Every finding on record at Liberty Commons Rehabilitation Center

Based on record review and interviews with staff, Emergency Medical Services (EMS) personnel, and pest control specialist, the facility failed to ensure a resident's dignity was maintained when Resident #86 was observed by EMS personnel with multiple live cockroaches crawling on his body and in his bed prior to transferring the resident to the hospital. EMS personnel indicated the resident was not aware of the cockroaches. A reasonable person expects their dignity to be maintained by their caregivers and would have been traumatized and experienced feelings such as fear, dehumanization, humiliation, and anxiety. The deficient practice affected 1 of 2 residents (Resident #86) reviewed for dignity.Findings included:Resident #86 was admitted to the facility on [DATE].Resident #86's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment with no behaviors, required a wheelchair for mobility and supervision with bathing and dressing. A nursing progress note written by Nurse #5 dated 1/3/26 at 8:02 PM indicated Resident #86 was oriented to himself earlier in the day but became increasingly confused with disorientation to self and place. The provider was notified of Resident #86's change in condition with altered mental status. Emergency Medical Services (EMS) arrived at 6:25 PM to transport Resident #86 to the emergency department for evaluation. Review of an Emergency Medical Services (EMS) report dated 1/3/26 indicated that EMS personnel arrived at the facility at 6:25 PM on 1/3/26. The EMS report indicated that while assessing Resident #86 prior to transporting him to the emergency department for evaluation, an unspecified number of live insects consistent with cockroaches were noted crawling on the resident and in his bed when he was turned over. The note indicated that when the EMS personnel asked the facility staff about a bug problem, the staff confirmed that the facility had a cockroach infestation. The note stated that Resident #86 was transported to the hospital and following the transport, EMS personnel completed an Adult Protective Services report due to the mandated reporter requirement. A telephone interview was conducted on 3/9/26 at 11:10 AM with EMS personnel that arrived at the facility on 1/3/26 to transport Resident #86 to the emergency department. The EMS personnel stated that on 1/3/26 when he arrived to transport Resident #86 to the hospital, he turned the resident over and observed several roaches, he was unable to recall how many, on the resident's body and in his bed. The EMS personnel stated that he informed the staff that he observed roaches on Resident #86 and the staff reported that the facility was infested with them. The EMS personnel stated that Resident #86 was unaware of having roaches on him or in his bed. Review of the Emergency Department provider note dated 1/3/26 indicated that Resident #86 presented to the emergency department for evaluation of altered mental status. The provider note stated that Resident #86 arrived in the emergency department with an unspecified number of insects on him and was immediately cleaned by the nursing staff. Resident #86 was minimally able to participate in the evaluation due to altered mental status and was able to nod or shake his head but was unable to answer questions consistently. Review of Resident #86's electronic health record showed that the resident was readmitted on [DATE] and subsequently discharged to the hospital on 2/6/26. He did not return to the facility. An interview was conducted with Nurse #5 on 3/10/26 at 3:25 PM. Nurse #5 stated that Resident #86 had confusion and on the evening of 1/3/26, she transferred Resident #86 to the emergency department for a change in condition related to his medical condition. She stated that EMS personnel did not report to her that they observed cockroaches on the resident or in his bed at the time of transfer and she did not observe any roaches on the resident. Nurse #5 stated she learned later that the Director of Nursing received a report that the EMS personnel observed cockroaches on Resident #86. An interview was conducted with Nurse Aide (NA) #5 on 3/11/26 at 8:45 AM. NA #5 stated that she was assigned to Resident #86 on 1/3/26 from 7:00 AM to 7:00 PM. NA #5 stated that she heard from the other NA that was working with her on the hall, she did not recall which NA, that the EMS personnel observed cockroaches on Resident #86 and were stomping the cockroaches out on the floor when they were preparing to take the resident to the hospital for evaluation on 1/3/26. NA #5 indicated that she personally did not observe the cockroaches on the resident. NA #5 stated that Resident #86 was transferred to the hospital in the evening shortly after dinner. She added that it had been several hours before the transfer that she last assisted the resident with personal care. An interview was conducted with NA #6 on 3/11/26 at 10:41 AM. NA #6 stated that the cockroaches were terrible in the facility, especially in the fall and winter of last year. NA #6 stated that she observed cockroaches on the medication carts, on residents, in their beds, on the ceilings and in the resident rooms. NA #6 recalled an incident in the winter with a resident, she could not recall which resident or the date, in which she went to put a jacket on the resident and observed a cockroach on the resident. NA #6 stated that the resident was unaware that a roach was on him. NA #6 indicated that she felt badly that the residents had cockroaches in their rooms. An interview was conducted with the Maintenance Director on 3/10/26 at 1:18 PM. The Maintenance Director acknowledged that the facility experienced an infestation of cockroaches in November and December 2025 and stated that the staff reported they observed cockroaches as recently as approximately one month ago. He further stated he was told by an individual he could not recall on a date he could not recall that cockroaches were found on residents. A telephone interview conducted with the Pest Control Specialist on 3/18/26 at 12:45 PM revealed that he was the owner of the new pest control company that began providing services to the facility in late January 2026. He reported that he completed a comprehensive evaluation of the facility, which included staff interviews, observations across all shifts, and assessments of resident rooms, offices, the kitchen, and common areas. He stated that during his initial evaluation, the facility was heavily infested with active cockroach activity.An interview was conducted with the Administrator on 3/11/26 at 11:30 AM. He stated that cockroaches were frequently observed in the facility in October and November and that he realized the pest control company being used was not effective. He stated that he was aware that in January, EMS reported seeing cockroaches on a resident being transferred to the hospital and an Adult Protective Services report was filed. During a follow up interview on 3/12/26 at 2:14 PM, the Administrator stated that his expectation was that all residents be treated with dignity and respect at all times, which included ensuring they were free from insects on their bodies and in their rooms.

Based on observation, staff interviews, and record review, the facility failed to maintain a pest free environment for 3 of 3 residents reviewed for pest control (Resident #86, Resident #16 and Resident#5). Findings included:Resident # 86 was admitted on [DATE].A review of Resident #86's admission Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment with no behaviors, required a wheelchair for mobility and supervision with bathing and dressing. A review of the pest control company's invoices from December showed that weekly services were provided. The invoices dated December 3 and December 17, 2025, indicated that rooms on the 100 and 200 halls were treated with an aerosol product; however, they did not document the reason for the treatment or provide details about the specific application. The invoice dated December 24, 2025, noted evidence of German cockroaches in room [ROOM NUMBER]. The invoices did not include documentation of staff reports regarding cockroach activity, nor did they specify what pests the treated areas were being addressed for.A nursing progress note written by Nurse #5 dated 1/3/26 at 8:02 PM indicated Resident #86 was oriented to himself earlier in the day but became increasingly confused with disorientation to self and place. The provider was notified of Resident #86's change in condition with altered mental status. Emergency Medical Services (EMS) arrived at 6:25 PM to transport Resident #86 to the emergency department for evaluation. Review of an Emergency Medical Services (EMS) report dated 1/3/26 indicated that EMS personnel arrived at the facility at 6:25 PM on 1/3/26. The EMS report indicated that while assessing Resident #86 prior to transporting him to the emergency department for evaluation of altered mental status, an unspecified number of live insects consistent with cockroaches were noted crawling on the resident's body and in his bed. The note indicated that when the EMS personnel asked facility staff about a bug problem, the staff confirmed that the facility had a cockroach infestation. The note stated that Resident #86 was transported to the hospital and following the transport, EMS personnel completed an Adult Protective Services report due to the mandated reporter requirement. Review of the Emergency Department provider note dated 1/3/26 indicated that Resident #86 presented to the emergency department for evaluation of altered mental status. The provider note stated that Resident #86 arrived in the emergency department with insects (number and site note specified) on him and was immediately cleaned by the nursing staff. Resident #86 was minimally able to participate in the evaluation due to altered mental status and was able to nod or shake his head but was unable to answer questions consistently. Resident #86 was admitted for treatment of altered mental status secondary to recurrent hepatic encephalopathy with history of cirrhosis. An interview was conducted on 3/9/26 at 11:10 AM with the Emergency Medical Services (EMS) personnel that arrived at the facility on 1/3/26 to transport Resident #86 to the emergency department. The EMS personnel stated that on 1/3/26 when he arrived to transport Resident #86 to the hospital, he observed several roaches (he could recall the exact number) on the resident's body and in his bed when he turned the resident over. The EMS personnel stated that he informed the staff that he observed roaches on Resident #86's body and in his bed and the staff reported that the facility was infested with them and there was nothing that could be done about it. An initial tour of the facility on 3/9/26 at 12:15 PM revealed that insects were not observed in the resident rooms on the 200 hall. An invoice dated 1/16/26 showed that a new pest control company completed a triage and remediation of the facility, including first pass treatment for German cockroaches in selected rooms on the 100 and 200 halls and in room [ROOM NUMBER].An invoice dated 2/6/26 from the new pest control company indicated monthly maintenance was completed. The remarks on the invoice indicated that the 500 hall nursing staff reported cockroach sightings and treatment was provided. The invoice did not include details about the specific application. An interview was conducted with Resident #16 on 3/9/26 at 12:05 PM. Resident #16 stated that there had been a bad roach problem in the facility since last fall. Resident #16 stated that she observed cockroaches were in her room, on the walls, floor and other surfaces. Resident #16 stated that the cockroaches were better in the last few weeks.An interview on 3/10/26 at 9:00 AM with Resident #5, a cognitively intact resident, revealed that he had last observed cockroaches in his room a few weeks ago. An interview on 3/11/26 at 4:15 PM with Resident #16 revealed that she had observed a cockroach in her room on the evening of 3/10/26 and she reported this to the Administrator. An interview was conducted with the Maintenance Director on 3/10/26 at 1:18 PM. The Maintenance Director reported he had been in the position for two years and explained that there were paper work order forms at each nursing station to record any maintenance issues and/or pest concerns. He stated he checked for work orders two times per day and there had not been any reports of pests. He reported the pest control service visited weekly and that the facility recently changed pest control companies due to ongoing issues with the previous company. The Maintenance Director initially stated there had been no pest problems in the past several months. However, he later acknowledged that the facility experienced an infestation of cockroaches in November and December 2025, primarily on the 200 hall. He stated there had been no reports of roaches recently, but then reported staff observed roaches approximately one month ago. He further stated he had been told-by an individual and on a date he could not recall-that cockroaches had been found on residents. He acknowledged that after receiving this information, he did not contact the pest control company, adjust the pest control program, or implement any monitoring. The Maintenance Director stated he did not participate in Quality Assurance Performance Improvement meetings and was not aware of any QA program related to pests. Although he initially stated he had a system to track work orders submitted and completed he later stated that he had no records of work orders, including orders regarding pest issues, and primarily learned of maintenance issues through word of mouth.An interview was conducted with Nurse #5 on 3/10/26 at 3:25 PM. She stated she was primarily assigned to the 200 hall. She reported that she informed the Administrator and Director of Nursing-date not recalled-that she observed cockroaches on the 200 hall. She did not report the issue to the Maintenance Director because she believed it was a serious problem that the Administrator should address. She stated that work orders were available at the nurses' station for other maintenance issues. Nurse #5 stated that Resident #86 had confusion and on the evening of 1/3/26, she transferred Resident #86 to the emergency department for a change in condition. She stated that EMS personnel did not report to her that they observed cockroaches on the resident or in his bed at the time of transfer and she did not observe any roaches on the resident, but she learned of this allegation afterward. She stated that had EMS informed her of seeing roaches, she would have reported it to the Administrator or Director of Nursing. She further stated that several days after Resident #86 was transferred, the Director of Nursing informed her that there was a report that indicated cockroaches were observed on the resident when he was picked up by EMS at the facility and when he arrived at the hospital. An interview was conducted with Nurse Aide (NA) # 5 on 3/11/26 at 8:45 AM. NA stated that there were a lot of cockroaches in the facility since last summer and she did not report to administration that she observed cockroaches as she assumed that they knew. NA #5 stated that she was assigned to Resident #86 on 1/3/26 from 7:00 AM to 7:00 PM. NA #5 stated that she heard that the EMS personnel observed cockroaches (she did not know how many) on Resident #86 and were stomping the cockroaches out on the floor when they were preparing to take the resident to the hospital for evaluation on 1/3/26 but she did not observe the cockroaches on the resident. An interview was conducted with NA #6 on 3/11/26 at 10:41 AM. NA #6 stated that the cockroaches were terrible in the facility, especially in the fall and winter of last year. NA #6 stated that she observed cockroaches on the medication carts, on residents, in their beds, on the ceilings and in the resident rooms. NA #6 indicated that cockroaches were everywhere on 100 and 200 hallways including on resident beds and clothing. NA #6 recalled an incident in the winter with a resident, she could not recall which resident or the date, in which she went to put a jacket on the resident and observed a cockroach on the resident. NA #6 stated that the resident was unaware that a roach was on him. NA #6 indicated that housekeeping cleaned during the daytime but there was no housekeeping in the evening and at night. NA #6 stated that most residents on 200 hallway ate meals in their rooms and food was frequently spilled on the floors. NA #6 indicated that she felt badly that the residents had cockroaches in their rooms, but everyone knew about it. NA stated that she did not report the cockroaches that she observed in the resident rooms as she assumed the administration and maintenance already knew. An interview was conducted with NA #2 on 3/11/26 at 10:00 AM. NA #2 stated that there had been a significant cockroach problem in the facility for a long time and that the exterminator did not know what he was doing. She stated she observed the exterminator enter the facility every few weeks with a small can of spray and that he never thoroughly treated the building. She stated that everyone in the facility was aware of the pest problem. She did not report the issue to the Administrator or Maintenance because she assumed they already knew how severe the infestation was. NA #2 stated the roach problem had been ongoing for months, likely since October or November. She stated she observed heavy cockroach activity in November, December, and January, including roaches in resident beds and on surfaces in resident rooms. NA #2 further stated that cockroaches were frequently found behind refrigerators and coming from the heating and air conditioning units in resident rooms. She reported that although pests were still present, the situation had improved since the new pest control company began providing services.An interview was conducted with the Administrator on 3/11/26 at 11:30 AM. He stated that cockroaches were frequently observed in the facility in October and November and that he realized the pest control company being used was not effective. He stated that after the January incident in which EMS reported seeing cockroaches on a resident being transferred to the hospital, the facility cleaned rooms on the 200 hall, and he consulted a corporate consultant who recommended a different pest control company. He reported that the facility switched to the new company in late January, and since then pest activity had decreased. He stated he had been dissatisfied with the previous company's services for some time but had hoped the situation would improve. The Administrator stated the facility did not use a work order system to report pests and relied on word-of-mouth reporting. He stated there was no auditing of rooms for pest activity and that cockroaches were mainly observed on the 200 hall although they were reported in other parts of the facility as well. The housekeeping staff used an over the counter household spray if they were notified of pests. He stated he was informed that an Adult Protective Services (APS) report had been filed regarding a resident's condition, but he did not know the outcome of the APS investigation. He further stated he did not initiate monitoring, implement a performance improvement plan, or bring the issue to Quality Assurance for review.An interview was conducted with NA #7 on 3/11/26 at 12:04 PM. NA #7 stated she began working in the facility at the end of December 2025 and had observed cockroaches in resident rooms on the 200 hall since she started. An interview was conducted with the Housekeeping and Laundry Supervisor on 3/11/26 at 4:15 PM. She stated she had been in the position for two years, the department was fully staffed, and staff worked from 8:00 AM to 3:30 PM. She stated there were no housekeeping staff on duty in the evenings or at night, although some of the nursing staff assisted with cleaning spills in resident rooms at times. The Supervisor stated there had been a significant cockroach problem on the 100 and 200 halls for a long time and that the facility had been infested since the previous summer. She reported that staff sometimes informed her when they observed bugs, and she kept an over the counter spray that she used in resident rooms as needed between exterminator visits.The Supervisor stated that recently, she was instructed to accompany the exterminator on the visits. During a follow up interview on 3/12/26 at 2:14 PM, the Administrator acknowledged that the contracted pest control provider had not been successful in eliminating the pests. Despite this awareness, the facility did not implement additional corrective measures or alternative pest control services to adequately address the problem. The facility did not perform any documented monitoring, follow up, or escalation of the issue.An interview conducted with the Pest Control Specialist on March 18, 2026, at 12:45 PM revealed that he had more than 30 years of experience, including extensive education and training in the identification and treatment of German cockroaches. He explained that German cockroaches posed a significant health risk, carrying allergens and bacteria that can contaminate surfaces and lead to infections and gastrointestinal symptoms. The Pest Control Specialist stated that he was the owner of the new pest control company that began providing services to the facility in late January 2026. He reported that he completed a comprehensive evaluation of the facility, which included staff interviews, observations across all shifts, and assessments of resident rooms, offices, the kitchen, and common areas. He stated that during his initial evaluation, the facility was heavily infested with active cockroach activity; however, he noted a reduction in activity during subsequent visits.

