Every finding on record at Kinder Retirement and Rehabilitation Center

Based on record review and interview, the facility failed to develop and maintain a comprehensive, person-centered care plan with measurable goals and individualized interventions for 3 (Resident #2, Resident #3, and Resident #27) of 45 sampled residents. The facility failed to ensure:1. Resident #2 and Resident #27's comprehensive care plan addressed the assistance needed for the activities of daily living (ADL) care, such as toileting, oral hygiene, use of shower/bath, and personal hygiene; and 2. Resident #3's comprehensive care plan addressed the use of oxygen therapies. Review of facility undated policy titled Care Plans- Comprehensive, revealed in part. it is the policy of this facility to develop and implement a comprehensive person centered care plan for each resident consistent with resident rights, that includes measureable objectives and timeframes to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the residents comprehensive assessment. The comprehensive care plan will describe, at a minimum, the following.A. Services that are to be furnished to attain or maintain the residents highest practicable, mental, and psychosocial well-being. Resident specific interventions that reflect the resident's needs and preferences. Resident #2 Review of Resident #2's medical record revealed an admission date of 03/05/2026. Diagnoses included, in part, Cerebral infarction due to unspecified occlusion or stenosis of the right middle cerebral artery, Hypertensive Heart Disease with Failure, Morbid Obesity, Difficulty walking, Lack of Coordination, and Muscle Weakness (Generalized). Review of Resident #2's comprehensive care plan with initiation date of 03/05/2026 and next review date of 09/22/2026 revealed that the care plan did not address all of Resident #2's ADL needs, specifically toileting hygiene, oral hygiene, use of shower/bath, and personal hygiene. In an interview on 07/14/2026 at 2:46 p.m., S5 CP LPN stated she does the care planning for Resident #2. S5 CP LPN reported she typically does not enter specific ADL needs for each resident in their comprehensive care plan. S5 CP LPN stated she was unsure whether all specific ADL needs should be listed in each resident's comprehensive care plan, but would find out. In an Interview on 07/14/2026 at 3:01 p.m., S5 CP LPN revealed that each resident's specific ADL needs should be identified on their comprehensive care plan. Review of Resident #2's comprehensive care plan with S5 CP LPN at this time. S5 CP LPN confirmed Resident #2's comprehensive care plan does not reflect all of Resident #2's specific ADL needs and should. Resident #27 Review of Resident #27's medical record revealed an admission date of 04/24/2009 with diagnoses that included in part, Alcohol Dependence with Alcohol-Induced Persisting Dementia, Rash and Other Nonspecific Skin Eruption, and Unspecified Atherosclerosis of Native Arteries of Extremities. Review of Resident #27's Quarterly MDS with an ARD of 05/13/2026 revealed a BIMs summary score of 09, which indicated moderate cognitive impairment. Resident #27 required supervision or touching assistance with toileting hygiene, setup or clean-up assistance with oral hygiene, and partial/moderate assistance with showers/baths and personal hygiene. Review of Resident #27's care plan with a target completion date of 08/15/2026 did not address ADL care such as toileting hygiene, oral hygiene, showers/baths, and personal hygiene. Interview on 07/14/2026 at 3:01 p.m., S5 CP LPN revealed that ADL care should be reflected in each resident's care plan. S5 CP LPN stated she was responsible for completing Resident #27's care plan and confirmed his care plan did not address his ADLs such as toileting hygiene, oral hygiene, showers/baths, and personal hygiene, but should have. Resident #3 Review of Resident #3's medical record revealed an admission date of 10/21/2020 with diagnosis included in part. Cerebral Infarction, Unspecified, Chronic Obstructive Pulmonary Disease, and Hypertensive Heart Disease with Heart Failure. Review of Resident #3's 07/2026 Physician orders revealed orders in part. - Oxygen at 2LPM (liters per minute) via nasal cannula as needed; Saturation less than 92% every 5 minutes as needed for shortness of breath; wheezing related to Chronic Obstructive Pulmonary Disease, Unspecified. -Oxygen at 2LPM (liters per minute) via nasal cannula continuous; except for smoking every 5 minutes as needed for shortness of breath; wheezing related to Chronic Obstructive Pulmonary Disease, Unspecified. Review of Resident #3's current comprehensive care plan revealed in part.Initial Date: 11/20/2024- Focus: The resident has COPD. Further review of Resident #3's care plan revealed no documentation of oxygen therapy usage. In an interview on 07/14/2026 at 10:06 a.m., Resident #3 revealed she required oxygen therapy use daily. Observation revealed oxygen in progress via oxygen concentrator and administered at 2LPM. In an interview on 07/14/2026 at 2:53 p.m., S4 MDS LPN revealed she was responsible for Resident #3's care planning. S4 MDS LPN revealed that the comprehensive care plan should be updated with each MDS assessment and as needed, such as when new physician orders are acquired. During a record review, at the time of interview, S4 MDS LPN confirmed Resident #3 had active Physician orders for oxygen therapy related to COPD and the plan of care did not address the use of oxygen, but should have.

Based on observations and interviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure treatment physician orders were obtained for a newly identified wound for 1 (Resident #27) of 1 sampled residents. Findings: Review of the facility's undated policy and procedure titled Skin Program, Pressure Ulcers, and Other Wounds read in part.11. If a resident does develop a reddened area or wound, the licensed nurse will implement the following interventions: c. obtain treatment order from physician if needed or implement the facility's protocol if appropriate.Review of Resident #27's medical record revealed an admission date of 04/24/2009 with diagnoses that included in part, Alcohol Dependence with Alcohol-Induced Persisting Dementia, Rash and Other Nonspecific Skin Eruption, and Unspecified Atherosclerosis of Native Arteries of Extremities.Review of Resident #27's 07/2026 Physician Orders on 07/14/2026 at 9:58 a.m. revealed no treatment orders.Review of Resident #27's Quarterly MDS with an ARD of 05/13/2026 revealed a BIMs summary score of 09, which indicated moderate cognitive impairment. Resident #27 had no current skin issues.Review Resident #27's Skin Check Assessment conducted by S3TX RN, dated 07/13/2026 revealed in part, no skin issues identified.Review of Resident #27's Care Plan with a target date of 08/04/2026 revealed in part, Lesion right hand (initiated 07/14/2026) with an intervention of perform wound care as ordered (initiated 07/14/2026).Observation on 07/13/2026 at 10:50 a.m. of Resident #27 revealed an uncovered, large red lesion to his right hand.Observation on 07/14/2026 at 10:23 a.m. of Resident #27 revealed an uncovered, large red lesion that had burst with minimal blood oozing out on his right hand.In an interview on 07/14/2026 at 11:12 a.m., S3TX RN revealed that she is responsible for performing wound care treatments and conducting skin assessments on residents in the facility. S3 TX RN revealed that when she performs a skin assessment she assesses all areas of the resident's skin. S3 TX RN stated that she didn't notice the lesion to Resident #27's right hand until today.In an interview on 07/15/2026 at 9:26 a.m., S3TX RN stated she began treatment for Resident #27's lesion to his right hand.Review of Resident #27's 07/2026 physician orders on 07/15/2026 at 12:08 p.m., revealed no treatment orders for a lesion to right hand. Review of Resident #27's TAR revealed no treatments.Observation on 07/15/2026 at 12:25 p.m., revealed Resident #27 sitting up in his wheelchair, band-aid noted to his right hand, dated 07/15, and initialed by S3TX RN.In an interview on 07/15/2026 at 12:27 p.m., S3TX RN stated that on 07/14/2026 she cleaned the lesion to Resident #27's right hand with normal saline, applied TAO ointment, and placed a band-aid on it. S3 TX RN reviewed Resident #27's 07/2026 physician orders and confirmed there were no treatment orders obtained or any documentation on the TAR of the treatment performed. S3TX RN stated I just forgot to put in an order. S3TX RN confirmed she's supposed to have a physician's order, but did not.In an interview on 07/15/2026 at 12:32 p.m., S1 DON confirmed treatments should be done with a physician's order in place. S1 DON confirmed Resident #27 didn't have any treatments listed on his TAR because there wasn't a physician's order but should have been.

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 (Resident #27 and Resident #71) sampled residents. The facility failed to provide nail care for Resident #27 and Resident #71. Findings: Review of the facility undated policy titled, Nail Care revealed in part, Policy: The purpose of this policy is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: 1. Routine nail cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 2. Routine nail care, to include trimming and filing, will be provided by nurse on a regular schedule per care plan unless contraindicated. Nail care will be provided between scheduled occasions as the need arises. 3. Principles of nail care: b. only licensed nurses shall trim or file fingernails of residents with diabetes. Resident #27 Review of Resident #27's medical record revealed an admission date of 04/24/2009 with diagnoses that included in part, Alcohol Dependence with Alcohol-Induced Persisting Dementia, Rash and Other Nonspecific Skin Eruption, and Unspecified Atherosclerosis of Native Arteries of Extremities. Review of Resident #27's Quarterly MDS with an ARD of 05/13/2026 revealed a BIMs summary score of 09, which indicated moderate cognitive impairment. Resident #27 required partial/moderate assistance with showers/baths and personal hygiene. Review of Resident #27's facility task log revealed he required nail care to be performed by S3TX RN every Monday. Review of task log with a 30 day lookback period revealed the question asked Nail care performed by Licensed Nurse. S3TX RN documented for all days an answer of No. Review of Resident #27's record revealed no evidence or documentation of refusals of nail care between 06/15/2026-07/13/2026. Observation on 07/13/2026 at 10:30 a.m. revealed Resident #27 propelling himself in his wheelchair with thick, yellow-tinged, untrimmed, and jagged nails. Observation on 07/13/2026 at 10:50 a.m. revealed Resident #27 propelling himself in his wheelchair with thick, yellow-tinged, untrimmed, and jagged nails. Observation on 07/14/2026 at 10:23 a.m. revealed Resident #27 propelling himself in his wheelchair with thick, yellow-tinged, untrimmed, and jagged nails. Interview on 07/14/2026 at 11:12 a.m., S3TX RN stated Resident #27 would refuse care in the past but had no refusals recently. S3TX RN revealed Resident #27's nails would grow fast and she would trim them at times. At 11:18 a.m., S3TX RN observed Resident #27's nails with this surveyor and confirmed the above findings. S3TX RN confirmed that she documented No to performing Resident #27's nail care every Monday which meant she didn't perform nail care. S3TX RN confirmed Resident #27 hadn't had any nail care performed but should have. Resident #71 Review of Resident #71's medical record revealed an admission date of 08/15/2024 and diagnoses included in part. Cerebral Infarction, Unspecified, Type 2 Diabetes Mellitus Without Complications, and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side. Review of Resident #71's Quarterly MDS with an ARD of 05/31/2026 revealed a BIMS score of 15, which indicated intact cognition and had no behaviors. Resident #71 required assistance partial/moderate assistance with personal hygiene and use of shower/bath. Review of Resident #71's current comprehensive care plan revealed in part. no documentation of refusals of baths/showers or nail care for 07/13/2026 or 07/14/2026. The last documented refusal of a bath was documented on 03/09/2026. Review of Resident #71's Tasks revealed in part. -Nail care performed by licensed nurse: 06/15/2026, 06/22/2026, 06/29/2026, 07/06/2026, and 07/13/2026.documented as No. No documentation of refusals of care for these dates. -Bathing: 07/13/2026 and 07/14/2026.documented as a bed bath was given on both dates. No documentation of refusals of baths from 06/15/2026-07/14/2026. -Nail Care: 07/13/2026 at 4:42 p.m. and 07/14/2026 at 11:18 a.m.documented as nail care was provided to Resident #71. In an interview on 07/13/2026 at 10:21 a.m., Resident #71 revealed he did not have his fingernails trimmed or cleaned in a while. Observation, at the time of interview, revealed all the resident's fingernails were long/jagged and had yellow/brown substances underneath nails. Observed Resident #71's left hand was contracted with fingernails long/jagged and touching the palm of the resident's hand. Resident #71 stated he was scheduled to get a bath today and would ask the staff to cut, clean and trim his nails during his bath. In an interview on 07/14/2026 at 9:40 a.m., S8 CNA revealed Resident #71 required assistance with bed baths, showering, and nail care. S8 CNA revealed the resident did not refuse care or have behaviors and allowed her to perform a bed bath. S8 CNA stated that during a bed bath/shower, all CNAs should perform nail care including cleaning of fingernails and trimming (only if the resident were not diabetic). In an interview on 07/14/2026 at 9:49 a.m., Resident #71 stated he did not receive nail care yesterday (07/13/2026) or today, despite asking staff. Observation, at the time of interview, revealed resident's fingernails were still long and jagged with yellow/brown substance underneath his nails. Observation of left contracted hand still with long/jagged fingernails and touching the palm of the resident's hand. On 07/14/2026 at 12:00 p.m., S2 ADON accompanied this surveyor to Resident #71's bedside. S2 ADON confirmed all the above findings. In an interview and record review on 07/14/2026 at 12:09 p.m., S2 ADON confirmed the CNAs documented Resident #71 was given a bed bath on 07/13/2026 and 07/14/2026; the resident was not documented as refusal of care; and stated the CNAs should have cleaned Resident #71's fingernails during his bed baths performed, but did not. S2 ADON stated there was no way the fingernails could have gotten this dirty, at this time. S2 ADON stated Resident #71 was a diabetic and S3 TX RN should have trimmed and filed his fingernails. S2 ADON confirmed the documentation for nail care performed by the LPN from 06/22/2026- 07/13/2026 was documented as No and there was no documentation of refusals of nail care. In an interview and record review on 07/14/2026 at 12:14 p.m., S3 TX RN confirmed she documented No on the resident's nail care task from 06/22/2026- 07/13/2026 and stated, I just didn't do it., with no explanation given. S3 TX RN revealed the resident did not refuse nail care on these dates, and nail care should have been performed, but was not. In an interview 07/15/2026 at 11:24 a.m., S11 LPN revealed Resident #71 depended on the staff to perform nail care and trim his fingernails. S11 LPN revealed Resident #71 does not refuse care that she was aware of, including baths or nail care.

Based on record review and interview, the facility failed to complete an annual performance review at least once every 12 months for 1 (S12 CNA) of 5 CNA personnel records reviewed. Findings:Review of S12 CNA personnel records revealed the following:Review of S12 CNA's personnel record revealed a hired date of 06/16/2023. Further review revealed an annual performance review had not been completed and/or signed off in the past 12 months. Review of S12 CNA's last performance evaluation was completed on 06/16/2024. Review of S12 CNA's employee timecards revealed S12 CNA had worked 11 days in June 2026. Interview on 07/14/2026 at 2:52 p.m., S10 BOM confirmed the performance evaluation for S12 CNA was not completed annually as required but should have been.

