Every finding on record at Heritage Manor Health & Rehab

Based on observation, record review and interview the facility failed to have sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident by:Failing to provide a licensed nurse on a 24-hour basis to provide nursing care.Failing to answer or respond to call light in a timely manner for 1(#4) of 9 sampled residents. Findings: Upon entry to the facility on [DATE] at 7:35 a.m. an observation revealed one staff member seated in a chair on the hall. No other staff were observed. During an interview on 08/18/2026 at 7:35 a.m. S5 CNA (Certified Nursing Assistant), who was seated in a chair on the hall, reported she had not seen a nurse since she came in for her 7:00 a.m. to 3:00 p.m. shift. Observation in each resident room on 08/18/2026 from 7:35 a.m. to 7:40 a.m. did not reveal a nurse was present. Observation on 08/18/2026 at 7:40 a.m. revealed S3 LPN (Licensed Practical Nurse) walking into the building with handbag through the front hallway. During an interview on 08/18/2026 at 7:50 a.m. S3 LPN reported she was the day shift nurse and was running late for her shift due to a flat tire. S3 LPN further confirmed she had not seen the night shift nurse S4 LPN this morning. Review of 08/17/2026 Nursing Staff Clock-in and Clock-outs for 11:00 p.m. to 7:00 a.m. shift revealed S4 LPN had clocked out at 7:14 a.m. Review of 08/18/2026 Nursing Staff Clock-in and Clock-outs for 7:00 a.m. to 3:00 p.m. shift revealed S3 LPN had clocked in at 7:39 a.m. During an interview on 08/18/2026 at 11:40 a.m. S1 DON (Director of Nursing) reviewed the clock-in/out for S3 LPN and S4 LPN and reported there had been a gap when no licensed nurse was clocked in and there should have been a nurse on duty 24 hours a day and was not. During a phone interview on 08/20/2026 at 12:49 p.m. S4 LPN reported Tuesday (08/18/2026) morning at the end of her shift she had to leave emergently before the day nurse showed up. Resident #4 Review of policy titled Call Lights: Accessibility and Timely Response with Implementation date of 01/15/2026 revealed, in part:Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside . to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.Policy Explanation and Compliance Guidelines: .10. All staff members who see or hear an activated call light are responsible for responding. Observation on 08/19/2026 at 7:35 a.m. revealed Resident #4's call light on the ceiling just outside of Resident #4's room was illuminated. Observation on 08/19/2026 at 7:43 a.m. revealed Resident #4's call light on the ceiling just outside of Resident #4's room was illuminated. Observation on 08/19/2026 at 8:04 a.m. revealed Resident #4's call light on the ceiling just outside of Resident #4's room was illuminated. Observation on 08/19/2026 at 8:07 a.m. revealed Resident #4's call light on the ceiling just outside of Resident #4's room was illuminated. Observation on 08/19/2026 at 8:16 a.m. revealed Resident #4's call light on the ceiling just outside of Resident #4's room was illuminated. Observation on 08/19/2026 at 8:21 a.m. revealed a CNA go into Resident #4's room with breakfast tray and left room and call light was still illuminated. During an interview on 08/19/2026 at 8:24 a.m. Resident #4 reported he had hit his call light to get water a while ago and no one had responded. During an interview on 08/19/2026 at 8:25 a.m. S3 LPN reported she had not noticed Resident #4's call light was on. During an interview on 08/19/2026 at 8:27 a.m. S6 CNA reported she thought Resident #4's call light was one of the lights that would jam and stay on so did not answer the light.

Based on observations, record review, and interviews the facility failed to ensure there was a functioning call system to allow residents to call for assistance for 5 (#5, #6, #7, #8, #9) of 25 resident call lights checked. Findings:Review of policy titled Call Lights: Accessibility and Timely Response with Implementation date of [DATE] revealed, in part:Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside . to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.Policy Explanation and Compliance Guidelines:.8. Staff will report problems with a call light or a call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. (Examples include: replace call light, provide a bell or whistle, increase frequency of rounding, etc.)9. Ensure the call system alerts staff members directly or goes to a centralized staff work area.10. All staff members who see or hear an activated call light are responsible for responding. During an interview on [DATE] at 8:25 a.m. S3 LPN (Licensed Practical Nurse) reported sometimes the resident call lights would get jammed and stay on. During an interview on [DATE] at 8:27 a.m. S6 CNA (Certified Nursing Assistant) reported some of the call lights would jam and stay on when pressed. During an interview on [DATE] at 8:44 a.m. S1 DON (Director of Nursing) reported she was aware sometimes the call lights would stick and would not turn off. Observation of all current resident call lights on [DATE] from 12:50 p.m. to 1:20 p.m. with S7 Maintenance revealed Resident #5, #6, #7, #8, and #9's call lights did not illuminate the ceiling light outside resident door when pressed. During an interview on [DATE] at 1:20 p.m. S7 Maintenance confirmed Resident #5, #6, #7, #8, and #9's call button did not illuminate the light on ceiling outside of each of the resident's door so staff would know the button had been pushed. S7 Maintenance further reported he was not aware the lights did not work. S7 Maintenance also reported the call light system was old and sometimes it was hard to get parts. During an interview on [DATE] at 3:23 p.m. S2 CNA Coordinator confirmed Resident #5, #6, #7, #8 and #9 were able to reach for their call light and press it and had used their call light before. During an interview on [DATE] at 11:40 a.m. S8 Administrator reported he was not aware some of the call lights were not working until they were checked yesterday, but that sometimes it was just a bulb.

Based on observation and interview the facility failed to ensure the most recent survey results were readily accessible to the residents, family members or anyone to review. Findings: Observation on 06/15/2026 at 11:59 a.m. revealed the facility's survey binder was last updated on 10/01/2025. Further review of survey binder failed to reveal additional completed complaint surveys had been added. During an interview on 06/15/2026 at 12:10 p.m. S1 Administrator acknowledged the facility had additional complaint surveys since 10/01/2025. S1Administrator confirmed the completed complaint survey results were not updated the survey binder and should have been.

Based on record reviews and interviews, the facility failed to:1.) Provide written notice to residents and/or their RP (Responsible Party) which specified the reason for transfer, effective date, location and statement of the resident's appeal rights and duration of the bed hold for 1 (#38) of 4 residents reviewed for hospitalizations.2.) Update the emergency transfer log (Notice of Discharge to the Ombudsman) for 3 (#8, #38, and #55) of 4 residents reviewed for hospitalizations. Findings:Resident #8 Review of Resident #8's medical record revealed an admission date of 04/22/2026 with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, non-traumatic intracerebral hemorrhage in hemisphere, tracheostomy status and epileptic seizures related to external causes. Further review revealed Resident was transferred to the ER on [DATE] for respiratory failure.Review of the emergency transfer logs for January 2026 through May 2026 failed to contain Resident #8's transfer on 04/23/2026. During an interview on 06/17/2026 9:27 a.m., S5 Social Services confirmed the April 2026 emergency transfer log did not contain Resident #8's transfer on 04/23/2026 and should have. Resident #38 Review of Resident #38's medical record revealed an admission date of 08/28/2023 with diagnoses including other lack of coordination, acute embolism and thrombosis of unspecified deep veins of left lower extremity, acute respiratory failure, and bipolar disorder. Further review revealed Resident #38 was sent to the ER for altered level of consciousness on 05/26/2026. Review of the emergency transfer logs for January 2026 through May 2026 failed to reveal Resident #38's transfer on 05/26/2026.Review of Resident #38's medical record failed to reveal a bed hold notification was sent for transfer on 05/26/2026.During an interview on 06/17/2026 at 8:00 a.m., S5 Social Services confirmed Resident #38's bed hold notification was not sent at time of transfer on 05/26/2026.During an interview on 06/17/2026 at 9:27 a.m., S5 Social Services confirmed the May 2026 emergency transfer log did not contain Resident #38's transfer on 05/26/2026 and should have. Resident #55Review of Resident #55's medical record revealed an admission date of 02/11/2026 with diagnoses including Parkinson's disease, schizoaffective disorder, major depressive disorder, insomnia, and depression.Review of Resident #55's medical record failed to reveal a bed hold notification was sent for transfer on 05/28/2026.During an interview on 06/17/2026 at 8:00 a.m., S5 Social Services confirmed Resident #55's bed hold notification to resident #55 was not sent at time of transfer on 05/28/2026.During an interview on 06/17/2026 at 9:27 a.m., S5 Social Services confirmed the May 2026 emergency transfer log did not contain Resident #55's transfer on 05/28/2026 and should have.

Based on record reviews and interview, the facility failed to refer 1 (#49) of 1 (#49) resident with a 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. Findings:Review of facility's Resident Assessment - Coordination with PASARR Program policy (2025) revealed, in part: Policy Explanation and Compliance Guidelines: 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability.Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.Review of Resident #49's medical record revealed an admit date of 12/09/2014 with the following diagnoses, including in part: major depressive recurrent episode unspecified, bipolar disorder current episode depressed severe with psychotic features and anxiety disorder unspecified. Review of Resident #49's physician's orders revealed:11/20/2025 - Risperidone Oral Tablet 1 mg; Give 0.5mg by mouth at bedtime related to bipolar disorder current episode depressed severe with psychotic features.01/27/2025 - Cymbalta Oral Capsule Delayed Release Particles 20mg (Duloxetine HCl) Give 1 capsule by mouth one time a day related to major depressive disorder recurrent unspecified Review of Resident #49's medical record revealed nursing facility psychiatric follow up note dated 11/10/2023, in part: psychiatric diagnoses - Bipolar 2 Disorder with psychotic features; current psychotropic medications - Risperdal 1mg PO TID.Review of Resident #49's OBH-PASARR Level II Evaluation Summary & Determination Notices failed to reveal a referral was sent following a diagnosis of bipolar disorder current episode depressed severe with psychotic features treated with Risperidone. Further review revealed the last referral was sent on 10/23/2020.During an interview on 06/16/2026 at 12:30 p.m., S4 MDS Nurse reported on 01/31/2023 nursing facility psychiatric staff diagnosed Resident #49 with Bipolar 2 with psychiatric features active and started him on Seroquel 100mg h.s. S4 MDS Nurse acknowledged a PASARR referral should have been completed and was not.

