Every finding on record at Life Care Center of Old Hickory Village

Based on interview and facility document review, the facility failed to implement their infection control and prevention program when all facility staff were not fit-tested for N-95 respirator masks annually as required during the past year per their policy and procedure and per the Centers for Disease Control (CDC). This deficient practice had the potential to affect all 93 residents who resided in the facility. Findings included: A facility policy titled, Area of Focus: Fit Testing, last reviewed by the facility on 12/02/2025, revealed, Fit testing confirms the correct fit of any respirator that forms a tight seal on the user's face. This ensures that users are receiving the expected level of protection by minimizing contaminant leakage into the facepiece. The policy specified, Under 1910.134, fit testing must be performed initially (before the employee is required to wear the respirator in the workplace) and must be repeated at least annually. Fit testing must also be conducted whenever respirator design/type/model or facial changes occur that could affect the proper fit of the respirator. A CDC document titled, Filtering our Confusion: Frequently Asked Questions about Respiratory Protection, Fit Testing, dated April 2018, indicated, The Occupational Safety and health Administration (OSHA) (29 CFR [Code of Federal Regulations] 1910.134) requires an annual respirator fit test to confirm the fit of any respirator that forms a tight seal on the wearer's face before it is used in the workplace. The document further indicated, In addition to fit testing upon initially selecting a model of respirator, OSHA requires that fit testing be con ducted annually, and repeated 'whenever an employee reports, or the employer or the physician or other [NAME] censed health care professional makes visual observations of changes in the employee's physical condition that could affect respirator fit (e.g. [exempli gratia, for example], facial scarring, dental changes, cosmetic surgery, or an obvious change in body weight).' During an interview on 06/25/2026 at 10:40 AM, the Infection Preventionist (IP) stated N-95 fit testing was performed by the Staff Development Coordinator (SDC). During an interview on 06/25/2026 at 11:31 AM, the SDC stated she did not complete N-95 fit testing, and that she knew it was required to be done. The SDC stated she had never had a fit test done. The SDC stated the facility did not have any residents on droplet precautions. The SDC stated that facility staff had not been fit-tested recently. During an interview on 06/25/2026 at 11:44 AM, the Central Supply Director (CSD) stated they had been fit-tested, but not in the last year. The CSD stated the Former IP had completed the fit testing when he worked at the facility. The CSD stated the Former IP had not worked at the facility for about one year. During a telephone interview on 06/25/2026 at 2:02 PM, the Former IP stated he had not worked at the facility for over a year. The Former IP stated he was not sure that anyone was trained to complete N-95 fit testing when he left his role. During an interview on 06/26/2026 at 10:28 AM, the Director of Nursing (DON) stated fit testing for N-95 masks should be completed initially upon hire and once a year as indicated in the facility policy. The DON stated the educator and the IP were responsible for completing the N-95 fit testing. The DON stated she did not know why the N-95 fit testing was not completed. During an interview on 06/26/2026 at 10:41 AM, the Executive Director (ED) stated N-95 fit testing was to make sure that in case of an outbreak staff would have a mask that fits properly. The ED stated he expected N-95 fit testing to be completed. The ED stated the N-95 fit testing would be completed by the IP and the SDC During an interview on 06/26/2026 at 10:54 AM, the IP stated it was her understanding that the SDC had completed the N-95 fit testing. The IP stated N-95 fit testing was important because the masks came in different sizes and was not one size fits all, so the mask needed to fit to be effective.

Based on facility policy review, record review, obserevation and interview the facility failed to ensure the medication error rate was 5 percent (%) or less. The facility had 4 medication errors out of 30 opportunities affecting 4 (Residents #37, #110, #97, and #129) of 4 residents reviewed during the medication administration task, resulting in a medication error rate of 13.33%. Findings included: A facility policy titled, Administration of Medications, revised 05/06/2022, revealed, The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. Resident Assessment. Note the resident's history and any parameters around drug administration. 1. An admission Record revealed the facility admitted Resident #37 on 06/05/2026. According to the admission Record, the resident had a medical history that included diagnoses of essential hypertension and personal history of a transient ischemic attack (TIA) and cerebral infarction without residual effects. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/08/2026, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #37's Order Summary Report, with active orders as of 06/26/2026, revealed an order dated 06/05/2026 for amlodipine besylate oral tablet 5 milligrams (mg) twice a day for hypertension with instructions to hold for systolic blood pressure (SBP) of less than 100 millimeters of mercury (mmHg) or heart rate (HR) less than 60 beats per minute (bpm). An observation of medication administration on 06/26/2026 at 8:49 AM revealed Licensed Practical Nurse (LPN) #1 administered amlodipine besylate to Resident #37. During an interview on 06/26/2026 at 9:00 AM, LPN #1 stated she did not obtain vital signs for Resident #37 prior to administering the resident's amlodipine besylate. LPN #1 stated the resident had vital signs obtained around 5:00 AM each morning, and she was not required to obtain an additional set of vital signs prior to administering the resident's cardiac medications. She stated she was allowed to administer the cardiac medication, which included hold parameters based on vital signs obtained on a previous shift. Resident #37's Medication Administration Record [MAR)] dated 06/2026 revealed LPN #1 documented that she administered 5 mg of amlodipine besylate to Resident #37 on 06/26/2026. The MAR revealed staff documented a blood pressure reading of 114/68 mmHg and a HR of 76 bpm. Resident #37's Blood Pressure Summary revealed staff documented that on 06/26/2026 at 6:30 AM the resident's blood pressure was 114/68 mmHg. Further review revealed that there was no documented blood pressure for 06/26/2026 at 8:49 AM. Resident #37's Pulse Summary revealed staff documented that on 06/26/2026 at 6:30 AM the resident's HR was 76 bmp. Further review revealed there was no documented HR for 06/26/2026 at 8:49 AM. 2. An admission Record revealed the facility admitted Resident #110 on 06/09/2026 with a readmission on [DATE]. According to the admission Record, the resident had a medical history that included a diagnosis of diastolic (congestive) heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/19/2026, revealed Resident #110 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #110's Order Summary Report, with active orders as of 06/26/2026, revealed an order dated 06/17/2026 for carvedilol oral tablet 3.125 milligrams (mg) daily for hypertension with instructions to hold for systolic blood pressure (SBP) of less than 100 millimeters of mercury (mmHg) or heart rate (HR) less than 60 beats per minute (bpm). An observation of medication administration on 06/26/2026 at 8:34 AM revealed Licensed Practical Nurse (LPN) #1 administered carvedilol to Resident #110. During an interview on 06/26/2026 at 9:00 AM, LPN #1 stated she did not obtain vital signs for Resident #110 prior to administering the resident's carvedilol. LPN #1 stated the resident had vital signs obtained around 5:00 AM each morning, and she was not required to obtain an additional set of vital signs prior to administering the resident's cardiac medications. She stated she was allowed to administer the cardiac medication, which included hold parameters based on vital signs obtained on a previous shift. Resident #110's Medication Administration Record [MAR] dated 06/2026 revealed LPN #1 documented that she administered 3.125 mg of carvedilol to Resident #110 on 06/26/2026. The MAR revealed staff documented a blood pressure reading of 147/49 mmHg and a HR of 77 bpm. Resident #110's Blood Pressure Summary revealed staff documented that on 06/25/2026 at 4:30 PM the resident's blood pressure was 147/49 mmHg. Further review revealed that there was no documented blood pressure for 06/26/2026 at 8:34 AM. Resident #110's Pulse Summary revealed staff documented that on 06/25/2026 at 4:30 PM the resident's HR was 77 bpm. 3. An admission Record revealed the facility admitted Resident #97 on 10/04/2024. According to the admission Record, the resident had a medical history that included diagnoses of heart failure and hypertensive heart disease with heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/12/2026, revealed Resident #97 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #97's Order Summary Report, with active orders as of 06/26/2026, revealed an order dated 11/26/2025 for metoprolol tartrate tablet 25 milligrams (mg) twice a day for hypertension with instructions to hold for systolic blood pressure (SBP) of less than 100 millimeters of mercury (mmHg) or heart rate (HR) less than 60 beats per minute (bpm). An observation of medication administration on 06/26/2026 at 8:20 AM revealed Licensed Practical Nurse (LPN) #1 administered metoprolol tartrate to Resident #97. During an interview on 06/26/2026 at 9:00 AM, LPN #1 stated she did not obtain vital signs for Resident #97 prior to administering the resident's metoprolol tartrate. LPN #1 stated the resident had vital signs obtained around 5:00 AM each morning, and she was not required to obtain an additional set of vital signs prior to administering the resident's cardiac medications. She stated she was allowed to administer the cardiac medication, which included hold parameters based on vital signs obtained on a previous shift. Resident #97's Medication Administration Record [MAR], dated 06/2026, revealed LPN #1 documented that she administered 25 mg of metoprolol tartrate to Resident #97 on 06/26/2026. The MAR revealed staff documented a blood pressure reading of 115/77 mmHg. The MAR contained no documented heart rates. Resident #97's Blood Pressure Summary revealed staff documented that the resident's blood pressure was 115/77 mmHg on 06/25/2026 at 4:31 PM. Further review revealed there was no documented blood pressure obtained on 06/26/2026 at 8:20 AM. Resident #97's Pulse Summary revealed staff documented that the resident's HR was 71 bpm on 06/25/2026 at 4:31 PM. 4. An admission Record revealed the facility admitted Resident #129 on 06/16/2026. According to the admission Record, the resident had a medical history that included diagnoses of chronic systolic (congestive) heart failure and essential hypertension. Resident #129's Order Summary Report, with active orders as of 06/26/2026, revealed an order dated 06/16/2026 for losartan potassium tablet 25 milligrams (mg) daily for hypertension with instructions to hold for systolic blood pressure (SBP) of less than 100 millimeters of mercury (mmHg) or heart rate (HR) less than 60 beats per minute (bpm). An observation of medication administration on 06/26/2026 at 8:11 AM revealed Licensed Practical Nurse (LPN) #1 administered losartan potassium to Resident #129. During an interview on 06/26/2026 at 9:00 AM, LPN #1 stated she did not obtain vital signs for Resident #129 prior to administering the resident's losartan potassium. LPN #1 stated the resident had vital signs obtained around 5:00 AM each morning, and she was not required to obtain an additional set of vital signs prior to administering the resident's cardiac medications. She stated she was allowed to administer the cardiac medication, which included hold parameters based on vital signs obtained on a previous shift. Resident #129's Medication Administration Record [(MAR], dated 06/2026, revealed LPN #1 documented that she administered 25 mg of losartan potassium to Resident #129 on 06/26/2026. The MAR revealed staff documented a blood pressure reading of 141/73 mmHg and a HR of 70 bpm. Resident #129's Blood Pressure Summary revealed staff documented that the resident's blood pressure was 141/73 mmHg on 06/26/2026 at 5:05 AM. Further review revealed there was no documented blood pressure obtained on 06/26/2026 at 8:11 AM. Resident #129's Pulse Summary revealed staff documented that the resident's HR was 70 bpm on 06/26/2026 at 5:05 AM. During an interview on 06/26/2026 at 1:52 PM, the Pharmacist stated nurses should obtain vital signs within 30 minutes prior to administering medications that contained hold parameters because residents in the geriatric population could change quickly, which could cause a resident's blood pressure or HR to be too low. During an interview on 06/26/2026 at 1:33 PM, the Medical Director stated she expected nurses to obtain ordered vital signs when administering medications that contained hold parameters. During an interview on 06/26/2026 at 1:55 PM, the Director of Nursing (DON) stated she expected LPN #1 to obtain vital signs immediately before administering any drug with hold parameters. During an interview on 06/26/2026 at 2:32 PM, the Administrator stated he would defer his expectations of medication administration to the DON.

