Every finding on record at Lexington House

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 all 18 residents who received a puree diet.Findings:Review of a facility policy on 05/11/2026 at 3:15 p.m. titled, Standardized Recipes with a review date of 05/2023 revealed the following in part . Standardized recipes are used in preparation of food of control of quality, quantity, and uniformity of product. 5. The director of food and nutrition services requires the food and nutrition service staff to follow the standardized recipes. Review of the facility's standardized recipe for puree steamed rice revealed the following in part .Preparation for rice according to regular recipe: 20 servings, 1 1/4 cups 3 tablespoons of whole milk and 3/4 cups of soft margarine. Place food in processor, process until smooth adding 1.5 tablespoons of margarine per portion. Review of the facility standardized recipe for puree boneless pork chops revealed the following in part .Preparation for pork chop according to regular recipe: 20 servings, 1/4 cup 1 tablespoon of food thickener bulk. Mix broth and thickener to make slurry. Review of the facility standardized recipe for puree seasoned greens revealed the following in part .Preparation for seasoned greens/mustard greens according to regular recipe: 20 servings, 1/4 cup 2 tablespoons of food thickener bulk. Process until smooth adding 1 tablespoon of food thickener per serving. Kitchen observation on 05/11/2026 at 11: 05 a.m. revealed S4 [NAME] prepare the following pureed food items .-Observed S4 [NAME] pour an unmeasured amount of thickener into the blended pureed pork chops and stated, I am just going to eyeball it.-Observed S4 [NAME] prepare pureed rice using 2 ounces of chicken broth. S4 [NAME] did not use milk or margarine during preparation. -Observed S4 [NAME] prepare pureed mustard greens using 8 ounces of chicken broth. S4 [NAME] did not use thickener during preparation. In an interview on 05/11/2026 at 1:40 p.m., S3 DM revealed there were a total of 18 residents who received puree diets in the facility. S3 DM revealed S4 [NAME] was trained properly on how to follow the standardized puree recipes during preparation procedures. S3 DM confirmed the above recipes for puree pork chops, steamed rice, and mustard greens were not followed, but should have been. S3 DM confirmed S4 [NAME] should have measured the thickener for the pork chops, should have used measured milk and margarine for the steamed rice, and should have used measured thickener for the mustard greens, but did not.

Based on observation and interview, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store food in accordance with professional standards for food service safety. The facility census was 110. Findings: Review of a facility policy on 05/11/2026 at 3:15 p.m. titled, Food Storage Labeling with a review date of 05/2018 revealed the following in part .The facility will ensure the safety and quality of food by adhering to proper storage and labeling procedure. 1. Labelling: A. All temperature-controlled foods and ready-to-eat foods that are prepared in the facility and held for longer than twenty-four hours will be labelled. Information included on the label: Name of the food and date of storage. 3. Rotation: A. Identify the food item's use by date or expiration date. Store items with the earliest use by or expiration date in front of items with later dates. B. Foods stored in storage units will by surveyed routinely to identify and discard foods that have passed its manufacturer use by date or expiration date. Review of a facility policy on 05/11/2025 at 3:15 p.m. titled, Sanitary Conditions of the Food Service Department with a revision date of 05/2018 revealed the following in part .Facilities and equipment used in the preparation and serving of food provided to residents are to be safe and sanitary. Observation on 05/11/2026 at 8:10 a.m. of the facility kitchen accompanied by S3 DM revealed the following: Walk-In Refrigerator:- One container of Italian dressing with an expiration date of 04/15/2026; - One carton of sweet tea with an expiration date of 04/30/2026;- One container of ranch dressing with an expiration date of 04/30/2026; - Three containers of chopped garlic in water with an expiration date of 01/07/2026; - One container of chicken base with an expiration of 02/18/2026; - One carton of milk with an expiration date of 03/03/2026; - One opened cardboard box that contained: Opened, unsealed, and undated plastic wrap of sausage patties (9 individual sausage patties);- One opened cardboard box that contained: green bells peppers (over 50 bell peppers) with fuzzy, brown/grey substance on multiple green bell peppers- bell peppers were soggy and decomposing; and- One opened cardboard box that contained: oranges (over 50 oranges) with fuzzy, brown/grey substance on multiple oranges- oranges were soggy and decomposing; Walk-In Freezer:- One opened cardboard box that contained: opened, unsealed, and undated plastic wrap of biscuits (over 50 individual biscuits); - One opened cardboard box that contained: opened, unsealed, and undated plastic wrap of peanut butter cookie dough (over 100 individual cookie doughs); and- One opened cardboard box that contained: opened, unsealed, and undated plastic wrap of hamburger patties (over 50 hamburger patties). At the time of observation, S3 DM confirmed all of the above findings. S3 DM revealed that all dietary staff were aware of how to correctly label/store opened food items and to discard any expired food items in the kitchen. S3 DM confirmed the above listed items were expired, opened, unsealed, and/or undated and should have been disposed of properly. S3 DM confirmed the bell peppers and oranges were decomposing, had growing mold on them and should have been discarded, but were not.

Based on record review and interview, the facility failed to ensure that residents who required urostomy services received care consistent with professional standards of practice, as evidenced by the facility failing to ensure the physician's order for nephrostomy tube irrigation was followed for 1 (Resident #35) of 1 residents reviewed for catheter care. Total sample size: 37 Findings:Review of Resident # 35's medical record revealed an admission date of 02/27/2025, with diagnoses that included, in part.Encounter for Attention to other Artificial Openings of Urinary Tract; Chronic Kidney Disease, Stage 3; Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms; and Hydronephrosis with Renal and Ureteral Calculous Obstruction. Review of Resident # 35's Quarterly MDS with an ARD of 03/05/2026 revealed a BIMS score of 11, indicating moderate cognitive impairment. Resident #35 required supervision and/or touching assistance for toileting and personal hygiene. Review of Resident #35's Care Plan with a review date of 03/09/2026, read in part. Resident #35 has a diagnosis of Hydronephrosis with Renal and Ureteral Calculous Obstruction requiring a nephrostomy tube. Review of Resident # 35's Physician's Order dated 10/03/2025 read in part. Irrigate nephrostomy tube to the right mid-back with 3ml of wound cleanser twice daily to maintain tube patency. Review of Resident #35's Medication Administration Record for 05/1/2026-05/12/2026 revealed nursing staff signed off on the physician's order twice daily, indicating that Resident #35's nephrostomy tube irrigation was completed as ordered. On 05/12/2026 at 8:44 a.m., an interview with Resident #35 revealed that staff were not performing the ordered twice-daily irrigation of his nephrostomy tube. On 05/12/2026 at 11:43 a.m., an interview with S6LPN revealed she was unaware Resident #35 had a scheduled physician order to irrigate the nephrostomy tube twice daily. S6LPN stated she irrigated the nephrostomy tube as needed for patency. S6LPN confirmed she had not irrigated the tube since it was replaced on 05/06/2026 because she was unfamiliar with the procedure for irrigating the new nephrostomy tube. S6LPN further confirmed she did not notify the physician to obtain clarification or education regarding the nephrostomy tube maintenance. S6LPN acknowledged that she signed the physician orders on 05/07/2026 and 05/08/2026 indicating the nephrostomy tube irrigation had been completed; however, S6LPN confirmed the ordered treatment was not performed. On 05/13/2026 at 3:08 p.m., an interview with S7LPN revealed she routinely provided care for Resident #35 and was familiar with his treatment needs. S7LPN revealed she was unaware Resident #35 had a scheduled physician order to irrigate the nephrostomy tube twice daily. S7LPN further stated she had never irrigated Resident #35's nephrostomy tube. S7LPN acknowledged her initials on 05/04/2026, 05/06/2026, and 05/11/2026 indicating the nephrostomy tube irrigation had been completed. S7LPN confirmed the ordered treatment had not been performed. On 05/13/2026 at 3:20 p.m., S2DON acknowledged that the physician's order to irrigate Resident #35's nephrostomy tube was not being performed as ordered, but should have been.

Based on observation, interview, and record review, the facility failed to ensure that all mechanical, electrical, and patient care equipment were maintained in a safe operating condition for 1 (Resident #113) of 6 residents reviewed for physical environment. The total sample size was 37 residents.Review of facility policy with a last review date of 07/2025, titled Housekeeping Safety, revealed in part . Check for and report all defective equipment. Review of Resident #113's medical record revealed Resident #113 was admitted to the facility on [DATE] with diagnoses that included, in part., Parkinson's disease without Dyskinesia with Fluctuations, Neurocognitive Disorder with Lewy Bodies, and Essential Tremor. Review of Resident #113's Significant Change MDS with ARD 04/16/2026 revealed the resident had a BIMS score of 12, indicating moderate cognitive impairment. Resident #113 was dependent for all ADLs, including bed mobility. On 5/12/2026 at 8:45 a.m., observation revealed Resident #113 sitting up in bed with the head of the bed elevated. The resident's bed remote was observed located on the resident's right side rail, with the wire casing broken from the base of the remote, extending down about 4 inches, revealing approximately 4 inches of exposed frayed wire. Resident #113 stated she did not know how long her bed remote had exposed wire. On 5/12/2026 at 1:53 p.m., observation revealed Resident #113 sitting up in bed with the head of the bed elevated. The resident's bed remote was observed located on the resident's right side rail, with the wire casing broken from the base of the remote, extending down about 4 inches, revealing approximately 4 inches of exposed frayed wire. On 5/12/2026 at 2:35 p.m., observation of Resident #113's bed remote with S5 Maintenance at this time. S5 Maintenance confirmed Resident #113's bed remote wire casing was broken with exposed frayed wire, and should not be on the resident's bed. On 5/12/2026 at 2:46 p.m., observation of Resident #113's frayed wired bed remote with S1Admin at this time. S1Admin stated Resident #113 is dependent for all care, including bed mobility, and direct care staff should have identified the exposed wire as an issue and reported it. S1Admin confirmed the residents' bed remote should not have been on the residents' bed in that condition, but was.

