times.A record review of the admission Record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/2026 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Section GG documented impairment affecting one side of the resident's body.A record review of the Comprehensive Care Plan for Resident #7 revealed a focus of at risk for injury/falls r/t (related to) Hemiplegia, Dementia, Epilepsy, Muscle Weakness, Poor Safety Awareness. An intervention directed staff to keep the residents' call light within reach.A record review of In-service Training Topics dated 3/2/26 revealed call light placement was included as an educational topic with no concerns noted.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents' rights to privacy and confidentiality were maintained when personal care signage was posted on the wall for two (2) of three (3) survey days. Resident #10 and Resident #29. Findings Included: A review of the facility's policy, Promoting/Maintaining Resident Dignity, dated 10/10/24, revealed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .Compliance Guidelines: . 12. Maintain resident privacy . A review of the facility's policy, Resident Rights, dated 2/10/25, revealed, . The facility will inform the resident .of his or her rights and all the regulations governing resident conduct and responsibilities during the stay in the facility . Resident rights. The resident has the right to a dignified existence, self-determination . 7. Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. a. Personal privacy includes accommodations, medical treatment .personal care . b. The resident has a right to secure and confidential personal and medical records . Resident #10 On 4/29/25 at 10:00 AM, during an observation, Resident #10 was lying in bed with positioning pillows and wedges. Two (2) signs were posted above the head of the bed and one (1) on the bathroom door. The signs read, No more than 2 pads on the bed, and Don't remove pillows or wedges from the room, the latter bearing the Administrator's signature. The resident was non-verbal. On 4/29/25 at 1:29 PM, during a phone interview with Resident #10's family members, both reported they were unaware of the signage on the walls. On 4/30/25 at 9:55 AM, during a follow-up observation, the signage continued to be posted on Resident #10's bathroom door and wall. A record review of Resident #10's Admission Record revealed the facility admitted the resident on 9/26/14 with diagnoses including Hypoxia and Traumatic Subdural Hemorrhage without Loss of Consciousness, Subsequent Encounter. A record review of Resident #10's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/12/25 revealed he required a staff assessment for mental status assessment which indicated his cognitive skills for daily decision making were severely impaired. Resident #29 On 4/29/25 at 8:16 AM, during an observation, Resident #29 was lying in bed and there were two (2) signs posted above the head of the bed and on the bathroom door reading, No blood pressures or blood sticks in the left arm. On 4/29/25 at 1:00 PM, during an interview with Licensed Practical Nurse (LPN) #3, she reported Resident #29 had a dialysis shunt in her left arm and that this was care-planned. Staff were aware not to use the left arm for blood pressures or sticks. On 4/29/25 at 1:35 PM, during an interview with Resident #29's family member, she stated her mother had a dialysis shunt that was never used and was unaware of the signage posted. She confirmed the facility placed the signs to notify staff not to use the left arm and agreed this information should be in the care plan, not on the walls. On 4/30/25 at 10:00 AM, during an observation, the signs continued to be posted in Resident #29's room. A record review of Resident #29's Admission Record revealed the facility admitted the resident on 10/18/21 with diagnoses including Unspecified Dementia and Chronic Kidney Disease. A record review of the Medication Review Report revealed Resident #29 had a Physician's Order, dated 5/28/24 for Graft can be used if needed for dialysis. A record review of Resident #29's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/9/25 revealed she had a Brief Interview for Mental Status (BIMS) score of 4, indicating she was severely cognitively impaired. A record review of the Care Plan Detail revealed Resident #29 had an individual care plan for the dialysis port located on the left forearm, with interventions to protect the site and avoid any blood pressures or restrictive items on that limb. On 4/30/25 at 10:10 AM, during an observation and interview with Certified Nurse Aide (CNA) #2, she confirmed signage in both Resident #10 and #29's rooms included information already documented in the medical record or care plan. She was unsure why certain instructions were posted but confirmed the details pertained to personal care. On 4/30/25 at 10:30 AM, during an interview with LPN #2, she confirmed Resident #10 had been at the facility for years, was totally dependent, and non-verbal. She was not aware of why signage was posted in the room. She confirmed Resident #29 had a shunt in the left arm, no dialysis, and confirmed the signs for no blood pressure/sticks were still posted. She stated the care plan contained this information and signage was unnecessary. On 4/30/25 at 2:00 PM, during an observation with the Administrator and Director of Nursing (DON), both confirmed the signage contained medical information that should not be posted. The Administrator reported she signed the signage but did not know it was displayed on the walls. The DON stated the signs would be removed, and an audit would be completed to remove similar signs from other rooms. Both agreed residents' rights, dignity, and privacy must be honored.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate of less than five percent (5%) for four (4) of thirty-one (31) observed medication opportunities, resulting in a medication error rate of 12.9%. Findings included: A review of the facility's policy titled, Medication Administration, revised 2/1/25, revealed, .Medications are administered .in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines .17. Administer medications as ordered in accordance with manufacturer specifications .c .Do no crush medications with 'do not crush' instruction .Example guidelines for Medication Administration (unless otherwise ordered by physician) .Do Not Crush Medications: Crushed meds are not to be combined and given all at once, if via feeding tube . A review of the facility's policy titled, Medication Administration via Enteral Tube, revised 1/20/25, revealed, It is the policy of this facility to ensure the safe and effective administration of medication via enteral feeding tubes by utilizing best practice guidelines .Policy Explanation and Compliance Guidelines: 1. Provider pharmacy or consultant pharmacist will be utilized as a resource concerning potential interactions between medications and feeding formulas .4. Prior to crushing tablets, nurses will consult the Medications Not to Be Crushed list .6. Medications may be combined or added to an enteral feed formula per MD orders .8. Physician or practitioner documentation will be provided in the medical record stating the medical rational for crushing a medication against a manufacturer's instructions . A review of the clinical reference ISMP (Institute for Safe Medication Practices) Medication Safety Alert, dated 11/17/22, revealed Preventing errors when preparing and administering medications via enteral feeding tubes .Common inappropriate administration techniques include: 1) mixing multiple medications together to give at once .Safe Practice Recommendations .Seek expertise. Before a prescriber places a medication order, and prior to a nurse preparing and administering a medication via an enteral tube, consult a pharmacist with any questions about the safety of a drug to be given via an enteral feeding tube .Prepare each medication separately. Avoid mixing two or more medications together, whether solid or liquid formulations, as this can create a new unknown entity with an unpredictable release and bioavailability .Flush . flush the tube with at least 15 mL (milliliters) of water .before and after the administration of each medication .Administer separately. Give each medication separately through the feeding tube . A record review of the medication administration instructions from Drugs.com revealed for Aripiprazole, Swallow the regular table whole and do not crush, chew, or break it. Do not split the orally disintegrating tablet, and for Lansoprazole do not crush or chew tablets. On 4/30/25 at 9:30 AM, during a medication administration observation for Resident #11, Licensed Practical Nurse (LPN) #4 administered Norvasc 2.5 mg (milligrams), aripiprazole (Abilify)15 (mg), Lansoprazole DR (Prevacid)15 mg, and Pro Stat 30 ml. LPN #4 mixed all four (4) medications together in a cup with water and administered them via syringe in the residents Percutaneous Endoscopic Gastrostomy (PEG) tube. A record review of the Order Summary Report revealed Resident #11 had a Physician's Order, dated 11/22/2024, for .May crush all non-liquid meds together and mix together for administration. There was an order for Pro-state 30 ml per g (PEG) tube, dated 3/21/25, Amlodipine Besylate tablet via G-Tube, dated 3/8/2021, Aripiprazole tablet via G-Tube, dated 3/21/25, and Lansoprazole tablet disintegrating via G-Tube, dated 3/21/25. Review of Resident #11's medical record revealed there was no evidence of individualized assessments or pharmacy review to evaluate the safety or appropriateness of crushing, combining, and administering the medications through the enteral feeding tube. On 4/30/25 at 1:00 PM, during an interview with LPN #4, she stated that the facility has a standing order from the Medical Director allowing all PEG medications to be crushed and mixed for all residents with PEG tubes. She also stated she had never checked for compatibility or consulted a pharmacist to ensure it was safe to do so. On 4/30/25 at 1:15 PM, during an interview with the Director of Nursing (DON), she confirmed that crushing and combining medications without checking for compatibility could cause problems and stated she was aware staff were combining medications per the physician's orders. She also confirmed that the facility had not conducted individualized reviews for PEG tube residents regarding medications being administered together. On 4/30/25 at 1:30 PM, during an interview with the Medical Director (MD), he stated that he expects the pharmacy to review medications and check for compatibility. He confirmed that the facility asks for standing orders to administer medications together, but he did not know staff were combining all medications for PEG administration. On 4/30/25 at 1:45 PM, during an interview with the Consultant Pharmacist, she stated that she has explained to the nurses that safe practice standards for administering medication via PEG require medications to be given individually. She stated no blanket order should replace clinical judgment and individualized review and explained that combining crushed medications can lead to pharmacokinetic changes and tube blockage, especially in high-risk residents. She was aware staff were combining medications due to standing physician orders. On 4/30/25 at 2:00 PM, during an interview with the Administrator, he confirmed that the facility has standing orders to mix and give PEG medications together. He also confirmed that combining crushed medications can lead to pharmacokinetic changes and tube blockage. A record review of Resident #11's Admission Record revealed the resident was admitted on [DATE] with current diagnoses including Hypertension. A record review of Resident #11's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/26/25 revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident's cognition was moderately impaired.

Based on observation, interview, record review, and policy review, the facility failed to ensure medications were administered according to professional standards of practice by crushing and combining all medications into a single dose for administration via Percutaneous Endoscopic Gastrostomy (PEG) tube, without providing a rational for combining the medication or individualized resident needs, for one (1) of three (3) residents reviewed with feeding tubes. (Residents #11). Cross Reference F759 Findings included: A review of the facility's policy titled, Medication Administration, revised 2/1/25, revealed, .Medications are administered .in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines .17. Administer medications as ordered in accordance with manufacturer specifications .c .Do no crush medications with 'do not crush' instruction .Example guidelines for Medication Administration (unless otherwise ordered by physician) .Do Not Crush Medications: Crushed meds are not to be combined and given all at once, if via feeding tube . A review of the facility's policy titled, Medication Administration via Enteral Tube, revised 1/20/25, revealed, It is the policy of this facility to ensure the safe and effective administration of medication via enteral feeding tubes by utilizing best practice guidelines .Policy Explanation and Compliance Guidelines: 1. Provider pharmacy or consultant pharmacist will be utilized as a resource concerning potential interactions between medications and feeding formulas .4. Prior to crushing tablets, nurses will consult the Medications Not to Be Crushed list .6. Medications may be combined or added to an enteral feed formula per MD orders .8. Physician or practitioner documentation will be provided in the medical record stating the medical rational for crushing a medication against a manufacturer's instructions . A review of the clinical reference ISMP (Institute for Safe Medication Practices) Medication Safety Alert, dated 11/17/22, revealed Preventing errors when preparing and administering medications via enteral feeding tubes .Common inappropriate administration techniques include: 1) mixing multiple medications together to give at once .Safe Practice Recommendations .Seek expertise. Before a prescriber places a medication order, and prior to a nurse preparing and administering a medication via an enteral tube, consult a pharmacist with any questions about the safety of a drug to be given via an enteral feeding tube .Prepare each medication separately. Avoid mixing two or more medications together, whether solid or liquid formulations, as this can create a new unknown entity with an unpredictable release and bioavailability .Flush . flush the tube with at least 15 mL (milliliters) of water .before and after the administration of each medication .Administer separately. Give each medication separately through the feeding tube . A record review of the medication administration instructions from Drugs.com revealed for Aripiprazole, Swallow the regular table whole and do not crush, chew, or break it. Do not split the orally disintegrating tablet, and for Lansoprazole do not crush or chew tablets. During a medication administration observation on 4/30/25 at 9:30 AM, Licensed Practical Nurse (LPN) #4 administered Resident #11 the following medications: Norvasc 2.5 mg (milligrams) per peg, aripiprazole (Abilify)15 mg per peg, Lansoprazole DR (Prevacid)15 mg per peg and pro stat 30 milliliters per peg. LPN #4 mixed all four (4) medications together in a cup with water and administered them via syringe in the residents (PEG) tube. A record review of the Order Summary Report revealed Resident #11 had a Physician's Order, dated 11/22/2024, for .May crush all non-liquid meds together and mix together for administration. There was an order for Pro-state 30 milliliters per (PEG) tube, dated 3/21/25, Amlodipine Besylate tablet via G-Tube, dated 3/8/2021, Aripiprazole tablet via G-Tube, dated 3/21/25, and Lansoprazole tablet disintegrating via G-Tube, dated 3/21/25. Record review of Resident #11's medical record revealed there was no evidence of individualized assessments or pharmacy review to evaluate the safety or appropriateness of crushing, combining, and administering the medications through the enteral feeding tube. During an interview on 4/30/25 at 1:00 PM, LPN #4 stated that the facility has a standing order from the Medical Director allowing all PEG medications to be crushed and mixed for all residents with PEG tubes. She also stated she had never checked for compatibility or consulted a pharmacist to ensure it was safe to do so. During an interview on 4/30/25 at 1:15 PM, the Director of Nursing (DON) confirmed that crushing and combining medications without checking for compatibility could cause problems and stated she was aware staff were combining medications per the physician's orders. She also confirmed that the facility had not conducted individualized reviews for PEG tube residents regarding medications being administered together. During an interview on 4/30/25 at 1:30 PM, the Medical Director (MD) stated that he expects the pharmacy to review medications and check for compatibility. He confirmed that the facility asks for standing orders to administer medications together, but he did not know staff were combining all medications for PEG administration. During an interview on 4/30/25 at 1:45 PM, the Consultant Pharmacist stated that she has explained to the nurses that safe practice standards for administering medication via PEG require medications to be given individually. She stated no blanket order should replace clinical judgment and individualized review and explained that combining crushed medications can lead to pharmacokinetic changes and tube blockage, especially in high-risk residents. She was aware staff were combining medications due to standing physician orders. During an interview on 4/30/25 at 2:00 PM, the Administrator confirmed that the facility has standing orders to mix and give PEG medications together. He also confirmed that combining crushed medications can lead to pharmacokinetic changes and tube blockage. A record review of Resident #11's Admission Record revealed the resident was admitted on [DATE] with current diagnoses including Hypertension. A record review of Resident #11's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/26/25 revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident's cognition was moderately impaired.