Based on record review and interviews, the facility failed to ensure a plan of care had been implemented for 1 (#30) of 17 sampled residents whose care plans were reviewed. The facility failed to administer Resident #30's neuropathy medication as ordered by the physician.Findings: Review of Resident #30's medical record revealed an admission date of 09/03/2024 with diagnoses including in part, type 2 diabetes and essential hypertension. Review of Resident #30's physician orders revealed in part, an order dated 06/03/2026 for Gabapentin capsule 100 mg; give 2 capsules by mouth at bedtime for neuropathy. Further review revealed the 06/03/2026 gabapentin order had a status of Pending Confirmation (Read Back Required). Review of Resident #30's June 2026 MAR revealed in part, Resident #30 was last administered Gabapentin on 06/02/2026. During an interview on 06/16/2026 at 2:45 p.m., S8LPN reviewed Resident #30's physician orders and acknowledged an order dated 06/03/2026 for Gabapentin 100 mg; give 2 capsules by mouth at bedtime for neuropathy was pending confirmation by the nurse. S8LPN further acknowledged Gabapentin had not been administered to Resident #30 since 06/02/2026 and should have been. During an interview on 06/16/2026 at 2:50 p.m., S2ADON reviewed Resident #30's physician orders and acknowledged the order dated 06/03/2026 for Gabapentin 100 mg; give 2 capsules by mouth at bedtime for neuropathy had not been confirmed by the nurse. S2ADON further acknowledged Gabapentin had not been administered to Resident #30 since 06/02/2026 and should have been.

Based on record reviews, observations and interviews, the facility failed to ensure 2 (#8, #15) out of 2 residents who need respiratory care, including tracheostomy care and tracheal suctioning, are provided such care, consistent with professional standards of practice. The facility failed to:Store Resident #8 suctioning equipment to prevent contamination; and Change Resident #15's nasal cannula and humidifier weekly and clean and store BIPAP equipment according to policy and procedure. Findings: Review of facility's Oxygen Administration (2026) policy revealed in part:Policy Explanation and Compliance Guidelines: 5 Other infection control measures include: a. follow manufacturer recommendations for the frequency of cleaning equipment filters. b. change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. e. keep delivery devices covered in plastic bag when not in use. 8. Cleaning and care of equipment shall be in accordance with facility policies for such equipment.Resident #8Review of Resident #8's medical record revealed an admission date of 04/22/2026 with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, non-traumatic intracerebral hemorrhage in hemisphere, tracheostomy status and epileptic seizures related to external causes.Review of Resident #8's physician's orders revealed in part:04/22/2026 - Respiratory: Suction as needed at bedside for secretions; every shift for secretions.Observation on 06/15/2026 at 8:24 a.m. revealed Resident #8's suction tool on bedside table was unbagged.Observation on 06/16/2026 at 1:35 p.m. revealed Resident #8's suction tool on bedside table was unbagged.During an interview on 06/16/2026 at 1:37 p.m. S7LPN confirmed Resident #8's suction tool was unbagged and should have been. Resident #15Review of Resident #15's medical record revealed an admit date of 03/27/2026 with the following diagnoses, including in part: chronic obstructive pulmonary disease with (acute) exacerbation, obstructive sleep apnea, pneumonia due to klebsiella pneumonia and unspecified diastolic (congestive) heart failure.Review of Resident #15's physician's orders revealed in part:04/26/2026 - Change tubing, mask and / or nasal cannula weekly (may change sooner as needed) one time a day every Sunday.04/17/2026 - Respiratory: Oxygen - 3 liters continuous every shift.03/30/2026 - Clean mask daily every night shift.04/05/2026 - Clean tubing weekly every day shift every Sunday.03/30/2026 - Duration and Frequency of Therapy (16/8-30%) BIPAP every night shift.03/31/2026 - Empty water chamber and air dry every a.m. every day shift; empty water chamber and air dry every a.m.Review of Resident #15's medical record failed to reveal care was provided for BIPAP equipment.Observation on 06/15/2026 at 9:45 a.m. revealed Resident #15 wearing continuous oxygen at 3LPM via nasal cannula. Further observation revealed BIPAP mask lying on bedside table not bagged, nasal cannula dated 06/07/2026 and humidifier dated 06/06/2026.Observation on 06/16/2026 at 12:40 p.m. revealed Resident #15 wearing oxygen via nasal cannula. Further observation revealed Resident #15's BIPAP mask lying on bedside table not bagged, nasal cannula dated 06/07/2026, humidifier dated 06/06/2026, and filter on the oxygen concentrator had a white powdery substance. During an interview on 06/16/2026 at 1:30 p.m. S13WCN acknowledged Resident #15's BIPAP mask should be cleaned daily and placed in a bag. S13WCN further acknowledged the nasal cannula dated 06/07/2026 and the humidifier dated 06/06/2026 should have been changed weekly. S13WCN confirmed the filter had a white powdery substance and should be taken out and cleaned weekly. During an interview on 06/16/2026 at 3:45 p.m. S2ADON confirmed there was no documentation Resident #15's BIPAP equipment was cleaned as ordered.

Based on record reviews and interviews, the facility failed to ensure 2 (#15, #26) of 7 reviewed for unnecessary medications were monitored for edema while receiving a diuretic.Findings:Resident #15Review of Resident #15's medical record revealed an admit date of 03/27/2026 with the following diagnoses, including in part: chronic obstructive pulmonary disease with (acute) exacerbation and unspecified diastolic (congestive) heart failure.Review of Resident #15's physician's orders revealed the following in part: 05/20/2026 - Furosemide Tablet 20 mg. Give 1 tablet by mouth one time a day for edema. Review of Resident #15's medical record failed to reveal monitoring of edema. During an interview on 06/17/2026 S3 Clinical Consultant was unable to provide documentation of daily edema monitoring. Resident #26Review of Resident #26's medical record revealed an admit date of 11/21/2022 with the following diagnosis, including in part: essential (primary) hypertension.Review of Resident #26's physician's orders revealed an order dated 12/02/2025 for Furosemide tablet 20 mg. Give 1 tablet by mouth one time a day for edema.Review of Resident #26's medical record failed to reveal monitoring for edema.During an interview on 06/17/2026 S3 Clinical Consultant was unable to provide documentation of daily edema monitoring.

Based on observations and interviews the facility failed to maintain all kitchen equipment in safe operating condition as evidenced by the walk-in refrigerator and freezer leaking water and in need of repair. This deficient practice has the potential to affect any of the 50 residents consuming food from the kitchen according to S9Dietary Manager. Findings: An observation of the walk-in refrigerator and freezer on 06/15/2026 at 8:05 a.m. revealed approximately a two inch layer of ice completely covering the freezer floor. Further observation revealed a sprinkler device in the freezer ceiling had water dripping from the device into a plastic bucket holding approximately six inches of water. Observation of the walk-in refrigerator revealed water leaking from a sprinkler device in the refrigerator ceiling into a plastic bucket containing approximately two inches of water. During an interview on 06/15/2026 at 8:15 a.m., S9Dietary Manager, reported the walk-in freezer and refrigerator ceilings leak through the sprinkler every time it rains and have been for over a year. S9Dietary Manager acknowledged the build-up of ice covered the entire freezer floor. S9Dietary Manager reported she had to break up the ice on the walk-in freezer floor and shovel it out at least once a week. S9Dietary Manager reported she had reported the leaking freezer and refrigerator ceilings to facility administration multiple times. During an interview on 06/15/2026 at 10:15 a.m., S1Administrator reported the walk-in freezer and refrigerator ceilings had been leaking for approximately one year and acknowledged the leaks had not been adequately repaired. S1Administrator further reported the ice buildup on the freezer floor and was a safety issue.

Based on record reviews, observations, and interviews, the facility failed to ensure that it was free from a medication error rate of 5% or greater. The facility had a 5.41 % medication error rate with 2 medication errors out of 37 opportunities. Findings:Review of the facility's Medication Administration undated policy revealed in part: Policy:Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Policy Explanation and Compliance Guidelines: .10. Ensure that the six rights of medication administration are followed:a. Right residentb. Right drugc. Right dosage Resident #13An observation during medication administration pass on 06/16/2026 at 9:45 a.m. revealed S8LPN dispensed two buspirone hcl 10 mg tablets (20 mg total) into a medicine cup in preparation for the 9:00 a.m. administration to Resident #13. During an interview on 06/16/2026 at 9:45 a.m., S8LPN observed Resident #13's buspirone hcl blister packet and pharmacy label and acknowledged each buspirone tablet was 10 mg. S8LPN acknowledged he should have dispensed only one 10 mg tablet for the 9:00 a.m. dose instead of two tablets (20 mg). Review of Resident #13's current physician orders revealed in part: 04/21/2026 Buspirone hcl give 10 mg by mouth three times a day. Resident #44 An observation during medication administration pass on 06/16/2026 at 9:00 a.m. revealed S8LPN dispensed and administered one half of a Gabapentin 800 mg tablet (400 mg total) to Resident #44. During an interview on 06/16/2026 at 9:30 a.m., S8LPN reviewed Resident #44's Gabapentin blister packet, pharmacy label and physician order and acknowledged Resident #44 was administered one half of a gabapentin 800 mg tablet which totaled 400 mg. S8LPN further acknowledged the physician ordered Gabapentin 800 mg po tid and Resident #44 should have been administered one 800 mg tablet. Review of Resident #44's current physician orders revealed in part:04/08/2026 Gabapentin capsule 400 mg; give 800 mg by mouth three times a day for neuropathy. On 06/16/2026 at 11:00 a.m. S3Clinical Consultant was made aware of the two medication errors involving Resident #13 and Resident #44 which resulted in a medication error rate greater than 5%.

