Every finding on record at Lynwood Nursing and Rehabilitation

Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 (Resident #1) of 5 residents reviewed for laboratory services. The facility failed to timely obtain Resident #1's urinalysis (UA) and complete blood count (CBC) tests which were ordered on 08/04/26 and were not obtained until 08/06/26. This failure could place residents at risk of delayed treatment and overall decline in health.Record review of Resident #1's Face Sheet dated 08/19/26, revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses which included: chronic obstructive pulmonary disease (a progressive lung disease that blocks airflow and makes breathing difficult), dementia (a decline in mental ability that interferes with daily life), and UTI (an infection in any part of the urinary system, including the kidneys, bladder and tubes connecting the kidneys to the bladder and to the outside of the body). Record review of Resident #1's Annual MDS assessment, dated 06/10/26, revealed: Section C - Cognitive Patterns, BIMS was not scored due to the resident was rarely/never understood. Review of Section H - Bladder and Bowel, revealed the resident was always incontinent. Record review of Resident #1's Comprehensive Care Plan revealed: Problem Start Date: 11/11/2024. Resident has history of urinary tract infections. Approach Start Date: 11/20/2024. Ensure resident is cleansed appropriately with incontinent episodes. Offer increased fluids. Complete antibiotics as ordered. Record review of Resident #1's current Physician's Orders for 08/01/2026 - 08/20/2026 revealed: UA [a lab test that examines the physical, chemical, and microscopic properties of a urine sample] ReFlex Culture [a fast urine screening test that automatically triggers a detailed bacterial culture (a laboratory method used to grow and multiply microorganisms to identify infections) only if the initial results show an infection]. Start date - 08/04/2026. End date - 08/04/2026. Other test: (UA C&S [a lab test that grows germs from a body sample to find the cause of an infections and tests different medicines to see which one works best]) [Dx: Urinary tract infection, site not specified]. Once - One Time; 06:00 AM - 06:00 PM.May straight cath [procedure where a thin, flexible tube (catheter) is used to drain urine from the bladder then is immediately removed] to obtain urine sample. Once - One time; 05:30 PM. Start date - 08/06/2026. End date - 08/06/2026.Record Review of Resident #1's Hospice Physician's Orders revealed: 8/4/2026 3:00 PM - Facility nurse to collect CBC [a routine blood test that measures the cells in your blood to check your general health] and UA, may straight cath if need to collect UA. Record review of Nursing Progress Notes for Resident #1 revealed: Family Member [Name] is requesting a UA be done on resident, [Name] LVN C notified [Hospice] of [Family Member] request. [Hospice] ordered UA C&S per family request. 08/04/2026 at 5:46 AM by LVN C. several attempt [sic] to collect urine without success. will continue with attempt. 08/04/2026 at 3:18 PM by RN B. Received verbal order for UA, CBC with Differential [measures percentages of the five main types of white blood cells in the body] to evaluate for suspected infection from hospice nurse per family request. Lab requisition order to [Name] laboratory. Family notified by hospice nurse. 08/04/2026 at 5:30 PM by RN B. This nurse spoke with hospice nurse and received order to straight cath to obtain urine sample. UA sample obtained via straight cath using sterile technique [a strict set of medical practices used to keep environments free of germs to protect patients from infections] and sent to [Name] lab, results pending. On 08/06/2026 at 10:30 AM by RN A. UA results received and sent to [Hospice], no new orders at this time, will continue to monitor. On 08/06/2026 at 2:04 PM by RN A. Received call from Hospice nurse [Name] who states Doctor does not want to treat because there is not an active infection at this time, I will let [Family Member] know that the changes are part of her disease progression. On 08/10/2026 at 5:26 PM by RN A. Record review of Resident #1's laboratory document from [Name] Laboratory revealed: CBC with Differential. Collection Date: 8/6/2026 7:18 AM. Record review of Resident #1's laboratory document from [Name] Laboratory revealed: Urinalysis with Culture. Collected: 8/6/2026 10:58 AM. During an interview on 08/19/26 at 9:53 AM, Resident #1's Family Member stated, I believe it was 08/03/26 and I asked [LVN C] on the evening shift to contact hospice for an order for a UA due to [Resident #1] seeming anxious, which can sometimes be a sign of the start of an infection. At noon on 8/04/26, I contacted [Hospice] who said they had not gotten a request from the facility for a UA. I spoke to [Hospice Nurse] later that same day and she had a scheduled visit with [Resident #1] at 3:41 PM and told me she gave the order to [RN B] for UA and CBC. I was out of town on 08/05/26 and when I went to the nursing home on [DATE], [Resident #1] did not seem like herself. When I checked with the nurses, I was told by [RN A] that she [Resident #1] had been taken to the toilet several times to try to get a urine sample. I don't know how you do that with someone who is incontinent and why do you wait two days after the order is given? I asked [RN A] why it had not been done and she said she did not know about the order until 08/05/26 and they had tried to put her on the toilet that day too. The UA was done on 08/06/26 and it came back showing she [Resident #1] was colonized [meaning bacteria were present in the urine but were not causing an illness or physical symptoms] so [Hospice Physician] did not want to treat her [Resident #1] for an infection. I have some decisions to make on how to move forward with treatment for her [Resident #1], but I felt like the testing that was ordered on 08/04/26 should have been done before 08/06/26. During an interview on 08/19/26 at 2:27 PM, Hospice Nurse stated she was familiar with Resident #1 and had been conducting her facility visits once per week for approximately one year. Hospice Nurse stated Resident #1 had previously been on an antibiotic for prevention of UTI but was no longer taking it due to the medication not showing effectiveness on the C&S. She stated Resident #1 had become colonized and was being monitored for signs and symptoms of UTI. Hospice Nurse stated she conducted a visit with Resident #1 on 08/04/26 at approximately 3:00 PM and verified with RN B that Resident #1 had an order for a UA and CBC. She stated a facility nurse had called the hospice on-call provider earlier on the morning of 08/04/26 and was given an order for UA and CBC at that time. She stated the order included an order to straight cath Resident #1 to obtain the urine sample if needed. Hospice Nurse stated, When a resident is incontinent, we give the order to use a straight cath method if needed. Sometimes the provider will treat the patient prophylactically [treat the infection preventatively] but she [Resident #1] has a history of UTI so we ordered a straight cath for her. I was not on duty on 08/06/26 when [Resident #1's] Family Member called and spoke with my supervisor and told her she was upset that the UA and CBC had not