Every finding on record at Hearthstone Nursing and Rehabilitation

Based on interview, observation and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 3 residents (Resident #22, Resident #34, and Resident #61) reviewed for accuracy of assessments. The facility failed to ensure Resident #22's annual MDS, dated [DATE], accurately reflected her smoking status.The facility failed to ensure Resident #34's admission MDS, dated [DATE], accurately reflected her smoking status.The facility failed to ensure Resident #61's annual MDS, dated [DATE], accurately reflected his smoking status. These failures could place residents at risk of inadequate supervision due to an inaccurate assessment for smoking status.Findings included: 1. Record review of Resident #22's face sheet, dated 04/02/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #22 had diagnoses which included Schizophrenia (mental disorder that affects a person's ability to think, feel and behave clearly), dementia (memory, thinking, difficulty), dorsalgia (back pain), insomnia (difficulty sleeping) and osteoarthritis (joint disease), Record review of Resident #22's annual MDS, dated [DATE], revealed Resident #22 had a BIMS of 14, which indicated intact cognitive response. The MDS also revealed that current tobacco use was not marked at all. Record review of Resident #22's care plan, dated 03/11/2026, revealed Resident #22 was a smoker. The goal in place was the resident will not suffer injury from unsafe tobacco use/smoking practices through the review. Interventions were instructing resident about smoking or tobacco risks and hazards and about tobacco use cessation aids that were available. Instruct resident about the facility policy on smoking and tobacco use: locations, times, safety concerns. Record review of Resident #22's Smoking Assessment, dated 02/22/2026, revealed Resident #22 required supervision during smoke break. 2. Record review of Resident #34's face sheet, dated 04/02/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #34 had diagnoses which included protein-calorie malnutrition (inadequate intake of both protein and calories), type 2 diabetes mellitus without complications (high blood sugar), muscle weakness, muscle wasting, difficulty in walking, unsteadiness on feet, and cognitive communication deficit (problems with communication), Record review of Resident #34's admission MDS, dated [DATE], revealed Resident #34 had a BIMS of 15, which indicated intact cognitive response. The MDS also revealed current tobacco use was marked no on the MDS. Record review of Resident #34's care plan, dated 03/04/2026, revealed Resident #34 was a smoker. The goal in place was the resident will abide by the smoking policy. Resident will smoke safely without injury or fire hazard. Interventions: educate resident on smoking safety: no smoking in bed or room, use designated smoking areas only, times, fully extinguish cigarettes, no sharing of cigarettes, tobacco use cessation aids that were available. Ensure oxygen is removes and turned off before smoking. Record review of Resident #34's Smoking Assessment, dated 02/25/2026, revealed Resident #34 required supervision while smoking. 3. Record review of Resident #61's face sheet, dated 04/02/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #61 had diagnoses which included bipolar (extreme mood swings), hypertension (high blood pressure), muscle wasting, obstructive pulmonary disease (chronic progressive lung disease), and repeated falls. Record review of Resident #61's admission MDS, dated [DATE], revealed Resident #61 had a BIMS of 14, which indicated intact cognitive response. The MDS also revealed Resident #61's current tobacco use was marked as no on the MDS. Record review of Resident #61's care plan, dated 08/14/2025, revealed Resident #61 was a smoker. The goal in place was the resident will abide by the smoking policy. Resident will smoke safely without injury or fire hazard. Interventions: educate resident on smoking safety: no smoking in bed or room, use designated smoking areas only, times, fully extinguish cigarettes, no sharing of cigarettes, tobacco use cessation aids that were available. Ensure oxygen is removes and turned off before smoking. Record review of Resident #61's Smoking Assessment, dated 11/30/2024, revealed Resident #61 required supervision when smoking. Observation of smoking on 04/02/2026 at 9:00 a.m., revealed Resident #22, Resident #34 and Resident #61 were outside with staff smoking. During an interview with the MDSN on 04/03/2026 at 10:57a.m., she said she had been trained on MDS. She said the policy for completing the MDS was, it was to be completed at admission, quarterly and if a significant change. She said she was responsible for completing the MDS. She said some information required to be on the MDS was ADLs, resident assessments, therapy, incontinent care, and any wound information. She said a resident's smoking status was supposed to be on the MDS. She said she found out a resident was a smoker when she received the smoking assessment. She also said the smoking status was only on the annual and the admission MDS. She said if a resident's smoking status was not on the MDS the MDS did not accurately reflect the resident. She said the smoking status did not directly affect the residents because the smoking status was on the care plan. She said the ADM monitored to ensure the MDS was done correctly. She said the ADM monitored by reviewing the MDS. She said she did not know why Resident #22, Resident #34, and Resident #61's smoking status was not marked on the MDS. During an interview with the ADM on 04/03/2026 at 11:21 a.m., she said she had been trained on the MDS assessment. She said the policy was the MDS coordinator was to do the MDS within 14 days of admission. She said the MDS coordinator was responsible for completing the MDS correctly. She said the MDS contained information about the resident such as diagnosis, smoking status, therapy, and other information needed to care for the resident. She said the MDS was done annually, at admission and quarterly. She said the MDSN received documents such as assessments and admission paperwork that would have shown the resident was a smoker. She said there was direct effect on the resident if the resident's smoking status was not on the MDS. She said the MDS would just misrepresent the resident. She said she monitored to ensure the MDS was done correctly. She said she monitored by checking the MDS. She said the facility did not have an MDS person for a while. She stated the smoking status for Resident #22, Resident #34 and Resident #61 might have been an oversight. Record review of the Smoking Residents list provided on 04/01/20265 revealed Resident #22, Resident #34, and Resident #61 were all smokers. Record review of Resident Assessment Policy dated 11/20219 revealed A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews.Record review of the RAI User's Manual dated 10/2023 page 388-389 revealed J1300: Current Tobacco UseItem RationaleHealth-related Quality of LifeThe negative effects of smoking can shorten life expectancy and create health problems that interfere with daily activities and adversely affect quality of life.Planning for CareThis item opens the door to negotiation of a plan of care with the resident that includes support for smoking cessation.If cessation is declined, a care plan that allows safe and environmental accommodation of resident preferences is needed.Steps for AssessmentAsk the resident if they used tobacco in any form during the 7-day look-back period.If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes.If the resident is unable to answer or indicates that they did not use tobacco of any kind during the look-back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look-back period.Coding InstructionsCode 0, no: if there are no indications that the resident used any form of tobacco.Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for Food and Nutrition Services. 1. The facility failed to ensure the food Processor used for puree' was sanitized prior to use on 04/01/2026.2. The facility failed to ensure CK H used proper hand hygiene when preparing puree' foods on 04/01/2026.3. The facility failed to ensure CK H hair restraint was on properly and covered her hair completely to prevent hair from contacting food. These deficient practices could place residents at risk for food borne illness. Observation of CK H preparing puree food on 04/01/26 at 10:45 a.m., revealed CK H did not wash her hands before starting the puree process for the chicken. CK H did not wash or sanitize the preparation counter, and she did not wash or sanitize the puree machine prior to putting the chicken in the machine. Observation of CK H distributing food to trays on 04/01/26 at 12:45 p.m., revealed CK H's hair restraint was not adequately situated on her head. CK H's hair was observed to be approximately 3 inches outside the hairnet on the front and both sides of her head. Observation on 04/01/26 at 12:25 p.m., the DM was observed entering the kitchen without sanitizing her hand. During an interview on 4/01/26 at 9:28 a.m., the DM said she was trained on infection control. She said the policy was to practice hand hygiene when preparing or distributing food. The DM stated staff were supposed to wash their hands before and after using the food processor DM said everyone is supposed to wear hair covering from when they enter the kitchen until they leave the kitchen. During an interview on 04/02/26 at 1:34 p.m., the RD stated his role was clinical and he prepares menus for residents with special dietary needs. He stated, it was expected for the staff to sanitize the puree machine between uses and wash hands and use gloves when preparing and cooking food. During an interview on 04/02/26 at 1:45 p.m., CK H stated she has been trained in infection control. CK H stated, I am to wear gloves when I prepare food. She said if she did not use proper hand hygiene it could cause infections to spread. When asked why she did not sanitize the food processor prior to use, she stated, it was cleaned after the last time it was used. CK H stated she understood that the use of hair net was part of the food safety policy Record review of the facility's dated 2018, General Kitchen Sanitation. Policy: 'The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes to minimize the risk of infection and foodborne illness.Procedure:Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware and food-contact surfaces of equipment, except cooking surfaces of equipment and pots and pans that are not used to hold or store food and are used Soley for cooking purposes.4. Clean and sanitize all multi-use utensils and food-contact surfaces of equipment used in the preparation or storage of potentially hazardous food prior to each use. Clean and sanitize food-contact surfaces of equipment. Record review of handwashing -Hand Sanitation Policy notPolicy StatementThis facility considers hand hygiene the primary means to prevent the spread of infections.Policy Interpretation and Implementation not dated.All personnel shall follow handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors.Use an alcohol-based hand rub containing at least 62% alcohol: or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:O. Hand washing should be done before and after eating or handling food.ProcedureWashing HandsWet hands first with water, then apply an amount of product recommended by the manufacturer to hands.Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers.Rince hands with water and dry thoroughly with a disposable towel.Use towel to turn off the faucet.Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection for 19 of 103 residents reviewed for infection control: The facility failed to ensure staff used proper hand sanitation while serving meals to the residents. These deficient practices could place residents at risk for food borne illness. The Findings included:Observation of DM distributing drinks on 04/01/26 at 12:16 p.m., revealed DM did not use proper hand hygiene between serving drinks to residents.Observation on 04/01/26 at 12:25 p.m., revealed MDSN, CNA B and CNA C did not use hand sanitizer between serving trays to residents.During an interview on 04/01/26 at 12:26 p.m., it was revealed that CNA B said she had been trained on hand hygiene. She stated she did not know why she had not used hand sanitizer after serving each resident.During an interview on 04/01/26 at 12:28 p.m., it was revealed that CNA C had been trained in proper hand sanitation, and she demonstrated the use of hand sanitizer before she served the next resident.During an interview with MDSN on 04/01/2026 at 12:25 p.m., the MDSN stated she had been trained on food safety and hand washing. She said all staff were to use hand sanitizer prior to delivering a tray to a resident.During an interview with RN A on 04/02/16 at 8:15 a.m., RN A stated CNAs were expected to use hand sanitizer between serving each tray to the residents. She stated if staff did not wash their hands, it could cause food borne illness.During an interview with RD on 04/02/26 at 1:34 p.m., the RD stated his role was clinical and he prepares menus for residents with special dietary needs. He said staff were expected to use hand sanitizers between tray passes.Record review of handwashing -Hand Sanitation Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections.Policy Interpretation and Implementation.2. All personnel shall follow handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors.7. Use an alcohol-based hand rub containing at least 62% alcohol: or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:8. Before and after eating or handling food.ProcedureWashing Hands1. Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands.2. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers.3. Rince hands with water and dry thoroughly with a disposable towel.4. Use towel to turn off the faucet.5. Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 2 of 2residents (Resident #23 and ) reviewed for environmental concerns. The facility failed to ensure Resident #23's room was roach-free. This failure could place residents at risk of pests in their rooms that spread bacteria. Findings Include: A review of Resident #23's records reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Annual MDS Assessment, dated 12/19/25, her BIM was 15, and she was cognitively intact. The resident has a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident #23 was dependent on staff for Activities of daily living. Review of Resident #23's Care Plans reflected:Revised 12/31/25 - Resident had an activity of daily living deficit.Facility interventions: maximal assistance of one staff member for all ADLs. A review of Resident #35's records reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Annual MDS Assessment, dated 12/16/25, her BIM was 12, and she was cognitively intact. The resident has a diagnosis of Cardiovascular and Coagulations. Resident #35 was dependent on staff for Activities of daily living. Review of Resident #35's Care Plans reflected:Revised 12/28/25 - Resident had an activity of daily living deficit.Facility interventions: maximal assistance of one staff member for all ADLs. During an interview on 04/02/2026 at 11:31 AM, Resident #23 stated that there were roaches in the room and that the last time she saw them was today in the closet. The closet was observed, and there was a roach crawling up the door in the closet, and a roach on the floor. Resident #23 stated she previously complained about the roaches and continued to see them. During an observation and interview on 04/02/2026 at 11:48 AM, Resident #35 stated that she has seen roaches in the room before. Resident #35 stated the last time she saw roaches was a week ago. Resident #35 stated she previously complained about the roaches in the past and said that she was told the facility has sprayed for roaches. An interview on 04/03/26 at 11:43 AM with CNA E revealed the following. The CNA E stated that she had not seen any roaches in the facility. The CNA E stated that no one in her hall had complained about seeing roaches in the room. The CNA E stated that if she sees a Roach, she reports that to everyone in upper management. The CNA E stated that rooms are sprayed and cleaned by housekeeping. She stated that if roaches are in residence rooms, it could cause infections and scare the residents. An interview on 04/03/26 at 11:46 AM, CNA D stated that she had never seen roaches in the facility. CNA D stated a while back, a family member told her they had seen roaches in a resident's room. CNA D stated when the family member told her they had seen roaches in the room, she reported it to the ADM or the manager on duty. CNA D stated that pest control came to the facility and sprayed. CNA D was unaware if when the family made the comment about seeing the roaches if that was when the facility was sprayed. CNA D stated that residents could contract an infection from roaches in the room. An interview on 04/03/26 at 11:50 PM, LVN G stated he had not had any residents tell him they had seen any roaches in the facility. LVN G stated if he saw a roach or a resident reported seeing one in the facility, he would report it to the ADM. LVN G stated when a roach is seen in the facility, the pest control company is notified, and they come to spray for roaches. LVN G stated that roaches in a resident's room could make them sick. An interview on 04/03/26 at 1:54 PM, RN F stated that the last time he saw roaches in the facility was in 2024. The RN F stated that no residents had told him there were roaches in their rooms. RN F stated if a resident told him they had seen roaches in their room, he would notify the ADM. RN F stated that the resident would be moved so the room could be sprayed for roaches. RN F stated that roaches could negatively affect residents by spreading infections. An interview on 04/03/26 at 1:55 PM, the MAIN director stated that if a resident complains about roaches, he lets management know and records it in the pest control book. The MAIN director stated that pest control is called, and someone will come spray for roaches. The MAIN director stated the last complaint was a week ago, and that was the last time the facility was sprayed for roaches. The MAIN director stated that the facility had been sprayed for roaches two times over the past 2 months. The MAIN director stated this has been going on for a month and a half. The MAIN director stated that if roaches are in a resident's room, it could cause anxiety for the residents. An interview on 04/03/26 at 2:20 PM, the ADM stated she personally has not seen any roaches in the facility. The ADM stated floor staff have told her that some residents have reported seeing roaches in their rooms. The ADM stated this had not happened recently. The ADM stated if a resident reported seeing roaches in their room, pest control is called to spray the facility for roaches. The ADM stated if there are roaches in a resident room, it could make them uncomfortable and can cause infections, especially if there is an open wound. A record review of the pest control book revealed that residents have made several complaints about roaches and that pest control came ont one time to spray for roaches in two months. Record review of the facility policy, Pest Control, not dated, reflected:Policy StatementOur facility shall maintain an effective pest control program .

Based on interviews and record reviews, the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 6 residents (Resident #1) reviewed for care plan revisions.The facility failed to update Resident #1's care plan to reflect ongoing aggressive behaviors toward staff and interventions to meet her physical, psychosocial, and functional needs.This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.Findings included:Record review of Resident #1's face sheet dated 1/14/2026, revealed 75-years-old female was admitted on [DATE] with diagnoses of unspecified dementia, severe, without behavioral disturbance (describes a late-stage cognitive decline where memory, thinking, and daily function are significantly impaired, but without associated agitation, aggression, or psychosis), type 2 Diabetes Mellitus (a chronic condition where the body either doesn't use insulin effectively (insulin resistance) or can't produce enough insulin, leading to high blood sugar levels), delusional disorders (a psychotic condition where a person holds persistent, false beliefs (delusions) that aren't based in reality), depression ( a serious mood disorder causing persistent sadness, and loss of interest), and hypertension (high blood pressure when the force of blood pushing against the artery walls is consistently too high).Record review of Resident #1's MDS assessment dated [DATE], revealed a BIMS score of 2, indicating severe cognitive impairment, and documented behavioral symptoms of physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing) with behavior of this type occurred 1 to 3 days. Verbal behavior symptoms occurred 1 to 3 days and other behavioral symptoms not directed toward others occurred 4-6 days, but less than daily. Record review of Resident #1's comprehensive care plan, dated 10/31/2025 did not reflect documented Resident #1's aggressive behaviors problem area, goals and interventions in place. Record review of Resident #1's nursing progress notes, dated 9/17/2025, Throwing everything off the counter and hitting staff. Resident cussing at staff. Water offered and thrown on the floor. Resident continues 1:1. Will continue to monitor, dated 9/24/2025, Noted to have physically aggressive behavior directed toward staff and now noted to push another resident down when touched by this resident, report that patient has been having more aggressive behaviors during the day, and dated10/3/2025, Noted to be physically aggressive toward nursing staff when they have attempted to redirect her, revealed that Resident #1 had increased aggressive behaviors.During an interview with the DON on 01/14/2026 at 1:25 p.m., she said that she was trained and familiar with facility's Care Plan policy. She said that MDS Coordinator was responsible for completing residents' care plans, but all IDT members, including herself and the ADM, participated in updating the resident-centered care plans. The care plans completed at admission and continuously updated as new problem areas identified or resolved. She stated that Resident #1's aggressive behaviors needed to be documented in her care plan. She said she did not know why it was not updated. She stated that care plans were important to comprehensive care for residents, so all team members were on the same page.Attempted to interview MDS coordinator and she was not available for interview due to being ill and out of facility.During an interview with the ADON on 1/14/2026 at 1:36 pm, she stated that she was trained on Care Plans policy last week with continued training provided by the DON. She stated that she was trained in how to use and update care plans. She stated that Resident #1's care plan needed to be updated as soon as behaviors were reported by staff members. She said that the MDS coordinator, the ADM, the ADON and the DON from nursing department, in addition to other departments from the IDT, were responsible for updating the residents' care plans. She stated that updating care plans was important for Resident #1's safety, and the problem areas to look for in her care.During an interview with the ADM on 01/14/2026 at 1:19 pm, she stated that she had a Care Plan policy training a couple of months ago. She stated that training included sustaining compliance with care plan policy, what to do to complete and update the care plans, and the importance for residents to have updated resident-centered care plans. She stated that Resident #1's physical aggression should be documented in her care plan as soon as it was noticed, or as soon as possible. She stated that it was documented in her nursing progress notes, but she did not know why it was not documented in her care plan. She stated that IDT care plan meetings were held every morning to discuss care plans for residents. She said IDT members including the ADON, the MDS Coordinator, and herself were responsible for updating residents' care plans. Record review of the facility's Care Planning policy, dated December 2016, revealed A comprehensive, person-centered care plan that includes, measurable, objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.g. Incorporate identified problem areash. Incorporate risk factors associated with identified problems.k. Reflect treatment goals, timetables and objectives in measurable outcomes.13. Assessments of residents are ongoing, and care plans are revised as information about the residents and residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan:a. When there has been a significant change in the residents' condition.b. When the desired outcome is not met.

Based on observation, interview, and record review the facility failed to notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review for 1 of 6 (Resident #2) residents reviewed for PASARR. The facility failed to ensure that Resident #2 was referred to PASARR services after a positive level II PASARR screening. These failures could place residents at risk for not receiving services intended for the residents mental, intellectual or developmental disabilityFindings Included: RR of Resident #2's undated face sheet revealed a [AGE] year-old-male admitted to the facility on [DATE]. The face sheet revealed that Resident #2 had a diagnosis of Major Depressive Disorder as of 03/14/2013. RR of Resident #2's MDS record dated 09/01/2025 revealed that Resident #2 had a psychological diagnosis of depression. Resident #2 had a BIMS of 14, which indicate moderate impaired cognitive function. RR of Resident #2's undated care plan revealed that Resident #2 had a diagnosis of Major Depressive Disorder, mild. The care plan did not indicate if Resident #2 received PASARR services. RR of Resident #2's PASARR screening dated 06/19/2025 revealed the Recommended Nursing Facility Specialized Services for the following areas:1. Physical Therapy2. Occupational Therapy3. Speech Therapy RR of Resident #2's PASARR services letter dated 10/17/2024 revealed that Resident #2 was approved for Physical Therapy services. RR of Resident #2's PASARR services letter dated 10/18/2024 revealed that Resident #2 was approved for Occupational Therapy services. RR of a list of PASARR positive residents dated 11/19/2025 revealed, Resident #2 had been PASARR positive since 07/01/2021. An interview was conducted on 11/19/2025 at 11:12AM with the complainant who reported the facility neither initiated the PASARR Specialized services late (which should be done within 20 business days) and/or not at all for Resident #2. An interview on 11/19/2025 at 3:24 PM, the MDSC who had been employed at the facility since 2021. MDSC stated that he was in charge of PASARR screenings. The MDSC stated if a resident had received a positive PASARR 1 and positive PE, the facility should have submitted a referral within 90 days of the last IDT meeting. MDSC stated it could negatively affect a resident if their level 1 & 2 PASRR screenings were positive, but a referral had not been done because of discrepancy which would cause the resident to not have access to the services. An interview on 11/19/2025 at 3:43 PM, the DON who had been employed at the facility since October 2024,. stated she had received training on abuse and neglect. The DON stated that a new diagnosis of MD, ID or DD would initiate a new PASARR screening. The DON stated the function of PASARR would be to provide services for residents. The DON stated if the PASARR screening was incorrect, it could affect the resident by not receiving the services necessary. An interview was conducted on 11/19/2025 at 4:02 PM, the ADM who had been employed at the facility since March 2025The ADM stated that a resident who had a positive Level 1 and Level 2 PASARR screen qualify for more services. The ADM stated the facility would then send the referral for PASARR services. The ADM stated the timeline to complete the referral after the IDT meeting would be 20 days. The ADM stated it could negatively affect a resident if their level 1 & 2 screenings were positive, but a referral had not been done because a resident would not receive the services that are rendered for them. The ADM stated they had forgotten to send the referral over during the allotted timeframe of 20 days for Resident #2. RR of a facility provided document titled Pre-admission Screening & Resident Review dated 05/10/2021 which revealed the following:1. The PASARR Level 1 Screen, the MDS coordinator in the event of a positive PL1 will notify the LIDDA within 2 calendar days of admission to schedule the IDT and initiate the PE process.Will review the PE print the form and place in the medical record.