Based on observations and staff interviews, the facility failed to label and date opened food items in 1 of 1 walk in cooler and 1 of 1 walk-in freezer; failed to label, date, and discard expired food items stored on shelving in the kitchen; and failed to discard expired food items stored in 2 of 2 nourishment room refrigerators (100 and 300 hall nourishment rooms). This deficient practice had the potential to negatively affect the safety of food served to residents.Findings included:a. An initial tour of the kitchen was conducted on 3/9/26 at 10:50 AM in the presence of the Dietary Manager.- At 10:50 AM on 3/9/26 an opened plastic bag containing hard boiled eggs was observed in the kitchen walk in cooler undated.- At 10:55 AM on 3/9/26 an opened undated plastic bag of breadsticks and an opened plastic bag of shredded cheese with an opened date of 1/9/26 was observed in the walk-in freezer.An interview conducted with the Dietary Manager on 3/9/26 at 11:00 AM revealed that all food items were expected to be labeled and dated upon opening, and any expired items were to be discarded. b. An observation of the 100-hall nourishment room on 3/9/26 at 11:05 AM with the Dietary Manager present revealed a plastic grocery bag with apples and oranges was observed in the 100-hall nourishment room refrigerator without a resident name or date. Seven single serve plastic containers of orange juice were observed in the refrigerator with a best by date of 1/24/26. An observation of the 300-hall nourishment room on 3/9/26 at 11:15 AM with the Dietary Manager present revealed in the refrigerator there were four single serve plastic containers of orange juice with a best by date of 1/24/26 and six containers with a best by date of 1/17/26 observed in the 300-hall nourishment room refrigerator. An interview conducted with the Dietary Manager on 3/9/26 at 11:20 AM revealed that the Dietary Aides were responsible for checking the nourishment room refrigerators daily for expired items and for items that were not properly labeled or dated. The Dietary Manager stated that the refrigerator had been checked that day, and she did not know how the expired and unlabeled items were overlooked. c. During an observation in the kitchen on 3/10/26 at 12:10 PM with the Dietary Manager present, three opened bags of bread were observed on a shelf in very close proximity to two open half full containers of cleaning solution. The bread was not in its original packaging, instead each loaf was in clear, plain unmarked plastic bags with no stamped use by dates. One bag contained white bread dated 2/27, one bag of white bread had no date, and one bag of wheat bread was dated 3/6/26. An interview conducted with the Dietary Manager on 3/10/26 at 12:15 PM revealed that food items should not be stored near the buckets of cleaning solution and should be labeled and dated. The Dietary Manager verified that the buckets contained the sanitizing solution that was used to clean surfaces in the kitchen and the solution was harmful if ingested. An interview was completed with the Administrator on 3/12/26 at 1:15 PM. The Administrator stated that he expected the kitchen staff to check for expired food in the kitchen and nutrition rooms and to discard them. He further stated he expected the staff to label and date food stored in the kitchen and nutrition rooms.

Based on record review, observation, and interviews with the Physician, Nurse Practitioner, resident, and staff, the facility failed to protect a cognitively intact female resident's (Resident #2) right to be free of sexual abuse when another female resident (Resident #1), who was cognitively impaired entered Resident #2's room and got into the bed with Resident #2 on 2/25/25 at 6:19 am. While in the bed Resident #1 kissed Resident #2 on the face, touched Resident #1's breasts and placed her hand inside the front of Resident #2's brief and attempted to touch her vagina. Resident #2 yelled out and Resident #1 got out of the bed and left the room. Resident #2 stated she was scared at the time and was still upset that it happened but was no longer afraid. Resident #2 was initially afraid until she learned that it was Resident #1 in her bed and not a man. The deficient practice occurred for 1 of 5 residents reviewed for abuse (Resident #2). The findings included: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia. Resident #1's care plan dated 10/15/24 revealed a problem of impaired cognitive function related to dementia with interventions that included cue, orient, supervise, and assess for unmet needs as needed. A second problem revealed Resident #1 had increased wandering and confusion and wandered into other resident rooms, woke them up and attempted to help other residents. Interventions included to anticipate needs when possible. Resident # 1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 1 was severely cognitively impaired. She was not assessed to have behavioral problems or wandering during the assessment period. Resident #1 was coded as using a wheelchair for mobility but could ambulate with partial to moderate assistance for 150 feet. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] Resident # 2's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 2 was cognitively intact. She required substantial to maximum assistance for activities of daily living care and moderate to partial assistance with bed mobility and transfers. An initial report dated 2/27/25 at 3:10 pm revealed that on 2/27/25 Resident #2 reported an allegation of abuse perpetrated by Resident #1. The report stated that Resident #1 went into Resident #2's room on 2/25/25, got into bed with Resident #2 and felt her breasts. Resident #1 then put her hand into Resident #2's brief. Resident #2 yelled for help and Resident #1 got out of the bed and left the room. Resident #1 was placed on one-to-one supervision after the facility became aware of the allegation. The report was signed by the Administrator on 2/27/25. In an interview with Resident #2 on 3/11/25 at 10:33 am she stated Resident #1 came into her room about a week ago (could not recall date or time) and got into bed with her when it was still dark outside. Resident #2 stated it scared her at the time because she could not tell if it was a man or woman. She stated she was not strong enough to push Resident #1 off her bed. The interview further revealed Resident #1 lay down beside Resident #2 and touched her breasts, kissed her face, and placed her hand inside the front of her brief and tried to touch her vagina. Resident #2 stated Resident #1 said something to her, but she could not recall what was said. Resident #2 stated when she told Resident #1 that she was going to call the police and yelled for help that Resident #1 got out of her bed and went toward the door. Resident #2 stated when Resident #1 was near the doorway she could identify Resident #1, and she was no longer afraid but was still upset that it happened. Resident #2 stated she knew Resident #1 was a resident at the facility and had talked to her before. The interview further revealed that she felt safe and was no longer afraid. During an interview with the Director of Nursing (DON) on 3/12/25 at 8:52 am she stated on 2/27/25 the Administrator made her aware of an alleged sexual abuse concern made by Resident #2 and immediately interviewed Resident #2 and completed a full body audit to include a vaginal observation. She indicated that the allegation was Resident #1 entered Resident #2's room on 2/25/25 in the early morning and got into bed with her, told her she loved her and touched her inappropriately on the chest area and attempted to put her hand in her brief. The DON stated Resident #2 reported she was afraid until she learned that it was Resident #1 that got into her bed and not a man. The DON stated interventions we put in place immediately, Resident #1 was placed on 1 on 1 observation with a staff member, was given a baby doll as a distraction to wandering, a mesh stop sign was placed across Resident #2's room door, and Resident #2 was later relocated to another hallway per the family approval. The interview further revealed Resident #1 and Resident #2 were known to one another and Resident #1 often visited Resident #2's room. The DON stated that on 2/27/25, Resident #1 had been placed on one-to-one supervision pending investigation into the incident. On 3/5/25 the Interdisciplinary Team (IDT) reviewed Resident #1 for the continued need for a 1 on 1 sitter with an intervention of a weighted baby doll (a life sized baby doll intended to simulate a real baby, used as a diversional activity for cognitively impaired residents) implemented on 3/5/25 and Resident #1 had decreased wandering into other residents' rooms and a large picture of Resident #1 and her husband had been placed on Resident #1's doorway to help her identify her room. There had been no concerns reported/identified during the resident body audits and resident interviews related to abuse or inappropriate touching. The IDT felt 1 on 1 supervision could be removed when this was discussed on 3/7/25 during the weekly Quality Assurance (QA) Meeting. Resident #1 was observed on 3/11/25 at 10:25 am sitting in a wheelchair in her room beside her roommate's bed in a wheelchair holding a doll baby and talking about the sunshine outside. Attempts to interview Resident #1 were unsuccessful because Resident #1 was unable to hold a meaningful conversation and kept reverting to the baby doll and the sunshine. Resident #1's room was noted to be on the same hallway several rooms down the hallway from Resident #2's room. During a phone interview with Nurse #3 on 3/11/25 at 3:14 pm she worked the 7:00 pm to 7:00 am shift on 2/25/25. She stated Resident #2 had been on her assignment that night. Nurse #3 stated while Resident #1 would go into other resident's rooms that she had never attempted to get into anyone's bed with them. She stated she did not hear Resident #2 call out for help that night and did not witness Resident #1 enter Resident #2's room. In an interview with Nursing Assistant (NA) #3 on 3/11/25 at 3:53 pm she stated she worked the 7:00 pm to 7:00 am shift on 2/25/25 and had been assigned to Resident and #1 and #2. She further indicated she had not observed Resident #1 enter Resident# 2's room at any time and had not heard Resident #2 call out for help that night. She stated she would have been making rounds and may have been in another resident's room when Resident #2 called out. The interview further revealed Resident #1 could transfer herself from the bed to her wheelchair and could ambulate Independently. NA #3 further stated she assisted Resident #1 to bed at 11:00 pm on 2/25/25 and checked on her every 2 hours throughout the night and Resident #1 was not observed to be out of her bed at any time during her shift. In an interview with the Physician for Resident #1 and Resident #2 on 3/11/25 at 3:25 pm he revealed he had been made aware that Resident #1 had gotten into bed with Resident #2 and that was unusual behavior for Resident #1. He stated Resident #1 was pleasantly confused and oriented to person only and continually called out for her husband. He stated he did not meet with Resident #2, but the Nurse Practitioner (NP) had and did not report any concerns to him regarding her well-being. A phone interview with the NP on 3/12/25 at 10:08 am revealed she met with Resident #2 on 2/25/25 in the late afternoon and Resident #2 had not told her someone had gotten into her bed or touched her inappropriately. She stated Resident #2 was not distraught during her visit with her and was her normal happy self. The NP stated she was made aware of the concern of alleged sexual abuse a few days later by administration. She stated she did not order a psychiatric evaluation for Resident #2 because she was not distraught. She stated a vaginal exam was not ordered because there was no report or indication of penetration of any type. An interview with the Administrator on 3/12/25 at 10:18 am revealed he received a text from Resident #2's family member that someone had gone into Resident #2's room before lunch on 2/25/25 and he checked the facility camera's and could not verify that anyone had entered her room during that time frame. He stated he communicated back to Resident #2's family member that camera footage did not reveal anyone entering her room. He stated he talked to Resident #2 on 2/25/25 and she had not indicated that she had been sexually abused, just that someone came into her room. He stated he communicated back and forth with the family member and continued to review video camera footage until he finally saw Resident #1 enter Resident #2's room on 2/25/25 at 6:19 am and leave the room at 6:57 am. He stated at this time he still thought the concern was that someone had entered Resident #2's room and was not aware of a sexual abuse allegation. He told the family member he would put up a mesh stop sign across Resident #2's door to deter wandering residents from entering her room and they agreed. He stated he had not been made aware of the alleged sexual abuse concern until 2/27/25 at 3:10 pm when he went to put the stop sign on Resident #2's doorway and a family member was present and they told him Resident #2 failed to tell the Administrator what happened when the person entered his room on 2/25/25 because the Administrator was a male and Resident #2 was not comfortable talking to him. He stated he asked the DON to go in to interview Resident #2 and she told the DON about the sexual abuse concern. The Administrator stated upon learning of the alleged sexual abuse he contacted the Division of Health Service Regulation, local law enforcement, and Adult Protective Services within the required timeframes. He further indicated that he was able to identify the person that entered the room on 2/25/25 at 6:19 am as Resident #1. The Administrator stated after he learned of the alleged sexual abuse he started an investigation, completed education with staff on resident-to-resident abuse prevention, reporting and protection. Review of Surveillance video footage of the hallway outside of Resident #2's doorway was reviewed with the Administrator on 3/12/25 at 10:30 am and confirmed Resident #1 entered Resident #2's room on 2/25/25 at 6:19 am and exited the room at 6:57 am. The facility provided the following corrective action plan with a compliance date of 3/6/2025. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 2/27/2025, the Director of Nursing (DON) assessed Resident #2 for any noted change in condition or injuries with none noted. On 2/28 The IDT which consists of the DON, Unit Managers, Staff Development Coordinator, Administrator, Social Worker and MDS Coordinator completed a root cause analysis of Resident # 1's incident and determined she thought she was getting in bed with her husband based on Resident #2's statement that she (Resident #1) told her she has always loved her, and that Resident #1 frequently asked for her husband. On 2/27/25, Resident #1 was placed on one-to-one supervision pending investigation, a stop sign was placed on Resident #2's doorway to deter any wandering into her room. Resident #2 was moved to the rehab hall on 3/5/25 per family and resident's request. Resident #1 was to remain on one-to-one supervision until the IDT evaluated the effectiveness of the implemented interventions. On 2/27/25, the Administrator notified the local police department and Adult Protective Services (APS). On 2/27/25 the Administrator submitted the initial report to the State Agency. On 2/27/25, the DON/designee notified the Physician and responsible parties of Resident #1 & Resident #2. On 2/27/25 Resident #1's roommate had a skin assessment completed and was assessed for signs and symptoms of emotional distress with no noted decline. Resident #1 was on one-to-one during the abuse investigation. On 3/5/25 Resident #1's implemented interventions included a weighted babydoll, which has decreased residents wandering into other residents' rooms, and a large picture of Resident #1 and her husband was placed on her doorway to help her identify her room. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 2/28/25 the Social Worker (SW) interviewed alert and oriented residents concerning abuse with no noted concerns identified. On 2/28 /25 the Director of Nursing (DON) and Unit Managers (UMs) performed skin checks on cognitively impaired residents with no areas of concern identified. On 2/28/25 the Administrator reviewed grievances and Resident Council minutes for the previous 30 days with no concerns of inappropriate touching or abuse. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 2/28/25, the Staff Development Coordinator (SDC) and Director of Nursing (DON) began re-education for all staff regarding Abuse, which included reporting process and types of abuse along with Handling Challenging Behaviors. This education was completed by all staff including agency on 3/5/25. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The Facility initiated monitoring and one-to-one on 2/27/25. The Reportable Incident was reviewed on 2/28/25 in the weekly Quality Assurance Meeting. The Administrator or Social Worker are conducting random interviews on 6 cognitively intact residents. The interviews will include questions related to abuse and any inappropriate touching. Residents were, and are encouraged to report any issues related to abuse or inappropriate touching by Administrator or Social Worker during initial interviews and follow-up interviews conducted per the plan of correction. Nursing will conduct 3 body audits on non-cognitively intact residents to make sure there are no signs of suspicious skin injuries or signs of abuse. These interviews /audits will be conducted weekly for two weeks, and monthly for three months. The IDT will monitor the 24-hour report (a report shared between shift to communicate resident conditions) which is reviewed daily Monday through Friday and on the weekends the Shift Supervisors will report to the DON any concerns from 24-hour report or grievances for any safety concerns, or inappropriate touching. Staff will immediately place resident on one-to-one if identified. All data will be presented to the weekly Quality Assurance committee by the Administrator to ensure corrective action is initiated as appropriate. Compliance will be monitored and the ongoing auditing program reviewed at the weekly Quality Assurance Meeting. The weekly Quality Assurance Meeting is attended by the Administrator, Director of Nursing, Minimum Data Set Coordinator, Therapy, Health Information Manager, and the Dietary Manager. Alleged Date of compliance: 3/6/2025 Validation of the corrective action was completed on 3/12/25. This included staff interviews regarding resident-to-resident abuse. An observation of Resident #1 verified the weighted baby doll intervention was implemented. Education was verified for staff on abuse, resident protection, reporting, and handling challenging behaviors. The audits completed by the SW, DON, UMs, and Administrator were verified and there were no concerns identified. Skin assessment for Resident #2, documentation of one on one observation of Resident #1, and documents that indicated notification was made to the State Agency, local police, APS, Physician and responsible parties for Resident #1 and Resident #2 were all verified. As indicated in the corrective action plan, Resident #1 remained on one on one supervision until the IDT evaluated the effectiveness of interventions. On 3/7/25 the IDT determined the implemented interventions were affective and one on one supervision was removed. The facility's alleged compliance date of 3/6/25 was validated.