Based on observation, record review, and interview, the facility failed to ensure a resident's therapeutic diet was followed according to the physician's orders by failing to ensure a resident received double portion on her lunch tray for 1 resident (#14) in a total sample of 37 residents. Findings:Observation of Resident #14 during the lunch meal on 05/13/2026 at 11:45 a.m. revealed the resident was served one piece of chicken, instead of two pieces. Review of Resident #14's Electronic Health Record (EHR) revealed an admit date of 06/04/2021 and diagnoses that included in part, Type 2 Diabetes Mellitus with Hyperglycemia, Dementia in Other Diseases Classified Elsewhere, Severe, with Other Behavioral Disturbance, and Cognitive Communication Deficit. Review of the Physician's orders with a start date of 04/30/2026 revealed the diet ordered for Resident #14 was NSOT (No Salt on Tray) diet, Regular texture, Regular consistency, Double portion. Review of the resident's care plan also revealed the resident was identified with a potential for altered nutritional status.tries to take food off other trays.looks for food after she has eaten, with a revision date of 05/01/2026. Interventions included in part, double portions and diet as ordered, which were initiated on 05/01/2026. Interview with S3 DM on 05/13/2026 at 11:50 a.m. confirmed Resident #14 should have received double portions, which included two pieces of chicken, according to her therapeutic diet order, but did not.

Based on record review and interviews the facility failed to ensure grievances/complaints had been documented and investigated. The facility failed to open a grievance/complaint investigation for 1 (#9) of 37 sampled residents. Findings:Review of policy titled Grievances with revision date of 06/11 revealed under the section Procedure:When a complaint or grievance is voiced, a Grievance/Complaint for will be completed by the Administrator or Department Head with follow-up as appropriate. Review of Resident #9's medical record revealed an initial admission date of 02/12/2026 with diagnoses that included, in part, Encounter for Surgical Aftercare Following Surgery on the Nervous System. Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Syncope and Collapse, and Muscle Weakness (Generalized.) Review of Resident #9's electronic health record (EHR) revealed a Nursing Note written by S8LPN on 04/06/2026 at 2:20 p.m. S8LPN's note stated that Resident #9's family relayed to the nurse that the resident did not want to be here because staff was 'mean and rude to her.' The note continued to relay details of concerns voiced either by the resident or her family member. Review of 2026 Grievance/Complaint Log failed to reveal any documented grievance in regard to Resident #9. Interview on 05/13/2026 at 4:15 p.m. with S8LPN clarified that her note on 04/06/2026 referenced a grievance/complaint received from Resident #9's family on behalf of Resident #9. S8LPN stated that she had notified S2DON regarding the grievance/complaint as relayed by Resident #9's family. Interview on 05/13/2026 at 4:00 p.m. with S1Admin revealed that an Administrator or Department Head would have to open a grievance/complaint in the facility's computer system, the other staff cannot open the grievance/complaint. S1Admin stated that she was unaware the Resident #9's family had expressed any grievances or complaints. Interview on 05/13/2026 at 4:50 p.m. S2DON stated that a grievance/complaint had not been opened regarding the grievance/complaint voiced by Resident #9's family on behalf of the resident.

Based on interview and record review, the facility failed to complete a thorough investigation of an injury of unknown origin for 1 (Resident #1) of 4 sampled residents.Review of the facility's Critical Incident Report dated 12/08/2025 revealed Resident #1 complained of pain to her right lower extremity and x-rays revealed fractures of the tibial shaft and the proximal fibula. Statements were obtained from nursing staff who rendered care during the 48 hours prior to discovery of the injury. The facility substantiated an Injury of Unknown Origin.Review of the facility's policy titled Incident Investigation and Reporting revised 05/2024 revealed, in part.Criteria for an Injury of Unknown Origin include the source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury is suspicious due to the extent or location of the injury or the number of injuries at one time or the incidence of injury over time. In the event of an incident involving an allegation or suspicion of mistreatment, exploitation, neglect, abuse, misappropriation or other crime, as well as injuries of unknown origin.the administrator will begin an investigation. The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator.Review of Resident #1's EMR revealed an admission date of 03/15/2022 with diagnoses including Hemiplegia and Hemiparesis, Dementia, and Left Above-Knee Amputation.Review of Resident #1's Significant Change MDS with ARD of 12/18/2025 revealed a BIMS score of 3, indicating severely impaired cognition. Resident #1 was dependent for hygiene, bathing, dressing, and position changes.Review of Resident #1's History and Physical dated 12/09/2025 revealed, in part.X-rays of the right knee dated 12/08/2025 demonstrated partially visualized traumatic fractures of the proximal tibial and fibular diaphyses. X-rays of the right tibia and fibula dated 12/08/2025 demonstrated traumatic tibial and fibular fractures.Interview with S15CNA on 01/07/2026 at 3:41 p.m. revealed she provided care for Resident #1 from 3:00 p.m. until 11:00 p.m. on 12/06/2025 and 12/07/2025. S15CNA revealed she was not asked to provide a statement. S15CNA confirmed she provided care to Resident #1 in the 48 hours prior to identification of her injury of unknown origin, but was not interviewed or asked to provide a statement.Interview with S1ADM on 01/08/2026 at 10:05 a.m. revealed when Resident #1's injury was discovered on 12/08/2025 she had access to facility video surveillance footage for the previous 72 hours. S1ADM revealed she reviewed the facility's video surveillance for the previous 24 hours. S1ADM confirmed she did not review the facility's video surveillance footage from the 72 hours prior to discovery of Resident #1's injury, but should have.

Based on observation, interview, and record review, the facility failed to ensure reasonable accommodation of needs by failing to ensure the call light was accessible by a resident for 3 (Resident #2, Resident #3, and Resident R4) of 4 sampled residents.Review of the facility's policy titled Call Light/Bell revised 01/2024 revealed, in part.place the call light within the resident's reach before leaving the room.Resident #2Review of Resident #2's EMR revealed an admission date of 03/31/2022 with diagnoses including Hemiplegia and Hemiparesis, Generalized Muscle Weakness, Repeated Falls, and Personal History of Healed Traumatic Fracture.Review of Resident #2's Quarterly MDS with ARD of 10/07/2025 revealed a BIMS score of 13, indicating intact cognition. Resident #2 was dependent for toileting, hygiene, bathing, dressing, rolling, and transfers.Observation and interview of Resident #2 on 01/08/2026 at 8:54 a.m. revealed the call light was hanging off the left side of the bed, dangling below the bottom of the mattress. Resident #2 revealed she was unable to locate the call light.Observation of Resident #2 accompanied by S4LPN on 01/08/2026 at 8:56 a.m. revealed the call light should have been within reach of the resident at all times. S4LPN confirmed Resident #2's call light was not within reach of the resident, but should have been.Resident #3Review of Resident #3's EMR revealed an admission date of 03/01/2023 with diagnoses including Hemiplegia and Hemiparesis, Paroxysmal Atrial Fibrillation, Muscle Weakness, Syncope and Collapse, History of Falling, and Personal History of Healed Traumatic Fracture.Review of Resident #3's Significant Change MDS with ARD of 11/18/2025 revealed a BIMS score of 3, indicating severely impaired cognition. Resident #3 was dependent for toileting, bathing, and hygiene. Resident #3 required partial/moderate assistance with position changes and substantial/maximal assistance with transfers.Observation and interview of Resident #3 on 01/05/2026 at 3:15 p.m. revealed the call light was hanging off the left side of the bed, dangling near the floor. Resident #3 revealed she was unable to locate the call light.Observation of Resident #3 accompanied by S11CNA on 01/05/2026 at 3:16 p.m. revealed the call light should have been within reach of the resident at all times. S11CNA confirmed Resident #3's call light was not within reach of the resident, but should have been.Resident R4Review of Resident R4's EMR revealed an admission date of 12/27/2024 with diagnoses including Other Abnormalities of Gait and Mobility, Generalized Muscle Weakness, Age-Related Physical Debility, and Repeated Falls.Observation of Hall A on 01/06/2026 at 12:34 p.m. revealed Resident R4 lying in bed with call light laying on the floor to the left of the bed.Observation of Resident R4 accompanied by S6CNA on 01/06/2026 at 12:38 p.m. revealed the call light should have been within reach of the resident at all times. S6CNA confirmed Resident R4's call light was not within reach of the resident, but should have been.Interview with S10LPN on 01/06/2026 at 2:19 p.m. revealed call lights were to be on their beds, within reach of the residents, and in their hand when possible.Interview with S3QI on 01/07/2026 at 8:10 a.m. confirmed call lights were to be within reach of residents.

Based on observations, interviews and record review the facility failed to ensure that each Resident was treated with respect and dignity and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #2) out of 3 (Resident #1, Resident #2, and Resident #3) sampled Residents, by failing to ensure staff displayed respect when speaking to Resident #2.Findings:Review of the facility's policy titled Dignity and Respect, with a revision date of 07/2022 revealed in part.A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or quality of life recognizing each residents individuality. The facility shall protect and promote the rights of the resident.1. Facility staff shall display respect when speaking with, caring for and talking about residents, as constant affirmation of their individuality and dignity as human beings.2. Each resident of the facility has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.Review of Resident #2's medical record revealed an admit date of 05/20/2025, with diagnoses that included: Acute on Chronic Combined Systolic and Diastolic Congestive Heart Failure, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Paroxysmal Atrial Fibrillation, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Major Depressive Disorder, Cognitive Communication Deficit and Anxiety Disorder.Review of Resident #2's admission MDS with an ARD of 05/27/2025, revealed Resident #2 had a BIMS score of 12 indicating moderate cognitive impairment. The MDS revealed Resident #2 required partial/moderate assistance with toileting, bathing and personal hygiene; set up assistance with eating. Resident #2's MDS revealed Resident #2 used a wheelchair for mobility.Review of Resident #2's Care Plan with a Target Date of 06/03/2025 revealed in part.Resident #2 needed assistance with ADL's; Resident #2 has Altered Thought Process related to Dementia with interventions that included: Maintain a quiet calm environment, observe for changes in cognitive status and reality orientation.Observation on 08/04/2025 at 11:16 a.m., this surveyor heard S2 CNA tell Resident #2 Don't hit the call light anymore, because I'm busy. Interview with S2 CNA at time of observation confirmed she had told Resident #2 not to put her call light on again. S2 CNA stated to Surveyor Do you know how many times I have been in that room? S2 CNA stated I know that was rude.Observation and Interview on 08/04/2025 at 11:29 a.m. with Resident #2 revealed she was sitting in a wheelchair in the doorway of her bathroom, with her head down. Resident #2 stated S2 CNA had told her not to put her call light on again because she was busy. Resident #2 stated that was not the first time S2 CNA had told her not to put her call light on. Resident #2 stated she didn't want S2 CNA telling her not to put her call light on.Interview on 08/04/2025 at 1:43 p.m. with S1 DON confirmed it was not the expectation of any staff to tell a resident not to put their call light on. S1 DON confirmed S2 CNA should not have told Resident #2 not to put her call light on again because she was busy.

