Every finding on record at Jefferson Manor Nursing and Rehab Ctr, LLC

Based on observations, interviews, and record review, the facility failed to prepare food to conserve flavor and appearance and provide palatable and attractive food for 8 (#2, #9, #12, #36, #41, #43, #68 and #91) of 8 residents reviewed for dining. There were 92 residents who ate from the facility's kitchen.Findings: Review of Resident Council Meeting Minutes from November 2025 to present revealed the following: 11/22/2025 – XI. Dietary Services: Food is awful. 12/16/2025 – XI. Dietary Services: Alternates is always leftovers from the night before; wants fresh fruit, request salad but never have it; result is residents losing weight from lack of food; Eating too may sandwiches and only receiving small portions. 01/26/2026 – XI. Dietary Services: Too spicy; Not edible; Sends tray back every day; Will not make sandwiches/peanut butter when asked; Giving out food that resident doesn't eat or not fixed to texture. On 02/23/2026 at 11:00 a.m., a resident council meeting was held with Residents #8, #10, #41, and #76. During the meeting, Residents #8, #10, #41, and #76 complained about the food at the facility. Resident #8 stated the food tasted terrible and needed to be better. Review of the facility's lunch menu dated 02/24/2026 revealed chicken cacciatore was the main entrée. On 02/23/2026 at 9:32 a.m., an interview was conducted with Resident #2. Resident #2 stated the facility's food was not good. He stated the quality, consistency, and seasoning were not good. On 02/24/2026 at 10:45 a.m., a test tray was obtained from the facility's kitchen. Four surveyors observed the tray. There was shredded chicken with chunks of tomatoes over spaghetti noodles. There was a watery liquid substance covering the plate under the pasta. The food did not have an appetizing appearance or odor. Three surveyors were unable to taste the food due to appearance. One surveyor tasted the food, which revealed the entrée provided was bland in taste with minimal amount of sauce covering the noodles. Sauce on the test tray was thin in consistency resulting in plain spaghetti noodles being tasted. Surveyor described the presentation of the meal as not being appealing or palatable and was unable to further consume any of the test tray provided. On 02/24/2026 at 12:07 p.m., an observation was made of the steam table in the facility's kitchen. The main entrée was chicken cacciatore, which was in a metal container on the steam table. The container consisted of course shredded chicken, tomatoes, and a thin liquid covering the meat and tomatoes. There was a plate of food sitting on the kitchen line with spaghetti noodles and chicken cacciatore covering the noodles. There was a light red liquid substance, the consistency of water, covering the plate under the pasta and chicken cacciatore. On 02/24/2026 at 12:09 p.m., an interview was conducted with S4DM. She confirmed she cooked the chicken cacciatore for lunch today. She confirmed the chicken cacciatore was covered with a liquid. She confirmed the plated chicken cacciatore covering the noodles had a liquid substance covering the plate under the food. She confirmed the sauce for the chicken cacciatore should have been thicker to adequately coat the noodles to maintain the flavor. She stated she did not follow a recipe. She explained she had been cooking meals for twenty years and she no longer needed to follow recipes. On 02/24/2026 at 12:10 p.m., an interview was conducted with Resident #43. He stated he refused to eat lunch and the food was disgusting. He described the food as being cold, with a small amount of sauce and chicken over the noodles. He described the sauce appearing as throw up and stated it smelled awful. Resident #43 stated this is bad but the food gets worse than this at times, I wouldn't feed my dog this. Resident #43 showed surveyor cornbread on tray and bottom was observed to be burnt. On 02/24/2026 at 12:11 p.m., an interview was conducted with S9CNA. She stated the meal tray provided did not look appealing to eat. She stated the meal had more noodles than sauce and chicken. S9CNA stated she would refuse to eat the meal too. On 02/24/2026 at 12:17 p.m., an observation was made of Resident #2's lunch tray. He had chicken and tomatoes over spaghetti noodles with a liquid substance covering the bottom of the plate. An interview was conducted with Resident #2 at that time. Resident #2 stated the lunch meal was bland and there was no sauce for the pasta. He stated it tasted like chicken and tomatoes with plain noodles and no flavor. On 02/24/2026 at 12:20 p.m., an observation and interview was conducted with S7LPN and S8RN at Resident #43's bedside. Resident #43 had his lunch tray, which consisted of chicken and tomatoes over spaghetti noodles. S7LPN and S8RN described the meal provided as not being appealing in presentation and stated they would not eat the meal provided. S8RN picked up the plate and voiced the bottom of the plate temperature was luke warm. S7LPN and S8RN both confirmed the cornbread on the plate was burnt on the bottom. S7LPN and S8RN voiced food complaints had been common over the last six months. On 02/24/2026 at 12:20 p.m., an observation was made of Resident #36's lunch tray. She had chicken and tomatoes over spaghetti noodles and a liquid substance covering the bottom of the plate. An interview was conducted with Resident #36 at that time. Resident #36 stated the lunch today was not good and had no flavor. She stated some days food was good and others it was not. She stated today it was not good. She stated there was no sauce on the noodles. On 02/24/2026 at 12:30 p.m., an interview was conducted with Resident #41. He stated he didn't eat the food often because he disliked it. He stated he had his daughter bring him food from outside the facility. Resident #41 stated in resident council food complaints were the first topics brought to his attention during the meetings. He stated the food just don't taste right here, the kitchen needs to do better. He stated the food had been terrible since he was admitted in 2017. On 02/24/2026 at 12:30 p.m., an observation was made of Resident #91's lunch tray. She had chicken and tomatoes over spaghetti noodles and a liquid substance covering the bottom of the plate. An interview was conducted with Resident #91 at that time. Resident #91 stated her lunch was disgusting. She stated there was too much liquid and no sauce. She stated it was just noodles, chicken, and tomatoes with no flavor, and they added too much water to it. On 02/24/2026 at 12:40 p.m., an interview was conducted with Resident #12. He stated he refused to eat the lunch entrée provided today and described the food as not being fit to eat. He stated lunch and supper was always terrible. On 02/24/2026 at 12:45 p.m., an interview was conducted with Resident #9. She stated the food was awful. She stated the food had no seasoning, bland taste, or was overcooked causing food to be mushy. She stated she refused her meal tray today due to disliking what was served. She stated, I don't know what that was but it looked terrible. She stated she had to eat leftover pizza from yesterday. Resident #9 stated she had to eat out as much as she could afford due to the food being so terrible. On 02/24/2026 at 2:42 p.m., an interview was conducted with Resident #68. He stopped surveyor in hallway and stated he would like to report the food being terrible. Resident #68 stated I have been in prison and the food was better there than it is here. He described the food as being burnt, not cooked enough, or being served cold. On 02/24/2026 at 1:05 p.m., an interview was conducted with S3RD. She stated menus and recipes were provided by the facility's food supplier. She stated the cook should have followed the recipes.

Based on interviews and record review, the facility failed to accurately code PASRR Level IIs on the residents' MDS assessments for 2 (#8 and #25) of 3 residents reviewed with Level II PASRRs.Findings: Resident #8Review of Resident #8's Clinical Record revealed an admission date of 02/14/2022 and diagnoses, which included Schizophrenia and Major Depressive Disorder. Review of Resident #8's BHSF Form 142 dated 04/01/2025 revealed she was approved for admission by level II authority for a temporary period effective of 04/01/2025 through 03/31/2026. Review of Resident #8's Annual MDS with an ARD of 07/10/2025 revealed an answer of no to the following question:A1500 - Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Resident #25Review of Resident #25's Clinical Record revealed an admission date of 09/09/2025 and diagnoses, which included Delusional Disorder, Visual Hallucinations, Generalized Anxiety Disorder, Major Depressive Disorder, and Schizoaffective Disorder. Review of Resident #25's BHSF Form 142 dated 04/23/2014 revealed she was permanently approved for admission by level II authority. Review of Resident #25's Annual MDS with an ARD of 09/15/2025 revealed an answer of no to the following question:A1500 - Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? An interview was conducted with S6LPN on 02/25/2026 at 9:17 a.m. She confirmed Residents #8 and #25 both had Level II PASRRs. She reviewed Resident #25's Annual MDS dated [DATE] and confirmed the PASRR question was answered no and should have been answered yes. She reviewed Resident #8's MDS dated [DATE] and confirmed the PASRR question was answered no and should have been answered yes. She confirmed Residents #8 and #25's MDS assessments were completed inaccurately. An interview was conducted with S2DON on 02/25/2026 at 9:24 a.m. She confirmed Residents #8 and #25 both had Level II PASRRs. She confirmed Residents #8 and #25's most recent comprehensive MDSs were coded no on the PASRR question, which was inaccurate, and should have been coded yes.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and hygiene by failing to provide incontinence care timely for 1 of 1 (#5) resident reviewed for activities of daily living in the final sample. Review of the facility's undated policy titled, Incontinent care: Bladder revealed in part, the following: Perineal management is the cleansing of the perineal area that includes the genitalia and rectal areas. It promotes cleanliness and comfort and prevents infection by removing irritating secretions or excretions, microorganisms, and offensive odors. The care should be administered daily during bathing, and more frequently following urinary and/or fecal incontinence or if excessive secretions are present. Review of Resident #5's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Hemiplegia and Hemiparesis and Urinary Retention. Review of Resident #5's quarterly MDS with an ARD of 11/13/2025 revealed the resident was always incontinent of bowel and was dependent on staff all care. On 02/23/2026 at 9:17 a.m., an observation was made of Resident #5 lying in bed awake. A strong odor of feces was noted. S10CNA entered Resident #5's room at 9:19 a.m. Resident #5, who was nonverbal, began using hand signals to show S10CNA she needed to be changed. S10CNA stated to Resident #5, You are going to get a bath shortly. On 02/23/2026 at 10:27 a.m., an observation was made of Resident #5 lying in bed. Resident #5 remained in her soiled brief and had feces smeared on her cheek. S10CNA entered the room and stated, We are still waiting on the shower room. On 02/23/2026 at 10:40 a.m., an interview was conducted with S8RN. She confirmed Resident #5 was still soiled at this time. She confirmed an hour and a half was too long for a resident to be left in their feces soiled brief. She stated S10CNA should have changed Resident #5 immediately after being notified Resident #5 had a bowel movement. On 02/25/2026 at 11:58 a.m., an interview was conducted with S2DON. She confirmed an hour and a half was too long for a resident to be left in a soiled brief.

Based on observation, interviews, and record review, the facility failed to store food in accordance with professional standards for food service safety by failing to refrigerate opened food items and label and date opened frozen food items. There were 92 residents who received food from the facility's kitchen.Findings: Review of the facility's policy titled, Storage of Refrigerated Food with a revision date of 09/2012 revealed the following, in part:Policy: The facility ensures the quality and safety of refrigerated foods through accepted storage practices.Procedure:4. All non-hazardous, opened foods are labeled with name of food and date stored. An initial tour was conducted of the facility's kitchen on 02/23/2026 at 8:40 a.m. with S5CPM. The following was observed and S5CPM confirmed:The following opened items were located on the shelf in the dry storage and the item's label had directions to refrigerate after opening:1 - 1 gallon soy sauce 1/8 full;1 - 1 gallon soy sauce 3/4 full; and1 - 1 gallon citrus chipotle 1/4 full.Freezer:2 opened bags of dinner rolls not labeled or dated. An interview was conducted with S5CPM on 02/23/2026 at 8:50 a.m. S5CPM confirmed the above items should have been refrigerated after opening and the dinner rolls should have been labeled and dated. An interview was conducted with S1ADM on 02/24/2026 at 10:47 a.m. He stated food items labeled to refrigerate after opening should have been refrigerated after opening. He stated all opened, frozen items should have been labeled and dated.

Based on observation and interviews, the facility failed to maintain a clean, comfortable and homelike environment for 1 (#1) of 6 (#1, #2, #3, R7, R8, and R9) residents reviewed for environment. Findings:Review of the facility's undated policy titled, Resident Rights, revealed the following, in part: (h) Environment. The facility must provide-(1) A safe, clean, comfortable, and homelike environment.(2) Housekeeping services necessary to maintain a sanitary, orderly and comfortable interior. Review of Resident #1's Clinical Record revealed an admission date of 04/20/2023. Review of Resident #1's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/18/2025 revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated he was cognitively intact.On 09/03/2025 at 12:25 p.m., an interview was conducted with Resident #1. He stated he was not pleased with the conditions of his room. He stated since pest control last sprayed his room, approximately 2-3 weeks ago, dead bugs, specifically roaches, could be seen throughout his room. He stated housekeeping did not clean his room effectively. He stated they came each day to mop and sweep, but his room remained dirty. He stated, it makes me feel gross. On 09/03/2025 at 12:34 p.m., an observation of Resident #1's room was conducted and revealed the presence of 8, small (under 1/2 inch), dead roaches along the baseboards of the room, next to the fridge, in front and on the side of Resident #1's wardrobe, under the A/C unit, and next to Resident #1's laundry basket.On 09/03/2025 at 12:55 p.m., an interview was conducted with S3HOU. She stated each room was swept and mopped each morning, with touch-up cleanings performed after lunch. On 09/03/2025 at 12:57 p.m., an interview was conducted with S4HOU. She confirmed the daily cleaning of Resident #1's room had been completed. On 09/03/2025 at 1:00 p.m., an observation was made of Resident #1's room with S3HOU. She confirmed the aforementioned observations and stated Resident #1's room was not cleaned thoroughly and should have been. On 09/03/2025 at 1:03 p.m., an observation was made of Resident #1's room with S2CORP. He confirmed the room was not cleaned thoroughly and should have been.On 09/03/2025 at 1:26 p.m., an interview was conducted with S1ADM. He was made aware of the aforementioned observations. He stated he expected all rooms to be cleaned thoroughly by housekeeping staff.