Based on facility policy review, record review, facility document review, and interview, the facility failed to issue a beneficiary notification timely for 1 (Resident #128) of 3 sampled residents reviewed for beneficiary notices. Findings included: A facility policy titled, Notice of Charges, last reviewed by the facility on 04/01/2026, indicated, Notice of Medicare Non-Coverage (NOMNC) The NOMNC, Form CMS-10123, (form), (instructions) is given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The NOMNC informs the beneficiaries of the right to an expedited review by a Quality Improvement Organization. An admission Record indicated the facility admitted Resident #128 on 03/17/2026. The admission Record revealed the resident was discharged from the facility on 04/07/2026. According to the admission Record, the resident had a medical history that included encephalopathy and other speech and language deficits following cerebral infarction. A discharge Minimum Data Set (MDS), with an Assessment Reference Date of 04/07/2026, revealed Resident #128 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #128's Notice of Resident Transfer or Discharge, dated 04/07/2026, indicated, The resident's health has improved sufficiently that the resident no longer needs the services provided by this facility. The notice was signed and dated by the resident's family member on 04/07/2026. Resident #128's Notice of Medicare Non-Coverage indicated that Resident #128's Medicare coverage of services ended on 04/06/2026. Further review revealed a family member signed the form on 04/07/2026. During an interview on 06/23/2026 at 2:56 PM, the Social Services Director (SSD) stated she was responsible for beneficiary notifications, including NOMNCs. She stated she had been taking care of the NOMNCs for three years. She stated that she usually issued NOMNCs a week before they were due. She stated the requirement was to issue the NOMNC 72 hours before a resident was discharged or their Medicare covered services were ending. She stated Resident #128's services ended on 04/06/2026. She stated Resident #128's family member signed the NOMNC on 04/07/2026, and she did not have an explanation for the signature and delivery date being after the coverage end date. During an interview on 06/24/2026 at 11:36 AM, the Director of Nursing (DON) stated she was not involved with the beneficiary notification process. She stated that she had no knowledge of the requirements for beneficiary notifications. She stated that she expected the NOMNC to be issued in the time required by regulations. During an interview on 06/24/2026 at 11:50 AM, the Executive Director (ED) stated he was not involved in the NOMNC process. He stated that he knew they were supposed to notify residents three days prior to their discharge. He stated that he expected the NOMNC to be issued in the time required. He stated it was not appropriate for a resident to sign a NOMNC the day after their services ended.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to identify accident hazards to prevent falls and failed to ensure safety during care for 1 of 3 (Resident #1) sampled residents reviewed for accidents. Resident #1 had moderately impaired cognition, was dependent upon staff for assistance with transfers, and used a wheelchair for mobility. On 4/4/2025, Resident #1 had an unwitnessed fall. Certified Nurse Assistant (CNA) O discovered Resident #1 on the floor with her right arm lodged in the wheel of the wheelchair. CNA O pulled Resident #1's right arm out of the wheel and Resident #1 sustained a large avulsion wound (a traumatic injury where the skin and other underlying tissues are torn away from the body, can cause heavy bleeding and require immediate medical care) to the right arm that required a hospital transfer and surgical repair, which resulted in actual HARM to Resident #1. The findings include: 1. Review of the facility policy titled, .Incident and Reportable Event Management, dated 9/23/2025, revealed .The facility to the best of its ability strives to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents .Accidents refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident . Avoidable Accident means that an accident occurred because the facility failed to .Identify environmental hazards and or assess individual resident risk of an accident .Evaluate/analyze the hazards and risk and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible .Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident .Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice .The licensed nurse should evaluate the resident and render first aide if needed .The nurse evaluation should be completed prior to moving a resident who has fallen to determine presence of injury . Review of the facility policy titled, Fall Management, dated 9/25/2025, revealed .The facility must ensure that.The environment remains free of accident hazards as is possible .Each resident receives adequate supervision and assistance device to prevent accidents.Fall-Refers to unintentionally coming to rest on the ground, floor or other lower level.Residents will be assessed for fall indicators, upon admission, readmission, quarterly, change in condition .Adequate Supervision is determined by assessing the appropriate level and number of staff required, the competency and training of staff, and the frequency of supervision needed. This is determined on the individual resident's assessed needs and identified hazards in the resident environment .Hazards-Refers to elements of the resident environment that have the potential to cause injury or illness .Hazards over which the facility has control .are those hazards in the resident environment where reasonable efforts by facility could influence the risk for resulting injury or illness .The intervention to reduce the risk of falls should be individualized based on the residents risk factor and fall history . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Anxiety, Unspecified Blindness of One Eye, and Repeated Falls. Review of the Care Plan dated 3/29/2023, revealed .frequent falls, difficulty walking.hx [history] right hip contusion [bruise] and hx left hx [as written on care plan] fracture with prothesis .poor safety awareness.Interdisciplinary team to meet as needed to discuss resident's condition and interventions.ADL [Activity of Daily Living] Assistance and Therapy Services needed to maintain or attain highest level of function . The care plan revealed the following revised interventions: On 12/21/2023, .STAFF EDUCATION WHEN PT. [PATIENT/Resident #1] IS UP AND RESTLESS IN W/C [wheelchair]. STAFF WILL MONITOR CLOSELY UNTIL PT. IS AT REST INERVENE AS INDICATED . On1/6/2024, .Not to be left in room unattended when up in w/c . On 2/2/2024, .Transfers extensive X [times] 1 . On 2/23/2024, .PT TO NURSING STATION FOR CLOSE MONITORING. On 3/19/2024, .Provide light when pt. is in bed monitor frequently. On 4/10/2024, .Increase supervision to every 30 minutes when patient goes to bed until she gets up again. On 8/01/2024, .Care in Pairs . On12/26/2024, .Redirect resident from bedroom to dayroom or nurses' station when up in w/c for monitoring. Review of the facility investigation titled, Risk Management Follow Up Packet, dated 2/1/2025, revealed CNA called nurse to help with the resident in the bathroom. Resident says she was trying to get in her chair and she missed the chair and fell out on her right hip Review of the Care Plan dated 2/1/2025, revealed . unwitnessed fall .do fall huddle after each fall to work root cause analysis.PT NOT TO BE LEFT UNATTENDED IN BATHROOM . Review of the Fall Risk Evaluation dated 2/2/2025, revealed Resident #1 had a Category score of 10 or above, which indicated Resident #1 was a high risk for falls. The resident was confined to a wheelchair and not able to balance without physical help. Review of the facility investigation titled, Risk Management Follow Up Packet, dated 2/13/2025, revealed .[Resident #1] observed on the floor .on her buttocks by her wc [wheelchair] .[Resident #1] stated she was attempting to turn around in the w/c to go to her room and her feet got caught up and resulted in falling out of wc Review of the Fall Risk Evaluation dated 2/13/2025, revealed Resident #1 had a Category score of 10 or above which indicated Resident #1 was a high risk for falls. The resident was confined to a wheelchair and not able to balance without physical help. Review of the care plan revealed a revised intervention dated 2/13/2025, revealed .Dumped [refers to the seat angle, measured by how much lower the rear is than the front] W/C [wheelchair]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated Resident #1 had moderately impaired cognition. Resident #1 required substantial to maximum assistance from staff to transfer from bed to chair and to stand from a sitting position. Resident #1 required setup or clean-up assistance from staff for wheelchair mobility. Active diagnoses were Dementia, Anxiety, Bipolar, Blindness, One Eye (Unspecified eye), and Repeated Falls. A revised intervention dated 2/28/2025, was added to the care plan and revealed .provide frequent checks to monitor needs and assist . Review of the discharge MDS assessment dated [DATE], revealed Resident #1 was discharged to the hospital. Resident #1 had short-term memory problems and had some difficulty in new situations for making daily decisions. An undated IDT (Interdisciplinary team) Summary of event note revealed .Pt found per staff laying on the floor in room had been assisted to bed at approx. [approximately] 9 pm [9:00 PM] . Review of the Nursing Home to Hospital Transfer Form dated 4/4/2025, revealed Resident #1 was described as, while awake and responsive, awareness of surroundings is impaired, but can process and act on basic simple instruction. The resident was dependent upon staff to ambulate and had severely impaired vision described as almost blind. Review of the facility investigation titled, Risk Management Follow Up Packet, revealed .Resident #1.Occurred 4-4-25 [2025].Type Unwitnessed Fall.Immediate Intervention control bleeding and keep pt. [Resident #1] calm.Long Term Intervention (If different) Pt. not to be assisted to bed early due to restlessness at HS [Hour of Sleep]. The investigation also revealed, Resident #1's scream summoned CNA O into the Resident's room. When CNA O entered the room, Resident #1's right arm was stuck in the wheel of the wheelchair. CNA O pulled the resident' s arm out of the wheel of the wheelchair. Resident #1 sustained an injury to the right arm. CNA B observed the right arm and described the wound as .torn to the bone . Licensed Practical Nurse (LPN) P's update on the resident status after the Resident had been discharged to hospital revealed, .will be seen by a surgeon on Sunday 4-5-25 [4/5/2025] . The facility investigation did not include measurements of the large wound to Resident #1 right arm. 3. Review of the Hospital medical record dated 4/5/2025 at 1:34 AM, revealed . [Resident #1] presents to the Emergency Department after a fall to her right elbow . She is unable to tell me any details about the fall .patient has a large avulsion wound to the right elbow/forearm .Tendons visible . Admit to trauma Med surg [medical/surgical unit] .Radiology XR [X-ray] ELBOW RIGHT .large laceration [tear or cut in the skin] is present in the medial aspect of the proximal forearm . Resident #1 had surgery on 4/5/2025 to repair the large avulsion wound to the right upper extremity. 4. Review of an unsigned witness statement by CNA O dated 4/4/2025, revealed .I was walking down the hall at 20:45 [8:45 PM] , peek my head in room .and seen [Resident#1] in her w/c and at 9:45 p [PM] I heard screaming and I entered the room seen resident [Resident #1] on the floor with her arm stuck in the wheel of the w/c I pulled her right arm out of the w/c. I didn't notice her arm. I seen blood on the floor, then I notify the nurse . Review of a signed Witness Interview/Statement Form by CNA O dated 4/4/2025, revealed .I was walking down the hall heard screaming and I entered the room, seen resident on the floor, with her arm stuck in the wheel of w/c [wheelchair] pulled her arm out of the w/c. I didn't notice her arm. I seen the blood on the floor then I notify the nurse. The facility failed to follow the Resident's care plan intervention to not allow Resident #1 up in the wheelchair in her room unattended. The surveyor made multiple attempts to contact CNA O by phone. CNA O did not respond to requests for interview. Review of a signed Witness Interview/Statement Form by CNA B dated 4/4/2025, revealed CNA B had returned from lunch at 9:38 PM, and heard CNA O say Resident #1 is on the floor and [CNA B] entered [Resident #1's] room and observed [Resident #1] on the floor with what [CNA B] described as 'torn skin to the bone'. CNA B statement also revealed that around 8:50 PM on 4/4/2025 CNA I had exited [Resident #1's room and [Resident #1] was still in her wheelchair. Review of a signed Witness Interview/Statement Form by CNA I dated 4/4/2025, revealed .Went and answered call light at 9:10 pm [PM] resident [Resident #1] wanted to lay down so laid her down then not long after 9:38 [PM] that nurse came and told me Resident was in floor. Then I help to assist her to sit up. Review of a signed Witness Interview/Statement Form dated 4/4/2025, by LPN Q revealed .Incident Type unwitnessed fall.Incident Date/Time 4/4/25 9:40 pm. Nurse was asked by tech [CNA] to come assist with unwitnessed fall with injuries patient [Resident #1] was in the room calling for help nurse went into the room and sat with patient until EMS arrived she [Resident #1] sat propped up against my legs and was fussing about her son .not coming to her aid. Patient was saying she saw her son standing in the doorway looking at her. Nurse reassured her that her son was not on the premises. Nurse kept the injured limb [right arm] wrapped in a towel and reminded the patient to not move it around . Review of a signed Witness Interview/Statement Form by LPN P dated 4/6/2025, . I [LPN P] was passing medication down the hall near the lobby I heard help looked down the hall and saw [CNA O] go into [Resident #1] room and yelled out [Resident #1] is on the floor, I saw [CNA O] walk back into the room, came out yelling I need someone in here now, I ran down the hall into [Resident #1] room and observed her [Resident #1] on the floor lying on her right side in front of her dresser, resident had her arm up and it was bleeding with a large gash above the elbow. I asked [CNA O] what happened looking at her [Resident #1's] arm in disbelief that anything like that could ever happen here I yelled for someone to get some towels to wrap around her arm to stop the bleeding or at least control it. I and the other nurse[LPN Q] helped the resident to sit up so she would not be lying on the floor, as I and the other nurse was doing that the resident was yelling at us to hurry up and do something I explained to the resident in a calm voice there is nothing I can do and I am going to have to send her to the hospital .I [LPN P] asked the resident .what was she doing, she told me I was trying to straighten out my covers on the bed I told [LPN Q] to stay with her while I call 911 .one of the guys asked the resident how did she fall, and the resident told EMS [Emergency Medical Services] I did not fall was trying to get something out of the drawer .now lets get back to when I [LPN P]walked in the room, I observed the resident lying on the floor she had her clothes on but the jacket she had on, one sleeve was out and the other sleeve was in, the sleeve that was out was the one with the injured arm .her bed was messed up, her dresser did not have an open drawer. I [LPN P] asked [CNA O] what happened again and she stated [Resident #1] was on the floor with her arm caught in the wheel of the W/C and she [CNA O] had to pull it [the Resident's arm] out, she also stated that the second time she walked in there was blood everywhere when she had noticed that Resident #1 arm was stuck, I [LPN P] asked assigned CNA [CNA I] to the resident did she leave the resident up in her chair and she stated to that she did put the resident to bed . 5. Resident #1 was readmitted back to the facility on 4/7/2025 with diagnoses which included Encounter for Surgical Aftercare Following Surgery on the Skin and Subcutaneous Tissue, Disruption of Traumatic Injury Wound Repair, Subsequent Encounter, and Repeated Falls. Review of the Fall Risk Evaluation dated 4/7/2025, revealed Resident #1 had a Category score of 10 or above which indicated Resident #1 was a high risk for falls. The resident was confined to a wheelchair and not able to balance without physical help. Review of the quarterly MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 10, which indicated Resident #1 had moderately impaired cognition. Resident #1 required substantial to maximum assistance from staff to transfer from bed to chair and to reposition from lying back in bed to sitting on side of bed, required partial to moderate assistance from staff to come to a standing position, and required supervision to touching assistance from staff for wheelchair mobility. Active diagnoses were Dementia Anxiety, Bipolar, Blindness, One Eye, Unspecified, Traumatic Injury Wound Repair, Difficulty Walking, Laceration without Foreign Body of Right Arm. Review of the discharge MDS assessment dated [DATE], revealed Resident #1 was discharged to an Inpatient Psychiatric Facility on 6/15/2025. 6. During an interview on 10/8/2025 at 11:22 AM, the Assistant Director of Nursing (ADON) was asked what system the facility has in place to make sure staff were monitoring the residents. The ADON stated, If the care plan says to monitor, staff will take the resident at nurse station or day room. There is always someone walking back and forth. During an interview on 10/8/2025 at 2:57 PM, CNA B was read her witness statement and asked if the statement was true. CNA B stated, Yes. CNA B was asked where Resident #1 was before the incident happened. CNA B stated, She was in her room in the wheelchair in her room by herself. CNA B was asked about the resident being left in her room in wheelchair by herself. CNA B stated, Usually they have [Resident#1] in the lobby until she is ready for bed. I am not for sure of any incidents that would make them have her in the lobby and not in her room. CNA B was asked where the resident was when she entered the room. CNA B stated, Resident #1 was on the floor. CNA B was asked where the wheelchair was. CNA B stated, I cannot remember but know it was not on the resident. [CNA O] was in room with the resident. I think [CNA O] had pulled [Resident #1] arm out of the wheelchair. It looked like a big gash in the resident's arm. CNA B failed to follow Resident#1's care plan intervention that stated, .redirect resident from bedroom to dayroom or nurses' station when up in w/c for monitoring . During a telephone interview 10/8/2025 at 5:12 PM, LPN P was asked about Resident #1's unwitnessed fall on 4/4/2025. LPN P stated, . [CNA O] came out saying [Resident #1] was on the floor, bleeding. [CNA O] had walked by and saw [Resident #1] on the floor and [Resident #1] was yelling. [CNA O] pulled [Resident #1] arm out of the wheel of wheelchair. LPN P was asked the time of night. LPN P stated, I cannot remember, before midnight, maybe around 10 or 11 . LPN P was asked where [Resident #] was before the incident. LPN P stated, I remember [CNA I] had her that night, said that she had put Resident #1 to bed. LPN P was asked where the wheelchair was. LPN P stated, The resident was on the floor, and the wheelchair was by the dresser. The dresser was at the foot of the bed; the resident was at the foot of bed and dresser. It was [Resident #1], [CNA O], and the wheelchair was in front of the dresser. LPN P was asked before the incident when was the last time Resident #1 was seen. LPN P stated, Whenever I gave her medication, she was in the day room in her wheelchair. She cannot be in her room by herself unless in bed. You could not just roll her in her room and leave her in wheelchair. LPN P was asked the reason. LPN P stated, Because she will get up. LPN P was asked before this incident, did she have monitoring when in bed. LPN P stated, We did periodically, sometimes she would try to get up and we would get her up and back in wheelchair and keep her up and ask her if she wanted food or something to drink then asked if she was ready to go back in bed and she will say yes or no. We kept her in day room to be watched. During an interview on 10/8/2025 at 5:41 PM, the Director of Nursing (DON) was asked when there is an incident, and a CNA finds the resident on the floor what is the process. The DON stated, The CNA should immediately notify the nurse first, go get the nurse. The nurse will assess the resident and determine what should be done and the CNA will do what the nurse says. During an interview on 10/9/2025 at 11:04, the DON was asked what CNA O told her about Resident #1's unwitnessed fall on 4/4/2025. The DON stated, [CNA O] went in the room and [Resident #1's] arm was stuck in the wheelchair, there was blood on the floor, and [CNA O] removed the resident's arm .from where it was stuck in the wheelchair .[Resident #1] was hollering in pain. The DON was asked if [CNA O] had the training and medical knowledge to remove [Resident #1's] stuck arm from the wheel of the wheelchair and is it the facility's practice to allow a CNA to make a medical decision without consulting the licensed nurse. The DON stated, .I do feel [CNA O] removing the arm from wheelchair was a not medical decision but getting off the floor would have been a medical decision .I would say she [CNA O] prevented further injury. The DON was asked to explain how she was aware CNA O prevented further injury. The DON stated, I do not know that. The DON was asked what was the root cause of Resident #1's injury. The DON stated, According to what we determined it was too early for the resident to lay down. She was not sleeping very well . The DON was asked did the facility determine how the resident got her arm a stuck in the wheel of wheelchair The DON stated, No the statement from the resident said, 'I am trying to get something out of the drawer.' She may have put herself in the wheelchair or it could have been something for her to just say. I do not know if she did put herself back in [the] wheelchair. The DON was asked did the intervention for prevention of another fall address the wheelchair. The DON stated, We did not address the wheelchair . The DON was asked was the intervention for the prevention of another fall appropriate. The DON stated, Did not think it was necessary at that time, with the statements given, to not have wheelchair in the room. The facility failed to ensure the safety of Resident #1. During an interview on 10/9/2025 at 3:38 PM, the DON was asked how does the facility ensure frequent monitoring is conducted when Resident #1 is at the nurse station or in the day room. The DON stated Everyone ensures by keeping an eye on her, but it is not documented. If we specify, say every 15 minutes, it would be documented. During an interview on 10/9/2025 at 6:11 PM, the DON was asked was every 30 minute monitoring documented on Resident #1 when she was placed in bed on the evening of 4/4/205, because there is a care plan intervention dated 4/10/2024 that says every 30 minute monitoring when the resident goes to bed until she gets up again. The DON stated, This intervention was from 2024, and the intervention should have been removed because it is a year old. We make it for a period of time. It would be unrealistic over a long period of time. The DON was asked if there was no documentation of the monitoring, was the care plan followed. The DON stated, I do not know that it was not done. The DON was asked when intervals are in place should the monitoring be documented. The DON stated, Yes. The DON was asked were every 30-minute checks while in bed documented on Resident #1 on 4/4/2025 before she had the incident in her room. The DON stated, It should be documented. I will have to go look and see, it may be in the chart . The DON failed to provide documentation that Resident #1 was monitored every 30 minutes while in bed, before her fall on 4/4/2025. The facility failed to follow the care plan intervention to prevent a fall. During an interview on 10/9/2025 at 6:25 PM, the Administrator was asked who told him about Resident #1's injury to the arm on 4/4/2025. The Administrator stated, The DON told to me of the incident. The Administrator was asked did the DON tell him that the resident had to have surgery. The Administrator stated, .do not recall . The Administrator was asked if there was a Performance Improvement Plan (PIP) related to Resident #1's injury. The Administrator stated, Do not recall, I do not know what the DON implemented, no PIP. If it was, it would have been presented in QAPI [Quality Assurance and Performance Improvement] .