been done yet. The UA and CBC were done on 08/06/26 and the results took a day or two. [Hospice Physician] did not want to treat her [Resident #1] at that time due to colonization. I'm not sure why there would have been a delay in getting the UA when there was an order for a straight cath. During an interview on 08/19/26 at 2:56 PM, LVN C stated she was on duty on the evening shift of 08/03/26 when Family Member for Resident #1 requested that the resident have a UA due to a change in behavior. LVN C stated Family Member stated, She seems anxious and chattery. LVN C stated she called the provider for [Hospice] around 5:30 AM on 08/04/26 and received an order for Resident #1 to have a UA and CBC. LVN C stated she printed the order and passed it on to the oncoming day shift nurse [RN B] prior to leaving her shift. She stated she returned to duty the same day at 6:00 PM and RN B reported that Resident #1's UA and CBC were not collected during the day shift. LVN C stated she was not able to collect the urine sample for Resident #1 during the night shift, and she did not recall if she passed it on to the oncoming nurse (RN A) the next morning at shift change. She stated, It should have been on the 24-hour report, but it sometimes gets dropped off. I had a couple of days off after that and I didn't know it didn't get done the next day. Orders should be followed as quickly as possible and a UA and CBC should be done within a shift or two after the order is given, unless the order gives a specific time. LVN C stated she did not consider 48 hours to be timely in following a physician's order and the provider should be notified if there was an issue in following an order. LVN C stated a potential negative outcome for failure to follow physician's orders for a UA and CBC was worsening of symptoms, fever, increased risk of infection and sepsis (a life-threatening medical emergency that happens when the body has an extreme, harmful response to an infection). During an interview on 08/20/26 at 11:15 AM, RN B stated she worked the day shift on 08/04/26 and was made aware by LVN C during shift change that Resident #1 had an order for UA and CBC. She stated the procedure to collect a UA on an incontinent resident was to allow the resident to sit on the toilet every couple of hours to attempt to collect a urine sample prior to using a straight catheter to collect urine. RN B stated Resident #1 was taken to the toilet several times during the day shift, but a sample of urine was not obtained during the shift. RN B stated she placed an order request to [Name] lab for Resident #1's CBC to be drawn. She stated it was usual practice to attempt urine collection for 24 hours before calling the provider to get an order to obtain the sample by straight catheter. RN B stated she was not aware the order from hospice included the order to use a straight catheter to obtain the urine sample, if needed. She stated during her end-of-shift report to the oncoming nurse (LVN C) she made the nurse aware the urine sample had not been collected. RN B stated she was off duty for a few days after her 08/04/26 shift and was not aware of the delay in obtaining the UA and CBC for Resident #1. She stated physician's orders should be followed as timely as possible and she would not consider 48 hours to be timely in following an order. She stated a potential negative outcome for failure to follow physician's orders for UA and CBC was worsening of a UTI and sepsis. During an attempted interview on 08/20/26 at 11:50 AM, a telephone call was placed to [Name], hospice physician. There was no answer and a voicemail was left requesting a returned call. During an interview on 08/20/26 at 2:11 PM, RN A stated she worked the day shift on 08/05/26 and took care of Resident #1. She stated she was not made aware during shift change report with LVN C that Resident #1's UA and CBC were not collected. RN A stated, It was around lunchtime when I realized [Resident #1] had an order for UA and CBC so I encouraged [Resident #1] to drink some fluids and asked the CNAs to take her to the toilet during the shift so we could get a urine sample. I think the CBC was drawn by the lab earlier in the shift. We did not get the urine sample during the day shift, and I think I passed it on in report to the night shift nurse but I'm not sure since the orders can fall off after 24 hours. When I came to work the next morning (08/06/26) I realized the tests [UA and CBC] for [Resident #1] had not been done so I called [Hospice] first thing and got an order to straight cath [Resident #1] and got the urine sample and sent it to [Name] lab. RN A stated physician's orders should always be initiated as soon as possible. She stated she did not consider 48 hours to be timely for following an order. RN A stated, blood work like a CBC should be done within the shift that the order is received and a UA should be done within 24 hours. RN A stated a potential negative outcome for failure to follow physician's orders for a UA and CBC was sepsis. During an interview on 08/20/26 at 4:28 PM, the ADM stated he was in his second week as the facility ADM and he was not employed by the facility at the time of the incident with Resident #1. He stated the facility did not currently have a DON. The ADM stated he was not aware Resident #1 had an order for a UA and CBC that were not completed for 48 hours. He stated orders should be followed at the time the order was given and he did not consider 48 hours to be timely in following an order. The ADM stated his expectation of staff was to follow physician's orders immediately or as soon as possible, depending on the order. He stated staff were expected to pass information on at shift change on a 24-hour report in order to ensure orders for specimen collection, such as UA and CBC, were obtained timely. The ADM stated a potential negative outcome for failure to follow physician's orders in a timely manner was a decline in a resident's health or something not being treated. Record review of the facility's policy titled Provision of Physician Ordered Services, dated 7-2025, revealed: Policy:The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality.Definition:Professional Standards of Quality means that care and all services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting.Policy Explanation and Compliance Guidelines:1. Facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders.2. Qualified nursing personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations) to the appropriate entity. Record review of the facility's policy titled Specimen Collection, dated 7-2025, revealed: Policy:It is the policy of this facility to collect resident blood and body fluid specimens as per the physician's orders in accordance with current standards of practice and regulatory guidelines.Blood Culture Sample Collection:1. Verify practitioner's order for the test(s) requested. Record review of the facility's policy titled Urine Specimen Collection, dated 6-2025, revealed: Policy:To promote accurate diagnosis and treatment of a resident's medical conditions, staff will obtain urine samples in accordance with established standards of practice.Policy Explanation and Compliance Guidelines:1. Urine shall be collected for analysis or culture only with a physician's order.