Based on record review and interviews, the facility failed to ensure Minimum Data Set (MDS) assessments were completed and transmitted timely for 1 (#2) of 3 (#1, #2, and #3) sampled residents reviewed for resident assessment. Findings: Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE]. On 05/20/2025, review of Resident #2's Quarterly MDS with an ARD (Assessment Reference Date) of 05/01/2025 revealed the MDS assessment was incomplete and had a status of: in progress. On 05/20/2025 at 11:44 a.m., an interview was conducted with S3MDS. She stated she was responsible for completing Resident #2's MDS assessments. She reviewed the above-mentioned MDS and confirmed it was not completed within the required 14 days after the ARD date, and had not been transmitted. On 05/21/2025 at 11:20 a.m., an interview was conducted with S1DON. She reviewed the above-mentioned MDS and confirmed it was not completed within the required 14 days after the ARD date, and had not been transmitted.

Based on observation, interviews, and record review, the facility failed to: 1. Ensure nurse staffing data requirements were documented on daily postings, and 2. Ensure nurse staffing data was posted daily in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 97 residents residing in the facility. Findings: An observation was made on 05/19/2025 at 3:42 p.m. of the posted staffing data sheet dated 05/04/2025. Further review revealed no documentation of the facility name. An interview was conducted on 05/19/2025 at 3:42 p.m. with S1DON. She confirmed the date on the staffing data sheet was dated 05/04/2025. She stated S2WC was responsible for posting the staffing data sheets daily and 05/19/2025 should be posted. She confirmed the facility's name was not documented on the staffing data sheet and should have been. An interview was conducted on 05/20/2025 at 1:55 p.m. with S2WC. She stated she was responsible for completing and posting the staffing data sheets daily. She confirmed she had not posted the staffing data sheet since 05/04/2025 and should have. She confirmed the facility's name was not documented on the staffing data sheet. She stated she was unaware the facility's name was a requirement on the staffing data sheet.

Based on record review, video observation, and interviews the facility failed to ensure the residents' right to be free from neglect for all residents who resided on Hall A (Rooms ,d+[DATE]). Nursing staff neglected to respond to call lights and provide any care and services to all resident's residing on Hall A from 11:00 p.m. to 2:30 a.m. on the night of [DATE]. As a result of the identified noncompliance, serious harm, serious impairment, death, or psychosocial harm was likely to occur to the residents residing on Hall A. This deficient practice resulted in an Immediate Jeopardy (IJ) situation on [DATE] at approximately 11:00 p.m. when Resident #1, who had a physician's order for staff to visually check the resident every 2 hours, activated her call light for staff assistance. No staff responded to her call until approximately 2:39 a.m. when S6CNA found Resident #1 in here room on the floor, kneeling on a fall mat at the bedside, unresponsive and pulseless. Resident #1 expired after unsuccessful CPR was initiated. On [DATE] at approximately 2:53 a.m., S6CNA found Resident #3, who had a physician's order for staff to visually check the resident every 2 hours, lying on the floor. This resulted in psychosocial harm for Resident #3 who verbalized in an angry tone that she felt aggravated and neglected when staff did not help her after she slid out of bed and had to stay on the floor for a long time. Interviews with staff revealed the last time staff visualized or provided care for any residents residing on Hall A on [DATE] was at 10:00 p.m.; and not again until 2:30 a.m. on [DATE]. S2ADM was notified of the Immediate Jeopardy on [DATE] at 7:02 p.m. The Immediate Jeopardy was removed on [DATE] at 1:31 p.m., as confirmed by onsite verification through record reviews and interviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. This deficient practice continued at a potential for more than minimal harm to the remaining 100 residents residing in the facility. Findings: Review of the facility's policy titled Abuse/Neglect Prevention Program with a revision date of [DATE], revealed the following in part: Abuse/Neglect Policy Statement: Each resident also has the right to be free from neglect. 9. Neglect- Failure to provide goods and services necessary to avoid physical harm, mental or mental illness. Resident #1 Review of Resident #1's Clinical Record revealed she was readmitted to the facility on [DATE] with diagnoses, which included Foot Drop of Right and Left Foot, Repeated Falls, Muscle Weakness (generalized), Muscle Wasting and Atrophy, Primary Insomnia, Primary Generalized Osteoarthritis, Abnormal Posture, Cognitive Communication Deficit, and Need Assistance for Personal Care. Further review revealed Resident #1 resided on Hall A when she expired on [DATE]. Review of Resident #1's most recent completed Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #1 was dependent on staff assistance with bed mobility and transfers. Review of Resident #1's [DATE] Physician's Orders revealed an order was implemented on [DATE] for visual checks to be completed by staff every 2 hours for the resident's location. Review of Resident #1's Nurses' Note dated [DATE] revealed the following, in part: On [DATE] at 2:42 a.m.: Upon doing rounds, aide walked into room and found Resident #1 unresponsive on fall mat. Nurse was immediately called to the room. Upon entering room, nurse noticed resident on her fall mat in a kneeling position facing the bed. Unable to obtain pulse or blood pressure upon assessment. Initiated CPR immediately. 911 notified. CPR in progress. At 2:53 a.m., fire department arrived and continued CPR. Coroner's office notified, family notified. At 3:43 a.m., attempted to contact physician. At 4:00 a.m., coroner arrived, okay to release the body to funeral home. Signed by: S5LPN. Resident #3 Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Muscle Wasting, Muscle Weakness, and Lack of Coordination. Review of Resident #3's most recent completed MDS, with an ARD of [DATE], revealed a Brief Interview of Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. Further review revealed she required partial to substantial/max assist with bed mobility and transfers. Review of Resident #3's [DATE] active Physician's Orders revealed an order was on [DATE] for visual checks to be completed by staff every 2 hours for the resident's location. Review of Resident #3's Nurses Note dated [DATE] revealed the following, in part: On [DATE] at 2:53 a.m.: Upon doing rounds, aide found Resident #3 lying down on the floor, nurse was immediately called to the room. Signed by: S5LPN. Review of the CNA Daily Assignment Sheet from 10:00 p.m. to 6:00 a.m. dated [DATE] revealed the following, in part: S7CNA was assigned to care for the residents residing on Hall A Rooms ,d+[DATE] S8CNA was assigned to care for the residents residing on Hall A Rooms ,d+[DATE] S6CNA was assigned to care for the residents residing on Hall A Rooms ,d+[DATE] On [DATE] at 2:04 p.m., a review of the facility's video surveillance footage of Hall A, dated [DATE] from 12:00 a.m. until approximately 4:45 a.m., was conducted with S2ADM. Prior to reviewing the footage, S2ADM stated he did not have access to any surveillance footage prior to [DATE] at 12:00 a.m. The surveillance footage revealed from 12:00 a.m. to approximately 2:35 a.m., staff failed to perform visual checks on Resident #1 and #3 every two hours as ordered, or any other residents on Hall A. The surveillance footage further revealed during that time, staff neglected to provide any care and services to any resident's residing on Hall A, and at 12:35 a.m., a call light was observed to be on in Hall A but S2ADM was unable to identify if it was coming from Resident #1's room or the room next to her. S2ADM confirmed the above review of the facility footage revealed no staff rounded on or provided care to any resident on Hall A from 12:00 a.m., on [DATE] until approximately 2:37 a.m. On [DATE] at 11:58 a.m., an interview was conducted with S6CNA. She stated she worked the 10:00 p.m. to 6:00 a.m. shift on [DATE] and was assigned to provide care for Resident #1 and Resident #3, as well as the residents in Rooms ,d+[DATE] on Hall A. S6CNA stated Resident #1 and #3 required staff assistance to get out of bed. She stated Resident #1 and #3 were ordered to have visual checks every 2 hours, which meant the staff were to visualize the resident every two hours. She stated she typically rounded on her residents every two hours, beginning at 10:00 p.m., then again at 12:00 a.m., 2:00 a.m., 4:00 a.m., and 6:00 a.m. She stated CNAs should sit on the halls, in the section they were assigned, so they could respond to call lights and assist residents with needs because there was no ward clerk responsible to answer call lights after 10:00 p.m. She stated S5LPN notified her on [DATE], at the beginning of her shift that staff could not walk on the floor to get to the resident's rooms on Hall A due to floor maintenance. She stated she did not notify administration about not being able to see the residents and no staff monitored or provided care to any of the residents on Hall A from 10:00 p.m. to 2:30 a.m., when the floor maintenance was completed. She stated she sat in the day room across from the nurse's station with another aid waiting until the floors were finished and she could see call lights going off on Hall A. She stated she could not remember which residents needed assistance aside from Resident #1, and stated she did not respond to the call lights. She stated Resident #1's call light was on from approximately 10:00 p.m. to 2:30 a.m. She stated once the floor maintenance was completed at approximately 2:30 a.m., she started rounding on her residents. She stated she went into Resident #1's room first because she knew Resident #1's call light had been on for a while. She confirmed this was the first time during her shift she had visualized her assigned residents. She stated when she entered Resident #1's room she found the resident kneeling on the fall mat beside her bed, arm gripping the bed rail, unresponsive, cold, and pale. She stated she immediately notified S5LPN and left the room once help arrived. She stated she then rounded on Resident #3 and found Resident #3 lying on the floor uninjured. She stated Resident #3 did not say much to her other than she was not hurt and did not want to go to the emergency room . She stated she did not know how long Resident #3 was lying on the floor prior finding. She stated she notified S5LPN. She stated staff not performing visual checks or providing care to the residents on Hall A from 10:00 p.m. until 2:30 a.m., was neglect. She stated she should have performed visual checks and responded to call lights regardless of the floor maintenance and confirmed she had not. She stated she notified S2ADM once he had arrived to the facility, that staff were unable to perform rounds on residents on Hall A. On [DATE] at 3:29 p.m., an interview was conducted with S5LPN. S5LPN stated she was assigned to provide care for Resident #1, #3, and all of the residents on Hall A on [DATE] and worked the 10:00 p.m. to 6:00 a.m. shift. She confirmed Resident #1 and #3 had visual checks ordered every two hours which indicated staff were to visualize the resident every two hours. She stated Resident #1 and #3 required staff assistance to get out of bed. She stated she typically rounded on her residents beginning at 11:00 p.m., then again at 1:00 a.m., 3:00 a.m., and 5:00 a.m. She stated CNAs should sit on the halls, in the section they were assigned, so they could respond to call lights and assist residents with needs because there was no ward clerk responsible to answer call lights after 10:00 p.m. She stated on the night of [DATE], Hall A had floor maintenance being completed and the staff could not walk on the floor to get to the resident's rooms. She stated the floor maintenance started around 10:00 p.m., and did not finish until approximately 2:00 a.m. She stated during that time nursing staff did not round on the residents or provide any care on Hall A. She confirmed she did not communicate this with administration. She stated she was able to see all the resident on Hall A at 10:00 p.m., but did not see them again until approximately 2:30 a.m. She stated from 10:00 p.m. to 2:30 a.m., the CNAs were not allowed to sit on their assigned areas on the hall to respond to call lights and provide care like they normally would. She stated she sat behind the nursing station where the computers were at the charge nurse desk and could not see any call lights. She stated S6CNA went into Resident #1's room around 2:30 a.m., and found the resident unresponsive. She stated she immediately went into Resident #1's room and found Resident #1 on the floor kneeling on a fall mat at her bedside, unresponsive and pulseless. She stated shortly after that, S6CNA came to her and notified her Resident #3 had also been found on the floor. She stated once she got to Resident #3, she was lying on the floor, uninjured, with a pillow under her head. She confirmed staff not performing visual checks or providing care to the residents on Hall A from 10:00 p.m. until 2:30 a.m., was neglect. She stated the first time S2ADM was notified of staff not being able to round on the residents was when S2ADM arrived onsite around 4:00 a.m., after she had notified him of Resident #1's passing. On [DATE] at 10:58 a.m., an interview was conducted with S8CNA. S8CNA stated she worked the 10:00 p.m. to 6:00 a.m., shift on [DATE], and was assigned to Rooms ,d+[DATE] on Hall A. She stated she typically rounded on her residents every two hours, beginning at 10:00 p.m., then again at 12:00 a.m., 2:00 a.m., 4:00 a.m., and 6:00 a.m. She stated the CNAs should sit on the halls in the section they were assigned so they could respond to call lights and assist residents with needs because there was no ward clerk responsible to answer call lights after 10:00 p.m. She stated on [DATE], she did not go to any of the resident's rooms or provide care for the residents on Hall A due to floor maintenance. She stated she was able to round on her residents at 10:00 p.m., but not again until approximately 2:30 a.m. She stated during that time, she sat at the beginning of Hall A and could see the call lights on Hall A. She stated she saw three call lights on from her assigned residents, but did not recall which residents had requested assistance. She stated she did not to respond to the call light or provide any care to those residents and should have. She stated once the floor maintenance was completed at approximately 2:30 a.m., she started rounding on her residents. She stated staff not performing visual checks on the residents and not providing care on Hall A from 10:00 p.m. until 2:30 a.m., was neglect. She stated she should have performed visual checks and responded to call lights regardless of the floor maintenance and confirmed she had not. She confirmed she did not notify S2ADM staff were unable to perform rounds or care on residents on Hall A. On [DATE] at 2:20 p.m., an interview was conducted with S7CNA. She stated she worked the 10:00 p.m. to 6:00 a.m., shift on [DATE], and was assigned to Rooms ,d+[DATE] on Hall A. She stated she typically rounded on her residents every two hours, beginning at 10:00 p.m., then again at 12:00 a.m., 2:00 a.m., 4:00 a.m., and 6:00 a.m. She stated CNAs should sit on the halls, in the section they were assigned, so they could respond to call lights and assist residents with needs because there was no ward clerk responsible to answer call lights after 10:00 p.m. She stated S5LPN informed her staff could not get to the resident's rooms on Hall A due to floor maintenance. She explained the hall had been blocked off so she sat in the door way of the chapel and saw a resident call light on for about an hour at approximately 1:00 a.m. She stated she was unable to recall which resident required assistance, but she stated she did not respond to the call light. She stated once the floor maintenance was done around 2:30 a.m., all 3 CNAs working went down the hall to perform visual checks on the residents. She stated S6CNA found Resident #1 kneeling on her fall mat at her bedside, and Resident #3 lying on the floor in her room. She confirmed nursing staff not performing visual checks on their residents every two hours or providing care for the residents from 10:00 p.m. until 2:30 a.m., was neglect. She stated she should have performed visual checks and responded to call lights regardless of the floor maintenance and confirmed she had not. She stated she notified S2ADM once he had arrived to the facility, that staff were unable to perform rounds on residents on Hall A. On [DATE] at 4:15 p.m., an interview was conducted with Resident #3. She stated on [DATE] she slid out of bed onto the floor. She stated she tried calling for assistance before she slid out the bed, but no one came to help her. She stated once she was on the floor it took a long time for staff to come. She stated she did not try to get back in bed on her own because she needed staff assistance. She stated she called when she was on the floor with the call button and it took a long time for staff to come. She stated, in an angry tone, it made her feel neglected and very aggravated when the staff did not come help her after calling for help and lying on the floor. On [DATE] at 1:17 p.m., an interview was conducted with S3DON. She stated nursing staff were expected to perform visual checks on the residents every two hours based on their Physician's Order and provide any needed care. She stated staff should have notified the administrator immediately if they were ever unable to follow physician's orders, perform visual checks, or provide care to residents for any reason. She stated she expected staff to respond to call lights in a timely manner and as quickly as possible. She stated neglect would be staff not providing care to residents and ignoring the needs of residents. On [DATE] at 4:36 p.m., an interview was conducted with S2ADM. He stated through his investigation it was discovered that the floor maintenance impeded care by not allowing the nursing staff to perform visual checks or provide care to residents on Hall A from 10:00 p.m. until approximately 2:30 a.m., on [DATE]. He confirmed Resident #1 and #3 were both found on the floor on [DATE], and by the time Resident #1 was found she was unresponsive. He stated staff should have notified him immediately when the maintenance vendor did not allow staff on Hall A. He confirmed if a resident had an order for visual checks every 2 hours he expected staff to follow the physician's order and they had not. He stated he preferred for a call light to be responded to by staff between 30 to 45 minutes at most. The facility implemented the following actions to correct the deficient practice: 1. Resident #1 and Resident #3 were identified as having been affected by the alleged deficient practice of not making Q2 visual checks per physician order. All residents had the potential to be affects as the result of the alleged non-compliance. 2. a. An in-service was conducted on [DATE] by the Administrator, DON and ADON for all CNA's and LPN's regarding Q2hr visual rounds. The in-service also included if there was anything that would prevent them making Q2hr rounds they should immediately notify the Administrator. To ensure that the staff understood the in-service a questionnaire was initiated on [DATE]. b. Staff unable to be in-serviced on [DATE] and forward will not be permitted to work until they are in-serviced. All new employees will be in-serviced regarding the information listed above during their orientation period. c. A log of each resident arranged by room was reimplemented on [DATE] to document direct observation checks every two hours on each shift. The monitor is broken into 2-hour increments and designated nursing staff are to sign off that the observations have been made. This monitoring will continue 24 hours/day 7 days/week for two weeks and then will be reviewed by the DON/designee. d. On [DATE], the Administrator notified the Vendor that the company employee will not be allowed to perform floor services in the absence of the Administrator. The Administrator will ensure a schedule is set for floor service times that will ensure the vendor reports directly to him at the time of the floor service. e. A QAPI monitor was reimplemented on [DATE] to ensure Q2hr rounds are completed 24hr a day 7 days a week. A nurse will be assigned to complete the Q2hr visual rounds and document the rounds on the QA Monitor. The QA Monitor will be ongoing. f. Effectiveness of the corrective actions will be discussed weekly for 6 weeks at the Quality Assurance and Performance Improvement Meeting with findings added to the QAPI minutes. Additional in-services and/or corrective actions will be implemented as needed. 3. As of [DATE], the facility has resolved the likelihood of serious harm or injury to any resident no longer exists. Throughout the survey from [DATE] to [DATE], observations, interviews, and record review revealed the above listed actions were implemented. Random staff interviews and observations revealed the above education for staff was completed. Observations, interviews, and record review, revealed monitoring had begun as mentioned above in the POR with no further issues identified.