Based on record review and interview, the facility failed to ensure an RN was on duty for 8 consecutive hours per day, 7 days a week, for 5 days throughout dates 02/22/2026 through 03/24/2026. Findings:Review of the facility's time card report for S5RN for dates 02/22/2026 through 03/24/2026 failed to reveal 8 consecutive hours of RN coverage on:02/25/2026 (6.50 hours)02/26/2026 (7.48 hours)02/27/2026 (6.48 hours)02/28/2026 (7.50 hours)03/01/2026 (7.50 hours) During an interview on 03/25/2026 at 9:35 a.m. S1 Administrator confirmed S5RN was the only RN scheduled 02/22/2026 through 03/21/2026 and the facility did not have 8 consecutive hours of RN coverage on 02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026.

Based on record reviews and interviews, the facility failed to ensure residents had a safe, functional, sanitary, and comfortable environment by failing to provide clean bath towels and bed linen for Residents at all times. This deficient practice had the ability to affect the census of 58 Residents that resided in the facility. Findings:Review of the facility's Facility Assessment Tool updated on 03/23/2026 revealed:Physical environment and building/plant needs:Non-medical supplies: .bed and bath linen. maintain PAR levels at all times to ensure that adequate supplies are available Resident #2 Review of Resident #2's medical record revealed an admission date of 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis. Further review revealed a BIMS score of 15, indicating no cognitive impairment. During an interview on 03/24/2026 at 1:30 p.m. Resident #2 reported bath towels and bed linen are often unavailable, most recent was last week [03/15/2-26 through 03/21/2026]. Resident #3 Review of Resident #2's medical record revealed an admission date of 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma. Further review revealed a BIMS score of 15, indicating no cognitive impairment. Review of the facility's grievance log for dates 01/01/2026-03/24/2026 revealed on 01/10/2026 Resident #3 complained of personal bath towels and sheets missing from laundry. During an interview on 03/25/2026 at 8:50 a.m. Resident #3 reported family provided her own personal linen because the facility is frequently out of bath towels and bed linen. During an interview on 03/24/2026 at 1:40 p.m. S3Laundry Staff reported the facility frequently does not have clean bath towels and bed linen available for Residents. During an interview on 03/25/2026 at 11:40 a.m. S4CNA reported clean bath towels and bed linen were unavailable for Residents two weeks ago [03/08/2026 through 03/14/2026]. During an interview on 03/25/2026 at 12:01 p.m. S2ADON reported the facility did not have clean bath towels and bed linen available for Residents on 03/23/2026.

Based on record review and interviews the facility failed to implement a comprehensive person-centered care plan which met the needs of 1 (#1) of 4 sampled residents reviewed for falls. The facility failed to ensure Resident #1 received one on one monitoring at all times as ordered.Findings: Review of Resident #1's medical record revealed an admission date of [DATE] under hospice services with diagnoses including chronic obstructive pulmonary disease and major depressive disorder. Further review of Resident #1's medical revealed Resident #1 expired on [DATE].Review of Resident #1's admission MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 14, indicating intact cognition. Further review of Resident #1's admission MDS assessment revealed Resident #1 was dependent on staff for transfers.Review of Resident #1's physician orders revealed an order dated [DATE] which read Resident #1 is on 1:1 monitoring at all times for safety; Resident #1 to sit in wheelchair/Geri-chair near nurses station for monitoring; every shift.Review of Resident #1's comprehensive care plan dated [DATE] revealed Resident #1 had a fall on [DATE], [DATE], [DATE], and [DATE]. Further review of Resident #1's comprehensive care plan revealed Resident #1 would remove oxygen tubing, one on one monitoring at all times for safety was updated after a fall on [DATE] at 3:08 a.m. Review of the facility's incident log revealed Resident #1 had an unwitnessed fall on [DATE] at 1:30 a.m.Review of Resident #1's progress notes revealed Resident #1 had a fall on [DATE] at 3:08 a.m. with complaints of 10/10 right arm pain. Resident #1 was sent to the ER for further evaluation on [DATE] at 3:08 a.m. Resident #1 remained in the ER until Resident #1 returned to the facility on [DATE] with an arm sling in place for a radial head fracture. One on one monitoring began on [DATE]. Further review of Resident #1's progress notes revealed an entry by S5LPN on [DATE] at 7:58 a.m. noted Resident #1 was found on the floor, had removed oxygen tubing, removed sling, was lifted back into bed, and assessment performed with no bleeding or abrasions.During an interview on [DATE] at 3:40 p.m. S7LPN reported Resident #1 would remove oxygen tubing and become confused. S7LPN further reported Resident #1 would not use the call light, attempt to get up and walk around without assistance.During an interview on [DATE] at 9:00 a.m. S1Administrator reported the facility does not have a one on one monitoring policy.During an interview on [DATE] at 11:55 a.m. S3ADON reported one on one monitoring required a staff member to observe the resident at all times. S3ADON confirmed Resident #1 had an unwitnessed fall on [DATE] at 1:30 a.m.During an interview on [DATE] at 1:35 p.m. S2DON reported one on one monitoring required a staff member to observe the resident at all times. S2DON confirmed Resident #1 had an unwitnessed fall on [DATE] at 1:30 a.m. when S4CNA left Resident #1 unsupervised to gather supplies. S2DON further reported a staff member assigned to one on one monitoring would leave the room to answer other call lights for other residents.During the survey, multiple attempts to contact S4CNA on [DATE] at 10:21 a.m., 11:05 a.m., and 12:43 p.m., [DATE] at 07:34 a.m., and S2DON attempted on [DATE] at 8:08 a.m. with surveyors present. All attempts to contact S4CNA were unsuccessful. During an interview on [DATE] at 3:15 p.m. S1Administrator confirmed Resident #1's physician's order dated [DATE] for one on one monitoring was not followed when an unwitnessed fall occurred on [DATE] at 1:30 a.m. S1Administrator further confirmed staff member assigned to one on one monitoring would leave the room to answer other call lights for other residents.During a telephone interview on [DATE] at 3:55 p.m. S6MD confirmed one on one monitoring at all times was ordered for Resident #1 on [DATE] to increase supervision after multiple falls.

Based on record review and interviews, the facility failed to develop a Comprehensive Person Centered Care Plan, which met the needs of 1 (#1) of 3 sampled residents. The facility failed to ensure physician recommendations were followed and interventions were in place for a subacute-chronic olecranon fracture. Findings:Review of the facility's Comprehensive Care Plans undated policy revealed in part:Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality.Policy Explanation and Compliance Guidelines:3. The comprehensive care plan will describe, at a minimum, the following:a. the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.b. any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment. Review of Resident #1's medical record revealed an admit date of 08/08/2024 with diagnoses including in part, type 2 diabetes and chronic pain syndrome. Review of Resident #1's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed in part a BIMS (Brief Interview of Mental Status) score of 06, indicating severe cognitive impairment. Review of Resident #1's interdisciplinary notes revealed in part, Resident #1 returned from a local emergency department (ED) on 12/12/2025 at 6:21 p.m. after evaluation of a fall. Resident #1's left arm had a splint with a sling which was to stay in place until seen for follow-up. Resident #1's discharge instructions included orthopedic follow-up to be scheduled by the facility for a subacute-chronic left elbow fracture. Review of Resident #1's hospital records revealed in part, a CT (Computed Tomography) scan performed on 12/12/2025 revealed Resident #1 had a subacute to chronic appearing olecranon fracture with distraction and mild rotation of the olecranon fracture fragment. Further review of Resident #1's hospital records revealed a splint had been placed on Resident #1's left arm and Resident #1 was discharged back to the facility with an order to follow-up with an orthopedic physician. Review of Resident #1's physician orders failed to reveal orders had been entered for the management or follow-up of Resident #1's left subacute-chronic olecranon fracture. Review of Resident #1's Comprehensive care plan failed to reveal interventions had been put into place for the management or follow-up of Resident #1's left subacute-chronic olecranon fracture. Review of Resident #1's medical record failed to reveal Resident #1 received a follow-up appointment with an orthopedic physician. During an interview on 01/05/2026 at 12:25 p.m. Resident #1 reported he had rolled out of bed and landed on his left side. Resident #1 reported he went to the ED and the doctor applied a splint and a sling to his left elbow. Resident #1 further reported he had not been back to a doctor to have his elbow checked. During an interview on 01/06/2026 at 10:30 a.m. S4MDS Nurse reported she was not aware Resident #1 returned from the ED with a splint and sling to his left elbow with an order for orthopedic follow-up. S4MDS Nurse reported she was responsible for updating residents' care plans and acknowledged Resident #1's care plan had not been updated to reflect management of a subacute-chronic left elbow fracture. During an interview on 01/06/2025 at 11:45 a.m., S3ADON (Assistant Director of Nursing) acknowledged physician orders had not been entered for care and follow-up of Resident #1's subacute-chronic left elbow fracture. S3ADON further acknowledged Resident #1's care plan had not been updated and should have been. During an interview on 01/06/2026 at 1:20 p.m., S2DON (Director of Nursing) acknowledged Resident #1 failed to receive follow-up orthopedic care and care plan interventions were not updated.

