Every finding on record at Lily Springs Rehabilitation and Healthcare Center

Based on interview and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the residents through the means other than a postal service for 12 of 12 confidential residents reviewed for weekend mail delivery. The facility failed to ensure residents received their mail on the weekend, within 24 hours of delivery by the postal service. This failure could place residents at risk for not receiving mail in a timely manner that could result in a decline in residents' psychosocial well-being and quality of life.Findings included: During a confidential group interview on 06/23/26 at 09:38 AM, 12 of 12 residents stated mail was not distributed on Saturdays. They stated the mail delivered on Saturday did not get distributed until Monday or even picked up until Monday. The residents stated mail was distributed Monday through Friday only for what was delivered. During an interview on 06/24/26 at 01:19 PM with the AD, she confirmed that at one point there was no mail being distributed to residents on the weekends, however, recently there was a process change and that all of the leadership staff over every department was told that whomever the manager was on the weekend was responsible for distributing resident mail. She stated that mail was not being distributed on weekends because the BOM was concerned certain items belonging to her such as payments to the facility would go missing. The AD stated she believed mail was now being delivered/distributed on the weekends to residents by the department heads/ manager on duty. The AD stated it was a resident right to receive mail in the facility, including on weekends. She stated some residents relied on the weekend mail for activities such as books or other items they were expecting and if they didn't get it could lead them to become upset or disappointed. During an interview on 06/24/26 at 01:40 PM with the SW, she stated she was a department head and was a manager on duty on the weekend some times since all the department heads rotated. She stated she was recently the manager on duty at the beginning of the month in June 2026. She stated she did not deliver mail on the weekend; and further stated the manager on duty on the weekend would assist with meal trays, supervise meals and help the charge nurse in the halls with trays or dining room, would assist in rounds or answering call lights. The SW stated she was not assigned to mail delivery and did not know who was assigned to mail delivery on weekends. She stated weekend mail delivery as a resident right. She stated if she were a resident and she was not getting mail she would question why the mail was not being delivered. She stated the mailbox was not locked and any staff as able to get the mail and distribute It to residents. During an interview on 06/24/26 at 01:49 PM with the ADM, he stated it was the responsibility of the weekend manager on duty to deliver mail to the residents if any arrived on Saturday. He stated there was an in-service completed on 05/29/26 to all department heads training them on their duty to deliver mail on the weekend. He stated after reviewing the in-service, the SW had not been trained or signed off on the in-service for delivering mail. He stated weekend mail delivery was a resident right and he was not aware of it not being delivered. The ADM stated that if residents were not getting mail on weekends, it had the potential to cause some grief or frustration. Review of a separate Nursing Facility Resident Rights policy dated 3/6/26 reflected:The following rights are guaranteed to residents of Texas nursing facilities under federal law and Texas law. Facilities are required to protect and promote these rights for every resident.To send and receive unopened mail.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation in that: The facility failed to ensure scoops for dry storage food bins were stored separately. The facility failed to ensure expired food items were removed from dry storage and discarded. The facility failed to ensure a box of sugar was sealed in a manner that prevented contamination. The facility failed to ensure 6 bags of tortillas were free of contamination which resulted in permanent marker used to date bleeding through into the food. The facility failed to ensure the DC washed his hands and changed his gloves during food preparation after touching contaminated surfaces. These failures could place residents who received prepared meals from the kitchen at risk for foodborne illness and cross-contamination.The findings included: During an initial tour on 06/22/26 beginning at 09:00 AM of the one and only kitchen revealed:3 large, clear, plastic bins containing corn bread, sugar, and rice in the dry storage were observed with scoops/metal bowls left inside the bins with the food.A large white box of sweet potatoes with the receive date of 05/28/26 written in black marker was observed full of spoiled sweet potatoes that had sprouted and observed with large soft areas of spoilage/mold on them.1 large box of sugar was observed open and exposed to room air. There was a bag in the box holding the sugar but was left open. There was sugar out of the bag (but still in the box) mixed with dark crumbs/unknown substance.6 bags of flour tortillas were observed and ; the bags were clear/see through and labeled with black marker 6/4/26which bled through the bag and onto the tortillas leaving them with large black smudge areas from marker. During a follow-up observation of the kitchen on 06/22/26 at 10:40 AM the DC was observed completing the preparation of the pureed food for lunch service, which included pork chops, beans, turnip greens, and bread. After each pureed item the DC was observed rinsing the blender, blade, and spatula in the 3-compartment sink before going and placing items on a tray and into the dishwasher. The DC would then grab the blender and move onto the next food item puree without washing his hands or changing his gloves after handling items in the 3-compartment sink (soiled dishes) and touching the dishwasher. After completing the last pureed food item, the bread, the DC was observed leaving the completed pureed food item at the workstation, cleaning the blender and blade in the 3 compartment sink before putting it into the dishwasher; then was observed handling a bucket of dirty sanitizer liquid that he disposed of in the 3 compartment sink, filling it with new sanitizer and wiping down the prep counter, and then returning to handling the pureed bread and covering it with plastic wrap all without washing his hands or changing gloves throughout the process of handling contaminated items. The DC was then observed taking food temperatures of all the food items on the steam table. After each item that he took the temperature of he would walk to the 3 compartment sink to rinse the probe before walking back to the steamtable to wipe the probe with an alcohol swab. He was observed dripping with water from the 3 compartment sink and each time failed to wash his hands or change gloves after working in the 3 compartment sink. During an interview on 06/22/26 at 09:21 AM with the DM, she stated that scoops were not supposed to be left inside the containers as it could result in contamination and they were supposed to be stored separately. She stated she personally checked the dry storage room weekly at minimum every Monday. She stated the last time she checked the potatoes they had not appeared moldy or spoiled. She stated she recently changed from regular to industrial sharpies and did not realize that they were bleeding into the food. She stated that the sugar that was left open should be closed to prevent contamination. She said these failures had the potential to cause cross contamination of resident food. During an interview on 06/22/26 at 11:22 PM with the DC, he stated he did not change gloves or wash his hands during the pureed meal observation because he was not touching the food directly. He stated as long as he was not coming into contact with the actual food and only their containers there was no risk of cross contamination. During an interview on 06/22/26 at 11:25 PM with the DM, she stated it was her expectation that gloves were changed and hands were washed in between tasks. She stated that glove use or hand sanitizer was not a substitute for handwashing. She stated the DC should have changed his gloves and washed his hands after touching contaminated surfaces such as the 3-compartment sink or dishwasher before returning to food preparation. She stated a negative outcome of failing to wash hands or change gloves would be bacteria or allergens could spread and cross contamination with chemicals and resident food. During an interview on 06/22/26 at 11:32 PM with the RDN, she stated it was her expectation that expired food was removed and discarded. She stated that scoops should be kept separate and not left in the bins with dry food. She stated that hands should be washed and gloves were to be changed in between tasks. She stated wet hands should not be dripping into the food or on food items. The RDN stated that gloves were not a substitute for handwashing. She stated that she observed the DC not changing his gloves or washing his hands during food preparation while observed by surveyors. She stated a negative outcome of not washing hands or changing gloves would be infection control issues and cross contamination of resident food. During an interview on 06/24/26 at 01:49 PM with the ADM ,he stated that scoops were not to be stored with the dry food in the bins. He stated that the expectation was they were to be in a bag or pocket beside the container for which it belonged. He stated it was for sanitation reasons and it was not standard for them to be stored in the container with food and he could not guarantee they had been sanitized if left in the container. The ADM stated that sugar arrived in a sealed bag and that it was the expectation that it was poured into a clean bin and covered. He stated that the DM was responsible for checking the dry storage area at least weekly and that all expired food was to be removed and disposed of. The ADM stated that sharpie can be used but if writing on clear plastic it was best to use a label they could write on to prevent it from bleeding into the food. The ADM stated that while doing food preparation the expectation was to sanitize/wash hands and glove up and staff should complete the task of making the food item and then proceed to clean the equipment. He stated wearing gloves was not a substitute for hand washing. He stated glove use and regular handwashing was used to prevent the spread of infection. He stated handwashing should occur before donning gloves and after disposing of gloves and anytime you see something on your hands. He stated if staff were in the process of doing temperature checks and working with food they needed to ensure their hands remained clean to prevent cross contamination. Review of the facility policy titled Food Receiving and Storage Policy last revised on 03/05/26 reflected: The facility will ensure that all food received, stored, and maintained in the facility is handled safely, protected from contamination, and maintained at appropriate temperatures to ensure food quality and resident safety. Food storage area, refrigerators, freezers, and dry storage rooms will be maintained in a sanitary condition and monitored to ensure compliance with safe food handling practices. Opened containers must be sealed or covered and dated. Expired foods must be immediately removed from storage. Foods stored in bins must be removed from original packaging and place in clean labeled bins or kept in the original packaging with proper labeling and dating. Opened foods must be tightly sealed and dated. Review of the facility policy titled Food Preparation- Dining Services last revised on 12/2020 reflected: Safe food handling and preparation shall be maintained to prevent food borne illness. Sanitation and safe food handling procedures shall be observed during meal preparation:Hands and surfaces shall be washed often. Avoid cross contamination:Foods shall be prepared with the least possible manual contact, with suitable utensils, and on surfaces that have been cleaned, rinsed, and sanitized prior to use. Review of the facility policy titled Handwashing-Hand Hygiene Policy and Procedures last revised on 10/2020 reflected: This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The use of gloves does not replace hand washing/ hand hygiene. Integration of glove use along with routine. Hand hygiene is recognized as the best practice for preventing healthcare associated infections. Applying and Removing Gloves:Perform hand hygiene before and after applying non-sterile gloves. Review of the 2022 U.S. Food and Drug Administration Food Code revealed:3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: P if(1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Of and(2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition.(A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it:(2) Is in a container or PACKAGE that does not bear a date or day; or3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation.FOOD shall be protected from cross contamination by:(4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings.

Based on observation, interview, and record review, the facility failed to establish policies, in accordance with applicable federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents for 5 of (Resident #19, Resident #22, Resident #60, Resident #58 and Resident #07) of 7 residents reviewed for smoking. The facility failed to implement their smoking policy and conducted smoking evaluations as required per the policy for Residents #19, #22, #60, #58, and #07. The failure could place residents at risk of injury, burns and fire accidents from unsafe smoking practices. Findings included:Resident #19:Record review of Resident #19's face sheet dated 06/23/26 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of Alzheimer's disease, ulcerative blepharitis (acute inflammation of the eyelids ) of right and left eyes, major depressive disorder, Huntington's disease (rare, inherited neurodegenerative disorder that causes the progressive breakdown of nerve cells in the brain), behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.Record Review of Resident #19's quarterly MDS dated [DATE] reflected BIMS of 03 which indicated that his cognition was severely impaired.Record review of Resident #19's care plan revised on 04/03/25 reflected that Resident #19 was at risk of injury due to his smoking preference. The relevant intervention was evaluating and monitoring safe smoke practices such as dexterity and coordination and evaluating his safe smoking ability.Record review of the smoking evaluations of Resident#19 revealed that the facility conducted a quarterly evaluation on 01/31/26. Resident #19's evaluation must be supervised while smoking as he had hand tremors and decreased finger dexterity due to Huntington's disease with history of accidents . During an observation on 06/23/26 at 1:10pm revealed Resident #19 was smoking outside in the smoking area. He was supervised by staff and needed moderate level of help in smoking the cigarette. The staff provided cigarettes and the smoking paraphernalia. An attempt to interview him was unsuccessful due to his cognitive capacity.Resident #22:Record review of Resident #22's face sheet dated 06/23/26 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of pain in unspecified joint, dementia, psychotic disturbance, mood disturbance, anxiety lack of coordination and muscle weakness.Record Review of Resident #22's quarterly MDS dated [DATE] reflected BIMS of 10 which indicated that his cognition was moderately impaired.Record review of Resident #22's care plan dated 09/09/25 reflected Resident #22 was at risk of injury due to his smoking preference. The relevant intervention was evaluating his safe smoking ability.Record review of the smoking evaluations of Resident#22 revealed that the facility conducted a quarterly evaluation on 09/09/25. The evaluation reflected that Resident #22 must be supervised while smoking as he had history of smoking in places that were not designated as a smoking area. He was unable to safely light and extinguish smoking materials. He had history of keeping cigarettes on him and in his room when coming back for outings, and when a friend brought them to him. There were no smoking evaluations performed on Resident #22 after 09/09/25. During an interview and observation on 06/23/26 at 1:10pm revealed Resident #22 was smoking outside in the smoking area. He was supervised by staff and needed a minimal level of help with smoking the cigarette. The staff provided cigarettes and the smoking paraphernalia. During the interview Resident #22 stated he loved smoking, however staff did not allow him to keep the cigarettes and lighter with him. He stated he was able to smoke unsupervised without any supervision and wished to keep cigarettes and lighter with him. Resident #60:Record review of Resident #60's face sheet dated 06/23/26 reflected a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE] with diagnoses of legal blindness, severe obesity due to excess calories, muscle weakness , difficulty in walking, lack of coordination and pain in unspecified joint.Record review of Resident #60's quarterly MDS dated [DATE] reflected BIMS of 14 which indicated his cognition was intact.Record review of Resident #60's care plan dated 10/17/24 reflected Resident #60 was at risk of injury due to his smoking preference. The relevant intervention was evaluating his safe smoking ability.Record review of the smoking evaluations of Resident #60 revealed that there was an annual evaluation conducted on 10/02/25 and confirmed that Resident #60 was a safe smoker. There was no smoking evaluations performed on Resident #60 after 10/02/25. During an interview and observation on 06/24/26 at 1:30pm revealed Resident #60 was smoking unsupervised outside in the smoking area with the company of Resident #58. He stated he was allowed to keep the cigarettes and lighter with him because he was a sensible smoker. He stated there were residents who did not know where and when to smoke. He stated smoking inside the facility or near oxygen supply was dangerous due to the fire hazard and he was particular to avoid such situations as well as vigilant about the compliance of other smokers. Resident #58:Record review of Resident #58's face sheet dated 06/23/26 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction (motor impairments that occur on one side of the body following a stroke) affecting left non-dominant side, pain in right hip, nicotine dependence, difficulty in walking and lack of coordination.Record review of Resident #58's quarterly MDS dated [DATE] reflected a BIMS of 15 which indicated that her cognition was intact.Record review of Resident #58's care plan dated 10/08/24 reflected Resident #58 was at risk of injury due to her smoking preference. The relevant intervention was evaluating her safe smoking ability.Record review of the smoking evaluations on 06/24/26 revealed that there was a quarterly evaluation conducted on 01/14/26 and confirmed that he was a safe smoker. There was no smoking evaluations performed on Resident #58 after 01/14/26. During an interview and observation on 06/24/26 at 1:30pm revealed Resident #58 was smoking unsupervised outside the facility in the smoking area with the company of Resident #60. She stated she and Resident #60 were allowed to keep the cigarettes and lighters with them and allowed to smoke independently. Resident #58 stated she was a responsible smoker and was cautious about the fire hazard and burn from cigarette. She stated she was vigilant about the safety when other smokers were there at the facility and would report to the staff immediately if she see any activity that was a threat to fire safety.Resident #07:Record review of Resident #07's face sheet dated 06/23/26 reflected a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE] with diagnoses of dementia, psychotic disturbance, mood disturbance, anxiety, amnestic disorder (a condition characterized by a severe disruption of memory functions) , posttraumatic stress disorder (a mental disorder from experiencing or witnessing a deeply traumatic event), muscle weakness, difficulty in walking, lack of coordination, unsteadiness on feet and age-related cognitive decline. Record review of Resident #07's quarterly MDS dated [DATE] reflected BIMS of 13 which indicated that his cognition was intact.Record review of Resident #07's care plan revealed that none of the care plans after his admission had reflected Resident #07's smoking preference and his risk of injury from smoking.Record review of the smoking evaluations of Resident#07 revealed that the facility conducted a quarterly evaluation on 09/19/25. The evaluation reflected that Resident #07 must be supervised while smoking as he had the history of falling asleep at times while smoking. There were no smoking evaluations performed on Resident #07 after 09/19/25. During an interview on 06/24/26 at 11:30am Resident #07 stated the facility scheduled smoking times and he utilized some of them. He said the cigarettes were stored at the nursing station and staff provided cigarettes when required. He stated he did not have any problem with that arrangement and stated that he followed all the safety rules at the facility while smoking.During an interview on 06/24/26 at 3:30 pm, the ADON stated that routine smoking evaluations were necessary to ensure residents' safety while smoking. She explained that the evaluations, as recommended by the facility policy, were important because they helped identify any changes in residents' conditions. She checked the EHR and observed that some evaluations had not been completed quarterly. She stated that the evaluations were typically completed either by her or the charge nurses. The ADON stated she was unsure why the system did not trigger alerts for residents whose quarterly or annual evaluations were overdue. The ADON stated that she had worked at the facility for about five years, knew all the residents who smoked and was not aware of any changes in their conditions that would need reconciliation of the care plan that required closer supervision at this time.During an interview on 06/24/26 at 3:40 pm, the DON stated that she was new to the facility but had extensive experience as a DON. She stated that periodic smoking evaluations were important to ensure resident safety. She said that routine evaluations helped to identify any changes in residents' conditions that might require additional supervision or other interventions. The DON expressed uncertainty about whether the facility had completed these evaluations quarterly or if the system failed to populate the data correctly.Record review of the facility policy Facility Smoking Policy-Supervised and Unsupervised revised on 07/01/25 reflected : Smoking Evaluation: Residents wishing to smoke while at the facility will have a Smoking Safety Evaluation completed by the interdisciplinary team to determine the resident's ability to follow smoking policies safely.If resident is determined to be a Safe Smoker (Facility please check one option)Resident can smoke unsupervised, resident can keep their smoking supplies, and smoke in designated areas at their leisure.ORResident can smoke unsupervised, facility will keep all smoking supplies, and resident can smoke in designed areas at their leisure. If resident is determined to be an Unsafe Smoker then they must be supervised at all times when smoking. Facility staff will keep all smoking supplies and smoking times will be established by the facility and adhered to by the resident.A supervised smoking schedule will be posted and residents will be required to smoke with supervision only, according to the schedule. Resident smoking evaluations will be conducted:Admit / ReadmitQuarterlyChange in Condition.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Residents #07) reviewed for care plans in that:The facility failed to ensure Resident #07's comprehensive care plan addressed smoking and the risks related to the smoking at the facility. This failure could place residents at the risk of burns and fire hazards. The findings included:Record review of Resident #07's face sheet dated 06/23/26 reflected a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE] with diagnoses of dementia, psychotic disturbance, mood disturbance, anxiety, amnestic disorder (a condition characterized by a severe disruption of memory functions), posttraumatic stress disorder (a mental disorder from experiencing or witnessing a deeply traumatic event), muscle weakness, difficulty in walking, lack of coordination, unsteadiness on feet and age-related cognitive decline. Record review of Resident #07's quarterly MDS dated [DATE] reflected BIMS of 13 which indicated that his cognition was intact.The MDS had not indicated if he was a user of tobacco.Record review of the quarterly smoking evaluation dated 09/19/2025 reflected that the resident currently smoked. The evaluation reflected Resident #07 had a history of falling asleep at times while smoking, he was not a safe smoker and must be supervised while smoking.Record review of Resident #07's care plans revealed that none of the care plans after his admission addressed Resident #07's smoking preference and his risk of injury from smoking.During an interview on 06/24/26 at 3:20 pm, LVN M stated that she started working at the facility as MDS Coordinator in March 2026. She explained that she was in the process of addressing various issues because there had been no permanent MDS Coordinator at the facility for approximately one year prior to her joining. She stated that after reviewing Resident #07's records, that no care plan had been developed for Resident #07 regarding smoking. She stated that it was her responsibility to complete the care plan assessment and ensure it was done in a timely manner. She added that there were several residents at the facility who smoked, and all of them had care plans, however, she was unsure how Resident #07 was overlooked in the development of a smoking care plan.During an interview on 06/24/26 at 3:30 pm, the ADON stated that she had worked at the facility for about five years and knew Resident #07 very well. She said that Resident #07 required supervision while smoking. She stated that there was not a care plan for smoking for Resident #07. The ADON said that the facility did not have a permanent MDS Coordinator for about a year, and during that time the task was handled by an outside agency or the corporate office. She said that Resident #07 might have been inadvertently omitted from the smoking care plan due to this oversight. She stated that care plans were important for providing quality care, as they serve as a resource for staff to answer nursing-related questions and act as a guide for interventions.During an interview on 06/24/26 at 3:40 pm, the DON stated that a comprehensive care plan was an integral part of person-centered nursing care. She said that a care plan was a relevant document in nursing because it identified residents' issues at the personal level and outlined interventions to address those issues. The DON said that the care plan functioned as a communication tool for the interdisciplinary team, enabling professionals to implement interventions without ambiguity. She stated that Resident #07 was a smoker who required supervision while smoking. The DON stated the absence of a care plan for the resident could pose a safety risk, as staff might not be aware of the need for supervision or the appropriate level of oversight.Record review of the facility policy Care Plans, Comprehensive Person-Centered revised on 06/02/25 reflected: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Policy Interpretation and ImplementationThe Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.14. The Interdisciplinary Team must review and update the care plan:When there has been a significant change in the residents' condition.When the desired outcome is not met.When the resident has been readmitted to the facility from a hospital stay; andAt least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #13) of four residents reviewed for infection control. The facility failed to ensure staff practiced hand hygiene when performing perineal care (incontinence care) for Resident #13. The failure put residents at risk for infection, hospitalization, and decreased quality of life. Findings included:Review of Resident #13's face sheet on 6/23/2026 revealed that Resident #13 is a [AGE] year-old female, admitted on [DATE]. Resident #13 has a history of Cerebral infarction due to thrombosis of an unspecified cerebral artery (blood clot blocking blood flow to the brain), chronic obstructive pulmonary disease (difficulty with breathing), malignant neoplasm of the colon (cancerous tumor that develops in the colon), acute on chronic diastolic congestive heart failure (heart's ability to relax and fill with blood is impaired), major depressive disorder (persistent feelings of sadness and loss of interest in activities), dry eye syndrome of the bilateral lacrimal glands (eye does not produce enough tears), macular degeneration (individual can't see things directly in front of them), and neuromuscular dysfunction of the bladder (nerve or brain problems disrupt the normal control of bladder muscles, leading to difficulty storing or emptying urine).Record review of Resident #13's MDS assessment dated [DATE], revealed the resident had a BIMS score of 13.00, which indicated the resident was cognitively intact. Resident #13's MDS revealed that toileting hygiene, shower/bathe self, and personal hygiene required the assistance of 2 or more helpers for the resident to complete these activities.During an observation on 6/23/16 at 10:35 a.m., perineal care for Resident #13 revealed that CNA B did not immediately change her gloves after discarding the soiled brief for Resident #13. CNA B used the same pair of soiled gloves after cleaning the resident's perineal area, then touched Resident #13's blue chucks sheet (cloth placed under the resident to help with changing position and lifting) and Resident #13's unsoiled area during changing Resident #13 from her perineal area to the rectal area. CNA B did not perform any form of hand hygiene (sanitizing hands with alcohol-based hand rub containing at least 62% alcohol or alternatively soap) between glove changes during perineal care.Interview on 06/23/2026 at 11:09 a.m. CNA B stated that she had been working at the facility for 3 years and had become a CNA about 9 months ago. CNA B stated she used the same soiled gloves after cleaning Resident #13's perineum to touch Resident #13 and the chucks sheet underneath her during changing Resident #13's position from the front to the back. CNA B stated she changed gloves before cleaning Resident #13's rectal area. CNA B stated that a negative outcome of not using hand sanitizer between glove changes could cause bacteria to grow and infection. CNA B stated that preventive measures included sanitizing hands between glove changes to prevent the spread of infection and bacteria. CNA B stated she completed all her training, including perineal care competency and in-services, while she started working as a CNA in the facility. CNA B stated that between glove changes, she did not use hand sanitizer or perform any hand hygiene.Interview on 6/24/2026 at 1:36 p.m. RN A stated that at any point, any caregiver who changes their gloves during resident care and puts on new gloves must perform hand hygiene in between glove changes. RN A stated that the caregiver could not use soiled gloves to touch the resident's unsoiled areas, and the resident's clean blue chucks during reposition. RN A stated that failing to perform hand hygiene properly and using soiled gloves to touch the resident could cause the risk of infection. RN A stated that some preventive measures included hand washing, proper precautions, and having a nurse with CNAs to observe them.Interview on 6/24/2026 at 12:54 p.m. The DON stated that at any point, any caregiver who changes their gloves during resident care and puts on new gloves must perform hand hygiene in between glove changes. The DON stated that the caregiver could not use soiled gloves to touch the residents, and that the residents cleaned their blue chucks during repositioning. The DON stated that failing to perform hand hygiene properly and using soiled gloves to touch residents could lead to cross-contamination and increase the risk of infection. The DON stated that some preventive measures included ensuring caregivers had plenty of gloves and hand sanitizers, and that they changed gloves properly and sanitized their hands between glove changes.Interview on 6/24/2026 at 1:07 p.m. The ADM stated he expected staff members to follow hand-washing policies. The ADM stated that staff members could use gloves and wash their hands after finishing the work.Review of the facility policy titled, Handwashing-Hand Hygiene Policy and Procedures, Revision date 10-2020 revealed that, 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin. m. After removing gloves.

