Every finding on record at Granite Mesa Health Center

Based on record reviews and interviews, the facility failed to ensure a resident's environment remained free of accident hazards and received adequate supervision and assistance devices to prevent accidents for 1 of 12 residents (Resident #1) reviewed for transfers in that:CNA A failed to provide adequate supervision and transfer assistance on 06/21/26 for Resident #1 in her room during a bed to chair transfer requiring x2 person assistance per the plan of care. CNA A completed a transfer alone resulting in Resident #1 having a right tibia(inner and larger of the two bones between the knee and ankle)and fibula (outer and usually smaller of the two bones between the knee and the ankle) fracture and pain requiring hospitalization. The noncompliance was identified as PNC. The noncompliance began 06/21/26 and ended 06/26/26. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of harm and/or injury, pain and diminished quality of life. Findings included:Record review of Resident #1's face sheet dated 07/10/26 reflected a [AGE] year old female admitted to the facility on [DATE] with diagnosis that included muscle wasting and atrophy (decrease in size, wasting away of tissue), need for assistance with personal care, senile degeneration of the brain (gradual decline in cognitive abilities impacting memory, reasoning, and daily functioning), muscle weakness, lack of coordination, stiffness of unspecified joint, lack of coordination, and dementia (group of symptoms affecting memory, thinking, and social abilities). Record review of Resident #1's annual MDS assessment dated [DATE] reflected a BIMS score of 99, which indicated resident unable to complete the interview. Section GG for functional abilities reflected bed to chair transfers, Resident #1 was total dependent helper does all of the effort, resident does none of the effort or the assistance of 2 or more helpers is required for the resident to complete the activity. Record review of Resident #1's care plan revised 04/01/26 (care plan active during the incident but before most recent revision that occurred after the incident on 06/21/26) reflected that at the time of the incident there was a focus of [Resident #1] has ADL self-care performance deficit r/t impaired mobility with interventions that included bed to chair transfer- assist of 2. Record review of Resident #1's progress note dated 06/21/26 by RN B revealed: CNA informed this nurse that she was transferring resident from bed to WC and that resident lifted her r leg as she was being sat down as ended up sitting on her leg. the aide stated that she lifted the resident back up and got her leg out from under her and sat her down. she stated that the resident r leg was hurting. nurse assessed the resident and resident was unable to move her r leg as she was sitting in the wc and it caused her a lot of pain when she was touched. aide stated she was using a gait belt and the resident had grippy socks on, the resident was and is unable to communicate where exactly her leg hurt but she is very defensive about touching any part of her leg.Record review of Resident #1's progress note dated 06/21/26 by RN B on assessment there appeared to be no swelling of the knee. Resident was very defensive about moving her R knee and would not allow nurse to touch it or her leg. She would push nurses hands away, nurse gave resident PRN norco 5mg/325 mg. She is scheduled tid norco of the same strength, resident sat quietly in the hall in her wc and was taken to the dining room as it was dinner time. She was assisted in her eating in the assisted feeding room.Record review of progress note dated 06/21/26 by RN B, resident is unable to communicate to verbalize what happened. Record review of Resident #1's MAR/TAR reflected the administration of ordered Norco Oral Tablet 5-325 MG Give 1 tablet by mouth every 8 hours as needed for Pain DONOT EXCEED 3,000MGOF APAP FROM ALLSOURCES IN 24HOURS one tablet administered 06/21/26 at 4:35 PM. Follow up of its effectiveness was completed 06/21/26 at 07:31 PM and indicated PRN medication was effective.Record review of Resident #1's progress notes reflected an SBAR change of condition completed dated 06/21/26 09:47 PM: aide was transferring resident from bed to wc. Gait belt applied. resident has grippy socks on. resident lifted r leg when at wc and she sat down on her r leg. Resident exhibited pain at that time. Primary Care Provider feedback: Primary Care Provider responded with the following feedback: A. Recommendations: 2view stat x-ray of r hip, r femur, r knee, r tib-fib. Rankle B. New Testing Orders: - X-rayRecord review of progress note dated 06/22/26 at 04:31 AM Resident resting during night. No c/o pain or discomfort. Some swelling to right ankle. Resident with some indication of pain when turning resident and with peri care. V/S=122/72, 97.4, 77, 16, SPO2= 98% on room air. Will continue to monitor.Record review of Resident #1's progress note dated 06/22/26 at 10:05 AM reflected an SBAR change of condition Primary Care Provider responded with the following feedback: A. Recommendations: send to ER for eval and treat as indicated.Record review of Resident #1's progress note dated 06/22/26 at 10:30 AM reflected, resident seen by NP today. complaining of uncontrolled pain in BLE, new order to send to ER for eval and treat as indicated, call to [family member], to update. call to City Ambulance to transport resident to [hospital ER], call to DON to update of transfer.Record review of Resident #1's nursing progress note 06/22/26 at 06:09 PM reflected Resident #1 returned to the facility 06/22/26 at 05:30 PM and calls were placed to Resident #1's family, NP, and DON to update on resident status and return to facility. Record review of Resident #1's radiology results dated 06/22/26 reflected: Radiology of right tibia and fibula xray, 2v/ right femur xray, 2v bilateral (both sides) hip xray, 2v/ ankle right xray.RIGHT ANKLE, 3 VIEWSOsteoporotic bones. Healing fracture involving distal tibial metaphysis (the region of the leg located just above the ankle).Record Review of Resident #1's hospital records dated 06/22/26 reflected: [AGE] year-old female with baseline AAOx0 who presents with lower leg pain. Chronic contractures of bilateral lower extremities are observed. On examination denied pain, had bilateral lower extremity contractures, unable to follow directions (baseline altered mental status).Final Diagnosis: pain of left and right lower extremities, closed tibia fx, closed fibular fx. Acute nondisplaced comminuted (newly occurred) distal tibial fracture without intra-articular extension (a fracture or injury that extends across the joint surface). Acute nondisplaced distal fibular fracture. Scattered mid foot osteoarthritis. The osseous structures are demineralized (bones have lost minerals, losing their density and strength). Mild swelling about the ankle. Impression:1.Acute comminuted and nondisplaced distal right tibial fracture. 2.Acute nondisplaced right distal fibular fracture. Record Review of Resident #1's hospital records dated 06/24/26 reflected:Visit r/t orthopedics. Reason for visit was right lower leg pain and fracture. Patient follow up for repeat evaluation. Patient will not allow examination of her right ankle. She is able to wiggle her toes. The facility care worker reports that she is non-ambulatory at baseline even prior to this injury. Pain assessment does not communicate, poor historian. We discussed and reviewed imagining. This patient has a nondisplaced right distal tibia and fibula fracture. The fracture pattern appears stable and is in good alignment. Additionally, the patient has significant dementia and is non-ambulatory at baseline therefore we will proceed with conservative treatment. Patient was initially planned to have short leg cast but would not fit properly, therefore, she was placed back into a well padded posterior (further back in position) splint. She will come back in 2 weeks for repeat x-rays and skin check. Will plan for 6 weeks total immobilization. She will need to remain non-weightbearing to the right lower extremity. Stable alignment of the right distal tibial and fibular fractures. Record Review of Resident #1's hospital records dated 07/08/26 reflected a follow-up orthopedic visit: HPI: Patient presents for follow up of her right tibia. Patient sustained a nondisplaced right distal tibia fracture. She was splinted. Patient has significant dementia and is non-ambulatory at baseline. Patient was initially planned to undergo casting but would not tolerate cast. Decision was made to place her back into her splint and see her routinely to ensure no pressure issues given her inability to verbalize if there were issues with her splint. Xrays were obtained today. Right lower extremity swelling present about the distal tibia, tender to palpation (examine by touch) in this area, patient wiggles toes, unable to assess sensation, no pressure ulcers about the heel. We discussed and reviewed imaging. Patients fracture has maintained good alignment. Will need to immobilize her for at least a total of 6 weeks. Given her dementia and concern for pressure sores, I will see her back in 2 weeks for repeat evaluation and xray to ensure maintained alignment. Patient is ok for knee and hip range of motion. She can be lifted into a chair and wheelchair using the [mechanical] lift. Follow up in 2 weeks.Record review of the provider investigation report dated initiated 06/21/26 and submitted 06/26/26 reflected: Incident involving Resident #1 and AP (CNA A). AP was identified by name and confirmed allegations. The investigation revealed CNA A completed a x1 transfer instead of a x2 bed to chair transfer for Resident #1 as required by the plan of care which resulted in injury. CNA A was immediately suspended on 06/21/26 and later terminated on 06/22/26. Hospital x-rays from 06/22/26 showed an acute fracture to Resident #1's tibia and fibula. Resident #1 had a soft cast/wrap applied to R ankle and foot. The report indicated CNA was terminated due to transfer resulting in fracture. Record review of facility disciplinary action form dated 06/21/26 for CNA A reflected a suspension pending investigation that stated Reason: transfer of resident resulting in pain to resident warranting an order for xray; suspension pending investigation. Record review of facility disciplinary action form dated 06/22/26 reflected a discharge last day worked 06/21/26 for CNA A, Reason: Failure to provide care in accordance with resident care plan resulting in injury corrective action termination. Record review of facility termination form dated 06/22/26 reflected: Employee: CNA ALast day worked 06/21/26Termination 06/22/26 Reason: Failure to transfer a resident in accordance with care plan resulting in injury to patient.During an interview 07/10/26 at 12:00 PM with the DON, she stated she was alerted to the incident immediately after it occurred via phone by RN B the night of 06/21/26. She stated she had her computer at home and looked up Resident #1's transfer status which indicated x2 assist. She stated she could hear CNA A in the background while speaking to RN B, confirming she had done a x1 assist. She then advised RN B to send CNA A home on suspension pending further investigation of the incident. She stated Resident #1's provider was alerted of the incident by RN B and x-rays were ordered, and the family of the resident was notified. During an interview 07/10/26 at 01:22 PM with RN B, he stated he recalled the incident on 06/21/26 and was the nurse working with CNA A that evening. He stated CNA A came out of the room with Resident #1 in a wc, and Resident #1 was complaining of pain and was very defensive of her leg, not allowing him to touch it. He stated he learned she did a transfer by herself and the resident had put her R leg up while in the air and then sat on it while being placed in the wc. He stated CNA A perhaps didn't see it up based on the way she was holding her while doing the x1 assist. He stated based on his knowledge and care of the resident, Resident #1 was a x2 assist. He stated CNA A had not asked him to assist with the transfer and to his knowledge had not asked anyone else. The resident was given pain medication right away and the provider was called and x-rays were ordered. He stated he also immediately called the DON who advised that CNA A had to go home immediately. RN B stated he had asked CNA A why she transferred Resident #1 without assist and she responded by saying because I can do this myself and she claimed she had done it alone in the past. RN B stated Resident #1 did express pain but was not crying and there was not yet any swelling. He stated Resident #1 was hospitalized the next day due to ongoing complaints of pain. RN B stated that was the last day he saw CNA A working and since then the facility had been very verbal and aggressive about what should have been done he stated they have had multiple in-services on Kardex (quick reference system used by nurses to organize and access essential patient information for daily care), transfers and safety with return demonstration. During an interview 07/10/26 at 02:54 PM with Resident #1's FM, she stated she was alerted immediately of the incident that occurred on 06/21/26, and recalled getting a phone call from RN B. She stated that she was alerted about the injury to Resident #1 that required hospitalization. She stated she was later called by who she believed was someone from corporate to discuss the incident; that it had occurred because of an inappropriate transfer. The FM stated she was happy they alerted her right away. She stated they advised they were in the process of retraining all staff. She stated the facility took responsibility for the rogue employee and she stated she did not fault them and had not had any previous concerns with the care provided. During an interview on 07/11/26 at 11:15 AM with CNA A, she stated that during the incident on 06/21/26 she was getting Resident #1 up and ready for dinner. CNA A stated she did not see the other agency CNA she was working with that night in order to ask for help with a transfer. She stated she put the gait belt on and Resident #1, and became a x1 max assist. She stated she had done it many times before. CNA A stated she was very remorseful in how she completed the transfer. She stated she was not thinking and just trying to get things done as it was almost dinner time and stated Resident #1 required feeding assistance and needed to get her to the dining room quickly to make it in time to get that assistance. CNA A stated she believed the nurse (RN B) was busy at the time and did not attempt to ask for assistance with the transfer. She stated she did not attempt to ask for assistance from any other staff member in the building at the time either. CNA A stated when it came to the transfer of Resident #1, she raised the bed up, sat Resident #1 on the side of the bed, put the gait belt around her and was watching her arms but could not see Resident #1's feet. CNA A stated while moving Resident #1 from the bed to the wheelchair, Resident #1 picked up her right foot and after she placed Resident #1 in the wheelchair she noticed Resident #1's right leg was pinned underneath her. CNA A stated when she noticed that she then successfully repositioned it and that was when she noticed that Resident #1 was uncomfortable and in pain. CNA A stated she touched Resident #1's right leg and the resident drew it back in pain. She stated that as when she knew she had to notify the nurse. CNA A stated she believed Resident #1 was manageable due to her size and not being heavy. She stated she didn't think anything of it and had done it a few times before. CNA A stated before she transferred any resident, she looked at their height and weight and her ability to determine their assistance level. CNA A stated she was not looking at the Kardex to identify a resident's transfer status before she did a transfer. CNA A claimed Resident #1 was stiff (due to contractures) and was able to be moved easily. CNA A stated she did not note any swelling or redness to Resident #1's leg after the incident. She stated after she alerted RN B of the incident and he called the DON, she was asked to leave for the day. CNA A stated she was not allowed to return pending the investigation. She stated she was later contacted by the DON on 06/22/26 and was told she was terminated. CNA A stated, It was the stupidest move I had done ever. I wish I had followed protocol and done things the right way. CNA A stated she had received training on the Kardex and looking up residents' transfer status prior to the incident. She stated, We can look at the Kardex but very rarely do I have time. She went on to say she had not personally been using it but was aware Resident #1 was a 2 person assist and had completed 2 person assist on her in the past at other times. Record review of policy titled, Quality of Care, Transfer of a Resident, Safe last revised 05/2025 reflected:It is the policy of this facility to transfer a resident in a safe manner. Procedures: The procedures used to help residents during a transfer vary depending on the condition, abilities, and needs of the individual resident. The CNA should use the following guidelines to ensure safe and efficient transfers: -Know the residents abilities and limitationsTransfers to and from an bed and chair:Two-person transfers using a gait belt- -Follow instructions for moving to s sitting potion at the side of the bed. -Apply gait belt around the residents waist.-Place the residents wheelchair at a slight angle next to the bed. -Lock the wheelchair breaks. -Use good body mechanics at all times. -Provide the necessary help for the residents to stand up. The caregivers should stand on both sides of the resident and hold the gait belt. -Help the resident to pivot to stand in front of the chair. -Instruct the resident to reach back for the arms of the chair with one or both hands before sitting. -Instruct the resident to sit when he she feels the edge of the seat against the back of the legs. -Remove the gait belt when the resident is safely in the chair. The following was reviewed to determine the noncompliance was corrected prior to the survey. Record Review of the facility disciplinary action form dated 06/21/26 for CNA A reflected a suspension pending investigation that revealed Reason: transfer of resident resulting in pain to resident warranting an order for xray; suspension pending investigation. Record Review of the acility disciplinary action form dated 06/22/26 reflected a discharge last day worked 06/21/26 for CNA A, Reason: Failure to provide care in accordance with resident care plan resulting in injury corrective action termination. Record review of the facility termination form dated 06/22/26 reflected: Employee: [CNA A]Last day worked 06/21/26Termination 06/22/26 Reason: Failure to transfer a resident in accordance with care plan resulting in injury to patient.Record review of Resident #1's care plan (after the incident) reflected a revised date of 06/23/26 and included the following updates: Focus of [Resident #1] has alteration in musculoskeletal status r/t acute comminuted and nondisplaced distal tibial fracture. Acute nondisplaced right distal fibular fracture with interventions that included anticipating needs and responding to call lights, checking skin under soft cast for any skin impairments, following MD orders for weight bearing status, providing analgesics (pain medication) as ordered by physician and monitoring side effects, monitor and document risk for falls, monitor and document s/s or complications related to arthritis to include joint pain, stiffness, swelling, decline in mobility, self-care, contracture formation or changes, and pain. Non-weight bearing to RLE (right lower extremities). Resident #1's transfer status was also updated, [Resident #1] has an ADL Self Care performance deficit r/t impaired mobility with intervention chair to bed and bed to chair transfer: hoyer lift x2.Resident #1's pain was also a focus, [Resident #1] has acute/chronic pain r/t fracture with interventions that included to anticipate need for pain relief and respond immediately to any complaint of pain, evaluate effectiveness of pain interventions and review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Follow pain scale to medicate as ordered, monitor and document s/s of side effects such as constipation, agitation, restlessness, confusion, vomiting; monitor and record pain characteristics (quality, severity, anatomical location, onset/duration, aggravating factors and relieving factors); monitor, record, and report to nursing s/c of non-verbal pain changes in breathing, vocalizations, mood and behavior, eyes, face, body, pain assessments every shift, and notification to physician if interventions are unsuccessful or if current complaint is significant change from residents past experience to pain. Record review of the DON's outgoing text messages to all care staff reflected a message sent 06/21/26 at 08:35 PM Any resident that is hoyer, staff must use hoyer for every transfer. If they are one or two assist, staff must use gait belt and proper amount of staff assistance needed. Staff are not to break a resident's care plan.Record review of an in-service dated 06/22/26 for all staff on Abuse and neglect policy presented by the ADM and DON revealed the ANE policy was attached and reviewed which included sections on screening prospective employees, training of staff on recognizing signs of ANE, reporting, prevention, investigation and protection of the resident. Record review of an in-service dated 06/22/26 for nurses, med aides, and CNAs revealed the in-service was on Kardex- resident transfers CNAs will consult with the Kardex to determine a residents transfer status. In the event that the transfer status is not in the Kardex the CNA will consult the nurse. CNAs are not to transfer a resident without verifying the transfer status of the resident. Presented by the DON and ADM.Record review of an in-service dated 06/22/26 titled Transfer of residents revealed it was presented to all nursing and therapy staff by ADM and DON. Included the Quality of care - transferring a resident policy revised 05/25 it is the policy of this facility to transfer a resident in a safe manner. Know the residents' abilities and limitations.Record review completed of all direct care staff transfer safety quizzes dated 06/22/26 through 06/26/26 reflected staff tested on checking residents' care plans and Kardex before assisting with a transfer, and what to do if the Kardex did not contain information needed (consult with nurse). Record review completed of Kardex return demonstrations dated 06/22/26 through 06/26/26 revealed staff had to demonstrate and were evaluated by the DON, ADON, ADM; 2 page front and back covers assessment, pretransfer, transfer, and post transfer.Record review completed of a staff log covering the in-services, Kardex return demo, transfer safety quiz for nursing staff check offs completed. Of 65 staff, 4 not checked off (no shift yet), 1 showing termed, others checked off. 60/64=93.75% and included PRN staff. Record review of 12 resident safe surveys completed dated 06/23/26: -Asked about if staff have been rough with residents -If residents feel safe-Had any staff been inappropriate with residents -Do residents feel comfortable voicing a complaint/ concern-Do they know who to report concerns toNo concerns noted. Record review completed of the QAPI meeting dated 06/23/26 12:30pm revealed: Included medical director. Adhoc QAPI: Team reviewed a self-reported incident involving a resident who sustained a fracture during a staff assisted transfer. Required notifications completed:-Resident family-Nurse Practitioner -MD-Ombudsman -HHSCQAPI noted reflected: Review of self-reported incident: the team reviewed a self reported incident involving a resident who sustained a fracture during a staff- assisted transfer. Root cause analysis findings: The root cause was identified as staff failure to check and follow the residents Kardex prior to the transfer. The residents care plan included the specific transfer instructions that were not followed. Corrective actions taken: The resident was hospitalized for evaluation and treatment and has since returned to the facility. The involved CNA was suspended/ terminated following the investigation findings. The residents pain management regiment was reviewed and updated as indicated. Immediate inservicing and education were initiated for staff on safe transfer procedures, proper use and review of the Kardex, and abuse and neglect prevention. Staff were quizzed on transfer safety and demonstrated competency through return demonstrations related to transfers and accessing Kardex information. An adhoc QAPI meeting was conducted with the medical director. Facility wide safe surveys were conducted with residents to assess for any additional concerns. Record review completed of the AP, CNA A's personnel file which reflected:Misconduct registry and background checks completed. Inservice found dated 09/12/25 with a transfers (two person, standard, and mechanical lift) training presented by Rehab department with return demonstration indicating training prior to incident had been completed. During an interview and observation on 07/10/26 at 01:22 PM with CNA C, she stated that she had received training on the Kardex and locating a resident's transfer status, as well as safety of transfers presented by the DON after the incident that took place 06/21/26. She stated that she was given a packet with information to read, a quiz, and had to do return demonstration. CNA C stated that the DON had gone to her 3-4 times for random pop quizzes and stated the floor RNs had also asked her questions related to transfers to test her knowledge. She stated nurses also make sure that CNAs are always wearing their gait belts. CNA C stated she must follow the Kardex as it pertains to a residents' transfer abilities. She stated that it was not ok to transfer a resident even if they were small and believed they could handle it, if the Kardex indicated x2 then 2 people must be used. She stated she had also received training after 06/21/26 and stated the ADM was the abuse coordinator. CNA C was then observed able to successfully locate a resident's transfer status. During an interview and observation on 07/10/26 at 03:02 PM with CNA D, she stated if the transfer status was not indicated in the resident's Kardex she would not move the resident until she had something indicating safe transfer status provided by the nurses or the DON. She stated if a resident was small enough to move on her own but the Kardex indicated the resident was a x2 assist, then she would do a x2 assist as required. CNA D confirmed she recently received training over the Kardex and safe transfers and it was presented by the DON and ADON. She stated the training was hands on and she had to do return demonstration. She stated she also took a quiz that tested safe transfers and Kardex. She confirmed that training on ANE was also completed along with the Kardex and safe transfer training after 06/21/26. She stated the ADM was the abuse coordinator. CNA D was observed pulling up a resident's transfer status on the Kardex successfully.During an interview and observation on 07/11/26 at 12:18 PM with MT E, she stated she was knowledgeable on the Kardex and described where she can click to find a residents transfer status. She stated she had training that occurred after 06/21/26 presented by the DON over Kardex and transfer safety. MT E stated she had to perform a return demonstration and had to take a quiz provided by the facility. She stated if transfer information was not in the chart she would seek a charge nurse to know the safest way to transfer the resident. She stated even if a resident were small enough, if the Kardex indicated they were a x2 assist that she would perform a x2 assist. She stated a potential negative outcome of failing to follow the Kardex/plan of care would be the resident could fall, mechanical lift sling issues, skin tears or other injuries. MT E stated if there were no CNAs around or she believed nurses were busy she would look for someone in charge but would not complete a transfer until she had help. She stated he had also been trained on ANE after 06/21/26 and the ANE coordinator was the ADM. MT E was observed being able to pull up a resident's transfer status on the Kardex in the point of care system.During an interview on 07/11/26 at 12:30 PM with CNA F, she stated she was personally trained by the DON and was shown how to locate the Kardex. She stated in the training there was return demonstration provided and there was a quiz on transfer safety and the Kardex. CNA F was able to describe how to locate the Kardex and stated when logging into the POC system she would select a resident from the list, then select Kardex on the right hand side, she would then see the transfer information pull up. She stated if information was not available she would find a nurse to provide information on safe transfer status before continuing. She stated if a resident was small enough but the Kardex indicated x2 assist then she would use 2 people to complete the transfer. She stated a negative outcome of failing to follow the plan of care/Kardex would be that it could result in injuries, broken bones, or they could drop the resident. She stated if nursing staff were busy she would continue to locate another coworker on a different hall to help but would not complete the action by herself if a resident required x2 assist. She confirmed the ANE training took place after 06/21/26 as well and named the ADM as the abuse coordinator. During an interview on 07/11/26 at 12:38 PM with RN G, she stated she had completed recent training after 06/21/26 that covered safe transfers and the care plan/Kardex. She stated that it was presented by the DON and ADON. She stated there was a quiz and return demonstration in the training. RN G stated they have access to many records that provide safe transfer status of a resident. She stated if not yet in the system she could locate it through hospital records if recently admitted , or PT/OT records. RN G stated even if a resident were small enough she would not transfer them alone if the plan of care indicated they required 2 people to assist. She said You can always go up in assistance but never down. She stated a potential negative outcome of not transferring a required x2 assist with 2 people could result in a fall that took them both down. RN G stated that if a CNA were to come to her for help with transfers, even if she were busy she would go help. She stated It takes 10 seconds to help move someone. and said she could always stop to help with a transfer. RN G was able to describe how to locate the transfer status of a resident on the POC. During an interview and observation on 07/11/26 at 12:48 PM with CNA H, she stated she had training that occurred after 06/21/26 provided by the ADM pertaining to transfers and the Kardex. She stated she remembered taking a quiz and having to perform a return demonstration of locating the Kardex. She stated if she ever noticed that transfer information was not on a Kardex she would go to the charge nurse to notify them and ask what it was to ensure a safe transfer. She stated in the event a resident was very small and manageable, if the Kardex indicated they were a x2 assist she would still use 2 people or it could result in a fall with injury for both her and the resident. She stated to ensure a resident's safety she would continue to look for a staff member to assist if needed. She confirmed training on ANE and named the ADM as the abuse coordinator.During an interview on 07/11/26 at 12:55 PM with the DON, Resident #1 was a x2 assist and they would normally perform that with a stand and pivot. She stated she was not a mechanical lift transfer at the time but that the care plan was updated after the incident to make her a mechanical lift transfer due to her injuries. The DON stated she was notified of Resident #1's pain that night and she advised to let the NP know which RN B did and they provided the norco and a mobile x-ray was o[T

Based on observation, interview, and record review, the facility failed to ensure that each resident has the right to secure and confidential personal and clinical records for 1 of 34 residents (Resident #1) reviewed for Privacy and Confidentiality. The facility failed to ensure Resident #1's clinical records were protected from being viewed by unauthorized persons when CMA A left Resident #1's personal information visible on the computer's screen on unattended medication cart. This failure could place residents' personal information at risk of being exposed to unauthorized individuals. The findings included: Observation on 1/16/2026 at 9:42 a.m., revealed the computer screen on CMA A's medication cart on 400 Hall was open and unlocked, with Resident #1's medication administration information displayed and visible to unauthorized individuals, including visitors or other residents not observed at that time. During an interview on 1/16/2026 at 9:46 a.m. with CMA A, she stated she was in-serviced on HIPAA a few months ago which included instructions on not discussing residents' private clinical information with unauthorized individuals and locking the computer screen when stepping away from the medication cart. She stated everybody who worked with charting computers were responsible for closing and locking it when not in attendance. She stated that leaving the screen unlocked with clinical information displayed could be harmful for residents as anybody could see it. She stated she was at fault for not locking the computer. During an interview on 1/16/2026 at 12:23 p.m. with RN B, she stated CMA A was responsible for shutting down and locking the charting computer's screen when CMA A left the medication cart. She stated RN B completed HIPAA training annually. She stated everybody who worked with residents' private information and used charting computers were responsible for closing the screen when leaving the computer unattended. She stated leaving a computer without minimizing the computer screen could expose residents' private medical information to other residents or family members. During an interview on 1/16/2026 at 12:30 p.m. with LVN C, she stated staff who work with residents' personal information were responsible for shutting down the charting computers' screen when they needed to leave. She stated she received HIPAA training several months ago, but she could not recall the exact date. LVN C stated leaving a computer screen without locking the screen could lead to exposing residents' private medical information to unauthorized people and residents' privacy would be violated. During an interview on 1/16/2026 at 12:41 p.m. with DON, he stated the facility's policy was to minimize the charting computers' screens when stepping away. He stated that if the screen was not minimized, someone could have unauthorized access to private clinical information displayed on the screen. He stated HIPAA in-services were provided to all employees at hire and annually through computer modules which include instructions on locking the computer screens. He stated the person who worked with residents' private clinical information should lock the screen before walking away. He stated the potential negative effect was unauthorized disclosure of residents' confidential information. During an interview on 1/16/2026 at 12:54 p.m. with ADM, he stated he had HIPAA training yesterday which covered the importance of maintaining the residents' private information. He stated whoever used the computer was responsible for shutting it down to ensure the residents' information was not visible. He stated the potential risk for not shutting down charting computers was a breach of residents' privacy. He stated that all staff completed HIPAA in-services at hire and annually through computer modules. He stated CMA A completed her annual training, but could not provide documentation. Record review of facility's HIPAA in-services for last 6 months did not reveal HIPAA in-services completed by CMA A and documented before this incident. Record review of facility's Resident/Patient Confidentiality policy, undated, revealed, All resident Health information is confidential and protected by HIPAA Law. All staff, volunteers, and vendors must not disclose any medical information about a resident.