Based on observation, interview, record review, and facility policy review, the facility failed to prevent the possible spread of infection by not following manufacturer guidelines for cleaning and disinfecting the glucometer for one (1) of two (2) residents observed for blood glucose monitoring, Resident #95. Findings include: A review of the facility's policy, Blood Glucose Monitoring, dated 2/15/25, revealed, It is the policy of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders . Policy Explanation and Guidelines . 2. The nurse will perform the blood glucose test utilizing the facility's glucometer as per manufacturer's instruction. 3. The nurse will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy. 4. If possible, glucometers should not be shared between residents, but if this is not possible, the nurse is responsible for cleaning and disinfection of the machine between residents following the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy . A review of the facility's policy, Glucometer Disinfection, revised 7/24/24, revealed, The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees . Cleaning is the removal of visible soil from objects and surfaces normally accomplished manually or mechanically using water with detergents or enzymatic products. Disinfection is a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects. Policy Explanation and Compliance Guidelines 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use. 2. The glucometers will be disinfected with a wipe pre-saturated with an EPA (Environmental Protection Agency) registered healthcare disinfectant that is effective against HIV (Human Immunodeficiency Virus), Hepatitis C and Hepatitis B virus. 3. The Glucometer will be cleaned and disinfected after each use . A review of the General Guidelines for use of the Super Sani-Cloth, dated 2021, revealed, .3b. Unfold a clean wipe and thoroughly wet surface 4. Allow treated surface to remain wet for two (2) minutes. Let air dry . A record review of the Order Summary Report revealed Resident #95 had a physician's order, dated 4/22/25, for Accu-Chek AC (before meals) and HS (bedtime). On 4/30/25 at 11:15 AM, during an observation, Licensed Practical Nurse (LPN) #4 was observed using a glucometer to check Resident #95's blood sugar. After the procedure, she used a Sani wipe disinfectant cloth and rubbed the top of the glucometer for ten (10) seconds. On 4/30/25 at 1:00 PM, during an interview with LPN #4, she confirmed she failed to cleanse the glucometer with the Sani wipe for the required two (2) minutes. She stated she was not familiar with the manufacturer's guidelines that required a two (2) minute contact time. On 4/30/25 at 1:15 PM, during an interview with the Director of Nursing (DON), she stated that all nursing staff had been in-serviced on proper glucometer cleansing. The DON confirmed that the glucometer was shared among residents, and failure to cleanse it properly could lead to the transmission of blood borne diseases. She confirmed the facility did not currently have any residents with a blood borne disease. On 4/30/25 at 2:00 PM, during an interview with the Administrator, she stated that she expected staff to follow the manufacturer's guidelines for using Sani wipes to prevent infections. A record review of Resident #95's Admission Record revealed the facility admitted the resident on 4/22/25 with diagnoses including Type 2 Diabetes Mellitus. A record review of Resident #95's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/29/25 revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure daily nurse staffing information was posted in a visible and accessible location for two (2) of three (3) survey days. Findings included: A review of the facility's policy, Nurse Staffing Posting Information, dated 12/17/24, revealed, .It is the policy of this facility to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time . Policy Explanation and Compliance Guidelines: 1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility name b. The current date c. Facility's current resident census d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides 2. The facility will post the Nursing Staffing Sheet at the beginning of each shift . 3. The information posted will be: a. Presented in a clean and readable format. b. In a prominent place readily accessible to residents, staff, and visitors . On 4/29/25 at 8:30 AM, during an observation of the facility, there was no staffing posted throughout the building. On a bulletin board outside of the old day room on Hall 200, a sign stated, Assignment Sheet posted inside of the old day room. Inside the conference room, the monthly schedule was posted in a glass case, and the Certified Nurse Aide (CNA) Assignment Sheet was posted. The Assignment Sheet included the date and the assignments of the CNAs only but did not include the facility name, census, or the total number and actual hours worked. It listed four (4) CNAs with room assignments and one (1) shower aide. On 4/30/25 at 9:00 AM, during an observation there was no posting of the daily staffing. The CNA Assignment Sheet and monthly schedule remained posted in the old day room. On 4/30/25 at 11:55 AM, during an interview with the Licensed Practical Nurse (LPN) #1/Staff Development Nurse, she explained that she completed the nurse schedule, and the lead CNA completed the CNA schedule. She stated the staffing was posted in the break room/old day room only and included the monthly schedule and the CNA Assignment Sheet. She confirmed that she did not post the staffing information anywhere else. On 4/30/25 at 12:05 PM, during an interview with CNA #1/Lead CNA Supervisor, he confirmed that he prepared and posted the CNA assignment sheets daily in the old day room. He stated the Assignment Sheet did not include the census, only the names of CNAs and their assignments. On 4/30/25 at 3:30 PM, during an interview with the Administrator and Director of Nursing (DON), both reported they were unaware that the staffing was not being posted daily and thought it was posted in the old day room. They confirmed only the CNA Assignment Sheet and the monthly schedule were posted. The DON stated that the Staff Development Nurse was responsible for posting the daily staffing sheet, including all required information, in an accessible area. On 4/30/25 at 3:45 PM, during an interview with LPN #1, she confirmed that she had not been posting the daily staffing in a location visible to all visitors, staff, and residents. She explained that it was done in error because she had simply forgotten. She stated the error would be corrected and the daily staffing sheet would be posted going forward to include all required elements.

Based on observation, staff interviews, and facility policy review, the facility failed to store foods safely as evidenced by food left open and exposed on shelves, undated/unlabeled foods without a use-by -date, food stored without an identifying label, and not discarding food items after their use-by or sell-by date for one (1) of two (2) kitchen observations. Findings Include: A review of the facility's policy titled, Food and Supply Storage, review date ,d+[DATE], revealed, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . Most products contain an expiration date. The words sell-by or use-by should precede the date . The sell-by, best-by or use-by date is the last date that a food can be consumed . Foods past the use-by, sell-by, best-by, or enjoy-by date should be discarded .Cover, label and date unused portions and open packages . On [DATE] at 10:44 AM, an initial tour of the kitchen with the Dietary Manager revealed the following: 1. In refrigerator #1 there was (1) opened, undated container of sliced jalapeno peppers partially covered by plastic wrap, with one corner of the container exposed. There were three (3) one-pound blocks of margarine with no date on the wrapper. The margarine blocks had wrappers that were pulled back, exposing the margarine. There were 45 individual serving bowls of what the dietary manager identified as carrot cake, with no label or use by date noted on the bowls. There was (1) opened plastic bag, with decorating tip of dairy whipped topping, with no dates noted on the bag. There were (2) five-pound unopened plastic bags of shredded cheddar cheese with no date on the package Additionally, there was (1) unopened half gallon of butter milk with a sell by date of [DATE] and (1) large unopened plastic package of salad mix, containing lettuce, carrots, and purple cabbage, with a use by date of [DATE]. 2. An observation of the freezer revealed there was (1) undated, plastic storage bag of cornbread. There were two (2) undated, unopened packages of frozen waffles and (1) opened, undated package of waffles. Additionally, there were six (6) undated,unlabeled and unopened slabs of pork ribs as identified by the Dietary manager and (1) undated, turkey breast. 3. An observation of a shelf in the food preparatory area revealed seven (7) containers of seasonings with the lids opened and the seasonings exposed. There was also (1) bag opened bag of light brown sugar, leaving the sugar exposed. No staff were standing near the seasoning or sugar, indicating that they were being used. On [DATE] at 10:44 AM, during an interview with the Dietary Manager (DM), he acknowledged the outdated, unlabeled, opened, and exposed foods. The DM stated it is a mistake but understands the hazard of having outdated foods that a resident could consume. The DM stated these items should have been discarded. The DM revealed it is every kitchen employee's responsibility to watch for expired foods and discard food as it reaches the expiration date. The DM stated the staff that opens a container should put an open date on the package. On [DATE] at 10:52 AM, an interview with Kitchen Staff #2/Cook, revealed everyone is responsible for disposing of expired foods. The cook stated all kitchen staff are supposed to look at labels and are responsible for dating an item when it is opened. On [DATE] at 10:55 AM, during an interview with Kitchen Staff #3/Prep, revealed all staff are supposed to look at labels and are responsible for disposal of expired foods. Kitchen Staff #3 reported it is the responsibility of the person that opens a food item to date that item. On [DATE] at 11:36 AM, during an interview with the Administrator, acknowledged the failure of the facility to discard outdated foods, to label foods properly, and to securely close food containers. The Administrator confirmed the potential hazard of a resident consuming outdated foods. The Administrator stated her expectation is that the kitchen staff will monitor for outdated foods and dispose of these foods immediately, as she expects the kitchen staff to ensure food safety for residents.

Based on staff interview, record review, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to correct a quality deficiency from a previous survey for one (1) re-cited deficiency of five (5) cited deficiencies from a previous annual recertification survey in October 2021. The deficiency was related to initiating and implementing care plans. The facility's continued failure during two surveys shows a pattern of the facility's inability to sustain an effective QAPI Committee. Findings Include: Record Review of the facility's policy, Quality Assurance and Performance Improvement (QAPI) Program revised August 2017, revealed, .The facility shall .maintain an ongoing, facility-wide QAPI plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems .Policy Interpretation and Implementation The objectives of the QAPI Plan are to .5. Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome .Evaluation 1. The facility shall evaluate the effectiveness of its QAPI Program . During the current recertification survey, the State Agency (SA) identified deficient practice of F656: Based on observation, interviews, record review, and facility policy review, the facility failed to develop a comprehensive care plan for a resident (Resident #21) who had an indwelling catheter and failed to implement comprehensive care plan interventions for medication administration (Resident #21) and toenail care (Resident #34) for two (2) of 16 resident care plans reviewed. On 12/20/23 at 03:00 PM, in an interview with the Administrator, she confirmed the previous annual recertification survey conducted in October of 2023 included a citation regarding the development/implementation of the Comprehensive Care Plan. She explained the facility completed all the corrective action per the Plan of Correction (POC) from the survey and the facility continued to conduct monthly in-services related to resident care plans. The Administrator said the facility had a staff member that came to the facility monthly and audited charts and care plans, but this person had not completed the December audit. She stated that the facility conducts a daily morning meeting in which all new physician orders are discussed and determine any new care plans that needed to be initiated. She confirmed she has reviewed the CMS (Centers for Medicare and Medicaid Services)-2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction) and the facility completed the correction plan, however, the facility failed to develop and implement care plans for two residents during the current survey. On 12/20/23 at 03:15 PM, during an interview with the Director of Nursing (DON), she explained she was aware of the previous deficiencies from the recertification survey in October 2021 but had a different job title at that time. She confirmed on the previous recertification survey, the facility was cited for failing to develop/implement the comprehensive care plan.

Based on observation, interviews, record review, and the facility policy review, the facility failed to provide Activities of Daily Living (ADL) care for a resident who was dependent upon staff for toenail care for one (1) of two (2) residents reviewed for ADL care. Resident #34 Findings include: Review of the facility's policy Activities of Daily Living (ADLs), Supporting, revised 1/12/2021, revealed Policy Statement . Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .Policy Interpretation and Implementation .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .including appropriate support with: a. Hygiene (bathing, dressing, grooming) . Review of the facility's policy Fingernails/Toenails, Care of, revised 02/2018, revealed .Purpose: The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . General Guidelines 1. Nail care includes daily cleaning and regular trimming . 6. Stop and report to the nurse supervisor if . if nails are too hard or too thick to cut with ease . Documentation The following information should be recorded in the resident's medical record: 1. The date and time that nail care was given . On 12/18/23 at 11:09 AM, during an interview and observation, Resident #34 had long, thick toenails. Resident #34 explained that her toenails needed to be clipped and she was unable to do it herself because she had arthritis, and the nails were too thick. On 12/19/23 at 8:55 AM, during an interview and observation with Resident #34, her toenails remained long and untrimmed. She reported they were so long that they would get caught on her socks and bed linens. She expressed that she could not clip them herself and would like to have them trimmed. On 12/19/23 at 9:45 AM, during an interview with Certified Nurse Aide (CNA) #3, she explained that Resident #34 was very independent with ADLs but was unsure if the resident preferred to keep her toenails long. She explained the CNAs completed nail care, including clipping the nails, if the resident did not have a diagnosis of Diabetes Mellitus (DM). If the resident had DM, then a Registered Nurse (RN) had to clip or trim the nails. On 12/19/23 at 11:30 AM, during an interview with the Director of Nursing (DON), she explained that a podiatrist visited the facility every three (3) months and tried to see all the residents. The last time the podiatrist visited the facility was on 10/25/23. The RNs were responsible for clipping the toenails in-between the time of podiatrist visits. The facility also had a treatment nurse on weekends that clipped resident nails as needed. A record review of the Physician Orders for the month of December 2023, revealed Resident #34 had a Physician's Order, dated 11/20/23, for Weekly toenail audit on body audit day N= toenails do not need to be trimmed Y=request form for NP (Nurse Practitioner) to evaluate toenails on next visit . A record review of the electronic Treatment Administration Record (eTAR), for the month of December 2023 for Resident #34, revealed facility staff recorded N (toenails do not need to be trimmed) on 12/04/23, 12/11/23, and 12/18/23. On 12/20/23 at 10:50 AM, during an interview with Licensed Practical Nurse (LPN) #5/Wound Care Nurse, she explained she completed the weekly body audits for Resident #34 and the resident's toenails were part of the body audit. She stated that she only observed the toenails, but she did not touch them and does not know the purpose of the toenails being on the body audit. She confirmed Resident #34's toenails were long and had been long for some time. She stated that she charted no trim because she was not responsible for trimming them. LPN #5 also confirmed that she did not document that Resident #34 had long toenails, nor did she tell a RN that the toenails were long and needed to be trimmed. On 12/20/23 at 11:20 AM, during an interview with the DON and Resident #34, the DON observed Resident #34's toenails and confirmed the resident's toenails were long and thick. Resident #34 stated that her toenails needed to be clipped. The DON stated that she expected the RNs to clip resident toenails if needed. She also stated that she expected the wound care nurse to notify a RN if any resident's toenails needed to be clipped. A record review of the Face Sheet revealed the facility admitted Resident #34 on 05/11/20 with diagnoses including Type 2 Diabetes Mellitus, Unspecified Osteoarthritis, and Age-related Physical Debility. A record review of the Quarterly Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 11/01/23 revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact.

Based on interview, record review and facility policy review, the facility failed to complete the Discharge Minimum Data Set (MDS) assessments for one (1) of 16 residents sampled. Resident # 6 Findings Include: A review of the facility's policy titled, MDS 3.0 Completion, reviewed/revised 10/02/23, revealed, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan . Policy Explanation and Compliance Guidelines: 2f. Discharge Assessment - completed using the discharge date as the ARD (Assessment Reference Date). Must be completed within 14 days of the discharge date /ARD . A record review of the facility's Face Sheet, revealed the facility admitted Resident #6 on 07/20/23, with diagnoses that included Essential Hypertension. A record review of the facility's Discharge Summary, for Resident #6, revealed the facility discharged the resident to home on 09/15/23. A record review of the MDS, for Resident #6, revealed there was no Discharge Assessment completed. On 12/18/2023 at 12:13 PM, an interview with Licensed Practical Nurse (LPN) #1, revealed the nurse acknowledged her failure to complete a Discharge MDS assessment for Resident #6. LPN #1 stated it was her mistake and occurred due to an oversight. LPN #1 acknowledged the lapse in the Discharge MDS completion compromises communication related to resident care. On 12/19/23 at 8:32 AM, an interview with the Director of Nurses (DON), revealed she acknowledged the facility's failure in completing the Discharge MDS assessments for the Resident #6. The DON revealed she expects the facility to put bullet proof measures in place to prevent this from happening again, as the MDS is a significant piece of the puzzle in resident care. The DON stated she will provide more training opportunities for the MDS nurse and visual oversight of the process. On 12/19/23 at 9:50 AM, during an interview with the Administrator, she acknowledged the facility's failure in completing the discharge MDS assessment for the resident. The Administrator reported this is a learning process and she will work with her staff with additional training as needed.