Based on record review, staff, Physician, and the Consultant Pharmacist interviews the facility failed to prevent significant medication errors by administering Resident #223 the incorrect dose of a blood pressure medication, Losartan 50 milligrams (an antihypertensive), and administering blood pressure medications without following the physician's ordered parameters to hold the medication (Residents #223 and #47). This resulted in Resident #223 experiencing hypotension (low blood pressure) and symptoms of head pressure, neck pain, and nausea. There was no significant outcome for Resident #47. This deficient practice occurred for 2 of 2 residents reviewed for medication administration. Findings Included. 1.) Resident #223 was admitted to the facility on [DATE] with diagnoses including hypertension. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #223 was cognitively intact. A physician's order dated 07/23/24 for Resident #223 revealed Losartan 50 milligram tablets. Give via PEG (percutaneous endoscopic gastrostomy) tube at bedtime for hypertension. Hold if systolic blood pressure is less than 140 mmHg (millimeters of mercury). A nursing progress note dated 08/22/24 at 03:19 AM revealed Resident #223 requested to speak with the nurse at approximately 2:30 AM due to complaints of burning sensation, head pressure, neck pain, and nausea. Resident #223's blood pressure was 62/40 mmHg with a manual cuff, and 59/36 mmHg obtained by second nurse with an automatic cuff. His blood pressure was obtained again manually and was 62/40 mmHg and the second nurse obtained a reading of 65/45 mmHg manually. Resident #223's oxygen saturation was maintained around 95% and dropped as low as 82% with pulse oximetry. The physician was called and gave orders to have the resident sent out to the hospital for evaluation for low blood pressure. Resident #223 stated he didn't want to go to the hospital, but the physician insisted on calling the ambulance for further evaluation. Emergency Medical Services (EMS) arrived, and his blood pressure was 95/60 mmHg and pulse oximetry at 95%. His heart rate and temperature were within normal limits. EMS staff asked if the resident wanted to go to the hospital for further evaluation and Resident #223 declined. The Physician was made aware. During a phone interview on 01/09/25 at 10:33 AM Nurse #6 stated she was new to the facility at the time of the incident and was still in training. Nurse #6 stated she did give Resident #223 Losartan instead of holding the medication. She stated the blood pressure medication had hold parameters, but no box popped up in his electronic medical record to check the residents blood pressure. She stated that she administered the medication from the card that was in the medication cart. Later Resident #223 became lethargic, complained of headache, and nausea. His blood pressure was low, so they called the physician who instructed them to call 911. EMS arrived soon after. EMS asked if he wanted to go to the hospital, but the resident refused to go. She reported he did not go to the hospital, but they continued to do frequent blood pressure checks with no further complaints of headache or nausea and his blood pressure was trending up. She stated he was discharged home two days later. She stated the nurse that was orienting her questioned the dose after the resident became symptomatic when she told the nurse that she had administered it to him. She indicated she didn't realize she had given 100 milligrams instead of 50 milligrams, but she should have held the medication anyway according to the prescribed parameters. She indicated she received training on medication administration following the incident. A progress note dated 08/22/24 at 2:59 PM documented by Unit Manager #2 revealed Resident #223 was administered the right medication, but the wrong dose and the parameters were not followed per the Medication Administration Record. Resident #223's blood pressure dropped. The physician was notified, and actions were taken to improve his blood pressure. He refused to go to the hospital. Resident #223 was examined by the Physician at 8:00 this morning with this nurse present. No further adverse effects were noted. Resident #223 participated in physical therapy this morning and was up in his wheelchair. He and his family member were aware. During an interview on 01/08/25 at 1:30 PM Unit Manager #2 stated she was made aware of the incident the morning it occurred. Resident #223 was admitted for short term rehab therapy. They discovered that Nurse #6 gave the right medication but the wrong dose during the 9:00 PM medication pass. The order in Resident #223's electronic medical record revealed to administer 50 milligrams of Losartan, but the medication card read to give 100 milligrams. The order was changed from 100 milligrams to 50 milligrams, but the medication card was not updated because the new order was not sent to the pharmacy. She stated they also discovered that Resident #223's blood pressure recorded during the 9:00 PM medication pass was 117/69 mmHg so the resident should not have received the medication according to the parameters to hold the medication of the systolic blood pressure was less than 140 mmHg. She stated a few hours after receiving the medication around 2:30 AM the resident had complaints of headache and nausea, and his blood pressure was low. Resident #223 refused to go to the hospital, but EMS was called anyway. The resident continued to refuse to be sent out. The physician evaluated him later that morning and the assessment was within normal limits, and he had no further complaints. Resident #223 participated in physical therapy that morning and discharged home within a couple of days. A progress noted dated 08/24/24 at 3:19 PM Resident #223 discharged home with his family. During an interview on 01/08/24 at 1:00 PM the Director of Nursing (DON) stated on 08/21/24 Nurse #6 who was completing new hire orientation was working on the Rehab Hall on the night of the incident. Resident #223 was alert and oriented and called Nurse #6 to the room with complaints of nausea and other symptoms. His blood pressure was checked, and it was low. The physician was notified and ordered Resident #223 to be sent to the hospital for evaluation, but the resident refused to be sent out. EMS was notified to come evaluate and transport him but Resident #223 continued to refuse to go out. EMS also asked the resident if he wanted to go to the hospital, but he continued to refuse. She stated she was notified that morning, and they reviewed the Losartan medication card. She stated upon investigation they discovered that the Losartan order was changed on 07/23/24 from 100 milligrams to 50 milligrams. Nurse #6 gave 100 milligrams instead of the prescribed 50 milligram tablet. The order was updated in the electronic medical record, but the new order was not sent to the pharmacy. The nurses were still working from the old medication card that had the 100 milligram tablets. She stated the order should have been discontinued altogether and a new order entered for the 50 milligrams and the order sent to the pharmacy. The pharmacy would have sent a new card with the correct dosage and instructions. She stated they also discovered that the medication should have been held due to his systolic blood pressure being less than 140 mmHg, but Nurse #6 administered the medication. During an interview on 01/08/24 at 2:15 PM the Physician stated he was made aware of the medication error when it occurred. He indicated he evaluated Resident #223 following the incident. He stated Resident #223 was on long term antihypertensive therapy. Receiving the extra 50 milligrams would not have any severe outcome and there was no significant outcome regarding Resident #223 receiving Losartan 100 milligrams. He agreed that it was a medication error and stated he expected the nurses to follow the orders and the blood pressure parameters. During a phone interview on 01/09/25 at 1:38 PM the Consultant Pharmacist stated receiving a blood pressure medication when not indicated could cause symptoms such as low blood pressure, dizziness, nausea, and headache. 2.) Resident #47 was admitted on [DATE] with diagnoses including hypotension. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #47 was cognitively intact. A physician's order dated 12/05/24 for Resident #47 revealed Midodrine (prescribed to treat low blood pressure) 2.5 milligrams. Give 1 tablet by mouth three times a day for hypotension. Hold for systolic blood pressure greater than 95 mmHg (millimeters of mercury). Review of the Medication Administration Record (MAR) for Resident #47 dated January 2025 revealed on 01/02/25 Midodrine 2.5 milligrams was administered by Nurse #7 at the following times with blood pressure readings as follows: 01/02/25 a 6:00 AM with a blood pressure reading of 120/56 mmHg. (systolic/diastolic) 01/02/25 at 12:00 PM with a blood pressure reading of 120/62 mmHg. 01/02/25 at 5:00 PM with a blood pressure reading of 118/60 mmHg. During an interview on 01/08/25 at 1:00 PM the Director of Nursing (DON) stated there had been ongoing issues with staff not following medication parameters ordered by the physician. She indicated that according to the MAR, Nurse #7 signed off that the Midodrine was administered to Resident #47 although her blood pressure was outside of the prescribed parameters. She stated Nurse #7, who administered the Midodrine outside of parameters on 01/02/25, was out on medical leave and was unavailable for interview. During an interview on 01/08/25 at 2:15 PM the Physician stated he was made aware by Unit Manager #2 of Midodrine being administered outside of parameters to Resident #47 on 01/02/25. He reported that the medication was discontinued today as it was no longer indicated for her. He stated Resident #47 did not have any symptoms or outcome from receiving the medication. During an interview on 01/09/25 at 1:38 PM the Consultant Pharmacist stated she had identified not following blood pressure parameters in her monthly medication reviews. She reported this in her monthly reports that were sent to the DON. She stated she would work with the DON to help ensure parameters were being followed. She indicated taking Midodrine when not needed would increase the blood pressure unnecessarily, or cause side effects such as dizziness and headaches. During a follow up interview on 01/09/25 at 1:00 PM, the Director of Nursing stated they had provided education regarding not following physician orders to hold medications according to the prescribed parameters to all nursing staff beginning in August 2024. Education had also been provided verbally to individual staff members between August through December 2024. She stated she had been providing education and conducting audits regarding following medication parameters, but the problem continued. She reported further education and medication audits would be conducted.

Based on observations, record review, staff and the Nurse Practitioner interviews, the facility failed to comprehensively and effectively assess a resident's skin resulting in a delay in identifying and addressing a large, excoriated area (superficial wound or raw irritated patches with visible marks often caused by scratching, rubbing, or other mechanical trauma) behind the left knee of an immobile resident (Resident #25). The resident had a history of yeast developing in the folds of her skin. This deficient practice occurred for 1 of 1 resident reviewed for non-pressure related skin conditions. Findings included. Resident #25 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #25 was cognitively intact. She exhibited no behaviors and had no rejection of care. She required extensive two-person assistance with activities of daily living. Her weight was 240 pounds. A care plan revised 12/19/24 revealed Resident #25 had the potential for impaired skin integrity and was at risk for pressure ulcer development related to limited mobility and incontinence. Interventions included in part to report to the nurse immediately if redness, open areas, or skin irritation, and complete weekly full body skin assessments. A weekly skin evaluation documented by Nurse #5 dated 01/04/25 for Resident #25 revealed no new skin issues. During a phone interview on 01/09/25 at 12:00 PM Nurse #5 who completed the most recent weekly skin assessment dated [DATE] stated she typically completed the skin evaluations during the time the nurse aides were providing personal care. She stated she could have missed the excoriation on Resident #25's legs and abdomen because she just did a quick glance during her assessment. She stated she should not have rushed through the assessment. A Nursing Report Sheet (paper with written comments used by the nurse to report information regarding residents to the oncoming shift. It is not a part of the residents medical record) initially dated 01/06/25 but then crossed through and dated 01/07/25 revealed a note that Resident #25 had a left leg rash and rawness behind the left knee. The Director of Nursing (DON) reported this was documented by Nurse #7. During a phone interview on 01/22/25 at 4:20 PM Nurse #7 stated on the morning of 01/08/25 at approximately 6:30 AM, just before the end of her shift, Resident #25 had complaints of itching and burning to her left leg. She stated she observed a large red area behind the left knee, and she thought it was a rash. She reported this to Nurse #1, the oncoming nurse during end of shift report at approximately 6:45 AM. She stated Nurse #1 told her that she would notify the Wound Nurse and the Nurse Practitioner or Physician and make a note in the resident's medical record. She reported that she typically was not assigned to Resident #25 and did not know how long the rash could have been there. Review of Resident #25's progress notes from 01/01/25 through 01/08/25 was completed on 01/08/25 at 10:30 AM and revealed no documentation of any skin irritation. During an interview and observation conducted on 01/08/25 at 10:45 AM, Resident #25 was observed lying in bed. She was alert and oriented to person, place, and time. She complained of left knee pain. Nurse #1 was notified and entered Resident #25's room to evaluate. A large, excoriated area that appeared red and irritated was noted behind her left knee. Resident #25 stated the area behind her knee had been there for a month. She stated the nurses were aware but there had been no medications applied to the area. Resident #25 stated she didn't know what caused the area to be red and inflamed. Further observation of Resident #25 revealed she had excess skin folds hanging from her abdomen and thighs. Resident #25 stated she had gained a lot of weight and due to her excessive skin folds she relied on staff to check her skin between the large skin folds to determine if there were any concerns. She stated she would not refuse allowing staff to perform skin assessments in case she needed any type of treatment for her skin. During an interview on 01/08/25 at 10:50 AM Nurse #1 stated she was the assigned nurse. She indicated she was not aware that Resident #25 had excoriation behind her left knee. She stated she would notify the Wound Nurse. During a follow up phone interview on 01/22/25 at 4:15 PM Nurse #1 stated she was not made aware of the excoriated area behind Resident #25's left knee during shift change report on the morning of 01/08/25. She stated that had she been made aware she would have notified the Wound Nurse and Physician sooner so that treatment orders could be implemented. During an interview on 01/08/25 at 11:05 AM the Wound Nurse stated she was not aware of the excoriated area behind Resident #25's left knee until now. She did not say when the last time she had evaluated Resident #25, but she only evaluated residents when the nurses informed her of any skin concerns. The Wound Nurse stated the area behind the left knee had not been there for a month as indicated by Resident #25. She stated she would notify the Nurse Practitioner and implement treatment orders. A progress note dated 01/08/2025 at 11:07 AM for Resident #25 documented by the Wound Nurse revealed open excoriation was noted to the left leg folds. The physician was notified, and new orders were received. A physician's order dated 01/08/25 for Resident #25 revealed Nystatin external ointment 100000 units (antifungal). Apply to left leg folds topically every day and night shift for candida (fungal infection caused by an overgrowth of yeast). A skin evaluation form dated 01/09/25 documented by the Wound Nurse revealed Resident #25's left leg was noted with a red papular rash (solid raised bumps on the skin) behind the left knee with open excoriation noted at the crease of the left knee. The area behind the left knee measured 18 centimeters (cm) x 6 cm. The physician was notified, and an antifungal medication was applied to the area. During an interview on 01/09/25 at 12:42 PM the Nurse Practitioner stated she evaluated Resident #25 yesterday 01/08/25 after being notified of the excoriated skin condition. She implemented treatment orders at that time. She reported Resident #25 had large skin folds due to her weight and had issues before with yeast developing in the folds of her skin. She stated the nurses should be doing thorough skin assessments weekly to identify any issues or concerns so that treatment orders could be initiated promptly. During an interview on 01/09/25 at 1:00 PM the Director of Nursing (DON) stated Nurse #7 the night shift nurse identified the excoriation to Resident #25's knee on 01/06/25. She stated Nurse #7 made a handwritten note on the end of shift report sheet and wrote rash behind left knee but no description or measurements. She stated Nurse #7 did not document the area anywhere in the medical record. She stated the area should have been passed along in report the following morning and documented in the medical record. She indicated it should have been communicated to the Wound Nurse or to the Nurse Practitioner so that treatment could have been initiated sooner. She stated thorough skin assessments should be conducted and documented by the nurses and the Nurse Practitioner or Physician notified promptly for treatment orders. She indicated education would be provided. During a follow up phone interview on 01/22/25 at 4:30 PM the Director of Nursing stated upon further investigation, Nurse #7 stated to her that the area behind Resident #25's left knee was reported to Nurse #1 during shift report on the morning of 01/08/25. She indicated education would be provided regarding conducting thorough skin assessments and identifying and addressing any concerns.

Based on observations and staff interviews the facility, 1a) failed to remove black greenish substance from the commode base caulking in resident rooms (106,112, 214, 220, 303, and 410), 1b) failed to replace resident's missing florescent overbed light covers in rooms (201A, 201B, 203A, 203B, 207A, 207B, 208A, 208B, 212A, 212B, 214A, 214B, and 215B). These failures occurred on 4 of 4 hallways (100, 200, 300, and 400 Hall) observed for a safe, clean, homelike environment. Findings included: 1a. An initial observation on 01/08/25 at 8:10 AM revealed resident commodes (Rooms: 106, 112, 214, 220, 303, and 410) were noted to have black greenish substance located around the base of the commodes. An interview was conducted on 01/08/25 at 2:00 PM with the Housekeeping Supervisor. The Housekeeping Supervisor stated her staff was responsible for sweeping and mopping residents' rooms daily and the Maintenance Department was responsible for caulking and removing black greenish substances from commode bases. 1b. A follow-up observation on 01/09/25 at 7:30 AM with the Maintenance Director revealed missing florescent overbed light covers in rooms, which were occupied with residents at the time of the observation. (201A, 201B, 203A, 203B, 207A, 207B, 208A, 208B, 212A, 212B, 214A, 214B, and 215B). An interview and observation was conducted on 01/09/25 at 7:45 AM with the Maintenance Director. The Maintenance Director stated there were multiple resident room areas that still needed to be addressed. He stated he did not have an assistant but was slowly keeping up with facility repairs. He said he did not know what the black greenish substance was around some of the commodes on the 100,200,300 and 400 halls and did not notice resident rooms with missing overhead light covers. He said maintenance was responsible for repairing or replacing items in the facility, including removing blackened substances around commodes and re-caulking, as well as replacing missing fluorescent overbed light covers. No staff had reported to him the black greenish substance around the base of the commodes and no staff had reported to him the missing light covers. A follow-up facility tour was conducted on 01/09/25 at 11:15 AM of the 100 and 200 halls with the Administrator. The tour revealed: black greenish substance around the base of resident commodes and missing fluorescent overbed light covers. He stated the residents' rooms observed in the 100 and 200 halls with commodes that had black greenish substance around their bases and missing fluorescent overbed light covers needed to be addressed by the Maintenance Director. He revealed they were making progress and were improving residents' living environment to make it more home-like, and that it would take time. The Administrator stated it was his expectation for all the residents to have a safe and homelike environment that was clean and in good repair.