Based on interviews and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 10 of 19 residents in that: The facility failed to ensure staff were not on their personal cell phones while providing care, which included peri-care to residents. This could place residents at risk for diminished quality of life and loss of dignity and self-worth. Findings include: During an interview with confidential residents on January 12, 2026, at 10:00am ten confidential residents stated the use of cell phones by CNAs while performing care made them feel ignored, not a priority, embarrassed, concerned the CNA could make a mistake due to distraction by the cell phone conversation, and, most of all, their privacy was violated. During an interview on January 12, 2026, at 10:00am ten confidential residents stated the use of cell phones by CNAs occurred on every shift; however, primarily occurred during the night shift. During an interview on January 12, 2026, at 10:00am ten confidential residents stated they did not know the names of the CNAs who utilized their cell phones while performing care. The confidential residents stated cell phone usage of the CNAs while performing care happened in the facility so often, they said every CNA in the facility utilized their cell phone while performing care. During an interview on 1/13/26 at 1:21pm the DON stated staff should provide privacy any time they were performing resident care. She stated cell phones should only be used in the break room and outside of the facility. The DON stated cell phones should never be used in resident rooms, in the hallways of the facility, or at the nurses' stations. The DON stated she and her ADM oversaw training staff on cell phone usage in the facility. The DON stated there was continuous education provided to staff concerning cell phone usage via team meetings and in-service training. She stated the DON and ADM monitored staff by observing and addressing grievances and complaints regarding cell phone usage while performing care. She stated there was no reason privacy for residents should not be provided. She stated the potential negative outcome was HIPPA violations and the nursing staff could make a mistake. During an interview on 01/13/26 at 1:14pm, the ADM stated residents should be provided with privacy during resident care. She stated all staff were trained on privacy, dignity, and cell phone usage during orientation and through continuous education by the DON and the ADM. She stated staff were monitored by making rounds and correcting any issues found, and by addressing complaints and grievances concerning cell phone usage by staff while performing resident care. She stated cell phones should never be used in resident rooms, hallways, or nurses' stations. She stated the potential negative outcome could be mistakes and HIPAA violations. Record review of the undated facility policy titled Promoting/Maintaining Resident Dignity revealed the following: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Policy Interpretation and ImplementationAll staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 5. When interacting with a resident, pay attention to the resident as an individual. 8. Staff members do not talk to each other while performing a task for the resident as if the resident is not there. Conversation should be resident focused and resident centered. 12. Maintain resident privacy. 15. Random observations and/or verifications are conducted by the Director of Nursing Services (DNS), or designee, to ensure compliance with this policy.

Based on observation, interview, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (1/11/26 lunch). This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.The Findings included: During confidential individual interviews on an undisclosed date and time, 10 of 10 residents voiced concerns related to food palatability. They stated, the rolls were raw, and they could not chew them. They further stated, the vegetables are unrecognizable due to being cooked too long. The following dining observations were made during lunch meal on 1/11/26 that began at 12:22 a.m. and concluded at 1:03 p.m. Observation of the puree foods served for 6 of 6 residents on puree diet revealed, puree seasoned chicken thighs and pureed mac-n-cheese had a very coarse appearance. Pureed chicken gravy was also present. Temperatures were not taken of the pureed foods, but pictures were taken by the Surveyor. The following interviews and observations were made during a kitchen tour on 1/12/26 that began at 10:29 p.m. and concluded at 11:49 a.m. During an interview on 1/12/26 at 11:14 a.m. the DM was informed of a request for a test tray. On 1/12/26 at 11:43 AM temperatures were taken on the steam table by [NAME] A and the DM with the following results:Sausage 181 F.Red beans 192 FTurnip green 200 F.Puree sausage 168 F and had a coarse appearance.Puree red beans 195 F and had a coarse appearance.Puree turnip green 183 F and had poor flavor.Mechanical sausage 135 F The test tray arrived for testing at 12:28 p.m. The test tray temperatures were taken, and testing began with other surveyors at 12:29 p.m. with the following results:Sausage 152 F Red beans 162 FTurnip green 170 F.Puree sausage 168 F - had a coarse appearance.Puree red beans 195 F - had a coarse appearance.Puree turnip green 183 F - had poor flavor.Mechanical sausage 131 F - lukewarm4 of 7 foods tested had flavor, texture and temperature issues. During an interview on 1/13/2026 at 10:39 p.m. the RD stated regarding palatability issues with the food, that kitchen staff were responsible for ensuring foods were palatable. When shown the pictures and asked about the lunch meal of 1/11/26, she stated, Yes, I do see that the puree seasoned chicken thighs and pureed mac-n-cheese definitely doesn't look quite right, mac-n-cheese doesn't look smooth too. She further stated, from the pictures of the lunch meal of 1/11/26, the puree would be a potential problem for the resident on such special diet. The RD stated that she never heard any complaints from the residents on puree diet. She also stated, it could be a choking hazards since they are on such diet for a reason due to swallowing difficulties and chewing. During a phone interview on 1/13/26 at 10:41 a.m. a family member of Resident #15 stated she was aware resident #15 was on puree diet and that she came every day to feed him. When asked how long resident #15 has been on puree diet, family member stated, since when I brought him home on Thanksgiving, he choked on some food; turkey, and the next day at the facility he choked on slice peaches. The family member further stated, after the incident, the facility started resident #15 on puree diet but he didn't like how it looks and the taste. Family member of resident #15 stated that she was not at the facility for the lunch meal of 1/11. During an interview on 1/13/2026 at 1:05 p.m. with the DM regarding palatability issues with the food, she stated I and the cooks were responsible for making sure that the food would be palatable. When shown the pictures and asked about the lunch meal of 1/11/26, she stated yes, I do see the picture and that was the puree made by [NAME] A, the chicken thighs and mac-n-cheese, both look chunky. She further stated that the puree sausage, puree red beans and puree turnip green all tasted good, because whenever we make the puree, we do taste it and never heard any complaints from any of the residents. The DM stated that the kitchen staff were all trained on puree process and have come across the policy on food palatability. She further stated, from the pictures of the lunch meal of 1/11/26, no, it will not be palatable for residents on such meal type. She stated that the residents could refuse the food, resulting in weight loss. During an interview on 1/13/2026 at 1:53 p.m. with [NAME] A regarding palatability issues with the food, she stated yes, I made the lunch meal (puree) of 1/11/26 and 1/12/26. When shown the pictures and asked about the lunch meal of 1/11/26, she stated yes, I do see the picture and that was the puree I made, the chicken thighs, mac-n-cheese, both look chunky and that does not look like puree diet or meal. When asked about the food appearances, she stated, the puree sausage and puree red beans was harsh or grainy in appearance, when we tasted it, we think that was okay. She further stated that puree meals were not supposed to have hulls or bumps. [NAME] A stated that she has been trained on puree process and has come across the policy on food palatability. She further stated, from the pictures of the lunch meal of 1/11/26, no, it will not be palatable for residents on such meal type. She stated that the residents might not like or eat the food, resulting in weight loss. During an interview on 1/13/2026 at 2:24 p.m. with the ADM regarding palatability of the foods. She stated the DM and cooks were responsible for food palatability in the facility. When shown the pictures and asked about the lunch meal of 1/11, she stated it does not look like a smooth consistency. She added residents would not like the food because the food would not be palatable. The ADM stated the potential negative outcomes to the residents on such special meal type was, the residents could potentially choke or aspirate. Record review of the facility's policy titled, Food Preparation Guidelines, revised September 2023, reflected the following: Policy: It is the policy of this facility to prepare foods in a manner to preserve a resident's nutrition and hydration status. Policy Explanation and Compliance Guidelines: 2. Prepare food by methods that conserve nutritive value, flavor and appearance.a. Minimize exposure to light and air when storing food.b. Prepare foods as directed such as using the appropriate amount of liquid.c. Minimize holding time prior to meal service. 3. Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies include:a. Meals that vary in color and texture. b. Season food with spices or herbs in accordance with recipes and resident preference.c. Serve hot foods/drinks hot and cold foods/drinks cold.d. Address residence grievances about foods/drinks.e. Honor resident preferences, as much as possible. 4. Provide food in a form (i.e regular, cuts, chopped, ground, pureed) that meets the residents' needs in accordance with their physician order, assessment and care plan.