Based on observation, interviews, record review, and facility policy review, the facility failed develop a comprehensive care plan for a resident (Resident #21) who had an indwelling catheter and failed to implement comprehensive care plan interventions for medication administration (Resident #21) and toenail care (Resident #34) for two (2) of 16 resident care plans reviewed. Findings Include: Review of the facility's policy Care Plans, Comprehensive Person-Centered, revised December 2016, revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timelines to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Policy Interpretation and Implementation .8. The comprehensive, person-centered care plan will .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .13 .care plans are revised as information about the residents and the residents' conditions change . Resident #21 Record review of the Comprehensive Care Plan for Resident #21 revealed there was no care plan developed regarding an indwelling catheter. Further review revealed a care plan start date of 11/30/22, with a Care Plan Goal of (Proper Name of Resident #21) will have no acute hypertensive episodes thru next review date, and an intervention of Metoprolol tartrate per PCP (Primary Care Physician) Orders*Hold for HR (Heart Rate) less than 60 BPM (Beats Per Minute) . On 12/18/23 at 11:58 AM, during an observation, Resident #21 was lying in bed and there was an indwelling catheter drainage bag attached to the side of the bed. Record review of the Physician's Orders revealed there was an order, dated 12/15/23 Insert .Foley (type of indwelling urinary catheter) cath (catheter) leave for 7 days . Record review of the medical record revealed there was not a care plan developed for Resident #21's indwelling urinary catheter. During an observation on 12/18/23 at 4:24 PM, Licensed Practical Nurse (LPN) #2 administered Metoprolol Tartrate and did not obtain the resident's pulse prior to administering the medication. Record review of the Physician Orders, for the month of December 2023, revealed Resident #21 had a Physician's Order, dated 11/21/23 for Metoprolol Tartrate 25 MG (Milligrams) .Give 1/2 tab (tablet) to equal 12.5 MG PO (by mouth)/Per PEG BID (two times daily) .Obtain and record pulse before admin (administering) hold if less than 60 . Record review of the Face Sheet revealed the facility admitted Resident #21 on 9/27/19 and she had a diagnosis of Essential Hypertension. Resident #34 A record review of the Comprehensive Care Plan revealed a care plan, dated 11/2/22, with a Care Plan Description (Proper Name of Resident #34) is at risk for skin breakdown . Intervention .Observe skin during routine ADL (Activities of Daily Living) care and report any abnormal to nurse. Perform weekly body, fingernails, and toenails audit. During an interview and observation on 12/18/23 at 11:09 AM, Resident #34 had long, thick toenails. Resident #34 explained that her toenails needed to be clipped and she was unable to do it herself because she had arthritis, and the nails were too thick. A record review of the Face Sheet revealed the facility admitted Resident #34 on 05/11/20 with diagnoses including Type 2 Diabetes Mellitus, Unspecified Osteoarthritis, and Age-related Physical Debility. A record review of the Physician Orders for the month of December 2023, revealed Resident #34 had a Physician's Order, dated 11/20/23, for Weekly toenail audit on body audit day N= toenails do not need to be trimmed Y=request form for NP (Nurse Practitioner) to evaluate toenails on next visit . A record review of the electronic Treatment Administration Record (eTAR), for the month of December 2023 for Resident #34, revealed facility staff recorded N (toenails do not need to be trimmed) on 12/04/23, 12/11/23, and 12/18/23. On 12/20/23 at 10:38 AM, in an interview with Licensed Practical Nurse (LPN) #4, he stated that care plans should be developed when there is a new Physician's Order and confirmed there was no care plan developed for Resident #21's indwelling catheter. He stated the care plan is used by the nurses and Certified Nursing Assistant to provide optimal care. During an interview on 12/20/23 at 10:50 AM, with LPN #5/Wound Care Nurse, she explained she she only observed the toenails, but she did not touch them. LPN #5 confirmed that she did not document that Resident #34 had long thick toenails, nor did she tell a Registered Nurse (RN) that the toenails were long and thick and needed to be trimmed. On 12/20/23 at 1:20 PM, during an interview with the Administrator, she explained she expected staff to follow each resident centered care plan to provide care for the residents. 43283

Based on observations, staff interview, record review, and facility policy review the failed to ensure multidose insulin pens were dated when opened for six (6) of 19 diabetic residents who are prescribed multidose insulin pens. Findings Include: Review of the facility's policy, Labeling of Medication Containers, revised 4/2007, revealed, Policy Statement .All medications maintained in the facility shall be properly labeled in accordance with the current state and federal regulations .Policy Interpretation and Implementation .3. Labels for individual drug containers shall include all necessary information, such as .h. The expiration date when applicable; . On 12/18/23 at 3:30 PM, an observation of the 600 Hall medication cart, with Licensed Practical Nurse #2 (LPN), revealed an opened NovoLog FlexPen pre-filled multi-dose insulin pen with no date indicating when the pen was opened. LPN #2 confirmed there was no date on the multi-dose pen or the box the pen was stored in. LPN #2 stated that all insulin pens should have a date written on the pen or box indicating the date it was opened so the insulin could be discarded on the 28th day. LPN #2 explained that the nurse is responsible for dating the insulin when it is opened and that administering insulin after the discard date could cause the insulin to be less effective. On 12/19/23 at 9:39 AM, an observation of the 300 Hall medication cart, with LPN #3, revealed a NovoLog FlexTouch prefilled multi-dose insulin pen with no date indicating when the pen was opened. LPN #3 stated that the pen should be dated so the nurses would know when to discard the insulin. She explained that giving opened insulin past the discard date could make the insulin less effective. Record review of the Manufacturer's literature revealed the Novolog FlexPen and Novolog FlexTouch insulins that are In-use could be stored for 28 days and Instructions for Use indicated, .Do not use NovoLog past the expiration date printed on the label or 28 days after you start using the Pen . On 12/20/23 at 3:09 PM, in an interview with the Director of Nursing (DON), she stated that insulin should be dated when it is opened by the nurse to ensure they were discarded timely. The DON explained that if a nurse gave an insulin injection to a resident after the time it should have been discarded, the insulin might not work as well.

Based on observation, staff interview, record review, and facility policy review, the facility failed to follow a physician's order to obtain a resident's pulse before administering an antihypertensive medication for one (1) of four (4) medication administration observations. Resident #21 Findings Include: Review of the facility's policy, Medication Administration, with a revision date of 2/2023, revealed Policy: Medications are administered by licensed nurses .in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters .Example guidelines for Medication Administration .Medication requiring vital signs prior to administration .Anti-Hypertensives . On 12/18/23 at 4:24 PM, in an observation of medication administration, Licensed Practical Nurse (LPN) #2 administered Metoprolol Tartrate and did not obtain the resident's pulse prior to administering the medication. Record review of the Physician Orders, for the month of December 2023, revealed Resident #21 had a Physician's Order, dated 11/21/23 for Metoprolol Tartrate 25 MG (Milligrams) .Give 1/2 tab (tablet) to equal 12.5 MG PO (by mouth)/Per PEG (Percutaneous Endoscopic Gastrostomy) BID (two times daily) .Obtain and record pulse before admin (administering) hold if less than 60 . On 12/18/23 at 4:31 PM, in an interview with LPN #2, she confirmed that she did not check Resident #21's pulse before she administered Metoprolol Tartrate. She stated she should have checked the resident's pulse because the medication can cause a decreased heart rate. On 12/20/23 at 3:10 PM, in an interview with the Director of Nursing (DON), she confirmed that LPN #2 should have checked the resident's pulse before giving Metoprolol Tartrate because that medication can cause the resident's heart rate to drop. She stated LPN #2 did not follow the Physician Orders related to administering the medication. Record review of the Face Sheet revealed the facility admitted Resident #21 on 9/27/19 with diagnoses that included Essential Hypertension.

Amendment 12/07/2021 Upon secondary review with CMS Regional Office staff and State Quality Assurance, the State Survey Agency (SSA) determined the Immediate Jeopardy to be removed on July 8, 2021 for F600, F610, F656 and F689 and the scope and severity was lowered to D, while the facility develops and implements a plan of correction and monitors effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Based on observation, staff interviews, record review and facility policy review the facility failed to follow the comprehensive care plan for providing Activities of Daily Living (ADL's) for one (1) of sixteen care plans reviewed. Resident #31. The facility failed to follow the comprehensive care plan when Temporay Nurse Assistant (TNA) #1 provided incontinent care without the required two (2) person assistance licensed/certified staff needed which resulted in Resident #31 falling from the bed and sustaining a major injury. The facility's failure to follow the care plan caused Resident #31 to fall to the floor resulting in bilateral femur fractures. These actions had the likelihood to cause all residents residing in the facility serious harm, serious injury, serious impairment, or possible death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 7/3/21, when TNA #1 failed to follow the care plan and did not have the required assistance needed to provide care for Resident #31 that resulted in a fall with a major injury. The facility Administrator was notified of the IJ on 9/28/21 and the IJ templates were provided to the Administrator. The State Survey Agency (SSA) received an acceptable Removal Plan on 9/30/21, in which the facility alleged that all corrective actions were completed as of 9/30/21, and the IJ was removed on 10/1/21. (Amendment 12/2/21 - The SSA determined that the IJ was removed on 7/8/21). The SSA validated the Removal Plan and determined the IJ to be removed 7/8/21. Therefore, the scope and severity for IJ at CFR 483.21(b)(1)-Comprehensive Care Plans (F656) was lowered to D, while the facility develops and implements a plan of correction and monitors effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility policy, Care Plan, Comprehensive Person-Centered, revised December 2016, revealed, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Record review of Resident #31's Care Plan with a Problem Onset date of 03/27/2020 revealed (Formal Name) decline in ability to perform self care activities, (Formal Name) is unable to bear weight, (Formal Name) at risk for soiling clothing .Approaches: Provide extensive assistance X2 (of two persons) with bed mobility .Provide total assistance X2 with toileting . Record review of the Nurse Aides' Information Sheet, undated, revealed Resident #31 required total assistance X2 with incontinent care for bowel and bladder and extensive assistance X2 for turning and repositioning. Record review of Resident #31's Fall Risk Evaluation revealed the assessments were completed on 06/09/21, 07/06/21, and 07/21/21. All assessments revealed Resident #31 scored a total of 24 which indicated the resident was high risk for falls. During an interview on 09/16/21at 09:00 AM, with the Director of Nursing (DON) confirmed Resident #31 fell out of the bed to the floor on 7/3/21. The DON said on 7/6/21 she had TNA #1 come to the facility and re-enact the incident. The DON revealed TNA #1 provided incontinent care without a Certified Nursing Assistant (CNA) or Nurse assisting her. TNA #1 turned Resident #31 to the right side and did not remove the pillows from the resident's feet. TNA #1 said she forgot to remove Resident #31's pillows before turning her. Resident #31 slid to the floor on her knees. Resident #31 was still holding on to the bedrails. TNA #1 said she notified Licensed Practical Nurse (LPN) #1. The DON said TNA #1 said she had read Resident #31's plan of care. TNA #1 said she knew Resident #31 was a two (2) person assist with bed mobility, but she thought she could do it without help. The DON said TNA #1 and CNAs are trained that TNAs should not provide care without a licensed/certified person being present. The DON confirmed TNA #1 failed to follow Resident #31's Care Plan because the Care Plan says Resident #31 should have two (2) people with bed mobility and transfers. During an interview on 09/16/21 at 2:15 PM, LPN #2, said the staff is trained during orientation and annually on ADL task, skills, and checkoffs. LPN #2 said during her training she educates the TNA's and CNA's that the TNAs cannot provide care without licensed or certified personnel. LPN #2 confirmed she cannot provide an in-service with TNA #1 indicating she was trained to only provide care with a licensed or certified person. LPN #2 confirmed TNA #1 failed to follow the care plan because Resident #31 was a two (2) person assist with all ADL's. During an interview on 9/16/21 at 2:30 PM, with CNA #2 confirmed TNA #1 failed to follow the facility policy and failed to follow the care plan by providing incontinent care to Resident #31 without having a licensed or certified person present. interview on 9/16/21 at 3:30 PM, with TNA #1 confirmed she provided incontinent care without a CNA or Nurse with her. TNA #1 said she was told by CNA #1 her supervisor that she only needed another staff member in the room when a lift is used for transfer. TNA #1 said she was not told that she could not provide incontinent care to the residents alone. TNA #1 said she has provided incontinent care alone with multiple residents. TNA #1 also said she read Resident #31 care plan when she first started working at the facility. TNA #1 said she forgot what the care plan said. Resident #31 should have 2 people with care. TNA #1 confirmed she did not ask any of the other staff for assistance because she has provided incontinent care without help multiple times and there was no negative outcome. TNA #1 said she was not told that she could not provide care to residents without a CNA or nurse present. During an interview on 9/16/21 at 04:00 PM, with LPN #3 confirmed TNA #1 failed to follow the care plan because Resident #31's care plan indicates Resident #31 is extensive assist with all ADL's. Resident #31 should have 2 people while providing incontinent care, baths, tuning, positioning, dressing and Hoyer lifts. LPN #3 said she expects the staff to follow the care plan. Record review of Resident #31's Face Sheet revealed Resident #31 was admitted to the facility on [DATE], with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 06/09/21 revealed Resident#31 had a Brief Interview For Mental Status (BIMS) score of 14 which indicates Resident #31 is cognitively intact. The facility provided an acceptable Removal Plan on 9/30/21, for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan Immediate Jeopardy (IJ) was called on 9/28/2021 at 12:35 PM. The IJ template was provided on 9/28/2021 at 12:35 PM. Beginning 7/3/2021 when Temporary Nursing Assistant (TNA) #1 failed to obtain the necessary assistance to provide incontinent care to resident #31 resulting in a major injury with fracture of bilateral knees. The State Agency notified the Administrator and the Director of Nursing (DON) that an IJ had been identified. Brief Summary of Events The facility failed to ensure a resident was protected from neglect as evidence by (AEB) an unlicensed TNA neglected to obtain assistance required when providing incontinent care that resulted in Resident #31 obtaining a fracture. ON 7/3/21, immediate action was taken by the cart nurse to notify the doctor and obtain bilateral knee x-rays. The facility failed to follow the comprehensive care plan while providing incontinent care AEB Resident #31 is extensive assist and always needs two people during care. The facility failed to ensure a vulnerable resident was protected from accidents and hazards when a TNA #1 failed to ask for help while providing incontinent care, which caused Resident #31 to fall with a major injury to bilateral knees. The facility failed to protect Resident #31 and other residents from potential for further injury during the investigation process by not removing TNA #1 from the facility following an incident on 7/3/2021. The Facility continued to allow TNA #1 to work until 7/05/21. Corrective Action: 1. On 7/3/2021, the Administrator provided education to the Charge Nurse, two (2) TNAs, 2 Cart Registered Nurses (RN), and three (3) Certified Nursing Assistants (CNA) directly involved in the fall of Resident #31. On 7/3/2021, the in-service topics included following the Activities of Living (ADL) Care Plan and Care Guide, Abuse and Neglect, and Residents' Rights. On 7/4/2021 and 7/5/2021, the Administrator continued in-servicing with all staff on the above topics. No staff will be allowed to work until in-services are completed. 2. On 07/03/21, the Administrator identified that Resident #31 sustained a fall with injury and initiated an investigation. 3. On 07/05/2021 at 10:24 AM, the Administrator suspended TNA #1 until further notice to complete investigation. On 07/05/2021 the Administrator conducted and completed the investigation. On 07/12/21 the Administrator terminated TNA #1. 4. On 7/5/2021 at 10:00 AM, each resident under the care from TNA #1 who was identified as at risk for falls was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] 5. On 07/05/2021 at 10 AM, the Minimum Data Set Nurse (MDS) conducted a 100 percent audit of Resident's Fall Risk Assessments and Care Plans for accuracy with no concerns identified. 6. Each resident has a care guide specific to their needs located in a binder at each nurse's station. These are reviewed by the CNAs prior to the start of each shift and to be followed to provide care to the residents. On 07/05/2021, the MDS Nurse performed a 100 percent audit of the care guides with no concerns identified. On 07/05/2021 The Administrator in-serviced CNAs and TNAs on the following: ADL care guides specific to each resident. On 07/05/2021, the MDS Nurse performed a 100 percent audit on ADLs of residents identified at risk for falls and failure to follow the ADL Plan of Care. All residents at risk needing two-person assist were identified and reviewed. On 9/16/2021, the Staff Development Nurse educated all TNAs and CNAs on providing resident care only with a CNA or Nurse present, no staff will be allowed to work until in serviced. TNAs and CNAs were instructed to review ADL care plan prior to each shift. 19 of the 40 residents were identified as at risk for falls and failure for the ADL Plan of Care to be followed. A form was developed and created for all TNA new hires to have proper education, training, and understanding that they must work directly with a licensed CNA and to follow and know their ADL plan of care. On 9/21/2021, the Staff Development Nurse educated all staff that all TNA's can only provide resident care with a CNA or Nurse present, no staff will be allowed to work until in-serviced. 7. The Administrator requested an in-person Quality Assurance Performance Improvement (QAPI) meeting to review events leading to this occurrence and corrective action taken. QAPI meeting occurred on July 8, 2021, and included the Administrator, Director of Nursing, Medical Director, MDS Nurse, Wound Care Nurse, Care Plan Nurse, Medical Records Nurse, Infection Preventionist, Physical Therapist, Administrator Assistant, and the Billing Office Manager. The meeting specifically discussed this fall, identified cause of the fall, number of previous falls, fall risk and potential harm, prevention of recurrence, abuse/neglect, following ADL care plan, Resident's Rights, ADL support and serious injury/harm and reporting. On 07/06/21, the Administrator in serviced the DON and Charge Nurse on the topic of removing any staff from the building for alleged violations of abuse, neglect, exploitation, or misappropriation of resident property until the investigation is completed. No changes to fall policy were required after being reviewed by QAPI. 8. On 9/16/2021, a form was created for all TNA hire in packets to ensure all TNA new hires have proper education, training, and understanding that they must work directly with a licensed CNA. 9. The Administrator and DON conducted a 100 percent audit on all accidents and incidents from 07/04/2021 through 9/30/2021 to ensure that injury or negative outcomes was not identified related to unsupervised TNAs. On 07/05/21, the Administrator in-serviced all staff on fall related policies. Falls are reviewed at stand up meeting every morning and Quarterly Quality Assurance (QA) meeting. On 07/05/21 at 7AM, the Administrator continued on-going in servicing to reiterate with all staff that TNAs must provide care only with CNA assist. 10. The facility alleges that all corrective actions to remove the IJ were completed on 9/30/21, and the IJ was removed on 10/1/21. On 10/2/21, the State Survey Agency (SSA) validated the facility's Removal Plan by staff interviews, record reviews, and review of in-service sign-in sheets. The SSA verified the facility had implemented the following measures to remove IJ: Validation: 1. The SSA validated through interview with the Administrator and in-service sign in sheets that on 7/3/2021, the Administrator provided education to the Charge Nurse, two (2) TNAs, 2 Cart Registered Nurses (RN), and three (3) Certified Nursing Assistants (CNA) directly involved in the fall of Resident #31. On 7/3/2021, the in-service topics included following the Activities of Living (ADL) Care Plan and Care Guide, Abuse and Neglect, and Residents' Rights. On 7/4/2021 and 7/5/2021, the Administrator continued in-servicing with all staff on the above topics. No staff will be allowed to work until in-services are completed. 2. The SSA validated through interview on 10/1/21 that on 07/03/21, the Administrator identified Resident #31 sustained a fall with injury and initiated an investigation. 3. The SSA validated through interview and record review that on 07/05/2021 at 10:24 AM, the Administrator suspended TNA #1 until further notice to complete investigation and on 07/05/2021 the Administrator conducted and completed the investigation. On 07/12/21 the Administrator terminated TNA #1. 4. The SSA validated through interview with DON and record review that on 7/5/2021 at 10:00 AM, each resident under the care from TNA #1 who was identified as at risk for falls was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] 5. The SSA validated through interview with the Minimum Data Set Nurse (MDS) nurse and record review on 07/05/2021 at 10 AM, the MDS nurse conducted a 100 percent audit of Resident's Fall Risk Assessments and Care Plans for accuracy with no concerns identified. 6. The SSA validated through staff interviews, record reviews and signed in-services that each resident has a care guide specific to their needs located in a binder at each nurse's station. These are reviewed by the CNAs prior to the start of each shift and to be followed to provide care to the residents. On 07/05/2021, the MDS Nurse performed a 100 percent audit of the care guides with no concerns identified. On 07/05/2021 The Administrator in-serviced CNAs and TNAs on the following: ADL care guides specific to each resident. On 07/05/2021, the MDS Nurse performed a 100 percent audit on ADLs of residents identified at risk for falls and failure to follow the ADL Plan of Care. All residents at risk needing two-person assist were identified and reviewed. On 9/16/2021, the Staff Development Nurse educated all TNAs and CNAs on providing resident care only with a CNA or Nurse present, no staff will be allowed to work until in serviced. TNAs and CNAs were instructed to review ADL care plan prior to each shift. 19 of the 40 residents were identified as at risk for falls and failure for the ADL Plan of Care to be followed. A form was developed and created for all TNA new hires to have proper education, training, and understanding that they must work directly with a licensed CNA and to follow and know their ADL plan of care. On 9/21/2021, the Staff Development Nurse educated all staff that all TNA's can only provide resident care with a CNA or Nurse present, no staff will be allowed to work until in-serviced. 7. The SSA validated through staff interviews, record review and signed in-service sheets that the Administrator requested an in-person Quality Assurance Performance Improvement (QAPI) meeting to review events leading to this occurrence and corrective action taken. The QAPI meeting occurred on July 8, 2021, and included the Administrator, Director of Nursing, Medical Director, MDS Nurse, Wound Care Nurse, Care Plan Nurse, Medical Records Nurse, Infection Preventionist, Physical Therapist, Administrator Assistant, and the Billing Office Manager. The meeting specifically discussed this fall, identified cause of the fall, number of previous falls, fall risk and potential harm, prevention of recurrence, abuse/neglect, following ADL care plan, Resident's Rights, ADL support and serious injury/harm and reporting. On 07/06/21, the Administrator in serviced the DON and Charge Nurse on the topic of removing any staff from the building for alleged violations of abuse, neglect, exploitation, or misappropriation of resident property until the investigation is completed. No changes to fall policy were required after being reviewed by QAPI. 8. The SSA validated through an interview with the Administrator and record review that on 9/16/2021, a form was created for all TNA's hire in packets to ensure all TNA new hires have proper education, training, and understanding that they must work directly with a licensed CNA. 9. The SSA validated through record review, signed in-services and interview with the Administrator and DON that a 100 percent audit was conducted on all accidents and incidents from 07/04/2021 through 9/30/2021 to ensure that injury or negative outcomes was not identified related to unsupervised TNAs. On 07/05/21, the Administrator in-serviced all staff on fall related policies. Falls are reviewed at stand up meeting every morning and Quarterly Quality Assurance (QA) meeting. On 07/05/21 at 7AM, the Administrator continued on-going in servicing to reiterate with all staff that TNAs must provide care only with CNA assist. 10. Amendment 12/2/21 - The SSA validated that all corrective actions to remove the IJ had been completed as of 7/8/21, and the IJ removed on 7/8/21.