Based on observation, interview, and record review the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 6(Resident #1) residents reviewed for PASARR. The facility failed to ensure that Resident #1 was referred for a level II PASARR after an evident diagnosis of Major Depressive Disorder diagnosed on [DATE]. These failures could place residents at risk for decline and the inability to receive services. Findings Included:RR of Resident #1's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. The face sheet revealed that Resident #1 had a diagnosis of Major Depressive Disorder as of 10/06/2025. RR of Resident #1's MDS record dated 10/02/2025 revealed that Resident #1 had a psychological diagnosis of depression. RR of Resident #1's undated care plan revealed that Resident #1's diagnosis included major depressive disorder. The care plan did not indicate if Resident #1 received PASARR services. RR of Resident #1's Level 1 PASARR screening dated 09/27/2025 revealed a negative MD, ID and/or DD diagnosis. An interview on 11/19/2025 at 3:24 PM, the MDSC who had been employed at the facility since 2021,. stated that he had received training on abuse and neglect. The MDSC stated that he was in charge of PASARR screenings. The MDSC stated a Level 1 PASARR screening should be done upon admission and after a change of condition or new diagnosis. The MDSC stated that a diagnosis that could indicate a positive MD, ID, or DD would be Schizophrenia, bipolar disorder, major depressive disorder and epilepsy. The MDSC stated it could negatively affect a resident if their level 1 screening was inaccurate by the inability to receive services appropriate for their needs. The MDSC stated when a resident had a positive Level 1 and Level 2 PASARR, the facility should immediately alert the local authority to conduct an IDT meeting. An interview on 11/19/2025 at 3:43 PM, the DON who had been employed at the facility since October 2024,. stated she had received training on abuse and neglect. The DON stated that neglect could be identified as not providing care timely. The DON stated that a new diagnosis of MD, ID or DD would initiate a new PASARR screening. The DON stated the function of PASARR would be to provide services for residents. The DON stated if the PASARR screening was incorrect, it could affect the resident by not receiving the services necessary. The DON stated the MDSC is responsible for PASARR issues. An interview on 11/19/2025 at 4:02 PM, the ADM who had been employed at the facility since March 2025, stated she had received training for abuse and neglect. The ADM stated neglect could be recognized as the failure to provide services to residents. The ADM stated the policy on PASARR was to conduct a screening upon admission and at change of condition/diagnosis. The ADM stated that the MDSC conducts the PASARR screenings. The ADM stated that a diagnosis of MI would trigger a positive PASARR level 1 assessment. The ADM stated that if resident's level 1 PASARR was incorrect it could negatively affect a resident by not having access to services that they need that are provided though the state. RR of list of PASARR positive residents dated 11/19/2025 revealed, Resident #1 was not listed on the form.

Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 5 residents (Resident #10) reviewed for care plans. The facility failed to include Resident #10 was receiving hospice services in the comprehensive care plan. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings included: Record review of Resident #10's face sheet dated 01/30/25 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included: diabetes (a group of diseases that result in too much sugar in the blood), hyperlipidemia (abnormally high levels of any or all lipids or lipoproteins in the blood), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), and hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated). Record review of Resident #10's Admission MDS assessment dated [DATE], reflected that Resident #10 had a BIMS score of 07 which reflected the resident was severely cognitively impaired. Resident #10's Admission MDS assessment reflected that the resident was receiving hospice care. Record review of Resident #10's Physician's Orders, dated 12/05/24, reflected the resident had an order for: Admit to Hospice. Record review of care plan dated 11/13/2024 reflected Resident #10 was not care planned for receiving hospice services. In an observation and interview on 01/28/25 at 12:21 PM, Resident #10 stated she was doing ok. She stated staff treated her well and she had everything she needed. Resident appeared pleasantly confused and was clean and dressed appropriately with no sign of pain or distress noticed. In an interview on 01/30/25 at 09:52 AM, the MDS nurse stated he was responsible for completing care plans. He stated there was a group of staff that were included in completing care plans as well, but he was responsible for completing the hospice care plans. He stated he had been trained to complete care plans accurately. He stated if a resident received hospice services, it should have been included in their care plan. He stated he was aware Resident #10 received hospice services, but he was not aware that Resident #10's care plan had not included hospice services. He stated he thought there could be a negative impact on resident's if they received hospice services and it was not care planned. In an interview on 01/30/25 at 10:00 AM, the DON stated the MDS nurse was ultimately responsible for completing the care plans and he was responsible for care planning hospice services. She stated her and other staff reviewed the care plans as a group and made the MDS nurse aware if there were changes that needed to be made. She stated the MDS nurse and other staff had been trained on completing care plans accurately. She stated it was her expectation that hospice services be care planned. She stated she was aware that Resident #10 received hospice services. She stated she was not aware that Resident #10 was not care planned for hospice services, but she knew that Resident #10 should have been care planned for hospice services. She stated if hospice was not included in a resident's care plan or a care plan was completed inaccurately, it could have caused a delay in care or interventions, or certain things may or may not have happened if they were not care planned. Review of facility policy dated 2001 (complete revision December 2016) titled Care Plans, Comprehensive Person-Centered revealed Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; k. Reflect treatment goals, timetables and objectives in measurable outcomes; l. Identify the professional services that are responsible for each element of care; m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; d. At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 2 of 2 residents (Resident #17 and #44) reviewed for infection control. The facility failed to ensure MA performed proper hand hygiene and sanitized equipment between residents when passing medications to Residents #17 and #44. This failure could place residents at risk for development of communicable diseases and infections. Findings included: Record review of Resident #17's undated face sheet, reflected she was an [AGE] year-old female admitted [DATE] with diagnoses of Encephalopathy (brain disfunction), Acute Respiratory Failure, Diabetes, Pneumonia, Anxiety, and Major Depressive Disorder. Record review of Resident #17's Quarterly MDS assessment dated Dec. 25, 2024, reflected a BIMS score of 06, which indicated the resident's cognitive ability was severely impaired. Record review of Resident #17's Care Plan, reflected a Focus area was initiated for Acute Infection on 11/21/24 with a goal for the infection to resolve without complications. Record review of Resident #44's undated face sheet, reflected she was a [AGE] year-old female admitted [DATE] with diagnoses of Dementia, Depression, High Blood Pressure, and a Personal History of Urinary Tract Infections. Record review of Resident #44's Quarterly MDS assessment dated Dec. 24, 2024, reflected a BIMS score of 08, which indicated the resident's cognitive ability was moderately impaired. Record review of Resident #44's Care Plan, reflected a Focus area was initiated for Resident is at risk for infection-Covid 19 with a goal to not exhibit signs and symptoms of Covid-19. Observation on 1/29/25 at 9:03 a.m., revealed MA removed a blood pressure cuff from the top of the medication cart and entered the resident's room to take the blood pressure of Resident #17. Afterwards she placed the un-sanitized cuff back on the top of the medication cart. She then proceeded to prepare the medications and to administer the medications to Resident #17 in the resident's room. She returned to the medication cart and moved to the next resident without performing hand hygiene or cleaning the blood pressure cuff. Observation on 1/29/25 at 9:15 a.m., revealed MA removed the un-sanitized blood pressure cuff from the top of the medication cart and proceeded to take the blood pressure of Resident #44. Afterwards she placed the un-sanitized cuff back on the top of the medication cart. She then proceeded to prepare the medications and to administer the medications to Resident #44 in the resident's room. She returned to the medication cart and moved the cart back to the nurse's station where she left it. The blood pressure cuff was left on top of the first medication cart and was never sanitized. Hand hygiene was not done until MA moved to a different cart, where she performed hand hygiene before starting on the new cart. In an interview on 01/29/25 09:44 a.m., MA stated she forget the hand hygiene between Resident #17 and Resident #44 but does not know why. She stated that she did not clean the blood pressure cuff between residents. She stated she usually keeps the hand sanitizer near her on the cart and does do it. She stated it was important to do hand hygiene and clean the cuff to avoid spreading infections from resident to resident. She stated that the negative outcome to residents if it was not done, was they could develop infections and get sick. In an interview on 1/30/25 at 9:54 a.m., the DON stated, the policy for hand hygiene during medication administration was to clean hands before and after each resident and as needed. She stated the policy on cleaning equipment like blood pressure cuffs, was to clean between residents. She stated this is important for infection control and to not spread germs between residents which could give a resident an infection and make them sick. She said it was the responsibility of the DON, the Scheduler, and the ADON to train staff on this when staff is hired and at yearly competencies. In an interview on 1/30/25 at 10:28 a.m., RN, she stated the policy for hand hygiene on medication administration was to sanitize hands before and after each resident and as needed. She stated the policy on cleaning equipment like blood pressure cuffs, was to clean between residents. She stated this was important for minimize risk of spreading bacteria to other residents and causing cross contamination. She stated if this was not done, residents could get infections and become sick. She stated it was the responsibility of the DON, ADON and nurse management to train staff on this. In an interview on 1/30/25 at 10:38 a.m., the ADM stated the policy for hand hygiene on medication administration was to clean hands before and after each resident. He stated the policy on cleaning equipment like blood pressure cuffs was to clean between residents. He stated this is important for infection control and to prevent giving a resident an infection which could make them sick. He stated it is the responsibility of the DON and ADM to train staff on this. A record review of the facility policy titled, Handwashing/Hand Hygiene 2001 Med-Pass, Inc with a last revision date of 2019 reflected the following: The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand Hygiene is indicated before and after direct contact with residents and before handling medications. Hand Hygiene is indicated after handling contaminated equipment. A record review of the facility's undated policy titled, 9. Medication and Preparation Administration-9.2 Preparation of Medication reflected the person administering medications adheres to good hand hygiene, which includes washing or sanitizing hands: Before beginning a medication pass. Prior to handling any medication. After coming into direct contact with a resident. When returning to the medication cart or preparation area. After each room. A record review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment version 2.0 in the 2001 Med-Pass, Inc with a last revision date of 2022 reflected the following: Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). Durable medical equipment is cleaned and disinfected before reuse by another resident.

Based on interview and record review, the facility failed to protect one resident (Resident #1) out of seven residents reviewed for abuse and neglect in that: CNA A slapped Resident #1 on his head in the front lobby in the presence of the facility's Receptionist and the Van Driver from another facility. This noncompliance was identified as PNC. The deficient practice occurred on 11/30/2024 and in-service was completed on 12/03/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of abuse, injury, and psychosocial harm. Findings included: Review of Resident #1's undated care plan reflected a [AGE] year-old male that was admitted to the facility on [DATE] with re-admitted [DATE] with diagnoses including Cerebral infarction, Hemiplegia and hemiparesis following cerebral infraction, acute respiratory failure with hypercapnia, bipolar disorder, Review of Resident #1's quarterly care plan assessment, dated 11/29/24, reflected a BIMS score of 0, indicating he had a severe cognitive impairment. It was also noted a staff assessment for mental status was conducted which indicated short-term memory problem and cognitive skills for daily decision-making being moderately impaired. Section E (Behaviors) reflected he had not exhibited any physical or verbal behaviors. Review of Resident #1's quarterly care plan, initiated 08/30/24, reflected Resident #1 had ADL self-care deficit performance related to weakness and impaired vision; revised on 12/10/2024 reflected Resident #1 had the potential to be physically aggressive related to diagnosis of bipolar disorder, he had behavior problems related to him being physically aggressive with staff and others with interventions as follow: Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Review of Resident #1's skin assessment report reflected a skin assessment was completed on 11/30/2024 with no apparent injury on his head, bilateral toes DTI/flaky skin. Review of Resident #1's progress notes written by RN B dated 11/30/2024 at 2:35 pm reflected: this nurse was called to the front lobby by (RN D) at 12:20, who stated that it was reported to her that a CNA hit the resident on his forehead while trying to transfer him to a different wheelchair. On getting to the front lobby, found resident sitting up on the wheelchair. Assessed his forehead and found no mark of bruising and resident denies any discomfort or pain on the area. The incident was witnessed by () the receptionist and () the transporter from (another facility), , Tx. Received a written statement from (Receptionist). Abuse coordinator (Administrator) DON and NP on call for MD were all notified. Complete head to toe assessment of the resident has been done and no skin lesion noted. During a phone interview on 12/16/2024 at 09:55 am the local law enforcement officer stated he was assigned to the case regarding Resident #1 few days after the incident. The Law enforcement officer stated the allegation of the crime was made, Resident #1 pressed charges and he spoke with the 2 witnesses to the crime. He stated the physical abuse/assault was witnessed by one of the facility's staff and another facility staff (Van Driver). He stated based on his investigation, there was probable cause for assault to an elderly committed by CNA A and a warrant for her arrest was out. On 12/16/2024 at 10:03 am, attempts were made to speak with the Van Driver from the other facility and was told she was in an emergency and would call at her earliest convenience. During a phone interview on 12/16/2024 at 11:14 am, the facility's Receptionist stated she witnessed an incident with Resident #1 and CNA A on 11/30/2024 in the facility's lobby. The Receptionist stated while Resident #1 was about to be transfer to another facility, CNA A was called to assist Resident #1 transfer from one wheelchair to the other. The Receptionist stated Resident #1 made a kicking movement towards CNA A and CNA A stated, (Resident #1) we are not doing this today, CNA A backed up in the process and walked back to Resident #1 and slapped his head loud that they heard the sound from the pop as it echoed. The Receptionist stated the Van Driver from the other facility then asked CNA A if she had just slapped (Resident #1) on the head and CNA A stated no, she (CNA A) was removing a bug from Resident #1's head. The Receptionist stated that was not the case, Resident #1 did not have a bug on his head, and she could not understand why CNA A was so comfortable slapping Resident #1 in public like that. The Receptionist stated the Van Driver requested the state's complaint number, she (Receptionist) notified the manager on duty, the Administrator was called to the facility, the nurse was called to assess Resident #1. The Receptionist stated she was interviewed by the Administrator, and she wrote a statement regarding the incident. She stated they were in-serviced on abuse and neglect. During an interview on 12/16/2024 at 12:11 pm RN B stated she was the nurse on duty on 11/30/2024 for Resident#1 when the incident for physical abuse happened. RN B stated she did not witness the incident but was called to the front lobby to assess Resident #1. RN B stated she did a full skin assessment on Resident #1 and there were on apparent injury noted. RN B stated CNA A was pulled off the floor from working with other residents, full skin assessment was completed on all residents assigned to CNA A. RN B stated she had never seen CNA A hit another resident. She also stated facility's staff were in-serviced on abuse and neglect, the types of abuse, how to report and who to report to. During an interview on 12/16/2024 at 09:37 am the Van Driver stated on 11/30/2024 at about 12:20 pm she went to pick up (Resident #1) and Resident #3 to transport them to another facility. She stated while Resident #1 was being transferred from one wheelchair to the other in the front lobby, he made a kicking movement, pointing to the cushion in his old chair, trying to communicate to CNA A to put the cushion in his new chair. She stated CNA A stated not today Resident #1 and slapped Resident #1 on his head, it was loud, and she and the Receptionist heard it. The Van driver stated she was shocked at what she had just seen and asked CNA A, Did you just slapped his head? The Van driver stated CNA A stated she was removing something from Resident #1's head. The Van driver stated she then asked the receptionist for the State's complaint number, told her co-worker that went with her and called her Administrator. She stated she gave the facility's administrator a written statement of the incident after he got to the facility. During an interview on 12/16/2024 at 3:00 pm the Administrator stated he was the abuse and neglect coordinator. He stated staff were expected to report concerns of abuse and neglect to him. He stated if the instance of abuse and neglect resulted in injury, he has 2 hours window to report to Health and Human Services. He stated it was not his expectation for staff to hit a resident. He stated he was notified by his HR staff who was the manager on duty, and he immediately went to the facility to initiate an investigation. He stated CNA A was removed from the floor, suspended pending investigation, and has since been terminated. He stated he interviewed all witnesses, in-serviced staff on abuse and neglect, conducted safe survey with other residents without negative outcome and completed skin assessments on all residents assigned to CNA A on the day of the incident. He also stated he notified the police and there was an officer investigating the allegation. Surveyor was unable to interview the HR staff who was the manager on duty on 11/30/2024 due to her being overseas. During interview on 12/16/2024 through 12/19/2024 with 2 RNs, 3 CNAs, 1 CMA, the Receptionist revealed they were in-serviced on abuse and neglect after the incident with Resident #1 and CNA A. Staff denied seeing CNA A physically abusing other residents. Staff also stated they had not seen CNA A in the facility since the incident. Review of facility's in-services reflected an in-service dated 11/30/2024 through 12/03/2024 for all facility staff. In-service: Attach Lesson Plan with behavioral objectives, core curriculum, method(s) of teaching, method of evaluation. 1. Abuse, Neglect, Exploitation and Misappropriation Prevention Program 2. Abuse and Neglect Coordinator- Administrator (Administration) 3. Report immediately to the administrator. Review of CNA A's personnel file reflected she was terminated on 12/02/2024. Review of facility's investigation dated 12/06/2024 reflected a thorough investigation was completed, and the allegation of physical abuse was confirmed . Review of facility's Policy revised April 2021 titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program reflected: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff. b. other residents. c. consultants. d. volunteers. e. staff from other agencies. f. family members. g. legal representatives. h. friends. i. visitors; and/or j. any other individual. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.

Based on interview and record review, the facility failed to ensure that medical records were accurately documented for one (Resident #2) of five residents reviewed for accurate clinical records. The facility failed to ensure LVN C documented any follow-up observations or assessments of Resident #2 after she initiated treatments for his uncontrolled coughing. This failure could result in errors in care and treatment. Findings included: Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), disturbances of salivary secretion, and unspecified dementia. Review of Resident #2's quarterly MDS assessment, dated 11/25/24, reflected a BIMS score of 7, indicating a severe cognitive impairment. Section O (Special Treatments, Procedures, and Programs) reflected he did not receive tracheostomy care. Review of Resident #2's quarterly care plan, dated 09/27/24, reflected he had a tracheostomy stoma with an intervention of covering the trach with dry gauze and securing with tape. Review of Resident #2's progress notes, dated 12/14/24 at 1:32 PM and documented by LVN C, reflected the following: At about 9:29 am this writer was notified by [Resident #2]'s roommate that [Resident #2] is coughing. Upon assessment [Resident #2] seen coughing none [sic] stop, form [sic] like secretion coming out of his trach. Vital signs taken T 97.9, O2 97, P 134. BP 131/74. [Resident #2] C/O of dizziness and tiredness. NP on call called 9:29 am, called back 9:30 am, she ordered stat guanfacine 20mls. Stated should cont to suction and monitor the resident, PRN Levalbuterol HCl Inhalation Nebulization Solution, was given. Med was mild effective, [Resident #2] continue to cough with secretions from his trach and pulse rate still on [sic] 120's, [Resident #2] looks weak, NP notified again on the res condition @ 12:20 pm, called back at 12:23 pm ordered to send [Resident #2] to emergency room for further evaluation . During a telephone interview on 12/16/24 at 1:59 with, LVN C stated she worked with Resident #2 on the morning of 12/14/24. She stated he was coughing non-stop, having secretions from his stoma that were foam-like, and was in respiratory distress. She stated she contacted the NP on-call (NP D) and she provided her with orders for a nebulizer treatment, suctioning of his stoma, continuing to monitor him, and calling her back if his oxygen levels dropped. She stated the suctioning helped with the secretions and saw an improvement with his condition with the nebulizer treatment. She stated he was not in respiratory distress and his cough had subsided. She stated approximately three hours later, she noticed Resident #2 looked more tired and was complaining of feeling dizzy. She stated his heart rate was elevated and he did not look normal. She stated she then contacted NP D again who gave her orders to send him to the ER. She stated she was not sure why she had not documented that his condition had changed but remembered she had written it as one note in his progress notes. During an interview on 12/16/24 at 3:00 PM, the DON stated she remembered getting called by LVN C regarding Resident #2's condition on 12/14/24. She stated she had communicated to her about his improving condition and then when his condition worsened again, she sent him to the ER. She stated she would expect for all of the times she assessed Resident #2 to be documented in his progress notes to ensure he was receiving timely and appropriate care. During an interview on 12/19/24 at 10:18 AM, Resident #2 stated on the morning of 12/14/24 he could not stop coughing and that was why he was sent to the hospital. He stated the nurse had given him a breathing treatment and he was taken good care of. He stated the nurse did what she was supposed to do, and she did not wait too long to send him to the hospital. Interviews with NP D were attempted on 12/16/24 and 12/19/24. A returned call was not received prior to exiting. Review of the facility's Change of Condition Policy, dated 2003, reflected when to notify the NP of a resident's change in condition. It did not have anything related to nursing documentation.