Based on observation and interview, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store, prepare, and serve food in accordance with professional standards for food service safety. The deficient practice had the potential to effect all of the residents who received meals from the kitchen. There were 115 residents who resided in the facility. The facility failed to ensure: 1. Food items in the pantry were labeled with an open date; 2. Staff were wearing hair restraints including beard restraints to prevent hair from contacting food; 3. Maintenance of a clean and sanitary kitchen at all times; and 4. Dishes were sanitized appropriately. Findings: 1. Observation on 05/19/2025 at 8:40 a.m. of the facility pantry revealed one undated, open bag of penne pasta. S7 Dietary Manager confirmed open food in pantry should be labeled with an open date and was not. 2. Observation on 05/19/2025 at 8:40 a.m. revealed S8 Dietary Aide had long facial hair with no use of a beard restraint. S8 Dietary Aide confirmed he was supposed to wear a beard restraint but stated the facility was currently out. Interview on 05/19/2025 at 8:45 a.m. with S7 Dietary Manager confirmed S8 Dietary Aide should have been wearing a beard restraint while preparing food and was not. S7 Dietary Manager then provided S8 Dietary Aide with a beard restraint. 3. On 05/19/2025 at 8:40 a.m. during the initial kitchen observation revealed unsanitary air conditioner vents covered in a black substance. S7 Dietary Manager revealed air conditioner vents are cleaned every few months but was unsure the last time they were cleaned. S7 Dietary Manager confirmed that air conditioner vents in the kitchen were unsanitary and needed cleaning. Interview on 05/21/25 at 9:30 a.m. with S10 Maintenance confirmed air conditioner vents in the kitchen were unsanitary and needed to be cleaned. 4. On 05/19/2025 at 9:00 a.m. during the initial kitchen observation revealed S8 Dietary Aide failed to sanitize dishes appropriately when utilizing the 3 compartment sink. Sanitation strip was non-reactive x 2 attempts by S8 Dietary Aide. Observed sanitation hose in the 2nd compartment sink. Interview with S8 Dietary Aide revealed sanitization hose should be in the 3rd compartment of the sink (sanitization compartment) and was not. S8 Dietary Aide then moved sanitization hose to 3rd compartment of the sink. S7 Dietary Manager confirmed sanitation strip was non-reactive x 2 attempts. S7 Dietary Manager confirmed chemical sanitizer was not mixed to the proper concentration. Interview with S8 Dietary Aide revealed sanitization for the 3 compartment sink should be monitored three times a day and recorded in a sanitation log. S8 Dietary Aide confirmed he did not check water temperature or sanitization this morning prior to utilizing the 3 compartment sink. Interview with S7 Dietary Manager confirmed chemical sanitizer and temperatures for the 3 compartment sink should be monitored three times a day and recorded in the appropriate log. S7 Dietary Manager was not able to provide a temperature/chemical sanitization log. On 05/19/2025 at 9:00 a.m., a review of Dishwasher Temperature Logs dated 12/2024-05/2025 revealed missing temperature logs for multiple dates.

Based on observations and interviews, the facility failed to ensure recipes for pureed diets were followed during meal preparation. This failed practice had the potential to affect 12 residents (#6, #11, # 36, #37, #46, #53, #58, #69, #71, #76, #85, and #101) who received pureed diets. Findings: Review of the Facility's lunch menu for 05/19/2025 revealed, in part .Barbeque ribs, macaroni and cheese, peas, green salad, and a roll. An observation on 05/19/2025 at 09:45 a.m. revealed a pan of pureed meat in the kitchen. S8 Dietary aide revealed meat was pureed prior to observation. S8 Dietary aide was observed pouring an unknown amount of peas in the electric food processor. S8 Dietary aide was observed not measuring portions or following the pureed recipe. Interview with S8 Dietary aide at that time revealed he eyeballs portions based on the pan he uses for pureed foods. S8 Dietary aide confirmed he does not follow recipes or measure portions when preparing pureed foods. Interview on 05/19/2025 at 09:47 a.m., S7 Dietary Manager confirmed S8 Dietary aide did not measure or follow pureed recipe and should have. S7 Dietary manger revealed S8 Dietary Aide had not followed pureed recipes in the past resulting in disciplinary action. Interview on 05/19/2025 at 10:00 a.m., S9 Dietician confirmed if pureed recipes are not followed, required nutritional contents may not be accurate.

Resident #11 Review of Resident #11's medical record revealed an admit date of 02/28/2012 and a readmission date of 01/16/2023 with diagnoses that included in part .Chronic Respiratory Failure with Hypoxia, Dysphagia, Cognitive Communication Deficit, Stage 3 Chronic Kidney Disease and Pressure Ulcer of Sacral Region, Stage 3. Review of Resident #11's Significant Change MDS with an ARD of 05/01/2025 revealed a BIMS was not conducted because the resident was rarely or never understood. Further review revealed Resident #11 was dependent on staff with eating, toileting hygiene, rolling left and right, sitting to lying, and chair/bed to chair transferring. Review of Resident #11's current physician's orders revealed the following: 05/03/2025: Clean Stage 3 to sacrum with wound cleanser, pat dry, apply Santyl ointment to wound, and cover with a dermadress dressing every day until healed. Review of Resident #11's current care plan revealed the resident had a Stage 3 pressure ulcer to sacrum dated 03/27/2025. Interventions included: Administer treatments as ordered and observe for effectiveness as needed; Weekly treatment documentation to include measurement of each skin breakdown's width, length, and depth, type of tissue and exudate. Review of Resident #11's 04/2025 TAR (Treatment Administration Record) revealed Resident #11 had an order dated 03/28/2025 to Clean Stage 3 pressure ulcer to sacrum with wound cleanser, pat dry, apply Santyl ointment to wound and cover with a dermadress dressing every other day. Review of the TAR revealed wound care was not provided as ordered on 04/01/2025, 04/03/2025, 04/07/2025, 04/09/2025, 04/11/2025, 04/13/2025, 04/19/2025, 04/21/2025, 04/23/2025, 04/25/2025, and 04/27/2025. Further review revealed this wound care order was only completed 4 days in April 2025. Review of Resident #11's 05/2025 TAR revealed Resident #11's wound care orders for Stage 3 Sacral pressure ulcer were changed on 05/03/2025 to every day. Review of the TAR revealed wound care was not provided on 05/03/2025, 05/04/2025, 05/07/2025, 05/10/2025, and 05/11/2025. In an interview on 05/21/2025 at 10:50 a.m., S2 DON acknowledged wound care was not documented as completed each day as ordered, on Resident #11's 04/2025 and 05/2025 TARs and should have been. Resident #109 Review of Resident #109's medical record revealed an admit date of 11/15/2024 with the following diagnoses in part . Type 2 Diabetes Mellitus, Encounter for Orthopedic Aftercare following Surgical Amputation, Acquired Absence of Left Leg Below Knee, Peripheral Vascular Disease, and Non Pressure Chronic Ulcer of Right Foot. Review of Resident #109's Quarterly MDS with ARD of 02/21/2025 revealed Resident had a BIMS of 15 (Cognition Intact). Review of Resident 109's current plan of care revealed Resident had diabetic foot ulcer to right great toe. Interventions included: Treatment as ordered. Refer to eTAR. Review of Resident #109's Active Physician's Orders read in part . Clean diabetic ulcer to right tip of great toe with normal saline, pat dry, apply dermacol, then apply bordered dressing every day shift until healed. Clean MASD to bilateral buttock with normal saline, pat dry, apply nystatin powder 10000unit/gm every day and every evening shift until healed. Review of Resident #109's 04/2025 eTAR on 05/20/2025 at 11:30 a.m. revealed there was no evidence of a completed wound care for order of: Clean diabetic ulcer to right tip of great toe with normal saline, pat dry, apply dermacol, then apply bordered dressing every day shift until healed on 04/11/2025 and 04/18/2025. There was no evidence of completed wound care for order of: Clean MASD to bilateral buttock with normal saline, pat dry, apply nystatin powder 10000unit/gm every day and every evening shift until healed on 04/02/2025, 04/04/2025, 04/07/2025, 04/08/2025, 04/09/2025, 04/10/2025, 04/11/2025, 04/15/2025, 04/17/2025, and 04/18/2025. Review of Resident #109's 05/2025 eTAR on 05/20/2025 at 11:30 a.m. revealed there was no evidence of a completed wound care for order of: Clean MASD to bilateral buttock with normal saline, pat dry, apply nystatin powder 10000unit/gm every day and every evening shift until healed on 05/01/2025, 05/02/2025, 05/06/2025, 05/09/2025, 05/12/2025, 05/13/2025, 05/14/2025, 05/15/2025, and 05/16/2025. Interview on 05/21/2025 at 10:50 a.m., with S2 DON acknowledged wound care was not documented as completed each day as ordered, on Resident #109's April 2025 and May 2025 eTARs and should have been. Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure Physician's Orders were implemented. The facility failed to provide wound care as ordered for 3 (#6, #11, and #109) of 3 residents reviewed for skin and pressure ulcers. Total sample size was 41. Findings: Review of the facility's policy titled Prevention and Treatment of Skin Issues dated 11/2023 read in part . It is the policy to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. Treatment of Skin Issues: If a resident is admitted with or there is a new development of a skin issue, the following procedures are to be implemented. Notify Physician/NP and obtain treatment orders communicating facility wound care protocols for consideration. Notify Supervisor/DON as assigned. Initiate Weekly Wound Documentation in the Wound Assessment Manager (WAM electronic documentation) which will include: type of wound, location, date, stage (pressure ulcers only) length, width and depth; wound base description, wound edge description and if present: drainage, odor, undermining, and/or tunneling. Document on any changes or concerns in the resident's medical record. Resident #6 Review of Resident #6's medical record revealed an admit date of 02/05/2020 with the following diagnoses in part . Chronic Respiratory Failure with Hypoxia; Chronic Obstructive Pulmonary Disease; Parkinson's Disease without Dyskinesia; Localized Edema; and Dementia. Review of Resident #6's Quarterly MDS with ARD of 05/30/2025 revealed Resident had a BIMS of 5 (Severe Cognitive Impairment). Review of Resident 6's current plan of care revealed Resident had a skin tear and bruises related to fragile hemorrhagic skin, picks, and scratches. Interventions included: if skin tear occurs, treat per facility protocol and notify physician and family. Monitor/document location, size and treatment of skin tear. Review of Resident #6's Active Physician's Orders read in part . Clean open lesion to right eyebrow with normal saline, pat dry, apply triple antibiotic ointment to wound and cover with Band-Aid daily until healed. Review of Resident # 6's 05/2025 eTAR on 05/20/2025 revealed there was no evidence of an order to complete wound care to the open lesion to right eyebrow. Observation on 05/19/2025 at 10:02 a.m. of Resident #6 revealed she had a hematoma to upper right eyebrow with an undated Band-Aid in place. Resident #6 had dried blood over her right eyebrow. Observation on 05/20/2025 at 08:06 a.m. of Resident #6 revealed she had dried blood over her right eyebrow with undated Band-Aid in place. Observation on 05/20/2025 at 11:33 a.m. of Resident #6 revealed she had dried blood over her right eyebrow with undated Band-Aid in place. Interview on 05/20/2025 at 11:47 a.m. with S5 LPN revealed Resident #6 had skin cancer on several areas of her body. S5 LPN stated that Resident #6 picked at right upper eyebrow causing skin tear and bleeding, so it was covered with a Band-Aid. S5 LPN confirmed the treatment to Resident #6's right eyebrow area should be performed daily and the dressing should have a date on it, but it did not.