Based on record review and interviews, the facility failed to ensure 2 (#3, #5) out of 5 sampled residents were free from abuse resulting in resident to resident interactions. The facility failed to develop and implement ongoing monitoring to ensure resident safety.Findings:Review of Resident #3's medical records revealed an admit date of 12/05/2022 with the following diagnoses, in part: personal history of traumatic brain injury.Review of Resident #3's facility initiated investigation in part, revealed event occurred on12/03/2025 and type of injury was sexual assault. Further review revealed during the investigation, Resident #5 reported to Social Services Director (SSD) two weeks prior the accused tried to touch her but didn't report it because he stopped. The iknvestigation failed to include plans to conduct ongoing monitoring following the incident.Review of Resident #3's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating cognitively intact.During an interview on 12/16/2025 at 10:15 a.m. Resident #3 reported Resident #4 touched her private parts in the cafeteria and made her feel uncomfortable. Review of Resident #5's medical records revealed an admit date of 01/17/2025 with the following diagnoses, in part: hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, cognitive communication deficit, vascular dementia severe with agitation and metabolic encephalopathy. Review of Resident #5's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 14 indicating cognitively intact. During an interview on 12/16/2025 at 9:15 a.m. S5 SSD (Social Services Director) confirmed when conducting interviews, Resident #5 reported Resident #4 had come into her room and tried to put his hand down her diaper.During an interview on 12/16/2025 at 10:20 a.m. Resident #5 reported Resident #4 was coming in her room all the time and talking to her. Resident #5 further reported Resident #4 would grab her legs and run his hands up her leg making her feel uncomfortable. During an interview on 12/16/2025 at 2:30 p.m.S1 Administrator acknowledged Resident #4 was accused by Resident #3 and Resident #5 of making sexual advances. S1 Administrator further acknowledged the facility had not developed plans for ongoing monitoring following the incident of abuse.The investigation revealed a current level of non-compliance due to not implementing ongoing monitoring.The facility's plan included the following: Resident #4 was immediately separated from the other residents and placed on 1 on 1 monitoring in his roomPolice were notified and report filed.Resident #4 was discharged to behavioral health hospital on [DATE] and did not return to the facility.In-serviced conducted on 12/08/2025 staff on abuse and sexual inappropriate behavior.All female residents in the facility were interviewed on 12/05/2025.A trauma screen was conducted on Resident #3 and Resident #5.

Based on record review and interviews, the facility failed to provide needed care and services, in accordance with the resident's goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. The facility failed to ensure 1 (#4) out of 5 sampled residents received medication ordered upon re-ademission to the facility.Findings:Review of Resident #4's medical record revealed an admit date of 04/04/2022 with the following diagnoses, in part: major depressive disorder recurrent and unspecified and anxiety disorder.Review of Resident #4's hospital psychiatric evaluation revealed an admit date of 10/23/2025, date of evaluation 10/24/2025 and discharge date of 10/30/2025. Further review, in part revealed: .admitted for unstable mood and cannabis use disorder. Discharge goal: He needs to have a stable mood, be free of any agitation, maintain sobriety, and improve coping skills. Discharge medication summary included, in part: Divalproex Sodium DRT (delayed release time) 250 mg (milligarm) by mouth daily 9:00 a.m. and 9:00 p.m. - indication mood.Review of Resident #4's Physician's orders failed to reveal an order for Divalproex Sodium DRT 250 mg by mouth daily 9:00 a.m. and 9:00 p.m. - mood.During an interview on 12/16/2025 at 10:05 a.m. S3 Psych NP (Nurse Practitioner) reported when Resident #4 returned from the behavioral hospital the discharged psychotropic medications should have been ordered and administered to Resident #4 once returning to the facility.During an interview on 12/16/2025 at 10:30 a.m. S2 ADON (Assistant Director of Nursing) acknowledged Resident #4 did not have an order entered for Divalproex Sodium DRT 250 mg by mouth daily 9:00 a.m. and 9:00 p.m. for mood and should have.

Based on record review and interview, the facility failed to ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. The facility failed to document 1 (#1) out of 2 residents discharge from the facility.Findings:Review of Resident #1's medical records revealed an admit date of 10/09/2025 and a discharge date of 10/13/2025 with the following diagnoses, in part: chronic obstructive pulmonary disease unspecified, essential (primary) hypertension, other bipolar disorder, chronic kidney disease stage 3 unspecified, unspecified atrial fibillation, displaced subtrochanter fracture of right femur, displace transverse fracture of shaft of left ulna, displace fractureof medial condyle of left tibia, non-displced fracure of body of scapula left shoulder and contusion of lung unilateral subsequent encounter.Review of the facility census failed to reveal Resident #1 was in the facility.Review of Resident #1's medical record failed to reveal date, time, and events of discharge from the facility. Further review failed to reveal a discharge summary.During an interview on 12/16/2025 at 10:20 a.m. S2 ADON (Assistant Director of Nursing) acknowledged Resident #1 did not have a discharge note indicating date, time, and events of discharge from the facility and should have. S2 ADON reported Resident #1 was transferred to another nursing home facility.

Based on record review and interview, the facility failed to develop a baseline care plan for 1 (#1) out of 5 sampled residents reviewed.Findings:Review of Resident #1's medical records revealed an admit date of 10/09/2025 with the following diagnoses, in part: chronic obstructive pulmonary disease unspecified, essential (primary) hypertension, other bipolar disorder, chronic kidney disease stage 3 unspecified, unspecified atrial fibillation, displaced subtrochanter fracture of right femur, displace transverse fracture of shaft of left ulna, displace fractureof medial condyle of left tibia, non-displced fracure of body of scapula left shoulder and contusion of lung unilateral subsequent encounter. Review of Resident #1's medical record failed to reveal a baseline care plan. During an interview on 12/16/2025 at 10:25 a.m. S4 MDS (Minimum Data Set) nurse confirmed Resident #4 did not have a baseline care plan developed and should have.