Based on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with current accepted professional principles by failing to store all drugs and biologicals in locked compartment. The facility failed to ensure an unattended medication cart (Cart A) was locked appropriately. This deficient practice has the potential to effect 78 residents currently residing in the facility. Findings:Review of an undated facility policy on 07/14/2026 at 11:07 a.m. titled, Medications-Storage revealed in part.The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Observation on 07/13/2026 at 9:03 a.m. revealed Cart A was placed at the entrance of a busy hallway (Hall X) unattended, unlocked, and facing outward into Hall X. Observed multiple staff members and residents walking/wheeling by the unlocked medication cart.Observation on 07/13/2026 at 9:09 a.m. revealed Cart A was placed at the entrance of a busy hallway (Hall X) unattended, unlocked, and facing outward into Hall X. Observed multiple staff members and residents walking/wheeling by the unlocked medication cart.Observation on 07/13/2026 at 9:44 a.m. revealed Cart A was placed at the entrance of a busy hallway (Hall X) unattended, unlocked, and facing outward into Hall X. Observed multiple staff members and residents walking/wheeling by the unlocked medication cart.Observation on 07/13/2026 from 10:17 a.m. to 10:38 a.m. revealed Cart A was placed at the entrance of a busy hallway (Hall X) unattended, unlocked, and facing outward into Hall X. Observed multiple staff members and residents walking/wheeling by the unlocked medication cart. Observation of S6 LPN, who was assigned to Cart A, seated behind the nurse's station and out of sight of Cart A.In an interview on 07/13/2026 at 10:40 a.m., S6 LPN revealed he was assigned to Cart A and was aware all medication carts should be locked when not in use. S6 LPN confirmed Cart A was placed on Hall X, left unattended, unlocked, and unsecured, but should not have been. In an interview on 07/14/2026 at 11:08 a.m., S1 DON revealed she expected the nurses to lock their medication carts when not in use. S1 DON revealed all medication carts should be locked and secured at all times when not in use or left unattended.

Based on observation and interview, the facility failed to ensure menus were followed in order to meet the nutritional needs of residents who required a puree diet. The facility failed to follow the established recipes to ensure the nutritional adequacy of the meal for Resident #16 and Resident #22 who received puree diets. Findings:Review of a facility's undated policy titled, Puree Food Preparation revealed the following in part . Policy: It is the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance. Policy Explanation and Compliance Guidelines: 6. Residents receiving puree diets should always receive portions equivalent to those served on the regular or therapeutic diet ordered per facility policy and procedure. Observation on 07/13/2026 at 11:28 a.m. preparing puree meals revealed S13 [NAME] prepare the following pureed food items .Observed S13 [NAME] scoop 2 grey scoops equaling 8 oz of rice and put it in the blender, blend it, add an unmeasured amount of chicken broth, blend it again, add 2 pumps/squirts of thickener, and then blend again. Observed S13 [NAME] scoop 2 ladles of red beans and sausage equaling 12 ounces and put it in the blender. Observed S13 [NAME] scoop 2 ladles of green beans equaling 8 ounces and put it in the processor, blend it. S13 [NAME] then asked S9 DM if the consistency was ok once she had finished blending the green beans. S9 DM told S13 [NAME] to add some chicken broth to make it moist otherwise it looked like chopped consistency. S13 [NAME] added an unmeasured amount of chicken broth in the processor. Observed S13 [NAME] get 2 pieces of cornbread and put in the blender, blend it, add an unmeasured amount of milk, and then blend it again. S13 [NAME] stated to S9 DM it's still liquidy. S13 [NAME] added 2 pumps/squirts of thickener into the blender, blended it. S13 [NAME] stated to S9 DM it is still runny. S13 [NAME] added one more pump/squirt into the blender and then blended it again. S9 DM stated, We always blend everything first before adding liquids. Observed S13 [NAME] add 2 scoops equaling 4 ounces of chocolate pudding pie into blender, blend it and then show it to S9 DM. S9 DM told S13 [NAME] to add some milk into the blender to make it just a little bit, just to make it you know. S13 [NAME] added an unmeasured amount of milk into processor and blended it. S13 [NAME] showed it to S9 DM who nodded yes.07/13/2026 at 11:55 a.m. Review of the facility's standardized recipe for puree steamed rice revealed the following in part .Preparation for rice according to regular recipe: 10 servings, 1 1/4 Quart white rice steamed, 1 cups milk or appropriate liquid. Place food in processor-puree food should be soft and smooth without any lumps or visible particles. Liquids should not be separated from the solids. Serving size 1/2cup. Serving utensil #8 scoop. 07/13/2026 at 11:55 a.m. Review of the facility standardized recipe for puree green beans revealed the following in part .Preparation for green beans according to regular recipe: 10 servings, 1 1/4 quart green beans, 2/3 cup of milk or appropriate liquid. Drain any excess liquid from food. Place prepared recipe portion into a processor or blender. Blend until smooth. If additional liquid and/or thickener are needed, add 1 Tablespoon at a time until puree looks smooth and moist and is appropriate. Serving size 1/3 cup. Serving utensil #12 scoop.07/13/2026 at 11:55 a.m. Review of the facility standardized recipe for puree cornbread revealed the following in part .Preparation for cornbread according to regular recipe: 10 servings, 10 squares of cornbread, 2/3 cup of milk or appropriate liquid. Break cornbread into small pieces and place in food processor. Process until crumbled. In a separate bowl, place appropriate liquid that is thickened. Sprinkle finely crumbled cornbread over the thickened liquid. Gently stir to moisten all the crumbs. Moistened cornbread can be scooped or placed in mold to shape, chill for 2-3 hours. Moistened cornbread should be placed in steam table pan or steamer to warm before service. Serving size 1/4 cup. Serving utensil #16 scoop. 07/13/2026 at 11:55 a.m. Review of the facility standardized recipe for puree chocolate pie with pudding revealed the following in part. Preparation according to regular recipe: 10 servings, 9.91 slices of chocolate pie with pudding, 2/3 cup of milk. Drain any excess liquid from food. Place prepared recipe portion into a blender or food processor. Blend until smooth. Additional liquid and/or thickener may be needed to ensure puree is smooth, moist and appropriate. Serving size 1/3 cup. Serving utensil #12 scoop. 07/13/2026 at 11:55 a.m. Review of the facility standardized recipe for pureed red beans and sausage revealed the following in part .Preparation for red beans with sausage according to regular recipe: 10 servings, 2/3 cup of milk or appropriate liquid, 3 pounds 12 ounces of red beans with sausage. Drain any excess liquid from food. Place prepared recipe portion into blender or food processor. Blend until smooth. Serving size 6 ounces. Serving utensil 6oz spoodle.Observation on 07/13/2026 at 11:55 a.m. of S9 DM serving and preparing puree trays revealed the cornbread had a very, small portion size on the plates served to Resident #16 and Resident #22. During the serving, it was also observed that S9 DM ran out of pureed green beans after serving 1 of the 2 residents on puree diets. S9 DM asked S14 [NAME] to prepare more pureed green beans. S14 [NAME] was observed using a 4-ounce ladle and scooped 4 scoops into the processor, added 8 ounces of milk into the processor, blended it and then showed it to S9 DM. S9 DM told S14 [NAME] it is too liquidy, add more green beans. S14 [NAME] added 4 more ounces of green beans into the processor, blended it again and showed S9 DM. S9 DM told her, It looked ok.In an interview on 07/13/2026 at 3:15 p.m., S9 DM confirmed the recipes for the Puree meals were not followed to prepare the puree meals but should have been. S9 DM confirmed she used a 1-ounce scoop to serve the cornbread but should have used a 2-ounce scoop according to the recipe and did not. S9 DM confirmed Resident #16 and Resident #22 did not receive the appropriate serving size of cornbread. In an interview on 07/14/2026 at 3:33 p.m., S13 [NAME] acknowledged she did not follow the recipe menu to prepare puree meals. Surveyor asked S13 [NAME] why she didn't use the recipe menus and S13 [NAME] just shrugged her shoulders meaning, I don't know.

Based on observation, record review, and interview, the facility failed to ensure residents with an order for psychotropic medication were not subjected to chemical restraints for 7 (#9, #12, #13, #24, #25, #60, and #73) of 11 (#5, #8, #9, #10, #12, #13, #24, #25, #26, #60, and #73) residents reviewed for unnecessary medications. The facility failed to:Ensure PRN orders for psychotropic medication were limited to 14 days for Residents #9, #12, #13, #25, #60, and #73; andEnsure Resident #24 was free from chemical restraints imposed for discipline or convenience. Resident #12 Review of Resident #12’s medical record revealed an admission date of 07/17/2025 with diagnoses which included Spinal Stenosis and Pain. Review of Resident #12’s physician’s orders revealed the following, in part… 07/17/2025 Morphine Sulfate 30mg tablet by mouth every 12 hours as needed for pain. The order had no end date and was last revised on 07/17/2025. 07/17/2025 Hydrocodone-Acetaminophen 10-325mg tablet by mouth every 8 hours as needed for pain. The order had no end date and was last revised on 07/17/2025. Further record review revealed no documentation by the physician regarding the rationale for continued use of PRN psychotropic medications after 14 days. Resident #24 Review of Resident #24’s medical record revealed on admission date of 01/25/2016 with diagnoses which included Anxiety and Schizoaffective Disorder, Bipolar Type. Review of Resident #24’s physician’s orders revealed Buspirone 10mg by mouth three times a day for being combative with staff and excessive pacing related to Anxiety Disorder, dated 10/04/2024. Interview with S5 LPN on 08/06/2025 at 8:35 a.m. revealed Resident #24 had a history of being combative with staff. S5 LPN confirmed “his Buspar is for combativeness”. Resident #60 Review of Resident #60’s medical record revealed an admission date of 07/15/2025 with diagnoses which included Fracture of Left Clavicle and Non-displaced Fracture of Left Humerus. Review of Resident #60’s physician’s orders revealed, in part…Oxycodone 5mg by mouth every 6 hours as needed for moderate to severe pain, dated 07/15/2025. The order had no end date and was last revised on 07/15/2025. Further record review revealed no documentation by the physician regarding the rationale for continued use of the PRN psychotropic medication after 14 days. Review of Resident #13's medical record revealed a readmission date of 10/04/2024 with diagnoses that included End Stage Renal Disease, Anxiety Disorder, and Osteoarthritis. Review of Resident #13’s current medication orders revealed an order for Alprazolam 0.5 mg (a medication given to treat anxiety) with directions to Give 1 tablet by mouth every 12 hours as needed for Anxiety related to anxiety disorder, unspecified for 60 Days. The order had a start date of 07/16/2025 and an end date of 09/14/2025. Further review of Resident #13’s current physician’s orders revealed a PRN order for Tramadol 50 mg (an opioid medication given to treat pain) with a start date of 06/26/2025 and an indefinite or unspecified end date. The directions for the Tramadol order read, “Give 1 tablet by mouth every 6 hours as needed for Pain related to primary generalized osteoarthritis.” Review of the 07/14/2025 Medication Regimen Review by the pharmacist revealed the following, in part…PRN Alprazolam 0.5mg po q 12 hours prn anxiety started on 06/29/2025. Has no limits. Nursing notified to clarify this. Review of Resident #13’s medical record revealed there was no rationale provided for the continuation of Alprazolam and Tramadol by the attending physician or prescribing practitioner to extend the orders past 14 days. Resident #9 Review of Resident #9’s medical record revealed an admission date of 06/17/2024 with diagnoses that included in part: Pain, Unspecified and Other Acute Osteomyelitis, Right Ankle and Foot. Review of Resident #9’s 08/2025 current physician’s orders revealed the following in part: 04/15/2025-Hydrocodone-Acetaminophen 5-325mg (an opioid used to treat pain), give 1 tablet by mouth every 4 hours as needed for breakthrough pain 04/15/2025-Hydromorphone HCL (Hydrochloride) oral tablet 2mg (an opioid used to treat pain), give 2mg by mouth every 4 hours as needed for shortness of breath/air hunger/severe pain Review of Resident #9’s order entry report for Hydrocodone-Acetaminophen 5-325mg PRN and Hydromorphone HCl 2mg PRN revealed a start date of 04/15/2025 and no end date. Further record review revealed no documentation by the physician of a rationale or an evaluation of Resident #9 for continued use of both PRN psychotropic medications after 14 days of use. Resident #25 Review of Resident #25’s medical record revealed an admission date of 02/10/2025, with diagnoses that included in part… Chronic Obstructive Pulmonary Disease, Acquired Absence of Right Leg Below Knee, Pain, Muscle Spasm, and Hereditary and Idiopathic Neuropathy. Review of Resident #25’s current physician orders reveal an order for Norco oral tablet 5-325mg (Hydrocodone-Acetaminophen) 1 tablet by mouth every 4 hours as need for pain related to pain (start date: 02/10/2025). In an interview on 08/06/2025 at 1:40 p.m., S2 DON confirmed she was unaware of the need for reassessment of a PRN psychotropic medications after a 14-day period. On 08/06/2025, a review of the facility’s undated policy titled “Medications-Use of Psychotropic Drugs” revealed in part…5. PRN orders for psychotropic drugs are limited to 14 days, except as provided if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. He or she should document their rationale in the resident’s medical record and indicate the duration for the PRN order. 6. PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. Resident #73 Review of Resident #73's medical record revealed a readmission date of 04/30/2024 with diagnoses that included in part .Hypertensive Heart Disease with Heart Failure and Anxiety Disorder. Review of Resident # 73’s current physician’s orders revealed an order for Lorazepam 0.5mg (a medication given to treat anxiety) with directions to “Give 1 tab po q 6 hours prn Anxiety related to Anxiety Disorder, Unspecified for 60 Days.” The order had a start date of 06/17/2025 and an end date of 08/16/2025. Review of the Pharmacist’s Medication Regimen Review dated 06/17/2025 revealed in part… · PRN Lorazepam completed & discontinued on 06/10/2025 · PRN Lorazepam 0.5mg po q6h prn Anxiety x’s 60days reordered on 06/17/2025 Review of the Resident #73’s medical record revealed there was no rationale or documentation provided for the continuation of Lorazepam by the attending physician or prescribing practitioner to extend the order past 14 days. In an interview on 08/06/2025 at 1:42 p.m., S2DON acknowledged multiple sampled residents currently had PRN psychotropic medication orders at this time that exceeded the 14 day limit. S2DON stated she was unaware PRN psychotropic medication orders could not extend past 14 days and stated she thought the orders could remain in place for up to 60 days.

Based on interview and record review the facility failed to ensure all care and services were provided according to accepted standards of clinical practice. The facility failed to document appropriately in Resident #25's medical record the administration of controlled medications. Total sample size was 32. Findings: Review of an undated facility policy titled, Medications-Controlled Substances revealed the following in part.All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient-specific narcotic dispensed from the pharmacy. Review of Resident #25's medical record revealed an admission date of 02/10/2025, with diagnoses that included in part. Chronic Obstructive Pulmonary Disease, Acquired Absence of Right Leg Below Knee, Pain, Muscle Spasm, and Hereditary and Idiopathic Neuropathy.Review of Resident #25's Quarterly MDS with an ARD of 05/16/2025 revealed a BIMS score of 13, which indicated intact cognition and received opioids. Resident #25 used a manual wheelchair and was independently able to wheel himself 150 feet. Review of Resident #25's current physician orders revealed an order for Norco oral tablet 5-325mg (Hydrocodone-Acetaminophen) 1 tablet by mouth every 4 hours as need for pain related to pain (start date: 02/10/2025).Review of Resident #25's care plan with an initiated date of 02/10/2025, revealed the following in part.Focus: The resident has pain related to amputation. Interventions: Administer analgesia medication as per orders; Give 1/2 hour before treatments or care; Evaluate the effectiveness of pain interventions; Review for compliance, alleviating of symptoms, dosing schedules, resident satisfaction with results, impact on functional ability and impact on cognition; Monitor/document for probable cause of each pain episode; and Remove/limit causes where possible. Review of Resident #25's 05/2025, 06/2025, 07/2025, and 08/2025 EMAR, revealed multiple occasions where the Norco oral tablet was not signed out by the nurse or documented appropriately upon administration. The following dates had no documentation of medication administration: 05/12/2025, 05/29/2025, 06/06/2025, 06/11/2025, and 06/16/2025. Review of Resident #25's Narcotic Medication Reconciliation form for Norco 5-325mg tablet revealed the following in part.on dates 05/12/2025, 05/29/2025, 06/06/2025, 06/11/2025, and 06/16/2025 Resident #25 was administered the controlled medication. In an interview on 08/05/2025 at 4:13 p.m., S2 DON revealed the process for documentation of controlled medications included documenting simultaneously in the electronic record (EMAR) and on the control medication reconciliation form upon administration of the controlled medication. S2 DON stated she expects all nurses to follow this procedure for documenting all controlled medications. S2 DON stated that nurses are not to document only in one area. In an interview on 08/06/2025 at 1:40 p.m., S2 DON confirmed that on dates 05/12/2025, 05/29/2025, 06/06/2025, 06/11/2025, and 06/16/2025, the nurses did not correctly document in Resident #25's medical record the administration of his controlled medication (Norco), but should have.