Based on observations, interviews, and record review the facility failed to ensure residents were assessed for risk of entrapment from bedrails and informed consents were obtained prior to installation of bedrails for 4 (#1, #3, #R1, and #R2) of 4 sampled residents identified for having bedrails in use. This deficient practice had the potential to affect all 51 residents residing in the facility with bedrails in use. Findings: Resident #1 Review of Resident #1's Clinical Record revealed she was readmitted to the facility on [DATE] and had diagnoses, which included Foot Drop of Right and Left Foot, Muscle Weakness (generalized), Muscle Wasting and Atrophy, Primary Generalized Osteoarthritis, Abnormal Posture, Cognitive Communication Deficit, and Need of Assistance for Personal Care. Further review revealed Resident #1 expired on [DATE]. Review of Resident #1's most recent completed Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #1 was dependent on staff assistance with bed mobility and transfers. Review of Resident #1's current Physician Orders revealed the following, in part: Start date [DATE]: Mobility bars x2 to assist with bed mobility and repositioning every shift. Review of Resident #1's Medication Administration Record (MAR) dated [DATE] revealed the following, in part: Start date [DATE]: Mobility bars x2 to assist with bed mobility and repositioning every shift. Review of Resident #1's Clinical Record revealed no documentation of Entrapment Risk Assessments for bedrails. Review of Resident #1's Clinical Record revealed no documentation of informed consent for bedrails. An interview was conducted with S5LPN on [DATE] at 3:29 p.m. She stated anytime Resident #1 was in bed, her mobility bars were in a raised position. Resident #3 Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Muscle Wasting, Muscle Weakness and Lack of Coordination. Review of Resident #3's quarterly MDS with an ARD of [DATE] revealed she had a Brief Interview of Mental Status (BIMS) of 15, which indicated she was cognitively intact. Further review revealed she required partial to substantial/max assist with bed mobility and transfers. Review of Resident #3's current Physician Orders revealed the following, in part: Start date [DATE]: Mobility bars x2 to assist with bed mobility and repositioning, every shift. Review of Resident #3's MAR dated [DATE] revealed the following, in part: Start date [DATE]: Mobility bars x2 to assist with bed mobility and repositioning, every shift. Review of Resident #3's Clinical Record revealed no documentation of Entrapment Risk Assessments for bedrails prior to [DATE]. Review of Resident #3's Clinical Record revealed no documentation of informed consent for bedrails. An observation was made and interview was conducted with Resident #3 on [DATE] at 3:45p.m. Resident #3's bed had two mobility bars, one on each side of the bed, in an upright position. Resident #3 confirmed she had not signed a consent for bedrails when the bedrails were implemented, and she used the bedrails for mobility. Resident #R1 Review of Resident #R1's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Muscle Weakness and Acute Paralytic Poliomyelitis. Review of Resident #R1's quarterly MDS with an ARD of [DATE] revealed he had a BIMS of 15, which indicated he was cognitively intact. Further review revealed he required substantial/max assist with bed mobility. Review of Resident #R1's current Physician Orders revealed the following, in part: Start date [DATE]: Mobility bars x2 to assist with bed mobility and repositioning, every shift. Review of Resident #R1's MAR dated [DATE] revealed the following, in part: Start date [DATE]: Mobility bars x2 to assist with bed mobility and repositioning, every shift. Review of Resident #R1's Clinical Record revealed no documentation of Entrapment Risk Assessments for bedrails prior to [DATE]. Review of Resident #R1's Clinical Record revealed no documentation of informed consent for bedrails. An observation was made and interview was conducted with Resident #R1 on [DATE] at 4:15 p.m. Resident #R1's bed had two mobility bars, one on each side of the bed, in an upright position. Resident #R1 confirmed he had not signed a consent for bedrails when the bedrails were implemented, and he used the bedrail for mobility. Resident #R2 Review of Resident #R2's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Repeated Falls, Other Abnormalities of Gait and Mobility, Muscle Wasting and Atrophy, and Other Lack of Coordination. Review of Resident #R2's quarterly MDS with an ARD of [DATE] revealed she had a BIMS of 14, which indicated she was cognitively intact. Further review revealed she required substantial/max assist with bed mobility. Review of Resident #R2's current Physician Orders revealed the following, in part: Start date [DATE]: Mobility rails x2 to assist with bed mobility and repositioning, every shift. Review of Resident #R2's MAR dated [DATE] revealed the following, in part: Start date [DATE]: Mobility rails x2 to assist with bed mobility and repositioning, every shift. Review of Resident #R2's Clinical Record revealed no documentation of Entrapment Risk Assessments for bedrails prior to [DATE]. Review of Resident #R2's Clinical Record revealed no documentation of informed consent for bedrails. An observation was made and interview was conducted with Resident #R2 on [DATE] at 3:29 p.m. Resident #R2's bed had two mobility bars, one on each side of the bed, in an upright position. Resident #R2 confirmed she had not signed a consent for bedrails when the bedrails were implemented, and she used the bedrails for mobility. An interview was conducted with S9CRN on [DATE] at 1:35 p.m. She stated she and another staff member completed entrapment risk assessments. She stated the facility does not obtain consents for bed rails prior to installing them if they are not being used as a restraint. She confirmed they had not obtained informed consents for mobility bars prior to installing them, and no entrapment risk evaluations had been completed prior to [DATE]. An interview was conducted with S3DON on [DATE] at 3:01 p.m. She stated no staff was assigned to perform entrapment risk assessments or obtain informed consents for residents who had mobility bars ordered. She stated informed consents were not obtained to indicate Resident's #1, #3, #R1, and R#2 had given consent for the mobility bars. She stated entrapment risk assessments were not conducted for residents with mobility bars prior to [DATE]. She stated she was unaware consents and entrapment risk assessments should be completed prior to installing mobility bars.

Based on video observation, interviews and record review, the facility failed to ensure alleged violations involving neglect were reported to the state agency within 2 hours after the allegations of neglect were made for Resident #1, Resident #3, and all other residents residing all Hall A. Findings: Cross reference: F600 Review of the facility's Abuse/Neglect Prevention Program policy, revised [DATE], revealed the following in part: Each resident has the right to be free from mistreatment, neglect, and misappropriation of property. 9. Neglect: failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. In the event of any evidence involving neglect, an occurrence will be reported immediately to the Administrator or his or her designee of the facility, who will immediately notify corporate office and the appropriate state officials per state guidelines. Review of the facility's Mandated Reporting Flowsheet, revised [DATE], revealed the following in part: Does the incident or allegation involve abuse, with or without serious bodily harm, or neglect, exploitation, injury of unknown source or other reportable incident that results in serious bodily harm (an injury involving extreme physical pain, involving substantial risk of death; requiring medical intervention)? If yes, report immediately to the administrator and to law enforcement as applicable, but not later than 2 hours to the State Survey Agency. Resident #1 Review of the facility's self-reported incident dated [DATE] revealed the following: Events Entered: [DATE] at 9:43 a.m. Occurred and Discovered: [DATE] at 2:45 a.m. Type of injury: Blank Incident description: Initial investigation: The fall of Resident #1 was reported to S2ADM at 4:01 a.m. Developing Issues: While investigating the incident involving the resident, it came to light that a vendor working on the floors may have impeded making rounds every 2 hours. Review of Resident #1's Nurses' Note dated [DATE] revealed the following, in part: On [DATE] at 2:42 a.m.: Upon doing rounds aide walked into room and found resident unresponsive on fall mat. Nurse was immediately called to room upon entering room nurse noticed resident on her fall mat in a kneeling position facing the bed. Unable to obtain pulse or blood pressure upon assessment. Initiated CPR immediately. 911 notified. At 2:53 a.m., Coroner's office notified. Signed by: S5LPN. Resident #3 Review of Resident #3's Nurses Note dated [DATE] revealed the following, in part: On [DATE] at 2:53 a.m.: Upon doing rounds aide found Resident #3 lying down on the floor, nurse was immediately called to the room. Signed by: S5LPN. Review of the CNA Daily Assignment Sheet from 10:00 p.m. to 6:00 a.m. dated [DATE] revealed the following, in part: S7CNA was assigned to care for the residents residing on Hall A Rooms ,d+[DATE] S8CNA was assigned to care for the residents residing on Hall A Rooms ,d+[DATE] S6CNA was assigned to care for the residents residing on Hall A Rooms ,d+[DATE] On [DATE] at 2:04 p.m., a review of the facility's video surveillance footage of Hall A, dated [DATE] from 12:00 a.m. until approximately 4:45 a.m., was conducted with S2ADM. Prior to reviewing the footage, S2ADM stated he did not have access to any surveillance footage prior to [DATE] at 12:00 a.m. The surveillance footage revealed from 12:00 a.m. to approximately 2:35 a.m., staff neglected to provide any care and services to any resident's residing on Hall A. At 12:35 a.m., a call light was observed to be on in Hall A, which indicated a resident was calling for assistance. S2ADM confirmed the above review of the facility footage revealed no staff rounded on or provided care to any resident on Hall A from 12:00 a.m., on [DATE] until approximately 2:37 a.m. On [DATE] at 11:58 a.m., an interview was conducted with S6CNA. She stated she worked the 10:00 p.m. to 6:00 a.m. shift on [DATE] and was assigned to provide care for Resident #1 and Resident #3, as well as the residents in Rooms ,d+[DATE] on Hall A. She stated on [DATE], she was not able to provide care to her assigned residents on Hall A from 10:00 p.m. to 2:30 a.m., due to floor maintenance. On [DATE] at 3:29 p.m., an interview was conducted with S5LPN. S5LPN stated she was assigned to provide care for Resident #1, #3, and all of the residents on Hall A on [DATE] and worked the 10:00 p.m. to 6:00 a.m. shift. She stated on the night of [DATE] she did not provide care to her assigned residents on Hall A from 10:00 p.m. until 2:30 a.m. due to floor maintenance. On [DATE] at 10:58 a.m., an interview was conducted with S8CNA. S8CNA stated she worked the 10:00 p.m. to 6:00 a.m., shift on [DATE], and was assigned to Rooms ,d+[DATE] on Hall A. She stated on [DATE], she did not go to any of the resident's rooms or provide care for the residents on Hall A due to floor maintenance from 10:00 p.m. until 2:30 a.m. On [DATE] at 2:20 p.m., an interview was conducted with S7CNA. She stated she worked the 10:00 p.m. to 6:00 a.m., shift on [DATE], and was assigned to Rooms ,d+[DATE] on Hall A. She stated she did not perform visual checks every two hours or provide care for her assigned residents from 10:00 p.m. until 2:30 a.m. On [DATE] at 4:36 p.m., an interview was conducted with S2ADM. He stated on [DATE] at approximately 4:00 a.m., S5LPN made him aware the floor vendor impeded care by not allowing nursing staff to perform visual checks on residents on Hall A from 10:00 p.m. until approximately 2:30 a.m. He confirmed no residents residing on Hall A received care from 10:00 p.m. through 2:30 a.m. on [DATE]. He confirmed any allegations of neglect should be reported to the State Survey Agency within 2 hours. He confirmed he submitted the incident to the State Survey Agency on [DATE].