Based on record review and staff and resident interviews the facility failed to notify the nurse when a resident refused to be transferred with a mechanical lift and two nurse aides decided to transfer the resident (Resident #2) by manually lifting the resident from the bed to the shower bed causing her to fracture her tibia for 1 of 4 residents reviewed for accidents. Findings included: Resident #2 was admitted to the facility on [DATE]. Diagnoses included cerebral palsy (spastic paralysis causing impaired muscle coordination), osteoporosis (brittle and fragile bones), anxiety, vitamin D deficiency, contractures to left elbow and left wrist, and fracture of shaft of right tibia. A review of Resident #2's care plan updated 11/03/22 revealed a plan of care for at risk for falls related to resistance to getting out of bed and refusal of care of the mechanical lift. Requires a mechanical lift for all transfers out of bed with a goal that resident would not sustain serious injury over the next 90 days with interventions to include, in part, use mechanical lift with two staff to get in and out of bed. A plan of care for receiving pain medication therapy related to cerebral palsy with joint restrictions and muscle spasms with interventions to include, in part, reposition in bed for comfort and encourage to get out of bed, and a plan of care for osteoporosis with risk for injuries and fractures and pain related to hypocalcemia and vitamin deficiency. Goal to remain free of injuries or complications related to osteoporosis with interventions to include observe for and document/report to the physician any signs or symptoms of complications related to osteoporosis, acute fractures, compression fractures, and pain. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #2 was cognitively intact. She demonstrated no behaviors and required extensive assistance with two staff physical assistance with bed mobility and transfers. Resident #2 was not coded as having any falls during this assessment. A review of the physician's orders revealed Resident #2 was receiving the following medications: Tylenol 325 milligrams (mg) one tablet three times a day and 2 tablets every 4 hours as needed for pain/fever written on 04/22/22. Evista 60 mg give one tablet by mouth one time a day for osteoporosis written on 04/22/22. Norco (opioid pain medication) tablet 5-325 mg give one tablet three times daily for pain written on 04/23/21. Flexeril (muscle relaxing medication) 10 mg one tablet twice daily for muscle spasms written on 07/25/11. Pain assessment every shift - ask patient if in pain according to pain scale and document response written on 04/23/21. A review of the incident report dated 11/02/22 at 10:42 AM by Unit Manager revealed Resident #2 complained of pain in right leg, hip, and knee. Resident #2 was able to move right leg and toes and slightly bend her right knee. Resident #2 was offered Tylenol for pain but declined stating the medication she took routinely for pain was enough at this time. The Nurse Practitioner was in the building and made aware. A Nurse Practitioner (NP) progress note written on 11/02/22 AM revealed Resident #2 was seen on 11/02/22 resting in bed. Resident #2 reported pain to her right knee that radiated to right hip with onset after shower on 10/30/22. She had continuous sharp pain rating 8 out of 10 and was worse with moving or touching knee. Resident #2's right knee had mild edema (swelling) and no redness. Resident #2 stated when she was lying still it reduced the pain but did not alleviate the pain. There was no pain on palpation of right hip and an x-ray was ordered for the right knee and hip. A physician's order written on 11/02/22 revealed an x-ray to right knee and hip 2 views related to pain. A review of the x-ray results of the right knee dated 11/02/22 revealed Resident #2 had an acute obliquely oriented (broken at an angle) incomplete fracture at the proximal (near) tibial (shinbone) metaphysis (neck of bone where tibia starts to narrow) medially (middle), a new finding when compared to prior examination dated 01/18/19 and mild osteoarthritis predominantly involving the knee. A record review revealed on 11/03/22, Resident #2 was transferred via mechanical lift to a wheelchair for an appointment to a walk in clinic at nearby orthopedic center where resident was seen and a right leg immobilizer placed and resident returned to facility with orders. A review of a physician's order written on 11/03/22 from the orthopedic center revealed an order for a right knee immobilizer to be worn at all times for 6 to 8 weeks. A review of the Medication Administration Record from 10/30/22 through 11/02/22 revealed Resident #2 received her scheduled Norco 5-325 mg as ordered (three times daily). The Medication Administration Record from 10/30/22 through 11/02/22 revealed Resident #2's pain was assessed on 10/30/22 and 10/31/22, and 11/01/2 and was recorded as 0 for day, evening, and night shift pain assessments. Resident #2's pain was assessed on 11/02/22 and was recorded at 8 for the day shift. Review of an investigation conducted by the facility revealed on 11/02/22 Unit Manager was made aware by Resident #2 that her right leg was hurting. The Unit Manager completed a physical assessment on Resident #2 and reported findings to the Nurse Practitioner. The Nurse Practitioner assessed Resident #2 and ordered an x-ray of her right leg. On 11/03/22, Resident #2 was transferred via a mechanical lift to a wheelchair for an appointment at a walk-in orthopedic clinic where resident was seen and right leg immobilizer was placed. Resident returned to the facility with orders. On 11/04/22, Resident #2 reported she had no new pain from 10/30/22 to 11/02/22. Resident had a diagnoses of osteopenia, cerebral palsy and refused to use the mechanical lift. The root cause of the fractured leg was noted that Nursing Assistants demonstrated lack of knowledge about who to report residents' refusal of using the mechanical lift and did not follow the Kardex (care guide specific to resident's needs) in Resident #2's care plan. The MDS annual assessment dated [DATE] revealed Resident #2 was cognitively aware and required extensive assistance with two person physical assistance with bed mobility, total dependence with two staff physical assistance with transfers. An interview was conducted with Resident #2 on 10/30/23 at 1:10 PM. Resident #2 revealed she did not get out of bed and that was her choice. Resident #2 stated she had a fall and fractured her right leg because she fell off a mechanical lift. Resident #2 stated she could not recall what had happened when she fell off the lift or when she fell off the lift. Resident #2 stated she no longer had that pain in her right leg. An observation of Resident #2 on 10/30/23 at 1:10 PM revealed an alert and oriented resident lying in bed with head of the bed elevated. Resident #2 did not demonstrate any signs or symptoms of pain. Resident was watching TV and waiting for her lunch to arrive. An interview was conducted via phone with Nurse Aide (NA) #2 on 11/02/23 at 12:37 PM. NA #2 stated Resident #2 refused to use the mechanical lift so we transferred her with two person assistance. NA #2 stated that on 10/30/23 at around 7:00 PM she and NA #1 were putting Resident #2 in the shower bed using a two person technique with her at the head of the bed to move Resident #2's shoulders and NA #1 at the bottom of bed to move Resident #2's legs. NA #2 stated we had the shower bed beside Resident #2's bed and NA #1 placed bath blankets on the shower bed, a pillow for her head, a pillow for under her legs and a pillow for under her feet for cushioning. NA #2 reported NA #1 was holding Resident #2 from her legs and she was at the top holding the resident's arms and we shifted Resident #2 over to the shower bed. NA #2 stated Resident #2 had no complaints of new pain during the transfer, during her shower, or during the transfer from the shower bed back to her bed. NA #2 stated Resident #2 was always complaining of aches and pains, but she did not say she had new pain. NA #2 stated we have used the mechanical lift with her, but that particular time she refused. NA #2 stated she believed NA #1 (who was assigned to Resident #2) let the nurse know, but she could not remember because it was over a year ago. NA #2 stated Resident #2 complained of pain to her knees and legs all the time and that was why we kept pillows under her legs while in her bed and in the shower bed. A follow up interview was conducted with Resident #2 on 11/02/23 at 10:00 AM. Resident #2 revealed she recalled that NA #1 and NA #2 were getting her ready for her shower and they transferred her from the bed to the shower bed. Resident #2 confirmed she did not fall off the mechanical lift but that she refused to use the mechanical lift so the nurse aides transferred her with one of the aides holding her shoulders and one of the aides holding her legs and slid her on to the shower bed. She stated at the time she did not have any new pain to her right leg. She stated she took her shower and they transferred her back to bed the same way and she did not have any new pain to her right leg. Resident #2 stated she could not remember when her knee started to hurt or when she reported the new pain to the nurse. Resident #2 added, she did not like to be transferred on the mechanical lift but knew that it was for her safety. A phone interview was conducted with Nurse #2 on 11/02/23 at 12:48 PM. Nurse #2 stated she had no recollection of any nurse aides reporting to her that Resident #2 was refusing to use the mechanical lift to be transferred. Nurse #2 stated she did not recall being informed that Resident #2 had any complaints of new pain on 10/30/23. Nurse #2 added, Resident #2 had chronic pain and received routine pain medications. Nurse #2 added, if she had been told by the NA that Resident #2 was refusing to be transferred with the mechanical lift, she would have explained to Resident #2 that it was for her safety to use the mechanical lift whenever she was being transferred. A phone interview was conducted with Medication Aide (MA) #3 on 11/02/23 at 2:18 PM. MA #3 confirmed he was assigned to Resident #2 from 7:00 PM to 7:00 AM on 10/30/22 and 10/31/22. MA #3 stated he could not recall if any nurse aides reported to him that Resident #2 refused to be transferred with a mechanical lift on 10/30/22. He also stated Resident #2 had chronic pain but he was not made aware of any new pain from Resident #2. An interview was conducted with MA #2 on 11/02/23 at 9:50 AM. MA #2 reported she was assigned to Resident #2 on 10/31/23 from 7:00 AM to 7:00 PM. She stated she was not made aware of any new pain Resident #2 had nor was she made aware that Resident #2 had her shower on Sunday 10/30/23. She stated she usually had a shower on Mondays and Thursdays. MA #2 stated Resident #2 had chronic pain and she received scheduled pain medicine which she administered on 10/31/23, but Resident #2 never indicated she had new knee pain. An interview was conducted with the Unit Manager (UM) on 11/01/23 at 3:10 PM. The UM reported on 11/02/22 she was called to Resident #2's room because she was complaining of pain. She stated she offered Resident #2 Tylenol, but she refused and added she asked Resident #2 where she was hurting and she stated her right knee. The UM stated she told the Nurse Practitioner (NP) #1 and she ordered an x-ray. The UM stated when she assessed Resident #2 she was able to move her right leg and toes and slightly bend her right knee. The UM stated Resident #2 told her that she got hurt when she was transferred from her bed to the shower bed by NA #1 and NA #2 on Sunday 10/30/22. The UM reported Resident #2 refused to use the mechanical lift and the nurse aides decided to transfer her without using the mechanical lift. Attempted a phone interview with NA #1 on 11/01/23 at 7:30 PM, on 11/02/23 at 10:30 AM, and a text message at on 11/02/23 at 11:58 AM. NA #1 no longer worked at the facility and did not return any calls. Attempted a phone interview with the Nurse Practitioner (NP) #1 via phone on 11/02/23 at 2:20 PM. NP #1 no longer worked at facility and did not return call. Attempted a phone interview with the Director of Nursing (DON) on 11/02/23 at 3:10 PM. The DON no longer worked at the facility and did not return call. An interview was conducted with the Administrator on 11/02/23 at 3:15 PM. He reported it was determined that the nurse aides should have followed Resident #2's Kardex and transferred her with the mechanical lift for her safety. The Administrator added, the nurse aides should have informed the nurse that she refused to be transferred with the mechanical lift and they should not have transferred her without the lift. The Administrator stated once she complained of new pain, an x-ray was done and determined that she had a fracture to her tibia and she was sent to the orthopedic clinic for a brace. He stated he initiated a plan of correction as a result of her injury and the nurse aides not following the Kardex. Failure to provide supervision to prevent accidents: The facility initiated the following plan of correction. 1. On 11/02/22, the Unit Manager (UM) completed a head to toe assessment on Resident #2. The results included increase pain and edema to right knee. The UM reported the finding to NP #1 who then assessed Resident #2 and ordered an x-ray of the right leg. The x-ray was completed and resulted in fracture to right tibia on 11/03/22. Resident #2 was taken to the outpatient orthopedic clinic on 11/03/22 and was assessed by a provider who ordered a leg brace for 6-8 weeks. There were no changes to medications due to resident having scheduled Norco that was currently effective. Skin checks were ordered every shift to assess for any skin breakdown under the brace. 2. On 11/03/22, the Director of Nursing (DON) identified residents that were potentially impacted by this practice by completing a review of all interviewable residents for the last 14 days for any similar incidents of residents declining interventions for their transfer status. This was completed on 11/03/22. The results included: no other incidents identified. On 11/03/22, the DON and MDS Nurse audited all resident care plans to assure the transfer status was up to date. All care plans were up to date. On 11/03/22, the DON and Staff Development Coordinator (SDC) Nurse audited all NAs and nurses, including agency NAs and nurses, to assure they could access the Kardex and knew how to find the transfer status of the resident. The results included: All NAs and nurses, including agency NAs and nurses, were competent with using the Kardex. On 11/03/22, the DON interviewed NAs and nurses for incidents of refusal to follow the designated transfer status indicated on the Kardex/care plan. The results included: Resident #2 was the only resident refusing to use the mechanical lift and the resident's Kardex/care plan was updated to reflect resident's refusal of the mechanical lift. 3. On 11/03/22, the DON began in services on all NAs and nurses, including agency NAs and nurses, on following the resident care plan/intervention process. This training will include all current above staff including agency. This training included: accessing the Kardex prior to initiating care of transferring a resident, resident refusal to follow the identified transfer status and notification of the nurse before transferring the resident and how to access the Kardex. 4. As of 11/08/22, 100% staff members have attended the in-service. The DON will ensure that any of the above identified staff who did not complete the in service training by 11/08/22 will not be allowed to work until training was completed. The DON/designee will observe 5 resident transfers on various shifts/days of the week to include weekends, weekly for 2 weeks and monthly for 3 months or until resolved for compliance with following the Kardex/care plan. Reports will be presented to the weekly Quality Assurance (QA) Committee by the Administrator or DON to ensure corrective action initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA meeting. The weekly QA meeting was attended by the Administrator, DON , MDS Coordinator, Therapy, and the Dietary manager. Validation of the corrective action was completed on 11/02/23. This included staff interviews regarding transferring residents according to their Kardex/care plan and to report to nurse if a resident refused to be transferred according to their Kardex/care plan to ensure understanding and knowledge of the training provided. An interview with Resident #2 revealed she understood the use of the mechanical lift for her transfers was for her safety, and Resident #2's care plan was updated to reflect refusal of mechanical lift for transfers. The audits were verified and there were no concerns identified. The facility's alleged compliance with the corrective action plan on 11/08/22 was validated.