Based on record review and interviews, the facility failed to ensure 5 (#1, #6, #7, #8, and #49) of 5 (#1, #6, #7, #8, and #49) residents reviewed for unnecessary medications were informed of the risks, benefits, and side effects of psychotropic medication, and allowed to choose the treatment option they preferred prior to the start of the medication. Findings:Resident #1 Review of Resident #1's record revealed an initial admission date of 01/17/2025 with a re-entry admission date of 02/17/2025 with the following diagnoses but not limited to generalized muscle weakness, lack of coordination, difficulty in walking, cognitive communication deficit, severe vascular dementia with agitation, uncomplicated stimulant abuse, and metabolic encephalopathy. Review of Resident #1's Quarterly MDS (Minimum Data Sets) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 14 indicating intact cognition. Further review of Resident #1's MDS revealed Resident #1 received antipsychotic and antianxiety. Review of Resident #1's August 2025 Physician Orders revealed:-07/21/2025: Buspirone HCl (Hydrochloride) tablet 5 mg (milligram); Give 10 mg by mouth two times a day for anxiety give 2 tabs-05/29/2025: Clonazepam oral Tablet 1 mg; Give 1 tablet by mouth at bedtime for anxiety-03/04/2025: Donepezil HCl Tablet 10 mg; Give 1 tablet by mouth at bedtime for dementia-02/04/2025: Trileptal Oral Tablet 150 mg; Give 1 tablet by mouth two times a day for moodReview of Resident #1's July 2025 and August 2025 MAR (Medication Administration Records) revealed Resident #1 received Buspirone HCL, Clonazepam, Donepezil HCL, and Trileptal. Review of Resident #1's Chemical Restraint/Psychoactive Drug Consent signed by the resident on 01/17/2025 revealed the consent was incomplete and did not specify whether the resident did or did nor consent to the use of psychoactive medication. During an interview on 08/06/2025 at 10:30 a.m. S4 Social Services confirmed the Chemical Restraint/Psychoactive Drug Consent did not specify whether Resident #1 did or did not consent to the use of psychoactive medication, and it should.Resident #6Review of Resident #6's record revealed an initial admit date [DATE], readmission [DATE], and diagnoses including: unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, and bipolar disorder.Review of Resident #6's Significant Change MDS assessment dated [DATE] revealed the resident had a BIMS of 13 indicating intact cognition. Review of Resident #6's current physician orders revealed orders including: -07/15/2025-Sertraline Hydrochloride Tablet 100 mg (milligram) every evening for depression-05/02/2025-Quetiapine Fumarate Tablet 200mg give 0.5 tablet by mouth at bedtime for psychosis.Review of Resident #6's July 2025 and August 2025 MARs revealed the resident was receiving Sertraline Hydrochloride and Quetiapine Fumarate.Review of Resident #6's Chemical Restraint/Psychoactive Drug Consent signed by the resident 05/05/2025 revealed the consent was incomplete and did not specify whether the resident did or did not consent to the use of psychoactive medication. During an interview on 08/06/2025 at 1:03 p.m. S4 Social Services confirmed Resident #6's Chemical Restraint/Psychoactive Drug Consent did not specify whether the resident did or did not consent to the use of psychoactive medication, and it should.Resident #7 Review of Resident #7's medical record revealed an admission date of 12/09/2014 with diagnoses of, but not limited to, insomnia unspecified; major depressive disorder single episode unspecified; major depressive disorder recurrent unspecified; and bipolar disorder current episode, depressed, severe with psychotic features. Review of Resident #7's physician orders revealed the following orders:-01/27/2025 Risperidone oral tablet 1mg - give 1mg by mouth three times a day.-01/27/2025 Seroquel oral tablet 100mg - give 50mg by moth at bedtime.-01/28/2025 Cymbalta oral capsule delayed release particles 20mg - give 1 capsule by mouth one time a day.-01/27/2025 Temazepam oral capsule 30mg - give 1 capsule by mouth at bedtime. Review of Resident #7's July 2025 and August 2025 MAR revealed documentation of administration of Risperidone, Seroquel, Cymbalta, and Temazepam. Review of Resident #7's medical record failed to reveal consents for use of psychoactive medication therapy had been obtained. During an interview on 08/06/2025 at 3:20 p.m. S3 ADON (Assistance Director of Nursing) provided an incomplete form, with a signature on it, titled Chemical Restraint/Psychoactive Drug Consent with no medication, resident name, diagnosis, and no check indicating whether the resident consented for the use of psychoactive medication. S3 ADON further agreed the consent was incomplete, confirming Resident #7 did not give informed consent for the use of psychotropic medications. Resident #8 Review of Resident #8's record revealed an initial admission date of 03/14/2024, a readmission date of 08/14/2024, and diagnoses including: restlessness and agitation, paranoid schizophrenia, and major depressive disorder. Review of Resident #8's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 12 indicating moderately impaired cognition. Review of Resident #8's current physician orders revealed orders including: -07/21/2025-Risperdal oral tablet 3 mg (Risperidone) give 6 mg orally one time a day for Paranoid schizophrenia-01/28/2025- Risperdal oral tablet 4 mg (Risperidone) give 1 tablet by mouth at bedtime-01/28/2025-trazodone hydrochloride 75 mg by mouth at bedtime-01/28/2025-mirtazapine 15mg by mouth at bedtime for major depressive disorderReview of Resident #8's July 2025 and August 2025 MARs revealed the resident was receiving Risperdal, Trazodone, and Mirtazapine. Review of Resident #8's Chemical Restraint/Psychoactive Drug Consent signed by the resident but not dated, revealed the consent was incomplete and did not specify whether the resident did or did not consent to the use of psychoactive medication. During an interview on 08/06/2025 at 1:03 p.m. S4 Social Services confirmed Resident #8's Chemical Restraint/Psychoactive Drug Consent did not specify whether the resident did or did not consent to the use of psychoactive medication, and it should. Resident #49Review of Resident #49's medical record revealed an initial admit date of 12/12/2023 and a re-admission date of 06/02/2025 with diagnoses of but not limited to schizoaffective disorder, bipolar disease, morbid obesity, type 2 diabetes, oglivie syndrome, megacolon, hypomagnesemia, essential hypertension, and functional quadriplegia. Review of Resident #49's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition.Review of Resident #49's August 2025 physician orders revealed an order for Clonazepam 1mg (milligram) by mouth two times a day for anxiety, Olanzapine 20mg one tablet by mouth at bed time for schizophrenia, and Mirtazapine 15mg by mouth at bedtime for depression. Review of Resident #49's August 2025 MAR revealed documentation of the administration of clonazepam, olanzapine and mirtazapine as ordered. Review of Resident #49's medical record failed to reveal any documentation of Resident #49 or Resident #49's representative was informed of the risks, benefits, and side effects of clonazepam, olanzapine, and mirtazapine prior to starting the medication. During an interview on 08/06/2025 at 3:30 p.m., S3 ADON (Assistant Director of Nurses) confirmed Resident #49 was not informed of the risks, benefits and side effects of clonazepam, olanzapine, and mirtazapine prior to starting the medications and should have been.

Based on record review, observations, and interviews, the facility failed to ensure residents received services with reasonable accommodation of resident needs. The facility failed to ensure:1. Resident #54's call light functioned properly and Resident #54's calls for assistance were answered in a timely manner.2. The emergency call light in the hall bathroom between room A and room B had a pull cord in place. Findings: 1. Review of Resident #54’s medical record revealed an admit date of 07/31/2025 with a diagnoses of but not limited to spondylosis without myelopathy or radiculopathy lumbosacral region, scoliosis, unspecified and type 2 diabetes. Review of Resident #54’s Quarterly MDS (Minimum Data Set) dated 07/09/2025 revealed Resident #54 was assessed to have a BIMS (Brief Interview Mental Status) score of 13 indicating intact cognition. Review of Resident #54’s comprehensive plan of care revealed a problem of: the resident has an ADL (activities of daily living) self-performance deficit with interventions of total dependence with one person assistance for toilet use, total dependence with two person assistance with transfers and encourage resident to use call light to call for assistance. During an interview on 08/04/2024 at 8:33 a.m., Resident #54 stated, “When I call for help they take a long time to come because my call light does not work, the light does not come on outside of the door.” Observation on 08/04/2024 at 8:34 a.m. revealed when Resident #54 punched his call light, the light on the outside of Resident #54's door did not light up and no one answered the call light. Observation on 08/04/2025 at 11:35 a.m. revealed no one was sitting at the nurse’s station. Further observation revealed Resident #54’s room lit up on call system board. An audible buzzing continued unanswered for 15 minutes. Further observation revealed the light outside of Resident #54's door did not lit up to indicate Resident #54 was calling for assistance. Observation also revealed facility staff standing on the hallway not responding to Resident #54's call for assistance. During an interview on 08/04/2025 at 11:45 a.m. S5Medical Records reported the facility did not have a unit clerk or a ward clerk to answer the call system and the CNA’s (certified nursing assistants) would observe the lights outside of the door and assist residents when they call. During an interview on 08/04/2025 at 12:00 p.m. S9Maintenance reported he had not been made aware of Resident #54’s call light not working until this morning after the survey had begun. During an interview on 08/04/2025 at 3:00 p.m. S2DON (Director of Nurses) confirmed Resident #54’s call light was not functioning, and Resident #54’s needs were not accommodated and should have been. 2. Observation on 08/05/2025 at 11:30 a.m. revealed the bathroom between Room A and Room B, which had 2 entries from the hallway did not emergency call light cord in place. During an interview on 08/05/2025 at 1:55 p.m. S11LPN (Licensed Practical Nurse) observed the bathroom between Room A and Room B and confirmed there was no emergency call light cord and should have been.