Based on the facility policy review, medical record review, and interview, the facility failed to facilitate the residents' and/or resident representatives' participation in the care planning process for 3 of 3 (Resident #1, Resident #3 and Resident #4) sampled residents reviewed for care planning conferences. The findings include: 1. Review of the facility policy titled, Comprehensive Care Plans and Conferences, dated 8/29/2025, revealed .The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident representative.in developing the care plan and making decisions about his or her care.The facility has a responsibility to assist residents to engage in the care planning process.holding care planning meetings at the time of day when the resident is functioning best.encouraging a resident's representative to participate in care planning and attend care planning conferences.each resident has the right to participate in choosing treatment options and must be given the opportunity to participate in the development, review and revision of his/her care plan.The resident's care plan must be reviewed after each assessment. 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Anxiety, Unspecified Blindness of One Eye, and Repeated Falls. Review of the Care Plan dated 3/29/2023, revealed, .frequent falls, difficulty walking. An intervention dated 4/10/2024, revealed, .Increase supervision to every 30 minutes when patient goes to bed until she gets up again. An intervention dated 8/01/2024, revealed .Care in Pairs . An intervention dated 12/26/2024, revealed .Redirect resident from bedroom to dayroom or nurses' station when up in w/c for monitoring. 3. Review of medical record revealed Resident #3 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses including Traumatic Brain Dysfunction, Progressive Neurological Conditions and Hip and Knee Replacement. Review of the Care Plan dated 1/30/2025, revealed .impaired cognitive ability/impaired thought processes r/t [related to] Dementia.at risk for falls due to impaired mobility and weakness.at risk for change in mood or behavior.at risk for unavoidable pressure injury development or decline of skin integrity. Review of Care Conference Meeting notes dated 2/4/2025, revealed the daughter attended Resident #3's care conference meeting. Review of the significant change in condition MDS dated [DATE], revealed Resident #3 scored a 2 on the BIMS assessment, which indicated Resident #3 was severely cognitively impaired. There facility was unable to provide quarterly Care Conference Meeting notes for 4/24/2025 and 5/2/2025. 4. Review of medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Vascular Dementia and Diabetes. Review of the quarterly MDS dated [DATE], revealed Resident #4 scored a 3 on the BIMS assessment, which indicated Resident #4 was severely cognitively impaired. Review of the Care Plan dated 9/19/2025, revealed, .At risk for elopement [4/4/2025] .Add resident to the Elopement Book.Frequent monitoring q [every] 15min checks X [times] 72 hours.has impaired cognitive ability/impaired thought processes r/t [related to] vascular dementia. During a phone interview on 10/8/2025 at 1:04 PM, Family Member U of Resident #4 was asked what was discussed in Resident #4's Care Plan meetings following the alleged elopement. The family member stated she had not participated in Care Plan meetings related to Resident #4. During an interview on 10/9/2025 at 3:35PM, the Social Service Director (SSD) was asked how often care conference meetings were conducted for Long Term Care residents. The SSD stated, .I try to have the care plan meetings done within 72-hours of admission. and as needed or if family requests them . During an interview on 10/9/2025 at 6:10 PM, the Director of Nursing (DON) was asked how often should care plan conferences be conducted. The DON stated, .at admission, quarterly or if there has been a significant change in condition. The DON was asked if care conference meetings were being conducted. The DON stated, .I assumed they had not been being done since they cannot find any care conference meeting notes .