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 the facility's 1 of 1 kitchen reviewed for food safety. 1) The facility failed to ensure food items in the refrigerators (2) and freezers (2), were labeled and stored in accordance with the professional standards for food service. 2) The facility failed to ensure the iced tea machine's outer surface was free from dirt and stains. 3) The facility failed to ensure the refrigerators (2) and freezers (2) outer handle surface were free from greasy stains. These failures could place residents at risk for food-borne illness and cross contamination.These failures could place residents at risk for food-borne illness and cross contamination. The findings included: During kitchen tour observations on 1/11/26 that began at 10:08 a.m. and concluded at 10:51 a.m., revealed the following: Iced tea machine, located inside the kitchen's beverage station, had dirt and stains. Reach-in refrigerator #1 revealed the following: Both the right and left doors needed to be cleaned, to be free of greasy stains.What appeared to be covered sausages in a sheet pan, tomato paste (in a transparent container), sandwiches, and turkey bologna in two different clear plastic bags, all with no label, no use by date. Reach-in refrigerator #2 revealed the following: Both the right and left doors needed to be cleaned, to be free of greasy stains.What appeared to be cheese, liquid eggs (3), lettuce and turkey breast in different clear plastic bags with no label, no use by date. Walk-in Freezer #1 revealed the following: Both the right and left doors needed to be cleaned, to be free of greasy stains.What appeared to be ham, diced chicken, chicken thighs, fish sticks and beef burrito in different clear plastic bags with no label, no use by date. Walk-in Freezer #2 revealed the following:Both the right and left doors needed to be cleaned, to be free of greasy stains.What appeared to be waffles, frozen vegetables, cookies, and carrots in different clear plastic bags with no label, no use by date. During an interview on 1/13/2026 at 12:15 p.m. the RD, regarding kitchen observations, stated, I think it is the kitchen staff that were responsible for dating (use by date) and labelling the food items, whoever puts the truck away, as well keeping the general kitchen clean. When asked if the staff have been trained on such tasks, the RD stated, I am not sure, but have instructed them to put the dates/labels. She further stated that there should have been a use by date on those food items. The RD stated that the kitchen staff were not aware that use by date should have been indicated on those food items. The RD stated that food items not labeled or dated would potentially cause food borne illness to the residents. During an interview on 1/13/2026 at 1:05 p.m. the DM, regarding kitchen observations, stated, I and the cooks were responsible for dating (use by date) and labelling of all food items. The DM further stated that the food items should have a use by date, and she was not sure why. That probably because the kitchen staff were not aware of the use by date, should have been on those food items. When asked about the dirty stains on the iced machine, the refrigerators and freezers she stated, we should have cleaned them, and residents could get sick from taking food items from those dirty machines. She further stated that they have come across kitchen policies and have been trained to label and on how to clean the general kitchen. The DM stated, we would have served expired food items, which could harm them, when asked the potential negative outcome serving residents meals not labelled /dated. During an interview on 1/13/2026 at 1:53 p.m. with [NAME] A regarding kitchen observations, she stated the DM and aid were responsible for dating (use by date) and labelling all food items, that everything was supposed to be labelled and dated, and that the DM was responsible for monitoring that. When asked about the dirty stains on the iced machine, the refrigerators and freezers she stated, the aid is responsible to clean those machines, and he is not here today, and the residents can get sick from it. During an interview on 1/13/2026 at 2:24 p.m. with the ADM regarding kitchen observations, she stated all dietary staff were responsible for ensuring food was stored and dated properly, and the DM was responsible for overseeing dietary staff. When asked about the dirty stains on the iced machine, the refrigerators and freezers she stated, it needed to be cleaned as soon as possible, residents could get sick. She further stated that there should have been a use by date once those food items were opened. The ADM stated the kitchen staff were all trained on dating/labelling of food items, and yes they forgot to put it. The ADM stated the potential negative outcomes to the residents with unlabeled/undated food, was we can be serving something that is no longer good, thereby making the residents sick. Record review of the facility's undated policy and procedure titled, Food Storage, reflected the following: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US food codes and HACCP guidelines. Procedure:2. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. 3. Freezers e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Record review of the facility policy and procedure titled, General Kitchen Sanitation, date approved October 2018, reflected the following: Policy Statement: The facility recognizes that food borne illness has the potential to harm elderly and frail residents. All Nutrition and Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food codes in order to minimize the risk of infection and foodborne illness. Procedure:Keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil.After cleaning and until used, store and handle all food-contact surfaces of equipment and multi-use utensils in a manner that protects the surfaces from manual contact, splash, dust, dirt, insects and other contaminants.Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition.