Based on record reviews, observations, and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 4 (Resident #1, #2, #3, and #4) of 4 (Resident #1, #2, #3, and #4) sampled residents. The deficient practice resulted in an Immediate Jeopardy on 05/17/2024 when the facility's HVAC (Heating, Ventilation, and Air Conditioning) system, which regulated the temperature for the front section of the facility, failed. Observation on 05/22/2024 at 8:05 a.m. revealed Resident #1 lying in bed with oxygen infusing per nasal cannula with a personal fan in use and her face appeared flushed. Further observation failed to reveal a pitcher of ice water. Observation on 05/22/2024 at 8:05 a.m. revealed Resident #2 sitting upright in bed with red cheeks, appearing uncomfortable with personal fan blowing at highest speed at close proximity to her face. Observation on 05/22/2024 at 8:15 a.m. revealed Resident #3 sitting upright in bed covered with only a sheet, her face appeared flushed. Further observation revealed a small empty cup with straw on bedside table and failed to reveal a water pitcher or a bedside fan. Observation on 05/22/2024 at 2:00 p.m. revealed Resident #4 awake in bed with only a bed sheet for coverage and a personal fan blowing at close proximity. On 05/17/2024 S1FacilityOwner was notified by S2Former Maintenance Director of the broken HVAC system and the immediate need for replacement. Over the weekend of 05/18/2024 - 05/19/2024, residents and staff voiced complaints of warmer temperatures in the building. The facility failed to assess residents for heat related issues or monitor room temperatures to maintain the environment at a comfortable level. This deficient practice had the likelihood to cause more than minimal harm to the 32 residents housed on the front section of the facility, according to the Resident Census List dated 05/22/2024. S3DON (Director of Nursing) and S4Regional Clinical Consultant were notified of the Immediate Jeopardy on 05/23/2024 at 5:00 p.m. The Immediate Jeopardy was removed on 05/24/2024 at 1:00 p.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through onsite interviews, observations, and record reviews prior to exit. Findings: Review of the facility's Summer Heat Precautions policy (not dated) revealed in part: Policy: During periods of high humidity and high temperatures, special precautions are to be taken. Responsibility: All staff, monitored by the Director of Nursing and Executive Director Procedure: 1. Identify residents who are at high-risk for heat stroke or exhaustion: Those with circulation or respiration problems; cognitively impaired; certain medications such as diuretics, anti-hypertensives, sedatives, hypnotics and anti-cholinergics (i.e. antihistamines); dependent in mobility 2. Symptoms and signs of heat stroke and heat exhaustion . 3. Protect against temperature elevations within the facility by closing window blinds and shades and turning off unnecessary heat-producing devices. 4. Encourage fluid intake/offer water and other fluids. 5. Dress in non-constrictive, loose, light clothing. Review of the facility's Major Utilities Failure policy with a review date of 08/21/2023 revealed in part: Policy: Prompt action will be initiated by trained personnel in the event of a major utility failure to ensure a safe and healthful environment. Procedure: The Director of Environmental Services/Designee will: Determine the cause of the utility failure; Whether the utility can be made operational; Contact the Emergency Service Contractor/Provider for immediate response for the following: HVAC failure . Notify Executive Director and other appropriate staff on the emergency call list. Review of the facility's Clinical Power Outage Response policy with a revision date of 07/21/2023 revealed in part: Contact medical staff in advance if possible, for planning of care as certain medical conditions suggest increased awareness and or monitoring such as acute COPD (chronic obstructive pulmonary disease), Diabetes . Ensure an adequate amount of ice is available in the building. Assign staff members to offer additional fluids to residents. Evaluate residents every four hours and prn for normal body temperature, profuse perspiration, cool, clammy skin, tiredness, weakness, headache, cramps, n/v (nausea and vomiting), dizziness, fainting. Additional interventions include but are not limited to the following: Encourage hydration with frequent fluids made available and are offered. Keep shades, blinds, or curtains closed during the hottest part of the day and open windows at night. Consider the use of a cool water sponge bath, and consider use of cool wet towels around the resident's neck, underarms and groin area. Dim lights if deemed safe to decrease heat introduced into the environment. Review of the facility's Maintenance Log Book failed to reveal room temperatures had been measured on 05/17/2024 and continually monitored for resident rooms on the front section. Review of https://weatherspark.com/h/m/10178/2024/5/Historical-Weather-in-May-2024-in-[NAME]-City-Louisiana-United-States#Figures-GrowingSeason on-line temperature chartings for 05/18/2024 through 05/24/2024 for the surrounding area of the facility, with heat parameters of hot registered as 85-95 degrees, revealed in part: 05/18/2024 temperatures registered hot with a high of 91.4 degrees at 3:56 p.m. 05/19/2024 temperatures registered hot with a high of 93.2 degrees at 2:56 p.m. 05/20/2024 temperatures registered hot with a high of 91.4 degrees at 1:56 p.m. 05/21/2024 temperatures registered hot with a high of 91.4 degrees at 3:56 p.m. 05/22/2024 temperatures registered hot with a high of 89.6 degrees at 12:56 p.m. 05/23/2024 temperatures registered hot with a high of 86.0 degrees at 1:56 p.m. 05/24/2024 temperatures registered hot with a high of 91.4 degrees at 1:56 p.m. Initial observations upon entrance to the facility on [DATE] at 7:30 a.m. revealed in part, one medium sized industrial fan was positioned at the entrance of the single hallway and was noted to be blowing air down the front section of the facility. A small floor fan was noted at the end of this hallway where the front section of the facility is met with a central nursing station, which divides the two sections of the facility. The front hallway lights were observed to be on. Maintenance was not in the building to assess room temperatures and no thermometer gun available upon entrance. Resident #1 Resident #1 was initially admitted to the facility on [DATE] with re-entry on 11/20/2023. Diagnoses, included in part, metabolic encephalopathy, COPD, Type 2 Diabetes, and morbid obesity. Resident #1 resided in the front section of the facility. Review of Resident #1's Quarterly MDS (Minimum Data Set) dated 03/25/2024 revealed in part, Resident #1 had a BIMS (Brief Interview of Mental Status) score of 15 out of 15 indicating intact cognition. Resident #1 required extensive assist by two staff for bed mobility. Review of Resident #1's current Physician's orders revealed an order dated 05/16/2023 which read, O2 (oxygen) at 2.5l (liters) per nc (nasal cannula) per minute; continuous. Observation on 05/22/2024 at 8:05 a.m. revealed Resident #1 lying in bed with O2 infusing per nc and a personal fan in use. Resident #1's face appeared flushed. Further observation failed to reveal a pitcher of ice water. During an interview on 05/22/2024 at 8:05 a.m., Resident #1 reported the air conditioning had been out for weeks and she and her family had both reported it. Resident #1 reported she was uncomfortable and hot. Resident #1 reported by 4:00 p.m., her room is so hot, she can hardly breathe. Resident #1 reported the facility had not provided any provisions related to the air conditioning outage and a family member had purchased her a fan. Resident #1 reported the facility does not pass out ice and water unless we ask for it. Resident #1 reported the facility had not been making special rounds or checking the room temperature. Observation on 05/22/2024 at 12:30 p.m. revealed Resident #1 awake and lying in bed wearing only a gown with her legs uncovered and fully exposed. Further observation revealed Resident #1 was red in the face and appeared uncomfortable. During an interview on 05/22/2024 at 12:30 p.m., Resident #1 reported she had just woken up from a nap and her back and gown were wet from sweating. Resident #1 reported she had turned her fan up to the highest level but could not cool down. During an interview on 05/23/2024 at 2:45 p.m., Resident #1 stated, It is still hot in here. Resident #2 Resident #2 was admitted to the facility on [DATE] with diagnoses, which included in part, anoxic brain damage, major depressive disorder and morbid obesity. Resident #2 resided in the front section of the facility. Review of Resident #2's Quarterly MDS dated [DATE] revealed in part, Resident #2 had a BIMS score of 12 out of 15 indicating moderately impaired cognition. Observation on 05/22/2024 at 8:05 a.m. revealed Resident #2 sitting upright in bed with personal fan blowing at highest speed at close proximity to her face. Resident #2's cheeks were red and Resident #2 appeared uncomfortable. During an interview on 05/22/2024 at 8:05 a.m., Resident #2 reported the air conditioning had been out for weeks but her room started getting warmer over the past weekend of 05/18/2024. Resident #2 reported by mid-day her room gets extremely hot. Resident #2 reported rounds had not been made and provisions had not been offered by staff, specific to the air conditioning outage. Resident #2 reported the facility had not offered fans but she was lucky to have her own personal fan. Resident #2 further reported staff only provides water when asked and she has her own water cup she fills up. Resident #2 reported S2Former Maintenance Director informed her only one compressor was working when she inquired as to why her room was so hot. During an interview on 05/22/2024 at 4:30 p.m., Resident #2 was eating dinner in dining room and stated, Well, yeah it was hot in here this weekend. Resident #3 Resident #3 was initially admitted to the facility on [DATE] with re-entry on 12/28/2020. Diagnoses, included in part, unspecified dementia, essential primary hypertension and chronic kidney disease. Resident #3 resided in the front section of the facility. Review of Resident #3's Quarterly MDS dated [DATE] revealed in part, Resident #3 had a BIMS score of 00 out of 15 indicating Resident #3 was unable to participate in interview. Resident #3 required extensive assist with two staff for bed mobility. Observation on 05/22/2024 at 8:15 a.m. revealed Resident #3 sitting upright in bed eating breakfast, covered with only a sheet. Resident #3's face appeared flushed and further observation failed to reveal a bedside fan. Further observation revealed a small empty cup with straw on bedside table and failed to reveal a water pitcher. Resident #3 was unable to participate in interview. Resident #4 Resident #4 was initially admitted to the facility on [DATE] with diagnoses, which included in part, Type 2 Diabetes, functional quadriplegia and morbid obesity. Resident #4 resided in the front section of the facility. Review of Resident #4's MDS dated [DATE] revealed in part, Resident #4 had a BIMS score of 12 out of 15 indicating moderately impaired cognition. Resident #4 required extensive assist by one staff for bed mobility. Observation on 05/22/2024 at 2:00 p.m. revealed Resident #4 awake in bed with only a bed sheet for coverage and a personal fan blowing at close proximity. During an interview on 05/22/2024 at 2:00 p.m., Resident #4 reported her room was hot and she could not use a blanket until the air conditioning was repaired. Resident #4 reported she noticed her room getting warmer over the past weekend of 05/18/2024 and by mid-day, the room was barely tolerable. Resident #4 reported staff did not check on her over the weekend regarding heat related issues or monitor room temperatures. During an interview on 05/22/2024 at 4:30 p.m., Resident #4 reported her sister was bringing curtains for her room to block the sunlight and heat from coming in. During an interview on 05/22/2024 at 7:30 a.m., S5LPN (Licensed Practical Nurse) reported the facility has been having trouble with the air conditioner and that is why the fans are blowing in the hallway. S5LPN acknowledged the temperature felt warmer than usual in the facility. During an interview on 05/22/2024 at 7:35 a.m., S6LPN reported the air conditioner has not been working for a couple of days. During an interview on 05/22/2024 at 7:40 a.m., S7LPN reported facility's air conditioner has not been working for about 3 days. During an interview on 05/22/2024 at 7:45 a.m., S8Cook, reported the air has not been working since last Thursday, 05/16/2024 and maintenance had to keep coming back for repairs. S8Cook further reported the kitchen and dining room were extremely hot over the weekend of 05/18/2024. During an interview on 05/22/2024 at 8:30 a.m., S10CNA (Certified Nursing Assistant) reported she worked yesterday and it was hot and got hotter into the night. During an interview on 05/22/2024 at 9:00 a.m., S3DON reported she was notified on Friday, 05/17/2024, by S2Former Maintenance Director that the facility was down to one unit and the single unit was not working properly because it kept freezing up. S3DON reported S2Former Maintenance Director had gotten the single unit back working around 4:30 p.m. on 05/17/2024, but reported he was unsure how long it would be able to regulate the temperature for the front section. S3DON reported she did not return to the facility until Sunday, 05/19/2024 around 1:15 p.m. and Resident #1 told her it was hot in the facility. S3DON reported two or three other residents voiced it was warm along with some of the staff. S3DON reported she returned to work on Monday, 05/20/2024 and at 7:40 a.m. S2Former Maintenance Director informed her the air conditioning unit was acting up again. S3DON reported on Monday, 05/20/2024 around 2:30 p.m., residents on the front hall began complaining of the heat. S3DON reported S2Former Maintenance Director notified S1Facility Owner on Friday, 05/17/2024 at approximately 1:40 p.m. and again on 05/20/2024 of the HVAC system failure. S3DON reported S2Former Maintenance Director had not come in over the weekend to check on the HVAC system to her knowledge. S3DON acknowledged fans had not been provided to residents who resided on the front section of the facility. During an interview on 05/22/2024 at 12:15 p.m., S11Maintenance for sister facility reported he was first informed of the air conditioning issue on 05/21/2024 when he was asked to come over and assist S2Former Maintenance Director with the repair. S11Maintenance reported two 10-ton condensers are required and run in sync to cool and maintain the temperature in the front half of the building. S11Maintenance reported unit 1 had burned up wires, a bad contactor and the transformer kept overheating. S11Maintenance reported unit 2 was not working at all. S11Maintenance further reported he borrowed parts from unit 2 to use on unit 1 and was able to get unit 1 running. S11Maintenance stated he put a band-aid on the HVAC system and acknowledged the single unit would not provide the cooling capacity needed to regulate the temperature on the front half of the facility. S11Maintenance reported he had spoken to the S1Facility Owner this morning, 05/22/2024 and S1Facility Owner had me (S11Maintenance) go and purchase portable air conditioning units to install in the front section of the facility to help supplement the one unit. S11Maintence reported he was not sure how long this supplemental air would last. S11Maintenance further reported as far as he knew, fans had not been provided to the residents who reside on the front section of the facility. S11Maintenance acknowledged he had not monitored resident room temperatures since he entered the facility on 05/21/2024 to assist with repair. S11Maintenance confirmed he did not have a temperature gun to assess resident room temperatures and would have to go down to the sister facility and get a temperature gun in order to do so. During an interview on 05/22/2024 at 1:00 p.m., S4Regional Clinical Consultant reported she was made aware the air conditioning unit was not working on Tuesday, 05/22/2024. Observation of Dining Room on 05/22/2024 at 2:00 p.m. with S11Maintenance revealed a large open area on the right corner section of the ceiling. Further observation revealed the crawl space was exposed and hot air, temped at 126 degrees Fahrenheit by S11Maintenace, was blowing into the Dining Room. During an interview on 05/22/2024 at 2:20 p.m., S9Medical Records, reported the issues with the air conditioner had been going on for a while, but it was not until Monday, 05/20/2024 that she realized it was a problem. During an interview on 05/22/2024 at 3:45 p.m., S4Regional Clinical Consultant confirmed the outage of the HVAC system had not been reported to the State Agency per the LA Administrative Code (LAC) for Emergency Preparedness. S4Regional Clinical Consultant acknowledged one unit would not adequately cool the front of the facility. S4Regional Clinical Consultant confirmed she could not produce any documentation of resident room temperature monitoring or frequent resident assessments. During an interview on 05/23/2024 at 8:20 a.m. R1Owner of _____ Refrigeration acknowledged the invoice he provided to the facility was an estimated cost of replacing the HVAC system which required two 10-ton units to regulate the temperature adequately. R1Owner confirmed there was no current date for installation due to the S1Facility Owner seeking financing for the units. During an interview on 05/23/2024 at 9:35 a.m., S1Facility Owner reported the facility has had air conditioning issues for the last week or two with the system continually going out and being repaired. S1Facility Owner acknowledged one of the two 10-ton units stopped working completely on 05/17/2024 and he was informed of this by S2Former Maintenance Director. S1Facility Owner further acknowledged temperature regulation was dependent upon just one 10-ton unit to cool the front section of the facility since 05/17/2024 and it required two 10-ton units. S1Facility Owner confirmed he had not yet purchased a new HVAC system. During an interview on 05/23/2024 at 10:20 a.m., S12LPN reported she had worked on Friday, 05/17/2024 and noticed the facility was getting warm around morning medication pass. S12LPN further reported at least two residents voiced the same. S12LPN further reported she informed S3DON on 05/17/2024 the air was not working. S12LPN reported she worked Saturday, 05/18/2024 and Sunday, 05/19/2024 and the building remained warm. S12LPN acknowledged she was not given instructions specific to the frequency of resident safety checks or room temperature monitoring to be completed. During an interview on 05/23/2024 at 10:40 a.m., S3DON confirmed on 05/17/2024 being made aware the one air conditioning unit left to regulate the temperature was not working consistently and was frequently going in and out, freezing. S3DON acknowledged frequent checks on residents or monitoring of the facility temperatures had not been initiated and should have been. During an interview on 05/23/2024 at 11:00 a.m., S2Former Maintenance Director confirmed the building had only one working unit for at least the past two months. S2Former Maintenance Director acknowledged the building required two 10-ton units that have to be operational for the front half of the building to be cooled. S2Former Maintenance Director reported S1Facility Owner instructed him to take parts from one unit and place it on the other unit to make one operational unit. S2Former Maintenance Director confirmed multiple conversations with S1Facility Owner informing him the building needed a new HVAC system. S2Former Maintenance Director reported the one unit stopped working adequately on 05/17/2024 and S1Facility Owner was made aware early that afternoon. S2Former Maintenance Director confirmed checking resident room temperatures on Saturday, 05/18/2024 and Sunday, 05/19/2024 with temperatures in the 79 to 80 degree range but could not produce any documentation. During an interview on 05/23/2024 at 5:15 p.m., S13LPN reported she worked both evening and night shifts on Saturday, 05/18/2024 and Sunday, 05/19/2024 and the temperature in the facility was warm and awful. S13LPN reported the only thing the facility had been provided were the two fans for the hallway. S13LPN reported she had not observed maintenance take any room temperatures over the weekend. During an interview on 05/24/2024 at 9:10 a.m., S14Housekeeping reported she worked Monday, 05/20/2024 and she could not wait to go home because it was very warm in the facility and once she started mopping and sweeping, she got hot and sweaty. During an interview on 05/24/2024 at 8:20 a.m., S4Regional Clinical Consultant acknowledged the facility failed to monitor and document room temperatures and frequent resident assessments in order to maintain a safe and comfortable environment and should have.