Amendment 12/07/2021 Upon secondary review with CMS Regional Office staff and State Quality Assurance review, the State Survey Agency (SSA) determined the Immediate Jeopardy to be removed on 7/8/21 for F600 and the scope and severity was lowered to D, while the facility develops and implements a plan of correction and monitors effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Based on interviews, record reviews and facility policy review the facility failed to ensure a resident was protected from neglect as evidenced by a Temporary Nursing Assistant (TNA) neglected to obtain assistance required from licensed/certified staff when providing incontinent care that resulted in a resident obtaining a bilateral femur fracture for one (1) of three (3) residents reviewed for falls. Resident #31. On 7/3/21, TNA #1 neglected to obtain the assistance required when providing incontinent care for Resident #31. TNA #1 turned the resident to her side without removing the pillows from the resident's feet. This resulted in Resident #31 falling to the floor and sustaining bilateral femur fractures. The resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to protect Resident #31 and other residents from potential for further injury during the investigation process by not removing TNA #1 from the facility following the incident on 7/3/2021. The facility continued to allow TNA #1 to work until 7/05/21. The facility's failure to provide protection from abuse and neglect put Resident #31, a vulnerable resident and other residents at risk, and in a situation that caused and is likely to cause serious harm, serious injury, serious impairment, or possible death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 7/3/21 when TNA #1 provided care to Resident #31 without required assistance and the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] The facility Administrator was notified of the IJ and SQC on 9/28/21 and presented with the IJ Template. The facility provided an acceptable Removal Plan on 9/30/21, in which the facility alleged that all corrective actions were completed to remove the IJ and SQC on 9/30/21, and the IJ and SQC was removed on 10/1/21. (Amendment 12/2/21 - The SSA determined the IJ and SQC to be removed on 7/8/21). The State Agency (SA) determined the IJ to be removed 7/8/21 and the scope and severity for CFR 483.12(a)(1)- Freedom form Abuse, Neglect, and Exploitation (F600) was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy titled Abuse Prevention Program, revised September 2013, revealed, Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion . Review of the facility policy titled Abuse and Neglect - Clinical Protocol, revised April 2013, revealed the definition of neglect as, Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility's, Activities of Daily Living (ADLs), Supporting policy, revised January 12, 2021, revealed, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities pf daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Record review of the facility's, Resident Rights policy, revised December 2016, revealed, Policy Statement, Employees shall treat all residents with kindness, respect, and dignity .Policy Interpretation and Implementation .c. be free from abuse, neglect, misappropriation of property and exploitation . Record review of the Resident Incident Report, dated 7/3/21, revealed Incident Type: Fall/no head injury .Date/Time: 7/03/21 02:00 PM .Type of Injury: Fracture .Location: Resident room .Narrative of incident and description of injuries: Nurse entered room after being called by CNA, Resident on her knees on the floor at side of bed holding onto side rail. CNA providing incontinent care to resident, resident turned to right side of bed and she was holding to side rail CNA reports that resident started kicking her legs and fell out of the bed. To ER-X-Ray revealed bilateral femur fractures . Review of the local hospital emergency room Report dated 7/3/21 revealed Resident #31 was transferred to the local hospital emergency department on 7/3/21 due to a bilateral femur fracture from a fall. Record review of the Operative Report dated 7/8/21 revealed Resident #31 underwent intramedullary nailing surgery to her bilateral femur fractures on 7/8/21. Record review of Resident #31's Face Sheet revealed Resident #31 was admitted to the facility on [DATE], with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 06/09/21 revealed Resident#31 had a Brief Interview for Mental Status (BIMS) score of 14 that indicated Resident #31 was cognitively intact. During an interview on 09/16/21 at 09:00 AM, with the Director of Nursing (DON) confirmed Resident #31 fell out of the bed to the floor on 7/3/21. The DON said on 7/6/21 she had TNA #1 come to the facility and re-enact the incident. The DON said TNA #1 was in the room providing incontinent care without CNA #1. TNA #1 turned Resident #31 to the right side and did not remove the pillows from the resident's feet. TNA #1 said when she turned the resident, she slid onto the floor on her knees. Resident #31 was still holding on to the bedrails. TNA #1 said she notified LPN #1. The DON said TNA #1 said she had read Resident #31's plan of care. TNA #1 said she knew Resident #31 was a two (2) person assist with bed mobility, but she thought she could do it without help. The DON said the TNAs and Certified Nursing Assistants (CNA) are trained that TNAs should not provide care without a licensed person being present. The DON confirmed TNA #1 failed to follow Resident #31 Care Plan because the Care Plan reveals the resident should have two (2) people with bed mobility and transfers. During an interview on 09/16/21 at 10:25 AM, with the Administrator revealed TNA #1 had been through the CNA class but she has not taken her test. The Administrator said TNA #1 was paired with CNA #1. The Administrator said on 7/3/21 LPN #1 called her and said Resident #31 slid to the floor during care. The Administrator said she was told Resident #31's feet got tied up in the sheets. Resident #31 was kicking and fell out of the bed while TNA #1 was providing incontinent care. The Administrator said she came to the facility and started the investigation. The Administrator confirmed TNA #1 was not suspended at that time. The Administrator gave orders to the nurses that TNA #1 should not provide care to any of the residents without supervision. The Administrator said on 7/6/21 TNA #1 was called in to do a re-enactment of the incident. The Administrator said TNA #1 said she raised the bed to her waist. TNA #1 turned the resident over without moving the pillows. TNA #1 said she had just read Resident #31's Care Plan and knew that she was a two (2) person assist with Activities of Daily Living (ADL's). TNA #1 said she thought she could do the care without assistance. The Administrator said it was determined, because TNA #1 did not remove the pillows when she turned Resident #31 this caused the resident to fall out of bed. The Administrator said she started the in-services with the staff on Abuse/Neglect, Resident Rights, Following the Care Plan, ADL supporting and Accidents and Incidents. A Quality Assurance (QA) meeting was held on 7/8/21. The Administrator said she notified the ombudsman, the SA and the Attorney General's Office (AG) on 7/3/21. The Administrator stated that TNA #1 was suspended 7/5 21 and terminated 7/12/21 because she had been identified as having the potential of placing residents' safety at risk, leading the facility to terminate her employment. During an interview on 09/16/21 at 12:51 PM, with CNA #1 said she was paired with TNA #1 on 7/3/21. CNA #1 stated she went on the other side of the building to stock the linen cart. CNA #1 said TNA #1 was at the nurse's station when she went to stock the cart. CNA #1 also said she did not know TNA #1 was providing incontinent care without assistance until Resident #31 was noted on the floor. CNA #1 revealed Licensed Practical Nurse (LPN) #2 and CNA #2 educates the staff daily that TNAs cannot provide care without assistance from a licensed/certified staff member. CNA #1 said TNA #1 has not had any other instances where she provided care without assistance. During an interview on 09/16/21 at 01:54 PM, with RN #1 said she was the supervisor for the day on 7/3/21. RN #1 said LPN #1 came down the hall extremely upset stating Resident #31 got her feet tied up in the sheets and slid out of the bed. RN #1 said she did not realize LPN #1 was not in the room with TNA #1 while she was providing care. RN #1 said she called the doctor and got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 09/16/21 at 02:15 PM, with LPN #2/Staff Development, said the staff is trained during orientation and annually on ADL task, skills, and checkoffs. LPN #2 said during her training she tell the TNA's and CNA's that the TNAs cannot provide care without licensed/certified personnel. LPN #2 confirmed she cannot provide an in-service with TNA #1 stating she was trained to only provide care with a licensed person. LPN #2 confirmed TNA #1 failed to follow the care plan because Resident #31 was a two (2) person assist with all ADL's. During an interview on 9/16/21 at 02:30 PM, with CNA #2, said every day before the staff start working, he does a huddle with the CNA's and TNA's. CNA #2 said he reminds the staff that the TNA's can only provide care to residents with a licensed or certified person. TNAs cannot provide care without a certified CNA or a nurse being present. CNA #2 said he was off the day the incident took place. CNA #2 confirmed TNA #1 failed to follow the facility policy and failed to follow the care plan by providing incontinent care to Resident #31 without having a licensed or certified person present. During an interview on 9/16/21 at 2:45 PM, with TNA #2 confirmed she started working at the facility in August 2021 and was in-serviced that she cannot provide care to residents unless a CNA or Nurse is present. During an interview on 9/16/21 at 3:30 PM, with TNA #1 stated she checked on Resident #31 and noted the resident had an incontinent episode. TNA #1 confirmed she provided incontinent care without a CNA or nurse with her. TNA #1 said she was told by CNA #2 that she only needed another staff member in the room when a lift is used for transfer. TNA #1 said she was not told that she could not provide incontinent care to the residents alone. TNA #1 said she has provided incontinent care alone with multiple residents. TNA #1 said she had looked at Resident #31's Care Plan when she first started working at the facility. TNA #1 said she forgot what the Care Plan said and that Resident #31 should have 2 people with care. TNA #1 confirmed she did not ask any of the other staff for assistance because she has provided incontinent care without help multiple times and the resident was ok. Review of the facility's fall Risk Evaluation dated 3/10/21 revealed Resident #31 was a high fall risk. Record review of Resident #31's Care Plan with a Problem Onset date of 03/27/2020 revealed (Formal Name) decline in ability to perform self care activities, (Formal Name) is unable to bear weight, (Formal Name) at risk for soiling clothing .Approaches: Provide extensive assistance X2 (of two persons) with bed mobility .Provide total assistance X 2 with toileting . Record review of the Nurse Aides' Information Sheet, undated, revealed Resident #31 required total assistance X 2 with incontinent care for bowel and bladder and extensive assistance X 2 for turning and repositioning. Record review of the Time Card Report revealed on 7/3/21, TNA#1 clocked into work at 06:50 AM and clocked out at 19:25 (7:25 PM). On 7/4/21, TNA#1 clocked in at 06:49 AM and clocked out at 19:12 (7:12 PM). On 7/5/21, TNA #1 clocked in at 06:49 AM and clocked out at 10:34 AM. Record review of Resident #31's ADL RECORD, for the month of July 2021 revealed that TNA #1 provided personal care to the resident on 7/3/21 and 7/4/21. Record review of the facility's CNA Assignments sheet dated 7/3/21 and 7/4/21 revealed TNA #1 and CNA #1 were assigned to Resident #31. Record review of the facility Counseling Statement dated 7/4/21 revealed TNA #1 was counseled with respect to not following the ADL Plan of Care and the importance of following proper ADL assistance while providing care. TNA #1 was suspended by the Administrator on 7/5/21 at 10:24 AM while investigation of the fall was completed to ensure safety of all residents. Record review of the facility's Termination Report revealed TNA #1 was terminated on 7/12/21 because the employee has been identified as having the potential of placing residents' safety at risk, leading this facility to terminate her employment. Review of the facility Nurse Assistant Skills Check Off revealed TNA #1 was checked off PROVIDES PERINEAL CARE FOR FEMALE on 4/30/21. Review of the facility in-services revealed TNA # 1 was in-serviced on the following: Falls, Safety and Reporting in-service on 6/24/21, Abuse/Neglect on 1/12/21 and 6/24/21, Transfer in-service on 1/12/21, Accident, Incidents and Resident Rights and Vulnerable Adult in-service titled, History of the Vulnerable Persons Act, on 12/29/20. The facility provided an acceptable Removal Plan on 9/30/21, for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan Immediate Jeopardy (IJ) was called on 9/28/2021 at 12:35 PM. The IJ template was provided on 9/28/2021 at 12:35 PM. Beginning 7/3/2021 when Temporary Nursing Assistant (TNA) #1 failed to obtain the necessary assistance to provide incontinent care to resident #31 resulting in a major injury with fracture of bilateral knees. The State Agency notified the Administrator and the Director of Nursing (DON) that an IJ had been identified. Brief Summary of Events The facility failed to ensure a resident was protected from neglect as evidence by (AEB) an unlicensed TNA neglected to obtain assistance required when providing incontinent care that resulted in Resident #31 obtaining a fracture. ON 7/3/21, immediate action was taken by the cart nurse to notify the doctor and obtain bilateral knee x-rays. The facility failed to follow the comprehensive care plan while providing incontinent care AEB Resident #31 is extensive assist and always needs two people during care. The facility failed to ensure a vulnerable resident was protected from accidents and hazards when a TNA#1 failed to ask for help while providing incontinent care, which caused Resident #31 to fall with a major injury to bilateral knees. The facility failed to protect Resident #31 and other residents from potential for further injury during the investigation process by not removing TNA #1 from the facility following an incident on 7/3/2021. The Facility continued to allow TNA #1 to work until 7/05/21. Corrective Action: 1. On 7/3/2021, the Administrator provided education to the Charge Nurse, two (2) TNAs, 2 Cart Registered Nurses (RN), and three (3) Certified Nursing Assistants (CNA) directly involved in the fall of Resident #31. On 7/3/2021, the in-service topics included following the Activities of Living (ADL) Care Plan and Care Guide, Abuse and Neglect, and Residents' Rights. On 7/4/2021 and 7/5/2021, the Administrator continued in-servicing with all staff on the above topics. No staff will be allowed to work until in-services are completed. 2. On 07/03/21, the Administrator identified that Resident #31 sustained a fall with injury and initiated an investigation. 3. On 07/05/2021 at 10:24 AM, the Administrator suspended TNA #1 until further notice to complete investigation. On 07/05/2021 the Administrator conducted and completed the investigation. On 07/12/21 the Administrator terminated TNA #1. 4. On 7/5/2021 at 10:00 AM, each resident under the care from TNA #1 who was identified as at risk for falls was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] 5. On 07/05/2021 at 10 AM, the Minimum Data Set Nurse (MDS) conducted a 100 percent audit of Resident's Fall Risk Assessments and Care Plans for accuracy with no concerns identified. 6. Each resident has a care guide specific to their needs located in a binder at each nurse's station. These are reviewed by the CNAs prior to the start of each shift and to be followed to provide care to the residents. On 07/05/2021, the MDS Nurse performed a 100 percent audit of the care guides with no concerns identified. On 07/05/2021 The Administrator in-serviced CNAs and TNAs on the following: ADL care guides specific to each resident. On 07/05/2021, the MDS Nurse performed a 100 percent audit on ADLs of residents identified at risk for falls and failure to follow the ADL Plan of Care. All residents at risk needing two-person assist were identified and reviewed. On 9/16/2021, the Staff Development Nurse educated all TNAs and CNAs on providing resident care only with a CNA or Nurse present, no staff will be allowed to work until in serviced. TNAs and CNAs were instructed to review ADL care plan prior to each shift. 19 of the 40 residents were identified as at risk for falls and failure for the ADL Plan of Care to be followed. A form was developed and created for all TNA new hires to have proper education, training, and understanding that they must work directly with a licensed CNA and to follow and know their ADL plan of care. On 9/21/2021, the Staff Development Nurse educated all staff that all TNA's can only provide resident care with a CNA or Nurse present, no staff will be allowed to work until in-serviced. 7. The Administrator requested an in-person Quality Assurance Performance Improvement (QAPI) meeting to review events leading to this occurrence and corrective action taken. QAPI meeting occurred on July 8, 2021, and included the Administrator, Director of Nursing, Medical Director, MDS Nurse, Wound Care Nurse, Care Plan Nurse, Medical Records Nurse, Infection Preventionist, Physical Therapist, Administrator Assistant, and the Billing Office Manager. The meeting specifically discussed this fall, identified cause of the fall, number of previous falls, fall risk and potential harm, prevention of recurrence, abuse/neglect, following ADL care plan, Resident's Rights, ADL support and serious injury/harm and reporting. On 07/06/21, the Administrator in serviced the DON and Charge Nurse on the topic of removing any staff from the building for alleged violations of abuse, neglect, exploitation, or misappropriation of resident property until the investigation is completed. No changes to fall policy were required after being reviewed by QAPI. 8. On 9/16/2021, a form was created for all TNA hire in packets to ensure all TNA new hires have proper education, training, and understanding that they must work directly with a licensed CNA. 9. The Administrator and DON conducted a 100 percent audit on all accidents and incidents from 07/04/2021 through 9/30/2021 to ensure that injury or negative outcomes was not identified related to unsupervised TNAs. On 07/05/21, the Administrator in-serviced all staff on fall related policies. Falls are reviewed at stand up meeting every morning and Quarterly Quality Assurance (QA) meeting. On 07/05/21 at 7AM, the Administrator continued on-going in servicing to reiterate with all staff that TNAs must provide care only with CNA assist. 10. The facility alleges that all corrective actions to remove the IJ were completed on 9/30/21, and the IJ was removed on 10/1/21. Validation On 10/2/21, the State Survey Agency (SSA) validated the facility's Removal Plan by staff interviews, record reviews, and review of in-service sign-in sheets. The SSA verified the facility had implemented the following measures to remove IJ: 1. The SSA validated through interview with the Administrator and in-service sign in sheets that on 7/3/2021, the Administrator provided education to the Charge Nurse, two (2) TNAs, 2 Cart Registered Nurses (RN), and three (3) Certified Nursing Assistants (CNA) directly involved in the fall of Resident #31. On 7/3/2021, the in-service topics included following the Activities of Living (ADL) Care Plan and Care Guide, Abuse and Neglect, and Residents' Rights. On 7/4/2021 and 7/5/2021, the Administrator continued in-servicing with all staff on the above topics. No staff will be allowed to work until in-services are completed. 2. The SSA validated through interview on 10/1/21 that on 07/03/21, the Administrator identified Resident #31 sustained a fall with injury and initiated an investigation. 3. The SSA validated through interview and record review that on 07/05/2021 at 10:24 AM, the Administrator suspended TNA #1 until further notice to complete investigation and on 07/05/2021 the Administrator conducted and completed the investigation. On 07/12/21 the Administrator terminated TNA #1. 4. The SSA validated through interview with DON and record review that on 7/5/2021 at 10:00 AM, each resident under the care from TNA #1 who was identified as at risk for falls was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] 5. The SSA validated through interview with the Minimum Data Set Nurse (MDS) nurse and record review on 07/05/2021 at 10 AM, the MDS nurse conducted a 100 percent audit of Resident's Fall Risk Assessments and Care Plans for accuracy with no concerns identified. 6. The SSA validated through staff interviews, record reviews and signed in-services that each resident has a care guide specific to their needs located in a binder at each nurse's station. These are reviewed by the CNAs prior to the start of each shift and to be followed to provide care to the residents. On 07/05/2021, the MDS Nurse performed a 100 percent audit of the care guides with no concerns identified. On 07/05/2021 The Administrator in-serviced CNAs and TNAs on the following: ADL care guides specific to each resident. On 07/05/2021, the MDS Nurse performed a 100 percent audit on ADLs of residents identified at risk for falls and failure to follow the ADL Plan of Care. All residents at risk needing two-person assist were identified and reviewed. On 9/16/2021, the Staff Development Nurse educated all TNAs and CNAs on providing resident care only with a CNA or Nurse present, no staff will be allowed to work until in serviced. TNAs and CNAs were instructed to review ADL care plan prior to each shift. 19 of the 40 residents were identified as at risk for falls and failure for the ADL Plan of Care to be followed. A form was developed and created for all TNA new hires to have proper education, training, and understanding that they must work directly with a licensed CNA and to follow and know their ADL plan of care. On 9/21/2021, the Staff Development Nurse educated all staff that all TNA's can only provide resident care with a CNA or Nurse present, no staff will be allowed to work until in-serviced. 7. The SSA validated through staff interviews, record review and signed in-service sheets that the Administrator requested an in-person Quality Assurance Performance Improvement (QAPI) meeting to review events leading to this occurrence and corrective action taken. The QAPI meeting occurred on July 8, 2021, and included the Administrator, Director of Nursing, Medical Director, MDS Nurse, Wound Care Nurse, Care Plan Nurse, Medical Records Nurse, Infection Preventionist, Physical Therapist, Administrator Assistant, and the Billing Office Manager. The meeting specifically discussed this fall, identified cause of the fall, number of previous falls, fall risk and potential harm, prevention of recurrence, abuse/neglect, following ADL care plan, Resident's Rights, ADL support and serious injury/harm and reporting. On 07/06/21, the Administrator in serviced the DON and Charge Nurse on the topic of removing any staff from the building for alleged violations of abuse, neglect, exploitation, or misappropriation of resident property until the investigation is completed. No changes to fall policy were required after being reviewed by QAPI. 8. The SSA validated through an interview with the Administrator and record review that on 9/16/2021, a form was created for all TNA's hire in packets to ensure all TNA new hires have proper education, training, and understanding that they must work directly with a licensed CNA. 9. The SSA validated through record review, signed in-services and interview with the Administrator and DON that a 100 percent audit was conducted on all accidents and incidents from 07/04/2021 through 9/30/2021 to ensure that injury or negative outcomes was not identified related to unsupervised TNAs. On 07/05/21, the Administrator in-serviced all staff on fall related policies. Falls are reviewed at stand up meeting every morning and Quarterly Quality Assurance (QA) meeting. On 07/05/21 at 7AM, the Administrator continued on-going in servicing to reiterate with all staff that TNAs must provide care only with CNA assist. 10. Amendment 12/2/21 - The SSA validated that all corrective actions to remove the IJ had been completed as of 7/8/21, and the IJ removed on 7/8/21.