Based on observation, interview, and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services, in that: The facility failed to ensure LVN A confirmed Resident #1 consumed her morning medication on 04/03/24 as she was witnessed spitting her medication into the trashcan. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, type II diabetes, major depressive disorder, acute kidney failure, and hypertension (high blood pressure). Review of Resident #1's annual MDS assessment, dated 01/31/24, reflected a BIMS of 3, indicating a severe cognitive impairment. Section K (Swallowing/Nutritional Status) reflected she did not have any swallowing disorders. Review of Resident #1's quarterly care plan, revised 02/05/24, reflected she had impaired cognitive function with an intervention of administering medications as ordered. Observation on 04/03/24 at 9:24 AM in the MCU, revealed Resident #1 wandering around the living area and walking over to a trash can and spitting out her medication. LVN A was by the medication cart and saw the incident. During an interview on 04/03/24 at 9:26 AM, LVN A confirmed she did see Resident #1 spit out her medication and was glad none of them were narcotics. When asked if she was supposed to ensure all residents consumed their medications after administering them, she stated it was her first day in the MCU and was not aware Resident #1 had a history of pocketing/spitting out her medication. She stated she had mixed her medications with apple sauce and maybe it was too tart, and she was going to try again with chocolate pudding. During an interview on 04/03/24 at 11:45 AM, the DON from their sister facility stated her expectation during medication pass when a nurse or MA administered medication was that they wait with each resident to ensure they took them. She stated one negative outcome could be another resident could consume them, which could adversely affect them. She stated another negative outcome could be the resident who was supposed to be taking the medication might not get any therapeutic benefit. She stated there was also a concern of aspiration (choking) if a resident consumed their medication alone. Review if the facility's undated Medication and Preparation Administration Policy reflected the following: During medication administration, the facility staff should . confirm resident consumption of the medication.

Based on interview and record review, the facility failed to ensure residents were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 (Resident #1) of 5 residents reviewed for informed consent for treatment options. The facility failed to: 1. obtain a signed informed consent for the use of Seroquel for Resident #1 by her MPOA 2. obtain a signed informed consent for the use of ABH gel for Resident #1 by her MPOA This failure could affect all residents by placing them at risk of receiving psychotropic medications without informed consent which could cause decrease quality of life and increase the risk of injury and violate the rights of residents to make informed decisions related to care. Findings included: Record review of Resident #1's undated face sheet, printed on 02/10/24, revealed that he was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included depression, anxiety and dementia. It further revealed that her emergency contact and Responsible Party was FAM. Record review of Resident #1's 01/06/24 quarterly MDS revealed a BIMS of 3, which was indicative of severely impaired cognition. It further revealed her primary language was Spanish and she was usually understood and usually understood others. It revealed that she had no hallucinations nor did she have delusions that would be potential indicators of psychosis . In an interview on 02/10/24 at 2:00 pm with FAM, she stated that she was told the doctor wanted to start Resident #1 on Seroquel, but FAM wanted to research the medication before signing consent. She stated she never signed consent for the use of Seroquel for Resident #1. She also stated she never consented to use of ABH gel (Ativan, Benadryl, Haldol). In an interview on 02/11/24 at 2:45 pm with MD she stated that she had a duty to treat Resident #1 and had verbal consent for the use of seroquel by FAM and the medication was put on hold when the consent was not signed after several days. Record review of Resident #1's Orders revealed an order for QUEtiapine Fumarate (Seroquel) Tablet 25 MG Give 0.5 tablet by mouth at bedtime for behavioral disturbance; the order was started 01/29/24 at 8:00 pm. Further review revealed an order for Lorazepam-Diphenhydramine-Haloperidol mg (ABH Gel); Apply to skin topically every 2 hours as needed for agitation for 14 Days, order started 01/15/24. Record review of Resident #1's MAR, January/February of 2024, revealed she was administered Seroquel on the following dates; 1/29/24 1/30/24 1/31/24 2/1/24 2/2/24 2/3/24 2/4/24 Further review revealed the medication was marked as on hold starting 02/05/24. Further review of Resident #1's MAR, January of 2024, revealed she was administered ABH gel on the following dates: 01/15/24 01/17/24 01/18/24 (x2) 01/19/24 01/20/24 01/21/24 (x2) Record review of Resident #1's progress notes revealed a note by the MD on 01/29/24 at 4:26 pm that reflected that FAM was agreeable to start quetiapine (Seroquel). A progress note dated 02/05/24 at 8:47 am stated that FAM had not signed consent so medication was not given. Record review revealed a consent for Seroquel that was not signed by FAM. Record review revealed no signed consent for ABH gel.

Based on interview and record review, the facility failed to ensure care plans were developed in consultation with the resident and the resident's representative for one of one (Resident #1) of two residents reviewed for Comprehensive Care Plans, in that: The facility failed to schedule a care plan meeting with FAM and Resident #1 that involved a multidisciplinary team and instead documented a phone call between FAM and the Social Worker as the care plan meeting. This failure could place residents at risk of not receiving the highest practicable interventions, treatments and care by not involving the resident and FAM (MPOA) of a care plan meeting. Findings included: Record review of Resident #1's undated face sheet, printed on 02/10/24, revealed that he was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included depression, anxiety and dementia. It further revealed that her emergency contact and Responsible Party was FAM. Record review of Resident #1's 01/06/24 quarterly MDS revealed a BIMS of 3, which was indicative of severely impaired cognition. It further revealed her primary language was Spanish and she was usually understood and usually understood others. It revealed that she had no hallucinations nor did she have delusions that would be potential indicators of psychosis. Record review of the assessment titled Multidisciplinary Care Conference - V2 with an effective date of 12/28/23 revealed the meeting was 12/28/23 at 11:40 am and it was marked as the quarterly care conference. The only staff marked in attendance was the social worker. None of the l7 areas to be addressed per the form were marked as addressed, all were left blank. Under summarize discussion of the care plan conference there was a note stating FAM had a question about Resident #1's fall and the SW encouraged her to get with nursing about questions related to that. The SW said she was going to activities and the SW was making a referral to dental. It was further marked that the family member attended by phone and the only staff member who signed was SW. In an interview on 02/10/24 at 2:00 pm with FAM she stated that she had never attended a care plan meeting. She said she had called near the end of December (2023) about her Resident #1 having a fall that required stitches, but nothing else was discussed. She was not told in advance about a care plan meeting so she could attend . She also said her mother was not present on the phone call with SW. In an interview on 02/11/24 at 4:00 pm with the DON, she stated that a care plan meeting should be scheduled and include staff from all departments, the resident and the resident representative .

Based on interview and record review, the facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #1) of 5 residents reviewed for psychotropic drug use. The facility failed to: 1. ensure Resident #1 was prescribed Seroquel and ABH gel for a specific diagnosis and instead prescribed it for behavioral disturbance at bedtime This failure could affect all residents by placing them at risk of receiving psychotropic medications without a specific diagnosis and rather being prescribed psychotropic medication for behavior; this could cause decrease quality of life and increase the risk of injury. Findings included: Record review of Resident #1's undated face sheet, printed on 02/10/24, revealed that he was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included depression, anxiety and dementia. It further revealed that her emergency contact and Responsible Party was FAM. Record review of Resident #1's 01/06/24 quarterly MDS revealed a BIMS of 3, which was indicative of severely impaired cognition. It further revealed her primary language was Spanish and she was usually understood and usually understood others. It revealed that she had no hallucinations nor did she have delusions that would be potential indicators of psychosis . In an interview on 02/10/24 at 2:00 pm with FAM, she stated that she was told the doctor wanted to start Resident #1 on Seroquel, but FAM wanted to research the medication before the Seroquel was administered to Resident #1. In an interview on 02/11/24 at 2:45 pm with MD stated she had a duty to treat Resident #1's behaviors while awaiting signed consent from FAM. Record review of Resident #1's Orders revealed an order for QUEtiapine Fumarate (Seroquel) Tablet 25 MG Give 0.5 tablet by mouth at bedtime for behavioral disturbance; the order was started 01/29/24 at 8:00 pm. Further review revealed an order for Lorazepam-Diphenhydramine-Haloperidol mg (ABH Gel); Apply to skin topically every 2 hours as needed for agitation for 14 Days, order started 01/15/24. Record review of Resident #1's MAR, January/February of 2024, revealed she was administered Seroquel on the following dates; 1/29/24 1/30/24 1/31/24 2/1/24 2/2/24 2/3/24 2/4/24 Further review revealed the medication was marked as on hold starting 02/05/24. Further review of Resident #1's MAR, January of 2024, revealed she was administered ABH gel on the following dates: 01/15/24 01/17/24 01/18/24 (x2) 01/19/24 01/20/24 01/21/24 (x2) Record review of Resident #1's diagnoses list, on 02/10/24, revealed no diagnosis of psychosis, schizophrenia nor bipolar disorder, and her only mental health diagnoses were anxiety, depression, and insomnia (she also has a diagnosis of dementia). Record review of Resident #1's progress notes revealed a note by the MD on 01/29/24 at 4:26 pm that reflected that FAM was agreeable to start quetiapine (Seroquel). A progress note dated 02/05/24 at 8:47 am stated that FAM had not signed consent so medication was not given.

Based on observation, interview, and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible in 2 of 2 Common Baths (Pod A (SB) and Pod B (JH)) and 9 of 25 resident rooms (room [ROOM NUMBER]SB, 110SB, 111SB, 217SB, 218SB, 220SB, 108JH, 218JH and 326JH) reviewed. The facility failed to maintain resident use hot water at safe and comfortable temperatures. Resident-use hot water was not reliably controlled. Hot water temperatures ranged from 113 to 118.8 F, and The facility failed to ensure bathing and restroom area grab bars were securely attached to the walls. This failure could place residents at risk for injuries related to non-secure grab bars and could place residents at risk for sustaining scalding injuries when using resident-use/resident accessible hot water. The findings included: Observation on 12/13/23 at 1:08 PM the common bath on the A Pod (SB) unit hand sink had hot water at 114.3 F. Observation on 12/13/23 at 1:25 PM in room [ROOM NUMBER]SB, the hot water was 118.8 F at the hand sink and it was witnessed by CNA D. Observation on 12/13/23 at 1:30 PM in room [ROOM NUMBER]SB the hot water at the hand sink was 117.7 F. Observation on 12/13/23 at 1:37 PM in room [ROOM NUMBER]SB, the hot water at the hand sink was 116.6 F and the grab bar was loose in the restroom. Observation on 12/13/23 at 1:40 PM room [ROOM NUMBER]SB had one of two grab bars loose in the shower and the hot water was 115.3 F at the hand sink. Observation on 12/13/23 at 1:44 PM in room [ROOM NUMBER]SB, one of three grab bars was loose in the shower stall. The hot water was 114.8 F at the hand sink. Observation on 12/13/23 in room [ROOM NUMBER]SB at 1:50 PM, 1 of 2 grab bars was loose in the shower stall and the hot water was 113.2 F at the hand sink. Observation on 12/13/23 at 1:54 PM the B pod common bath (JH) had one of two shower stalls (#1) had one of three bars that was loose. The hot water at the hand sink was 114.4 F. Observation on 12/13/23 at 1:59 PM in the B pod area in room [ROOM NUMBER]JH the hot water at the hand sink was 114.1 F. Observation on 12/13/23 at 2:02PM in the B pod room [ROOM NUMBER]JH the hot water at the hand sink was 113.1 F. Observation on 12/13/23 at 2:04 PM in the B pod room [ROOM NUMBER]JH the hot water at the hand sink was 114.1 F. On 12/13/23 at 2:27 PM interview and observations of the boiler room were made with the Maintenance Supervisor. He stated that he tried to keep the hot water temperature between 105 degrees F and 111 to 112 F. He stated that he started his employment at the facility in September 2023. An observation was made in the boiler room revealed that the Domestic Water (resident use) temperature gauge read 123 F. The kitchen water temperature gauge read 105 F. He stated that the domestic water boiler was set at 120 F (domestic) and the other at 115 F (kitchen). Two boilers were attached to the domestic water system. Observation of the signage on the Domestic Water holding tank stated the following, 120 F Domestic Water. The Maintenance Supervisor stated, he just tested rooms 110SB and 220SB and had readings of 112 F and 115 F. He stated on a weekly basis he checked the water temperatures on the SB (Pod A) unit, Memory Care, and checked two rooms on each pod. He added, he did the same on the other pod (JH - Pod B) and then he checked the kitchen water and showers. He stated, the facility had a problem with the boilers, but it was repaired today (12/13/23). He stated that the times that he checked the water temperature were at different times of the day; morning, afternoon, and late afternoon. Observation of the mixing valve adjustment dial for the domestic water revealed that it was set slightly below the maximum heat setting mark. He stated, he heard 115 F was the maximum temperature allowed for resident use hot water and it is checked to keep it constant at 115 F. He stated that he last checked water temperatures last week. He stated he was responsible for ensuring that the water temperatures were appropriate in the facility and safe. He added that was why he checked water temperatures every week. He stated if the water was too hot residents, could get scolded. On 12/14/23 at 9:54 AM an interview was conducted with the Maintenance Supervisor, and he stated that he had not conducted any monitoring of grab bars, and he depended on the caregivers to tell him if there were repairs needed. He added, I don't check them. He stated over time, with use, they get loose. He stated he was responsible for ensuring that the grab bars were secure. He stated if there were loose grab bars, there was a chance of them coming off the wall, and a resident falling. He added it could make residents afraid to use the grab bars. He stated he retested the hot water today (12/14/23) and it was 112 F. now. Regarding why the hot water temperature was elevated, he stated now all the boilers were working; they may have needed adjusting. He added the problem may have been the extra boiler. On 12/14/23 at 12:06 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding the hot water and grab bars, she stated the Maintenance Supervisor now planned to have the grab bars checked on a regular basis, possibly with housekeeping assistance. She stated, the facility had the boiler serviced and most of the conversations had dealt with the water temperatures being cold. She added the Maintenance Supervisor was new, and he was more used to working in assisted living facilities where the water temperatures were allowed higher. She stated that the person responsible for maintaining water temperatures at a safe level was the Maintenance Supervisor. She stated that elevated hot water temperatures and loose grab bars could be a safety concern and result in potential harm. On 12/14/23 at 2:07 PM an interview was conducted with the Administrator regarding policies. She stated, the facility went by State regulations. She added, the facility had no policy regarding hot water temperatures and maintenance grab bar issues. Record review of the facility boiler repair vendor invoice dated 12/13/23 revealed the following documentation .All boilers are down. 12/1/23 Started troubleshooting three boilers. 12/2/23 . Two other boilers for domestic use set at 120 F. Work Performed. replaced flex coupling on both boilers for domestic water and flow switch on boiler close to storage tank. Record review of the facility Logbook Documentation for monitoring water temperatures revealed between 12/9/23 and 11/3/23, temperatures were taken of resident use hot water on an approximately weekly basis. Three of six test week results revealed hot water temperatures were not reliably maintained in a comfortable range. There were six weeks of temperatures taken during this period and it was documented that the week of 11/25/23 and the week of 11/17/23, the hot water temperatures taken in both A (SB) and B (JH) pods range from 110 F to 115 F. On 11/25/23 temperatures were documented between 100 F and 114 F. During the testing on 11/17/23, the hot water temperatures ranged from 112 F to 115 F. There were no times documented as to when these temperatures were taken. It was also documented that the water temperatures on 12/1/23 on both pods ranged from 89 F to 93 F. The documentation for 12/01/23 revealed the following, Comments: issues with boilers not staying on to heat water. Boiler tech came to restart boilers after these temps were taken. Further record review of the water temperatures taken on 12/9/23 revealed that the temperature range was 102 F to 105 F. Review of the current undated American Burn Association Scald Injury Prevention Educator's Guide provided the following information: .although scald burns can happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .Older adults, .have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs .Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person ' s perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100-degree F. water was a safe temperature for bathing. Water at 120 degrees F. would cause a third-degree burn (full thickness burn) in 5 minutes and 124 degrees F. water would cause a third-degree burn in 3 minutes. The Guide further documented that water at 127 degrees F. caused third degree burns in 1 minute and water at 133 degrees F. caused third degree burns within 15 seconds. Water temperatures at 140 degrees F. caused third degree burns within 5 seconds.

41480 42515 Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable and sanitary environment to help prevent the development and transmission of diseases for 4 of 5 residents (Residents #13, #14, #21, and #66) and 3 of 3 staff (LVN D, CNA B, and CNA C) reviewed for infection control. 1. LVN D failed to perform hand hygiene between glove changes during wound care for Resident #14 and Resident #66. 2. CNA B failed to perform hand hygiene between glove changes when providing incontinent care for Resident #13. 3. CNA C failed to perform hand hygiene between glove changes when providing incontinent care for Resident #21. These failures could place residents at risk for spread of infection and cross contamination. Findings included: Resident #14 A record review of Resident #14's face sheet, dated 12/13/23, revealed a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses to include parkinson's disease (progressive nervous system disorder), chronic respiratory failure (lung disease) and chronic pain syndrome. Record review of Resident #14's significant change Minimum Data Set (MDS) assessment, dated 10/26/23, revealed Resident #14 was understood and had a BIMS score of 10 which indicated the resident's cognition was moderately impaired. Record review of Resident #14's order listing report, dated 12/13/23, revealed the following orders: -Cleanse left outer foot with NS or wound cleanser, pat dry, apply calcium alginate, cover with silicone bordered dressing daily and prn every 1 hour as needed for saturation, with a start date of 12/08/23. -Cleanse sacrum wound with NS or wound cleanser, pat dry, apply anacept, pack and apply calcium alginate, and cover with silicone bordered dressing daily and prn every 1 hour as needed for wound tx, with a start date of 12/13/23. During an observation on 12/13/23 at 9:41 AM, LVN D walked in the room and performed hand hygiene using ABHR. LVN D donned (put on) a pair of clean gloves and removed the old dressing to Resident #14's sacral wound. LVN D cleansed the sacral wound with 4x4 gauze and wound cleanser, then patted dry. LVN D removed her gloves and donned a pair of clean gloves. LVN D packed the sacral wound with anacept (wound gel) and calcium alginate using a cotton-tipped applicator. LVN D removed her right-hand glove and placed a silicone bordered dressing on the sacral wound to cover it with one gloved hand and one ungloved hand. LVN D then removed her left-hand glove and used ABHR. LVN D donned a pair of clean gloves and removed the old dressing to Resident #14's left foot lateral (side) wound. LVN D cleansed the left foot lateral wound with 4x4 gauze and wound cleanser, then patted dry. LVN D removed her gloves and donned a pair of clean gloves. LVN D placed calcium alginate on the left foot lateral wound bed and covered it with a silicone bordered dressing. LVN D then removed her gloves and washed her hands with soap and water. LVN D did not perform hand hygiene between every glove change. Resident #66 Record review of face sheet for Resident #66, dated 12/13/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses to include necrotizing fasciitis (flesh eating disease), morbid obesity, and essential hypertension (high blood pressure). Record review of Resident #66's comprehensive MDS, dated [DATE] revealed Resident #66 was usually understood and had a BIMS score of 14 which indicated the resident's cognition was intact. Record review of Resident #66's order listing report, dated 12/13/23, revealed the following order: Cleanse left groin, perineum, buttock with wound cleanser or NS. Apply anacept and calcium alginate, pad with abdominal, cover with dressing daily and prn one time a day for wound tx, with a start date of 12/05/23. During an observation on 12/13/23 at 10:29 AM, LVN D walked in the room and performed hand hygiene using ABHR. LVN D donned a pair of clean gloves and removed the old dressing to Resident #66's groin wound. LVN D removed her gloves and donned a pair of clean gloves. LVN D cleansed Resident #66's groin wound with 4x4 gauze and wound cleanser, then patted dry. LVN D removed her gloves and donned a pair of clean gloves. LVN D applied anacept and calcium alginate to the groin wound and covered with an abdominal pad. LVN D removed her gloves and donned a pair of clean gloves and Resident #66 was turned on her side. LVN D removed the old dressing from Resident #66's perineum/buttocks wound. LVN D removed her gloves and performed hand hygiene using ABHR. LVN D donned a pair of clean gloves and cleansed the perineum/buttocks wound with 4x4 gauze and wound cleanser, then patted dry. LVN D removed her gloves and donned a pair of clean gloves. LVN D applied anacept and calcium alginate to the perineum/buttock wound and covered with an abdominal pad, using an island dressing to hold it in place. LVN D then removed her gloves and washed her hands with soap and water. LVN D did not perform hand hygiene between every glove change. During an interview on 12/13/23 at 2:18 PM, LVN D stated she has been trained to perform hand hygiene between glove changes. LVN D stated she did not know why she did not perform hand hygiene between every glove change. LVN D stated the residents are at risk of infection or bringing bacteria in due to the lack of hand hygiene between glove changes. Resident #13 Record review of face sheet for Resident #13, dated 12/12/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses to include hemiplegia and hemiparesis (one-sided paralysis), dysphagia (difficulty swallowing), and aphasia (language disorder). Record review of Resident #13's comprehensive MDS, dated [DATE] revealed that Resident #13 was sometimes understood and had a staff assessment for mental status that revealed Resident #13's cognition was moderately impaired. During an observation on 12/13/23 at 1:21 PM, CNA B performed incontinence care for Resident #13 with the help of CNA C. CNA B washed her hands with soap and water and donned a pair of clean gloves. CNA B unfastened Resident #13's brief and pulled it down. CNA B removed her gloves and donned a pair of clean gloves. CNA B wiped the groin area with wipes and removed her right-hand glove. CNA B then donned a clean glove to her right hand, Resident #13 was turned on her side and CNA B then wiped her buttocks. CNA B removed the old brief and removed her gloves. CNA B performed hand hygiene using ABHR and donned a clean pair of gloves. CNA B applied barrier cream to Resident #13's buttocks with her right hand, then removed her right-hand glove. CNA B donned a clean glove to her right hand and a clean brief was placed under the resident and fastened. CNA B then removed her gloves and performed hand hygiene using ABHR. CNA B did not perform hand hygiene between every glove change. Resident #21 Record review of Resident #21's face sheet dated 12/12/23 revealed a [AGE] year-old female with an admitted [DATE] with the following diagnoses: dementia (cognitive loss), acute and chronic respiratory failure (lung disease), and depression (mood disorder). Record review of Resident #21 comprehensive MDS dated [DATE] revealed Resident #21 was sometimes understood and had a staff assessment for mental status that indicated her cognition was moderately impaired. During an observation on 12/13/23 at 1:33 PM, CNA C performed incontinence care for Resident #21 with the help of CNA B. CNA C washed her hands with soap and water and donned a pair of clean gloves. CNA C unfastened Resident #21's brief and pulled it down. CNA C removed her gloves and donned a pair of clean gloves. CNA C wiped the groin area, removed her gloves and performed hand hygiene using ABHR. CNA C donned a pair of clean gloves and Resident #21 was turned on her side. CNA C wiped a bowel movement from Resident #21's buttocks and CNA C's gloves became visibly soiled. CNA C removed her gloves and donned a pair of clean gloves. CNA C wiped the buttocks until all the bowel movement was cleaned off and removed the old brief. CNA C removed her gloves and donned a clean pair of gloves. CNA C placed a clean brief under Resident #21 and applied barrier cream with her right hand. CNA C removed her right-hand glove and donned a clean glove to her right hand. CNA C secured the brief on Resident #21, removed her gloves and washed her hands with soap and water. CNA C did not perform hand hygiene between glove changes or when her gloved hands became visibly soiled. During an interview on 12/13/23 at 1:42 PM, CNA B and CNA C stated that they have been trained to perform hand hygiene between every glove change. CNA B and CNA C stated they were nervous and that is why they forgot. CNA B and CNA C stated the residents are at risk of cross-contamination due to the lack of hand hygiene between glove changes. During an interview on 12/14/23 at 9:18 AM, the DON stated she expected the staff to sanitize their hands between glove changes. The DON stated she expected staff to wash their hands with soap and water if their gloves became visibly soiled. The DON stated she expected staff to remove both right- and left-hand gloves when changing gloves during resident care. The DON stated the ADON, and she were responsible for ensuring staff adhered to infection control policies by making quality rounds throughout the day. The DON stated she did not know why the staff failed to perform hand hygiene between glove changes, they were probably nervous. The DON stated the residents had increased infection control risks due to the lack of hand hygiene between glove changes, only changing one glove during care and not washing hands with soap and water when gloves became visibly soiled. The DON stated she would have to look up training for LVN D, CNA B, and CNA C regarding infection control and hand hygiene. During an interview on 12/14/23 at 9:47 AM, the ADM stated she expected staff to perform hand hygiene between glove changes and to wash their hands with soap and water if their gloves became visibly soiled. The ADM stated the DON and ADON/Infection Control Nurse were responsible for ensuring staff adhered to infection control policies. The ADM stated staff were being trained during their on boarding to the facility, so she did not know why staff did not perform hand hygiene as they should. The ADM stated the potential negative outcome to the residents were possible infection risks. During an interview on 12/14/23 at 10:39 AM, the ADON stated she expected staff to sanitize their hands between glove changes. The ADON stated she expected staff to remove both gloves during resident care when going from dirty to clean, perform hand hygiene and put on clean gloves. The ADON stated she expected staff to perform proper handwashing (meaning soap and water) when their gloves became visibly soiled. The ADON stated as the infection preventionist for the facility, the DON and she were responsible for ensuring staff were washing their hands between glove changes or when their gloves became visibly soiled. The ADON stated she did not know why the staff removed only one glove during resident care instead of both gloves. The ADON stated staff could not see if the other glove was dirty with bacteria not seen by the eye, so they should have changed both gloves instead of just one. The ADON stated the staff were probably nervous and that is why they forgot to perform hand hygiene between every glove change. The ADON stated the potential negative outcome to the residents were infection transmission risks. Record review of facility's Treatment Nurse Competency Check Off which included hand washing for LVN D revealed she completed this check off on 11/08/23 with a met status. Record review of facility's Record of Inservice - Infection Control, dated 05/01/23 revealed the following: -Objectives of the in-service: Please be mindful that it is very important to wash your hands and change gloves between patients. -Brief evaluation of the participants' responses to the in-service: This helps prevent infection control and keeps down on resident complaints. CNA B and CNA C's signatures were noted on the in-service form. Record review of the facility's Record of In-Service: Infection Control, dated 05/07/23 revealed the following: Objectives of the In-Service: Gloves are not to be stored in your pockets. They are also not to be pulled out of the rooms. Part of Infection Control is handwashing. You are required to wash your hands upon entering the room(s) and before leaving the room(s). Room will/are stocked every Monday and Friday. Brief evaluation of the participants' responses to the in-service: Again please do not pull gloves out of the residents room/bathrooms. Thank you. CNA B and CNA C's signatures were noted on the in-service form. Record review of the facility's Record of In-Service: Dignity/Resident Rights, dated 08/09/23 revealed the following: Objectives of the in-service: When giving peri-care please ensure that you first 1. Knock on the door. 2. Wash your hands. 3. Pull privacy curtain. 4. Close blinds. Brief evaluation of the participants' responses to the in-service: These in-services are all final warnings. Please ensure that you follow all residents rights and dignity rights. CNA B and CNA C' signatures were noted on the in-service form. Record review of the facility's policy, titled Infection Prevention and Control Program, with a revised date of September 2022 reflected the following: Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections Record review of facility policy titled Handwashing/Hand Hygiene, with a revised date 08/19 revealed the following: Policy statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors . 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. when hands are visibly soiled . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: h. before moving from a contaminated body site to a clean body site during resident care; k. after handling used dressings, contaminated equipment, etc; m. after removing gloves . 9.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