Based on observation, interview, and record review, the facility failed to ensure that the menu was followed for the lunch meal on 1/11/26 for 1 of 1 meal (the lunch service on 1/11/26) reviewed for nutritional adequacy. The facility failed to follow the lunch menu for 1/11/2026 and did not inform the residents that a substitute would be served. This failure could place residents at risk of not receiving adequate nutritive food value needed to promote/maintain health. The Findings included: Record review of the weekly menu for week five's Sunday lunch revealed braised beef tips with gravy, steamed rice, roasted brussels sprouts, dinner rolls and frosted cake. During a dining observation on 1/11/2026 from 12:22 p.m. to 12:51 p.m., a handwritten message written on a whiteboard next to the kitchen entrance said, Lunch: seasoned chicken thighs, chicken gravy, mac and cheese, dinner roll, frosted cake. Only two food items, dinner rolls and frosted cake, were observed to be included in the lunch meal served. During a confidential meeting on an undisclosed date and time, ten of ten confidential residents stated the menu was rarely followed, menus were not posted for their reviews and not posted on common bulletin boards. Ten confidential residents stated they were given choices at breakfast to choose lunch and dinner, but at times even after they made those choices, they were still not served what they chose for lunch or dinner. The confidential residents stated they were not notified that the lunch menu on 1/11/2026 was changed. During an interview on 1/13/2026 at 10:39 a.m. the RD, stated she was not aware the lunch menu of 1/11/2026 was not followed and stated, I am not sure the residents were informed too. She stated that DM was responsible to follow menu, and I always check during my visits to make sure that they do follow the menu. She stated, probably some items were not delivered from the truck. The RD stated the potential negative outcome would be residents not getting the required nutritional values of expected meal, leading to nutritional inadequacies. During an interview on 1/13/2026 at 1:05 p.m. the DM stated, I am responsible for making sure that the menu was followed, if food is not in stock, I have to replace with items that we have. When asked about the lunch menu of 1/11/2026 not followed, the DM stated, Yes, I am aware that the menu was not followed, and I said the same thing yesterday based on the weekly menu week five's Sunday lunch. The DM stated she informed all the residents that the menu was being substituted, because she was not in the facility and that was the first time the menu was not followed. She stated that it would cause residents' dissatisfaction resulting in weight loss. During an interview on 1/13/2026 at 1:53 p.m. [NAME] A, stated Yes, the lunch menu of 1/11/2026 was not followed, because sometimes the DM switches the menu. [NAME] A further stated that the DM was responsible for making sure that the menu was followed. She stated that the residents might not like or eat the food, resulting in weight loss. During an interview on 1/13/2026 at 2:24 p.m. the ADM, stated she was aware that lunch menu of 1/11/2026 was not followed, and stated, it was the responsibility of the DM to make sure menus were followed. When asked how residents were communicated on the changed lunch menu of 1/11/2026 that was not followed, the ADM stated, the residents were informed verbally.The ADM stated the potential negative outcomes to the residents, without following the menu would be, the residents might not like the meal served, may not eat it resulting to weight loss. Record review of the facility's undated policy and procedure manual titled, Standardized Menus, reflected the following: Policy: The facility should provide nourishing, palatable meals to meet the nutritional needs of the residents based on the Recommended Daily Allowances (RDA) of the Food and Nutritional Board of the National Research Council, of the National Academy of Sciences, standardized cycle menus are planned in advance and utilized. Compliance Guidelines: 1. The facility will make reasonable efforts to provide food that is appetizing and culturally appropriate to meet the nutritional needs of the residents. 6. Menus should be approved and signed by the registered dietitian. 8. The current week at a glance menu should be posted in designated common area(s) where it will be readily available to residents, facility staff and visitors. 12. The facility will support the resident's right to make personal dietary choices.

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 of 3 (Resident #27) reviewed for wound care.RN A failed to change her gloves during wound care for Resident #27.This failure could place residents at risk for cross contamination and infection.Findings included:Record review of Resident #27's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #27 had a medical history of pulmonary embolism (a sudden blockage in a lung artery), respiratory failure, and heart failure.Record review of Resident #27's MDS, dated [DATE], Section C- Cognitive Patterns, revealed a BIMS score of 13 which indicated Resident #27 was cognitively intact.Record review of Resident #27's care plan, dated 12/10/2025, revealed (Resident #27) refuses or resists repositioning in bed, contributing to existing pressure injuries on the heels and buttocks/sacrum and increasing risk for deterioration. Follow wound care orders for heel and bottom wounds.Record review of Resident #27's physician orders, dated 12/05/2025, revealed, Wound Treatment Order: Location Coccyx (a small triangular bone at the base of the spinal column in humans ) Clean with Normal Saline/Wound Cleanser Apply: Triad (used for managing light-to-moderate wound drainage, creating a moist healing environment, and facilitating natural debridement (the essential medical removal of dead, damaged, or infected tissue)) and leave open to air.Left heel Clean with Normal Saline/Wound Cleanser Apply: Betadine and cover with gauze and tape.right ankle Clean with Normal Saline/Wound Cleanser Apply: betadine and leave open to air.During an observation of wound care on 1/12/2026 at 10:20 a.m., RN A cleaned Resident #27s left heel wound, dried the wound and applied a wound dressing to the left heel. RN A failed to change gloves and utilize hand hygiene after cleaning Resident #27's wound. RN A cleaned Resident #27s right ankle and applied betadine. RN A failed to change gloves and utilize hand hygiene after cleaning Resident #27's right ankle. RN A cleaned Resident #27s coccyx wound and applied Triad. RN A failed to clean change gloves and utilize hand hygiene after cleaning Resident #27s coccyx wound.During an interview on 1/13/2026 at 11:08 a.m., RN A stated the infection preventionist was the DON. She stated she was trained on infection control and wound care. She stated her last training was approximately three months ago. She stated she was trained to change her gloves when going from dirty to clean and to use hand hygiene in between. She stated she changed her gloves after removing the dirty dressing but not after cleaning the wound. She stated a potential negative outcome of not changing gloves after cleaning a wound could be spreading infection.During an interview on 1/13/2026 at 12:17 p.m., the DON stated she was the infection preventionist. She stated staff were trained on infection control and wound care. She stated the last training was approximately two months ago for competency checkoffs. She stated she expected staff to utilize glove changes during wound care anytime a wound dressing was removed and when they went from a dirty area to a clean area. She stated infection was a potential negative of not utilizing glove change after going from dirty to clean. She stated compliance was monitored through random observations. She stated she was not aware staff were not changing gloves after cleaning a wound and before applying the clean dressing.During an interview on 1/13/2026 at 12:36 p.m., the ADM stated the infection preventionist was the DON. She stated they had skills competency checkoffs in November 2025 included infection control and wound care. She stated she expected staff to change gloves and use hand hygiene anytime they went from a dirty area to a clean area. She stated the potential negative outcome of not changing gloves during wound care could be spreading infection. She stated the DON conducted random wound care observations due to rounding with the wound care physicians weekly.Record review of facility policy titled Clean Dressing Change, dated 7/2025, revealed, Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Policy Explanation and Compliance Guidelines:9. Loosen the tape and remove the existing dressing. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves.12. Cleanse the wound as ordered. Pat dry with gauze.13. Remove gloves and wash hands.14. Wash hands and put on clean gloves.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 (Resident # 1) residents reviewed for pharmaceutical services. The facility failed to ensure MA A completed the medication administration for Resident #1 according to standard of practice when she placed the medications in Resident #1's mouth during the breakfast meal and left prior to observing that Resident #1 had swallowed the medications. Resident #1's medications were found in a cup beside the resident's breakfast tray by the resident's family member who assisted Resident #1 to finish taking the medications. This failure could place residents at risk of not receiving the full medication dosage or intended therapeutic benefit of ordered medications.Record review of Resident #1's undated face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Alzheimer's Disease (a progressive brain disorder that causes memory loss), coronary artery disease (a condition where the arteries that supply blood to the heart muscle become narrow or blocked), hypertension (high blood pressure), and major depressive disorder (a mental health condition characterized by persistent feelings of sadness, hopelessness and loss of interest or pleasure in activities). Record review of Resident #1's Quarterly MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 02, indicating the resident had severe cognitive impairment. Further review revealed Resident #1 received the following classes of medications: antidepressant (given for depression), anticoagulant (given to prevent blood clots), diuretic (given to treat or prevent fluid buildup in the body), antiplatelet (given to prevent blood clots), and anticonvulsant (given to prevent seizures; may also be given as a treatment for behavioral disturbances in patients with dementia). Record review of Resident #1's comprehensive care plan, date initiated 07/28/2022, revealed Resident #1 had cognitive loss/dementia. Record review of Resident #1's physician's orders dated 10/22/25, the following orders for morning medications:7:00 AM - 10:00 AM - Aspirin [OTC] 81 mg tablet, delayed release; 1 po QD; start date 09/20/20227:00 AM - 10:00 AM - Clopidogrel 75 mg tablet; 1 tablet po QD; start date 07/27/20227:00 AM - 10:00 AM - Divalproex 125 mg delayed release; 1 tablet; oral; start date 07/14/20257:00 AM - 10:00 AM - Guaifenesin [OTC] 400 mg tablet, 1 tablet; oral; start date 10/04/20227:00 AM - 10:00 AM - Lasix (furosemide) 40 mg tablet, 1 tablet; oral; start date 06/17/20247:00 AM - 10:00 AM - Metoprolol succinate tablet extended release 25 mg tablet, 1 tablet po QD; start date 07/08/20247:00 AM - 10:00 AM - Pantoprazole 20 mg delayed release tablet, 1 tablet po Q AM; start date 11/25/20237:00 AM - 10:00 AM - Potassium chloride 20 mEq extended-release tablet, 1 tab; oral; start date 08/12/20237:00 AM - 10:00 AM - Rosuvastatin 5 mg tablet, 1 tablet by mouth; start date 07/27/20227:00 AM - 10:00 AM - Sodium chloride 1 gram tablet, 1 tab po QD; start date 07/27/20227:00 AM - 10:00 AM - Zoloft 50 mg tablet, 1 tablet; oral; start date 07/14/2025 Record review of Resident #1's MAR dated 10/18/25, revealed MA A administered the following morning medications:Aspirin 81 mg tablet, 1 tablet by mouthClopidogrel 75 mg tablet, 1 tablet by mouthDivalproex 125 mg delayed release tablet, 1 tablet by mouthGuaifenesin 400 mg tablet, 1 tablet by mouthLasix 40 mg tablet, 1 tablet by mouthMetoprolol succinate 25 mg extended-release tablet, 1 tablet by mouthPantoprazole 20 mg delayed release tablet, 1 tablet by mouthPotassium chloride 20 mEq extended-release tablet, 1 tablet by mouthRosuvastatin 5 mg tablet, 1 tablet by mouthSodium chloride 1 gram tablet, 1 tablet by mouthZoloft 50 mg tablet, 1 tablet by mouth During an interview on 10/22/25 at 9:53 AM, Family Member stated Resident #1's morning medications were observed in a plastic cup next to Resident #1's tray during breakfast. Family Member stated a couple of the medications appeared to be wet like they had been in [Resident #1's] mouth. Family Member stated Resident #1 took the medications that were in the cup and MA A was made aware that the resident had taken the medications. Family Member stated Resident #1 had a history of refusing medications at times and holding medications in her mouth or spitting them out. Family Member stated they called the facility to report to a nurse that Resident #1's medications were not properly administered. During an interview on 10/22/25 at 2:45 PM, MA A stated she routinely gave scheduled medications to Resident #1. She stated Resident #1 would occasionally refuse to take her medications. MA A stated she had also observed Resident #1 pocket her medications in her mouth on one occasion, meaning she would hold the pills in her cheek rather than swallowing them. MA A stated she recalled giving Resident #1 her medications in the dining room during breakfast. She stated she prepared the medications in an administration cup and wrote Resident #1's initials on the outside of the cup. She stated she put the medications in Resident #1's mouth and gave her a drink of water from a plastic drinking cup. MA A stated she asked Resident #1 if she swallowed the medication and she nodded her head. MA A stated she walked away and threw the initialed medication cup in the trash on the side of her medication cart. She stated as she was leaving the dining room following the breakfast meal, Resident #1's family member stated, She took her medications. MA A stated she was unsure what the family member was referring to at that time. She stated RN C questioned her about administering Resident #1's medications after RN C received a phone call from Resident #1's family member stating a cup with the resident's medications was observed by her plate at breakfast. MA A stated she showed RN C the administration cup with the resident's initials in her trash on her medication cart and told RN C the resident must have spit the medications out after she walked away. MA A stated she had been trained on proper medication administration and had just renewed her certification recently. She stated the steps to properly administer medication were: check your order, make sure who the resident is, check medication, right dosage, check vital signs, then give the medication and stand there to be sure they take it and swallow it before walking away, then document in the MAR. MA A stated she failed to assure Resident #1 swallowed her medication before walking away. She stated she should have asked Resident #1 to open her mouth so she could be sure the medication was swallowed, especially since she refuses and pockets her meds sometimes. MA A stated she was in-serviced on proper medication administration by RN C on the same day the incident occurred. She stated the DON had also re-educated her on proper medication administration over the phone on the same day. MA A stated a potential negative outcome for failure to observe a resident swallow their medications was the resident getting sick from not taking meds, or another resident taking meds that aren't theirs and becoming sick. During an interview on 10/22/25 at 3:04 PM, RN C stated she received a phone call from Resident #1's family member who stated the resident's cup of pills were observed next to Resident #1's breakfast plate and the family member assisted the resident to take the medication. RN C stated she relayed the information to LVN B who was taking care of Resident #1 that day. RN C stated she then called the DON to make her aware of the situation. RN C stated MA A showed her the medication administration cup from the trash can on the medication cart with Resident #1's initials on the cup. RN C stated the proper steps to administer medication were: check order, check correct patient, right med, dose, route, time, then administer the medication and be sure they swallow it and check their mouth. RN C stated if a resident is known to hold medications in their mouth, the person administering the medications should check the resident's mouth and under the tongue thoroughly to be sure the medications were ingested. She stated she had not observed medications being left by the MA's for the resident to take without supervision. RN C stated she re-educated MA A on proper oral medication administration following