Based on observation, record review and interview, the facility failed to ensure the person-centered care plans were developed and implemented for 2 (#25 and #90) of 41 sampled residents. The facility failed to: 1. Ensure Resident #25 did not have a cigarette and lighter in his/her possession, as care planned; and 2. Ensure a care plan was developed timely for Resident #90 to address her known history of eating non-food items. Findings: Resident #25 Review of facility policy titled Smoking Policies and Regulation with a revision date of 10/2024, revealed in part . Cigarette lighters and matches are not permitted in a resident's room and will be kept at the nurses' stations. The facility will provide lighting devices and will light cigarettes upon request in designated areas set aside for smoking. Review of the electronic health record for Resident #25 revealed an original admit date of 11/06/2015 with a re-entry date of 10/23/2024 with diagnoses which included: Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Diabetes, Hemiplegia and Hemiparesis following CVA of right dominate side, and Hypertensive Heart Disease without Heart Failure. The Quarterly MDS with an ARD of 04/08/2025, revealed Resident #25 has a BIMS score of 11, which indicated moderate cognitive impairment. Review of care plan initiated 06/29/2024 revealed Resident #25 was at risk for complications related to nicotine dependence (smoking). Resident #25 is a safe smoker. Interventions included: Cigarettes and smoking supplies are kept by nurses, Resident #25 is able to smoke at her reasonable request, and Resident #25 is to return all smoking supplies back to staff after each smoking session. Interview on 05/20/2025 at 2:37 p.m., Resident #25 revealed cigarettes are kept in a pouch on her wheelchair. Observed one pack of cigarettes and one lighter in resident's wheelchair pouch. Interview on 05/20/2025 at 2:46 p.m., S5 LPN revealed Resident #25 is a safe smoker. S5 LPN confirmed cigarettes and smoking supplies are stored at the nurses' station. S5 LPN confirmed Resident #25 should not have a lighter and pack of cigarettes in her wheelchair pouch. Interview on 05/20/2025 at 2:52 p.m., S12 CNA confirmed Resident #25 keeps smoking supplies in her wheelchair pouch regularly. Interview on 05/20/2025 at 3:15 p.m., S2 DON and S1 Corp RN confirmed smoking supplies should be kept at the nurses' station and were not. Resident #90 Review of Resident #90's electronic health record revealed an admission date of 05/13/2024 with pertinent diagnoses that included: Type 2 Diabetes Mellitus with other Specified Complication, Generalized Muscle Weakness, Cognitive Communication Deficit, Chronic Kidney Disease stage 1, Senile Degeneration of Brain, Severe Unspecified Dementia with other Behavioral Disturbance, Hypothyroidism, Iron Deficiency Anemia, Chronic or Unspecified Gastric Ulcer with Hemorrhage. Review of Resident #90's Significant Change MDS with ARD of 04/15/2025 revealed Resident #90 had a BIMS score of 4, indicating severe cognition impairment. Resident #90 required a mechanically altered diet and partial to moderate assistance with eating. Review of Resident #90's electronic health record progress notes revealed in part . Progress note dated 05/05/2025 at 08:58 a.m. created by S5 LPN on 05/21/2025 08:59 a.m. Resident #90 noted sitting at dining room table chewing on her straw, staff able to redirect Resident #90 attention at this time and S15 MD notified of behaviors with no new orders at this time. Resident #90 does have occasionals when she will chew on non-food items. Able to remove items from view at this time . Progress note dated 04/16/2025 1:16 p.m. created by S5 LPN revealed in part . Resident was seen by S15 MD discuss with MD about Resident #90 restless behaviors and paranoid behaviors. Resident has anxiety behaviors. Resident #90 will eat plastics, paper, will tear up different items, along with lap tray. Orders are to restart Risperdal 0.5mg bid . Review of Resident #90's current care plan on 05/20/2025 revealed Resident #90 was not care planned for the resident's behavior of eating non-food items. On 05/21/25 08:53 a.m., an observation revealed Resident #90 in bed positioned on her right side with head of bed elevated. Resident #90 was awake, alert, and observed to be chewing with string like material coming from her mouth. Resident #90 was observed holding a bib with several holes that had been bitten or chewed. Resident #90 was noninterviewable. Surveyor immediately requested S5 LPN come to Resident #90's bedside and notified S5 LPN of surveyor observation. S5 LPN immediately removed bib from Resident #90. S5 LPN requested Resident #90 open her mouth and spit out material. Resident #90 did not follow command to open mouth and spit out material. S5 LPN applied gloves and performed finger sweep of Resident #90's mouth. S5 LPN confirmed eggs and small pieces of cloth material were removed from Resident #90's mouth. S5 LPN stated Resident #90 did have a history of chewing on non-food items. On 05/21/2025 at 02:02 p.m., a review of Resident #90's electronic health record care plan revealed a care focus area was created by S13 MDS on 05/21/2025 and read in part . Focus: The resident has a behavior problem: resident eats/chews on nonfood items such as bibs, paper towel, blankets, sheets, magazines, tissues/napkins, etc. Goals: The resident will have fewer episodes of eating nonfood items by review date. Interventions: Labs as ordered, notify MD as indicated, observe behavior episodes as needed, redirect behaviors, offer food items in place, redirect for a potentially difficult situation. On 05/21/2025 at 02:30 p.m., an interview was conducted with S13 MDS. S13 MDS stated Resident #90 was care planned for behavior problem of eating nonfood items on 04/18/2025. S13 MDS stated Resident #90's electronic health record revealed a created date of 05/21/2025 because S13 MDS revised the care plan on 05/21/2025. Surveyor questioned what part of care plan was revised on 05/21/2025. S13 MDS stated nothing was revised, she was just looking at it. On 05/21/2025 at 03:28 p.m. Resident #90's care plan with a start date of 04/15/2025 and completion date of 04/24/2025 was reviewed with S13 MDS. S13 MDS confirmed Care Plan Focus: The resident has a behavior problem: resident eats/chews on nonfood items such as bibs, paper towel, blankets, sheets, magazines, tissues/napkins, etc. was not present in the care plan reviewed for those dates. S13 MDS confirmed if care plan focus was initiated on 04/18/2025, it should have been in the care plan reviewed for those dates and was not.

Based on record review and interview, the facility failed to ensure the SNF ABN Form CMS-10055 (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form CMS-10055) was provided to the resident and/or the resident's responsible party prior to the discontinuation of Medicare Part A services for 2 (#34 and #61) of 2 residents reviewed for Beneficiary Notification who required the notification. Findings: Resident #34 Review of Resident #34's clinical record revealed the resident was being discharged from Physical and Occupational Therapy on 05/08/2025 due to non-compliance or refusal to participate in therapy with benefit days remaining. In an interview on 05/21/2025 at 4:00 p.m., S16 Accounts Manager reported Resident #34 was discharged from Skilled Services due to refusing to participate in therapy but remained in the facility. S16 Accounts Manager confirmed a SNF ABN, Form CMS-10055 was not provided to the resident or their responsible party prior to discharge from skilled services because she was unaware of the form or that it needed to be sent. Resident #61 Review of Resident #61's SNF Beneficiary Notification Review form revealed Resident #61 was discharged from Medicare Part A services when benefit days were not exhausted. Further review revealed a SNF ABN, Form CMS-10055 was not provided to the resident or their RP prior to discharge from the services. In an interview on 05/21/2025 at 4:10 p.m., S17 MDS stated Resident #61 was discharged from therapy because she was not cognitively able to participate in therapy. In an interview on 05/21/2025 at 4:15 p.m., S16 Accounts Manager confirmed Resident #61 remained in the facility with benefit days remaining. S16 Accounts Manager confirmed she did not send the SNF ABN Form CMS-10055 to Resident #61 or her RP because she was unaware of the form or that it needed to be sent prior to discharge from skilled services.