Based on observation, interview, and record review the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (12/14/23 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During confidential individual interviews 1 of 12 residents voiced concerns related to food palatability. During a confidential interview on 12/12/23 at 9:50 AM, a resident stated she did not like to eat in her room for meals because the food was cold by the time it got to her. The resident stated staff would warm up the food for her if she asked, but it would still be cold at times. The resident stated she had complained about this issue before, but nothing was changed. On 12/13/23 at 10:54 AM, an interview was conducted with the Dietary Manager, and he was informed of a test tray request for hall carts. Observation on 12/13/23 at 11:19 AM revealed Dietary staff E took temperatures on the service line with the following results: Seasoned Green beans, 206 F. Mashed potatoes 208.4 F. Smothered Pork chops with gravy 193.4 F. Puree seasoned green beans 204 F. Puree pork chops 204 F. Ground pork chop 195 F. Pureed bread no temperature taken and stored at room temperature. Hall tray meal service started at 11:27 AM on 12/13/23. Observation revealed the last Pod B (JH) unit tray was prepared at 11:41 AM. The sample tray preparation began at 11:41 AM and ended at 11:42 AM. The unheated cart left the kitchen at 11:44 AM. The cart arrived at Pod B unit at 11:47 AM. The service for B100 pod trays started at 11:48 AM and ended at 11:51 AM. At 11:51 AM the cart arrived on the B200 pod and staff began serving trays at 11:52 AM and the doors were open on the cart. The staff were checking and identifying trays on the cart and uncovering trays. The doors were closed on the cart at 11:56 AM. The cart left for the B300 unit at 11:56 AM. It arrived on the unit at 11:57 AM and staff started serving at 11:57 AM and the doors were left open. The doors were left open to the cart until 12:01 PM. The last tray for the B unit was served to Resident #15 at 12:02 PM. The resident began eating at 12:08 PM. The test observation began on 12/13/23 at 12:11 PM with the following results: Seasoned Green beans - 120 F bland. Smothered Pork chop with gravy - 122 F bland and dry Mashed potatoes - 130 F bland and had an instant flavor. Ground pork with gravy on top - 128 F had an off flavor unlike pork, tangy, old/stale flavor. Pureed pork - 115 F. There were bits and pieces of whole pork. Pureed bread - 102 F had a tangy off flavor unlike bread. Pureed seasoned green beans - 110 F Cold, flat on the plate and had elevated pepper flavor. Seven of nine foods tested had palatability issues of temperature, flavor, and appearance. On 12/14/23 at 9:50 AM an interview was conducted with the Dietary staff E. She stated that she was unsure why the pork chops were dry. She stated she followed the recipe on the pork chops, but the thyme was missing. She added she used chicken base, onions, and heavy cream and the mashed potatoes were a powder mix. On 12/14/23 at 9:56 AM an interview was conducted with the Dietary Manager regarding issues in the dietary department. He stated he told staff to follow the recipe and had told them many times. He stated, green beans may have gotten cold by sitting there and got cold after being prepared. He added staff may have turned the steam table off. He stated, he monitored the palatability of foods by tasting the food and monitor staff. He further stated he and the staff were responsible for the palatability of food. He stated he was not present in the kitchen all day. He added he would attend resident counsel if invited. He stated the last Resident Council meeting he attended was in June 2023. He added he addressed grievances individually. He stated unpalatable food could affect residents happiness and decrease independence. He added, good food made residents happy. On 12/14/23 at 12:06 PM an interview was conducted with the Administrator regarding issues found in the facility. She stated that she was unsure why the food palatability issues occurred. She added the person responsible for food palatability was the Dietary Manager and the result of these issues could be possible weight loss and residents not eating the food. Record review of the Resident Council Minutes dated 9/18/23 revealed a resident comment that stated, Food Service - stop making (resident) eggs hard . Record review of the Resident Council Minutes dated 10/23/23 revealed resident comments that stated, Old Business. Dietary . would help to get plate warmers, not cold food. Food does come cold often. Record review of the facility policy, titled Nutrition and Food Service Policies and Procedures Manual, Policy: Test Trays, Policy Number: 10.001, Date Approved: October 1, 2018, reveal the following documentation, Policy: the facility recognizes the importance of routine quality assurance monitoring to ensure that its residents are provided food that is appealing, palatable and served at the correct temperatures. Routine test tray will be evaluated by the Nutrition and Food Service Manager or designated employee. Procedure: 1. The Nutrition and Food Service Manager or designated employee will conduct a test tray evaluation at least once each month. The evaluation will be conducted at each meal to ensure that food temperatures, portion sizes, and that orders are followed. A sample test tray checklist is attached. 2. A test tray checklist should be completed at least monthly at each meal service site to ensure that temperatures, palatability, and accuracy are maintained at each location .

Based on observation, interview, and record review the facility failed to ensure menus were followed for 3 of 3 food forms (regular, mechanical soft and puree) for 4 residents (Residents #2, 7, 22 and 25) reviewed during mealtime. The facility failed to ensure Residents #2, 7, 22, and 25 received their meals according to the menu. This failure could place residents at risk for unwanted weight loss and hunger. The findings included: Resident #2: Record review of the current care plan dated 12/13/23 for female Resident #2 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Repeated Falls, Dysphagia, Oral Phase (swallowing disorder) and Moderate Protein-Calorie Malnutrition (malnutrition). Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of Regular diet Pureed texture, Regular consistency, Ice cream TID // fortified foods TID, Active 01/18/2023 . Resident #7: Record review of the current care plan dated 12/13/23 for male Resident #7 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Lymphedema, Not Elsewhere Classified (fluid buildup in lymph system), Displaced Intertrochanteric Fracture Of Right Femur, Subsequent Encounter For Closed Fracture With Routine Healing (Femur Fracture), Weakness, and Age-Related Physical Debility. Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of No Salt on Tray (NSOT) diet Regular texture, Regular consistency, fortified meal plan at all meals for Nutrition, Active 10/27/2023 . Resident #22: Record review of the current care plan dated for female Resident #22 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Unspecified Protein-Calorie Malnutrition (Malnutrition), Heart Failure, Unspecified, Encounter for Palliative Care, and Pressure Ulcer Of Sacral Region, Stage 3 (pressure ulcer - tissue injury). Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of 2g Na Diet, Mechanical Soft texture, Regular consistency, for Heart Failure, Active 08/25/2023 . Resident #25: Record review of the current care plan dated for female Resident #25 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Encephalopathy, Unspecified (change in brain function), Anorexia (eating disorder), Unspecified Severe Protein-Calorie Malnutrition (Malnutrition), Weakness, Acute Kidney Failure, Unspecified, Dysphagia, Unspecified (Swallowing Disorder), Pain, Unspecified, and Pressure Ulcer of Sacral Region, Stage 4 (pressure ulcer - tissue injury). Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of Puree diet Pureed texture, Regular consistency, Active 11/07/2023 . - The following observations were made during a kitchen tour on 12/12/23 that began at 10:45 AM and concluded at 12:33 PM: An observation was made of the service line of the following foods at 11:20 AM: Beef enchiladas (premade in individual rolls) served with a #8 scoop. Rice served with the #8 scoop (1/2 cup). Refried beans serve with a #8 scoop (1/2 cup). Pureed beans serve with a #8 scoop (1/2 cup). Pureed enchiladas served with a #10 scoop (3/8 cup). Pureed rice served with a #10 scoop (3/8 cup). Dietary staff A served the meal. These foods were served one scoop each. Observation on 12/12/23 at 11:38 AM revealed Resident #7 was served #8 scoop of beans, #8 scoop of beef enchiladas, and #8 scoop of rice. The resident should have received Beef enchiladas with chili sauce 2 each + 4 ounces sauce . for his regular texture diet. It was unknown if the #8 scoop of enchilada equated to 2 enchiladas with 4 ounces of sauce. Observation on 12/12/23 at 11:39 AM revealed Resident #25 was served a #8 scoop of pureed beans, #10 scoop of pureed rice, and a #10 scoop of pureed enchilada. The resident should have received Pureed beef and enchilada with chili sauce #6 dip (2/3 cup scoop) . for her pureed texture diet. Observation on 12/12/23 at 11:44 AM revealed Resident #2 was served a #8 scoop of pureed beans, #10 scoop pureed rice, and #10 scoop pureed beef enchiladas. The resident should have received Pureed beef and enchilada with chili sauce #6 dip (2/3 cup scoop) . for her pureed texture diet. Observation on 12/12/23 at 11:55 AM revealed Resident #22 was served a #8 scoop of rice, #8 scoop of beans, and a #8 scoop of beef enchiladas. The resident should have received Chopped beef enchilada with chili sauce, two each + 4 ounces sauce . for her mechanical soft texture diet. It was unknown if the #8 scoop of enchilada equated to 2 enchiladas with 4 ounces of sauce. On 12/14/23 at 9:56 AM an interview was conducted with the Dietary Manager regarding issues in the dietary department. Regarding following the menu, he stated Dietary staff A went to a scoop from a spatula when serving the enchiladas. He stated that with the use of the #8 scoop, it was unknown if it was two, three, or less enchiladas served in the #8 scoop serving. He added, he told Dietary staff A she needed more pans of enchiladas prepared. Regarding the incorrect scoop sizes, he stated Dietary staff A did what she wanted to do. He stated Dietary staff A aid she was a cook, but he saw indications that required more training and gave her more. He stated to ensure the menu was followed, he printed the menus, and tray card so they would know what was needed and gave staff the tools needed. He stated he and staff were responsible to ensure that the menu was followed. Regarding what could result from the menu not being followed, he stated decreased resident expectations and we get complaints. On 12/14/23 at 11:47 AM an interview was conducted with Dietary staff A. She stated, she changed from a spatula to an #8 scoop for the enchiladas because they had gotten cooked and fell apart. She added, The #8 scoop is a normal serving. I did not want it (enchiladas) to look too messy. She stated, she used the #10 scoop instead of a #6 for the pureed enchiladas because the facility only had one #6 scoop. She added there were not many #10 scoops available. On 12/14/23 at 12:06 PM an interview was conducted with the Administrator regarding issues found in the facility. She stated that she was unsure why the staff did not follow the menu. She added the person responsible for ensuring the menu was followed was the Dietary Manager and the result of not following the menu could be a potential change in weight and nutrition for residents. Record review of the facility's, Diet Roster - By Texture dated 12/12/23 revealed the following documentation: Resident #2 - Regular (diet), puree (texture) diet. Resident #7 - Regular (diet), 2 gm sodium (diet other), regular (texture) diet. Resident #22 - Regular (diet), 2 gm sodium (diet other), mechanical soft (texture) diet, Resident #25 - Regular (diet), puree (texture) diet. Record review of the facility Diet Spreadsheet, Menu: .Week 1, Day: 3 - Tuesday Lunch revealed that residents on a regular diet should have received: Beef enchiladas with chili sauce 2 each + 4 ounces sauce, Cilantro Lime Rice #8 dip Charro beans 4 ounce spoodle (draining ladle) -Residents on mechanical soft diets should have received: Chopped beef enchilada with chili sauce, two each + 4 ounces sauce. Cilantro, lime rice with salsa #8 dip + 2 ounces Charro beans 4 ounce spoodle (draining ladle). -Residents on puree diets should have received: Pureed beef and enchilada with chili sauce #6 dip Puree, Cilantro Lime Rice, #10 dip. Puree Charro beans #8 dip Record review of the facility's recipe titled Beef Enchiladas with Chili Sauce, Recipe Number: 195614 revealed the following documentation. To serve: serve two beef enchiladas with 4 ounces prepared and heated chili sauce over all . Record review of facility's recipe titled Chopped Beef Enchilada with Chili Sauce, Recipe Number: 195615, revealed the following documentation, . To serve: serve two beef enchiladas hand chopped into bite-size pieces with 4 ounces prepared and heated chili sauce over all . Record review of the facility policy titled Nutrition and Food Service Policies and Procedures Manual, Section 3-11, Policy: Tray Service, Policy Number: 03.006 Date Approved: October 1, 2018, Date Revised: June 1, 2019, revealed the following documentation, Policy: the facility believes that accurate tray service and adequate portion sizes are essential to the resident's well-being and safety. The facility will ensure that diets are served accurately, and in the correct portions, and that resident's preferences are met. Procedure . 3. For tray line service, Nutrition and Food Service staff will check each resident's tray card prior to service to ensure their preferences and dislikes are honored, the correct diet is served, portion sizes are accurate and appropriate substitutions provided . 6. The Nutrition and Food Service Manager or consultant . will conduct in-services with the nutrition, food services as needed to ensure all serving staff are familiar with portion, sizes and therapeutic and mechanically altered diets . Record review of the facility policy, titled Nutrition and Food Service Policies and Procedures Manual, Policy: Test Trays, Policy Number: 10.001, Date Approved: October 1, 2018, reveal the following documentation, Policy: the facility recognizes the importance of routine quality assurance monitoring to ensure that its residents are provided food that is appealing, palatable, and served at the correct temperatures. Routine test tray will be evaluated by the Nutrition and Food Service Manager or designated employee. Procedure: 1. The Nutrition and Food Service Manager or designated employee will conduct a test tray evaluation at least once each month. The evaluation will be conducted at each meal to ensure that food temperatures, portion sizes, and that orders are followed. A sample test tray checklist is attached. 2. A test tray checklist should be completed at least monthly at each meal service site to ensure that temperatures, palatability, and accuracy are maintained at each location .