the incident. During an interview on 10/22/25 at 2:18 PM, LVN B stated the facility MA's were responsible for administering all scheduled medication. LVN B stated if medication needs to be given while a resident is in the dining room, the medication cart is left outside the dining room, and the prepared medications are brought in a medication cup to the resident for administration. LVN B stated she was informed by RN C that Resident #1's family member called the facility and stated the family member had observed Resident #1's medications in a plastic cup sitting beside the resident's breakfast plate. LVN B stated she spoke to MA A who stated she had given Resident #1 her medications and she must have spit them out. LVN B stated the steps to administer a medication to a resident were: first, check the order, check you have the right resident, check vitals, check the right route, give the medication and assure the medication was actually swallowed by checking the resident's mouth, then document what was done. LVN B stated she had not observed an MA leave unsupervised medications for a resident to take. LVN B stated if a resident has a history of pocketing medications in their mouth, the person administering medications should check the resident's mouth, cheeks and under the tongue to assure the medication was swallowed before walking away from the resident. During an interview on 10/22/25 at 3:40 PM, the DON stated RN C called her to report Resident #1's medications were observed by Resident #1's family member in a cup by the resident's breakfast plate. The DON stated she called the facility and spoke to RN C and LVN B regarding Resident #1's morning medications. She stated it was determined that the medications belonged to Resident #1 by the description of the pills by the family member. She stated MA A had already given the other two residents at the table their medications prior to those residents entering the dining room. The DON stated the family member told MA A that Resident #1 took the medications in her cup. She stated she instructed RN C to in-service MA A on assuring all residents swallow oral medications at the time of administration. The DON stated she also spoke to MA A on the phone and re-educated her on proper medication administration and assuring the resident takes the medications that are administered. She stated her expectation of the MA was to assure medications were taken properly by checking the resident's mouth after administration. She stated she had not received any complaints from residents or family members that medications were not being administered properly. The DON stated a potential negative outcome for failure to ensure residents take their medications, would depend on the type of medication - a missed seizure med could result in a resident having seizures or a resident not getting good pain control if a pain med is missed or other residents could take medications that are not ordered for them. During an interview on 10/22/25 at 4:07 PM, the ADM stated she was informed by the DON of an incident with Resident #1's medications being found in a cup beside her breakfast tray by her family member. She stated the DON determined that Resident #1 had been given her medications after initially not ingesting them when MA A administered the medications. She stated her expectation of staff was to administer medications according to facility procedure and to assure all medications were taken at the time of administration. She stated the system for monitoring proper medication administration was through periodic staff competency assessments. Record review of the facility's competency assessment for Administering Oral Medications dated 09/10/25, was signed by MA A and the facility's ADON. Record review of the facility's document titled, Competency Assessment Administering Oral Medications revised October 2010 revealed: A) PurposeThe purpose of this procedure is to provide guidelines for the safe administration of oral medications.E) Steps in the Procedure 9. Prepare the correct dose of medication.10. Confirm the identity of the resident.16. Allow the resident to swallow oral tablets or capsules at his or her comfortable pace.21. Remain with the resident until all medications have been taken.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure adequate supervision of Resident #1 who was newly admitted to the facility on [DATE] and was exhibiting signs of confusion and exit-seeking behavior. Resident #1 then eloped from the facility approximately 27 (twenty-seven) hours later on 07/20/25 between 7:45 PM and 8:00 PM. Staff were unaware of Resident #1's elopement when the facility was notified by a citizen of the community via telephone on 07/20/25 at approximately 8:15 PM that the resident had wandered to a nearby apartment complex and appeared confused. The noncompliance was identified as PNC. The IJ began on 07/20/25 and ended on 07/21/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of harm, serious injury or death.Record review of Resident #1's face sheet, dated 09/02/25 revealed Resident #1 was admitted to the facility on [DATE] with the following diagnoses: dementia (progressive decline in cognitive functions), and anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear and nervousness). Record review of the Assessment for Risk of Elopement, created by LVN C and dated 07/19/25 at 5:09 PM, revealed Resident #1 was not at risk for elopement. Record review of Resident #1's Baseline Care Plan, dated 07/20/25 revealed elopement risk factors would be evaluated to minimize risk of elopement. Record review of Resident #1's Resident Progress Report, created by LVN B on 07/20/25 at 5:47 AM revealed: Resident restless continues to wander in and out of rooms with exit seeking behavior, gave 1 ml lorazepam. Increased supervision and had resident sit with me at the nurse's station. Gave resident a memory board to help keep her busy. Record review of Resident #1's Resident Progress Report, created by LVN B on 07/20/25 at 8:54 PM revealed LVN B received a phone call that the resident was outside at a nearby apartment complex. Resident #1 was observed by LVN B at the apartments next door to the facility sitting down talking to the people. The resident was redirected back to the facility and assessed without noted injury. The hospice agency, Medical Director, and the resident's family member were contacted. No new orders were received. The resident was placed on one-to-one monitoring. Record review of the facility's Form 3613-A (Provider Investigation Report), dated 7/20/25, revealed LVN B was notified via telephone on 07/20/25 at 8:15 PM, of Resident #1's elopement from the facility. A community member called the facility and reported that Resident #1 had been found at the neighboring apartment complex and was confused. LVN B and CNA F went to the apartment complex and assisted Resident #1 back to the facility. The resident was assessed and found to have no injuries and did not require medical treatment. Resident #1 stated she was trying to go home. Resident #1 was placed on one-to-one supervision upon return to the facility and remained on one-to-one supervision until being discharged on 07/21/25 with family. A head count was conducted to account for all residents. Door alarms were checked and found to be functioning properly. Staff in-services were initiated for ANE, elopement, and responding to door alarms. Following the elopement, proper functioning of door alarms continued to be monitored, and elopement assessments and care plans were updated for all residents who were deemed at-risk for elopement. Additionally, a sign was placed at the lobby door directing visitors to notify staff if the door alarm was sounding upon approach. An elopement binder was updated for current at-risk residents and placement at the nurse's station was verified. Record review of Resident #1's Discharge MDS, dated [DATE], revealed:Section C - Cognitive Patterns - BIMS was blank and did not contain a score for Resident #1.Section E - Behavior - revealed the resident exhibited wandering behavior 1 to 3 days. Section GG - Functional Abilities revealed the resident was able to stand from a sitting position with supervision or touching assistance and was able to walk 150 feet independently.Section I - Active Diagnosis - revealed the resident had an anxiety disorder. During an interview on 09/02/25 at 9:15 AM, the DON stated Resident #1 was admitted to the facility on [DATE] around 5:00 PM for a 5-day respite stay. She stated the resident was independently ambulatory upon admission and had a diagnosis