Based on record review and staff and resident interviews, the facility failed to resolve repeat grievances that were reported to the resident council meetings for 3 of 3 months that resident council meetings were held (June 2023, July 2023, and September 2023). Findings included: The June 21, 2023, meeting minutes recorded by the Activity Director indicated concerns were expressed with dietary. The Resident Council stated meals were up to an hour late, were cold when received, and the food was overcooked and hard to chew. The June Grievance log listed no grievance dated 6/21/23 on behalf of the Resident Council related to the concerns expressed at the meeting regarding late meals, cold food and food that was overcooked and hard to chew. The July 31, 2023, meeting minutes recorded by the Activity Director indicated concerns were expressed with dietary. The Resident Council indicated meals were up to an hour late and were cold when received. Meals were served on Styrofoam trays instead of proper dinnerware. The council requested to meet with the Dietary Manager as soon as possible. The July Grievance log listed no grievance dated 7/31/23 on behalf of the Resident Council related to the concerns expressed at the meeting regarding late meals, cold food and meals served on Styrofoam. The August 23, 2023, meeting minutes indicated the meeting was canceled by the facility. The September 26, 2023, meeting minutes recorded by the Activity Director indicated concerns were expressed with dietary. The Resident Council stated meals had no regular schedule and were served very late. The Resident Council expressed that the Resident Council choice meal was of poor quality and meals were frequently served on Styrofoam trays and they did not like it. The September grievance log listed no grievance dated 9/26/23 filed on behalf of the Resident Council related to the concerns expressed at the meeting regarding late meals, poor overall food quality and meals served on Styrofoam trays. The October 18, 2023 meeting minutes indicated the meeting was postponed by the facility. A Resident Council meeting was conducted on 11/1/23 at 10:00 AM with a sample of 5 cognitively intact members of the Resident Council in attendance. The members revealed there was an issue with resolution of grievances regarding food service. The residents in the meeting expressed concern about the food including timeliness and overall quality of the food served. The residents stated they discussed these concerns regarding food in the Resident Council meetings repeatedly and nothing was done. Multiple members of the Resident Council explained for several months they had expressed a variety of concerns regarding food service and had not received a response or resolution to the concerns. The Resident Council president stated concerns regarding dietary service were discussed by the council with the Dietary Manager. The residents expressed that for a long time now the overall quality of the food was poor, and it frequently did not look or taste good. The residents stated they received lots of excuses why there were problems with the food, but ultimately nothing was done to change it. The residents stated breakfast was served as late as 9:30 AM, lunch as late as 2:00 PM and dinner as late as 8:00 PM. The residents indicated lunch was served at 2:00 PM and dinner at 8:00 PM on 10/30/23. The residents stated food was a huge concern, it felt like no one cared when the concerns discussed in Resident Council were not addressed and they were frustrated by this. An interview on 11/1/23 at 12:42 with the Administrator discussed the process for addressing concerns voiced during the resident council meetings. He stated he received the monthly Resident Council Meeting minutes, reviewed them, and initiated grievance forms for concerns expressed in the meetings. The grievance forms were then distributed to the appropriate department manager. Once addressed by the department manager, the forms were returned to the Administrator for his review and to generate a letter detailing the resolution of the grievance. The Administrator revealed he was aware of the food concerns and the timing of the meals expressed repeatedly at the Resident Council meetings. He stated he did not recall filing a formal grievance on behalf of the Resident Council for the concerns expressed at the meetings held in June, July, or September. The Administrator admitted a grievance should have been filed regarding the food concerns with follow-up completed. The Administrator revealed there had been changes in the department managers with the Dietary Manager and Activity Director new in their roles and the Social Worker recently left. These changes contributed to grievances not being filed and addressed. The Administrator stated he thought the Dietary Manager attended the Resident Council meetings to address the residents' food concerns. The Administrator stated there was no formal monitoring of the food issues in place and that each department manager was responsible for addressing the grievances reported during the resident council meetings. Interview with the Dietary Manager on 11/1/23 at 2:50 PM revealed she was aware of the issues with the overall food quality and the times for meal service delivery expressed by the Resident Council, but she had not attended a meeting to address the concerns with the residents. The Dietary Manager stated she had not done any root cause analysis of the problem regarding the food or the meal service times. The Dietary Manager stated there was no auditing in place for monitoring the concerns. A follow-up interview was conducted with the Administrator on 11/2/23 at 4:50 PM regarding the concerns expressed at the Resident Council meeting held on 11/1/23. The Administrator revealed he was responsible for ensuring grievances were addressed but acknowledged there had not been follow-up with the dietary issues expressed at the Resident Council meetings. The Administrator stated he tried to let the Dietary Manager grow in her role, develop leadership and accountability, and address the Resident Council concerns without a formal monitoring plan in place. The Administrator revealed there had been more concerns regarding food recently and he should have implemented measures to address the concerns expressed by the Resident Council members.

Based on observation, record review, resident and staff interviews, the facility failed to ensure food was palatable for 6 of 6 residents (Resident #66, Resident #9, Resident #15, Resident # 45, Resident #55, Resident #30) reviewed for food palatability. Findings included: a). Resident #66 was admitted to the facility on [DATE]. Review of Resident #66's 9/26/23 annual Minimum Data Set (MDS) indicated resident was cognitively intact. Interview on 10/30/23 at 11:53 AM with Resident #66 revealed the food was usually cold, he often could not tell what the meals were, and the food usually did not taste good A follow up interview with Resident #66 on 10/31/23 at 5:45 PM, Resident #66 stated it was frustrating when the food was not palatable. b). Resident #9 was admitted to the facility on [DATE]. Review of Resident #9 ' s 9/18/23 quarterly MDS assessment indicated resident was cognitively intact. Interview with Resident #9 on 10/30/23 at 12:21 PM revealed the food was not prepared good and the meals did not look or taste good. Observation of the lunch meal on 10/30/23 at 2:10 PM revealed Resident #9 was served a patty melt sandwich on bread and a small dish of brussels sprouts in liquid. Resident #9 tasted the sandwich and stated she could not eat it as it did not taste good. Resident # 9 requested the meal tray be removed and proceeded to eat snacks that her family provided. A follow up interview with Resident #9 on 10/31/23 at 5:15 PM revealed she kept snacks in her room and her family brought her meals because the food did not look or taste good. Resident #9 indicated dinner usually did not look or taste good. Resident stated she would really like a good meal. c). Resident #15 was admitted to the facility on [DATE]. Review of Resident #15 ' s 9/22/23 quarterly MDS assessment indicated resident was cognitively intact. Interview with Resident #15 on 10/30/23 at 11:31 AM revealed the food did not taste good or look appetizing. Resident #15 indicated the food was often served cold. A follow up interview with Resident #15 on 10/31/23 at 5:40 PM revealed dinner was served whenever they decided to send it. Resident #15 stated the supper meal on 10/30/23 was a large, greasy turkey wing that was not edible, so she just went to bed without much to eat that night. 37673 d). Resident #45 was admitted to the facility on [DATE]. Review of a quarterly MDS assessment dated [DATE] indicated Resident #45 had intact cognition. In an interview with Resident #45 on 10/30/23 at 12:07 PM she stated the food at the facility was terrible. She commented that she could not eat it. An observation of her room during the interview revealed copious amounts of snacks stored in plastic bins beside her bed and 1/4 of her bed covered with more bags of store bought snacks that had been brought in for her. e). Resident #55 was admitted to the facility on [DATE]. Review of a quarterly MDS assessment for Resident #55 indicated he was cognitively intact. In an interview with Resident #55 on 10/31/23 at 12:05 PM he stated he had the turkey wings the evening before that he thought were fully cooked, but they were cold in the middle and didn't taste very good to him. f). Resident #30 was admitted to the facility on [DATE]. Review of a quarterly assessment dated [DATE] for Resident #30 indicated she had intact cognition. In an interview with Resident #30 on 11/2/23 at 9:05 AM she stated most of the time the food she was served was not warm. She noted the turkey wing she had been served was skin and bone with no meat and she could not eat it. A picture she had taken of the meal was viewed. She stated she had recently been served corn chowder and the carrots in the soup were served whole-they were not sliced or chopped. She also reported she was recently served mashed potatoes that were so cold they had crusted and had to be chipped off and fell off in blocks. She could not eat them. Interview with the Dietary Manager on 11/1/23 at 2:50 PM revealed she had been in the position since April of this year. The Dietary Manager stated she was aware of the issue with the food and the concerns expressed. The Dietary Manager stated she had not done any analysis of the problem regarding the food and there was no auditing in place for monitoring. Interview with the Administrator on 11/2/23 at 4:50 PM revealed he was aware of the residents ' concerns regarding the food but there had not been any follow-up with the dietary issues. The Administrator stated he had tried to let the staff grow in their role and develop leadership and accountability. The Administrator revealed there were more concerns regarding food lately and he should have implemented measures to address the concerns.

Based on observation and staff interviews the facility failed to clean 1 of 3 ice machines used to provide ice for residents (300-400 hall ice machine). The findings include: An observation of an ice machine on 11/02/23 at 11:30 AM located in the nutrition room on the 300-400 hall revealed a black tinged substance located on the silver galvanized linear plate located inside the machine over the ice. This black substance was observed by the Maintenance Director. An interview was conducted on 11/02/23 at 11:35 AM with the Maintenance Director. The Maintenance Director stated the ice machine was last serviced and cleaned by their vendor on 07/18/23. He said nursing staff were supposed to clean out and wipe down the ice machine monthly and sign off on a log that the ice machine was wiped-out and cleaned, which they did not do. The Maintenance Director stated the ice machine needed to be consistently cleaned and sanitized to prevent mold or water borne pathogens from developing. The Maintenance Director stated the blackened substance he observed should not have been present inside the 300-400 hall ice machine with the ice, which could adversely affect the health of residents on the 300 and 400 halls. An interview was conducted on 11/02/23 at 11:40 AM with the Administrator. The Administrator indicated there was no current cleaning schedule log for the 300-400 halls ice machine. He stated the Maintenance Director contacted their outside vendor to perform cleaning and maintenance on the ice machine that day, and that the ice machine was currently shut down until it could be cleaned and sanitized by the vendor.

Based on record review, observations and staff interviews the facility's Quality Assessment and Assurance (QAA) program failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification and complaint investigation survey completed on 7/15/22 and the recertification survey completed on 05/03/21. This was for three repeat deficiencies originally cited in the areas of accuracy of assessments (F641), Label/Store Drugs and Biologicals (F761), and Food Procurement, Store/Prepare/Serve - Sanitary (F812). The continued failure during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective QA program. Findings included: This tag is cross-referenced to: F641: Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of 1) nutritional status (Resident #66), 2) skin conditions (Resident #88), and 3) urinary continence (Resident #86) for 3 of 26 residents whose MDS assessments were reviewed. During the recertification and complaint investigation survey of 7/15/22 the facility failed to accurately code the Minimum Data Set (MDS) in the area of activities of daily living assistance. During the recertification and complaint investigation survey of 05/03/21 the facility failed to accurately code the quarterly Minimum Data Set (MDS) assessments in the areas of prognosis, falls, wander/elopement alarm, and medications. F761: Based on observation and staff interview the facility failed to discard expired bottles of medication that were stored in the Rehab medication cart for 1 of 3 medication carts inspected. During the recertification and complaint investigation survey of 05/03/21 the facility failed to report an equipment failure of a medication dispensing machine and dispose of expired medications. F812: Based on observation and staff interviews the facility failed to clean 1 of 3 ice machines used to provide ice for residents (300-400 hall ice machine). During the recertification and complaint investigation survey of 05/03/21 the facility failed to replace abraded bowls, to remove grease and filters above the stove/oven system, label unopened food, discard compromised pans and remove stains from coffee mugs. In an interview with the Administrator on 11/02/23 at 4:07 PM he stated he thought the previous plans of correction failed due to a lack of communication and a lack of auditing for correctness. He noted both of these aspects would be implemented in the new plans of correction. He also noted he would be consulting other sister facilities for plan of correction ideas.