Based on observation, interview, and record review the facility failed to offer, based on a resident's comprehensive assessment, a therapeutic diet when there was a nutritional problem, and the health care provider ordered a therapeutic diet for 4 of 4 residents (Residents #2, 7, 22, and 39). The facility failed to provide Residents #2, 7, 22, and 39 with their physician ordered therapeutic diets that included fortified foods, Cardiac diet, and 2GM Sodium for the noon and evening meals on 12/12/23 and the noon meal on 12/13/23. This failure could place residents at risk for hunger, weight loss, and chemical imbalances. The findings included: Resident #2 Record review of the current care plan dated 12/13/23 for female Resident #2 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Repeated Falls, Dysphagia- Oral Phase (swallowing disorder) and Moderate Protein-Calorie Malnutrition (malnutrition). Record review of the Significant Change MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of two indicating severe cognitive impairment. Further record review revealed the resident had no documented oral, dental, or swallowing issues. The resident had an active diagnosis of malnutrition. There was no documented weight loss or gain. Record review of the current undated care plan for Resident #2 revealed a Problem of (Resident #2) is at risk for alteration in nutrition related to impaired cognition/disease process dementia, disease process GERD, dysphagia, low BMI, dietary restrictions Date Initiated: 02/09/2022. Revision on: 12/15/2022. Interventions listed were, . House Supplement 2.0 four times a day Give 120mL four times a day between meals Date Initiated: 12/15/2022. Ice cream TID // fortified foods TID Date Initiated: 12/15/2022 . Provide and serve diet as ordered. Monitor intake and record every meal. Receives Regular diet Dysphagia Puree texture, Regular consistency Date Initiated: 12/15/2022. Revision on: 12/15/2022 . Record review of the Nutritional Risk Assessment V2 for Resident #2 dated 9/18/23 revealed the following, .C. Identification of Risk Indicators. 1. Rate of unplanned Weight Gain/Loss. stable . 2. Current Food and Fluid Intake. 25-100%, variable dependence at meals. 3. Relevant Labs. no new labs . 6. Chewing/Swallowing Difficulties . on puree - dysphagia noted . 8. Current Diet Orders .reg/puree/reg . D. Estimated Needs .5. Nutrition summary and interventions for plan of care: Resident annual assessment. BMI 16 - underweight. Resident on hospice - some decline in weight/appetite may be unavoidable due to progression. Resident likely not meeting estimated needs with oral intake at this time and underweight. Recommend continue to offer and encourage oral intake as appropriate. Goal to maintain resident comfort and honor goals of care while on hospice. RD to continue to monitor and follow up as needed . Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of Regular diet Pureed texture, Regular consistency, Ice cream TID (3 times a day) // fortified foods TID, Active 01/18/2023 . Record review of the tray card for Resident #2 dated 12/12/23 (lunch - day 3) revealed that the resident was documented as being on a regular puree diet with foods listed as: Pureed beef enchilada with chili sauce, pureed cilantro lime rice, pureed charro beans. Notes: ice cream; fortified foods . Observation on 12/12/23 at 11:44 AM Resident #2 was served a puree diet and it was also noted that the beans were flat on the plate. The pureed beans were a #8 scoop, pureed rice was a #10 scoop, pureed enchiladas were a #10 scoop, and they had a course or chunky appearance. No foods were identified as fortified. On 12/14/23 at 11:56 AM an interview was conducted with the DON regarding resident diets. She stated the probable reason for Resident #2's diet was due to swallowing issues and to maintain weight. She stated by residents not receiving their therapeutic diet, it could affect them depending on the diagnosis and the reason for the diet. Resident #7 Record review of the current care plan dated 12/13/23 for male Resident #7 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Lymphedema, Not Elsewhere Classified (fluid buildup in lymph system), Displaced Intertrochanteric Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing (Femur Fracture), Weakness, and Age-Related Physical Debility. Record review of the Admission MDS assessment dated [DATE] revealed Resident #7 had a BIMS score of 12 indicating he was moderately cognitively impaired. Further record review revealed the resident was on a therapeutic diet. The resident had an active diagnosis of a hip fracture. Record review of the current undated care plan for Resident #7 revealed no specific care plan related to nutrition or diet. There was a Problem addressed that stated, .The resident has potential to skin integrity of the related to impaired mobility. Date Initiated: 10/04/2023. An Intervention listed was documented as, .Identify/document potential causative factors and eliminate/resolve where possible. Date Initiated: 10/04/2023 . Record review of the Weight Summary for Resident #7 revealed he sustained 11.8% weight loss in 1 month from 10/04/23 he was at 309.6 lbs to 11/16/23 with the weight of 273 lbs. On 12/05/23 he gained 2 pounds up to 275 lbs. Record review of the Nutritional Risk Assessment V2 for Resident #7 dated 10/27/23 revealed the following, .5. Pressure Injury . 4) Unstageable 5. Nutrition summary and interventions for plan of care: Resident admitted post-surgery for hip fracture. Resident has unstageable breakdown to coccyx. He states that he has lost a lot of weight in past 6-8 months He states he has been eating very sparingly. PO intake potentially inadequate due to skin breakdown/increased needs. Recommend Fortified Meal Plan be added to increase kcal (calories) & pro (protein) intake. Goal healing of skin, stable wt . Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of No Salt on Tray (NSOT) diet Regular texture, Regular consistency, fortified meal plan at all meals for Nutrition, Active 10/27/2023 . Record review of the tray card for Resident #7 for 12/12/23 (lunch - day three) revealed the resident was on a regular, 2 g sodium diet. The menu listed, beef enchilada with chili sauce, cilantro lime rice, Charro beans . Notes: fortified foods . Observation on 12/12/23 at 11:38 AM, Resident #7 was served #8 scoop of beans, #8 scoop of enchiladas, #8 scoop of rice, and a regular cinnamon apple dessert. No foods were identified as fortified. Review of the tray card for Resident #7, dated 12/12/23 (supper - day three) revealed the resident was on a regular 2 g sodium diet. The menu listed: cream of tomato soup, grilled cheese sandwich, marinated vegetable salad. Notes: fortified foods. Observation on 12/12/23 at 4:32 PM, Resident #7 was served a grilled cheese, mixed vegetable salad, and regular tomato soup. No foods were identified as fortified. On 12/14/23 at 11:56 AM an interview was conducted with the DON regarding resident diets. She stated the reason for Resident #7's diet was the resident was possibly at risk for weight loss. She stated by residents not receiving their therapeutic diet, it could affect them depending on the diagnosis and the reason for the diet. Resident #22 Record review of the current care plan dated for female Resident #22 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Unspecified Protein-Calorie Malnutrition (Malnutrition), Heart Failure, Unspecified, Encounter for Palliative Care, Essential (Primary) Hypertension (high blood pressure), and Pressure Ulcer of Sacral Region, Stage 3 (pressure ulcer - tissue injury). Record review of the annual MDS assessment for Resident #22 dated 11/22/23 revealed that the resident had a BIMS score of 13 indicating the resident was cognitively intact. The resident had documented active diagnoses of hypertension, malnutrition, and heart failure. There was no documented weight loss or weight gain. Record review of the current undated care plan for Resident #22 revealed a Problem of the resident has cardiac disease related to Heart Failure. Date Initiated: 08/26/2023. Revision on: 09/24/2023. No interventions were listed related to nutrition or diet. There was an intervention listed related to a care plan for the resident's diabetes mellitus that stated, .Encourage . compliance with dietary restrictions .Date Initiated: 09/24/2023 . Record review of the Nutritional Risk Assessment V2 for Resident #22 dated 9/18/23 revealed the following, C. Identification of Risk Indicators. 1. Rate of unplanned Weight Gain/Loss. -4% (loss) in 30 days, +11% (gain) in 90 days, stable in 180 (days), diuretic .8. Current Diet Orders. 2g NA/mech soft/reg .5. Nutrition summary and interventions for plan of care: Resident readmit after hospitalization for sepsis pneumonia (infection). Edema noted 09/14. Diuretic (water pill) noted - fluid shifts may impact weight trends Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of 2g Na Diet, diet Mechanical Soft texture, Regular consistency, for Heart Failure, Active 08/25/2023 . The diet was updated 12/12/23 at 12:27 PM to 2g Na Diet Regular texture, Regular consistency, for diet please include broth with each meal . Review of the tray card for Resident #22 dated 12/12/23 (lunch-day 3) revealed the resident was on a regular, 2 g sodium diet with menu foods listed as: chop beef enchilada with chili sauce, cilantro lime rice with salsa, Charro beans. Note: need assistance with meals. Observation on 12/12/23 at 11:55 AM revealed Resident #22, who was on a 2 g sodium diet, received a #8 scoop of rice, #8 scoop of beans, and a #8 scoop of enchiladas. No defined 2gm sodium menu foods. Record review of their tray card for Resident #22dated 12/12/23 (supper-day three) revealed the resident was documented as being on a regular 2 g sodium diet with menu foods listed as: Cream of tomato soup, grilled cheese sandwich, soft cooked broccoli. Notes: needs assistant with meals . Observation on 12/12/23 at 4:44 PM revealed Resident #22 received broccoli, regular tomato soup, grilled cheese sandwich, and a brownie. The resident did not receive any broth. No identified 2gm sodium menu foods. On 12/14/23 at 11:56 AM an interview was conducted with the DON regarding resident diets. She stated the reason for Resident #22's diet could be for sodium reduction due to blood pressure and cardiac issues. She added the broth could be for an upset stomach. She stated by residents not receiving their therapeutic diet, it could affect them depending on the diagnosis and the reason for the diet. Resident #39 Record review of the current care plan dated for female Resident #39 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Alzheimer's Disease, Unspecified(dementia), Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris (heart disease), Presence of Cardiac Pacemaker (heart rhythm regulating device), and Unspecified Protein-Calorie Malnutrition (Malnutrition). Record review of the quarterly MDS assessment for Resident #39 dated 11/3/23 revealed that the resident had a BIMS score of 6 indicating that she had severe cognitive impairment. Active diagnosis listed was Alzheimer's disease, coronary artery disease, hypertension, and malnutrition. There was no documentation of known weight loss or weight gain. Record review of the current undated care plan for Resident #39 revealed a Problem of The resident has potential nutritional problem. r/t poor intake and impaired cognition as evidence by diagnosis of protein calories malnutrition Date Initiated: 04/24/2023. Revision on: 05/24/2023. Interventions listed were, Provide and serve diet as ordered. Date Initiated: 05/24/2023. Provide and serve supplements as ordered. Date Initiated: 05/24/2023. Revision on: 05/24/2023. Provide, serve diet as ordered. Monitor intake and record q meal. Date Initiated: 05/24/2023 . Record review of the Nutritional Risk Assessment V2 for Resident #39 dated 4/22/23 revealed the following, 8. Current Diet Orders. cardiac, reg, thin liquids . 5. Nutrition summary and interventions for plan of care: Resident recently admitted . Able to feed self primarily, varied intake of meals Record review of the Weight summary for Resident #39 revealed her weight was stable at 171lbs. Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of Cardiac diet Regular texture, Regular consistency. Active 04/11/2023 . ensure or boost supplement with each meal with meals for malnutrition, Active 05/04/2023 . Record review of the tray card for Resident #39 dated 12/12/23 (lunch - day three) revealed the resident was documented as being on a regular 2 g sodium diet with menu foods listed as: beef enchilada with chili sauce, cilantro lime rice, Charro beans. Notes: house shake. Observation on 12/12/23 at 11:34 AM revealed Resident #39 was served a #8 scoop of rice, #8 scoop of regular beans, #8 scoop of enchiladas, and a cinnamon apple dessert. No health shakes were observed served. Review of the tray card for Resident #39, dated 12/12/23 (supper - day three) revealed the resident was documented as being on a regular 2 g sodium diet with menu foods listed as: cream of tomato soup, grilled cheese sandwich, marinated vegetable salad. Notes: house shake. Observation on 12/12/23 at 4:31 PM revealed Resident #39 was served regular tomato soup, mixed vegetable salad, and a grilled cheese. No health shakes were observed served. On 12/14/23 at 11:56 AM an interview was conducted with the DON regarding resident diets. She stated the probable reason for Resident #39's diet was due to her increased walking activity as a dementia resident and needing additional calories from a supplemental drink. She stated by residents not receiving their therapeutic diet, it could affect them depending on the diagnosis and the reason for the diet. Observation on 12/12/23 at 11:20 AM revealed Dietary staff A served and took temperatures of the noon meal foods on the service line. No foods were identified as fortified. No health shakes were observed served during the meal. On 12/12/23 at 4:15 PM a kitchen observation and interview were conducted. Observation of the service line at this time revealed temperatures were taken, and foods were served by Dietary staff D on the steam table. No foods were identified as fortified. No health shakes were observed served during the meal. On 12/12/23 at 4:47 PM an interview was conducted with Dietary staff D regarding what she used to make the foods she served. She stated: Mixed vegetable salad included vegetable blend and Italian dressing. Tomato soup was canned regular Tomato Soup. Record review of the Diet Spreadsheet, Menu . Week 1, Day: 3 - Tuesday lunch and supper revealed that there was no menu guidance listed for Cardiac diets and 2gm Na (sodium) diets. Further documentation on the Diet Spreadsheet for Week 1 Day: 3 Tuesday revealed the following, Fortified enhanced foods: follow the consistency diet ordered and offer a minimum of one fortified food item per meal, unless otherwise directed. On 12/13/23 at 3:35 PM an interview was conducted with Dietary staff A regarding fortified foods for the meals she prepared. She stated, I think pudding is just fortified. She identified no other food options as being fortified. On 12/13/23 at 3:36 PM an interview was conducted with the Dietary Manager regarding therapeutic diets. He stated mashed potatoes were fortified usually. He added Dietary staff A did not make fortified foods for the noon meal on 12/12/23. He stated the fortified tomato soup was made with milk on the evening meal of 12/12/23. He stated there was a small amount of fortified mashed potatoes in a bin for the noon meal on 12/13/23. He stated, the facility ran out of shakes yesterday (12/12/23) at the noon and evening meal and none were served. He added he thought someone was taking the shakes. He also stated he did not know that Resident #22 needed broth with her meal. He stated there were issues with diet communication and at times he was not made aware of resident dietary changes in a timely manner from nursing. He further stated that the tray card and diet software had a limited amount of options regarding orders. He added that the Cardiac diet is 2 gm sodium or no added salt diet. He stated he had no other choices in the dietary department software that documents orders. He stated, regarding guidance for a 2gm sodium diet, that everything he had was low sodium and all my seasonings are low sodium. He further stated, regarding diets in the dietary software, that the diets on the menus listed were what he had, and he had no other options to match the physician orders. On 12/14/23 at 9:56 AM an interview and observation were conducted with the Dietary Manager regarding issues in the dietary department. Observation of the pantry revealed that [NAME] Tomato Soup was present. The label on the [NAME] Tomato Soup stated that it was made with tomato puree, seasonings, wheat flour, and no milk products. There was no Cream of Tomato soup. Regarding the 2 gm sodium diet, the Dietary Manager stated most foods and ingredients they used was low sodium. He stated he used direct monitoring of staff to ensure that therapeutic diets were served correctly. He stated he and staff were responsible for ensuring that therapeutic diets were served correctly. He stated residents could experience heart complications, weight loss which could lead to death and malnutrition if therapeutic diets were not served correctly as ordered. He added, he tried to avoid canned vegetables to reduce the sodium. Regarding how staff knew what a 2 gm sodium diet consisted of, he stated in-services. He further stated he was unsure of the last in-service on 2 gm sodium. He stated it had been a long time. He stated, Resident #22 wanted broth because the facility lost her teeth, and she could not eat other food. On 12/14/23 at 12:06 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding therapeutic diet, she stated the issues occurred due to poor planning. She added, the facility had three cases of shakes on Friday, and she found out later there were no shakes available and she got some. She stated she told the Dietary Manager to take action and follow up. She stated that the Dietary Manager was responsible for ensuring therapeutic diets were served correctly. She added residents could experience weight loss and their nutrition could be affected if they did not receive their therapeutic diet. On 12/14/23 at 1:30 PM an interview was conducted with the Dietary Manager. He stated, the facility had no specific guidance for a Cardiac Diet. He added, We only have the choices in the system (computer). He stated the diet options included Food forms - regular, mechanical soft, and purees. Diets are regular, mechanical soft, puree, low concentrated sugar, small portion and large portion. Record review of the facility's, Diet Roster - By Texture dated 12/12/23 revealed the following documentation: Resident #2 - Regular (diet), puree (texture) diet. Resident #7 - Regular (diet), 2 gm sodium (diet other), regular (texture) diet. Resident #22 - Regular (diet), 2 gm sodium (diet other), mechanical soft (texture) diet Resident #39 - Regular (diet), 2 gm sodium (diet other), regular (texture) diet Record review of the facility presented Recipe Listing, Corporate Recipes for the Category of fortified foods revealed that the facility had recipes for 9 fortified foods which included, fortified cereal, fortified milk, fortified milkshake, fortified potatoes mashed, fortified pudding parfait, fortified fruit smoothie, fortified creamed soup, fortified streusel topping, and Vanilla mighty shakes. Record review of the recipe for Fortified Soup, Creamed, (assorted), Corporate Recipe - Number: 1823 revealed that the ingredients for fortified soup, consisted of assorted creamed soup, nonfat powdered milk, and bulk sour cream. Further documentation revealed the following, Notes: .2. For pureed: measure out desired number of servings into food processor. Blend until smooth. Add liquid if product needs thinning. Add commercial thicker if product needs thickening. Record review of the facility recipe titled Cream of Tomato Soup, Recipe Number: 179757 revealed that the cream of tomato soup should have included the following ingredients: water, chicken base, tomato juice, chopped garlic, dried basil leaves, ground oregano, margarine, solids and milk, and parsley flakes dried. Record review of the facility's recipe titled Pureed Cream of Tomato Soup, Recipe Number: 170386 revealed that the ingredients consisted of cream of tomato soup. Further documentation revealed the following, .Note . 2. If product needs thinning, gradually add an appropriate amount of liquid. to achieve a smooth, pudding, or soft mashed potato consistency. 3. If the product needs thickening, gradually add a commercial or natural food thicker. To achieve a smooth pudding or soft mashed potato consistency . Review of the facility policy titled, Nutrition and Foodservice Policies and Procedures Manual, 2018, Section 1-3, Policy: Menu Planning. Policy Number: 01.002, Date Approved: October 1, 2018, Date Revised: June 1, 2019, revealed the following documentation, Policy: the facility believes that nutrition is an important part of maintaining the well-being and health of its residents, and is committed to providing a menu that is well balanced, nutritious and meets the preferences of the resident population. A standardize menu which meets the nutritional recommendations of the residents, in accordance with the recommended dietary allowances of the Food and Nutrition Board of The National Research Council, National Academy of Sciences will be used. Modifications for resident population and preferences may be made as appropriate. Procedure: 1. Menus will be prepared for each facility by their food vendor. Menus are updated twice each year with the Spring - Summer and Fall - Winter cycles and updated intermittently based on resident preferences. The menus will be for a five-week cycle and will include a week at a glance menu, alternates, diet extensions for all diets offered for each day, nutritional analysis, standardized recipes, a production guide and an order guide . Record review of the Long-Term Care Diet Manual, 2017 Edition, revealed the following documentation, 2 g Sodium Diet. Indications for use: the 2 g sodium diet is provided for individuals needing a significant reduction in sodium to control blood pressure and/or fluid retention for the treatment of hypertension, chronic or congestive heart failure, renal failure, or other conditions where fluid retention is a problem . General Principles and Guidelines: 1. The 2 g sodium diet is planned using the menu components as outline in Section 2: Guidelines For Menu Planning. 2. The 2 g sodium diet is planned to provide 2000-2300 mg of sodium per day. 3. The 2 g sodium diet does not use salt at the table or on meal trays. 4. The 2 g sodium diet limits the use of very high sodium foods to the limit of 2000 mg to 2300 mg per day. 5. Recipes should be followed carefully when cooking .