Based on interviews and record review, the facility failed to ensure residents' assessments accurately reflected the residents' status by failing to ensure the Minimum Data Set (MDS) was accurately coded for PASRR (Preadmission Screening and Resident Review) for 1 of 1 (#99 ) resident reviewed for PASRR. Findings: Review of the facility's undated policy titled Resident Assessment Instrument (RAI) Policy revealed, in part: Policy: It is the policy of this facility to conduct and document, initially and periodically, a comprehensive, accurate assessment on all residents. Comprehensive assessments will accurately describe each resident's functional capacity using a standardized, reproducible, state approved form, referred to as the MDS or RAI. The assessment will be completed by following the specific directions found in the RAI manual. Review of Resident #99's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Autistic Disorder. Review of Resident #99's 142 Form Notification of Medical Certification revealed, an approval for admission by the state Level II Authority for a temporary period effective 11/04/2024 through 08/04/2025. Review of Resident #99's Admission MDS with an Assessment Reference Date (ARD) of 11/12/2024 revealed, Section A1500 PASRR: Is the resident currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as 0-No. Section A1510 Level II PASRR conditions was blank. An interview was conducted with S15CCC on 02/27/2025 at 10:49 a.m. S15CCC stated she was responsible for completing Resident #99's MDS assessment. She verified Resident #99's Form 142 indicated Resident #99 was approved for nursing home admission by Level II authority effective 11/04/2024. She reviewed Resident #99's Admission MDS dated [DATE]. S15CCC confirmed Section A1500 should have been coded as 1-Yes, and was not. An interview was conducted on 02/27/2025 at 10:55 a.m. with S2DON. S2DON verified Resident #99's Form 142 indicated Resident #99 was approved for nursing home admission by Level II authority effective 11/04/2024. She reviewed Resident #99's Admission MDS dated [DATE]. S2DON confirmed Section A1500 should have been coded as 1-Yes, and was not.

Based on observations, interviews, and record reviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards for 1 (#56) of 3 (#52, #56, #80) residents reviewed for respiratory services. The facility failed to ensure Resident #56's oxygen tubing and humidifier bottle were properly labeled. Findings: Review of the facility's undated policy titled Oxygen Administration (Concentrator or Tank) revealed, in part: Policy: Humidifier bottles, cannulas and oxygen (O2) tubing will be changed at least once weekly and dated. Review of Resident #56's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Alzheimer's Disease and Dependence on Supplemental Oxygen. Review of Resident #56's Physician's Orders revealed the following, in part: Start date: 02/23/2025: Oxygen at 3 liters per nasal cannula continuously for comfort. On 02/24/2025 at 10:25 a.m., an observation was made of Resident #56's oxygen tubing and humidifier bottle which were not properly labeled with the date last changed. On 02/24/2025 at 10:49 a.m., an observation was made of Resident #56's oxygen tubing with S3ADON. S3ADON confirmed the oxygen tubing was not labeled with the date last changed. On 02/24/2025 at 10:56 a.m., an observation and interview was conducted with S2DON. S2DON confirmed Resident #56's oxygen tubing was not labeled with the date last changed and should have been. She stated the facility's oxygen administration policy was for the oxygen tubing and humidifier bottles to be changed weekly by nursing staff. S2DON confirmed all oxygen tubing and/or humidifier bottles should be labeled with the date last changed.

Based on interviews and record reviews, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) received trauma-informed care and services in accordance with professional standards of practice for 1 of 1 (#93) resident residing in the facility with PTSD. The facility failed to assess and develop a plan of care for Resident #93's history of trauma. Findings: Review of Resident #93's Clinical Record revealed an admitted [DATE] with diagnoses, which included PTSD and Major Depressive Disorder. Review of Resident #93's Quarterly MDS with an ARD of 01/03/2025 revealed a diagnosis of PTSD. Further review of the MDS revealed a BIMS of 15, which indicated he was cognitively intact. Review of Resident #93's Physician History and Physical by S4NP, dated 04/02/2024, revealed a diagnosis of PTSD. Further review revealed no documentation of an assessment and identification of triggers for the PTSD. Review of Resident #93's Initial Social Service History completed by S10SSD dated 03/29/2024 revealed the following, in part: Disabilities: PTSD Further review revealed no documentation of an assessment of the trauma, triggers, and/or interventions. Review of Resident #93's electronic and physical Clinical Record revealed no documentation of a trauma assessment, identification of triggers, and/or any interventions in place regarding his PTSD. Review of Resident #93's current Care Plan provided by the facility revealed no documentation regarding PTSD. An interview was conducted with Resident #93 on 02/25/2025 at 12:29 p.m. He confirmed he had PTSD. Resident #93 identified the source of his trauma. An interview was conducted with S11LPN on 02/26/2025 at 9:59 a.m. She stated she was unaware of Resident #93's PTSD. She stated she should have been aware Resident #93 had PTSD. She stated Resident #93 should have had a care plan identifying triggers so they could have been avoided. An interview was conducted with S8CNA on 02/26/2025 at 10:03 a.m. She stated she was unaware of Resident #93's PTSD. An interview was conducted with S13CNA on 02/26/2025 at 10:54 a.m. She stated she was assigned to Resident #93 daily. She stated she was unaware of Resident #93's PTSD. She stated she should have been aware of Resident #93's PTSD and any interventions in place. An interview was conducted with S14CCC on 02/26/2025 at 12:05 p.m. She confirmed she was responsible for Resident #93's care plan. She confirmed there was not documentation on Resident #93's current care plan regarding his PTSD, and there should have been. She stated she would have relied on a trauma assessment to develop interventions for Resident #93's PTSD. An interview was conducted with S2DON and S10SSD on 02/25/2025 at 1:38 p.m. S2DON and S10SSD confirmed there was no PTSD or Trauma Assessment in Resident #93's Clinical Record. S2DON confirmed there was no documentation on Resident #93's current Care Plan of his PTSD diagnosis, history of trauma, triggers, and/or interventions. S2DON confirmed Resident #93's Care Plan should have included his PTSD and interventions. An interview was conducted with S12CN on 02/26/2025 at 10:41 a.m. She stated, at the time of admission, a PTSD assessment should have been completed for a resident with a PTSD diagnosis. She stated any PTSD triggers should have been identified and the interdisciplinary team should have put interventions in place. She stated the PTSD diagnosis, cause of the PTSD, and all interventions should have been on the care plan. She stated the direct care staff should have been aware of the PTSD diagnosis and any interventions in place. An interview was conducted with S9PNP on 02/26/2025 at 11:58 a.m. He confirmed Resident #93 had PTSD. He stated he did not perform PTSD or trauma assessments. He stated he had not identified the source or triggers of Resident #93's trauma. An interview was conducted with S1ADM on 02/26/2025 at 2:15 p.m. He confirmed Resident #93's PTSD and interventions should have been on his care plan and were not.

Based on observation, interviews and record review, the facility failed to ensure medications were administered to meet the needs of each resident by failing to ensure orders were accurately transcribed for 1 of 1 (#49) residents reviewed for pressure ulcers. Findings: Review of the undated policy titled, Orders: Medications, revealed the following, in part: Policy: Medications are administered only upon the clear and complete order of a person lawfully authorized to prescribe. Verbal Orders are received only by licensed nurses or physician assistants and confirmed in writing by the prescriber within 7 days. Procedure: 1. Elements of the medication order: a. Medication orders specify the following: v. Route of the medication order Review of Resident #49's clinical record revealed Resident #49 was admitted to the facility on [DATE] and had diagnoses, which included, Pressure Ulcer of Sacral Region. Review of Resident #49's Order Summary Report dated 02/27/2025 revealed the following, in part: Order Date: 02/03/2025 -Flagyl Oral Tablet 500 mg. Give 1 tablet enterally every day shift every Monday, Wednesday, Friday related to Pressure Ulcer of Sacral Region. Review of Resident #49's Treatment Administration Record (TAR) dated 02/01/2025 to 02/28/2025 revealed the following, in part: Flagyl Oral Tablet 500 mg. Give 1 tablet enterally every day shift every Monday, Wednesday, Friday related to Pressure Ulcer of Sacral Region. On 02/26/2025 at 9:03 a.m., an observation was made of S5WCN and S6LPN perform wound care on Resident #49's pressure ulcer of sacral region. S5WCN stated Flagyl 500 mg is crushed and placed into the wound bed. On 02/26/2025 at 9:03 a.m., S6LPN was observed to cleanse Resident #49's sacral wound and apply crushed Flagyl 500 mg to the wound bed. On 02/27/2025 at 3:20 p.m., an interview was conducted with S5WCN. S5WCN confirmed Flagyl 500 mg was crushed and applied to Resident #49's wound bed during wound care. S5WCN confirmed she received and entered the order to crush and apply Flagyl 500 mg to sacral wound. S5WCN reviewed Resident #49's MD order for Flagyl and the TAR. S5WCN confirmed the orders was not accurately transcribed. On 02/27/2025 at 3:30 p.m., an interview was conducted with S4NP. S4NP confirmed the order for Flagyl 500 mg, Give 1 tablet enterally was incorrect. S4NP stated the order for Flagyl 500 mg was supposed to read crush and apply to wound bed. On 02/27/2025 at 3:32 p.m., an interview was conducted with S3ADON. S3ADON reviewed the order for Resident #49's Flagyl 500 mg and confirmed it read for the medication to be administered enterally. S3ADON confirmed the order was not accurately transcribed. On 02/27/2025 at 3:58 p.m., an interview was conducted with S2DON. S2DON reviewed Resident #49's order for Flagyl 500 mg to give one tablet enterally was not accurately transcribed. S2DON confirmed the order should have been transcribed to read, crush and apply to wound bed.

Based on observations, record reviews, and interviews, the facility failed to ensure a resident received the correct food portions as ordered by a physician for 1 (#13) of 2 (#13 and #90) sampled residents reviewed for dietary services. Findings: Review of the undated facility policy titled Diet Orders/Changes revealed the following, in part: Policy: New diet orders and changes in diet will be communicated in writing to the Dietary Department by the Nursing Staff in a timely manner. Purpose: To assure each resident receives the diet as ordered by the physician. Procedure: 1. Upon receiving the diet order, the Food Service Supervisor will change the resident tray card as needed. 2. The dietary kardex will be updated with the new diet and date of change in order. Review of Resident #13's clinical record revealed Resident ##13 was admitted to the facility on [DATE] and had diagnoses, which included Iron Deficiency Anemia, Deficiency of Other Vitamins, Gastrointestinal Hemorrhage, and Chronic Kidney Disease, Stage 3. Review of Resident #13's Order Summary Report dated 02/26/2025 revealed the following, in part: 08/19/2024 Regular Diet Mechanical Soft Texture, Regular/Thin consistency - double portions (lunch/supper). Review of Resident #13's current care plan revealed the following, in part: Problem: Potential for altered nutrition and dehydration related to Chronic Kidney Disease, History of Gastrointestinal Bleed, Anemia, and Vitamin Deficiency. Goal: Will maintain adequate nutritional status as evidenced by maintaining a stable weight. Review of Resident #13's undated dietary meal ticket revealed the following, in part: Diet: Regular Texture: Mechanical Soft Fluid: Thin Liquids On 02/26/2025 at 11:58 a.m., an observation was made of S8CNA delivering Resident #13's meal tray. S8CNA observed and confirmed the following: 1 piece of white bread 1 serving of broccoli 1 serving rice 1 serving of ground Salisbury steak 1 serving of dessert. On 02/26/2025 at 11:58 a.m., an interview was conducted with S8CNA. S8CNA observed Resident #13's meal tray and confirmed the meal tray did not contain double portions. On 02/26/2025 at 1:40 p.m., an interview was conducted with S7DM. S7DM reviewed Resident #13's meal ticket and confirmed it did not indicate double portions. S7DM reviewed Resident #13's orders and confirmed Resident #13 had an order for double portions. S7DM confirmed Resident #13 should have received double portions. On 02/26/2025 at 2:35 p.m., an interview was conducted with S1ADM. S1ADM confirmed if Resident #13 had a doctor's order for double portions, the resident should have received double portions.

Based on record reviews and interviews, the facility failed to maintain accurate documentation of the route of medication administration for 1 of 1 (#49) residents reviewed for pressure ulcers. Findings: Review of the undated policy titled Orders: Medications revealed the following, in part: Policy: Medications are administered only upon the clear and complete order of a person lawfully authorized to prescribe. Verbal Orders are received only by licensed nurses or physician assistants and confirmed in writing by the prescriber within 7 days. Procedure: 1. Elements of the medication order: a. Medication orders specify the following: v. Route of the medication order Review of Resident #49's clinical record revealed Resident #49 was admitted to the facility on [DATE] and had diagnoses, which included, Unstageable Pressure Ulcer of Sacral Region and Osteomyelitis of Sacral and Sacrococcygeal Region Vertebra. Review of Resident #49's Order Summary Report dated 02/27/2025 revealed the following, in part: Order Date: 02/03/2025 - Flagyl Oral Tablet 500 mg. Give 1 tablet enterally every day shift every Monday, Wednesday, and Friday related to Pressure Ulcer of Sacral Region. Review of Resident #49's Treatment Administration Record dated 02/01/2025 to 02/28/2025 revealed the Flagyl 500 mg was administered enterally on the following dates by the following staff: the following, in part: 02/05/2025 by S6LPN, 02/07/2025 by S6LPN, 02/10/2025 by S6LPN, 02/12/2025 by S6LPN, 02/14/2025 by S5WCN, 02/17/2025 by S6LPN, 02/19/2025 by S6LPN, 02/21/2025 by S5WCN, and 02/24/2025 by S6LPN. On 02/27/2025 at 3:30 p.m., an interview was conducted with S4NP. S4NP confirmed the order for Flagyl 500 mg Give 1 tablet enterally was incorrect. S4NP stated the order for Flagyl 500 mg should have read crush and apply to wound bed. On 02/27/2025 at 3:40 p.m., an interview was conducted with S5WCN. S5WCN reviewed Resident #49's TAR and confirmed she and S6LPN were signing off the orders for Flagyl 500 mg as being administered enterally. S5WCN confirmed she and S6LPN were crushing the Flagyl 500 mg and applying it to Resident #49's wound bed. S5WCN confirmed she and S6LPN were signing off the Flagyl 500 mg was administered to Resident #49 by an incorrect route, which was inaccurate documentation. On 02/27/2025 at 3:58 p.m., an interview was conducted with S2DON. S2DON reviewed Resident #49's order for Flagyl 500 mg to give one tablet enterally. S2DON reviewed Resident #49's TAR and confirmed S5WCN and S6LPN were documenting Resident #49's Flagyl as being administered enterally. S2DON confirmed if S5WCN and S6LPN were applying to Flagyl to Resident #49's wound bed, the documentation on the TAR was inaccurate.