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 3 residents (Resident #1, Resident #26 and Resident #70) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #1's admission MDS, dated [DATE], accurately reflected his smoking status.2. The facility failed to ensure Resident #26's admission MDS, dated [DATE], accurately reflected her smoking status. 3. The facility failed to ensure Resident #70's admission MDS, dated [DATE], accurately reflected her smoking status.These failures could place residents at risk of inadequate supervision due to an inaccurate assessment of smoking status. Findings include:1. Record review of Resident #1's face sheet, dated 12/30/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included peripheral vascular disease (abnormal narrowing of arteries), adult failure to thrive (a progressive overall decline), localized swelling, tinea unguium (fungal nail infection), muscle weakness, lack of coordination, and abnormalities of gait and mobility.Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 had a BIMS score of 14, which indicated intake cognitive response. Resident #1's MDS current tobacco use was marked as no.Record review of Resident #1's care plan, dated 12/02/2025, revealed Resident #1 has the potential for injury related to smoking. Resident #1's goal was Will be compliant with individual smoking plan until next review. Will have no injuries related to smoking. The interventions were Complete smoking assessment as needed. Explain smoking policy. Maintain smoking materials at nurses' station or other designated area. Observe smoking while in designated area. Report non-compliance or unsafe smoking habits to MD and responsible party. Staff will provide a copy of the smoking policy on admission and as the policy is revised.Record review of Resident #1's smoking assessment, dated 11/21/2025, revealed resident don't smoke.2. Record review of Resident #26's face sheet, dated 12/30/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #26 had diagnoses which included chronic obstructive pulmonary disease (chronic progressive lung disease), protein-calorie malnutrition (inadequate intake of both protein and calories), heart disease, fall, muscle wasting, cannabis dependency, metabolic encephalopathy (brain disease), and lack of coordination. Record review of Resident #26's admission MDS, dated [DATE], revealed Resident #26 had a BIMS of 10, which indicated moderate impairment. The MDS also revealed current tobacco use was not on the MDS. Record review of Resident #26's care plan, dated 07/05/2025, revealed Resident #26 has the potential for injury related to smoking. Resident #26's goal was Will be compliant with individual smoking plan until next review. Will have no injuries related to smoking. The interventions were Complete smoking assessment as needed. Explain smoking policy. Maintain smoking materials at nurses' station or other designated area. Observe smoking while in designated area. Report non-compliance or unsafe smoking habits to MD and responsible party. Resident #26 required a smoking apron. Utilize smoking apron during smoking activities.Record review of Resident #26's Smoking Assessment, dated 12/08/2025, revealed Resident #26 smoked three times a day. Resident #26 required supervision and a smoking apron.3. Record review of Resident #70's face sheet, dated 12/30/2025, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #70 had diagnoses which included lack of coordination, hypertension (high blood pressure), muscle wasting, muscle weakness, type 2 diabetes mellitus with diabetic neuropathy (nerve damage due to diabetes), tinea unguium (fungal nail infection), heart disease, acquired absence of unspecified leg below knee, and malaise (feeling of general discomfort).Record review of Resident #70's admission MDS, dated [DATE], revealed Resident #70 had a BIMS of 99, which reflected the resident was unable to complete the interview. The MDS also revealed current tobacco use was checked NO. Record review of Resident #70's care plan, dated 12/15/2025, revealed Resident #70 has the potential for injury related to smoking. Resident #70's goal was Will be compliant with individual smoking plan until next review. Will have no injuries related to smoking. The interventions were Complete smoking assessment as needed. Educate resident on smoking practices. Explain smoking policy. Maintain smoking materials at nurses' station or other designated area. Observe smoking while in designated area. Report non-compliance or unsafe smoking habits to MD and responsible party.Record review of Resident #70's Smoking Assessment, dated 12/15/2025, revealed Resident #70 smoked three times a day. The smoking assessment did not indicate the resident needed to be supervised.During an observation of smoking on 12/30/2025 at 2:00pm revealed resident #1 and Resident #26 were outside with staff smoking. Both residents had smoking aprons on. During an interview with Resident #1 on 12/30/2025 at 2:05p.m., revealed that he goes out to smoke with staff three times a day. He said that all residents who smoke wear the smoking apron and that the staff watch them and are with them the whole time. During an interview with Resident #26 on 12/30/2025 at 2:13p.m., revealed that she smokes three times a day. She said staff are always made them wear a smoking apron. She said they disposed of the cigarettes in the ash tray and made sure not to throw the cigarette butts on the ground. During an interview with the ADM on 12/30/2025 at 3:55 p.m., he said he had not been trained on the MDS. He said the MDSN was responsible for ensuring the MDS was done. He said general information for the residents' care and history would be on the MDS. He said the resident/family requested smoking upon admission. He said if the resident's smoking status was not on the MDS the resident could miss smoking times. He said he did not know who monitored the MDS. He said the resident's smoking status, not being on the resident's MDS, was a mistake. During an interview with the MDSN on 12/30/2025 at 4:10 p.m., she said she had been trained on the MDS. She said she was responsible for completing the MDS. She said every fact about the resident and head to toe assessments went on the MDS. She said the MDS was updated when there was a significant change in status and quarterly. She said the DON would tell her what residents smoked. She said a resident's smoking status went on the comprehensive MDS but did not go on the quarterly MDS. She said if the resident's smoking status was on the MDS, there would not be communication to other staff about the resident smoking. She said the MDS was not monitored. She said the resident's smoking status would not be on the admission MDS if the resident's smoking assessment was done after the admission assessment.During an interview with the DON on 12/30/2025 at 4:30 p.m., revealed he had not been trained on the MDS. He said the MDSN was responsible for doing the MDS. He said everything that had to do with the resident's care profile, diagnoses, treatments, and the resident's ADLs. He said he did not know if the resident's smoking status went on the MDS. He also said he did not know how the resident's smoking status on the MDS would affect the resident's care. He said the resident's smoking status was missed on admission. Record review of the Smoking Residents list provided on 12/29/2025 revealed Resident #1, Resident #26, and Resident #70 were all smokers.Record review of Resident Assessment and Associated Processes Policy, dated 4/2025, revealed It is the policy of this facility that resident will be assessed, and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessments of each resident, and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified. Comprehensive Assessment: includes the completion of the MDS (Minimum Data Set) as well as the CAA {Care Area Assessment) process, followed by development and/or review of the comprehensive care plan. Comprehensive MDS assessments include Admission, Annual, Significant Change in Status Assessment and Significant Correction to Prior Comprehensive Assessment. An accurate Comprehensive Assessment will be made of the resident's needs, strengths, goals, life history, and preferences, using the RAI (Resident Assessment Instrument).

Based on observation, interview, and record review, the facility failed to be ensure they were adequately equipped to allow residents to call for staff assistance through a communication system which relays relayed the call directly to a staff member or a centralized staff work area from each resident's bedside for 5 of 10 residents (Residents # 13, # 31, # 47, # 48 and # 67) reviewed for call lights.The facility failed to ensure Residents # 13, # 31, # 47, # 48 and # 67's call lights were within reach of the residents. These failures could place residents at risk of not being able to call for staff assistance to meet care needs or at risk of injury, pain, hospitalization, and a diminished quality of life.Findings included:1. Record review of Resident #13's face sheet, dated 12/30/2025, revealed she was a 68 -year-old female who was admitted to the facility on [DATE]. Resident #13's had diagnoses which included anxiety (feeling uneasiness or worry), dementia (memory, thinking, difficulty), Schizoaffective Disorder, Bipolar Type (including bouts of hypomania or mania ( Increased energy, reduces need for sleep) and hypomania ( a milder form of mania) or and sometimes major depression and ), hypertension (high blood pressure), ( mood disturbances, anemia (not enough healthy red blood cells), muscle wasting and muscle weakness.Record review of Resident #13's Quarterly MDS, dated [DATE], revealed Resident #13 had a BIMS score of 12, which indicated moderate cognitive impairment, suggesting that the individual may need additional support and monitoring.During an observation on 12/30/2025 at 9:51 a.m., revealed Resident #13 was asleep in her wheelchair, located to the left of the bed. The call light was on the far-right side of the bed, not within reach of residents.2. Record review of Resident #31's face sheet, dated 12/31/2025, revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #31's had diagnoses which included unspecified dementia (memory, thinking, difficulty), muscle wasting, muscle weakness, Osteoarthritis (progressive deterioration of the articular cartilage in the right hip), and abnormalities with gait and mobility. Record review of Resident #31's Quarterly MDS, dated [DATE], revealed Resident #31 had a BIMS score of 5, indicating which indicated moderate cognitive impairment, suggesting that the individual may have difficulties with memory and thinking skills.During an interview and observation with Resident #31 on 12/29/2025 at 10:36 a.m., he said he was waiting for someone to come help him. He said staff did not answer his call light. Resident #31 was lying on his bed with his legs hanging halfway off the bed. His call light was on the floor between the wheelchair tire and the seat of the wheelchair.3. Record review of Resident #47's face sheet, dated 12/30/2025, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #47's had diagnoses which included Alzheimer's Disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior.), Need for assistance with personal care, Pain in right wrist and muscle wasting and atrophy.Record review of Resident #47's Quarterly MDS, dated [DATE], revealed Resident #47's BIMS score was unable to be calculated. During an interview and observation with Resident #47 on 12/29/2025 at 9:24 a.m., revealed the resident was lying in bed awake. Resident # 47 could not locate the call light button. Resident #47 stated she did not use the call light button often. Observation noted the call light button was on the right side of the bed on the floor, out of reach of Resident # 47.4. Record review of Resident #48's face sheet, dated 12/31/2025, revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #48's had diagnoses which included unspecified dementia (memory, thinking, difficulty), Cognitive Communication deficit, anxiety disorder (feeling of uneasiness or worry), muscle weakness, Lack of coordination, Anorexia Nervosa, (an eating disorder). Unspecified (eating disorder). Record review of Resident #48's Quarterly MDS, dated [DATE], revealed Resident #48 had a BIMS score of 04, which indicated severe cognitive impairment, suggesting that the individual may require significant assistance with daily activities and cognitive tasks. During an interview and observation with Resident #48 on 12/29/2025 at 12:32 p.m., revealed the resident was awake and lying in bed. Resident #48 stated she often used her call light button when she needed to be changed. A flat call light pad was observed to be located out of the resident's reach, on the right side of the bed on the floor.5. Record review of Resident #67's face sheet, dated 12/31/2025, revealed he was a 62- year-old female who was admitted to the facility on [DATE]. Resident #67's had diagnoses which included Alcoholic Cirrhosis of the liver ( toxic fat to build up in the liver), low platelet count in the blood, Blindness left eye category 5 (severe visual impairment), dementia (memory, thinking, difficulty), muscle weakness, pneumonia ( an infection that inflames the air sacs in one or both lungs.), Anxiety Disorder (feeling of uneasiness or worry) and unsteadiness on feet.Record review of Resident #67's Quarterly MDS, dated [DATE], revealed Resident #67 had a BIMS score of 15, indicating which indicated intact cognitive Response.During an interview with Resident #67 on 12/30/2025 at 9:29 a.m., revealed that the resident was sitting in her wheelchair on the right side of her bed. The resident's call light button was hanging off the left side of the bed, out of reach of the resident. During an interview with RA on 12/31/2025 at 9:47 a.m., revealed that she had been trained on resident rights. She said the policy for call light placement was that it must be within reach of the resident and if a staff member was working with a resident, they were responsible for making sure the call light was within the resident's reach. She stated if they were unable to push the button, they may require a special, larger call light button for that resident. She stated that some residents preferred to have the call light out of sight. She stated if a call light was not within reach of a resident, they may not be able to call for help. During an interview with the ADON on 12/31/2025 at 10:00 a.m., revealed that she had been trained on resident rights. She said that staff were in-serviced on the policy regarding call light button locations and response times. She stated all the staff were responsible for locating the call light within the residents' reach. She stated if a resident could not reach the call light, they may have an accident or a fall.During an interview with CNA D on 12/31/2025 at 10:19 a.m., she stated that she has been trained on resident rights and call light location in the last in-service training. She stated all of us were responsible for monitoring and making sure the call light button was within reach of the residents. The call light should always be within reach of the resident for the safety of the resident. If the call light was not within reach the resident could fall. During an interview with the ADM on 12/31/2025 at 11:54 a.m., he revealed that all the staff were responsible for making sure the call light was within the resident's reach. The call light should be within reach of the resident following care. The ADM stated it depended on the resident as to what could happen if the call light was not within the reach of the resident. He stated, if the patient was bed bound and they couldn't use the call light, the staff may not be able to get to them in time. The ADM stated that some of the residents were mobile and if the call light buttons were not nearby, they could get up and get it by themselves. It is the nursing staff's responsibility to make sure the call lights are within reach of each resident. During an interview with the DON on 12/31/2025 at 11:37 a.m., revealed that he had been trained in resident rights and making sure the environment was safe. He stated that every signal person who walked by or entered a resident room was responsible for making sure the residents call light button was within the resident reach. Record review of In-services reflected the following:9/15/2025 In-service Training Topic: Ice water/ Call lights12/17/2025 In-service Training Topics: Call lights, Rounding.Record review of the facility's undated Policy/ Procedure- Nursing Clinical- Policy reflected the following: Subject: Call lightsPolicy: it is the policy of this facility to provide the residents with a means of communication with nursing staff.Procedure:5. Leave the resident comfortable. Place the call device within residents reach before leaving the room. If the call light/ bell is defective, immediately report this information to the unit supervisor.

Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for complete and accurate medical records.The facility failed to ensure Resident #1's smoking assessments, dated 11/21/2025, accurately reflected his smoking status. Resident #1's smoking assessment said, resident don't smoke.This failure could place residents at risk of not having the right to smoke or not having adequate supervision while smoking. Findings include:Record review of Resident #1's face sheet, dated 12/30/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included peripheral vascular disease (abnormal narrowing of arteries), adult failure to thrive (a progressive overall decline), localized swelling, tinea unguium (fungal nail infection), muscle weakness, lack of coordination, and abnormalities of gait and mobility.Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 had a BIMS score of 14, which indicated intake cognitive response. Resident #1's MDS current tobacco use was marked as no.Record review of Resident #1's care plan, dated 12/02/2025, revealed Resident #1 has the potential for injury related to smoking. Resident #1's goal was Will be compliant with individual smoking plan until next review. Will have no injuries related to smoking. The interventions were Complete smoking assessment as needed. Explain smoking policy. Maintain smoking materials at nurses' station or other designated area. Observe smoking while in designated area. Report non-compliance or unsafe smoking habits to MD and responsible party. Staff will provide a copy of the smoking policy on admission and as the policy is revised.Record review of Resident #1's smoking assessment, dated 11/21/2025, revealed resident don't smoke.During an observation of smoking on 12/30/2025 at 2:00pm revealed resident #1 and Resident #26 were outside with staff smoking. Both residents had smoking aprons on. During an interview with Resident #1 on 12/30/2025 at 2:05p.m., revealed that he goes out to smoke with staff three times a day. He said that all residents who smoke wear the smoking apron and that the staff watch them and are with them the whole time. During an interview with Resident #26 on 12/30/2025 at 2:13p.m., revealed that she smokes three times a day. She said staff are always made them wear a smoking apron. She said they disposed of the cigarettes in the ash tray and made sure not to throw the cigarette butts on the ground. During an interview with the ADM on 12/30/2025 at 3:55 p.m., he said he was not trained on the smoking assessment. He said the nurse on the hall was responsible for ensuring the smoking assessment was done. He said the smoking assessment was done when a resident expressed an interest in smoking. He said if a resident stopped smoking and started back up the nurse would need to do another smoking assessment. He said if the smoking assessment was not done the resident would not be able to smoke. He said the smoking assessment was monitored by the DON. He said the DON monitored the smoking assessment by reviewing it when it was done. He said he assumed Resident #1's smoking assessment was put as nonsmoker by mistake. During an interview with the MDSN on 12/30/2025 at 4:10 p.m., revealed she was trained on completing the smoking assessments. She said the smoking assessment was completed at admission if the resident was a smoker. She said the smoking assessment was also done when the resident requested one or if a resident had a change in condition. She said if the resident stopped smoking and started back up, she would have to do another smoking assessment on the resident. She said if the smoking assessment was not completed correctly the resident may not be safe due to a bad assessment. She said the ADON monitored to ensure the smoking assessments were done correctly and completely. She said she did not know how the ADON monitored the smoking assessments. She said she did not know why Resident #1 was marked as nonsmoker.During an interview with the DON on 12/30/2025 at 4:30 p.m., revealed he was trained on the smoking assessments. He said the smoking assessment had information that included the mental and physical capacity of which the resident could smoke. He said the smoking assessment was done upon request from the residents or family. He said the admitting nurse was responsible for filling out the smoking assessment. He said if the smoking assessment was not filled out correctly the staff would not know the status or resident's function ability. He said the IDT team monitored to ensure the smoking assessments were done correctly. He said the IDT team monitored by doing audits. He said the residents may not have been a smoker when admitted . Record review of Resident Assessment and Associated Processes Policy, dated 4/2025, revealed It is the policy of this facility that residents will be assessed, and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident, and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for Food safety and Nutrition Services.The facility failed to ensure food safety by not performing proper hand hygiene when preparing puree foods.This failure could place residents at risk for food-borne illnesses.Findings include:Observation of DA A preparing puree food on 12/29/2025 at 10:29 a.m. revealed that DA A did not wash her hands before starting the puree process for the meatballs. She gave the puree machine to the dishwasher and went to wash her hands. She put meatballs into steamer. She then got a rag and wiped the counter down, got the puree machine. She put the noodles in the puree machine without washing her hands. She gave the puree machine back to dishwasher, got foil wrapped noodles put the noodles in the steamer, got water to add to steamer, and got a rag to wipe down the counter. She did not wash hands between any of the tasks she completed. She got the broccoli and put it in the puree machine, got the spatula for the broccoli, and put foil over the pureed broccoli and got a rag to wipe down the counter. She did not wash her hands between any of the tasks she completed. During an interview with the ADM on 12/30/2025 at 3:55 p.m., he said he was trained on infection control. He said the policy for hand hygiene was that all staff were to follow the proper hand hygiene protocol. He said staff were to wash their hands before and after providing care to a resident or after touching something soiled or dirty. He said if proper hand hygiene was not followed it could cause infection control issues, and the residents could get sick. He said the ADM and management monitored to ensure staff were washing their hands. He said the ADM and management monitored through yearly skills checks, and random in-services throughout the year.During an interview with DA A on 12/31/2025 at 8:31 a.m., she said she was trained on infection control. She said the policy was to wash your hands between each task. She said all staff were responsible for washing their hands. She said if staff did not wash their hands, it could cause infections to spread to the residents. She said the management and the ADM monitored it to ensure staff were washing their hands. She said she did not know why she did not wash her hands between each task. During an interview with the DM on 12/31/2025 at 9:00 a.m., she said she was trained on infection control. She said the policy was to wash your hands any time staff went into the kitchen. She said all staff were responsible for washing their hands. She said if staff did not wash their hands, it could cause the facility to have to throw food away or the residents could get sick. She said the Dietary manager monitored it to ensure staff were washing their hands. She said she was not sure why DA A did not wash her hands. She said DA A needed more training.Record review of the facility's, undated, Infection Control Policy/Procedure- Dietary Department revealed It is the policy of this facility to comply with all state, federal and local infection control standards and regulations concerning: Personnel requirements Preparation and service Food storageEquipment, care and storage Isolation procedures and techniquesFollow all hand washing policies.Record review of the facility's Policy/Procedure Hand Hygiene, dated 12/2023, revealed It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards. Residents, family, and visitors will be encouraged to practice hand hygiene. Procedure1. Wash hands with soap and water for the following situations:a. When hands are visibly soiled. 2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap(antimicrobial or non-antimicrobial) and water before and after eating or handling food.Washing Handsa. Vigorously lather hands with soap and rub them together, creating friction on all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. Hot water is unnecessarily rough on hands. b. Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch fingertips to inside of sink.c. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel.d. Discard towels into trash.e. Use lotions throughout the day to protect the integrity of the skin.Using Alcohol-Based Hand Rubsa. Apply generous amounts of product to palm of hand and rub hands together.b. Cover all surfaces of hands and fingers until hands are dry.c. Follow manufacturers' directions for volume of product to use.

Based on observation, interview, and record review, the facility failed to ensure sufficient fluid intake is offered to maintain proper hydration and health provide hydration care and services to each resident, consistent with the resident's comprehensive assessment for 2 of 10 residents (Residents #10 and # 47) reviewed for hydration .The facility failed to follow the facility policy and did not provide adequate hydration for 2 residents. Residents #10 and #47. These failures could place residents at risk of not having hydration needs met and/or becoming dehydrated.Findings include: 1. Record review of Resident #10's face sheet, dated 12/31/2025, revealed a 92 -year-old female originally admitted on [DATE]. A Resident #10's relevant diagnoses included Alzheimer's Disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia.), Muscle wasting and atrophy, Muscle weakness, Anxiety Disorder (feeling of uneasiness or worry), Need for assistance with personal care and hypertension (high blood pressure).Record review of Resident # 10's [NAME] MDS, submitted 11/28/2025, revealed a BIMS score of 99, indicating which indicated the resident was unable to complete the interview. MDS revealed Resident # 10 has functional limitation in range of motion in the lower extremities and use of a mobility device (wheelchair) is needed.Record review of Resident # 10's care plan dated 1/25/2025 reflected:Diagnosis of gout increases her risk of joint pain, with a goal to be free of complications related to gout. Interventions include encouraging adequate nutrition and hydration. During an observation and interview on 12/29/2025 at 9:18 a.m., revealed Resident #10 was lying in bed awake. Resident #10 stated she could see her water across the room, but she could not reach it. The water cup was located over 5' away from the resident's bed. Resident #10 stated, they gave me drinks with my breakfast.2. Record review of Resident #47's face sheet, dated 12/30/2025, revealed a 100 -year-old female originally admitted on [DATE]. A Resident #47's relevant diagnoses included Alzheimer's Disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia.), Muscle wasting and atrophy, Muscle weakness, Anxiety Disorder (feeling of uneasiness or worry), Need for assistance with personal care and hypertension (high blood pressure). Record review of Resident # 47's [NAME] MDS, submitted 11/18/2025, revealed a BIMS score of 00, indicating which indicated a severe problem with thinking and memory. Review of Section GG- Functional Abilities reflected. The resident needed set up or clean-up assistance while eating food and/or liquid once meal was placed before the resident. During an observation on 12/29/2025 at 10:54 a.m., revealed Resident # 47 was lying in bed, asleep with a blanket covering her from chin to toe. There was no hydration was observed within the residents' reach. Attempted interview with Resident # 47 but the resident was unable to respond because she was asleep. During an interview with the Restorative Nursing Assistant on 12/31/2025 at 9:47 a.m., revealed that she had been trained on resident rights. She said fluids should be placed within reach of the resident and if a staff member was working with a resident, they were responsible for making sure the call light and fluids were within the resident's reach. She stated we the staff lay eyes on them constantly. If someone sees it, we the staff fix it. She stated that the facility has had 1 hospitality Aid who helped fill water cups for residents. She stated, if the residents don't didn't get adequate hydration, they might need to get evaluated by the nurse and some residents may need IV hydration. During an interview with the ADON on 12/31/2025 at 10:00 a.m., revealed that she had been trained on resident rights. She said that staff were in-serviced in Residents Rights, hydration and call lights. She stated each resident should have fluids within reach of a resident and every time I went into the room, I the ADON stated she checked that hydration was near a resident. ADON stated, she did not know why 2 two residents were not provided with fluid within reach. She stated it must have been between visits from the hospitality Aid. She stated all staff were responsible for ensuring residents always have fluid within reach. She stated if the resident was not provided with adequate hydration it could lead to dehydration, UTIs or acute illness.During an interview with CNA on 12/31/2025 at 10:19 a.m., she stated that she has been trained on resident rights and call light location in the last in-service training. She stated it was the expectation of the facility that each resident should always have fluids within reach, on the bedside table. She stated that residents should be checked for fluids during rounds. She stated, residents could get dehydrated if they did not have fluids available to them. She did not know why 2 two residents didn't have fluids available. During an interview with the ADM on 12/31/2025 at 11:54 a.m., he revealed that the nursing staff were responsible for monitoring that fluids were provided for residents, and that the fluids were within reach of the residents. He stated We have room rounds in the morning, and we always check to be sure all residents have fluids nearby. The Hospitality aid is the primary person responsible for making sure all residents have hydration nearby. He stated a resident could become dehydrated if they did not get enough water. He stated he did not know why 2 two residents did not have fluids near their beds.Record review of In-services:On 9/15/2025 In-service Training was completed for staff on Topics: Ice water/ Call lights. Record review of the facility's, undated, policy titled Policy & Procedure Subject: Hydration. Policy: It is the policy at this facility that each resident will be provided with sufficient fluid intake to maintain proper hydration and health.Procedures:2. Fluids will be offered/provided between meals for the dependent residents, unless contraindicated.4. Additional beverages or alternatives (popsicles, gelatin, and other similar non-liquid foods) will be distributed throughout the day, depending on physician orders and resident preference. Resident [NAME] request additional fluids and receive them, if not contraindicated.