Based on interview and record review, the facility failed to ensure pain management was provided to a resident who requires such services, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 (Resident #25) of 2 (Resident #9 and Resident #25) sampled residents reviewed for pain. The facility failed to ensure Resident #25, who reported pain, received a thorough pain assessment and medication or interventions to alleviate the pain.Findings: Review of an undated facility policy on 08/06/2025 at 9:47 a.m. titled, Pain Management revealed the following in part.To help the resident attain his or her highest practicable level of well-being through effective interventions for pain. Pain is subjective and complex experience. All pain is real regardless of its cause and must be treated even then the cause remains unknown. Ask the resident about pain regularly. Assess pain systematically. Believe the resident and family in their reports of pain and what relieves it. Choose appropriate pain control options for the resident, family and setting. Deliver interventions in a timely, logical, and coordinated fashion. Enable residents to control their course of treatment to the greatest extent possible. 5. For residents that are identified has having pain, further assessment will be completed and if needed, physician orders requested, and finally, a care plan developed to include medication, potential side effects from medications and other interventions that may be effective in controlling the resident's pain. Review of Resident #25's medical record revealed an admission date of 02/10/2025, with diagnoses that included in part. Chronic Obstructive Pulmonary Disease, Acquired Absence of Right Leg Below Knee, Pain, Muscle Spasm, and Hereditary and Idiopathic Neuropathy.Review of Resident #25's Quarterly MDS with an ARD of 05/16/2025 revealed a BIMS score of 13, which indicated intact cognition and received opioids. Resident #25 used a manual wheelchair and was independently able to wheel himself 150 feet. Resident had no behaviors related to medication refusal. Review of Resident #25's current physician orders revealed an order for Norco oral tablet 5-325mg (Hydrocodone-Acetaminophen) 1 tablet by mouth every 4 hours as need for pain related to pain (start date: 02/10/2025). Review of Resident #25's care plan with an initiated date of 02/10/2025, revealed the following in part.Focus: The resident has pain related to amputation. Interventions: Administer analgesia medication as per orders; Give 1/2 hour before treatments or care; Evaluate the effectiveness of pain interventions; Review for compliance, alleviating of symptoms, dosing schedules, resident satisfaction with results, impact on functional ability and impact on cognition; Monitor/document for probable cause of each pain episode; and Remove/limit causes where possible. Review of Resident #25's 06/2025 EMAR revealed the last dose of Norco 5-325mg was received on 06/21/2025. Resident had no documentation of medication refusals. Review of Resident #25's medical record revealed the last assessment for pain level summary was on 06/21/2025. Review of Resident #25's medical record revealed Resident #25 complained of pain on 07/07/2025 at 12:01 p.m., 07/08/2025 at 9:33 a.m., 07/16/2025 at 12:04 p.m., 07/17/2025 at 11:04 p.m., 07/21/2025 at 1:28 p.m., 07/22/2025 at 6:35 p.m., 07/25/2025 at 9:34 a.m., 07/27/2025 at 6:59 p.m., 07/31/2025 at 5:45 p.m., 08/04/2025 at 6:15 p.m., and 08/05/2025 at 5:41 p.m. In an interview on 08/06/2025 at 9:41 a.m., Resident #25 revealed he attended therapy for about 1 month and his pain worsened due to working with therapy. Resident #25 stated he reported to multiple nurses about his pain level and was told by nursing staff they would call the physician. Resident #25 stated he has not received anything for pain in the last month and has stopped asking because it was no use and the nurses did not listen to his reports of pain. Resident #25 stated he knew he had physician orders for pain medications and did not understand why the nurses do not offer him these medications.In a telephone interview on 08/06/2025 at 12:59 p.m., S6 LPN revealed that Resident #25 has occasionally complained of pain to her in the past month. S6 LPN stated that yesterday (08/06/2025) she documented Resident #25 had complained of pain but she did not administer his PRN Norco as ordered for pain nor had she completed a pain assessment. In an interview on 08/06/2025 at 1:40 p.m., S2 DON revealed after nurses are made aware of a residents complaints of pain, she expected the nurse to perform a full and complete pain assessment, document the finding's, verify the current physician's orders for pain interventions (including medications), administer medications as ordered, and reassess for effectiveness. S2 DON confirmed that nursing staff should have completed an assessment of Resident #25's pain and administered PRN Norco as ordered but did not.

Based on interview and record review the facility failed to provide pharmaceutical services to ensure procedures that assure accurate acquiring, receiving, dispensing and administration of medications to meet the needs of residents for 1 (Resident #25) of 32 sampled residents. The facility failed to provide pain medications and/or biologicals to Resident #25, who complained of pain. Findings:Review of an undated facility policy on 08/06/2025 at 9:47 a.m. titled, Pain Management revealed the following part.To help the resident attain his or her highest practicable level of well-being through effective interventions for pain. Pain is subjective and complex experience. All pain is real regardless of its cause and must be treated even then the cause remains unknown. Deliver interventions in a timely, logical, and coordinated fashion. 5. For residents that are identified has having pain, further assessment will be completed and if needed, physician orders requested, and finally, a care plan developed to include medication, potential side effects from medications and other interventions that may be effective in controlling the resident's pain. Review of Resident #25's medical record revealed an admission date of 02/10/2025, with diagnoses that included in part. Chronic Obstructive Pulmonary Disease, Acquired Absence of Right Leg Below Knee, Pain, Muscle Spasm, and Hereditary and Idiopathic Neuropathy. Review of Resident #25's Quarterly MDS with an ARD of 05/16/2025 revealed a BIMS score of 13, which indicated intact cognition and received opioids. Review of Resident #25's current physician orders revealed an order for Norco oral tablet 5-325mg (Hydrocodone-Acetaminophen) 1 tablet by mouth every 4 hours as need for pain related to pain (start date: 02/10/2025). Review of the resident's discontinued/completed medication orders revealed no other physician orders or interventions to manage pain. Review of Resident #25's Norco 5-325mg medication record reconciliation form revealed that the resident last received the medication on 06/21/2025. Review of Resident #25's 06/2025 EMAR revealed the last dose of Norco 5-325mg was administered to Resident #25 on 06/21/2025. Review of Resident #25's medical record revealed a Pain Monitor Task which the nurse documented every shift and answered the question: Resident complained of pain? Review of the Pain Monitor Task revealed the resident complained of pain starting on 07/07/2025 at 12:01 p.m. Further review of the Pain Monitor Task revealed the following dates of when the resident complained of pain: 07/07/2025 at 12:01 p.m., 07/08/2025 at 9:33 a.m., 07/16/2025 at 12:04 p.m., 07/17/2025 at 11:04 p.m., 07/21/2025 at 1:28 p.m., 07/22/2025 at 6:35 p.m., 07/25/2025 at 9:34 a.m., 07/27/2025 at 6:59 p.m., 07/31/2025 at 5:45 p.m., 08/04/2025 at 6:15 p.m., and 08/05/2025 at 5:41 p.m. After complete record review, there was no documentation that the physician was notified to address if the Norco 5-325mg PRN order should had been renewed/reordered or discontinued. In an interview and record review on 08/06/2025 at 9:00 a.m., S2 DON revealed Resident #25 had a current and active order for Norco 5-325mg Q4H PRN. S2 DON stated the resident has not received the medication since 06/21/2025 due to the medications running out. After review of the medical record, S2 DON confirmed the nurse should have notified the doctor on 06/21/2025 when the medications ran out and verified with the doctor if the medication should have been renewed or discontinued. In an interview on 08/06/2025 at 9:41 a.m., Resident #25 revealed he reported to multiple nurses about his pain level and was told by nursing staff they would call the physician. Resident #25 stated he knew he had physician orders for pain medications and did not understand why the nurses do not offer him these medications. Resident #25 stated that about 3 weeks ago, one nurse (could not remember her name) stated that his pain medications ran out' and she needed to call the physician. In an interview and record review on 08/06/2025 at 12:35 p.m., S5 LPN revealed Resident #25 had current physician orders for Norco 5-325mg Q4H PRN for pain but the medication had ran out. In a telephone interview on 08/06/2025 at 12:59 p.m., S6 LPN revealed that Resident #25 has occasionally complained of pain to her in the past month. S6 LPN stated that yesterday (08/05/2025) she documented the resident complained of pain. S6 LPN stated she did not offer Resident #25 the Norco PRN medication because she knew there were no actual pills available in the facility. S6 LPN confirmed she did not notify the physician that the current order for Norco ran out. In an interview on 08/06/2025 at 1:40 p.m., S2 DON confirmed that on yesterday (08/05/2025) and all other instants when Resident #25 complained of pain, the nurse should have administered the active PRN order for Norco, but did not. S2 DON confirmed that since the facility did not have the PRN Norco medication on hand, the nurse should have also notified the physician to obtain an order for renewal, but did not.

Based on observations and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure: Nursing carts were free of loose pills for 1 (Cart C) of 2 (Cart B and Cart C) carts reviewed; Medications were labeled with the date they were opened; Expired medications were not available for use on 1 (Cart C) of 2 (Cart B and Cart C) medication carts reviewed; and Expired medications were not available for use in 1 (Room X) of 1 medication room reviewed.Observation of Cart C on 08/05/2025 at 12:14 p.m. with oversight from S7 LPN revealed the following: One loose and unidentified tablet in the bottom of the 2nd drawer of the cart An opened and undated 16oz bottle of Geri-Tussin oral solution An opened and undated Lispro KwikPen with an expiration date of 07/29/2024 An opened and undated 30mL bottle of Morphine Sulfate oral solutionAn interview was conducted with S7 LPN at this time who confirmed a loose tablet and opened/undated medications were in Cart C, but should not have been. S7 LPN confirmed an expired medication was in Cart C and available for use, but should not have been.Observation of Room X on 08/05/2025 at 12:31 p.m. with oversight from S7 LPN revealed one Lispro KwikPen with an expiration date of 06/23/2025. An interview was conducted with S7 LPN at this time who confirmed an expired medication was in Room X and available for use, but should not have been. Interview with S2 DON on 08/05/2025 at 1:20 p.m. confirmed a loose tablet should not have been in a medication cart, medications should have been labeled with the date they were opened, and expired medications should not have been available for use in medication carts or medication rooms.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 (Resident #60) resident. The total sample size was 32 residents. Review of Resident #60's admission MDS with an ARD of 07/18/2025 revealed Resident #60 was not taking an opioid medication.Review of Resident #60's physician's orders revealed Oxycodone 5mg capsule by mouth every 6 hours as needed ordered on 07/15/2025.Review of Resident #60's 07/2025 MAR revealed Oxycodone 5mg was administered on 07/16/2025 and 07/17/2025. Interview with S8LPN on 08/06/2025 at 1:11 p.m. revealed Resident #60 received Oxycodone 5mg on 07/16/2025 and 07/17/2025. S8LPN confirmed Resident #60's admission MDS with an ARD of 07/18/2025 did not accurately reflect the resident's status, but should have.

Based on observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to ensure staff decontaminated reusable medical equipment between residents. Observation on 08/05/2025 from 8:00 a.m. until 8:50 a.m. revealed S7 LPN using a wrist blood pressure (BP) cuff to monitor the BP of multiple residents. The BP cuff was not decontaminated between uses on different residents. Interview with S7 LPN on 08/05/2025 at 8:50 a.m. confirmed she did not decontaminate the wrist BP cuff between uses on residents, but should have.Observation on 08/06/2025 from 8:35 a.m. until 8:55 a.m. revealed S5 LPN using a wrist BP cuff to monitor the blood pressure of a resident. The BP cuff was then returned to the medication cart, without being decontaminated. Interview with S5 LPN on 08/06/2025 at 8:55 a.m. confirmed she did not decontaminate the wrist BP cuff between uses on residents, but should have.

Based on observation, record review and interview, the facility failed to maintain an accurate account of controlled drugs for 2 residents (#5 and #6) of 7 sampled residents (#1, #2, #3, #4, #5, #6 and #7). The facility had a total census of 73 residents. Findings: Review of the facility's undated policy titled, Medications-Controlled Substances revealed in part .Policy Statement. The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation. Shift Change Controlled Drug Count. 8. The nurse coming on duty and the nurse going off duty must make the count together. Resident #5: Observation of the locked controlled medication drawer and log book on Medication Cart B with S3 LPN on 03/12/2025 at 10:00 a.m., revealed Resident #5's Clonazepam 1mg tablet blister package card with a total of 55 tablets remaining. The controlled medication log book revealed 56 tablets were documented as remaining. S3 LPN confirmed the number of tablets remaining in Resident #5's Clonazepam 1mg blister package did not match the number that was recorded in the log book, and it should have. Resident #6: Observation of the locked controlled medication drawer and log book on Medication Cart B with S3 LPN on 03/12/2025 at 10:00 a.m., revealed Resident #6's Lorazepam 0.5 mg tablet blister package with a total of 15 tablets remaining. The controlled medication log book revealed 16 tablets were documented as remaining. S3 LPN confirmed the number of tablets remaining in Resident #6's Lorazepam 0.5 mg tablet blister package did not match the number that was recorded in the log book, and it should have. Interview with S1 DON on 03/12/2025 at 3:45 p.m., revealed that S3 LPN did not count the controlled medications at shift change. S1 DON confirmed that the controlled substance count is to be conducted by both the off-going and oncoming nurses at the beginning and end of their shifts and it had not been completed. S1 DON confirmed controlled medications are to be documented electronically and on paper in the log book when administering the medication to the resident and it had not been completed.

Based on observation and interview, the facility failed to ensure that items in the Medication Carts were properly stored by: 1. Having loose pills in all 3 medication carts. 2. Failing to remove discontinued controlled medications from Medication Cart B. There was a total of 73 residents residing in the facility. Findings: Review of the facility's undated policy titled, Medications-Controlled Storage revealed in part . Policy Statement. The facility shall store all drugs and biologics in a safe, secure and orderly manner. Policy Interpretation and Implementation. Medication Containers. 1. Drugs shall be stored in the packaging, containers or other dispensing systems in which they are received. Maintaining Storage and Preparation Areas. 2. The nursing staff shall be responsible for maintaining medication storage . in a clean, safe, and sanitary manner. Unusable Drugs or Biologicals. The facility shall not use discontinued drugs . All such drugs shall be returned to the dispensing pharmacy or destroyed. Observation of Medication Cart C with S2 RN on 03/12/2025 at 9:43 a.m., revealed two loose pills in the medication cart. Observed one circular white pill with no identified markers and one circular white pill with an S and a U printed on it. S2 RN confirmed that loose pills should not be in the medication cart. Observation of Medication Cart B with S3 LPN on 03/12/2025 at 10:00 a.m., revealed four loose pills in the medication cart. Observed one oblong-shaped white pill with L484 printed on it, one white circular pill with no identified markers, one circular black pill with no identified markers, and one peach colored circular pill with no identified markers. Observation of the locked controlled medication drawer on Medication Cart B with S3 LPN revealed Resident #4's Tramadol 50mg pill bottle wrapped in Resident #4's controlled medication log count sheet. Review of Resident #4's Tramadol medication log sheet revealed a discontinue date of 02/27/2025 with 83 pills remaining in the bottle. Observed Resident #7's Lyrica 75mg blister package card wrapped in Resident #7's log count paper which revealed a date of 02/04/2025 with 3 pills remaining on the card. S3 LPN confirmed that Resident #4's 50 mg Tramadol and Resident #7's 75mg Lyrica were no longer in use and should have been removed from the medication cart and disposed of properly. Observation of Medication Cart A with S4 LPN on 03/12/2025 at 10:15 a.m., revealed two loose pills in the medication cart. Observed one blue circular pill and one small white circular pill with ZD over 15 printed on one side of the pill. Interview with S1 DON on 03/12/2025 at 3:45 p.m. confirmed that all medication carts should be clean and never have loose pills. S1 DON confirmed that Resident #4's and Resident #7's controlled medications were discontinued and should have been pulled from the medication cart within the same shift they were discontinued and were not.