Amendment 12/07/2021 Upon secondary review with CMS Regional Office staff and State Quality Assurance review, the State Survey Agency (SSA) determined the Immediate Jeopardy to be removed on 7/8/21 for F610 and the scope and severity was lowered to D, while the facility develops and implements a plan of correction and monitors effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Based on staff interviews, record review and facility policy review, the facility failed to prevent the potential for further injury during the investigation process by not removing Temporary Nursing Assistant (TNA) #1 from the facility following an incident on 7/3/21 which resulted in a major injury to Resident #31, for one (3) of three (3) investigations reviewed. On 7/3/21, TNA #1 neglected to obtain the assistance required when providing incontinent care for Resident #31. TNA #1 turned the resident to her side without removing the pillows from the resident's feet. This resulted in Resident #31 falling to the floor and sustaining bilateral femur fractures. The resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to protect Resident #31 and other residents from the potential for further injury during the investigation process by not removing TNA #1 from the facility following the incident on 7/3/2021. The facility continued to allow TNA #1 to work until 7/05/21. The facility's failure to remove TNA #1 from the facility immediately placed Resident #31, a vulnerable resident, and other residents at risk. These actions had the likelihood to cause all residents residing in the facility serious harm, serious injury, serious impairment, or possible death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 7/3/21 when TNA #1 failed to obtain assistance to provide incontinent care and Resident #31 fell from the bed and received a major injury. The facility Administrator was notified of the IJ and SQC on 9/28/21 at 12:35 PM, and the IJ templates were provided to the Administrator. The State Survey Agency (SSA) received an acceptable Removal Plan on 9/30/21, in which the facility alleged that all corrective actions were completed as of 9/30/21, and the Immediate Jeopardy was removed on 10/1/21. (Amendment 12/2/21 - The SSA determined the IJ and SQC to be removed on 7/8/21). The SSA validated the Removal Plan and determined the IJ to be removed on 7/8/2021. Therefore, the scope and severity for CFR 483.12(c)(2)(3)-Investigation (F610) was lowered to a D, while the facility develops and implements a plan of correction and monitors effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy, Abuse Investigations, revised September 2013, revealed Policy Statement, All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Review of the facility's policy Abuse Prevention Program, revised September 2013, revealed Policy Statement: Our residents have the right to be free from abuse, neglect .Policy Interpretation and Implementation: 3 Our abuse prevention program provides policies and procedures that govern, as a minimum: .d. The protection of residents during abuse investigations; .f. Timely and thorough investigations of all reports and allegations of abuse . Review of the facility's investigation revealed the facility started the investigation immediately on 7/3/21by the Administrator. Resident #31's X-rays revealed the resident was noted with bilateral femur fractures on 7/3/21. TNA #1 was suspended on 7/5/21 pending further investigation. TNA #1 was terminated 7/12/21. Quality Assurance (QA) meeting was held to discuss in-services to be completed due to the fall, ways to prevent re-occurrences and fall prevention, identify all residents at risk, with potential to be harmed by this incident, how many falls Resident #31 has had, harm caused by the fall and the residents outcome, serious injury/harm and reporting, Abuse-Neglect, Following Activities of Daily Living (ADL) care plan, ADL supporting. During an interview on 09/16/21 at 10:25 AM, with the Administrator she confirmed the facility notified her of Resident #31's fall on 7/3/21 and she came to the facility and immediately started the investigation. The Administrator confirmed TNA #1 was not suspended at that time. The Administrator gave orders to the nurses that TNA #1 should not provide care to any of the residents without assistance. The Administrator said she started the inservices with the staff on Abuse/Neglect, Resident Rights, Following the Care Plan, ADL Supporting and Accidents and Incidents. A QA meeting was held on 7/8/21. The Administrator said she notified the Ombudsman, the SSA and the Attorney General's Office (AG) on 7/3/21. The Administrator stated that TNA #1 was suspended on 7/5/21 and terminated on 7/12/21 because she had been identified as having the potential of placing residents' safety at risk, leading the facility to terminate her employment. Record review of the Time-Card Report revealed on 7/3/21, TNA#1 clocked into work at 06:50 AM and clocked out at 19:25 (7:25 PM). On 7/4/21, TNA#1 clocked in at 06:49 AM and clocked out at 19:12 (7:12 PM). On 7/5/21, TNA #1 clocked in at 06:49 AM and clocked out at 10:34 AM. Record review of Resident #31's ADL RECORD, for the month of July 2021 revealed that TNA #1 provided personal care to the resident on 7/3/21 and 7/4/21. Record review of the facility's CNA Assignments sheet dated 7/3/21 and 7/4/21 revealed TNA #1 and CNA #1 were assigned to Resident #31. Record review of Resident #31's Face Sheet revealed Resident #31 was admitted to the facility on [DATE], with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #31's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/09/2021, Section C, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #31 is cognitively intact. The facility provided an acceptable Removal Plan on 9/30/21, for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan Immediate Jeopardy (IJ) was called on 9/28/2021 at 12:35 PM. The IJ template was provided on 9/28/2021 at 12:35 PM. Beginning 7/3/2021 when Temporary Nursing Assistant (TNA) #1 failed to obtain the necessary assistance to provide incontinent care to resident #31 resulting in a major injury with fracture of bilateral knees. The State Agency notified the Administrator and the Director of Nursing (DON) that an IJ had been identified. Brief Summary of Events The facility failed to ensure a resident was protected from neglect as evidence by (AEB) an unlicensed TNA neglected to obtain assistance required when providing incontinent care that resulted in Resident #31 obtaining a fracture. ON 7/3/21, immediate action was taken by the cart nurse to notify the doctor and obtain bilateral knee x-rays. The facility failed to follow the comprehensive care plan while providing incontinent care AEB Resident #31 is extensive assist and always needs two people during care. The facility failed to ensure a vulnerable resident was protected from accidents and hazards when a TNA#1 failed to ask for help while providing incontinent care, which caused Resident #31 to fall with a major injury to bilateral knees. The facility failed to protect Resident #31 and other residents from potential for further injury during the investigation process by not removing TNA #1 from the facility following an incident on 7/3/2021. The Facility continued to allow TNA #1 to work until 7/05/21. Corrective Actions: 1. On 7/3/2021, the Administrator provided education to the Charge Nurse, two (2) TNAs, 2 Cart Registered Nurses (RN), and three (3) Certified Nursing Assistants (CNA) directly involved in the fall of Resident #31. On 7/3/2021, the in-service topics included following the Activities of Living (ADL) Care Plan and Care Guide, Abuse and Neglect, and Residents' Rights. On 7/4/2021 and 7/5/2021, the Administrator continued in-servicing with all staff on the above topics. No staff will be allowed to work until in-services are completed. 2. On 07/03/21, the Administrator identified that Resident #31 sustained a fall with injury and initiated an investigation. 3. On 07/05/2021 at 10:24 AM, the Administrator suspended TNA #1 until further notice to complete investigation. On 07/05/2021 the Administrator conducted and completed the investigation. On 07/12/21 the Administrator terminated TNA #1. 4. On 7/5/2021 at 10:00 AM, each resident under the care from TNA #1 who was identified as at risk for falls was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] 5. On 07/05/2021 at 10 AM, the Minimum Data Set Nurse (MDS) conducted a 100 percent audit of Resident's Fall Risk Assessments and Care Plans for accuracy with no concerns identified. 6. Each resident has a care guide specific to their needs located in a binder at each nurse's station. These are reviewed by the CNAs prior to the start of each shift and to be followed to provide care to the residents. On 07/05/2021, the MDS Nurse performed a 100 percent audit of the care guides with no concerns identified. On 07/05/2021 The Administrator in-serviced CNAs and TNAs on the following: ADL care guides specific to each resident. On 07/05/2021, the MDS Nurse performed a 100 percent audit on ADLs of residents identified at risk for falls and failure to follow the ADL Plan of Care. All residents at risk needing two-person assist were identified and reviewed. On 9/16/2021, the Staff Development Nurse educated all TNAs and CNAs on providing resident care only with a CNA or Nurse present, no staff will be allowed to work until in serviced. TNAs and CNAs were instructed to review ADL care plan prior to each shift. 19 of the 40 residents were identified as at risk for falls and failure for the ADL Plan of Care to be followed. A form was developed and created for all TNA new hires to have proper education, training, and understanding that they must work directly with a licensed CNA and to follow and know their ADL plan of care. On 9/21/2021, the Staff Development Nurse educated all staff that all TNA's can only provide resident care with a CNA or Nurse present, no staff will be allowed to work until in-serviced. 7. The Administrator requested an in-person Quality Assurance Performance Improvement (QAPI) meeting to review events leading to this occurrence and corrective action taken. QAPI meeting occurred on July 8, 2021, and included the Administrator, Director of Nursing, Medical Director, MDS Nurse, Wound Care Nurse, Care Plan Nurse, Medical Records Nurse, Infection Preventionist, Physical Therapist, Administrator Assistant, and the Billing Office Manager. The meeting specifically discussed this fall, identified cause of the fall, number of previous falls, fall risk and potential harm, prevention of recurrence, abuse/neglect, following ADL care plan, Resident's Rights, ADL support and serious injury/harm and reporting. On 07/06/21, the Administrator in serviced the DON and Charge Nurse on the topic of removing any staff from the building for alleged violations of abuse, neglect, exploitation, or misappropriation of resident property until the investigation is completed. No changes to fall policy were required after being reviewed by QAPI. 8. On 9/16/2021, a form was created for all TNA hire in packets to ensure all TNA new hires have proper education, training, and understanding that they must work directly with a licensed CNA. 9. The Administrator and DON conducted a 100 percent audit on all accidents and incidents from 07/04/2021 through 9/30/2021 to ensure that injury or negative outcomes was not identified related to unsupervised TNAs. On 07/05/21, the Administrator in-serviced all staff on fall related policies. Falls are reviewed at stand up meeting every morning and Quarterly Quality Assurance (QA) meeting. On 07/05/21 at 7AM, the Administrator continued on-going in servicing to reiterate with all staff that TNAs must provide care only with CNA assist. 10. The facility alleges that all corrective actions to remove the IJ were completed on 9/30/21, and the IJ was removed on 10/1/21. On 10/2/21, the State Survey Agency (SSA) validated the facility's AOC Removal Plan by staff interviews, record reviews, and review of in-service sign-in sheets. The SSA verified the facility had implemented the following measures to remove IJ: Validation: 1. The SSA validated through interview with the Administrator and in-service sign in sheets that on 7/3/2021, the Administrator provided education to the Charge Nurse, two (2) TNAs, 2 Cart Registered Nurses (RN), and three (3) Certified Nursing Assistants (CNA) directly involved in the fall of Resident #31. On 7/3/2021, the in-service topics included following the Activities of Living (ADL) Care Plan and Care Guide, Abuse and Neglect, and Residents' Rights. On 7/4/2021 and 7/5/2021, the Administrator continued in-servicing with all staff on the above topics. No staff will be allowed to work until in-services are completed. 2. The SSA validated through interview on 10/1/21 that on 07/03/21, the Administrator identified Resident #31 sustained a fall with injury and initiated an investigation. 3. The SSA validated through interview and record review that on 07/05/2021 at 10:24 AM, the Administrator suspended TNA #1 until further notice to complete investigation and on 07/05/2021 the Administrator conducted and completed the investigation. On 07/12/21 the Administrator terminated TNA #1. 4. The SSA validated through interview with DON and record review that on 7/5/2021 at 10:00 AM, each resident under the care from TNA #1 who was identified as at risk for falls was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] 5. The SSA validated through interview with the Minimum Data Set Nurse (MDS) nurse and record review on 07/05/2021 at 10 AM, the MDS nurse conducted a 100 percent audit of Residents Fall Risk Assessments and Care Plans for accuracy with no concerns identified. 6. The SSA validated through staff interviews, record reviews and signed in-services that each resident has a care guide specific to their needs located in a binder at each nurse's station. These are reviewed by the CNAs prior to the start of each shift and to be followed to provide care to the residents. On 07/05/2021, the MDS Nurse performed a 100 percent audit of the care guides with no concerns identified. On 07/05/2021 The Administrator in-serviced CNAs and TNAs on the following: ADL care guides specific to each resident. On 07/05/2021, the MDS Nurse performed a 100 percent audit on ADLs of residents identified at risk for falls and failure to follow the ADL Plan of Care. All residents at risk needing two-person assist were identified and reviewed. On 9/16/2021, the Staff Development Nurse educated all TNAs and CNAs on providing resident care only with a CNA or Nurse present, no staff will be allowed to work until in serviced. TNAs and CNAs were instructed to review ADL care plan prior to each shift. 19 of the 40 residents were identified as at risk for falls and failure for the ADL Plan of Care to be followed. A form was developed and created for all TNA new hires to have proper education, training, and understanding that they must work directly with a licensed CNA and to follow and know their ADL plan of care. On 9/21/2021, the Staff Development Nurse educated all staff that all TNA's can only provide resident care with a CNA or Nurse present, no staff will be allowed to work until in-serviced. 7. The SSA validated through staff interviews, record review and signed in-service sheets that the Administrator requested an in-person Quality Assurance Performance Improvement (QAPI) meeting to review events leading to this occurrence and corrective action taken. The QAPI meeting occurred on July 8, 2021, and included the Administrator, Director of Nursing, Medical Director, MDS Nurse, Wound Care Nurse, Care Plan Nurse, Medical Records Nurse, Infection Preventionist, Physical Therapist, Administrator Assistant, and the Billing Office Manager. The meeting specifically discussed this fall, identified cause of the fall, number of previous falls, fall risk and potential harm, prevention of recurrence, abuse/neglect, following ADL care plan, Resident's Rights, ADL support and serious injury/harm and reporting. On 07/06/21, the Administrator in serviced the DON and Charge Nurse on the topic of removing any staff from the building for alleged violations of abuse, neglect, exploitation, or misappropriation of resident property until the investigation is completed. No changes to fall policy were required after being reviewed by QAPI. 8. The SSA validated through an interview with the Administrator and record review that on 9/16/2021, a form was created for all TNA's hire in packets to ensure all TNA new hires have proper education, training, and understanding that they must work directly with a licensed CNA. 9. The SSA validated through record review, signed in-services and interview with the Administrator and DON that a 100 percent audit was conducted on all accidents and incidents from 07/04/2021 through 9/30/2021 to ensure that injury or negative outcomes was not identified related to unsupervised TNAs. On 07/05/21, the Administrator in-serviced all staff on fall related policies. Falls are reviewed at stand up meeting every morning and Quarterly Quality Assurance (QA) meeting. On 07/05/21 at 7AM, the Administrator continued on-going in servicing to reiterate with all staff that TNAs must provide care only with CNA assist. 10. Amendment 12/2/21 -The SSA validated that all corrective actions to remove the IJ had been completed as of 7/8/21, and the IJ removed on 7/8/21.