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care, in that: The facility failed to ensure Resident #1 was properly assessed after being found on the floor of her room on 11/10/23. Resident #1 was picked up by CNA B, there was no assessment documented by the nurse, the on-coming nurse nor NP were notified of the fall. On 11/15/23 she was sent to the ER and diagnosed with a left hip fracture requiring surgery. An Immediate Jeopardy (IJ) existed on 11/16/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure could place residents at risk of experiencing unmanaged pain, a decreased quality of life, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including fracture of right humerus (long bone in the arm or forelimb that runs from the shoulder to the elbow), dementia, and unspecified protein-calorie malnutrition. Review of Resident #1's quarterly MDS assessment, dated 11/03/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected she required supervision or touching assistance with transferring and chair/bed-to-chair transfers. Section J (Health Conditions) reflected she had not had any falls since admission. Review of Resident #1's quarterly care plan, revised 09/24/23, reflected she was at risk for falls with an intervention of educating resident/family/caregivers about safety reminders and what to do if a fall occurred. Review of Resident #1's NP progress note, dated 11/14/23, reflected the following: Today, [Resident #1] was seen in the day room, sitting up in her WC. AAOx3 with mild impairment. [Resident #1] reports her legs hurt x 4 days. She describes it being a constant, deep/dull pain, ranging from the hips to above the knees. [Resident #1] reports she has never had this feeling before. [Resident #1] can't remember if she fell or not over the weekend. There were no reports of any falls from staff, but [Resident #1] does have new bandages on both elbows. No new bruises on [Resident #1]'s body. Staff reports that the pain has been very disabling to [Resident #1]. [Resident #1] normally would be a [NAME]-by or contact assist with ADLs, but today, [Resident #1] has been having difficulties transferring to toilet from WC d/t pain in her lower extremities. Abdominal swelling generalized: Ordered ultrasound of abdomen and pelvis. Pain in right and left leg: Order x-ray of femur. Added Tylenol 500mg tid for pain x 7 days. Review of Resident #1's physician order, dated 11/14/23, reflected the following: Acetaminophen tablet 500 MG - Give 1 tablet by mouth three times a day for pain for 7 days. Review of Resident #1's physician order, dated 11/14/23, reflected the following: Muscle Rub External Cream 10-15% (Menthol-Methyl Salicylate) - Apply to thighs and knees topically two times a day for pain. Review of Resident #1's progress notes in her EMR, dated 11/15/23 at 10:57 AM, reflected the following: [Resident #1] appears comfortable but with distended abdomen and a bulging area on the left side of the abdomen. Has order for abdominal ultrasound which has not been done . Called and notified NP and asked if [Resident #1] can be sent to ER for evaluation, she objected to that. Called (x-ray company) for ETA for the procedures and the don't have any at this time but will come today. Review of Resident #1's progress notes in her EMR, dated 11/15/23 at 4:21 PM, reflected the following: Returned to the floor following lunch break at 3:30 PM and received a note that the ultrasound tech called and will not be coming in to perform the procedure today. No specific date or time was given. Called NP and rec'd phone order to send [Resident #1] to ER for evaluation/treatment . Review of Resident #1's progress notes in her EMR, dated 11/16/23 at 7:19 AM, reflected the following: Called (hospital ER) this morning and was informed that [Resident #1] was admitted and will be going for surgery this morning - left hip fracture. Review of the facility's investigation regarding Resident #1's injury, dated 11/16/23, reflected the following: Description of Allegation: The facility was informed of a fracture of left hip of [Resident #1] on morning of 11/16 by hospital staff. Initial Investigation: Upon investigation, [CNA A] informed Administrator that she was informed by [CNA B] on morning of 11/17 that on 11/12 [Resident #1] had slid out of bed during her shift with [LVN C] being informed of incident. The fall was reported to have happened in the early hours of Saturday (11/11/23). [CNA B], worked 11/10/23 10p - 6am [CNA B] stated that around midnight she witnessed [Resident #1] sitting next to her bed with her left hip against the bed and she (Resident #1) had been in bed previously. [CNA B] tried to locate [LVN C] but was unable to at that time due to resident care. [CNA B] placed [Resident #1] in wheelchair with no complaints of pain. Shortly thereafter, [Resident #1] complained of pain with [LVN C] giving her medication. [LVN C], worked 11/10/23 10p - 6am [LVN C] stated that it was reported to her that [Resident #1] had slid out of bed and had been placed in wheelchair when she was notified of incident. [LVN C] stated that [Resident #1] had tried to get out of bed without help. [LVN C] stated she assessed [Resident #1]'s left leg/hip and vitals with no concerns. [LVN C] noted two skin tears that she treated on [Resident #1]'s elbow. [Resident #1] agreed to take pain medication. [LVN C] reported having message the physician and passed along to the following nurse. [LVN C] admitted that no incident report was generated, or nurses note made regarding the incident. [CNA D], worked 11/11/23 6a - 10p [CNA D] noted [Resident #1]'s change with mobility however did not report change to nurse. Educated that all changes need to be investigated. [RN E], worked 11/11/23 6a - 6p [RN E] stated she was unaware of fall and was not informed of any changes with [Resident #1] from [LVN C]. [CNA A], worked 11/13/23 6a - 10pm [CNA A] informed NP that she noticed [Resident #1] having change of mobility during her rounds. [LVN G] worked 11/13/23 6a - 10pm [LVN G] received an order for Acetaminophen TID, and a muscle rub cream medication continued to be given. [CNA A], worked 11/15/23 6a - 10pm [CNA A] stated that [Resident #1] still had difficulty with mobility and was aware we were waiting on x-ray and ultrasound. [RN E], worked 11/15/23 6a - 6pm [RN E] contacted (x-ray company) as ultrasound of abdomen and x-ray of bilateral hips had not been conducted. At approximately 3:30pm, [RN E] received a message that they will be unable to perform ultrasound. [RN E] notified NP of issue with ultrasound and was notified to send to ER. Immediate actions taken: Pain medication ordered for comfort and effective. Abdominal ultrasound and x-rays of both hips ordered, however was unable to obtain. [Resident #1] has a history of bruising easy with NP stated she noted swelling in the abdomen, however, did not visualize anything during assessment that would even suggest a fracture. Post actions taken: - Nursing staff educated on change of condition and reporting expectations, ensuring that nurses are informed of any pending procedures/orders at shift change, completing of incident report, notification of DON, Physician, and RP. - Skin assessments completed on all residents in Memory Care Unit with no skin findings to falls. - Pain assessment conducted on all residents in Memory Care Unit with no concerns noted. - [LVN C] was terminated due to failure to complete incident report, pass on information during shift transfer, and notify physician, family, and DON. - All falls and discharges are to be reported to DON in a timely manner. Review of an in-service entitled Incident and Accident Reporting, dated 07/31/23, reflected CNA B and LVN C had been in attendance for the in-service given on notifying the ADM and DON for all incidents and accidents, all falls, etc. Review of an in-service entitled CNA Fall Procedure, dated 11/16/23 and conducted by the ADON, reflected CNAs were in-serviced on the following: When a resident is on the floor, whether witnessed or not witnessed, at no point should you lift resident off the floor or move them without a nurse assessing that resident. If resident complains of pain when moving resident, leave resident and follow fall protocol through the nurse. At no circumstance should a CNA or MA lift a resident from the floor without a nurse assessing the resident. Failure to comply will lead to disciplinary action up to termination. Review of an in-service entitled Nurse Fall Procedure, dated 11/16/23 and conducted by the ADON, reflected nurses were in-serviced on the following: When a CNA reports a fall, whether witnessed or un-witnessed, nurse need to follow the following protocols: - Assessment of resident, head to toe, vitals, and range of motion. If resident is in pain or cannot bear weight, call for help and call on-call for order to either transfer the resident to the hospital of non-weight bearing. - Follow physician instructions. - Notify DON/ADM. - Notify family. - Do proper documentation - incident report, nursing notes, pain and fall evaluation. - If reside is in pain and cannot get x-ray on time, get order to send resident out for further evaluation. Failure to follow these procedures will lead to disciplinary action up to termination. Review of an in-service entitled Fall Precautions and Interventions, dated 11/16/23, reflected all staff were in-serviced on fall precaution educating and fall interventions to reduce falls. During an interview on 12/02/23 at 12:11 PM, the DCO stated she did meet with the NP on 11/14/23 after she assessed Resident #1 but she did not make the situation sound as dire as it had been documented in the progress note. She stated the aide should have never gotten Resident #1 off the floor without notifying a nurse first so that appropriate assessments could have been conducted. She stated the nurse (LVN C) admitted to not completing an incident report. She stated it was unacceptable that Resident #1 did not receive the proper care or treatment due to the fall not being reported. She stated LVN C was terminated and the staff were in-serviced on fall precautions, who to notify, and what assessments needed to be done after a witnessed or un-witnessed fall. During an interview on 12/02/23 at 1:46 PM, CNA H stated she had been in-serviced on falls and notifying nurses of changes-in-condition. She stated she would never try to pick a resident up off the floor if they had fallen. She stated she would get a nurse immediately. She stated the nurses needed to conduct their assessments to ensure residents were not hurt or bleeding. During an interview on 12/02/23 at 2:32 PM, LVN I stated she expected CNAs to notify her when there was any kind of change-in-condition regarding a resident, especially a fall. She stated when a resident falls, she assessed them, checked their range of motion, completed an incident report, documented in the resident's chart, and notified the NP and resident RP. During an interview on 12/02/23 at 2:41 PM, LVN J stated of a resident was found on the ground by an aide, she would expect the aide to notify her immediately. She stated she would check vitals, conduct a full-body assessment, conduct neuro checks, notify the NP, complete an incident report, and ensure she notified the on-coming nurse. During an interview on 12/02/23 at 2:49 PM, CNA K stated if she found a resident on the ground, she would immediately notify a nurse. She stated a nurse needed to be notified so they could ensure the resident was not bleeding or had a broken bone. During an interview on 12/04/23 at 2:05 PM, Resident #1's NP stated she was never notified of the fall that occurred. She stated she saw Resident #1 on Friday 11/10/23 and she was doing great - she was acting completely normal, making jokes, and there were no issues. She stated on Tuesday 11/14/23, staff informed her that Resident #1 was having difficulty with transferring. She stated Resident #1 was usually able to transfer herself with minimal assistance. She stated the resident was complaining of pain whenever she moved her legs. She stated she did a skin assessment and noted no bruising. She stated the only thing that could have suggested she had a fall were two bandages on her elbows that were dated 11/11/23. She stated she asked the charge nurse who was working who stated he had not heard of Resident #1 sustaining a fall over the weekend. She stated it was her expectation that she be notified of every fall. She stated even if a resident falls over the weekend, their on-call team should be notified. She stated she ordered x-rays on 11/14/23 and was not aware they had not gotten done that day until she was called in the morning of 11/15/23 by a nurse requesting to send Resident #1 to the hospital because she was complaining of pain. She stated she did not want her to go to the hospital since she had personally called the x-ray order to put in the order and she had PRN pain medication. She stated the nursing staff from the night before on 11/15/23 should have followed up on the x-rays because they should have been done that day. She stated it was unacceptable they were not followed-up on or at least should have called the on-call medical team. She stated when she calls in a STAT x-ray, she had rarely seen it take over an hour for them to get to the facility. She stated once she was notified later in the day on 11/15/23 that the x-rays still had not been done, she requested Resident #1 be sent to the ER immediately. An attempt to interview CNA B was made on 12/04/23 at 3:08 PM. A returned phone call was not received. An attempt to interview CNA B was made on 12/04/23 at 3:13 PM. A returned phone call was not received. Review of the facility's Change in a Resident's Condition or Status Policy, revised February 2021, reflected the following: 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source . 8. The nurse will record in the resident's medical record information relative to change in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to ensure the residents had the right to be free from neglect for one (Resident #1) out of three residents reviewed for neglect. The facility failed to ensure Resident #1 was properly assessed after being found on the floor of her room on 11/10/23. Resident #1 was picked up by CNA B, there was no assessment documented by the nurse, the on-coming nurse nor NP were notified of the fall. On 11/15/23 she was sent to the ER and diagnosed with a left hip fracture requiring surgery. An Immediate Jeopardy (IJ) existed on 11/16/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure could place residents at risk of experiencing unmanaged pain, a decreased quality of life, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including fracture of right humerus (long bone in the arm or forelimb that runs from the shoulder to the elbow), dementia, and unspecified protein-calorie malnutrition. Review of Resident #1's quarterly MDS assessment, dated 11/03/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected she required supervision or touching assistance with transferring and chair/bed-to-chair transfers. Section J (Health Conditions) reflected she had not had any falls since admission. Review of Resident #1's quarterly care plan, revised 09/24/23, reflected she was at risk for falls with an intervention of educating resident/family/caregivers about safety reminders and what to do if a fall occurred. Review of Resident #1's NP progress note, dated 11/14/23, reflected the following: Today, [Resident #1] was seen in the day room, sitting up in her WC. AAOx3 with mild impairment. [Resident #1] reports her legs hurt x 4 days. She describes it being a constant, deep/dull pain, ranging from the hips to above the knees. [Resident #1] reports she has never had this feeling before. [Resident #1] can't remember if she fell or not over the weekend. There were no reports of any falls from staff, but [Resident #1] does have new bandages on both elbows. No new bruises on [Resident #1]'s body. Staff reports that the pain has been very disabling to [Resident #1]. [Resident #1] normally would be a [NAME]-by or contact assist with ADLs, but today, [Resident #1] has been having difficulties transferring to toilet from WC d/t pain in her lower extremities. Abdominal swelling generalized: Ordered ultrasound of abdomen and pelvis. Pain in right and left leg: Order x-ray of femur. Added Tylenol 500mg tid for pain x 7 days. Review of Resident #1's physician order, dated 11/14/23, reflected the following: Acetaminophen tablet 500 MG - Give 1 tablet by mouth three times a day for pain for 7 days. Review of Resident #1's physician order, dated 11/14/23, reflected the following: Muscle Rub External Cream 10-15% (Menthol-Methyl Salicylate) - Apply to thighs and knees topically two times a day for pain. Review of Resident #1's progress notes in her EMR, dated 11/15/23 at 10:57 AM, reflected the following: [Resident #1] appears comfortable but with distended abdomen and a bulging area on the left side of the abdomen. Has order for abdominal ultrasound which has not been done . Called and notified NP and asked if [Resident #1] can be sent to ER for evaluation, she objected to that. Called (x-ray company) for ETA for the procedures and the don't have any at this time but will come today. Review of Resident #1's progress notes in her EMR, dated 11/15/23 at 4:21 PM, reflected the following: Returned to the floor following lunch break at 3:30 PM and received a note that the ultrasound tech called and will not be coming in to perform the procedure today. No specific date or time was given. Called NP and rec'd phone order to send [Resident #1] to ER for evaluation/treatment . Review of Resident #1's progress notes in her EMR, dated 11/16/23 at 7:19 AM, reflected the following: Called (hospital ER) this morning and was informed that [Resident #1] was admitted and will be going for surgery this morning - left hip fracture. Review of the facility's investigation regarding Resident #1's injury, dated 11/16/23, reflected the following: Description of Allegation: The facility was informed of a fracture of left hip of [Resident #1] on morning of 11/16 by hospital staff. Initial Investigation: Upon investigation, [CNA A] informed Administrator that she was informed by [CNA B] on morning of 11/17 that on 11/12 [Resident #1] had slid out of bed during her shift with [LVN C] being informed of incident. The fall was reported to have happened in the early hours of Saturday (11/11/23). [CNA B], worked 11/10/23 10p - 6am [CNA B] stated that around midnight she witnessed [Resident #1] sitting next to her bed with her left hip against the bed and she (Resident #1) had been in bed previously. [CNA B] tried to locate [LVN C] but was unable to at that time due to resident care. [CNA B] placed [Resident #1] in wheelchair with no complaints of pain. Shortly thereafter, [Resident #1] complained of pain with [LVN C] giving her medication. [LVN C], worked 11/10/23 10p - 6am [LVN C] stated that it was reported to her that [Resident #1] had slid out of bed and had been placed in wheelchair when she was notified of incident. [LVN C] stated that [Resident #1] had tried to get out of bed without help. [LVN C] stated she assessed [Resident #1]'s left leg/hip and vitals with no concerns. [LVN C] noted two skin tears that she treated on [Resident #1]'s elbow. [Resident #1] agreed to take pain medication. [LVN C] reported having message the physician and passed along to the following nurse. [LVN C] admitted that no incident report was generated, or nurses note made regarding the incident. [CNA D], worked 11/11/23 6a - 10p [CNA D] noted [Resident #1]'s change with mobility however did not report change to nurse. Educated that all changes need to be investigated. [RN E], worked 11/11/23 6a - 6p [RN E] stated she was unaware of fall and was not informed of any changes with [Resident #1] from [LVN C]. [CNA A], worked 11/13/23 6a - 10pm [CNA A] informed NP that she noticed [Resident #1] having change of mobility during her rounds. [LVN G] worked 11/13/23 6a - 10pm [LVN G] received an order for Acetaminophen TID, and a muscle rub cream medication continued to be given. [CNA A], worked 11/15/23 6a - 10pm [CNA A] stated that [Resident #1] still had difficulty with mobility and was aware we were waiting on x-ray and ultrasound. [RN E], worked 11/15/23 6a - 6pm [RN E] contacted (x-ray company) as ultrasound of abdomen and x-ray of bilateral hips had not been conducted. At approximately 3:30pm, [RN E] received a message that they will be unable to perform ultrasound. [RN E] notified NP of issue with ultrasound and was notified to send to ER. Immediate actions taken: Pain medication ordered for comfort and effective. Abdominal ultrasound and x-rays of both hips ordered, however was unable to obtain. [Resident #1] has a history of bruising easy with NP stated she noted swelling in the abdomen, however, did not visualize anything during assessment that would even suggest a fracture. Post actions taken: - Nursing staff educated on change of condition and reporting expectations, ensuring that nurses are informed of any pending procedures/orders at shift change, completing of incident report, notification of DON, Physician, and RP. - Skin assessments completed on all residents in Memory Care Unit with no skin findings to falls. - Pain assessment conducted on all residents in Memory Care Unit with no concerns noted. - [LVN C] was terminated due to failure to complete incident report, pass on information during shift transfer, and notify physician, family, and DON. - All falls and discharges are to be reported to DON in a timely manner. Review of an in-service entitled Incident and Accident Reporting, dated 07/31/23, reflected CNA B and LVN C had been in attendance for the in-service given on notifying the ADM and DON for all incidents and accidents, all falls, etc. Review of an in-service entitled CNA Fall Procedure, dated 11/16/23 and conducted by the ADON, reflected CNAs were in-serviced on the following: When a resident is on the floor, whether witnessed or not witnessed, at no point should you lift resident off the floor or move them without a nurse assessing that resident. If resident complains of pain when moving resident, leave resident and follow fall protocol through the nurse. At no circumstance should a CNA or MA lift a resident from the floor without a nurse assessing the resident. Failure to comply will lead to disciplinary action up to termination. Review of an in-service entitled Nurse Fall Procedure, dated 11/16/23 and conducted by the ADON, reflected nurses were in-serviced on the following: When a CNA reports a fall, whether witnessed or un-witnessed, nurse need to follow the following protocols: - Assessment of resident, head to toe, vitals, and range of motion. If resident is in pain or cannot bear weight, call for help and call on-call for order to either transfer the resident to the hospital of non-weight bearing. - Follow physician instructions. - Notify DON/ADM. - Notify family. - Do proper documentation - incident report, nursing notes, pain and fall evaluation. - If reside is in pain and cannot get x-ray on time, get order to send resident out for further evaluation. Failure to follow these procedures will lead to disciplinary action up to termination. Review of an in-service entitled Fall Precautions and Interventions, dated 11/16/23, reflected all staff were in-serviced on fall precaution educating and fall interventions to reduce falls. During an interview on 12/02/23 at 12:11 PM, the DCO stated she did meet with the NP on 11/14/23 after she assessed Resident #1 but she did not make the situation sound as dire as it had been documented in the progress note. She stated the aide should have never gotten Resident #1 off the floor without notifying a nurse first so that appropriate assessments could have been conducted. She stated the nurse (LVN C) admitted to not completing an incident report. She stated it was unacceptable that Resident #1 did not receive the proper care or treatment due to the fall not being reported. She stated LVN C was terminated and the staff were in-serviced on fall precautions, who to notify, and what assessments needed to be done after a witnessed or un-witnessed fall. During an interview on 12/02/23 at 1:46 PM, CNA H stated she had been in-serviced on falls and notifying nurses of changes-in-condition. She stated she would never try to pick a resident up off the floor if they had fallen. She stated she would get a nurse immediately. She stated the nurses needed to conduct their assessments to ensure residents were not hurt or bleeding. During an interview on 12/02/23 at 2:32 PM, LVN I stated she expected CNAs to notify her when there was any kind of change-in-condition regarding a resident, especially a fall. She stated when a resident falls, she assessed them, checked their range of motion, completed an incident report, documented in the resident's chart, and notified the NP and resident RP. During an interview on 12/02/23 at 2:41 PM, LVN J stated of a resident was found on the ground by an aide, she would expect the aide to notify her immediately. She stated she would check vitals, conduct a full-body assessment, conduct neuro checks, notify the NP, complete an incident report, and ensure she notified the on-coming nurse. During an interview on 12/02/23 at 2:49 PM, CNA K stated if she found a resident on the ground, she would immediately notify a nurse. She stated a nurse needed to be notified so they could ensure the resident was not bleeding or had a broken bone. During an interview on 12/04/23 at 2:05 PM, Resident #1's NP stated she was never notified of the fall that occurred. She stated she saw Resident #1 on Friday 11/10/23 and she was doing great - she was acting completely normal, making jokes, and there were no issues. She stated on Tuesday 11/14/23, staff informed her that Resident #1 was having difficulty with transferring. She stated Resident #1 was usually able to transfer herself with minimal assistance. She stated the resident was complaining of pain whenever she moved her legs. She stated she did a skin assessment and noted no bruising. She stated the only thing that could have suggested she had a fall were two bandages on her elbows that were dated 11/11/23. She stated she asked the charge nurse who was working who stated he had not heard of Resident #1 sustaining a fall over the weekend. She stated it was her expectation that she be notified of every fall. She stated even if a resident falls over the weekend, their on-call team should be notified. She stated she ordered x-rays on 11/14/23 and was not aware they had not gotten done that day until she was called in the morning of 11/15/23 by a nurse requesting to send Resident #1 to the hospital because she was complaining of pain. She stated she did not want her to go to the hospital since she had personally called the x-ray order to put in the order and she had PRN pain medication. She stated the nursing staff from the night before on 11/15/23 should have followed up on the x-rays because they should have been done that day. She stated it was unacceptable they were not followed-up on or at least should have called the on-call medical team. She stated when she calls in a STAT x-ray, she had rarely seen it take over an hour for them to get to the facility. She stated once she was notified later in the day on 11/15/23 that the x-rays still had not been done, she requested Resident #1 be sent to the ER immediately. An attempt to interview CNA B was made on 12/04/23 at 3:08 PM. A returned phone call was not received. An attempt to interview CNA B was made on 12/04/23 at 3:13 PM. A returned phone call was not received. Review of the facility's Falls and Fall Risk Policy, revised April 2022, reflected the following : According to the MDS, a fall is defined as unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Review of the facility's Abuse and Neglect Policy, revised April 2021, reflected the following: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change for one (Resident #1) of three residents reviewed for notification of changes, in that: The facility failed to ensure Resident #1 was properly assessed after being found on the floor of her room on 11/10/23. Resident #1 was picked up by CNA B, there was no assessment documented by the nurse, the on-coming nurse nor NP were notified of the fall. On 11/15/23 she was sent to the ER and diagnosed with a left hip fracture requiring surgery. An Immediate Jeopardy (IJ) existed on 11/16/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure could place residents at risk of experiencing unmanaged pain, a decreased quality of life, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including fracture of right humerus (long bone in the arm or forelimb that runs from the shoulder to the elbow), dementia, and unspecified protein-calorie malnutrition. Review of Resident #1's quarterly MDS assessment, dated 11/03/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected she required supervision or touching assistance with transferring and chair/bed-to-chair transfers. Section J (Health Conditions) reflected she had not had any falls since admission. Review of Resident #1's quarterly care plan, revised 09/24/23, reflected she was at risk for falls with an intervention of educating resident/family/caregivers about safety reminders and what to do if a fall occurred. Review of Resident #1's NP progress note, dated 11/14/23, reflected the following: Today, [Resident #1] was seen in the day room, sitting up in her WC. AAOx3 with mild impairment. [Resident #1] reports her legs hurt x 4 days. She describes it being a constant, deep/dull pain, ranging from the hips to above the knees. [Resident #1] reports she has never had this feeling before. [Resident #1] can't remember if she fell or not over the weekend. There were no reports of any falls from staff, but [Resident #1] does have new bandages on both elbows. No new bruises on [Resident #1]'s body. Staff reports that the pain has been very disabling to [Resident #1]. [Resident #1] normally would be a [NAME]-by or contact assist with ADLs, but today, [Resident #1] has been having difficulties transferring to toilet from WC d/t pain in her lower extremities. Abdominal swelling generalized: Ordered ultrasound of abdomen and pelvis. Pain in right and left leg: Order x-ray of femur. Added Tylenol 500mg tid for pain x 7 days. Review of Resident #1's physician order, dated 11/14/23, reflected the following: Acetaminophen tablet 500 MG - Give 1 tablet by mouth three times a day for pain for 7 days. Review of Resident #1's physician order, dated 11/14/23, reflected the following: Muscle Rub External Cream 10-15% (Menthol-Methyl Salicylate) - Apply to thighs and knees topically two times a day for pain. Review of Resident #1's progress notes in her EMR, dated 11/15/23 at 10:57 AM, reflected the following: [Resident #1] appears comfortable but with distended abdomen and a bulging area on the left side of the abdomen. Has order for abdominal ultrasound which has not been done . Called and notified NP and asked if [Resident #1] can be sent to ER for evaluation, she objected to that. Called (x-ray company) for ETA for the procedures and the don't have any at this time but will come today. Review of Resident #1's progress notes in her EMR, dated 11/15/23 at 4:21 PM, reflected the following: Returned to the floor following lunch break at 3:30 PM and received a note that the ultrasound tech called and will not be coming in to perform the procedure today. No specific date or time was given. Called NP and rec'd phone order to send [Resident #1] to ER for evaluation/treatment . Review of Resident #1's progress notes in her EMR, dated 11/16/23 at 7:19 AM, reflected the following: Called (hospital ER) this morning and was informed that [Resident #1] was admitted and will be going for surgery this morning - left hip fracture. Review of the facility's investigation regarding Resident #1's injury, dated 11/16/23, reflected the following: Description of Allegation: The facility was informed of a fracture of left hip of [Resident #1] on morning of 11/16 by hospital staff. Initial Investigation: Upon investigation, [CNA A] informed Administrator that she was informed by [CNA B] on morning of 11/17 that on 11/12 [Resident #1] had slid out of bed during her shift with [LVN C] being informed of incident. The fall was reported to have happened in the early hours of Saturday (11/11/23). [CNA B], worked 11/10/23 10p - 6am [CNA B] stated that around midnight she witnessed [Resident #1] sitting next to her bed with her left hip against the bed and she (Resident #1) had been in bed previously. [CNA B] tried to locate [LVN C] but was unable to at that time due to resident care. [CNA B] placed [Resident #1] in wheelchair with no complaints of pain. Shortly thereafter, [Resident #1] complained of pain with [LVN C] giving her medication. [LVN C], worked 11/10/23 10p - 6am [LVN C] stated that it was reported to her that [Resident #1] had slid out of bed and had been placed in wheelchair when she was notified of incident. [LVN C] stated that [Resident #1] had tried to get out of bed without help. [LVN C] stated she assessed [Resident #1]'s left leg/hip and vitals with no concerns. [LVN C] noted two skin tears that she treated on [Resident #1]'s elbow. [Resident #1] agreed to take pain medication. [LVN C] reported having message the physician and passed along to the following nurse. [LVN C] admitted that no incident report was generated, or nurses note made regarding the incident. [CNA D], worked 11/11/23 6a - 10p [CNA D] noted [Resident #1]'s change with mobility however did not report change to nurse. Educated that all changes need to be investigated. [RN E], worked 11/11/23 6a - 6p [RN E] stated she was unaware of fall and was not informed of any changes with [Resident #1] from [LVN C]. [CNA A], worked 11/13/23 6a - 10pm [CNA A] informed NP that she noticed [Resident #1] having change of mobility during her rounds. [LVN G] worked 11/13/23 6a - 10pm [LVN G] received an order for Acetaminophen TID, and a muscle rub cream medication continued to be given. [CNA A], worked 11/15/23 6a - 10pm [CNA A] stated that [Resident #1] still had difficulty with mobility and was aware we were waiting on x-ray and ultrasound. [RN E], worked 11/15/23 6a - 6pm [RN E] contacted (x-ray company) as ultrasound of abdomen and x-ray of bilateral hips had not been conducted. At approximately 3:30pm, [RN E] received a message that they will be unable to perform ultrasound. [RN E] notified NP of issue with ultrasound and was notified to send to ER. Immediate actions taken: Pain medication ordered for comfort and effective. Abdominal ultrasound and x-rays of both hips ordered, however was unable to obtain. [Resident #1] has a history of bruising easy with NP stated she noted swelling in the abdomen, however, did not visualize anything during assessment that would even suggest a fracture. Post actions taken: - Nursing staff educated on change of condition and reporting expectations, ensuring that nurses are informed of any pending procedures/orders at shift change, completing of incident report, notification of DON, Physician, and RP. - Skin assessments completed on all residents in Memory Care Unit with no skin findings to falls. - Pain assessment conducted on all residents in Memory Care Unit with no concerns noted. - [LVN C] was terminated due to failure to complete incident report, pass on information during shift transfer, and notify physician, family, and DON. - All falls and discharges are to be reported to DON in a timely manner. Review of an in-service entitled Incident and Accident Reporting, dated 07/31/23, reflected CNA B and LVN C had been in attendance for the in-service given on notifying the ADM and DON for all incidents and accidents, all falls, etc. Review of an in-service entitled CNA Fall Procedure, dated 11/16/23 and conducted by the ADON, reflected CNAs were in-serviced on the following: When a resident is on the floor, whether witnessed or not witnessed, at no point should you lift resident off the floor or move them without a nurse assessing that resident. If resident complains of pain when moving resident, leave resident and follow fall protocol through the nurse. At no circumstance should a CNA or MA lift a resident from the floor without a nurse assessing the resident. Failure to comply will lead to disciplinary action up to termination. Review of an in-service entitled Nurse Fall Procedure, dated 11/16/23 and conducted by the ADON, reflected nurses were in-serviced on the following: When a CNA reports a fall, whether witnessed or un-witnessed, nurse need to follow the following protocols: - Assessment of resident, head to toe, vitals, and range of motion. If resident is in pain or cannot bear weight, call for help and call on-call for order to either transfer the resident to the hospital of non-weight bearing. - Follow physician instructions. - Notify DON/ADM. - Notify family. - Do proper documentation - incident report, nursing notes, pain and fall evaluation. - If reside is in pain and cannot get x-ray on time, get order to send resident out for further evaluation. Failure to follow these procedures will lead to disciplinary action up to termination. Review of an in-service entitled Fall Precautions and Interventions, dated 11/16/23, reflected all staff were in-serviced on fall precaution educating and fall interventions to reduce falls. During an interview on 12/02/23 at 12:11 PM, the DCO stated she did meet with the NP on 11/14/23 after she assessed Resident #1 but she did not make the situation sound as dire as it had been documented in the progress note. She stated the aide should have never gotten Resident #1 off the floor without notifying a nurse first so that appropriate assessments could have been conducted. She stated the nurse (LVN C) admitted to not completing an incident report. She stated it was unacceptable that Resident #1 did not receive the proper care or treatment due to the fall not being reported. She stated LVN C was terminated and the staff were in-serviced on fall precautions, who to notify, and what assessments needed to be done after a witnessed or un-witnessed fall. During an interview on 12/02/23 at 1:46 PM, CNA H stated she had been in-serviced on falls and notifying nurses of changes-in-condition. She stated she would never try to pick a resident up off the floor if they had fallen. She stated she would get a nurse immediately. She stated the nurses needed to conduct their assessments to ensure residents were not hurt or bleeding. During an interview on 12/02/23 at 2:32 PM, LVN I stated she expected CNAs to notify her when there was any kind of change-in-condition regarding a resident, especially a fall. She stated when a resident falls, she assessed them, checked their range of motion, completed an incident report, documented in the resident's chart, and notified the NP and resident RP. During an interview on 12/02/23 at 2:41 PM, LVN J stated of a resident was found on the ground by an aide, she would expect the aide to notify her immediately. She stated she would check vitals, conduct a full-body assessment, conduct neuro checks, notify the NP, complete an incident report, and ensure she notified the on-coming nurse. During an interview on 12/02/23 at 2:49 PM, CNA K stated if she found a resident on the ground, she would immediately notify a nurse. She stated a nurse needed to be notified so they could ensure the resident was not bleeding or had a broken bone. During an interview on 12/04/23 at 2:05 PM, Resident #1's NP stated she was never notified of the fall that occurred. She stated she saw Resident #1 on Friday 11/10/23 and she was doing great - she was acting completely normal, making jokes, and there were no issues. She stated on Tuesday 11/14/23, staff informed her that Resident #1 was having difficulty with transferring. She stated Resident #1 was usually able to transfer herself with minimal assistance. She stated the resident was complaining of pain whenever she moved her legs. She stated she did a skin assessment and noted no bruising. She stated the only thing that could have suggested she had a fall were two bandages on her elbows that were dated 11/11/23. She stated she asked the charge nurse who was working who stated he had not heard of Resident #1 sustaining a fall over the weekend. She stated it was her expectation that she be notified of every fall. She stated even if a resident falls over the weekend, their on-call team should be notified. She stated she ordered x-rays on 11/14/23 and was not aware they had not gotten done that day until she was called in the morning of 11/15/23 by a nurse requesting to send Resident #1 to the hospital because she was complaining of pain. She stated she did not want her to go to the hospital since she had personally called the x-ray order to put in the order and she had PRN pain medication. She stated the nursing staff from the night before on 11/15/23 should have followed up on the x-rays because they should have been done that day. She stated it was unacceptable they were not followed-up on or at least should have called the on-call medical team. She stated when she calls in a STAT x-ray, she had rarely seen it take over an hour for them to get to the facility. She stated once she was notified later in the day on 11/15/23 that the x-rays still had not been done, she requested Resident #1 be sent to the ER immediately. An attempt to interview CNA B was made on 12/04/23 at 3:08 PM. A returned phone call was not received. An attempt to interview CNA B was made on 12/04/23 at 3:13 PM. A returned phone call was not received. Review of the facility's Change in a Resident's Condition or Status Policy, revised February 2021, reflected the following: 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source . 8. The nurse will record in the resident's medical record information relative to change in the resident's medical/mental condition or status.