Based on observations, record review and staff, resident and physician interviews, the facility failed to provide evening snacks to diabetics and non-diabetics and failed to provide residents with lunch and dinner meals according to the meal schedule comparable to normal mealtimes in the community for 4 of 4 halls observed for dining causing residents (Resident #55, #1, #34, #12, # 46, #30 #45, #332, #6, #33, #9, and #66) to complain of feeling hungry. Findings included: A meal schedule was provided on 10/30/23 with meal delivery times recorded as scheduled in 10 minute intervals for the 4 different halls (100 Hall, 200 Hall, 300 Hall and 400 Hall). Breakfast schedule serving times were ranged from 7:30 AM - 8:10 AM Lunch schedule serving times were ranged from 12:00 PM - 12:50 PM Dinner schedule serving time were ranged from 5:30 PM - 6:10 PM 1. a.) Resident #55 was admitted to the facility on [DATE]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #55 documented he had intact cognition. In an interview with Resident #55 on 10/31/23 at 12:05 PM, he stated the night before (10/30/23) dinner did not come until 7:45 PM and he was very hungry. He stated he does not receive a snack at bedtime and he was not offered one. b.) Resident #1 was most recently admitted to the facility on [DATE]. Review of a quarterly MDS assessment dated [DATE] for Resident #1 documented she had intact cognition. In an interview with Resident #1 on 11/02/23 at 8:47 AM, she stated the evening meal was usually late and she got hungry. Resident #1 reported she was a diabetic and did not get a snack at bedtime and was not offered one. Resident #1 stated she felt she needed a snack at bedtime because of her diabetes. c.) Resident #34 was most recently admitted to the facility on [DATE]. Review of a quarterly MDS assessment dated [DATE] documented Resident #34 had intact cognition. In an interview with Resident #34 on 11/02/23 at 8:52 AM, she stated lunch and supper were usually late and she got hungry waiting for the meals to arrive. Resident #34 reported she was a diabetic and was not offered or provided a snack at bedtime. d.) Resident #12 was most recently admitted to the facility on [DATE]. Review of an annual MDS assessment dated [DATE] for Resident #12 documented she had intact cognition. In an interview with Resident #12 on 11/02/23 at 8:55 AM, she stated she got a snack at bedtime if she asked for one but staff did not always come around so she could ask and therefore she doesn't receive a snack. Resident #12 stated she does get hungry waiting for supper because it comes so late in the evening. e.) Resident #46 was most recently admitted to the facility on [DATE]. Review of a quarterly MDS assessment dated [DATE] for Resident #46 documented he had intact cognition. In an interview with Resident #46 on 11/02/23 at 9:01 AM, he stated his meals come very late in the evening and his stomach [NAME] with hunger. He reported he only got a snack at bedtime if he asked for one. f.) Resident #30 was most recently admitted to the facility on [DATE]. Review of a quarterly MDS assessment dated [DATE] for Resident #30 documented she had intact cognition. In an interview with Resident #30 on 11/02/23 at 9:10 AM, she reported most of the time the food was served late. Resident #30 commented that she got hungry between meals and she did not receive a snack at bedtime and she was not offered one. g.) Resident #45 was admitted to the facility on [DATE]. Review of quarterly MDS assessment dated [DATE] for Resident #45 documented she had intact cognition. In an interview with Resident #45 on 11/02/23 at 11:00 AM with Resident #45, she stated the food was served late and she did not receive a snack at bedtime. In an interview with the Dietary Manager on 10/31/23 at 2:25 PM, she stated she had been working at the facility since the middle of April 2023. She stated the kitchen started plating food at 8:00 AM, 12:00 PM and 5:00 PM. She reported she did not keep a log of when meal trays left the kitchen. She commented that she had discussed with the residents about mealtimes and let them know she was working on getting the meal trays out on time. She stated the kitchen did not pass out snacks and that snacks were kept in the nourishment station and the nurse aides were supposed to let the kitchen know if the snacks needed to be replenished. The Dietary Manager added, the kitchen staff did not monitor the nourishment rooms and the kitchen staff did not prepare or provide individually labeled bedtime snacks for diabetics. 32968 2. a) Resident #332 was admitted to the facility on [DATE]. MDS assessment revealed Resident #332 was moderately impaired. An interview was conducted on 11/01/23 at 8:20 AM with Dietary Cook #3. When asked about evening snacks, who offered or prepared them, and which halls received them, the cook said he was not sure about snacks and who provided them. He said as far as he knew the kitchen staff did not provide evening snacks to the nurses for residents who were diabetics. An interview was conducted on 11/01/23 at 11:40 AM with Nurse #3. Nurse #3 stated the meals were always delivered late, with an example of 10/30/23 dinner trays arriving on the 300 and 400 halls close to 8:00 PM. The nurse said up to that point she had been passing out crackers to hungry residents right and left. She said the 300 and 400 halls did not offer or provide diabetic residents with specific labeled evening snacks. An interview was conducted on 11/01/23 at 11:45 AM with Medication Technician (MT) #1. She said they did not offer or provide snacks like a sandwich. She said she usually passed out crackers when meals were late, which was usually all the time. An interview was conducted on 11/01/23 at 11:50 AM with Physician #2. The Physician said the standard of care was that meals be delivered on time, which was important for diabetic residents. He also said it was important for evening snacks to be offered and provided to diabetics. An interview was conducted on 11/02/23 at 12:15 PM with Resident #332's family member. The family member stated on 11/01/23 she was with Resident #332 all day and evening. She said at no time during that time did staff offer Resident #332 any snacks. The family member stated the resident had a history of diabetes and should have been offered or given an evening snack. She indicated that she had asked staff several times for a bedtime snack to be given to the resident, and still no snacks had been offered or given to the resident. An interview was conducted on 11/01/23 at 2:25 PM with the Dietary Manager (DM). The DM said she did not have a list of bedtime (HS) snacks available for all residents that were to receive a diabetic specific snack. The DM said they were not preparing or labeling any HS snacks for diabetic residents or non-diabetic residents. An interview on 11/01/23 at 8:25 AM with the Administrator who stated his expectation was that all residents be offered HS snacks, and that the diabetic snacks should be labeled resident specific per their need. 35173 3. During the initial tour on 10/30/23 at 11:30 AM, Resident #6 and Resident #33 reported that lunch and dinner were always late. Resident #6 and #33 stated lunch would arrive more often than not around 2:00 PM and dinner would arrive around 7:30 - 8:00 PM. Resident #33 stated it was a long time between meals and by the time the meals arrived she was hungry. An interview was conducted with Nurse Aide (NA) #9 who was assigned to the 200 hall on 10/30/23 at 12:50 PM. NA #9 was asked when the meal trays were typically delivered to the hall. He stated that the lunch meal trays were sometimes on time and arrived around 12:30 to 12:45 and sometimes were later and added, I guess it depends on the what they are cooking. NA #9 stated sometimes the residents would complain when lunch was served late. An interview was conducted with Nurse #8 on 10/30/23 at 12: 17 PM. Nurse #8 reported she worked from 7:00 AM to 7:00 PM. She stated the meal trays were getting passed out to the residents later and later every day. She stated the breakfast meal was not served until 9:00 AM this morning and it should be on the 200 hall between 7:45 and 8:15 AM. She stated the lunch meal was not served until 2:00 PM on 10/29/23 and the residents did not receive their dinner tray until after 7:00 PM on 10/29/23. Nurse #8 stated she believed it has been brought to the management's attention by the residents via formal written complaints. Nurse #8 stated residents have complained to her about the meal trays being so late and she had reported the issue to the Director of Nursing (DON) who no longer worked at the facility. An observation of the lunch meal was conducted on 10/30/23 starting at 12:45 PM on the 200 hall. The lunch tray meal cart arrived on the 200 hall (rooms 201 - 212) at 1:28 PM and the second meal cart arrived on the 200 hall (rooms 214 - 220) at 2:00 PM. This hall was the last scheduled hall to receive lunch meal trays. a.) Resident #6 was admitted to the facility on [DATE]. The MDS quarterly assessment dated [DATE] revealed Resident #6 was cognitively intact. An interview was conducted with Resident #6 on 10/30/23 at 2:10 PM. While interviewing Resident #6 her lunch meal tray arrived in her room. Resident #6 stated she was hungry and was happy lunch had finally arrived. Resident #6 added, I don't eat a lot but I'm hungry! A follow up interview was conducted with Resident #6 on 10/31/23 at 9:40 AM. Resident #6 reported she did not get her dinner tray until close to 8:00 PM on 10/30/23. She stated she ate what she could but it was an enormous turkey wing and it was not very good. b.) Resident #33 was admitted to the facility on [DATE]. The MDS quarterly assessment dated [DATE] revealed Resident #33 was cognitively intact. An interview was conducted with Resident #33 on 10/30/23 at 2:35 PM. Resident #33 was eating her lunch upon arrival to her room. Resident #33 stated I was starving and it was about time the lunch tray arrived. She stated she received her lunch tray at 2:15 PM. Upon arrival to the kitchen for a dinner observation, an interview was conducted with the Dietary Manager (DM) at 5:05 PM. The meal schedule was reviewed with the DM at this time and she reported the first cart should be out to the dining room by 5:15 PM and the second meal cart should be on the 100 hall by 5:30 PM. The DM affirmed the 100 hall tray cart would be on the floor by 5:30 PM. An observation of the kitchen staff while preparing the dinner meal was conducted starting at 5:05 PM on 10/31/23. Upon arrival to the kitchen, there was noted to be 4 staff in the kitchen to include the Dietary Manager (DM), the cook, and two dietary aides (DA). The steam table was not prepared with any food at this time and the cook was noted to be mixing the cooked entree which was beef stroganoff with sour cream and placing it back in the oven at 5:10 PM. The DAs were noted to be preparing the beverages at 5:20 PM and the DM had just started preparing the baked bananas for dessert at 5:20 PM. At 5:25 PM, the cook began to prep the steam table with the entree and mixed vegetables and checked the food temperatures. All the food was prepared and on the steam table with temperatures checked by 5:45 PM. The tray line had begun to start and the first cart was sent to the dining room at 6:00 PM. A follow up interview with the Dietary Manager on 10/31/23 at 6:00 PM revealed she did not know why they were so late serving the meal trays this evening. She stated the cook started at 1:00 PM and some meals were harder to prepare than others. When asked if this was a difficult meal to prepare she stated, No it was not. When asked why she supposed she got behind with getting the meal trays out on time, she replied, I will have to get back to you on that. A follow up interview was conducted with Resident #33 on 11/01/23 at 10:18 AM. Resident #33 reported she did not get her dinner meal tray until close to 7:00 PM on 10/31/23. She added, I was hungry and this is ridiculous, having to wait so long for our dinner. A follow up interview was conducted with the DM along with the cook on 11/01/23 at 11:00 AM when asked why they thought the cook was not ready on time to get the dinner trays out to the 100 hall by 5:30 PM, the DM stated the staff was trying to meet the times on the schedule and we were doing the best we could. The DM stated she did not need more staff but she could not definitively say why the lunch and dinner trays were being served late. The cook stated she was doing the best she could. An interview was conducted with the Administrator on 11/01/23 at 12:37 PM. The Administrator stated the time frame schedule for meals that was provided was in place for the previous Dietary Manager and there was no reason why the current Dietary Manager could not follow the same meal schedule. The Administrator stated he has had a performance improvement plan (PIP) in place with the Dietary Manager due to her poor time management for the last two weeks and will continue for another two weeks. He stated he has seen no improvement since the PIP was put in place. The Administrator stated he agreed that 2:00 PM for lunch being served and 8:00 PM for dinner was pushing it and was a little late. The Administrator added he was made aware that the meals were being served late by various residents as he walked the halls. He stated there were no formal grievances filed regarding meals being late, but there were some concerns from the Resident Council Meeting and that was when he put a PIP in place for the DM to include improvement with timeliness of meals, leadership, holding staff accountable, addressing issues timely, and engaging the dietary staff to help instead of the DM doing it all herself. 45711 4. a.) Resident #9 was admitted to the facility on [DATE]. Review of Resident #9's 09/18/23 quarterly MDS assessment revealed Resident #9 was cognitively intact. An observation on 10/30/23 at 2:00 PM revealed the meal trays arrived on the hall for the top of the 200 Hall, the last scheduled hall to receive lunch meal trays. An interview with Resident #9 on 10/31/23 at 5:15 PM revealed Resident #9 ate her meals in her room on the 200 Hall. Resident #9 stated meals were frequently served late and were served whenever the kitchen decided to send them. Resident #9 stated there was supposed to be a schedule for meals, but they did not follow it. Resident #9 stated breakfast was frequently served as late as 9:30 AM, lunch frequently served as late as 2:00 PM and dinner frequently served as late as 8:00 PM. Resident #9 also stated no snacks were offered during the day or at night and she was often hungry between meals. b.) Resident #66 was admitted to the facility on [DATE]. Review of Resident #66's 10/08/23 annual MDS assessment revealed Resident #66 was cognitively intact. An interview with Resident #66 on 10/31/23 at 5:45 PM revealed he ate meals in his room on the 200 Hall. Resident #66 stated meals were frequently late, and he was so hungry by the time dinner was served. Resident #66 stated it was frustrating. An interview with the Dietary Manager on 11/01/23 at 2:50 PM revealed she had been in the position since April of this year. The Dietary Manager stated she was aware of the issue with meals served late and the concerns expressed by the resident council. The Dietary Manager indicated the lunch meal was served late on 10/30/23 due to the cook did not properly preparing the sandwiches that were to be served and she had to start the meal over. The Dietary Manager further stated there was a [NAME] effect since the lunch meal was late then the dinner was also late. The Dietary Manager reviewed the meal schedule that was provided to the survey team and stated she had not seen this schedule before. She later stated she might have seen a copy of the meal schedule posted in the kitchen, but she was not sure of this. The Dietary Manager stated she had not done any analysis of the problem regarding the meals being served late and there was no auditing in place for monitoring meal service times. An interview on 11/01/23 at 12:42 PM with the Administrator revealed he was aware of a problem in the facility with meals frequently served late and this was reported by the residents and the staff. The Administrator stated he reviewed the meal schedule with the Dietary Manager and discussed adhering to the schedule. The Administrator further stated there was no auditing or monitoring in place to track the adherence to the meal schedule.

Based on record review and the Administrator's interview, the facility failed to prevent a staff member from taking personal property from a resident's room (Resident #85) for 1 of 1 residents reviewed for misappropriation of property. Findings included: Resident #85 was admitted to the facility on [DATE] and discharged on [DATE]. Admitting diagnoses included, in part, non-displaced fracture of left radius and fracture of nasal bones. The Minimum Data Set admission assessment dated [DATE] revealed Resident #85 was cognitively intact. Resident #85's hearing and vision were adequate and he required limited assistance with one staff physical assistance with activities of daily living. An initial allegation report dated 08/07/23 was completed by the Administrator. The incident type was misappropriation of property. The facility became aware of the misappropriation of Resident #85's missing wallet at 1:45 PM. A summary of the allegation revealed Resident #85 stated a man came in his room and the resident woke up to see he was going through his bedside drawer. Resident #85 asked the man to give him his call light, and shortly thereafter, he noticed his wallet missing. Resident was upset with having to cancel his credit cards. The report was sent to the state agency on 08/07/23 at 3:27 PM. The investigation report was completed by the Administrator on 08/10/23 and submitted to the state agency at 4:09 PM. A summary of the allegation details revealed the following: Resident #85 was at the facility for short term rehabilitation from a fall and fracture. Resident #85 stated a tall man came in his room and he woke to find him going through his bedside table, he asked what he was doing. The aide stated he was looking for a cord. After the aide left, Resident #85 checked his drawer and his wallet was missing. He called the nurse and the nurse notified the Administrator. Review of the cameras identified Nursing Aide (NA) #8 entering Resident #85's room at 12:07 PM and departing the resident's room at 12:09 PM. NA #8 was asked to go to the Administrator's office and police were notified. NA #8 left the Administrator's office to use the men's room in the main lobby near the Administrator's office. The police arrived minutes later and NA #8 returned to the Administrator's office where an interview was conducted. NA #8 denied the theft and was asked to leave the facility. The officer and the Administrator interviewed Resident #85 and when they returned to the front lobby, they searched the men's room and found the toilet to be overflowing. Housekeeping was notified to unclog the toilet and were able to recover four credit cards, a driver's license, membership warehouse card, an insurance card, and boater's registration belonging to Resident #85. Resident #85 stated he had about $50.00 in cash in his wallet. Resident #85 canceled his credit cards. Adult Protective Services was notified and video footage and pictures of evidence were uploaded to the police department evidence share site. The agency NA #8 was employed with was notified of the allegation and subsequent findings. After the investigation, witness (Resident #85) statement and review of cameras, and finding items discarded in the restroom, it was reasonable to conclude NA #8 stole Resident #85's wallet. Review of the North Carolina Nurse Aide Registry for NA #8 revealed the staff member had no criminal record to speak of. He had a misdemeanor in 2001 for writing bad checks on 11/23/2001 and 12/23/2001. The facility provided the abuse policy to include misappropriation of property which was noted to have NA #8's signature to indicate it was reviewed and dated on 04/26/23 by NA #8. A phone interview was attempted with NA #8 on 10/31/23 at 4:35 PM. NA #8 did not return call. An interview was conducted with the Administrator on 11/01/23 at 2:57 PM. The Administrator stated NA #8 was assigned to the assisted living side of the facility. The Administrator stated NA #8 informed him that he was going over to the skilled nursing side to get a mechanical lift. The Administrator stated when he reviewed the cameras, he watched NA #8 go down the hall that Resident #85 resided on, but he did not seem to be looking for a mechanical lift. He stated he saw NA #8 go into Resident #85's room and come out. The Administrator stated he asked NA #8 to come to his office and while we were waiting for the police to arrive, NA #8 asked to use the men's room. While NA #8 was in the rest room, the officer arrived. The officer searched NA #8 and he found a couple of dollars on him, but that was all. The Administrator stated NA #8 denied taking Resident #85's wallet and was sent home. The Administrator stated the officer wanted to check the men's room NA #8 used and we found the toilet was overflowing. The Housekeeping Director was notified and started snaking (using a long thin drain cleaning tool) the toilet and little by little one of Resident #85's items would come out after another. The Administrator stated he notified the officer and sent pictures of what was retrieved from the toilet for evidence. The Administrator stated no wallet or cash was found but we retrieved everything else. The Administrator stated NA #8 was an agency nurse aide and had received orientation regarding the long term abuse policy and procedure when he began working at the facility. The Administrator stated the investigation was still in process with the Police Department and he did not know the outcome of the investigation at this time.

Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of 1) nutritional status (Resident #66), 2) skin conditions (Resident #88), and 3) urinary continence (Resident #86) for 3 of 26 residents whose MDS assessments were reviewed. Findings included: 1). Resident #66 was admitted to the facility on [DATE] with diagnosis which included in part: stroke with hemiparesis, dysphagia (swallowing difficulty), congestive heart failure, and diabetes. Review of Resident #66's electronic health record revealed a 1/28/22 physician order for low concentrated sweets diet regular texture with thin consistency liquids. Review of Resident #66's progress notes revealed a 8/16/23 registered dietician note, which indicated resident received a low concentrated sweets diet with double portions and had significant weight gain in the past 180 days. Review of Resident #66's weight summary indicated: 9/22/2023 210.0 8/2/2023 205.2 7/13/2023 201.0 6/1/2023 194.8 5/18/2023 188.6 4/7/2023 189.2 3/29/2023 187.2 2/10/23 185.2 Review of Resident #66's 9/26/23 annual Minimum Data Set (MDS) indicated resident was cognitively intact, required supervision with eating. The Nutritional Status section of the MDS indicated Resident #66 had no swallowing or chewing difficulty, had a weight of 210 pounds and did not have a 10 percent weight gain in the last 180 days. Therapeutic diet was not coded in the nutritional approaches section of the MDS. Interview with the MDS Nurse on 11/2/23 at 12:51 PM revealed Resident #66 received a low concentrated sweets diet which was classified as a therapeutic diet per the Resident Assessment Instrument manual. The MDS Nurse reviewed Resident #66's weights and indicated the resident had a significant weight gain in the past 6 months and this should have been coded on the 9/26/23 annual MDS assessment. The MDS Nurse stated the weight change and diet were coded incorrectly. The MDS Nurse further stated that she had been in the position for about a year and was still learning and sometimes she completed the nutritional section of the MDS and sometimes the Dietary Manager completed it. Interview with the Administrator on 11/2/23 at 4:50 PM revealed he expected the MDS assessments would be accurate, and that further education and monitoring was needed to ensure this. 2). Resident #88 was admitted to the facility on [DATE] with diagnoses which included: influenza, emphysema, congestive heart failure, and dementia. Review of Resident #88's electronic medical record revealed the following physician orders dated 12/2/22: - Vashe Wound Therapy Solution (antimicrobial wound cleanser) apply to Left iliac crest topically every day and night shift for pressure injury stage 4. Cleanse wound with Vashe solution, moisten plain packing strips with Vashe solution and insert moistened strips loosely into the wound tunnel. Cover with an abdominal pad and secure with cloth tape. - Apply Vashe Wound Therapy Solution (antimicrobial cleansing solution) to sacral topically every day and evening shift for Pressure Injury Stage 4. Cleanse wound with Vashe moistened gauze, moisten rolled gauze with Vashe and insert into wound including undermined area at 6 o'clock margin. Cover with gauze, abdominal pad, then secure with cloth tape. Review of Resident #88's progress notes revealed a 12/5/22 Nursing Review note which indicated resident had wounds to the buttocks and ischial crest. Resident #88's 12/5/22 admission MDS assessment indicated resident had severe cognitive impairment, required extensive assistance with bed mobility and transfers and had 1 unhealed Stage 4 pressure ulcer present on admission. Review of a Weekly Pressure Ulcer Review assessment signed on 12/13/22 indicated Wound #1 was assessed as a Stage 4 pressure ulcer to the left iliac crest with an onset date of 12/2/22. Review of a Weekly Pressure Ulcer Review assessment signed on 12/13/22 indicated Wound #2 was assessed as a Stage 4 pressure ulcer to the sacrum with an onset date of 12/2/22. Interview on 11/1/23 at 11:05 AM with the Wound Care Nurse revealed Resident #88 had 2 Stage 4 pressure ulcers present on admission. The Wound Care Nurse indicated Resident #88 had a Stage 4 pressure ulcer to the left iliac crest and a Stage 4 pressure ulcer to the sacrum on admission. Interview with MDS Nurse on 11/2/23 at 12:51 PM revealed she had been in the position for the past year. The MDS Nurse acknowledged that Resident #88 had 2 pressure ulcers noted on admission and the MDS should have been coded as 2 pressure ulcers instead of 1. The MDS Nurse did not know why the 12/5/22 admission MDS was coded as 1 pressure ulcer instead of 2, other than human error. Interview with the Administrator on 11/2/23 at 4:50 PM revealed he expected the MDS assessments would be accurate, and that further education and monitoring was needed to ensure this. 37673 3) Resident #86 was admitted to the facility on [DATE] and discharged on [DATE]. Review of a quarterly MDS assessment dated [DATE] documented Resident #86 had an indwelling urinary catheter and was occasionally incontinent of urine. In an interview with the MDS Nurse on 11/2/23 at 3:30 PM she stated urinary incontinence should have been coded not rated because the resident had a catheter. She noted this field in the assessment was auto populated from the aide charting and was incorrect. She explained she should have noticed it was incorrect and changed the answer to not rated. She said she simply missed it, and it was a coding error. In an interview with the Administrator on 11/02/23 at 4:07 PM he stated he expected the information in the MDS assessments to be accurate.