Amendment 12/07/2021 Upon secondary review with CMS Regional Office and State Quality Assurance review, the State Survey Agency (SSA) determined the Immediate Jeopardy to be removed on 7/8/21 for F689 and the scope and severity was lowered to D, while the facility develops and implements a plan of correction and monitors effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Based on staff interview, record reviews and facility policy review the facility failed to ensure a vulnerable resident was protected from accidents and hazards when a Temporary Nursing Assistant (TNA) failed to obtain the required assistance while providing incontinent care which caused a fall with a major injury for Resident #31. The facility failed to ensure the residents were free from rodents in the facility as evidenced by (AEB) a mouse was seen in the bed with Resident #31 and mouse droppings were under four (4) residents beds and in chests of drawers for seven (7) of 16 residents reviewed for accidents and hazards. Resident #3, Resident #6, Resident 12, Resident #13, Resident #31 and Resident #35, Resident #42. On 7/3/21, TNA #1 neglected to obtain the assistance required when providing incontinent care for Resident #31. TNA #1 turned the resident to her side without removing the pillows from the resident's feet. This resulted in Resident #31 falling to the floor and sustaining bilateral femur fractures. The resident underwent intramedullary nailing surgery to her bilateral femur fractures on 7/8/21. The facility failed to protect Resident #31 and other residents from potential for further injury during the investigation process by not removing TNA #1 from the facility following the incident on 7/3/2021. The facility continued to allow TNA #1 to work until 7/05/21. The State Survey Agency (SSA) extended the survey upon receipt of two (2) complaint investigations, CI: # dated 10/08/21 and CI# dated 10/11/21 from an anonymous complainant alledging the facility is infested with rats. The complainant revealed that a rat was observed chewing on Resident #'s 13 feeding tube. The Complainant also said a rat was observed in the Resident's boot on one of her feet. The Complainant said the rat had eaten part of Resident #31's foot. The Complainant also said the staff is killing the rats because the facility Administration refuses to do anything about them. The facility's failure to provide supervision for a resident who is vulnerable and needs extensive assistance with all care is likely to cause injury and harm to other residents. This is evidenced by Resident #31 falling to the floor receiving bilateral femur fractures. These actions had the likelihood to cause all residents residing in the facility serious harm, serious injury, serious impairment, or possible death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 7/3/21 when TNA #1 failed to obtain the required assistance resulting in Resident #31 falling from bed and receiving a major injury. The facility Administrator was notified of the IJ on 9/28/21 and provided the IJ Template. The State Survey Agency (SSA) received an acceptable Removal Plan on 9/30/21, in which the facility alleged that all corrective actions were completed as of 9/30/21, and the IJ was removed on 10/1/21. (Amendment 12/2/21 - The SSA determined that the IJ was removed on 7/8/21) The SSA validated the Removal Plan on 10/2/21 and determined the IJ to be removed on 7/8/21. Therefore, the scope and severity for IJ at CFR 483.25(d)(1)(2)-Accidents Hazards/supervision/devices (F689) was lowered to D, while the facility develops and implements a plan of correction and monitors effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Accident and Incidents-Investigating and Reporting, dated 07/2017, revealed Policy Statement: It is the policy that all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator . Policy Interpretation and Implementation .5. The Nurse Supervisor/ Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/ Accident form and submit the original of the Director of Nursing services within 24 hours. of the incident or accident. 6.The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence. 7.Incident/Accident reports will be reviewed by the Quality Assurance (QA) committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Review of the facility's Fall Risk Assessment Policy, revised March 2018, revealed Policy Statment, The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information . Policy Interpretation and Implementation .7.The staff, with the support of the attending physician, will evaluate functional and psychological factors that my increase fall risk, including ambulation, mobility, gait balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition Interview on 09/16/21 at 09:00 AM, with the Director of Nursing (DON) revealed on 7/3/21 Resident #31 fell out of the bed to the floor while TNA #1 as providing care. The DON also stated that on 7/6/21 TNA #1 came to the facility and re-enacted the incident. The DON said TNA #1 said she was providing incontinent care alone and turned Resident #31 to the right side. TNA #1 said she did not remove the pillows from the resident's feet. TNA #1 said Resident #31 slid to the floor on her knees. Resident #31 was still holding on to the bedrails. TNA #1 revealed she notified Licensed Practice Nurse (LPN) #1. The DON said TNA #1 confirmed she had read Resident #31's plan of care. TNA #1 said she knew Resident #31 was a two (2) person assist with bed mobility, but she thought she could do it without help. The DON said the TNA's and Certified Nursing Assistants (CNA) are trained that TNAs should not provide care without a license person being present. During an interview on 09/16/21 at 10:25 AM, with the Administrator revealed TNA #1 had been through the CNA class but she has not taken her test. The Administrator said TNA #1 was paired with CNA #1. The Administrator said on 7/3/21 LPN #1 called her and said Resident #31 had slid to the floor during care. The Administrator said she was told Resident #31's feet got tied up in the sheets. Resident #31 was kicking and fell out of the bed while TNA #1 was providing incontinent care. The Administrator said she came to the facility and started the investigation. The Administrator confirmed TNA #1 was not suspended at that time. The Administrator gave orders to the nurses that TNA #1 should not provide care to any of the residents without supervision. The Administrator said on 7/6/21 TNA #1 was called in to do a re-enactment of the incident. The Administrator said TNA #1 said she raised the bed to her waist. TNA #1 turned the resident over without moving the pillows. TNA #1 said she had just read Resident #31 care plan and knew that she was a two (2) person assist with Activities of Daily Living (ADL's). TNA #1 said she thought she could do the care without assistance. The Administrator said it was determined during the investigation TNA #1 did not remove the pillows when she turned Resident #31, this caused the resident to fall out of bed. The Administrator said in-services were started with the staff on Abuse/Neglect, Resident rights, Following the care plan, ADL supporting and Accidents and Incidents. A Quality Assurance (QA) meeting was done 7/8/21. The Administrator said the Ombudsman, Mississippi State Department of Health (MSDH) and the Attorney General's (AG's) Office was notified on 7/3/21. The Administrator stated that TNA #1 was suspended 7/5/21 and terminated 7/12/21 because she had been identified as having the potential of placing residents' at a safety at risk, leading the facility to terminate her employment. Interview on 09/16/21 at 12:51 PM, with CNA #1 said she was assigned to work with TNA #1 on 7/3/21. CNA #1 she went on the other side of the building to stock the linen cart. CNA #1 also revealed TNA #1 was at the nurse's station when she went to stock the cart. CNA #1 said she did not know CNA #1 was providing incontinent care without her until Resident #31 was reported on the floor. CNA #1 revealed LPN #2 and CNA #2 in-serviced the staff daily that TNAs cannot provide care without assistance of a licensed or certified staff member. CNA #1 said TNA #1 has not had any other instances where she provided care without assistance. Interview on 09/16/21 at 01:54 PM, with Registered Nurse (RN) #1 said she was the supervisor for the day. RN #1 said LPN #1 came down the hall extremely upset stating Resident #31 got her feet tied up in the sheets and slid out of the bed. RN #1 said she thought LPN #1 was in the room with TNA #1 while she was providing care. RN #1 said she received an order for an X-ray of Resident #31's bilateral knees from the medical doctor. During an interview with LPN #2 on 09/16/21 at 2:15 PM, confirmed the staff is trained during orientation and annually on Activities of daily Living (ADL) task, skills, and checkoffs. LPN #2 said during her training she tells the TNA's and CNA's that the TNAs cannot provide care without licensed or certified personnel. LPN #2 confirmed she cannot provide an in-service with TNA #1 indicating she was trained to only provide care with a licensed or certified person. During an interview with CNA #2 on 9/16/21 at 2:30 PM, revealed he is at work every day at 6:00 AM. CNA #2 said he has a meeting with the CNA's and TNA's. CNA #2 reminds the staff that the TNA's can only provide care to residents with a licensed or certified person. TNAs cannot provide care without a certified CNA or a nurse being present. CNA #2 confirmed TNA #1 failed to follow the facility policy by providing incontinent care to Resident #31 without having another CNA or nurse present. During an interview with TNA #1 on 9/16/21 at 3:30 PM, revealed she checked on Resident #31 and noted the resident had an incontinent episode. TNA #1 confirmed she provided incontinent care without a CNA or Nurse with her. TNA #1 revealed she was told by CNA #2 that she only needed another staff member in the room when a lift is used for transfer. TNA #1 said she was not told that she could not provide incontinent care to the residents alone. TNA #1 said she has provided incontinent care alone with multiple residents. TNA #1 said she reviewed Resident #31's care plan when she first started working at the facility. TNA #1 said she did not remember Resident #31 plan of care required two (2) persons assist with ADL's. TNA #1 confirmed she did not ask any of the other staff for assistance because she has provided incontinent care without help multiple times and the resident was ok. Review of the facility's Nurse Aides Information Sheet plan of care revealed Resident #31 requires two person/extensive assist with incontinent care, Hoyer lifts, bed baths, showers, turn and reposition and dressing. Record review of Resident #31's Care Plan with a Problem Onset date of 03/27/2020 revealed (Formal Name) decline in ability to perform self care activities, (Formal Name) is unable to bear weight, (Formal Name) at risk for soiling clothing .Approaches: Provide extensive assistance X2 (of two persons) with bed mobility .Provide total assistance X2 with toileting . Record review of the Face Sheet revealed Resident #31 was admitted to the facility on [DATE] with diagnoses which included Major depressive disorder, Dementia,Psychotic disorder with delusions, Anxiety disorder, and Sarcopenia. Record review of Resident #31's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/09/2021 revealed Resident # 31 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #31 is cognitively intact. CI # and CI # Review of the facility's, Pest Control, dated 8/20/18, revealed policy to establish a safe and reliable method of pest and rodentcontrol for (Formal Name of Facility) .Procedure:1. Pest Control for the facility will be through a licensed, bonded commercial firm. 2. The pest control action will be carefully coordinated with appropriate Administrator and/or Director of Nursing and the Director of Maintenance. 3. Spraying and other means of pest control will be performed during a time of low patient flow. Generally, the day will be Friday afternoon to reduce the level of fumes for patients, staff. 4. Recording of chemical spraying for (Formal Name) will be done through the use of a pest control spray log. The person in charge of maintenance will insure that entries in the log are completed in an accurate and timely basis.5. Spraying and pest control activities will be kept to an absolute minimum. During an observation of the facility on 10/12/21 at 09:00 AM, revealed Resident # 13 lying in bed with the head of the bed elevated. The Resident was nonverbal with [MEDICATION(S)] 1.2 infusing at (@) 50 cubic centimeters (cc)/hour (hr) per continuous tube feeding. The Resident did not have any [CONDITION(S)] or broken skin noted on either foot. The SSA observed mice droppings in the residents chest of drawers. The SSA also observed a cardboard mouse hotel noted under the resident's bed. The SSA also observed Resident #31's left big toe on 10/12/21 at 9:00 during the tour. The toe had two (2) red areas. No blood or drainage was noted. The SSA observed mice hotels in all the residents' rooms on the 300 halls underneath their beds. During an interview on 10/12/21 at 09:15 AM, the Administrator confirmed the facility has a problem with mice. The Administrator said the staff notified her of the mice in the building about a month and a half ago. The Administrator said the staff told her they saw mice at the nurse's station and in the offices on the 300 halls. The Administrator said the maintenance department put out sticky traps at the nurse's station, offices, and utility rooms. The Administrator said she was notified on 10/7/21 at 06:00 AM that Resident #31 had a mouse in her bed. The Administrator also said she was told Resident #31 had a possible bite on her left toe. The Administrator said she immediately notified maintenance and started an investigation. Resident #31 was assessed and removed from that room. The Resident's room was thoroughly cleaned. The Administrator said she was told the mice has only been seen at night. The day shift said they have not seen any mice. The Administrator said the (Formal name of pest control company) comes out monthly and sprays for all pest and rodents. The facility is in the process of reconstruction of the 200, 300 and 400 halls. The Administrator also said the facility is removing all the residents off the 300 hall and re-doing their rooms first because of the mice citings. Review of the facility's, pest control invoice, revealed the pest control company made a visit to the facility on [DATE] and 9/30/21. During an interview on 10/12/21 at 10:30 AM, CNA #2 confirmed the facility has problems with mice. CNA #2 said he has removed 4 mice out of the building in the last few months. CNA #2 said he removed two (2) out of Residents rooms and two (2) out of the nurse's offices. CNA #2 said the mice were in the mice hotels. CNA #2 revealed he started seeing and hearing about the mice in the building about eight months ago when the facility started reconstruction on the kitchen. CNA #2 said maintenance put out sticky traps at the nurse's station and in the utility closet. CNA #2 said the staff will call him if a mouse enters the mouse hotel to remove it. During an interview on 10/12/21 at 11:00 AM, with RN # 2 revealed he was consulted to assess Resident #31's wound on her left great toe. RN #2 said the lesion measured at 0.4 centimeters (cm) x 0.3 cm x 0.2 cm. The wound was red and open with no drainage or odor. RN #2 said he received an order to cleanse the area with normal saline, apply triple antibiotic cream and cover with a dry dressing. RN #2 said he has seen CNA #2 taking a mouse out of the facility in the mouse hotel. He has not removed any mice himself. During an interview on 10/12/21 at 11:15 AM, with the Maintenance Director confirmed the facility has a problem with mice in the facility. The Maintenance Director said this was bought to his attention about a month and a half ago. The staff complained of seeing mice running across the nurse's station. The Maintenance Director said he put out sticky traps at the nurses station and in the utility rooms. The Maintenance Director also said (name of pest control company) comes out monthly and as needed. The pest control company has placed five (5) bait stations under the facility with mice bait. The Maintenance Director said it was bought to his attention again on the 10/7/21, when he was told Resident #31 had a mouse in her bed. The Maintenance Director said he put out 38 mouse baits on the rehab side of the facility in the residents' rooms and 17 on the long-term side. The Maintenance Director said no one has reported seeing any mice on the Rehab side. During an interview on 10/12/21 at 12:30 PM, with the Medical Director (MD) revealed he looked at the resident's foot and believe she has two (2) [CONDITION(S)] on her left toe. From what, he does not know. The MD said he could not tell what kind of bite it is. The MD said the Resident was started on [MEDICATION(S)] which is appropriate for a mouse bite. The Resident is also orderd triple antibiotic cream every shift and as needed. During an interview on 10/12/21 at 1:00 PM, with Resident #31's primary Physician confirmed he was notified on 10/7/21 that Resident #31 could have received a possible mouse bite. The primary Physician said he ordered [MEDICATION(S)] 100 milligrams (mg) orally twice a day, for ten days. During an interview on 10/12/21 at 2:00 PM, with the local pest control staff revealed he treats the facility once a month for all pest and rodents. The facility will call him for extra treatments when needed. He said he was called on 10/7/21 for an extra treatment because the facility saw a mouse in a resident's bed. He stated he placed bait stations under the facility. He has recommended that the facility would put snap traps out at the nurse's station and in the utility closets. He said he told them not to put them in the resident's room. He said he doesn't know why the facility has seen an increase in mouse citings. During an interview per phone on 10/12/21 at 8:30 PM, with CNA #3 said she pulled Resident #31's cover back to provide incontinent care. CNA #3 said she saw the mouse run in Resident #31's boot. CNA #3 said she screamed. CNA #4 pulled the cover off the bed. The mouse ran down the bed and jumped off the bed and ran in a hole that was next to the closet in the resident's room. CNA #3 said she had never seen a mouse in a resident's bed before. CNA #3 said she has seen mice for several months running down the hall and at the nurse's station. CNA #3 said she has seen mice droppings in several residents' drawers. She reported the mice to CNA #2. She reported the maintenance department put out sticky traps. During an interview per phone on 10/12/21 at 8:45 PM, with LPN #3 confirmed she was called into Resident #31's room by CNA #3 and CNA #4. LPN #3 said the mouse ran out of Resident #31's Prevalon boot and jumped off the bed onto the floor and ran in a hole in the wall under the closet door. LPN #3 said there was mouse droppings on the floor and in the residents' bed linen from top to bottom of the bed. Resident #31 had two (2) open [CONDITION(S)] to her left great toe, active bright red blood was noted on the residents left toe. The primary Physician ordered [MEDICATION(S)] 100 mg orally twice a day times ten days. The wounds were cleansed with normal saline and triple antibiotic ointment was applied. The Administrator, DON and family was notified of the incident. During an interview per phone on 10/12/21 at 9:00 PM, with CNA #4 revealed she was attempting to provide incontinent care to Resident #31. CNA #4 said CNA #3 pulled the cover back on Resident #31. A mouse ran into Resident #31's Prevalon boot. CNA #4 said she pulled the cover off the bed and the mouse ran out of the boot up to the head of the bed and jumped off the bed and ran in a hole in the wall near the closet. CNA #4 also said the mouse had droppings from the head of the bed to the bottom. There were mouse droppings all over the floor. CNA #4 said she has seen mice running up and down the halls several times ever since the facility started tearing down the kitchen eight months ago. CNA #4 said she reported the mice to the CNA #2. CNA #2 reported it to maintenance. CNA #4 said maintenance put out sticky traps. CNA #4 said she has seen mouse droppings in several of the resident's drawers on the 300 hall. During an observation on 10/13/21 at 10:00 AM, of the rooms on the 300 halls with CNA #2 revealed mouse droppings in the chest of drawers and on the floor under the Residents beds in four (4) resident rooms. Resident #3, Resident #6, Resident #12, and Resident #35 resided in the rooms that were identified with mouse droppings. Record review of the Face Sheet revealed Resident #3 was admitted to the facility with the diagnoses that included Dementia with behavioral disturbance, Hypertension, and History of falls. Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/18/21 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of eight (8) that indicated Resident #3 has moderate cognitive impairment. Record review of the Face Sheet revealed Resident #6 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, Diabetes Mellitus, and Hypertension. Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/25/21 revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of three (3) that indicated Resident #6 has severe cognitive impairment. Record review of the Face Sheet revealed Resident #12 was admitted to the facility on [DATE] with diagnoses that included Multiple [CONDITION(S)], Dementia and Rhabdomyolysis. Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/8/21 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of ten (10) that indicated Resident #12 has moderate cognitive impairment. Interview with Resident #12 on 10/13/21 at 10:15 AM, revealed she has not seen any mice in her room. She did not know she had mice droppings in her chest of drawers and under her bed. Record review of the Face Sheet revealed Resident #31 was admitted to the facility on [DATE] with diagnoses that included Major depressive disorder, Dementia, Psychotic disorder with delusions, Anxiety disorder, and Sarcopenia. Record review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/21/2021 revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of one (1) which indicated Resident #31 has severe cognitive impairment. Record review of the Face Sheet revealed Resident #35 was admitted to the facility on [DATE] with diagnoses that included Amputation of the Right Leg, Peripheral Vascular Disease (PVD), Diabetes Mellitus and High Blood Pressure. Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/28/21 revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) that indicated Resident #35 is cognitively intact. Record review of the Face Sheet revealed Resident #42 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], Diabetes Mellitus, and Hypertension. Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/5/21 revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) that indicated Resident #42 is cognitively intact. Interview on 10/13/21 at 10:42 AM, with Resident #42 confirmed he saw a mouse run across the floor in his room. He also said he has reported it to CNA #2 that he saw mice droppings under his bed. The Resident said CNA #2 put a mouse hotel in his room and he has not seen them again. The facility provided an acceptable Removal Plan on 9/30/21, for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan Immediate Jeopardy (IJ) was called on 9/28/2021 at 12:35 PM. The IJ template was provided on 9/28/2021 at 12:35 PM. Beginning 7/3/2021 when Temporary Nursing Assistant (TNA) #1 failed to obtain the necessary assistance to provide incontinent care to resident #31 resulting in a major injury with fracture of bilateral knees. The State Agency notified the Administrator and the Director of Nursing (DON) that an IJ had been identified. Brief Summary of Events The facility failed to ensure a resident was protected from neglect as evidence by (AEB) an unlicensed TNA neglected to obtain assistance required when providing incontinent care that resulted in Resident #31 obtaining a fracture. ON 7/3/21, immediate action was taken by the cart nurse to notify the doctor and obtain bilateral knee x-rays. The facility failed to follow the comprehensive care plan while providing incontinent care AEB Resident #31 is extensive assist and always needs two people during care. The facility failed to ensure a vulnerable resident was protected from accidents and hazards when a TNA #1 failed to ask for help while providing incontinent care, which caused Resident #31 to fall with a major injury to bilateral knees. The facility failed to protect Resident #31 and other residents from potential for further injury during the investigation process by not removing TNA #1 from the facility following an incident on 7/3/2021. The Facility continued to allow TNA #1 to work until 7/05/21. Corrective Actions: 1. On 7/3/2021, the Administrator provided education to the Charge Nurse, two (2) TNAs, 2 Cart Registered Nurses (RN), and three (3) Certified Nursing Assistants (CNA) directly involved in the fall of Resident #31. On 7/3/2021, the in-service topics included following the Activities of Living (ADL) Care Plan and Care Guide, Abuse and Neglect, and Residents' Rights. On 7/4/2021 and 7/5/2021, the Administrator continued in-servicing with all staff on the above topics. No staff will be allowed to work until in-services are completed. 2. On 07/03/21, the Administrator identified that Resident #31 sustained a fall with injury and initiated an investigation. 3. On 07/05/2021 at 10:24 AM, the Administrator suspended TNA #1 until further notice to complete investigation. On 07/05/2021 the Administrator conducted and completed the investigation. On 07/12/21 the Administrator terminated TNA #1. 4. On 7/5/2021 at 10:00 AM, each resident under the care from TNA #1 who was identified as at risk for falls was assessed with no further falls identified. 5. On 07/05/2021 at 10 AM, the Minimum Data Set Nurse (MDS) conducted a 100 percent audit of Resident's Fall Risk Assessments and Care Plans for accuracy with no concerns identified. 6. Each resident has a care guide specific to their needs located in a binder at each nurse's station. These are reviewed by the CNAs prior to the start of each shift and to be followed to provide care to the residents. On 07/05/2021, the MDS Nurse performed a 100 percent audit of the care guides with no concerns identified. On 07/05/2021 The Administrator in-serviced CNAs and TNAs on the following: ADL care guides specific to each resident. On 07/05/2021, the MDS Nurse performed a 100 percent audit on ADLs of residents identified at risk for falls and failure to follow the ADL Plan of Care. All residents at risk needing two-person assist were identified and reviewed. On 9/16/2021, the Staff Development Nurse educated all TNAs and CNAs on providing resident care only with a CNA or Nurse present, no staff will be allowed to work until in serviced. TNAs and CNAs were instructed to review ADL care plan prior to each shift. 19 of the 40 residents were identified as at risk for falls and failure for the ADL Plan of Care to be followed. A form was developed and created for all TNA new hires to have proper education, training, and understanding that they must work directly with a licensed CNA and to follow and know their ADL plan of care. On 9/21/2021, the Staff Development Nurse educated all staff that all TNA's can only provide resident care with a CNA or Nurse present, no staff will be allowed to work until in-serviced. 7. The Administrator requested an in-person Quality Assurance Performance Improvement (QAPI) meeting to review events leading to this occurrence and corrective action taken. QAPI meeting occurred on July 8, 2021, and included the Administrator, Director of Nursing, Medical Director, MDS Nurse, Wound Care Nurse, Care Plan Nurse, Medical Records Nurse, Infection Preventionist, Physical Therapist, Administrator Assistant, and the Billing Office Manager. The meeting specifically discussed this fall, identified cause of the fall, number of previous falls, fall risk and potential harm, prevention of recurrence, abuse/neglect, following ADL care plan, Resident's Rights, ADL support and serious injury/harm and reporting. On 07/06/21, the Administrator in serviced the DON and Charge Nurse on the topic of removing any staff from the building for alleged violations of abuse, neglect, exploitation, or misappropriation of resident property until the investigation is completed. No changes to fall policy were required after being reviewed by QAPI. 8. On 9/16/2021, a form was created for all TNA hire in packets to ensure all TNA new hires have proper education, training, and understanding that they must work directly with a licensed CNA. 9. The Administrator and DON conducted a 100 percent audit on all accidents and incidents from 07/04/2021 through 9/30/2021 to ensure that injury or negative outcomes was not identified related to unsupervised TNAs. On 07/05/21, the Administrator in-serviced all staff on fall related policies. Falls are reviewed at stand up meeting every morning and Quarterly Quality Assurance (QA) meeting. On 07/05/21 at 7AM, the Administrator continued on-going in servicing to reiterate with all staff that TNAs must provide care only with CNA assist. 10. The facility alleges that all corrective actions to remove the IJ were completed on 9/30/21, and the IJ was removed on 10/1/21. On 10/2/21, the State Survey Agency (SSA) validated the facility's Removal Plan by staff interviews, record reviews, and review of in-service sign-in sheets. The SSA verified the facility had implemented the following measures to remove IJ: Validation: 1. The SSA validated through interview with the Administrator and in-service sign in sheets that on 7/3/2021, the Administrator provided education to the Charge Nurse, two (2) TNAs, 2 Cart Registered Nurses (RN), and three (3) Certified Nursing Assistants (CNA) directly involved in the fall of Resident #31. On 7/3/2021, the in-service topics included following the Activities of Living (ADL) Care Plan and Care Guide, Abuse and Neglect, and Residents' Rights. On 7/4/2021 and 7/5/2021, the Administrator continued in-servicing with all staff on the above topics. No staff will be allowed to work until in-services are completed. 2. The SSA validated through interview on 10/1/21 that on 07/03/21, the Administrator identified Resident #31 sustained a fall wit [TRUNCATED]