Based on observation, interview, and record review the facility failed to have the results of the most recent survey of the facility posted in a place readily available to residents, family members, and legal representatives for 1 of 1 survey results books. The facility failed to ensure a binder placed in a bin at the entrance of the facility and titled Survey Binder contained the results of the most recent health recertification survey or all surveys, certifications and complaint/ incident investigations during the 3 preceding years and any plan of correction in effect with respect to the facility. This failure placed residents at risk of not having all the information necessary to make decisions about living at the facility.Findings included: Observation and record review on 06/10/26 at 10:11 AM revealed, a white three-ring binder placed in a clear bin next to the entrance door. The binder had Survey Binder printed on the front. Within the binder were results (Forms 3614, 3630, and 2567) from a health visit dated 04/22/26, were the only available results to view in the binder. The binder did not contain the results of the previous health recertification dated 05/05/25 or any other health visits pertaining to incident or complaint investigations for the 3 proceeding years or their plan of correction if applicable. During a confidential group interview on 06/23/26 at 09:38 AM, 12 of 12 confidential residents stated they did not know where the results of the recent health inspections/ investigations were located and did not believe they were made available to them. During an interview on 06/24/26 at 01:19 PM with the AD, she stated the survey binder was the responsibility of the ADM. She stated the purpose of the survey binder was for family or residents to see the results of the surveys, what was done wrong and corrections. She stated a negative outcome of not having those results available would be it would make them wonder why they don't have the results; it could affect visitors' decisions on the facility. Everyone goes to reviews these days. During an interview on 06/24/26 at 01:49 PM with the ADM, he stated it was the administrator's responsibility to keep up with the survey binder. He stated the purpose of the binder was to inform the public of the latest survey outcome. He stated he believed he had to maintain the last recertification survey and anything after it in the binder. He stated Everyone has a right to it; it's public information and might influence a person's decision to admit someone here. During an interview on 06/24/26 at 02:17 PM the facility policy was requested from the ADM specifically the right to view survey results. The ADM stated there was not a policy specific on the right to view survey results.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Residents #1) reviewed for care plans. The facility failed to have a comprehensive person-centered care plan for Resident #1 to address herbehavior of banging on the wall of her room that occurred on 05/05/2026 and two other times, dates unknown. This failure could place residents at risk of not receiving care and services to meet individualized, behavioral, medical and nursing needs.Findings included: Record review of Resident #1's face sheet, undated, revealed a ninety year-old female who was admitted to the facility on [DATE] with a diagnosis that included Alzheimer's Disease (a progressive neurodegenerative brain disorder and the most common cause of dementia), major depressive disorder (a serious mood disorder characterized by persistent feelings of sadness, a loss of interest in activities, and low energy that significantly disrupt daily functioning), and anxiety disorder (mental health condition characterized by excessive, persistent, and disproportionate fear or worry in everyday situations). Record review of Resident #1's care plan revealed no focus or interventions for behaviors of Resident #1 banging or hitting the walls in her room. Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) dated 05/06/2026 Nursing Home Comprehensive Section C - Cognitive Patterns revealed a score of 5 indicating severe cognitive issues. Record review of Resident #1's General Nurses Notes - narrative by LVN A dated 05/06/2026 reflected Resident #1 was highly agitated during shift and Resident #1 was closed fist banging on the wall. Resident #1 continued to not want staff in the room while also continuing to bang on the bedroom wall. Record review of Health and Human Services Facility Provider Investigative Report dated 05/12/2026 Intake number 1089942 injury of an unknown origin reflected, upon observation resident noted to have a bruise across her right eyebrow and bruising noted to her right forearm X3. All three bruises noted to have a scab over the center of them, and resident was unable to give description of the events. Skin assessment completed noting all new skin. Facility investigative summary reflected, Banging her first against the wall may have contributed to bruising on the forearm. During an interview on 05/19/2026 at 12:53 PM LVN A said on 05/06/2026 Resident #1, who lived in the facility secured unit, was closed fist banging on the wall. LVN A said Resident #1 had a significant history of banging on the walls. LVN A said Resident #1 had three incidents that LVN A knew about that Resident #1 banged on the wall of her room. LVN A said Resident #1 should be care planned for banging on the walls of her room because it was Resident#1's form of communication. LVN A said all staff members knew when Resident #1 was banging on the wall it was to get the attention of everyone in the building. LVN A said Resident #1 could potentially be harmed because she banged on the wall. LVN A said she had not told the MDS coordinator about Resident #1 banging on the wall of her room. LVN A said a care plan was a form of charting that was related to the whole healthcare for the residents. She said a care plan was something that helped staff understand how the residents communicated, what their care needs were, and how to better help residents. She said the possible negative effect of not-care planning for Resident #1's banging on the wall behavior was that staff would not have to have knowledge of the situation to apply critical thinking and realize how to intervene and prevent Resident #1 from injuring herself. During an interview on 05/19/2026 at 1:40 PM with the CCS he said Resident #1's history of beating on the walls should be care planned. He said it should be care planned so staff could be aware of the behavior and anyone who was unfamiliar with Resident #1 could be aware of the behavior. The CCS said a care plan was a listing of everything about that resident and what was particular to that resident. The CCS said anyone could do a care plan but if the MDS coordinator was not told about something that needed to be added to a resident's care plan it might not be added. He said the possible negative effect of Resident #1's behavior of beating on the walls of her room would be that a staff member would not know this behavior. The CCS said if staff knew this behavior from the care plan it might have helped in the understanding of Resident #1. The CCS said the MDS coordinator was responsible for entering items into resident care plans and staff told her about behaviors to be added. The CCS said the behavior of Resident #1 beating on the walls of her room could include more specific intervention regarding her safety and wellbeing. During an interview on 05/19/2026 at 2:59 PM with the ADON she said a care plan showed a description of resident ADLs and anything about the care for the residents including wound care and behaviors. The ADON said a care plan was important because it showed how to care for a resident and included interventions. She said care planning was not her area. She said Resident #1's behavior of her banging on the wall should be care planned. The ADON said a CNA should tell a nurse about the resident behavior so a nurse could add it to the care plan. ADON said nursing was responsible for care plans. The ADON said a possible negative effect of not care planning was missing out on any needed care that could possibly not have a good outcome for the residents. Record review of facility Care Plan Policy dated August of 2006 reflected that the care plan shall be used in developing the residents daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Policy Interpretation and Implementation Completed care plans are placed in the resident's chart and/or in a 3-ring binder located at the appropriate nurses' station. The Nurse Supervisor uses the care plan to complete the CNAs daily/weekly work assignment sheets and/or flow sheets.CNAs are responsible for reporting to the Nurse Supervisor any change in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved. Other facility staff noting a change in the resident's condition must also report those changes to the Nurse Supervisor and/or the MDS Assessment Coordinator. Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made.Documentation must be consistent with the resident's care plan.

Based on observation, interview, and record review, the facility failed to ensure the resident had a right to be treated with respect and dignity for 2 of 8 residents reviewed for dignity. The facility failed to ensure Residents #1 and 2 were spoken to with dignity by LVN A on 01/07/2026 during their smoke break. This failure placed residents at risk of anger and diminished quality of life. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure), schizophrenia, and history of traumatic brain injury. Review of the admission MDS for Resident #1 dated 11/11/2025 reflected a BIMS score of 12, indicating only mildly impaired cognition. Review of the undated face sheet for Resident #2 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included anxiety disorder, vascular dementia, and depression. Review of the quarterly MDS for Resident #2 dated 11/04/2025 reflected a BIMS score of 6, indicating severely impaired cognition. Observation on 01/07/2026 at 01:04 PM revealed Residents #1 and 2, among four other residents, participating in smoke break. LVN A supervised the smoke break and had resident cigarettes and a lighter in her possession. When she arrived at Resident #1, she informed him that she did not have cigarettes for him as the staff had not been to the store. He was visibly upset by his pursed brown, frown, and looking away but did not speak. After less than one minute, Resident #2 was observed handing her cigarette to Resident #1 for him to partake in some of it. LVN A said, in a sharp and condescending tone audible to all residents and the surveyor, No! No! Yall can't be sharing. nuh-uh (meaning no), no ma'am! Resident #2 stated, When did they change that? and LVN A stated, It's just policy you cannot share. It's been a thing for a while. Resident #2 stated, Are you serious? and LVN A said, Uh huh (meaning yes) 100%. Resident #1 made an angry facial expression and left the smoking area. When Resident #2 stubbed out her cigarette before it was finished and attempted to pocket it in her hand, LVN A said No, ma'am, you cannot take that with you, and held an ashtray out in front of Resident #2. Resident #2 looked at LVN A for three seconds and then angrily threw her cigarette butt in the ashtray. She left the smoking area. During an interview on 01/07/2026 at 01:10 PM, Resident #1 stated he was angry about what had happened on the smoking porch. He stated that he felt as if he had been spoken to as a child and that made him feel shitty. He stated he was used to it, because that was how they spoke to him there. During an interview on 01/07/2026 at 01:20 PM, Resident #2 stated LVN A always spoke to them like that. She stated she had not reported it as a grievance, because she knew it would just make things worse. She stated she thought LVN A did not like black people, and that was why she spoke to Resident #1 and 2 that way. Resident #2 stated she always tried to treat everyone with respect, and she did not know of any reason why LVN A would not have spoken to her with respect just because she wanted to share with Resident #1. She stated she understood that sharing the same cigarette could be an infection control problem and make one or both of the resident's sick, but she was not aware before today that it was against the rules. During an interview on 01/07/2026 at 01:23 PM, LVN A stated she had been told the residents were not allowed to share cigarettes and that it was a rule. She stated Resident #1 was known to accept cigarettes from other residents, and she was not sure why that was against the rules or who told her, but she knew they could not share the same cigarette due to infection control. She stated she tried to follow the rules. She stated she had received a ton of training, but she could not recall any training on dignity or on how to enforce facility rules while maintaining resident dignity. She stated she could not believe she had been interpreted to have been speaking to residents without maintaining their dignity, because she was the nicest person in the world. She stated she did not mean to talk to Residents #1 and 2 as if they were naughty children, but it was hard to figure out how to enforce the smoking rules. During an interview on 01/07/2026 at 04:00 PM, the ADM stated he had spoken to Residents #1 and 2 and both had denied being spoken to without respect or dignity. He stated he was responsible for ensuring residents were treated with dignity and respect. He stated he was the abuse coordinator and ensured compliance with the regulations about treating resident with dignity and respect through investigation, in-services, 1:1 counseling, and disciplinary action if necessary. He stated the potential negative effect of staff speaking to residents without respect was sadness, depression and anger along with lowered feelings of self-worth. Review of the facility's in-services from October 2025 through January 2026 reflected no in-service specific to treating residents with dignity and respect. An undated in-service titled Resident Rights was located between unrelated in-services dated 11/30/2025 and 12/17/2026. Review of the facility policy dated 07/21/2018 and titled Rights of the Elderly reflected the following: An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual, without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment. This means that the elderly individual; (1) has the right to make the individual's own choices regarding the individual's personal affairs, care, benefits, and services.

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 7 residents (Resident #1) reviewed for resident rights.The facility failed to ensure Resident #1 call light was within reach on 11/12/2025.This failure could place residents at risk of their needs not being met.Findings include:Record review of Resident #1's admission record, dated 11/12/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), chronic obstructive pulmonary disease (lung disease that makes it hard to breathe due to airflow obstruction and lung damage), lack of coordination (inability to perform smooth, controlled movements), and muscle weakness (loss of strength in muscles making it difficult to move or perform physical task).Record review of Resident #1's Quarterly MDS assessment, dated 09/24/2025, reflected Resident #1 had a BIMS score of 08, which indicated moderate cognitive impairment. Resident #1 required partial/moderate assistance in the areas of toileting hygiene, shower/bathe self, upper body dressing, and putting on/taking off footwear. Resident #1 required substantial/maximal assistance in the area of lower body dressing. Record review of Resident #1's care plan, dated 11/12/2025, reflected Resident #1 was care planned for ADL self-care performance deficit r/t Alzheimer's disease, COPD, failure to thrive, HTH, malnutrition, osteoarthritis (when the smooth, protective cartilage in your joints were down overtime, causing bones to rub against each other, leading to pain and stiffness), and reduce mobility and had an intervention of tub/shower transfer: partial/moderate assistance. Resident #1 is care planned for falls and had an intervention of maintain call light within reach resident uses a touch pad call light. During an interview and observation on 11/12/2025 at 9:06 AM., Resident #1 was observed laying in bed while her call light pad was on the dresser approximately 1 foot away from her. Resident #1 stated that that the CNA must have moved her call pad during care and didn't put it back. Resident #1 stated she could not reach her call light if she needed it. Further observations on 11/12/2025 from 9:06 AM to 11:05 AM revealed Resident #1's call light pad remained out of reach of Resident #1. During an interview on 11/12/2025 at 1:35 PM, CNA A stated that she was not aware that the resident's call light was not within reach from 9:06am - 11:05 AM. CNA A stated that during the CNAs round they should ensure a resident is comfortable and ensure the call light is within reach. CNA A stated it was everyone's responsibility to ensure call lights were always within reach. CNA A stated if a resident's call light was not within reach, then the resident would not be able to call for assistance.During an interview with the ADON on 11/12/2025 at 3:10 PM, the ADON stated all residents call lights should be always within reach. The DON stated it was everyone's responsibility to ensure residents call lights were always within reach. The ADON stated if a resident's call light was not within reach, the resident would not be able to call for assistance.During an interview with the ADM on 11/12/2025 at 3:30 PM, the ADM stated call lights should always be within reach. The ADM stated it was everyone's responsibility to ensure the call lights were within reach. The ADM stated if a resident's call light was not within reach, then the resident would not be able to express their needs nor have their needs met. The ADM stated his expectation was for staff members to ensure call lights were within reach prior to exiting the resident's rooms.A record review of the facility's Resident Call System policy, dated October 2022, reflected Resident are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Policy Interpretation and Implementation1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bath facilities and from the floor 4. If the resident has a disability that prevent him/her from making use of the calls system, an alternative means of communication that unable for the resident is provided and documented in the care plan

Based on interview, and record review, the facility failed to ensure residents were provided care and services to carry out activities of daily living to maintain personal hygiene for 1 of 7 residents (Resident #2) reviewed for quality of life.The facility failed to provide showers to Resident #2 in compliance with her shower schedule.This deficient practice could place residents at risk of decline in overall health.Findings included:Record review of Resident #2's admission record, dated 11/12/2025, reflected an [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #2 had diagnoses which included: unspecified dementia (memory loss and problems with thinking and reasoning), generalized anxiety disorder (mental health condition characterized by excessive and uncontrollable worry about everyday things), and major depressive disorder (persistent feeling of sadness and loss of interest, making it hard to function in daily life). Record review of Resident #2's Quarterly MDS assessment, dated 09/17/2025, reflected Resident #2 had a BIMS score of 07, which indicated severe cognitive impairment. Resident #2 required substantial/maximal assistance in the areas of toileting hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear. Resident #2 was dependent in the area of shower/bathe self.Record review of Resident #2's care plan, dated 11/12/2025, reflected Resident #2 was care planned for ADL self-care performance deficit r/t limited mobility and had an intervention of shower/bathe self: dependent.Review of Resident #2's EMR task Shower/Bathe self Prefers: Specify T-TH-Sat evenings dated 11/12/2025, reflected no documentation that Resident #2 received a shower /bath on the following dates: 10/30/2025, 11/01/2025, 11/04/2025, or 11/06/2025During an interview on 11/12/2025 at 09:06 AM, Resident #2 stated she has not received a bath in a while but could not provide dates.During an interview on 11/12/2025 at 2:30 PM, CNA A stated she was not aware that Resident #2 did receive a shower/bath on the following dates: 10/30/2025, 11/01/2025, 11/04/2025, or 11/06/2025. CNA A stated that resident's bath/shower schedule was located on the POC in EMR. CNA A stated she was not assigned to Resident #2 on the following dates: 10/30/2025, 11/01/2025, 11/04/2025, or 11/06/2025. CNA A stated that if a resident did not receive scheduled a bath/shower they would smell bad or could have skin breakdown.During an interview with the ADON on 11/12/2025 at 3:10 PM, the ADON stated CNAs were responsible for giving the residents a bath/shower. The ADON stated if a resident did not receive their scheduled bath/shower they could develop an odor or a skin issue. The ADON stated she expected for all residents to receive a bath/shower as scheduled.During an interview with the ADM on 11/12/2025 at 3:30 PM, the ADM stated the CNAs were responsible for giving the residents a bath/shower. The ADM stated that residents would develop an odor if they were not receiving a bath/shower per the residents' bath/shower schedule. The ADM stated that he expected for all residents to receive a bath/shower as scheduled.A record review of the facility's ADL Care & Personal Hygiene policy, dated 12/2020, reflected staff provides assistance to residents who need assistance with personal hygiene to prevent an odor problem and to prevent skin breakdown. Procedure All residents are encouraged and responsible for their personal hygiene. Personal hygiene tasks include: washing up, bathing, dressing, mouth care, shaving, and hair care. The amount of hygiene assistance provided to a resident will be discussed with the resident and indicated in his/her Person-Centered Service Plan (PSCP). The PCSP and amount of hygiene assistance given will be reviewed at regular intervals and appropriate changes made on an as needed basis. Independence will be encouraged and supported. If more help is needed than can be provided, alternatives will be explored (e.g. family, home health agency, etc.) .