Based on facility policy review, medical record review, and interview, the facility failed to revise the Care Plan for 2 of 6 (Residents #2 and #3) residents reviewed. The findings include: 1. Review of the facility's policy titled, Comprehensive Care Plans and Revisions, dated 3/2/2022, revealed, The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team .The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care . 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], discharged home on 7/26/2023, and readmitted on [DATE] with diagnoses which included Encounter for Orthopedic Aftercare Following Surgical Amputation, Acute Osteomyelitis Left Ankle and Foot, Cellulitis of Left Lower Limb, Type 2 Diabetes Mellitus with Hyperglycemia, and Peripheral Vascular Disease. Review of the Order Summary Report for Resident #2 revealed orders for, .8/17/2023 Clean 5th left toe on the left foot with NS [Normal Saline] apply black foam on wound, secure with [named transparent dressing], machine at 120 mmg [milligrams of mercury] change M [Monday]/W [Wednesday]/F [Friday] and PRN [as needed] .8/25/2023 Continue [named negative pressure device] left foot .8/31/2023 Clean right surgical wound with NS apply [named Hydrocolloid wound filler paste] wrap with [named gauze bandage] every day shift . (This order was written in error as the right surgical wound, when in fact it was the left foot surgical wound. The Director of Nursing (DON) and the Treatment Nurse wrote an attestation to confirm the order was written as the right foot, but was in fact pertaining to the left foot, and the treatments were performed on the left foot.) Review of the Admission Minimum Data Set (MDS) assessment for Resident #2 dated 8/19/2023 revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Continued review revealed an infection of the foot and application of dressings to feet. Review of the undated Care Plan for Resident #2 revealed Focus/Assessments for, .Has break in skin integrity, BUE [Bilateral Upper Extremity] and BLE [Bilateral Lower Extremity] has several blisters that opened and are draining from cellulitis . Resident #2's Care Plan did not address the wound to his left foot post surgical amputation, nor the laceration with sutures to his right foot post fall, and did not include achievable goals or interventions. During an interview on 9/19/2023 at 3:18 PM, the DON stated, There should be a care plan entry when someone receives sutures from an injury. Typically, the nurses do not add to the care plans. The MDS person puts the care plan together. The Assistant Director of Nursing (ADON) or the MDS nurse will update the care plan as needed. [Named Resident #2]'s care plan should have been updated to include the laceration with sutures. 3. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included Surgical Aftercare Following Surgery on the Skin and Subcutaneous Tissue, and Acute Osteomyelitis of Left Foot and Ankle. Review of the Order Summary Report for Resident #3 revealed an order dated 8/25/2023, R [right] ankle, Non removable drsg [dressing], Monitor daily for integrity and s/sx [signs/symptoms] of infection. Review of the Admission MDS assessment for Resident #3 dated 8/28/2023 revealed a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed Resident #3 had a surgical wound and received surgical wound care. Review of Resident #3's undated Care Plan revealed the care plan did not include an assessment related to a surgical wound, achievable goals, or appropriate interventions. During an interview on 9/19/2023 at 4:08 PM, the MDS Coordinator reviewed Resident #3's Care Plan. The MDS Coordinator confirmed Resident #3's care plan did not address the surgical wound, have achievable goals, or appropriate interventions.

Based on medical record review and interview, the facility failed to obtain physician's orders for 1 of 6 (Resident #2) residents reviewed. The findings include: 1. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], discharged home on 7/26/2023, and readmitted on [DATE] with diagnoses which included Encounter for Orthopedic Aftercare Following Surgical Amputation, Acute Osteomyelitis Left Ankle and Foot, Cellulitis of Left Lower Limb, Type 2 Diabetes Mellitus with Hyperglycemia, and Peripheral Vascular Disease. Review of the notes from the Infectious Disease physician's office visit for Resident #2 dated 6/22/2023, revealed, .Chronic ulcer of toes of left foot .should perform 3/x [times] week dressing changes and apply [named Hydrophobic microbe binding wound contact layer] to the would bed ulcer . Review of the Wound Observation Tools for Resident #2 revealed there were no wound assessments documented until 7/18/2023, which stated, .left foot .First observation .Granulation tissue present .Drainage: Serosanguinous [clear liquid mixed with blood] .Length (cm) [centimeters] 1.0 .Width (cm) 1.0 .Depth (cm) 0.1 .Resident's wound bed with granular tissue wife reported that he sees a podiatrist he has PVD [Peripheral Vascular Disease] scab removed dressed, NP [Nurse Practitioner] and family aware .Treatment: [named Hydrophobic microbe binding wound contact layer] . Continued review dated 7/25/2023, revealed, .left foot .Improving .Granulation tissue present .Drainage: Serosanguinous [clear liquid mixed with blood] .Length (cm) 1.0 .Width (cm) 1.0 .Depth (cm) 0.1 .Resident's wound bed with granular NP and family aware .Treatment: [named Hydrophobic microbe binding wound contact layer] . Review of the Order Summary Report for Resident #2 revealed orders for, .7/20/2023 Clean left foot with NS [Normal Saline] apply [named Hydrophobic microbe binding wound contact layer] every day shift every 3 days for PVD . Review of the hospital emergency room (ER) notes for Resident #2 dated 8/24/2023 revealed, .a fall and right foot injury .has a laceration in the webspace between the 4th and 5th toes .LLE [Left Lower Extremity] w [with] .bandage taken down and wound healing well w/o [without] infection/drainage/erythema [redness] . Radiology report of the Right foot revealed, .there has been a partial resection of the distal [end of] phalanx of the great toe .Severe arterial vascular calcification present .Acute nondisplaced fracture present involving the proximal phalanx [lower end] of the fifth digit/little toe . Continued review revealed, .Disposition Decision .Discharge to home[nursing home.] Additional Instructions: Your labs and imaging were unremarkable today except for a fracture of your pinky toe. You had sutures to repair your laceration. Please continue antibiotics at . nursing home as previously prescribed and follow-up with your foot surgeon for suture removal in 7-10 days . Review of the Order Summary Report for Resident #2 revealed orders for, .8/31/2023 Clean right surgical wound with NS [Normal Saline] apply [named Hydrophobic microbe binding wound contact layer] wrap with [named gauze bandage] every day shift . (This order was actually written for the left foot amputation performed on 8/2/2023 and was mistakenly entered as the right foot. The Director Of Nursing (DON) and Treatment Nurse both wrote an attestation indicating the order was entered into the system wrong, but the treatments were conducted correctly on the left foot.) Review of the Progress Note for Resident #2 dated 9/5/2023, written by the NP, revealed, . dressing to R [right] foot for protection of sutures-after fall/laceration . Review of the Progress Note for Resident #2 dated 9/11/2023, written by the NP [Nurse Practitioner], revealed, .Patient also with L [left] foot wound and sutures to R foot. Both feet covered with dressings on assessment today-dry and intact . During an interview on 9/19/2023 at 1:19 PM, the Treatment nurse stated when Resident #2 was admitted to the facility in May 2023, he did not have any open areas to his skin. The treatment nurse stated there was a note in Resident #2's chart from the facility's doctor stating the skin on his feet was intact. The Treatment Nurse stated Resident #2 came from a doctor's appointment on 6/22/2023 and had orders for a treatment to his foot. The Treatment Nurse stated the doctor had debrided (removed) the scab that had been on his foot, and after the debridement (removal), there was an open wound. She stated she was not made aware of the treatment order, did not know there was a wound, and therefore did not monitor the wound on a weekly basis. The Treatment nurse stated the Charge nurse who had Resident #2 that day, should have obtained the order for the treatment. During an interview on 9/19/2023 at 2:55 PM, the DON stated Resident #2 had a fall in his room on 8/24/2023, which resulted in a fracture to his toe on his right foot, and a laceration that required sutures. The DON confirmed there were no orders obtained related to monitoring the laceration and no treatment orders. The DON stated, The only orders I see in the chart are to remove the sutures in 8-10 days. There is no order for wound care or observing the wound. I would have expected an order written to change the dressing and to monitor the wound for infection. During an interview on 9/19/2023 at 3:18 PM, the DON confirmed the orders written by the Infectious Disease doctor on 6/22/2023 were not carried over. The DON confirmed, I would expect the nurse to enter the new order. During an interview on 9/20/2023 at 11:29 AM, The NP stated, .resident had an injury to his right foot when he got up and tried to walk . When asked if the NP would have expected an order to be written for monitoring the wound with sutures for infection, she replied, yes. During an interview on 9/20/2023 at 12:00 , the DON reviewed Resident #2's physician orders. The DON confirmed there was no order for a treatment to Resident #2's left foot on 6/13/2023. The DON reviewed the Infectious Disease doctor's progress note for Resident #2 dated 6/13/2023 which stated the dressing to the resident's left foot was clean, dry, and intact. The DON stated the Infectious Disease doctor's office could have applied a dressing over the left foot and did not write an order for it. The DON stated when the resident returned to the facility after the MD appointment, the nurse should have noted the dressing and investigated why the dressing was there and should have notified the Treatment Nurse.