Based on interview and record review, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 4 (#1, #2, #3, and #4) of 4 residents (#1, #2, #3, and #4) sampled residents. The facility failed to ensure a system was in place to assess residents for heat related issues and monitor room temperatures to maintain environment at a comfortable level when the HVAC (Heating, Ventilation, and Air Conditioning) system failed. The deficient practice resulted in an Immediate Jeopardy on 05/17/2024 when the facility's HVAC system, which regulated the temperature for the front section of the facility, failed. Observation on 05/22/2024 at 8:05 a.m. revealed Resident #1 lying in bed with oxygen infusing per nasal cannula with a personal fan in use and her face appeared flushed. Further observation failed to reveal a pitcher of ice water. Observation on 05/22/2024 at 8:05 a.m. revealed Resident #2 sitting upright in bed with red cheeks, appearing uncomfortable with personal fan blowing at highest speed at close proximity to her face. Observation on 05/22/2024 at 8:15 a.m. revealed Resident #3 sitting upright in bed covered with only a sheet, her face appeared flushed. Further observation revealed a small empty cup with straw on bedside table and failed to reveal a water pitcher or a bedside fan. Observation on 05/22/2024 at 2:00 p.m. revealed Resident #4 awake in bed with only a bed sheet for coverage and a personal fan blowing at close proximity. On 05/17/2024 S1FacilityOwner was notified by S2Former Maintenance Director of the broken HVAC system and the immediate need for replacement. Over the weekend of 05/18/2024 - 05/19/2024, residents and staff voiced complaints of warmer temperatures in the building. The facility failed to assess residents for heat related issues or monitor room temperatures to maintain the environment at a comfortable level. This deficient practice had the likelihood to cause more than minimal harm to the 32 residents housed on the front section of the facility, according to the Resident Census List dated 05/22/2024. S3DON (Director of Nursing) and S4Regional Clinical Consultant were notified of the Immediate Jeopardy on 05/23/2024 at 5:00 p.m. The Immediate Jeopardy was removed on 05/24/2024 at 1:00 p.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through onsite interviews, observations, and record reviews prior to exit. Findings, Cross Reference F584: During an interview on 05/22/2024 at 12:15 p.m., S11Maintenance for sister facility reported he was first informed of the air conditioning issue on 05/21/2024 when he was asked to come over and assist S2Former Maintenance Director with the repair. S11Maintenance reported two 10-ton condensers are required and run in sync to cool and maintain the temperature in the front half of the building. S11Maintenance reported unit 1 had burned up wires, a bad contactor and the transformer kept overheating. S11Maintenance reported unit 2 was not working at all. S11Maintenance further reported he borrowed parts from unit 2 to use on unit 1 and was able to get unit 1 running. S11Maintenance stated he put a band-aid on the HVAC system and acknowledged the single unit would not provide the cooling capacity needed to regulate the temperature on the front half of the facility. S11Maintenance acknowledged he had not monitored resident room temperatures since he entered the facility on 05/21/2024 to assist with repair. S11Maintenance confirmed he did not have a temperature gun to assess resident room temperatures and would have to go down to the sister facility and get a temperature gun in order to do so. During an interview on 05/22/2024 at 3:45 p.m., S4Regional Clinical Consultant confirmed the outage of the HVAC system had not been reported to the State Agency per the LA Administrative Code (LAC) for Emergency Preparedness. S4Regional Clinical Consultant acknowledged one unit would not adequately cool the front of the facility. S4Regional Clinical Consultant confirmed she could not produce any documentation of resident room temperature monitoring or frequent resident assessments. During an interview on 05/23/2024 at 9:35 a.m., S1Facility Owner reported the facility has had air conditioning issues for the last week or two with the system continually going out and being repaired. S1Facility Owner acknowledged one of the two 10-ton units stopped working completely on 05/17/2024 and he was informed of this by S2Former Maintenance Director. S1Facility Owner further acknowledged temperature regulation was dependent upon just one 10-ton unit to cool the front section of the facility since 05/17/2024 and it required two 10-ton units. S1Facility Owner confirmed he had not yet purchased a new HVAC system. During an interview on 05/23/2024 at 10:40 a.m., S3DON confirmed on 05/17/2024 being made aware the one air conditioning unit left to regulate the temperature was not working consistently and was frequently going in and out, freezing. S3DON acknowledged frequent checks on residents or monitoring of the facility temperatures had not been initiated and should have been. During an interview on 05/24/2024 at 8:20 a.m., S4Regional Clinical Consultant acknowledged the facility failed to monitor and document room temperatures and frequent resident assessments in order to maintain a safe and comfortable environment and should have.