Based on interview and record review, the facility failed to maintain the residents' freedom retain and use personal possessions for one (Resident #1) of one resident reviewed for personal property.The facility failed to allow Resident #1 to have a powered wheelchair because she had display aggressive behaviors.This failure could place resident at risk of not being able to retain personal property, at risk of feeling disrespected, having reduced dignity and diminished quality of life.Findings included:Record review of Resident #1's undated Clinical sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (damage occurred in the right side of the brain, as the brain's right hemisphere controls the left side of the body), heart failure, unspecified (a general diagnosis of heart failure without further detail about its type or cause), muscle weakness (generalized) (a decrease in overall muscle strength that affects multiple muscle groups throughout the body), difficulty in walking, not elsewhere classified (a patient's inability to walk effectively when a more specific diagnosis is not yet available, such as a particular neurological condition, musculoskeletal issue, or specific type of abnormal gait), unspecified lack of coordination (a difficulty in performing smooth, controlled movements when the specific cause or type of coordination problem is not identified or documented), unsteadiness on feet (a lack of stability while walking or standing, characterized by symptoms like stumbling, difficulty with balance, a broad or staggering walk, or feeling rooted to the ground), need for assistance with personal care (the inability of an individual to independently perform daily self-care activities, such as bathing, dressing, grooming, and toileting, due to a physical or cognitive impairment, illness, or temporary condition), adult failure to thrive(a complex syndrome, not a specific disease, characterized by unexplained weight loss, malnutrition, and a decline in functional ability, leading to increased disability and potential premature death), alcohol abuse with other alcohol-induced disorder (a persistent pattern of alcohol use that leads to significant impairment or distress). Record review of Resident #1's comprehensive MDS assessment, dated 08/06/2025, Section C (Cognitive Patterns) reflected a BIMS score of 15, which intact cognition.Record review of Resident #1's care plan initial dated 5/30/2025 and revised on 7/22/2025, reflected Focus: she has a history of Trauma and ongoing anger issues resulting in verbal outbursts. Known triggers are loud noises, overstimulation, and peer interactions, partial denial of issues and reluctant participation in care planning. Currently working with LCSW and on medication regimen for emotional regulation. Goal: Resident #1 will inform staff of any increased levels of anxiety/depression or exposure to identified triggers. Resident will participate in scheduled therapy sessions with LCSW to address root cause or trauma and anger. Resident will demonstrate reduced frequency of angry outbursts in the dining room and other communal areas. Resident #1 will report feeling emotionally and safe environment. Intervention: Engage resident in ongoing sessions with LCSW to address trauma and anger. Monitor and document triggers such as loud noises, overstimulation, and irritating peer interaction. Offer calm quiet environment. Reinforce consistent medication administration as ordered to support emotional regulation. Educate staff on Trauma-informed approach and environmental sensitivity for Resident #1. Revisit Care Plan with resident regularly to promote engagement and reinforce care plan preferences and being respected. Give meds, psych services as ordered, staff will offer support and encouragement. During an interview with the Resident #1 on 9/17/25 at 2:57 pm stated she felt safe living at the facility. Resident #1 stated she was going to get a power wheelchair, but she doesn't know why the facility staff keeps telling her she cannot have one. Resident #1 stated she was pushing herself in her own wheelchair. She stated she was holding on to someone else's chair, and they stopped, and she fell. She stated she was cussing up a storm. She hit her nose and arm. EMS was called and the police came. Resident #1 stated the staff, and LE stated she was drunk. Resident #1 stated LE gave her the option to either go to the hospital or go to jail. She stated if she had her own chair she would have not fallen. She stated her right shoulder was bad. She thinks therapy was prejudice against her because she was aggressive. She was not able to have a drink anymore.During an interview with the DON on 9/17/25 at 4:42 pm stated Resident #1 had a history of being aggressive. She had a past of driving a car and being aggressive. He stated the PsyD she suggested that she does not have an electric wheelchair. DON stated she thought she could become aggressive towards other residents while utilizing the motorized wheelchair. DON stated they were going to have a care plan meeting, and the PsyD will be in the meeting. During an interview with the ADON on 9/19/25 at 1:10 pm stated Resident #1 had aggression, and the IDT would discuss her receiving a powered wheelchair next week. The ADON stated Resident #1was aggressive towards another residents, Resident #1 bumped into other people to get them out of her way. She stated the other day Resident #1 told her she asked her friend to order her an electric wheelchair and Resident #1 advised her friend to wait until next week until the meeting was conducted before ordering it. The ADON stated the IDT meeting has not been denied yet. Therapy must evaluate her first; then they must order one to see how she does use it. The ADON stated the facility had also ordered her a new manual bariatric wheelchair. During an interview with the PsyD on 9/19/25 at 1:45 pm stated she was advised of the behaviors of Resident #1 would be a danger to herself and others with an electric wheelchair because she rams into people when she doesn't get her way with a manual wheelchair. She stated Resident #1's was not fully cognitive, and she has had some confusion. She stated she gets information from OTA, ADON and DON when she came to speak with the residents. OTA stated they wanted her to use the shoulder she complained about to help her with ROM. An electric wheelchair would be detrimental with using the arm. She stated Resident #1 wanted it because of shoulder pain. She stated orthopedic cleared her and was doing therapy to get stronger. She stated when she doesn't get her way and not have the last word, she gets mad and run out the room. She stated therapy asked to have a review of her medication, they stated she get mad and aggressive as if she is going through a crowd. OTA wanted her to use the arm and not demobilize it. She stated from her standpoint, Resident #1 was going to use the power wheelchair to be aggressive.During an interview with the OTA on 9/19/25 at 2:03 pm stated Resident #1 complained to her a couple of weeks ago about shoulder pain. She stated before making any decisions the IDT team were having a meeting to discuss why it was or why it isn't safe for her to have a powered wheelchair due to behaviors and anger. She stated it had been documented that she had been placed on 1:1 from lashing out at other residents. She stated she had told Resident #1 she hasn't been told no yet; they will still be discussing it. She thought an electric wheelchair will not be good for her because in the time she has known her and treated her, she can get upset very easily. She doesn't know if it will be a good or bad idea, but she was concern about her and other resident safety from what she had observed. She had just addressed wanting an electric wheelchair about a week ago. She stated she had difficulty pushing herself in the manual wheelchair because of her shoulder pain. She stated directly when she went to screen her for therapy she could no longer push her manual wheelchair any longer because her shoulder hurt.Record review of the facility's policy Resident Rights revised dated 12/2016, reflected:Employees shall treat all residents with kindness, respect, and dignity.1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of five residents reviewed for care plans, in that: The facility failed to care plan Resident #1's history of refusal of Nystatin Powder medication from 06/13/25 to 08/12/25. This failure placed residents at risk of not receiving goals and interventions for the residents' individual needs for person-centered care.Findings included:Review of Resident #1's face sheet dated 08/22/25 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction (paralysis (hemiplegia) or weakness (hemiparesis) of one side of the body, resulting from the damage to the brain by a lack of blood flow), mood disorder due to known physiological condition with depressive features (mood disorder due to a known physiological condition with depressive features), type 2 diabetes mellitus with diabetic neuropathy (a complication where high blood sugar from poorly managed T2DM (type 2 diabetes mellitus) damages nerves.Review of Resident #1's quarterly MDS assessment, dated 08/06/25, reflected a BIMS score of 15, indicating no cognitive impairment.Review of Resident #1's care plan reflected no identified focus, goals, or interventions/tasks for her history of refusal of any medications.Record review of Resident #1's order for Nystatin Powder (a prescription antifungal antibiotic used for topical treatment of fungal skin infections) apply to affected area/breast topically two times a day for skin integrity/fungal order date 05/30/2025 D/C Date 08/10/2025.Record review of Resident #1's order for Nystatin Powder (a prescription antifungal antibiotic used for topical treatment of fungal skin infections) apply to affected area/breast topically two times a day for skin integrity/ fungal order date 08/10/2025 no D/C date.Review of Resident #1's June 2025 eMAR reflected LVN A attempted to administer to Resident #1, on 06/13/25 at 6:00 am and 6:00 pm, and 06/14/25 at 6:00 pm Resident #1's Nystatin Powder. The eMAR reflected Resident #2 refused the medication.Review of Resident #1's July 2025 eMAR reflected LVN A attempted to administer to Resident #1, on 07/15/25, 07/29/25, and 07/30/25 at 6:00 am, Resident #1's Nystatin Powder. The eMAR reflected Resident #2 refused the medication.Review of Resident #1's August 2025 eMAR reflected LVN B attempted to administer to Resident #1, on 08/08/25 and 08/09/25 at 6:00 pm, Resident #1's Nystatin Powder. The eMAR reflected Resident #2 refused the medication. Review of Resident #1's August 2025 eMAR reflected LVN C attempted to administer to Resident #1, on 08/12/25 at 6:00 am, Resident #1's Nystatin Powder. The eMAR reflected Resident #2 refused the medication. Interview on 08/22/25 at 2:13 pm with the ADON reflected Resident #1 was prescribed Nystatin Powder and refused to have it administered to her. The ADON said a care plan tells the facility staff what was needed for the resident how you take care of resident. The said the refusal of Nystatin Power should have been care planned. She said the refusal of medication in a resident's eMAR should correlate to a refusal of the medication in the care plan. The possible negative effect of not care planning for medication refusals was that the resident was not provided the proper care. She said the person ultimately responsible for care plans was the MDS coordinator and the nurse who signed the care plan and approved it. She said she did not have any additional information to add regarding the necessity to care plan resident medication refusal. Interview on 08/22/25 at 2:43 pm with LVN C reflected she was a wound care nurse. She said Resident #1 had redness on her groin area and she had had it for a long time. LVN C said Resident #1 refused the application of Nystatin Power to her groin area a lot. She said Resident #1 would say she knew she had a rash in her groin area, and she was fine, and it did not look bad then later tell staff the redness looked bad. LVN C said it would be important for Resident #1's refusals of the application of her Nystatin Powder to be in Resident #1's care plan. She said if the refusal for the powder was care planned, they might figure out another way to encourage Resident #1 to accept the application of the power. A care plan was in place for the proper care plan of a resident. She said nurses were able to add and subtract and improve care plans but there was an actual MDS nurse who did care plans. LVN C said care plans should be person centered and if resident's refusals to take medication was not care planned it would not be a person centered care plan. She said it was important to care plan refusals to get an overall picture of the resident. LVN C said it would be important that Resident #1's Nystatin Powder refusal be care planned because there was a potential for Resident #1 having a rash and getting redness in her groin area. She said she had told the MDS nurse that Resident #1 had refused her treatments of Nystatin Powder.Interview on 08/22/25 at 3:19 pm with LVN B reflected Resident #1 had a history of refusing her Nystatin Powder. LVN B said if the Nystatin Powder was not applied to Resident #1's groin area, the groin area would get red and painful and Resident #1's groin area was somewhat red. She said she would think that Resident #1's refusal of her Nystatin Powder would be documented in the care plan. She said a care plan was the outlined how the facility was supposed to take care of a resident, from head to toe. She said if there was something that the resident was refusing that would benefit them it should be care planned and it would benefit the new staff because they would know about resident. She said everything should be care planned. She said if Resident #1's refusal of her Nystatin Power was care planned, it would help track any issues with redness in her groin area. She said this facility had never instructed her in care plans. She had read Resident #1's her care plan. LVN B thought it would be beneficial for Resident#1's refusal of her Nystatin Powder to be documented the care plan and to have had a plan of action to address Resident #1's refusal of the powder. She said if you don't have the refusal care planned, the care was not person centered and it would affect patient centered care. Interviewee had no additional information to add about the need for Resident #1's refusal of her Nystatin Powder to be documented in the care plan.Interview on 08/22/25 at 4:04 pm with the NP via phone reflected Resident #1's Nystatin Powder could be applied under her breasts and in the groin area if the groin area was red. She said the Nystatin Powder would kill the yeast in those areas. The NP said that if Resident #1 refused the application of the Nystatin Powder to her groin area it could get irritated. The NP said she knew Resident #1 routinely refused her Nystatin Powder and the refusal should be care planned.Interview on 08/22/25 at 5:41 pm with the MDSC reflected she was aware that Resident #1 declined her Nystatin Powder. She said she attempted to administer Resident #1 her Nystatin Powder and Resident #1 refused the powder. MDSC said she did the care plan but had not been informed by other staff that Resident #1 declined her Nystatin Powder. She said the MDS coordinator was responsible for care plans, and she went through them every three months and she had to rely on the input from floor nurses to update care plans and she did not always get information necessary for resident care plans, particularly on the weekends. She said it was important to care plan when a resident refused medications and to care plan anything that was out of the ordinary. She said a care plan was a road map to the residents' life. She said a possible negative affect of not care planning medication refusals was it could affect their care. She said if a resident was not taking medications, and the refusal was not care planned, it would not be communication to the staff. She said no one would know that the resident was not taking the medication except the person the resident made the refusal to. She said she was responsible for the care plans.Interview on 08/22/25 at 6:15 pm with LVN A reflected she had tried to give Resident #1 her Nystatin powder and Resident #1 had refused. LVN A said a care plan was the plan of how to take care of each resident should be based on the individual needs of each resident. She said if a resident declines to take medication the resident's refusal of the medication should be reported to the DON and ADON and the refusal of the medication should be care planned. She said the nurses contributed to the care plans, but the DON ultimately completed care plans. She said when Resident #1 had refused her Nystatin powder, she reported it to the MD, but she can't remember if she told the DON or ADON. She said possible negative effect of not care planning for medication refusals was that the condition for which the medication was prescribed could get worse. She said she did not know the facility system for care planning, and she did not have any additional information to add regarding not care planning for medication refusals.Attempted interview on 08/22/25 at 5:22 pm with the DON but she had left the facility because she was ill. Surveyor called and left her a voice mail and sent her a text message with no response.Interview on 08/22/25 at 6:03 pm with the Administrator reflected a care plan was a document that gave instructions on how to care for the residents, including resident preferences. She said if a resident was refusing to take a medication that should be care planned. She said a possible negative affect of not care planning for medication refusals would be that it would be more difficult for the team and doctors to figure out how to care for that resident. She said the MDS Coordinator and the ADON are responsible for care plans, but it ultimately falls under the responsibility of the DON. She said if the nurses are attempting to give medications to residents who are refusing medications the nurses needed to inform the DON. When the DON knew about the medication refusal, it should be care planned. She confirmed that she had looked at Resident #1's care plan and, as much as they talked about Resident #1 not taking her medications, Resident #1's refusal of her Nystatin Power should have been care planned. She said her facility's system for care planning was when the nursing staff identified any preferences, significant changes, or anything else that could change the current plan of care they reported it in the 24-hour report or as needed to the DON or ADON. This report was communicated to the IDT team (a collaborative group of professionals from different fields who work together to provide comprehensive, coordinated care for a resident) and the physician and any changes were made to the care plan and orders as indicated to reflect the resident's current status and needs. Review of Facility Care Plans, Comprehensive Person-Centered dated January 2023 reflected policy statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive person-centered care plan will include measurable objective and time frames, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being, describe serviced that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident # 24) reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Five staff (LVN D, LVN E, CNA, ADON, and ADM) reviewed for infection control. 1. The facility failed to ensure hand hygiene practices were used when passing resident lunch trays to residents in the dining room. These failures could place residents at risk of transmission of disease and infection. Findings include: Observation on 07/10/2025 at 12:15 PM. During lunch service in the dining room, four staff members were getting food trays for the residents. LVN E, LVN D, and CNA were not sanitizing their hands between handing out food trays to residents in the dining area. Not once did LVN E, LVN D, and CNA sanitize their hands during lunch. This could have affected everyone in the dining room at the time. Interview on 07/10/2025 at 12:35 PM with LVN D revealed she had worked at the facility for almost a year. She stated she had been trained on infection control. LVN D stated it was policy to perform hand hygiene, either wash hands or sanitize hands, before picking up a new tray for a resident. LVN D stated she didn't sanitize her hands between each resident while passing trays. She stated she knew she was supposed to, but didn't do it . LVND said she usually does not forget to sanitize her hands. LVN D stated if hands were not sanitized between touching residents, then an infection could be passed from one resident to another. Interview on 07/10/2025 at 12:35 PM with CNA revealed she had been trained on infection control. She stated it was policy to perform hand hygiene every time between residents when passing out meal trays. She stated that not doing so could spread infection between the residents. She stated that she usually sanitizes her hands. She said she was not sure why she forgot to sanitize her hands this time. Interview on 07/10/2025 at 12:43 PM with LVN E gave the steps of giving residents their trays but did not mention that she needed to sanitize her hands. She revealed she had been trained on infection control. She stated that when passing meals trays, it was important to wash hands or sanitize her hands between grabbing each resident's tray. She stated that not cleaning her hands could cause cross-contamination. She said she forgot to sanitize when she was serving resident their food. LVN E stated not performing hand hygiene is the #1 cause of spreading infections . 1. Record review of Resident #24's had diagnoses which included: muscle weakness, difficulty walking, lack of coordination, symbolic disfunctions (difficulty reading), cerebral infarction (stroke), morbid obesity, chronic obstructive pulmonary disease, mood disorder, visual disturbance, type 2 diabetes, alcohol use, heart failure, nicotine dependance, hypothyroidism, vitamin deficiency, failure to thrive, hypertension, type two diabetes, and cognitive communications. Record review of Resident #24's Quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated no cognitive impairment. Record review of Resident #24's care plan, dated 10/08/2024 and last revised on 01/23/2025, reflected: Focus: [Resident #24 has an ADL self-care performance deficit r/t showering, fluid deficit, Diabetes Mellitus, hemiplegia/hemiparesis, Diabetic neuropathy, and related to [JM5] cerebral infarct.[JM6] .Interview on 07/10/2025 at 1:08 PM with the DM [JM7] revealed she had she had received training on infection control. She stated when staff pass out trays of food to the residents their hands should be clean each time a tray is grabbed. She said if she sees staff not cleaning their hands then she will correct the staff. Interview on 07/10/2025 at 2:40 PM with the ADON revealed she received training on infection control. She stated she expected staff to sanitize their hands when entering the dining room and between each resident's tray. The ADON stated there was a member of the nursing administration team in each dining room for each meal and they were required to monitor for hand hygiene with tray pass. She stated if hand hygiene wasn't performed between contact with each resident, then germs could be spread between residents. [JM8] ADON said that the DON and the administrator are responsible for training staff on hand hygiene. An interview on 7/10/2025 at 2:52 PM with the ADM revealed that she had received training on infection control. She stated she expected all staff to perform some sort of hand hygiene before handling each resident's tray. The ADM stated if hand hygiene was not performed, it could cause an infection between the residents. Requested policy related to hand hygiene and dining service on 07/10//2025 at 3:00 PM. Received an email with the Infection Prevention and Control Program and Handwashing-Hand Hygiene Policy and Procedures. Record review of facility policy titled, Handwashing-Hand Hygiene Policy and Procedures dated 01/2020 and last revised in 10/2022 reflected the following: Policy . Policy Interpretation and Implementation1. All personnel shall be trained and regularly in-serviced on the importance of hand.hygiene in preventing the transmission of healthcare-associated infections.2. All personnel shall follow the handwashing/hand hygiene procedures to helpprevent the spread of infections to other personnel, residents, and visitors.3. Hand hygiene products and supplies (sinks, soap, towels, alcohol -based handrub, etc.) shall be readily accessible and convenient for staff use to encouragecompliance with hand hygiene policies. Record review of facility policy titled, Infection Prevention and Control Program dated 01/2020 and last revised in 01/2022 reflected the following: Policy . Policy Interpretation and Implementation1. The infection prevention and control program is developed to address the facility -specificinfection control needs and requirements identified in the facility assessment and the infectioncontrol risk assessment. The program is reviewed annually and updated as necessary.2. The program is based on accepted national infection prevention and control standards.3. The infection prevention and control program is a facility-wide effort involving all disciplinesand individuals and is an integral part of the quality assurance and performance improvementprogram.4. The elements of the infection prevention and control program consist of coordination/oversight,policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management,prevention of infection, and employee health and safety.

Based on observation interview and record review the facility failed to ensure residents had adequate supervision and assistance devices to prevent accidents for 1 (resident #51) of 10 residents reviewed for accidents and hazards. The facility failed to provide safe transport for Resident #51 on 01/17/25 that resulted in a fall and fracture to the right femur. This has led to anxiety around shower times, and a reduced quality of life. An IJ was identified on 05/02/2025 at 4:30 PM. The initial IJ template was provided to the facility on [DATE] at 4:38 PM. While the IJ was removed on 05/04/25 at 12:21 pm, the facility remained out of compliance at the scope of isolated and a severity of no actual harm due to the injury sustained by Resident #51. Findings Included: Record review of Resident #51's face sheet dated 04/16/25 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included unspecified fracture of the right femur, chronic obstructive pulmonary disease(a disease that makes it hard to breath and causes lung deterioration, morbid obesity, fall from non-moving wheelchair, and osteoarthritis (arthritis of the bones which causes widespread generalized pain.) Record review of Resident #51's care plan revised 02/12/25 reflected Resident #51 has impaired visual function related to legal blindness, had a right femur and right tibia fracture related to fall with interventions to initiate PT, OT, and pain treatment as indicated by MD. Record Review of Resident #51's MDS dated [DATE] indicated a BIMS score of 15 indicating intact cognition, a mood interview score of 5, and extensive assistance for bed mobility, transfers, and toilet use. He required two person assist for transfers between surfaces; MDS states this excludes to/from bath and toilet. Resident #51 had received 150 minutes of physical therapy starting on 01/22/25 and ended 02/28/25. Review of Resident #51's incident report dated 01/17/2025 at 11:12 am reflected the following, This nurse seen when resident fell out of the shower chair while shower aid was bringing him back to his room from just receiving a shower. EMS has been called and are here at the facility as the resident states he thinks he broke his right knee. (Family) has been contacted a few times without success will attempt to contact later. MD aware. Incident and vitals initiated at this time. Resident stated, I think I heard a loud pop. I think I broke my right knee. A section within the incident report titled, Other Info, reflected the following, Resident was being transported to a room after a shower. Resident states he adjusted himself in chair and although he was not completely settled, he told CNA he was ready to go back to his room. Resident and staff educated on importance of sitting properly in chair prior to transporting. Review of Resident #51's discharge placement sheet from hospital dated, 01/18/25 reflected, Resident #51 is a [AGE] year old right-hand dominant male with a past medical history reported by the patient to have morbid obesity, CHF, Afib, congenital hydrocephalus (blindness), HTN, OSA who presents with a right distal shaft femur fracture after falling out of the shower chair at the nursing home today. He said that the while sitting on the chair the wheels broke down and he fell to the ground with his knee bent underneath him. Injury occurred at (name) nursing home. He reports experiencing immediate pain, gross deformity, and inability to bear weight about his right distal thigh after the accident. Patient was initially taken to the (name) emergency room where x-rays were obtained and then a decision was made to transfer the patient by ambulance to hospital for further evaluation and care. Preliminary x-rays were obtained revealing the above-mentioned fracture(s)/injury(s) and Orthopedic surgery was consulted. It stated Resident #51's weight was 575 lbs. During an interview on 04/14/25 03:47 PM, Resident #51 stated that he fell out of the shower chair in January of 2025. He stated he was in the hospital for 3 days and came back to receive physical therapy that had been working. The accident occurred after his shower while he was still wet. The wheels were crooked the CNA they rounded a corner and the CNA to pushed him forward, his leg got caught underneath his body. When he fell, and he heard a pow. He stated he was embarrassed because his covering came off, he was naked on the floor. The staff ended up covering him up. He did have a pending litigation with the facility. He believed they are using the same shower chair, and it causes his anxiety around shower time. He stated he only trusts one specific CNA to shower him because the CNA is strong enough to handle him. He did have a pending litigation with the facility. If the facility had been more apologetic to what happened to him, he would not bring legal action against the facility. During an interview with the Corp N. on 04/16/25 10:28 AM revealed they completed an in-house investigation to rule out neglect. She stated they checked the wheelchairs and did an in-service to retrain everyone. She stated the fall was witnessed so they ruled out abuse. They ruled out neglect earlier and major bodily injury was not sign of neglect according to her policies. During an interview with LVN A on 04/16/25 at 12:12 pm, she was a witness to the incident, and she did not suspect abuse or neglect. She stated the wheel of the chair just gave out and he slid forward onto the floor out of the chair. She saw his leg get twisted underneath him and was apart of the team that helped him get situated correctly. She stated she knew the wheelchair was ok for him and normally had one person wheeling him. She stated she thought maybe in that situation he should have been wheeled backwards, but was unsure of anything that could have been done differently to prevent the situation. During an interview with DON on 04/16/25 at 2:30 pm. She stated the event with Resident #51 happened on her second day and she was not involved in the incident. She did not have any further comments about the accident. During an interview with ADM on 04/16/25 at 3:01 pm revealed that she did not report to the stated because she believed the fall was witnessed and the facility had done their due diligence ruling out abuse and neglect within the two-hour period. They had checked that the weight limit was under his weight and verified that the aide had not done anything wrong. They were able to clear it in-house. According to her it was not suspicious. The investigation was reopened on 05/02/25. Observation of the shower chair as identified by the resident on 05/2/25 at 10:15 am revealed it was properly working and had a weight limit of 600 lbs. Interview with CNA at 05/02/25 at 10:21 am revealed that she had showered him three times before. She was sure that the shower chair's weight was certified for him. She stated she was confident the wheelchair was working because she looked at it and pushed it from the shower room to his room to transfer him. She stated when they went around the corner the wheel got stuck and I pushed him at a different angle. When I pushed the chair forward it tipped forward and was unable to catch him. He had fell on his right leg. She waited with him until EMS arrived. Interview with MAINT on 05/02/25 at 11:09 am, stated that he is up to date on most of the maintenance and he had looked at the shower chairs that month and saw nothing unusual. He stated he looked at the chair after the fall and saw no issues with the chair. He stated he didn't know if they had replaced the shower chairs. Interview with RP from the manufacturing company on 05/2/25 at 11:56 am said the shower chairs were able to be used for transportation. Record review on 05/02/2025 at 12:30 pm revealed shower chair maintenance had been completed January 7, 2025. Record review of shower chair's owner's manual states, Always abide by weight capacity. Never allow the user to suddenly shift weight in any way creating a tipping hazard for the user and the equipment. Equipment may not be appropriate for all individuals. Assessment should be conducted by a skilled caregiver for proper suitability for the individual using the equipment. Record review of facility policy titled, Policy for Resident Incident and Visitor Accident Reports dated 07/23/18 stated, The facility will conduct an investigation of all incidents involving residents of the facility. Incidents/Accidents of Unknown Origin will be reported in accordance with state and federal regulations. Any employee witnessing or having knowledge of an incident or accident involving a resident or visitor must immediately report such occurrence to his/her supervisor. The supervisor and/or employee must immediately notify the charge nurse to ensure proper medical attention can be provided. Regardless of how minor an incident/accident appears to be, it must be reported to the Department Supervisor, Administrator, or DON /designee. As soon as possible after becoming aware of an incident/accident, the Witness Form must be completed by any person witnessing the incident or any person thought to have witnessed the incident. An Incident Report must be completed by the person reporting the incident or the supervisor on the shift that the incident occurred. The Investigation must be initiated by the Department Supervisor or Charge Nurse and completed by the Administrator or DON/designee. Record review of facility policy titled, Abuse Prohibition Policy, reviewed May 17, 2024. 2. The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law and will take all necessary corrective actions depending on the results of the investigation. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury immediately or within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries. a.Initial Reporting i.Facility must provide sufficient information to describe the alleged violation and indicate how residents are being protected. Information should include, but is not limited to: 1.Basic facility information 2.Allegation type 3.When the facility became aware of the incident 4.Information about the alleged victim and perpetrator 5.Witnesses 6.Details about the allegation, including outcomes to the alleged victim 7.Notifications that were made to law enforcement or other agencies 8.Steps taken immediately to ensure resident(s) are properly protected 9.Who is submitting the report An IJ was identified due to the above findings on 05/02/25 at 4:30 PM The POR was as follows: On 5/2/2025 an abbreviated survey was initiated at Nursing Facility. On 5/2/2025 the surveyor an immediate jeopardy (IJ) Template notification that the regulatory Services has determined that the condition of the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to provide safe transport for Resident #51 on 01/17/25 that resulted in a fall from his shower chair and fracture to the right femur. Action: Resident #51 was assessed on 5/2/2025 for safety during bathing, including the use of the bariatric shower chair which was confirmed for continue use by DON. Other options were explored to include bed bath per resident preference and caregiver preference per resident preference. If assistance is needed, staff knowledgeable on how to stop and ask for support during transport. As changes arise, care plan and Kardex will continue to be modified and staff will receive education tailored to mobility needs of individual residents. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible: DON Action: Audit completed with other residents, no other residents identified to be using the bariatric shower chair. As is standard protocol and nursing procedures, unless a resident is self-ambulatory, a resident is transported in a shower chair or gurney. Resident #51 was noted to be the only resident utilizing the bariatric shower chair. Also, during transport, caregivers will continuously remind resident of safety awareness such as placement of feet, arms, etc. to mitigate accidents during transport. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible: DON Action: Corporate Clinical Nurse in-serviced ADM, DON, Maintenance Director, and ADON on accidents and hazards to include safe transport practices (intact, free of debris, functionality) including navigating shower chairs and responding to concerns. Verbal quiz was given to ensure competency. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible: Corporate Clinical Nurse Action: All nursing staff in-serviced on accidents and hazards to include safe transport practices, including navigating shower chairs and responding to concerns, process if issue is identified, who to report to, and when to report. Verbal quiz was given to ensure competency. If resident is noted to shift weight or become unstable during transport, then staff is trained to stop transport and request assistance. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible: DON/Designee Action: All training material will be incorporated into the new hire orientation. The training material to be included for all current nursing staff, new hires, PRN, and agency to show they were in-serviced on accidents and hazards to include safe transport practices, including navigating shower chairs and responding to concerns, process if issue is identified, who to report to, and when to report. If resident is noted to shift weight or become unstable during transport, then staff is trained to stop transport and request assistance. No employee will be allowed to work without completion of this training. Competency will be validated by verbal quizzing which will be recorded in an in-service and a copy placed in their employee file. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible: Administrator Action: Maintenance director in serviced by Regional Nurse on proper navigation and handling of shower chairs, accidents and hazards to include safe transport practices (intact, free of debris, functionality) including navigating shower chairs and responding to concerns. Maintenance Director conducted full audit of all shower chairs on 5/2/25 to ensure safety and integrity. No negative findings noted. Maintenance director will continue to monitor and audit shower chairs through TELS monthly tasks. Any issues to be reported to Administrator and Director of Nursing/designee and shower chair to be taken out of service until issue is resolved. Any issues and their coordinating resolution to be documented in TELS work orders. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible: Maintenance Director Action: DON/designee will observe shower completion and transportation 3x a week x 4 weeks to validate compliance and safety. Findings will be documented on audit tool. DON/designee looking to identify appropriate transport device and validate the plan of care per individual resident and staff transports are conducted appropriately. Start Date: 5/2/2025 Completion Date: ongoing Responsible: DON Action: The DON/designee will review incident reports weekly to detect trends, intervene promptly, complete root cause analysis, implement interventions, and present findings to the QA Committee for review and necessary revisions. Start Date: 5/2/2025 Completion Date: ongoing Responsible: DON THE POR WAS MONITORED AS FOLLOWS: Initial facility walk-thru on 05/03/2025 at 11:00 am revealed 7 residents up in wheelchairs to be sitting in common area next to nurse station watching television. All residents appeared neatly groomed. Further observation revealed 2 residents in wheelchairs near medication cart. One resident having vitals taken by RN A second resident receiving medications from MA G . CNA I sitting outside of room [ROOM NUMBER] for resident providing one to one sitting. CNA I stated she has provided one-to-one yesterday and today. Observation of resident coming down 200 hall walking with rolling walker to common area to watch television. Observation of housekeeping staff on 300 hall cleaning rooms. Record review of in-service of Safe Transport Practices-Shower Chair Safety and Response on 05/03/25 revealed 37 staff members have documentation of receiving in-service. In an interview on 5/3/25 at 2:41 PM with CNA J revealed CNA J stated she has received ANE in-service recently. CNA J states ANE is reported to the charge nurse and the ADM. CNA stated any suspicion of ANE is to be reported. CNA J stated if a resident falls either witnessed or unwitnessed then that is also to be reported to the charge nurse and the ADM. CNA J stated she recently received an in-service on safe transporting with the shower chairs. CNA J stated the shower chair needs to be inspected prior to use by the staff member and if the chair does not roll properly or is any form of disrepair then it should not be used and it should be reported to the charge nurse and maintenance. CNA J states if a resident shifts or slides while in shower chair then the staff member should get help from another staff member to readjust resident before continuing transport. In an interview on 5/3/25 at 3:00 PM with CNA I revealed CNA I stated she had recently received an in-service about abuse neglect and exploitation and who to report to. CAN I stated any concerns would be reported to the ADM. CNA I stated all falls are reported to the charge nurse and the ADM. CNA I stated she had received an in-service about safe transport with the shower chairs. CNA I states the shower chairs are to be inspected for safety before using with a resident. CNA I states if the shower chair is unsafe then it is to be reported to the charge nurse and the ADM. CNA I stated she thinks there is a book where it is documented and reported to maintenance, but she is not positive as she has never had to complete a work order or document on any unsafe equipment. CNA I stated if she had a resident in a shower chair and they started to slide out or readjusted and became unstable she would stop and try to secure the resident and call out for assistance from another staff member if needed. Observation on 05/04/25 at 11:13 am revealed no foul smells, the building was clean, residents in were in TV area watching TV, all residents interviewed for safety in showers chairs had call lights close to them. During interviews on 05/04/25 from 11:30 am - 5:15 pm 2 RNs, 8 LPN/LVN, and 20 CNAs from different shifts all stated they were in-serviced before working their shift. Their in-service included assessing shower chairs for safety before they were used, what to do if a resident shifts their weight, reporting unsafe shower chairs, and abuse and neglect. Interview with Corp N. on 05/04/25 at 2:30 pm she stated that she in-serviced the ADM, DON, ADON, MAINT on shower chairs and equipment, reminding residents of their safety, who to report shower chairs to and how to take it out of service and replace it. Interview with MAINT on 05/04/25 at 2:41 pm, he stated he was in-serviced by the Corp. N. about abuse and neglect, auditing the shower chairs, reviewed shower chair safety, and how to remove unworking shower chairs from service. Interview with ADON on 05/04/25 at 2:55 pm, she state that she was in serviced on abuse and neglect, safe transport in the shower chair, how to assess shower chairs for safety and how to assess resident safety in the shower chairs. Interview with DON on 05/04/25 at 3:05 pm revealed she was in-serviced on abuse and neglect, shower chair safety, inspections of shower chairs, reporting broken equipment to ADM and how to take broken shower chairs out of service. Record review of Shower Chair Inspection Audit document on 05/04/25 completed by MAINT revealed Shower chairs were audited on 02/02/25 and passed the audit. Record review of Staff In-service training record on 05/03/25 revealed that ADM, ADON, DON, and MAINT were in serviced by Corp. N on safe transport practices on 05/02/25. Record review of progress notes dated 05/03/25 at 12:55 am stated, Resident transferred to bariatric shower chair via lift and assist of 2 staff for purpose of assessing the resident' seated balance and positioning outside the scheduled shower time. Resident remained seated in chair without difficulty. Resident did not display any signs of leaning, instability, or distress during this assessment. No concerns identified at this time. Finding are consistent with safe use of current equipment and staff assistance. Record review of statement submitted on 05/04/25 stated, this is a written statement verifying that [Resident #51] is the only resident who currently uses the bariatric shower chair at [Facility name] in [City, State] as of this date. Record review of New Hire Orientation paperwork packet on 05/04/25 revealed safe transport practices for shower chairs were a part of the education and orientation. Record review of statement provided on 05/04/25 revealed an AD HOC QAPI plan meeting took place on 05/02/25 that included ADM, DON, ADON, and Medical Director. The ADM was informed the IJ was removed on 05/04/25 at 12:12 PM. The facility remained out of compliance at a scope of isolated and a severity level of no actual harm that was not immediate threat, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interviews, and record review the facility failed to provide, based on the preferences of each resident, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 5 of 5 confidential residents reviewed for activities. The facility failed to provide activities to meet the residents' interests on Saturdays and Sundays for 5 confidential residents. The facility failed to provide activities to support the mental and physical wellbeing of the residents in the secured unit. These failures could place residents at risk for decline in quality of life, social and mental psychosocial wellbeing. Findings Include: Observation on 04/14/25 at 10:30 am in the hallways of the secured unit revealed 3 residents in the hallway walking in and out of open rooms. The ACT was conducting an activity with two residents and was walking in and out of the doorway watching the 3 wandering residents. Observation on 04/14/25 at 2:30 pm in the main room of the secured unit revealed the ACT was the only staff member visible for 15 minutes while LVN E and CNA D were attending to residents. Resident's were sitting at the table. 2 residents were holding babies. There was no formal activities being done. Observation on 04/15/25 at 10:30 am the ACT was doing an activity with eggs with 4 resident's at a table. 5 Residents were watching TV. 3 residents were at another table that the ACT had to walk away from her egg activity 3 times in order to deescalate a situation between residents where there was no nursing staff available to intervene. In a confidential interview on 04/14/25 at 11:33 am the person revealed they did not see why people would not be bored. There were very few staff members there and nothing to do that they wanted to do. During a confidential group interview on 04/15/25 at 02:04 p.m., 5 confidential residents, stated there are no weekend activities. They stated it was boring and that all they did was smoke and grab games from the activities director office. Interview with CNA D on 04/15/25 at 2:30 pm, he stated he felt the residents needed more to do because the was only there from 10 am - 4 pm. CNA D stated he turned on the TV for them and would play music they like to fill the hours in between activities so the residents do not become bored and agitated. He states it was hard for ACT to get all the activities done because she's trying to get people to participate who walk away . He stated she can't bring people outside because most of the time there's not enough staff to safely watch the individuals left inside. Interview with LVN E on 04/15/25 at 3:30 pm, she stated she normally worked 2-10 and when activities are over and it was her responsibility to figure out what to do for them. The residents were bored of watching TV or coloring when she arrived for her shift. She wished she had more support for activities later into the day. Interview with PA on 04/15/25 at 7:20 pm she revealed the residents in the memory care are under-stimulated and they need something simple like an educational DVD. She noted, they primarily hang out in the lobby. She knew the residents were bored and looked for something to do when they wander. Interview with LVN F on 04/15/25 at 10:37 am she stated that on the weekends when she worked they did not have activities. She was unable to provide activities for the residents other than grabbing baby dolls or colors because she was busy providing oversight for all the residents. She stated they do not have volunteers come on the weekends and all that was available is colors, puzzles, and baby dolls. She stated it made her sad because she knew the residents want to do more. She stated that when they have an activities person come on the weekends it made a big difference for the residents. Interview with Resident #50's RP 04/15/25 at 1:30 pm she stated Resident # 50 was very social, but was struggling to interact appropriately and it will get her in trouble. She stated that she would have liked someone there to consistently guide Resident #50 in an appropriate way . Interview with ACT H 04/15/25 at 2:45 pm, she stated that her mother is in the locked unit where she works. She stated she has worked at the facility for over a year as an activities assistant. She stated they have a travel club every month and do activities related to the destination of the travel club. She stated it was hard to keep all the residents engaged. She stated they have a new activities aide that worked 9am -4 pm. She planned a few activities, helped the residents prepare for lunch, pass out lunch, and then do a few more activities. She noted it was difficult to get the entire job done between 9 am and 4 pm because there were many interruptions and the residents do not transition well. Interview with ACT 04/16/25 at 9:45 am she stated that she works back there daily, and she did her best to complete the activities, but she was called on frequently to help residents who were wandering or exhibiting inappropriate behaviors. She stated she gets interrupted very often to deal with behavioral issues. She stated it's decreasing their engagement because they are constantly interrupted with residents with behavioral issues. She noted, they needed to be engaged all day until bedtime, but sometimes they just watch TV all evening. Interview with MA G 04/16/25 at 11:33 am she stated that they did mostly coloring activities with the residents. She stated they did not sit on the patio and they did not do any physical activity related activities. Interview with DON 04/16/25 02:30 PM she stated that the ACT was only part time. She expected the ACT to only focus on activities as that was her job title. She was unsure if a part-time roll was adequate for the secured unit. She expected the staff to be creative in finding things to do. She stated that they are working on a different approach to manage behaviors and would start working on non-pharmacological interventions for their dementia patients. Interview with ADM 04/16/25 03:01 PM she stated the activities aide was a supplement to other nursing staff for supervision. The ADM stated the ACT's position was a part of the enrichment. She stated they tried to adjust activities based on the resident's needs. The schedule was supposed to be flexible. She stated she would ideally like the ACT to work full-time, but the budget did not allow it. They had to rely on the aides that are there on the weekend to fulfill her activities roll. She stated they did the best they can given the budget constraints. Record Review of the Activities Calendar for April of 2025 for the 600-hallway secured unit revealed that: Sunday's residents are offered a Word Search Packet, Lifeworks Daily and Refreshment and Coloring and Music in the afternoon. Saturday's residents are offered a crossword packet, Balloon Toss and movie and refreshments and matching games. Activities on April 14th included a bunny dice game at 10 am, egg matching at 10:30 am, a trip outside at 1:30 and matching games at 2 PM. Activities on April 15th included Perfect Pair at 10 am, Balloon Toss at 10:30 am , painting at 1:30, and discussions at 2 PM Activities on April 16th included Bunny Racing at 10 am, making music at 10:30 am, movement at 1:30 and coloring at 2 PM During a review of Facility's policy Activity Programs dated 2001 stated 1. Our activity program is designed to encourage restoration to self-care and maintenance of normal activity which is geared to the individual resident's needs. 3. Our activity program consists of individual, and small and large group activities which are designed to meet the needs and interests of each resident and includes, as a minimum: a. Social activities; b. Indoor and outdoor activities; c. Activities away from the facility; d. Religious programs; e. Creative activities; f. Intellectual and educational activities; g. Exercise activities; h. Individualized activities; i. In-room activities; j. Community activities. 6. Individualized and group activities are provided that- a. Reflect the schedules, choices and rights of the residents; b. Are offered at hours convenient to the residents, including evenings, holidays and weekends; c. Reflect the cultural and religious interests of the residents; and d. Appeal to both men and women as well as all age groups of residents residing in the facility.