Based on facility policy review, medical record review, and interview, the facility failed to report allegations of abuse for 2 of 2 sampled residents (Resident #1 and Resident #5) reviewed. The findings include: Review of the facility policy titled, Area of Focus: Abuse & Neglect, reviewed 11/21/2022, revealed, .To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse .In response to allegations of abuse .the facility must .Ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after allegations is made .not later than 24 hours if the events that cause the allegation do not involve abuse .In response to allegations of abuse .the facility must .Have evidence that all alleged violations are thoroughly investigated .Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Age-Related Osteoporosis with Current Pathological Fracture, Right Humerus, Age-Related Osteoporosis with Current Pathological Fracture, Right Forearm, and Generalized Weakness. During an interview on 4/3/2023 at 9:58 AM Ombudsman #1 stated, I spoke with [Resident #1] and her family about the allegations of abuse. [Resident #1] told me [Certified Nursing Assistant (CNA) #2] had been too rough with her and she was terrified of [CNA #2]. [Resident #1] said [CNA #2] was mean to her the first night she stayed in the facility [Facility #1]. [Family Member #5] said the DON [Director of Nursing] said she would investigate [CNA #2] and she [CNA #2] would not be allowed back in [Resident #1]'s room. I talked to the DON and she was aware of the allegations made by [Resident #2] and she had taken care of the situation and [CNA #2] would not be caring for [Resident #1] anymore. During a telephone interview on 4/3/2023 at 11:49 AM, Family Member #1 stated, [Resident #1] was terrified the morning of 2/25/2023 and tearful when she described how [CNA #2] had treated her during her first night in the facility. I came to the facility on [DATE] and met with the DON, We discussed the allegations of abuse made by [Resident #2] and she [DON] said she would report the allegations to the State and investigate thoroughly. The DON said in the meantime she would move [Resident #1] and [CNA #2] would not be taking care of [Resident #1]. During an interview on 4/4/2023 at 1:50 PM, Resident #1 stated, [CNA #2] had been really rough when she turned me on my side to change me. I told her she was hurting me and she still pushed me around and was really rough turning me. She [CNA #2] seemed mad at me for needing help. She told me I called too much. I have been okay since [family member #5] has been able to stay with me and the other techs [CNAs] are pretty good to take care of me. Continued interview Resident #1 described CNA #2 as the tech that was too rough with her and scared her on 2/24/2023. During an interview on 4/4/2023 at 2:00 PM, Family Member #5 stated, I came to the facility on [DATE] and [Resident #1] told me she didn't think she could stay in the facility after the bad treatment from a CNA she received from [CNA #2] during the night. I told the nurse about what [Resident #1] said about the CNA. The nurse said she would report it to the DON. I stayed with her that night [2/25/2023] and [Resident #1] pointed the CNA out to me when she came in the room. The CNA was an older woman with long gray hair, her name was [CNA #2]. On Monday, 2/27/2023 we [Family Member #1 and Family Member #5] met with the DON in her office. She [DON] told us [CNA #2] would not be taking care of [Resident #1] anymore because we were moving to a private room that wasn't on [CNA #2]'s assignment. She [DON] told us she was going to investigate the incident and turn it in to the State. After she said that, she called the Social worker and the Administrator into the office and told them about the incident. The Social worker said she would make arrangements to move [Resident #1] right away. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Unspecified Intracranial Injury with Loss of Consciousness Status Unknown Subsequent Encounter, Unspecified Fracture of Left Acetabulum Subsequent Encounter for Fracture with Routine Healing, Pain in Left Hip, and Unspecified Injury of Bladder Subsequent Encounter. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated no cognitive impairment. During an interview on 4/3/2023 at 3:45 PM, Family Member #3 stated, I was on the phone with my dad [Resident #5], and a staff member come in the room and started yelling at him regarding pressing his call light too many times. Family Member #3 stated that the Resident #5 started crying and was confused on why he was being yelled at, so she hung up and called the facility immediately to report what had just happened. Family Member #3 stated that she spoke with the nurse on duty and was told that the tech would be reassigned and would not provide care for [Resident #5] anymore. During an interview on 4/4/2023 at 3:30 PM, LPN #1 stated, I wasn't working down on that hall, but I went down there when I got the call. [CNA #1] was working, and she has a tendency of speaking loudly. I [LPN #1] reported the incident to the DON, but I don't remember an investigation being done. The DON and I [LPN #1] met with the family the following week and informed the family that [CNA #1] would no longer be providing care to [Resident #5]. During an interview on 4/5/2023 at 9:35 AM, Resident #5 stated that a CNA came into his room and yelled at him regarding pressing his call light too many times. Resident #5 stated the CNA spoke very loudly with him. Resident #5 stated that his daughter was on the phone with him and called the facility to report what happened immediately. Resident #5 stated, After the incident, I felt uncomfortable pressing call light when I needed help. During an interview on 4/4/2023 at 4:11 PM, the DON confirmed the definitions of abuse according to the facility policy. She stated verbal abuse included talking mean to a resident and mistreatment of a resident. She stated, If a resident alleges abuse by a staff member, the staff member would be suspended pending an investigation. The DON confirmed she did not report or investigate an allegation of abuse made by Resident #1 and Resident #5. She stated she remembered a meeting in her office between Resident #1's family members and administration. She was unable to recall why Resident #1's family members did not want CNA #2 to take care of Resident #1. The DON also stated that she didn't remember meeting with Resident #5 or Resident #5's family.

Based on facility policy review, medical record review, and interview, the facility failed to investigate allegations of abuse for 2 of 2 sampled residents (Resident #1 and Resident #5) reviewed. The findings include: Review of the facility policy titled, Area of Focus: Abuse & Neglect, reviewed 11/21/2022, revealed, .To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse .In response to allegations of abuse .the facility must .Ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after allegations is made .not later than 24 hours if the events that cause the allegation do not involve abuse .In response to allegations of abuse .the facility must .Have evidence that all alleged violations are thoroughly investigated .Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Age-Related Osteoporosis with Current Pathological Fracture, Right Humerus, Age-Related Osteoporosis with Current Pathological Fracture, Right Forearm, and Generalized Weakness. During an interview on 4/3/2023 at 9:58 AM Ombudsman #1 stated, I spoke with [Resident #1] and her family about the allegations of abuse. [Resident #1] told me [Certified Nursing Assistant (CNA) #2] had been too rough with her and she was terrified of [CNA #2]. [Resident #1] said [CNA #2] was mean to her the first night she stayed in the facility [Facility #1]. [Family Member #5] said the DON [Director of Nursing] said she would investigate [CNA #2] and she [CNA #2] would not be allowed back in [Resident #1]'s room. I talked to the DON and she was aware of the allegations made by [Resident #2] and she had taken care of the situation and [CNA #2] would not be caring for [Resident #1] anymore. During a telephone interview on 4/3/2023 at 11:49 AM, Family Member #1 stated, [Resident #1] was terrified the morning of 2/25/2023 and tearful when she described how [CNA #2] had treated her during her first night in the facility. I came to the facility on [DATE] and met with the DON, We discussed the allegations of abuse made by [Resident #2] and she [DON] said she would report the allegations to the State and investigate thoroughly. The DON said in the meantime she would move [Resident #1] and [CNA #2] would not be taking care of [Resident #1]. During an interview on 4/4/2023 at 1:50 PM, Resident #1 stated, [CNA #2] had been really rough when she turned me on my side to change me. I told her she was hurting me and she still pushed me around and was really rough turning me. She [CNA #2] seemed mad at me for needing help. She told me I called too much. I have been okay since [family member #5] has been able to stay with me and the other techs [CNAs] are pretty good to take care of me. Continued interview Resident #1 described CNA #2 as the tech that was too rough with her and scared her on 2/24/2023. During an interview on 4/4/2023 at 2:00 PM, Family Member #5 stated, I came to the facility on [DATE] and [Resident #1] told me she didn't think she could stay in the facility after the bad treatment from a CNA she received from [CNA #2] during the night. I told the nurse about what [Resident #1] said about the CNA. The nurse said she would report it to the DON. I stayed with her that night [2/25/2023] and [Resident #1] pointed the CNA out to me when she came in the room. The CNA was an older woman with long gray hair, her name was [CNA #2]. On Monday, 2/27/2023 we [Family Member #1 and Family Member #5] met with the DON in her office. She [DON] told us [CNA #2] would not be taking care of [Resident #1] anymore because we were moving to a private room that wasn't on [CNA #2]'s assignment. She [DON] told us she was going to investigate the incident and turn it in to the State. After she said that, she called the Social worker and the Administrator into the office and told them about the incident. The Social worker said she would make arrangements to move [Resident #1] right away. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Unspecified Intracranial Injury with Loss of Consciousness Status Unknown Subsequent Encounter, Unspecified Fracture of Left Acetabulum Subsequent Encounter for Fracture with Routine Healing, Pain in Left Hip, and Unspecified Injury of Bladder Subsequent Encounter. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated no cognitive impairment. During an interview on 4/3/2023 at 3:45 PM, Family Member #3 stated, I was on the phone with my dad [Resident #5], and a staff member come in the room and started yelling at him regarding pressing his call light too many times. Family Member #3 stated that the Resident #5 started crying and was confused on why he was being yelled at, so she hung up and called the facility immediately to report what had just happened. Family Member #3 stated that she spoke with the nurse on duty and was told that the tech would be reassigned and would not provide care for [Resident #5] anymore. During an interview on 4/4/2023 at 3:30 PM, LPN #1 stated, I wasn't working down on that hall, but I went down there when I got the call. [CNA #1] was working, and she has a tendency of speaking loudly. I [LPN #1] reported the incident to the DON, but I don't remember an investigation being done. The DON and I [LPN #1] met with the family the following week and informed the family that [CNA #1] would no longer be providing care to [Resident #5]. During an interview on 4/5/2023 at 9:35 AM, Resident #5 stated that a CNA came into his room and yelled at him regarding pressing his call light too many times. Resident #5 stated the CNA spoke very loudly with him. Resident #5 stated that his daughter was on the phone with him and called the facility to report what happened immediately. Resident #5 stated, After the incident, I felt uncomfortable pressing call light when I needed help. During an interview on 4/4/2023 at 4:11 PM, the DON confirmed the definitions of abuse according to the facility policy. She stated verbal abuse included talking mean to a resident and mistreatment of a resident. She stated, If a resident alleges abuse by a staff member, the staff member would be suspended pending an investigation. The DON confirmed she did not report or investigate an allegation of abuse made by Resident #1 and Resident #5. She stated she remembered a meeting in her office between Resident #1's family members and administration. She was unable to recall why Resident #1's family members did not want CNA #2 to take care of Resident #1. The DON also stated that she didn't remember meeting with Resident #5 or Resident #5's family.