Based on observation, interview and record review, the facility failed to ensure a resident received reasonable accommodation of needs by failing to ensure the call light was accessible by a resident for 1 (Resident #7) of 41 sampled residents. Findings: On 05/21/2025, Review of facility policy titled, Call Light/Bell, with revision date of 01/2024, revealed in part . Purpose: To provide the resident a means of communication with staff members. To provide staff members a means of summoning assistance when they are with the resident. Process: Ensure resident has call light in reach when in resident room . Leave the resident comfortable. Place the call light within the resident's reach before leaving the room . Resident #7 Review of Resident #7's electronic medical record revealed an admission date of 06/10/2022 with diagnoses that included: Type 2 Diabetes Mellitus with Hyperglycemia, Protein Calorie Malnutrition, Alzheimer's, Essential Primary Hypertension, Schizophrenia, Tachycardia, Edema, unspecified Dementia, severe with other behavior disturbances, History of Urinary Tract Infections (UTIs). Review of Resident #7's Quarterly MDS with ARD of 02/20/2025, revealed a BIMS Score of 3, indicating severe cognitive impairment. Resident #7 required total care and extensive assistance for bed mobility. Review of Resident #7's Care Plan revealed in part . Resident #7 had a high risk for falls related to decreased mobility, weakness, severe cognitive impairment, and poor safety awareness. Interventions included in part . place call light within reach. On 05/19/2025 at 09:35 a.m. Observation revealed Resident #7 lying in bed. Resident #7 was noninterviewable. Call light was observed on the floor next to Resident #7's bed. Resident #7 could not reach the call light. On 05/20/2025 at 11:39 a.m. Observation revealed Resident #7 lying in bed awake and alert. Call light was observed on the floor next to Resident #7's bed. Resident #7 could not reach the call light. On 05/20/2025 at 03:15 p.m. Observation revealed Resident #7 lying in bed awake and alert. Resident #7 was calm with no abnormal behaviors. Call light was observed on the floor next to Resident #7's bed. Resident #7 could not reach the call light. On 05/20/2025 at 03:16 p.m. S14 LPN accompanied surveyor to Resident #7's room. S14 LPN confirmed the call light was not accessible to the resident and should have been. On 05/20/25 at 03:20 p.m. above findings discussed with S1 Corp RN. S1 Corp RN acknowledged above findings and confirmed Resident #7's call light should have been within reach.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services that assured accurate acquiring, receiving, dispensing and/or administration of medications to meet the needs of each resident. The facility had a total census of 115 residents. The facility failed to: 1. Ensure an accurate account for controlled medications was completed at the time of administering narcotics on 1 (Cart 4) of 4 (Cart 1, Cart 2, Cart 3, and Cart 4) medication carts for Resident #28; and 2. Ensure proper nursing procedures and documentation were completed at the time of wasting/destroying narcotics on 1 (Cart 1) of 4 (Cart 1, Cart 2, Cart 3, and Cart 4) medication carts for Resident #1 Findings: Review of a facility policy on [DATE] at 11:54 a.m. titled, Destruction of Unused, Expired or Discontinued Medications revised on 10/2019 revealed the following in part .1. Unused or discontinued non-controlled medications are to be destroyed by the Director of Nursing (DON) or designee and another licensed nurse. Review of a facility policy on [DATE] at 4:15 p.m. titled, Administration of Medications revised on 03/2025 revealed the following in part .Purpose: To administer medications in accordance with best practice.14. Document all applicable information in the clinical record. 1. On [DATE] at 10:20 a.m., a controlled medications reconciliation was conducted with S3 LPN of Cart 4. At the time of the medication reconciliation, review of Resident #28's document titled, Individual Resident Narcotic Inventory Count for Clonazepam 0.5mg tablets revealed a total count of 60 tablets remaining. Observation of Resident #28's Clonazepam 0.5mg narcotic blister package revealed a total count of 59 tablets remaining. S3 LPN confirmed he administered one Clonazepam tablet this morning as ordered and failed to document timely in Resident #28's clinical record, but should have. 2. On [DATE] at 10:38 a.m., a controlled medications reconciliation was conducted with S4 LPN of Cart 1. At the time of medication reconciliation, review of Resident #1's document titled, Individual Resident Narcotic Inventory Count for Oxycodone/Acetaminophen 5mg/325mg tablets revealed two entries on [DATE] at 9:00 p.m. where two tablets were documented as wasted/dropped on floor by a nurse. Further review of the document revealed no evidence of a destruction witness signature for neither of the two waste entries. S4 LPN confirmed there should had been a witness/second signature when Resident #1's Oxycodone/Acetaminophen tablets were wasted on [DATE], but there was not. In an interview and record review on [DATE] at 11:00 a.m., S1 Corp RN and S2 DON revealed all floor nurses were aware they should document narcotics in the clinical record as soon as the narcotic is administered to the resident. S2 DON confirmed S3 LPN should have documented timely on Resident #28's clinical record upon administration of the Clonazepam tablet, but had not. S2 DON revealed all floor nurses were aware they must have a witness/second signature when wasting narcotic medications and properly document in the clinical record. S2 DON confirmed the nurse failed to follow proper nursing procedures for wasting Resident #1's narcotic medications. S2 DON confirmed there should have been a witness/second signature when Resident #1's Oxycodone/Acetaminophen tablets were wasted/destroyed on [DATE] on both occasions, but there was not.

Based on record review, observation, and interview the facility failed to provide fluids sufficient to maintain adequate hydration. The facility failed to provide a water pitcher or any fluid for hydration at the bedside to 1 (Resident #37) of 41 sampled residents. Findings: On 05/21/2025, Review of facility policy titled, Hydration Provision of Fluids for Residents, with a revision date of 05/2018, revealed in part . Policy: The facility ensures that all residents receive sufficient amounts of fluids based on individual needs to maintain proper hydration and health. Procedure: The Director of Food and Nutrition Services/consultant assesses fluid needs based on the following guidelines . A minimum of 2000cc's (cubic centimeter) per day while on antibiotic therapy for UTI . .The nursing assistants offer fluids every 2 hours to residents, unless restricted .A water pitcher with water and ice is placed by the bedside of all residents unless contraindicated (NPO (nothing by mouth), Fluid Restriction, etc.). Resident #37 Review of Resident # 37's electronic medical record revealed an initial admission date of 06/15/2015 and a re-entry admission date of 08/10/2018 with diagnoses that included: Alzheimer's, Mild Protein- Calorie Malnutrition, Non Pressure chronic Ulcer of left ankle limited to break down of skin, Peripheral Vascular Disease, Anxiety disorder, Dysphagia, unspecified, Primary Generalized Osteoarthritis, History of Urinary Tract Infections. Review of Resident #37's Quarterly MDS with ARD of 03/19/2025, revealed Resident #37 was rarely/never understood with severely impaired cognition. Resident #37 required supervision or touching assistance with eating. Review of Residents #37's 05/2025 orders revealed in part . 09/18/2024: Doxycycline Hyclate Oral Tablet 100 mg (milligram) Give 1 tablet by mouth every 12 hours related to Non-pressure Chronic Ulcer to Left Ankle indefinitely. 05/16/2025: Macrodantin Oral Capsule 50mg Give 1 capsule by mouth one time a day related to history of UTI (Urinary Tract Infection) indefinitely. 05/09/2025: Ertapenem sodium injection solution 1 GM (gram) Inject 1 gram intramuscularly in the afternoon R/T (related to) UTI for 5 days. (Discontinued 05/14/25) 06/13/2024: Probiotic Oral Capsule give 1 capsule by mouth two times a day for R/T Prophylactic ABT (antibiotic). Review of Resident #37's Care Plan with an initiation date of 06/01/2024 revealed in part . 05/05/2025 Resident #37 was receiving antibiotic therapy r/t UTI/Sepsis. 05/09/2025 IM (intramuscular) antibiotic therapy for 5 days and oral antibiotic therapy BID (two times daily) for 5 days r/t UTI. Interventions included in part .Encourage fluids. Resident #37 had alteration in elimination r/t difficult stool and or loose stool. Interventions included in part . Encourage to drink all fluids on meal trays and fluids offered between meals. On 05/19/2025 at 10:05 a.m. Observation revealed Resident #37 sitting up in wheelchair in room. Resident #37 was awake, alert, and confused. Resident #37 was noninterviewable. No observation of a water pitcher or any other fluid for hydration at Resident #37's bedside. On 05/20/2025 at 08:31 a.m. Observation revealed Resident #37 sitting up in wheelchair in room awake and alert. Resident #37's speech was garbled and unintelligible. No observation of a water pitcher or any other fluid for hydration at Resident #37's bedside. On 05/20/2025 at 02:09 p.m. Observation reveals Resident #37 lying in bed resting with eyes closed. No water pitcher observed at the bedside. On 05/20/2025 at 02:27 p.m. review of Resident #37's electronic health record Facility Task: Offer Fluid Every 2 Hours While Awake with review dates of 05/16/2025- 05/20/2025 revealed in part . 05/16/2025 fluids offered: 1:11 p.m. and 3:48 p.m. 05/17/2025 fluids offered: 12:00 a.m., 07:39 a.m., 4:05 p.m., and 11:29 p.m. 05/18/2025 fluids offered: 07:37 a.m. and 4:44 p.m. 05/19/2025 fluids offered 06:06 a.m., 07:23 a.m., 6:54 p.m. 05/20/2025 fluids offered 07:25 a.m. On 05/21/2025 at 08:40 a.m. Observation reveals Resident #37 sitting up in wheelchair in room. Resident #37 was awake and alert. Resident #37 lips appeared dry. No observation of a water pitcher or any other fluid for hydration at Resident #37's bedside. On 05/21/2025 at 09:06 a.m. interview conducted with S12 CNA. S12 CNA revealed she was assigned to Resident #37's hall and familiar with Resident #37. S12 CNA stated Resident #37 required total care with the exception of feeding. S12 CNA states Resident #37 did drink well when offered fluids. S12 CNA confirmed all residents should have water pitcher at the bedside, unless they had restrictions. S12 CNA unable to recall if Resident #37 had restrictions. On 05/21/2025 at 09:08 a.m. S12 CNA accompanied surveyor to bedside. S12 CNA confirmed Resident #37 did not have a water pitcher at the bedside and should have one. On 05/21/2025 at 09:15 a.m. interview with S5 LPN revealed Resident #37 could drink from a cup independently once staff poured water into cup from water pitcher. S5 LPN confirmed Resident #37 did not have any fluid restrictions and should have water pitcher at the bedside. On 05/21/2025 at 09:25 a.m. interview conducted with S1 Corp RN and S2 DON to discuss above findings. S1 Corp RN and S2 DON acknowledged Resident #37 did not have a water pitcher at the bedside on multiple observations and should have.