Based on observation, interviews, and review, the facility failed to have sufficient staff who provide direct services to residents to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 14/14 residents that reside in the secured unit. The facility failed to adequately staff the secured memory care unit (600 hallway) which resulted in a disproportionate number of incidents affecting the 600 hallway. This failure could place residents at risk for accidents with major injuries, boredom, depression, and a decreased quality of life. Findings include: Resident #60 Record review of Resident #60's face sheet dated April 15, 2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's Disease with late onset (a late onset of brain degeneration that include cognitive and memory functions), Dementia, and unspecified lack of coordination. Record review of Resident #60's Quarterly MDS dated [DATE] indicated a BIMS score of 04 indicting severe cognitive impairment, and supervision for bed mobility, transferring, eating, and toileting. Record review of Resident #60's Care Plan, last revised on 02/21/2025 stated, resident had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's Disease with late onset interventions include cue reorient, and supervise as needed. Resident #50 Record review of Resident #50's face sheet dated April 15, 2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's Disease with late onset (a late onset of brain degeneration that include cognitive and memory functions), anxiety disorder, and major depressive disorder. Record review of Resident #50's Quarterly MDS dated [DATE] indicated a BIMS score of 99 indicting severe cognitive impairment. MDS indicated wandering activity happened 1-3 days a week, and resident needed limited assistance for bed mobility, transferring, eating, and toileting. Record review of Resident #50's Care Plan, last revised on 02/21/2025 stated she was evaluated as a wandering risk related to decreased safety awareness, confusion, and wandering behaviors. Interventions included checking location frequently, encouragement to participate in activities, observation for agitation, pacing, restlessness and to report behaviors for increased interventions. Observation on 04/14/25 at 10:30 am in the hallways of the secured unit revealed 3 residents in the hallway walking in and out of open rooms. The ACT was conducting an activity with two residents. CNA D was in the shower room with a resident and the LVN E was not in sight. Observation on 04/14/25 at 2:30 pm in the main room of the secured unit revealed the ACT was the only staff member visible for 15 minutes while LVN E and CNA D were attending to residents. Observation on 04/15/25 at 9:30 am in the secured unit hallway revealed while interviewing LVN E, 2 residents in wheelchairs were being pushed by two ambulatory residents. A moment later the light in the shower room of the secured unit came on and the resident inside started screaming. CNA D stuck his head out to call for help. The nurse walked by the two ambulatory residents while on her way to the shower room and instructed them to stop pushing the wheelchair. She then continued walking. The ambulatory residents did not stop pushing the wheelchairs. The nurse then went into the bathroom and closed the door. There were no other staff members in the unit available for assistance. Observation on 04/15/25 at 10:30 am the ACT was doing an activity with eggs with 4 residents at a table. 5 Residents were watching TV. 3 residents were at another table that the ACT had to walk away from her egg activity 3 times in order to deescalate a situation between residents where there was no nursing staff available to intervene. Observation on 04/16/25 at 3:36 pm, while interviewing LVN E, 10 residents were eating a snack while watching TV. The room was crowded and loud with residual noise of resident's eating, moving around or coughing. A resident walked out of the room crying and began to knock on the locked exit doors for 10 minutes. At the same time, two other residents were fighting over their snack. There was no other staff member in sight to assist with the residents. Interview with Resident #60 was unsuccessful due to her cognitive impairments. In a confidential interview on 04/14/25 the person revealed they did not see why people would not be bored. There were very few staff members there and nothing to do that they wanted to do. Interview with CNA D on 04/15/25 at 2:30 pm, he stated he felt the residents are unsafe in the locked unit because they all have severe memory impairment and need constant supervision. To him, it was impossible to provide them with the necessary supervision while only two people are working back there. He felt like incidents and accidents happened disproportionately to his residents in the secured unit compared to the main community. He had communicated his opinions with the ADON with no response. He stated the resident's wandering tendencies are harder to control and they take things from other people's rooms. He stated that many falls happened when he was busy helping another resident. He stated he felt like he's always tied up caring for other residents and cannot provide them the oversight they need. He has been trained on dementia specific trainings multiple times a year, but it did not help him because they needed more physical presence. Interview with LVN E on 04/15/25 at 3:30 pm, she stated she had been trained on dementia behaviors. She had been working at the facility since January of 2025. She stated there was inadequate support when incidents happen. She would call for help and no one would come. She stated it was impossible for two people to keep an eye on the residents. If the CNA called her into the shower for a skin issue it would be inevitable that when she walked out something would happen. She stated it was a lack of CNA presence that was an issue, but another nurse would be nice. She stated they needed assistance with ADL's and supervision. Interview with PA on 04/15/25 at 7:20 pm she revealed that she has been the Psychiatric Physician's Assistant at the facility for over a year. She said They do not have enough staff to get it done. The staffing is so short handed that if the residents want to fall asleep on the couch they would just leave them. I don't know if and how they are making it happen. She wandered what happened when no one was watching because it happened often. She noted the lack of urgency with some of the nurses because she believed they were burned out. Interview with LVN F on 04/15/25 at 10:37 am she stated it was very hard to get all the work done with only two sets of eyes on the residents. She stated they would absolutely benefit from a second aide being back there. She stated on the overnight shifts there are just two aides and the nurse stayed outside the locked unit. She stated the resident's do not stay asleep throughout the night and it could get dangerous with just two aides in the locked unit. She reported to the bad days and agitated unit makes everyone in a bad day no matter how many people are back there . Interview with RP of Resident #50 on 04/15/25 at 1:30 pm she stated Resident #50 was being cared for in an O.K. manner. Resident #50 was very social, but was struggling to interact appropriately and it will get her in trouble. She stated she would have liked someone there to consistently guide her Resident #50 in an appropriate way. Interview with ACT H/ RP of Resident #60 on 04/15/25 at 2:45 pm, she stated Resident #60 was in the locked unit where she worked. She stated she worked at the facility for over a year. They have recently increased the number of residents to 14 and are full. She stated in October of 2024 they removed the second aide off the hall during the daytime because of low numbers. They had not increased the staff with the capacity increase. She stated there were more unexplainable falls and aggression incidents. The residents were wandering more into other's rooms. She stated the residents look for the bathroom, but no one was there to show them their room. She stated the residents fall often. There was one resident who had fallen 4 times in a week because she thought it was the lack of supervision. She stated the staff were so busy when she arrived in the morning, she would make Resident #60 bed and dress her. Her family member had the same experience on the weekends. She stated she had been trained on dementia specific behaviors. Interview with ACT 04/16/25 at 9:45 am she stated she worked in the secured unit daily, and she did her best to complete the activities, but she was called on frequently to help residents who were wandering or exhibiting inappropriate behaviors. She stated she got interrupted very often to deal with behavioral issues. She stated it was decreasing their engagement because they are constantly interrupted with residents with behavioral issues. She stated she had been trained on dementia specific behaviors. Interview with MA G 04/16/25 at 11:33 am she stated some days are better than others, but she felt like there was an uptick in the number of bad days over the last week. She stated when residents were having a bad day they should have had a floating staff member come back and assist for multiple hours. Floating staff members in the past had only assisted for less than an hour. She was concerned about the resident's wandering habits when staff were engaged in ADL provision. She stated she was nervous that they would have hurt themselves while unattended. Interview with LVN A on 04/16/25 at 12:45 pm, she stated they do not have enough people to staff the locked unit. She would substitute a few times weekly. She stated she would be giving medications to someone in their room and the CNA will be doing ADL's with someone and in that situation there was always someone exhibiting aggressive behaviors. She stated when I am back there, I don't have enough arms. I can not be in 14 places at the same time and the resident's genuinely need it. Interview with AD 04/16/25 at 2:04 pm, she stated her activity assistant had only been there a month, but she had to stop and help with basic care and supervision needs multiple times daily. She stated it concerned her that there were only two people staffed back there. They did not know where the residents were at all times. If they are not around they are wandering in the hallway or were taking things from other resident's rooms. She stated because of their level of impairment they need eyes on them always. It made her worry that bad things are happening because of the lack of supervision. Interview with DON 04/16/25 02:30 PM she stated if the secured unit staff need assistance that they will ask. Yesterday was the first day they had asked for an additional staff member for support. She stated the activities aide should be back there to support them, but should be able to focus on their job. The DON stated she does not want her staff to feel overwhelmed. She stated they make sure the quality of care was not decreased as they meet their minimum scheduling. She stated they make adjustment to staffing with their PRN staff members. Interview with ADM 04/16/25 03:01 PM she stated they have a nurse and a CNA staffed at all times. They should have at least two people at minimum back there. She stated the activities director was there and was available to help out as needed, but should focus on her job. She stated it was hard to say if there was a lack of staffing in the secured unit. She stated at the end of the day they are safe and that she was aware it can look like there was no staff back there. She had heard complaints from the staff that they are overwhelmed regularly, but they do not communicate to her while events get bad. She stated she believes the staffing shared a fair load. Record Review of Incident Logs on 04/14/25 revealed that 60 of 147 or 40% of the total incidents occurring since January 1, 2025 involved the 14 residents (22% of the total facility population) that resided in the secured unit of the 600 hallway. Physical Aggression Received Incidents: 3/4 residents resided in the 600 hallway. Exit Seeking Incidents: 3/4 residents resided in the 600 hallway. Bruise Incidents: 9/14 residents resided in the 600 hallway. Physical Aggression Initiated Incidents: 3/5 residents resided in the 600 hallway. Fall without Injury Incidents: 15/35 residents resided in the 600 hallway. Unwitnessed Fall Incidents 18/45 residents resided in the 600 hallway. Record Review of nursing staff logs indicates from 04/14/25-04/16/25 only one CNA for 14 residents was assigned for the overnight shift. There were only two nurses on staff overnight shift for the whole facility, 61 residents. Review of Policy Entitled Staffing, Sufficient and Competent Nursing dated 10/2022 stated, Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including: a. assuring resident safety; b. attaining or maintaining the highest practicable physical, mental, and psychosocial well-being of each resident; c. assessing, evaluating, planning, and implementing resident care plans; and d. responding to resident needs. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments, and the facility assessment.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 7 residents (Resident #116 and Resident #55) reviewed for infection control. The facility failed to ensure CNAs were conducting hand hygiene when changing gloves when providing peri-care to Resident #116 The facility failed to ensure CNAs were following Enhanced Barrier Precautions by donning a gown with gloves when providing care to Resident #116 and Resident #55. The facility failed to ensure hand hygiene was being conducted with glove changes during Resident #116's wound care. These failures could place residents at risk of transmission of disease and infection. Findings included: Resident #116 Record review of Resident #116's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included a pressure ulcer of sacral region at stage 4, diabetes mellitus type 2, pressure ulcer of the left heel, hypertension, and a history of falling. Record review of Resident #116's Quarterly MDS dated [DATE] reflected she had a BIMS Score of 15, indicating no cognitive impairment. The MDS further reflected Resident #116 needed the assistance of two or more helpers for her activities of daily living and used a mechanical lift with two people assisting for transfers, and a wheelchair for mobility. She had one unstageable deep tissue pressure injury to her sacrum. Record review of Resident #116's Care Plan, last revised on 04/14/25, reflected a focus on impairment to skin integrity described as wound to left superior sacrum. The goals were for Resident #116 to have no complications related to the sacrum through the review date. The interventions included providing incontinent care as needed, pressure ulcer/injury to show signs of healing as evidenced by a decrease in size/measurements, and to remain free from signs and symptoms of complications such as infections. Observation on 04/15/25 at 10:31 AM of Foley catheter care for Resident #116 revealed signage on her door for Enhanced Barrier Precautions. CNA A and the ADON did not put on a gown before providing Foley catheter care for Resident #116. CNA A cleansed her peri-area with wipes and changed gloves without conducting hand hygiene prior to providing Foley catheter care. The ADON assisted in positioning Resident #116 on her side, and CNA A changed his gloves, but did not conduct hand hygiene before cleansing her bottom with wipes. A clear plastic trash bag was observed on and at the foot of bed that contained multiple wipes from cleansing a bowel movement, and a couple of the wipes were observed touching the resident's top sheet that was folded down. When CNA A removed his gloves after cleansing Resident #116's bottom, the ADON squirted some hand sanitizer into CNA A's hands and then CNA A donned clean gloves. Resident #116 was assisted/rolled to her right side to apply a clean brief, and her feet touched the soiled wipes that were in the clear plastic trash bag on the foot of the bed. Resident #116's black wound vac sponge was observed loose on her sacral area, and ADON removed the wound vac dressing so that wound care could be done. CNA A removed the soiled trash bag from the foot of the bed, and then pulled the contaminated sheet up over resident's waist for privacy. Observation on 04/15/25 10:54 AM of wound care for Resident #116 with LVN A and RN A revealed both of them donned a gown with gloves, per Enhanced Barrier Precautions signage on door. LVN A removed her gloves and conducted hand hygiene after cleansing Resident #116's sacral wound. LVN A did not put on gloves and picked up the black foam dressing with bare hands cut the black foam dressing to fit inside the sacral wound. LVN A then placed the black foam dressing on the clean field, sanitized her hands and donned gloves before proceeding with dressing the wound. Resident #55 Review of Resident #55's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including colon cancer and neuromuscular dysfunction of the bladder,. Review of Resident #55's Quarterly MDS assessment, dated 02/08/25, reflected a BIMS Score of 14, which indicated mild cognitive impairment. The MDS further reflected Resident #44 needed the assistance of two or more helpers for her activities of daily living and used a mechanical lift with two people assisting for transfers, and a wheelchair for mobility. Observation on 04/15/25 at 11:32 AM of peri-care for Resident #55 with CNA A, and CNA B assisting. Signage was observed on Resident #55's door for Enhanced Barrier Precautions. Neither CNA A nor CNA B donned a gown before providing care. CNA B was observed providing hand sanitizer to CNA A while he was providing peri-care to Resident #55. CNA A was observed holding a glove in his right hand while haphazardly applying hand sanitizer to his hands, and then he put on the gloves. Interview on 04/15/25 at 11:46 AM with CNA A revealed he had worked as a CNA for 16 years. CNA A stated the facility did provide pocket hand sanitizer to the staff. CNA A further stated the ADON had been squirting hand sanitizer in his hand when he was providing care to Resident #116. CNA A further stated he had forgotten to put on a gown when providing care to Resident #116 and Resident #55, and a consequence could be passing infection on to another resident. Interview on 04/16/25 at 09:55 AM with the ADON revealed she had worked at the facility since January 2025. The ADON started the facility had hand sanitizer available for all the staff members to use when they were providing care. The ADON stated she had been giving CNA A hand sanitizer when this writer was observing Foley catheter care for Resident #116. The ADON stated all staff providing direct care to a resident that was on Enhanced Barrier Precautions should put on a gown with gloves. The ADON further stated a gown should be put on when doing wound care, foley catheter care, and peri-care. The ADON stated CNA A should have put on a gown when he provided care to Resident #116 and Resident #55. Interview on 04/16/25 at 09:55 AM with the DON revealed she had worked at the facility since January 2025. The DON started the facility had hand sanitizer available for all the staff members to use when they were providing care. The DON stated all staff providing direct care to a resident that was on Enhanced Barrier Precautions should put on a gown with gloves. The DON further stated a gown should be put on when doing wound care, foley catheter care, and peri-care. The DON further stated CNA A should have put on a gown when he provided care to Resident #116 and Resident #55. The DON further stated the policy reflected all direct care staff should be washing their hands with soap and water when their hands are visibly soiled. Staff should perform hand hygiene before and after contact with the resident, after contact with blood, body fluids, or visibly contaminated surfaces, after contact with objects and surfaces in the resident's environment, and after removing personal protective equipment. Staff should also perform hand hygiene and put on clean gloves before performing a procedure such as an aseptic task of handling clean wound dressings. Record review of an In-service Record dated 11/01/24 for Infection Control/Enhanced Barrier Precautions/Contact Precautions reflected CNA A had signed the in-service. Record review of an In-service Record dated 01/16/25 for Enhanced Barrier Precautions reflected CNA A had signed the in-service. Review of Policy & Procedure on Handwashing/Hand Hygiene Residents 03/19/25 reflected: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1. Residents, family members and/or visitors will be encouraged to practice hand hygiene. 2. Residents may be trained and encouraged on the importance of hand hygiene in preventing the transmission of infections. 3. Handwashing posters will be displayed in various parts of the facility to serve as a reminder to residents regarding the importance of handwashing 4. Hand hygiene products and supplies (sinks, soap, towels, alcohol -based hand rub, wipes etc.) shall be readily accessible and convenient for resident use to encourage compliance with hand hygiene policies. 5. For residents who are unable to complete handwashing or require reminders, facility staff will provide assistance and encouragement as needed. A review of the CDC Long Term Care Facilities reflected when implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g. gown and gloves) For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. Review of Enhanced Barrier Precautions, signage observed at the facility posted on the doors of other resident rooms, not posted on Residents #460 and #461's doors reflected: Enhanced Barrier Precautions: Providers and staff must: wear gloves and a gown for the following High-Contact Resident Care Activities. Do not wear the same gown and gloves for the care of more than one person. Providers and staff must also: Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheotomy Wound Care: any skin opening requiring a dressing. Review of facility Enhanced Barrier Precautions policy dated 03/19/25 reflected it is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Multidrug-resistant organism (MDRO) transmission is common in long term care (LTC) facilities. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. A single set of PPE cannot be used for more than 1 patient. EBP are indicated for residents with any of the following: o Colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply (see MDRO list on page 3); or o Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid®) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheotomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP. The facility will ensure PPE and alcohol-based hand rub are readily accessible to staff prior to entry to their room. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. For example, staff entering the resident's room to answer a call light, converse with a resident, or provide medications who do not engage in a high-contact resident care activity would likely not need to employ EBP while interacting with the resident.