Based on Interview and Record Review, the facility failed to ensure licensed nurses had the appropriate competencies and skill sets to provide nursing services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being as evidenced by the failure to ensure two transcribed verbal narcotic medication orders included the strength of the drug, failure to ensure two written narcotic orders were correctly entered into the electronic medical record, failure to ensure electronic narcotic medication orders included valid dosing instructions, failure to ensure dosing of narcotic medication on narcotic sign-out log matched dosing information on Medication Administration Record, and by failing to ensure all narcotic medication doses signed out on Narcotic Medication Record were documented as given on Medication Administration Record for 1 (#2) of 14 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14) sampled residents. Findings: Review of handwritten Physician Orders dated 09/25/2024 revealed an order for Morphine 100mg/5mL, Give 0.25mL SL/PO Q2H as needed pain or shortness of breath (SOB). Review of MAR for 10/01/2024 through 10/08/2024 included Morphine Sulfate Oral Solution 20mg/5mL Give 0.25mL by mouth every 2 hours as needed for pain; SOB related to Pain - GIVE 0.25ML PO Q2HR PRN PAIN/SOB with start date of 10/01/2024 . Unable to find this order during review of electronic and paper records. Review of verbal orders written by S2 LPN on 10/08/2024 revealed the following: 1mL Morphine PO now one time dose Dx: air hunger Increase Morphine to 0.5mL Q2H PO PRN for air hunger No concentration noted on either order. Review of facility policy entitled Orders - Medication stated orders for medications must include name and strength of drug, quantity of specific duration of therapy, dosage and frequency of administration, route of administration if other than oral, and reason for which given. Review of MAR for 10/08/2024 included Morphine Sulfate oral solution 100mg/5mL give 1mL by mouth one time only for air hunger/SOB, although this concentration was not included on the written order. Review of MAR for 10/08/2024 through 10/09/2024 included Morphine Sulfate oral solution 20mg/5mL give 0.5mg by mouth every 2 hours as needed for pain, SOB related to pain - GIVE 0.25ML PO Q 2 HR PRN PAIN/SOB, although this concentration was not included on the written order. Order was inconsistent/ambiguous as 0.25mL does NOT provide 0.5mg. Additionally, order was written for 0.5mL, but entered electronically as 0.5mg. Interview on 12/17/2024 at 2:40 p.m., S1 DON confirmed she was unable to locate an order changing dose of Morphine Sulfate on 10/01/2024. S1 DON stated the information was entered incorrectly when the facility changed to PCC (Point Click Care) from their previous electronic health record on 10/01/2024. S1 DON asked if the two different orders provided the same dose of medication- advised her they did not. S1 DON stated she wanted to review what was given by reviewing the paper they write on rather than the copy of the MAR provided by the facility. Informed S1 DON two verbal narcotic orders written on 10/08/2024 did not include dose/concentration of medication. S1 DON viewed orders and confirmed the orders did not include dose/concentration and should have. Advised S1 DON the order to increase oral PRN narcotic on 10/08/2024 indicated mL, but when entered electronically was entered as mg. Additionally, informed S1 DON the same order stated to give 0.5mg and 0.25mL, which were not the same dose. S1 DON viewed copy of order and stated she would follow up regarding these issues. Interview on 12/17/2024 at 2:55 p.m., S1 DON brought Morphine Sulfate box, which she stated was from locked narcotic box, labeled with resident name and initial concentration/order. S1 DON stated Resident #2 had received the 100mg/5mL concentration from 09/25/2024 through 10/09/2024. S1 DON also provided copy of narcotic medication records (narcotic sign-out sheets) for Resident #2 with Morphine 100mg/5mL dosing indicated. S1 DON confirmed both Morphine orders dated 10/08/2024 were incomplete and should have contained dose/concentration. S1 DON confirmed the order to increase Morphine dated 10/08/2024 included MG but was entered into PCC as ML and should not have been. S1 DON stated the order was transcribed incorrectly. During an interview on 12/17/2024 at 3:00 p.m., S2 LPN confirmed the Morphine dose on the narcotic medication record (sign-out sheet) did not match the Morphine dose on the MAR and should have. S2 LPN confirmed she had signed out and administered Morphine on multiple occasions, despite this inconsistency. S2 LPN confirmed she should have ensured the dosing matched. S2 LPN reviewed Morphine orders written on 10/08/2024. S2 LPN confirmed she wrote verbal orders for morphine on 10/08/2024. S2 LPN confirmed both orders did not include dose/concentration and should have. Orders - Medication policy reviewed with S2 LPN. S2 LPN confirmed she did not follow the policy when she wrote the orders and should have.

Based on record review and interview, the facility failed to ensure responsible party notification was documented in the medical record of a resident who was tranferred to the hospital for 1 (#12) of 14 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) sampled residents. The total facility census was 75 residents. Findings: Review of the facility's undated policy titled Change in a Resident's Condition Status read in part . Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. Procedure: 3. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when: E. It is necessary to transfer the resident to a hospital/treatment center. If unable to contact RP, the charge nurse shall document changes on the resident's medical record 6. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of Resident #12's Medical Record revealed an admitted [DATE] with diagnoses that included Peripheral Vascular Disease; End Stage Renal Disease; Chronic Venous Hypertension with Ulcer of right lower extremity; Anxiety disorder; Chronic Obstructive Pulmonary disease; Pressure Ulcer of Sacral Region stage 4; Pressure Ulcer of Right heel Unstageable; Acute Embolism and Thrombosis of left femoral vein; Osteomyelitis; Hypotension; Obesity; Type 2 Diabetes Mellitus; Edema; Hypertensive Heart Disease with Heart Failure; Review of Resident #12's Significant Change MDS revealed a BIMS score of 13 which indicated the resident was cognitively intact. Resident #12 required extensive assistance with bed mobility, transfers, and toilet use. Supervision required for eating. Resident had shortness of breath or trouble breathing when lying flat. Review of Resident #12's Care Plan with a Target date of [DATE] revealed the resident has shortness of breath. Interventions included, Resident sent to emergency room (ER) to evaluate (eval) and treat for Hypoxia (initiated [DATE]). The resident has asthma. Interventions included: Give nebulizer treatments and oxygen therapy as ordered; Monitor vital signs, skin color, pulse oximetry, airway functioning, and degree of restlessness which may indicate hypoxia (initiated [DATE]); Position resident in Fowlers to facilitate breathing. Review of Resident #12's Physician Orders revealed in part .Oxygen (o2) at 4L/MIN (Liters per minute) via nasal cannula continuously every shift related to wheezing with a start date of [DATE]. Review of Resident #12's Discharge Summary dated [DATE] revealed resident discharged to hospital. discharge date : [DATE]. Summary of treatment: skilled services provided upon admission. Discharge condition: expired at hospital. Review of the resident #12's Nurse Progress Notes for [DATE] revealed the following: [DATE] at 1:30 p.m.-Resident sent to ER to eval and treat for Hypoxia [DATE] at 9:56 a.m.-AT hospital [DATE] at 9:45 a.m.-continues to be at hospital [DATE] at 10:00 p.m.-Daughter, RP; came to facility and stated, daddy just gained his wings. [DATE] at 12:26 p.m.-Resident expired at hospital Review of Resident #12's Nurses Notes revealed no documentation for notification of Resident #12's transfer to the hospital on [DATE] to Resident #12's RP. In a telephone interview on [DATE] at 12:26 p.m. with resident's RP stated the facility did not notify her that resident #12 was sent out to the hospital on [DATE]. She stated the resident called her on [DATE] from the hospital and informed her he had been admitted to the hospital. In an interview on [DATE] at 12:48 p.m. with S1 DON confirmed no documentation in Resident #12's medical record notifying resident #12's responsible party that he was transferred to the hospital on [DATE] and there should have been. In an interview on [DATE] at 12:50 p.m. with S3 LPN stated she was resident #12's nurse on [DATE]. S3 LPN stated the resident began having some respiratory difficulty suddenly after drinking water, vital signs were obtained, and his oxygen sat was low despite being on oxygen. Resident #12 was then transferred to hospital on [DATE]. S3 LPN stated she didn't document notifying the RP when the resident was transferred to the hospital on [DATE] and should have.

Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the meal for 51 residents that received regular diets prepared by the facility kitchen. Findings: Review of the facility's undated policy titled: Menu Planning on 06/18/2024 read in part . Purpose: To assure that a variety of nutritious foods that meet the residents' needs are purchased, prepared and served to the residents. Policy: 3. All items on the menu must have a standardized recipe that has an ingredient listing which will yield the appropriate number off portions. Existing recipes must be adjusted as necessary to guarantee adequate yield. Review of the facility's approved Menu Matrix menu revealed on 06/17/2024 the facility was on week 4. The regular diet lunch to be served with serving size consisted of red beans and sausage -6 oz., steamed rice -4 oz., mustard greens -4 oz., and cornbread 1 sq. Observation on 06/17/2024 at 11:40 a.m. revealed S2 Dietary Manager serving mustard greens using a 3 oz. scoop and Red beans and sausage using a 4 oz. scoop for 5 resident trays receiving regular diets. Interview on 06/17/2024 at 11:52 a.m. S2 Dietary Manager revealed after a review of the menu and serving size S2 Dietary Manager confirmed the residents served received only 3 oz. of greens instead of 4 oz. and 4 oz. of beans/sausage instead of 6 oz. S2 Dietary Manager confirmed she and staff were to serve residents according to the serving sizes posted on the menu but had not done so. S2 Dietary Manager confirmed the residents were served using the wrong scoop size, and the scoops and ladles should have checked prior to the meal service but had not been.

Based on interview and record review the facility failed to ensure pureed foods were prepared according to the approved recipe by methods, which conserved nutritional value for 7 residents that are served pureed diets by the facility's kitchen. Findings: Review of the facility's undated policy on 06/18/2024 titled: Use of Recipes read in part . Policy: Recipes are to be used when preparing menu items. Procedure: 3. Cooks are expected to use and follow the recipe provided. Observation on 06/17/2024 at 11:04 a.m. revealed S3 Dietary [NAME] preparing puree meal of mustard greens, red beans/sausage, and rice. S3 Dietary [NAME] was observed placing an unmeasured amount of each food item into the blender, and did not refer to a recipe prior to preparing the items. S3 Dietary Aide stated she did not refer to the recipe as she only knew to place the food in the blender and blend until the food was blended to the appropriate thickness. S3 Dietary [NAME] stated if she had to add juices and the item came out too thin she would add thickener. Observation revealed S3 Dietary [NAME] placed (3) 3 oz. scoops of greens into blender, blend the food, then added an unmeasured amount of thickener. S3 Dietary [NAME] then placed the greens on the steam table to be served. Observation of puree beans/sausage/rice revealed S3 Dietary [NAME] placed (2) 8 oz. scoops of rice and (6) 1 oz. scoops of beans/sausage into the blender, blended the food, and placed on steam line for serving. Interview on 06/17/2024 at 02:30 p.m. S2 Dietary Manager confirmed S3 Dietary [NAME] did not utilize the recipe to prepare puree meals and should have. S2 Dietary Manager stated she had not trained staff to use the recipe when preparing meals, but confirmed she should have.

Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for 1 (Resident #10) out of 21 sampled residents. Findings: Review of Resident #10's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included but not limited to, End Stage Renal Disease and Dependence on Renal Dialysis. Review of Resident #10's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/03/2024 revealed in Section O (Special Treatments, Procedures and Programs) that the resident was not coded for dialysis treatment. Review of Resident #10's June 2024 Physician Orders read in part, 05/15/2024 Dialysis Q (every) Mon (Monday)/Fri (Friday). On 06/18/2024 at 4:09 p.m., an interview and record review with S1MDSC (Minimum Data Set Coordinator) was conducted of Resident #10's MDS, with an ARD of 06/03/2024, and June 2024 physician orders. She confirmed that Resident #10 had a current order for dialysis treatment and that the MDS was coded inaccurately.