Based on facility policy review, observation, and interview, the facility failed to follow infection control guidelines to minimize the risk of potential exposure to the Coronavirus (COVID-19) for 75 residents. The facility also failed to properly dispose of a urinary catheter drainage system in a manner to prevent transmission of potential infectious agents for 1 of 5 sampled residents (Resident #54) requiring a urinary catheter. The findings include: Review of the facility's policy titled, Coronavirus (COVID 19) ([CONDITION(S)]-CoV-2) revised 9/6/2022, revealed, .to minimize the risk of potential exposure to the Coronavirus .All recommended COVID-19 PPE [Personal Protective Equipment] should be worn during care of residents under quarantine, which includes use of an N95 or higher-level respirator . Observation of #206's bathroom and interview on 9/12/2022 at 12:15 PM, Licensed Practical Nurse (LPN) #3 was wearing a KN95 (type of face covering made in China, not approved by NIOSH [National Institute of Occupational Safety and Health]) mask and goggles while in patient care areas. She stated the KN95 mask was appropriate PPE. Observation and interview on 100 Hall on 9/12/2022 at 12:20 PM, revealed Certified Nursing Assistant (CNA) #4 entered a room with Transmission Based Precautions (TBP). She donned goggles, mask, gown and gloves before entering the room. During an interview at 12:23 PM, CNA #4 stated she donned a KN95 mask when she entered the TBP room. She confirmed the TBP signage required the use of an N95 mask. During an interview on 9/12/2022 at 12:27 PM, Registered Nurse (RN)/Staffing Development Coordinator stated staff was required to wear an N95 mask and face covering or goggles in the facility when in patient care areas. Observation of 100 Hall on 9/12/2022 at 1:33 PM, revealed Physical Therapist (PT) #1 wearing a KN95 mask while providing care for a resident ambulating in the hall. During an interview on 9/12/2022 at 1:33 PM, PT #1 stated she understood the KN95 mask was all that she needed and confirmed she was wearing a KN95 mask. Review of the facility policy titled, Condom Catheter Application, reviewed 8/22/2022, revealed, .facility will provide Condom Catheter Application in accordance with professional standards of practice .facility will utilize the [Named] procedure . Review of facility documentation titled, External Urine Collection Device Use, Male, revised 11/19/2021, revealed, .Removing the device .Discard the device and drainage bag in an appropriate receptacle . Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. Continued review revealed the resident had an external catheter, and was always incontinent of urine. Review of the Comprehensive Care Plan for Resident #54 revealed, .Potential for complications related to incontinence .orders for condom catheter . Review of the current Order Summary Report for Resident #54 revealed, .8/5/2022 .Ok to use Condom Catheter every shift for Incontinence . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in Resident #54's bathroom on 9/12/2022 at 12:08 PM, revealed a urinary drainage bag and tubing laying on top of clothing in a wheelchair. The tubing and bag had white cloudy debris inside. Observation and interview in Resident #54's bathroom on 9/12/2022 at 12:15 PM, Licensed Practical Nurse (LPN) #3 stated the urinary drainage bag and tubing looked dirty and confirmed the used urinary drainage bag was in the wheelchair. During an interview on 9/13/2022 at 4:45 PM, the Director of Nursing (DON) stated she expected staff to follow Professional Standards of Practice for Infection Control when caring for residents. She confirmed storing a used urinary drainage bag in a chair was not in accordance with Professional Standards of Practice.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure dignity for 1 of 5 sampled residents (Resident #30) who required an indwelling urinary catheter. The findings include: Review of the facility's policy titled, Resident Rights, dated 5/6/2021, revealed, .The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . Review of the facility's policy titled, Indwelling Urinary Catheter (Foley) Management, dated 8/22/2022, revealed, .The facility will ensure that residents admitted with urinary catheter, .the facility must ensure that residents receive treatment and care in accordance with professional standards . Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #30 had an indwelling catheter. Observation in Resident #30's room on 9/12/2022 at 12:30 PM, revealed Resident #30's catheter bag was on the left side of the bed without a privacy cover. Observation in Resident #30's room on 9/13/2022 at 12:30 PM, revealed Resident's #30 catheter bag was on the right side of the bed without a privacy cover. During an interview on 9/13/2022 at 9:41 AM, Licensed Practical Nurse (LPN) #1 confirmed Resident #30's catheter bag was not covered with a privacy cover.

Based on facility policy review, medical record review, and interview, the facility failed to ensure a new Pre-Admission Screening and Resident Review (PASARR) screen was completed after an identified mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's policy titled, PRE-ADMISSION SCREENING and RESIDENT REVIEW [PASARR], dated 8/7/2021 revealed, .[PASARR] is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care .the facility is required to notify the appropriate state mental health authority or state intellectual disability authority when a resident with a mental disorder [MD] or intellectual disability [ID] has a significant change in their physical or mental condition . Review of the medical record revealed Resident #16 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #16 received an antipsychotic over the last 7 days. Review of Resident #16's current Order Summary Report revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's Psychiatric Evaluation dated 4/29/2022, 6/3/2022, 6/17/2022, 6/28/2022, and 7/8/2022 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's PASARR revealed, .Check any or all of the following mental health conditions that are diagnosed or suspected for this individual now or in the past .Depression . Review of the medical record revealed Resident #82 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS dated [DATE] revealed Resident #82 had a BIMS score of 13 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #82 received an antipsychotic and antidepressant over the last 7 days. Review of Resident #82's current Order Summary Report revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #82's PASARR revealed .Check any or all of the following mental health conditions that are diagnosed or suspected for this individual now or in the past .No mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .yes .[MEDICATION(S)] . During an interview on 9/14/2022 at 12:10 PM, Social Service Director confirmed Resident #82's PASAAR was not correct and should be updated. During an interview on 9/14/2022 at 2:45 PM, Executive Director confirmed Resident #16's PASARR was not correct and should be updated.

Based on facility policy review, documentation review, medical record review, observations, and interviews, the facility failed to provide Activities of Daily Living (ADL) care for 1 of 24 sampled residents (Resident #30) reviewed. The findings include: Review of facility's policy titled, Activities of Daily Living (ADLs), dated 8/22/2022, revealed, . Assist resident with bed/wheelchair repositioning as necessary to promote good body alignment and prevent skin breakdown . Review of the undated facility documentation titled, Area of Focus: Basic Skin Management, revealed, .All residents have preventive measures in place that include pressure redistribution mattresses on all beds, wheelchair cushion, heel boots or suspension if needed, frequent repositioning per CNA [Certified Nursing Assistant] and ADL care, incontinent care provided with skin cleansers/wipes and barrier cream application if needed . Review of facility's policy titled, Skin Integrity & Pressure Ulcer/Injury Prevention and Management, dated 4/19/2022, revealed, .Certain risk factors have been identified that increase a resident's susceptibility to develop or impair healing of pressure injuries .diabetes mellitus .reposition at least every 2 .as consistent with overall patient goal and medical condition . Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #30 required total assistance with two person physical assist with bed mobility. Continued review revealed the resident had one unhealed Stage 3 pressure ulcer. Review of Resident #30's Wound Center documentation dated 8/19/2022, revealed, .Off-loading .alternate from side to side every hour. Do not allow patient to lay flat on back . Observation on 9/13/2022 at 9:33 AM, 11:10 AM, 1:24 PM, and 2:20 PM, revealed Resident #30 was lying in the same position. Resident #30 was lying partially on her right side, wedge to left side of shoulder with head of bed elevated. During an interview on 9/12/2022 at 12:30 PM, Resident #30's family member stated, I am concerned about her bed sore. I come for 2 meals daily and she is not being turned every 2 hours. I was here most of the day yesterday and she was never turned while I was here. During an interview on 9/13/2022 at 1:45 PM, CNA #5 confirmed she was assigned to provide care for Resident #30. CNA #5 confirmed she had not turned and repositioned Resident #30 since she clocked in at 7:00 AM. During an interview in Resident #30's room on 9/13/2022 at 2:10 PM, Resident's family member confirmed she had not been turned or repositioned since he arrived at 12:00 PM. During an interview on 9/13/2022 at 2:30 PM, the Wound Care Nurse stated she provided wound care at 7:30 AM. She confirmed Resident #30 should be turned and repositioned every 2 hours. During an interview on 9/13/2022 at 2:45 PM, the Director of Nursing (DON) confirmed a dependent resident should be turned every two hours and as the resident desires.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's policy titled, Physician Orders, revised 3/17/2022, revealed .A physician, physician assistant or nurse practitioner must provide orders for the resident's immediate care and ongoing care of the resident. The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable and federal guideline .Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #589 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current Order Summary Report for Resident #589 revealed, .9/11/2022 Oxygen at 2 liters/minute continuously per nasal cannula. Document every shift for chronic [CONDITION(S)] . Observations in Resident #589's room on 9/13/2022 at 8:30 AM and 9:52 AM, revealed the oxygen flow was set to deliver 3 liters per minute. During an interview on 9/13/2022 at 9:52 AM, Licensed Practical Nurse (LPN) #2 confirmed resident #589's oxygen was set to deliver 3 liters per minute, and should have been set to deliver 2 liters per minute. During an interview on 9/13/2022 at 10:58 AM, Director of Nursing (DON) confirmed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/13/2022 at 1:40 PM, Family Member #1 confirmed he has never changed the oxygen settings.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to label oxygen tubing when changed for 1 of 10 sampled residents (Resident #589) reviewed. The findings include: Review of the facility's policy titled, Oxygen Administration/Safety/Storage/Maintenance, revised 8/2/2021, revealed, .Change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with patient name and dated when setup or changed . Review of the medical record revealed Resident #589 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current Order Summary Report for Resident #589 revealed an order to change oxygen tubing every Sunday night. Observations in Resident #589's room on 9/13/2022 at 8:30 AM, revealed the oxygen cannula tubing was not labeled or dated. Observation and interview in Resident #589's room on 9/13/2022 at 9:52 AM, Licensed Practical Nurse (LPN) #2 confirmed resident #589's oxygen tubing was not labeled or dated. During an interview on 9/13/2022 at 10:58 AM, Director of Nursing (DON) confirmed oxygen tubing should be changed weekly on Sunday night and should be labeled and dated.