Based on observations, interviews, and record review the facility failed to provide reasonable accommodations to meet the needs and preferences for 1 of 6 residents reviewed for accommodations. The facility failed to ensure that Resident #47 had the call light device in reach while lying in bed. The facility failed to accommodate Resident #47 with a call light device that would meet their individual needs. This deficient practice could affect and diminish the resident's quality of life by potentially placing the resident at risk of injury, not receive timely care or receive nursing interventions to meet the resident's needs. Findings include: Record review of Resident #47's Face Sheet dated 04/16/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included Sepsis (condition that occurs when the body's response to an infection causes injury to its own tissues and organs), Kidney Failure (condition where the kidney reaches advanced state of loss of function. This causes changes in urination, fatigue, swelling of feet, high blood pressure, and loss of appetite), Contracture of Muscles; right hand and left wrist (abnormal shortening of muscle tissue that makes the muscle highly resistant to stretching), Dysphagia (difficulty swallowing), Cognitive Communication Deficit (difficulties in communication that arise from impairments in cognitive processes such as attention, memory, perception, and executive function), Delusional Disorder (fixed, false conviction in something that is not real or shared by other people), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities once enjoyed), Anxiety (feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), Psychosis (is a mental health condition characterized by a disconnection from reality), Paroxysmal Atrial Fibrillation (is an irregular heart rhythm that can cause symptoms including fatigue, lightheadedness, and stroke), and Spinal Stenosis (narrowing of spaces in the spine). Record review of Resident #47's quarterly Minimum Data Set, dated [DATE] reflected a Brief Interview for Mental Status Score of 99, which indicated severe cognitive impairment. Record review of Resident #47's Care Plan dated 02/26/2025 reflected Resident #47 required extensive assistance with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. The goals were for Resident #47 to maintain current level of function with assistance in his daily living care needs. Record review of Resident #47 Care Plan dated 02/26/2025 stated for the facility staff to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. Resident #47 needs prompt response to all requests for assistance. In an observation on 04/14/2025 at 9:59 AM of Resident #47 the call light button was out of reach located on the right side of the resident's bed laying on the floor. Resident #47 was observed to have contracted hands. There was no observation of additional call light pad button device for the resident. The resident was not interviewable. In an observation on 04/15/2025 at 12:17 PM of Resident #47, the call light button was clipped on the resident's right side of the bed in which it was out of reach due to resident having contracted hands. During the observation, there was no visual of a call light pad button device on his chest in order to assist and accommodate the resident's needs. In an interview on 04/15/2025 at 12:25 PM with LVN A, stated Resident #47 should have a call light pad button device on his chest. LVN A went and checked on Resident #47 herself stated the resident did not have a call light pad button device. LVN A advised that it will be brought up with facility staff and she would have it taken care of right away. In an interview on 04/16/2025 at 11:43 AM with MA G, she stated Resident #47 had not used the original call light button system set in place and there was not a call light pad button used prior. MA G stated Resident #47 would benefit from a call light pad button device on his chest for easier usage as he has contracted hands and was unable to reach. MA G stated a negative effect on the resident would be that he cannot push the call light button for assistance. In an interview on 04/16/2025 at 11:45 AM with Responsible Party, she stated Resident #47 did have the capability to use the original call light button device. Responsible Party stated a call light pad button device would be easier for Resident #47 to utilize in the events of daily assistance and needing it in the event of an emergency considering he has contracted hands. In an interview on 04/16/2025 at 12:15 PM with LVN A, stated Resident # 47 was able to manage pushing the call light pad button device now set in place since it's located on his chest in easy reach. LVN A stated if there was an issue prior before with the resident, they would have missed it. LVN A stated some effects of not having the appropriate call light button system set in place was the resident not able to push it for assistance and staff are unable to meet the resident's needs in which can pose effects on the resident's quality of life. In an interview on 04/16/2025 at 2:20 PM with Director of Nursing (DON), stated if a resident had the call light button device on the floor and if that resident had contracted hands, the resident would not be able to reach the call light button device nor potentially be able to use it in which the call light pad button device would be easier for the resident to use such as, Resident #47. The DON stated her expectations for call light devices are to be within reasonable reach of residents and assessing residents for call pads or accommodation needs. The DON stated resident's quality of life can be affected, but it would depend on the resident. In an interview on 04/16/2025 at 2:50 PM with Administrator, she stated staff are responsible for having call light devices in appropriate reach for residents. Administrator stated that herself and DON are in charge of making sure that the residents have the appropriate call light device system set in place for their individual needs. Administrator stated, the original call light button device for Resident #47 was not feasible, and the call light pad button device set in place now was more feasible for the resident. Administrator stated her expectations for call light device systems was for all residents to have a functioning call light button device that residents can use to meet their individualized needs. Administrator stated resident's quality of life can be affected if they don't have access to call light button device due to not getting attention or their needs met, or it can make a resident feel neglected affecting their mental health. Record review of Accommodation of Needs Policy stated: the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. Policy Interpretation and Implementation; The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. Examples of such adaptations may include providing access to assistive devices. Record review of Resident Call System Policy stated: residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Policy Interpretation and Implementation; Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Call system communication may be audible or visual. The system may be wired or wireless. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan.

Based on interviews and record review, the facility failed to develop and implement abuse reporting policies for one (Resident #51) of five residents reviewed for abuse and neglect. The facility failed to implement policies that required reporting of major injury after an incident on 01/17/25 where Resident #51 fell out of the shower chair while transporting back to his room from the shower and sustained a fracture to the right femur. This deficient practice could place residents at risk of continued abuse and neglect if abuse policy is not properly implemented. Findings included: Record review of Resident #51's face sheet dated 04/16/25 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included unspecified fracture of the right femur, chronic obstructive pulmonary disease(a disease that makes it hard to breath and causes lung deterioration, morbid obesity, fall from non-moving wheelchair, and osteoarthritis (arthritis of the bones which causes widespread generalized pain.) Record review of Resident #51's care plan revised 02/12/25 reflected Resident #51 has impaired visual function related to legal blindness, had a right femur and right tibia fracture related to fall with interventions to initiate PT, OT, and pain treatment as indicated by MD. Record Review of Resident #51's MDS dated [DATE] indicated a BIMS score of 15 indicating intact cognition, a mood interview score of 5, and extensive assistance for bed mobility, transfers, and toilet use. He required two person assist for transfers between surfaces; MDS states this excludes to/from bath and toilet. Resident #51 had received 150 minutes of physical therapy starting on 01/22/25 and ended 02/28/25. Review of Resident #51's incident report dated 01/17/2025 at 11:12 am reflected the following, This nurse seen when resident fell out of the shower chair while shower aid was bringing him back to his room from just receiving a shower. EMS has been called and are here at the facility as the resident states he thinks he broke his right knee. Daughter has been contacted a few times without success will attempt to contact later. MD aware. Incident and vitals initiated at this time. Resident stated, I think I heard a loud pop. I think I broke my right knee. A section within the incident report titled, Other Info, reflected the following, Resident was being transported to a room after a shower. Resident states he adjusted himself in chair and although he was not completely settled, he told CNA he was ready to go back to his room. Resident and staff educated on importance of sitting properly in chair prior to transporting. Review of Resident #51's discharge placement sheet from hospital dated, 01/18/25 reflected, Resident #51 is a [AGE] year old right-hand dominant male with a past medical history reported by the patient to have morbid obesity, CHF, Afib, congenital hydrocephalus (blindness), HTN, OSA who presents with a right distal shaft femur fracture after falling out of the shower chair at the nursing home today. He said that the while sitting on the chair the wheels broke down and he fell to the ground with his knee bent underneath him. Injury occurred at Lily Spring Nursing home. He reports experiencing immediate pain, gross deformity, and inability to bear weight about his right distal thigh after the accident. Patient was initially taken to the ER where x-rays were obtained and then a decision was made to transfer the patient by ambulance to hospital for further evaluation and care. Preliminary x-rays were obtained revealing the above-mentioned fracture(s)/injury(s) and Orthopedic surgery was consulted. It is also noted, (Resident #51) says fall was mechanical when was accidentally pushed out of wheelchair. Review of facility's record in TULIP reflected the incident was not reported to the State Agency. A complaint was filed by Resident #51 alleging neglect due to his fracture on 03/28/25. During an interview on 04/14/25 03:47 PM Resident #51 stated that he fell out of the shower chair in January of 2025. He stated he was in the hospital for 3 days and came back to receive physical therapy that had been working. He stated that the wheels were not properly functioning, and he tipped forward with his leg underneath him. He did have a pending litigation with the facility. If the facility had been more responsive to what happened to him, he would not bring legal action against the facility. During an interview with the Corp N. on 04/16/25 10:28 AM revealed they did not report the incident to the State Agency. They did an in-house investigation to rule out neglect. She mentioned she investigated the incident in the event that there was pending legal action, which there was none. She stated that the fall was witnessed so they did not say abuse. They ruled out neglect earlier and major bodily injury was not sign of neglect according to her policies. She stated they checked the wheelchairs and did an in-service to retrain everyone. During an interview with MA G on 04/16/25 at 11:33 am she stated that she was down the hall when the incident happened. She stated it was a big deal and seemed like it should have been a reportable incident because he went to the hospital. She stated they were in-serviced, the shower chairs were maintenance. She noted Resident #51 telling her he was filing a lawsuit against the facility, and she had helped him fill out the forms and gather information for his lawyers. During an interview with LVN A on 04/16/25 at 12:45 pm, she stated that she was unaware if there was a pending lawsuit. She was a witness to the incident, and she did not suspect abuse or neglect. She stated the wheel of the chair just gave out. She thought any fracture should be reported to the state. She had received many in-services on abuse and neglect and knew the ADM was the abuse and neglect coordinator. She noted that if she had known it wasn't reported to the State she would have reported it. During an interview with DON on 04/16/25 at 2:30 pm she said that the abuse and neglect coordinator was the ADM. She stated she does not know Texas law for reportable yet. She stated that any event needs to be reported if it's within the law. She stated the event with Resident #51 happened on her second day and she was not involved in the incident. During an interview with ADM on 04/16/25 at 3:01 pm revealed that she did not report to the stated because she believed the fall was witnessed and the facility had done their due diligence ruling out abuse and neglect within the two-hour period. They had checked that the weight limit was under his weight and verified that the aid had not done anything wrong. They were able to clear it in-house. According to her it was not suspicious. They didn't report it within two hours of learning about the injury because they weren't aware it was a major injury until he arrived back at the facility. She stated that it was not up to the state to be the determining factor if an injury was considered neglect. 5/3/25 10:00 AM Initial facility walk-thru revealed 7 residents up in wheelchairs to be sitting in common area next to nurse station watching television. All residents appeared neatly groomed. Further observation revealed 2 residents in wheelchairs near medication cart. One resident having vitals taken by RN A second resident receiving medications from MA G . CNA I sitting outside of room [ROOM NUMBER] for resident providing one to one sitting. CNA I stated she has provided one-to-one yesterday and today. Observation of resident coming down 200 hall walking with rolling walker to common area to watch television. Observation of housekeeping staff on 300 hall cleaning rooms. Record review of in-service of Safe Transport Practices-Shower Chair Safety and Response revealed 37 staff members have documentation of receiving in-service. In an interview on 5/3/25 at 2:41 PM with CNA J revealed CNA J stated she has received ANE in-service recently. CNA J states ANE is reported to the charge nurse and the ADM. CNA stated any suspicion of ANE is to be reported. CNA J stated if a resident falls either witnessed or unwitnessed then that is also to be reported to the charge nurse and the ADM. CNA J stated she recently received an in-service on safe transporting with the shower chairs. CNA J stated the shower chair needs to be inspected prior to use by the staff member and if the chair does not roll properly or is any form of disrepair then it should not be used and it should be reported to the charge nurse and maintenance. CNA J states if a resident shifts or slides while in shower chair then the staff member should get help from another staff member to readjust resident before continuing transport. In an interview on 5/3/25 at 3:00 PM with CNA I revealed CNA I stated she had recently received an in-service about abuse neglect and exploitation and who to report to. CAN I stated any concerns would be reported to the ADM. CNA I stated all falls are reported to the charge nurse and the ADM. CNA I stated she had received an in-service about safe transport with the shower chairs. CNA I states the shower chairs are to be inspected for safety before using with a resident. CNA I states if the shower chair is unsafe then it is to be reported to the charge nurse and the ADM. CNA I stated she thinks there is a book where it is documented and reported to maintenance, but she is not positive as she has never had to complete a work order or document on any unsafe equipment. CNA I stated if she had a resident in a shower chair and they started to slide out or readjusted and became unstable she would stop and try to secure the resident and call out for assistance from another staff member if needed. During interviews on 05/04/25 from 11:30 am - 5:15 pm 3 Housekeeping, 2 maintenance, 2 cooks, 2 RNs, 8 LPN/LVN, and 20 CNAs from different shifts all stated they were in-serviced before working their shift. Their in-service included when to report abuse, the types of abuse, examples of abuse and that covered that employees are free from retaliation if they report abuse. Interview with Corp N. on 05/04/25 at 2:30 pm she stated that she in-serviced the ADM, DON, ADON, MAINT on reporting requirements for abuse and neglect, reviewed the provider reports and facility policy for abuse and neglect reporting. Interview with RDO on 05/04/25 at 2:39 pm, she stated she in-serviced the DON and ADM on reporting and requirements for reporting. She reviewed what consisted a serious injury and reviewed the provider letter and corporate policy with them. Interview with MAINT on 05/04/25 at 2:41 pm, he stated he was in-serviced by the Corp. N. about the facility's abuse and neglect policy. Interview with ADON on 05/04/25 at 2:55 pm, she state that she was in serviced on abuse and neglect, the facility abuse coordinator, and what events are reportable. Interview with DON on 05/04/25 at 3:05 pm revealed she was in serviced on abuse and neglect, reporting timelines, retaliation for reporting, and the facilities abuse and neglect policy. Record review of Staff In-service training record revealed that ADM, ADON, DON, and MAINT were in-service by Corp. N on abuse and neglect on 05/02/25. Record review of New Hire Orientation paperwork packet on 05/04/25 revealed abuse and neglect reporting were apart of the education and orientation. Record review of statement provided on 05/04/25 revealed an AD HOC QAPI plan meeting took place on 05/02/25 that included ADM, DON, ADON, and Medical Director. Review of facility policy titled, Abuse Prohibition Policy, reviewed May 17, 2024. 2. The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law and will take all necessary corrective actions depending on the results of the investigation. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury immediately or within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries. a.Initial Reporting i.Facility must provide sufficient information to describe the alleged violation and indicate how residents are being protected. Information should include, but is not limited to: 1.Basic facility information 2.Allegation type 3.When the facility became aware of the incident 4.Information about the alleged victim and perpetrator 5.Witnesses 6.Details about the allegation, including outcomes to the alleged victim 7.Notifications that were made to law enforcement or other agencies 8.Steps taken immediately to ensure resident(s) are properly protected 9.Who is submitting the report

Based on interviews and record review, the facility failed to ensure that all allegations involving abuse, neglect, or serious bodily injuries were reported immediately but not later than 24 hours after the allegation was made for one (Resident #51) of five residents reviewed for abuse and neglect. The facility failed to report to the State Agency an incident on 01/17/25 where Resident #51 fell out of the shower chair while transporting back to his room and sustained a fracture to the right femur. This deficient practice could place residents at risk of abuse and neglect. Findings included: Review of Resident #51's face sheet dated 04/16/25 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included unspecified fracture of the right femur fall from non-moving wheelchair, and osteoarthritis (arthritis of the bones which causes widespread generalized pain.) Review of Resident #51's MDS updated March 2, 2025 indicated he needed extensive assistance for bed mobility, transfers, and toileting. MDS indicated he received physical therapy for 150 minutes a week that began 01/22/25 and ended 02/28/25. Review of Resident #51's care plan revised 02/21/25 reflected Resident #51 has impaired visual function related to legal blindness, had a right femur and right tibia fracture related to fall with interventions to initiate PT, OT, and pain treatment as indicated by MD. Review of Resident #51's incident report dated 01/17/2025 at 11:12 am reflected the following, This nurse seen when resident fell out of the shower chair while shower aid [sic] was bringing him back to his room from just receiving a shower. ISNIP has been informed, EMS has been called and are here at the facility as the resident states he thinks he broke his right knee. [family] has been contacted a few times without success will attempt to contact at a later time. MD aware. Incident and vitals initiated at this time. Resident stated, I think I heard a loud pop. I think I broke my right knee. A section within the incident report titled, Other Info, reflected the following, Resident was being transported to a room after a shower. Resident states he adjusted himself in chair and although he was not completely settled, he told CNA he was ready to go back to his room. Resident and staff educated on importance of sitting properly in chair prior to transporting. Review of Resident #51's discharge placement sheet from hospital dated, 01/18/25 reflected, Resident #51 presents with a right distal shaft femur fracture after falling out of the shower chair at the nursing home today. He said while sitting on the chair the wheels broke down and he fell to the ground with his knee bent underneath him. Injury occurred at [name] Nursing home. He reported experiencing immediate pain, gross deformity, and inability to bear weight about his right distal thigh after the accident. Patient was initially taken to the [name] ER where x-rays were obtained and then a decision was made to transfer the patient by ambulance to the hospital for further evaluation and care. Preliminary x-rays were obtained revealing the above-mentioned fracture(s)/injury(s) and Orthopedic surgery was consulted. It is also noted, (Resident #51) says fall was mechanical when was accidentally pushed out of wheelchair. Review of facility's record in TULIP reflected the incident was not reported to the State Agency. A complaint was filed by Resident #51 alleging neglect due to his fracture on 03/28/25. This complaint was investigated and found to be unsubstantiated. During an interview on 04/14/25 03:47 PM Resident #51 stated that he fell out of the shower chair in January of 2025. He stated he was in the hospital for 3 days and came back to receive physical therapy that had been working. He stated the wheels were not properly functioning, and he tipped forward with his leg underneath him. He did have a pending litigation with the facility. If the facility had been more responsive to what happened to him, he would not bring legal action against the facility. During an interview with the Corp N. on 04/16/25 10:28 AM revealed they did not report the incident to the State Agency. They did an in-house investigation to rule out neglect. She mentioned she investigated the incident in the event that there was pending legal action, which there was none. She stated the fall was witnessed so they did not say abuse. They ruled out neglect earlier and major bodily injury was not sign of neglect according to her policies. She stated they checked the wheelchairs and did an in-service to retrain everyone. During an interview with LVN A on 04/16/25 at 12:45 pm, she was a witness to the incident, and she did not suspect abuse or neglect. She stated the wheel of the chair just gave out. She thought any fracture should be reported to the state. She had received many in-services on abuse and neglect and knew the ADM was the abuse and neglect coordinator. She noted that if she had known it was not reported to the State she would have reported it. During an interview with DON on 04/16/25 at 2:30 pm she said that the abuse and neglect coordinator was the ADM. She stated she does not know Texas law for reportable yet. She stated that any event needs to be reported if it's within the law. She stated the event with Resident #51 happened on her second day and she was not involved in the incident. During an interview with ADM on 04/16/25 at 3:01 pm revealed that she did not report to the stated because she believed the fall was witnessed and the facility had done their due diligence ruling out abuse and neglect within the two-hour period. They had checked that the weight limit was under his weight and verified that the aide had not done anything wrong. They were able to clear it in-house. According to her it was not suspicious. They did not report it within two hours of learning about the injury because they weren't aware it was a major injury until he arrived back at the facility. She stated that it was not up to the state to be the determining factor if an injury was considered neglect. Review of facility policy titled, Abuse Prohibition Policy, reviewed May 17, 2024. 2. The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law and will take all necessary corrective actions depending on the results of the investigation. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury immediately or within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries. a.Initial Reporting i.Facility must provide sufficient information to describe the alleged violation and indicate how residents are being protected. Information should include, but is not limited to: 1.Basic facility information 2.Allegation type 3.When the facility became aware of the incident 4.Information about the alleged victim and perpetrator 5.Witnesses 6.Details about the allegation, including outcomes to the alleged victim 7.Notifications that were made to law enforcement or other agencies 8.Steps taken immediately to ensure resident(s) are properly protected 9.Who is submitting the report