Based on interview and record review the facility failed to ensure all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment were referred for 1 of 2 residents (Resident #4 and Resident #99) reviewed for PASSAR. The facility failed to ensure Resident #99's level 1 PASSAR accurately reflected her Mental Illness diagnosis.The facility failed to ensure Resident #4 received a new level 1 PASSAR screening after having a new diagnosis that would reflect a Mental Illness diagnosis.This failure could place residents at risk of loss of specialized services for their Mental Illness, Developmental Disability and Intellectual Disability. Findings include:Record review of Resident #4's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included Bipolar Disorder (serious mental illness causing extreme mood swings, from manic highs to depressive lows), Acute Embolism and Thrombosis of unspecified Deep Veins (serious condition where a blood clot forms in a deep vein), and Type 2 Diabetes (chronic condition where the body either doesn't make enough insulin or doesn't use insulin effectively leading to high blood sugar levels, as sugar can't enter cells for energy ). Record review of Resident #4's quarterly MDS, dated [DATE], revealed a diagnosis which included bipolar disorder and a BIMS of 06, which indicate impaired cognitive function. Record review of Resident #4's care plan revealed the resident could be resistive to care related to bipolar disorder, dated 01/17/2024.Record review of Resident #4's Level 1 PASSAR screening, dated 07/17/2013, revealed there was no evidence of any Mental Illness, Intellectual Disability or Developmental Disabilities. Record Review of Resident #99's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #99 had diagnoses which included Muscle Wasting and Atrophy (thinning and loss of muscle tissue, causing decreased mass and strength), Major Depressive Disorder (a serious mood disorder causing persistent sadness, loss of interest, and impacts feelings, thinking, and behavior, leading to impaired daily functioning, with causes involving genetic, environmental, and biological factors), and Generalized Anxiety Disorder (a mental health condition marked by persistent, excessive, and uncontrollable worry about everyday things). Record review of Resident #99's quarterly MDS, dated [DATE], revealed diagnoses of anxiety disorder and Depression. The MDS also revealed no BIMS score. Record review of Resident #99's care plan revealed the resident had anxiety disorder and was receiving anxiety medication, dated 08/29/2023. It also revealed residents were receiving antidepressant medication related to a diagnosis of depression, dated 08/29/2023. Record review of Resident #99's level 1 PASSAR screening, dated 08/21/2023, revealed no evidence of Mental Illness, Intellectual Disability and/or Intellectual Disability. An interview on 12/31/2025 at 1:52 PM with MDSC revealed that MDSC had been employed at the facility for 8 years. The MDSC said they received training on PASSAR which included steps to take when a resident entered a facility which included how to enter the PL1 when it was received from the hospital, the facility would have 14 days to do their evaluation on the resident and move forward based on their decision. The MDSC stated the last time they received PASSAR training was in 2025. The MDSC stated the policy for PASSAR was to complete a PASSAR screen on every admission and the MDSC was responsible for the screening and ensured the screening was done correctly. If a resident was identified as having newly evident or possible MD, ID or a related condition after admission, the facility's process for referring the resident to the appropriate state designated authority would be to do the 1312 form, have the physician sign it, and do a new PASSAR and send it through according to the MDSC. The MDSC stated Resident #4's diagnosis of bipolar disorder diagnosed on [DATE] would indicate a positive level 1 PASSAR. The MDSC stated a new PASSAR should have been completed since the diagnosis came after the previous PASSAR screening. The MDSC stated this could negatively affect the residents by not getting the services they needed. The MDSC also stated a PASSAR should be done on admission and if they received services by psychiatry at the facility. The MDSC stated a resident could have a negative level 1 if there was a positive diagnosis if dementia overrode the diagnosis which was not the case for Resident #99. The MDSC stated Resident #99's diagnosis of Major Depressive Disorder would indicate a positive level 1 PASSAR. The MDSC stated Resident #99's PASSAR was negative on 08/22/2023 because a Level 1 PASSAR document was not sent off yet. The MDSC stated the PASSAR being incorrect could negatively affect Resident #99 by not receiving designated services for her diagnosis. An interview on 12/31/2025 at 2:08 PM with the DON revealed the DON had been employed at the facility for 4 months and 3 days. The DON stated he received training on PASSAR which covered there was certain diagnosis that made a person PASSAR qualified. The training also included interviewing residents with local authorities and would receive special benefits if the PASSAR was positive or not. The training included developmental diagnosis, and mental diagnosis would qualify. The DON stated he had the training in August 2025. The DON stated the policy for PASSAR was it should be done upon admission and/or diagnosis change by the MDSC who also should verify if it was correct. An interview on 12/31/2025 at 3:13 PM with the ADM revealed the ADM had been employed at the facility since October 2023 and received training on PASSAR. The training covered how staff completed a PASSAR for all residents. The ADM stated the policy for PASRR said the PASSAR screenings were completed according to regulation. The ADM stated the MDSC was responsible for completing the PASSARs or ensuring the facility had a PASSAR and should be completed upon admission and/or change of diagnosis. The ADM stated Resident #4's diagnosis of bipolar disorder would indicate a positive level 1 PASSAR. The ADM also stated a new PASSAR should have been completed since the diagnosis was after the previous PASSAR screening. The ADM stated it could negatively affect her if it was incorrect by certain services under PASSAR may have been missed. The ADM stated a resident could have a negative level 1 PASSAR if there was a positive diagnosis if there was a misunderstanding. The ADM stated Resident #99's diagnosis of Major Depressive Disorder which was diagnosed on [DATE] should have indicated a positive level 1 PASSAR. The ADM stated he was unsure why the PASSAR was negative on 08/22/2023. This inefficiency could affect the residents negatively by resulting in missing services. Record review of an undated document provided by the facility titled Nursing Facilities Responsibilities Related to PASSAR which include the following steps:1. If an individual seeks admission to a facility, they must have completed PL1 before admitting to the facility. 2. If PL1 identifies MI, ID or DD then a LIDDA or LMHA completes and enters a PE.3. Withing 7 calendar days the facility must review recommended list of NF/LIDDA/LMHA specialized services and certify in the LTC online portal whether the individual needs can be met at the facility.

Based on observation, interview, and record review the facility failed to provide a resident or family group with private space, and take responsible steps, with the approval of the group, to make residents and family members aware of upcoming meeting in a timely manner ensure the confidentiality offer Residents participating in Resident Council meetings in dining room [ROOM NUMBER] of 1 resident council meetings reviewed for resident rights.The facility failed to ensure that Staff members did not enter the dining room uninvited during the meeting, resident council meetings exposing residents to loss of privacy. This failure could affect place residents by placing them at risk for loss of privacy and dignity.The Findings included: Observation of the resident council meeting on 12/29/2024 at 2:30 PM, revealed that 2 staff members, (Hospitality Aide and Dietary Aide) entered the dining room entry doors during the resident council meeting. During an interview on 12/31/2025 at 9:08 AM, revealed that the Activities Director had been trained in Resident Rights and in Abuse Neglect and Exploitation. The Activities Director has received training through Relias Training online and in- services on these subjects as well. She stated residents have had the right to make complaints and to be able to speak privately. She stated that a sign should be posted on each of the doors to the dining room in order that uninvited staff did not enter when the meeting was going on. She stated that no sign was posted prior to the Resident Council meeting on 12/29/2025 because the meeting was changed from 12/31/2025 to 12/29/2025 and it was an oversite. The Activities Director stated she was responsible for ensuring residents have had a private place to meet. The Activities Director stated the Resident Council President and the Resident council Secretary have had the right to run their meeting without staff present and that only invited staff members were to be present. During an Interview with the Resident Council President on 12/29/2025 at 3:01 PM, revealed that only staff members that had been were invited to the meetings were allowed to enter the Resident Council meeting. Resident Council President stated, the Activities Director had an ongoing invitation to their meeting, and she did not know of any other staff who were invited.She stated that the Activities Director has had an ongoing invitation to their meeting, and she does did not know of any other staff that had been invited. During an interview with the Resident Council Secretary on 12/29/2025 at 3:07 PM, revealed the meetings are always held in the dining room. The Secretary stated that she has invited the Activities Director to the Council Meetings for the purpose of taking notes. Record review of the facility's, undated, Resident Council meeting policy for Granite Mesa Health Center, reflected the following:Policy:It is the policy of this facility to: 1. Provide a forum through which constructive suggestions, ideas and concerns may be offered and projects initiated for the mutual benefit of the institution and the residents of the facility.Procedures: 2/ Invited guest speakers: such as the Director of Nursing Services.or even persons from outside agencies may be invited to speak for resident's benefit.Record review of the facility's policy on Resident Rights reflected the following:Dignity and respect Be treated with dignity, courtesy, consideration and respect.Freedom of choiceYou have the right to: Make your own choices regarding personal affairs, care and services.Privacy and confidentiality You have the right to: Privacy, including privacy during visits and telephone calls and while attending to personal needs.

Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 7 residents (Resident #1) reviewed for complete and accurate records. The facility failed to ensure Resident #1's medication and treatment was documented in PCC (electronic health records) for October 20th, November 13, November 14th, November 17th, November 18th, November 19th and November 20th. This failure could place residents at risk of not receiving care and services to meet their needs. Findings include:A record review of Resident #1's face sheet, dated 11/29/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included hypothyroidism (thyroid gland does not make enough thyroid hormones to meet the body needs), hemiplegia (paralysis that affects one side of the body), insomnia (difficulty falling on staying asleep), diabetes insipidus (kidneys unable to conserve water), and muscle weakness (loss of muscle strength).A record review of Resident #1's care plan, dated 11/29/2025, reflected Resident #1 had hypothyroidism with interventions to give thyroid replacement therapy as ordered. Monitor/document for side effects and effectiveness.A record review of Resident #1's Quarterly MDS assessment, dated 11/15/2025, reflected no BIMS score as Resident #1 was unable to complete the interview.A record review of Resident #1's physician's order dated 07/31/2025 and DC 10/28/2025 reflected Levothyroxine sodium tablet (treats underactive thyroid) 125 MCG. Give one tablet by mouth in the morning for low thyroid hormone.A record review of Resident #1's physician's order dated 11/12/2025 and DC 11/25/2025 reflected Levothyroxine sodium oral tablet (treats underactive thyroid) 125 MCG. Give one tablet via PEG-Tube in the morning for hypothyroidism (low thyroid hormone).A record review of Resident #1's physician's order dated 11/13/2025 and DC 11/25/2025 reflected Midodrine HCL Oral tablet 5 MG (low blood pressure). Give one tablet via PEG-tube three times a day for supine hypotension (low blood pressure) SBP >140 not be administered after evening meal 3-4 hrs of bedtime.A record review of Resident #1's physician's order dated 11/13/2025 and DC 11/25/2025 reflected secure catheter with a leg strap/leg band or anchor to minimize catheter related injury and accidental removal or obstruction of urine outflow check placement.A record review of Resident #1's physician's order dated 11/12/2025 and DC 11/25/2025 reflected suprapubic catheter care every shift monitor S/P insertion site for S/S of skin breakdown, pain/discomfort, unusual odor, urine characteristics or secretions catheter pulling causing tension.A record review of Resident #1's MAR dated 10/20/2025 reflected Levothyroxine sodium tablet (treats underactive thyroid) 125 MCG was not signed off given by RN A .A record review of Resident #1's MAR dated 11/13/2025 reflected Levothyroxine sodium oral tablet (treats underactive thyroid) 125 MCG was not signed off given by RN A .A record review of Resident #1's MAR dated 11/13/2025 reflected Levothyroxine sodium oral tablet (treats underactive thyroid) 125 MCG was not signed off given by LVN B.A record review of Resident #1's MAR dated 11/17/2025, 11/19/2025, and 11/20/2025 reflected Midodrine 5 MG oral tablet (low blood pressure) was not signed off given by RN AA record review of Resident #1's MAR dated 11/19/2025 and 11/20/2025 reflected Levothyroxine sodium oral tablet (treats underactive thyroid) 125 MCG was not signed off given by LVN B A record review of Resident #1's MAR dated 11/14/2025 reflected secure catheter with a leg strap/leg band or anchor to minimize catheter related injury and accidental removal or obstruction of urine outflow check placement was not signed off on by LVN BA record review of Resident #1's MAR dated 11/18/2025 and 11/19/2025 reflected secure catheter with a leg strap/leg band or anchor to minimize catheter related injury and accidental removal or obstruction of urine outflow check placement was not signed off on by RN A.A record review of Resident #1's MAR dated 11/14/2025 reflected suprapubic catheter care every shift monitor S/P insertion site for S/S of skin breakdown, pain/discomfort, unusual odor, urine characteristics or secretions catheter pulling causing was not signed off on by LVN B .A record review of Resident #1's MAR dated 11/18/2025 and 11/19/2025 reflected suprapubic catheter care every shift monitor S/P insertion site for S/S of skin breakdown, pain/discomfort, unusual odor, urine characteristics or secretions catheter pulling causing[ tension was not signed off on by RN A.A record review of RN A's written statement dated 11/29/2025 at 6:00 pm stated that on 11/17/2025 , 11/19/2025, and 11/20/2025 she stated she did administer Resident #1 the Midodrine (low blood pressure), Levothyroxine (underactive thyroid), secured the catheter and monitored the insertion site for any complications. RN A stated that she forgot to sign off on them when she had administered. RN A educated to make sure all documentation was completed when the medication was administered.A record review of LVN B written statement dated 11/30/2025 at 10:00 am stated that on 11/13/2025 and 11/14/2025 he statedd he did administer the Levothyroxine (underactive thyroid) and completed the catheter care but forgot to document after completing. LVN B was educated to make sure his documentation was completed when medications and task was done.Attempted to interview RN A on 11/29/2025 at 2:04 pm, 11/30/2025 at 12:05 pm, and 1:38 pm. Voice messages were left and no call back was received by exit date 11/30/2025.Attempted to interview LNV B on 11/29/2025 at 2:15 pm, 11/30/2025 at 12:03 pm, and 1:35 pm. Voice messages were left and no call back was received by exit date 11/30/2025.During an interview with the ADON on 11/29/2025 at 2:07 pm, the ADON stated she was not able to say why RN A and LVN B did not sign off when they completed the task. The ADON stated it was expected for the MAR to be signed off on once administered to show that the medication or treatment was given. The ADON stated by RN A and LVN B not signing off on the MAR it would not have been known if it was given or not. The ADON stated that if it was not signed off on it would indicate that it did not happen and depending on the medication could result in further illness.During an interview with the ADM on 11/30/2025 at 1:40 pm, the ADM stated it was expected for RN A and LVN B to have signed off on the MAR to ensure documentation was entered timely and accurately. The ADM stated if the MAR was not signed off on it would have indicated that it did not happen and may cause a decline in health. Record review of the facility's, undated, policy titled medication and treatment administration reflected It is the policy of this facility that medications and treatments are administered only upon the clear, complete, and prescribed by lawfully authorized provider. Verbal orders are received only by licensed nurses or pharmacists and confirmed by electronic signature by the prescriber. Documentation of the Medication. Each medication order is documented in the resident's medication Administration Record (MAR) with the date, time, and signature of the person administering the medication''. [KS1]The layperson does not know what Point Click Care is - please use plain language here [KS2]There's no review of the MAR/TAR for 11/17 [KS3]This does not really make sense [KS4]Are there words missing? [CW5]Tension added [KS6]How do we know RN A administered Levothyroxine on 10/20? Was this a medication error instead of a documentation error? [CW7]The statement the RN A was it was giving but just not signed off on this documentation and not med error [KS8]How do we know RN A administered Levothyroxine on 11/13? Was this a medication error instead of a documentation error? [CW9]The statement the RN A was it was giving but just not signed off on this documentation and not med error [KS10]How do we know RN A administered Levothyroxine on 11/13? Was this a medication error instead of a documentation error? [CW11]The statement the RN A was it was giving but just not signed off on this documentation and not med error [KS12]How do we know LVN B administered Levothyroxine on 11/19 and 11/20? Was this a medication error instead of a documentation error? [CW13]The statement the LVN B was it was giving but just not signed off on this documentation and not med error [KS14]How do we know LVN B checked the catheter placement on 11/14? Was this a failure to provide care or a failure to document? [CW15]Written statement documentation error [KS16]How do we know RN A checked the catheter placement on 11/18? Was this a failure to provide care or a failure to document? [CW17]Written statement document error [KS18]It seems like there are missing words after causing [KS19]How do we know LVN B performed catheter care on 11/14? Was this a failure to provide care or a failure to document? [CW20]The statement the LVN B was it was done but just not signed off on this documentation and not med error failure to document [KS21]How do we know RN A performed catheter care on 11/18? Was this a failure to provide care or a failure to document? [CW22]The statement the RN A was it was done but just not signed off on this documentation and not med error [KS23]It seems like there are missing words after causing [CW24]tension [KS25]There is no review of the MAR/TAR for 11/17 [KS26]There's no review of the MAR saying she didn't administer the Midodrine on 11/19 [CW27]added [KS28]There's no review of the MAR saying LVN B didn't administer the Levothyroxine on 11/13. Our review of the MAR for 11/13 says Levothyroxine was not signed off by RN A. [KS30]There's no review of the MAR saying LVN B didn't administer the Levothyroxine on 11/14. The only MAR review we have for 11/14 was about catheter placement/care. [CW31]Not 11/14

Based on interviews and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for one (Resident #1) of three residents reviewed for respiratory care. The facility failed to ensure RN A documented Resident #1's response to oxygen therapy after she administered a nebulizer treatment on 04/03/25. This deficient practice could place residents that receive oxygen therapy at risk for inadequate care and respiratory distress. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), dysphagia (difficulty in swallowing), and muscle wasting and atrophy (wasting away). Review of Resident #1's admission MDS assessment, dated 03/06/25, reflected a BIMS was not conducted due to him rarely/never being understood. Section O (Special Treatments, Procedures, and Programs) reflected he did not require respiratory treatments. Review of Resident #1's admission care plan, dated 03/10/25, reflected he had a cerebral vascular accident with an intervention of taking vital signs and documenting them as ordered. Review of Resident #1's physician order, dated 03/15/25, reflected an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML - 1 vial inhale orally three times a day for SOB. Review of Resident #1's MAR, dated April 2025, reflected he last received his nebulizer treatment on 04/03/25 at 9:14 PM. Review of Resident #1's progress notes in his EMR, on 04/09/25, reflected no documentation by RN A after the nebulizer treatment on 04/03/25 at 9:14 PM. Review of Resident #1's vitals in his EMR, on 04/09/25, reflected no vitals were taken after 3:37 PM on 04/03/25. During an interview on 04/09/25 at 10:53 AM, Resident #1's NP stated she would expect nurses to assess all residents within an hour after nebulizer treatments to ensure they were responsive to the treatment. She stated a negative outcome of not assessing after a treatment could be hypoxia (low levels of oxygen in body tissues) or an increased pulse rate. During an interview on 04/09/25 at 12:40 PM, the DON stated if there was an acute change with a resident's vitals, such as low oxygen saturation or a high temperature, she would expect the nurses to continue to follow-up, monitor, and document their vitals throughout their shift or follow the orders from the NP. She stated a resident's vitals should be monitored after receiving oxygen therapy of any kind. She stated documentation was part of continuity of care and without it, the reader (of their EMR) could not get the whole view of the resident. She stated the resident could go without the care they needed, or their health could deteriorate. She stated she definitely had some education to do with the nurses after being informed of the lack of documentation/assessments by RN A after administering a nebulizer treatment to Resident #1. During an interview on 04/09/25 at 12:58 PM, RN A stated she did not follow up with Resident #1 after she administered the nebulizer treatment. She stated she should have assessed him 30 minutes after, and she must have forgotten. She stated it was important to assess after a nebulizer treatment to ensure the resident responded well to it and their heart rate had not increased significantly. Review of the facility's Documenting and Charting Policy, revised 07/2023, reflected the following: It is the policy of this facility to provide a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. Review of the facility's Aerosol Drug Delivery Policy, revised 12/2023, reflected the following: Check pulse before and after procedure. If deviated from resident's baseline pulse, delay treatment and notify physician.

Based on interview and record review, the facility failed to ensure all residents were free from abuse for one (Resident #1) of four residents reviewed for abuse. The facility failed to keep Resident #1 safe from being yelled at, humiliated, and being denied care by CNA B. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/24/2025 at 5:42 PM . While the IJ was removed on 01/25/2025 at 2:45 PM, the facility remained out of compliance at a level 2 of no actual harm at a scope of isolated that was no immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of abuse, injury and psychosocial harm. Findings included: Review of Resident #1's face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of multiple sclerosis (a chronic autoimmune disease that affects the central nervous system, which includes the brain and spinal cord), muscle wasting and atrophy (loss of muscle mass and strength), other reduced mobility (a situation where someone has difficulty moving around due to a condition), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), and unspecified lack of coordination (difficulty with movement coordination where the exact cause is not identified). Review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 required partial/moderate assistance (staff does less than half the effort, holds supports trunk or limbs) with shower/bathing, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. Further review reflected Resident #1 usually required partial/moderate assistance with chair to bed/bed to chair transfers, toilet transfers, sit to stand and lying to sitting on edge of bed. Review of quarterly MDS reflected no BIMS was conducted. Review of Resident #1's care plan dated 07/22/2023 revealed resident had multiple sclerosis. Her goals included: resident will maintain optimal status and quality of life within limitations imposed by disease processed. Resident #1 had an ADL self-care performance deficit related to multiple sclerosis and weakness, interventions included that toilet use and transfers required staff participation. Further review of Resident #1's care plan revealed Resident #1 was a risk for falls related to weakness and interventions included: encourage use of call light for assistance as needed. During an interview on 01/24/2025 at 12:15 PM, Resident #1 stated that she had a grievance with CNA B last month. She stated she still had issues with CNA B. Resident #1 stated that CNA B worked nights and yelled at her. She stated that it made her really uncomfortable when she had to wait and see if CNA B was going to be on shift for the evening. Resident #1 stated that usually she was able to do most transfers by herself but by the evening she got tired and needed help. Resident #1 stated that CNA B came into her room and yelled at her and told Resident #1 you can do it (transfer) yourself, you do not need help. Resident #1 started a few weeks ago and CNA B refused to help her go to the bathroom. Resident #1 stated that she ended up having an accident in her brief and that CNA B did not transfer her to the toilet. Resident #1 stated that another time CNA B yelled over her while she was laying in bed to another CNA that Resident #1 did not need help and could do it herself. Resident #1 stated that she told the ED about her concerns a few weeks ago. Resident #1 stated that she told ED that CNA B yelled at her, but she was unsure what the outcome was. Resident #1 stated that ED told her he had to do his due diligence regarding the concerns. Resident #1 stated she was not sure what due diligence meant. Resident #1 stated she did not think she should continue getting yelled at. Resident #1 stated she recently told ED again about her continued issues with CNA B still bullying her, and she asked him if he had done his due diligence and , she felt the ED brushed her off and laughed after she spoke with him. Resident #1 stated that CNA B made her feel bad about herself because she could not do everything by herself and needed help. Resident #1 stated that CNA B made her feel bad about her diagnoses. Resident #1 stated she should be able to do things by herself, but she could not all the time and gets tired. Resident #1 stated that she liked to try to be independent. Resident #1 stated she got nervous when CNA B worked because she knew she would have to strain herself by transferring herself without help. During an interview on 01/24/2025 at 1:22 PM, Resident #1 stated that she also told CNA C that CNA B yelled at her, and CNA C told Resident #1 that was not right. Resident #1 stated she told ED time was up and asked if he had done his due diligence, and it was not right for her to continue to get bullied. Resident #1 stated she also told CNA C her concerns the other day and he told her that no residents on the hall like CNA B. During an interview on 01/24/2025 at 12:40 PM, SW stated that she did not follow up with Resident #1 after her grievance in December, and that she probably should have made sure everything was okay. SW stated she had not received any additional complaints regarding CNA B. During an interview on 01/24/2025 at 1:22 PM, Resident #1's FM stated that she did not believe Resident #1 should have had to put up with being bullied in her own home and wanted the issues with CNA B to be addressed. During an interview on 01/24/2025 at 1:25 PM, RN A stated that she had witnessed CNA B talking down to residents multiple times. RN A stated that she talked with ED about her concerns and she felt CNA B retaliated and refused to talk with RN A for the rest of the shift or help with resident care. RN A stated that she received complaints at least every shift about CNA B. RN A stated CNA B refused to assist Resident #1, and Resident #1 could perform that care herself. RN A stated that Resident #1 often felt talked down to because she could not always transfer t on her own. RN A stated that generally CNA B would tell residents with dementia you do not have a clue what is going on. RN A stated CNA B also yelled down the hall for staff not to help another resident because she did not do anything by herself. RN A stated that she also was not able to find CNA B during their shift, and CNA B would often be on her phone during her shift. During an interview on 01/24/2025 at 2:00 PM, ED stated that he did not remember the day or time regarding Resident #1's grievance. ED stated that Resident #1's grievance was that CNA B's interactions were less courteous than Resident #1 liked. ED stated that he did customer service training with CNA B and reminded her of his expectations to be courteous and answer call lights timely. ED stated CNA B was surprised and stated all the residents love me, I will be more courteous. ED stated Resident #1 had an additional concern this month (January 2025) that Resident #1 had continued customer services concerns. ED stated Resident #1 had concerns that CNA B was not very polite and did no answer call light as quickly as Resident #1 had liked. ED stated that Resident #1 did not tell him that CNA B yelled at her or refused to provide care for her. ED stated RN A did bring up concerns to him regarding CNA B on 1/15/2025. ED stated that RN A was concerned that she could not find CNA B while she was on her shift and that CNA B was on her phone. ED stated that RN A did not let him know CNA B talked down to residents or refusing to provide care to Resident #1. ED stated he provided additional customer service training and reminded her again of expectations of interactions and customer service. During an interview on 01/24/2025 at 2:10 PM, CNA C stated that Resident #1 did not like CNA B. CNA C stated that when he worked with both, CNA B and Resident #1, he provided the care for Resident #1 because CNA B and Resident #1 did not get along. CNA C stated that he believed Resident #1 and CNA B had personality differences. CNA C denied Resident #1 telling him that CNA B yelled at her. During an interview on 01/24/2025 at 2:53 PM, CNA D stated that Resident #1 may need more assistance with transfers after exercise or bathing, but other than that she could usually do transfers herself. CNA D stated some tasks made Resident #1 more tired and then she may ask for her help. During an interview on 01/24/2025 at 3:05 PM, DOR stated that Resident #1 sometimes needed increased assistance and when that occurred it was usually in the afternoon, but it was inconsistent. DOR stated that therapy educated Resident #1 to ask for assistance when she was more fatigued. During an interview on 01/24/2025 at 4:33 PM, CNA B stated she was familiar with Resident #1. She stated she usually went into Resident #1's room with another staff because Resident #1 made an allegation about her. CNA B stated that Resident #1 had stated CNA B was mean and that she did not like handicapped people. CNA B denied having ever raised her voice to Resident #1 or denying her care. CNA B denied telling Resident #1 she could transfer herself and that Resident #1 usually only wanted assistance with pulling up her brief or having it changed. CNA B stated she was not abusive to Resident #1, During an interview on 01/24/2025 at 4:38 PM, Resident #1 stated she felt CNA B's behavior toward her was abusive. Resident #1 appeared worried and asked if CNA B would be returning to the facility over the weekend. During an interview on 01/24/2025 at 5:35 PM, ED stated that CNA B was scheduled to work 01/26/2025 in the morning. Review of facility in-service dated 01/16/2025 reflected that all staff were in-serviced on Abuse and Neglect. Review of facility policy titled Abuse: Prevention of and Prohibition Against with revision date of 12/2023 reflected the following; Each resident has the right to be free from abuse, neglect and misappropriation of resident property, exploitation and mistreatment. Abuse is the willful infliction of intimidation or mental anguish and includes deprivation by a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Mental abuse includes, but is not limited to humiliation, harassment and threats or punishment or deprivation. Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or facility administrator immediately. Some cases of abuse are not directly observed, understanding resident outcomes of abuse can assist in identifying whether abuse is occurring or has occurred; possible indicators could include sudden or unexplained changes in behavior or activities (fear of a person or place, feels of guilt or shame). The ED and DON were notified on 01/24/2025 at 5:42 PM that an IJ had been identified and an IJ template was provided and a POR was requested. The following POR was approved on 01/25/2024 at 11:57 AM and indicated: Plan of Removal Immediate Jeopardy On 1/24/25 an abbreviated survey was initiated at [facility]. On 1/24/25 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Threat states as follows: The facility needs to take immediate action in order to prevent psychosocial harm to other residents. Action: CNA B terminated. Start Date: 1/24/25 Completion Date: 1/24/25 Responsible: ED Action: Medical Director notified of IJ Start Date: 1/24/25 Completion Date: 1/24/25 Responsible: DON, ED Action: Train the trainer in-service given to ED and DON on Abuse. Start Date: 1/24/25 Completion Date: 1/24/25 Responsible: Clinical Resource Action: Safe surveys will be completed on all residents with a BIMS score 12 and higher. Start Date: 1/24/25 End Date: 1/24/25 Responsible: ED/DON/Designee Action: Training and knowledge skill checks completed with all staff regarding abuse/neglect who are at facility currently. Prior to any other staff working the floor they will be in-serviced on abuse/neglect. All staff will not be allowed to work until completing the training and knowledge checks. The training will also be included in new hire orientation. Staff training on abuse and neglect was completed by ED/ DON or designee by 1/25/25. Knowledge check completed. Start Date: 1/24/25 End Date: 1/25/25 Responsible: ED/DON/Designee Action: An Ad hoc QA meeting will be completed. Attendees will include ED, DON, ADON, Clinical Resource, and Medical Director. Meeting will include the Plan of Removal and interventions. Start Date: 1/24/25 End Date: 1/24/25 Responsible: ED/DON Action: ED or Designee will verify staff knowledge on abuse prevention with 10 staff weekly using the abuse and neglect knowledge checks. This will be completed weekly following the initial training and knowledge checks. Start Date: 1/26/25 End Date: 4/26/25 Responsible: ED/Designee Action: Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 1/24/25 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Start Date: 1/24/25 End Date: 5/26/2025 Responsible: ED/DON Action: Resident #1 Licensed Social Worker reassessed resident. Resident feels safe and does not feel anxious. Start Date: 1/24/24 End Date: 1/24/25 @21:20 Responsible: SW Action: Ombudsman will be notified of the IJ. Start Date: 1/25/25 End Date: 1/25/25 @9:45am Responsible: ED Surveyor monitored the POR on 01/25/2025 as followed: During an interview on 01/25/2025 at 11:45 AM, ED stated that he sent all the recommended changes to the PM that morning. ED stated Ombudsman was contacted 01/25/2025 at 9:45 AM about the incident. CNA B was terminated on 1-24-2025 by phone. ED stated SW reassessed Resident #1 on 01/24/2025 and 01/25/2025 and Resident #1 stated she felt safe. All staff that were in the building on 01/25/2025 have been trained on abuse and neglect. Staff were reached by phone and would have training prior to the start of their shift. New hires would be trained in orientation. No new policies were implemented, and no changes were made to existing polices. ED stated safe surveys were completed on 01/24/2025 for all residents with BIMS over 12 and this was conducted by DON. Clinical Resource provided training to ED and DON on abuse and neglect on 01/24/2025. ED, DON and assigned designee conducted trainings. AD Hoc QA meeting was completed on 01/24/2025 and will be done weekly until substantial compliance and continued monthly for 90 days. ED stated 10 staff weekly will be tested on their knowledge of abuse and neglect. Review of Alleged Perpetrator Termination notice reflected date of 01/24/2025. Review of abuse/neglect in-service conducted on 01/24/2025 and 01/25/2025 reflected all staff were in-serviced who were present at work and prior to beginning their shift. Review of resident safe surveys dated 01/24/2025 reflected no concerns with residents. Review of ad hoc QAPI sign-in sheet reflected meeting was completed 01/24/2025. During an interview on 01/25/2025 at 12:20 PM, Resident #1 appeared neat and well-groomed sitting in bed eating her lunch. The resident stated she was safe and very pleased that CNA B was no longer working in facility. Resident #1 stated she was very relieved and so was her FM that CNA B was no longer at the facility. Resident #1 stated that all the other staff were wonderful, and she did not have any issues or concerns, and she was very thankful that the situation had been resolved. During interviews on 01/25/2025 between 12:20 PM and 2;40 PM, 5 CNAs, 1 MA, 1 NA, 1 LVN, 1 RN, DON, HSK, and DA stated they were aware of who to report any alleged abuse, to report immediately and provided examples of potential abuse. The ED was notified on 01/25/2025 at 2:45 PM that the IJ had been removed. While the IJ was removed, the facility remained out of compliance at a level of no actual harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interviews, observations, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 19 of 94 days reviewed for RN coverage. The facility failed to ensure they had an RN scheduled on duty for 19 days (07/04/2024, 07/08/2024, 07/09/2024, 07/14/2024, 07/22/2024, 08/05/2024, 08/19/2024, 08/30/2024, 09/03/2024, 09/04/2024, 09/10/2024, 09/16/2024, 09/17/2024, 09/18/2024, 09/24/2024, 09/25/2024, 09/26/2024, 10/01/2024, and 10/02/2024) and failed to ensure the DON was not acting as the charge nurse when the facility had an average daily occupancy of more than 60 residents. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment. Findings included: Review of the daily staffing for July 1, 2024, through October 2, 2024, reflected zero hours worked by an RN on the following days: -07/04/2024, -07/08/2024, -07/09/2024, -07/14/2024, -07/22/2024, -08/05/2024, -08/19/2024, -08/30/2024, -09/03/2024, -09/04/2024, -09/10/2024, -09/16/2024, -09/17/2024, -09/18/2024, -09/24/2024, -09/25/2024, -09/26/2024, -10/01/2024, and -10/02/2024. During an observation on 10/01/2024 and 10/02/2024, the staffing schedule posted at the nursing station revealed 12-hour shifts for nursing staff. There was no RN listed on the schedule for 10/01/2024 and 10/02/2024. During an interview on 10/01/2024 at 02:09 PM, LVN B stated RNs worked 12-hour shifts and a RN was available at least 8 consecutive hours in the day. When the regular RNs were not available, the DON served as the nurse for that day. LVN B was not aware of any residents going without their needs being met due to a RN not being scheduled because the DON was available to meet those needs. During an interview on 10/01/2024 at 02:16 PM, SC A stated she made the schedule for the facility. There were two RNs that worked 12-hour shifts and if they were not available, then the DON worked as the RN for that shift when available. SC A sent a What's Up chat to let staff know when there was not a RN available in the facility. When a RN was not at the facility, she called the DON to cover the shift. SC A had never known a time when a resident needed care or services by a RN and did not receive care because the facility called an agency RN through a service called Dynamic access that provided resident care in the absence of a scheduled RN. During an interview on 10/02/2024 at 08:39 AM, the DON stated they do not have a facility policy for RN coverage. They used the regulation language in Appendix PP, which stated, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. The DON stated there are two full time RNs and one RN that worked PRN. The DON stated that she worked as the RN on shift when there was not a RN available for the 8 consecutive hours each day as often as she could, but she was not always available. DON stated she was aware there was supposed to be 8 hours of RN coverage every day in the facility, which was why she worked to cover those hours. The DON stated she had interpreted the policy differently and did not know her 8 hours could not count as the required RN 8 hours since the facility census was over 60. The DON stated the current census was 86 and the average census was around 80 for the past three months. The DON did not believe she was working as the charge nurse when she was working in the facility as the only RN. The DON did not believe the charge nurse needed to be a RN. The DON stated there was not a potential negative outcome to residents for not having a RN scheduled because her LVNs were very well trained. The DON stated that it was difficult to hire an RN to work at the facility. The DON reviewed the staffing schedule for 07/01/2024, through 10/02/2024 and agreed there was not a scheduled RN on 19 days. The DON stated she did not work on 07/04/2024 when no RN was scheduled that day. The DON stated she wanted to consider a waiver for RN coverage. During an interview on 10/02/2024 at 09:22 AM, the ADM stated they do not have a facility policy for RN coverage. They used the regulation language provided by CMS, which stated, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. The ADM stated he was aware there was supposed to be 8 hours of RN coverage every day in the facility, which was why the DON worked to cover those hours, when a RN was not scheduled. The ADM stated he had interpreted the policy differently and did not know the DON's hours could not count as the required RN 8 hours. The ADM stated that the DON tried to cover the shifts when the usual two full time RNs were not available for the 8 hours. For the last three months, there were 17 days when there was not a RN on schedule and the DON covered most of those days. The ADM stated he did not think of the DON as the charge nurse and did not think the charge nurse had to be an RN. The ADM stated potential adverse outcome to residents for not having RN on shift was decrease in the quality of care. The ADM stated their census was over 80 and he agreed that there was no RN on the schedule for 17 days during July-September and no RN on schedule 10/01/2024 and 10/02/2024. The ADM stated he had been trying to hire an RN for the last several months with no success. He had an ad on Indeed and one person accepted the job, but then took a different job offer before starting. The ADM stated he wanted to consider a waiver for RN coverage.