Based on observations, record reviews, and interviews the facility failed to ensure residents received adequate supervision to prevent accidents for 1 (#3) of 5 (#1, #2, #3, #4, #5) residents reviewed for accidents out of a total sample of 5 residents. An actual harm occurred 3/22/15 when staff failed to follow the plan of care by not using the mechanical lift while transferring resident #3 from her wheelchair to her bed. One of the two CNAs that were manually transferring the resident lost her grip on resident #3 causing the other CNA to fall into and across the bed with resident #3 and resident #3's right knee hit the bed frame. An x-ray of the right knee completed 3/24/15 revealed a depressed lateral tibial plateau fracture of indeterminate age. Findings: Observation on 3/30/15 at 1:15 p.m. revealed resident #3 lying in bed with eyes open and head of bed elevated. Resident #3 had no visible bruising noted. Resident #3 was non-verbal when attempted to ask questions. Observation revealed resident #3's had no siderails up or fall mats noted to be in use next to the bed. Review of the facility's Incident Log revealed resident #3 had an incident on 3/24/15 related to a transfer injury at 2:00 p.m. Review of the facility's Grievance Log revealed a grievance filed on 3/24/15 by resident #3's family member regarding resident #3's swollen knee. Review of the facility's OTIS Log revealed an OTIS report for resident #3 regarding an incident that occurred on 3/22/15, but was not discovered in facility until 3/24/15. Review of the OTIS report summary revealed on 3/22/15 S10 CNA and S11 CNA did not follow facility policy for utilizing the mechanical lift/low lift for a non-weight bearing patient. Both S10 CNA and S11 CNA attempted to transfer resident #3 from her wheelchair to the bed causing resident #3 to bump her right knee on the bed frame. Further review of the OTIS summary revealed on 3/24/15 the nursing staff was notified that resident #3's right knee was red and swollen and slightly warm. An x-ray was ordered of the right knee and results were obtained that evening at 7:21 p.m. and showed a fracture of the right tibia of an undetermined age with a recommendation to consider an MRI. Approximately 8:30 p.m. resident #3 was transferred to the ER for further evaluation. Resident #3's family called and notified S1 Administrator at 9:05 p.m. the CT scan of resident #3's right knee showed a fracture of the plateau of the tibia. Upon completion of the OTIS investigation, S10 CNA and S11 CNA admitted to unintentionally bumping resident's knee on the bed during a transfer. S10 CNA and S11 CNA did not report anything to the nurse concerning the situation. An immediate in-service was performed for all staff on the mechanical lift/low lift policy, policy for reporting incidents/accidents, abuse and neglect reporting, and transfer/mobility, but no monitoring was noted to ensure the transfers were being completed as required. The facility will continue to in-service staff upon hire and through-out the year. S10 CNA and S11 CNA were both terminated on 3/25/15 after providing statements for failure to follow the facility's low lift/mechanical policy. Observation on 3/31/15 at 9:55 a.m. revealed resident #3 awake in bed with a brace to her right leg from just above the knee down to the ankle. During an interview on 3/31/15 at 10:00 a.m. S4 CNA stated she had several residents who required assistance with their transfers. S4 CNA stated she was able to determine what level of transfer assistance the resident needed by how much help the resident could provide. S4 CNA stated if the resident could not do anything to help then she would have to get the lift and another person to assist her with the transfer. S4 CNA stated the facility trained the CNAs on the different types of transfers, as well as how to use the lifts properly and when to use the lift. S4 CNA stated the CNAs also had to provide a return demonstration on how to properly use the lifts before being allowed on the floor, but there was no monitoring after that to make sure staff were actually transferring the resident correctly. During interview on 3/31/15 at 12:30 p.m. S4 CNA stated resident #3 was not able to do anything for herself and was really not even able to move without assistance. S4 CNA stated resident #3 was a two person assist with transfers and the lift had to be used as well. S4 CNA stated they did not currently get resident #3 up due to her broken leg, but before the incident resident #3 was transferred to her wheelchair twice daily using the lift each time. During an interview on 3/31/15 at 12:35 p.m. S5 Restorative CNA stated she provided care for the residents who required restorative services, but she also helped the other CNAs who were working the floor when needed if she had time. S5 Restorative CNA stated she has assisted S4 CNA with transferring resident #3 in and out of the bed. S5 Restorative CNA stated resident #3 was transferred using the lift and two people to assist because resident #3 was not able to move at all on her own. S5 Restorative CNA stated she was trained on resident transfers, along with how to use each type of lift and provide a return demonstration. S5 Restorative CNA stated all CNAs were trained upon hire on transferring residents and proper lift procedures, but there was no supervision once starting on the floor to make sure the CNAs were using the lifts if required. Review of resident #3's Telephone physician's orders [REDACTED].#3's right knee related to swelling. Review of the x-ray of the right knee 2 views completed 3/24/15 revealed a depressed lateral tibial plateau fracture of indeterminate age. Consider MRI. Review of resident #3's medical record revealed a Nurses' Note dated 3/24/15 at 2:30 p.m. written by S3 ADON with the following documentation-Called to resident #3's room by resident's daughter. Daughter stated that resident's right knee was "swollen." Upon assessment, resident #3's right knee noted swollen and warm to touch. Daughter requesting x-ray to be done at this time. Mobile x-ray notified of request for x-ray of right knee 2 views. Daughter notified that x-ray requested. Physician was notified. Review of Discharge Paperwork from the local ER dated 3/24/15 at 11:57 p.m. revealed resident was diagnosed with [REDACTED]. Review of resident #3's Quarterly MDS dated [DATE] revealed resident was assessed as having severely impaired cognitive skills for daily decision making and showed signs of inattention and disorganized thinking that was continuously present and does not fluctuate. Resident #3 was assessed as extensive 2+ person assist with bed mobility and total dependence with 2+ person assistance with transfers. Review of S10 CNA's employee file revealed a Separation Notice indicating S10 CNA was fired due to not reporting an incident of possible injury to resident when transferring resident #3 without the lift, which resulted in a fracture to the resident's leg. Review of S11 CNA's employee file revealed her CNA certification was obtained on 12/8/14. Review revealed a Separation Notice with documentation S11 CNA had been fired due to not reporting an incident of possible injury to resident #3, which resulted in a fracture to resident #3's leg. During an interview on 4/1/15 at 2:10 p.m. S1 Administrator stated S10 CNA and S11 CNA transferred resident #3 from her wheelchair to the bed and S10 CNA lost her grip on resident #3 and S11 CNA fell into and across the bed with resident #3 and resident #3's right knee hit the bed frame. S1 Administrator stated S10 CNA and S11 CNA repositioned resident #3 in the bed and stated they looked over resident and she had no signs of injury so neither one of them reported the fall to anyone. S1 Administrator resident #3 should have been transferred with a lift and not manually like S10 CNA and S11 CNA did and that was why they were fired. During an interview on 4/1/15 at 2:40 p.m. S1 Administrator agreed S10 CNA and S11 CNA didn't follow facility policy to use the lift when transferring resident #3 and didn't report the fall after it occurred. S1 Administrator agreed resident #3 spent two days with a broken tibia before the incident was discovered leaving resident #3 to suffer actual harm. S1 Administrator agreed S10 CNA and S11 CNA had only been working for the facility for 1-2 months. S1 Administrator agreed the facility had no measures in place to supervise new CNA staff to ensure policy and procedures were carried out. During an interview on 4/1/15 at 4:00 p.m. S2 Interim DON stated S10 CNA and S11 CNA didn't follow facility policy and procedure for transferring resident #3 and should have used a lift. S2 Interim DON stated both S10 CNA and S11 CNA were new to the facility and S11 CNA had only been a CNA for a few months and S10 CNA had been a CNA previously, but was new to the facility. S2 Interim DON stated S3 ADON did most of the CNA training for new hires and was considered the CNA Supervisor. S2 Interim DON stated the Administrative staff had to do a lot of different jobs, especially with the DON being out right now. During an interview on 4/1/15 at 4:10 p.m. S3 ADON stated she was the CNA Supervisor and all new CNA staff received a minimum of 4 days training with another experienced CNA. S3 ADON stated after 4 days the new CNAs ask questions over things they are not familiar with and the areas are gone more in depth on and specific training is given. S3 ADON stated S10 CNA was oriented almost 8 days. S3 ADON stated S10 CNA was shown her first day on floor by herself how to use the lift and knew how to transfer with the lift. S3 ADON stated S11 CNA also completed a return demonstration on how to use the lift correctly. S3 ADON stated all the information was covered in the orientation checklist to ensure CNAs know how and when to report injuries, how and when to use the lifts, what to do if an employee falls, and many other topics. S3 ADON stated S10 CNA and S11 CNA didn't follow the facility's policy for transferring residents. S3 ADON stated she had no measures in place to make sure new staff was supervised and able to carry out the facility's policy and procedures.