Based on observation, interview, and record review the facility failed to provide adequate supervision and devices to prevent accidents for 1(Resident # 1) of 7 residents reviewed for accidents and supervision. Staff attempted to use the mechanical lift to transfer Resident # 1 from her wheelchair to her bed with one person. As a result, the mechanical lift fell on top of Resident # 1, causing injury and pain to her head in which she was prescribed medication for the pain. This failure placed all residents who require the use of a mechanical lift at risk for accidents, harm, and injuries. An (IJ) Immediate Jeopardy was identified on 7/31/2023 at 1:35pm. While the (IJ) Immediate Jeopardy was removed on 7/31/2023 at 5:00pm, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is Immediate Jeopardy identified because all staff had not been trained on Abuse/Neglect, mechanical lifts and the effectiveness of their systems. Findings included: Review of Resident #1 face sheet dated 7/28/2023, reflected Resident # 1 was a 70- year- old woman, admitted to the facility on [DATE]. Resident # 1 was diagnosed with UNSPECIFIED OSTEOARTHRITIS (typically affects the hips, spine, hands, and knees, causing joint stiffness and pain)., WEAKNESS (the state or condition of lacking strength), UNSPECIFIED FALL (falls due to slipping or tripping), SEQUELA (a condition of a previous injury of infection) and BODY MASS INDEX [BMI] 50.0-59.9, In an interview on 7/28/2023 at 3:00pm with Resident # 1 revealed on 7/5/2023 at 9:00pm the CNA A (agency staff) was attempting to transfer her from her wheelchair to her bed. She stated the CNA A did not know how to appropriately use the mechanical lift or he would have known that he needed another person to safely operate the machine. Resident # 1 stated CNA A went to the other side of the bed and attempted to pull her from the mechanical lift onto the bed. She stated she fell on the bed and the mechanical lift fell on top of her, and the grab bar from the lift hit her in the head. Resident # 1 stated she had a headache, and her head was sore in the spot where the bar struck her in her head. She stated she was prescribed Tylenol for her pain. Review of care plan dated 6/20/2023, reflected Resident #1 required a mechanical lift for transfers. Review of quarterly MDS dated [DATE] reflected Section G functional section indicated Resident # 1 required extensive assist with bed mobility and transfers, Mechanical lift 2x person assist. In an interview on 7/28/2023 at 5:42pm with CNA C, revealed she recently started working at the facility. She stated she had not been trained on how to use the mechanical lift at this facility. Stated if they needed to transfer a resident using the mechanical lift stated they would get another person to assist with the transfer while using the lift. In an interview on 7/28/203 at 6:09pm with CNA B revealed she was agency staff. She stated the facility had not trained her on how to properly use the mechanical lift. However, stated whenever they needed to do a list using the mechanical lift, they needed two people to use the lift. In an interview on 7/28/2023 at 3:49pm with the DON, revealed she could not find any of her in-services for the month of July. The DON stated she thought she did a training on mechanical lifts. The DON stated they have a competency checklist that they use for the mechanical lift but stated she had not completed this form with any of the staff. The DON stated she has gone over the checklist with staff but was not able to state which staff or any documentation where the checklist had been completed with any staff. In an interview on 7/28/2023 at 4:43pm with the ADM, he revealed the facility does not have a formal process in which agency staff are oriented to the facility or resident needs. The ADM stated the staff had access to Point Click Care for the resident's care needs. The ADM stated it was the DON's responsibility for the care staff to be trained, however reported that agency staff have to be trained and worked as a CNA for a year before being able to work for the agency. He stated they had completed trainings through the agency but was not able to indicate if this training had been completed. Record review of MDS reflected there are 14 other residents that require the of a mechanical lift. Review of progress notes reflected no incident report completed of the incident. Policies reviewed: Review of facility policy Resident rights dated Dec. 2016 reflect the following: Residents have to right to be free from neglect The facility does not have a Mechanical Lift policy This was determined to be an Immediate Jeopardy on 7/31/2023 at 1:35-m. The ADM was notified. The ADM was provided with the IJ template on 7/31/2023 at 1:35pm. The following Plan of Removal submitted by the facility was accepted on 7/31/2023 at 5:30pm. Plan of Removal: Immediate Jeopardy The notification of Immediate Threat states as follows: F689 The facility failed to ensure that the resident that the resident received adequate supervision and assistive devices to prevent accidents. Statement of Deficient Practice: All residents who require a Mechanical lift could be at risk of harm and injury from incidents and accidents Action Item 1 Direct Care Staff, including agency, to be in-serviced on 2-person transfer and how to identify transfer status of residents. Direct Care Staff will be in-serviced before the start of their shift. Results will be reported to and reviewed by the QAPI committee monthly x3 months starting in August. RNC or Designee Regional Nurse Consultant has been onsite and is providing in-service education to direct care staff Target date: 7/28/2023 Action Item 2 Direct Care Staff, including agency, to provide return demonstration and competency on Hoyer lift transfers. RNC or Designee Target date: 7/28/23 Action Item 3 Facility staff and agency staff will be in-serviced on Abuse and Neglect and proper reporting process, Includes Administrator and Director of Nursing. RNC and Designee Target date: 7/28/2023 Action Item 4 All current Residents who require Hoyer lift transfer will be assessed by licensed nurses for injury. All resident current and future will have weekly skin assessments completed to assess for injury. RNC or Designee Regional Nurse Consultant is onsite and conducted assessments with assistance of charge nurses on 7/28/23. Target date: 7/28/2023 Action Item 5 All facility Hoyer lifts will be inspected to assure safe operation. Director of Maintenance Target date: 7/28/2023 Action Item 6 Regional Nurse Consultant to in-service Administrator and Director of Nursing on Incident Accident Process. Including reporting allegations of abuse. Regional Nurse Consultant Target date: 7/28/2023 Action Item 7 Regional Nurse Consultant and Regional Director of Operations to in-service Administrator and Director of Nursing on process for agency staff orientation to facility and resident needs. Regional Nurse Consultant and Regional Director of Operations Target date: 7/28/2023 Action Item 8 Agency staff will be provided orientation on facility and residents needs per facility process. Orientation will include a check off form that include but is not limited to essential job functions, facility tour and procedures, medical and emergency equipment, specialty equipment, assignment sheets, point click care Kardex to identify resident needs. DON or designee Target date: 7/29/2023 Action Item 9 Facility staff and agency staff will be in-serviced on a) Abuse, Neglect, Exploitation and Misappropriation Prevention, and Resident Rights. RNC and designee Target date 7/31/2023 Action Item 10 Facility and agency Licensed Nurses nursing staff will be in-serviced on proper completing of Incident and Accident process, identification, documentation and notification. All staff and agency will be in-serviced on reporting of incidents and accidents. RNC and Designee. Target date: 7/31/2023 Action Item 11 The facility has a system to evaluate and improve safety for all residents who reside at the facility. The incident accident system is used as a tool to track facility incidents that have been reported to the facility QAPI where the safety of the facility is assessed, and action plans developed. Administrator Target date: 7/31/2023 Plan of removal monitoring 7/31/2023 An interview on 7/31/2023 at 5:09pm with the ADON, revealed she has been trained on abuse/ neglect, resident rights, safe transfer of residents using the mechanical lift. The ADON stated the abuse/neglect coordinator is the ADM. She was able to discuss the procedures if she see or suspect abuse/neglect. The ADON stated she had never seen or suspected abuse/neglect at this facility. She stated she had completed the competency check on how to use the mechanical lift. She was able to discuss the process of using the mechanical lift. Stated she has been able to discuss the process for reporting accidents/ incidents and assessment of the resident. An interview on 7/31/2023 at 5:20pm with RN, revealed she had been trained on how to use the [NAME] lift, abuse/neglect, resident rights, incident and accident reports and reporting. She was able to discuss the process for reporting abuse/neglect stated the abuse/neglect coordinator is the administrator. RN was able to discuss the process and steps of using the mechanical lift. The RN was able to discuss the process for reporting incidents and accidents. Stated all incidents and accidents should be reported and documented immediately. She stated she had never seen or suspected abuse /neglect at this facility. An interview on 7/31/2023 at 5:29pm with CNA D, revealed she worked 6pm-6am and had been in-serviced on abuse/neglect, resident rights, incidents/accidents of residents and the mechanical lift. She was the process for reporting abuse /neglect is the ensure that the resident is safe and alert a nurse to assess the resident for further injuries. Stated the administrator is the abuse/neglect coordinator stated she has never seen or suspected abuse /neglect at this facility. Staff reported the nurse complete the incident reports and they write statement of what they saw. Staff was able to discuss process in using the [NAME] lift with a resident. CNA D stated she completed the competency skills test to use the mechanical lift. An interview on 7/31/2023 at 5:51pm with CNA E, revealed she worked 6am to 6pm shift. Stated she had been in-serviced on abuse/neglect, resident rights, incident and accidents reports, and how to operate the mechanical lift. Record review of in-services on the following dated: 7/31/2023 Abuse/Neglect - 75%of staff and ongoing Resident Rights - 75% staff have been in-serviced and ongoing Incidents/Accidents- 75% staff have been in-serviced and ongoing An (IJ) Immediate Jeopardy was identified on 7/331/2023 at 1:35pm. While the (IJ) Immediate Jeopardy was removed on 7/31/2023 at 5:00pm, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is Immediate Jeopardy identified because all staff had not been trained on Abuse/Neglect, resident rights, mechanical lifts and the effectiveness of their systems. The ADM was advised that the (IJ) Immediate Jeopardy was lifted on 7/31/2023 at 5:45pm.