Based on record review, video observation, and interviews the facility failed to ensure residents received adequate supervision to prevent elopement from the facility for 1 (#1) of 5 (#1, #2, #3, R1 and R2) sampled residents reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy (IJ) situation on 12/14/2024 at 4:32 a.m. when Resident #1, a moderately cognitively impaired resident with a physician's order for staff to visually check the resident every 2 hours, eloped from the facility. On 12/14/2024, staff last visualized Resident #1 at approximately 4:00 a.m. Resident #1 was observed on video footage eloping from the facility by climbing over the patio fence at 4:32 a.m., without staff knowledge. Facility staff had not realized Resident #1 eloped from the facility until approximately 8:00 a.m. The resident was found by local police officers at a local gas station on 12/18/2024 at approximately 2:38 p.m. S2ADM was notified of the Immediate Jeopardy on 12/19/2024 at 6:14 p.m. This deficient practice continued at a likelihood to cause more than minimal harm to the remaining 100 residents residing in the facility with orders to be visually checked. The Immediate Jeopardy was removed on 12/20/2024 at 2:03 p.m., when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through onsite interviews, observations, and record review. Findings: Review of the facility's undated policy, titled Wandering or Missing Resident, read in part . Procedure: 4. Any staff member becoming aware of a resident not being at the designated area or activity shall proceed to notify the charge nurse, Director of Nursing and the Administrator. Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE], and had diagnoses which included in part, Type 2 Diabetes Mellitus, Undifferentiated Schizophrenia and Disorganized Schizophrenia. Review of Resident #1's Quarterly Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 08/21/2024, revealed a Brief Interview for Mental Status (BIMS) of 12, which indicated Resident #1 had moderate cognitive impairment. Review of Resident #1's 12/2024 Physician's Orders revealed in part: Visual check for resident's location every 2 hours, every shift. Start date: 09/03/2024. Review of Resident #1's Nurses' Note dated 12/2024 revealed the following, in part: On 12/14/2024 at 11:38 a.m., Resident not noted in his room at breakfast time. Asked his roommate but he was unsure. Checked rooms on the hallway and the shower. Checked the patio areas. Notified RN supervisor and CNA supervisor. S4ADON called and informed S2ADM. Call placed to Resident's brother-in-law at 10:15 a.m. to let him know that resident was missing. Resident's sister called back about 10:50 a.m., and spoke to S2ADM. Staff drove on local highway to look for resident but were unsuccessful. After replaying the video footage resident climbed the patio fence at approximately 4:30 am. Call placed to physicians on call answering service. Signed by: S5LPN. Review of a written statement from S6CNA dated 12/14/2024 revealed the following: Upon arriving I did my room rounds, all residents was accounted for. Around 3:00 a.m. or 4:00 a.m., Resident #1 came out room to get ice and walk hall, this is a regular routine. On my last round, I went into Resident #1's room to turn his roommate, I noticed that Resident #1 wasn't in room, I finished my last round getting resident up. On 12/19/2024 at 10:37 a.m., a review of the facility's video surveillance footage dated 12/14/2024 from 4:00 a.m. until 9:00 a.m. was conducted with S2ADM of the hall Resident #1 resided on as well as the patio area. Review of the surveillance footage revealed on 12/14/2024 at 4:32 a.m., Resident #1 was observed using a chair to climb over the patio gate and left the facility's premises. Further review of the surveillance footage revealed staff failed to perform visual checks on Resident #1 every two hours as ordered, after he left the facility at 4:32 a.m., until 8:30 a.m. when staff are seen looking for Resident #1. On 12/19/2024 at 10:20 a.m., a telephone interview was conducted with S9LPN. She stated she was the nurse assigned to Resident #1 on 12/13/2024 and worked the 10:00 p.m. to 6:00 a.m. shift. She stated Resident #1 was cognitive and able to understand and be understood. She stated he was also able to ambulate independently. She confirmed Resident #1 had visual checks ordered every two hours which meant staff were to visualize the resident every two hours. She stated she conducted rounds at 10:00 p.m., 12:00 a.m., 2:00 a.m., and 4:00 a.m. She stated at approximately 4:00 a.m., she went in Resident #1's room to give his roommate medication, and saw Resident #1 in his bed. She confirmed this was the last time she visually saw Resident #1 on 12/14/2024 as her final round was at 4:00 a.m., and her shift ended at 6:00 a.m. She confirmed no staff had notified her Resident #1 had not been seen after 4:00 a.m. On 12/19/2024 at 1:48 p.m., a telephone interview was conducted with S6CNA. She stated was assigned to Resident #1 on 12/13/2024 and worked the 10:00 p.m. to 6:00 a.m. shift. She stated Resident #1 ambulated independently. She confirmed Resident #1 had visual checks ordered every two hours which meant staff were to visualize the resident every two hours. She stated she conducted rounds at 10:00 p.m., 12:00 a.m., 2:00 a.m., and begins her last round at about 4:00 a.m. She stated she last saw Resident #1 between 3:30 a.m. and 4:00 a.m. on 12/14/2024 getting ice from cooler in hallway. She stated she went into the resident's room to perform her last round between 4:45 a.m. and 5:00 a.m. and Resident #1 was not in his room at that time. She confirmed she did not notify staff Resident #1 was not observed during her last round, nor did she try to locate him at that time, and should have. On 12/19/2024 at 2:27 p.m., an interview was conducted with S7CNA. She stated she worked on 12/14/2024 on the 6:00 a.m. to 10:00 p.m. shift passing meal trays on Resident #1s hall but she was not his CNA for that day. She stated Resident #1 was ordered visual checks every 2 hours, which meant staff were to visualize the resident every two hours. She stated when she went in Resident #1's room around 7:30 a.m. to pass breakfast trays she asked his roommate if he had seen Resident #1. She stated his roommate said he just left out, but he would be right back. She stated she left Resident #1's tray in his room and walked out. On 12/19/2024 at 2:45 p.m., an interview was conducted with S11CNA. She stated she worked the 6:00 a.m. to 2:00 p.m. shift on 12/14/2024 and was the CNA assigned to Resident #1 on 12/14/2024. She stated Resident #1 was ordered visual checks every 2 hours, which meant staff were to visualize the resident every two hours. She stated she began rounding on residents at around 6:30 a.m. She stated by the time she made it into Resident #1's room it was about 7:30 a.m., and she did not see Resident #1. She stated she notified S5LPN that Resident #1 was not in his room. On 12/20/2024 at 1:05 p.m., a telephone interview was conducted with S5LPN. He stated he was the nurse assigned to Resident #1 on 12/14/2024. He stated Resident #1 had visual checks ordered every two hours. He stated he rounded on residents every two hours or every one hour if ordered sooner. He stated he did not observe Resident #1 come get his morning medication on 12/14/2024 before breakfast around 7:00 a.m., which was unusual since Resident #1 typically came out to the hall to receive his morning medications. He stated he asked Resident #1's roommate if he had seen him, and he answered no. He stated he asked CNAs if they had seen him and they were not sure. He stated between 8:00 a.m. and 8:30 a.m. after searching for Resident #1 and being unable to locate him, he notified the RN supervisor and the CNA supervisor that the resident could not be found. He stated staff searched the facility for Resident #1 and were unable to locate him. He stated at that time the supervisor notified S4ADON and S2ADM Resident #1 was missing from the facility. On 12/20/2024 at 1:50 p.m., an interview was conducted with S12CNAS. She stated at approximately 8:00 a.m. on 12/14/2024, S5LPN notified her he could not locate Resident #1. She stated she notified S13RNS and a Code W was called. She stated a Code w meant she and staff CNAs would go room to room and completed a total count of all residents. She confirmed Resident #1 was not present in the facility during the head count. She stated CNAs were expected to perform visual checks on residents every two hours and if the staff were unable to locate the resident upon visual checks they were to notify the nurse immediately. She stated nursing staff were expected to search the facility and locate the resident if unable to visualize the resident in their room prior to documenting completion of a round. On 12/20/2024 at 1:43 p.m., an interview was conducted with S3DON. She stated she was notified on 12/14/2024 sometime between 9:00 a.m. and 9:30 a.m. Resident #1 had eloped from the facility by S13RNS. She stated staff initiated a code W, which meant staff search the entire facility for the resident, and do a complete head count to ensure all other residents are accounted for, and inform Resident representative, doctors, and local law enforcement that a resident was missing. She confirmed Resident #1 eloped from the facility on 12/14/2024 at approximately 4:32 a.m. She stated on 12/18/2024 S1CADM notified her Resident #1 was located at a local gas station. At that time, Resident #1 signed the Against Medical Advice (AMA) form, and refused to return to the facility or seek medical attention. She stated nursing staff were expected to perform visual checks on the residents every two hours based on their Physician's Order. She stated staff were expected to search the facility if unable to visually observe the resident during rounds, and notify the nurse, herself, S4ADON, or S2ADM immediately. On 12/26/2024 at 2:10 p.m., an interview was conducted with S2ADM. S2ADM confirmed Resident #1 was missing for four days and no staff had visually observed him since 12/14/2024 at 4:00 a.m. until he was found on 12/18/2024 at 2:38 a.m. He stated he was notified by staff on 12/14/2024 around 9:00 a.m. that Resident #1 was not on the premises. He then reviewed the facility surveillance footage where Resident #1 was observed climbing over the patio fence and left the facility premises on 12/14/2024 at 4:32 a.m. S2ADM confirmed staff did not realize he was gone until approximately 8:00 a.m. S2ADM further confirmed staff failed to adequately supervise Resident #1 by not performing visual checks every two hours on Resident #1 as ordered. The facility had implemented the following actions to correct the deficient practice on 12/19/2024: 1) Resident #1 left the facility against medical advice on 12/14/2024. The facility allegedly failed to effectively maintain its highest practical physical, mental, psychosocial well-being for this 1 resident by failing to ensure the resident was adequately supervised to monitor a resident who is leaving against medical advice without signing the sign-out log. All residents had the potential to be affected as the result of the alleged non-compliance. 2) The Administrator and DON in-serviced all present nursing staff on 12/19/2024 at 6:30 p.m. The in-service included performing every 2 hour visual checks on all residents. The in-services also included the existing policy Wandering or Missing Resident that includes Code W. Staff unable to be in serviced on 12/19/2024 at 6:30 p.m. will not be permitted to work until they are in-serviced. All new employees will be in-serviced regarding the information listed above during their orientation period. A log of each resident arranged by room was implemented on 12/19/2024 to document direct observation checks every two hours on each shift. The monitor is broken into 2-hour increments and designated nursing staff are to sign off that the observations have been made. This monitoring will continue 24 hours/day 7 days/week for two weeks and then will be reviewed by the DON/designee. Resident patios will be monitored by a designated staff member to help ensure resident safety. Beginning at 7 p.m. on 12/19/2024, the staff will sit at the north and south smoking patio doors and go outside to monitor any resident who exits. This monitoring will continue 24 hours/day 7 days/week for two weeks and then 3 times a week for six weeks and then as needed thereafter. The Wander Data Collection Tool is completed by the MDS nurses at time of admission, quarterly, significant change in status. The tool is a scoring system indicating if a resident has a Definite Risk for elopement with a score of 3 or more YES answers, and is At Risk with a YES answer. The tally of the answers for YES is completed, and the nurse summarizes her findings on the back of the risk page which determines the most appropriate intervention accordingly, or if needed. On 12/20/2024, the MDS nurses began an audit of all elopement risk assessments. All residents that are identified as a risk for elopement will be discussed with the IDT in the QA meeting to determine if a plan of action is needed for those residents. To ensure the facility staff understand the in-service that was started on 12/19/2024, a questionnaire will be created by the Administrative Staff. Beginning on 12/20/2024, employees will complete the questionnaire to validate their understanding of the facility policy related to Wandering or Missing Resident. 3) As of 12/19/2024, the facility has resolved the likelihood of serious harm or injury to any resident no longer exists. Throughout the survey from 12/19/2024 to 12/26/2024, observations, interviews, and record review revealed the above listed actions were implemented. Random staff interviews revealed staff received training on supervision, visual checks, wandering or missing residents and completed questionnaires testing their knowledge. Observations were made throughout the survey with no supervision concerns identified. Observations, interviews, and record review, revealed monitoring had begun with no further issues identified.