Based on observation, interview, and record review, the facility failed to ensure the environment was as free of accident hazards as possible, by failing to ensure hot water temperatures were not greater than 120 degrees Fahrenheit on 3 of 3 halls (Hall A, Hall B, and Hall C). This deficient practice resulted in an Immediate Jeopardy situation on 01/23/2024 at 11:29 a.m., when hot water temperatures were observed to be 122 degrees Fahrenheit to 148 degrees Fahrenheit in the following rooms: 1. Hall A - Bathrooms sinks in Room A, the adjoining bathroom of Rooms B and C, and Room M; 2. Hall B - Bathroom sinks in the adjoining bathroom of Rooms D and E, the adjoining bathroom of Rooms F and G, and the adjoining bathroom of Rooms H and I; and 3. Hall C - Bathroom sink in the adjoining bathroom of Rooms J and K. 4. Resident #1 stated the water from his bathroom sink was very hot, and had been hot since the day he was admitted to the facility. 5. Resident #2 revealed the water in her bathroom was Hot. Hot. Hot, as she touched the tops of her hands repeatedly. 6. #R1 stated the hot water from her bathroom got extremely hot. #R1 reported she informed S2 Maintenance Supervisor, he came and looked at it, but did not fix it. These failures placed Resident #1, Resident #2, and #R1 at risk for skin irritation, rash, redness, pain and blistering. S1 Administrator was notified on the Immediate Jeopardy situation on 01/23/2024 at 4:41 p.m. The Immediate Jeopardy was removed on 01/25/2024 at 11:05 a.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice had the potential to affect all 81 residents who reside at the facility. Findings: Review of the facility's policy titled Safe Water Temperatures, read in part . It is the policy of this facility to maintain appropriate water temperatures in resident care areas. Policy Explanation and Compliance Guidelines: Staff will report abnormal findings, such as complaints of water too cold or hot, burns or redness, or any problems with water temperature (ex. water is painful to touch or causes redness) to the supervisor and/or maintenance staff. Water temperatures will be set to a temperature of no more than 120 degrees Fahrenheit. Maintenance Staff will check hot water temperature weekly and as needed. Review of a document titled Commercial Gas Water Heater Use and Care Manual, read in part . General Safety Precautions To meet commercial water use needs, the thermostat on this water heater is adjustable up to 180 degrees Fahrenheit. However, water temperature over 125 degrees Fahrenheit can cause severe burns instantly or death from scalds. Review of the Weekly Maintenance Log revealed hot water temperatures were checked weekly on Wednesday, in random rooms of each hall in the facility. The last documented hot water temperatures were dated 01/17/2023, with temperature readings that ranged from 110 to 116 degrees Fahrenheit. Hall A Observation on 01/23/2024 at 11:15 a.m. of the hot water in the bathroom sink in Room A, revealed it was extremely hot to the surveyor's hands. Steam was noted coming from the hot water. Interview with Resident #1 at that time revealed he resided in Room A, and stated the water from his bathroom sink was very hot, and had been hot since the day he was admitted to the facility (12/01/2023). Review of Resident #1's clinical record revealed an admitted [DATE], with diagnoses that included: Diabetes Mellitus and Neuropathy. Review of Resident #1's Admission MDS with an ARD of 12/06/2023, revealed a BIMS score of 15, indicating intact cognition. Review of Resident #1's care plan with a target date of 04/02/2024 revealed a problem of required assistance with ADLs. Interventions included in part .assist with ADLs as needed, and encourage to perform each ADL as independently as possible. Interview with #R1 on 01/23/2024 at 11:21 a.m., revealed she resided in Room O. #R1 stated the hot water from her bathroom got extremely hot. #R1 reported she informed S2 Maintenance Supervisor, he came and looked at it, but did not fix it. (didn't remember date). Review of #R1's clinical record revealed an admitted [DATE], with diagnoses that included: Chronic Pain Syndrome, and muscle wasting and atrophy. Review of #R1's Admission MDS with an ARD of 11/28/2023 revealed a BIMS score of 11, indicating moderate cognitive impairment. Review of the MDS revealed #R1 required partial/moderate assistance with toileting and bathing, and supervision with personal hygiene. Observation on 01/23/2024 at 11:29 a.m. revealed S2 Maintenance Supervisor checked the temperature of the hot water in the sink in Room M, and obtained a temperature reading of 139 degrees Fahrenheit. Interview at that time with S2 Maintenance Supervisor confirmed the temperature. Observation on 01/23/2024 at 11:30 a.m., revealed S2 Maintenance Supervisor checked the temperature of the hot water in the bathroom sink in Room A, and obtained a temperature reading of 145 degrees Fahrenheit. Interview with S2 Maintenance Supervisor at that time revealed the hot water temperature was too high, and should be between 110 to 120 degrees Fahrenheit. Observation on 01/23/2024 at 12:00 p.m., revealed S2 Maintenance Supervisor checked the hot water temperature in the sink of the bathroom that adjoined Rooms B (#R2 and #R3), and C (#R4 and #R5). A temperature reading of 131 degrees Fahrenheit was obtained. Interview at that time with S2 Maintenance Supervisor confirmed the temperature of 131 degrees Fahrenheit. Hall B Observation on 01/23/2024 at 11:37 a.m., revealed S2 Maintenance Supervisor checked the temperature of the hot water in the bathroom sink of adjoining Rooms H (unoccupied room) and I (#R13). A temperature reading of 148 degrees Fahrenheit was obtained. Interview at that time with S2 Maintenance Supervisor confirmed the temperature of 148 degrees Fahrenheit. Review of #R13's clinical record revealed an admitted [DATE], with diagnoses that included: Chronic Kidney Disease and Dependence on Renal Dialysis. Review of #R13's Admission MDS with an ARD of 11/21/2023, revealed a BIMS score of 7, indicating severe cognitive impairment. The MDS revealed #R13 required partial/moderate assistance with toileting and bathing, and supervision with personal hygiene. Interview with S4 CNA on 01/29/2024 at 5:55 a.m., revealed #R13 could transfer to his wheelchair, and propel around the facility without assistance. Interview on 01/29/2024 at 10:20 a.m. with S5 CNA revealed #R13 could transfer to his wheelchair and go to the bathroom without assistance. Observation on 01/23/2024 at 11:38 a.m. with S2 Maintenance Supervisor, accompanied by S1 Administrator, revealed S2 Maintenance Supervisor checked the temperature of the hot water in the bathroom sink of adjoining Room D (#R6 and #R7), and Room E (#R8 and #R9). A temperature reading of 142 degrees Fahrenheit was obtained. Interview with S1 Administrator on 01/29/2024 at 11:38 a.m. revealed she was not aware of the acceptable temperature for hot water. Review of #R7's clinical record revealed and admitted [DATE], with diagnoses that included: Cerebral Infarction due to Embolism, Aphasia, and Hemiplegia affecting Right Dominant Side. Review of #R7's Significant Change MDS with an ARD of 10/20/2023, revealed a BIMS was not conducted, as #R7 was rarely/never understood, and had moderately impaired skills for daily decision making. The MDS revealed #R7 required substantial/maximal assistance with bathing, partial/moderate assistance with toileting, and supervision with personal hygiene. Interview on 01/29/2024 at 5:55 a.m. with S4 CNA revealed #R7 was not able to speak, and would try to point to what she needed. S4 CNA reported #R7 would not use the call light, and propelled herself in her wheelchair to the door to get attention for assistance. Observation on 01/23/2024 at 12:03 p.m., revealed S2 Maintenance Supervisor checked the hot water temperature in the bathroom sink of adjoining Rooms F (#R10 and #R11), and G (Resident #3 and #R12). A temperature reading of 134 degrees Fahrenheit was obtained. Interview at that time with S2 Maintenance Supervisor confirmed the temperature of 134 degrees Fahrenheit. Observation on 01/23/2024 at 2:15 p.m. revealed Resident #2 in Room L, with a rolling walker at her bedside. Interview at that time with Resident #2 revealed the water in her bathroom was Hot. Hot. Hot, as she touched the tops of her hands repeatedly. Review of Resident #2's clinical record revealed an admitted [DATE] with diagnoses which included: Alzheimer's disease and Neuropathy. Review of Resident #2's Quarterly MDS with an ARD of 11/10/2023 revealed a BIMS score of 9, indicating moderate cognitive impairment. Review of Resident #2's care plan revealed a problem of required assistance with ADLs. Interventions included in part .assist with ADLs as needed, and encourage to perform each ADL as independently as possible. Hall C 1. Observation on 01/23/2024 at 11:39 a.m. of S2 Maintenance Supervisor, accompanied by ADM, revealed the hot water temperature was checked in the bathroom sink that adjoined Room J (#R14 and #R15), and Room K (#R16 and #R17). A temperature reading of 122 degrees Fahrenheit was obtained. Review of #R15's clinical record revealed an admitted [DATE], with diagnoses that included in part: Unspecified Dementia. Review of #R15's Quarterly MDS with an ARD of 12/22/2023 revealed a BIMS score of 3, indicating severe cognitive impairment. Interview on 01/29/2024 at 5:55 a.m. with S4 CNA revealed #R15 could transfer to her wheelchair and propel her wheelchair throughout the facility without assistance from staff. Observation of #R15 on 01/29/2024 at 10:11 a.m. revealed her in the dining area putting a puzzle together. Interview with #R15 at that time revealed #R15 did not respond when interview attempted. Room N Observation of Room N on 01/23/2024 at 11:45 a.m., accompanied by S2 Maintenance Supervisor and S1 Administrator, revealed the presence of 2 hot water heaters. Both hot water heaters were set at 180 degrees Fahrenheit. One of the hot water heaters had a temperature reading of 178 degrees Fahrenheit, and the other hot water heater had a temperature reading of 162 degrees Fahrenheit. Interview with S2 Maintenance Supervisor on 01/23/2024 at 11:45 a.m., revealed the temperature on the hot water heaters should have been set at 150 degrees Fahrenheit. Interview on 01/23/2024 at 2:07 p.m. with S2 Maintenance Supervisor revealed around 01/15/2023 (could not recall exact date), CNAs reported to him the water was too cold on Hall C, and in all of the Shower/Whirlpool rooms. S2 Maintenance Supervisor stated he turned each hot water heater thermostat up to 180 degrees Fahrenheit at that time. Interview on 01/23/2024 at 3:10 p.m. with S1 Administrator revealed she was aware the temperature of hot water should be between 110 degrees Fahrenheit to 120 degrees Fahrenheit. S1 Administrator confirmed the hot water temperatures above 120 degrees Fahrenheit in the facility put the residents at risk for injury to the skin, such as redness and burns.