Based on record review and interview, the facility failed to ensure services were provided to meet professional standards of quality by failing to ensure a resident with a UTI received timely and appropriate treatment for 1 (#1) of 3 (#1, #2, & #3) sampled residents reviewed for UTIs. Findings: Resident #1 Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses that included in part .Unspecified Dementia, Urinary Tract Infection, Overactive Bladder, Uterovaginal Prolapse, and Anxiety disorder. Review of Resident #1's Significant Change MDS with an ARD of 06/22/2024 revealed a BIMS score of 9, which indicated the resident had moderate cognitive impairment. Review of the MDS revealed Resident #1 required substantial to maximal assistance with toileting hygiene, rolling left and right, sitting to lying, lying to sitting, sit to stand and chair/bed to chair transferring. Review of Resident #1's record revealed she was care planned for a history of UTIs and bladder spasms with an onset date of 07/07/2021. Interventions included administer medications as ordered, notify MD of any complications or any decreased urine output, observe for effectiveness of medications, encourage fluid intake, and fluids with meals. Review of Resident #1's urinalysis collected and reported on 05/08/2024 revealed Resident #1's urinalysis was positive for leukocytes, nitrites, and blood. The urinalysis was date stamped on the bottom of the results and revealed S7 MD notified on 05/08/2024 at 6:00 p.m. with an order written that read Start Bactrim DS BID x 7 days r/t elevated leukocyte and bacteria in urine. Review of Resident #1's culture and sensitivity revealed it was reported originally on 05/09/2024 at 1:25 p.m. and revealed the pathogen of Escherichia Coli was resistant to Trimethoprim/Sulfamethoxazole (Bactrim DS) as well as Cefazolin, Cefepime, and Ceftriaxone (Cephalosporins). An antibiotic note on the report revealed ESBL detected and stated these organisms tend to be resistant to all Penicillins, Cephalosporins, and Aztreonam and are usually multi-drug resistant. Review of the report revealed the pathogen was susceptible to Ertapenem. Review of Resident #1's physician's orders revealed the following: 05/08/2024: Sulfamethoxazole-TMP DS (Bactrim DS) tablet give one tab PO BID X 7 days R/T elevated leukocytes and bacteria in urine. 05/17/2024: Cefuroxime Axetil (Ceftin-a cephalosporin) 500mg Tab give 1 PO BID x 7 days R/T UTI 05/27/2024: Ertapenem (Invanz) 1 GRAM vial Reconstitute with 3.2ml 1% Lidocaine HCL and administer IM QD x 7 days R/T UTI Review of Resident #1's May and June 2024 MARs revealed Resident #1 received the following: Received Sulfamethoxazole-TMP DS po bid from 05/08/2024-05/15/2024 Received Cefuroxime Axetil 500mg po bid from 05/17/2024-05/23/2024 Received Ertapenem 1 gram vial reconstitute w/ 3.2 ml 1% Lidocaine HCL IM every day from 05/27/2024-06/02/2024 In an interview on 07/31/2024 at 10:14 a.m. S3 LPN acknowledged he wrote the telephone/verbal order for Ceftin on 05/17/2024 but couldn't remember why S7 MD gave the order for Ceftin. In an interview on 07/31/2024 at 10:19 a.m., S4 RN reported she was looking through the lab binder for another resident and saw Resident #1's culture and sensitivity results on the top. S4 RN reported she looked at Resident #1's results and recognized that she had not been treated with an appropriate antibiotic. S4 RN stated she contacted the doctor and obtained the order for Ertapenem/Invanz on 05/27/2024. In a telephone interview on 07/31/2024 at 10:39 a.m. with the lab who ran Resident #1's urinalysis and culture and sensitivity, the lab staff confirmed all lab results are automatically faxed to the nursing facility when they are resulted. Lab personnel reported the nursing home has passwords and can pull up the results as soon as they are ready on a computer. In an interview on 07/31/2024 at 10:45 a.m. with S5 LPN and S6 [NAME] Clerk, S5 LPN reported the lab results come across the fax or we can go in the computer and print them. S6 [NAME] Clerk reported she takes the lab off the fax and gives them to the assigned nurse. In an interview on 7/31/2024 at 11:15 a.m., S1 DON stated results of labs are faxed to them and they get the C&S about 72 hours later. S1 DON stated the [NAME] Clerk stamps the labs and gives them to the nurse assigned to the resident and the assigned nurse handles it. In an interview on 07/31/2024 at 2:00 p.m., S2 ADON stated all labs come across the fax machine. An observation at that time of page 2/2 of Resident #1's culture and sensitivity (C&S) results revealed it was originally reported on 05/09/2024 at 1:25 p.m. and stamped by the facility on 05/10/2024. S2 ADON confirmed this was page 2 of the C&S and it was date stamped by the facility on 05/10/2024. S2 ADON reported if the results have not been received, nurses working with the resident should be looking for C&S results because they know it was ordered. In an interview on 07/31/2024 at 2:25 p.m., S1 DON acknowledged Resident #1 was not treated timely with an appropriate antibiotic until 05/27/2024. S1 DON reported treatment of Resident #1's UTI was delayed because they didn't get the C&S results until almost the end of the month. S1 DON confirmed staff can look up lab results in the computer.

Based on observation and interview, the facility failed to maintain an effective pest control program by failing to ensure the facility was free from insects. The deficient practice had the potential to affect 113 residents who resided in the facility. Findings: Review of the facility's pest control service agreement revealed in part the following . The facility will be treated at least once monthly and/or as often as necessary to satisfactorily control said pest in the critical areas, such as food preparation areas, nursing stations, storage areas, offices, tv rooms, common areas, bathrooms and the eating areas. During an observation in the kitchen on 03/11/2024 at 8:30 a.m. (1) live insect was observed crawling across the steam table on the serving line. S4 Dietary Manager confirmed the presence of the insect crawling across the steam table and removed the insect at that time. S4 Dietary Manager stated the kitchen was last sprayed by pest control 3 weeks ago. During an observation on 03/11/2024 at 10:55 a.m., (2) live insects were observed crawling on the steam table serving line. S4 Dietary manager confirmed the (2) live insects, removed the insects and stated she would call the exterminator. An interview 03/11/2024 at 11:40 a.m. with S3 Administrator revealed a pest control company sprayed the facility for pest monthly and that she had not received any complaints of pest issues in the facility. Review of the facility's pest control receipts revealed the facility had been treated once per month with the last treatment on 02/23/2024. During a Resident Council meeting on 03/11/2024 at 1:31 p.m. several residents brought up concerns of seeing pest in the facility daily.

Based on observation and interview the facility failed to ensure a cognitively impaired resident was treated with respect and dignity and cared for in a manner that promotes enhancement of his or her own quality of life. The facility failed to ensure that thickened water placed in front of the resident was offered as a drink for 1 (Resident #11) resident reviewed for dignity in a total sample of 28. Findings: Review of a Quarterly MDS Assessment with an ARD of 01/23/2024 revealed Resident #11's BIMS was coded as 99, indicating severe cognitive impairment. Resident #11 required dependent assistance with eating, with no swallowing disorder. Review of Resident #11's Care Plan with a target date of 04/24/2024 revealed altered nutritional status, approaches included resident is on a therapeutic diet- total assist with meals, Diet- Pureed NSOT (no sugar on tray), Honey thickened liquids. Observation of Resident #11 on 03/11/2024 at 11:51 a.m. revealed the resident seated in the facility's dining room at a table. S6 Activity Staff sat a 7 oz. glass of thickened water in front of the resident. Observations on 03/11/2024 at 12:06 p.m., and 12:19 p.m. revealed the glass of thickened water remained in front of Resident #11 and no staff had offered the water to the resident. Observation on 03/11/2024 at 12:22 p.m., a CNA came over to feed Resident #11. Interview on 03/12/2024 at 11:45 a.m. with S6 Activity Staff stated the activity department staff passed out water approximately 15- 20 minutes before lunch to all the residents seated in the dining room. S6 Activity Staff stated the activity staff will offer and/or assist residents who are able to drink water of natural consistency. S6 Activity Staff stated residents who have thicken added to his/her water was not offered and/or assisted to drink water by the activity staff because of choking precautions. S6 Activity Staff confirmed she had placed a glass of thickened water on the table in front of Resident #11 on 03/11/2024; not offering her any water; and leaving it for the CNA to offer the water to the resident while feeding her lunch. Interview on 03/13/2024 at 12:38 p.m. with S5 DON stated the activity department passed out water to all residents with the exception of the residents who receive thickened water. S5 DON stated thickened water was placed on the residents' tray by the dietary staff at the time the tray was prepared. S5 DON confirmed the activity staff should not have served Resident #11 thickened water nor should the thickened water been left in front of the resident.