Based on record review and interviews, the facility failed to ensure an allegation of neglect was reported to the State Survey Agency in the required timeframe for 1 (#1) of 5 (#1, #2, #3, #R1 and R2) sampled residents reviewed for elopement. Findings: Review of the facility's Abuse/Neglect Prevention Program policy (Revised 09/08/2021) revealed the following in part: B. Neglect: Neglect is defined as 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. A Nursing Facility must report to the State Survey Agency incidents of alleged neglect and all situations in which a Nursing Facility has cause to believe that the physical or mental health and/or welfare of a resident has been or may be adversely affected by neglect caused by another person. Neglect may include but is not limited to: Failure to provide adequate supervision . In the event of any evidence involving neglect, an occurrence will be reported immediately to the Administrator of his or her designee of the facility, who will immediately notify corporate office and the appropriate state officials per state guidelines. Review of the facility's Mandated Reporting Flowsheet revealed the following in part: Does the incident or allegation involve neglect, exploitation or other reportable incident that poses a threat to the resident's health and safety but does not result in serious bodily harm? Report immediately to the Administrator, but not later than 24 hours to the State Survey Agency. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses, including: Type 2 Diabetes Mellitus with Hyperosmolarity Without Nonketotic Hyperglycemic-Hyperosmolar Coma, Undifferentiated Schizophrenia and Disorganized Schizophrenia. Review of Resident #1's 12/2024 Physician's Orders revealed in part: Visual check for resident's location every 2 hours, every shift. Start date: 09/03/2024. Review of Resident #1's Nursing Progress Note dated 12/14/2024 at 11:38 a.m. revealed the following, in part: Resident not noted in his room at breakfast time. Asked his roommate, but he was unsure. Checked rooms on the hallway and the shower. Checked the patio areas. Notified RN Supervisor and CNA Supervisor. Call placed to S4ADON by RN Supervisor. S4ADON called and informed S2ADM. Call placed to Resident #1's brother-in-law at 10:15 a.m. to let him know resident was missing. Resident #1's sister called back about 10:50 a.m. and spoke to S2ADM. Staff drove on nearby highway to look for Resident #1 but were unsuccessful. After review of the facility's video footage, it appeared resident climbed over the fence on patio at about 4:30 a.m. Call placed to Resident #1's physicians on call answering service. Signed by: S5LPN Review of facility's Incident Investigation Report dated 12/14/2024, titled Elopement revealed documentation Resident #1 elopement from the facility on 12/14/2024. On 12/19/2024 at 2:45 p.m., an interview was conducted with S11CNA. She stated she worked the 6:00 a.m. to 2:00 p.m. shift on 12/14/2024 and she was the CNA assigned to Resident #1 on 12/14/2024. She stated on 12/14/2024 at approximately 7:30 a.m. she walked in Resident #1's room and she only saw his roommate in bed and she did not see Resident #1. She stated she notified S5LPN, Resident #1's nurse that Resident #1 was not in his room. On 12/20/2024 at 1:05 p.m., a telephone interview was conducted with S5LPN. He stated he worked on 12/14/2024 and was the nurse assigned to Resident #1 that day. He stated he did not see Resident #1 come get his morning medication on 12/14/2024 before breakfast around 7:00 a.m. He stated after searching for Resident #1 he notified the RN supervisor on weekends and the CNA supervisor. He stated staff searched the facility for Resident #1 and were unable to locate him. He stated at that time the weekend supervisor notified S4ADON and S2ADM. On 12/26/2024 at 2:10 p.m., an interview was conducted with S2ADM. S2ADM stated Resident #1 was missing for four days and no staff had physically seen him from 12/14/2024 until he was found on 12/18/2024. He stated he was notified by staff on 12/14/2024 at approximately 9:00 a.m. that Resident #1 was not on the property and no one could find him. He confirmed by reviewing the facility surveillance footage, Resident #1 was seen leaving the facility on 12/14/2024 at 4:32 a.m. He confirmed staff failed to adequately supervise Resident #1 by not performing visual checks every two hours on Resident #1 as ordered. S2ADM further confirmed he did not report the incident to the State Survey Agency.

Based on observations, interviews, and record review, the facility failed to provide privacy to residents when receiving assistance with personal care for 3 (#2, #R1 and #R5) of 5 (#2, #3, #R1, #R3, and #R5) residents observed during Activities of Daily Living. The facility failed to ensure: 1. Privacy curtains were pulled and the room door was closed prior to staff providing incontinence care to Resident #2 and Resident #R1; and 2. Resident #R5 had privacy curtains around his bed and were pulled prior to staff providing incontinence care. Findings: 1. Resident #2 Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses of Urinary Tract Infections and Cerebral Infarction. On 08/13/2024 at 5:10 a.m., an observation was made of S11CNA performing incontinence care for Resident #2. Resident #2 shared a room with one other resident, and Resident #2's bed was located closest to the door/entrance into the room. Resident #2's roommate was present in the room. S11CNA did not close the door or pull the privacy curtain before providing care to Resident #2. During the care, S11CNA exited the room, left the room door open and Resident #2's buttocks and legs were exposed. Resident #R1 Review of Resident #R1's Clinical Record revealed he was admitted to the facility on [DATE] with a diagnosis of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-dominant Side. On 08/13/2024 at 5:02 a.m., an observation was made of S11CNA performing care for Resident #R1. The room door was open and S11CNA was observed in Resident #R1's room from the hallway. Resident #R1 shared a room with one other resident, and Resident #R1's bed was located closest to the door/entrance into the room. The privacy curtains were not pulled between Resident #R1 and the door, or between the resident and his roommate who was awake watching television. Resident #R1 was in bed, brief exposed, and was removing his soiled shirt. On 08/13/2024 at 5:15 a.m., an interview was conducted with S11CNA. S11CNA confirmed the aforementioned observations. S11CNA confirmed she did not close the door or pull the privacy curtains in Resident #R1's room and he could be visualized during care to anyone who entered the room and to his roommate. S11CNA confirmed she did not close the door or pull the privacy curtains in Resident #2's room and she could be visualized during care to anyone who entered her room and to her roommate. 2. Resident #R5 Review of Resident #R5's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia without Behavioral Disturbance and Alzheimer's Disease with Late Onset. On 08/13/2024 at 5:33 a.m., an observation was made of S12CNA performing incontinence care for Resident #R5. Resident #R5 shared a room with one other resident, who was awake, alert and sitting in a wheelchair in the room. Further observation revealed there were no privacy curtain attached to the track on the ceiling. S12CNA provided incontinence care and dressed Resident #R5 with his roommate present in the room. On 08/13/2024 at 5:55 a.m., an interview was conducted with S12CNA. S12CNA stated Resident #R5 was incontinent. S12CNA confirmed there was no privacy curtain in Resident #R5's room. S12CNA stated the privacy curtain was taken down about one month ago to be washed and was never put back up. S12CNA confirmed there was no barrier to keep Resident #R5 from being visualized during care to anyone who entered his room or to his roommate who was in the room during the care provided. On 08/13/2024 at 6:15 a.m., an interview was conducted with S2DON. S2DON was made aware of the above findings. S2DON stated for a residents' privacy, the CNAs should close the resident's room door and pull the privacy curtains prior to performing care. S2DON stated she would not expect staff to provide care with the residents' room door open, privacy curtains not pulled and the residents being visualized by their roommate. S2DON stated she was not aware the privacy curtain had been removed out of Resident #R5's room. S2DON stated S1ADM had been working with S13MS to get the facility's privacy curtains cleaned and replaced. On 08/13/2024 at 6:27 a.m., an interview was conducted with S1ADM. S1ADM stated S13MS had been taking down, cleaning and rehanging the privacy curtains. S1ADM stated the facility was swapping out the old privacy curtains and replacing them with new ones. S1ADM stated if a resident did not have a privacy curtain in their room, staff should try and make it as private as possible. S1ADM stated the curtains were to provide privacy and dignity to the residents. S1ADM was made aware of the above findings. S1ADM stated the CNA should not have provided care to Resident #R5 where he was visible to his roommate. S1ADM stated the CNAs should pull the privacy curtains and close room doors prior to providing care to provide as much privacy as possible for the residents. On 08/13/2024 at 7:45 a.m., an interview was conducted with S13MS. S13MS stated he took down and threw away Resident #R5's privacy curtain because it was dry rotted. S13MS stated he could not recall exactly when he took down Resident #R5's privacy curtain, but it had been more than one week ago.

Based on observations, interviews and record reviews the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain good hygiene for 3 (#2, #R1, and #R3) of 6 (#1, #2, #3, #R1, #R3, and #R5) residents reviewed for ADL's. The facility failed to ensure: 1. Resident #2 and Resident #R1 received incontinence care timely; and 2. Resident #2 and #R3 received oral care daily. Findings: 1. Resident #2 Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses of UTI's and Cerebral Infarction. Review of Resident #2's Quarterly MDS with an ARD of 06/21/2024 revealed she had a BIMS of 6, which indicated she was severely cognitively impaired. Further review revealed she required substantial/maximum assistance for toileting. Review of Resident #2's Care Plan revealed the following, in part: Problem: 03/27/2024: Toileting deficit: needs assistance related ho history of Cerebral Infarction. Is unaware of the urge to toilet. Interventions: Provide assist with toileting as needed; perineal care every 2 hours and as needed Problem: 03/27/2024: Self-care ADL deficit: needs assist with toileting, bathing and hygiene Interventions: Assist with hygiene Review of Resident #2's Physician Orders dated August 2024 revealed the following, in part: Start date: 03/26/2024. Incontinence care. Check for incontinence at least every 2 hours. Cleanse periarea/buttock with perifresh, pat dry, apply periguard as a preventative measure. On 08/13/2024 at 5:10 a.m., an observation was made of S11CNA performing incontinence care for Resident #2. S11CNA confirmed Resident #2's incontinence brief and incontinence pad were wet with urine. Resident #R1 Review of Resident #R1's Clinical Record revealed he was admitted to the facility on [DATE] with a diagnosis of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-dominant Side. Review of Resident #R1's Quarterly MDS with an ARD of 05/06/2024 revealed Resident #R1 was always incontinent of urine. Further review revealed he required substantial/max assist with dressing, personal hygiene, transfers, and toilet transfers. Review of Resident #R1's Care Plan revealed the following, in part: Problem: 01/11/2024: Resident will remain free of altered skin integrity. Interventions: Incontinence care: check for incontinence at least every 2 hours. Cleanse periarea/buttocks with Perifresh, pat dry. On 08/13/2024 at 5:02 a.m., an observation was made S11CNA performing care for Resident #R1. Resident #R1 was observed in bed removing his soiled shirt. S11CNA stated she had just completed changing Resident #R1's soiled brief. There was a strong urine odor in his room. S11CNA removed a wet pad from underneath the resident, along with his shirt and jacket, which S11CNA stated were soiled with urine. On 08/13/2024 at 5:15 a.m., an interview was conducted with S11CNA. S11CNA stated she worked 10:00 p.m. to 6:00 a.m. and was assigned to Resident #2 and Resident #R1. S11CNA stated the last time she rounded on her assigned resident's, including Resident #2 and Resident #R1 was around 1:00 a.m. S11CNA stated she was supposed to round on the resident's every 2 hours. On 08/13/2024 at 6:15 a.m., an interview was conducted with S2DON. S2DON was made aware of the above findings. S2DON stated CNAs should round on the residents every 2 hours and as needed. S2DON stated she would not expect the CNAs to wait more than 3 hours to make rounds and provide incontinence care. 2. Review of the facility's undated policy titled, Care: A.M. revealed the following, in part: Procedure: 6. If resident has teeth, proceed with oral hygiene. 7. If resident has had dentures soaking overnight, remove from denture cup, rinse in cool water. Have resident rinse mouth with water or mouthwash. A soft toothbrush can be used to stimulate gum and tongue circulation by gentle brushing. Insert the dentures. Review of the facility's undated policy titled, Care: P.M. revealed the following, in part: Procedure: 9. If the resident has dentures, remove them. Clean the dentures appropriately. Provide water or mouthwash for resident to rinse mouth. Place resident's cleaned dentures in a covered denture cup of water with the resident's name on it. A soft toothbrush can be used to stimulate gum and tongue circulation by gentle brushing. Resident #2 Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses of UTI's and Cerebral Infarction. Review of Resident #2's Quarterly MDS with an ARD of 06/21/2024 revealed she had a BIMS of 6, which indicated she was severely cognitively impaired. Further review revealed she required partial/moderate assistance for oral hygiene. Review of Resident #2's Care Plan revealed the following, in part: Problem: 03/27/2024: Self-care ADL deficit: needs assist with toileting, bathing and hygiene Interventions: Assist with hygiene Review of Resident #2's Resident Care Details dated from 07/17/2024-08/13/2024 revealed no oral care was documented on the dates of 07/27/2024, 07/28/2024, 07/30/2024-08/10/2024, and 08/13/2024. On 08/13/2024 at 10:34 a.m., an interview was conducted with Resident #2. She was oriented to person and place. She stated staff did not perform oral care to her daily. On 08/14/2024 at 11:07 a.m., an interview was conducted with S9CNA. She stated she worked the 6:00 a.m.-2:00 p.m. shift and was assigned to Resident #2 when she worked. She stated each CNA was responsible ensure oral care was performed on their assigned residents. She stated there was a place to document oral care in the kiosk system. She was notified of the findings on Resident #2's Detail Summary Sheet and stated if she did not document oral care on Resident #2, she did not do it. Resident #R3 Review of Resident #R3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses of UTI and Pressure Ulcer of Sacral Region. Review of Resident #R3's Quarterly MDS with an ARD of 06/17/2024 revealed she had a BIMS of 15, which indicated she was cognitively intact. Further review revealed she required setup or clean-up assistance with oral care. Review of Resident #R3's Resident Care Details from 07/16/2024-08/13/2024 revealed no oral care was documented on the dates of 07/18/2024-07/22/2024, 07/24/2024-07/29/2024, and 07/31/2024-08/10/2024. On 08/13/2024 at 12:41 p.m., an interview was conducted with Resident #R3. She stated staff did not provide oral care to her daily. She stated she wore dentures, and had asked staff to clean them but they never did. She stated if she was given the supplies, she could clean them herself. She stated she did not eat with her dentures in place anymore and did not try to wear them unless she had a visitor because she did not want them to get dirty. At that time, upper and lower dentures were to be observed lying on her torso, and Resident #R3 was observed to not have any dentures in her mouth. On 08/14/2024 at 12:53 p.m., an interview was conducted with S8CNA. She stated she was assigned to Resident #R3 on several occasions. She stated she worked both the 6:00 a.m.-2:00 p.m. shift and the 2:00 p.m.-10:00 p.m. shift. She stated cleaning dentures was part of oral care and should be performed each morning and night. She confirmed she never cleaned Resident #R3's dentures. She was notified of the findings on Resident #R3's Detail Summary Sheet, and stated if she did not document oral care on Resident #R3, she did not do it. On 08/14/2024 at 2:03 p.m., an interview was conducted with S2DON. She stated oral care was part of the CNA's a.m. care they were to provide to their assigned residents. She stated oral care was to be performed daily and included cleaning resident's dentures. She stated she reviewed both Resident #2 and #R3's Resident Care Detail Sheets and confirmed oral care was not documented as being performed daily and should have been. 46975