Based on facility documentation review and interview the facility failed to ensure there was a Registered Nurse (RN) on duty for 8 consecutive hours a day, 7 days a week for the 18 months reviewed. The findings include: Review of the daily staffing sheets from 3/1/2021-9/13/2022, revealed the following days 6/18/2021, 7/12/2021, 7/16/2021, 7/17/2021, 7/26/2021, 7/31/2021, 8/1/2021, 7/30/2021, 8/5/2021, 8/9/2021, 8/10/2021, 8/17/2021, 8/18/2021, 8/19/2021, 8/28/2021, 8/29/2021, 10/1/2021, 10/8/2021, 10/9/2021, 10/10/2021, 10/18/2021, 10/19/2021, 10/23/2021, 10/24/2021, 11/19/2021, 12/31/2021, 6/18/2022, and 7/2/2022 without 8 consecutive hours of RN coverage. During an interview on 9/13/2022 at 9:24 AM, Executive Director confirmed facility should have 8 hours of RN coverage.

Based on facility policy review, facility documentation review, observations, and interviews, the facility failed to have the Daily Nurse Staffing form posted for 1 of 3 days of survey. The findings include: Review of the facility policy titled, Staffing, dated 7/27/2022, revealed, .The facility posts daily staffing information in a clear readable format in a prominent place that is easily accessible to residents and visitors at any given time . Observation on 9/12/2022 at 1:00 PM and 4:30 PM, there was no Daily Nurse Staffing form posted. During an interview on 9/12/2022 at 4:54 PM, Staffing Coordinator and Registered Nurse #1 confirmed that Daily Nurse Staffing form was not posted.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medication was stored properly for 1 of 24 sampled residents (Resident #43) reviewed. The findings include: Review of the facility's policy titled, Administration of Medications, revised 5/6/2022, revealed, .facility will ensure medications are administered safely and appropriately per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed there was no assessment completed for Self Administration of Medication. Review of the Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Review of the Comprehensive Care Plan for Resident #43 revealed, .resident has a swallowing problem r/t [related to] Complaints of difficulty or pain with swallowing .resident is at risk for aspiration . Review of the Order Summary Report for Resident #43 revealed the resident did not have an order to self administer medications and no order for the resident's daughter to administer medications. Observation and interview in Resident #43's on 9/12/2022 at 1:50 PM, revealed a medicine cup containing medication, sitting on the table in front of the resident. Resident #43 stated the nurse leaves the vitamins in the room for her daughter to administer to her. Continued interview family member #2 stated the vitamins are difficult for Resident #43 to swallow. She stated the nurses always leaves the vitamins for her to give throughout the day. Observation and interview in Resident #43's room on 9/12/2022 at 1:58 PM, revealed Unit Manager #1 confirmed the medicine cup containing medication had been left in the resident's room. During an interview on 9/12/2022 at 3:40 PM, the Director of Nursing (DON) stated she had reviewed Resident #43's medical record and confirmed there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on facility policy review, observations, and interview, the facility failed to dispose of expired food items in the nourishment room refrigerators. The findings include: Review of the facility's policy titled, Safe Food Handling, revised [DATE], revealed, .All food purchased, stored and distributed is handled with accepted food-handling practices .Snacks and other food items sent from the foodservice department will be handled safely in regard to temperature, labeling and storage . Review of the facility's staff information poster regarding Use By Date, revealed, .Thickened Liquids Use By Date 7 days .Once the supplement/thickened liquid reaches it's use by date, throw it in the trash can . Observation and interview in the 100 Hall nourishment room on [DATE] at 11:20 AM, there was an opened carton of thickened apple juice with an opened date of [DATE]. The Registered Dietician (RD) confirmed the opened date of the apple juice was [DATE]. She confirmed that the apple juice was expired. Observation and interview in the 200 Hall nourishment room on [DATE] at 11:25 AM, there was an opened carton of thickened sweet tea with an opened date of [DATE]. The RD confirmed the thickened sweet tea was expired.

Based on review of CDC Guidelines, facility policy review, record review, observations, and interviews the facility failed to ensure effective infection control practices were followed to monitor and prevent the spread of Covid-19 to residents and staff in the facility. The findings included: Review of the CDC (Center for Disease Control and Prevention) publication titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated [DATE], revealed, .Healthcare facilities responding to [CONDITION(S)]-CoV-2 transmission within the facility should always notify and follow the recommendations of public health authorities .When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority . Asymptomatic residents with close contact with someone with [CONDITION(S)]-CoV-2 infection, regardless of vaccination status, should have a series of two [CONDITION(S)] tests for [CONDITION(S)]-CoV-2 infection. In these situations, testing is recommended immediately (but generally not earlier than 24 hours after the exposure) and, if negative, again ,d+[DATE] days after the exposure .Educate residents and families through educational sessions and written materials on topics, including information about [CONDITION(S)]-CoV-2, actions the facility is taking to protect them and their loved ones from [CONDITION(S)]-CoV-2, and actions they should take to protect themselves and others in the facility, emphasizing when they should wear source control, physically distance, and perform hand hygiene .Notify HCP, residents, and families promptly about identification of [CONDITION(S)]-CoV-2 in the facility and maintain ongoing, frequent communication with HCP, residents, and families with updates on the situation and facility actions. Review of the CDC publication titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated [DATE], revealed, .If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-level or group-level (e.g., unit, floor, or other specific area(s) of the facility) .Broader approaches might also be required if the facility is directed to do so by the jurisdiction ' s public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission .Perform testing for all residents and HCP on the affected unit(s), regardless of vaccination status, immediately (but generally not earlier than 24 hours after the exposure, if known) and, if negative, again ,d+[DATE] days later . Review of the facility policy titled, Coronavirus (COVID 19) ([CONDITION(S)]-CoV-2), reviewed [DATE], revealed, .To provide a framework to minimize the risk of potential exposure to the Coronavirus .in the long-term care facility .Effective cohorting of residents (e.g., separate areas dedicated COVID-19 care) .Resident and staff testing conducted as required .Inform residents, their representatives, and families of those residing in facilities by 5 P.M. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other .each time a confirmed infection of COVID-19 is identified .Close Contact refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period . Review of the facility policy titled, COVID-19 Outbreak Investigation, reviewed [DATE], revealed, .To provide guidance on how to perform outbreak testing during a newly identified case of an Associate or resident with COVID-19 .Close Contact refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minute or more over a 24-hour period .must test residents and facility staff .Broader approaches might also be required if the facility is directed to do so by the jurisdiction's public health authority .when contact tracing fails to halt transmission . Review of the facility document titled, COVID + [positive] Residents/Associates since [DATE]. revealed there were 28 Residents and 12 Associates that tested positive for Covid-19 between [DATE] and [DATE]. Review of the facility document titled, Infection Surveilance Line Listing Report, dated [DATE]-[DATE], revealed 3 identified Coronavirus Disease 2019 (Covid-19) infections. All infections listed were resident involved. Review of the facility document titled, Abt [antibiotic] Tracking, dated ,d+[DATE] and ,d+[DATE], revealed 13 identified Covid-19 infections. All infections listed were resident involved. Review of the facility PI (Performance Improvement) Meeting minutes dated [DATE], revealed, .Health Department Recommendation test 100 % [percent] of facility, committee will follow CDC guidelines and Life Care Center of America testing guidelines . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day MDS assessment dated [DATE], revealed Resident #7 had a BIMS score of 13, which indicated no cognitive impairment. Resident #7 required supervision to extensive assistance of one person physical assist with ADLs. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 had a BIMS score of 14, which indicated no cognitive impairment. Resident #9 required extensive assistance of one person physical assist with all ADLs. Observation of the Infection Control Notebook kept by the Infection Control Preventionist (ICP) revealed the dates of resident positive Covid-19 test. No documentation of contact tracing noted during observation. During an interview on [DATE] at 9:00 AM and at 3:18 PM, the Infection Control Preventionist (ICP) stated there were currently 3 residents on isolation related to Covid-19 positive testing. She stated the facility followed an isolate in place policy for the residents rather than a designated care area/unit. She stated there had been no facility wide testing as recommended by the Health Department. She stated the only people tested were the symptomatic residents and staff. She stated the unvaccinated staff are tested twice weekly. She stated Resident #6 had been sent to the hospital and expired there due to Covid-19. She stated he had acquired Covid-19 during a stay in the hospital prior to the most recent stay. She confirmed Resident #6 was not isolated when he returned from the hospital prior to testing positive to Covid-19. She stated he had been vaccinated and was not required to be isolated upon returning from the hospital. She stated the policy for new/readmissions was to be tested on the day of admission, day 5 following admission and day 12 following admission. She confirmed there was no documentation of Resident #6 being tested on the day of readmission. She stated she used the contact based tracking method during the recent Covid-19 outbreak. She stated she had asked staff if they had been in direct contact with Covid-19 positive residents for 15 minutes at one time. She stated during the recent outbreak she had tested on e nurse and two Certified Nursing Assistant (CNA)s that had answered yes to the question related to close contact. She was then asked to read the facility definition of close contact and confirmed it referred to 15 minutes of cumulative contact within 24 hours. She stated there was an application on the computer that she completed with the Covid-19 positive cases. She stated she also wrote the Covid-19 positive results in a notebook. She stated that she did not map or track the current Covid-19 outbreak physically or on the computer. She confirmed the facility did not use an adequate method of tracking the recent Covid-19 outbreak. She confirmed there were a total of 28 residents and 12 staff members that tested positive for Covid-19 from [DATE] through [DATE], and 1 reported death. During an interview on [DATE] at 10:08 AM, the Administrator stated the facility had been investigated recently by OSHA (Occupational Safety and Health Administration) related to allegations of improper infections control methods for taking care of Covid-19. He stated he did not have the report related to the investigation back at this time. He stated the facility had recently accepted a CDC (Centers for Disease Control and Prevention) consultation related to the high number of Covid-19 positive cases and 1 death related to Covid-19 reported via NSHN (National Healthcare Safety Network). He stated the consultation has not been completed at this time. During a telephone interview on [DATE] at 11:17 AM, the complainant/also known as an Epidemiologist with the State of Tennessee Department of Health, stated she had spoken to the DON and the ICP (Infection Control Preventionist) at the facility several times. She stated she had recommended measures which included facility wide testing instead of the contact based tracking during the recent outbreak due to the high number of Covid-19 positive residents and staff. She stated despite her recommendations the facility continued to have poor tracking methods and testing during the outbreak. During an interview on [DATE] at 10:39 AM, Resident #9 stated she had not been questioned about close contacts related to Covid-19 after she tested positive. During an interview on [DATE] at 11:10 AM, Resident #7 stated he had tested positive for Covid-19 after going out to the doctor. He stated no one had ever asked him about the people he had been around in the facility. During an interview on [DATE] at 3:51 PM, CNA #1 stated she had not been questioned by anyone about being in direct contact with the Covid positive residents and coworkers for 15 minutes during her shift. During an interview on [DATE] at 5:26 PM, CNA #2 stated she was tested for Covid-19 because she had symptoms. She stated she was positive for Covid-19. She stated she had not been questioned by anyone related to direct contact for 15 minutes with any of the Covid-19 positive residents or employees. During an interview on [DATE] at 5:47 PM, Licensed Practical Nurse (LPN) #1 stated she had not been questioned by anyone related to direct contact for 15 minutes with any Covid-19 positive resident or employee. During an interview on [DATE] at 6:06 PM, CNA #3 stated she had not been questioned about close contacts when she tested positive for Covid-19. During an interview on [DATE] at 6:23 PM, CNA # 4 stated she tested at the facility because she was having symptoms and was positive for Covid-19 on [DATE]. She stated she was not questioned about direct contact with anyone with or without Covid. During an interview on [DATE] at 6:33 PM, CNA #5 stated she had not been questioned about close contact with Covid-19 positive staff or residents. During an interview on [DATE] at 1:42 PM, the DON stated the Department of Health had recommended a broad based method of infection control preventive measures which included Covid-19 testing. She stated the Department of Health contact alleged the facility's current contact tracing method was not adequate. She confirmed the Administrator had decided not to follow the recommendations of the Epidemiologist with the Department of Health.