Based on observation and staff interview the facility failed to discard expired bottles of medication that were stored in the Rehab medication cart for 1 of 3 medication carts inspected. Findings included: The Rehab medication cart was inspected on 11/02/23 at 9:25 AM with the Director of Nursing present and was found to have the following expired medications on the cart: 1. [NAME]-Vite supplement that had expired 10/23. 2. Sodium Chloride 1 gram that had expired 9/23. 3. Aspirin 325mg that had expired 10/23. 4. Travel Ease Meclizine 25mg that had expired 9/23. 5. Gas Relief 180 mg (Smethicone) that had expired 9/23. 6. Zinc 50 mg that had expired 10/23. In an interview with the Director of Nursing on 11/02/23 at 9:30 AM she stated the cart had been inspected on 10/30/23 by a Medication Tech and nurse. She had expected any expired medications to be removed from the cart and destroyed.

Based on staff interviews, Hospice staff interviews and record review the facility failed to maintain communication and coordination of services provided by Hospice in the medical record for 1 of 1 resident reviewed for Hospice services (Resident #70). The findings included: Resident #70 was admitted to the facility on [DATE]. His diagnosis included cerebral infarction, hypertension, tachycardia, neurogenic bowel, and anemia. A Weekly Hospice note dated 08/04/23 for Resident #70 revealed Hospice Nurse (SN) visit for facility patient with diagnosis of hemiplegia following cerebral infarct affecting left side. Upon visit, the patient is in bed with head elevated. He is nonverbal and contracted in all extremities, with no signs or symptoms of pain or distress. He does blink and occasionally will track with his eyes when spoken to. He is frail and his skin is fragile and has an air mattress in use. Foam boots on feet. His trach is intact, with clear frothy sputum noted on gown, with tube feeding infusing, and his urine catheter was in place with yellow mucous urine in tubing. The patient's safety was maintained, and Activities for Daily Living (ADLs) were provided by facility staff and Hospice Aide (HA). A review of Resident #70's Quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #70 was severely cognitively impaired and needed total assistance with activities for daily living (ADLs). A review of Resident #70's care plan dated 09/15/23 identified Resident #70 had a progressive decline, and Hospice care was provided due to progressive decline. The resident had a tracheostomy with risk for complications including decreased oxygenation, infection, nutritional imbalance, and decreased ability to communicate due to respiratory distress, and was receiving Hospice services related to terminal condition. A review of Resident #70's Electronic Medical Record (EMR) from 08/04/23 through 11/01/23 revealed no documentation or evidence of Hospice services. The last documented Hospice note for Resident #70 was dated 08/04/23. An interview on 11/02/23 at 1:40 PM with the Director of Nursing (DON) revealed that it was her expectation that Hospice should have communicated more fully to facility staff as well as provided Hospice Nurse's complete visit documentation prior to leaving the facility and did not. She said Hospice failed, per their Hospice agreement dated 01/01/2016, to communicate and coordinate of services provided by facility personnel and Hospice personnel and the providing of Hospice services 24-hours per day. And failed to provide Resident #70's Hospice information from Hospice to the facility, which included resident assessments, vital signs, medications, care plan updates, physician order updates or notifications, discussions with facility nursing staff, nursing notes, and Hospice physician orders. The DON said it was her expectation that there be a complete verbal and paper communication process between Hospice and her nursing staff, and there was not. An interview on 11/02/23 at 1:45 PM with the facility Administrator revealed that it was expectation that the Hospice Nurse follow the Nursing Facility Hospice Services Agreement dated 01/01/2016 to provide information from Hospice to the facility to include: The Hospice Patient Care Coordinator will coordinate all aspects of patient care by assuring an adequate exchange of information and facilitating communication and interaction among the Inter Disciplinary Group (IDG) and family, and Nursing Facility personnel. The Administrator revealed that the facility and their Hospice provider failed to communicate or share Resident #70's documentation with facility's nursing staff, which was not available to facility staff on a 24-hour basis per Hospice agreement. An interview was conducted on 11/02/23 at 1:50 PM with Nurse #7 (Hospice Nurse). She stated the resident was visited weekly by her and 3-times per week by a Hospice Aide. She stated the resident was being well cared for by her and the facility's nursing staff. And if further assistance was needed, the facility could reach her 24/7 by phone. The Hospice nurse revealed that not all her notes or complete Hospice documentation had been provided to the facility to scan into their electronic medical record. She said it was her expectation that Resident's #70 complete Hospice medical records be available to facility staff on a 24-hour, 7-days per week, per facility agreement, and were not. The Hospice nurse agreed that a complete communication structure should have been set up (verbal and written form) between the facility and Hospice staff, and present at the facility, and was not. She said she kept most of the resident's orders, assessments, and notes on her computer. It was her expectation, that from now on, she would print off resident #70's complete visit notes, assessments, updated orders, timely for Medical Records to scan them into the facility's EMR system. She said she would also document after each visit, a visit summary electronically and place it in the resident's electronic medical chart, titled Hospice Note. An interview on 11/02/23 at 2:00 PM with Medical Records #1 revealed that it was her expectation that Resident #70's complete Hospice medical records be available to staff on a 24-hour, 7-days per week, per facility agreement, and were not. The Hospice nurse agreed that a complete communication structure should have been set up (verbal and written form) between the facility and Hospice staff, and was present at the facility, and was not.

Based on record review, police report and interviews with the resident, staff and nurse practitioner interview the facility failed to ensure a resident was free of staff to resident physical abuse for 1 of 3 residents reviewed for allegations of abuse (Resident #69). Resident #69 had bruises on her right arm and right forehead as well as a laceration to the bridge of her nose. The findings included: Resident #69 was admitted to the facility on [DATE]. Resident #69 ' s significant change Minimum Data Set assessment dated [DATE] revealed she was assessed as having a moderate cognitive impairment. She was assessed to have adequate hearing, clear speech and was able to make herself understood by others. She had no behaviors during the lookback period. She required extensive assistance with bed mobility and toilet use. Resident #69 was assessed as requiring physical assistance with bathing. Resident #69 ' s care plan dated 3/22/22 revealed no care plan for behaviors. Review of Resident #69 ' s physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Nurse Aide (NA) #2 on 7/13/22 at 10:22 AM who stated she worked with Resident #69 on 6/8/22 and 6/9/22. She stated she is very familiar with Resident #69 and Resident #69 frequently sleeps in her glasses and utilizes a bed rail for transfers and turning. NA #2 reported when she worked with Resident #69 on 6/8/22 she observed no bruising or lacerations on Resident #69. She reported she did not observe Resident #69 on 6/9/22 until lunchtime when she observed the bruising and laceration. Na #2 stated she saw the bruising to Resident #69 ' s forehead and the laceration to the right side of her face. She reported she observed blood on Resident #69 ' s pillow. NA #2 stated the employee with the outside agency was in Resident #69 ' s room when she entered the room. She stated Resident #69 stated that a nurse aide punched her and stated she would teach her a lesson. NA #2 stated she went to get the Unit Manager. She reported the Program of All-Inclusive Care for the Elderly (PACE) employee was in the room and asked Resident #69 if the person who struck her was NA #2. NA #2 stated she heard Resident #69 state she was not the employee who struck her. During an interview with Resident #69 on 7/13/22 at 11:04 AM she stated a nurse aide who worked at the facility hit her in the eyes. She reported the aide was wearing pink pants. Resident #69 stated she has not seen the nurse aide since it occurred. She reported she felt safe since the nurse aide no longer worked in the facility. An interview was conducted with Resident #11 on 7/13/22 at 11:05 who shared a room with Resident #69. She stated she did not see or hear the incident occur. Resident #11 stated she knew it happened because she saw the bruising and laceration on Resident #69 ' s face but did not know any details. During an interview with Nurse Aide (NA) #1 conducted on 7/13/22 at 11:45 AM. She reported she worked with Resident #69 from 3:00 PM until 8:00 PM on 6/8/22. NA #1 stated she did not provide any care to Resident #69. She reported she came in at approximately 3:00 PM and did a quick check on all her assigned residents. NA #1 stated she left the facility and returned at 4:15 PM. She reported when she returned an unnamed resident needed changing. NA #1 stated trays came out at approximately 5:00 PM and she assisted with passing trays. She stated she picked up finished dinner trays and then she changed Resident #11 who shared a room with Resident #69. She reported at approximately 7:30 PM she no longer was assigned Resident #69 ' s room. NA #1 stated she was contacted the next day and informed that Resident #69 specifically pointed her out as the person who struck her. She stated she resigned from the facility when she was questioned about striking Resident #69. She reported she did not strike the resident. NA #1 reported she was asked by the Director of Nursing to write a statement and she agreed. She stated she was arrested prior to writing a statement so it was never done. NA #1 indicated she was charged with felony abuse of an elderly person and has a court date scheduled for 11/17/22. A PACE social work progress note dated 6/9/22 revealed Resident #69 reported NA #1 was assisting her and pulled her right arm and she pulled back. She stated the aide pulled back and struck her with a fist twice in the face. The PACE social worker reported the incident to Adult Protective Services. The PACE social worker was unavailable for interview. Review of a skin review sheet completed by Nurse #3 on 6/9/22 at 12:35 PM revealed bruising on her forehead and right forearm. It also indicated another wound at her right eye and nose area. An interview was conducted with Nurse #3 on 7/14/22 at 2:00 PM who was the assigned nurse on 6/9/22. She stated Resident #69 told her that she was punched in the face. She reported the bridge of Resident #69 ' s face was burgundy and above her right elbow was light blue. Nurse #3 also stated Resident #69 ' s forearm has a light blue bruise which looked like two fingers had been pushed on her forearm. Nurse #3 stated Resident #69 did not give her any additional details. During an interview with the Unit Manager on 7/13/22 at 12:31 PM she stated she worked with Resident #69 on 6/8/22 and the resident did not have any injuries. She reported she did not work with Resident #69 on 6/9/22 and had no knowledge of the injuries. An interview was conducted with Nurse #4 on 7/13/22 at 2:06 PM who stated she worked the night shift on 6/8/22 and she had no knowledge of Resident #69 ' s injuries. She reported Resident #69 was asleep when she began her shift, and the room was dark. The police report dated 6/9/22 revealed a police officer was dispatched to the facility and was informed by Resident #69 that she was assaulted by a nurse aide when she was trying to get her up to get a bath. The police officer charged Nurse Aide #1 with abuse of an elderly person. Review of the facility incident report dated 6/9/22 revealed Resident #69 reported to PACE worker that a staff member punched in the face on the afternoon of 6/8/22. Resident #69 had a bruise on the bridge of her nose with a small laceration on the right bridge of her nose. A smaller bruise was noted on her forehead and a larger bruise on the right forearm. The facility ' s investigation report dated 6/16/22 revealed the allegation of abuse was substantiated. The incident report read in part, The resident stated the NA (nurse aide) grabbed her right arm. The resident pulled back and said to the NA ' don ' t do that, it hurts ' . The resident states the NA balled her fist and hit her twice in the face and told her, ' That would teach her how to treat people ' . The resident identified the alleged employee from a photo and identified the outfit she was [NAME] the day/time frame the incident occurred. Reviewing the camera footage confirmed the alleged perpetrator was wearing what the resident described. Review of a note written by the facility Nurse Practitioner (NP) on 6/9/22 read in part, Patient seen today due to bruising to face and arm. Found to have bruising to mid forehead and hematoma with laceration to bridge of the nose. Drops of dried blood noted to nose as well as glasses to right nose pad and on right side of bridge of nose. Bruising and minor swelling noted to right forearm. An interview was conducted with the facility Nurse NP on 7/13/22 at 11:06 AM who stated there were bruises on Resident #69 ' s face. She reported the bruising was very noticeable on Resident #69 ' s face. The NP stated after her examination she requested x-rays of her right humerus, elbow, wrist, forearm, and hand. She also requested x-rays of nasal bones and paranasal sinuses. All x-rays were negative. An interview with the Director of Nursing (DON) on 7/15/22 at 2:30 PM revealed the facility substantiated abuse due to the consistency of Resident #69 ' s statements through time and the fact the police charged NA #1 with a felony. She further stated review of surveillance camera footage revealed Nurse #2 was wearing pink pants. The DON also stated Resident #69 identified NA #1 by a picture on her Facebook page. The DON stated the surveillance camera footage was not saved. The facility provided a statement written by the Administrator which stated the footage of the incident was not available. The Administrator was notified of immediate jeopardy on 7/13/22 at 5:55 PM. The facility provided the following corrective action plan: F600 · For the resident affected by the deficient practice. All residents are at risk to be affected by the deficient practice. Resident #69 reported to an outside agency on 6/9/22 that she was struck by a Nurse Aide on the evening of 6/8/22. Records from the outside agency revealed Resident stated she was struck twice in the face by the nurse aide. Facility record review revealed Resident #69 had bruising to her face and right arm. She also had a laceration to the right bridge of her nose. Interviews with staff who worked on day shift on 6/8/22 revealed Resident #69 had no bruising or laceration at the end of the day shift. During an interview with the nurse aide who worked with Resident #69 on 6/9/22 she reported Resident #69 had bruising and a laceration on her face. Resident was examined on 6/9/22 by the facility Nurse Practitioner who ordered Resident #69 x-rays of her right arm (hand, wrist, forearm, elbow, upper arm, shoulder). She also requested x-rays of nasal bones and paranasal sinuses. All x-rays were negative. Resident #69 guardian was notified of the injuries and allegation on 6/9/2022. An interview was conducted with the nurse aide who was accused of hitting Resident #69. She stated she resigned from the facility when she was questioned. The nurse aide stated she did not strike Resident #69. She reported she was asked by the Director of Nursing if she would write a statement and she agreed. She stated she was arrested prior to writing a statement so it was never done. The accused nurse aide was charged with felony abuse of an elderly person and has a court date scheduled for 11/17/22. The accused CNA was suspended on 6/9/22 when the facility was made aware of the allegation. The employee remained on suspension until terminated. · Identification of potentially affected residents and corrective actions taken. All residents have the potential to be affected by this deficient practice. On 6/9/22, all current residents were audited by the Nurse Management team for abuse. Alert and oriented residents with a BIMS of 13 or higher were interviewed for abuse by asking the resident if they had been harmed, abused, or threatened in any way. Residents with a BIMS of 12 or less had full body skin assessments completed by the RN Supervisor for signs of abuse or injuries. No new allegations of abuse or injuries were identified. · Systemic Changes Training began on 6/9/22 by the Nurse Administration Team (Assistant Director of Nursing, Staff Development Coordinator and RN Supervisor). This training included all full time, part time, and as needed- all staff including agency staff. This training included: Education topic included abuse and burnout. This included how to prevent abuse, how to identify residents at risk for abuse, how to report suspicion of abuse and how to recognize and avoid burnout. Strategies for how to care for residents who are at high risk due to refusing care was also discussed. The Director of Nursing and Staff Development Coordinator will ensure that any staff who does not complete the in-service training by 6/13/22 will not be allowed to work until the training is completed. ·Quality Assurance (QA) The Director of Nursing or designee will interview and audit a sample of residents for concerns of abuse, neglect, or injury of unknown origin and timely reporting of these areas. The audits will be completed by the Director of Nursing or designee interviewing residents for concerns of abuse and neglect. Non-interview able residents will be assessed for injuries of unknown origin, tearfulness, or withdrawal from activities. QA audits will be completed weekly x 2 weeks then monthly x 3 months. Reports will be presented weekly in QA committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed in the weekly QA Meeting. The QA Meeting is attended by the Administrator, Director of Nursing, Assistant Director of Nursing, Infection Preventionist, Admissions Marketing, Dietary Manager, Maintenance Director, Social Services, Activities Director, Business Office Manager, Minimum Data Set Nurse, Medical Director, and Director of Rehab. Date of corrective action plan completion: 6/13/22 The plan of correction was validated through review of verification of education provided to both residents and staff, a review of the audits and monitoring documentation and quality assurance meeting minutes. Staff interviews verified the education provided. The facility reported the incident of alleged abuse and submitted their investigation. The facility ' s date of compliance of 6/13/22 was verified.