Based on record reviews and interviews, the facility failed to ensure residents, who required two person assistance with mechanical lift transfers, remained free of accident hazards for 1 (#1) of 8 (#1, #2, #3, R1, R2, R3, R4, and R5) residents reviewed for transfers. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at approximately 1:12 p.m. for Resident #1, a resident requiring mechanical lift with 2 person assistance for transfers, when S8CNA transferred the resident without another staff member's assistance. The transfer resulted in Resident #1 falling from the lift to the floor. Resident #1 was found unresponsive at 1:45 p.m., CPR initiated, and transferred to the hospital via emergency transportation. Resident #1 expired in the hospital at 2:24 p.m. from cardiac arrest. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. S1ADM was notified of the Past Noncompliance Immediate Jeopardy on [DATE] at 1:30 p.m. Findings: Review of the facility's undated policy Hydraulic Lift revealed the following, in part: Policy: The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair. Require two or three staff members to operate and accomplish the transfer. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Guillain-Barre Syndrome, Lack of Coordination, Contracture of Right and Left Hand and Muscle Wasting and Atrophy. Review of Resident #1's most recent MDS with an ARD of [DATE] revealed Resident #1 required two-person staff assistance for transfers. Review of Resident #1's current Care Plan revealed: Problem: Self -care ADL deficit: dependent upon staff for transfers related to Bilateral Hand Contractures and limited range of motion due to multiple muscles in bilateral lower extremities and bilateral upper extremities. Intervention: [DATE]- Use mechanical lift for transfers times 2 person Review of Resident #1's current Physician Orders revealed, in part: [DATE] Resident requires 2 person assist with transfers, uses a mechanical lift. Review of the facility's surveillance video footage on [DATE] at 1:30 p.m. with S1ADM and S2DON revealed the following: Date: [DATE] 1:12 p.m., S8CNA transported Resident #1 via geriatric chair into her room. 1:16 p.m., S8CNA retrieved a mechanical lift and entered Resident #1's room alone. No other staff member was seen to enter Resident #1's room with S8CNA. 1:19 p.m., S9CNA was in the hallway by Resident #1's door and S8CNA stepped into the hallway to talk to S9CNA. 1:21 p.m., S3LPN, S9CNA, S2DON and other nursing staff entered Resident #1's room. 1:55 p.m., S2DON entered Resident #1's room. Review of the facility's Investigation Report dated [DATE] at 1:05 p.m. revealed: S8CNA transferred Resident #1 by herself with the mechanical lift. Resident #1 fell from the lift and landed with her shoulders/back on the leg of the lift. S8CNA immediately called for assistance, and nurses assessed Resident #1. At that time, the only complaint Resident #1 had was she felt she had cracked some ribs. Resident #1 maintained her normal faculties and was able to appropriately, answer all questions. Approximately forty minutes later, S2DON made a round on Resident #1 and found her to be unresponsive. At that time, CPR was started and Resident #1 was taken to a local hospital for evaluation and treatment. Review of the facility's written staff member statements revealed the following: Staff member: S8CNA. Staff Statement on the fall that occurred on [DATE]: After lunch when I was making my last round I went to get Resident #1 to put her in bed before I went home. When I rolled Resident #1 into the room I went to get the lift from down the hallway and didn't see anyone. When I went back to Resident #1's room, I hooked her up to the lift and lifted her up and that's when the lift bars were tilted, and Resident #1 was leaning sideways on the lift pad. I put her back into her Geri chair and tried to fix the lift pad under her correctly. When I lifted her out of her chair and pulled the lift from under it, Resident #1 said she was falling. That is when Resident #1 slid out of the side of the lift pad on the right and hit her side on the legs of the lift. Review of the [DATE] Nurse's Notes for Resident #1 revealed the following: [DATE] at 1:34 p.m.-1:15 p.m. S3LPN was called to Resident #1's room by S9CNA, and observed Resident #1 lying supine with her head on the feet on the mechanical lift and lower extremities on the floor. Resident #1 complained of pain to the sacrum, back and right flank. S12NP gave an order to send the resident to the local hospital for evaluation. At 1:45 p.m. nursing staff was summoned to Resident #1's room due to Resident #1 becoming unresponsive. Nursing staff and administration begun CPR efforts. At 1:51 p.m., the ambulance arrived on scene and continued CPR. At 1:58 p.m. Resident #1 was intubated, no pulse. At 2:00 p.m. Resident #1 exited facility via ambulance for local hospital. Signed by S3LPN. Review of the hospital's Emergency Department Provider's Notes for Resident #1 dated [DATE] at 2:31 p.m. revealed the following, in part: Resident #1 was a level 1 trauma activation after a fall and cardiac arrest in the field. Per ambulance Resident #1 had a fall at her nursing home and was transported back to her room. Approximately 15 minutes later she was found pulseless. Ambulance arrived and performed ACLS with 3 rounds of Epinephrine and pulseless electrical activity consistently. Resident #1 arrived with supraglottic airway in place and compressions being performed. Total time of ACLS prior to arrival 35 minutes. At that time bedside cardiac ultrasound showed no cardiac activity, patient's pupils were fixed and dilated, no spontaneous breathing noted, no pulses palpable. Time of death called on [DATE] at 2:24 p.m. An interview was conducted on [DATE] at 8:27 a.m. with S8CNA. She stated on [DATE] she transported Resident #1 via geriatric chair to her room. S8CNA stated she then retrieved the mechanical lift and pushed it to Resident #1's room. S8CNA stated during transfer of Resident #1 with the mechanical lift, Resident #1 slipped out of the lift pad and fell on top of the legs of the lift hitting her right flank. She stated she did not ask for help with the mechanical lift transfer and transferred Resident #1 without assistance. S8CNA stated she knew she was supposed to use two person assistance with the lift. An interview was conducted on [DATE] at 11:37 a.m. with S13CNAS. She stated she required the CNA's to use two person assistance with all mechanical lift transfers. She stated S8CNA should have had another staff member to assist her with the mechanical lift transfer with Resident #1. An interview was conducted on [DATE] at 2:18 p.m. with S2DON. S2DON stated she was made aware of the incident with S8CNA and Resident #1 on [DATE]. She stated the facility's policy had always been two person assistance with a mechanical lift transfer. She stated she would expect all mechanical lift transfers to be completed with two staff members. She stated S8CNA was suspended and sent home immediately after the incident with Resident #1. S2DON stated she started the plan of correction immediately after the incident with Resident #1 on [DATE]. The facility implemented the following actions to correct the deficient practice: 1. Resident #1 was sent out to local hospital for evaluation and treatment on [DATE]. 2. A root cause analysis and 5 Whys was completed by the Administrator/DON on [DATE] to help identify the reason for the employee non-compliance. 3. Lift and lift pad were both checked by DON on [DATE] after the incident - no issues noted with lift and the lift pad was in good repair. 4. S8CNA was immediately pulled from the section on [DATE]. She gave a statement and was sent home pending investigation. 5. A list of Physician Orders were printed to determine lift status for all residents. All residents who require assistance via lifts have the potential to be affected on [DATE]. 6. All lifts were immediately taken out of service on [DATE] by DON/Maintenance until re-education and lift check-offs of present staff were completed. 7. No staff were allowed to use a lift until after education and check-off by DON/nursing administration. 8. The lift competency check-off created by Central Management (and a part of orientation) was used to re-educate staff beginning [DATE]. A post-test was created from the check-off, and was utilized to help ensure understanding. 9. Throughout the evening of [DATE] and the weekend of [DATE] through [DATE], the Administrative Nursing staff came to the facility to re-educate, test, and check-off all CNA, LPN, and RN prior to using a lift to ensure compliance. Return demonstrations were observed on all above-listed staff. Hours were staggered by the Nursing Administration to ensure supervisor and training on all shifts. 10. A new protocol by DON/nursing administration was implemented on [DATE] that all lifts must be completed with at least 3 certified/licensed/registered staff members (and 2 CNAs must have an LPN or RN present to perform a lift transfer) to ensure compliance with protocol. 11. Effective [DATE], the hall LPNs were required to sit on the hall to do documentation to help ensure availability and accessibility during transfers if needed. 12. All lifts and lift pads were inspected on [DATE] by mechanical lift medical supply company- no issues noted with lift operability or lift pads. One lift did have a part ordered and was taken out of commission until [DATE] to ensure maximum safety. 13. All wall care plans were checked by MDS on [DATE] to ensure that transfer status was correct for each resident. 14. Monitors were implemented beginning [DATE] by Nursing Administration to help ensure lifts were being done per care plan and safely. Re-educated provided as needed. 15. An in-service staff on the reporting of changes of resident condition was begun on [DATE] in regards to a different matter, but was applicable to this plan of correction also. 16. A multifaceted monitor on nurse's notes, treatment notes, physician orders, incident/accidents, and verbal notifications was put into place to help ensure the reporting of potential changes of resident status. This was implemented on [DATE]. 17. A QAPI monitor had been developed to ensure that lift transfers were done correctly and per care plan. This monitor was to be performed twice weekly for 6 weeks on a random sample by the DON or their designee, and then monthly thereafter until compliance was maintained. 18. Effectiveness of the corrective actions will be discussed weekly for 6 weeks at the Quality Assurance and Performance Improvement Meeting with findings added to the QAPI minutes. Additional in-services and/or corrective actions will be implemented as needed. 19. Date of completion will be [DATE].