Based on interview and record review the facility failed to provide basic life support, including CPR, to a resident requiring emergency care prior to the arrival of emergency medical personnel and related physician orders and the residents advance directives for one of seven (Resident #1) residents reviewed for CPR . The facility failed to update Resident #1's records to reflect he requested a change in his code status on [DATE] from DNR (do not resuscitate) to Full Code. As a result, basic life support measures, which included CPR (Cardiopulmonary Resuscitation) were not provided to Resident #1 when Resident #1 fell back in his bed while talking to Emergency Medical Services and expired on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE] at 3:11 pm, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of injury, harm, impairment or death. Findings include: Record review of Resident #1's face sheet, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included heart failure (heart does not pump as well as it should), diabetes (body have trouble controlling blood sugar energy), and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 14, which indicated intact cognition. Resident #1 could make himself understood and was able to understand verbal content. Record review of Resident #1's care plan, dated [DATE], did not reflect an Advance Directive. Record review of Resident #1's care plan meeting notes, dated [DATE] , signed by SW reflected under the Advanced Directive section: Want to change to full code, currently DNR. Record review of Resident #1's progress notes, dated [DATE] at 10:20 AM, written by the SW, reflected SW met with [Resident #1] at bedside to conduct MDS assessment. Resident #1 appears to be alert and oriented, [Resident #1] hearing is minimal difficulty, but vision is adequate with glasses, impaired without them. [Resident #1] has clear speech and able to voice his needs/wants. [Resident #1] stated that he had been doing okay but he was having a hard time breathing, gaining weight so he may be overeating and feeling depressed because of his heart. [Resident #1] discharge plan is to remain at the facility LTC. [Resident #1] is his own RP. Resident #1 wishes to change from DNR to full code. Record review of Resident #1's progress notes, dated [DATE] at 10:32 AM, written by the SW, reflected SW met with [Resident #1] at bedside to conduct MDS assessment. [Resident #1] appears to be alert and oriented. [Resident #1] hearing is minimal difficulty, but vision is adequate with glasses, impaired without them. [Resident #1] has clear speech and able to voice his need/wants. [Resident #1] stated that he has been doing okay but still gets depressed because of his health condition. [Resident #1] discharge plan is to remain at the facility LTC. [Resident #1] is his own RP. [Resident # 1] wishes to remain full code. Record review of Resident #1's progress notes, dated [DATE] at 8:00 PM, written by RN A, reflected [Resident #1] presented to nurse with chest pain and shortness of breath, swearing, anxious. Saturations 84% on room air. Oxygen 2 liters applied. Blood pressure ,d+[DATE], heart rate 88. One sl not given. Rated pain ,d+[DATE]. 8:10 B/P ,d+[DATE], hr 89. 2nd sl not given. 8:15 B/P ,d+[DATE], hr 76. Aspirin 81 mg po given, EMS, DON, Family. EMS arrived at 8:23 pm. Record review of Resident #1's progress notes, dated [DATE] at 8:30 PM, written by RN A, reflected EMS placed resident on monitor. Talking to resident, all of a sudden resident fell back in bed and became non-responsive. Monitor showed PEA(without pulse). Patient was pronounced at 8:36 PM. No pulse, no respirations, no signs of life. Family arrival pending. Funeral home notified. Record review of Resident #1's DNR form, dated [DATE], reflected a form signed by Resident #1 and two witnesses. During an interview with the SW on [DATE] at 4:05 PM, the SW stated Resident #1 requested at the care plan meeting on [DATE] that Resident #1 requested his code status of DNR to full code. The SW stated the MDS Coordinator was responsible for updating the care plan from DNR to full code. The SW stated after the care plan meeting on [DATE], she removed the DNR from the binder at the nurse's station. The SW stated she met with Resident #1 on [DATE] to conduct his Quarterly MDS and Resident #1 had expressed he wanted to remain full code . During an interview with the MDS Coordinator on [DATE] at 10:25 AM, she stated she started in [DATE] date not recalled as the MDS Coordinator. The MDS Coordinator stated she was not the MDS coordinator when Resident #1 requested his code status be changed from DNR to full code. The MDS Coordinator stated the MDS Coordinator would be responsible for updating the code status to reflect the change of the DNR to full code . During an interview with the NP on [DATE] at 1:00 PM, the NP stated she was not told about Resident #1's code status was an error until after he expired on [DATE]. The NP stated her records reflected Resident #1's code status was DNR. The NP stated it was expected for the directive to have been updated and Resident #1's code status be followed per his wishes. The NP stated with no attempt to provide life saving measures Resident #1's wishes were not followed. During an interview with RN A on [DATE] at 1:29 PM, RN A stated Resident #1 came out of his room to the nurse's station on [DATE] around 8:00 PM and she immediately noticed Resident #1 was in distress. RN A stated Resident #1 was sweating and she started assessing Resident #1 's blood pressure and it was elevated. RN A stated she gave Resident #1 oxygen, a nitro, and called 911. RN A stated when EMS arrived and talked to Resident #1, he fell back in the bed and became nonresponsive. RN A checked in PCC, and it had DNR for Resident #1 and that was followed. RN A stated no CPR was performed because the code status in PCC showed DNR . During an interview with RN B on [DATE] at 2:19 PM, she stated she was finishing up on notes in the evening time not recalled on [DATE] when Resident #1 walked up to the nurse's station to state he did not feel well. RN B stated RN A assessed Resident #1 and called 911. RN B stated the last thing she knew, Resident #1 was DNR. RN B stated it was expected to follow the resident's wishes of the directive. RN B stated PCC showed DNR and that was followed. During an interview with FM #1 on [DATE] at 2:00 PM, FM #1 stated RN A stated to her when Resident #1 expired that he was DNR. The FM stated the last she knew Resident #1 was DNR and he did not tell her he was a full code. The FM stated all along she thought DNR was what Resident #1 had wanted. The FM stated she was blown away that EMS was right there with Resident #1 and could have possibly saved him. The FM stated RN A told her Resident #1 died immediately and there was nothing they could have done for Resident #1 because he was DNR. The FM stated she was so upset the facility had messed up and did not grant Resident # 1 his wishes he had requested. The FM stated the facility dropped the ball with Resident #1. During an interview with the DON on [DATE] at 6:22 PM, she stated she started with the facility on [DATE]. The DON stated she was not at the facility when Resident #1 had expired. The DON stated the current MDS Coordinator was not working in the facility during the time of the incident with Resident #1. The DON stated the MDS Coordinator would have been responsible for making the change of the DNR to full code. It was expected for the MDS Coordinator to make the change to make sure Resident #1's wishes were honored. The DON stated Resident #1's rights were not honored when his code status of DNR to full code were never changed after Resident #1 requested. During an interview with the ADM on [DATE] at 6:48 PM, the ADM stated the Prev MDS Coordinator would have been responsible for changing Resident #1's code status after the care plan meeting on [DATE]. The ADM stated Resident #1's code status was never changed from DNR to full code when Resident #1 had changed it from DNR to full code. The ADM stated it was expected for Resident #1's code status to be changed from DNR to full code when he requested at the care plan meeting. The ADM stated with the code status not being updated Resident #1's wishes were not get granted. Interview attempted with the Prev MDS Coordinator on [DATE] at 1:28 PM was unsuccessful. Left voice message for the Prev MDS Coordinator to return call. The Prev MDS never returned the call. Interview attempted with the Prev DON on [DATE] at 1:30 PM was unsuccessful. Left voice message for the Prev DON to return call. The Prev DON never returned call. Record review of the facility's policy, dated [DATE], revised [DATE], titled Advance Directives reflected. Advanced directives will be respected in accordance with state law and facility policy. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 7:42 PM. The ADM was notified. The ADM was provided with the IJ template on [DATE] at 7:42 PM . The following Plan of Removal submitted by the facility was accepted on [DATE] at 7:25 am: F678- The facility failed to ensure Resident #1 was provided CPR. [DATE] The following actions were immediately put into place: A comprehensive review of all residents was conducted DON, ADON, and Corporate Clinical Specialists to verify code status, medical orders, care plan, and DNR documentation on [DATE]. Care plans were checked to ensure alignment with advance directive documentation DON, ADON, and Corporate Clinical Specialists on [DATE]. Advance directive binders at the nurses' station were cross-checked, with necessary adjustments made to DNR documentation by DON, ADON, and Corporate Clinical Specialists on [DATE]. DON/Designee will keep binders updated on ongoing basis. All staff were in-serviced on binder's kept at nursing station. An Ad Hoc QAPI was held on [DATE], to include Medical Director, DON, Administrator and Corporate Clinical Specialist. Inservice DON and ADON was completed by Corporate Clinical Specialist on [DATE] on the following: How to document, identify and update code status on residents. CCS/DON/Nursing Administration will in-service licensed staff on the following: How to document, identify and update code status on residents. Competency was validated by verbal quizzes. Any staff that were no in-serviced will not be able to work the floor until training and competency is validated by DON/Designee. Inservice was provided to all staff on how to identify code status by nursing admin on [DATE]. Competency validated by verbal quizzes. The above information will be included in new hire orientation by Administrator effective [DATE]. Monitoring and Audits: The Administrator /designee will conduct audits of advance directive documentation to ensure accuracy in electronic medical records (E.M.R.) weekly x 4 weeks. After 4 weeks, the Adm/Designee will follow the above process twice a month for 8 weeks, then monthly thereafter. Mock Code Drills: DON/designee will perform quarterly mock code drills for 1 year to ensure staff can effectively identify code status and respond correctly to emergencies . The facility QA Committee will meet weekly starting [DATE], for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. Monitoring of the POR included the following: During an interview with the ADON on [DATE] at 12:30 PM, she stated she had in serviced over advanced directives with CCS on [DATE]. The ADON stated after she received her training, she assisted with training staff. The ADON stated a short quiz was conducted after the training and she passed the quiz. She stated she was trained making sure the Advanced Directive was in place, make sure the code status was entered in PCC under the resident's name, and to make sure the binder at the nurses' station stayed updated. During an interview with RN B on [DATE] at 12:57 PM, she stated she had received her training on [DATE] with the ADON over advanced directives. The ADON stated the Advanced Directives training included making sure code status was entered in PCC and making sure the binder at the nurse's station was updated with the code status. During an interview with RN C on [DATE] at 1:03 PM, she stated she was trained on [DATE] with the ADON over Advanced Directives. RN C stated the training was over code status and where you can find the code status in PCC. RN C stated the code status could also be found in the black binder at the nurse's station. During an interview with LVN D on [DATE] at 1:20 PM, she stated she was trained on [DATE] on advanced directives with the DON. LVN D stated she was trained on the location of finding the code status and making sure the code status was updated. LVN D stated code status would be located in the black binder at the nurse's station and in PCC . During an interview with LVN E on [DATE] at 1:29 PM, she stated the CCS trained her on [DATE] over advanced directives. She was in serviced on knowing the difference between DNR and full code. LVN knew code status was able to be located in PCC and in the black binder at the nurse's station. During an interview with Med Tech F on [DATE] at 1:40 PM, she stated she completed the training on Advanced Directives on [DATE] with the ADON. Med Tech F stated she was trained on finding the code status. Med Tech F stated the code status could be found in PCC and in the black binder at the nurse's station. During an interview with CNA G on [DATE] at 1:55 PM, she stated she completed the code states training on [DATE] with the ADON. CNA G stated the training was on the location of finding the code status. CNA G stated the code status could be located in the black binder at the nurse's station and in PCC. During an interview with CNA H on [DATE] at 2:00 PM, he stated he was trained on the code status on [DATE] with the ADON. CNA H stated he was trained on how to find the code status in PCC. CNA H stated the code status could also be found in the black binder at the nurse's station. During an interview with Med Tech I on [DATE] at 2:05 PM, he stated he was trained on the code status on [DATE] with the DON. Med Tech I stated he learned where to find the code status at the nurse's station in the black binder. Med Tech I stated he also learned where to find the code status in PCC. During an interview with the DON on [DATE] at 2:30 PM, she stated she was trained on Advanced Directives on [DATE] by the CCS. The DON stated all facility staff training was completed on Advanced Directives on [DATE]. The DON stated all staff were trained on the location to find the code status on residents. The DON stated the comprehensive audit of all residents to verify code status, medical orders, and DNR documentation was completed on [DATE]. The DON stated all staff knew every resident had a right to have their wishes followed . During an interview with the ADM on [DATE] at 2:45 PM, she stated she completed her in service on [DATE] with the CCS over code status. The ADM stated all facility staff were trained on code status as of [DATE]. The ADM sated the code status audit were completed on [DATE], on all residents. The ADM stated the DON or a designee would be responsible for the audits and mock trials that will be conducted. The ADM stated any new staff will be trained at the new hire orientation. Record review of the comprehensive audit of all residents to verify code status, medical orders, and DNR documentation was completed on [DATE]. Record review of how to document and verify code status in service with all facility staff was completed on [DATE]. The ADM was informed the Immediate Jeopardy was removed on [DATE] at 3:11 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes that met a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to develop a care plan which reflected Resident #1's Advanced Directive was full. Resident # 1 expired at the facility on [DATE] and there was no CPR performed . An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE] at 3:11 pm, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems . This failure could place residents at risk of injury, harm, impairment or death to a resident receiving care in this facility. Findings include: Record review of Resident #1's face sheet, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included heart failure (heart does not pump as well as it should), diabetes (body have trouble controlling blood sugar energy) and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 14, which indicated intact cognition. Resident #1 could make himself understood and was able to understand verbal content. Record review of Resident #1's care plan, dated [DATE], did not reflect an Advance Directive. Record review of Resident #1's care plan meeting notes, dated [DATE], signed by the SW reflected under the Advanced Directive section: Want to change to full code, currently DNR. Record review of Resident #1's progress notes, dated [DATE] at 10:20 AM, written by the SW, reflected SW met with [Resident #1] at bedside to conduct MDS assessment. [Resident #1] appears to be alert and oriented, [Resident #1] hearing is minimal difficulty, but vision is adequate with glasses, impaired without them. [Resident #1] has clear speech and able to voice his needs/wants. [Resident #1] stated that he had been doing okay but he was having a hard time breathing, gaining weight so he may be overeating and feeling depressed because of his heart. [Resident #1] discharge plan is to remain at the facility LTC. [Resident #1] is his own RP. [Resident #1] wishes to change from DNR to full code. Record review of Resident #1's progress notes, dated [DATE] at 10:32 AM, written by the SW, reflected SW met with [Resident #1] at bedside to conduct MDS assessment. [Resident #1] appears to be alert and oriented. [Resident #1] hearing is minimal difficulty, but vision is adequate with glasses, impaired without them. [Resident #1] has clear speech and able to voice his need/wants. [Resident #1] stated that he has been doing okay but still gets depressed because of his health condition. [Resident #1] discharge plan is to remain at the facility LTC. [Resident #1] is his own RP. [Resident # 1] wishes to remain full code. During an interview with the SW on [DATE] at 4:05 PM, the SW stated the MDS Coordinator would have been responsible for making sure Resident #1's code status was updated in the care plan. The SW stated that it was expected for the care plan to be reflected with Resident #1's code status so his wishes would have been followed. During an interview with the MDS Coordinator on [DATE] at 10:25 PM, stated she was not working as MDS Coordinator when Resident #1 changed his code status from DNR to full code at the care plan meeting [DATE]. The Prev MDS Coordinator would have been responsible for making sure Resident #1's code status was updated. The MDS Coordinator stated the MDS Coordinators were responsible for making sure the care plans were updated. The MDS Coordinator stated it was expected for Resident #1's code status to be included on the care plan. The MDS Coordinator stated without the care plan being updated there was no way to know what care to provide and the care would not have been provided . During an interview with the DON on [DATE] at 6:22 PM, she stated she was not working at the facility when Resident #1 changed his code status on [DATE]. The DON stated there was a Prev MDS Coordinator who was no longer at the facility who would have been responsible for developing Resident #1's care plan to show an Advanced Directive of Full Code. The DON stated it was expected for Resident #1's Advanced Directive to be developed in the care plan. Resident #1's wishes were not followed, and his rights were not followed. During an interview with the ADM on [DATE] at 6:48 PM, the ADM stated it was the Prev MDS Coordinator who would have been responsible for implementing and changing the code status on the care plan for Resident #1. The ADM stated it was expected for the code status to be documented in Resident #1's care plan. The ADM stated the Prev DON would have been responsible for making sure the care plans were correct. The ADM stated without the code status being documented in the care plan Resident #1 was not provided CPR and his wishes were not followed. Interview attempted with the Prev MDS Coordinator on [DATE] at 1:28 PM was unsuccessful. Left voice message for the Prev MDS Coordinator to return call. The Prev MDS never returned call . Interview attempted with the Prev DON on [DATE] at 1:30 PM was unsuccessful. Left voice message for the Prev DON to return call. The Prev DON never returned call. Record review of the facility's policy, dated [DATE], reviewed [DATE], titled Care Plans, Comprehensive Person -Centered reflected, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional need is developed and implemented for each resident. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 7:42 PM. The ADM was notified. The ADM was provided with the IJ template on [DATE] at 7:42 PM . The following Plan of Removal submitted by the facility was accepted on [DATE] at 7:25 am: [DATE] F657 - The facility failed to ensure Resident #1 code status was care planned. The following actions were immediately put into place: A comprehensive review of all residents was conducted to verify code status and to ensure care plan status reflects resident current choices by DON, ADON, and Corporate Clinical Specialists on [DATE] . An Ad Hoc QAPI was held on [DATE], to include Medical Director, DON, Administrator and Corporate Clinical Specialist. A care plan training session was successfully conducted by Corporate Clinical Specialist with the interdisciplinary team, focusing on the detailed process of updating code status within the care plan, as well as providing clear instructions on how to effectively implement and modify any necessary changes. During the training, the participants demonstrated their ability to competently identify the Interdisciplinary Team (IDT), showcasing their understanding of the collaborative roles involved on [DATE]. DON/Designee will be responsible for oversight of the IDT process for updating code status within care plan . The above information will be included in new hire orientation, by the Administrator effective [DATE]. Monitoring and Audits: The DON/designee will ensure advance directive care plans are updated immediately following a status change and will conduct audits of advance directive care plans to ensure accuracy in electronic medical records (E.M.R.) weekly x 4 weeks. After 4 weeks, the DON/designee will follow the above process twice a month for 8 weeks, then monthly thereafter. The facility QA Committee will meet weekly starting [DATE], for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. Monitoring of the POR included the following: Record review of the comprehensive audit of all residents to verify care plan reflected residents current Advanced Directive choice was completed on [DATE] . Record review of care plan training in service with facility nursing staff was completed on [DATE] . During an interview with the ADON on [DATE] at 12:30 PM, she stated she was trained on [DATE] with the CCS on care plans. The ADON stated care plans would need to be updated by any nurse. The ADON stated no one person was responsible for updating the care plans. The ADON stated the DON would be responsible for making sure the care plans were correct. During an interview with RN B on [DATE] at 12:57 PM, she stated she received her training on [DATE] with the ADON on care plans. RN B stated changes to care plans would need to be made immediately. RN B stated the DON would be responsible for checking the care plans for accuracy. During an interview with RN C on [DATE] at 1:03 PM, she stated she was trained on [DATE] with the ADON over care plans. RN C stated she trained on making sure care plans were updated immediately when there was a change or change in condition. RN C stated any nurse could update the care plan and the DON would be responsible to make sure the care plans were correct. During an interview with LVN D on [DATE] at 1:20 PM, she stated she was trained on [DATE] on care plans with the DON. LVN D stated care plans could be updated by any nurse and would need to be updated immediately. LVN D stated when a code status changed it would need to be updated immediately. During an interview with LVN E on [DATE] at 1:29 PM, stated the CCS trained her on [DATE] over care plans. LVN E stated care plans were updated immediately, and any nurse could update. LVN E stated the care plans would be checked by the DON. During an interview with the DON on [DATE] at 2:30 PM, she stated she received her care plan training on care plans on [DATE] with the CCS. The DON stated there was not one person responsible for updating care plans and all nursing staff could update or implement. The DON stated care plans would be updated immediately at the change or change in condition. The DON would be checking for accuracy on care plans and it also could be delegated to a nurse. The DON stated all nursing staff completed their care plan training on [DATE] and any new hires would receive their care plan training at new hire orientation. During an interview with the ADM on [DATE] at 2:45 PM, stated she completed her in service on [DATE] with the CCS over care plans. The ADM stated all nursing staff were trained on care plans as of [DATE]. The ADM stated all nursing staff were able up implement and update care plans. The ADM stated the DON or designee would be responsible for making sure the care plans were correct. The ADM was informed the Immediate Jeopardy was removed on [DATE] at 3:11 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and failed to protect and promote the rights of the residents for one of four residents (Residents #1) reviewed for resident rights. The facility failed ensure CNA A and CNA B identified themselves and explained or asked permission to perform a mechanical lift transfer and incontinent care for Resident #1 on 06/13/24. This failure led to Resident #1 exhibiting nonverbal signs of fear and/or pain including widened eyes, an open mouth, and facial grimacing during the procedure. This deficient practice could place residents at risk of a decline of their sense of dignity, level of satisfaction with life, and feelings of self-worth. Findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included unspecified dementia , generalized muscle weakness, osteoarthritis (a type of generative joint disease), and senile degeneration of the brain (mental deterioration). Record review of Resident #1's quarterly MDS Assessment, dated 03/19/24, reflected a BIMS could not be conducted due to her rarely/never being understood. Section GG (Functional Abilities and Goals) reflected she was dependent for chair/bed-to-chair transfers. Record review of Resident #1's quarterly care plan, dated 02/01/24, reflected she was at low risk for falls related to deconditioning and paralysis with an intervention of following the facility fall protocol. There was no focus area related to ADLs or transferring status. Record review of Resident #1's physician order, dated 01/13/24, reflected using a hoyer lift for transfers every shift. During a telephone interview on 06/13/24 at 11:15 AM, Resident #1's FM D stated they placed a surveillance monitor in her room and one of her biggest frustrations was staff did not announce who they were, did not explain what they were going to do, and often would just socialize with each other and not pay attention to the resident. FM D stated Resident #1 may not be able to communicate verbally, but she did understand when she was spoken to, and she knew she did not want to listen to the staff gossip. She stated there were many instances where Resident #1 was showing signs of fear when they were providing care due to the lack of knowledge as to what was happening . During an observation and interview on 06/13/24 at 11:31 AM revealed CNA A and CNA B getting ready to transfer Resident #1 with the use of a hoyer lift. Upon entering the room, they did not address Resident #1 or state their names or what they were going to do. CNA A attached the front loops of the sling to the lift while CNA B was behind her and attached the back loops to the lift. CNA B adjusted the sling by pulling it up which went over Resident #1's head and her eyes opened wide, opened her mouth and appeared panicked. CNA A stated, Going up and pushed the button to lift her from her wheelchair. Once she was maneuvered to the bed, they let the sling down onto the bed. They began to perform peri care by pulling down her pants and changing her brief. They rolled her from side to side without engaging with her. CNA A was talking to CNA B about how she had been working on another hall and CNA B was expressing how tired he was from working multiple shifts. Due to Resident #1's leg contractions, CNA B had to use slight force to open her knees so CNA A could perform peri care. Resident #1 at that point appeared to be fearful or in pain as her mouth opened and she grimaced. The State Surveyor then asked if either had been trained on explaining to the residents what they were going to do while providing care for residents. They both stated they had and CNA B stated he usually did but he was just tired and forgot. After State Surveyor intervention, they began letting Resident #1 know what was going on, for example, Okay we are going to pull your pants up now . During an interview on 06/13/24 at 3:19 PM, the DON stated her expectations when staff were providing care to residents, they speak to them like you and I are speaking to each other right now. She stated they needed to be professional and anything spoken about needed to be about nothing other than the resident and their care. She stated causing a resident to be scared or causing issues psychologically could be a negative outcome of staff not communicating to the resident . Record review of an in-service, dated 05/29/24, and conducted by the DON, reflected staff were educated on the following: Customer Service: Never have personal conversations with coworkers in front of residents or resident rooms. . AIDES - do this EVERY SINGLE TIME. Residents WILL FORGET YOU. They will get CONFUSED. Family members may mistake you for someone else as well. - Acknowledge - hello, How can I help you? - Introduce - My name is (name) and I am your aide today. - Duration - I just came to check on your water pitcher. - Explanation - and see if you need a refill. - Thank you - Ok you're all set. Thank you. Record review of the facility's Resident Rights Policy, revised February of 2021, reflected the following: Employees shall treat residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence b. be treated with respect, kindness, and dignity

Based on observations, interviews, and record reviews, the facility failed to ensure the residents had the right to be free of discrimination from the facility in exercising his or her rights and to be supported by the facility to exercise his or her rights for 1 of 15 residents (Resident #3) reviewed for resident rights. The facility failed to ensure Resident #3 had a place to have private telephone conversations when she did not consent to her roommate having electronic monitoring that included audio monitoring. The facility failed to ensure Resident #3 gave permission before her property was searched by staff. These failures could place residents at risk of loss of privacy and loss of the ability to communicate privately which could result in a decline in their psychosocial well-being and quality of life. Findings included: Review of Resident #3's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female originally admitted to the facility on [DATE] and recently readmitted on [DATE]. Section C (Cognitive Patterns) reflected a BIMS score of 14 indicating intact cognition. Section GG (Functional Abilities) reflected she was dependent on staff for all ADL care including bed mobility and transfers. Section I (Active Diagnoses) reflected, hypertension (high blood pressure), renal insufficiency (kidneys not working right), neurogenic bladder (lack of bladder control due to a nerve problem), quadriplegia (paralysis of all four limbs), anxiety disorder (intense and excessive worry and fear), depression (a mood disorder with persistent feeling of sadness and loss of interest), malnutrition, and osteomyelitis of vertebra (infection of the bone in the spine). Review of Resident #3's electronic medical record reflected no CONSENT BY ROOMMATE FOR AUTHORIZED ELECTRONIC MONITORING. Review of Resident #3's census information in the medical record reflected, she moved into the room with Resident #4 on 12/26/23. Review of Resident #4's quarterly MDS assessment dated [DATE], A (Identification Information) reflected a [AGE] year-old female admitted [DATE]. Section C (Cognitive Patterns) reflected the resident was unable to participate in a BIMS assessment. The section reflected impaired long- and short-term memory problems. Section GG (Functional Abilities) reflected the resident required substantial/maximal assistance with all ADL care including bed mobility and transfers. Section I (Active Diagnoses) reflected anemia (lack of red blood cells in the blood), heart failure, hypertension (high blood pressure), neurogenic bladder (lack of bladder control due to a nerve problem), Alzheimer's disease (dementia that damages the brain), anxiety (intense and excessive worry and fear), and depression (a mood disorder with persistent feeling of sadness and loss of interest). Review of Resident#4's electronic medical record reflected an Information Regarding Authorized Electronic Monitoring form and a Request for Electronic Monitoring form dated 02/03/21. There was no CONSENT BY ROOMMATE FOR AUTHORIZED ELECTRONIC MONITORING in the record. Review of Resident #4's census information in the medical record reflected, except for 21 days, the resident had been in the same room since 02/03/21. An observation on 04/03/24 at 9:42 AM revealed a sign outside of the room shared by Resident #3 and Residents #4 that reflected, Security camera in use. During an observation and attempted interview on 04/03/24 at 9:41 AM, Resident #4 was lying in bed with her breakfast tray in front of her. Resident smiled but did not give any verbal response to questions asked. During an observation and interview on 04/03/24 at 9:43 AM, Resident #3 was lying in bed in her room. She stated she woke up the other day to find RN H going through one of the drawers next to her bed. Resident #3 stated RN H said she was looking for the vape pens so she could put them in the medication room. Resident #3 stated she told RN H she had not given her permission to go through her things. Resident #3 stated it made her feel Pissed off and she felt like she had no privacy. Resident #3 then stated the camera that her roommate's family put in the room also picks up audio. She stated she became aware of the audio feature after the roommate's family called the facility and reported something that she had said during what she thought was a private conversation. She stated it made her feel horrible and now she is afraid to talk with anyone because her medical information or other private information may be overheard. She stated she had started asking the staff to unplug the camera when the roommate is out of the room so she can have private phone conversations. She stated she talked with the DON on 04/01/24 about the lack of privacy. She stated she had never given consent nor had she been asked to consent to be in the room with the electronic monitoring and she did not and does not consent to audio monitoring. The resident stated the DON offered to move her to another room but the room change did not happen. Resident #3 stated she told the DON she wanted to move to another facility but in the meantime, the problem needed to be taken care of. During an interview on 04/04/24 at 10:54 AM, the ADON stated she expected there to be proper documentation and consent for Authorized Electronic Monitoring. She stated a sign was supposed to be posted outside of the room so everyone would know the room was monitored. She stated the camera needed to be focused on the resident being monitored. She stated the ADM had the forms but she was not sure who was responsible for completing the forms. The ADON stated a lack of privacy would be a negative outcome for a resident if they had not consented to monitoring. She stated she would not have unplugged a camera to provide privacy but said there could have been a room change made. During an interview on 4/04/24 at 11:21 AM, the DON stated it was her expectation that cameras for electronic monitoring were on or near the wall of the resident being monitored and aimed at the resident being monitored. She stated a sign was to be posted outside the room to notify everyone that monitoring was taking place. She stated the person who obtained the consent for the monitoring was the one responsible to place the sign outside the room. She stated roommates should have been notified and asked to sign a consent. If the roommate did not consent, they would have gone to another room. The DON stated she did have a conversation with Resident #3 on 04/01/24 about not consenting to audio monitoring in the room. She stated she did not move Resident #3 to another room because Resident #3 stated she wanted to move to another facility within 30 days. She stated at some point, she became aware that Resident #3 had asked staff to unplug the camera. The DON stated it was a privacy issue if consent had not been obtained. She stated, They may not have wanted all their business out there. The DON stated Residents had the right to make private phone calls. She stated there could have been HIPAA issues if privacy was not maintained. During an interview on 04/04/24 at 11:50 AM, the ADM stated she encouraged electronic monitoring as it was the resident's right. She stated all the paperwork had to be in place. She stated she would help set it up as needed but the resident or family was responsible for the purchase of the device. She stated staff were not supposed to touch the cameras. She stated the process included a review of the forms with the resident or family. Then they obtained the request from the family and consent from the roommate. Next a sign was posted near the door to the room, then the device was installed. She stated the social worker, nursing or administration could post the sign. The ADM stated roommates had the right to refuse consent or change their mind. She stated both residents had the right to stay in the room, and neither Resident #3 nor Resident #4 wanted to change rooms. She stated when she asked Resident #3 about a room change, Resident #3 stated she did not want to move rooms but wanted to transfer to another facility. The ADM stated Resident #3 wanted privacy for calls and she found out last week that Resident #3 was asking staff to unplug the monitoring device. She stated she did not know if she could restrict the audio on the device. She stated by not having privacy for phone calls, HIPAA information could get out or get compromised. She stated residents could get embarrassed, angry or anxious if their privacy was violated. The ADM stated staff are not allowed to search resident property without consent. She stated if there was something visible that posed a danger, staff could take that item for safekeeping. She stated it would be a violation of the resident's privacy. Review of the policy titled, Resident Rights, revised February 2021, reflected in part, Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; e. self-determination; f. communication with and access to people and services, both inside and outside the facility; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights: t. privacy and confidentiality; cc. access to a telephone, mail, and email; dd. Communicate in person and by mail, email and telephone with privacy . 3. The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues . Review of the policy titled, Personal Property Policy, reviewed January 2023, reflected in part, Residents are permitted to retain and use personal possessions, including furniture and clothing, as space permits, unless doing so would infringe on the rights or health and safety of other residents. 2. Resident belongings are treated with respect by facility staff, regardless of perceived value. 8. If items or illegal substances that belong to the resident are in plain view, and these pose a risk to the residents' health and safety, the items may be confiscated by facility staff. The circumstances, description of the item(s), and rationale for confiscating are documented in the resident's records. 9 Facility staff does not conduct searches of a resident or their personal belongings, unless the resident or representative agrees to the search and understands the reason for the search. 11. The facility promptly investigates any complaints of misappropriation or mistreatment of resident property. A policy regarding Authorized Electronic Monitoring was requested on 04/03/24 at 1:10 PM and again at 3:54 PM. No policy was provided prior to exit.

Based on observation, inter, and record review, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for three (Resident #1, Resident #2, and Resident #3) of seven residents reviewed for pressure ulcers. The facility failed to: 1) - Provide treatment and services to heal Resident #2's PUs on the gluteus, sacrum, and left heel and the wounds became larger. - Provide treatment and services to prevent infection to Resident #2's sacral PU and it became infected. An IJ situation was identified on 03/18/24.L The IJ template was provided to the facility on [DATE] at 2:40 PM. While the IJ was removed on 03/19/24 the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective actions. 2) - Provide treatment and services to heal Resident #1's three pre-existing stage 2 PU for nine days when he returned from a brief stay at the acute care hospital. - Provide treatment and services to heal Resident #1's stage 2 pressure ulcer acquired on 3/15/24. - Provide treatment as ordered on 03/04/24, 03/06/24, 03/09/24, and 03/12/24 to Resident #3's stage 2 PU These failures could place residents at an increased risk of complications such as pain, acquiring new ulcers, worsening of existing ulcers, and infection. Findings included: 1) Review of Resident #2's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected resident is a [AGE] year-old female originally admitted to the facility 07/28/23 and readmitted [DATE] after an admission to an acute care hospital. Section C (Cognitive Patterns) reflected a BIMS score of 14 indicating intact cognition. Section GG (Functional Abilities) reflected resident was dependent on staff for all ADL care including, eating, hygiene, dressing, rolling left and right, and transfers. Section I (Active Diagnoses) reflected hypertension (high blood pressure), orthostatic hypotension (blood pressure drops when changing position from sitting to standing), renal insufficiency (poor kidney function), neurogenic bladder (lack of bladder control due to nerve or spinal cord problem), septicemia (blood infection), quadriplegia (paralysis of arms and legs), malnutrition, anxiety disorder (intense and excessive worry and fear), depression (feeling of sadness and loss of interest), osteomyelitis of vertebra sacral and sacrococcygeal region (bone infection of the tailbone), and other lack of coordination. Section M (Skin Conditions) Reflected resident had one Stage 2 PU (a break in the top two layers of skin), one Stage 3 PU (the injury goes through the layers of the skin into the fatty tissue), and one Stage 4 PU (deep injuries that may go into the muscle, tendons, ligaments, and bone) all at the time of admission/entry or reentry. Review of Resident #2's Physician Order dated 01/19/24 reflected, Gluteus Rift Distal Wound (in the crease between the buttocks)- Cleanse the wound with Dakin's Sol 0.25% using gauze sponges. Do not scrub. Allow Dakin's to remain on wound bed for 10 minutes. Then rinse with N/S using gauze sponges. Then apply Triple Helix to the wound bed - fill remaining cavity with xerofoam and the cover with sacral foam dressing (3x week M-W-F. External foam dressing should be changed prn if soiled). Review of Resident #2's Physician Order dated 03/11/24 reflected, Per wound care clinic: calcaneus wound left lateral: Cleanse wound with Dakin's solution 0.25%. Apply iodosorb gel. Apply calmoseptine ointment to peri-wound. Apply Mepilex Heal AG dressing every M, W, F x 30 days. An order dated 03/10/24 reflected, NPWT to Right Distal Gluteus at 150 mm/hg pressure. Prisma to wound bed, black foam. Check Wound vac q shift. Wound Care will apply the wound vac. If wound vac become dysfunctional and is not able to restore to proper functioning within 2 hours, please follow previous dressing orders. ***Check wound vac q shift. An order dated 3/12/24 reflected, Medial Sacral Wound (Wound #1) NPWT to wound continuously at 150 mm/hg Black foam. (NPWT is a therapeutic technique using a suction pump, tubing, and a dressing to remove excess exudate and promote wound healing) Review of Resident #2's care plan initiated 12/12/23 reflected, The resident has a stage 3 to the right buttock wound #2 related to disease process and Resident has a stage 4 to the sacrum/coccyx wound #1 related to disease process. Care plan initiated 03/16/24 reflected, I have a stage 3 pressure injury/ulcer (Left posterior calcaneus wound #5) r/t disease process. An intervention for the calcaneus wound included Turn and reposition when direct care provided and PRN. Review of Resident #2's wound clinic notes from 03/14/24 visit reflected: Wound #8 left calcaneus wound was acquired 02/05/24. Measurements as follows: 02/09/24 1 cm x 1 cm x 0.1 cm 02/23/24 1.5 cm x 1cm x 0.1cm 3/8/24 2.5 cm x 2.5 cm x 0.2 cm 3/14/2024 2.1 cm x 2 cm x 0.2 cm. Wound #4 acquired 07/05/23 Pressure ulcer gluteus, right distal measurements included: 03/01/24 1 cm x 0.9 cm x 1 cm 03/08/24 1.5 cm x 2 cm x 2 cm 3/14/24 2 cm x 2 cm x 3 cm Wound #1 acquired 11/01/22 Pressure ulcer sacrum medial measurements included: 03/04/24 2.5 cm x 2.7 cm x 1.5 cm 3/8/24 3 cm x 3 cm x 3 cm 3/14/24 2.5 cm x 2.7 cm x 2.5 cm. Review of Resident #2's wound care clinic noted dated 02/23/24 reflected, Upon arrival there is, again, no dressing to the left calcaneal decubitus ulcer, she states the staff hasn't been dressing it NPWT was initiated today and wound vac with black foam applied to both sacral and gluteal pressure ulcers Review of Resident #2's wound care clinic noted dated 03/01/24 reflected, Upon arrival there is, again, no dressing to the left calcaneal decubitus ulcer, and even more there was no dressing to ANY of her wounds . the right buttocks seems to have additional depth today. Patient also indicates that the staff are not turning her routinely for off-loading. Orders attached to the note reflected in part, .Calcaneus, left cleanse with Dakin's Solution . peri-wound calmoseptine ointment . Iodosorb gel, primary dressing mepilex heel Ag Dressing . 3 x per week/30 days. Turn and reposition every 2 hours. Review of Resident #2's wound care clinic noted dated 03/08/24 reflected, Upon arrival there is, again, no dressing to the left calcaneal decubitus ulcer, and even more there was no dressing to ANY of her wounds .She reports that she has been asking the staff about her dressing changes and has not gotten anyone to perform the care. Upon exam, the calcaneal heal has more non-viable tissue to the wound bed . The right gluteal ulcer has increased drainage and increased size to the sacral ulcer with some deeper red color to portion of wound bed that is suspicious for deep tissue injury. Culture obtained and will follow up with sensiva report next week. Review of Resident #2's wound care clinic noted dated 03/14/34 reflected, Patient present to her f/u appointment .She is noted to have unfortunately developed a new wound to right hip - skin tear from dressing possibly. Dressing to heel was not as ordered. She has started the antibiotics prescribed per sensiva report after culture last week. Upon exam the calcaneal heal has more non-viable tissue .The right gluteal and sacral ulcers again have increased drainage and increased size . Review of Resident #2's Order Summary Report of active order printed on 03/18/24, reflected and order written 10/11/23, Completely float bilateral heels off the bed with pillows and apply egg crate to bilateral feet. Only remove to do wound care and showers then replace every shift. There were no orders to turn or reposition the resident. Review of Resident #2's Treatment Administration Record for March 2024 reflected no treatment orders for the calcaneal wound from 03/01/24 through 03/10/24. The treatment record reflected the gluteal wound and sacral wound treatments were not completed on 03/04/24 and 03/06/24. Review of Resident #2's evaluations/assessments reflected wound assessments were not completed weekly for each identified wound: 02/02/24 for wounds #1, #2, #4, and #5 02/14/24 for wounds #1, #2, #4, and #5 02/23/24 for wounds #1, #2, and #5 03/01/24 for wound #1 03/14/24 for wounds #1 and #2 03/16/24 for wound #5. During an observation and interview on 03/16/24 at 2:10 PM, with Resident #2, resident was observed lying in bed with the head of the bed elevated. Resident was observed with boots on her feet but no pillow under her legs. Resident stated she had been at the facility since July 2023. She stated she was in a motorcycle accident in 2022. As a result of the accident, she was quadriplegic and had an infection in her tailbone from a piece of asphalt. She stated she had received several rounds of IV antibiotics for the infection. She stated she came to this facility because the wound clinic nearby had a great reputation and success rate and she hoped to get her wounds healed. She stated the staff did not reposition her regularly and she often had to ask for a pillow to float her heals. She stated the facility did not perform wound care daily and had not done the treatments to her feet all week. She stated one day the facility took off all the dressings to assess the wounds but they never put the dressings back on. Resident stated NPWT dressing were on her back side. NPWT machine observed near bedside table, fluid was visible moving through tubing. During an interview on 03/16/24 at 2:00 PM, with LVN C, she stated they did not have a wound care nurse so the nurse assigned to the resident was responsible for performing wound care. She stated RN A often did all the treatments on the weekend. She stated weekly skin assessments are completed by the assigned nurse and weekly wound assessments were done by the RN supervisor, ADON, or DON. During an interview on 03/17/24 at 12:36 with ADON, she stated the RN or DON was responsible for measuring wounds. She assisted by entering the data collected by the RN on to the weekly wound report. She stated she usually entered the data a couple days after it was collected. She stated she did not enter the data as a late entry so the assessment appeared to be done on the day the data was entered. She stated if there had been a new wound or a wound had worsened, the RN would have been responsible for contacting the doctor or NP on the day the wound had been observed. During an interview on 03/17/24 at 3:33 PM, the DON stated the on-duty nurse was responsible for calling the doctor or NP to obtain new orders. She stated it was her expectation that residents were turned/repositioned at least every two hours unless otherwise ordered. During an interview on 03/17/24 at 3:55 PM, the ADM stated the nurse assigned to the hall was responsible to complete wound care. She stated it was her expectation that treatments were completed as ordered. She stated not treating the resident could cause more wounds or make current wounds worse . During a telephone interview on 03/18/24 at 8:07 AM with the clinical nurse manager from the wound care clinic, she stated the team at the clinic is concerned about the care provided at the facility as the resident's wounds have been getting worse. She stated the resident was in her right mind and she was able to speak to the care provided. She stated she would re-send notes from the most recent visits to the facility. During an observation and interview on 03/18/24 at 10:54 AM, Resident #2 was observed lying on her back with the head of the bed elevated. Resident #2 had a pillow under her legs. She stated, They only put the pillow under my legs if I ask them to do it. During an interview on 03/18/24 at 12:53 PM with RN B, she stated Resident #2 has wound care to her left foot daily. She stated she had not done the treatment to the gluteus wound in a long time. After looking at the TAR, she stated she signed for the treatment on 03/08/24 because the NPWT machine was turned off for an undetermined amount of time, so she removed the NPWT dressing and she replaced it with the dressing ordered in case the NPWT dressing came off. She then stated the resident was not receiving NPWT on 03/08/24. During an interview on 03/18/24 at 1:02 PM with CNA G, she stated, Resident #2 was turned every two hours. She stated sometimes they get busy so she may not have been turned every two hours but she tried. She stated the resident is supposed to have a pillow under her legs. She stated she used a pillow under the draw sheet to help position and off-load pressure. She stated by not turning residents, they could get wounds or the wounds could get worse. During an interview on 03/18/24 at 1:13 PM with LVN D, she stated she worked intermittently at the facility but she was somewhat familiar with Resident #2. She stated she did not remember what specific devices the resident used for pressure ulcer prevention but knew the resident had pressure ulcers. She stated she had not performed wound care on Resident #2 in quite a while. When asked why she had signed for the treatment to the gluteus wound on 03/13/24 she stated, We don't do any treatment on her butt because she has the NPWT treatment. During a telephone interview on 03/18/24 at 1:35 PM with the wound clinic nurse manager, she stated the NPWT had been discussed in January 2024 then reordered on 02/16/24. She stated the facility used their own contracted company to provide the machine. The machine was finally provided and the dressing applied to the resident on 03/08/24. The clinic changed the NPWT dressings every Monday, Wednesday, and Friday to both the sacral and gluteus wounds. Review of the facility's in-service records reflected an in-service dated 02/03/24, At any time any skin issues that is seen/arises, report to nurse, report to medical doctor, to obtain orders and give treatment to resident. Ensure to document at all times and follow up with proper documentation. [sic] Review of the Facility Skin Integrity Prevention and Treatment Program, last revised 01/23, reflected in part, Skin Essentials Assessment and Documentation Standards include but no limited to: Braden Skin Risk Assessment Skin Risk Analysis and Interventions Developed Weekly Skin Integrity Checks Weekly Wound assessment a. Each identified skin issue/area is assessed weekly in electronic medical record. b. If treatment or interventions change or wound presentation is reclassified update care plan d. Physician updated. Wound Care Review of the Pressure Injury Prevention Program Procedure last revised 01/23, reflected in part, Standard - All Residents will be assessed for the risk of pressure injury development at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Each resident will also receive a weekly skin check to identify new areas of concern or the development of new pressure injuries to ensure a timely adjustment to the resident's change in condition/risk level. Based on the results of these assessments, specific interventions will be implemented to prevent the development of avoidable pressure injuries, or, to treat new/existing pressure injuries. Procedure - 1. Braden Skin Risk Assessment 2. Skin Risk Analysis and Interventions Developed 3. The following is a list of commonly used interventions to possibly prevent the development of pressure injuries a. Frequent turning and positioning b. Do not massage over any reddened areas c. Keep residents clean and dry d. Provide incontinent care as appropriate e. Monitor resident's nutritional intake f. Pad between bony prominences g. Keep linens clean and wrinkle free h. Utilize pressure reducing devices as needed (ex. Cushions, Therapeutic Support Surfaces, Positioning Devices) . 4. All residents will have a head-to-toe assessment (shin check) completed on a weekly basis . 5. If a pressure injury/skin breakdown is identified, the following will be done - a. If new area found .complete new wound evaluation/ assessment b. Assessment must include Size Stage Location Drainage amount . c. Notify MD - obtain treatment orders d. Notify RP/ or family . e. Update care plan . This was determined to be an Immediate Jeopardy (IJ) on 03/18/24 at 2:43 PM the Administrator and Director of Nurses were notified. The Administrator was provided with the IJ template on 03/18/24 at 2:43 PM and a Plan of Removal was requested The following Plan of Removal submitted by the facility was accepted on 03/19/24 at 10:37 AM: F686 - The facility failed to provide treatment and services, consistent with professional standards of practice to Resident #2 with pressure ulcers to promote healing, prevent infection and prevent new ulcers from developing. Six Residents with current pressure injuries had potential to be affected by this failure. The following actions were immediately put into place: Resident #2 was evaluated, and wound treatment orders verified and completed per MD orders and plan of care updated by DON on March 18, 2024 An Ad Hoc QAPI was held on March 18, 2024, to include Medical Director, DON, Administrator and Corporate Clinical Specialist. A complete head to toe skin sweep was initiated and completed on all residents on 3/18/2024 and completed by DON, ADON, RN Weekend Supervisor include updated assessments which includes pressure and non-pressure assessments, measurements, staging and description of wound appearance updating/initiating treatment orders if indicated, notification of MD/ family, care plans update. On 3/18/2024 reassessment of residents with pressure and non-pressure wounds was completed by DON/Designee, to include current measurements and staging as well as any required treatment changes. An audit was completed of Braden Scales, for all current residents /current treatment/wound orders, and care plans to ensure accuracy. Audit was completed by CCS/DON/Designee on March 18, 2024. Inservice for nursing administration was completed by CCS on 3/18/2024 on the following: Skin policy and protocol to include reporting protocol of all skin changes, process of assessment and documentation of all skin concerns, how to conduct a skin assessment, notification of MD/family and carrying out physician orders. Competency was validated for DON, ADON and MDS by CCS on March 18, 2024. On March 18, 2024, the DON/Designee completed in servicing of all nurses on the skin policy and protocol to include reporting of all skin changes to nursing administration, process of assessment and documentation of all skin concerns, how to conduct a skin assessment, notification of MD/family, and carrying out of physician orders. All nurses will receive education prior to being allowed to work. Staff will receive a quiz to ensure competency of all education provided. On March 18, 2024, an Inservice for certified nursing assistants was completed by DON/Designee on immediate notification to their licensed nurse of any skin concerns that they observe. Inservice was completed on March 18, 2024. No CNAs will be allowed to work their scheduled shift until they complete the Inservice. Employees will receive education prior to being allowed to work. Staff will receive a quiz to ensure competency of all education provided. The above information will be included in new hire orientation, by Administrator effective March 18, 2024. In order to monitor current residents for potential risk, DON/Designee will conduct a skin sweep weekly x 4 weeks. After 4 weeks, the DON/Designee will follow the above process twice a month for 8 weeks, then monthly thereafter. CCS will monitor DON compliance weekly. The facility QA Committee will meet weekly starting March 18, 2024, for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. The Surveyor monitored the Plan of Removal on 03/19/24 as followed: During an interview on 03/19/2024 10:37 AM with CNA/MA E, she stated she had worked in the facility for about a year. She stated she had been in-serviced on notifying the charge nurses of any issues with residents' skin on 03/18/2024. She stated they called and in-serviced her on the phone on 03/18/2024 and she signed the in-service today. She stated she observed and checked all of her resident's skin daily during showers and incontinent care when she is working as a CNA. She stated when she is working as a medication aide, she also looks at the resident's visible skin. She stated if a resident had a new skin issue, she would go immediately and report it to the nurse. During an interview on 03/19/2024 at 11:18 AM with RN B, she stated she had worked in the facility for about 2 years. She stated she had been in-serviced on skin policy and protocol, reporting skin changes, process of assessment and documentation of all skin concerns, how to conduct skin assessments, notifying resident's doctor and family, and carrying out physicians' orders when she first began working here and also just this week. She stated they were in-serviced on how to stage wounds and how to do treatments correctly and follow wound care doctors' orders also. She stated all the residents have weekly skin assessments and if there is something found in between that time they would write up a new report. She stated they have a nurse practitioner that is on call 24 hours a day and they would report any new skin concerns to her or the resident primary physician. She stated if a resident had a new skin issue, she would do a basic assessment, full skin assessment, vital signs, and a skin report, call and notify family, DON, and doctor, and follow doctor's orders. During an interview on 03/19/2024 at 12:00 PM with LVN C, she stated she had worked in the facility for about a year and 5 months. She stated she had been in-serviced on skin policy and protocol, reporting skin changes, process of assessment and documentation of all skin concerns, how to conduct skin assessments, notifying resident's doctor and family, and carrying out physicians' orders on 03/17/24. She stated skin assessments are done on a weekly basis on residents scheduled shower days and they check to see if there are any changes to residents' skin. She stated if a resident had a new skin issue, she would notify her DON, ADON, doctor, family and hospice if resident is on hospice services, receive new orders for treatment to area, and follow through with the doctor's orders. During an interview on 03/19/2024 at 12:06 PM with CNA G, she stated she had worked in the facility for about 2 years. She stated she had been in-serviced on notifying the charge nurses of any issues with residents' skin on 03/18/24. She stated she observed and checked all of her resident's skin daily during showers and incontinent care. She stated if a resident had a new skin issue, she would report it to the nurse immediately. During an interview on 03/19/2024 at 12:12 PM Interview with CNA H, she stated she had worked in the facility for about 1 month. She stated she had been in-serviced on notifying the charge nurses of any issues with residents' skin on 03/18/24 and also this morning. She stated she also was in-serviced on the phone 03/17/24 plus a few more times. She stated she observed and checked all of her resident's skin daily during showers and incontinent care. She stated if a resident had a new skin issue, she would immediately write it on the shower sheet and report it to the nurse. During an interview on 03/19/2024 at 12:19 PM with CNA I, she stated she had worked in the facility for about a year. She stated she had been in-serviced on notifying the charge nurses of any issues with residents' skin on 03/19/24. She stated she observed and checked all of her resident's skin daily during showers and incontinent care. She stated if a resident had a new skin issue, she would let the nurse know right away. During an interview on 03/19/2024 at 12:34 PM with CNA/MA F, he stated he had worked in the facility for about a year. He stated he had been in-serviced on notifying the charge nurses of any issues with residents' skin on 03/18/24 and one other time but he cannot remember the date. He stated he observed and checked all of his resident's skin daily during showers and incontinent care. He stated if a resident had a new skin issue, he would report it to the nurse and the DON/ADON. During an interview on 03/19/2024 12:41 PM with the DON, she stated she had worked in the facility for 1 week today. She stated she had been in-serviced by corporate and she had in-serviced nurses on skin policy and protocol, reporting skin changes, process of assessment and documentation of all skin concerns, how to conduct skin assessments, notifying resident's doctor and family, and carrying out physicians' orders on 03/17/24 - 03/19/24. She stated she in-serviced CNA's on notification to nurses about any skin concerns on 03/17/24 - 03/19/24. She stated all staff were in-serviced on pressure ulcer prevention and turning and repositioning on 03/17/24 - 03/19/24. She stated all nursing staff have been in-serviced. She stated education on skin assessments and protocol for new skin issues would be included in new hire orientation from here on out. She stated she would be performing skin sweeps on all residents weekly for 4 weeks and then as planned in the facility plan of correction. She stated if a resident had a new skin issue, the CNA should go immediately to her and the charge nurse. She stated if she found a new skin concern, she would report it to the resident's nurse, call the doctor and family to inform them, and get some type of treatment to prevent further injury to that wound and something to treat the wound as well. She stated they had a QAPI meeting on 03/18/2024 with Medical Director, the Administrator, herself, and a regional nurse, regarding the plan of removal and they went over all wounds in the facility and how to take care of and treat and also to prevent other wounds from occurring. She stated they also discussed the plan of removal with the medical director so he would be aware of the plan. During an interview on 03/19/2024 at 1:51 PM with Resident #2, she stated she was doing fine, and the staff had been taking care of all of her wound care needs and she had received a shower today. She stated she had a concern about her Medicare or Medicaid benefits which was passed on to the DON. Resident was sitting up in wheelchair with blankets covering her up to chest area. Resident was in no sign of pain or distress and her call light was in reach. Reviewed QAPI meeting held on 03/18/2024 which included medical director, Administrator, DON, and Corporate Clinical Specialist and regarded abatement plan for immediate jeopardy citation. Reviewed records on skin sweep performed for all residents on 03/18/2024 with a Skin Monitoring: Comprehensive CNA Shower Review sheet. Reviewed in-servicing for nursing management and nurses completed on 03/18/24 which covered skin policy and protocol to include reporting of all skin changes to nursing administration, process of assessment and documentation of all skin concerns, how to conduct a skin assessment, notification of MD/family, and carrying out of physician orders. Reviewed in-servicing for CNA's completed on 03/18/24 which covered immediate notification to their licensed nurse of any skin concerns or dressing soiled or dislodged that they observe. Reviewed in-servicing for all staff completed on 03/18/24 which covered turning, repositioning, and off-loading. Reviewed nurse and CNA skin quizzes all completed on 03/17/24 and 03/18/24. Record Review of Resident #2 admitted - 07/28/2023 DX - Quadriplegia, Osteomyelitis of Vertebrae (Infection of bone in spine), Dysphagia (difficulty swallowing), Chronic Pain Syndrome Full Code BIMS - 14 Care plan updated - 03/17/24 Braden Scale completed - 02/03/2024 Record Review of Resident #3 admitted - 05/12/2023 DX - COPD, Diabetes, Dementia, Osteoarthritis Full Code BIMS - 07 Care plan updated - 03/17/24 Braden Scale - 02/01/2024 Record Review of Resident #4 admitted - 11/30/2023 DX - Dementia, Osteoarthritis, Hypertension, Muscle Weakness DNR BIMS - 99 Care plan updated - 03/17/24 Braden Scale - 03/17/2024 Record Review of Resident #5 admitted - 06/12/2023 DX - Colon Cancer, Anxiety, Dementia, Rheumatic Tricuspid Valve (a condition that affects a valve in the heart) DNR BIMS - 10 Care plan updated - 03/16/24 Braden Scale - 03/17/2024 Record Review of Resident #1 admitted - 04/21/2018 DX - Lobar Pneumonia (infection that affects a lobe of the lung), Atrial Fibrillation, Dementia, Cerebrovascular Disease DNR BIMS - 08 Care plan updated - 03/17/24 Braden Scale - 03/17/2024 Record Review of Resident #6 admitted - 05/02/2023 DX - Fibrosis, Anxiety, Dementia, Catatonic Disorder (a complex behavioral syndrome characterized by abnormal movements, immobility, abnormal behaviors, and withdrawal) Full Code BIMS - 99 Care plan updated - 12/12/2023 Braden Scale - 02/01/2024 On 03/19/24 at 10:37 AM, the Administrator and Director of Nurses were informed the IJ was removed however the facility remained out of compliance at a severity of potential for more than minimal harm that was not Immediate Jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. 2) Review of the facility pressure injury report dated 03/16/24 reflected Resident #1 had the following pressure injuries: One un-staged pressure injury measuring 2 cm x 0.2 cm x 0.2 cm (wound #2) acquired 03/01/24 located on middle buttock left. One Stage 2 pressure injury measuring 2 cm x 2 cm x 0.1 cm (wound #3) acquired 03/01/24 located on right medial buttock. One Stage 2 pressure injury measuring 0.5 cm x 0.4 cm x 0.1 cm (wound #4) acquired 03/15/24 located on right wound. One Stage 2 pressure injury measuring 1 cm x 0.8 cm x 0.1 cm (wound #1) acquired 03/01/24 located on right buttock lateral. Review of the facility pressure injury report dated 03/16/24 reflected Resident #3 had the following pressure injury: One Stage 2 pressure injury measuring 1.6 cm x 0.5 cm x 0.2 cm (wound #1) acquired 03/10/24 located on the coccyx. Review of Resident #1's 5-day MDS assessment, dated 12/30/23, Section A (Identification Information), reflected an [AGE] year-old male originally admitted to the facility on [DATE]. Section C (Cognitive Patterns) reflected a BIMS score of 8 indicating moderately impaired cognition. Section GG (Functional Abilities) reflected he was independent for most ADLs including bed mobility and transfers. Section H (Bowel and Bladder) reflected he was frequently incontinent of bladder and always incontinent of bowel. Section I (Active Diagnoses) reflected hypertension (high blood pressure), hyperlipidemia (high cholesterol), cerebrovascular accident (stroke), non-Alzheimer's dementia, malnutrition, anxiety (intense and excessive worry and fear), depression (persistent feeling of sadness), lobar pneumonia (infection in a lobe of the lung), difficulty walking, muscle weakness, intermittent explosive disorder (sudden outbursts of intense anger and aggression), and osteoarthritis (a joint disease that causes breakdown of cartilage and bone). Section M (Skin Conditions) reflected no pressure or other skin ulcers. Review of Resident #1's census reflected he went to the acute hospital on 03/04/24 and returned to the facility on [DATE]. Review of Resident #1's Physician's Orders printed 03/16/24 reflected orders for weekly skin check order dated 03/09 [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for (Resident #1) of 5 residents reviewed for accidents and supervision. Resident # 1 eloped from facility on 2/5/2023 and fractured her left rib. An (IJ) Immediate Jeopardy was identified on 4/12/2023 at 4:45PM. While the (IJ) Immediate Jeopardy was removed on 4/13/2023 at 6:00PM, the facility remained out of compliance at a level of actual harm that was not immediate Jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their corrective systems. This failure could place all residents at risk for accidents and harm. Findings included: Observation on 4/11/2023 at 3:00PM, reflected the facility is located on a main highway that had high traffic. The highway was approximately 50feet from the facility. The facility had a fence around one side of the building where Resident # 1's room was located. The fence was observed with no lock it was able to be pushed open with no resistance, no alarm noted on the fence, the fence lead to the west side of the parking lot and then to the main highway. The police station where Resident # 1 eloped to was approximately 1.1 miles from the facility driving and located on a busy street. Observation on 4/12/2023 at 3:15PM of Resident # 1 room window room [ROOM NUMBER], the window was observed to be low about 2feet from the floor. The window had 2 hinges that lock the window, both hinges must be pressed at the same time to open the window. All the windows in the facility have the 2 hinge lock. During a phone interview on 4/11/2023 at 11:45AM with LVN A, stated she was one of the nurses on duty the night Resident # 1 eloped from the facility. She stated she gave Resident # 1 her night medication about 9:30pm. She stated Resident # 1 was observed walking around the facility and in the common area watching television with others the night of the incident. LVN A stated she last saw Resident # 1, around 1:00AM walking down 600 Hall. She stated then around 4:30A, she was in the process of admitting another resident back into the facility when the local law enforcement showed up at the facility asking if they had a resident and gave Resident # 1 name. LVN A stated when she spoke with the police, she was advised that Resident # 1 had walked to the police station and that she had been held captive by some men in an apartment. She stated the police reported that Resident # 1 complained of pain and fell in their lobby floor, she stated she was then transported to the hospital for further treatment and examination. LVN A stated when they went and checked Resident # 1 room, they found the window up and screen pushed out, she stated she was not aware that the resident was missing. LVN A stated they usually make rounds every two hours or when the residents turn on their call light. During a phone interview with LVN B at 12:07PM, revealed she worked the night Resident # 1 eloped from the facility, she stated she worked from 6:00PM to 6:00AM. LVN B stated she remembered seeing Resident # 1 walking around the facility throughout the night. She stated Resident # 1 asked her a few times that night for the number to the police department. LVN B stated the last time she saw Resident # 1 was around 12midnight and 1:00AM. She stated when she took her break outside is when the police showed up around 4:30AM asking if they had a resident and gave Resident # 1 name. LVN B stated, she and LVN A went down to Resident # 1 room and noticed that her window was wide open, and the screen was off. She stated the police reported that Resident # 1 complained of pain and was transported to the local hospital. LVN A stated she was not aware that Resident # 1 was missing from the facility. She stated they make rounds every two hours and reported that she tried to coordinate her rounds with the aides, so checks are completed ever hour. LVN B stated she had never seen Resident # 1 try to elope before but stated she would often get her to dial the police for her. She stated Resident # 1 would walk all the time around the building. In an interview on 4/11/2023 with CNA A, stated she worked another hall when Resident # 1 eloped from the facility. She stated they usually make their rounds every two hours and reported they make their last rounds about 3:30AM. CNA A stated around 4:00AM the police showed up at the facility asking if they were missing a resident and gave Resident # 1 name. She stated they immediately went down to Resident # 1 room and observed Resident # 1 was gone. CNA A stated earlier that day Resident # 1 was walking around asking for different phone numbers for different people. CNA A stated they were not aware that Resident # 1 was gone from the facility. She stated she had been in-serviced on elopement process and procedures, abuse and neglect, she stated the ADM was the abuse/neglect coordinator. In an interview on 4/11/2023 at 4:30pm with DON, stated she received the call about 4:30am from LVN A, who was on duty. She stated the police were still at the facility when she called and advised her that Resident # 1 had eloped from the facility and walked to the police station. DON stated the resident was able to elope from the facility by raising her window and pushing the screen out. She stated Resident # 1 had never tried to elope before, she stated Resident # 1 would often check doors, and go out the dining room door and pull on that gate, but that gate has a lock. DON stated she just thought Resident # 1 likes the security of checking doors but had never seen her actually try to elope from the facility. The DON stated the fences around that side of the building did not have any locks. DON stated after Resident # 1 elopement she was placed on one-on-one supervision until she was able to be placed in another facility on a secure unit. The DON stated once Resident # 1 arrived at the new facility she continued to complain about pain in her back a side, stated the facility completed more x-rays and saw that Resident # 1 had a fractured left rib, from her recent fall when she eloped. Record review of facility incident report dated 2/5/2023 reflected, on 2/5/2023 at approximately 4:30am the facility was notified by the local police department that Resident # 1 had eloped and walked to the police station. The facility was advised that Resident #1 reported she fell and hurt her back/left rib area Resident # 1 was transported to the local hospital. Record review of police report dated 2/5/2023, reflected Resident # 1 entered the police lobby at around 3:38AM. The report reflected at 3:44AM, EMS was contacted due to Resident # 1 complaining of pain on left side. The report stated Resident # 1 fell in the lobby and had labored breathing. The report reflected Resident # 1 claimed that she had been held against her will for several days and escaped. The report reflected law enforcement made contact with the facility at 4:26AM and learned that Resident # 1 had been a current resident. Record review of hospital records dated 2/5/2023, reflected Resident # 1 was admitted to on 2/5/2023 for rib/trunk pain- swelling. The report reflected Resident # 1 stated she was drugged with a cloth over her mouth and tripped while escaping hitting her left flank on a curb. The report reflected CT (computerized tomography) scan of the head/brain reflected no intercranial abnormalities, X-Ray of chest -No acute cardiac or pulmonary abnormalities, vitals HB (heart- beat)-78 bpm (beats per minute), Oxygen saturation -96%, respiratory rate-18 br (breathes/ per minute), temp.- 97.8 BP (blood pressure) 133/82. Discharge disposition: Good, stable oriented x 2 (to place and time), to return resident to ER (emergency room ) if any new or worsening symptoms. Review of Resident #1 face sheet dated 4/12/2023, reflected Resident # 1 was a 94- year- old woman, admitted to the facility on [DATE]. Resident # 1 was diagnosed with Unspecified Dementia without behavioral disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions and to solve problems), psychotic disturbance (severe mental disorder that causes abnormal thinking and perceptions), Mood disturbance (feelings or distress, sadness or symptoms of depression and anxiety) and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of Resident #1 quarterly MDS dated [DATE] reflected a BIMS score of 03 which indicated severe impairment. Section E of MDS (behavior) reflected, Resident # 1had a behavior of wandering. Review of Resident # 1 care plan dated 10/17/2022, reflected the following: Problem: Resident is unaware of safety needs, Gait/balance problems, cognitive deficits with Dementia. Interventions: Bed in low position, floors free from clutter, glare free light, call light within reach personal items within reach. The care plan did not reflect any interventions regarding elopement or wandering. Record Review of quarterly Wander assessments dated10/25/2022 reflected, Resident # 1 was at a high risk for wandering with a score of 14. assessment dated , 1/25/2023 reflected, Resident # 1 was a moderate risk for wandering with a score of 8. Wander assessment dated [DATE] reflected, Resident # 1 was at a high risk for wandering with a score of 21. Record Review of progress notes dated 9/2022- 1/2023 reflected since admittance to the facility Resident #1 often spoke of leaving the facility. Resident#1 often talked about family members and friends coming to get her to take her home to live in Dallas or Mexico. Record Review of facility one on one monitoring for Resident # 1 dated 2/5/2023 -2/7/2023 reflected, the facility provided 30min. monitoring starting when Resident # 1 initially returned to the facility. 2/6/2023- 2/7/2023 monitoring reflected 24-hour monitoring of Resident # 1 until she discharged on [DATE] to another facility with a secure unit. Record Review of facility Wander Management, Monitoring System & Resident Elopement Protocol policy dated: 1/2023 reflected: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. To provide a system to alert staff that a resident may be attempting to leave the facility All staff is responsible to ensure resident safety Record Review of facility Abuse/Neglect policy 12/12/2019 reflected: Neglect is the failure of the facility, to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Record Review of facility in-services dated 2/5/2023, reflected all staff have been in-serviced on Elopement, abuse/neglect, how to supervise, monitor, and redirect residents, Notifications to responsible parties and emergency contacts for incidents/accidents Record Review of QAPI - (Quality Assurance and Performance Improvement) held quarterly dated-September 2022- February 2023 to address elopement. An (IJ) Immediate Jeopardy was identified on 4/12/2023 at 4:45PM. The ADM was notified on 4/12/2023. The ADM was provided with the (IJ) Immediate Jeopardy template on 4/12/2023 at 4:45PM. A Plan of Removal was first submitted by the ADM on 4/13/2023 at 11:31am. The Plan of removal accepted on 5/3/2023 at 4:00pm Plan of Removal April 12, 2023 Immediately on Regional Director of Operations conducted a post incident huddle with, prior Administrator, DON/RN to conduct a root cause analysis and to develop a list of actions. During the post investigation huddle and Administrator were in-serviced on Elopement Policy to include Identification & Prevention of elopement, interventions, and documentation, at risk for elopement; monitoring, interdisciplinary interventions, procedure for missing residents/elopement, what to do when resident is found, and actions post elopement. Upon review of the IJ template written on 4/12/2023, it was noted that Resident #1 would often check doors and pull on doorknobs. Immediately we spoke to DON regarding this notation. DON explained that the conversation she had with the surveyor was regarding behaviors of the resident prior to the elopement on 2/5/2023. When the elopement occurred on 2/5/2023, DON was trained on the elopement policy along with how to identify exit seeking behaviors as notated above by, RDO. On 4/12, Regional Director of Operations, Regional [NAME] President and Chief Operating Officer re-in-serviced the Interim Admin and DON on the elopement policy with a focus on identification of elopement risk to include exit seeking behaviors, verbalizations of a plan to exit the facility as well as how to intervene when these behaviors are noted to include 1:1 supervision and discharge to an appropriate setting. Resident #1 remained on 1:1 supervision from time of elopement until she was discharged [DATE] to a secure unit in Copperas Cove. Resident #2 was place on 1:1 supervision as a result of a suicidal ideation on March 9, 2023 until discharged for further psychiatric evaluation and treatment to Oceans Behavioral Hospital on 4/24/2023. On 4/12/2023 Maintenance Director rechecked all exit doors for functionality and closure/locking. The facility put a precautionary lock on the fence on 4/12/2023. Maintenance Director checked all windows to ensure the locks were functional 4/12/2023 Wander /elopement risk assessments were updated by Nursing admin on 4/12/2023, for all residents to ascertain risk for wandering, and appropriate interventions implemented. Elopement binder was checked and up to date on 4/12/2023. On 4/12/2023, The DON/designee initiated in-servicing of department heads and staff on the policy and procedures of elopement which included but does not limit to: Identification & Prevention of elopement, interventions, and documentation, at risk for elopement; monitoring, interdisciplinary interventions, procedure for missing residents/elopement, what to do when resident is found, and actions post elopement. Additional in-servicing done 4/12/2023 on policy and procedures of elopement which included but does not limit to: Identification & Prevention of elopement, interventions, and documentation, at risk for elopement; monitoring, interdisciplinary interventions, procedure for missing residents/elopement, what to do when resident is found, and actions post elopement. On 4/12/2023, Administrator/Designee initiated training with department managers on the roles of the nursing department and non nursing departments when a resident is exit seeking and when a resident elopes, and our elopement policy. The department managers trained staff on the roles of the nursing department and non nursing departments when a resident is exit seeking and when a resident elopes, and our elopement policy. Each role was discussed in the scenario of an active elopement occurrence. In addition, the Administrator, Maintenance Director, and DON verbally conducted an elopement drill where each role was discussed in different active elopement occurrence scenarios. Staff was able to verbalize understanding. Additional elopement drills were completed 4/12/2023 The elopement mitigation policy is part of new hire orientation. In order to monitor current residents for potential risk, IDT team will review and discuss all wander risk residents daily for 30 days to identify any potential behavior changes. After 30 days, the IDT will follow the above process monthly. Thereafter, QA will monitor quarterly up to a year for. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns noted, will continue to monitor as per routine facility QA Committee. Monitoring of Plan or Removal on 4/13/2023 is as follows: Observation on 4/13/2023 at 3:00pm walk around with Maintenance director, checked locks on the outside fence, observed nails placed in the windows 6inches up. Observation on 4/13/2023 at 3:30PM, random check on rooms on 600 hall this hall is still under construction rooms observed screw in window 6inch up, maintenance man measured to ensure placement. Observation on 4/13/2023 at 3:45PM random check on rooms 306, 605, 406 observed screws in each window. In an interview on 4/13/2023 at 5:00PM with interim ADM, stated on 4/12/2023 she verbally advised the MD of the IJ (Immediate Jeopardy) concerns identified. In an interview on 4/13/2023 at 3:33PM with Maintenance director, stated he would put a nail in all the windows at facility. He stated he would continue to check the locks and alarms of the doors and use the Tels system (maintenance system that electronically tracks checks on the facility alarm system). to document these checks and any irregularity. He stated he would develop a form to document the checks made on the fence and all the windows. In an interview on 4/13/2023 at 4:45PM with CNA D, stated they had a resident on one- to- one supervision for behavioral issues. Observed on 4/13/2023 aide sitting at door, resident observed in room asleep. CNA D stated she was trained on the elopement process and procedure. She stated she was trained on abuse/ neglect and reported that abuse neglect coordinator was the ADM. In an interview on 4/13/2023 at 5:00PM with LVN C, stated she completed the elopement drill and was in-serviced of on the policy, procedures and steps to take when there was a missing resident. LVN C, stated she was in -serviced on abuse/ neglect, elopement, and documentation. She reported the ADM was the abuse/neglect coordinator. LVN C was able to identify elopement behavior as attempting to go out doors, sitting close to doors. In an interview on 4/13/2023 at 5:10PM with LVN D, stated she participated in the elopement drill today. She stated she was in-serviced on abuse/neglect, elopement, and resident documentation. She stated she understood the process when they have a resident missing, she stated she contacted the ADM immediately if she suspected abuse/ neglect, and that she understood the importance of charting on residents. LVN D was able to identify elopement behavior as attempting to go out doors, sitting close to doors. In an interview on 4/13/2023 at 5:20PMwith CNA C, stated she participated in the elopement drill. CNA C stated She stated she was trained on the elopement process and procedure. She stated they made rounds every two hours or when the resident turned on their call light. She stated she was trained on abuse/ neglect and documentation, she stated the ADM was the abuse/neglect coordinator and they needed to report immediately if they saw or suspected abuse/neglect. CNA C was able to identify elopement behavior as attempting to go out doors, sitting close to doors. In an interview on 4/13/2023 at 5:30PM with CNA D, stated she was agency staff, she stated she had not yet completed the elopement drill yet. She stated she was trained on the elopement process and procedure. She stated they made rounds every two hours or when the resident turned on their light. She stated she was trained on abuse/ neglect and documentation, she stated the ADM was the abuse/neglect coordinator and they needed to report immediately if they saw or suspected abuse/neglect. In an interview on 4/13/2023 at 5:40PM with CNA E, stated she participated in the elopement drill. CNA C stated she was trained on the elopement process and procedure. She stated they make rounds every two hours or when the resident turned on their call light. She stated she was trained on abuse/ neglect and documentation, she stated the ADM was the abuse/neglect coordinator and they needed to report immediately if they had seen or suspect abuse/neglect. In an interview on 4/13/2023 at 6:00PM with DON, stated she and most of the staff were trained on the elopement drill and what to do when they have a missing resident. She stated any staff that have not been trained had been contacted and advised of the required training. DON stated the rest of the staff even agency staff when they came to work were trained over the elopement process, abuse/neglect, and documentation. In an interview on 4/13/2023 at 5:30PM with ADM, stated 55 of 80 staff were trained on the elopement process. She stated the day staff participated in the elopement drill skills test on what to do if they had a missing resident. She stated evening and night staff were contacted to advise them of the required training. She stated the elopement mitigation policy would be a part of the onboarding for new hires packet. The ADM advised agency staff would be trained as they use them. She stated was their responsibility to ensure that all the residents in the facility were safe. The ADM stated The IDT would review and discuss all wander risk residents daily in the morning meeting starting 4/14/2023. Records review on 4/13/2023 of Root cause analysis dated 2/5/2023 reflected, the facility completed a Root cause analysis regarding missing resident and interventions. Intervention identified was to add a screw to the window for further protection. Record review on 4/13/2023 of POR binder, reflected all residents had wander elopement assessment completed on 4/12/2023. All assessments reflected no wander or elopement risk residents in facility. Record review on 4/13/2023 of wander assessment, reflected the resident who was at a high risk of elopement and still at facility was re-assessed on 4/12/2023 for wander elopement risk and determined to be a moderate risk at this time, no longer high risk for elopement. Record review 4/13/2023, at elopement binder checked all resident wander elopement assessments in the binder had been updated to reflect current elopement status. Record review on 4/132023 of in-services completed by 60% of staff for the following: Identification & Prevention of elopement, interventions, and documentation, at risk for elopement; monitoring, interdisciplinary interventions, procedure for missing residents/elopement, what to do when resident is found, and actions post elopement Record review of Elopement drills completed with staff by ADM and department managers. Dates of drills noted were 4/13/2023, 2/5/2023, 2/18/2023. The ADM was informed the (IJ)immediate Jeopardy was removed on 4/13/2023. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents when Certified Nurse Aide (CNA) A attempted to transfer one (1) of three (3) residents reviewd for mechanical lift transfers (Resident #3) Resident #3 fell out of the mechanical lift during a transfer conducted by CNA A. The resident sustained [REDACTED]. CNA A failed to transfer the resident with assistance as indicated in her plan of care. This deficient practice could place 3 residents at risk falls, injury and possible death due to improper transfer technique. Findings include: Review of Resident #3's face sheet reflected an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] reflected moderately impaired decision making and supervision required; inattention; total dependence with activities of daily living; incontinence of bowel and bladder; and oxygen as needed. Review of Resident #3's current care plan dated 9/6/13 reflected she was unable to make decisions; dependent on staff for all activities of daily living; incontinent of bowel and bladder; and had very fragile skin. Encourage and support participation in activities; Oxygen by nasal cannula. An update on 9/13/13 reflected risk for falls: fall with laceration to the back of her head and skin tears to bilateral elbows. Use sleeves on bilateral arms related to fragile skin. Review of Resident #3's weekly nurse summary reflected total dependence related to dementia. Review of the incident/accident report dated 9/13/13 at 10:30 AM reflected the following: Resident #3 sustained a head laceration and skin tears to both elbows during a fall. Outcome of interview with staff: CNA A transferring out of policy & procedure did not follow care plan. One strap was not secure and once in the air strap released completely. State Cause: CNA transferred with one and did not assure all straps were secure. Describe immediate action taken: Immediate assessment holding resident in C-spine sent CNA to get ice pack while another nurse called 911 and got paperwork together. Assisted EMS team to get (Resident #3) on back board. Final disposition: Sent to local emergency room for evaluation and treatment. Sister notified. What measures were put in place or what systematic changes were made? 1.) Termination of CNA A due to investigation determined CNA A lied to nurse about having a second staff present, and not following policy & procedure with transfers 2.) Inservice on transfers and not moving resident after a fall 3.) Therapy to inservice and evaluate staff on Hoyer transfers. Brief Summary of Incident: Approximately 10:00 AM CNA A comes to desk and said resident fell out of Hoyer sling. While running to room asked CNA how did that happen. Stated Hoyer strap broke. Then while holding resident in C-spine asked again to explain how it happened with one CNA with Hoyer and second CNA with hands on the resident. The CNA states, "I did have my left hand on her while CNA D pulled wheel chair away when strap gave way and resident slid to the floor head first. Hoyer lift sling assessed; no tears, no fray noted asked how did sling break when all intact. Review of a telephone order in Resident #3's record dated 9/13/13 reflected 'Send patient to emergency room for evaluation: [DIAGNOSES REDACTED].' Resident #3 was transferred to the local hospital emergency room by ambulance. There she had four staples placed to the back of her head. Resident #3 returned to the facility via ambulance alert and in no distress. Neuro checks remained within normal limits. During an interview on 10/3/13 at 9:50 AM with CNA D stated that on the day of the incident (9/13/13) CNA A asked her to help with a Hoyer lift transfer for Resident #3. She was on the way to help her with the transfer but she had two other residents that needed assistance transferring. CNA A helped her with a Hoyer lift transfer and when CNA D came out of that room to get the lift it was gone. She went down to Resident #3's room and the resident was on the floor and CNA A was trying to get her in bed. She asked CNA A, "What the hell happened! You're not supposed to move the resident if she falls to the floor." She told CNA A to get the nurse and she would stay with Resident #3. She didn't feel safe leaving CNA A in the room with Resident #3 after what she saw. CNA A kept saying "The strap broke, the strap broke!" When CNA A was talking it didn't make sense. She kept telling the Assistant Director of Nurses (ADON) that CNA D was helping her and the strap broke. CNA A was worried about losing her job, but CNA D was worrying about the safety of the resident. CNA D just didn't expect that from CNA A when CNA D told her she'd be right there to help her and she lied to the nurse about CNA D being in the room. An interview with the ADON on 10/3/13 at 4:25 PM revealed she was the Charge Nurse (CN) that day and CNA A came to tell her Resident #3 fell out of the Hoyer lift sling and was on the floor. CNA A was telling her what happened as they ran to the room. The CN stated, it didn't look right. The blood was in a different place than where the resident was. Resident #3 was on the floor with blood around her head. She did a thorough assessment, held Resident #3's head to stablize it and asked a CNA A to get an ice pack and the other Charge Nurse to call the doctor and 911. CNA A had attempted a Hoyer lift transfer alone and did not check that the straps were secure. Resident #3 was elevated in the lift and moved toward the wheel chair when one strap of the sling came off the lift causing Resident #3 to slide out of the sling and onto the floor. She sustained a head injury on the way down when she hit her head on the lift. Multiple attempts on 10/3/13 for a telephone interview with CNA A were unsuccessful. Review of a written statement by CNA A reflected that: "All was going well until the wheel chair moved and with one hand on the resident I was trying to pull the Hoyer lift to turn it toward the bed. I struggled to get it turned. When clear of the chair, I didn't notice that (the) sling was not all the way secured on the hook so it was in mid turn when the strap popped off and the resident slid out before I could get her to the bed. She (Resident #3) slid out from the left side of the sling striking her head on the leg of the lift. I removed the lift from under her head so she wouldn't be laying on it. Got nurse to come down stating to her that resident fell out of the sling onto the floor. First I said it (the strap) broke because thats what it sounded like. But it wasn't broke it had popped off." Review of CNA A's employee file on 10/3/13 reflected that in 2006 CNA A had been referred to The CNA board when she failed to follow the care plan for a resident, resulting in a fall with injury. However, that referral was not upheld. CNA A also had numerous written warnings with suspension for not following policy and procedure that didn't result in injuries to residents. Review of the facility's policy and procedure dated 3/2012 titled 'Falls-Evaluation and Prevention' POLICY: It is the policy of this home to evaluate residents for their fall risk and develop interventions for prevention... FOLLOWING A FALL,THE FOLLOWING STEPS SHOULD BE UNDERTAKEN * Evaluate the resident promptly in order to identify and treat injuries. The resident should not be moved until a licensed nurse has evaluated their condition, unless absolutely necessary. The evaluation should include vital signs and neurological status... EDUCATION OF STAFF RELATED TO FALL PREVENTION * Safe transferring techniques... A list of three (3) residents tht require a mechanical lift for transferring was provided by the ADON.