Based on observation, record review, resident interview, staff interview, and facility policy review, the facility failed to prevent harm to Resident #2 as evidenced by ant bites which developed into pustules on the resident's body after ants were found in the resident's bed. Resident #2 was transferred to the emergency room (ER), per family, and received medication related to the bites. This affected one (1) of six (6) residents reviewed, Resident #2. Findings include: A review of the facility's policy entitled Pest Control, revised August 2013, revealed: Policy Statement: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 2. Pest control services are provided by (company name). 6. Maintenance services assist, when appropriate and necessary, in providing pest control services. An interview and observation of Resident #2, at the hospital, on 10/23/17 at 1:40 PM, revealed the resident had two (2) small, round healed areas on her right forearm. Resident #2 stated she did have ants in her room at one time which bit her. Resident #2 stated she did not feel the ants sting her but she felt something crawling on her skin. No ants were observed in the resident's room on 10/24/17. Review of an incident report, dated 10/13/17, revealed Resident #2's daughter reported ant bites to the resident's arm, back, thigh and leg. Observed bites to right upper shoulder times (x) three (3), three (3) bites on the back of the right arm, three (3) on the right upper thigh and one (1) on the left lower leg. The physician was notified at 7:25 PM. Review of Resident #2's Nurse's Notes, revealed the following documentation: -10/11/17, documented as delayed notes, with no time, revealed the nurse was informed per Certified Nursing Assistants (CNAs) that ants were found in the resident's bed. A body audit revealed no evidence of ant bites, with no reddened or raised areas. -10/11/17 at 1:00 PM, documented no reddened or raised areas and no ants in the room. -10/13/17, with no time, documented no noticeable insect bites to Resident #2. -10/13/17-7:45 PM, order to monitor ant bites to right thigh, right back of arm, right inner arm, back of right shoulder and left lower leg. -10/13/17 at 7:55 PM, documentation included a late entry for 10/11/17 at 6:00 AM, which documented no complaints by resident and no bite marks. -10/13/17 at 9:00 PM, Resident's daughters entered the building and said they were taking the resident to the emergency room (ER) for evaluation of ant bites on her body and left at 9:15 PM with the resident with no new skin issues noted documented. -10/13/17 at 11:00 PM, Resident returned with new orders for Bactrim and Benadryl for seven (7) days. No new skin issues noted upon return. A review of Resident #2's Weekly Skin Integrity Review, dated 10/16/17 at 9:00 AM, revealed: Other: Ant Bites, and a symbol of no ants in the room, signed by RN #3 and Licensed Practical Nurse (LPN) #1. Sites where bites were located on the anatomical picture included one (1) bite on top of each foot, two (2) bites on back of the right lower leg, three (3) bites on right upper back at the shoulder, three (3) bites to the front top of the right thigh, and four (4) bites to the inner aspect of the right forearm for a total of 14 bites. Review of the ER report, for Resident #2, dated 10/13/17, revealed a triage note: patient's family states they noticed multiple ant bites all over her body. Stated they had to move her from her room three (3) days ago because of ants found in the room. The Chief Complaint included Bites to the left lower extremity, bilateral upper extremity and back, with a Clinical Impression of Ant bites. Prescriptions included Bactrim DS twice daily for seven (7) days and Benadryl three (3) times daily as needed for itching. Review of Resident #2's Physician order [REDACTED]. Review of physician's orders [REDACTED]. An interview with the Administrator of the facility, on 10/23/17 at 11:45 AM, revealed, We were kind of expecting you. When asked why, the Administrator stated Because of the ants. He stated the resident's (Resident #2) room had been cleaned after the ants were spotted. On 10/24/17 at 10:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated Resident #2 and her bed were moved on 10/11/17, and moved back on 10/12/17, due to ants. The DON stated body audits were done twice on 10/11/17, and no areas were found on the resident. She stated on the morning of 10/13/17, no areas were noted. The DON stated at 6:30 PM on 10/13/17, the Resident's daughter came to her about the bites. She stated the resident was assessed at that time and small pustules were noted in different areas of the resident's body. She stated the Resident's daughter took the resident to the hospital that evening and she returned with prescriptions for antibiotics. The DON stated she in-serviced the staff to check for ants on their rounds. The DON stated two (2) emergency Quality Assurance (QA) meetings were held on 10/18/17, to address the ant bite incident. QA sign in sheets for 10/18/17 were reviewed and confirmed the DON's statement. In an interview, on 10/24/17 at 1:55 PM, Certified Nurse Aide (CNA) #1 stated she found the ants in Resident #2's bed. She stated after the resident was toileted, she noticed approximately 10 ants in the resident's bed. CNA #1 stated As soon as I saw the ants, I stripped the bed. I sent the resident to the dining room after I checked her and LPNs #1 and #2 checked her for bites. CNA #1 stated no red spots or anything else was seen on Resident #2's body. CNA #1 stated she saw no food or crumbs in the bed. The CNA stated this all occurred around 7:30 AM, right after coming on duty and staff were in-serviced that evening about checking rooms for ants when making their every two (2) hour checks. In an interview on 10/24/17 at 2:20 PM, CNA #2 stated all staff were in-serviced about checking for ants when making every two (2) hour rounds. CNA #2 stated All I saw were dead ants in Resident #2's room after they sprayed. In an interview on 10/24/17 at 2:40 PM, LPN #1 stated the CNAs came to her, on 10/11/17, and said Resident #2 had ants in her bed. LPN #1 stated We got the resident out of the bed and I did a body audit on her and didn't see any red spots on her at all. LPN #1 stated that Resident #2 liked to eat in bed all the time. She stated she went back that evening and did another body audit and still saw no red spots or bites of any kind on the resident. LPN #1 stated they were all in-serviced about checking for ants on rounds. In an interview, on 10/24/17 at 2:55 PM, LPN #2 stated she didn't see any bites or red spots on Resident #2 on 10/11/17. She stated she did another body audit on the morning of 10/13/17 and still didn't see any red spots or bites. LPN #2 stated she didn't see the bites until 10/16/17. During a telephone interview, on 10/23/17 at 5:40 PM, Housekeeper #1 stated that on Wednesday 10/11/17, she was told to go clean some rooms on the 600 hall. She stated Resident #2 and her bed had been moved to another room until the room could be cleaned. She stated when she went to the room she saw dead ants on the floor where the bed would normally be. Housekeeper #1 stated Maintenance had sprayed the ants. She stated she didn't see ants in any of the other rooms she cleaned that day. She stated she has never seen any ants or other pests in the facility. In an interview on 10/23/17 at 1:00 PM, the Facility Maintenance Director stated, We check every week for pests and ants. The pest control company comes out once a month. They were here last week and sprayed specifically for the ants inside and out. He stated he's never seen any fire ants and these came after a lot of rain. He stated We had put granules out on ant beds last Tuesday. We broadcast granules monthly and then spot check weekly and put granules if beds are noted. Outside rounds were made with the Maintenance Director around the perimeter of the nursing home as well as the inner courtyard on 10/23/17 from 1:10 PM - 1:35 PM. One (1) dead ant bed with granules was observed outside room 603, approximately 12 inches from wall. No other ant beds or pests noted around outside of nursing home. In the inner courtyard, there were three (3) ant beds observed outside the lab area, partially dead. Granules were observed on these beds. One (1) live ant bed was observed outside room 309. The Maintenance Director stated this ant bed was to be treated with granules today. An interview with the Facility Housekeeping Director on 10/23/17 at 3:05 PM, revealed, On Wednesday, 10/11/17, the Administrator called me and told me to send a housekeeper to Resident #2's room to clean up due to ants being in the room. My housekeeping staff let me know if they see any pests and they had not said anything to me about ants. I sent Housekeeper #1 to clean that room. A telephone interview on 10/23/17 at 3:50 PM, with the pest control company's Representative, who comes to the facility monthly and as needed, stated he was called out to the facility on Saturday morning on 10/14/17, and he sprayed a fire ant bed on the side of the nursing home building. He stated fire ants when asked what kind of ants they were. He stated he came out to the facility again on Wednesday 10/18/17, and found no live ant beds around the facility. He stated ants are a problem right now everywhere because of all the rain they've had since the hurricane. He stated the facility had not had any pest problems in the past. A review of the pest control company documentation confirmed the dates and services provided by the company on 10/14/17 and 10/18/17. A Review of Resident #2's face sheet revealed the facility admitted the resident on 11/26/13, with [DIAGNOSES REDACTED]. A review of Resident #2's quarterly MDS with an Assessment Reference Date (ARD) of 8/13/17, revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment.