Based on observation, interview and record review, the facility failed to provide an ongoing program of activities based on the comprehensive assessment, care plan and the preferences of each resident to meet the interests of and support the physical, mental, and psychosocial well-being for 2 of 5 (Resident #46 and #71) reviewed for activities . The facility failed to develop an ongoing activity program for Resident #46 and Resident #71. This failure placed residents at risk of not having their recreational and social needs met. Findings included: 1. Review of Resident #46's face sheet dated 10/02/2024 revealed a [AGE] year-old female admitted on [DATE] and had diagnoses of unspecified dementia (condition that causes a decline in cognitive abilities), Parkinson's disease (chronic brain disorder that causes movement problems), cognitive communication deficit (difficulty with communication cause by disruption to cognition) and major depressive disorder (serious mental disorder that affects how a person, feels, thinks and functions). Review of Resident #46's physician orders 02/12/2022 to 09/20/2024 revealed Resident #46 had an order that she may participate in social activities as tolerated. Review of Resident #46's quarterly MDS dated [DATE] revealed a BIMS score of 2 which indicated severe cognitive impairment. Review of Resident #46's care plan dated 06/08/2023 revealed Resident #46 was dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits. Interventions included for staff to invite to scheduled activities. Resident #46's care plan revealed that she required assistance or escort to activity functions. Further review revealed Resident #46 was taking an antidepressant related to depression and an antianxiety medication related to anxiety disorder and interventions included to take to activities. Review of Resident #46's activity admission assessment dated [DATE] revealed resident #46 enjoyed listening to music and church and bible study. Additional comments included that resident should be invited and reminded and assisted to activities. Review of Resident #46 quarterly evaluation dated 08/21/2024 revealed Resident #46 will attend if brought to activities and watches. Review of Resident #46's individual resident daily participation record for 08/2024 revealed resident did not participate in any activities from 08/22/2024 to 08/31/2024. Review of resident daily participation record of 09/2024 revealed resident attended religious services on 09/30/2024 and did not attend any additional activities on 09/30. 2. Review of Resident #71's face sheet revealed a [AGE] year-old woman admitted on [DATE] and had diagnoses of unspecified dementia (condition that causes a decline in cognitive abilities), generalized anxiety disorder (a mental disorder that causes people to experience excessive, persistent, and uncontrollable worry) and cognitive communication deficit (difficulty with communication that's caused by a disruption in cognition). Review of physician orders for Resident #71 dated 07/29/2024 to 09/27/2024 revealed an order that Resident #71 may participate in social activities as tolerated. Review of Resident #71's quarterly MDS dated [DATE] revealed a BIMS score of 3, which indicate severe cognitive impairment. Review of Resident #71's care plan dated 07/30/2024 revealed Resident #71 was taking an antidepressant related to depression and an antianxiety medication related to anxiety disorder and interventions included to take to activities. Review of Resident #71's admission activity evaluation dated 06/05/2024 revealed resident had interest in crafts, music, singing, watching TV and movies, with assessed needs that included to offer activities to keep her occupied. Resident #71 did not have individual resident daily participation record for the past two months (August 2024 and September 2024). Review of September 2024 activity calendar revealed 09/30/2024 activities as mail run, bib study/music group, bingo and activities. Review of October 2024 activity calendar revealed 10/01/2024 activities as mail run, drum team, nails in room, movie, and TV. 10/02/2024 activities were listed as mail run, front lobby games, and bingo. Observation on 09/30/2024 at 9:53 AM, revealed Resident #71 attempted to stand in hallway and walk away from her wheelchair. Observation on 09/03/2024 at 10:38 AM, revealed Resident #46 sat in the hallway in her wheelchair. Resident was observed attempting to talk to individuals and staff that walked by. Observation on 09/30/2024 at 1:26 PM, revealed Resident #71 sat in her wheelchair in hallway. Observation on 09/30/2024 at 1:28 PM, revealed Resident #46 sat in her wheelchair in the hallway. Resident held a baby doll. Observation on 09/30/2024 at 1:55 PM, revealed Resident #46 and Resident #71 sat in hallway in their wheelchairs. Observation on 09/30/2024 at 2:10 PM, revealed Resident #71 attempted to stand up from her wheelchair. Observation 09/30/2024 at 2:24 PM, revealed Resident #46 sat in hallway in her wheelchair with her baby doll and Resident #71 sat in her wheelchair. Observation 09/30/2024 at 3:26 PM, revealed Resident #46 sat in hallway in her wheelchair. Observation on 09/30/2024 at 3:27 PM, revealed Resident #71 sat in the hallway in her wheelchair. Observation on 10/01/2024 at 9:51 AM, revealed Resident #71 asleep in her room. Observation on 10/01/2024 at 10:39 AM, revealed Resident #46 sat in hallway in her wheelchair with her baby doll. Observation on 10/01/2024 at 11:44 AM, revealed Resident #46 and Resident #71 sat in hallway in their wheelchairs. Observation on 10/01/2024 at 1:31 PM, revealed Resident #46 and Resident #71 sat in hallway in their wheelchairs. Observation on 10/01/2024 at 1:33 PM, revealed AD F say there was activities in the dining room and encouraged resident is near nurses station to attend. AD F did not walk down the hallway and ask Resident #71 or Resident #46 if they wanted to attend. Observation on 10/01/2024 at 2:23 PM, revealed Resident #46 and Resident #71 sat in hallway in their wheelchairs. Observation on 10/02/2024 at 10:33 AM, revealed Resident #46 sat in hallway in her wheelchair with her baby doll. Observation on 10/02/2024 at 10:35 AM, revealed Resident #71 sat in hallway in her wheelchair. During an interview on 10/01/2024 at 10:11 PM, Resident #71's FM stated that the facility had games if people were interested in them and stated that Resident #71 was much for playing games. He stated that Resident #71 used to enjoy housework such as cooking and watched certain TV shows in the afternoon. FM stated that he was unsure what activities Resident #71 participated in or attended. During an interview on 10/02/2024 at 10:32 AM, SC A stated that the facility has bingo, painting, things to do in the dining room and church music. She stated that Resident #46 was taken to the dining room if there was a music activity. SC A stated that Resident #46 usually watches activities. SC A stated that Resident #46 liked to sing, and she did not participate in any activities yesterday. SC A stated that when Resident #46 sat in the hall she usually just held her baby doll. SC A was not aware of any staff playing music for Resident #46 in hall or in her room. During an interview on 10/02/2024 at 10:34 AM, SC A stated that resident goes to therapy and walks with therapy as what she usually does day to day. SC A stated that she may go to church and stated that the church/music is once a week. SC A stated that Resident #71's FM visits. SC A stated that when Resident #71 is in the hallway she screams at people and sits and watches the staff most of the day when she's in the hallway. SC A stated she was not sure why Resident #71 was in the hallway. During an interview on 10/02/2024 at 10:44 AM, CNA E stated that there were activities for residents to do such a drumming group, music and bingo. She stated that CNA would help residents get to the activity and bring them back after there were finished. She stated that if a resident were sitting in the hallway she would ask if there was something they wanted to do or offer them something to do. During an interview on 10/02/2024 at 10:52 AM, LVN B stated that the facility had activities such as bingo, church, singing and one on one visits with AD F. She stated that Resident #46 attended church services as activities she attended, and she was unsure how often Resident #46 was offered to attend activities. LVN B stated that when Resident #46 sat in the hallway she is offered fluids, asked about her needs and talked with. LVN A stated that Resident #46 does not like to be by herself. LVN B stated that it was important to residents to engage in activities for socialization, mental health and physical health. LVN B stated that Resident #71 liked to attend bingo and church. She stated that she had a puzzle for her to do that staff put out for her. LVN B stated that Resident #71 did not have the puzzle right now. LVN B stated that Resident #71 does not like to be in her room by herself and likes to be around people. During an interview on 10/02/2024 at 11:02 AM, LBSW stated that she was not sure what Resident #71 liked to do that she did not do a whole lot. LBSW stated that she was not sure what Resident #71 did when she says in the hallway or why she was sitting in the hallway. LBSW stated that she was not sure what Resident #46 liked to do and why she sat in the hallway. LBSW stated that Resident #46 say in the hallway and watched the world go by. She stated that she thought Resident #46 attended music activities and parties. LBSW stated that it was important for residents to participate in activities because it gave them socialization and helped with mood and depression. During an interview on 10/02/2024 at 11:18 AM, AD F stated that she has been the activity director for about 6 months. She stated that Resident #46 loved music, liked to sing and attend church music service on Mondays. She stated that Resident #46 also liked to color and her baby doll. She stated that Resident #46 was confused, and a fall risk and that staff needed to keep an eye on her and that was why she sat in her wheelchair with her baby doll. AD F stated that Resident #46 liked to talk with everyone and is social. AD F stated that Resident #71 was not able to sit and stay focused but liked to watched bingo and liked to talk. She stated that Resident #71 liked to color and listen to music. She stated that she tried to bring Resident #71 into activities. AD F stated that when Resident #71 was in the hallway she tried to stand up. AD F stated that there were activity pages for Resident #71 to do when she sat in the hall. AD F stated that the nurse would put soothing music on. AD F stated that the activity pages were in her office and not on the hallway. She stated that Resident #71 like magazines as well. AD F stated that she recently started to keep a log of activities residents attended. She stated that it was important to residents to participate in activities for cognition, mobility socialization, and all-around well-being. AD F stated that participation in activities kept residents active and well. During an interview on 10/02/2024 at 1:04 PM, the DON stated that usually Resident #71 participated in bingo or did coloring page and was encouraged to stay in communal areas due to a history of falls. She stated that Resident #46 did not like to be alone and has been a social person. The DON stated that she expected residents to be offered to go to activities or encouraged to go. During an interview on 10/02/2024 at 1:12 PM, the ADM stated that he expected AD F maintained activities that were engaging and that they enjoyed. He stated that activities and preferences were discussed during resident council meetings. ADM stated that if residents were unable to participate in group activities, he expected that they be provided with coloring or word searches. The ADM stated that he expected residents who sat in the hallway were offered activities that interested them. Review of facility policy titled Activities Programming with revision date 12/2023 revealed it is the policy of this facility to ensure that activities are available to meet resident needs and interests that support the physical, mental, and psychological well-being of the resident. Activities are defined as any endeavor, other than routine ADLs, in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical, cognitive, and emotional health.

Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 4 (Resident #33, Resident #46 and Resident #69,and Resident #433 ) of 18 residents reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #33's quarterly MDS dated [DATE] accurately reflected her psychiatric/mood disorder. 2. The facility failed to ensure Resident #46's quarterly MDS date 07/21/2024 accurately reflected her psychiatric/mood disorder. 3. The facility failed to ensure Resident #69's quarterly MDS dated [DATE] accurately reflected his psychiatric/mood disorder. 4. The facility failed to ensure Resident #433's admission MDS dated [DATE] accurately reflected her psychiatric/mood disorder. This failure could result in inadequate care due to an inaccurate assessment of psychiatric and mood disorders. Findings include: 1. Review of Resident #33's face sheet dated 10/02/2024 revealed a [AGE] year-old female was admitted on [DATE] and had diagnoses of major depressive disorder (serious mental disorder that affects how a person feels, thinks, and functions in daily life), unspecified macular degeneration (age-related degeneration of vision), and cognitive communication deficit (difficulty with communication that's caused by a disruption in cognition). Review of Resident #33's physician orders dated 08/22/2023 to 09/26/2024 revealed Resident #33 had an order for Venlafaxine indicated for major depressive disorder with a start date of 12/12/2023. Review revealed an order for psych to eval and treat dx: Anxiety with a start date of 08/28/2023. Further review revealed an order for Xanax indicated for anxiety two times a day with a start date of 08/28/2023 and an additional order of Xanax as needed indicate for anxiety with a start date of 09/29/2024 and end date of 10/13/2024. Review of Resident #33's quarterly MDS dated [DATE] revealed depression was selected as an active diagnosis in the last 7 days for Resident #33. Further review revealed anxiety disorder was not selected. Review of Resident #33 psychiatric progress note dated 11/2/2023 reflected major diagnoses as major depressive disorder and GAD (generalized anxiety disorder). Review of Resident #33 psychiatric progress note dated 07/29/2024 revealed major diagnoses as major depressive disorder and GAD (generalized anxiety disorder) with an anxious mood during the session. Review of Resident #33 care plan dated 08/29/2023 revealed resident #33 received an anti-anxiety medication related to anxiety disorder. 2. Review of Resident #46's face sheet dated 10/02/2024 revealed a [AGE] year-old female admitted on [DATE] and had diagnoses of unspecified dementia (condition that causes a decline in cognitive abilities), Parkinson's disease (chronic brain disorder that causes movement problems), cognitive communication deficit (difficulty with communication cause by disruption to cognition) and major depressive disorder (serious mental disorder that affects how a person, feels, thinks and functions). Review of Resident #46's physician orders 02/12/2022 to 09/20/2024 revealed Resident #46 had an order for Alprazolam indicated for anxiety with a start date of 04/24/2024. Review revealed an order for citalopram indicate for depressive disorder and anxiety with a start date of 10/03/2023. Review of Resident #46's quarterly MDS dated [DATE] revealed depression was selected as an active diagnosis in the last 7 days. Further review revealed that anxiety disorder was not selected. Review of Resident #46's psychiatric progress note dated 07/19/2024 revealed resident's current psychiatric medications were citalopram and alprazolam. Review of Resident #46's care plan dated 05/26/2023 revealed resident was taking an anti-anxiety medication related to anxiety disorder. 3. Review of Resident #69's face sheet revealed a [AGE] year-old man admitted on [DATE] and had diagnoses of unspecified sequela of cerebral infarction various symptoms after a stroke), type 2 diabetes (chronic condition that occurs when the body does not properly use insulin to process blood sugar), dysphagia (difficulty swallowing), and cognitive communication deficit (difficulty with communication cause by disruption to cognition). Review of Resident #69's physician orders dated 02/06/2024 to 09/10/2024 revealed Resident #46 had an order for alprazolam indicated for anxiety with a start date of 09/01/2024 and an order for citalopram indicated for anxiety with a start date of 02/11/2024. Review of Resident #69's quarterly MDS dated [DATE] revealed there were no psychiatric/mood disorders selected under active diagnoses for the last 7 days. Review of Resident #69's psychiatric progress note dated 06/18/2024 revealed resident's major diagnoses was anxiety and vascular dementia. Review of Resident #69's care plan dated 08/21/2024 revealed resident was taking anti-anxiety medication related to anxiety disorder. Further review revealed Resident #69 was taking an anti-depressant related to depression. 4. Review of Resident #433 face sheet revealed a [AGE] year-old female admitted on [DATE] and had diagnoses of anoxic brain damage (occurs is when brain is deprived of oxygen), post-traumatic stress disorder (mental condition that can develop after a person experiences or witnesses a traumatic event), and bipolar disorder (a mental illness that causes extreme shifts in mood, energy and activity levels). Review of Resident #433's physician orders dated 09/16/2023 to 09/27/2024 reveled and order for buspirone indicated for anxiety with a start date of 09/16/2024, an order for clonazepam (as needed) indicated for anxiety with a start date of 09/27/2024 and end date of 10/11/2024, an order for divalproex indicated for anxiety with a start date of 09/30/2024, and an order of l-methyl folate indicated for depressive disorder with a start date of 09/22/2024. Review of Resident #433's hospital discharge orders date 09/16/2024 revealed resident admitted to facility with orders for buspirone, clonazepam, and divalproex. Review of Resident #433's admission MDS dated [DATE] revealed bipolar disorder and post-traumatic stress disorder selected under active psychiatric/mood disorder diagnoses. Further review depression and anxiety were not selected. Review of Resident #433's care plan date 09/17/2024 revealed resident received an anti-anxiety medication related to anxiety disorder. Further review revealed resident was at risk for depression with interventions to administer medications as ordered. Review of Resident #433's initial psychiatric evaluation dated 09/19/2024 revealed resident's mood during assessment was depressed and anxious. Further review revealed diagnoses of depression. Review of Resident #433's admission history and physical physician note dated 09/18/2024 revealed Resident #433 had diagnoses for mixed anxiety and depressive disorder and a diagnosis for other specified anxiety disorder. During an interview on 10/02/2024 at 11:02 AM, LBSW stated that Resident #46 was prescribed citalopram for depressive disorder and anxiety. LBSW stated that resident has restlessness and agitation. LBSW stated that did not see mixed anxiety on Resident #46's diagnoses list. LBSW stated that she was not sure who was responsible to add information to a resident's diagnosis list. LBSW stated that she was not sure who was responsible to ensure psychiatric diagnoses were added to the MDS. During an interview on 10/02/2024 at 12:18 PM, LVN G stated that when a new admission or order was received, she would check to see that there was a corresponding diagnosis for that order. She stated that if a resident had an order indicated for anxiety, they should have a diagnosis of anxiety. She stated that she would get updates about diagnosis from the admissions nurse, MDS or DON. During an interview on 10/02/2024 at 12:24 PM with MDSN H, she stated that the resident should have a corresponding diagnosis on their diagnoses list if they have an order indicated for those diagnoses. She stated that diagnoses could come from the hospital or provider's progress notes. MDSN H stated she was responsible for adding diagnoses to a resident's diagnoses list. She stated that if a resident received a medication for anxiety or depression it should be on the MDS. MDSN H stated that Resident #46's alprazolam was indicated for anxiety, and she did not have an anxiety diagnosis listed and it was not on her MDS under psychiatric and mood disorders. MDSN H stated that there was not any additional staff who review the MDS to ensure all diagnoses were added and it was only her. She stated that it is important that all diagnoses be on the MDS for accuracy. MDSN H stated that she reviewed progress notes from providers for any updated diagnoses or information. During an interview on 10/02/2024 at 10/02/2024 at 1:01 PM, the DON stated that MDSN H was responsible for ensuring diagnoses were added to a resident's diagnoses list, but that the NP or MD would also add diagnosis. She stated that she expected a resident to have a corresponding diagnosis on their diagnosis list if they received a medication indicated for that diagnosis. The DON stated that she also expected that diagnoses to be listed on the resident's MDS. She stated that the IDT care planned information, and she expected the MDS and care plan to match. During an interview on 10/02/2024 at 1:14 PM, the ADM stated that the nurse was responsible to ensure the diagnosis was added to the diagnosis list. He stated that the DON, ADON audit the diagnosis list. The ADM stated that he expected the information on the care plan and MDS to match. He stated that he would expect that if a resident had an order for a medication indicated for depression or anxiety that they have an associated diagnosis. The Team Coordination on 10/02/2024 at 11:20am asked ADM for the policy related to accuracy of assessments. The policy was not provided. 49097

Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect, dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 4 (Resident #46, Resident #56, Resident #76, and Resident #78) of 18 residents reviewed for resident rights. The facility failed to ensure Resident #46 was changed after food was spilled on her clothes after meal service. This failure placed residents at risk for diminished quality of life and at risk for decreased feelings of self-worth and dignity. 1. Review of Resident #56's Face Sheet dated 10/02/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #56's diagnoses included heart failure, severe protein-calorie malnutrition, sleep apnea (breathing pauses while sleeping), hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), hyperlipidemia (high cholesterol), cardiac defibrillator (detects and stops irregular heartbeats), muscle wasting and lack of coordination. Record review of Resident #56's Quarterly MDS dated [DATE] revealed Resident #56 had a BIMS score of 15 indicating resident was intact cognitively. 2. Review of Resident #76's Face Sheet dated 10/02/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #76's diagnoses included displaced fracture of coronoid process of left ulna (traumatic elbow fracture), atrial fibrillation (irregular heartbeat), cerebral infraction (stroke), hyperlipidemia (high cholesterol), hypertension (high blood pressure), gastroesophageal reflux disease without esophagitis (reflux), hemiplegia and hemiparesis following cerebral infraction affecting right dominant side (paralysis and weakness on right side after stroke), muscle wasting, muscle weakness, lack of coordination and need for assistance with personal care. Record review of Resident #76's Quarterly MDS dated [DATE] revealed Resident #78 had a BIMS score of 15 indicating resident was intact cognitively. 3. Review of Resident #78's Face Sheet dated 10/02/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #78's diagnoses included surgery on the digestive system, intestinal obstruction, large intestine abscess, atrial fibrillation (irregular heartbeat), muscle wasting, muscle weakness, lack of coordination, cognitive communication deficit (problems with communication), and need for assistance with personal care. 4. Record review of Resident #78's Quarterly MDS dated [DATE] revealed Resident #76 had a BIMS score of 15 indicating resident was intact cognitively. 5. Review of Resident #46's face sheet dated 10/02/2024 revealed a [AGE] year-old female admitted on [DATE] and had diagnoses of unspecified dementia (condition that causes a decline in cognitive abilities), Parkinson's disease (chronic brain disorder that causes movement problems), cognitive communication deficit (difficulty with communication cause by disruption to cognition) and major depressive disorder (serious mental disorder that affects how a person, feels, thinks and functions). 6. Review of Resident #46's quarterly MDS dated [DATE] revealed a BIMS score of 2 which indicated severe cognitive impairment. Resident #46 required substantial/maximum assistance (more than half the effort) by staff for upper and lower body dressing and personal hygiene. Observation on 09/30/2024 at 1:28 PM, Resident #46 was observed sitting in hallway with food on her pants. Observation on 09/30/2024 at 1:55 PM, Resident #46 was observed sitting in hallway with food on her pants. Observation on 09/30/2024 at 2:12 PM, revealed staff ask Resident #46 if she wanted to lay down. Staff did not ask Resident if she wanted to change her clothes. Observation on 09/30/2024 at 2:24 PM, revealed Resident #46 sat in hallway in her wheelchair and observed with food on her pants. Observation on 09/30/2024 at 3:24 PM, revealed Resident #46 sat in hallway in her wheelchair and observed with food on her pants. Observation on 10/01/2024 at 1:31 PM, revealed Resident #46 sat in hallway in her wheelchair with food on her pants and shirt. Observation of hall trays being passed on 09/30/2024 at 12:33 p.m., revealed that MR C did not knock on Resident #76's door before entering. Observation of hall trays being passed on 09/30/2024 at 12:37 p.m., revealed that LVN D did not knock on Resident #56 and Resident #78's door before entering. An interview with Resident #56 on 10/02/2024 at 9:22 a.m., revealed that staff do not always knock on her door before entering. She said that staff do not knock at least twice a day and that it was usually when her door was open. She said she does not get upset when staff do not knock. She said she would like staff to knock all the time unless she sees the staff and staff see her then it would be silly to knock. An interview with Resident #78 on 10/02/2024 at 9:27 a.m., revealed that staff usually knock before coming into his room. He stated that staff only come into his room without knocking when he pushes the call light. He said they do not come in unauthorized. He said he would like staff to knock all the time unless he has already called them. An interview with Resident #76 on 10/02/2024 at 9:21a.m., revealed that she thought staff always knocked. She said she had not paid much attention to staff knocking before coming in she said now that she had a roommate, she would like staff to knock because there are men and women working at the facility and she was able to close her door and keep staff out with the bathroom door open. She said now she had a roommate and cannot do that and did not want staff to expose her while in the bathroom. She said she would like staff to knock all the time. An interview with MR C on 10/02/2024 at 9:37 a.m., revealed she had been trained on resident rights. She stated the policy was to knock on the resident's door, announce yourself and tell the resident what you are there to do. She said staff were supposed to knock on the resident's door all the time. She said if staff did not knock on the resident door before entering it might surprise them. she stated that she had her hands full and said knock, knock after she entered. She also said she should have said knock, knock and waited for the resident to tell her to come in. An interview with the DON on 10/02/2024 at 9:45 a.m., revealed that she was trained on resident rights. She stated staff were to knock on the resident's door when they are going into the room. She said staff were to knock all the time. She said if staff do not knock on the resident's door the resident may get upset depending on the resident. She also said that even if the resident did not mind it staff do not knock the staff need to give the resident the courtesy of knocking. She stated staff may not have been knocking because they got too comfortable and that they are used to the residents. She said they still needed to knock. An interview with the ADM on 10/02/2024 at 9:53 a.m., revealed staff had been trained on resident rights. He stated that staff should be knocking on the resident's door before entering the room. He stated it was the resident's right to privacy. He stated all staff were to knock before entering a resident's room. He said if staff do not knock the resident may feel embarrassed. He stated that all of management was responsible for monitoring staff were knocking on the residents door. He stated that management monitors it by doing observation rounds. He stated he thought staff were not knocking because they were familiar with the residents. Observation on 10/01/2024 at 2:23 PM, revealed Resident #46 laid in bed with her same clothes with food on her pants and shirt. During an interview on 10/02/2024 at 10:36 AM, SC A stated that after meals residents are supposed to have their clothes changed if they get food on them. She stated that Resident #46 usually spilled food on her clothes. SC A stated she was not sure why Resident #46 was not changed after lunch. During an interview on 10/02/2024 at 10:52 AM, LVN B stated that usually after meals Resident #46 did have food on her clothes. She stated that she would get changed. LVN B stated that residents should not sit with food on their clothes for hours after meals. During an interview on 10/02/2024 at 11:02 PM, LBSW stated that she expected residents not to have food on their clothes after meals and stated that should have been cleaned up and stated that she would want to be cleaned up. She stated that even if resident was not aware of it, it was not right. During an interview on 10/02/2024 at 12:18 PM, LVN G stated that residents are changed after meal services if that had food on their clothes. She stated that she changed residents as soon as she saw that they had food or would ask other staff to help change the resident. She stated that residents should not sit in the hall for hours with food from lunch on their clothes. During an interview on 10/02/2024 at 1:04 PM, the DON stated that she expected that if residents had food on their clothes that they would be changed. She stated that if staff saw at it, they should change the resident. She stated that the resident could be embarrassed. During an interview on 10/02/2024 at 1:04 PM, the ADM stated that he expected that if residents had food on their clothes after they completed their meal that their clothes be cleaned, or they be changed. He stated that he expected this to happen timely. The ADM stated that this could make the resident feel dirty or sloppy. Record review of Resident Rights dated October 4, 2016, revealed residents have the right to be treated with dignity and respect. The resident also has the right to personal privacy. Review of facility policy titled Resident Rights and Responsibilities, notice of with revision date of 12/2023 revealed resident had the right to a dignified existence.

Based on observations, interviews, and record review, the facility failed to ensure each resident had the right to be free from misappropriation of property for 3 of 6 residents (Resident #1, Resident #2 and Resident #3) reviewed for pharmacy services. The facility failed to follow their procedures that prevent drug diversions. This failure placed residents at risk for not receiving prescribed medications. Findings included: Record review of Resident #1's AR, dated 5/4/2022, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. She was diagnosed with Dementia (the loss of cognitive functioning), cognitive communication deficit (disorder that could cause trouble reasoning and making decisions while communicating) and muscle weakness. Record review of Resident #1's Quarterly MDS, dated [DATE], reflected Section C., Cognitive Patterns: Resident had no cognitive impairment. Section J: Health Condition; Resident received scheduled pain medication regimen. Section N., Medications: Resident received antidepressant and opioid medications. Record review of Resident #1's CP reflected a focused area, initiated on 3/29/2023, evidenced for chronic pain. The goal initiated on 3/29/2023, was that resident will be free of any discomfort or adverse side effects from pain or medication through the review date. The Intervention initiated 3/29/2023, was that staff was supposed to administer medications as ordered. Record review of Resident #1's Order Summary Report, viewed on 9/26/2024, reflected the resident was ordered 1 (one) hydrocodone-acetaminophen tablet, 5-325 mg by mouth three times a day, for pain; Ordered 07/10/2024. Record review of Resident #2's AR, dated 9/26/2024, reflected an [AGE] year-old male, who was admitted to the facility on [DATE]. He was diagnosed with disturbance, unilateral primary osteoarthritis left arm (joint condition that primarily affects one side of the body), and Muscle Wasting and Atrophy (which was a condition that caused muscle decrease in size and ability). Record review of Resident #2's Quarterly MDS, dated [DATE] reflected Section C., Cognitive Patterns: Resident had a BIMS Score of 06. A BIMS score of 06 indicated the resident had moderate cognitive impairment. Section N., Medications: Resident received antidepressants and opioid medications. Record review of Resident #2's CP reflected a focused area, initiated on 12/31/2023 evidenced resident was on pain medication therapy. The goal initiated on 12/31/2023, was that resident will be free of any discomfort or adverse side effects from pain medication through the review date. The Intervention initiated 12/31/2023, was to administer medications as ordered. Record review of Resident #2's Order Summary Report, viewed 09/26/2024, reflected the resident was ordered 2 (two) hydrocodone-acetaminophen 10-325 mg tablet by mouth every 6 hours as needed; ordered 07/05/2024. Record review of Resident #3's AR, dated 09/26/2024, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. She was diagnosed with surgical aftercare, osteoporosis (a condition in which bones become weak and brittle), and chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems). Record review of Resident #3's Quarterly MDS, dated [DATE] reflected Section C., Cognitive Patterns: Resident had a BIMS Score of 07. A BIMS score of 07 indicated the resident had moderate cognitive impairment. Section N., Medications: Resident received antidepressants and opioid medications. Record review of Resident #3's CP reflected focused area, initiated on 09/17/2022 evidenced resident has chronic pain. The goal initiated on 09/17/2022 was that the resident will not have an interruption in normal activities due to pain through the review date. Record review of Resident #3's Order Summary Report, viewed 09/26/2024, reflected the resident was ordered 2 (two) hydrocodone-acetaminophen 10-325 mg tablet by mouth every 6 hours; ordered 06/17/2024. Record review of the facility's PIR, dated 07/25/2024, indicated an allegation of drug diversion occurred on 07/24/2024; reported to the state offices on 07/24/2024. The alleged victims were Resident #1, Resident #2 and Resident #3 who all allegedly had hydrocodone-acetaminophen misappropriated. There was no alleged perpetrator listed on the PIR. RR of packing slip proof for Resident #1 revealed that hydrocodone-acetaminophen 5-325 mg 90 tablets was delivered to the facility on [DATE]. RR of packing slip proof for Resident #2 revealed that hydrocodone-acetaminophen 10-325 mg 172 tablets was delivered to the facility on [DATE]. RR of packing slip proof for Resident #3 revealed that hydrocodone-acetaminophen 5-325 mg 176 tablets was delivered to the facility on [DATE]. RR of medication administration log for Resident #1 revealed that on 07/11/2024 at 1PM the resident had 6 hydrocodone-acetaminophen 5-325 mg tablets left. This document was folded up and found in the locked shred bin. Another log for this same medication revealed on 07/11/2024 at 1PM the top of the log revealed there were 27 tablets. RR of medication administration log for Resident #2 revealed that on 07/22/2024 at 11PM the resident had zero hydrocodone-acetaminophen 10-325 mg tablets left for one blister pack. Resident #2 was missing two more medication administration logs. RR of medication administration log for Resident #3 revealed that on 07/11/2024 at 6AM the resident had 8 hydrocodone-acetaminophen 10-325 mg tablets left. This document was folded up and found in the locked shred bin. RR of MT A's employee file revealed that MT A's date of hire was 03/30/2012 and her employment was terminated on 07/26/2024. had received training on Abuse, Neglect and Exploitation on 09/03/2023. MT A had also received training on Medication Administration 04/28/2019, Avoiding Medication Related Problems 03/19/2022, Drug Diversion 09/11/2023, Drug Diversion in Healthcare 10/11/2021, and Protecting Resident's Right in Nursing Facilities 08/14/2020. These trainings were completed by MT A. MT A's employee file also revealed criminal background checks and the national registry had been checked which had no results. RR of employee schedule dated Thursday 07/11/2024 it revealed that MT A was scheduled to work on the 100 hall, which also revealed MT A's signature matched with the medication administration sheet. Interview on 09/26/2024 at 02:20PM with LVN A revealed at shift change, the two workers assigned to the medication cart will do a drug count and confirm with each other. Interview on 09/26/2024 at 3:00PM with LVN B revealed during shift change the oncoming nurse would typically stand at the medication in the cart and the off going nurse would be at the book and they will confirm he numbers in the cart and the book. During an interview with the DON on 09/26/2024 at 3:30PM revealed that DON had initiated a drug diversion investigation that was discovered on 07/24/2024. The DON stated that they were alerted of Resident #2 needed a new order for his hydrocodone-acetaminophen 10-325 mg. The DON stated that they reached out to, the resident provider, who stated that the resident should have plenty of that medication left. The DON stated this opened an investigation. The DON stated that they found the tops of the medication blister packs in the trash but could not locate the medication administration chart log. The DON had an outside source unlock the shred bin to check for the documents. The DON stated that she had found two resident medication administration chart logs folded up inside the shred bin. The DON stated this was unusual as the documents should be provided to records for proper discarding of resident information. The DON stated she found which staff member had access to these medications, as the medication administration charts showed numbers of medications still being left on the blister pack. The DON stated she had narrowed down who was working on the hall as Resident #1, Resident #2 and Resident #3 all resided on the 100 hall and was being provided medications by one staff member. The DON stated she found new medication administration charts started for each resident in the medication cart. The DON stated during her investigation she asked MT A why the documents were in the shred bin and where the missing medication was. The DON stated that MT A stated it looked like MT A had taken the medication. When the DON asked MT A if she had taken the medications in which MT A did not respond. The DON stated MT A was placed on suspension pending the investigation, which resulted in MT A's employment at the facility being terminated. The DON stated that staff are no longer able to remove medications from the carts, even if the blister pack is empty. An interview was completed with ADM on 09/26/2024 at 05:30PM. ADM revealed that he had expectations for staff to follow the policy regarding medication administration otherwise disciplinary action would occur. ADM reported that the DON would be notified of a possible drug diversion due to ADM not being a nurse. ADM reported that the facility has provided trainings over Relias. ADM reported that a possible negative outcome of a resident did not provide their medication was that it could be life threatening, if the medicine was for a pain medication it could result in the resident being in constant pain. Interview completed with Consultant Pharmacist on 09/26/2024 at 6:00PM over the telephone. reported that the facility had reported to her about the drug diversion investigation the last time she entered the facility. She stated that she ensured that the processes were followed as far as corrective actions that were made. She stated that the facility notified her of the drug diversion that had been investigated. She stated that the facility's process was reviewed and found no discrepancies. Interview with RP on 09/26/2024 at 06:15PM over the telephone. RP reported that he was a geriatric doctor who has provided diagnosis and dosage to residents at the facility. RP reported that he was informed of the drug diversion investigation. He stated the facility had called him and let him know that Resident #2 needed more hydrocodone-acetaminophen 10-325 mg tablets. He stated that he told the facility that he would not refill the medication as the facility should have had enough. He stated that he told the facility to investigate for a possible diversion. He said that the facility suspended the employee and kept him informed about what was going on in the investigation. Interview was attempted with MT A on 09/26/2024 at 06:40PM over the telephone. MT A did not answer the phone call.

Based on interview and record review, the facility failed to ensure each resident had the right to be free from misappropriation of property for 3 of 6 residents (Resident #1, Resident #2 and Resident #3) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Residents #1, #2, and #3's hydrocodone/APAP tablets (a schedule II controlled opioid medication used to treat pain). This failure placed residents at risk for not receiving prescribed medications. Findings included: 1. Record review of Resident #1's AR, dated 5/4/2022, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. She was diagnosed with Dementia (the loss of cognitive functioning), cognitive communication deficit (disorder that could cause trouble reasoning and making decisions while communicating) and muscle weakness. Record review of Resident #1's Quarterly MDS assessment, dated 09/16/2024, reflected based on Section C: Cognitive Patterns, the resident had no cognitive impairment. Based on Section J: Health Conditions, the resident received scheduled pain medication regimen. Based on Section N: Medications, the resident received antidepressant and opioid medications. Record review of Resident #1's CP reflected a Focused area, initiated on 3/29/2023, evidenced for chronic pain. The goal initiated on 3/29/2023, was that the resident would be free of any discomfort or adverse side effects from pain or medication through the review date. The Intervention, initiated 3/29/2023, was that staff was supposed to administer medications as ordered. Record review of Resident #1's Order Summary Report, viewed on 9/26/2024, reflected the resident was ordered 1 hydrocodone-acetaminophen tablet, 5-325 mg by mouth three times a day, for pain; Ordered 07/10/2024. 2. Record review of Resident #2's AR, dated 9/26/2024, reflected an [AGE] year-old male, who was admitted to the facility on [DATE]. He was diagnosed with disturbance, unilateral primary osteoarthritis left arm (joint condition that primarily affects one side of the body), and Muscle Wasting and Atrophy (which was a condition that caused muscle decrease in size and ability). Record review of Resident #2's Quarterly MDS, dated [DATE] reflected Section C., Cognitive Patterns: Resident had a BIMS Score of 06. A BIMS score of 06 indicated the resident had moderate cognitive impairment. Section N., Medications: Resident received antidepressants and opioid medications. Record review of Resident #2's CP reflected a [Focused] area, initiated on 12/31/2023 evidenced resident was on pain medication therapy. The [Goal,] initiated on 12/31/2023, was that resident will be free of any discomfort or adverse side effects from pain medication through the review date. The [Intervention,] initiated 12/31/2023, was to administer medications as ordered. Record review of Resident #2's Order Summary Report, viewed 09/26/2024, reflected the resident was ordered 2 (two) hydrocodone-acetaminophen 10-325 mg tablet by mouth every 6 hours as needed; ordered 07/05/2024. 3. Record review of Resident #3's AR, dated 09/26/2024, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. She was diagnosed with surgical aftercare, osteoporosis (a condition in which bones become weak and brittle), and chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems). Record review of Resident #3's Quarterly MDS, dated [DATE] reflected Section C., Cognitive Patterns: Resident had a BIMS Score of 07. A BIMS score of 07 indicated the resident had moderate cognitive impairment. Section N., Medications: Resident received antidepressants and opioid medications. Record review of Resident #3's CP reflected [Focused] area, initiated on 09/17/2022 evidenced resident has chronic pain. The [Goal] initiated on 09/17/2022 was that the resident will not have an interruption in normal activities due to pain through the review date. Record review of Resident #3's Order Summary Report, viewed 09/26/2024, reflected the resident was ordered 2 (two) hydrocodone-acetaminophen 10-325 mg tablet by mouth every 6 hours; ordered 06/17/2024. Record review of the facility's PIR, dated 07/25/2024, indicated an allegation of drug diversion occurred on 07/24/2024; reported to the state offices on 07/24/2024. The alleged victims were Resident #1, Resident #2 and Resident #3 who all allegedly had hydrocodone-acetaminophen misappropriated. There was no alleged perpetrator listed on the PIR. RR of packing slip proof for Resident #1 revealed that hydrocodone-acetaminophen 5-325 mg 90 tablets was delivered to the facility on [DATE]. RR of packing slip proof for Resident #2 revealed that hydrocodone-acetaminophen 10-325 mg 172 tablets was delivered to the facility on [DATE]. RR of packing slip proof for Resident #3 revealed that hydrocodone-acetaminophen 5-325 mg 176 tablets was delivered to the facility on [DATE]. RR of medication administration log inside the PIR for Resident #1 revealed that on 07/11/2024 at 1:00 PM, the resident had 6 hydrocodone-acetaminophen 5-325 mg tablets left. This document was folded up and found in the locked shred bin. Another log for this same medication revealed on 07/11/2024 at 1PM, the top of the log specified there were 27 tablets. RR of medication administration log for Resident #2 revealed that on 07/22/2024 at 11PM the resident had zero hydrocodone-acetaminophen 10-325 mg tablets left for one blister pack. RR of medication administration log for Resident #3 revealed that on 07/11/2024 at 6AM, the resident had 8 hydrocodone-acetaminophen 10-325 mg tablets left. This document was folded up and found in the locked shred bin. RR of MT A's employee file revealed that MT A's date of hire was 03/30/2012 and her employment was terminated on 07/26/2024. MT A had received training on Abuse, Neglect and Exploitation on 09/03/2023. MT A had also received training on Medication Administration 04/28/2019, Avoiding Medication Related Problems 03/19/2022, Drug Diversion 09/11/2023, Drug Diversion in Healthcare 10/11/2021, and Protecting Resident's Right in Nursing Facilities 08/14/2020. MT A's employee file also revealed criminal background checks and the national registry had been checked which had no results. RR of MT A's schedule dated Thursday 07/11/2024 revealed that MT A was scheduled to work on the 100 hall. MT A's signature matched with the signature on the medication administration sheet for Resident #1, Resident #2 and Resident #3. An interview with the DON on 09/26/2024 at 3:30 PM revealed that the DON had initiated a drug diversion investigation that was discovered on 07/24/2024. The DON stated that they were alerted that Resident #2 needed a new order for his hydrocodone-acetaminophen 10-325 mg. The DON stated that they reached out to, the resident's physician who stated that the resident should have had plenty of that medication left. The DON stated this opened an investigation. The DON stated that they found the tops of the medication blister packs in the trash but could not locate the medication administration chart log. The DON had an outside source unlock the shred bin to check for the documents. The DON stated that she had found two resident medication administration chart logs folded up inside the shred bin. The DON stated this was unusual as the documents should be provided to records for proper discarding of resident information. The DON stated she found which staff member had access to these medications, as the medication administration charts showed numbers of medications still being left on the blister pack. Resident #2 was missing two more medication administration logs. The DON stated she had narrowed down who was working on the hall with Resident #1, Resident #2 and Resident #3. She stated all resided on the 100 hall and was being provided medications by one staff member. The DON stated she found new medication administration logs started for each resident in the medication cart. The DON stated during her investigation she asked MT A why the documents were in the shred bin and where the missing medication was. The DON stated that MT A said that based off of evidence presented to her, it looked like MT A had taken the medication. When the DON asked MT A if she had taken the medications, MT A did not respond. The DON stated MT A was placed on suspension pending the investigation, which resulted in MT A's employment at the facility being terminated. An interview was completed with the ADM on 09/26/2024 at 05:30 PM revealed that he had expectations for staff to follow the policy regarding medication administration otherwise disciplinary action would occur. ADM reported that the DON would be notified of a possible drug diversion due to ADM not being a nurse. ADM reported that the facility provided trainings for resident rights and misappropriation of property, over Relias. ADM reported that a possible negative outcome of a resident not being provided their medication was that it could be life threatening. He stated if the medicine was for pain, it could result in the resident being in constant pain. Interview with RP on 09/26/2024 at 06:15 PM over the telephone. RP reported that he was a geriatric doctor who has provided diagnoses and dosage of medications to residents at the facility. RP reported that he was informed of the drug diversion investigation. He stated the facility had called him and let him know that Resident #2 needed more hydrocodone-acetaminophen 10-325 mg tablets. He stated that he told the facility that he would not refill the medication as the facility should have had enough. He stated that he told the facility to investigate for a possible diversion. He said that the facility suspended the employee and kept him informed about what was going on in the investigation. Interview was attempted with MT A on 09/26/2024 at 06:40 PM over the telephone. MT A did not answer the phone call. Record review of the facility's policy Abuse Prevention of and Prohibition Against, dated 11/2017, revealed misappropriation of property meant the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. According to the document, the steps that are to be taken for potential misappropriation of property is to: 1. Interview the person who is reporting the incident 2. Interview the residents 3. Interview with any witnesses to the incident, including the alleged perpetrator, as appropriate 4. A review of the resident's medical record 5. An interview with staff members on all shifts who may have information regarding the alleged incident. The facility would complete the following regarding reporting/response: 1. All allegations of abuse, neglect, misappropriation of resident's property or exploitation will be reported immediately to the administrator. 2. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to the appropriate state or federal agencies in the applicable timeframes, as per this policy and applicable regulations. 3. The facility will ensure that all individuals who are involved in the reporting or investigation process are free from retaliation or reprisal. 4. Post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if they believe the facility has retaliated against an employee or individual who reported a suspected crime and how to file such a complaint. 5. At the conclusion of the investigation, the facility will take action, as necessary in light of the information gathered, which may include but is not limited to - If the allegations are substantiated, analyzing the occurrence to determine why abuse, neglect, misappropriation of resident's property, or exploitation occurred, and determining what changes are needed to prevent further occurrences - Defining how care provision will be changed and/or improved to protect residents receiving services if appropriate. - Training all staff on changes made and demonstration of staff competency after training was implemented - Identifying staff responsible for the implementation of corrective action - The expected date for implementation and - Identifying staff responsible for monitoring the implementation of the plan 6. A summary of investigative findings will be reported to the Quality Assessment and Assurance Committee for coordination with the Quality Assurance and Performance Improvement Program.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to conduct activities of daily living received necessary services to maintain personal hygiene for 2 of 6 residents reviewed for ADLs. (Resident #3, and Resident #5) The facility did not provide scheduled showers for Resident #3. The facility did not assist Resident #5 close his gown causing him to expose his butt to the female across the hall from him on at least two occasions. This failure could place all residents who were dependent on staff for ADLs at risk for embarrassment, rashes, infections, discomfort, and skin break down. Findings Include: Record review of Resident #2's face sheet dated 04/16/2024 revealed Resident #2 was admitted to the facility on [DATE]. Resident #2 was a [AGE] year-old female. Her diagnoses included faster than normal heartbeat, diabetes, protein-calorie malnutrition, urinary tract infection, muscle wasting, lack of coordination, elevated levels of fat particles in the blood, high blood pressure, sleep apnea, difficulty communicating, heart flutter, reflux, and kidney infection. Record review of Resident #2's MDS dated [DATE] indicated Resident #2 understood others and made herself understood. The MDS indicated Resident #2 was cognitively intact with a BIMS score of 14. Record review of Resident #2's comprehensive care plan dated 03/11/2024 indicated Resident #2 had an ADL self-care performance deficit related to weakness and deconditioning following recent hospitalization . The care plan indicated Resident #2 required staff participation to use the bathroom and staff assistance with dressing upper and lower body. Record review of Resident #5's face sheet revealed the resident admitted to the facility on [DATE] dated 04/16/2024. Resident #5 was a [AGE] year-old male. His diagnoses included irregular heartbeat, stroke, paralysis of the left side, muscle wasting, lack of coordination, need for assistance with personal care, heart disease, elevated levels of fat particles in the blood, high blood pressure and colon cancer. Record review of Resident #5's MDS dated [DATE] indicated Resident #5 understood others and made himself understood. The MDS indicated Resident #5 was cognitively intact with a BIMS score of 14. Resident #5 MDS revealed he needed partial/moderate assistance with dressing. Record review of Resident #5's comprehensive care plan dated 03/18/2024 indicated Resident #5 had an ADL self-care performance deficit related to a recent stroke with left sided deficits. The care plan indicated Resident #5 required staff participation to use the bathroom and staff assistance with dressing upper and lower body. Record review of Resident #3's face sheet dated 04/16/2024 revealed Resident #3 was a [AGE] year-old female admitted to facility on 04/11/2024. Her diagnoses included broken hip, aftercare following joint replacement surgery, high blood pressure, Protein-calorie malnutrition, weight loss surgery, and elevated levels of fat particles in the blood. Record review of Resident #3's MDS dated [DATE] indicated Resident #3 understood others and made herself understood. The MDS indicated Resident #3 was cognitively intact with a BIMS score of 15. The MDS was still in progress. Record review of Resident #3's comprehensive care plan dated 04/11/2024 indicated Resident #3 had an ADL self-care performance deficit related to a recent right hip fracture. The care plan indicated Resident #3 required staff participation when bathing and dressing upper and lower body, putting on and taking off footwear. An interview with Resident #2 on 04/16/2024 at 11:04am revealed that Resident #5 exposed his butt to Resident #2 when he came out the bathroom on at least two occasions. Resident #2 stated Resident #5 would wear a hospital gown and no under pants. She stated that he had come out of the bathroom two times and his butt was not covered and she had seen it. She stated she did not inform the staff because she did not want to embarrass Resident #5. An interview with Resident #3 on 04/16/2024 at 1:04pm and again at 2:35pm revealed that she had been admitted to the facility on [DATE]. Resident #3 revealed that she had not had a shower since she was admitted to the facility. She stated that she has had the same socks on since she got to the facility. She stated that when she was admitted she could not get her incision wet, and staff told her she would need to do a bed bath. She stated that staff had not offered her a shower or a bed bath. Record Review of Resident Shower log box for 04/11/2024 to 04/16/2024 revealed that Resident #3 had not had a shower since she had been at the facility. An interview with LVN E on 04/16/2024 at 1:18pm revealed residents were given clean socks after the resident had their shower. She stated that most of the socks the facility had were yellow and the resident may not have realized she had clean socks on. She stated when she would come, and a resident had a night gown or hospital gown she would try to encourage the resident to change. She stated she had just met Resident # 3 and that she did not know if the resident had changed socks. She also stated she did not know anything about Resident #5 exposing his butt to other residents. An interview with CNA G on 04/16/2024 at 1:40pm revealed that each resident had their shower days and if the resident did not have socks the facility provided socks for the resident. She stated that the main socks in the facility were yellow. She stated that Resident #5 wore a gown and did not fasten it in the back but did not hear of him exposing his butt to any residents. She stated that she never mentioned to him to close the back so he would not be exposed. She stated that he had difficulty putting on his clothes and pulling them up, so he wore the gowns because they were easier. She stated that they must assist the resident with all ADLs. An interview with LVN F on 04/16/2024 at 1:54pm revealed that she did not know if Resident #3 had gotten a shower or changed her socks since she had been at the facility. She stated the facility had a shower list that staff would check off the residents that they gave a shower to. She stated that she had not known about Resident #5 exposing his butt to other residents. She stated he liked to wear the gown because he had trouble putting on his pants. An interview with Resident #5 on 04/16/2024 at 2:03pm revealed that he wore hospital gowns because he had trouble getting his clothes on and off and had accidents. He stated that he did not know that his butt was exposed, and other residents saw it. Resident #5 stated that he will push the button to get help and staff would not come, so he just started to wear the gown so he would not have an accident on himself. He stated that he had a tough time closing the gown in the back. He stated he did not want to expose his butt to anyone. An interview with CNA G on 04/16/2024 at 3:23pm revealed that if a resident was out due to a medical appointment and the resident missed their shower, then the resident would not get one until their next shower day. She stated she did not know why Resident #3 did not get a shower. She stated the shower aide was out the day after the resident was admitted . She also stated that Resident #3 was at a doctor's appointment on the previous Monday and she that could have been why she did not get a shower. CNA G stated that the resident could have skin breakdown from not getting a shower. She also stated she did not know why Resident #6 had not had his bed changed after staff took out his IV. An interview with CNA F on 04/16/2024 at 3:32pm regarding Resident #3 revealed that the shower aide was out the day after the resident was admitted and that the shower aide was not at the facility all day . She stated that she would try to get the resident in the shower when they were admitted since the staff had to do a skin assessment. An interview with the Administrator on 04/16/2024 at 3:40pm revealed that there was no reason for a resident to not get a shower. He stated staff should offer the resident a shower if they miss their shower due to being at a doctor's appointment. The administrator stated that staff should have changed the sheets and gown on the resident as soon as the staff took the IV out. He stated he did not know why Resident #5 did not get assistance to help him close his gown. He also stated he does not know why Resident # 3 did not get a shower because he normally checks the shower log. Record Review of the Restorative Nursing Assistant Job Description dated 12/17/2021 revealed that an essential duties and responsibility was for the Nursing Assistant to change bed linens, assist residents with bath functions (bed bath, tub, or shower bath) and keep the resident dry (change gown, clothing, and linen). Record Review of the Policy/Procedure- Nursing Administration Nursing Services- ADLs dated 05/2007 revealed that nursing service staff are to care for residents in a manner and in an environment that promotes maintenance or enhancement of each residents' quality of life and promotes care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Record Review of the Policy/Procedure- Nursing Administration Nursing Services- ADLs dated 05/2007 also revealed that each resident receive assistance as needed to manage their physical needs which includes personal hygiene grooming, toileting, transferring, ambulating, and eating. Each resident receives or provided the necessary care and services enabling him/her to attain or maintain the highest practicable physical, mental, or psychosocial well-being, in accordance with the comprehension assessment and plan of care.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to conduct activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 1 of 6 residents reviewed for ADLs (Resident# 6) The facility did not provide Resident #6 clean sheets or gown when blood got on this sheet and gown. These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings Included: Record review of Resident #6's face sheet dated 04/16/2024 revealed resident was admitted to the facility on [DATE]. Resident #6 was an [AGE] year-old male. His diagnoses included Dementia, protein-calorie malnutrition, difficulty with thinking and how someone uses language, heart failure, muscle wasting, edema, lack of coordination, iron deficiency anemia, high levels of fat particles in the blood, difficulty swallowing, high blood pressure, heart disease, reflux, altered mental status, long term use of anticoagulants, pacemaker, heart bypass and irregular heartbeat. Record review of Resident #6's MDS dated [DATE] indicated Resident #6 could not understand others and make himself understood. The MDS indicated Resident #6 was with a BIMS score of 1. Resident #6 cognitive pattern is severely impaired. The MDS indicated resident was dependent on personal hygiene. Record review of Resident #6's comprehensive care plan dated 04/16/2024 indicated Resident #6 had an ADL self-care performance deficit related to a recent impaired mobility weakness. The care plan indicated Resident #6 required 1 person assistance with dressing and personal hygiene. Observation of Resident #6 on 04/16/2024 at 2:15pm revealed that dried blood was on his sheet and gown, there was a round amount of blood about a golf ball size. The blood on the sheet was a long rectangle strip about 4 inches long and 1 1/2 inches across Resident #6 was noninterviewable. An interview with LVN H on 04/16/2024 at 2:49pm revealed that staff took out Resident # 6's IV at approximately 12:45pm and that was how the blood got on the resident's sheet and gown. She stated that staff would change the sheets and gown when she got done writing an incident report on another resident. The nurse stated her, and the CNA was going to clean it up. An interview with CNA F on 04/16/2024 at 3:32pm revealed she did not know why staff did not change Resident #6's sheets and gown when blood got on it. She stated that the resident could have skin breakdown or get an infection from not having a shower or not changing the sheets and gown. An interview with the Administrator on 04/16/2024 at 3:40pm revealed the nurses, and the aides were responsible for changing the resident's gown and sheets when needed. He stated it was important because the residents would be at risk of infections by not having a shower and changing sheets. He also stated that it was a dignity issue for the resident to not have help with his ADLs Record Review of the Restorative Nursing Assistant Job Description dated 12/17/2021 revealed that an essential duties and responsibility was for the Nursing Assistant to change bed linens, assist residents with bath functions (bed bath, tub, or shower bath) and keep the resident dry (change gown, clothing, and linen). Record Review of the Policy/Procedure- Nursing Administration Nursing Services- ADLs dated 05/2007 revealed that nursing service staff are to care for residents in a manner and in an environment that promotes maintenance or enhancement of each residents' quality of life and promotes care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Record Review of the Policy/Procedure- Nursing Administration Nursing Services- ADLs dated 05/2007 also revealed that each resident receive assistance as needed to manage their physical needs which includes personal hygiene grooming, toileting, transferring, ambulating, and eating. Each resident receives or provided the necessary care and services enabling him/her to attain or maintain the highest practicable physical, mental, or psychosocial well-being, in accordance with the comprehension assessment and plan of care. Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to conduct activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 1 of 6 residents reviewed for ADLs (Resident# 6) The facility did not provide Resident #6 clean sheets or gown when blood got on this sheet and gown. These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings Included: Record review of Resident #6's face sheet dated 04/16/2024 revealed resident was admitted to the facility on [DATE]. Resident #6 was an [AGE] year-old male. His diagnoses included Dementia, protein-calorie malnutrition, difficulty with thinking and how someone uses language, heart failure, muscle wasting, edema, lack of coordination, iron deficiency anemia, high levels of fat particles in the blood, difficulty swallowing, high blood pressure, heart disease, reflux, altered mental status, long term use of anticoagulants, pacemaker, heart bypass and irregular heartbeat. Record review of Resident #6's MDS dated [DATE] indicated Resident #6 could not understand others and make himself understood. The MDS indicated Resident #6 was with a BIMS score of 1. Resident #6 cognitive pattern is severely impaired. The MDS indicated resident was dependent on personal hygiene. Record review of Resident #6's comprehensive care plan dated 04/16/2024 indicated Resident #6 had an ADL self-care performance deficit related to a recent impaired mobility weakness. The care plan indicated Resident #6 required 1 person assistance with dressing and personal hygiene. Observation of Resident #6 on 04/16/2024 at 2:15pm revealed that dried blood was on his sheet and gown, there was a round amount of blood about a golf ball size. The blood on the sheet was a long rectangle strip about 4 inches long and 1 1/2 inches across Resident #6 was noninterviewable. An interview with LVN H on 04/16/2024 at 2:49pm revealed that staff took out Resident # 6's IV at approximately 12:45pm and that was how the blood got on the resident's sheet and gown. She stated that staff would change the sheets and gown when she got done writing an incident report on another resident. The nurse stated her, and the CNA was going to clean it up. An interview with CNA C on 04/16/2024 at 3:04pm revealed that Resident #3 was on the shower list for Monday, Wednesday, and Friday. She stated that she did not know why Resident #3 did not get a shower or a bed bath. She stated that Resident #3 did not ask for anything unless staff were already in the room. She stated that by the resident not getting her shower it could cause the resident to get an infection from not being clean. An interview with the Administrator on 04/16/2024 at 3:40pm revealed the nurses, and the aides were responsible for changing the resident's gown and sheets when needed. He stated it was important because the residents would be at risk of infections by not having a shower and changing sheets. He also stated that it was a dignity issue for the resident to not have help with his ADLs Record Review of the Restorative Nursing Assistant Job Description dated 12/17/2021 revealed that an essential duties and responsibility was for the Nursing Assistant to change bed linens, assist residents with bath functions (bed bath, tub, or shower bath) and keep the resident dry (change gown, clothing, and linen). Record Review of the Policy/Procedure- Nursing Administration Nursing Services- ADLs dated 05/2007 revealed that nursing service staff are to care for residents in a manner and in an environment that promotes maintenance or enhancement of each residents' quality of life and promotes care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Record Review of the Policy/Procedure- Nursing Administration Nursing Services- ADLs dated 05/2007 also revealed that each resident receive assistance as needed to manage their physical needs which includes personal hygiene grooming, toileting, transferring, ambulating, and eating. Each resident receives or provided the necessary care and services enabling him/her to attain or maintain the highest practicable physical, mental, or psychosocial well-being, in accordance with the comprehension assessment and plan of care.

Based on interview and record review the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (1) of four (4) residents (Resident #1) reviewed for accidents/supervision in that: The facility failed to provide appropriate supervision to assist Resident #1 after he was lowered to his knees by CNAs K and L three times during two consecutive failed slide board transfers. Attempting to transfer Resident #1 from the floor, Resident #1 sustained bilateral femur fractures. This deficient practice could affect two residents who used a slide board for transfers by not providing enough assistance to avoid sustaining injuries. Finding include: Review of Resident #1 ' s face sheet reflected an [AGE] year old male that was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #1 ' s Quarterly Minimum Data Set ((MDS) dated [DATE] reflected Resident #1 had a Brief Interview of Mental Status (BIMS) score of 04 out of 15 indicating significant cognitive impairments. The MDS reflected Resident #1 required one person physical assist with most activities of daily living (ADL) except with transfers were Resident #1 required two person physical assistance. The MDS reflected Resident #1 ' s range of motion was impaired bilaterally in his lower extremities and no limitations in his upper extremities. The MDS reflected that Resident #1 was not steady, and he was only able to stabilize with staff assistance during surface to surface transfers. Review of Resident #1 ' s Comprehensive Care Plan dated 02/25/13 reflected: 1. Pain related to [DIAGNOSES REDACTED], generalized and muscle spasms. The problem on-set date was 05/21/13 and last revised 11/01/13. The goal reflected for Resident #1 to be adequately relieved of pain within 45 minutes of receiving interventions as verbally expressed by Resident #1 and/or a calm countenance. The approaches the facility would utilize reflected the use of pain medication and antispasmoic medication as ordered monitoring the pain relief and assistive devices as ordered (trapeze above bed, wheelchair and slide board). The care plan noted that on 12/10/13 the family declined the use of slide board and Resident #1 was to be a mechanical lift. 2. Activities of Daily living. The problem onset date was 02/25/13 and last revised 11/01/13. The goal reflected that Resident 31 will participate at the highest level of functioning that is safe and appropriate. The approaches reflected to encourage resident to participate in all ADL ' s as able. Under approaches " other " was filled out that reflected slide board transfer related to [DIAGNOSES REDACTED]/knee contractures. An update on 10/23/13 reflected must wear post op shoes during all transfers out of bed and while in wheelchair. 3. At risk for falls due to generalized weakness, cognitive/safety deficits, limited range of motion in lower extremities related to [DIAGNOSES REDACTED] and contractures. Problem on-set date was 02/25/13 and last revised 11/01/13. The goal reflected Resident will not fall over the next 90 days. The approaches reflected staff to assist with bed mobility, transfers, locomotion, toileting and showering as needed. The approaches reflected Resident #1 to use slide board for transfers. An update on 11/20/13 reflected Resident #1 was lowered to the floor twice due to slide board sliding during transfer with injury to left lower extremity and sent to emergency room for evaluation and treatment. Review of Resident #1 ' s Incident/Accident Report dated 11/20/13 reflected at approximately at 11:20 am Resident #1 sustained an injury to his left outer thigh while in his room. Resident #1 had swelling and " crepitus with movement " (Crepitus is a medical term to describe the grating, crackling or popping sounds and sensations experienced under the skin and joints or a crackling sensation due to the presence of air in the subcutaneous tissue). The report reflected a section to describe what happened; that section reflected " see attached " . Resident #1 was sent to the hospital for further evaluation. Review of Resident #1 fall investigation worksheet dated 11/20/13 reflected Resident #1 was on antihypertensive medication, cardiovascular medication and laxatives. Resident #1 was not on any new medications and no medications that would contribute to bruising. Resident #1 was being transferred to a shower chair with a slide board. Resident #1 had zero falls within the last 180 days, but required supervision. Resident #1 was using an assistive device of the slide board, which was being used to manufacturer ' s specifications and fitted to the resident ' s needs. Resident #1 sustained a fracture and was sent to the emergency room for evaluation and treatment. Review of Resident #1 ' s Nurse ' s Notes dated 11/20/13 reflected at 11:20 am, LVN E was called to Resident #1 ' s room by a CNA stating that Resident #1 was on the floor. The statement reflected that LVN E noted that Resident #1 had a CNA on both sides of him holding onto a gait belt assisting Resident #1 in maintaining an " upright position " , next to his bed facing a shower chair. Resident #1 was sitting with bilateral lower extremities bent underneath him. The CNAs stated that the sliding board slid out from underneath Resident #1 during the transfer. The CNAs eased Resident #1 to the floor. Resident #1 denies any pain, however Resident #1 has [DIAGNOSES REDACTED] to lower extremities. LVN E and the two CNA assisted Resident #1 into the bed, where LVN E performed further assessment. Resident #1 had bilateral lower extremity " slightly contracted and malformed per baseline. " There was no immediate swelling or discoloration noted. The statement stated that the transfer was attempted again and Resident #1 had to be lowered to the floor again. Resident #1 was assisted back into bed and LVN instructed the CNA ' s to use a mechanical lift to transfer Resident #1. The statement reflected that an RA went into the room and noticed the left lower extremity that was always stiff was not moving freely. LVN E noted crepitus with careful passive range of motion just above the knee. The lateral side of the lower extremity above the knee was now swollen. NP was notified and assessed Resident #1. NP ordered x-rays of the knee. At 11:40 the notes reflected that MD came in to assess Resident #1 and wrote new orders, to discontinue the x-ray and send Resident #1 to hospital for further evaluation and treatment. At 12:00 pm Resident #1 was transported to hospital. At 3:00 pm Orthopedic Surgeon from hospital called and reported that Resident #1 had " a spiral fracture, consistent with being lowered to the floor and leg bending. " Review of LVN E written statement of Resident #1 ' s Incident dated 11/20/13 reflected LVN E was called to Resident #1 ' s room by a CNA stating that Resident #1 was on the floor. The statement reflected that LVN E noted that Resident #1 had a CNA on both sides of him holding onto a gait belt assisting Resident #1 in maintaining an " upright position " , next to his bed facing a shower chair. The statement reflected Resident #1 was sitting with bilateral lower extremities bent underneath him. The statement reflected the CNA (the CNA was not identified in the written statement) stated that the sliding board slid out from underneath Resident #1 during the transfer. The statement reflected the CNA eased Resident #1 to the floor. The statement reflected Resident #1 denied any pain, however Resident #1 has [DIAGNOSES REDACTED] to lower extremities. The statement reflected LVN E and the two CNAs assisted Resident #1 into the bed, where LVN E performed further assessment. The statement reflected Resident #1 had bilateral lower extremity " slightly contracted and malformed per baseline. " There was no immediate swelling or discoloration noted. The statement reflected that the transfer was attempted again and Resident #1 had to be lowered to the floor again. The statement reflected Resident #1 was assisted back into bed and LVN instructed the CNA ' s to use a mechanical lift to transfer Resident #1. The statement reflected that an RA (Ra was not identified in the statement) went into the room and noticed the left lower extremity that was always stiff was not moving freely. The statement reflected LVN E noted crepitus with careful palpations and passive range of motion just above the knee Nurse Practitioner and MD were notified of the fall and change to left lower extremity. The statement reflected LVN E received a new order to send Resident #1 to the hospital for further evaluation. During an interview on 12/19/13 at 2:18 pm LVN E stated concerning the incident with Resident #1, she was called into Resident #1 ' s room by a CNA. LVN E stated as she entered the room, she seen Resident #1 was being held in an upright position with a CNA on each side of Resident #1 holding onto a gait belt. LVN E stated Resident #1 ' s legs were bent underneath him and Resident #1 was partially balancing on his legs. LVN E stated that one of the CNAs had explained that Resident #1 was in the middle of a transfer from the bed to a shower chair when the sliding board that Resident #1 uses to transfer " slid out from underneath him. " LVN E stated she was told that the two CNAs were able to lower Resident #1 to the floor. LVN E stated prior to her getting to the room the two CNAs attempted to transfer Resident #1 to the bed, but were not able to complete the transfer and set Resident #1 back down to the floor, in the same position. LVN E stated she was not able to assess Resident #1 in the position that he was in, so LVN E assisted the two CNAs to transfer Resident #1 from the floor to the bed. LVN E stated once Resident #1 was in bed his leg looked a " little misshapen. " LVN E stated she had told the CNAs that Resident #1 would be a mechanical lift transfer after that point. LVN E stated a restorative aide had come to her and told her something looked wrong with Resident #1 ' s leg. LVN E stated she went back into the room and noticed that crepitus with passive range of motion just above the knee. LVN E stated the Nurse Practitioner and MD were in the facility and was able to get the nurse practitioner to assess Resident #1. LVN E stated the Nurse Practitioner had ordered mobile x-rays of the leg. LVN E stated MD had come to Resident #1 ' s room and also assessed the leg. LVN E stated MD cancelled the x-ray orders and wrote new orders to send Resident #1 to the emergency room . LVN E stated she learned about CNA K hearing a " pop " in Resident #1 ' s leg when she read CNA K ' s written statement. LVN E stated she was not told about any noise during the transfer of Resident #1. During an interview on 01/10/14 at 11:00 am LVN E stated she had instructed the CNAs to perform a second slide board transfer while she was in the room, which also resulted in Resident #1 having to be lowered to the floor, on to his knees. LVN E stated that after each time he was placed back into the bed she performed an assessment for signs and symptoms of injury. LVN E stated that she did not find any signs or symptoms of injury until after the Restorative Aide (RA) came and notified her of Resident #1 ' s left leg having passive movement, which was not common for Resident #1. Review of CNA L written statement of Resident #1 ' s Incident undated reflected that CNA L and CNA K were transferring Resident #1 with a slide board and gait belt onto a shower chair. Resident #1 slide off the slide board and both CNA L and K lowered Resident #1 to the floor slowly. The statement reflected that a nurse came in the CNAs put Resident #1 into bed after the CNAs were not able to get resident #1 into the shower chair. The statement reflected that the nurse noticed the leg was broken, so they got the Nurse Practitioner and MD in the room and sent Resident #1 to the hospital. During an interview on 12/20/13 at 12:54 pm CNA L stated she and CNA K were in Resident #1 ' s room assisting him to transfer from the bed to the shower chair. CNA L stated Resident #1 uses a sliding board for his transfers. CNA L stated she was on the left side of Resident #1 facing him and holding on to the gait belt, while CNA K was on the side of Resident #1 doing the same. CNA L stated during the transfer procedure the slide board came out from underneath Resident #1. CNA L stated that she and CNA K lowered Resident #1 to his knees with the gait belt. CNA L stated CNA K and her attempted to transfer Resident #1 back to the bed, " but he was too heavy. " CNA L stated that they had to lower him back down to his knees. CNA L stated that is when LVN E came into the room. CNA L stated that LVN E and both the CNAs were able to transfer Resident #1 back into the bed. CNA L stated that is when she heard " the pop. " CNA L stated CNA K asked if anyone else heard the noise, while LVN E was standing next to them. CNA L stated the Nurse Practitioner and MD came into the room and Resident #1 was sent to the hospital. During an interview on 01/10/14 at 10:22 am CNA L stated two failed slide board transfers were performed with Resident #1. CNA L stated the popping noise that heard after the second failed slide board transfer when Resident #1 was lowered to his knees. CNA L stated that at no time was Resident #1 transferred using a mechanical lift. Review of CNA K written statement of Resident #1 ' s Incident dated 11/20/13 reflected while Resident #1 was being transferred from his bed to the shower chair using a gait belt and sliding board, Resident #1 " slipped off the slide board. " The statement reflected that Resident #1 was gently brought to the floor. The statement reflected a shower aide entered the room and then left to get a nurse. After the nurse had come into the room the CNAs attempted to get Resident #1 off the ground and were not able to and had to lower him back to the floor, " then I heard something pop. " The statement reflected that the two CNAs and the nurse were able to get Resident #1 to the bed. Resident #1 was sat up and with just the gait belt the two CNA and nurse attempted to put him into the shower chair, but were not able to, so he had to be put back into the bed. At that time LVN E stated that the CNA use a mechanical lift with Resident #1. CNA K went to get the mechanical lift and when she returned the leg did not look right and nurse got MD. During an interview on 01/10/14 at 10:15 am CNA L stated she went to get the Resident #1 ready for a shower and put the slide board under him and angled the shower chair under the slide board. CNA L stated she put the gait belt on the resident and there was one Certified Nurse Aide (CNA) on each side of Resident #1. CNA L stated when they started to move Resident #1 the slide board moved and the resident started to slide off. CNA L stated they were holding him up using the gait belt when a third CNA came into the room and they sent her to get the nurse. CNA L stated they had lowered Resident #1 to the floor and he was on his knees. CNA L stated that LVN E came and tried to help get him up and all three (3) of them tried to lift him but he was too heavy and they lowered the resident slowly to the floor and she heard a " pop " noise but she wasn ' t sure what it was, and thought something may have hit the shower chair. CNA L stated they tried again to lift Resident #1 using the gait belt and were able to get him onto the bed. CNA L stated there were a total of three (3) attempts to get the resident up using the gait belt and then they went to get the Hoyer Lift. CNA L stated that Restorative Aide (RA) P came to help get the resident up and it was RA P that noticed the resident ' s knee did not look right. CNA L stated that when LVN E first entered the room she stated they needed to get the resident off the floor first and that ' s what they tried to do then the nurse assessed the resident after the restorative aide reported the knee did not look right. CNA L stated Resident #1 stated he was a little uncomfortable but he denied pain, he was just uncomfortable sitting like that. CNA L stated she had been trained in resident fall procedures and once the resident is safely on the floor she should go for help, get the nurse to examine the resident, and get the vital signs. CNA L stated she feels that they followed their training with regard to this resident fall. CNA L stated that to do a slide board transfer she would sit the resident on the side of the bed, place the slide board Velcro side down so it doesn ' t slide off the bed and the bed should be positioned slightly above the chair level, then she would move the resident onto the slide board after putting the gait belt on the resident and slide them onto the chair. CNA L stated the slide board shifted and it came up from under Resident #1 and he was in the middle of the slide board when the resident came forward and the slide board when backward. CNA L stated neither CNA (CNA K or L) did not see anything wrong with Resident #1 but when RA P came in she noticed his knee was swollen and the knee moved and could come almost straight. CNA L stated that the nurse called the physician and received an order to send the resident to the hospital for an x-ray. CNA L stated they had no previous problems with slide board transfers, and Resident #1 had always been heavy and difficult to transfer. CNA L stated the Certified Nurse Aides didn ' t understand why Resident #1was a slide board transfer but the physical therapists stated it was okay because the resident was always able to do it with them when he was in the Physical Therapy department. CNA L stated Resident #1didn ' t do the transfer for the Certified Nurse Aides the way he did it for the therapists and the therapists would come and show them how to transfer the resident and the resident would do it when they were there. CNA L stated that the physical therapist have more training in transferring residents. CNA L also stated the CNAs told the charge nurse he was a difficult transfer but CNA L stated doesn ' t know if the charge nurse told anyone else. After the incident there were no in-services on falls but physical therapy did come show the CNAs how to use the Hoyer lift to transfer Resident #1 when he returned from the hospital. During an interview on 01/10/14 at 11:50 am CNA L stated she and CNA K attempted the slide board transfer twice and both times Resident #1 had to be lowered to his knees. CNA L stated she and CNA K attempted once to put Resident #1 back into the bed prior to LVN E coming into the room, which resulted in them having to lower Resident #1 back to his knees and waiting for LVN E. During an interview on 12/19/13 at 9:30 am the Therapy Director stated when Resident #1 admitted to the facility, he wanted to be more independent. The Therapy Director stated the therapy department along with nursing worked with Resident #1 and taught him how to use a slide board for transfers. The Therapy Director stated that Resident #1 has been using the slide board for almost a year prior. The Therapy Director stated that Resident #1 had not had any falls during the transfer process until the fall on 11/20/13. The Therapy Director stated that a person the size of Resident #1 and with his unique situation, of being paraplegic, would need to more than two CNAs to properly transfer him off the ground to be safe. The Therapy Director stated Resident #1 was not able to provide any support or lift with his legs to assist the CNAs. The Therapy Director stated all the CNAs had been trained on slide board transfers recently but was not able to state when the training occurred. Review of CNA K proficiency check list reflected CNA K received training on use of slide board on 10/21/13. Review of CNA L proficiency check list reflected CNA L received training on use of slide board on 07/12/13. Review of Report Regarding Resident #1 written by DON undated reflected on 11/20/13 LVN E requested MD, DON and Nurse Practitioner assess Resident #1 " because he was having too much movement in a led that been very stiff historically. " The report revealed that upon assessment of Resident #1 ' s left knee bent very easily, but crepitus was felt with movement. Resident #1 had been a paraplegic for many years. Legs have been stiff since resident transferred to us over a year ago. When Resident #1 came to the facility, his method of transfer was mechanical lift. Resident #1 had wanted more independence and therapy had trained him to use the slide board. On this day, resident was using the slide board. Legs do have spasms at times. It is unclear whether he had a spasm or simply scooted off balance. Two aides were present and a gait belt was on him. When aides saw that he was going down, they lowered him to the floor. However, his resting position was on his knees. LVN E entered the room and assessed Resident #1. All three staff members used a mechanical lift to place him back in bed. No bruising was noted to resident, no breaks in the skin, either. MD ordered to transfer to hospital for further testing. " Conclusion: " Resident #1 ' s " legs are quite atrophied from years of paralysis. Bones are very fragile. Fractures were not due to neglect or abuse. " During an interview on 12/18/13 at 2:00 pm the DON stated Resident #1 was being transferred on a sliding board when he had to be lowered to the ground. The DON stated Resident #1 had sustained bilateral femur fractures. The DON continued to state that the incident was not called into to the State for investigation. The DON stated that the incident was witnessed and the facility investigated the incident. The DON stated based on the facility ' s investigation, no abuse or neglect had believed to have occurred. During an interview on 01/10/14 at 10:00 am the DON stated she was told that Resident #1 was mechanically lifted off the ground prior to writing her statement. The DON stated that she was not told of a second slide board transfer that failed with Resident #1. The DON stated it was her understanding at that time only one failed slide board transfer was performed and the LVN E must have misstated in her documentation. The DON stated currently the facility has no other slide board transfers. The DON stated that the other slide board transfer had discharged to another location. During an interview on 01/10/14 at 1:00 am the DON stated there was only on incident report performed for the multiple falls. The DON stated that multiple incident reports should have been filed out indicating that there were more falls then just the initial one. Review of the facility sliding board transfer instructions undated reflected: Getting ready: Have 2 people; Use a wheelchair with removable arm and leg rests. The transferring surfaces should be as close to the height of the wheelchair as possible. Position the wheelchair at a slight angle next to the transferring surface. Lock the wheelchair brakes and remove the foot pedals. Step one: Firmly fastening the transfer bet around the patient ' s waist. Remove the wheelchair are rest closest to the transferring surface. Scoot the patient forward towards the edge of the chair. Have the patient lean towards the remaining arm rest, away for the sliding board. Position the sliding the board underneath the patient ' s buttocks (approximately ? of the board should under the patient). Step Two: Place our hands on the transfer belt. Face the patient. Bend your knees. Keep you back straight. Step Three: Have the patient lean forward. One of the patient ' s hands should be flat on the board with the other hand on the arm rest. Coordinate your efforts by counting to three, then slide. As the patient slides across the board, his/her hands should be flat on the board. Repeat the sliding efforts as necessary until the patient is on the surface. Step Four: Make sure the patient ' s hips are firmly seated on the surface before removing the sliding board (remove the board by having he patient lean away from the board). The facility provided a list that reflected 2 residents that transfer with the use of a slide board.