Based on interview and record review the facility failed to ensure 2 residents' (#3 and #5) rights to be free from abuse by facility staff in a sample of 5 residents (#1, #2, #3, #4 and #5). The facility failed to Protect Resident #3 from verbal abuse by S15 CNA, and failed to immediately protect Resident #5 from unwanted, non-consensual sexual contact by Resident #1. This deficient practice resulted in an Immediate Jeopardy situation on 12/07/2022 at 3:55 p.m. when S16 CNA reported witnessing S15 CNA telling Resident #3, a moderately cognitively impaired resident, that her vagina stinks, she is gross, she hopes she dies, and she hopes she would fall out of the lift. The Immediate Jeopardy continued on 12/27/2022 at 7:26 a.m., when Resident #5, a moderately cognitively impaired resident with left sided paralysis, was sitting at the dining table resting her eyes, when Resident #1 walked up to Resident #5, exposed his genitals, and placed his penis in Resident #5's hand and fondled her breasts and genitals. S5 Floor Tech, S6 Housekeeping, S7 Dietary and S8 Dietary watched Resident #1 sexually abuse Resident #5, and failed to immediately intervene. The inappropriate, unwanted, non-consensual contact sexual abuse continued until staff walked and informed the nurse at the nursing station, who then came to the dining room to intervene. As of 01/24/2023, all facility staff had not been retrained regarding the facility's Abuse Prevention and Investigation Policy. The deficient practice continued at more than minimal harm for all 69 residents who reside in the facility. S1 Administrator was notified of the deficient practice at the Immediate Jeopardy level on 01/24/2023 at 3:29 p.m. The Immediate Jeopardy was removed on 01/25/2023 at 4:00 p.m. after it was verified through observation, interview and record review that the facility submitted and implemented a Plan of Removal that included the following: The facility identified two instances of abuse in the facility: 1. Employee to Resident #3 verbal abuse on 12/07/2022. 2. Resident #1 to Resident #5 sexual abuse 12/27/2022, which was witnessed by facility staff who failed to intervene immediately. These instances have the ability to affect all residents that reside in the facility. Employee to Resident #3 Verbal Abuse Incident: Plan: Facility will ensure all residents are kept safe from any type of abuse. Accused CNA was immediately suspended upon facility knowledge of verbal abuse. The accused CNA was terminated following completion of investigation/closure of SIMS report. Accused CNA did not follow facility abuse related to verbal abuse of residents. Local police department called and report created 12/07/2022. Facility abuse reporting policy followed with regards to SIMS report for incident on 12/07/2022 and 12/27/2022. All residents interviewed 12/07/2022 by SSD regarding abuse. Interview of facility residents has continued weekly following the 12/07/2022 incident. SSD reports the findings to the Administrator upon completion of weekly questioning. If negative findings are reported by the residents, the Administrator or designee will take appropriate action according to abuse policy. The facility did not in-service all staff regarding abuse following 12/07/2022 verbal abuse incident. DON/Admin/Designee has in-serviced 58 staff on current abuse policy, 72 total staff are employed at the facility. In-service began on 01/23/2023 and is to be completed by 01/25/2023. Staff will not be allowed to work until they have been in-serviced. Admin/DON/Designee will monitor and compare signature list to active employee list to ensure compliance. Admin/DON/Designee will ensure staff will be in-serviced before clocking in, new hires are in-serviced upon hire, agency staff are in-serviced before their contracted shift. Admin/DON/Designee will compare staff list, upcoming schedule to ensure compliance. Resident #1 to Resident #5 Sexual Abuse Incident: Plan: Immediately following the sexual abuse on 12/27/2022, at 7:30 a.m. Resident #5 was given a full assessment to check for injuries. Resident #5 was interviewed for statement, prior trauma assessment completed, and emotional support was offered. Resident #5 who was sexually abused was referred to psychiatric counseling services on 01/06/2023 by PCP. Resident #5 was seen by a counselor on 01/10/2023 and 01/17/2023. The counselor visits weekly. PCP referred Resident #5 to Psychiatrist on 01/06/2023. Psychiatrist visited on 01/23/2023, he counseled with Resident #5, acknowledged past trauma and changed medications. Resident #1 (accused resident) was placed 1x1 immediately after incident at 7:30 a.m. on 12/27/2022. On the same day, 12/27/2022 at 1:34 p.m., Resident #1 was sent to a behavioral health hospital and on 12/30/2022 transferred to another facility for long-term care placement. Trauma centered care plans were updated by MDS for all residents on 12/27/2022. The facility's two housekeeping and two dining staff failed to intervene when witnessing Resident #1 to Resident #5 sexual abuse incident on 12/27/2022. The facility did not in-service all staff regarding abuse following 12/27/2022 sexual abuse incident. Facility policies reviewed were: Abuse Prevention and Investigation Policy. No revisions were made. The four staff that witnessed the event on 12/27/2022 were counseled by Administrator on 12/27/2022. Monitoring and Supervision: All residents in the facility were monitored for abuse weekly by the Admin/DON/Designee starting on 12/07/2022 and continued 12/27/2022. To ensure the abuse policy is being followed by all staff, staff will be monitored by Admin/DON/Designee weekly for ongoing compliance starting 01/24/2023. QA Committee: QA committee started weekly meeting on 12/07/2022 to discuss current monitoring that is in place for residents and staff. The expected outcomes would be no findings of abuse. The committee will evaluate effectiveness of interventions during weekly meetings. Estimated completion date 01/25/2023. Findings: Review of the facility policy titled: Abuse Prevention and Investigation revealed in part Residents have the right to be free from verbal, sexual, physical, and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of property, exploitation, and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents will not be subjected to abuse by anyone. Policy Interpretation and Implementation: Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Facility staff will identify, and intervene for residents whose behavior or medical condition puts them at increased risk for abuse. Resident #3 Review of the clinical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included in part . Spastic Hemiplegia affecting Left non-dominant side, Bipolar Disorder, Chronic Pain Syndrome, Dementia and Anxiety disorder. Review of Resident #3's MDS Quarterly Assessment with an ARD of 10/14/2022 revealed a BIMS of 12 (moderate cognitive impairment). The MDS revealed Resident #3 required extensive 2 person physical assistance for bed mobility, transfers, dressing, and toilet use; and extensive 1 person physical assistance for personal hygiene and bathing. Resident #3's ROM was coded as one side physical impairment for upper and lower extremities. Review of a facility Investigation Report revealed that on 12/07/2022 at approximately 3:55 p.m., S16 CNA reported to S17 ADON that she had witnessed S15 CNA verbally abuse Resident #3. S16 CNA stated that while performing personal care, S15 CNA told Resident #3 that her vagina stinks, she is gross, she hoped she would die, and she hopes she would fall out of the lift. The investigation information of the incident on 12/07/2022 revealed S15 CNA was sent home immediately. There was no statement made by S15 CNA concerning the incident. The report revealed S17 ADON interviewed all Residents concerning abuse allegations, and there were no abuse issues found. Review of the personnel record for S15 CNA revealed A15 CNA had been trained on the facility's abuse policy and had attended in-services on 06/30/2020, 08/31/2020, 08/31/2021 and 08/31/2022. Interview on 01/23/2023 at 1:20 p.m. with Resident #3 revealed she was sitting in her wheelchair waiting to be taken outside to smoke. Resident #3 stated she was unable to remember the incident that occurred on 12/07/2022. A telephone call to S15 CNA on 01/23/2023 at 1:20 p.m. was unsuccessful. Interview on 01/23/2023 at 1:30 p.m. with S16 CNA revealed she had been working in the facility for a few months, and confirmed she reported S15 CNA to S17 ADON for verbally abusing Resident #3. S16 CNA stated that was the first time she had witnessed S15 CNA not treating a Resident appropriately. Interview with S1 Administrator on 01/24/2023 at 10:30 a.m. revealed all staff were in-serviced after the verbal abuse incident on 12/07/2022; however, review of staff in-services revealed there were staff who had not been retrained on the facility's Abuse Prevention and Investigation Policy. Interview on 01/24/2023 at 10:45 a.m. with S1 Administrator confirmed that as of today, 01/24/2023 at 10:35 a.m., all staff had not been in-serviced on the facility's Abuse Prevention and Investigation Policy after the 12/07/2022 incident of employee to resident verbal abuse, and should have been. Resident #5 Review of the clinical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses that included: Cerebral Infarction, Hemiplegia affecting left Non-dominant side, Type II Diabetes Mellitus, Dysphagia following Cerebral Infarction, Cognitive Communication Deficit, Major Depressive Disorder, Anxiety Disorder, Abnormal Weight Loss and Muscle Wasting. Review of Resident #5's Quarterly MDS Assessment with an ARD of 12/23/2022 revealed Resident #5 had a BIMS score of 12 (moderately impaired cognitively), no behaviors, bowel and bladder incontinence, and required extensive physical assistance of one person for bed mobility, transfers, dressing, toileting and personal hygiene. Resident #5 also had ROM impairment on one side to upper and lower extremities. Mobility devices used were walker and wheelchair. Review of a facility investigation report on 12/27/2022 at approximately 7:26 a.m. read as follows: Resident #5 was seated at a table in the facility dining room when Resident #1 walked up to Resident #5 exposed his genitals, placed his penis in Resident #5's hand, and fondled her breasts. Local police department notified. Resident #1 placed on 1:1 with staff, and was later transferred to a behavioral health facility. Resident #5 was assessed for injuries. On 12/27/2022 at 3:17 p.m., Resident #5 stated she was resting her eyes at the dining table when Resident #1 put his penis in her hand. She said that when she told him to stop he backed away and stood beside her. Resident #5 denies he touched her anywhere other than his penis in her hand. Resident #5 was upset and said she did not want her mother to know. She did not want to speak to a counselor. Local police interviewed her and she did not want to press charges. Resident #1 denied any involvement with Resident #5 and would not elaborate or say much at all during his statement. Review of hand written statements from S5 Floor Tech, S6 Housekeeping and S7 Dietary revealed they had witnessed Resident #1 touching Resident #5's breast and groin area, with his penis exposed, in the facility dining room on 12/27/2022. Review of S5 Floor Tech's statement revealed she notified the Resident's nurse of the incident. Resident #1 Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included in part .Alzheimer's disease, Unspecified Dementia, and Major Depressive Disorder. Review of Resident #1's Quarterly MDS with an ARD of 09/30/2022 revealed Resident #1 had a BIMS score of 12 (mild cognitive impairment), had no physical or verbal behaviors directed toward others, and did not reject care or wander. The MDS revealed Resident #1 required supervision of 1 person for Bed mobility, Transfers, Walking and Locomotion on and off unit; and extensive 1 person physical assistance for dressing, toileting and hygiene. Resident #1 did not have upper or lower extremity ROM impairments. Review of Resident #1's Comprehensive Care Plan revealed a problem of Altered Cognition related to the diagnosis of Alzheimer's Dementia. Approaches included: Give verbal cues to help prompt, and assist with decision making as needed. The Plan of Care revealed Resident #1 was not care planned for, and had no history of inappropriate sexual behaviors. Review of Resident #1's nurses' note dated 12/27/2022 at 7:25 a.m. revealed Resident #1 was noted standing in the facility dining room near another resident, with his penis exposed and pants pulled down. Resident #1 was brought back to his room and placed on 1:1 supervision. Review of Resident #1's nurses' note dated 12/27/2022 at 1:35 p.m. revealed Resident #1 was transferred to a behavioral health hospital. Review of a Discharge Summary revealed Resident #1 was discharged from the behavioral health hospital to another nursing facility on 12/30/2022. Interview on 01/23/2023 at 12:28 p.m. with S5 Floor Tech revealed she walked into the dining room on 12/27/2022 between 7:15 a.m. and 7:30 a.m., and was called over to the serving window by S7 Dietary. S5 Floor Tech stated at that time, she saw Resident #1 standing next to Resident #5's wheelchair fondling Resident #5's groin and breast area. S5 Floor Tech stated she did not hear either resident say anything at that time. S5 Floor Tech stated she ran to the nurses' station and got the nurse, and S3 LPN and S13 LPN ran over and separated the residents. S5 Floor Tech stated she did not redirect Resident #1 or intervene after observing Resident #1 touching Resident #5, because she was not sure she could, and thought it had to be direct care staff to separate residents. S5 Floor Tech stated she had never witnessed any type of behaviors from Resident #1 before. S5 Floor Tech stated Resident #5 had bad eyesight, weakness in her left arm, but could use her right arm. Interview on 01/23/2023 at 12:32 p.m. with S7 Dietary revealed that on 12/27/2022 at approximately 7:30 a.m., she was preparing trays in the serving window of the facility dining room. S7 Dietary stated when she looked out of the serving window, she saw Resident #1 standing at the end of a table next to Resident #5 who was in a wheelchair. Resident #1 had one hand between Resident #5's legs and was rubbing her chest with the other hand. S7 Dietary stated she called S8 Dietary over to observe Resident #1, as well to make sure what she was seeing was really happening. S8 Dietary confirmed what she saw. S7 Dietary stated she then went over to the Dietary department phone and paged for a CNA to come to the dining room. S7 Dietary stated she did not hear Resident #1 or Resident #5 say anything during the incident, she did not attempt to intervene or redirect Resident #1 away from Resident #5, and did not go over to the residents because she didn't want to make a big deal out of it. S7 Dietary stated she could not tell if Resident #5's genitals were exposed or not. S7 Dietary stated S5 Floor Tech left and went to get the nurse, and confirmed Resident #1 was still touching Resident #5 when S5 Floor Tech left the dining room to get the nurse. Interview on 01/23/2023 at 1:30 p.m. with S3 LPN revealed she was the nurse assigned to Resident #1 and Resident #5 on 12/27/2022 for the 7:00 a.m. to 7:00 p.m. shift. S3 LPN stated both residents resided on the same hall, and had no interactions prior to 12/27/2022 that she was aware of. S3 LPN stated on 12/27/2022 at about 7:30 a.m., S5 Floor Tech came running up to the nurses' station and told her she needed to come see about the residents in the dining room. Upon entering the dining room, S3 LPN stated she saw Resident #1 standing next to Resident #5, holding his jogging pants open with one hand and masturbating with the other. S3 LPN stated Resident #5 was seated in her wheelchair with her head turned away from Resident #1, and as she approached, Resident #5 stated, Get him away from me, He put his stuff in my hand. S3 LPN stated she told Resident #1 to move away from Resident #5, and he did. S3 LPN stated Resident #1 told her Resident #5 was his friend, and he was just talking to her. Resident #1 denied exposing himself. Resident #1 was placed on 1:1 with a CNA until he was transferred to a behavioral health facility for evaluation. Resident #5 was checked for injuries and had none. S3 LPN stated prior to being transferred, Resident #1 could not recall events from that morning. During a Face-time interview on 01/23/2023 at 1:45 p.m., Resident #5 revealed the following: On 12/27/2022 she was waiting for breakfast in the facility's dining room. While seated at the table she felt something on her shoulder. Resident #5 stated after she got a good look, and felt it, she realized it was Resident #1's stuff (penis). Resident #5 stated she told Resident #1 to get his hands off of her and he did. Resident #5 denied that Resident #1 touched her breast or private area, and stated Resident #1 never said anything to her during the encounter. Resident #5 stated she was shocked because Resident #1 was the last person she would suspect to do something like that. Interview on 01/23/2023 at 2:15 p.m. with S6 Housekeeping, revealed she worked the 6:30 a.m. to 3:00 p.m. shift on 12/27/2022. S6 Housekeeping stated she was in the dining room around 7:15 a.m. that morning talking to S7 Dietary through the serving window. S6 Housekeeping stated she turned to her right and saw Resident #1 and Resident #5 at the far table near the smoking room exit door. S6 Housekeeping stated she could see that Resident #1's penis was out of his pants and Resident #5's hand was on Resident #1's penis. S6 Housekeeper stated at that point she turned back around and walked over to shield other residents that were coming into the dining room while S5 Floor Tech went to get the nurse. S6 Housekeeping stated she did not walk over and intervene or separate Resident #1 and Resident #5, because she did not know the protocol at that time. S6 Housekeeping confirmed Resident #1 was still standing next to Resident #5 with his penis exposed when S5 Floor Tech went to get the nurse. Review of S6 Housekeeper's personnel record revealed she had abuse training on hire dated 05/10/2022. Telephone interview on 01/23/2023 at 2:46 p.m. with S8 Dietary revealed she was preparing breakfast in the facility's kitchen around 7:30 a.m. on the morning of 12/27/2022. S7 Dietary called her over to the server window and pointed out Resident #1 and Resident #5. S7 Dietary stated she saw Resident #1 rubbing Resident #5's front/chest area. Resident #5 was just sitting there not saying anything. S8 Dietary stated she did not remember who notified the nurse, but a nurse came over and separated the residents. S8 Dietary stated S7 Dietary told her they could not intervene and that someone was getting the nurse. S8 Dietary stated she did not recall being in-serviced on abuse after the incident occurred. Telephone interview on 01/24/2023 at 3:19 p.m. with S13 LPN revealed he was the nurse assigned to Resident's #1 and Resident #5 on the 7:00 p.m. to 7:00 a.m. shift on 12/26/2022. S13 LPN stated after giving shift report to S3 LPN, he heard a commotion coming from the dining area, but it didn't sound desperate. S3 LPN stated an employee, whom he could not recall, came over and said they needed a nurse in the dining room. S13 LPN stated he and S3 LPN ran over, and upon entering the dining room he could see Resident #1 standing next to Resident #5's wheelchair with his hands near his crotch area. S13 LPN stated Resident #5's right hand was up in a stop position with her palm towards Resident #1, and her face was turned away from Resident #1. S13 LPN stated he approached both residents and asked what was going on. Resident #1 looked surprised and almost childlike, his genitalia was not exposed, and he was not touching Resident #5 when he (S13 LPN) approached. S13 LPN stated S3 LPN told Resident #1 to back away from Resident #5, and he did. S13 LPN stated he had never seen any sexually inappropriate behaviors from Resident #1 prior to this incident. S13 LPN stated he had not attended any in-services or received any additional training related to abuse after the incident on 12/27/2022. Interview on 01/24/2023 at 10:30 a.m. with S1 Administrator and S2 DON revealed they were not in the facility at the time of the incident involving Resident #1 and Resident #5 on 12/27/2022. S2 DON stated the staff that witnessed the incident should have separated the residents immediately, but did not. S2 DON stated because the witnessing staff were indirect caregivers, they had always been told they could not touch residents. S2 DON confirmed staff could have stood between the residents or verbally redirected Resident #1 to prevent Resident #1 from touching Resident #5 any further until staff got there, but they did not, and should have. Interview on 01/24/2023 at 10:40 a.m. with S1 Administrator revealed an in-service was done on 12/27/2022 by S2 DON, who was responsible for ensuring all staff were in-serviced. S1 Administrator stated that all staff including housekeeping and dietary had been in-serviced on abuse on 12/07/2022. S1 Administrator confirmed that despite being in-serviced on 12/07/2022, S5 Floor Tech, S6 Housekeeping, S7 Dietary and S8 Dietary witnessed Resident #5 being sexually abused by Resident #1 on 12/27/2022, and did not immediately intervene. Review of a facility in-service sign in sheet titled: Abuse Policy and dated 12/07/2022 revealed S5 Floor Tech, S6 Housekeeping, S7 Dietary and S8 Dietary had been in-serviced on that date, and had not followed the facility's Abuse Policy. Review of facility in-service sign in sheets titled: Abuse Policy, and dated 12/27/2022 and 01/16/2023 revealed there were 26 current employees that had not been in-serviced. Interview on 01/24/2023 at 10:42 a.m. with S2 DON revealed she in-serviced staff on the facility abuse policy on 01/16/2023. S2 DON stated the abuse policy in-service on 01/16/2023 was not facility wide. Interview on 01/24/2023 at 10:45 a.m. with S1 Administrator confirmed all staff had not been in-serviced on the facility abuse policy after confirmed incidents of employee to resident verbal abuse on 12/07/2022, and resident to resident sexual abuse on 12/27/2022, and should have been. Interview on 01/24/2023 at 1:05 p.m. with S20 Dietary revealed he had been hired approximately 6 months ago. S20 Dietary stated he had received abuse training and was told to report any cases of abuse to his Supervisor. S20 Dietary stated he was not sure what to do if he witnessed abuse occurring and no one else was around. Interview on 01/24/2023 at 1:07 p.m. with S21 Dietary revealed he had been an employee of the facility for about 3 or 4 months. S21 Dietary stated he had not received abuse training. Further interview revealed he was not sure if he should go out and say something if he witnessed abuse occurring in the facility dining room. S21 Dietary stated he would probably go and get the Supervisor.