Based on observation, interview and record review the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation for 1 (Resident #1) of 7 residents reviewed for abuse and neglect. On 7/5/2023 at 9:00pm, CNA A attempted to transfer Resident # 1 from her wheelchair to her bed using a mechanical lift. CNA A attempted the transfer with one person, although Resident # 1 required two-person assistance. As a result, the mechanical lift fell on top of Resident # 1 and the cross bar struck Resident # 1 in head causing a bump, soreness, headache causing injury to her head in which she had to take medication. An (IJ) Immediate Jeopardy was identified on 7/28/2023 at 6:45pm. While the (IJ) Immediate Jeopardy was removed on 7/30/2023 at 5:00pm, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed all residents who require the use of a mechanical lift at risk to be neglected. Findings included: Review of Resident #1 face sheet dated 7/28/2023, reflected Resident # 1 was a 70- year- old woman, admitted to the facility on [DATE]. Resident # 1 was diagnosed with UNSPECIFIED OSTEOARTHRITIS (typically affects the hips, spine, hands, and knees, causing joint stiffness and pain), WEAKNESS (the state or condition of lacking strength), UNSPECIFIED FALL (falls due to slipping or tripping), SEQUELA (a condition of a previous injury of infection) and body mass index of 50.0-59.9. Review of care plan dated 6/20/2023, reflected Resident #1 required a mechanical lift for transfers. Review of quarterly MDS dated [DATE] reflected Section G functional section indicated Resident # 1 required extensive assist with bed mobility and transfers, Mechanical lift 2x person assist. In an interview on 7/28/2023 at 3:00pm with Resident # 1 stated on 7/5/2023 at 9:00pm the CNA A (agency staff) was attempting to transfer her from her wheelchair to her bed. She stated she asked CNA A where the other staff was to assist him, she stated CNA A responded, don't worry he was going to do it himself and that he didn't have anyone to help him at the time. Resident # 1 stated she didn't think that CNA A knew what he was doing. Resident # 1 stated when she was up in the sling, that CNA A went to the opposite side of the bed leaning across the bed to pull her from the sling onto the bed. She stated once he pulled her, she went down on the bed and the mechanical lift came down on top of her on the bed. Resident # 1 stated when the mechanical lift fell over the grab bar struck her in her head causing her head to hurt. In an interview on 7/28/2023 at 1:34pm with NP, revealed Resident # 1 had a faint bruise to the right side of her forehead. NP stated the incident occurred on 7/5/2023, she stated Resident # 1 reported that CNA A was trying to transfer her using the mechanical lift and the lift fell on top of her. The NP stated Resident # 1 stated she was hit in the head with the bar from the mechanical lift causing her head to hurt. She stated she assessed Resident #1 on 7/6/2023. The NP stated Resident #1 complained of a headache and soreness to the touch she stated she prescribed Tylenol. NP stated Resident # 1 was agreeable to take the tylenol and rest, as Resident # 1 stated she did not want to participate in therapy due to her head hurting. In an interview on 7/28/2023 at 3:49pm with the DON, revealed Resident # 1required a mechanical lift and that Resident # 1 was a two-person assist. The DON stated staff have access to PCC (Point Click Care) system in which staff could review to know what the care needs were for the residents. The DON stated they have a competency checklist that they use for the mechanical lift but stated she had not completed this form with any of the staff. The DON stated she has gone over the checklist with staff but was not able to state which staff or any documentation where the checklist had been completed with any staff. In an interview with the ADM on 7/28/2023 at 4:43pm, revealed Resident # 1 was hit on the is of her face by one of the arms from the mechanical lift. The ADM stated the facility does not have a formal process in which agency staff are oriented to the facility or resident needs. The ADM stated the staff had access to Point Click Care system for the resident's care needs. The ADM reported that the staff was agency staff and that he advised that the staff could not return to the facility. Review of progress notes reflected no incident report completed of the incident. Policies reviewed: Review of facility policy Resident rights dated Dec. 2016 reflect the following: Residents have to right to be free from neglect This was determined to be an (IJ) Immediate Jeopardy (IJ) on 7/28/2023 at 6:45pm. The ADM was notified. The ADM was provided with the IJ template on 7/28/2023 at 6:45PM. The following Plan of Removal submitted by the facility was accepted on 7/29/2023 at 6:22PM Plan of Removal: Immediate Jeopardy The notification of Immediate Threat states as follows: F600 The facility failed to ensure that the resident was free from neglect. Statement of Deficient Practice: All residents who require a Mechanical lift could be at risk of harm and injury from neglect. Action Item 1 Direct Care Staff, including agency, to be in-serviced on 2-person transfer and how to identify transfer status of residents. Direct Care Staff will be in-serviced before the start of their shift. Results will be reported to and reviewed by the QAPI committee monthly x3 months starting in August. RNC or Designee Regional Nurse Consultant has been onsite and is providing in-service education to direct care staff Target date: 7/31/2023 Action Item 2 Direct Care Staff, including agency, to provide return demonstration and competency on Hoyer lift transfers. RNC or Designee Target date: 7/28/23 Action Item 3 Facility staff and agency staff will be in-serviced on Abuse and Neglect and proper reporting process, Includes Administrator and Director of Nursing. RNC and Designee Target date: 7/28/2023 Action Item 4 All current Residents who require Hoyer lift transfer will be assessed by licensed nurses for injury. All resident current and future will have weekly skin assessments completed to assess for injury. RNC or Designee Regional Nurse Consultant is onsite and conducted assessments with assistance of charge nurses on 7/28/23. Target date: 7/28/2023 Action Item 5 All facility Hoyer lifts will be inspected to assure safe operation. Director of Maintenance Target date: 7/28/2023 Action Item 6 Regional Nurse Consultant to in-service Administrator and Director of Nursing on Incident Accident Process. Including reporting allegations of abuse. Regional Nurse Consultant Target date: 7/28/2023 Action Item 7 Regional Nurse Consultant and Regional Director of Operations to in-service Administrator and Director of Nursing on process for agency staff orientation to facility and resident needs. Regional Nurse Consultant and Regional Director of Operations Target date: 7/28/2023 Action Item 8 Agency staff will be provided orientation on facility and residents needs per facility process. Orientation will include a check off form that include but is not limited to essential job functions, facility tour and procedures, medical and emergency equipment, specialty equipment, assignment sheets, point click care Kardex to identify resident needs. DON or designee Target date: 7/29/2023 Action Item 9 Facility staff and agency staff will be in-serviced on a) Abuse, Neglect, Exploitation and Misappropriation Prevention, and Resident Rights. RNC and designee Target date 7/31/2023 Action Item 10 Facility and agency Licensed Nurses nursing staff will be in-serviced on proper completing of Incident and Accident process, identification, documentation and notification. All staff and agency will be in-serviced on reporting of incidents and accidents. RNC and Designee. Target date: 7/31/2023 Action Item 11 The facility has a system to evaluate and improve safety for all residents who reside at the facility. The incident accident system is used as a tool to track facility incidents that have been reported to the facility QAPI where the safety of the facility is assessed, and action plans developed. Administrator Target date: 7/31/2023 Monitoring: 7/30/2023 Observation on 7/30/2023 at 11:00am, observed CNA D and CNA F complete a resident transfer using the mechanical lift. Staff were observed using appropriate hand hygiene, staff observed talking with Resident # 2 and explaining the process as they started. CNA D and CNA F were able to complete a successful transfer from the bed to the wheelchair. Observation on 7/30/2023 at 11:30am, observed CNA C and CNA G completed a transfer for a Resident # 3 from her wheelchair into her bed. Staff were able to complete the transfer successfully, Resident # 3 stated she felt safe. Interview on 7/30/2023 at 11:50am with CNA D, revealed she worked the 6am to 6pm shift, she stated she was facility staff not agency. She had been trained on how to use the mechanical lift and abuse/neglect she stated she used the Kardex in PCC to see what the care needs are for residents. CNA D was able to explain the process of how to use the mechanical lift. Interview on 7/30/2023 at 11:55am with CNA G, revealed she was agency staff, she stated she had been trained on how to use the mechanical lift safely and abuse/neglect She reported she had also been trained on how to access the PCC system to review the care needs for each resident. Interview on 7/30/2023 at 12:00pm with CNA F, revealed she worked through a (staffing agency) she stated it was her second day at the facility. CNA F stated she had been in-serviced on how to use the mechanical lift safely, abuse/neglect, and how to access PCC for resident's care needs. Interview on 7/30/2023 at 2:30pm with Resident # 2 revealed, she was doing fine and stated she felt safe at the facility. Interview on 7/30/2023 at 3:00pm with Resident # 3 revealed, he felt safe at facility. Record review on 7/30/2023 of in-services on abuse/neglect, Mechanical lift competency checklist dated 7/29/2023 reflected 20 staff had completed the training. The ADM was informed the Immediate Jeopardy was removed on 7/30/2023 at 5:00PM. The facility remained out of compliance at the severity level of potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, record review, policy review and interviews, the facility failed to ensure one of seven sampled residents (Resident (R) 17) reviewed for abuse/neglect received the necessary care to prevent the harm of a fracture of the right humorous. A Certified Nursing Assistant (CNA) 24 failed to follow the care plan when providing care for R17, rolled the resident to the side without the assistance of a second staff as required on the plan of care which directed two person assist for bed mobility. This resulted in the resident experiencing pain and sustaining a fracture. Failure of the facility staff not to follow resident specific care plans has the potential to result in resident injury for dependent residents. Findings include: Review of the facility's policy titled, Abuse and Neglect-Clinical Protocol, dated March 2018 indicated Neglect, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility's policy titled, Resident Rights, dated December 2016 indicated, Team members shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to .be free from neglect. Review of an Incident Report dated 10/16/2020 for R17 (provided by the current Administrator) indicated, Incident Location: Resident's room. Incident Description: CNA was rounding and reported to nurse that when she was providing incontinent care for resident and while turning res (resident) she noticed res (resident) right arm was very loose, not tight & rigid as it normally is. Res (resident) right arm is her weak side post an old CVA ([CONDITION(S)] Accident) and has contractures. Right arm is normally drawn up into res (resident) chest tightly .nurse was able to move right arm into a straightened position, which is not normal for this res (resident) .Level of Pain: 6. Negative Vocalization: Repeated Troubled Calling out. Loud Moaning or Groaning. Crying. Facial Expression- Facial Grimacing. Body Language: Tensed .Loud Yelling out with movement of right arm. Review of an undated Administrator Note provided by the current Administrator indicated, Reference to Injury of Unknown Source- RE (regarding) [name of R17]. October 16: Xray showed a Fracture to the right humorous [sic] .Course of Events: During investigation process .it was found that the fracture likely occurred during bed mobility, turning and positioning on the 10PM-6AM shift by CNA (Certified Nursing Assistant) performing peri-care. Further review of the note indicated, Resident was not indicating any indication of pain until CNA was performed routine peri-care .While turning resident, that resident cried out in pain .Care plan/Kardex review shows that a two (2) person assist is required for transfer. During an observation of R17 on 05/24/21 at 9:50 AM, R17 was observed to be sitting in a wheelchair. Both upper extremities were severely contracted. The left arm was observed to be contracted at the elbow and the arm resting on the resident's chest. R17's right arm was observed to have a white brace in place. When attempting to interview the resident, R17 was not able to communicate and was non-verbal. During a second observation of R17 on 05/25/21 at 8:50 AM, R17 was observed to be lying in bed covered with a blanket and not responsive to attempted interview. During a third observation of R17 on 05/25/21 at 3:30 PM, R17 was observed to be sitting in a wheelchair in the common day area. At this time, R17 did not respond to interview and both upper extremities were observed to be severely contracted, and the right arm observed to have a white brace in place. Review of a Face Sheet found in R17's Electronic Medical Record (EMR) under the Profile tab indicated R17's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an annual Minimum Data Set (MDS) found in R17's EMR under the MDS tab revealed an Assessment Reference Date (ARD) of 10/05/20. The MDS revealed R17 has both a short-term and long-term memory problem and cognitive skills for daily decision making are severely impaired. Further review of the MDS indicated R17 requires extensive assistance with two+ persons physical assist for bed mobility and is totally dependent with two+ person physical assist for transfers. The MDS indicated R17 also is totally dependent with two+ person physical assist for toilet use. The MDS further indicated R17 has impairment on both sides of upper and lower extremities. Review of a Care Plan found in R17's EMR under the Care Plan tab revised on 10/19/2018 indicated ADL Self-care performance deficit r/t (related to) impaired mobility, contractures, impaired cognition. Interventions revised on 02/16/2019 indicated: Bed Mobility: the resident requires 2x [two] staff to turn and reposition in bed Q 2 hrs [every two hours] and as necessary. Transfer: The resident requires Hoyer lift for transfers with 2x staff assistance. Review of an undated Visual/Bedside Kardex Report found in R17's EMR under the Kardex tab indicated Bed Mobility: The resident requires 2x staff to turn and reposition in bed Q2HRS (every 2 hours) and as necessary .Dressing/Splint Care-Dressing: The resident requires 2 x staff to dress .Transfer: The resident requires Hoyer lift for transfers with 2x staff assistance. Review of Nursing Progress Notes found in R17's EMR under the Progress Notes tab dated 10/16/20 indicated, Rec'd (received) report from CNA that res (resident) right arm which is her weak side post old CVA was not tight and rigid as it normally is. Res (resident) has right fingers and elbow contractures and wears splint during day hours. Nurse went to assess res (resident), right arm is in usually contracted position however very gently able to move arm into a straightened position, which is not normal for this res (resident) .Also res (resident) yelled out in pain when moving arm .Res (resident) unable to verbalize any needs or follow commands . Review of Nursing Progress Notes found in R17's EMR under the Progress Notes tab dated 10/16/20 indicated, Resident continue showing s/s (signs/symptoms) of pain to the right arm, appear to be swollen around the shoulder area in comparison to the other arm . Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . (patient) with increased pain and shows facial grimacing, moaning, and crying with movement of right arm .On passive ROM (Range of Motion) of right upper ext. (extremity), pt. (patient) starts crying and seems uncomfortable. Pain worse with shoulder movement only. Mild [CONDITION(S)] to right shoulder noted. Review of Nursing Progress Notes found in R17's EMR under the Progress Notes tab dated 10/16/20 indicated, Xray to right side done, per the tech that is appear that there is a fx (fracture) to the right humerus . Review of a Radiology Report found in R17's EMR under the Miscellaneous tab dated 10/16/20 indicated, There is a fracture involving the proximal humerus with modest displacement .There is osteopenia. Conclusion: Acute appearing humerus fracture. Review of an Admitting Hospital History and Physical found in R17's EMR under the Miscellaneous tab dated 10/16/20 indicated, Fracture involving the proximal shaft of the humerus. Assessment & Plan: Right humeral fracture, acute, traumatic .Physician Attestation: Patient is .admitted for humerus fracture. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] .She was sent to the ER (emergency room ) on 10/16/20 for right shoulder pain with Xray showing right humerus fracture. She was evaluated by Ortho (Orthopedics) with no interventions. Pt. (patient) was stabilized and sent back with orders for sling to right arm/shoulder. Review of a typed document dated October 22, 2020 (provided by the Assistant Director of Nursing (ADON) of an interview conducted by the ADON with CNA 24 (who was the CNA working with R17 at the time the fracture occurred) indicated, On October 21, 2020 during a telephone interview with [name of CNA24], the CNA admitted .that when she was performing routine peri-care, by herself, that while turning the resident, the resident yelled out in pain. The team member was clear that the injury appeared to have been caused by her turning the resident during care. Upon further interview team member first said she did not know that the resident required two-person assist. Later in the conversation, the employee (CNA24) contraindicated herself, and admitted that she was performing peri-care and turning, and that she should have had another team member to assist in that care . Review of a written statement from CNA24 dated 10/23/20 indicated, I went back to her [referring to R17] room around one o'clock am and when I pulled the blankets, she did her growls so when I turn her to change her, I used the pad under her to turn her. I then saw that her right arm was loose/weak when its normally contracted and tight. When I turn her with the pad, she start [sic] to cry and I held her back when I was cleaning her. After I finished change [sic] her I immediately went to go get the nurse. She came in and noticed that the arm was loose and weak .I went back to her room around 3am to check to see if she needed to be changed .I pulled the blanket back and she seemed fine. I left the room, and I went back around 5am on my last rounds. I pulled the blanket back. She growls and become [sic] agitated. I told her that I was going to change you, so I used the pad to turn her again. She growls and cry out. I got her changed by myself and covered her. Back positioned the right way and left the room. During an interview on 05/24/21 at 9:45 AM, Registered Nurse (RN)14 stated, She (referring to R17) is non-verbal, and requires total assistance for everything. She is not able to communicate and is paralyzed. She cannot move her legs and can move her left arm very little. She moans when she is in pain, and we have to look at her body language to gauge if she is in pain. She is total care meaning we have to do everything for her. She is a two person assist for bed mobility and transfers with a Hoyer lift. During an interview on 05/25/21 at 9:45 AM, the ADON stated, This happened over the night shift. I remember during the morning meeting, I was told her [R17] arm was swollen, and the nurse did notice pain when doing passive range of motion with the right arm and it was flaccid. Normally, her [R17] right arm was very contracted .I was told that other than Tylenol no other orders were given during the night. It didn't sit right with me, so I insisted our Nurse Practitioner get an x-ray. The ADON then stated, She [referring to CNA24] could have gotten help with turning her. If she was unsure of the amount of extent of help that was needed, she [CNA24] should have gotten help. The CNA had access to the residents Kardex which clearly showed she was a two-person. She [R17] can't help in turning, both arms were contracted, and she cannot follow verbal commands. She [CNA24] should not have turned her by herself. The ADON then stated, I feel it was neglect because the CNA didn't turn the person the way she was supposed to with two people. It was also neglect not to check the Kardex to make sure she was a two person. During a phone interview on 05/25/21 at 12:33 PM, Licensed Vocational Nurse (LVN)18 stated, With [name of R17] the right arm is very contracted, the fingers are contracted and the elbows. You just can't open it. Her elbow is so contracted on the left, the arm just lays on her chest. LVN18 stated, I was at the desk charting, and I remember the CNA (identified as CNA24) coming to me after 1:00 AM saying 'You need to come. Something is wrong with her [R17] arm. It's just hanging there' LVN18 then stated, I got up and went to her room and CNA24 said When I went to turn her, it fell over on her side.' LVN18 stated, She [R17] was on her back. There was no bruising, no swelling nothing. Then I went to lift her arm thinking there was something on the underside. When I went to take her arm to straighten it, her arm was easy to pull. She screamed out. She was in pain when I moved it. I got her Tylenol then I called the Nurse Practitioner on call of my findings. The Nurse Practitioner on call who didn't know R17 very well told me without anything obvious, we will wait until morning and have the day Nurse Practitioner check her out. LVN18 then stated, I asked the CNA what happened, and she told me during her second rounds at 1am, she [referring to R17] was wet and she turned her. She picked up the pad by herself at the time and turned the resident. LVN18 stated, she [referring to CNA24] was by herself. She [R17] has always been a two-person assist for everything. During an interview on 05/25/21 at 1:30 PM, Licensed Vocational Nurse (LVN)19 stated, From what I recall, I came in at 6am and got report from the night nurse [name of LVN18]. The LVN told me she went in to assess her [referring to R17] and she had pain to the touch. When I saw her [R17] the right arm was swollen around the shoulder compared to the other arm. She had some discomfort. I called the Nurse Practitioner, and we got an X-ray. The X-ray results showed a fracture to the right humerus. We then sent her to the emergency room . During an interview on 05/25/21 at 4:12 PM, the Medical Director stated that he was aware of the fracture that R17 sustained. The Medical Director stated, She is very high risk for fracture due to being contracted. She has severe [CONDITION(S)], and I am not sure how the injury happened. We could not pinpoint at the time the cause of the fracture. Possible during rotation. Her bones are very weak. She [R17] has a lot of muscle tightness and when they moved the arm or turned her it could potentially cause a fracture. She [R17] is very compromised and now she has to wear a brace which is uncomfortable. During an interview on 05/25/21 at 4:30 PM, CNA22 stated, With [name of R17], she cannot voice her needs, and cannot tell us if she is in pain. She cannot raise her hands or her arms and is very stiff. It takes two people to change her, turn her, pull her up in bed, and to put her in the Hoyer lift. CNA22 then stated, as a CNA, we are always supposed to check the Kardex if we don't know about a resident or ask the nurse if we are unsure. During an observation of a transfer for R17 on 05/26/21 2:17 PM, CNA22 and LVN16 transferred R17 from special motorized w/c into bed using a mechanical lift. Resident had handroll bilateral hands, had brace upper right hand with gauze wrap underneath. CNA22 stated She [R17] cannot move in bed and we turn her every two hours. R17 was also observed with bilateral foot drop. During an interview on 05/27/21 at 10:55 AM, the Physical Therapist (PT) stated, We did training with the staff on how to move her (R17) in bed. She cannot follow commands at all. She has always been a total assist. Even if we cued her, she would not be able to help turn in bed at all. We have to do 100% of the work. The PT then stated, She has always been a two-person for turning side-to-side in bed. Staff would have to use her hips to turn her, but definitely not the shoulders to turn. Citation issued related to TX 411 and TX 324 substantiated complaints with the same incident and same resident identified.

Based on observation, interview and record review, the facility failed to train all employees in emergency procedures that provide plan for the protection of all residents in the event of a fire, for their evacuation to areas of refuge, and for their evacuation from the building for one (1) of one (1) residents. (Resident #14) Resident #14 utilized a Bariatric bed (specialty heavy-duty beds that are wider than average and can support the excess weight of bariatric/morbidly obese individuals). The facility failed to train staff on a disaster plan to include evacuation procedures for Bariatric bed residents or residents that could not self evacuate in the event of an emergency evacuation from the facility. . This failure resulted in identification of an Immediate Jeopardy (IJ) on 07/17/13. While the IJ was removed on 07/17/13, the facility remained out of compliance at a severity level of potential for more than minimal harm with a scope as a isolated that is not IJ. This deficient practice had the potential to delay or prevent the safe, rapid, and efficient evacuation from the facility, for one (1) resident identified as utilizing the Bariatric beds, in the event of an emergency. Findings include: Review of the Face Sheet for Resident #14, dated 6/18/13, reflected she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #14's Guidelines For Taking Report reflected the weight as 392 pounds at time of transfer to the facility. Review of Resident #14's Care Plan dated 06/06/13 reflected the resident had a "self-care deficit" related to physical declines, Left [MEDICAL CONDITION], and Bed Bound. Requires staff assistance times two with bed mobility, and total staff assistance when she gets out of bed. Observations on 7/15/13 at 9:35 p.m., during initial tour revealed Resident #14 lying in bed in her room. Resident bed is a Bariatric bed. During an interview on 07/17/13 at 10:30 a.m., the Certified Nurse Aide A (CNA A) stated that it would take three (3) people to get Resident #14 out of her room. CNA A continued that she would have to use the Hoyer Lift to get her out of the room because the bed would not fit through the door. CNA A denied having any training on emergency evacuation of residents in the Bariatric bed. During an interview on 7/17/13 at 10:40 a.m., CNA B stated that you pull a release, the mattress will go to the floor, and you pull the resident out of the room on the mattress. It will take at least two (2) people to do this. During an interview on 7/17/13 at 10:45 a. m., Registered Nurse A (RN A) stated that we would have to use at least two (2) people and use the Hoyer lift to evacuate the resident. The bed in that room does not break down. RN A denied any special training on the Bariatric bed. During an interview on 7/17/13 at 10:55 a.m., CNA C stated that the bed can be broken down. There is a button that you push and the bed will go in and you can push the bed out of the room. During an interview on 7/17/13 at 12:20 p.m. the Facility Corporate Nurse stated that she was unable to provide documentation of previous in-services on the Bariatric Bed. Observations on 07/17/13 between 12:25 p.m. and 1:00 p.m., revealed Resident # 14 lying in bed. The footboard on the bed (Room A216) measured 38 inches in width and the mattress measured 48 inches in width. The Resident room door measured 43 inches wide. During an interview on 7/17/13 at 12:25 p.m., CNA D stated that the bed mattress will not fit through the door, so we cannot take the resident out of the room in the bed. During an interview on 7/17/13 at 12:30 p.m., Resident # 14 stated that she cannot get out of the bed and is unable to even sit in a chair. Therapy is currently working with her to be able to stand at the bedside and transfer but she is unable at this time. Resident denied any teaching on emergency evacuation. Review of an In-Service record dated 7/17/13 given to this surveyor reflected that CNA D had attended the In-Service Titled " Emergency Evacuation " Objectives of the In-Service were: 1. Use of Bariatric Bed 2. Evacuation of a Bariatric Bed Review of the facility undated document entitled, Evacuation Procedure, reflected the following: 3rd Bedridden Residents who shall be removed in the following order: (a) Leave resident in bed and roll out (b) Carry on bed linins with edges rolled as a stretcher, using two people or dragged by one person. Review Disaster Plan Manual did not reflect any information regarding the specialized bariatric beds or procedures needed to reduce the size of the bed to properly remove the bed from the facility. In an interview on 07/17/13 at 1:10 p.m., the Administrator stated there were no additional disaster plan documents. The only way to remove a bariatric resident is to pull them out on a sheet. On 07/17/13 at 1:10 p.m., the facility Administrator was informed that an Immediate Jeopardy (IJ) existed. On 07/17/13 at 3:18 p.m., the Administrator provided surveyors with a written Plan of Removal that included: 1. All Bed Ridden residents to be identified for evacuation purposes including Bariatric. 2. Staff to be in-serviced on how to evacuate a resident in the bed. a. Staff to be in-serviced with return demonstration on how to collapse the Bariatric Bed so it will fit through all doors. i. All staff in building to be in-serviced today, July 17, 2013, with return demonstration. ii. All on-coming staff to be in-serviced with return demonstration before start of shift. 1. All in-services to be conducted and monitored by Administrator/Director of Nursing and/or designee. 3. Disaster Plan will be adjusted to show bed ridden residents will be evacuated from the building in a bed. a. Process of collapsing Bariatric Beds will be added to disaster plan. 4. Process of collapsing Bariatric Bed to be added to new employee orientation. 5. Process of removing all bed ridden residents to be added to Monthly Fire Safety Evacuation Drills. 6. All admissions will be reviewed, prior to admission, for potential needs required during an evacuation. 7. Facility QAPI Committee will review all findings monthly for the next 90 days and quarterly thereafter. Observations on 7/17/13 from 4:24 p.m. to 4:36 p.m. revealed staff " breaking down " the bariatric bed and removing the bed from a resident room. Four (4) staff was observed evacuating another staff member in a bariatric bed out of the room. On 7/17/13 at 4:38 p.m., the Facility Administrator was informed that the Immediate Jeopardy (IJ) had been removed. However, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated that is not IJ due to the facility requiring time to train all staff and monitor their Plan of Removal for effectiveness. The Facility Administrator stated on 7/17/13 that only 1 Resident in the facility was using a Bariatric bed.