Based on observation, record review and interviews, the facility failed to implement their policy on COVID-19 vaccinations and to meet the requirement for staff vaccination when Dietary Aide (DA) #1, DA #2, and DA #3 worked without being fully vaccinated and without an exemption. This was for 3 of 3 kitchen staff reviewed for vaccinations. The facility was in COVID-19 outbreak status and had 18 residents test positive for COVID-19 since 6/15/22 (Resident #31, Resident #64, Resident #21, Resident#1, Resident #17, Resident #40, Resident #35, Resident #270, Resident #5, Resident #38, Resident #24, Resident #54, Resident #3, Resident #36, Resident #39, Resident #42, Resident #101, Resident #102). Findings included: The facility ' s Covid-19 Staff Vaccination Policy revised 2/2/22 read in part Staff must have the necessary vaccines to be fully vaccinated by February 26, 2022 and newly hired employees and other new staff will also be required to comply with this policy. In order for a person to be hired or eligible to provide services at the facility after 2/26/22, all such individuals must be fully vaccinated or request a medical/religious exception. Proof of vaccination will be required. Under the heading New Hires, the policy stated, Employees will not be allowed to work with residents unless they have either one vaccine or an approved exception. A review of the National Healthcare Safety Network (NHSH) data reported the week of 6/26/2022 indicated 84% of the staff had completed COVID-19 vaccinations and 84% of the staff had completed or was partially COVID-19 vaccinated. A review of the facility ' s surveillance COVID-19 log revealed 18 residents (Resident #31, Resident #64, Resident #21, Resident#1, Resident #17, Resident #40, Resident #35, Resident #270, Resident #5, Resident #38, Resident #24, Resident #54, Resident #3, Resident #36, Resident #39, Resident #42, Resident #101, Resident #102) residing in the facility tested positive for COVID-19 since 6/15/2022. a. A review of the facility ' s COVID-19 Staff Vaccination Status for Providers spreadsheet revealed DA #1 was partially vaccinated and DA #1 received the first dose of a two dose vaccination series on 7/5/2022. The kitchen schedule for dietary employees revealed DA#1 was scheduled to work on 7/9/22, 7/10/22 and 7/12/22 through 7/14/22. An observation and interview were conducted on 7/13/22 at 3:08 PM with DA #1. DA #1 was observed working in the facility ' s kitchen. He stated he started last week and started training after orientation. He stated he worked in the kitchen and had delivered meal carts to resident halls. An interview was conducted with the Corporate Nurse Consultant on 7/13/22 at 3:30 PM and she stated the facility was following their policy for new hires. She stated she thought new employees could work in the facility if they had their first dose of a vaccine as long as they followed personal protective equipment and testing protocols for exempt employees. b. A review of the facility ' s COVID-19 Staff Vaccination Status for Providers spreadsheet revealed DA #3 was partially vaccinated and received the first dose of a two dose vaccination series on 5/23/22. She was scheduled to work 7/7/22, 7/8/22, 7/10/22 and 7/12/22. An interview was conducted with DA #3 on 7/14/22 at 4:00 PM, and she stated she had been working at the facility for approximately 2 weeks. She also stated she received her second shot on 7/14/2022. An interview was conducted with the Corporate Nurse Consultant on 7/13/22 at 3:30 PM and she stated the facility was following their policy for new hires. She stated she thought new employees could work in the facility if they had their first dose of a vaccine as long as they followed personal protective equipment and testing protocols for exempt employees. c. A review of the facility ' s COVID-19 Staff Vaccination Status for Providers spreadsheet revealed DA #2 was partially vaccinated and received the first dose of a two dose vaccination series on 6/28/22. Dietary work schedules revealed DA #2 was scheduled to work 7/7/22, 7/8/22, 7/11/22, and 7/15/22. An interview was conducted with the Corporate Nurse Consultant on 7/13/22 at 3:30 PM and she stated the facility was following their policy for new hires. She stated she thought new employees could work in the facility if they had their first dose of a vaccine as long as they followed personal protective equipment and testing protocols for exempt employees.

Based on record review, observation, and interviews with resident representative and staff, the facility failed to provide effective leadership and oversight to ensure systems and policies were implemented related to COVID-19 staff vaccinations for 3 of 3 dietary staff (Dietary Aide #1, Dietary Aide #2, and Dietary Aide #3), resident vaccinations for 1 of 5 residents (Resident #39), and staff testing for 3 of 3 unvaccinated staff (Nurse #3, Nurse Aide #3 and Housekeeper #1). The facility was in COVID-19 outbreak status and had 18 residents test positive for COVID-19 since 6/15/22 (Resident #31, Resident #64, Resident #21, Resident#1, Resident #17, Resident #40, Resident #35, Resident #270, Resident #5, Resident #38, Resident #24, Resident #54, Resident #3, Resident #36, Resident #39, Resident #42, Resident #101, and Resident #102). Findings included: This tag is cross reference to: F888: Based on observation, record review and interviews, the facility failed to implement their policy on COVID-19 vaccinations and to meet the requirement for staff vaccination when Dietary Aide (DA) #1, DA #2, and DA #3 worked without being fully vaccinated and without an exemption. This was for 3 of 3 kitchen staff reviewed for vaccinations. The facility was in COVID-19 outbreak status and had 18 residents test positive for COVID-19 since 6/15/22 (Resident #31, Resident #64, Resident #21, Resident#1, Resident #17, Resident #40, Resident #35, Resident #270, Resident #5, Resident #38, Resident #24, Resident #54, Resident #3, Resident #36, Resident #39, Resident #42, Resident #101, Resident #102). F887: Based on record review, resident representative interview and staff interviews, the facility failed to ensure residents not up to date with COVID-19 vaccinations were offered the COVID-19 vaccine prior to scheduled COVID-19 clinics and failed to maintain a record of refusal for the COVID-19 vaccine for 1 of 5 residents (Resident #39) reviewed for COVID-19 immunizations. This occurred during a COVID-19 pandemic, and the facility was in outbreak status for COVID-19. F-886: Based on record review and staff interviews, the facility which was located in a county with a high community transmission level and was in an outbreak status for COVID-19 failed to conduct COVID-19 testing per Centers for Medicare and Medicaid guidelines every three days and track documentation of COVID-19 testing twice a week for 3 of 3 COVID-19 unvaccinated staff members (Nurse #3, NA #3 and Housekeeper #1) reviewed for COVID-19 testing. Eighteen residents and eleven staff members tested COVID-19 positive since the outbreak. This occurred during a COVID-19 pandemic. In an interview with the Administrator on 7/15/2022 at 12:25 p.m., he stated the facility used broad based measures in response to the COVID-19 outbreak that began on 6/10/2022. He stated the last positive COVID case was on 6/30/2022 and the facility would remain in outbreak status until fourteen days without new positive cases. In an follow-up interview with Administrator on 7/15/202 at 5:16 p.m., he stated he had not explored into how residents were offered COVID-19 vaccination or the process when residents refused the COVID-19 vaccine and stated all staff were COVID-19 tested because of county's high community transmission level.

Based on record review and staff interviews the facility failed to use the assigned total lift to transfer a resident from a shower chair to the bed, resulting in a left shoulder dislocation and fracture which required surgery for [REDACTED].#41). Findings included: Review of Resident #41's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a readmission date of [DATE] and [DIAGNOSES REDACTED]. Resident #41 was moderately cognitively impaired. Resident #41 needed the extensive assistance of two people for bed mobility and transfers and had no impairment in the functional range of motion in the upper and lower extremities. Resident #41 was alert and able to make her needs known. Resident #41 was not resistant to care. Review of Resident #41's Care Plan revised 06/30/16 revealed the resident was at risk for falls with the goal of not sustaining serious injury over the next 90 days. An Intervention/Task listed to accomplish this goal was to transfer the resident out of bed with a mechanical lift with two staff. USE BLUE SLING. Review of the Health Status Note written by Nurse #1 dated 09/07/16 at 3:43 PM and designated as a Late Entry, revealed Resident #41 had been scheduled to receive a shower on day shift. Nursing Assistant (NA) #1 approached Nurse #1 to request assistance in transferring Resident #41 out of the shower chair after the shower was completed. When Nurse #1 entered Resident #41's room she observed NA #1 attempting to transfer Resident #41 using a sit to stand lift. NA #2, who was in training at that time, was also in the room. Nurse #1 informed NA #1 that Resident #41 required the use of a total lift for transfers. Nurse #1 with the assistance of NA #1 and NA #2 transferred Resident #41 to the bed. Resident #41 was assessed by Nurse #1 and denied pain related to the transfer. Review of the undated and unsigned investigation report showed under Conclusion: It was determined that the involved employee's use of a stand aide lift to transfer the resident on 09/07/16 instead of the assigned total lift (Brand Name) contributed to the resident's injury. Review of the Health Status Note dated 09/09/16 at 11:02 AM and designated as a Late Entry revealed Resident #41 complained of pain to both arms and both legs and knees that morning. According to the note this was a common complaint for Resident #41 although active participation with care using the left arm was noted to be decreased. There was no difference noted in the length of the arms and pain medications were given. Review of the Health Status Note dated 09/10/16 at 6:25 PM revealed Nurse #2 noted increased combativeness with staff during care and appeared to have pain to the left shoulder on movement. Pain medication was administered with good result. Resident #41 had no further complaints of pain for several hours. Later in the shift, Resident #41 was noted to be moaning and verbally complained of pain to the left shoulder during care. Pain medications were again administered with good result. Resident #41 received scheduled narcotic pain medication twice each day and also as needed narcotic pain medications. Review of the Health Status Note dated 09/11/16 at 4:19 AM revealed Nurse #3 noted new swelling to Resident #41's left hand. The arm and hand were elevated on a pillow and pain medication was provided. The pain was relieved and Resident #41 slept for long intervals without complaint of pain. Review of the Health Status Note dated 09/11/16 at 6:51 PM revealed Nurse #2 noted Resident #41 continued to be combative with care. Resident #41 also continued to have pain in the left shoulder on movement. Pain medications were administered with positive results. Resident #41 rested quietly throughout the day with no complaints of pain at rest. Review of the Doctor's Progress Note dated 09/12/16 revealed Resident #41 had been seen by the Family Nurse Practitioner (FNP). The nursing staff had reported that Resident #41 had a cough over the weekend. The note indicated Resident #41 was feeling well and had no complaints. A respiratory assessment was completed. Review of the Health Status Note dated 09/13/16 revealed Resident #41 complained of increased pain to the left shoulder when moved and repositioned. The FNP was notified and an order for [REDACTED]. Review of the Doctor's Progress Notes dated 09/13/16 revealed the FNP had seen Resident #41 for a complaint of severe left shoulder pain. Resident #41 was noted to be yelling when touched. No trauma had been noted. There was decreased range of motion to the left shoulder and a new order for a pain patch and a shoulder x-ray were written. Review of the left shoulder x-Ray report dated 09/13/16 revealed under Impression: Apparent fracture/dislocation type injury. Review of the Health Status Note dated 09/13/16 at 6:35 PM revealed Resident #41's x-ray results were provided to Resident #41's Physician. The Physician requested a visit to the orthopedic clinic for the following morning. Review of the Health Status Note dated 09/14/16 at 11:32 AM revealed Resident #41 had been seen at the orthopedic clinic and was sent to the hospital Emergency Department from there. Resident #41 was admitted to the hospital and required surgery to the left shoulder. Review of the Hospital Discharge Summary dated 09/19/16 revealed a discharge [DIAGNOSES REDACTED]. Resident #41 required surgical intervention to repair the shoulder. Review of the incident investigation provided by the facility revealed they believed Resident #41's shoulder injury had occurred during the transfer with the sit to stand lift. The Nurse, NA #1 and NA #2 had all provided written statements regarding the incident. Review of Nurse #1's written witness statement dated 09/14/16 revealed a sit to stand lift had been used by NA #1 for transfer instead of the appropriate total lift. After putting Resident #41 back to bed complaints of pain to the legs and hips were noted. Complaints of pain were not new for Resident #41. The note indicated there were no further complaints of pain from Resident #41 until 09/09/16 when she complained of pain to the left arm. The note indicated Nurse #1 notified the FNP via the communication book. In an interview on 02/09/17 at 4:05 PM Nurse #1 stated she attempted to help transfer Resident #41 back to bed when she saw the incorrect lift was being used on 09/07/16. She indicated the lift strap was under Resident #41's arms and was pulling on the arms. Nurse #1 stated she and the aides disconnected the lift and physically assisted Resident #41 into bed. She stated NA #1 and NA #2 did not ask her which lift Resident #41 used for transfers. Nurse #1 stated she assessed Resident #41 who complained of generalized pain but nothing specific. She indicated this was normal for Resident #41. There was no notification to the physician or family because no injury was noted at that time. Review of NA #1's written witness statement dated 09/14/16 revealed Resident #41 complained to her of arm pain in the morning so she informed Nurse #1. When NA #1 informed Nurse #1 of Resident #41's pain Nurse #1 told NA #1 that Resident #41 was scheduled for a shower that day and if she needed help with the transfer to let her know. According to the statement, NA #1 asked Nurse #1 which lift to use and was told to use the sit to stand lift. A telephone interview with NA #1 was attempted on 02/09/17 at 11:52 AM. Contact was not possible. Review of NA #2's written witness statement dated 09/21/16 revealed NA #2 was observing NA #1 use the sit to stand lift. According to the statement, another aide whom she could not identify, told them to use the sit to stand lift but the strap of the lift kept sliding up Resident #41's back. Resident #41 complained of pain and Nurse #1 made sure there were no injuries. In an interview on 02/09/17 at 3:40 PM NA #2 verified Resident #41 complained of arm pain after the sit to stand lift was used. She indicated she had been in-serviced on lifts and knew two aides were needed for all the lifts. She stated another aide told them to use the sit to stand lift but could not remember the name of the aide. She indicated she was with NA #1 and she did not check the Kardex to verify which lift to use. In a telephone interview on 02/09/17 at 3:25 PM the FNP stated she had seen Resident #41 on 09/12/16 due to a complaint of cough and congestion. She stated she would have asked the resident about pain and would have addressed the issue at that time if there had been any. She stated she had also seen Resident #41 on 09/13/16 and she did have pain at that time. She confirmed Resident #41 was yelling out and could not stand for the shoulder to be touched and that was why she ordered the x-ray. She indicated she had become upset when she found out there had been an incident with a lift that she was unaware of. In an interview on 02/09/17 at 5:22 PM the Director of Nursing (DON) stated it was her expectation that staff look at the Master Lift List or the Kardex to see which lift and what size sling to use for residents and she expected them to use what was listed. Review of the facility Plan of Action dated 09/15/16 for this incident revealed Resident #41 had been sent to the orthopedic clinic on 09/14/16 for evaluation of the left shoulder and was then transferred to the hospital. On 09/15/16 the management team reviewed all the current resident's most recent reviews for type of lift designation. A master lift list was placed at each nursing station. The Nurse Consultant reviewed all Care Plans to ensure lifts were in place. On 09/15/16 In-servicing began for all Registered Nurses (RN), Licensed Practical Nurses (LPN), Medication Technicians (Med Tech), and NA's who worked full-time, part-time or on as needed basis. The In-servicing included to check the Kardex to make sure the correct lift and correct sling size were used and that 2 assistants were needed to perform a mechanical lift. Staff members who did not receive in-service training after 09/21/16 would not be allowed to work until the training was completed. The in-service training was incorporated into the standard orientation training for nurses, med techs, and NA's. The change was to be reviewed by the Quality Assurance (QA) process to verify it had been maintained. The QA support nurse was to monitor the plan using the QA Tool for Monitoring Transfer Devices weekly for 4 weeks and then monthly for 2 months. 5 transfers were to be observed each time for correct lift and correct technique. The Care Plan for each resident was also to be reviewed. The Action Plan showed in-servicing of staff had been completed by 09/21/16. Master Lift Lists were seen at the nursing stations. Audits were done and in-servicing had been completed for current staff. New hires were receiving lift information during orientation. The plan was in the QA process for the specified amount of monitoring time. In an interview on 02/08/17 at 3:44 PM NA #3, who had recently started working at the facility, stated when a sit to stand lift was used for transfers only one aide was needed. If the total lift was used then two aides were needed. She indicated she received a lot of information during orientation and could not remember if she received a packet on lifts. In an interview on 02/08/17 at 4:55 PM NA #4, who had been employed at the facility for approximately one year, stated a sit to stand lift could be used with only one person but a total lift needed two people. She indicated she received lift training yearly. NA #4 stated a Master Lift List was available at the nurse's desk and should list the size and color of the lift sling.