Based on record review and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and protect Resident #3 from verbal abuse by staff, and protect Resident #5 from sexual abuse by a resident, in a sample of 5 (#1, #2, #3, #4 and #5). The facility's administration failed to: 1. Protect Resident #3 from verbal abuse by S15 CNA; 2. Protect Resident #5 from sexual abuse by Resident #1 and ensure staff (S5 Floor Tech, S6 Housekeeping, S7 Dietary and S8 Dietary) implemented the facility's Abuse Preventions and Investigation Policy, and immediately intervene while watching Resident #5 being sexually abused by Resident #1; 3. Ensure all facility staff were effectively trained on their Abuse Prevention and Investigation Policy after the 12/07/2022 incident, and again after the 12/27/2022 incident; and 4. Ensure an effective system was in place to prevent the reoccurrence of abuse of facility residents. This deficient practice resulted in an Immediate Jeopardy situation that began on 12/07/2023 when Resident #3 was verbally abused by S15 CNA, and the facility failed to effectively train staff to prevent the sexual abuse of Resident #5 by Resident #1 on 12/27/2023. S1 Administrator was notified of the Immediate Jeopardy situation on 01/24/2023 at 3:29 p.m. The Immediate Jeopardy Situation was removed on 01/25/2023 at 4:00 p.m. when the Facility submitted an acceptable plan of removal, and the surveyors determined through observation, record review and interview that the plan of removal was implemented. The Facility's plan to remove the immediate jeopardy situation included: Plan: The Administrative Team composed of the Administrator, Director of Nursing, Assistant Director of Nursing, CNA supervisor, Dietary Manager, and Housekeeping supervisor were in-serviced on the abuse policy by corporate designee on 01/25/2023. The administrative team conducted retraining by reading policy given by corporate designee to ensure staff was knowledgeable for prevention of resident's verbal and sexual abuse. Starting 12/7/2022 the Administrator will monitor residents weekly for 8 weeks for abuse which will include resident interview for cognitively intact residents and weekly body audits such as bruising of unknown origin and bruising in unusual places for residents unable to speak for themselves. Resident interviews will be conducted by the social service director and treatment nurse will conduct weekly body audits. Any negative findings for resident interview for social services and body audits will be acted on by the Administrator. After abuse investigation is complete the corporate designee will review. Findings will be reported during weekly and quarterly QA meetings starting 1/25/2023. Beginning 1/25/2023, corporate designee will conduct one visit a month for three months to review Administrator's compliance with the resident and staff monitoring regarding abuse policy. Estimated completion date for this is 1/25/2023. The deficient practice continued at more than minimal harm for all 69 residents who reside in the facility. Findings: Cross Refer to F600 Review of the facility policy titled: Abuse Prevention and Investigation revealed in part . Residents have the right to be free from verbal, sexual, physical, and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of property, exploitation, and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents will not be subjected to abuse by anyone. Policy Interpretation and Implementation: Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Facility staff will identify, and intervene for residents whose behavior or medical condition puts them at increased risk for abuse. Interview on 01/24/2023 at 10:45 a.m. with S1 Administrator confirmed that as of today, 01/24/2023 at 10:35 a.m., all staff had not been in-serviced on the facility's Abuse Prevention and Investigation Policy after the 12/07/2022 incident of employee to resident verbal abuse, and should have been. Interview on 01/24/2023 at 10:30 a.m. with S1 Administrator and S2 DON revealed they were not in the facility at the time of the incident involving Resident #1 and Resident #5 on 12/27/2022. S2 DON stated the staff that witnessed the incident should have separated the residents immediately, but did not. S2 DON stated because the witnessing staff were indirect caregivers, they had always been told they could not touch residents. S2 DON confirmed staff could have stood between the residents or verbally redirected Resident #1 to prevent Resident #1 from touching Resident #5 any further until staff got there, but they did not, and should have. Interview on 01/24/2023 at 10:40 a.m. with S1 Administrator revealed an in-service was done on 12/27/2022 by S2 DON, who was responsible for ensuring all staff were in-serviced. S1 Administrator stated that all staff including housekeeping and dietary had been in-serviced on abuse on 12/07/2022. S1 Administrator confirmed that despite being in-serviced on 12/07/2022, S5 Floor Tech, S6 Housekeeping, S7 Dietary and S8 Dietary witnessed Resident #5 being sexually abused by Resident #1 on 12/27/2022, and did not immediately intervene. Interview on 01/24/2023 at 10:42 a.m. with S2 DON revealed she in-serviced staff on the facility abuse policy on 01/16/2023. S2 DON stated the abuse policy in-service on 01/16/2023 was not facility wide. Interview on 01/24/2023 at 10:45 a.m. with S1 Administrator confirmed all staff had not been in-serviced on the facility abuse policy after confirmed incidents of employee to resident verbal abuse on 12/07/2022, and resident to resident sexual abuse on 12/27/2022, and should have been. Interview on 01/24/2023 at 1:05 p.m. with S20 Dietary revealed he had been hired approximately 6 months ago. S20 Dietary stated he had received abuse training and was told to report any cases of abuse to his Supervisor. S20 Dietary stated he was not sure what to do if he witnessed abuse occurring and no one else was around. Interview on 01/24/2023 at 1:07 p.m. with S21 Dietary revealed he had been an employee of the facility for about 3 or 4 months. S21 Dietary stated he had not received abuse training. Further interview revealed he was not sure if he should go out and say something if he witnessed abuse occurring in the facility dining room. S21 Dietary stated he would probably go and get the Supervisor.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 (#2 and #6) of 7 residents that required the use of a mechanical lift with the assistance of 2 persons during transfers (#2, #6, #7, #8, #9, #10 and #11). This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at approximately 10:45 a.m. for resident #2 who had a [DIAGNOSES REDACTED]. Resident #2 was care planned to transfer with a lift times 2 person assist. After placing the resident on the mechanical lift pad, 1 CNA left the resident's room to get the resident's wheelchair. The other CNA who was left in the room lifted the resident from the bed and placed the resident in a dangling position over the floor. The resident fell from the mechanical lift to the floor. The resident was transferred to the emergency department of a local hospital. The Emergency Physician Record revealed a clinical impression of closed fracture of tibia/fibula - bilateral tib/fib fractures, 6mm and 8mm [MEDICAL CONDITION], hematoma of head, and laceration of head. The resident was transferred to another hospital on [DATE] at 1:35 p.m. This deficient practice continued resulting in an Immediate Jeopardy situation on 01/29/2020 at 9:30 a.m. for Resident #6 who was care planned to transfer with a lift and 2 person assist, and was placed on a mechanical lift/Hoyer lift. The resident was then moved from over the bed to a dangling position over the floor by one CNA, while the other CNA remained standing on the opposite side of the bed during the transfer. The Administrator was notified of deficient practice at the Immediate Jeopardy level on 01/30/2020 at 11:26 a.m. The Immediate Jeopardy was removed on 01/31/2020 at 2:20 p.m. when the facility submitted an acceptable Plan of Removal. Observations, interviews and record reviews, confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Review of the Plan of Removal revealed the following: All nursing staff was in-serviced on appropriate use and transfer with mechanical lift on 01/30/2020 - 01/31/2020. All nursing staff were monitored for competency and checked off by the DON; however, this was not documented appropriately. All nursing staff was again checked for competency with use of the lift and competency documented on 01/30/2020 and 01/31/2020. DON/designee will monitor at least 7 lift transfers per week for 12 weeks then randomly using the attached audit tool (Hoyer Lift Audit). Any concerns during transfer will be addressed with the responsible staff member and that staff member will be retrained and monitored for competency before performing another lift transfer on a resident. All staff have been in-serviced on location of information regarding resident care -transfer status, etc. This was completed on 01/30/2020 - 01/31/2020. DON/designee will monitor at least 8 nursing staff members per week for 8 weeks then randomly to ensure staff knowledge. Audit tool attached. Lifts will be monitored monthly by the maintenance supervisor for any maintenance needs. Any maintenance concerns will be addressed immediately and before the lift is used for resident transfers. Audit tool attached. The deficient practice continued at a potential for more than minimum harm for a total of 6 residents who required transfers with the use of a mechanical lift with 2 person assistance. Findings: Review of a Mechanical Lift Training Manuel entitled Lifting and Positioning Training - Equipment Specific revealed the following: Lifting and positioning overview, Safe client handling and movement, Mechanical lifts: Hoyer, The sling, and positioning of equipment. Resident#2 Review of resident #2's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of a Quarterly MDS Assessment with an ARD of 10/04/2019 revealed the resident had a BI[CONDITION] of 8 indicating moderate cognitive impairment, required 2 + person physical assist for bed mobility, transfers, dressing, toileting, and personal hygiene, was total dependence for bathing, had upper and lower extremity impairment on one side, and utilized a wheelchair for mobility. Review of resident #2's care plan with a target date of 01/01/2020 revealed a problem of Physical Mobility Impairment r/t generalized weakness, debility, and dx of [MEDICAL CONDITION]. Approaches included: assistance as needed with all transfers, obtain assistive devices as needed, and use lift for transfers x 2 person assist. Review of the resident's December 2019 physician's orders [REDACTED]. Review of the resident's nurses' notes revealed a 10:45 a.m. entry on [DATE] by S5 RN in which she documented she had responded to the call light in resident #2's room. The note revealed that resident #2 was on the floor on her left side and was bleeding from her scalp. Pressure was applied and E[CONDITION] and the resident's RP were called. The resident complained of left hip and leg pain at that time. Review the resident's nurse's note dated 12/21/19 at 3:03 p.m. revealed an entry by S3 LPN that at 10:45 a.m. she was called to the room by a CNA stating that resident #2 had fallen. Upon entering the room she noted the resident on the floor lying on her left side and bleeding from her head. Further review revealed that there was a nurse assessing the resident at that time and she (S3 LPN) was told to call E[CONDITION]. The resident's PCP, RP and E[CONDITION] were called. The resident left the facility via E[CONDITION] at approximately 11:15 a.m. Further review of the nurse's note revealed that the resident had slipped out of the sling while up on the Hoyer lift. Review of a hospital Emergency Department Summary revealed that resident #2 arrived at the Emergency Department on [DATE] at 11:26 a.m. with complaints that included headache, bilateral leg pain and fall, and that the resident was sent to the Emergency Department after the strap on a lift broke resulting in a fall from about 3-4 feet. The summary further revealed that a laceration was noted to the top of the residents head, a large hematoma to her right posterior head, and that the resident complained of right knee pain and moaned to pain all over. Review of a hospital Emergency Physician Record Clinical Impressions dated [DATE] at 1:11 p.m. revealed closed fracture of tibia/fibula, [MEDICAL CONDITION], hematoma of head, and laceration of head. The report further revealed that the resident was transferred to another hospital with [DIAGNOSES REDACTED]. Review of a statement written by S6 CNA dated [DATE] revealed the following: She and S7 CNA provided incontinent care and attempted to transfer resident #2 with the lift. The resident was coughing, but refused to stay in bed, and the lift was shaking due to the resident's coughing episode. S6 CNA documented that she heard a pop sound after the resident was moved from her bed to an area in front of her closet. S6 CNA then noted that the right top strap of the lifter pad had come off. S6 CNA attempted to hold the resident up and screamed to S7 CNA to get help. A nurse outside the room came in as the resident continued to fall hitting her head on the leg of the lift. Review of an undated statement written by S7 CNA revealed that she and S6 CNA went into the resident's room with the lifter and lifted the resident with the lift. S7 CNA went to get the wheelchair and when she returned saw resident #2 falling out of the lift and hitting her head. Review of a statement written by S4 LPN dated 1[DATE]19 revealed that she was outside of the room when she overheard S6 CNA tell S7 CNA to go get some help. S4 LPN stepped in the room and saw the resident's head on the floor and leg of the lift. The rest of her body was falling. She noticed the resident's head was bleeding and told S7 CNA to get the resident's nurse and call an ambulance. She pulled the resident away from the lift. The resident complained of leg pain only at that time. Towels were brought in and pressure was applied to the residents head until E[CONDITION] arrived. Interview on 01/28/2020 at 9:25 a.m. with S7 CNA, revealed that at around 10:00 a.m. on [DATE], she and S6 CNA went into resident #2's room to get her up for bingo. She stated that the resident was awake, alert and had a bad cough. S7 CNA stated she and S6 CNA positioned the resident on the lift pad. S6 CNA hooked the blue top straps to the lifter hooks and she hooked the green bottom straps. S7 CNA stated that S6 CNA started lifting the resident with the remote control device and she left the room at that time to get the resident's wheelchair from across the hall. S7 CNA stated that when she entered the room with the wheelchair, she saw the resident falling out of the lift, and S6 CNA was calling out for help and trying to catch the resident. She stated that she tried to help, but the resident was already on the floor and had hit her head on the leg of the lift. S7 CNA stated that S4 LPN was outside the door and came into the room when she heard the call for help. S7 CNA further stated that she should not have left the room and the wheelchair should have been brought into the room before the transfer was attempted. Interview on 01/28/2020 at 10:05 with S6 CNA revealed that she went to resident #2's room at about 10:00 a.m. on [DATE] to perform incontinent care, and dress and get the resident up to play bingo. S6 CNA stated that the resident was coughing, but was in good spirits and was singing. She stated that after care was provided a lift pad was placed underneath the resident by her and S7 CNA. She stated that the lift was brought into the room by S7 CNA and that she (S6 CNA) hooked the top straps onto the lift hooks and S7 CNA hooked the bottom straps. She stated that she raised the resident off the bed using the lift's remote control device, and sent S7 CNA to get the resident's wheelchair which was located across the hall from the resident's room. S6 CNA stated that while waiting for S7 CNA to return, she pulled the lift away from the bed with the resident in the sling and turned the lift toward the door. She stated that she looked away from the resident to see what was taking S7 CNA so long to bring in the wheelchair, and that's when she heard a pop noise. S6 CNA stated that she saw that the top right strap, which would have been on the resident's left, had come undone and the resident was falling out of the sling. She stated that she started screaming for help and tried to hold the resident up, but she couldn't. S6 CNA then stated that within seconds, S7 CNA and S4 LPN ran into the room as the resident was falling. She stated that she thought the resident hit her head on the leg of the machine, but was not sure. S6 CNA stated that she should have waited for S7 CNA to return with the wheelchair before moving the resident away from the bed in the lift sling. S6 CNA confirmed that none of the straps on the lift pad used on resident #2 were noted to be broken after the incident occurred. S6 CNA stated I guess it just came loose. Interview on 01/28/2020 at 11:00 a.m. with S1 Administrator revealed that she felt that the lift pad used on resident #2 on [DATE] was in working condition, appropriate for use and had been tested by herself and the S2 DON. S1 Administrator stated that the sling pads and lift should be inspected by the staff before each use. Interview with S2 DON on 01/28/2020 at 1:32 p.m. revealed that the mechanical lift training manual was used as the facility's mechanical lift policy and procedure, and that the residents' care plans dictated how much assistance was needed for resident transfers with the lift. Telephone interview on 01/29/2020 at 10:26 a.m. with S4 LPN revealed that she was assigned to resident #2's roommate on the date of the incident. She stated that at approximately 10:40 a.m. while preparing medications at her cart, she heard S6 CNA call out and say tell S7 CNA to get some help. S4 LPN stated that when she looked up, S7 CNA was in the doorway of resident #2's room with a wheelchair. S4 LPN stated she entered the room and saw the resident on the floor with her head partially resting on the leg of the lifter, and noted that she was bleeding. She stated she told S7 CNA to get towels and call for help. S4 LPN stated she moved the resident's head off of the leg of the lift by grabbing her shoulders and sliding her over so that she could assess her. She stated that S3 LPN came into the room while she was holding pressure on the resident's head, and she told her to call the ambulance. Interview of S8 CNA Supervisor on 01/29/2020 at 10:57 a.m. revealed that she did not visualize a return demonstration of Hoyer lift use with all CNAs, and did not increase monitoring of the CNAs using the Hoyer lift after the incident on [DATE]. Interview on 01/29/2020 at 1:32 p.m. with S2 DON revealed that S7 CNA should not have left the room during the transfer. She confirmed that the CNAs should have called for assistance if they needed a wheelchair for the resident. Interview on 01/30/2020 at 9:04 a.m. with S5 RN Weekend Supervisor revealed that she was the supervisor on duty on [DATE]. She stated that at approximately 10:30 a.m. on the [DATE], she responded to a call light from resident #2's room. She stated that when she entered the room she observed resident #2 on the floor lying on her left side and bleeding from her head. She stated that S6 CNA and S7 CNA were in the room as well as S4 LPN. She stated that initially the resident did not complain of pain, but later said her left leg and hip were hurting. She then stated that S3 LPN entered the room and she told her to call E[CONDITION] and the resident's PCP. Telephone interview on 01/30/2020 at 9:25 a.m. with S3 LPN revealed that she was the nurse assigned to resident #2 on [DATE]. She stated that at approximately 10:45 a.m. she heard a staff person call out Code Green on the 100 hall. She stated that when she walked into resident #2's room, she observed the resident lying on her left side. S5 RN and S4 LPN were attending to the resident, and she was instructed to call E[CONDITION] and the resident's doctor. Resident #6 Review of resident #6's Face Sheet revealed an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident's 01/2020 Physician order [REDACTED]. Review of the resident's 12/12/2019 Quarterly MDS revealed the resident had a BI[CONDITION] of 15 (cognitively intact), and required 2-person physical assist with transfer. Review of the resident's current Care Plan Smart Chart revealed the approach: Mechanical lift x 2 staff members. Review of the resident's 12/2019 - 01/21/2020 Departmental Notes revealed that the resident required the use of a lift and 2 staff members for transfer. On 01/29/2020 at 9:30 a.m. an observation was conducted of a transfer of resident #6 using a Hoyer lift by S20 CNA and S13 CNA. While S20 CNA positioned the lift in preparation for the transfer, S13 CNA went to the opposite side of the resident's bed. The sling was applied to the resident and the straps were tugged to make sure they were secure. S20 CNA lifted the resident off the bed slightly, kept him over his bed, opened the legs of the lift, and turned to position the wheelchair. S20 CNA pulled the resident away from the bed with the lift while S13 CNA remained on the opposite side of the resident's bed. S13 CNA hurriedly came around the end of the bed; however, the resident was already hanging suspended in the sling with the support of S20 CNA only when he was moved away from the bed. S20 CNA stated at that time that she had made a boo boo, and stated that she should have allowed time for S13 CNA to come around the bed to the resident prior to her (S20 CNA) moving him away from the bed. Interview of S2 DON on 01/29/2020 at 12:28 p.m. revealed the S2 DON was informed of surveyor observation of the transfer of resident #6 with the Hoyer lift on 01/29/2020 at 9:30 a.m. by S20 CNA and S13 CNA. The S2 DON confirmed that both CNAs should have been on the same side of the resident's bed prior to the resident being moved away from the bed.