Based on observation, interview, record review, and policy review, the facility failed to revise the care plan for Resident #2, for ants/ant bites and have interventions in place due to the resident's choice of eating in bed. This affected one (1) of six (6) residents reviewed for care plans. Findings include: A review of the facility's policy entitled Care Plans-Comprehensive, revised December, 2010, revealed: Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation: 6. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. A review of Resident #2's care plan revealed a handwritten entry Resident is self-directed to eat in bed, not dated, in the Resident's Activities of Daily Living (ADL) care plan. There were no interventions addressed for the resident eating in her bed. On 10/13/17, approaches under the Skin Risk care plan, included Bactrim DS by mouth twice daily for seven (7) days and [MEDICATION NAME] 25 milligram (mg) three (3) times daily as needed for seven (7) days. The care plan did not document any indication of ant bites or include interventions to monitor the bites. Review of an incident report, dated 10/13/17, revealed Resident #2's daughter reported ant bites to the resident's arm, back, thigh and leg. Observed bites to right upper shoulder times (x) three (3), three (3) bites on the back of the right arm, three (3) on the right upper thigh and one (1) on the left lower leg. The physician was notified at 7:25 PM. An observation of Resident #2 on 10/23/17 at 1:40 PM, revealed the resident sitting up in a hospital bed (unrelated to ant bites), awake and alert, watching television. Resident #2 recalled there had been ants in her bed at the facility at one time, which had bitten her and revealed two (2) small round areas on her right forearm, which were healed. Review of Resident #2's Physician order [REDACTED]. The care plan did not include monitoring these ant bites. Review of physician's orders [REDACTED]. In an Interview on 10/24/17 at 5:25 PM, Registered Nurse (RN) #1 and RN #2, Minimum Data Set (MDS) Nurses, stated that care plans on long term residents were updated with the quarterly MDS. RN #1 stated if anything significant occurred, the cart nurses were responsible for updating the care plans when they received orders. Both RNs stated they were not sure what approaches to put in Resident #2's care plan related to the resident choosing to eat in the bed or the ant bites. A Review of Resident #2's face sheet revealed the facility admitted the resident on 11/26/13, with [DIAGNOSES REDACTED]. A review of Resident #2's quarterly MDS with an Assessment Reference Date (ARD) of 8/13/17, revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment.