Every finding on record at Haralson NSG & Rehab Center

Based on staff interviews, record review, and review of the facility policy titled, Transfer or Discharge, Preparing a Resident for, the facility failed to provide a 30-day notice to one of three residents (R) (R14). This deficient practice had the potential to place the resident and resident representative at risk of being uninformed about their rights related to being transferred to another facility. Findings include:Review of the facility policy titled, Transfer or Discharge, preparing a Resident For with a revised date of April 2024, revealed, Residents will be prepared in advance for discharge. The facility shall develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Under Policy Interpretation and Implementation: 1. The facility shall support each resident and/or representative in the exercise of his or her right to participate in his or her care and treatment, including planning for discharge. 4. A notice of transfer or discharge and /or Bed-hold shall be provided to the resident/representative prior to or at or discharge or as soon as practicable. 5. The nursing services shall assist with: a. Obtaining orders for discharge or transfe4, as well as the recommended discharge services and equipment.Review of R14's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R14 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, dysarthria following cerebral infarction, paraplegia, unspecified cerebral infarction, unspecified, adult failure to thrive, poly osteoarthritis, unspecified, insomnia, unspecified, major depressive disorder, recurrent, unspecified, constipation, unspecified, gastro-esophageal reflux disease without esophagitis, nicotine dependence, unspecified, uncomplicatedReview of R14's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/07/2025 Discharge Return Not Anticipated revealed R14 had a Brief Interview for Mental Status (BIMS) score of 14, indicating little to no cognitive impairment.Record review revealed a progress note dated 11/07/2025 initiated by the Social Worker (SW) revealed, Due to repeated behaviors, facility initiated a Discharge/transfer to another SNF {skilled nursing facility.} Resident was informed of this intention and agreed to the transfer. Resident was accepted at {name of other facility} Healthcare. DC {discharge} will be today. Facility will transport.Review of R14's progress notes revealed no prior conversation of transfer documented between the SW and the resident. Review of R14's medical record revealed no evidence that a 30-day notice was provided to R14. An interview on 05/06/2026 at 10:10 AM, the Administrator stated that the discharge notice process was initiated after the resident was discussed during the facility's morning meeting. The Administrator further stated that she began the discharge paperwork and, in her absence, the social worker completed the process. The Administrator also stated that the ombudsman was notified regarding the discharge.During a telephone interview conducted on 05/06/2026 at 10:17 AM, the Ombudsman stated that the facility did not inform her of R14's discharge. The Ombudsman stated that she reviewed her records and confirmed there was no notification regarding R14. She further stated that, had the facility informed her of the discharge, she would have opened a case regarding the matter. The Ombudsman stated that she did not receive any communication from the facility regarding R14.An interview on 05/07/2026 at 10:08 AM with the Social Worker confirmed no 30-day discharge notice was issued for R14. She stated that she had a conversation with R14 regarding the discharge; however, she could not recall when R14 requested the discharge. The Social Worker acknowledged that the discharge was a facility-initiated transfer and confirmed that the Ombudsman was not notified.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Administering Medications and the Standing Orders-Medication Protocols, the facility failed to ensure systems were in place to accurately document medication administration in the Medication Administration Record (MAR) for two of five residents (R) (R16 and R2) reviewed during medication administration. These deficient practices resulted in incomplete clinical records with the potential to negatively impact safety for R16 and R2. Findings include:Review of the facility policy titled Administering Medications, dated February 2020, revealed: The individual administering the medication should document the administration on the eMAR.Review of the facility's Standing Orders-Medication Protocols revealed an order for Acetaminophen 325 mg, two tablets every six hours as needed for pain for seven days; however, the standing order did not include instructions regarding transcription of the medication into the electronic medication administration record (MAR) prior to administration.Review of the Electronic Medical Record (EMR) revealed R16 was admitted to the facility on [DATE] with diagnoses including, but not limited to, tubulo-interstitial nephritis, congestive heart failure, Parkinson's disease, type 2 diabetes mellitus, aphasia, polyneuropathy, atrial fibrillation, spinal stenosis, failure to thrive, obesity, and history of myocardial infarction and lung cancer.Review of R16's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact.Review of R16's care plan, reviewed 03/23/2026, indicated problems related to use of muscle relaxant medication for muscle spasms and pain management, anticonvulsant medication used for neuropathic pain, and pain associated with spinal stenosis and mobility deficits requiring ongoing pain management. Goals included but were not limited to the resident having little to no unaddressed adverse reactions and verbalizing adequate pain relief or ability to cope with incompletely relieved pain through the review date. Interventions included administering medications as ordered and monitoring for potential side effects including abdominal pain, abnormal gait, blurred vision, dizziness, drowsiness, fatigue, tremors, weakness, and decreased memory.Review of R16's physician orders included, but was not limited to: Order dated 04/07/2026 and discontinued 05/05/2026 for Tramadol HCL (hydrochloride) 50 mg (milligram,) one tablet every six hours as needed (PRN) for chronic shoulder pain. Order dated 05/05/2026 for Tramadol HCL 50 mg, one tablet by mouth every four hours as needed for pain. Order dated 04/07/2026 for Gabapentin 300 mg, one capsule at bedtime for polyneuropathy. Order dated 12/05/2025 for Baclofen 10 mg, 0.5 tablet three times daily for muscle spasms; hold for sedation. Order dated 01/13/2026 for Lidocaine External Patch 4% (percent,) apply to left shoulder topically one time daily for chronic left shoulder pain, patch on for 12 hours and off for 12 hours.Review of R16's EMR conducted on 05/05/2026 through 05/07/2026 revealed no progress note documenting the administration of acetaminophen and no corresponding MAR documentation indicating Acetaminophen had been administered. Further review revealed the only medication order change during that time frame was the discontinuation of Tramadol HCL 50 mg on 5/5/2026 and replacement with a new order changing the indication from chronic right shoulder pain to pain.Interview and observation on 05/05/2026 at 12:50 PM with R16 revealed she had been given a pain medication, Tylenol, around 11:30 AM; however, she stated it was not helping and she continued to experience pain.Interview on 05/05/2026 at 12:59 PM with Licensed Practical Nurse (LPN) CC on Wing 1-A during narcotic count and medication cart review, revealed she administered Tylenol 325 mg, two tablets every six hours as needed, to R16 from the facility's standing orders list. LPN CC stated she followed up with the resident after administration and the resident later reported improvement in pain. When asked why the medication administration was not documented in the MAR, LPN CC stated she documents these medications in the progress notes because they were PRN medications. When further questioned regarding MAR documentation requirements, LPN CC stated she was unsure and would need to check with the Unit Manager.Review of the EMR revealed R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, nonrheumatic aortic valve stenosis, pericardial effusion, chronic respiratory failure with hypoxia, acute on chronic diastolic heart failure, Parkinson's disease, and presence of cardiac pacemaker.Review of R2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment.Review of R2's care plan indicated a problem of risk for pain related to osteoarthritis (OA) and age-related factors. Goals included but were not limited to the resident verbalizing adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions included administering analgesia as ordered, anticipating pain relief needs and responding immediately to complaints of pain, notifying the physician if interventions were unsuccessful or if pain significantly changed from baseline, monitoring and documenting side effects of pain medication including constipation, agitation, confusion, hallucinations, nausea, vomiting, dizziness, and falls, and observing for non-verbal signs and symptoms of pain including changes in breathing, vocalizations, mood and behavior, facial expressions, and body movements.Review of R2's physician orders included, but was not limited to: Order dated 04/22/2026 for acetaminophen 325 mg, two tablets every six hours as needed for pain. Order dated 04/22/2026 for Clonazepam 0.5 mg, one tablet three times daily for irritability.Review of R2's EMR revealed Acetaminophen 325 mg, two tablets, was administered on 04/30/2026; however, administration was not documented in the MAR. Review of the MAR revealed the administration entry for that date was left blank with no documentation indicating the medication had been administered.Interview on 05/05/2026 at 1:17 PM with the Director of Nursing (DON) regarding medication administration processes and standing orders revealed that any medication listed on the facility's standing orders list must be entered into the MAR prior to administration. The DON stated that medications administered for pain management required nursing staff to assess and follow up on the resident's pain response to ensure appropriate evaluation and intervention. The DON further stated accurate MAR documentation was necessary to maintain medication tracking and reduce the risk of duplicate administration or medication errors. The DON stated the expectation was that medication orders were transcribed into the MAR prior to administration.

Based on observations, staff interviews, record review, and review of the facility's policies titled Administering Medications, Medication and Treatment Orders, Insulin Administration, and package insert titled, Lantus (insulin glargine injection), the facility failed to ensure medications were administered accurately for four of 25 medication administration opportunities observed, resulting in a medication error rate of 16 percent. This deficient practice had the potential to adversely affect residents' clinical conditions.Findings include:Observation on 05/05/2026 at 9:58 AM on Wing 2-B with Registered Nurse (RN) AA revealed R17 had a physician order for Lantus SoloStar (insulin glargine) 50 units subcutaneously every 12 hours for diabetes mellitus type II (DMII). During medication administration, RN AA dialed the prescribed dose but failed to prime the insulin pen prior to injection. RN AA administered the medication to the abdomen and removed the pen after approximately three seconds. Medication leakage was observed at the injection site, and RN AA stated, let me wipe what is coming out. During interview, RN AA stated she did not know the meaning of priming in relation to insulin pens.During the same observation, R17 had a physician order for Metformin HCl ER 500 mg, give two tablets by mouth twice daily for DMII. The medication was not available in the medication cart at the scheduled administration time and was not administered. RN AA notified the Unit Manager FF, who stated that the pharmacy reported that this medication was on backorder and the Nurse Practitioner (NP) was notified. The NP discontinued the existing order effective 05/05/2026 and initiated a new order for Metformin HCl 500 mg, give 2 tablets by mouth twice daily for DM2. Review of the Medication Administration Record (MAR) on 05/06/2026 for 05/05/2026 revealed Metformin HCl ER was not administered during the scheduled morning and evening medication passes, resulting in two missed doses.Review of MARs on 05/06/2026 revealed the pharmacy subsequently supplied Metformin HCl ER (hydrochloride extended release) 500 mg (milligram); however, the MAR reflected Metformin HCl 500 mg (non-extended release), indicating a discrepancy between the physician order, MAR documentation, and dispensed medication. R17 received Metformin ER 500 mg, two tablets twice daily on 05/06/2026, despite the revised physician order for Metformin (non-ER formulation).Interview on 05/05/2026 at 3:35 PM with the pharmacist at outside contracted pharmacy revealed no refill requests had been received for R17 prior to 05/05/2026. The pharmacist stated that the only refill request received was the morning of 05/05/2026 for Metformin and Metformin ER had been discontinued. The pharmacist further stated Metformin ER was not on backorder.Observation on 05/05/2026 at 10:17 AM on Wing 2-B with RN AA revealed R18 had a physician order for Biotin 1 mg oral capsule, give 1 mg by mouth once daily for supplement. During medication administration, RN AA administered Biotin 5,000 mcg (micrograms) (5 mg), a dose five times greater than the ordered dose.Additionally, R18 had a physician order for Psyllium 3.4-gram oral packet, give one packet by mouth once daily mixed with 8 oz (ounces) of water or juice of choice, hold for loose stool. The medication was not available in the medication cart at the time of administration and was not administered. Review of the MAR revealed repeated instances of coded unavailability of Psyllium including 04/28/2026, 04/29/2026, 05/01/2026, 05/03/2026, 05/04/2026, and 05/05/2026 indicating multiple missed or interrupted administrations.Interview on 05/05/2026 at 1:17 PM with the Director of Nursing (DON) regarding medication supply and reordering, the DON stated that routine pharmacy turnaround time was approximately 72 hours. The DON stated nursing staff were expected to monitor medication supply levels and reorder medications prior to reaching a low or critical stock level. The facility utilizes a backup pharmacy when medications were not available through the primary pharmacy.The DON stated that all disciplines share responsibility for ensuring timely medication reordering. The DON further stated when medications were unavailable, nursing staff were expected to notify the Nurse Practitioner for further direction. Based on clinical need and provider orders, medications may be rerouted or expedited through the pharmacy, or, in urgent circumstances, requested as STAT (right away) delivery from the pharmacy. The DON stated that nursing staff communicated medication availability concerns to Unit Managers, and if the issue was not resolved at that level, it was escalated to the DON. The DON confirmed ongoing communication with the pharmacy to address supply issues and ensure residents received medications.Follow-up interview on 05/05/2026 at 2:06 PM with DON revealed that insulin pens needed to be set to the amount of dosage, check BG prior. Prime the pen with at least 1 unit to ensure pushing out any air bubbles, hold pen in place for at least 10 seconds after administration. This was all important to ensure the correct administration was given. Observation and interview on 05/07/2026 at 8:35 AM with Licensed Practical Nurse (LPN) DD revealed Metformin ER remained in the medication cart and had been administered to R17 during both the morning and evening medication passes on 05/06/2026. The DON was informed that the resident had received Metformin ER twice daily on 05/06/2026 despite the new order for Metformin (non-ER formulation). LPN DD removed the Metformin ER medication card from the medication cart and provided it to the DON who stated she would be completing an investigation.Interview on 05/06/26 at 2:47 PM with RN EE confirmed that R18 received Biotin 5,000 mcg and not 1 gm as this is the only bottle available in the medication cart. RN EE stated she would contact the NP for further guidance.Interview and observation on 05/06/2026 at 2:48 PM with RN EE confirmed that R18 Psyllium was not in the medication cart, however, RN EE marked this medication as given this morning, but when questioned about it, she changed it to not available, and stated, I did not mean to mark it as given. Then walked to the Nurse's station and was informed by RN Unit Manager FF that Psyllium was at the nurse's station.Interview on 05/07/2026 at 1:46 PM with DON regarding medication reconciliation revealed nursing staff compare the medication received from the pharmacy with the physician order, pharmacy manifest, and MAR to ensure accuracy. The DON stated any nurse receiving the medication served as the first line of review to ensure medications matched the active physician orders. The DON further stated she had investigated the medication issue involving R17 and completed staff competency training with involved nurses and provided immediate education after identifying concerns with the medication reconciliation process.The DON further stated agency nurses were expected to follow the six rights of medication administration and the facility expectation was for the medication error rate was zero.Review of facility policy titled, Administering Medications dated February 2020 revealed item 3. Medications must be administered in accordance with the orders, including any required time frame. Further review of item 1. The individual administering the medication should check the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.Review of facility policy titled, Medication and Treatment Orders revised July 2016 revealed item 10. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy prior to that last dosage being administered to ensure that refills are readily available.Review of facility policy titled, Insulin Administration revised September 2014 revealed under section Nursing Competency item 3. Checking the flow of the delivery device (Air shot) and item 4. Giving the injection: PRIME the pen before injection; Hold needle in place for 5-10 seconds.Review of package insert titled, Lantus (insulin glargine injection) revised May 2019 revealed under section Important information for use of SoloStar: step 3. Perform a Safety test. Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that pen and needle work properly; removing air bubbles. Item A. Select a dose of 2 units by turning the dosage selector. Tap the insulin reservoir so that any air bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of the needle tip. You may have to perform the safety test several times before insulin is seen. Further review revealed step 5. Inject the dose item D. Keep the injection button pressed all the way in. Slowly count to 10 before you withdraw the needle from the skin. This ensures that the full dose will be delivered.

Based on observation, staff interviews, and review of the facility policy titled Ice Machines and Ice Storage Chests, the facility failed to ensure the ice machine was maintained in a clean and sanitary condition. This deficient practice had the potential to place the 86 residents who received hydration and nutrition from the kitchen at increased risk of foodborne illness. Findings include:Review of the facility policy titled Ice Machines and Ice Storage Chests, dated 10/2022, revealed the Policy Statement section stated, Ice machines and ice storage/distribution containers will be used and maintained to assure [sic] a safe and sanitary supply of ice. The Policy Interpretation and Implementation section included, 1. To prevent contamination of ice machines, ice storage chests/containers or ice, staff, shall follow these precautions: . f. Clean and sanitize the ice chests and ice scoop daily.Review of a facility-provided document titled Ice Machine Cleaning Log revealed three dates of 6/3/2025, 7/8/2025, and 8/22/2025. There was a signature next to each date. Observation on 9/9/2025 at 10:10 am, of the ice machine in the kitchen, with the Dietary Manager (DM), revealed that, inside the door, the left and right corners and crevices had a brown substance buildup. The brown substance wiped off with a white paper towel. The DM confirmed the buildup of the brown substance inside the ice machine. In an interview, the DM stated that the Maintenance Director cleaned the ice machine. In an interview on 9/11/2025 at 1:45 pm, the Maintenance Director stated that he cleaned the ice machine and that he had a schedule that he followed to clean it. He confirmed the last documented cleaning was 8/22/2025.

Based on observations, staff interviews, record review, and review of the facility policies titled Handwashing/Hand Hygiene and Handling of Linen, the facility failed to ensure infection control practices were followed during disposal of soiled items, resident equipment maintenance, during laundry processes, and during meal tray delivery. These deficient practices had the potential to place the residents residing in the facility at increased risk of infections due to cross-contamination. The facility census was 100. Findings Include: Review of the facility's undated policy titled “Handwashing/Hand Hygiene” revealed the “Policy Statement” stated, “This facility considers hand hygiene the primary means to prevent the spread of infections.” The “Policy Interpretation and Implementation” section included, “… 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. … 6. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.” Review of the facility's undated policy titled “Handling of Linen” revealed the “Infection Control” section included, “… 3. Never bring soiled linen into washroom while clean linen is exposed.” 1. Observation on 9/10/2025 at 9:40 am revealed Certified Nursing Assistant (CNA) LL transporting soiled linen and trash in bags through the hallway while wearing gloves. She used her gloved hand to punch in a code on a keypad to access the soiled utility room, removed her gloves, and did not perform hand hygiene. Further observation at 10:03 am revealed CNA LL discarding the soiled items without performing hand hygiene upon exiting the soiled utility room. In an interview on 9/10/2025 at 9:40 am, CNA LL confirmed she wore gloves while transporting soiled bags to the soiled utility room and touched the room's keypad with the soiled gloves. She confirmed she did not perform hand hygiene after discarding the soiled bags and removing her gloves. 2. Observations on 9/10/2025 at 11:10 am of the Laundry Room, conducted with the Environmental Services (EVS) Director, revealed more than nine open boxes of clean clothing stacked against a wall on the dirty side of the Laundry Room. Observation revealed that the clothing was overflowing from the boxes and in direct contact with the wall. Further observation revealed that one table, designated for folding clean linens, was cluttered with non-linen items, including binders, food, a microwave, drinks, and various office supplies. Food crumbs were visibly present, and clean linens were observed to be in contact with these items. In an interview on 9/10/2025 at 11:10 am, the EVS Director revealed that the clean clothing had been accumulating along the laundry room wall for over three years. She stated that staff routinely rummaged through the clothing to distribute items to residents. She acknowledged that storing clean clothing on the dirty side of the laundry area posed an infection control risk and stated she planned to relocate the items. Additionally, she confirmed that the table designated for folding clean linens should not be used for any other purpose and agreed that food, drinks, a microwave, binders, and office supplies should not be on the table. In an interview on 9/10/2025 at 5:00 pm, the Infection Preventionist (IP)/Assistant Director of Nursing (ADON) stated that staff should perform hand hygiene before and after entering resident rooms, and after removing gloves. The IP/ADON confirmed that clean clothing should not be stored on the dirty side of the laundry room, and stated that those items would then be considered contaminated and should be re-laundered. She further stated that the table designated for folding clean linens should not be used for items such as binders, food, drinks, a microwave, or office supplies. She stated that these practices were not in compliance with the standards for infection control. 3. Observations on 9/9/2025 at 12:07 pm, of the 100 Hall, revealed CNAs delivering meal trays between residents' rooms without performing hand hygiene.During an interview on 9/9/2024 at 12:19 pm, CNA BB, CNA CC, and CNA DD confirmed they did not sanitize their hands between resident rooms during meal tray delivery. They stated they were not aware that they should. During an interview on 9/10/2025 at 2:11 pm, the IP/ADON stated the staff received infection control education during orientation and monthly in-services on hand hygiene. The IP/ADON continued to state that the staff should be aware to perform hand hygiene between trays while delivering meal trays. During an interview on 9/10/2025 at 2:47 pm, the DON stated the staff should perform hand hygiene between meal tray passes on the halls and in the dining room.

Based on observations, staff and resident interviews, record review, and review of the facility policies titled Resident Rights, Dining and Meal Service, and Quality of Life-Dignity, the facility failed to ensure that dining practices supported and maintained the dignity and person-centered preferences for two of 49 sampled residents (R) (R43 and R53). This deficient practice had the potential to place R43 and R53 at risk of a decreased sense of dignity, autonomy, and person-centered care. Findings include:Review of the undated facility policy titled Resident Rights revealed the Policy Interpretation and Implementation section included, 1. b. be treated with respect, kindness, and dignity.Review of the policy titled Dining and Meal Service, revised 4/5/2024, revealed that The dining experience will be person-centered with the purpose of enhancing each individual patient's/resident's quality of life and being supportive of everyone's needs during dining.Review of the policy titled, Quality of Life-Dignity, undated, revealed under section 2. 'Treated with Dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth, and further review of section 11. Demeaning practices and standards of care that compromise dignity is prohibited.1. Review of the Quarterly Minimum Data Set (MDS) assessment for R43, dated 7/7/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented the resident was independent with eating. 2. Review of the Quarterly MDS assessment for R53, dated 7/1/2025, revealed Section C (Cognitive Patterns) documented a BIMS score of 9 (indicating moderate cognitive impairment). Section GG (Functional Abilities and Goals) documented the resident was independent with eating. Observations on 9/10/2025 at 11:37 am and 5:16 pm revealed that during both lunch and dinner meals in the main dining room, all residents were observed eating directly from serving trays placed on the tables. Further observations revealed that plate warmers remained under the dishes throughout the entire meal. In an interview on 9/10/2025 at 12:19 pm, R43 revealed that meal serving trays had been used in the dining room for some time and stated she did not care for the tray or plate warmer. She stated that food gets caught between the plate and the warmer. She also stated she has never been asked if she prefers the tray.In an interview on 9/10/2025 at 2:02 pm, R53 revealed that she dislikes the serving trays and prefers the food plate to be placed directly on the table. She stated that she preferred a tray-free dining experience.In an interview on 9/10/2025 at 12:01 pm, Licensed Practical Nurse (LPN) JJ revealed that the serving trays and plate warmers stayed on the table and further stated that was how it had always been done at the facility. In an interview on 9/10/2025 at 12:06 pm, the Activities Assistant revealed that she always leaves the serving trays on the tables and had not been instructed otherwise.In an interview on 9/10/2025 at 12:10 pm, the Activities Director confirmed that serving trays were never removed and acknowledged that she wouldn't consider it home-like. She stated that it was just how it had always been done.In an interview on 9/10/2025 at 12:18 pm, the Director of Nursing (DON) confirmed that serving trays were always used and was uncertain whether they contributed to a home-like environment.

Based on observations, staff interviews, and review of the facility's policy titled Hazardous Area, Devices, and Equipment, the facility failed to ensure an environment free from hazards in three of 30 rooms on the 100 Hall. This deficient practice had the potential to place the residents residing in the rooms at increased risk of exposure to harmful substances and items. Findings include:Review of the facility's undated policy titled Hazardous Area, Devices, and Equipment revealed the Policy Interpretation and Implementation section included, 1. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the Safety Committee. The Identification of Hazards section included, 1. A hazard is identified as anything in the environment that has the potential to cause injury or illness. c. sharp objects that are accessible to vulnerable residents. g. access to toxic chemicals.Observation on 9/9/2025 at 10:28 am in Resident room [ROOM NUMBER] revealed a manual razor on the resident's nightstand.Observation on 9/9/2025 at 10:41 am in Resident room [ROOM NUMBER] revealed alcohol wipes and a manual razor on the resident's nightstand, and an aerosol spray on the bedside table.Observation on 9/9/2025 at 11:47 am in Resident room [ROOM NUMBER] revealed alcohol wipes and an aerosol spray on the resident's nightstand.During a walking-through observation and interview on 9/9/2025 at 2:25 pm, Unit Manager/Licensed Practical Nurse (UM/LPN) AA confirmed the manual razors in Resident rooms [ROOM NUMBERS] were to be kept on each nursing cart or in the shower room. UM/LPN AA confirmed that the alcohol wipes and aerosol sprays in Residents' rooms [ROOM NUMBERS] should not be in the rooms. UM/LPN AA stated environmental rounds from leadership were conducted on a weekly basis, and the nurses and CNAs were expected to round daily. During an interview on 9/10/2025 at 2:27 pm, the Administrator and Director of Nursing (DON) stated that each administration personnel was assigned a room to conduct rounds to ensure hazardous products were not in the resident's room. The DON stated that if items were found, the residents were educated, and the items were removed. The Administrator confirmed the identified items should not be in residents' rooms.

Based on observation, staff interview, record review, and review of the facility policy titled Dining and Meal Service, the facility failed to ensure one of 13 residents (R) (R117) with pureed diet orders was served a diet in accordance with the physician's orders. This deficient practice had the potential to place R117 at risk of medical complications and a diminished quality of life. Findings include:Review of the facility policy titled Dining and Meal Service, revised 4/5/2024, revealed the Policy section included, . Individuals will be provided with nourishing, palatable, attractive meals that meet daily nutritional and special dietary needs. The Procedure section included, . 8. Food will be at the proper texture/consistency to meet everyone's needs and desires.Review of the admission Record revealed R117 was admitted to the facility on [DATE] with diagnoses including, but not limited to, type 2 diabetes with unspecified complications, Alzheimer's disease, cerebral infarction, hemiplegia, and hemiparesis.Review of the admission Minimum Data Set (MDS) for R117, dated 9/7/2025, revealed Section K (Swallowing and Nutritional Status) documented that the resident received a mechanically altered diet. Review of the Physician's Orders for R117 revealed an order dated 9/2/2025 for a reduced concentrated sweets diet, no added salt, pureed texture, and nectar consistency. Review of the resident's tray card, printed on 9/9/2025, confirmed R117's prescribed diet was pureed texture. Review of a facility-provided document titled Diet Type Report, dated 9/10/2025, revealed R117 was listed as requiring a pureed diet texture. Observation on 9/9/2025 at 12:46 pm revealed that R117 was served a regular consistency diet at the lunch meal.During an interview on 9/9/2025 at 1:21 pm, Certified Nurse Assistant (CNA) VV confirmed she delivered the lunch meal tray to R117, and it was a regular consistency meal and should have been a pureed consistency meal. During an interview on 9/10/2025 at 1:09 pm, Dietary Aide TT stated her responsibility as the final checker on the tray preparation line was to ensure that the tray and meal ticket corresponded. Dietary Aide TT acknowledged the error she made and indicated that she was moving too quickly. During an interview on 9/10/2025 at 1:13 pm, the Food Service Manager (FSM) acknowledged being aware of the error regarding the resident's meal tray and diet order, which consisted of a regular diet instead of a pureed one. The FSM indicated that the risk associated with R117 meal conflicting with the physician's order could lead to choking.

Based on record review, observations, interviews, and a review of the facility policy titled Hot Beverage Policy, the facility failed to ensure that one of 14 sampled residents (R) (R4) was free from accident hazards. Harm was identified to have occurred on 11/12/2024 when staff served R4 hot liquids, which resulted in a second-degree burn.Findings included:An undated facility policy titled Hot Beverage Policy revealed that serving hot beverages that are at exceedingly high temperatures can increase the risk of burns and scalding amongst elderly residents. It is important to provide hot beverages at a safe temperature. Hot beverages should be served between 130 [degrees] and 160 [degrees]. The policy further indicated to check the temperature of the coffee/hot water from the dispenser daily with a calibrated thermometer to ensure the temperature management system of the coffee machine is accurate. Do not fill the cup to the brim to avoid spilling. To-go coffee cups should have securely fastened lids.A review of the electronic medical record revealed that R4 was admitted to the facility on [DATE] and readmitted on [DATE]. According to the admission Record, the resident had a medical history that included a diagnosis of cerebral palsy.A review of the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 10/18/2024 revealed that R4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated R4 was cognitively intact. According to the assessment, R4 required setup or clean-up assistance for eating and used a manual wheelchair independently for mobility to mobilize greater than 150 feet in a corridor or similar space.A review of the Care Plan Report dated 11/12/2024 included a focus area that indicated the resident was at risk for skin breakdown and had blisters from a burn on 11/12/2024. Interventions included that staff applied Silver External Gel (an antimicrobial wound gel) to the resident's left upper thigh (initiated 11/14/2024 and resolved 01/20/2025).A document titled #4126 Other Skin Issue dated 11/12/2024 at 10:45 am revealed that R4 spilled a hot beverage on their left upper thigh when attempting to place the beverage in their cup holder. The document further revealed that the interdisciplinary team (IDT) met on 11/14/2024 and identified that the resident had a cup holder modification on their wheelchair that had broken and exposed a screw. The document indicated the modification was removed from the resident's wheelchair.A review of the Change in Condition Evaluation dated 11/13/2024 at 10:44 am revealed that R4 experienced a coffee spill on 11/12/2024 in the morning. The report indicated the resident had skin changes of a burn with a description of any burn other than a minor first degree burn with no significant pain. The Change in Condition Evaluation indicated the skin change area was red with slight pain and was located on the left trochanter (hip). The Change in Condition Evaluation further indicated the resident had coffee and wanted to put it in their cup holder, but something caused a hole in the cup, and coffee spilled on the resident.A review of the provider's Progress Notes dated 11/12/2024 revealed that R4 was seen due to spilling a hot beverage on their leg. Per the Progress Notes, R4 complained of stinging to the area.A review of the Weekly Skin Observation dated 11/13/2024 at 8:51 pm revealed that R4 had blisters to [left] hip.A wound provider's Progress Note dated 11/19/2024 identified that initial wound visits for R4 occurred. The wound Progress Notes indicated the resident had a second-degree burn on their left thigh with an etiology of a hot coffee spill.During a concurrent observation and interview on 4/8/2025 at 2:15 pm, R4 sat in a wheelchair in the resident's room. R4 said they recalled being burned the prior year when a Styrofoam cup was provided to the resident during an activity that contained hot coffee. The resident said they placed the cup in a cupholder on the wheelchair to allow the beverage to cool. The resident stated that when the beverage was placed in the cupholder, it immediately began to run out of the cupholder and onto the resident's left thigh and hip, causing severe pain and a burning sensation. R4 stated they immediately yelled in pain, and the activity staff responded and sought assistance from the nursing department. The resident stated the burn took one to two months to heal and was very uncomfortable. R4 said the facility removed the cupholder from the wheelchair immediately. R4 said the coffee served by the activities staff was always hot and had to be allowed to cool off before drinking. R4 said on the day of the incident, the beverage burned them through their clothing, noting the cupholder was loose and not attached to the chair properly.During an interview on 4/8/2025 at 3:14 pm, the Activity Director (AD) recalled the facility was conducting an activity (on the day R4 was burned) that was held daily around 9:30 am, noting the residents were served coffee. She stated she was not in the activity at the time of the incident; however, she stated Activity Assistant (AA)1, AA2, and AA3 were in the activity at the time, and she saw AA3 wheeling R4 down a hallway after the coffee was spilled on the resident's leg. She said she noticed a screw was loose in the center of the cup holder where it was not screwed into the bottom side of the cupholder. She described the cupholder as a c-shaped cupholder that was fastened to the wheelchair with the use of three screws (two screws on the back portion and one screw in the bottom of the cupholder). She stated she asked the resident about pain, but the resident responded that once the nurse treated the area, it began to cool down. She stated the coffee was always extremely hot. The AD stated that, following the incident, the Administrator informed the activity staff that the temperature of the coffee had to be checked and had to be 160 degrees Fahrenheit (F) or less before serving.During a telephone interview on 4/9/2025 at 8:06 am, AA1 stated she was assisting with another resident at the time of the incident involving R4; however, she stated all activity staff handed out cups containing hot liquids to residents, who were not seated at a table at the time of distribution. She said R4 was not at a table that morning and placed the cup containing hot liquid in the holder on their wheelchair themselves. She said that when activity staff passed out the beverages that morning, she was not aware of the loose screw in the cupholder on R4's wheelchair. AA1 explained that the facility had begun using Styrofoam cups during periods of increased coronavirus disease 2019 (COVID-19) outbreaks and had continued to utilize them for the coffee activity. She stated the facility was still using the Styrofoam cups after the incident occurred for hot beverages and had not stopped the practice prior to her leaving employment. She stated she left employment sometime between Christmas 2024 and New Year's Day of 2025.During a telephone interview on 4/9/2025 at 11:19 am, AA2 stated she recalled the event when Resident #4 was burned with coffee. She stated that, at the time, she was retrieving a soda from a vending machine for another resident when suddenly she heard activity staff and other residents yelling, after which she noticed coffee everywhere. AA2 said she asked R4 if they were injured, and the resident repeated, My leg, my leg, and pointed to the coffee spill. She described the coffee as being all over the resident and down the resident's pant leg. AA2 said the cup had been punctured from the cup holder, causing a hole in the bottom of the Styrofoam cup. AA2 stated the facility stopped the practice of using Styrofoam cups around the time she left employment in March 2025. AA2 said that after the incident, maintenance staff removed the cup holder from R4's wheelchair. She stated that before R4's incident, the facility was not checking the temperature of the coffee for the daily coffee hour activity, but was providing residents with the option to put ice in the coffee because it was so hot.During an interview on 4/11/2025 at 12:25 pm, AA3 stated she was in the morning activity in question, where she poured and served coffee for residents. She stated she poured R4's coffee and set it on a table. AA3 said she told R4 the coffee was hot and then noticed the resident had spilled the coffee. She stated her back was to the resident when the incident occurred. AA3 said that at the time of the incident, activity staff were serving coffee in Styrofoam cups with lids and were not checking the temperatures of the hot beverages before serving them to residents. AA3 stated she felt bad when the incident occurred because she knew the coffee was extremely hot. She stated that the coffee was so hot when it came from the kitchen, they told residents to be careful and said they even tried to put ice in the residents' cups to prevent the beverage from burning the residents.During an interview on 4/9/2025 at 3:27 pm, Certified Nursing Assistant (CNA)5 said he recalled an activity staff member bringing R4 to their room to be checked following the incident in question. Per CNA5, R4 had multiple blisters on their legs, noting a treatment nurse applied ointment and a cool, wet washcloth. CNA5 stated R4 said, I have to get out of these pants, it's burning like [expletive]. CNA5 said the resident was scared and tearful.During an interview on 4/9/2025 at 7:43 pm, Licensed Practical Nurse (LPN)4 recalled R4 was brought to the unit after hot coffee spilled on the resident's leg. LPN4 stated CNA5 placed R4 in bed so she could observe the resident's skin. She stated initially the area was reddened and the resident voiced some pain; however, CNA5 notified her later in the shift that the areas had blistered. LPN4 stated the spill was caused from a puncture hole in the Styrofoam cup, which was a caused from a screw in a cupholder.During an interview on 4/9/2025 at 1:45 pm, the Assistant Director of Nursing (ADON) indicated she thought the cupholders in question had been donated by a family member and installed by the maintenance department staff on multiple residents' wheelchairs who had requested the cupholders.During an interview on 4/10/2025 at 8:19 am, the Maintenance Director revealed the cupholders in question were ordered by the facility from a contracted vendor, noting maintenance staff had installed them on resident wheelchairs the prior fall season. The Maintenance Director could not recall being asked to remove the cupholder from R4's chair following the burn incident.During an interview on 4/10/2025 at 2:55 pm, CNA6 said she did not check the functioning of cupholders on residents' wheelchairs.During an interview on 4/10/2025 at 3:05 pm, CNA7 stated she had not checked the functioning of cupholders on residents' wheelchairs.During an interview on 4/10/2025 at 3:10 pm, CNA8 said he had never checked the cupholders on resident wheelchairs for their functional status.During an interview on 4/10/2025 at 5:00 pm, the Administrator stated the facility did not have a policy regarding modification of wheelchairs or oversight of the ongoing functionality of the wheelchairs. She stated maintenance staff repaired wheelchairs as staff reported concerns. There is no routine wheelchair maintenance.During a follow-up interview on 4/15/2025 at 12:00 pm, the Administrator stated she was in the facility at the time of the incident involving R4's burn. The Administrator said it was determined that R4's wheelchair's cupholder screw was loose and punctured the Styrofoam cup containing hot coffee. She stated she expected staff to check the temperature and serve coffee at temperatures less than 160 degrees F so as not to cause a burn.

Based on observations, interviews, and a review of the facility policy titled, Floor Care, the facility failed to ensure that the shower rooms were maintained in a clean condition and free from dark brown to black fuzzy and slimy substances on the walls in two of the two halls (Hall 100 and Hall 200). Findings included: An undated facility policy titled, Floor Care, revealed, MONTHLY CARE - All bathroom ceramic tile floors should be scrubbed with a buffing machine or appropriate scrubbing brush (depending on size of the floor-- a buffing machine may not fit in smaller bathrooms). A combination of cleanser with bleach and warm water should be used when scrubbing. Bleach cleanser will help to clean and disinfect difficult-to-reach grout areas and will help prevent bacterial growth. An observation on 4/9/2025 at 4:15 pm of the shower rooms on the 100 and 200 Halls revealed dark brown to black fuzzy and slimy substances on the walls in each of the shower units near cracks in the grout/caulking. The shower rooms had a slightly musty odor. During a concurrent observation and interview on 4/9/2025 at 4:30 pm, the Maintenance Director confirmed the observation of the black substance on the shower room walls. He stated he performed monthly pressure washing and scrubbing of the walls of the shower rooms and used a sprayer to get rid of the black substance, and was not sure how those areas were missed. He stated he would shut down the shower rooms and perform cleaning. During an interview on 4/9/2025 at 5:36 pm, the Administrator stated the nursing department was responsible for tidying up the shower room after providing a shower, and maintenance was to perform a monthly deep cleaning of the shower room. She stated that monthly cleaning should include an inspection of unsanitary/unclean areas in each shower room, and that if any black-colored substance is located, the shower should be taken out of operation immediately and cleaned that day.

Based on record review and interviews, the facility failed to ensure that the medical record documentation was completed and/or accurate for one of three residents (R) (R2) reviewed for pressure ulcers. Findings included: A review of the electronic medical record (EMR) revealed that R2 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, type 2 diabetes mellitus, and unspecified diarrhea. A review of the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/31/2024 revealed that R2 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS assessment revealed that R2 had an unstageable pressure ulcer that was present on admission. A review of the Care Plan Report dated 6/10/2024 revealed that R2 had a pressure ulcer or potential for pressure ulcer development due to immobility. Interventions directed staff to provide weekly treatment to include measurement of each area of skin breakdown. A review of the Treatment Administration Record (TAR) dated June 2024 revealed an order entry with a start date of 6/1/2024 and an end date of 6/28/2024 that directed staff to clean R2's sacrum wound with wound cleanser, pat dry, apply skin barrier and then Santyl ointment, and secure with a silicone dressing daily. The TAR lacked documentation to indicate whether the treatment was provided on 6/1/2024, 6/2/2024, 6/4/2024, or 6/9/2024. During an interview on 4/11/2025 at 7:58 am, Licensed Practical Nurse (LPN)4 stated she was certain that she performed the sacral wound treatment for R2 on 6/4/2024 but became distracted and did not sign the TAR afterwards. She stated she was trained to document work once it was completed. During an interview on 4/15/2025 at 12:00 pm, the Administrator stated she expected all treatments to be documented after completion.

Based on staff and family interviews, and review of the PBJ (payroll-based journal) Staffing Data Report Quarter 1 2024 (October 1, 2023, through December 31, 2023), the facility failed to ensure that the facility had adequate nursing staff. The deficient practice had the potential to affect the care provided to the 104 residents that resided in the facility. Findings include: Review of the PBJ Staffing Data Report Quarter 1 2024 (October 1, 2023, through December 31, 2023) revealed based on the data submitted, the facility triggered for a One-Star Staffing Rating (Failure to submit PBJ data by the deadline, more than 4 days in the quarter without RN (Registered Nurse) Staffing hours, failure to respond to, submit documentation for, or failure to pass a CMS (Centers for Medicare and Medicaid Services) audit designed to discover discrepancies in PBJ data). Interview on 5/30/2024 at 2:30 pm with the Human Resources (HR) Director revealed she assumed scheduling responsibility due to the Scheduler being on maternity leave. She went on to reveal that the facility had about 75 percent (%) full-time staff and 25% agency nurses and CNAs. She stated that normally she scheduled five to six CNAs per hall during the day shift (7:00 am to 3:00 pm), four to five CNAs during evening shift (3:00 pm to 11:00 pm), and two to three CNAs during the night shift (11:00 pm to 7:00 am). She stated in case someone called out, the Charge Nurse was notified first, then the Charge Nurse let the Scheduler know. The Scheduler would reach out to full-time staff first and offer the extra shift, if no one was available, she would contact the staffing agency and offer the additional shift. She revealed that most of the agency nurses and CNAs had been working in this facility for one or two years. Interview on 5/30/2024 at 4:45 pm with the Administrator revealed that the facility had a high turnover during the first quarter of 2024 when several Licensed Practical Nurses (LPNs), Unit Managers, and CNAs resigned. Currently, full-time positions were offered to agency staff. Company recruiters are seeking ways to connect with potential candidates in local communities.

Based on observations, staff interviews, and review of the facility policy titled, Water Temperatures, Safety of, the facility failed to maintain a safe, clean, comfortable, homelike environment related to water temperatures above 110 degrees Fahrenheit (F) on one of two wings in the facility affecting 27 resident rooms and the shower room, and failed to change bed linen for one resident (R) (R103). The deficient practice had the potential for water over 110 degrees F to cause skin burns. Findings include: 1. Review of the undated facility policy titled Water Temperatures, Safety of, under policy Interpretation and Implementation revealed, 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 degrees F, or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. 3. Maintenance staff shall conduct periodic tap water temperature checks and record temperatures in a safety log. 4. If at any time water temperatures feel excessive to the touch (i.e. hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor. Review of undated facility document titled Job Description and Performance Evaluation-Maintenance Director revealed, 4. Ensure that the plant and equipment are properly maintained for patient/resident comfort and convenience. 8. Inspect the facility, on a regular basis, to ensure that the grounds, facility, and equipment are maintained in accordance with established policies and procedures and all hazardous areas properly identified. Review of the facility's Weekly Water Temperature logs from October 2023 to May 2024 revealed several temperatures that were above the stated 110 degree F facility policy. Review of the facility's Weekly Water Temperature logs for Wing 100 revealed within range temperatures. Observations on 5/28/2024 between 11:06 am and 11:56 am during the initial tour of the facility and screening of the residents revealed water temperatures over 110 degrees F in resident rooms on the 200 wing as follows: room [ROOM NUMBER] hot water temperature from the sink was 119.3 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 119.1 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 119.7 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.3 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 119.5 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 121.5 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 115.0 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.4 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.0 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.4 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.1 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.4 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.1 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 119.5 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.0 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 119.5 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.2 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 119.6 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 119.7 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 116.5 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 119.0 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.1 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.5 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 121.0 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 121.1 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 121.1 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.1 degrees F. Observation on 5/28/2024 at 12:01 pm revealed the shower room sink temperature was 121.4 degrees F, shower one had a water temperature of 120.3 degrees F, and shower two had a water temperature of 119.8 degrees F. Interview on 5/28/2024 at 11:50 am with R412 in room [ROOM NUMBER], the resident stated, the water is too hot sometimes. He denied any burns or injuries from the water temperature. Interview during walking rounds on 5/28/2024 at 10:59 am with the Maintenance Director (MD), he was notified of the water feeling hot. Water temperatures were taken in all rooms on Wing 200. The MD verified that the water temperatures were high and out of compliance with the facility policy. The MD admitted that the mixing valve had been giving him issues for a couple of months and that he had been trying to regulate the water temperatures by the valves. He also revealed that he had checked temperatures last week, in the early am, and temperatures were fine. He was then asked for the temperature logs to show these temperatures. He stated that he was going to turn off the hot water immediately. Interview on 5/28/2024 at 5:48 pm with the Administrator, she was notified of the water temperature concerns and revealed that she was just made aware of the findings by the MD. She stated that the hot water to Wing 200 was currently turned off and will not be in used until the part was ordered to fix the water temperature issue. When asked what her plan was for resident care and the availability of hot/warm water, she revealed that the staff had been made aware that hot water would not be available on Wing 200 and that staff would have to get hot/warm water from Wing 100, which was not affected by the malfunctioning part. She also stated that residents would be taken to Wing 100 for showers and baths. She also revealed that she was not aware of any water temperature issues prior to the survey. She stated that the part had been ordered and was expected to arrive this week. 47947 2. Interview on 05/28/2024 at 12:11 pm with R103 revealed that they received a shower on 5/27/2024, but staff did not change bed linens. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] for R103, documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating that the resident is cognitively intact. Interview on 5/30/2024 at 1:15 pm R103 stated that staff had not changed her bed linens. Review of the Task section of electronic medical records (EMR) revealed that R103 received showers on 5/28/2024 at 9:30 pm, and on 5/29/2024 at 2:59 pm. Interview on 5/30/2024 at 1:20 pm with Certified Nursing Assistant (CNA) BB, she stated that bed sheets must be changed each time a resident received a shower. R103 was scheduled for evening showers and staff from the evening shift were responsible for changing bed linens. Interview on 5/30/2024 at 2:25 pm with DON revealed that the bed sheets should be changed on shower days. If a resident complained that sheets did not get changed after two previous showers, then this was grounds for in-service education and an employee write up. If CNAs note the need for deep bed cleaning, they would notify the Environmental Department and coordinate scheduling of the cleaning.

Based on observations, record review, staff interviews, and review of the facility policy titled, Oxygen (O2) Administration, the facility failed to administer O2 therapy as ordered for one of 20 residents (R) (R21) receiving O2 therapy. The deficient practice had the potential to place R21 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the undated facility policy titled Oxygen Administration revealed under the section titled Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Section titled Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Under section titled Steps in the Procedure . 6. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Review of this policy also revealed that it did not include policies and procedures for maintaining O2 concentrators (machine that produces O2), proper storage of O2 devices (i.e. mask, nasal cannula (NC) and/or nasal catheter), and nursing staff responsibilities for assuring that the flow of O2 is at the level ordered. Review of the electronic medical record (EMR) revealed R21 was admitted to the facility with diagnoses including, but not limited to heart failure, morbid (severe) obesity due to excess calories, hypertension, transient cerebral ischemic attack, and sleep apnea. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating R21 was cognitively intact. Section O-Special Treatments and Programs revealed resident receives O2 therapy while a resident. Review of R21's Physician's order dated 1/9/2024 for oxygen (O2) at 2 (liters) L per (nasal canula) NC to keep O2 above 92% [percent]. Observation on 5/28/2024 at 10:00 am of R21, the resident had an O2 concentrator at bedside, turned on at 3 liters per minute (LPM). Observation on 5/29/2024 at 8:19 am, R21 was resting in a recliner chair in her room with O2 via NC in place at 3 LPM. Observation on 5/29/2024 at 2:00 pm, R21 was reclined back in a recliner chair in her room, dozing off to sleep with O2 in place via NC at 3 LPM. Staff Interview/Walking Rounds on 5/29/2024 at 2:02 pm with LPN AA confirmed that R21's O2 was at 3 LPM and immediately turned the O2 down to 2 LPM. She stated that the resident sometimes adjusts the machine herself when she feels it's not pushing out enough. She also revealed that residents that were receiving O2 were to have pulse oximetry (O2 saturation test) checks as ordered. Interview on 5/30/2024 at 10:35 am with the Assistant Director of Nursing/Infection Preventionist (ADON/IP) revealed that she and the Unit Managers do daily rounds and check O2 concentrators and settings of residents that are receiving O2. She stated that the nurses were primarily responsible for checking the settings of the O2. Interview on 5/30/2024 at 2:13 pm with the Director of Nursing (DON), she stated that her expectation was for nurses to follow the Physician's orders. She also revealed that the nurses were to monitor O2 levels every shift, especially when doing assessments and passing medications. She also stated that when residents were self-adjusting O2, they should be care planned for such actions.

Based on record review, document review, interviews, and a review of facility policy, the facility failed to protect two of two residents (R) (R#205 and R#98) from abuse from R#204. On 7/20/21, the psychiatrist indicated there was an alarming change in R#204's impulsivity and recommended staff should watch R#204 more carefully while the medications get stabilized. However, there was no documented evidence the facility increased the resident's supervision to protect residents. On 7/30/21, staff found R#204 hitting the resident's roommate (R#205) in the face with a fist. The facility implemented interventions including moving the resident's roommate; however, the facility failed to implement interventions to supervise R#204. Interviews with staff revealed R#204 had to be redirected from R#98's room and/or threatened the resident; however, no interventions were implemented to protect R#98. On 9/14/21, R#204 was captured on video coming out R#98's room. R#98 was found to have bruising to the face under the eye, on the cheek, and around the lip on the left side. R#204 admitted to hitting R#98 repeatedly on the face/head for 45 minutes to one hour. Findings include: A review of the facility's Abuse, Neglect and Exploitation policy, dated December 2017, revealed Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy indicated, Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. According to the policy, The center [facility] will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents. Assess, monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other resident's rooms, residents with self-injurious behaviors, residents with communication disorders and those that require heavy nursing care and/or are totally dependent on staff. A review of R#204's Admission Record revealed the facility admitted the resident on 2/26/21. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#204's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating moderately impaired cognition. The MDS indicated the resident had not demonstrated any behaviors affecting the resident or others. R#204 was able to walk in the room with minimal assistance and required maximum assistance to walk in the corridor. R#204 required the use of a walker and a wheelchair for mobilization. According to the MDS, R#204 took antipsychotic and antidepressant medications. A review of R#204's comprehensive care plan revealed the facility initiated a care plan on 3/12/21 that was revised on 9/15/21, regarding [CONDITION(S)] medication usage related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a psychiatry Subsequent Medication Evaluation, dated 7/20/21, revealed R#204 had changed dramatically since the [MEDICATION(S)] (antipsychotic medication) 100 milligrams (mg) was discontinued and [MEDICATION(S)] (a liquid medication used to treat behaviors) was tried. The resident did not want the liquid and had not been taking the medication. The resident was more unpredictable with odd stereotypic movements of banging doors. The note stated the resident was fine during the interview and was later found with a belt around the neck. Further review revealed R#204 had an alarming change in impulsivity and depression. The only trigger seemed to be stopping [MEDICATION(S)] and not taking [MEDICATION(S)]. The note stated the resident was not really suicidal but depressed and has many impulsive thoughts that need to be controlled. Further review revealed staff should watch [the resident] more carefully while the medications get stabilized. A review of R#204's comprehensive care plan revealed, the facility initiated a care plan on 7/21/21 because the resident received anti-psychotic medication daily for delusional disorder. The facility developed interventions to administer medications as ordered; assess and monitor for behaviors that show [CONDITION(S)] or [CONDITION(S)], present a danger to self or others, cause a significant decline in function, or cause major difficulty in receiving care that warrants medication; conduct a pharmacy consult and request gradual dose reductions of medications; and conduct a psychiatry consultation as needed to monitor medications and behaviors for adjustments as needed. There was no documented evidence the facility implemented interventions to supervise the resident and/or watch the resident more carefully as requested by the psychiatrist. According to R#204's Progress Notes, dated 7/30/21 at 3:36 p.m., staff observed the resident standing next to the roommate's bed, leaning over, and hitting the roommate in the face with his/her fist. R#204 was accusing the roommate of theft. After staff intervention, the resident continued to try to hit the roommate and was being verbally aggressive. A review of a Facility Incident Report Form revealed on 7/30/21 that R#204 was involved in an altercation with R#205, their roommate. R#204 accused his/her roommate of stealing a walking cane. R#204 became verbally abusive towards the roommate, hitting the roommate with a fist and had to be physically separated from the roommate. The incident report indicated R#205 had a BIMS score of 00, indicating the resident was severely cognitively impaired and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed R#204 stated R#205 took his/her cane so I punched [R#205] in the face. According to the report, R#205 nodded yes that R#204 hit the resident and nodded no when asked if the resident was hurt. According to the incident report, R#205 had no injuries. Further review revealed 'the interventions put into place to keep this from happening in the future was to move the roommate, R#205, to another hallway and R#204 was sent to the emergency room for evaluation and referred to psychiatric service for follow up at the facility. A review of a facility statement obtained from Certified Nursing Assistant (CNA) BB following the 7/30/21 incident revealed the CNA was walking by R#204/R#205's room when she saw another CNA who looked as if she needed help. The CNA stated R#204 was hitting R#205. CNA BB stated she went to get a nurse and the CNA came to the door and said that R#204 had hit R#205 again. A review of the Director of Nursing (DON) statement revealed R#204 assaulted the roommate but was not aware of what they were doing. According to the statement, staff would continue to be in-serviced on abuse prohibition. During an interview conducted on 7/20/22 at 11:43 a.m., Licensed Practical Nurse (LPN) BB stated while delivering briefs, she observed R#204 standing over the roommate, who was lying in the bed. LPN BB stated she saw R#204 beside the roommate's bed with a fist raised above the resident but did not see R#204 hit R#205. LPN BB stated that she had never known R#204 to be violent prior to this incident. A review of Progress Notes dated 8/2/21 at 7:04 p.m. revealed R#204 continues to brag about hitting past roommate over and over again, laughs about it over and over indicating that [R#204] is not sorry about it. Further review of R#204's care plan revealed the facility initiated a care plan on 8/4/21 regarding the resident's potential to be physically aggressive to other residents at times. The facility developed interventions that included giving the resident as many choices as possible about care and activities. monitoring/documenting/reporting any sign/symptom of a threat to self and others; a psychiatric/psychogeriatric consult as indicated; when agitated, intervene before agitation escalates; guide the resident away from the source of distress; engage calmly in conversation; and if the resident's response is aggressive, staff should walk calmly away, and approach the resident later. There was no documented evidence the facility developed/implemented interventions to supervise R#204 to prevent further incidents. A review of a psychiatry Subsequent Medication Evaluation, dated 8/17/21, revealed R#204 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The evaluation indicated last month R#204 impulsively put a belt around neck and staff stopped the resident. The resident had recently been taken off medications due to a gradual dose reduction. In crisis, the resident's medications were restarted, and the resident was much better but made odd statements, got confused, and was impulsive. There was no documentation regarding hitting the roommate in the psychiatrist's evaluation. A review of a Facility Incident Report Form, dated 9/14/21, revealed R#204 was captured on video coming out of R#98's room. R#98 was noted to have bruising to the face under the eye, on the cheek, and around the lip on the left side. R#204 admitted to the staff that he/she was going to the resident's room to find out what the yelling was about and to shut [the resident] up. According to the incident report, R#98 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#98 had a BIMS score of 00, indicating the resident was severely cognitively impaired. The facility substantiated that R#204 entered the other resident's room and hit the resident. R#204 was moved to a room close to the nurse's station and 15-minute checks were initiated. The 15-minute check documentation was reviewed and verified to be completed as ordered. A review of Progress Notes for R#204, dated 9/14/21, revealed the Social Services Director (SSD) met with the resident regarding the incident. The SSD informed the resident of the reason for the visit and asked R#204 to discuss any information the resident may have. The resident stated during the night, R#204 heard R#98 screaming, stated the resident screamed daily, and it upset R#204. R#204 stated he/she used a wheelchair to enter R#98's room and assault the resident to ensure the resident would remain quiet. R#204 stated he/she sat in R#98's room for 45 minutes to one hour punching R#98 repeatedly due to frustration. R#204 stated R#98 did not speak during the assault or attempt to defend him/herself. A review of the physician's Progress Notes, dated 9/16/21 at 9:02 p.m., revealed R#204 admitted to striking another resident repeatedly over the span of 45 minutes to an hour with blows landing on the face and head. The other resident was defenseless to protect themself against such attacks. The physician indicated he had suggested to the SSD that the ombudsman be contacted as well as the potential for a police report. Further review of the physician's progress note revealed it was the second incident that R#204 had struck another resident. The resident was impulsive and has psychiatric illness which yielded the resident being unpredictable at times and capable of inflicting harm. A review of a [city] Police Dept. [Department] Incident Report, dated 9/16/21, revealed the police responded to the facility due to the report that R#204 struck R#98 in the face several times, causing a black eye, bruising to the left side of the face, and a busted lip. The officer was unable to talk to the resident who was injured; however, did see the bruising on the resident's face. The report indicated the incident would be turned over to an investigator. During an interview on 7/20/22 at 11:30 a.m., CNA III stated that R#204 was very aggressive, had attacked the roommate (who was moved) and then attacked a resident who lived in a room across from R#204. CNA III further stated that staff had prevented R#204 from going into the other resident's room several times due to R#204's threats. CNA III stated that R#204 needed to leave as the resident was not appropriate for the facility. R#204 was a safety risk to other residents. A review of staff statements provided to the facility, dated 9/13/21, revealed LPN III documented that they had to remove R#204 from R#98's room a couple of times because R#204 indicated wanting to see what all the yelling was about. A review of LPN UU's statement, dated 9/13/21, revealed R#204 was moved to another room due to safety concerns. R#204 asked why they were being moved and the LPN explained that the resident was seen coming out of another resident's room that had been hurt last night. When asked if the resident hit R#98, R#204 replied, yes and I thought it was a man. According to the statement, LPN UU told R#204 that they had hurt the other resident and explained that it was not okay to hit anyone. R#204 replied, I know that now. During an interview on 7/20/22 at 11:30 a.m., LPN III stated R#204 admitted to hitting R#98 in the face 40 times because the resident was yelling and threatened to do it again if the yelling continued. LPN III stated that R#204 was a safety risk to other residents and when the physician saw a picture of the injuries R#98 sustained, he ordered R#204 to be discharged from the facility. During an interview conducted on 7/20/22 at 4:20 p.m. the Ombudsman stated she remembered R#204 and was aware that the resident was a difficult person. The Ombudsman stated that she was unaware of the extent of R#98's injuries related to the altercation and agreed that the resident could not stay in the facility with that level of aggression. The Administrator, Director of Nursing, and Social Worker were not employed at the facility when the incidents involving R#204 occurred and were unable to provide any information.

Based on interviews, record review, and facility policy review, the facility failed to ensure a root cause was identified and person-centered interventions were developed after a fall for one of three sampled residents (R) (R#69) reviewed for falls. Specifically, R#69 had an unwitnessed fall in the resident's room on 4/2/22 and the root cause of the fall was not identified nor were new interventions developed. The resident experienced another unwitnessed fall in the resident's room on 6/27/22 and sustained a fracture to the left hand. Findings include: A review of the undated facility policy titled, Cypress Skilled Nursing Clinical Standard of Practice, revealed, Subject: Fall Management Standard: 1. The facility will identify residents at risk for falls and will care plan and implement interventions to minimize fall occurrences and injury due to falls. A review of the Admission Record for R#69 revealed the resident's diagnosis included Alzheimer's disease. A review of the annual Minimum Data Set (MDS), dated [DATE], indicated that R#69 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated severe cognitive impairment. R#69 required supervision of one person with bed mobility, transfer, and eating. Further review of the MDS revealed R#69 required limited assistance of one person with toileting. A review of the care plan, initiated on 1/1/19, revealed the resident was at risk for falls related to confusion, deconditioning, gait/balance problems, and unaware of safety needs. Further review revealed interventions included to review information on past falls and attempt to determine cause of falls and record possible root causes (initiated 1/16/19), physical therapy to evaluate and treat as ordered or PRN (as needed) (initiated 1/16/19), encourage resident to wear nonskid footwear when up out of bed (initiated 1/25/19), encourage resident to not sit in the floor if visually seen attempting to seat self (initiated 1/16/19), be sure the call light is within reach and encourage the resident to use it for assistance as needed (initiated 01/16/2019), and visual reminder to call for assistance (initiated 8/18/20). Additional review revealed an update on 4/2/22 to continue current interventions. A review of an incident report, dated 4/2/22 at 10:30 p.m., revealed it was completed by Licensed Practical Nurse (LPN) DDD. An unwitnessed fall occurred in the resident's room. A certified nurse aide (CNA) found the resident on the floor beside the end of the bed. R#69 stated the resident slid off the edge of the bed onto the floor. There were no injuries at the time of the incident and no complaints of pain. A head-to-toe assessment was completed, and they instructed R#69 to use the call light for assistance with activities of daily living (ADLs). The resident verbalized understanding, and the family and physician were notified. Further review revealed that on 4/6/22, the Assistant Director of Nursing (ADON) recommended to continue with the current interventions. The root cause of the fall was not identified. An interview on 7/20/22 at 2:10 p.m. with LPN DDD revealed that when a fall occurred, nursing staff completed a head-to-toe assessment, checked vital signs, notified the physician and family, completed neurological (neuro) checks if the fall was unwitnessed or if the resident hit their head, completed an incident report, a change of condition, and something else, but the LPN could not remember off the top of their head. LPN DD stated staff did not identify root cause after a fall, and she thought the physician would identify that. LPN DDD stated she did not know who was responsible for identifying fall interventions, but she stated that nursing staff should review care plans for current fall interventions when they investigated a fall. LPN DDD stated she did not remember R#69's fall that occurred on 4/2/22 that she completed the incident report for. However, LPN DDD stated it would not have been an appropriate intervention to educate or remind R#69 due to R#69's impaired cognition, and that it was an error on her part to tell R#69 to use the call light when the resident needed assistance. LPN DDD said she did not know who identified the intervention after the fall on 4/2/22, and she did not remember what, if any, interventions were currently in place. LPN DDD stated she believed it was a team of people, but she was unsure who reviewed falls. They would adjust interventions as needed, but she was not sure how often that occurred. LPN DDD stated new interventions were reported by outgoing nursing staff to on-coming nursing staff, and it would be put on the 24-hour report. LPN DDD stated she thought staff should have documented follow-up documentation post fall for three days. LPN DDD stated she was not aware that R#69 had had multiple falls. An interview on 7/21/22 at 9:08 a.m. with the Assistant Director of Nursing (ADON) revealed that after a fall occurred, staff should take care of the resident first, complete a risk management, change of condition, neuro checks, complete post-fall documentation for 72 hours after the fall occurred, get vitals, notify the family and physician if there was an injury, and notify the Director of Nursing (DON). The ADON stated all falls were discussed during morning meeting and that was when root cause and care plan interventions were identified. The ADON stated care plan interventions were identified by everyone present in morning meeting. The ADON stated a unit manager, wound care nurse, Staff Development Coordinator (SDC), ADON, DON, Administrator, MDS Coordinator and therapy participated. The ADON stated R#69 had a low BIMS score, and the resident's ability to retain information was not great. The ADON stated a fall mat at the bedside had not been explored for R#69 due to the resident not being educatable or able to retain information. The ADON stated the root cause of a fall should have been identified. The ADON stated the resident stated falling out of the bed on 4/2/22, but the mattress was never examined or any potential interventions for the mattress. She did not try to figure out what R#69 was doing in the bed prior to the fall that may have contributed to R#69 slipping out of bed, but it should have been. The ADON verified that post-fall documentation after the fall on 4/2/22 was not completed and it should have been. She stated staff had been trained on the falls process but was unable to state how often or when the last one was completed. She stated staff would benefit from additional education. The ADON agreed the care plan intervention she put into place on 4/2/22 to continue current interventions was not appropriate since the current intervention already in place was not appropriate or person-centered. The ADON stated the interventions that were in place at the time the fall occurred on 4/2/22 were not put into place by her and were prior to her employment. The ADON stated that at the time of the fall on 4/2/22, she had only been employed with the facility for a couple weeks and she had learned more since that time. The ADON stated she had not completed any trainings related to falls and the process/protocol, and she was not aware of any trainings that had been completed in the facility for other staff about the fall's process/protocol. A review of an incident report, dated 6/27/22 at 10:07 a.m., revealed it was completed by the Assistant Director of Nursing (ADON). An unwitnessed fall occurred in the resident's room. Staff did not witness the fall but observed R#69 holding their hand. When asked, R#69 stated they fell . Per the incident report, the physician and Director of Nursing were notified. No orders were received and there were no injuries observed at the time of the incident. The ADON identified an intervention of more frequent rounds when the resident was in their room. Additional documentation on the incident report later in the day noted R#69 to have bruising/swelling to their left hand, tenderness on palpation, complaints of pain to touch, and complaints of right rib pain on palpation. R#69 stated they had fell but was unable to recall events, or when the fall occurred. The physician was notified and ordered an x-ray which revealed R#69 had a fractured pinky. The root cause of the fall was not documented as identified. A review of a physician progress note, dated 6/29/22, revealed the physician was asked to evaluate the resident due to a recent fall and x-rays were ordered. All x-rays were normal except for the left hand. An acute fracture involving the left 4th distal metacarpal and 5th mid metacarpal with mild displacement was diagnosed . An interview on 7/20/22 at 1:35 p.m. with CNA DD revealed although he was not familiar with R#69 and the resident's fall interventions, he would not know what fall interventions were in place for any resident unless a nurse informed him. CNA DD stated there was a binder located at the nurse's station with resident care plans. CNA DD stated there had been times when he was aware that a resident was a frequent [NAME], and he would request a fall mat and inform the charge nurse that a mat had been placed by the bed. CNA DD was unable to answer why a CNA would identify the need for a fall mat and not nursing or administrative staff. CNA DD said that CNA staff were not involved during the falls investigation process and nursing staff did not ask CNAs about a resident after a fall occurred. An interview on 7/20/22 at 2:04 p.m. with CNA CCC, who provided care for R#69, revealed R#69's mental cognition was in and out and the resident was usually in another world cognitively. CNA CC stated education would not have been an appropriate fall intervention for R#69. CNA CCC was not aware if R#69 was a fall risk or what current fall interventions were in place. An interview on 7/20/22 at 2:38 p.m. with the Director of Nursing (DON) revealed when a resident fall occurred, the staff who found the resident should notify a nurse, and the nurse should take vitals, complete a head-to-toe assessment, and assess for any injuries. The DON stated if the resident had any injuries, those would have been treated first, and staff would make sure to notify the physician and family, complete a change of condition, assessments, complete neuro checks every 15 minutes for four hours, then every 30 min for 72 hours, and every shift for three days post fall. The DON stated the floor nurse identified a new fall intervention and then that intervention was discussed the following morning during the clinical meeting. The DON stated the ADON and MDS Coordinator were responsible for updating the care plan. The DON stated the ADON was also responsible for reviewing the fall risk management report (incident report), to ensure that a new fall intervention was put in place, a change of condition was completed, the care plan had been updated, and there was documentation every shift for 72 hours post fall. The DON stated it was the responsibility of the floor nurses to identify root cause, and they should know that was their responsibility. The DON reviewed the post-fall documentation on the resident's falls that occurred on 4/2/22 and 6/27/22 and verified there was no post-fall documentation after either fall. The last one that was completed was in September 2021. The DON stated R#69 would not have benefited from education or reminders as fall interventions and verified that the care plan intervention implemented after the fall that occurred on 4/2/22 was not appropriate. The DON stated all the interventions to educate or remind the resident were inappropriate. An interview with LPN JJ (Staff Development Coordinator) on 7/20/22 at 4:04 p.m. revealed that after a fall occurred, nursing staff should assess the resident, check vitals, notify the family and physician, treat any injury, complete a change in condition, complete a fall risk assessment, and complete an incident report. LPN JJ stated there was a list at the nurse's station staff could refer to with all the steps that needed to be completed after a fall. LPN JJ stated that CNAs and nurses on shift that a fall occurred collaborated on possible fall interventions. LPN JJ stated that all falls were supposed to be reviewed during morning clinical meeting post fall, and he believed that root cause was identified during those meetings. LPN JJ further stated he thought the MDS Coordinator was responsible for updating the care plan but he was not certain. LPN JJ stated CNA staff had access to the Kardex that listed current interventions, and any changes during the day or night shift were communicated at shift change. LPN JJ stated R#69 was a fall risk, but he was not sure of what fall interventions were currently in place for the resident. LPN JJ stated R#69 was not cognitively intact and would not have been able to retain any information from reminders or educating, and that would not have been an appropriate intervention. LPN JJ stated R#69 was at the nurse's station multiple times a day asking where the resident's room was. An interview on 7/20/22 at 4:46 p.m. with Temporary Nurse Aide (TNA) II who provided care for R#69 revealed he was familiar with R#69 but he was not sure if the resident was a fall risk or what current fall interventions were in place for the resident. TNA II stated he would have to ask a nurse about what fall interventions were in place for a resident. TNA II stated that nurses did ask CNA staff about any change in residents' behavior at times. An interview on 7/20/22 at 4:53 p.m. with TNA EEE who provided care for R#69 revealed she thought the resident was a fall risk, and she knew this through observation. TNA EEE stated she had never been told by any staff about the resident's falls status, and residents that were a fall risk were not distinguished in any way. TNA EEE stated R#69 wore sticky socks, and staff had the resident sit at the nurse's desk. TNA EEE stated R#69 was not a cognitively intact resident and would not remember anything staff told the resident. TNA EEE was not familiar with R#69's care plan and did not have access to care plans. An interview on 7/21/22 at 1:03 p.m. with the Administrator revealed that after a fall staff should complete documentation if the fall was witnessed or unwitnessed, check for injuries, and put in a plan to prevent future falls, and notify the physician, family, DON, and Administrator. The Administrator stated she did not feel interventions to remind or educate R#69 were appropriate due to the resident's impaired cognition. The Administrator stated staff should have explored other more appropriate interventions after the fall that occurred on 4/2/22.

Based on record review and staff interviews, the facility failed to ensure that the staff designated as Dietary Manager (DM) was a Certified Dietary Manager (CDM) or had a similar food service management certification or degree. This had the potential to affect the 101 residents receiving an oral diet. Findings include: A policy was requested but not provided before the end of the survey related to the qualifications for the Dietary Manager. During a tour of the kitchen and corresponding interview on 7/18/22 at 12:00 p.m., Dietary Manager Supervisor (DM) XX confirmed having a Serv Safe Certification and a General Food Dietary Training Certificate from the State of Alabama. When the surveyor inquired if the certificate for the General Food Dietary Certification was an equivalent to the CDM Certificate, the DM answered yes. During a later interview on 7/20/22 at 10:13 a.m., DM XX reported that she started at the facility on June 30, 2022. She had only been employed for two weeks at the facility as the Dietary Manager. She retracted her statement about having a certification that was equivalent to the CDM. She reported that she was not CDM certified. She reported not enrolling in the class at this time for the CDM. In an attempt to follow up to see if DM XX received any onsite training or supervision from any Certified Dietary Manager or Registered Dietician, the Certified Dietary Managers and Registered Dietician staff who were present during the survey reported not providing training to DM XX during her two weeks of employment at the facility. In an interview on 7/20/22 at 11:09 a.m., CDM VV confirmed not providing any onsite training with the newly hired DM XX. She stated that the plan was for DM XX to come over to her facility and work with her. CDM VV stated that this training never occurred. During an interview on 7/20/22 at 11:21 a.m., CDM YY confirmed and verified not providing any onsite training for DM XX. CDM YY stated that the new protocol was for him to begin working with DM XX. During an interview on 7/20/22 at 11:25 a.m., Corporate CDM ZZ confirmed and verified not providing any onsite training to DM XX. He confirmed providing training that day to DM XX. When the surveyor inquired how many times he visited the facility to provide any oversight training, CDM ZZ reported only visiting the facility twice; once to drop off an item and the second time for only three hours. This occurred within the last three weeks. He stated that the plan was to get the newly hired DM XX in the Certified Dietary Manager Training Course (CDM). In an interview on 7/20/22 at 3:10 p.m., Administrator AAA reported being unaware that the newly hired DM XX was not a CDM. Administrator AAA reported the facility policy was that the DM was supposed to be certified upon hire. The Administrator provided conflicting information, stating that she was informed prior that DM XX was scheduled to take the CDM two weeks ago. She was not aware that DM XX did not have any training. She reported speaking to DM XX and that DM XX had informed her that she was studying to take the CDM exam. The Administrator confirmed being misinformed and was unaware that the Corporate CDM ZZ (who is the Contract Manager) was not onsite at the facility to provide training to DM XX. She reported that Corporate CDM ZZ was in the building one day to do an audit and inventory. It was during her first two weeks of working. He was there for only two days. She did not recall him being in the building all day. She had no record of him providing training to DM XX. In an interview on 7/21/22, Director of Nursing (DON) CC reported that her expectation was that the Dietary Manager was certified and met the requirement for the position in order to ensure residents' food items were good. She reported being unaware until yesterday that DM XX was not certified. In an interview on 7/21/22 at 11:17 a.m., Register Dietician (RD) NN confirmed and verified not providing onsite training for the newly hired DM, DM XX. She was not providing a check-off list of training for DM XX and was not serving as DM XX's supervisor. RD NN reported visiting the facility at least once a week. RD NN reported that on her days visiting the facility, the protocol for her visits was to complete clinical assessments for each resident. As the RD, her onsite visit included auditing the tray lines and auditing the textures of the food being prepared for the resident meals and the residents' diets. RD NN reported being aware of the newly hired DM's past work experience as a Food General Manager in a restaurant. Because of this information, she did not provide oversite training with the DM. RD NN reported that she was under the impression that the Contract Corporate Dietary Office Management and Corporate CDM ZZ was providing any training to new employees for the company. She was informed that CDM VV, who came to the facility during the survey on Tuesday 7/19/22, and Corporate CDM ZZ, who reported to the building on 7/20/22, was doing a follow-up training.

Based on interviews, observations, and review of facility menus, the facility failed to ensure that the menu was followed to ensure appropriate nutrition for the residents. This deficient practice had the potential to affect the 101 residents receiving an oral diet in the facility. Findings include: During an interview and observation of the posted calendars/menus on 7/19/22 at 1:44 p.m. with a visiting Certified Dietary Manager (CDM), CDM WW in the kitchen, CDM WW confirmed that the facility dietary staff had the wrong menu calendars posted. CDM WW stated staff should be following the spring instead of the fall menu. She reported visiting the facility today in order to assist the newly hired Dietary Manager (DM), DM XX during the survey. An observation in the kitchen of the lunch meal on 7/18/22 at 12:20 p.m. revealed the following food items on the steam table being plated for the residents: hot dogs with chili, baked beans, cole slaw, and banana bread. The items were sent out on the hall lunch tray and served in the dining room to the residents. A review of the Week-At-A-Glance Spring 2022 Week 3 menu revealed that the following food items were to be served for the resident's lunch on 7/18/22: choice of entrée, a bun, baked beans, and baked cookies. In an interview on 7/18/22 at 1:30 p.m., Cook/Dietary Aide (DA) LLL confirmed changing the food items. DA LLL reported being unaware that she was not following the menu. She reported that the facility was on the Week-At-A-Glance Fall Week 2 menu. After requesting a copy of the menu calendar from the dietary staff on 7/18/22, DA LLL provided a copy of the Week-At-A-Glance Fall Week 2 instead of the Week-At-A-Glance Spring Week 3 menu. Later the next day on 7/19/22, the facility provided copies of the menu calendars for the entire year, which included the Week-At-A-Glance for Week (Fall Week 2, Spring Week 3, and Summer Week 4). An observation in the kitchen on the tray line on 7/19/22 at 8:55 a.m. revealed the resident breakfast meal consisted of the following food items: grits, bacon, egg, and toast. There was no milk provided for the residents' breakfast meal. A review of the breakfast menu for Week-At -A-Glance Spring 2022 Week 3 revealed that the following food items should have been served for breakfast: egg of the day, sausage, French toast, cereal of choice, juice of choice, and milk. During an interview on 7/19/22 at 9:20 a.m., DA LLL stated that the kitchen did not have any milk. She stated that the truck had not made a delivery today. DA LLL stated she had not been instructed on what to do if there was no milk for residents. DA LLL provided no explanation for why the wrong food items were served for breakfast. An observation of the resident lunch meal on Tuesday, 7/19/22 at 1:00 p.m. revealed food served for the resident lunch included lemon pepper chicken, collard greens, apple sauce, peas and carrots mixed, and salad instead of the food items listed on Week-At-A-Glance Spring 2022 Week 3 menu. According to the Week-At-A-Glance Spring 2022 Week 3 for Tuesday, 7/19/22, the food items listed to be served for lunch were shrimp alfredo, garlic bread sticks, cherry cobbler, and cucumber and tomato salad. Interview with DA/Cook MMM on 7/18/22 at 1:45 p.m. revealed the reason why the menu was not followed for the lunch meal on 7/19/22 was because some of the food items for the lunch meal were substituted for last night's dinner meal (on 7/18/22). DA MMM stated the shrimp alfredo and garlic bread (food items scheduled for Tuesday, 7/19/22 lunch menu) were substituted for last night's meal. She reported that she could not serve the original Monday dinner meal based on the Week-At-A-Glance due to having a shortage of food items in the kitchen. In an interview on 7/20/22 at 9:41 a.m., Interim Administrator AA reported being unaware of the milk not being available and dietary staff being out of the milk products and groceries. She reported having a prior problem with the dietary staff running out of meals due to a shortage of food items. Interim Administrator AA reported becoming involved and speaking with some of the dietary staff about the previous issue with a suspected problem of food items being taken out or removed from the kitchen. The corporate office became involved and assisted with monitoring of grocery orders. Interim Administrator AA reported that her expectation was that the correct menu should be posted every day. In an interview on 7/20/22 at 3:10 p.m., Administrator AAA reported that her expectations were that the menu was posted in legible font size (meaning visible to residents) and that if the dietician (meaning dietary staff) changed the food items on the menu, then the dietary staff should post that menu. During the survey, a policy was requested related to following menus and there was no policy provided by the facility by the end of the survey.

Based on observations, interviews, and facility policy review, the facility failed to ensure proper labeling of food items, storage of food items, and discarding of expired food items; failed to ensure hair nets were available for use by dietary staff; and failed to ensure one floor ice milk chest freezer, one low temperature dishwasher, and one grease trap were operating properly. This had the potential to affect 101 residents who received an oral diet. Findings include: 1. A review of the facility policy titled, Procedures for Dating and Labeling, Items for Storage areas, Coolers, and Freezers, dated [DATE], revealed, Foods for meal service for same day service must be labeled and dated. Product name and date must be on the foods. All opened items in the storage area must have an opening date and use by date. Do not label the lid from a container, put label on the side of the container. Further review of the policy revealed Left-over foods must be discarded after 72 hours or 3 days. Continued review of the policy revealed All items in the storage area, cooler freezer, and kitchen area must have dates and labels on them. Observation in the kitchen of reach-in refrigerator #1 on [DATE] at 9:15 a.m. revealed the following food items were not dated and/or labeled or not stored properly, and the expired foods were not discarded: - one open bag of shredded cheese with no open date - one large pan of chipped bacon with a dark greenish substance growing on it stored in a deep aluminum waiter pan - bologna wrapped in plastic wrap, part of the commercial wrapping was removed, revealing no opening or expiration date - one cooked boiled egg in a cup with no expiration date - nine small bowls of gelatin covered with plastic wrap with no opening or expiration date - eight individual bowls of chicken soup (removed from the original container) stored in small plastic storage containers not dated or labeled - eight cups of nectar thick liquid (removed from the original container) stored in plastic cups not dated or labeled Observation in the kitchen of reach-in refrigerator #2 on [DATE] at 9:16 a.m. revealed no thermometer in the refrigerator to monitor the temperature to ensure the food items were kept at the recommended temperature and food items were not dated, not labeled, and not stored properly. Additionally, expired foods were not discarded. These food items included the following: - six chicken breast chunks in a large aluminum waiter pan with the top covered with plastic wrap, not dated or labeled (no cook date) - beets stored in a large aluminum waiter pan with the top covered with plastic wrap, undated and unlabeled - lunch meat turkey slices stored in a small aluminum pan covered with plastic wrap with no open date and no expiration date - carrots stored in a small aluminum pan covered with plastic wrap, undated and no expiration date available - tomato paste stored in a large plastic container undated and no expiration date - a large pan containing cooked hot dogs stored in a large aluminum waiter pan, covered with plastic wrap, undated and with no expiration date - cooked chicken noodle soup stored in a large plastic (removed from the original container), not dated - individual cheese slices stored in a dirty container, undated and no expiration date available; dark brown and white particles coated the bottom of the container - two small puddings stored in plastic storage cups (removed from the original container), not dated or labeled - a salad on a plate covered with plastic wrap, not dated and not labeled - broccoli stored in a small plastic container, undated and not labeled - spinach stored in a large plastic container with a lid labeled as mushroom, with a date of [DATE] - cheese sauce stored in a large plastic container (removed from the original container,) not dated or labeled - ,d+[DATE] stick of butter not completely covered and not dated Observation in the kitchen of reach-in refrigerator #3 on [DATE] at 9:18 a.m. revealed the following food items not dated and not labeled or not stored properly, and with expired foods not discarded: - a container of whipped topping, no open date (with no expiration date as it was removed from the original container) - ,d+[DATE] block of cheese wrapped in plastic wrap, not dated - a large bowl of Jell-O stored in a plastic container with the top covered with plastic wrap (removed from the original container) - five spoiled tomatoes stored in a large box with two large watermelons - ,d+[DATE] bag of mixed salad that was spoiled, not dated - a large cucumber, spoiled, lying on the top rack in the refrigerator - 32 small bowls of pears stored in plastic bowls (removed from the original container), not dated During an interview on [DATE] at 9:58 a.m., Dietary Aide/Cook (DA) LLL stated she had received training on labeling and dating, food storage, and discarding of expired food. She stated that she was the cook for the morning shift. Per the DA LLL, she was not aware of food being unlabeled and undated until doing the observation today with the surveyor. She stated there had always been a problem with the weekend staff not labeling and dating food. The DA LLL stated she had complained about this before to the former Dietary Manager. Per DA LLL, she had spoken with the newly hired Dietary Manager about the problem. DA LLL confirmed that the white speckle food items in the bottom of the container containing the cheese slices were white cheese food particles. She described the dark green colored substances in the pan of chipped bacon as mold. During an interview on [DATE] at 10:01 a.m., DA NNN stated he worked for the facility at least one and a half months. He reported receiving some training on labeling and dating but training was from DA OOO and not from the Dietary Managers. He described the training as not formal training. In an interview on [DATE] at 1:13 p.m., DA RRR reported receiving training on labeling, dating of food, and food storage. DA RRR stated he was aware of expired food being discarded but was not sure of the date and timeframe leftover food should be discarded. In an interview on [DATE] at 3:10 p.m., Administrator AAA reported that her expectation was that food items were dated. In an interview on [DATE] at 1:00 p.m., DA QQQ stated he was hired in 2021 and confirmed receiving previous training on dating and labeling food items. DA QQQ stated he also received a refresher training this past Tuesday, [DATE]. During an interview with the Director of Nursing (DON) on [DATE] at 10:35 a.m., the DON reported that her expectation was that kitchen staff followed the dietary policy. The DON continued to state that her expectation was that food items were labeled, dated, and stored correctly. 2. During a tour of the kitchen, which began on [DATE] at 9:10 a.m., Dietary Aides (DA) RRR and MMM were observed in the kitchen without hair nets. The staff were observed assisting with prepping food items for lunch. During an interview on [DATE] at 9:10 a.m., DA MMM reported that the facility had been out of hair nets for the last two days. In an interview on [DATE] at 1:00 p.m., Dietary Manager (DM) XX confirmed she was aware that the kitchen staff did not have hair nets for the last two days. Per DM XX, her plan was to purchase new hair nets today but was not able to purchase the hair nets on her way to work. She stated that she had planned to purchase the hair nets from a local retail store. In an interview with the Administrator on [DATE] at 3:10 p.m., the Administrator reported being unaware of the problem with the staff not wearing hair nets. Administrator AAA reported that her expectation was that the staff wore hair nets in the kitchen. Administrator AAA indicated they had now received hair nets from other facilities. 3. An observation on [DATE] at 9:22 a.m. with Dietary Aide/Cook DA LLL revealed a large floor model chest cooler/refrigerator (used as a milk freezer) located in the kitchen area. A continued observation of the floor model chest refrigerators' latch doors revealed broken latches, causing the door to not properly close. A close observation of the refrigerated chest door revealed a large gap on the side of the door preventing the door from being sealed tightly. On the bottom floor of the refrigerator was a dark thick liquid substance with food debris and lumps of a darkish brown substance. Observation of the milk cartons in the chest freezer with DA LLL revealed a total of 35 chocolate milk cartons, 101 2% cartons of milk, five Mighty Shakes, and four whole milk cartons. The milk was cool to touch and not very cold. DA LLL removed the milk from the chest. The milk was discarded by Dietary Manager (DM) XX when she arrived at work. Further observation revealed no thermometer in the chest refrigerator to monitor the temperature of the milk. In a later interview on [DATE] at 11:47 a.m. with the Maintenance Supervisor and DM XX, the Maintenance Supervisor and DM XX described the dark liquid substances as mold and mildew on the floor of the floor model chest freezer. Both reported being unaware of the condition of the freezer. 4. An observation was conducted in the kitchen on [DATE] at 9:23 a.m. of DA OOO operating the facility's low-temperature (temp) dishwasher with no sanitation solution in the large bucket. The dishwasher was not meeting the minimum wash temp of 120 degrees Fahrenheit (F). DA OOO reran the dishwasher three times and the highest the wash temperature reached was 110 degrees F. During the three attempts, the rinse temperature only reached 110 degrees F which was less than the required 140 degrees F. Additionally, during the sanitation cycle the maximum temperature obtained was 118 degrees F which was less than the required 140 degrees. DA OOO stated there were problems with the dishwasher wash cycle and not registering the required temperatures at times. DA OOO stated he was unaware of whether the dishwasher was a low temperature or a high temperature dishwasher. He stated that manufacture information related to the dishwasher operating cycles was not provided to him. Per DA OOO, the rinse temperature sometimes got up to 160 degrees F, and he was not sure of the sanitizer. He stated it may be 130 degrees F or 138 degrees F. He stated that morning it was 138 degrees F for the rinse and sanitizer. He stated he logged the dishwasher temperature every day. A review of the dishwasher revealed a label which listed the dishwasher as a low temperature dishwasher. Review of the manufacture guidelines revealed the dishwasher recommended temperatures for the wash cycle be at 120 degrees F, rinse cycle at 140 degrees F, and sanitizer at 140 degrees F. During an interview on [DATE] at 11:00 a.m., DM XX stated she was not sure of the model/type of dishwasher. She described the dishwasher as a regular dishwasher and was unsure what a low-temp or high-temp dishwasher was. During an interview on[DATE] at 3:10 PM and at 4:14 p.m., Administrator AAA stated she was unaware of the dishwasher not working. She stated that the dietary staff informed her that the dishwasher needed more solutions, and she was not aware that as of today the dishwasher remained broken. Administrator AAA stated that her expectation was that staff continue to notify her if the problem with the dishwasher continued to exist. 5. An observation in the kitchen on [DATE] at 1:11 p.m. with the Maintenance Supervisor and DM XX revealed a puddle of dirty dark brown water on the floor, protruding from the grease trap. A continued observation revealed thick, dark, blackish, greasy substances with dirt and debris. In an interview at the time of the observation, the Maintenance Supervisor stated that this problem existed prior to [DATE]. DM XX reported being aware of the problem and reported that Administrator AAA was aware. During an interview on [DATE] at 4:14 p.m., Administrator AAA stated she started working as the Administrator on [DATE]. She stated she was made aware of the problem of a leakage from the grease trap in the kitchen. Per the Administrator, in [DATE], a service company was contacted to fix the problem. The root cause of the problem was clogged pipes, and the service company reported that pipes needed to be unclogged. The service company did come out to unclog the pipes and pump out the grease trap. The Administrator AAA stated the problem was resolved in [DATE]. She stated she toured the kitchen two weeks ago and was unaware of a continued problem with the grease trap.

Based on observations, interviews, and review of the facility policy, the facility failed to maintain one of two facility dumpsters in a sanitary condition by ensuring the dumpster had fitted lids. Findings include: A review of the facility policy titled, Food Related Garbage and Refuse Disposal, revised October 2017, revealed Food-related garbage and refuse are disposed of in accordance with current state laws. 1. All food waste shall be kept in containers. 2. All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. Further review of the policy revealed 5. Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests. Continued review of the policy indicated 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. An observation on 7/18/22 at 11:58 p.m. with Dietary Manager (DM) XX, revealed the dumpster lid was unsecure and not tightly closed. The dumpster had a large gap, resulting in a large open space causing the trash not to be secure inside and allowing exposure to insects and rodents. Flies were observed swarming around the dumpster. The newly hired DM XX offered no explanation for the dumpster lid not being tightly fitted or closed. Continued observations of the dumpster were conducted throughout the survey on 7/19/22 at 10:13 a.m. and 7/20/22 at 11:59 a.m Each observation revealed the dumpster lid remained not tightly fitted and exposing a wide gap. During an interview on 7/20/22 at 9:41 a.m., Interim Administrator AA reported being made aware of the condition of the dumpster lid not tightly fitting by their visiting DM WW. Interim Administrator AA stated she had sent notifications to the company that handled the dumpster yesterday afternoon to have the dumpster replaced. She stated that Maintenance was responsible for ensuring that the dumpster lid was secure and for monitoring the dumpster for any problems. She further stated that a tightly fitted lid on the dumpster was important to prevent critters and insects from having access to the dumpster. During an interview on 7/20/22 at 3:10 p.m., Administrator AAA, stated that Maintenance was responsible to ensure the dumpster lid was tightly fitted to ensure rodents did not have access to the dumpster. The Administrator reported not being able to recall the last time she observed the dumpster area. In an interview with the Director of Nursing (DON) on 7/21/22 at 10:35 a.m., the DON reported not visiting the dumpster area. She stated her expectation was that the dumpster lid remained secure (meaning tightly fitted) to prevent access to any pests and flies.

Based on record review, and staff interviews the facility failed to accurately assess one resident (R) #33 for contractures of three sample residents, who was transferred improperly resulting in actual harm due to bilateral femur fractures. Findings include: Record review revealed that R#33 was originally admitted to the facility on [DATE] and the resident was discharge home, against medical advise on 9/7/18. Review of the hospital history and physical dated 1/27/16 revealed that R#33 had the following Diagnosis: [REDACTED]. The physician noted the resident had lived at home and was bed-bound for the past five years. Review of the facility Nursing Evaluation dated 2/2/16 under Contractures/Limited Range of Motion (ROM) excluding fractures: that the resident was checked as having of the arm (including shoulder and elbow) and leg (including hip or knee). Review of R#33 Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed as requiring extensive assist, by two persons, for bed mobility, transfer, dressing and toilet use. Walking did not occur during the look back period and the resident was not assessed with [REDACTED]. Review of the Annual MDS assessment dated [DATE] revealed the resident was assessed for total dependence, by two persons, for transfer. The resident was assessed for total dependence, by one person, for bed mobility, dressing, toilet use and personal hygiene. The resident was not assessed as having impairment of the upper or lower extremities. Review of the hospital emergency room (ER) Physician Documentation, dated 9/5/18, revealed the resident is contracted in both the left and right knee. The resident was noted to have bilateral femur fractures. Review of the hospital Nurses Report dated 9/5/18 revealed: Assessment- unable to straighten patient's legs for recommended bilateral knee immobilizer. Legs are contracted and unable to fit appropriately into knee brace. Review of the facility investigation revealed an interview with Licensed Practical Nurse (LPN) JJJ on 9/10/18 stating that she was called to the resident's room by Certified Nursing Assistant (CNA) KKK and that when she came into the room the resident was lying on the floor with no Maxi Lift securing her. She stated that she assessed the resident and found no injuries. She stated the resident commented that her knees were hurting. Because she didn't think the resident was injured she did not document the incident. However, the resident has [MEDICAL CONDITION], is very contracted in the legs. A telephone interview on 10/5/18 at 1:01 p.m. with the MDS Coordinator, Registered Nurse (RN) III revealed that she had conducted the Annual MDS assessment for R#33 dated 7/17/18. Further interview with RN III revealed that the resident did have contractures of both knees although there was no documentation by the physician. She stated that due to the resident's cognitive status, the contractures had no impact on her Activities of Daily Living (ADL) therefore she did not assess the resident as having impairments to her lower extremities. She confirmed the resident was not care planned for contractures. Review of R#33's care plan, dated as last updated 7/31/18, revealed that contractures were no care planned. Cross refer to F689

Based on record review and staff interviews the facility failed to followed the care plan related to use of a mechanical lift for one resident (R) #33 who was transferred improperly, without the use of a mechanical life, resulting in actual harm due to bilateral femur fractures of three sampled residents. Findings include: Review of R#33's care plan, last revised 7/31/18, revealed a focus area: resident requires max assist with all ADLs (Activity of Daily Living). She is non-ambulatory but prefers to stay in bed most of the time. The resident will get up to a Geri chair at times. Resident is incontinent of bowel and bladder. Interventions: Transfer: The resident requires Mechanical lift and max assist of two for transfers but is generally bedfast except for showers. review of the resident's medical record revealed [REDACTED]. Review of a Facility Incident Report dated 9/5/18 revealed that R#33 had an injury of unknown origin on either 8/22/18 or 8/23/18 resulting in bilateral fractured femur and was sent to the emergency room . Review of the facility investigation dated 9/18/18 regarding Allegation of Neglect revealed that the Certified Nursing Assistants (CNA)s caring for R#33 reported lowering the resident to the floor on either 8/22/18 or 8/23/18. They reported this to the Licensed Practical Nurse (LPN) JJJ at this time. LPN JJJ reported that she performed an assessment and did not believe the resident suffered an injury and therefore did not document this incident in the resident's chart or report to management. The investigation further states that between 8/22-23/18 and 8/30/18 the resident did not exhibit any signs or symptoms of a fracture and did not complain of pain in her lower extremities. Further review of the investigation revealed an interview with LPN JJJ on 9/10/18 when she stated that she was called to the resident's room by CNA KKK. When she came into the room the resident was lying on the floor with no Maxi Lift securing her. She stated that she assessed the resident and found no injuries. She stated the resident commented that her knees were hurting. However, the resident has [MEDICAL CONDITION], is very contracted in the legs. An interview on 9/24/18 at 5:48 p.m. with CNA KKK revealed that she had been employed at the facility for about one month. She revealed that she had been assigned to R#33 either 8/22/18 or 8/23/18 when the incident occurred which was after her week of orientation. She stated that R#33 expressed a desire to get out of bed. She further revealed that LPN JJJ had been consulted as to if the resident could get out of bed and was told she could get up. CNA KKK then asked CNA LLL (who was also new to the facility) to assist her to get the resident up. They attempted to get the resident up to the chair without using a lift and they found the resident was too heavy, therefore they lowered her to the floor. They notified LPN JJJ who came into the room, looked at the resident and said the resident is fine and put her into the chair. She stated that LPN JJJ did not assess or touch the resident. The resident was complaining of pain in her knees. When asked how the CNA's should know how to transfer someone, she stated that this information would be found on the electronic record Kardex although they were not shown how to check the electronic Kardex rather only how to chart in the electronic record. She stated that after this incident the facility in-serviced the CNA's on how to check the Kardex to make certain the resident received the appropriate care and transfers. She confirmed that the Kardex stated the resident should be transferred using a lift and they did not use a lift to transfer the resident. An interview on 9/24/18 at 6:05 p.m. with CNA LLL revealed that CNA KKK had asked her to help getting R#33 out of bed. They were both new and didn't realize the resident needed a mechanical lift to get up. They tried to transfer the resident without a lift and that they could not hold the resident up long enough to get her to the chair. They eased her to the floor and alerted LPN JJJ. She further revealed that LPN JJJ did not assess the resident and told them to get R#33 into the chair. She had not been trained on using the electronic record to check the Kardex for care of the residents, where the documentation was located for appropriate transfer of residents. She stated the facility trained all the CNAs after the incident was discovered and that the resident should have been transferred using a lift and they had not used a lift to transfer the resident. An interview with the Administrator and the Director of Nursing on 9/24/18 at 6:15 p.m. revealed that after the investigation, which revealed the CNAs were unsure how to access the electronic Kardex, then all CNAs were trained on using the electronic medical record and Kardex for ADL instructions. Cross refer to F689

Based on record review, staff interviews and review of the Georgia Board of Nursing Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, review of the police report, the facility failed to ensure that licensed nurses followed procedures for assessing residents who had a fall (eased to the floor) due to an improper transfer and to accurately relay to the Physician X-ray findings of a fracture for one resident (R) #33, resulting in actual harm due to bilateral femur fractures, of three sampled residents. Findings include: Review of the Georgia 410-10-.02 Standards of Practice for Licensed Practical Nurses (LPN) 1. (a) Participating in patient assessment activities and the planning, implementation, and valuation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulation. 1. (e) Participating in the management and supervision of unlicensed personnel in the delivery of patient care. 410-10-.03 Definition of Unprofessional Conduct. 2. (a) Using inappropriate or unsafe judgement, technical skill or interpersonal behaviors in providing nursing care. 2. (g) failing to take appropriate action to safeguard a patient's welfare. 3. Documentation (a) Failing to maintain a patient record that accurately reflects the nursing assessment, care, treatment, and other nursing services provided to the patient. Review of the facility's Skill Nursing, Clinical Standard of Practice, Subject: Fall Management, Definition: 7. Staff lowers resident to floor. Practice Guidelines: 4. If a fall occurs, the licensed staff assesses for injury, immediately investigate the cause using the Fall Investigation Tool and determines the interventions to prevent further occurrences. The Licensed Nurse must complete the incident report, provide neuro assessments as per protocol. Complete a SBAR (Situation, Background, Assessment, Recommendation) for a change in condition. The care plan is updated to reflect changes in the resident's status, new interventions in place to prevent re-occurrence of the fall or minimize potential injury. 5. The physician and family are notified. Record review revealed that R#33 was originally admitted to the facility on [DATE] and was discharged home, against medical advice, on 9/7/18. Review of the hospital history and physical dated 1/27/16 revealed that R#33 had the following Diagnosis: [REDACTED]. The physician noted the resident had lived at home and was bed-bound for the past five years. Review of the facility Nursing Evaluation dated 2/2/16 under Contractures/Limited Range of Motion (ROM) excluding fractures: that the resident was checked as having of the arm (including shoulder and elbow) and leg (including hip or knee). Review of the facility Investigation regarding allegation of abuse dated 9/18/18 revealed that on either 8/22/18 or 8/23/18, two Certified Nursing Assistants (CNA) KKK and LLL attempted to transfer R#33 from the bed to a chair without using a mechanical lift. The CNA's were not able to transfer the resident and they lowered her to the floor. The CNAs notified Licensed Practical Nurse (LPN) JJJ and asked her to please check the resident. Further review of the Investigation Report revealed an interview with LPN JJJ on 9/10/18 stating that she did go into the room and check the resident. The resident did complain of leg and knee pain. The resident always complains of leg pain and that they were sometimes swollen. LPN JJJ stated the CNAs told her they eased the resident to the floor and that she didn't fall. LPN JJJ further stated that she didn't think the resident was hurt so I didn't write it down. An additional facility investigation comment on 9/18/18 by LPN JJJ stated that during routine medication pass, she was called into R#33's room by the CNAs. She found the resident on the floor without a Maxi lift securing her. She further stated that she assessed the resident for injuries and found no bruises or skin tears. The resident did comment that her knees were hurting, however, the resident has [MEDICAL CONDITION] and is very contracted in the legs. The investigation goes on to say the resident did not complain of pain until 8/30/18 when the Physician was notified and ordered pain relieving gel twice daily to the resident's knees. The Responsible Party (RP) was notified. On 9/2/18 a CNA notified LPN MM that the resident was complaining of pain. LPN MM contacted the Physician who ordered Tylenol 625 milligrams (mg) twice daily. On 9/3/18, LPN FF documented the resident had pain to the left calf, with no redness or increased warmth noted, pain to the right foot and knee. The Physician was notified with LPN FF receiving orders for laboratory test and to X-ray the right knee. On 9/5/18, the Physician checked the resident and was assessed that both knees were hurting. He ordered bilateral knee X-rays and the resident was transferred to the hospital. Further review of the investigation revealed the resident was found to have bilateral fractured femurs and was returned to facility to follow up with an Orthopedic Surgeon. An appointment was made with the Orthopedic Surgeon for 9/6/18. The investigation stated the resident was seen by the Orthopedic surgeon on 9/6/18 and that the Orthopedic surgeon and R#33's Physician discussed the resident's injuries. The Physician documented I have seen these types of fractures before in individuals who are being transferred back and forth from a wheelchair. It is uncommon to see both, but possible. Review of the electronic record for R#33 revealed a Nurses Note dated 9/3/18 at 12:28 p.m. by LPN FF, res (resident) noted to have pain to left calf, no redness or warmth noted. Resident c/o (complaining of) pain to right foot and right knee. Noted [DIAGNOSES REDACTED] to right medial foot with two small open areas. Res has tx (treatment) in progress, Spoke with physician, new orders for uric acid, CBC (complete blood count) with differential. Blood drawn. Resident to have X-ray of right knee 9/4/18. Res continues on Tylenol and pain-relieving gel. Review of a Nurses Note dated 9/4/18 at 12:49 p.m. revealed that X-ray, no acute or recent fracture noted, lab results 9/3/18 and (inaccurate) X-ray results were given to Physician, no new orders. Review of a Physician Note dated 9/5/18 at 11:40 a.m. revealed Active Complaints: Patient denies any specific complaints but when I ask her pointedly (sic) does her knee hurt she states yes pointing to each knee. Review of X-ray report from yesterday was reviewed. There are (sic) some irregularity with possible fracture in the right distal femur in the right knee. Exam: There is approximately a 6 cm (centimeter) yellowish tint to the skin around the knee area. This is distal thigh to proximal tibia. This is on the left knee. There is mild tenderness was question of slight lateral pop to full extension of the left knee. Patient does not like full extension. There is mild swelling. Right knee shows some mild tenderness and each joint line with no specific swelling except perhaps slightly supra patellar. Range of motion at baseline presently with a little discomfort. Add: possible fracture, supracondylar with no obvious displacement on exam or angulation. Please see original X-ray report. This list the right knee though the left knee is in question on exam. Will maintain her current position. I have ordered an X-ray on the knee, bilateral, to clarify the issue. Will send resident to Orthopedics to follow up. If unable to see the Orthopedics over the next two days, will send the resident to the hospital for further evaluation and possible splinting versus long leg immobilizer for now versus cast. I have discussed with both her current nurse as well as the administrator (sic) to look into whether there was a report of a fall or other injury or not. I do not recall receiving such a report. Review of the Radiology Report for R#33 dated 9/4/18 revealed a right knee AP (anterior/posterior) and two lateral views. Conclusion: Acute or recent appearing right supracondylar fracture. Review of a Nurses Note dated 9/5/18 at 15:15 (military time) revealed that the Orthopedic surgeon could not see the resident until 9/11/18 and the resident was sent to the hospital for X-ray and evaluation. Review of a Nurses Note dated 9/5/18 at 21:24 (military time) revealed the resident returned from the emergency room (ER) with order for [MEDICATION NAME] 50 mg every 8 hours as needed for pain. Resident has appointment with Orthopedic surgeon tomorrow which was communicated to the RP. An interview with CNA KKK on 9/24/18 at 5:48 p.m. revealed that she and CNA LLL had attempted to transfer R#33 from the bed to the chair on either 8/22/18 or 8/23/18. She stated that she and CNA LLL were both new to the facility and did not know the resident. CNA KKK further revealed that during their orientation training they had not been trained on accessing the care plan or Kardex in the electronic record system although had asked LPN JJJ if the resident could get out of bed and was told yes. CNA KKK revealed that she and CNA LLL had lifted the resident under her arms but were unable to move the resident to the chair. They eased the resident to the floor and notified LPN JJJ. CNA KKK stated that LPN JJJ came into the room, with R#33 on the floor and complaining of pain in her legs and knees, although she did not assess the resident. She instructed the CNAs to put her in the chair, from the floor. She now knows that the resident should have been transferred using a mechanical lift and they did not use the lift. An interview with CNA LLL on 9/24/18 at 6:05 p.m. revealed that she had assisted CNA KKK to transfer R#33 from the bed to the chair and they had lifted her under the resident's arms, but they could not hold the resident up. They lowered her to the floor and notified LPN JJJ who came into the room but did not assess the resident. She further stated that she had started at the facility a few weeks before CNA KKK and had not been trained on how to check the electronic record on how residents should be transferred. She now knows how to check the electronic record and that R#33 should have been transferred via a mechanical lift. An interview with the Administrator and the Director of Nursing (DON) on 9/24/18 at 6:20 p.m. to request CNA training material and competency check list which were provided. They both confirm not being aware of R#33 being transferred inappropriately until 9/5/18 when the Physician brought to their attention that the resident had fractures. It was at that point that they began the investigation and reported the injury of unknown origin to the State Survey Agency (SSA) on 9/5/18 then on 9/7/18 reported the same incident as an allegation of abuse. Before the Administrator could complete the investigation, the local police arrested LPN JJJ, on 9/10/18 for neglect, and therefore additional investigation, by the facility, was required. The final report was sent to the SSA on 9/18/18. The Administrator revealed that CNA KKK and LLL were suspended and returned to work today (9/24/18). An interview with Staff Development LPN EEE on 9/25/18 at 1:43 p.m. revealed that she had been in the position since (MONTH) (YEAR). She was unable to provide a competency checklist for CNAs KKK and LLL although she did supply several sample Competency checklists dated 2/27/06 and 7/2012 which included 4.) verbalizes the requirements for resident use in regard to the type of lift to be used and to determine the size of sling to be used and 5.) Reviews resident's care plan for type of lift to be used. Kiosk Competency was reviewed and did not include instructions on how to access a resident's care plan rather instructs on how to record ADL care. Review of three, undated, education confirmation sheets revealed 1.) Staff education for retrieving of the resident Kardex (from the electronic record system, 2.) Staff education for stand/pivot transfers and 2 person assist Maxi/Sara lift transfers, and 3.) Gait Belt Policy. LPN EEE confirmed that the three forms were new and she had been using for about a week now as a result of the investigation related to R#33. LPN EEE confirmed that she was unaware of the sample competency checklist until after the incident with R#33 and therefore had not used them for the training program. A telephone interview with the Physician on 9/25/18 at 2:25 p.m. confirmed that the he was not made aware by LPN YYY on 9/4/18 that the X-ray results for R#33 revealed a fractured femur. The physician discovered the X-ray results indicating a fractured femur on 9/5/18 when he came to the facility to see the resident and was reviewing the medical record. He confirmed that bilateral femur fractures were unusual and were most likely the result of staff easing the resident to the floor. He cannot say why LPN JJJ did not notify him when the incident occurred or why LPN JJJ did not document the incident. He has no explanation as to how LPN YYY could have missed the X-ray results indicating a fracture when he was informed there was no fracture. Review of a Witness Statement dated 9/6/18 by LPN YYY who stated that on 9/4/18 she called the Physician and gave the report of the labs and X-ray in a hurry and hoped that he understood there was a fracture. Review of Notice of Disciplinary Action dated 9/7/18 for LPN YYY revealed that she failed to provide accurate information to a Physician related to a critical lab/X-ray result. Education was given to the LPN. Multiple attempts were made on 9/25/18 and 10/5/18 to contact LPN YYY via telephone although the LPN was not available and did not return any calls. Review of the Voluntary Statement, local police department, dated 9/10/18 at 3:00 p.m. revealed that LPN JJJ was called to the room by CNA KKK and that the resident was on the floor. She did go in and check the resident. The resident did complain of leg and knee pain. Resident always complains of leg pain and sometimes they are swollen. The CNAs stated the resident had not fallen but had put her down on the floor gently. The CNAs told LPN JJJ that they did not know the resident was a lift. I didn't think the resident was hurt so I didn't write it up. Review of the local Police Department Incident Report dated 9/10/18 revealed that LPN JJJ was interviewed by the investigator and was then arrested for Cruelty to person [AGE] years or older. An interview with the Administrator, DON and Corporate Clinical Nurse, Registered Nurse (RN) SS on 9/25/18 at 4:20 p.m. revealed that LPN JJJ had been terminated after her arrest and that LPN YYY was given a written reprimand and that CNA KKK and LLL had been suspended. Further interview revealed there is no evidence that LPN JJJ followed the facility's policy for falls. The Administrator and DON stated they were not aware that R#33 had bilateral fractured femurs until after 5:00 p.m. on 9/5/18. The Administrator provided minutes from an emergency QAPI (Quality Assurance Performance Improvement) meeting held on 9/19/18 which included Staff education for reporting labs and X-rays, improper transfers, use of Kardex for ADL care plans and transfers, prompt notification to Physician of any incidents. The Medical Director to provide an in-service from an Orthopedic stand point. Cross refer to F689

Based on record review, staff and Physician interviews and review of the local police department records, the facility failed to ensure that one resident (R) #33, was transferred properly from the bed to a chair. Actual harm was identified when two Certified Nursing Assistants failed to use a mechanical lift during a transfer with R#33 and had to lower the resident to the floor. The resident was sent to the hospital which revealed bilateral femur fractures. The resident sample size was three. Findings include: Review of the facility's Skill Nursing, Clinical Standard of Practice, Subject: Fall Management, Definition: 7. Staff lowers resident to floor. Practice Guidelines: 4. If a fall occurs, the licensed staff assesses for injury, immediately investigates the cause using the Fall Investigation Tool and determines the interventions to prevent further occurrences. The Licensed Nurse must complete the incident report, provide neuro assessments as per protocol. Complete a SBAR (Situation, Background, Assessment, Recommendation) for a change in condition. The care plan is updated to reflect changes in the resident's status, new interventions in place to prevent re-occurrence of the fall or minimize potential injury. 5. The physician and family are notified. Record review revealed that R#33 was originally admitted to the facility on [DATE] and was discharged home, against medical advice, on 9/7/18. Review of the hospital history and physical dated 1/27/16 revealed that R#33 had the following Diagnosis: [REDACTED]. The Physician noted the resident had lived at home and was bed-bound for the past five years. Review of the electronic record [DIAGNOSES REDACTED]. Review of the facility Nursing Evaluation dated 2/2/16 under Contractures/Limited Range of Motion (ROM) excluding fractures: that the resident was checked as having of the arm (including shoulder and elbow) and leg (including hip or knee). Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed for total dependence, by two persons, for transfer. The resident was assessed for total dependence, by one person, for bed mobility, dressing, toilet use and personal hygiene. The resident was not assessed as having impairment of the upper or lower extremities. Review of R#33's care plan, last revised 7/31/18, revealed a focus area: resident requires max assist with all ADLs (Activity of Daily Living). She is non-ambulatory but prefers to stay in bed most of the time. The resident will get up to a Geri chair at times. Resident is incontinent of bowel and bladder. Interventions: Transfer: The resident requires Mechanical lift and max assist of two for transfers but is generally bedfast except for showers. Review of the facility Investigation Report regarding allegation of abuse dated 9/18/18 revealed that on either 8/22/18 or 8/23/18, two Certified Nursing Assistants (CNA) KKK and LLL attempted to transfer R#33 from the bed to a chair without using a mechanical lift. The CNA's were not able to transfer the resident and they lowered her to the floor. The CNAs notified LPN JJJ and asked her to please check the resident. Further review, of the Investigation, revealed an interview with LPN JJJ on 9/10/18 stating that she did go into the room and check the resident. The resident did complain of leg and knee pain. The resident always complains of leg pain and that they were sometimes swollen. LPN JJJ stated the CNAs told her they eased the resident to the floor and that she didn't fall. LPN JJJ further stated that she didn't think the resident was hurt so I didn't write it down. Further review of the facility Investigation report revealed an additional comment on 9/18/18 by LPN JJJ stated that during routine medication pass, she was called into R#33's room by the CNAs. She found the resident on the floor without a Maxi lift securing her. She further stated that she assessed the resident for injuries and found no bruises or skin tears. The resident did comment that her knees were hurting, however, the resident has [MEDICAL CONDITION] and is very contracted in the legs. The Investigation goes on to say the resident did not complain of pain until 8/30/18 when the Physician was notified and ordered pain relieving gel twice daily to the resident's knees. The Responsible Party (RP) was notified. On 9/2/18 a CNA notified LPN MM that the resident was complaining of pain. LPN MM contacted the Physician who ordered Tylenol 625 milligrams (mg) twice daily. On 9/3/18, LPN FF documented the resident had pain to the left calf, with no redness or increased warmth noted, pain to the right foot and knee. The physician was notified, with LPN FF receiving new orders for laboratory test and to X-ray the right knee. The Investigation further revealed that on 9/5/18, the Physician checked the resident and confirmed that both knees were hurting. He ordered bilateral knee X-rays and the resident was transferred to the hospital. Further review of the Investigation report revealed the resident was found to have bilateral fractured femurs and was returned to facility to follow up with an Orthopedic Surgeon. An appointment was made with the Orthopedic Surgeon for 9/6/18. The Investigation stated the resident was seen by the Orthopedic surgeon on 9/6/18 and that the Orthopedic surgeon and R#33's Physician discussed the resident's injuries. The Physician documented I have seen these types of fractures before in individuals who are being transferred back and forth from a wheelchair. It is uncommon to see both, but possible. Review of the electronic record for R#33 revealed a Nurses Note dated 9/3/18 at 12:28 p.m. by LPN FF, res (resident) noted to have pain to left calf, no redness or warmth noted. Resident c/o (complaining of) pain to right foot and right knee. Noted [DIAGNOSES REDACTED] to right medial foot with two small open areas. Res has tx (treatment) in progress, Spoke with Physician, new orders for uric acid, CBC (complete blood count) with differential. Blood drawn. Resident to have X-ray of right knee 9/4/18. Res continues on Tylenol and pain-relieving gel. Review of a Nurses Note dated 9/4/18 at 12:49 p.m. revealed that X-ray, no acute or recent fracture noted, lab results of 9/3/18 given to physician, no new orders. Review of a Physician note dated 9/5/18 at 11:40 a.m. revealed Active Complaints: Patient denies any specific complaints but when I ask her pointedly does her knee hurt she states yes pointing to each knee. Review of X-ray report from yesterday was reviewed. There are (sic) some irregularity with possible fracture in the right distal femur in the right knee. Exam: There is approximately a 6 cm (centimeter) yellowish tint to the skin around the knee area. This is distal thigh to proximal tibia. This is on the left knee. There is mild tenderness, was question of slight lateral pop to full extension of the left knee. Patient does not like full extension. There is mild swelling. Right knee shows some mild tenderness and each joint line with no specific swelling except perhaps slightly supra patellar. Range of motion at baseline presently with a little discomfort. Review of the Physician note of 9/5/18 revealed Add: possible fracture, supracondylar with no obvious displacement on exam or angulation. Please see original X-ray report. This list the right knee though the left knee is in question on exam. Will maintain her current position. I have ordered an X-ray on the knee, bilateral, to clarify the issue. Will send resident to Orthopedics to follow up. If unable to see the Orthopedics over the next two days, will send the resident to the hospital for further evaluation and possible splinting versus long leg immobilizer for now versus cast. I have discussed with both her current nurse as well as the Administrator to look into whether there was a report of a fall or other injury or not. I do not recall receiving such a report. Review of a Nurses Note dated 9/5/18 at 15:15 (military time) revealed that the Orthopedic surgeon could not see the resident until 9/11/18 and the resident was sent to the hospital for X-rays and evaluation. Review of a Nurses Note dated 9/5/18 at 21:24 (military time) revealed the resident returned from the emergency room (ER) with order for [MEDICATION NAME] 50 milligrams (mg) every 8 hours as needed for pain. Resident has appointment with Orthopedic surgeon tomorrow which was communicated to the RP. Review of the Radiology Report for R#33 dated 9/4/18 revealed a right knee AP (anterior/posterior) and two lateral views. Conclusion: Acute or recent appearing right supracondylar fracture. Review of the hospital emergency room (ER) Physician Documentation, dated 9/5/18, revealed that R#33 was received in the ER via EMS (Emergency Medical System) due to complaint of bilateral knee pain. Resident is unable to provide any history. The ER Physician spoke with Licensed Practical Nurse (LPN) JJJ, from the facility, who stated the resident had been complaining of knee pain and had a right knee X-ray two days ago showed a distal femur fracture but was sent to the ER for a left knee X-ray. LPN JJJ could provide no other history information. Exam: Musculoskeletal/extremity: Extremities: noted in the right and left knee, swelling, tenderness. Resident is contracted in both the left and right knee, ROM: resident is contracted. Review of the hospital X-ray report dated 9/5/18 revealed Impression: 1. Demineralized bone 2. Mildly displaced comminuted fractures of the bilateral distal femoral metadiaphyses 3. Knee effusions and soft tissue swelling. Review of the hospital Discharge Summary dated 9/5/18 at 18:24 (military time): I spoke with LPN JJJ who did not provide details of the patient's injury. Knees are contracted bilaterally and are swollen, tender diffusely. She has good distal pulses. X-ray shows bilateral comminuted distal femur fractures. The on-call ortho recommended posterior long leg splints and will see the resident tomorrow. Directions given to the facility and family. The patient will be discharged back to the nursing facility with orders to follow up with ortho and pain medication. Review of the ER Nurse Report dated 9/5/18 revealed: Assessment- unable to straighten patient's legs for recommended bilateral knee immobilizer. Legs are contracted and unable to fit appropriately into knee brace. Record review revealed a Minimum Data Set (MDS) discharge assessment dated [DATE] of the resident being discharged home. Review of a Communication note dated 9/7/18 and signed by the Administrator, revealed that the family wished to take the resident home against medical advice. The physician was notified and agreed to write an against medical advice order with her medications except for narcotics. The resident left the facility via stretcher on 9/7/18 at 16:36 (military time 4:36 p.m.) Review of the facility witness statements revealed the following: LPN NN statement dated 9/14/18 revealed that on 8/30/18 a CNA mentioned that R#33 right knee was red, and the Nurse Practitioner was in the building who was asked to evaluate the resident. She did and wrote new orders. CNA NNN statement dated 9/25/18 revealed that she was assigned to the R#33 for the month of (MONTH) (YEAR) and the resident complained of pain with her knees every time. LPN MM applied topical cream to R#33's knees. There was no unusual swelling or redness that I noticed at that time. CNA OOO statement dated 9/25/18 revealed that she worked the evening shift on 8/30/18 and she didn't notice any bruising or abnormal swelling. However, the resident was more nervous about me performing care, she did not want to be cleaned or repositioned. She complained of severe leg pain which I reported to the nurse (unknown). CNA QQQ statement dated 9/25/18 revealed that she worked 7:00 a.m. to 7:00 p.m. on 9/2/18 and noticed the resident's knees were swollen and discolored (yellow bruising). Resident was in more pain than usual. I notified the charge nurse who rubbed medication cream on her knees and legs. CNA RRR statement dated 9/25/18 revealed that she worked the night shift but cannot remember the date although she thinks it was late August. The CNA remembers R#33 complaining of leg pain but cannot remember what day. She remembers swelling in the left extremity. Once they realized something was wrong, we wouldn't get the resident up and told the nurse. An interview with CNA KKK on 9/24/18 at 5:48 p.m. revealed that she and CNA LLL had attempted to transfer R#33 from the bed to the chair on either 8/22/18 or 8/23/18. She stated that she and CNA LLL were both new to the facility and did not know the resident. CNA KKK further revealed that during their orientation training they had not been trained on accessing the care plan or Kardex in the electronic record system although had asked LPN JJJ if the resident could get out of bed and was told yes. CNA KKK revealed that she and CNA LLL had lifted the resident under her arms but were unable to move the resident to the chair. They eased the resident to the floor and notified LPN JJJ. CNA KKK stated that LPN JJJ came into the room, with R#33 on the floor and complaining of pain in her legs and knees, although she did not assess the resident. She instructed the CNAs to put her in the chair, from the floor. She now knows that the resident should have been transferred using a mechanical lift and they did not use the lift. An interview with CNA LLL on 9/24/18 at 6:05 p.m. revealed that she had assisted CNA KKK to transfer R#33 from the bed to the chair and they had lifted her under the resident's arms, but they could not hold the resident up. They lowered her to the floor and notified LPN JJJ who came into the room but did not assess the resident. She further stated that she had started at the facility a few weeks before CNA KKK and had not been trained on how to check the electronic record for how residents should be transferred. She now knows how to check the electronic record and that R#33 should have been transferred via a mechanical lift. An interview with the Administrator and the Director of Nursing on 9/24/18 at 6:20 p.m. to request CNA training material and competency check list which were provided. They both confirmed, not being aware of R#33 being transferred inappropriately until 9/5/18 when the Physician brought to their attention that the resident had fractures. It was at that point that they began the investigation and reported the injury of unknown origin to the State Survey Agency (SSA) and on 9/7/18 reported the incident as an allegation of abuse. Before the Administrator could complete the investigation, the local police arrested LPN JJJ for neglect on 9/10/18 and therefore additional investigation, by the facility, was required. The final report was sent to the SSA on 9/18/18. The Administrator revealed that CNA KKK and LLL were suspended and had returned to work today (9/24/18). An interview with Staff Development LPN EEE on 9/25/18 at 1:43 p.m. revealed that she had been in the position since (MONTH) (YEAR). She was unable to provide a competency checklist for CNAs KKK and LLL although she did supply several sample Competency checklists dated 2/27/06 and 7/2012 which included 4.) verbalizes the requirements for resident use in regard to the type of lift to be used and to determine the size of sling to be used and 5.) Reviews resident's care plan for type of lift to be used. Kiosk Competency was reviewed and did not include instructions on how to access a resident's care plan rather instructs on how to record ADL care. Review of three, undated, education confirmation sheets revealed 1.) Staff education for retrieving of the resident Kardex (from the electronic record system, 2.) Staff education for stand/pivot transfers and 2 person assist Maxi/Sara lift transfers, and 3.) Gait Belt Policy. LPN EEE confirmed that the three forms were new, and she had been using for about a week now as a result of the investigation related to R#33 although she had not utilized the sample Competency Checklist. A telephone interview with the Physician on 9/25/18 at 2:25 p.m. confirmed that the he was not made aware by LPN YYY on 9/4/18 that the X-ray results revealed a fractured right femur. The Physician discovered the X-ray results, indicating a fractured right femur, until 9/5/18 when he came to the facility to see the resident and was reviewing the medical record and was concerned that the X-ray company had either X-rayed the wrong leg or mislabeled the X-ray. As a result, it felt that both knees should be re-X-rayed to clarify the issue and gave a new order to the facility staff. He confirmed that bilateral femur fractures were unusual and were most likely the result of staff easing the resident to the floor. He cannot say why LPN JJJ did not notify him when the incident occurred or why LPN JJJ did not document the incident. He has no explanation as to how LPN YYY could have missed the X-ray results, of a fracture, when he was informed there was no fracture. Review of a Witness Statement dated 9/6/18 by LPN YYY who stated that on 9/4/18 she called the physician and gave the report of the labs and X-ray in a hurry and hoped that he understood there was a fracture. Review of Notice of Disciplinary Action dated 9/7/18 for LPN YYY revealed that she failed to provide accurate information to a Physician related to a critical lab/X-ray result. Education was given to the LPN. Multiple attempts were made on 9/25/18 and 10/5/18 to contact LPN YYY via telephone although the LPN was not available and did not return the surveyor's calls. Review of the local Police Department, Voluntary Statement (written), dated 9/10/18 at 3:00 p.m. by LPN JJJ, revealed that LPN JJJ was called to the room by CNA KKK and that the resident was on the floor. She did go in and check the resident. The resident did complain of leg and knee pain. Resident always complains of leg pain and sometimes they are swollen. The CNAs stated the resident had not fallen but had put her down on the floor gently. The CNAs told LPN JJJ that they did not know the resident was a lift. I didn't think the resident was hurt so I didn't write it up. Further review revealed that on 9/10/18 that LPN JJJ was interviewed by the investigator and was then arrested for Cruelty to person [AGE] years or older. An interview with the Administrator, Director of Nursing (DON) and Corporate Clinical Nurse, Registered Nurse (RN) SS on 9/25/18 at 4:20 p.m. revealed that LPN JJJ had been terminated after her arrest, that LPN YYY (who is part-time) was given a written reprimand and that CNA KKK and LLL had been suspended. The Administrator and DON stated they were not aware that R#33 had bilateral fractured femurs until after 5:00 p.m. on 9/5/18. The Administrator and DON could not provide any documentation that LPN JJJ had followed the facility's fall policy. The Administrator provided minutes from an emergency QAPI (Quality Assurance Performance Improvement) meeting held on 9/19/18 which included Staff education for reporting labs and X-rays, improper transfers, use of Kardex for ADL care plans and transfers, prompt notification to Physician of any incidents. The Medical Director to provide an in-service from an Orthopedic stand point.