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for three (3) of 19 residents (Residents #1, #15, and #17) when: A) Resident #1 sustained bilateral femur fractures during a transfer that was not reported to the State Agency. B) Resident #15 made a sexual abuse outcry that was not reported to the State Agency. C) Resident #17 had bruising on her jawline of unknown origin that was not reported to the State Agency. These deficient practices affected three (3) residents and could affect 114 residents by placing them at risk for abuse, neglect, or mistreatment. Findings include: Review of the Abuse Prevention Program-Policy and Procedures revised 01/2000 reflected under Policy Statement "All reports of resident abuse, neglect, and injuries of an unknown source shall be promptly and thoroughly investigated by facility management." The Policy reflected under Reporting Suspected Cases and/or Incidents of Rape Policy Statement "All suspected cases or incidents of rape MUST be reported immediately to the administrator and director of nursing services...4. Procedures for reporting/investigating incidents of abuse (including rape) are outlined in separate policies. (See policies entitled 'Abuse Investigations', 'Reporting Abuse to Facility Management' and 'Reporting Abuse to State Agencies and Other Entities/Individuals.')". The Policy reflected under Reporting Abuse to State Agencies and Other Entities/Individuals "All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law." The Policy reflected under "Policy Interpretation and Implementation 1. Should an alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of and unknown source, or abuse (including resident to resident abuse) be reported, the facility administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident. a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services; e. Law Enforcement Officials; f. The Resident's Attending Physician; and g. The Facility Medical Director. 2. Verbal/written notices to the above agencies will be made immediately upon the occurrence of such incident and such notice may be submitted via US mail, special carrier, fax, e-mail, or by telephone. Notices will include, as a minimum: a. The name of the resident; b. The number of the room in which the resident resides; c. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.); d. The date and time the alleged incident occurred; e. The name(s) of all personal involved in the alleged incident; and f. What immediate action was taken by the facility. 3. The administrator, or his/her designee, will provide the appropriate agencies/individuals listed above with a written report of the findings of the investigation within 5 days of the occurrence for the incident. 4. Should the findings reveal that abuse did occur, the written report will include the corrective actions taken by the facility to prevent abuse from recurring. 5. Appropriate professional and licensing boards will be notified when an employee if found to have committed abuse. 6. Inquiries concerning the reporting of abuse to state agencies should be referred to the administrator." The Policy reflected under Reporting Abuse to Facility Management Policy Statement "It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source, and theft or misappropriation of resident property to facility management." The Policy reflected under "Policy Interpretation and Implementation...4. When an alleged or suspected case of mistreatment, neglect injuries of an unknown source, or abuse is reported, the facility administrator, or his/her designee, will notify the following persons or agencies of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The Resident's Representative (Sponsor) of Record; c. Adult Protective Services (if applicable); d. Law Enforcement Officials (if applicable); e. The Resident's Attending Physician; and f. The Facility Medical Director."... A) Review of Resident #1 ' s face sheet reflected an [AGE] year old male that was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #1 ' s Quarterly Minimum Data Set ((MDS) dated [DATE] reflected Resident #1 had a Brief Interview of Mental Status (BIMS) score of 04 out of 15 indicating significant cognitive impairments. The MDS reflected Resident #1 required one person physical assist with most activities of daily living (ADL) except with transfers were Resident #1 required two person physical assistance. The MDS reflected Resident #1 ' s range of motion was impaired bilaterally in his lower extremities and no limitations in his upper extremities. The MDS reflected that Resident #1 was not steady, and he was only able to stabilize with staff assistance during surface to surface transfers. Review of Resident #1 ' s Comprehensive Care Plan dated 02/25/13 reflected: 1. Pain related to [MEDICAL CONDITION], generalized and muscle spasms. The problem on-set date was 05/21/13 and last revised 11/01/13. The goal reflected for Resident #1 to be adequately relieved of pain within 45 minutes of receiving interventions as verbally expressed by Resident #1 and/or a calm countenance. The approaches the facility would utilize reflected the use of pain medication and antispasmoic medication as ordered monitoring the pain relief and assistive devices as ordered (trapeze above bed, wheelchair and slide board). The care plan noted that on 12/10/13 the family declined the use of slide board and Resident #1 was to be a mechanical lift. 2. Activities of Daily living. The problem onset date was 02/25/13 and last revised 11/01/13. The goal reflected that Resident 31 will participate at the highest level of functioning that is safe and appropriate. The approaches reflected to encourage resident to participate in all ADL ' s as able. Under approaches " other " was filled out that reflected slide board transfer related to [MEDICAL CONDITION]/knee contractures. An update on 10/23/13 reflected must wear post op shoes during all transfers out of bed and while in wheelchair. 3. At risk for falls due to generalized weakness, cognitive/safety deficits, limited range of motion in lower extremities related to [MEDICAL CONDITION] and contractures. Problem on-set date was 02/25/13 and last revised 11/01/13. The goal reflected Resident will not fall over the next 90 days. The approaches reflected staff to assist with bed mobility, transfers, locomotion, toileting and showering as needed. The approaches reflected Resident #1 to use slide board for transfers. An update on 11/20/13 reflected Resident #1 was lowered to the floor twice due to slide board sliding during transfer with injury to left lower extremity and sent to emergency room for evaluation and treatment. Review of Resident #1 ' s Incident/Accident Report dated 11/20/13 reflected at approximately at 11:20 am Resident #1 sustained an injury to his left outer thigh while in his room. Resident #1 had swelling and " crepitus with movement " (Crepitus is a medical term to describe the grating, crackling or popping sounds and sensations experienced under the skin and joints or a crackling sensation due to the presence of air in the subcutaneous tissue). The report reflected a section to describe what happened; that section reflected " see attached " . Resident #1 was sent to the hospital for further evaluation. Review of Resident #1 fall investigation worksheet dated 11/20/13 reflected Resident #1 was on antihypertensive medication, cardiovascular medication and laxatives. Resident #1 was not on any new medications and no medications that would contribute to bruising. Resident #1 was being transferred to a shower chair with a slide board. Resident #1 had zero falls within the last 180 days, but required supervision. Resident #1 was using an assistive device of the slide board, which was being used to manufacturer ' s specifications and fitted to the resident ' s needs. Resident #1 sustained a fracture and was sent to the emergency room for evaluation and treatment. Review of Resident #1 ' s Nurse ' s Notes dated 11/20/13 reflected at 11:20 am, LVN E was called to Resident #1 ' s room by a CNA stating that Resident #1 was on the floor. The statement reflected that LVN E noted that Resident #1 had a CNA on both sides of him holding onto a gait belt assisting Resident #1 in maintaining an " upright position " , next to his bed facing a shower chair. Resident #1 was sitting with bilateral lower extremities bent underneath him. The CNAs stated that the sliding board slid out from underneath Resident #1 during the transfer. The CNAs eased Resident #1 to the floor. Resident #1 denies any pain, however Resident #1 has [MEDICAL CONDITION] to lower extremities. LVN E and the two CNA assisted Resident #1 into the bed, where LVN E performed further assessment. Resident #1 had bilateral lower extremity " slightly contracted and malformed per baseline. " There was no immediate swelling or discoloration noted. The statement stated that the transfer was attempted again and Resident #1 had to be lowered to the floor again. Resident #1 was assisted back into bed and LVN instructed the CNA ' s to use a mechanical lift to transfer Resident #1. The statement reflected that an RA went into the room and noticed the left lower extremity that was always stiff was not moving freely. LVN E noted crepitus with careful passive range of motion just above the knee. The lateral side of the lower extremity above the knee was now swollen. NP was notified and assessed Resident #1. NP ordered x-rays of the knee. At 11:40 the notes reflected that MD came in to assess Resident #1 and wrote new orders, to discontinue the x-ray and send Resident #1 to hospital for further evaluation and treatment. At 12:00 pm Resident #1 was transported to hospital. At 3:00 pm Orthopedic Surgeon from hospital called and reported that Resident #1 had " a spiral fracture, consistent with being lowered to the floor and leg bending. " Review of LVN E written statement of Resident #1 ' s Incident dated 11/20/13 reflected LVN E was called to Resident #1 ' s room by a CNA stating that Resident #1 was on the floor. The statement reflected that LVN E noted that Resident #1 had a CNA on both sides of him holding onto a gait belt assisting Resident #1 in maintaining an " upright position " , next to his bed facing a shower chair. The statement reflected Resident #1 was sitting with bilateral lower extremities bent underneath him. The statement reflected the CNA (the CNA was not identified in the written statement) stated that the sliding board slid out from underneath Resident #1 during the transfer. The statement reflected the CNA eased Resident #1 to the floor. The statement reflected Resident #1 denied any pain, however Resident #1 has [MEDICAL CONDITION] to lower extremities. The statement reflected LVN E and the two CNAs assisted Resident #1 into the bed, where LVN E performed further assessment. The statement reflected Resident #1 had bilateral lower extremity " slightly contracted and malformed per baseline. " There was no immediate swelling or discoloration noted. The statement reflected that the transfer was attempted again and Resident #1 had to be lowered to the floor again. The statement reflected Resident #1 was assisted back into bed and LVN instructed the CNA ' s to use a mechanical lift to transfer Resident #1. The statement reflected that an RA (Ra was not identified in the statement) went into the room and noticed the left lower extremity that was always stiff was not moving freely. The statement reflected LVN E noted crepitus with careful palpations and passive range of motion just above the knee Nurse Practitioner and MD were notified of the fall and change to left lower extremity. The statement reflected LVN E received a new order to send Resident #1 to the hospital for further evaluation. During an interview on 12/19/13 at 2:18 pm LVN E stated concerning the incident with Resident #1, she was called into Resident #1 ' s room by a CNA. LVN E stated as she entered the room, she seen Resident #1 was being held in an upright position with a CNA on each side of Resident #1 holding onto a gait belt. LVN E stated Resident #1 ' s legs were bent underneath him and Resident #1 was partially balancing on his legs. LVN E stated that one of the CNAs had explained that Resident #1 was in the middle of a transfer from the bed to a shower chair when the sliding board that Resident #1 uses to transfer " slid out from underneath him. " LVN E stated she was told that the two CNAs were able to lower Resident #1 to the floor. LVN E stated prior to her getting to the room the two CNAs attempted to transfer Resident #1 to the bed, but were not able to complete the transfer and set Resident #1 back down to the floor, in the same position. LVN E stated she was not able to assess Resident #1 in the position that he was in, so LVN E assisted the two CNAs to transfer Resident #1 from the floor to the bed. LVN E stated once Resident #1 was in bed his leg looked a " little misshapen. " LVN E stated she had told the CNAs that Resident #1 would be a mechanical lift transfer after that point. LVN E stated a restorative aide had come to her and told her something looked wrong with Resident #1 ' s leg. LVN E stated she went back into the room and noticed that crepitus with passive range of motion just above the knee. LVN E stated the Nurse Practitioner and MD were in the facility and was able to get the nurse practitioner to assess Resident #1. LVN E stated the Nurse Practitioner had ordered mobile x-rays of the leg. LVN E stated MD had come to Resident #1 ' s room and also assessed the leg. LVN E stated MD cancelled the x-ray orders and wrote new orders to send Resident #1 to the emergency room . LVN E stated she learned about CNA K hearing a " pop " in Resident #1 ' s leg when she read CNA K ' s written statement. LVN E stated she was not told about any noise during the transfer of Resident #1. During an interview on 01/10/14 at 11:00 am LVN E stated she had instructed the CNAs to perform a second slide board transfer while she was in the room, which also resulted in Resident #1 having to be lowered to the floor, on to his knees. LVN E stated that after each time he was placed back into the bed she performed an assessment for signs and symptoms of injury. LVN E stated that she did not find any signs or symptoms of injury until after the Restorative Aide (RA) came and notified her of Resident #1 ' s left leg having passive movement, which was not common for Resident #1. Review of CNA L written statement of Resident #1 ' s Incident undated reflected that CNA L and CNA K were transferring Resident #1 with a slide board and gait belt onto a shower chair. Resident #1 slide off the slide board and both CNA L and K lowered Resident #1 to the floor slowly. The statement reflected that a nurse came in the CNAs put Resident #1 into bed after the CNAs were not able to get resident #1 into the shower chair. The statement reflected that the nurse noticed the leg was broken, so they got the Nurse Practitioner and MD in the room and sent Resident #1 to the hospital. During an interview on 12/20/13 at 12:54 pm CNA L stated she and CNA K were in Resident #1 ' s room assisting him to transfer from the bed to the shower chair. CNA L stated Resident #1 uses a sliding board for his transfers. CNA L stated she was on the left side of Resident #1 facing him and holding on to the gait belt, while CNA K was on the side of Resident #1 doing the same. CNA L stated during the transfer procedure the slide board came out from underneath Resident #1. CNA L stated that she and CNA K lowered Resident #1 to his knees with the gait belt. CNA L stated CNA K and her attempted to transfer Resident #1 back to the bed, " but he was too heavy. " CNA L stated that they had to lower him back down to his knees. CNA L stated that is when LVN E came into the room. CNA L stated that LVN E and both the CNAs were able to transfer Resident #1 back into the bed. CNA L stated that is when she heard " the pop. " CNA L stated CNA K asked if anyone else heard the noise, while LVN E was standing next to them. CNA L stated the Nurse Practitioner and MD came into the room and Resident #1 was sent to the hospital. During an interview on 01/10/14 at 10:22 am CNA L stated two failed slide board transfers were performed with Resident #1. CNA L stated the popping noise that heard after the second failed slide board transfer when Resident #1 was lowered to his knees. CNA L stated that at no time was Resident #1 transferred using a mechanical lift. Review of CNA K written statement of Resident #1 ' s Incident dated 11/20/13 reflected while Resident #1 was being transferred from his bed to the shower chair using a gait belt and sliding board, Resident #1 " slipped off the slide board. " The statement reflected that Resident #1 was gently brought to the floor. The statement reflected a shower aide entered the room and then left to get a nurse. After the nurse had come into the room the CNAs attempted to get Resident #1 off the ground and were not able to and had to lower him back to the floor, " then I heard something pop. " The statement reflected that the two CNAs and the nurse were able to get Resident #1 to the bed. Resident #1 was sat up and with just the gait belt the two CNA and nurse attempted to put him into the shower chair, but were not able to, so he had to be put back into the bed. At that time LVN E stated that the CNA use a mechanical lift with Resident #1. CNA K went to get the mechanical lift and when she returned the leg did not look right and nurse got MD. During an interview on 01/10/14 at 10:15 am CNA L stated she went to get the Resident #1 ready for a shower and put the slide board under him and angled the shower chair under the slide board. CNA L stated she put the gait belt on the resident and there was one Certified Nurse Aide (CNA) on each side of Resident #1. CNA L stated when they started to move Resident #1 the slide board moved and the resident started to slide off. CNA L stated they were holding him up using the gait belt when a third CNA came into the room and they sent her to get the nurse. CNA L stated they had lowered Resident #1 to the floor and he was on his knees. CNA L stated that LVN E came and tried to help get him up and all three (3) of them tried to lift him but he was too heavy and they lowered the resident slowly to the floor and she heard a " pop " noise but she wasn ' t sure what it was, and thought something may have hit the shower chair. CNA L stated they tried again to lift Resident #1 using the gait belt and were able to get him onto the bed. CNA L stated there were a total of three (3) attempts to get the resident up using the gait belt and then they went to get the Hoyer Lift. CNA L stated that Restorative Aide (RA) P came to help get the resident up and it was RA P that noticed the resident ' s knee did not look right. CNA L stated that when LVN E first entered the room she stated they needed to get the resident off the floor first and that ' s what they tried to do then the nurse assessed the resident after the restorative aide reported the knee did not look right. CNA L stated Resident #1 stated he was a little uncomfortable but he denied pain, he was just uncomfortable sitting like that. CNA L stated she had been trained in resident fall procedures and once the resident is safely on the floor she should go for help, get the nurse to examine the resident, and get the vital signs. CNA L stated she feels that they followed their training with regard to this resident fall. CNA L stated that to do a slide board transfer she would sit the resident on the side of the bed, place the slide board Velcro side down so it doesn ' t slide off the bed and the bed should be positioned slightly above the chair level, then she would move the resident onto the slide board after putting the gait belt on the resident and slide them onto the chair. CNA L stated the slide board shifted and it came up from under Resident #1 and he was in the middle of the slide board when the resident came forward and the slide board when backward. CNA L stated neither CNA (CNA K or L) did not see anything wrong with Resident #1 but when RA P came in she noticed his knee was swollen and the knee moved and could come almost straight. CNA L stated that the nurse called the physician and received an order to send the resident to the hospital for an x-ray. CNA L stated they had no previous problems with slide board transfers, and Resident #1 had always been heavy and difficult to transfer. CNA L stated the Certified Nurse Aides didn ' t understand why Resident #1was a slide board transfer but the physical therapists stated it was okay because the resident was always able to do it with them when he was in the Physical Therapy department. CNA L stated Resident #1didn ' t do the transfer for the Certified Nurse Aides the way he did it for the therapists and the therapists would come and show them how to transfer the resident and the resident would do it when they were there. CNA L stated that the physical therapist have more training in transferring residents. CNA L also stated the CNAs told the charge nurse he was a difficult transfer but CNA L stated doesn ' t know if the charge nurse told anyone else. After the incident there were no in-services on falls but physical therapy did come show the CNAs how to use the Hoyer lift to transfer Resident #1 when he returned from the hospital. During an interview on 01/10/14 at 11:50 am CNA L stated she and CNA K attempted the slide board transfer twice and both times Resident #1 had to be lowered to his knees. CNA L stated she and CNA K attempted once to put Resident #1 back into the bed prior to LVN E coming into the room, which resulted in them having to lower Resident #1 back to his knees and waiting for LVN E. During an interview on 12/19/13 at 9:30 am the Therapy Director stated when Resident #1 admitted to the facility, he wanted to be more independent. The Therapy Director stated the therapy department along with nursing worked with Resident #1 and taught him how to use a slide board for transfers. The Therapy Director stated that Resident #1 has been using the slide board for almost a year prior. The Therapy Director stated that Resident #1 had not had any falls during the transfer process until the fall on 11/20/13. The Therapy Director stated that a person the size of Resident #1 and with his unique situation, of being paraplegic, would need to more than two CNAs to properly transfer him off the ground to be safe. The Therapy Director stated Resident #1 was not able to provide any support or lift with his legs to assist the CNAs. The Therapy Director stated all the CNAs had been trained on slide board transfers recently but was not able to state when the training occurred. Review of CNA K proficiency check list reflected CNA K received training on use of slide board on 10/21/13. Review of CNA L proficiency check list reflected CNA L received training on use of slide board on 07/12/13. Review of Report Regarding Resident #1 written by DON undated reflected on 11/20/13 LVN E requested MD, DON and Nurse Practitioner assess Resident #1 " because he was having too much movement in a led that been very stiff historically. " The report revealed that upon assessment of Resident #1 ' s left knee bent very easily, but crepitus was felt with movement. Resident #1 had been a paraplegic for many years. Legs have been stiff since resident transferred to us over a year ago. When Resident #1 came to the facility, his method of transfer was mechanical lift. Resident #1 had wanted more independence and therapy had trained him to use the slide board. On this day, resident was using the slide board. Legs do have spasms at times. It is unclear whether he had a spasm or simply scooted off balance. Two aides were present and a gait belt was on him. When aides saw that he was going down, they lowered him to the floor. However, his resting position was on his knees. LVN E entered the room and assessed Resident #1. All three staff members used a mechanical lift to place him back in bed. No bruising was noted to resident, no breaks in the skin, either. MD ordered to transfer to hospital for further testing. " Conclusion: " Resident #1 ' s " legs are quite atrophied from years of paralysis. Bones are very fragile. Fractures were not due to neglect or abuse. " During an interview on 12/18/13 at 2:00 pm the DON stated Resident #1 was being transferred on a sliding board when he had to be lowered to the ground. The DON stated Resident #1 had sustained bilateral femur fractures. The DON continued to state that the incident was not called into to the State for investigation. The DON stated that the incident was witnessed and the facility investigated the incident. The DON stated based on the facility ' s investigation, no abuse or neglect had believed to have occurred. During an interview on 01/10/14 at 10:00 am the DON stated she was told that Resident #1 was mechanically lifted off the ground prior to writing her statement. The DON stated that she was not told of a second slide board transfer that failed with Resident #1. The DON stated it was her understanding at that time only one failed slide board transfer was performed and the LVN E must have misstated in her documentation. The DON stated currently the facility has no other slide board transfers. The DON stated that the other slide board transfer had discharged to another location. During an interview on 01/10/14 at 1:00 am the DON stated there was only on incident report performed for the multiple falls. The DON stated that multiple incident reports should have been filed out indicating that there were more falls then just the initial one. Review of the facility sliding board transfer instructions undated reflected: Getting ready: Have 2 people; Use a wheelchair with removable arm and leg rests. The transferring surfaces should be as close to the height of the wheelchair as possible. Position the wheelchair at a slight angle next to the transferring surface. Lock the wheelchair brakes and remove the foot pedals. Step one: Firmly fastening the transfer bet around the patient ' s waist. Remove the wheelchair are rest closest to the transferring surface. Scoot the patient forward towards the edge of the chair. Have the patient lean towards the remaining arm rest, away for the sliding board. Position the sliding the board underneath the patient ' s buttocks (approximately ? of the board should under the patient). Step Two: Place our hands on the transfer belt. Face the patient. Bend your knees. Keep you back straight. Step Three: Have the patient lean forward. One of the patient ' s hands should be flat on the board with the other hand on the arm rest. Coordinate your efforts by counting to three, then slide. As the patient slides across the board, his/her hands should be flat on the board. Repeat the sliding efforts as necessary until the patient is on the surface. Step Four: Make sure the patient ' s hips are firmly seated on the surface before removing the sliding board (remove the board by having he patient lean away from the board). B) Review of Resident #15's face sheet reflected a [AGE] year old female that was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #15's Comprehensive Care Plan does not reflect any identified problems with cognitive impairments, hallucinations or sexual abuse outcries. Review of Resident #15 Psychiatric Progress Note dated 11/08/13 reflected Resident #15 made an outcry of sexual abuse. The note reflected that this is her second report since admitting to the facility. The note reflected the first outcry was approximately 2 years prior. The note reflected a male went into Resident #15 room and digitally penetrated her. The note reflected the story had not been consistent and it was not reported until 36 hours after the alleged incident. The note reflected Resident #15 continued to participate in activities without distress. The note continued to reflect that Resident #15 began to cry relating the incident, she was quickly laughing and engaging in conversation about crafts. The note reflected Resident #15 was "convinced the event occurred", but "her telling is not consistent." The note reflected a recommendation of no male care givers in her room unless attended by a female caregiver. Review of Resident #15's Nurse's Notes did not reflect any nurse entries after 06/05/13. Review of Resident #15's Nurse's Notes dated 11/02/13, with a late entry date of 12/20/13 at 3:00 pm, reflected Resident #15 went to the nurse's station and spoke with LVN F. The note reflected Resident #15 requested to speak with LVN F in private. The note reflected that Resident #15 reported that she felt that someone came into her room and put their finger into her. The note reflected LVN F referred Resident #15 to talk with the DON. The note reflected that Resident #15 refused stating that she would not be believed and would just be called crazy. The note reflected LVN F reported to her supervisor. The note further reflected that Resident #15 was crying and asked that no one be told. During an interview on 12/20/13 at 4:55 pm Resident #15 stated in November 2013 she was sleeping with her face to the wall, when she "kind of" woke because she felt some fingers in her vagina. Resident #15 stated that she takes [MEDICATION NAME] at night and when she "kind of" woke up she remained drowsy and could not stay awake. Resident #15 stated that by the time she was able to turn around the person had already left. Resident #15 stated that she was not supposed to talk about it and when she does her physician (MD) tell her it was just in her mind. Resident #15 stated that she just got tired of hearing people tell her that it did not happen, "so I just let it go." Resident #15 stated that she had a stroke and her mind plays tricks on her. Resident #15 stated that she believes that it happened to her and the incident was real. "I cried about it a lot and let it go. It still hurts." Resident #15 stated that the morning after the incident happened she had told the nurse on duty and several other nurses. Resident #15 stated that she was told to talk with the DON, but before she could MD came in and told her that "it was all in my head". Resident #15 stated that she has had another incident over a year ago. Resident #15 stated that she went to the Administrator that time, but he was on vacation. Resident #15 stated that when the Administrator came back he told Resident #15 that he did not believe her because the person that she reported "was too professional, a therapist, like a doctor." Resident #15 stated that she had a history of [REDACTED]. Resident #15 stated she knows she has some memory problems, "but stuff like that, that happened to me, that was real and I can remember that kind of stuff." Review of Resident #15 Physician's Progress Notes dated 11/20/13 reflected Resident #15 had a change in behavior and mood over past few weeks. The note reflected that Reside