Based on observation, record review, and interview the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered plan of care, for 1 (#5) of 5 (#1, #3, #5, #6, & #7) sampled residents who received nutrition via a PEG (percutaneous endoscopic gastrostomy) tube. The facility failed to: 1. Ensure Resident #5's physician was notified of any signs or symptoms of infection when brown drainage was noted from a Peg-tube site. This deficient practice resulted in an actual harm for Resident #5 on 05/12/2023 at 6:37 p.m. when Resident #5, who had been sent to the ED (Emergency Department) for shortness of breath, was found upon arrival to the ED to have putrid, malodorous, brown discharge emanating from around her PEG tube by the ED physician. Resident #5 was found to have an elevated white blood cell count of 13.0 (normal is 5.0-10.0), admitted to the hospital for antibiotics, and the PEG tube was removed. Due to Resident #5's moribund condition, she was too sick for surgery to replace the PEG tube and was placed on hospice. Findings: Review of the facility's policy titled Charting-Guidelines for Follow-Through Charting revealed in part . Acute Episodes-48 hours acute charting if stable-Notify doctor and document results of physician contact. Review of the facility's policy titled Tube Feedings revealed in part . 1. All tube feedings will be administered in accordance with verified medical necessity, established infection control policies and procedures and physician's orders . Review of the medical record for Resident #5 revealed an admitted [DATE] with diagnoses that included in part .Alzheimer's Disease, CKD, Quadriplegia, and Encounter for Attention to Gastrostomy. Review of Resident #5's 04/19/2023 Admission MDS revealed a BIMS was not conducted as the resident was rarely or never understood. The MDS revealed Resident #5 was totally dependent on two persons for bed mobility, transferring, and toilet use; and totally dependent on one person for eating. Reveal of Resident #5's Physician Orders revealed the following order: 04/13/2023: Cleanse around G-tube site with Normal Saline, pat dry, apply split gauze daily. Monitor daily for signs and symptoms of complications. Review of Resident #5's Care Plan revealed a problem of potential for infection and impaired skin integrity related to abdominal opening secondary to G-tube stoma site. Interventions included: change dressing daily as ordered, monitor stoma site for signs or symptoms of infection or skin impairment, notify physician of any sign or symptom of infection or skin impairment to stoma site, monitor for signs or symptoms of pain, medicate as needed, and Direct Care Staff to report to nurse if any problems that may arise pertaining to dressing site while giving care. Review of Resident #5's SNF Documentation revealed the following entries in part . 05/06/23 at 11:29 p.m.No drainage from G-tube site at this time, dressing in place .Abdomen remains slightly distended. Completed by S6 LPN. 05/08/2023 at 1:16 p.m.Slight brown drainage from G-tube site, dressing replaced with clean and dry gauze. Abdomen remains slightly firm and distended. Completed by S3 LPN. 05/09/2023 at 2:29 p.m.Resident still with brown drainage from G-tube site, dressing replaced with clean and dry gauze as needed .Abdomen remains slightly firm and distended. Completed by S3 LPN. 05/10/2023 at 2:08 p.m.Resident still with brown drainage from G-tube site, dressing replaced with clean and dry gauze as needed .Abdomen remains slightly firm and distended. Observation to continue. Completed by S3 LPN. Review of Resident #5's EMAR revealed S3 LPN was the nurse on the 7:00 a.m. to 3:00 p.m., and 3:00 p.m. to 11:00 p.m. shifts on 05/11/2023; however, there was no nursing documentation for those shifts. Review of a Progress Note documented by the Medical Director dated 05/12/2023 (no time documented) read as follows in part .Patient with moderate to severe Alzheimer's disease, CKD, osteoarthritis, iron deficiency anemia, left hand contracture, bilateral foot drop, CVA with aphasia, dysphagia, acute. Patient seen at bedside. Does not respond to commands. Coarse breath sounds, will continue breathing treatments. Blood pressure optimal. Continue antiplatelet statins for CVA. Continue Tylenol for Osteoarthritis. Continue present. No issues reported. Review of symptoms-Denies chest pain, shortness of breath, nausea, vomiting, or diarrhea Physical exam: Gastrointestinal-soft, none tender Assessment & Plan: Alzheimer's dementia-moderate to severe, patient responded to commands. Osteoarthritis-continue Tylenol. Dysphagia-continue Peg tube feeds, monitor for aspiration. CKD-continue monitor renal panel, electrolytes avoid nephrotoxic agents. Iron deficiency anemia-continue iron supplementation. There was no documentation on the Medical Director's Progress Note that indicated he was notified of a problem with the G-tube site, or documentation regarding the G-tube site. The surveyor was unsuccessful in contacting the Medical Director as he was out of the country and would not return until August 2023. Review of Resident #5's SNF Documentation Record completed 06/05/2023 at 2:00 p.m. by S1 DON read as follows in part . 05/12/2023 at 5:00 p.m. - Resident lying in bed with eyes open, head of bed elevated, tube feeding continuous per pump, non-verbal, abdominal area distended, with hypoactive bowel sounds. Resident just had a large soft bowel movement earlier today (morning shift per staff that was attending to her this morning). When repositioned, resident started demonstrating grunting and moaning. Respirations are rapid and shallow. Resident's oxygen saturation ranges from 88-92%. No cough or congestion at this time.G-tube stoma site intact without drainage or redness to stoma site. Tube feeding turned off per nursing measure, dressing reapplied, Vital signs 134/61 89 25 99.9. 5:00 p.m. - Resident #5's physician/Medical Director notified of tube feeding being turned off and agreed with nursing measure, also notified of current condition and symptoms displayed, received new order to send to ____(hospital name) for eval and treatment. 5:10 p.m. - RP Notified 5:37 p.m. - Ambulance arrived in the facility 5:44 p.m. - Resident left facility per stretcher . Form Participants: S7 LPN, S2 RN/ADON, S1 DON Form Completed by: S1 DON Review of the Ambulance report dated 05/12/2023 at 5:38 p.m. revealed the following in part . Chief Complaint (Primary) - Respiratory Distress Provider Impression: Dyspnea/SOB. Head to Toe: Abdomen and Pelvis: - RLQ and LLQ Distended: Yes Narrative History Text: Patient was having periods of apnea and working to breathe, patient's abdomen was swollen with blood and crust around peg tube going through abdominal wall. Review of Resident #5's Emergency Provider Report dated 05/12/2023 at 6:37 p.m. revealed the following in part . Patient is an [AGE] year old female who presents to the ED via EMS for supposed difficulty breathing .On arrival, patient has putrid, malodorous, brown discharge emanating from around her PEG tube. Patient is in moribund condition, unable to answer questions . WBC on 5/12/23 at 6:41 p.m. is 13.0 (normal is 5.0-10.0) Patient appears ill on arrival, concerns about her overall mortality. She has her eyes open spontaneously, however, is otherwise unresponsive .She has putrid discharge emanating from around her PEG tube. Sepsis order set placed, however, due to patient having some edema and distention of her abdomen, will forego IV fluid bolus at present. Antibiotics ordered. Had [NAME] discussion with son regarding PEG tube. I spoke to Dr. ___ as well. The consensus is if patient is to get another feeding tube, it would be a fairly significant operation. Patient's son does not want her to have an operation. I discussed palliative care, being discharged on hospice, however, patient's son not ready to make that decision. I am unable to discharge the patient safely back to the nursing home at this point due to the concern for infection of her abdomen as well as stercoral colitis. admitted to the hospital. Clinical Impression: Abdominal wall cellulitis In an interview on 07/19/2023 at 9:15 a.m., S4 CNA stated she worked Resident #5's hall six days per week. S4 CNA stated she worked the day shift on 05/12/2023 and bathed Resident #5. S4 CNA stated on 5/12/2023, she knew something wasn't right because Resident #5 did not respond with facial expressions, as she usually did. S4 CNA stated there was a thick, snotty-like discharge around the peg tube site. S4 CNA stated the drainage did have a little odor to it. S4 CNA stated she notified her nurse, S3 LPN, who assessed Resident #5, and agreed her stomach was hard with thick and snotty drainage from the PEG tube. In an interview on 07/19/2023 at 9:10 a.m., S3 LPN stated on 05/12/2023 Resident #5's PEG tube had snotty and thick drainage coming out of it. S3 LPN stated the PEG tube site was draining and her stomach was hard, so she notified S2 RN/ADON, and the resident was sent out to the ED later that day. In a telephone interview on 07/19/2023 at 10:00 a.m., S5 LPN stated he worked with Resident #5 from 11:00 p.m. on 05/11/2023 until 7:00 a.m. on 05/12/2023. S5 LPN said he changed the dressing to the PEG tube and there was a lot of drainage on the dressing. S5 LPN said he reported it to the oncoming nurse (S3 LPN), and she said the doctor was going to see Resident #5 that day. In an interview on 07/19/2023 at 10:40 a.m., S7 LPN confirmed she worked the evening shift (3:00 p.m.-11:00 p.m.) on 05/12/2023 when Resident #5 was sent out to the hospital. S7 LPN stated during shift change/report at 3:00 p.m., she was told by the off-going nurse (S3 LPN) that Resident #5 had no complications, had a bowel movement that day, and was okay with no problems being reported to her. S7 LPN stated she went in Resident #5's room during med pass, found the resident short of breath, and did a head to toe assessment. S7 LPN stated Resident #5's oxygen saturation was low, she had fever, and was sweating. S7 LPN said she notified the Medical Director who said to send the resident out. S7 LPN stated S3 LPN had not mentioned during report that there was a problem with Resident #5' peg tube. S7 LPN stated during her assessment, she found Resident #5's abdomen to be a little distended; however she wasn't familiar with Resident #5, and had nothing to compare it to. S7 LPN stated she didn't see the peg tube site because it was covered with a clean, dry dressing. S7 LPN stated the dressing was coming up and she reapplied it to the skin but didn't look at the site. In an interview on 07/19/2023 at 11:50 a.m., S2 RN/ADON stated Resident #5 was seen by the Medical Director on 05/12/2023. S2 RN/ADON stated she reported Resident #5's PEG tube drainage to the Medical Director, and he told them it could be stomach contents. S2 RN/ADON stated the Medical Director told them to look for red, bloody, or thick white purulent drainage, or to notify him if stoma was red. S2 RN/ADON said she saw Resident #5's PEG tube site before she was sent to the hospital on 05/12/2023, and said Resident #5's stoma was fine and only had brown drainage. In an interview on 07/19/2023 at 12:20 p.m., S9 LPN/Treatment nurse acknowledged she documented on the ETAR on 05/11/2023 for providing care to Resident #5's peg tube, as ordered. S9 LPN/Treatment Nurse stated she could not remember Resident #5 or what the peg tube looked like on 05/11/2023. In a telephone interview on 07/19/2023 at 2:52 p.m. with the EMT/Paramedic who transported Resident #5 from the facility to the hospital on 05/12/2023, he stated he remembered picking up Resident #5 for shortness of breath. The EMT/Paramedic stated Resident #5's PEG tube was rotting and severely infected. He said he visualized the PEG tube site and it was oozing black stuff. The EMT/Paramedic described the drainage as dark, brownish-black stuff that smelled bad. He stated it was obviously infected and her whole belly was swollen. In an interview at 9:28 a.m. on 07/24/2023, S3 LPN stated when she documented Resident #5's brown drainage on 05/08/2023, 05/09/2023, and 05/10/2023, she thought the drainage was just stomach contents. S3 LPN said she didn't recall S5 LPN mentioning anything at report on 05/12/2023 about the drainage from Resident #5's peg tube. S3 LPN said on 05/12/2023, when S4 CNA came to her to report the drainage was thick and snotty, she reported it to S2 ADON because she was still orienting, and S2 ADON was more familiar with Resident #5. S3 LPN confirmed Resident #5's drainage had increased on 05/12/2023. S3LPN stated she handed it off to S2 ADON instead of calling the doctor because she wasn't sure if it was a problem, and wanted S2 ADON to look at the resident. In an interview on 07/19/2023 at 3:08 p.m., S2 RN/ADON stated she did not know for certain if the Medical Director looked at Resident #5's peg tube site on 05/12/2023 when he saw her, as he sometimes sees the patients alone, and she did not go in Resident #5's room with him. S2 RN/ADON acknowledged the progress note did not mention that the Medical Director had assessed the PEG tube, and that he documented that No issues reported. In an interview on 07/24/2023 at 11:15 a.m., S1 DON stated she knew the doctor went in Resident #5's room during rounds, but doesn't remember if he touched Resident #5's abdomen or visualized her PEG tube. S1 DON acknowledged S3 LPN had documented Resident #5's peg tube was draining brown liquid for multiple days, but stated she was unsure if S3 LPN should have reported it to the physician because she didn't see it herself.