Based on interviews and record reviews, the facility failed to ensure a resident's significant change in status was reported to the physician for 1 (#1) of 3 (#1, #2 and #3) sampled residents reviewed for notification of change. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at approximately 1:12 p.m. for Resident #1, a resident requiring mechanical lift with 2 person assistance for transfers, when S8CNA transferred the resident without another staff member's assistance. The transfer resulted in Resident #1 falling from the lift to the floor. On [DATE] from 1:48 p.m. to 1:53p.m., Resident #1 told S5CNA, S6CNA and S7CNA, I am going to die and showed symptoms of increased anxiety. None of the CNAs reported this to the nurse. Resident #1 was found unresponsive at 1:55 p.m., CPR initiated, and transferred to the hospital via emergency transportation. Resident #1 expired in the hospital at 2:24 p.m. from cardiac arrest. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. S1ADM was notified of the Past Noncompliance Immediate Jeopardy on [DATE] at 1:30 p.m. Findings: Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Guillain-Barre Syndrome, Lack of Coordination, Contracture of Right and Left Hand, Hypertensive Heart Disease with Heart Failure, Generalized Pain, Muscle Wasting and Atrophy, Schizoaffective Disorders, Bipolar Disorder, Severe Recurrent Major Depressive Disorder with Psych Symptoms, and Generalized Anxiety Disorder. Review of Resident #1's MDS with an ARD of [DATE] revealed Resident #1 had a BIMS of 10, which indicated her cognition was moderately impaired. Further review of the MDS revealed Resident #1 had speech difficulty with communicating some words or finishing thoughts, and if prompted or given time, made herself understood. Review of Resident #1's current Care Plan revealed the following, in part: Problem: [DATE] Mood Disorder related to diagnosis of Depression, Schizophrenia, and Anxiety. Intervention: Assess for changes in mood status. Review of the facility's Investigation Report dated [DATE] at 1:05 a.m. revealed: S8CNA transferred Resident #1 by herself with the mechanical lift. Resident #1 fell from the lift and landed with her shoulders/back on the leg of the lift. S8CNA immediately called for assistance, and nurses assessed Resident #1. At that time, the only complaint Resident #1 had was she felt she had cracked some ribs. Resident #1 maintained her normal faculties and was able to appropriately, answer all questions. Approximately forty minutes later, S2DON made a round on Resident #1 and found her to be unresponsive. At that time, CPR was started and Resident #1 was taken to a local hospital for evaluation and treatment. Review of the facility's surveillance video footage on [DATE] at 1:30 p.m. with S1ADM and S2DON revealed the following: Date: [DATE] 1:48 p.m. S6CNA entered Resident #1's room. 1:49 p.m. S6CNA exited Resident #1's room. 1:50 p.m. S7CNA and S5CNA entered Resident #1's room. 1:52 p.m. S7CNA and S5CNA exited Resident #1's room. 1:52 p.m. S5CNA re-entered Resident #1's room. 1:53 p.m. S5CNA exited Resident #1's room. 1:55 p.m. S2DON entered Resident #1's room and Resident #1 was found unresponsive. Review of the hospital's Emergency Department Provider's Notes for Resident #1 dated [DATE] at 2:31 p.m. revealed the following, in part: Resident #1 was a level 1 trauma activation after a fall and cardiac arrest in the field per ambulance, Resident #1 had a fall at her nursing home and was transported back to her room. Approximately 15 minutes later, she was found pulseless. Ambulance arrived and performed ACLS with 3 rounds of Epinephrine and pulseless electrical activity consistently. Resident #1 arrived with supraglottic airway in place and compressions being performed. Total time of ACLS prior to arrival 35 minutes. At that time bedside cardiac ultrasound showed no cardiac activity, patient's pupils were fixed and dilated, no spontaneous breathing noted, no pulses palpable. Time of death called on [DATE] at 2:24 p.m. An interview was conducted on [DATE] at 8:27 a.m. with S8CNA. She stated, on [DATE], during transfer of Resident #1 with the mechanical lift, the resident fell from the lift. S8CNA stated, after the fall, Resident #1 was agitated and anxious, but easily consoled. An interview was conducted on [DATE] at 9:46 a.m. with S6CNA. S6CNA stated, on [DATE] Resident #1 fell from the mechanical lift. S6CNA stated at 1:48 p.m., Resident #1 said she fell off the mechanical lift and thought her ribs were broken. The resident then stated, I think I am going to die. S6CNA stated Resident #1 was hyperventilating and seemed anxious. S6CNA stated she did not report the resident's statement or appearance to the nurse. An interview was conducted on [DATE] at 11:26 a.m. with S7CNA. S7CNA stated, on [DATE], Resident #1 fell from the mechanical lift. S7CNA stated at 1:50 p.m., she checked on Resident #1, and when she entered the room, Resident #1 looked panicked. S7CNA stated Resident #1 said her ribs were broken, call my sister, and I am about to die. S7CNA stated she did not report Resident #1's statement or appearance to the nurse. An interview was conducted on [DATE] at 2:52 p.m. with S5CNA. S5CNA stated, on [DATE], Resident #1 fell from the mechanical lift. S5CNA stated at 1:50 p.m., she checked on Resident #1, and when she entered the room, Resident #1 was nervous and fidgety and asking to call her sister. S5CNA stated she tried to calm Resident #1 down and was unsuccessful. S5CNA stated Resident #1 said, I am about to die, I am about to die. S5CNA stated at 1:52 p.m., she reentered Resident #1's room and the resident was screaming call my sister, call my sister. She stated she did not report Resident #1's statements or appearance to the nurse. An interview was conducted on [DATE] at 11:08 a.m. with S16RN. S16RN stated she was made aware Resident #1 fell from the mechanical lift soon after the incident happened. S16RN stated she did not receive report Resident #1 was showing signs of increased anxiety and difficult to calm or that Resident #1 was saying I am about to die. S16RN stated if a resident stated to a CNA I am about to die, she would expect the CNA to report it to the nurse immediately. She confirmed she would have assessed the resident and contacted the doctor had she known. An interview was conducted on [DATE] at 1:16 p.m. with S3LPN. S3LPN stated, on [DATE], Resident #1 fell from the mechanical lift. S3LPN stated when she got to Resident #1's room, the resident was on the floor. S3LPN stated Resident #1 complained of pain to her upper back at first and then her right flank area. S3LPN stated she did not receive report from nursing staff that Resident #1 had increased anxiety and was difficult to calm or that Resident #1 was saying I am about to die. S3LPN confirmed she would have contacted the doctor had she known. An interview was conducted on [DATE] at 11:07 a.m. with S12NP. S12NP stated Resident #1 was cognitive and able to communicate her needs. S12NP stated, on [DATE] at 1:15 p.m., she was notified Resident #1 fell from the mechanical lift and complained of back pain. S12NP said she was again contacted on [DATE] at 1:40 p.m. about Resident #1's complaint of rib pain. S12NP stated she was not notified of Resident #1's increased anxiety, hyperventilation, inability to be calmed, or the resident's statements that she thought she was going to die. She stated she received a text on [DATE] at 1:56 p.m. reporting Resident #1 was receiving CPR. An interview was conducted on [DATE] at 3:14 p.m. with S2DON. S2DON stated, on [DATE], she was made aware Resident #1 fell from the mechanical lift. S2DON stated she entered Resident #1's room at 1:55 p.m. and found her with eyes open, agonal breathing and a faint, thready pulse. S2DON stated Resident #1 was unresponsive. S2DON stated she started CPR. S2DON stated if a resident were to state to staff I am about to die, she would expect the staff to notify the nurse immediately. S2DON stated she started the plan of correction immediately on [DATE] after the incident with Resident #1. The facility implemented the following actions to correct the deficient practice: 1. Resident #1 was sent out to local hospital for evaluation and treatment on [DATE]. 2. A root cause analysis and 5 Whys was completed by the Administrator/DON on [DATE] to help identify the reason for the employee non-compliance. 3. Lift and lift pad were both checked by DON on [DATE] after the incident - no issues noted with lift and the lift pad was in good repair. 4. S8CNA was immediately pulled from the section on [DATE]. She gave a statement and was sent home pending investigation. 5. A list of Physician Orders were printed to determine lift status for all residents. All residents who require assistance via lifts have the potential to be affected on [DATE]. 6. All lifts were immediately taken out of service on [DATE] by DON/Maintenance until re-education and lift check-offs of present staff were completed. 7. No staff were allowed to use a lift until after education and check-off by DON/nursing administration. 8. The lift competency check-off created by Central Management (and a part of orientation) was used to re-educate staff beginning [DATE]. A post-test was created from the check-off, and was utilized to help ensure understanding. 9. Throughout the evening of [DATE] and the weekend of [DATE] through [DATE], the Administrative Nursing staff came to the facility to re-educate, test, and check-off all CNA, LPN, and RN prior to using a lift to ensure compliance. Return demonstrations were observed on all above-listed staff. Hours were staggered by the Nursing Administration to ensure supervisor and training on all shifts. 10. A new protocol by DON/nursing administration was implemented on [DATE] that all lifts must be completed with at least 3 certified/licensed/registered staff members (and 2 CNAs must have an LPN or RN present to perform a lift transfer) to ensure compliance with protocol. 11. Effective [DATE], the hall LPNs were required to sit on the hall to do documentation to help ensure availability and accessibility during transfers if needed. 12. All lifts and lift pads were inspected on [DATE] by mechanical lift medical supply company- no issues noted with lift operability or lift pads. One lift did have a part ordered and was taken out of commission until [DATE] to ensure maximum safety. 13. All wall care plans were checked by MDS on [DATE] to ensure that transfer status was correct for each resident. 14. Monitors were implemented beginning [DATE] by Nursing Administration to help ensure lifts were being done per care plan and safely. Re-educated provided as needed. 15. An in-service staff on the reporting of changes of resident condition was begun on [DATE] in regards to a different matter, but was applicable to this plan of correction also. 16. A multifaceted monitor on nurse's notes, treatment notes, physician orders, incident/accidents, and verbal notifications was put into place to help ensure the reporting of potential changes of resident status. This was implemented on [DATE]. 17. A QAPI monitor had been developed to ensure that lift transfers were done correctly and per care plan. This monitor was to be performed twice weekly for 6 weeks on a random sample by the DON or their designee, and then monthly thereafter until compliance was maintained. 18. Effectiveness of the corrective actions will be discussed weekly for 6 weeks at the Quality Assurance and Performance Improvement Meeting with findings added to the QAPI minutes. Additional in-services and/or corrective actions will be implemented as needed. 19. Date of completion [DATE].

Based on interviews and record reviews, the facility failed to ensure a resident received adequate supervision to prevent accidents with injury for 1 (#5) of 3 (#2, #3, and #5) residents reviewed for accidents. This deficient practice resulted in actual harm for Resident #5 when the resident was left unattended by staff on 10/14/2022. On 11/23/2021, Resident #5's physician ordered 1:1 staff supervision due to increased number of falls. On 10/14/2022, an injury of unknown origin was discovered for the resident. Resident #5 was sent to the ER, which resulted in four skin tears and a laceration to the back of the head that required 5 staples, and [MEDICATION(S)] for pain. Upon investigation, it was discovered S5CNA left the resident unattended in the shower room. Findings: Review of the clinical record for Resident #5 revealed she was admitted on [DATE] with diagnoses, which included Dementia, Anxiety, Repeated Falls, Abnormalities of Gait and Mobility, Difficulty in Walking, Cognitive Communication Deficit, and Lack of Coordination. Review of the Quarterly MDS with an ARD of 09/05/2022 revealed Resident #5 had a BIMS of 3, which indicated severe cognitive impairment. Functional Status included Resident #5 was able to ambulate and get in and out of the bed with stand by assist. Resident #5 needs 1-2 person assistance with all other ADLs. A review of the care plan revealed Resident #5 was at risk for falls and placed on 1:1 monitoring on 11/23/2021. Review of Physicians Orders dated 11/23/2021, for Resident #5 revealed an order for 1:1 monitoring for increased falls. Review of the facility's investigation dated 10/14/2022 revealed the following: 10/14/2022 at 8:31 a.m., S5CNA called S4LPN to the shower room. Resident #5 was found, in the shower room, with a laceration to the back of her head and skin tears to her right shoulder, right arm, and right leg. She was transferred to the ER and received 5 staples to the back of her head. Investigation- Review of surveillance video. On 10/18/2022 at 11:45 a.m., an observation was made of the surveillance video with S1ADM present. He identified the staff with the timeline of events for the incident on 10/14/2022: At 7:51 a.m., S5CNA and Resident #5 were walking down the hallway to the shower room. There was no wounds to the back of Resident #5's legs noted. At 7:52 a.m., S5CNA walks away from the shower room and down the hallway. Resident #5 is not with S5CNA at this time. At 7:54 a.m., S5CNA reappears on the camera walking towards the shower room. At 8:11a.m., S5CNA steps away from the shower room alone and calls for the nurse. At 8:11:26 a.m., S5CNA and S4LPN was observed going to the shower room. At 8:11:45 a.m., S6CNA was observed walking to the shower room. At 8:12:10 a.m., S4LPN walks away from the shower room towards the nurses' station. Review of hospitals records for Resident #5 revealed the following: 10/14/2022- laceration at the back of the head, received 5 staples and multiple skin tears. [MEDICATION(S)] was administered two times in the ER for pain and she received [MEDICATION(S)] for agitation. On 10/18/2022 at 9:00 a.m., an interview was attempted with Resident #5. She was unable to understand any questions and could not respond appropriately. She could not recall the incident on 10/14/2022. On 10/18/2022 at 9:10 a.m., an observation of Resident #5 observed going from lying to a sitting position and then from sitting to a standing position. She walked around the room then went back to the bed and laid down. On 10/18/2022 at 9:45 a.m., an interview was conducted with S5CNA. She confirmed Resident #5 required 1:1 supervision and should not be left alone. She said on Friday 10/14/2022, she walked Resident #5 into the shower room and sat the resident on a stationary chair. She said there was no blood noted anywhere. She said she stepped out of the room for two minutes to find the shower aide who usually bathes the resident. When she returned, the resident was in the same place and she noticed blood on the resident's gown and to her right elbow. She said she thought the blood was from the resident picking at her elbow. She said she decided to bathe the resident because of the blood on her arm. S5CNA put the resident in the whirlpool tub and washed her off. When she started washing her hair, she noticed a laceration to the back of her head and it was bleeding. She said while the resident was in the whirlpool, she stepped out of the shower room to get the nurse. She confirmed there was no one else in the shower room at the time of the incident. She said the only thing she could think of that happened was the resident tried to stand up and hit her head on the cabinet above the chair then fell back down into the chair. She said S7LPNWC assessed the resident's wounds. She said there were other times staff including herself, would leave the resident to go to the bathroom, to get food or to heat up food during a break. She said she knew the resident was supposed to be supervised at all times, but she would step out for a brief moment at times. She said she would leave the room door open so that someone in the hall could see the resident. On 10/18/2022 at 10:05 a.m., an interview was conducted with S4LPN. She said Resident #5 was a 1:1 supervision. S5CNA called for S4LPN on 10/14/2022 to the shower room and the resident was sitting in the whirlpool. She said the resident's right shoulder, right elbow and the back of her head were bleeding. She said she did not know how this happened to the resident. She said S7LPNWC assessed the wounds. She said S7LPNWC told her the resident needed to go out to the ER because of the deep head laceration. She said the NP and RP were notified and Resident #5 was sent to the ER. S4LPN verified she did not see wounds on Resident #5 prior to when she saw the resident in the shower room. On 10/18/2022 at 10:40 a.m., an interview was conducted with S6CNA. She said on 10/14/2022, she arrived to the shower room and found the resident sitting in the whirlpool. She said Resident #5 had injuries to the back of her head, right shoulder and elbow, and right leg. She said the resident was saying it hurt and ouch repeatedly while they were drying the resident off. She confirmed the resident was to be supervised at all times. On 10/18/2022 at 10:30 a.m., an interview was conducted with S7LPNWC. She said on 10/14/2022, she was called to the shower room for new injuries discovered on Resident #5. She stated Resident #5 had a deep laceration to the back of her head and she was unable to close the edges together to apply a dressing. She said she had skin tears to her right shoulder, right elbow, and lower right leg. She said she cleaned the areas, applied collagen, and transparent dressing to the skin tears. She said the laceration to the back of the head was deep and the resident needed to go to the ER. She said the NP was notified of a head injury and the NP ordered for Resident #5 to go to the hospital. S7LPNWC confirmed Resident #5 did not have those wounds prior to this incident. On 10/18/2022 at 1:45 p.m., an interview was conducted with S9LPNCC. She said on 10/14/2022, S4LPN notified S7LPNWC of the incident in the shower room and the injury to Resident #5's head. She said she went to the shower room to assist the other staff. She said Resident #5's right shoulder and elbow had a bruise with a skin tear, an actively bleeding skin tear to the back lower right leg, and a laceration to the back of her head. She confirmed Resident #5 was a 1:1 supervision resident due to high risk for falls. On 10/18/2022 at 10:27 a.m., an interview was conducted with S8CNA. She said Resident # 5 was a 1:1 supervision and had been for a while, but could not give an approximate length of time. On 10/17/2022 at 4:55 p.m., an interview was conducted with S12LPN. She said she cared for Resident #5 on the evening 2p-10p shift, of 10/13/2022. She said the resident was on 1:1 supervision and should not be left alone. She said she was not aware of the resident having any wounds prior to the incident on 10/14/2022. On 10/19/2022 at 10:15 a.m., an interview was conducted with S10CNA. She confirmed Resident #5 was 1:1 monitoring and should not be left unsupervised. On 10/19/2022 at 12:40 p.m., an interview was conducted with S3ADON. S3ADON confirmed Resident #5 had an order for 1:1 monitoring since 11/23/2021 and should have been supervised at all times. On 10/19/2022 at 12:30 p.m., an interview was conducted with S2DON. She confirmed the S5CNA should not have left the resident unsupervised, on 10/14/2022. She said S5CNA should have been present with the resident every minute of the shift unless she had relief for a break. On 10/18/2022 at 11:45 a.m., and interview was conducted with S1ADM. He confirmed Resident #5 should not have been left alone in the shower room on 10/14/2022. He said the S5CNA should have stayed with the resident.