Based on interview and record review the facility failed to keep one (1) of four (4) resident (Resident #1) reviewed for incident and accidents free from neglect when: Resident #1 was not provided appropriate supervision to assist him after he was lowered to his knees by CNAs K and L three times during two consecutive failed slide board transfers. Attempting to transfer Resident #1 from the floor, Resident #1 sustained bilateral femur fractures. This deficient practice could affect two residents who used a slide board for transfers by not providing enough assistance to avoid sustaining injuries. Finding include: Review of Resident #1 ' s face sheet reflected an [AGE] year old male that was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #1 ' s Quarterly Minimum Data Set ((MDS) dated [DATE] reflected Resident #1 had a Brief Interview of Mental Status (BIMS) score of 04 out of 15 indicating significant cognitive impairments. The MDS reflected Resident #1 required one person physical assist with most activities of daily living (ADL) except with transfers were Resident #1 required two person physical assistance. The MDS reflected Resident #1 ' s range of motion was impaired bilaterally in his lower extremities and no limitations in his upper extremities. The MDS reflected that Resident #1 was not steady, and he was only able to stabilize with staff assistance during surface to surface transfers. Review of Resident #1 ' s Comprehensive Care Plan dated 02/25/13 reflected: 1. Pain related to [MEDICAL CONDITION], generalized and muscle spasms. The problem on-set date was 05/21/13 and last revised 11/01/13. The goal reflected for Resident #1 to be adequately relieved of pain within 45 minutes of receiving interventions as verbally expressed by Resident #1 and/or a calm countenance. The approaches the facility would utilize reflected the use of pain medication and antispasmoic medication as ordered monitoring the pain relief and assistive devices as ordered (trapeze above bed, wheelchair and slide board). The care plan noted that on 12/10/13 the family declined the use of slide board and Resident #1 was to be a mechanical lift. 2. Activities of Daily living. The problem onset date was 02/25/13 and last revised 11/01/13. The goal reflected that Resident 31 will participate at the highest level of functioning that is safe and appropriate. The approaches reflected to encourage resident to participate in all ADL ' s as able. Under approaches " other " was filled out that reflected slide board transfer related to [MEDICAL CONDITION]/knee contractures. An update on 10/23/13 reflected must wear post op shoes during all transfers out of bed and while in wheelchair. 3. At risk for falls due to generalized weakness, cognitive/safety deficits, limited range of motion in lower extremities related to [MEDICAL CONDITION] and contractures. Problem on-set date was 02/25/13 and last revised 11/01/13. The goal reflected Resident will not fall over the next 90 days. The approaches reflected staff to assist with bed mobility, transfers, locomotion, toileting and showering as needed. The approaches reflected Resident #1 to use slide board for transfers. An update on 11/20/13 reflected Resident #1 was lowered to the floor twice due to slide board sliding during transfer with injury to left lower extremity and sent to emergency room for evaluation and treatment. Review of Resident #1 ' s Incident/Accident Report dated 11/20/13 reflected at approximately at 11:20 am Resident #1 sustained an injury to his left outer thigh while in his room. Resident #1 had swelling and " crepitus with movement " (Crepitus is a medical term to describe the grating, crackling or popping sounds and sensations experienced under the skin and joints or a crackling sensation due to the presence of air in the subcutaneous tissue). The report reflected a section to describe what happened; that section reflected " see attached " . Resident #1 was sent to the hospital for further evaluation. Review of Resident #1 fall investigation worksheet dated 11/20/13 reflected Resident #1 was on antihypertensive medication, cardiovascular medication and laxatives. Resident #1 was not on any new medications and no medications that would contribute to bruising. Resident #1 was being transferred to a shower chair with a slide board. Resident #1 had zero falls within the last 180 days, but required supervision. Resident #1 was using an assistive device of the slide board, which was being used to manufacturer ' s specifications and fitted to the resident ' s needs. Resident #1 sustained a fracture and was sent to the emergency room for evaluation and treatment. Review of Resident #1 ' s Nurse ' s Notes dated 11/20/13 reflected at 11:20 am, LVN E was called to Resident #1 ' s room by a CNA stating that Resident #1 was on the floor. The statement reflected that LVN E noted that Resident #1 had a CNA on both sides of him holding onto a gait belt assisting Resident #1 in maintaining an " upright position " , next to his bed facing a shower chair. Resident #1 was sitting with bilateral lower extremities bent underneath him. The CNAs stated that the sliding board slid out from underneath Resident #1 during the transfer. The CNAs eased Resident #1 to the floor. Resident #1 denies any pain, however Resident #1 has [MEDICAL CONDITION] to lower extremities. LVN E and the two CNA assisted Resident #1 into the bed, where LVN E performed further assessment. Resident #1 had bilateral lower extremity " slightly contracted and malformed per baseline. " There was no immediate swelling or discoloration noted. The statement stated that the transfer was attempted again and Resident #1 had to be lowered to the floor again. Resident #1 was assisted back into bed and LVN instructed the CNA ' s to use a mechanical lift to transfer Resident #1. The statement reflected that an RA went into the room and noticed the left lower extremity that was always stiff was not moving freely. LVN E noted crepitus with careful passive range of motion just above the knee. The lateral side of the lower extremity above the knee was now swollen. NP was notified and assessed Resident #1. NP ordered x-rays of the knee. At 11:40 the notes reflected that MD came in to assess Resident #1 and wrote new orders, to discontinue the x-ray and send Resident #1 to hospital for further evaluation and treatment. At 12:00 pm Resident #1 was transported to hospital. At 3:00 pm Orthopedic Surgeon from hospital called and reported that Resident #1 had " a spiral fracture, consistent with being lowered to the floor and leg bending. " Review of LVN E written statement of Resident #1 ' s Incident dated 11/20/13 reflected LVN E was called to Resident #1 ' s room by a CNA stating that Resident #1 was on the floor. The statement reflected that LVN E noted that Resident #1 had a CNA on both sides of him holding onto a gait belt assisting Resident #1 in maintaining an " upright position " , next to his bed facing a shower chair. The statement reflected Resident #1 was sitting with bilateral lower extremities bent underneath him. The statement reflected the CNA (the CNA was not identified in the written statement) stated that the sliding board slid out from underneath Resident #1 during the transfer. The statement reflected the CNA eased Resident #1 to the floor. The statement reflected Resident #1 denied any pain, however Resident #1 has [MEDICAL CONDITION] to lower extremities. The statement reflected LVN E and the two CNAs assisted Resident #1 into the bed, where LVN E performed further assessment. The statement reflected Resident #1 had bilateral lower extremity " slightly contracted and malformed per baseline. " There was no immediate swelling or discoloration noted. The statement reflected that the transfer was attempted again and Resident #1 had to be lowered to the floor again. The statement reflected Resident #1 was assisted back into bed and LVN instructed the CNA ' s to use a mechanical lift to transfer Resident #1. The statement reflected that an RA (Ra was not identified in the statement) went into the room and noticed the left lower extremity that was always stiff was not moving freely. The statement reflected LVN E noted crepitus with careful palpations and passive range of motion just above the knee Nurse Practitioner and MD were notified of the fall and change to left lower extremity. The statement reflected LVN E received a new order to send Resident #1 to the hospital for further evaluation. During an interview on 12/19/13 at 2:18 pm LVN E stated concerning the incident with Resident #1, she was called into Resident #1 ' s room by a CNA. LVN E stated as she entered the room, she seen Resident #1 was being held in an upright position with a CNA on each side of Resident #1 holding onto a gait belt. LVN E stated Resident #1 ' s legs were bent underneath him and Resident #1 was partially balancing on his legs. LVN E stated that one of the CNAs had explained that Resident #1 was in the middle of a transfer from the bed to a shower chair when the sliding board that Resident #1 uses to transfer " slid out from underneath him. " LVN E stated she was told that the two CNAs were able to lower Resident #1 to the floor. LVN E stated prior to her getting to the room the two CNAs attempted to transfer Resident #1 to the bed, but were not able to complete the transfer and set Resident #1 back down to the floor, in the same position. LVN E stated she was not able to assess Resident #1 in the position that he was in, so LVN E assisted the two CNAs to transfer Resident #1 from the floor to the bed. LVN E stated once Resident #1 was in bed his leg looked a " little misshapen. " LVN E stated she had told the CNAs that Resident #1 would be a mechanical lift transfer after that point. LVN E stated a restorative aide had come to her and told her something looked wrong with Resident #1 ' s leg. LVN E stated she went back into the room and noticed that crepitus with passive range of motion just above the knee. LVN E stated the Nurse Practitioner and MD were in the facility and was able to get the nurse practitioner to assess Resident #1. LVN E stated the Nurse Practitioner had ordered mobile x-rays of the leg. LVN E stated MD had come to Resident #1 ' s room and also assessed the leg. LVN E stated MD cancelled the x-ray orders and wrote new orders to send Resident #1 to the emergency room . LVN E stated she learned about CNA K hearing a " pop " in Resident #1 ' s leg when she read CNA K ' s written statement. LVN E stated she was not told about any noise during the transfer of Resident #1. During an interview on 01/10/14 at 11:00 am LVN E stated she had instructed the CNAs to perform a second slide board transfer while she was in the room, which also resulted in Resident #1 having to be lowered to the floor, on to his knees. LVN E stated that after each time he was placed back into the bed she performed an assessment for signs and symptoms of injury. LVN E stated that she did not find any signs or symptoms of injury until after the Restorative Aide (RA) came and notified her of Resident #1 ' s left leg having passive movement, which was not common for Resident #1. Review of CNA L written statement of Resident #1 ' s Incident undated reflected that CNA L and CNA K were transferring Resident #1 with a slide board and gait belt onto a shower chair. Resident #1 slide off the slide board and both CNA L and K lowered Resident #1 to the floor slowly. The statement reflected that a nurse came in the CNAs put Resident #1 into bed after the CNAs were not able to get resident #1 into the shower chair. The statement reflected that the nurse noticed the leg was broken, so they got the Nurse Practitioner and MD in the room and sent Resident #1 to the hospital. During an interview on 12/20/13 at 12:54 pm CNA L stated she and CNA K were in Resident #1 ' s room assisting him to transfer from the bed to the shower chair. CNA L stated Resident #1 uses a sliding board for his transfers. CNA L stated she was on the left side of Resident #1 facing him and holding on to the gait belt, while CNA K was on the side of Resident #1 doing the same. CNA L stated during the transfer procedure the slide board came out from underneath Resident #1. CNA L stated that she and CNA K lowered Resident #1 to his knees with the gait belt. CNA L stated CNA K and her attempted to transfer Resident #1 back to the bed, " but he was too heavy. " CNA L stated that they had to lower him back down to his knees. CNA L stated that is when LVN E came into the room. CNA L stated that LVN E and both the CNAs were able to transfer Resident #1 back into the bed. CNA L stated that is when she heard " the pop. " CNA L stated CNA K asked if anyone else heard the noise, while LVN E was standing next to them. CNA L stated the Nurse Practitioner and MD came into the room and Resident #1 was sent to the hospital. During an interview on 01/10/14 at 10:22 am CNA L stated two failed slide board transfers were performed with Resident #1. CNA L stated the popping noise that heard after the second failed slide board transfer when Resident #1 was lowered to his knees. CNA L stated that at no time was Resident #1 transferred using a mechanical lift. Review of CNA K written statement of Resident #1 ' s Incident dated 11/20/13 reflected while Resident #1 was being transferred from his bed to the shower chair using a gait belt and sliding board, Resident #1 " slipped off the slide board. " The statement reflected that Resident #1 was gently brought to the floor. The statement reflected a shower aide entered the room and then left to get a nurse. After the nurse had come into the room the CNAs attempted to get Resident #1 off the ground and were not able to and had to lower him back to the floor, " then I heard something pop. " The statement reflected that the two CNAs and the nurse were able to get Resident #1 to the bed. Resident #1 was sat up and with just the gait belt the two CNA and nurse attempted to put him into the shower chair, but were not able to, so he had to be put back into the bed. At that time LVN E stated that the CNA use a mechanical lift with Resident #1. CNA K went to get the mechanical lift and when she returned the leg did not look right and nurse got MD. During an interview on 01/10/14 at 10:15 am CNA L stated she went to get the Resident #1 ready for a shower and put the slide board under him and angled the shower chair under the slide board. CNA L stated she put the gait belt on the resident and there was one Certified Nurse Aide (CNA) on each side of Resident #1. CNA L stated when they started to move Resident #1 the slide board moved and the resident started to slide off. CNA L stated they were holding him up using the gait belt when a third CNA came into the room and they sent her to get the nurse. CNA L stated they had lowered Resident #1 to the floor and he was on his knees. CNA L stated that LVN E came and tried to help get him up and all three (3) of them tried to lift him but he was too heavy and they lowered the resident slowly to the floor and she heard a " pop " noise but she wasn ' t sure what it was, and thought something may have hit the shower chair. CNA L stated they tried again to lift Resident #1 using the gait belt and were able to get him onto the bed. CNA L stated there were a total of three (3) attempts to get the resident up using the gait belt and then they went to get the Hoyer Lift. CNA L stated that Restorative Aide (RA) P came to help get the resident up and it was RA P that noticed the resident ' s knee did not look right. CNA L stated that when LVN E first entered the room she stated they needed to get the resident off the floor first and that ' s what they tried to do then the nurse assessed the resident after the restorative aide reported the knee did not look right. CNA L stated Resident #1 stated he was a little uncomfortable but he denied pain, he was just uncomfortable sitting like that. CNA L stated she had been trained in resident fall procedures and once the resident is safely on the floor she should go for help, get the nurse to examine the resident, and get the vital signs. CNA L stated she feels that they followed their training with regard to this resident fall. CNA L stated that to do a slide board transfer she would sit the resident on the side of the bed, place the slide board Velcro side down so it doesn ' t slide off the bed and the bed should be positioned slightly above the chair level, then she would move the resident onto the slide board after putting the gait belt on the resident and slide them onto the chair. CNA L stated the slide board shifted and it came up from under Resident #1 and he was in the middle of the slide board when the resident came forward and the slide board when backward. CNA L stated neither CNA (CNA K or L) did not see anything wrong with Resident #1 but when RA P came in she noticed his knee was swollen and the knee moved and could come almost straight. CNA L stated that the nurse called the physician and received an order to send the resident to the hospital for an x-ray. CNA L stated they had no previous problems with slide board transfers, and Resident #1 had always been heavy and difficult to transfer. CNA L stated the Certified Nurse Aides didn ' t understand why Resident #1was a slide board transfer but the physical therapists stated it was okay because the resident was always able to do it with them when he was in the Physical Therapy department. CNA L stated Resident #1didn ' t do the transfer for the Certified Nurse Aides the way he did it for the therapists and the therapists would come and show them how to transfer the resident and the resident would do it when they were there. CNA L stated that the physical therapist have more training in transferring residents. CNA L also stated the CNAs told the charge nurse he was a difficult transfer but CNA L stated doesn ' t know if the charge nurse told anyone else. After the incident there were no in-services on falls but physical therapy did come show the CNAs how to use the Hoyer lift to transfer Resident #1 when he returned from the hospital. During an interview on 01/10/14 at 11:50 am CNA L stated she and CNA K attempted the slide board transfer twice and both times Resident #1 had to be lowered to his knees. CNA L stated she and CNA K attempted once to put Resident #1 back into the bed prior to LVN E coming into the room, which resulted in them having to lower Resident #1 back to his knees and waiting for LVN E. During an interview on 12/19/13 at 9:30 am the Therapy Director stated when Resident #1 admitted to the facility, he wanted to be more independent. The Therapy Director stated the therapy department along with nursing worked with Resident #1 and taught him how to use a slide board for transfers. The Therapy Director stated that Resident #1 has been using the slide board for almost a year prior. The Therapy Director stated that Resident #1 had not had any falls during the transfer process until the fall on 11/20/13. The Therapy Director stated that a person the size of Resident #1 and with his unique situation, of being paraplegic, would need to more than two CNAs to properly transfer him off the ground to be safe. The Therapy Director stated Resident #1 was not able to provide any support or lift with his legs to assist the CNAs. The Therapy Director stated all the CNAs had been trained on slide board transfers recently but was not able to state when the training occurred. Review of CNA K proficiency check list reflected CNA K received training on use of slide board on 10/21/13. Review of CNA L proficiency check list reflected CNA L received training on use of slide board on 07/12/13. Review of Report Regarding Resident #1 written by DON undated reflected on 11/20/13 LVN E requested MD, DON and Nurse Practitioner assess Resident #1 " because he was having too much movement in a led that been very stiff historically. " The report revealed that upon assessment of Resident #1 ' s left knee bent very easily, but crepitus was felt with movement. Resident #1 had been a paraplegic for many years. Legs have been stiff since resident transferred to us over a year ago. When Resident #1 came to the facility, his method of transfer was mechanical lift. Resident #1 had wanted more independence and therapy had trained him to use the slide board. On this day, resident was using the slide board. Legs do have spasms at times. It is unclear whether he had a spasm or simply scooted off balance. Two aides were present and a gait belt was on him. When aides saw that he was going down, they lowered him to the floor. However, his resting position was on his knees. LVN E entered the room and assessed Resident #1. All three staff members used a mechanical lift to place him back in bed. No bruising was noted to resident, no breaks in the skin, either. MD ordered to transfer to hospital for further testing. " Conclusion: " Resident #1 ' s " legs are quite atrophied from years of paralysis. Bones are very fragile. Fractures were not due to neglect or abuse. " During an interview on 12/18/13 at 2:00 pm the DON stated Resident #1 was being transferred on a sliding board when he had to be lowered to the ground. The DON stated Resident #1 had sustained bilateral femur fractures. The DON continued to state that the incident was not called into to the State for investigation. The DON stated that the incident was witnessed and the facility investigated the incident. The DON stated based on the facility ' s investigation, no abuse or neglect had believed to have occurred. During an interview on 01/10/14 at 10:00 am the DON stated she was told that Resident #1 was mechanically lifted off the ground prior to writing her statement. The DON stated that she was not told of a second slide board transfer that failed with Resident #1. The DON stated it was her understanding at that time only one failed slide board transfer was performed and the LVN E must have misstated in her documentation. The DON stated currently the facility has no other slide board transfers. The DON stated that the other slide board transfer had discharged to another location. During an interview on 01/10/14 at 1:00 am the DON stated there was only on incident report performed for the multiple falls. The DON stated that multiple incident reports should have been filed out indicating that there were more falls then just the initial one. Review of the facility sliding board transfer instructions undated reflected: Getting ready: Have 2 people; Use a wheelchair with removable arm and leg rests. The transferring surfaces should be as close to the height of the wheelchair as possible. Position the wheelchair at a slight angle next to the transferring surface. Lock the wheelchair brakes and remove the foot pedals. Step one: Firmly fastening the transfer bet around the patient ' s waist. Remove the wheelchair are rest closest to the transferring surface. Scoot the patient forward towards the edge of the chair. Have the patient lean towards the remaining arm rest, away for the sliding board. Position the sliding the board underneath the patient ' s buttocks (approximately ? of the board should under the patient). Step Two: Place our hands on the transfer belt. Face the patient. Bend your knees. Keep you back straight. Step Three: Have the patient lean forward. One of the patient ' s hands should be flat on the board with the other hand on the arm rest. Coordinate your efforts by counting to three, then slide. As the patient slides across the board, his/her hands should be flat on the board. Repeat the sliding efforts as necessary until the patient is on the surface. Step Four: Make sure the patient ' s hips are firmly seated on the surface before removing the sliding board (remove the board by having he patient lean away from the board). Review of the Abuse Prevention Program-Policy and Procedures revised 01/2000 reflected under Policy Statement "All reports of resident abuse, neglect, and injuries of an unknown source shall be promptly and thoroughly investigated by facility management." The Policy reflected under Reporting Suspected Cases and/or Incidents of Rape Policy Statement "All suspected cases or incidents of rape MUST be reported immediately to the administrator and director of nursing services...4. Procedures for reporting/investigating incidents of abuse (including rape) are outlined in separate policies. (See policies entitled 'Abuse Investigations', 'Reporting Abuse to Facility Management' and 'Reporting Abuse to State Agencies and Other Entities/Individuals.')". The Policy reflected under Reporting Abuse to State Agencies and Other Entities/Individuals "All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law." The Policy reflected under "Policy Interpretation and Implementation 1. Should an alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of and unknown source, or abuse (including resident to resident abuse) be reported, the facility administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident. a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services; e. Law Enforcement Officials; f. The Resident's Attending Physician; and g. The Facility Medical Director. 2. Verbal/written notices to the above agencies will be made immediately upon the occurrence of such incident and such notice may be submitted via US mail, special carrier, fax, e-mail, or by telephone. Notices will include, as a minimum: a. The name of the resident; b. The number of the room in which the resident resides; c. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.); d. The date and time the alleged incident occurred; e. The name(s) of all personal involved in the alleged incident; and f. What immediate action was taken by the facility. 3. The administrator, or his/her designee, will provide the appropriate agencies/individuals listed above with a written report of the findings of the investigation within 5 days of the occurrence for the incident. 4. Should the findings reveal that abuse did occur, the written report will include the corrective actions taken by the facility to prevent abuse from recurring. 5. Appropriate professional and licensing boards will be notified when an employee if found to have committed abuse. 6. Inquiries concerning the reporting of abuse to state agencies should be referred to the administrator." The Policy reflected under Reporting Abuse to Facility Management Policy Statement "It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source, and theft or misappropriation of resident property to facility management." The Policy reflected under "Policy Interpretation and Implementation...4. When an alleged or suspected case of mistreatment, neglect injuries of an unknown source, or abuse is reported, the facility administrator, or his/her designee, will notify the following persons or agencies of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The Resident's Representative (Sponsor) of Record; c. Adult Protective Services (if applicable); d. Law Enforcement Officials (if applicable); e. The Resident's Attending Physician; and f. The Facility Medical Director."... The facility provided a list that reflected 2 residents that transfer with the use of a slide board.

Based on interview and record review the facility failed to ensure: 1. that adequate supervision and assistance devices were utilized by two (2) of (2) two Certified Nurses Aides (CNA's A and B) to provide a safe transfer for (1) of 23 residents reviewed for two person staff assistance or mechanical device assistance to transfer.(Resident #1) Resident #1 had a history of [REDACTED]. During a staff assisted transfer from chair to bed by Certified Nursing Assistant (CNA) A and CNA B, a gait belt came off and Resident #1 was lowered to the floor. Resident #1 suffered a fracture to the left humerus bone (upper arm) requiring emergency treatment. 2. that seven (7) of 7 Certified Nurses Aides (CNAs - C, D, E, F, G, H and I) and one (1) of one (1) Licensed Vocational Nurses (LVN) utilized proper transfer assistance technique for 5 of 7 sampled residents observed during staff assisted transfers (Residents #2, #3, #4, #5 and #6). Substandard Quality of Care (SQC) was identified at 42 CFR 483.25(H) (1) and (2)- Accidents and Supervision. These facility deficient practices resulted in a fractured arm requiring emergency medical treatment for [REDACTED]. Findings include: A. Review of Resident #1's Nurse's note dated 03/28/2011 at 9:30 P.M. reflected that two CNA's were transferring the resident from the wheelchair to the bed when the gait belt came loose and the resident was lowered to the floor. Review of Resident #1 ' s care plan dated 01/03/2001 reflected: " resident transfers with Hoyer lift x 2 staff. " Review of Nurse ' s note dated 03/29/2011 at 5:03 A.M. reflected that Resident #1's left shoulder was swollen with some light bruising. Review of Nurse's note dated 03/29/2011 at 10:00 A.M. reflected that Resident #1 complained of pain in left shoulder and an x-ray was ordered by the physician. Review of an x-ray report dated 03/29/2011, from a local hospital where Resident #1 received emergency services, reflected Resident #1 had a fracture of the proximal humeral bone (upper arm) with anterior and medial displacement of the shaft in relation to the head. Review of Nurse's documentation dated 04/02/2011 revealed that the resident was to stay in bed even for meals for immobilization since the injury would not be surgically repaired. Observation during initial tour on 04/19/2011 at 9:55 A.M. revealed Resident #1 laying in bed eating breakfast using her right hand. Observation on 04/19/2011 at 4:10 P.M. revealed Resident #1 in bed in a gown. In an interview on 04/19/2011 at 4:10 P.M. with Resident #1 she revealed that she does not remember the incident that caused the injury to her shoulder, but her shoulder is causing her pain. Review of facility training records for 12/01/2010 through 03/29/2011 revealed there was no evidence of training of CNA A or CNA B regarding transfers. Review of the undated facility policy on transfers and body mechanics stated, " Do not guard the patient by using his/her arm or armpits. " Review of the Hoyer lift instructions dated 2001 revealed one of the steps in the instructions is to lock the wheels of the wheelchair before transferring the resident to the chair. In an interview with the Director of Nursing (DON) it was revealed that the she does not know why CNA A and CNA B did not use the mechanical lift to transfer resident #1 on 03/28/2011. B. Observation of Staff Transfers: 1. An observation of a mechanical transfer of resident #2 from bed to wheelchair done by CNA C and CNA D on 04/19/2011 at 10:30 A.M. revealed they did not lock the wheels on the wheelchair prior to transferring the resident into the chair. 2. An observation of a two-person transfer of resident #3 from wheelchair to bed done by CNA C and CNA D on 04/19/2011 at 10:50 A.M. revealed that CNA C lifted the resident by grabbing under the resident ' s arm. 3. An observation of a two-person transfer of resident #4 from bed to wheelchair done by CNA E and CNA F on 04/19/2011 at 2:35 P.M. revealed that CNA E lifted the resident by grabbing under the resident ' s arm. 4. An observation of a two-person transfer of resident #5 from bed to wheelchair done by CNA G and CNA H on 04/20/2011 at 2:49 P.M. revealed that CNA H lifted the resident by grabbing under the resident ' s arm. 5. An observation of a mechanical transfer of resident #6 from bed to wheelchair done by CNA I and Licensed Vocational Nurse (LVN) A on 04/20/2011 at 3:45 P.M. revealed that the two staff members were not familiar with the type of sling used for this resident and were not sure how to hook it properly to the mechanical lift. In an interview with CNA E on 04/19/2011 at 3:18 P.M. she revealed that she goes by what the other CNAs tell her on what method to use to transfer a resident. In an interview with CNA J on 04/19/2011 at 3:30 P.M. she revealed that there is supposed to be a CNA care plan binder at the nurses station on each hall that tells you how a resident should be transferred. In an interview with the DON on 04/19/2011 at 3:40 P.M. she revealed that they quit using the binders several months previously because the CNAs were not using them and they were difficult to keep updated. The facility census was 97 at the time of this investigation with 74 residents identified as requiring staff assistance with transfers, as provided by the administrator on 04/19/2011.