Based on observation, interview and record review, the facility failed to ensure 1 (#108) of 3 sampled residents (#75, #99, and #108), who were totally dependent and required two-person assistance with the use of a mechanical lift for transfers, received adequate assistance to prevent accidents. An Actual Harm occurred for Resident #108 on 08/23/2020 at approximately 11:30 a.m., when S3 CNA transferred the resident from the wheelchair to the bed by herself. S3CNA was aware that the resident required two-person assistance with the use of a mechanical lift for transfers, but she did not use the mechanical lift or wait for assistance from another staff person when transferring the resident. During the transfer from the wheelchair to the bed, the resident's left foot was caught in the foot rest of the wheelchair. The CNA then proceeded to undress the resident in bed and again transferred the resident without the assistance of another staff person from the bed to the shower chair. After the resident's shower, while drying the resident's feet, the CNA noticed redness to the resident's left ankle, and the resident complained of pain with touch to her left foot. The CNA notified the resident's nurse. The nurse notified the resident's doctor after her assessment and orders for an x-ray were obtained. The x-ray results revealed the resident had an Acute Medial Malleolus [MEDICAL CONDITION] ankle. The facility implemented corrective actions prior to the State Agency's investigation therefore, it was determined to be a Past Noncompliance citation. Findings: Observation of resident #108 on 10/05/2020 at 10:23 a.m. revealed the resident was asleep in bed. The resident was clean and soft boots noted in chair at resident's bedside. Review of resident #108's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of a Quarterly MDS Assessment with an ARD of 09/17/2020 revealed the BIMS Summary Score was left blank, and there was documentation that the resident was rarely/never understood. Further review revealed the resident was totally dependent upon staff and required 2 + person physical assist for bed mobility, transfers, had upper and lower extremity ROM impairment on both sides, and utilized a wheelchair for mobility. Review of resident #108's care plan with a target date of 12/17/2020 revealed a problem of: At risk for falls r/t [MEDICAL CONDITION] and decreased safety awareness. Approaches included: Staff assistance with lift x 2. Manual staff assistance when exception applies x 2. Sling type: Regular, Sling size: Large. Review of the resident's nurses' notes dated 08/23/2020 at 5:00 p.m. revealed at 1:30 p.m. S3 CNA reported that while transferring resident #108 alone, the resident's left foot had gotten caught in the footrest of her wheelchair. The resident grimaced when the foot was moved or touched. The resident's PCP was notified, and an order for [REDACTED]. Review of a Radiology Interpretation dated 08/23/2020 revealed Significant Findings: Left Ankle, 2 View (AP, LAT). Impression: Acute Medial Malleolus Fracture. Further review of the nurses' notes revealed x-ray findings were received on 08/23/2020 at 4:50 p.m. The resident's RP and PCP were notified and a new order obtained to consult an orthopedic specialist. Review of a statement dated 08/23/2020 and written by S3 CNA, revealed in part While transferring the resident from her wheelchair to her bed, her foot got caught in the footrest of her wheelchair. Review of a statement dated 08/23/2020 and written by S2 LPN revealed in part S3 CNA reported to her that while transferring resident #108 from the wheelchair to the bed by herself, the resident's left foot got caught on the foot rest of her wheelchair. S3 CNA reported the resident grimaced in pain and jumped when the CNA moved her left foot. Review of a SNF documentation record dated 08/24/2020 at 11:58 a.m. revealed the resident's family did not wish to consult Ortho at that time. Therapy was ordered on [DATE] and treatment consisted of stabilizer wedge duo to left foot to be worn daily for protection measures. Interview on 10/07/2020 at 11:08 a.m. with S3 CNA, revealed there were color coded dots on the walls over all residents' beds that indicated how much assistance the resident required. Further interview revealed that she worked from 7:00 a.m. to 3:00 p.m. on 08/23/2020 and was assigned to resident #108. She stated that around 11:30 a.m. on 08/23/2020 she was attempting to transfer resident #108 from the wheelchair to the bed by herself, and during the transfer the resident's left foot became caught in the footrest of her wheelchair. She stated the resident did not complain of pain or have any visible injuries at the time. She stated she proceeded to undress the resident in bed and then again transferred the resident without the assistance of another staff person, from the bed to the shower chair. She stated that while drying the resident's feet after her shower she noted redness to her left ankle, and the resident complained of pain with touch to her left foot. She stated she brought the resident back to her room and notified the nurse before she dressed the resident, so the nurse could check her for injuries. S3 CNA revealed there were 2 other CNA's assigned to the 300 hall that day from 7:00 a.m. to 3:00 p.m. She stated she was waiting for another CNA to help her put the resident back to bed, but decided to transfer the resident herself and she should not have. She confirmed that she was aware the resident was a 2 person assist with lift for transfers on the day of the incident. Telephone interview on 10/11/2020 at 6:00 p.m. with S2 LPN revealed she was the nurse assigned to resident #108 on 08/23/2020. She stated that on 08/23/2020 at around lunch time S3 CNA came to the desk to report that resident #108's foot had gotten stuck in the foot rest, the resident was grimacing, and her ankle was red. She stated she went down to the resident's room and assessed her. She stated the resident was in the bed at the time she assessed her, and her left ankle was red and swollen. She stated the resident didn't complain of pain, but pulled away when her ankle was touched. She stated she notified the Supervisor on duty, PCP, and RP after assessing the resident. She stated an order for [REDACTED]. Interview on 10/12/2020 at 11:30 a.m. with S1 DON revealed that she was notified of the incident on 08/23/2020. She stated that after interviewing staff it was determined S3 CNA transferred the resident without the required 2 person assistance, resulting in an injury to the resident's left ankle. She stated that information boards were located on the wall above the head of each resident's bed and that all boards were updated after assessments by the facility's Medicare assessment nurses to maintain accuracy. She further stated S3 CNA did not wait for assistance before transferring the resident and should have. Throughout the survey from 10/05/2020 thru 10/13/2020, random interviews of staff were conducted. Staff members were asked how they determined the type of assistance a resident required for transfers. All staff questioned stated that they had received training on transferring residents, and had been recently in-serviced on transferring residents. Staff stated transfer assistance requirements could be found in the ADL books kept on each hall, and on the information boards on the wall above the head of each resident's bed. Observation on 10/06/2020 at 10:27 a.m. revealed resident #108 was transferred from her bed to a wheelchair with the use of a mechanical lift and the assistance of 2 CNAs. There were no concerns observed with the transfer. The facility implemented the following actions to correct the deficient practice prior to survey: 1. Employee directly involved in the incident was immediately counseled by the resident's nurse regarding transferring the resident without 2 person assistance and the use of a mechanical lift. 2. Employee directly involved in the incident was counseled, in-serviced regarding the facility's policy for utilizing mechanical lift with two staff members when necessary, and disciplined by the DON. 3. All nursing staff was in-serviced on the facility's abuse/neglect, resident lifting and transfers, and injury of unknown origin policies on 08/23/2020. 4. Transfer requirements remain posted on the Information Board above the head of each resident's bed. The Information Board for each individual resident is updated after assessment and when there is a change in a resident's assessment by the Medicare Assessment Nurse to maintain accuracy. 5. QAPI Action Plan implemented with a start date 08/23/2020. Root Cause Analysis formulated with Problem identified: Improper transfer was completed causing injury. 6. Monitoring tools will be utilized doing random audits to ensure compliance for all residents identified and affected by the deficient practice. 7. In-service staff on location of information and utilizing nurses as additional resources. 8. DON or Designee to monitor random lifts/transfers twice weekly until compliance is achieved per QA committee. Beginning on 08/23/2020. 9. Corrective Action Plan effective as of 09/23/2020.