Based on medical record review and interview, the facility failed to complete a comprehensive admission Minimum Data Set (MDS) to assess a resident's needs for pressure ulcers for 1 resident (#90) of 3 residents reviewed for pressure ulcers of 28 residents reviewed. The facility's failure resulted in Harm to Resident #90. The findings included: Medical record review revealed Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the resident was discharged home on[DATE]. Medical record review of the Initial Data Collection Tool/Nursing Service dated 10/2/15 revealed .Open [MEDICAL CONDITION] .Coccyx .unstaged red ulcer (coccyx) .RN (Registered Nurse) Completing Form (and the form was not signed as completed by an RN) . Medical record review of the Nurse's Note dated 10/2/15 revealed .skin assessment completed .unstaged area to coccyx . Continued review of the Nurse's Note dated 10/2/15 revealed the note was signed by Licensed Practical Nurse (LPN) #1. Medical record review of a History and Physical Note by the Nurse Practitioner (NP) dated 10/5/15 revealed .Endorses painful pressure sores at his buttocks .wounds clean and covered in dressings . Medical record review of the admission MDS dated [DATE] revealed the resident had one unstageable pressure ulcer. Medical record review of Section V (Care Area Assessment) revealed there was no documentation of the analysis of findings to indicate where the pressure ulcer was located, the risk, causes or contributing factors related to the pressure ulcer. Medical record review of the Pressure Ulcer Status Record dated 10/14/15 revealed Date first observed: Admit .coccyx/sacrum .(unstageable) surface area 3 x (by) 3 .Depth 0 .Granulation 0 .(percent) necrotic tissue 100 (percent) . Medical record review of the Treatment Administration Record dated October 2015 revealed no documentation treatment had been provided to the pressure ulcer on the coccyx until 10/15/15. Interview with Registered Nurse (RN) #1 on 3/23/16 at 10:20 AM, in the Admission Office, confirmed Section V of the admission MDS was not complete. Refer to F-314

Based on review of facility policy, medical record review, and interview, the facility failed to promote healing and prevent decline of a pressure ulcer for 1 (#90) of 3 residents reviewed for pressure ulcers of 28 residents reviewed. The facility's failure resulted in Harm to Resident #90. The findings included: Review of the facility policy Assessment of Wounds . revealed .It is the responsibility of a licensed nurse to complete the wound assessment and to document the findings on the Treatment Record-Wound Assessment .Assessment and documentation are completed upon admission, re-admission, weekly, and PRN (as needed) .Pressure ulcers are staged . Medical record review revealed Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home on[DATE] with Home Health Services. Medical record review of the Braden Scale for Predicting Pressure Ulcer Risk dated 10/2/15 revealed the resident was at risk for pressure ulcers. Medical record review of the Initial Data Collection Tool/Nursing Service dated 10/2/15 revealed .Open [MEDICAL CONDITION] .Coccyx .unstaged red ulcer (coccyx) .RN (Registered Nurse) Completing Form (and the form was not signed as completed by an RN) . Medical record review of the Nurse's Note dated 10/2/15 revealed .skin assessment completed .unstaged area to coccyx . Continued review of the Nurse's Note dated 10/2/15 revealed the note was signed by Licensed Practical Nurse (LPN) #1. Medical record review of a History and Physical Note by the Nurse Practitioner (NP) dated 10/5/15 revealed .Endorses painful pressure sores at his buttocks .wounds clean and covered in dressings . Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had one unstageable pressure ulcer. Medical record review of the Pressure Ulcer Status Record dated 10/14/15 revealed Date first observed: Admit .coccyx/sacrum .(unstageable) surface area 3 x (by) 3 .Depth 0 .Granulation 0 .(percent) necrotic tissue 100 (percent) . Medical record review of the Treatment Administration Record dated October 2015 revealed no documentation treatment had been provided to the pressure ulcer on the coccyx until 10/15/15. Medical record review of a Physician's Order dated 10/15/15 revealed .Wound to sacrum with slough present. Clean site. Cover wound bed with alginate (absorbent dressing). Secure with [MEDICATION NAME] or duoderm (opaque dressing for wounds). Change every 3 days and prn (as needed) . Medical record review of a Physician's Order dated 10/16/15 revealed .cleanse sacrum/coccyx with normal saline, apply santyl ointment (ointment to clean the wound) 3x (times) week and prn .D/C (discontinue) previous tx (treatment) orders . Medical record review of a Physician's Progress Note dated 10/20/15 revealed .Endorses a painful wound at his coccyx. He endorses that this wound has been present for an unknown duration but was being treated at the hospital .The sacral wound is annular (ring shaped) and covers the entirety of the sacral skin .This is largely an unblancheable [DIAGNOSES REDACTED] with central erosion to the SQ (subcutaneous) tissues .I repositioned him in bed today and he is to alternate weight with a pillow. Nursing will prompt him in this regard but he has the strength to reposition appropriately . Medical record review of a Physician's Order dated 10/21/15 revealed .air mattress . Medical record review of the Pressure Ulcer Status Record dated 11/3/15 revealed .(unstageable) .surface area 4 x 3.8 .depth 0.5 .color yellow .Tunneling 12 (o'clock)-2 cm (centimeters) 3 (o'clock) -2 cm 6 (o'clock) - 0.5 cm 9 (o'clock) - 1 cm . Medical record review of a Physician's Order dated 11/5/15 revealed .Apply wet to dry drsg (dressing) to coccyx .and santyl (change daily) . Medical record review of a Physician's Order dated 11/11/15 revealed .continue wet to dry drsg: clean (with) NS (Normal Saline), pat dry, apply wet to dry drsg to coccyx (change) daily (and) prn . Medical record review of the Pressure Ulcer Status Record dated 11/23/15 revealed .surface area 3.5 x 3 .Depth 1cm .Tunneling 12 (oclock) - 1 cm 3 (o'clock) - 0.2 6 (o'clock) - 2 cm 9 (o'clock) - 0.8 (cm) . Medical record review of the 60 day MDS dated [DATE] revealed the resident had a stage 4 pressure ulcer. Medical record review of the Physician's Discharge Summary dated 12/1/15 revealed .stable to modestly improved stage (4) sacral decubitus .at time of discharge his wound is healing nicely . Interview with LPN #1 on 3/22/16, at 2:10 PM, in the conference room, confirmed the wound on the coccyx on 10/2/15 was very red, LPN #1 did not know how to stage a wound, and the RN or wound care nurse was to follow up and complete the wound assessment. Interview with the Director of Nursing (DON) on 3/22/16 at 2:15 PM, in the conference room, confirmed the wound assessment had not been completed by the RN and the assessment of the wound was incomplete. Interview with the NP on 3/23/16 at 9:00 AM by telephone, confirmed the NP did not remember the type of dressing on the coccyx wound as documented on the History and Physical Note dated 10/5/15. Continued interview with the NP confirmed wounds present and not treated would be a problem. Interview with the Assistant Director of Nursing (ADON) (nurse who completed the Pressure Ulcer Status Record on 10/14/15) on 3/23/16 at 9:30 AM, in the conference room, confirmed the ADON had not observed the wound on the coccyx prior to 10/14/15. Interview with the DON on 3/23/16 at 9:50 AM, in the DON's office, revealed the facility had discovered a problem with gaps in treatment to wounds on 10/12/15 and there was no documentation to indicate treatment had been provided to the pressure ulcer on the coccyx prior to 10/15/15.