Based on observation, record review, and interview, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to transfer residents using a Hoyer lift for 2 (#2 and #6) of 7 residents (#2, #6, #7, #8, #9, #10 and #11) who required the use of a mechanical lift and 2 persons assistance during transfers. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at approximately 10:45 a.m. for resident #2, who had a [DIAGNOSES REDACTED]. Resident #2 was care planned to transfer with a lift times 2 person assist. After placing the resident on the Hoyer lift pad, 1 CNA left the resident's room to get the resident's wheelchair. The other CNA who was left in the room lifted the resident from the bed and placed the resident in a dangling position over the floor. The resident fell from the Hoyer lift to the floor. The resident was transferred to the emergency department of a local hospital. The Emergency Physician Record revealed a clinical impression of closed fracture of tibia/fibula - bilateral tib/fib fractures, 6mm and 8mm [MEDICAL CONDITION], hematoma of head, and laceration of head. The resident was transferred to another hospital on [DATE] at 1:35 p.m. This deficient practice continued resulting in an Immediate Jeopardy situation on 01/29/2020 at 9:30 a.m. for Resident #6 who was care planned to transfer with a lift and 2 person assist, and was placed on a mechanical lift/Hoyer lift. The resident was then moved from over the bed to a dangling position over the floor by one CNA, while the other CNA remained standing on the opposite side of the bed during the transfer. The Administrator was notified of deficient practice at the Immediate Jeopardy level on 01/30/2020 at 11:26 a.m. The Immediate Jeopardy was removed on 01/31/2020 at 2:20 p.m. when the facility submitted an acceptable Plan of Removal. Observations, interviews and record reviews, confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Review of the Plan of Removal revealed the following: All nursing staff was in-serviced on appropriate use and transfer with mechanical lift on 01/30/2020 - 01/31/2020. All nursing staff were monitored for competency and checked off by the DON; however, this was not documented appropriately. All nursing staff was again checked for competency with use of the lift and competency documented on 01/30/2020 and 01/31/2020. DON/designee will monitor at least 7 lift transfers per week for 12 weeks then randomly using the attached audit tool (Hoyer Lift Audit). Any concerns during transfer will be addressed with the responsible staff member and that staff member will be retrained and monitored for competency before performing another lift transfer on a resident. All staff have been in-serviced on location of information regarding resident care -transfer status, etc. This was completed on 01/30/2020 - 01/31/2020. DON/designee will monitor at least 8 nursing staff members per week for 8 weeks then randomly to ensure staff knowledge. Audit tool attached. Lifts will be monitored monthly by the maintenance supervisor for any maintenance needs. Any maintenance concerns will be addressed immediately and before the lift is used for resident transfers. Audit tool attached. The deficient practiced continued at a potential for harm for a total of 6 residents who required transfer with the use of a mechanical lift with 2 person assistance. Findings: Review of a Mechanical Lift Training Manuel entitled Lifting and Positioning Training - Equipment Specific revealed the following: Lifting and positioning overview, Safe client handling and movement, Mechanical lifts: Hoyer, The sling, and positioning of equipment. Resident #2 Review of resident #2's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of a Quarterly MDS Assessment with an ARD of 10/04/2019 revealed the resident had a BI[CONDITION] of 8 indicating moderate cognitive impairment, required 2 + person physical assist for bed mobility, transfers, dressing, toileting, and personal hygiene, was total dependence for bathing, had upper and lower extremity impairment on one side, and utilized a wheelchair for mobility. Review of resident #2's care plan with a target date of 01/01/2020 revealed a problem of Physical Mobility Impairment r/t generalized weakness, debility, and dx of [MEDICAL CONDITION]. Approaches included: assistance as needed with all transfers, obtain assistive devices as needed, and use lift for transfers x 2 person assist. Review of the resident's December 2019 physician's orders [REDACTED]. Review of the resident's nurses' notes revealed a 10:45 a.m. entry on [DATE] by S5 RN in which she documented she had responded to the call light in resident #2's room. The note revealed that resident #2 was on the floor on her left side and was bleeding from her scalp. Pressure was applied and E[CONDITION] and the resident's RP were called. The resident complained of left hip and leg pain at that time. Review the resident's nurse's note dated 12/21/19 at 3:03 p.m. revealed an entry by S3 LPN that at 10:45 a.m. she was called to the room by a CNA stating that resident #2 had fallen. Upon entering the room she noted the resident on the floor lying on her left side and bleeding from her head. Further review revealed that there was a nurse assessing the resident at that time and she (S3 LPN) was told to call E[CONDITION]. The resident's PCP, RP and E[CONDITION] were called. The resident left the facility via E[CONDITION] at approximately 11:15 a.m. Further review of the nurse's note revealed that the resident had slipped out of the sling while up on the Hoyer lift. Review of a hospital Emergency Department Summary revealed that resident #2 arrived at the Emergency Department on [DATE] at 11:26 a.m. with complaints that included headache, bilateral leg pain and fall, and that the resident was sent to the Emergency Department after the strap on a lift broke resulting in a fall from about 3-4 feet. The summary further revealed that a laceration was noted to the top of the residents head, a large hematoma to her right posterior head and that the resident complained of right knee pain and moaned to pain all over. Review of a hospital Emergency Physician Record Clinical Impressions dated [DATE] at 1:11 p.m. revealed closed fracture of tibia/fibula, [MEDICAL CONDITION], hematoma of head, and laceration of head. The report further revealed that the resident was transferred to another hospital with [DIAGNOSES REDACTED]. Review of a statement written by S6 CNA dated [DATE] revealed the following: She and S7 CNA provided incontinent care and attempted to transfer resident #2 with the lift. The resident was coughing, but refused to stay in bed, and the lift was shaking due to the resident's coughing episode. S6 CNA documented that she heard a pop sound after the resident was moved from her bed to an area in front of her closet. S6 CNA then noted that the right top strap of the lifter pad had come off. S6 CNA attempted to hold the resident up and screamed to S7 CNA to get help. A nurse outside the room came in as the resident continued to fall hitting her head on the leg of the lift. Review of an undated statement written by S7 CNA revealed that she and S6 CNA went into the resident's room with the lifter and lifted the resident with the lift. S7 CNA went to get the wheelchair and when she returned saw resident #2 falling out of the lift and hitting her head. Interview on 01/28/2020 at 9:25 a.m. with S7 CNA, revealed that at around 10:00 a.m. on [DATE], she and S6 CNA went into resident #2's room to get her up for bingo. She stated that the resident was awake, alert and had a bad cough. S7 CNA stated she and S6 CNA positioned the resident on the lift pad. S6 CNA hooked the blue top straps to the lifter hooks and she hooked the green bottom straps. S7 CNA stated that S6 CNA started lifting the resident with the remote control device and she left the room at that time to get the resident's wheelchair from across the hall. S7 CNA stated that when she entered the room with the wheelchair, she saw the resident falling out of the lift, and S6 CNA was calling out for help and trying to catch the resident. She stated that she tried to help, but the resident was already on the floor and had hit her head on the leg of the lift. S7 CNA stated that S4 LPN was outside the door and came into the room when she heard the call for help. S7 CNA further stated that she should not have left the room and the wheelchair should have been brought into the room before the transfer was attempted. Interview on 01/28/2020 at 10:05 with S6 CNA revealed that she went to resident #2's room at about 10:00 a.m. on [DATE] to perform incontinent care, and dress and get the resident up to play bingo. S6 CNA stated that the resident was coughing, but was in good spirits and was singing. She stated that after care was provided a lift pad was placed underneath the resident by her and S7 CNA. She stated that the lift was brought into the room by S7 CNA and that she (S6 CNA) hooked the top straps onto the lift hooks and S7 CNA hooked the bottom straps. She stated that she raised the resident off the bed using the lift's remote control device, and sent S7 CNA to get the resident's wheelchair which was located across the hall from the resident's room. S6 CNA stated that while waiting for S7 CNA to return, she pulled the lift away from the bed with the resident in the sling and turned the lift toward the door. She stated that she looked away from the resident to see what was taking S7 CNA so long to bring in the wheelchair, and that's when she heard a pop noise. S6 CNA stated that she saw that the top right strap, which would have been on the resident's left, had come undone and the resident was falling out of the sling. She stated that she started screaming for help and tried to hold the resident up, but she couldn't. S6 CNA then stated that within seconds, S7 CNA and S4 LPN ran into the room as the resident was falling. She stated that she thought the resident hit her head on the leg of the machine, but was not sure. S6 CNA stated that she should have waited for S7 CNA to return with the wheelchair before moving the resident away from the bed in the lift sling. S6 CNA confirmed that none of the straps on the lift pad used on resident #2 were noted to be broken after the incident occurred. S6 CNA stated I guess it just came loose. Interview on 01/28/2020 at 11:00 a.m. with S1 Administrator revealed that she felt that the lift pad used on resident #2 on [DATE] was in working condition, appropriate for use and had been tested by herself and the S2 DON. S1 Administrator stated that the sling pads and lift should be inspected by the staff before each use. Interview with S2 DON on 01/28/2020 at 1:32 p.m. revealed that the mechanical lift training manual was used as the facility's mechanical lift policy and procedure, and that the residents' care plans dictated how much assistance was needed for resident transfers with the lift. Interview on 01/29/2020 at 1:32 p.m. with S2 DON revealed that S7 CNA should not have left the room during the transfer. She confirmed that the CNAs should have called for assistance if they needed a wheelchair for the resident. Resident #6 Review of resident #6's Face Sheet revealed an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident's 01/2020 Physician order [REDACTED]. Review of the resident's 12/12/2019 Quarterly MDS revealed the resident had a BI[CONDITION] of 15 (cognitively intact), and required 2-person physical assist with transfer. Review of the resident's current Care Plan Smart Chart revealed the approach: Mechanical lift x 2 staff members. Review of the resident's 12/2019 - 01/21/2020 Departmental Notes revealed that the resident required the use of a lift and 2 staff members for transfer. On 01/29/2020 at 9:30 a.m. an observation was conducted of a transfer of resident #6 using a Hoyer lift by S20 CNA and S13 CNA. While S20 CNA positioned the lift in preparation for the transfer, S13 CNA went to the opposite side of the resident's bed. The sling was applied to the resident and the straps were tugged to make sure they were secure. S20 CNA lifted the resident off the bed slightly, kept him over his bed, opened the legs of the lift, and turned to position the wheelchair. S20 CNA pulled the resident away from the bed with the lift while S13 CNA remained on the opposite side of the resident's bed. S13 CNA hurriedly came around the end of the bed; however, the resident was hanging suspended in the sling with the support of S20 CNA only when he was moved away from the bed. S20 CNA stated at that time that she had made a boo boo, and stated that she should have allowed time for S13 CNA to come around the bed to the resident prior to her (S20 CNA) moving him away from the bed. Interview on 01/29/2020 at 9:30 a.m. with S9 RN, Treatment Nurse revealed she was in-serviced within the last 3 months on the Hoyer lift, but she had not performed a return demonstration on the use of the lift. Interview on 01/29/2020 at 9:40 a.m. with S11 LPN and S12 LPN revealed that they had not received any recent training on the Hoyer lift and had not been asked to demonstrate their ability to work a lift properly. Interview on 01/29/2020 at 9:48 a.m. with S14 CNA revealed she had received training on the Hoyer lift in the last 1-2 weeks, but she had not performed a return demonstration on the use of the lift. Interview on 01/29/2020 at 9:55 a.m. with S15 CNA revealed she had received a recent in-service on the Hoyer lift, but she could not remember when. She stated she had not actually performed a return demonstration herself. Interview on 01/29/2020 at 12:28 p.m. with S2 RN DON revealed there was a reference table that staff was aware of that documented the resident's names, weights and what color transfer belt loop was to be used on each of the residents in the facility that required the use of a lift for transfer. She stated the table was created after the Hoyer lift incident on [DATE]. Additionally, S2 DON was informed of surveyor observation of the transfer of resident #6 with the Hoyer lift on 01/29/2020 at 9:30 a.m. by S20 CNA and S13 CNA. The S2 DON confirmed that both CNAs should have been on the same side of the resident's bed prior to the resident being moved away from the bed. Interview on 01/29/2020 at 12:30 p.m. with S14 CNA revealed that she was not aware of a reference table concerning the Hoyer Lift. She stated that if she had to use a lift on a resident, she would get someone who had used the lift on the resident to tell her what color transfer belt loop to use. S14 CNA stated that she had not performed a demonstration on the use of the Hoyer lift. Interview on 01/29/2020 at 12:35 p.m. with S15 CNA revealed that she would ask the nurse if she had to use the lift on a resident that she was not familiar with. She confirmed that she was not aware of a reference table concerning the Hoyer Lift, and had not performed a return demonstration on how to use the lift. Interviews on 01/29/2020 at 12:40 p.m. with S20 CNA, S18 CNA, S13 CNA, and S19 CNA/Restorative revealed that they were not aware of a reference table concerning the use of the Hoyer lift. S20 CNA stated that she would ask a nurse if faced with the issue of using the lift on an unfamiliar resident. S18 CNA, S13 CNA, and S19 CNA/Restorative verbally agreed with S20 CNA, and all stated they had not performed a demonstration on how to use a Hoyer lift. Interview on 01/29/2020 at 4:12 p.m. with C16 CNA revealed that he would talk to the nurse if he had a resident that he was not familiar with and had to get up in a lift. He stated that he had an in-service about a week ago that the staff quickly reviewed; however, he had never performed a demonstration on the use of a lift after the Hoyer lift incident on [DATE]. Interview on 01/29/2020 at 4:16 p.m. with S17 CNA revealed that she would ask a nurse in reference to information about an unfamiliar resident, and that she was not aware of the reference table concerning information on residents requiring the use of lifts. She stated that she had never used a mechanical lift; and had not demonstrated the use of a Hoyer lift to anyone at the facility. Interview on 01/29/2020 at 4:20 p.m. with S21 CNA revealed that he had attended a recent in-service which did not include return demonstration of the lift. Interview on 01/29/2020 at 4:24 p.m. with S22 CNA revealed that she was not aware of where to locate information concerning residents who needed a lift for transfer. S22 CNA further stated that she had not performed a return demonstration on how to use the Hoyer lift. Interview on 01/29/2020 at 4:30 p.m. with S23 CNA revealed that she had been employed at the facility for 4 months, and would ask a nurse about information on a resident. S23 CNA stated she had not performed a return demonstration on how to use the lift. Interview on 01/29/2020 at 4:38 p.m. with S24 CNA revealed that she had worked in the facility for 2 weeks and had never performed a return demonstration on the use of a mechanical lift. Interview on 01/29/2020 at 4:42 p.m. with S10 RN revealed that she had worked at the facility for 3-4 weeks. She stated she was a floor nurse and had not received any recent training on the Hoyer lift, and never used a lift.