of dementia. She stated LVN C admitted Resident #1 then passed care on to LVN B approximately one hour later, due to shift change. The DON stated Resident #1 did not immediately show signs of exit-seeking behavior on the day of admission, but she began to show signs of increased confusion and wandering behavior in the evening shortly after shift change. She stated LVN B implemented interventions for Resident #1's wandering behavior and anxiousness by allowing her to sit at the station with him, provide games for redirection and administer ordered PRN anxiety medication. The DON stated, according to staff, the resident was more content during the day shift on 07/20/25 and wandering and exit-seeking behavior were less pronounced. She stated on the evening shift of 07/20/25 the resident was seen ambulating in the hallways. She stated, according to staff interviews, the front door alarm sounded around 7:45 PM, which was manually silenced by RN A who reported seeing a visitor exiting from the door. She stated RN A believed the door alarm had been set off by the visitor and did not check the exterior of the building to see if a resident had exited. The DON stated another exit door alarm was also sounding around the same time as the front door alarm, which may have been staff taking residents out for the evening smoking break. She stated around 8:15 PM the facility received a call from a community member stating Resident #1 was found at a neighboring apartment complex. LVN B and CNA F went to the apartment complex and redirected Resident #1 back to the facility without incident. The DON stated Resident #1 was assessed and found to have no injuries and was immediately placed on one-to-one supervision. She stated all exit doors were checked and found to be functioning properly. She stated staff in-services for wandering, elopement and responding to door alarms were immediately initiated. The DON stated all staff on duty on 07/20/25 were in-serviced immediately following the incident and other staff were in-serviced upon return to duty on 07/21/25, before being allowed to start their shift. She stated on 07/21/25, the ADM and nursing administration began conducting random drills for staff response time to door alarms and doors continued to be monitored for proper functioning. She stated Resident #1 remained on one-to-one supervision until discharge on [DATE]. During an interview on 09/02/25 at 2:22 PM, LVN B stated he worked the 6 PM-6 AM shift on the evening Resident #1 was admitted . He stated the resident was admitted by LVN C prior to the beginning of his shift and he observed the resident in her room after receiving report at shift change. He stated LVN C did not report any observations of Resident #1 wandering or demonstrating exit-seeking behavior on her shift. LVN B stated Resident #1 became more active and began to demonstrate wandering behavior shortly after shift change. He stated Resident #1 was confused and would answer questions but her answers did not make sense. He stated Resident #1 told him someone was coming to get her and stated, I'm on my way out. He stated he observed the resident's belongings were packed up in the corner of her room. LVN B stated he allowed Resident #1 to ambulate in the hallways with him while doing his medication pass and rounds. He stated she followed along with him in the hallways and seemed like she didn't want to be alone. He stated Resident #1 set off the door alarm for Hall 500 while ambulating with him and he redirected her from the area of the door. LVN B stated Resident #1 sat with him at the nurse's station and he provided her with a memory game to play. He stated he administered Resident #1's PRN anti-anxiety medication, per orders. He stated Resident #1 went to bed around 9:00 PM and slept through the night without incident and he gave report to the oncoming nurse (LVN C) around 6:00 AM. He stated he reported to LVN C that Resident #1 demonstrated wandering and exit-seeking behaviors during his shift. LVN B stated he returned to duty for the 6:00 PM - 6:00 AM shift on 07/20/25 and received report from LVN C who stated Resident #1 had no issues with wandering behavior throughout the day shift. LVN C stated Resident #1 had spent the day doing activities with other residents and had not required PRN medication for anxiety. LVN B stated he observed Resident #1 in areas with other residents and interacting with others during the first part of the shift and he observed her sitting in the tv area when he was on Hall 600 which he estimated was close to 8:00 PM. He stated he recalled a door alarm going off but did not see staff taking residents out for their smoke break. He stated he saw RN A coming from the lobby area. RN A stated the alarm was going off due to a family member exiting the facility. LVN B stated around 8:15 PM he received a call from a community member stating a resident with dementia was found at the apartment complex next to the facility. He stated he and CNA F went to the apartment complex to bring the resident back to the facility. LVN B stated Resident #1 was observed sitting on a bench with several people around. He stated Resident #1 did not appear to be in any distress. He stated Resident #1 was redirected to the facility without incident and he called the ADON on the way back to the facility to notify her of the resident's elopement. LVN B stated he assessed Resident #1 upon re-entry to facility and no injuries were noted. He stated notifications were made to Resident #1's family member as well as the nurse practitioner and no new orders were received. He stated one-to-one supervision was immediately implemented for Resident #1 and no further incidents occurred during his shift. LVN B stated he had been trained on wandering and exit-seeking behavior prior to Resident #1's elopement and was in-serviced again immediately following the elopement. He stated he did not see the admission Elopement Risk Assessment, but he implemented various interventions based on Resident #1's wandering behavior. LVN B stated he did not initially notify nursing administration or the physician on 07/19/25 because Resident #1 was easily redirected by ambulating with him in the facility and engaging in activities at the station. He further stated he did not need to contact the physician since Resident #1 was admitted with a PRN order for anti-anxiety medication which was effective after being administered. During an interview on 09/02/25 at 3:13 PM, RN A stated she worked the 6 AM - 6 PM shift and worked night shift PRN. She stated she worked 6 AM - 10 PM on 07/20/25 but was not assigned to Resident #1. She stated Resident #1 was independently ambulatory and, during her shift, she observed the resident looking at a magazine, walking from her room to the nurse's station and eating two meals in the dining room. She stated Resident #1 was confused and stated she had been at church and asked if it was time to leave. RN A stated she did not observe Resident #1 exhibiting exit-seeking behavior during her shift on 07/20/25. She stated around 8:00 PM she was finishing medication pass and heard the front door alarm sounding. She stated she walked from Hall 100 to the front lobby and saw a family member exiting the front door using a walker. She stated the family member had set the alarm off in the past due to being slower to exit with the walker. RN A stated she silenced the alarm as the family member exited. She stated she did not do a perimeter check because she thought the alarm was sounding due to the family member's exit. RN A stated around the same time another door alarm was sounding and another staff member responded to the door alarm, but she was unsure which door it was, and which staff responded. RN A stated it was unclear whether Resident #1 exited from the front door or another exterior door. She stated interventions for a resident would be implemented based on exit-seeking and wandering behavior exhibited by the resident. She stated she had been trained on elopement, identifying wandering and exit-seeking behaviors, and checking doors when alarms sounded prior to Resident #1's elopement and was in-serviced on ANE, elopement/wandering and door alarms on 07/20/25, following the elopement. During an interview on 09/02/25 at 3:35 PM, CNA F stated she worked the 6 PM - 6 AM shift on the evening Resident #1 eloped. She stated she worked on a different hall but had observed Resident #1 walking in the hallways without an assistive device. She stated she observed the resident near the nurse's station and observed her interacting with others. CNA F stated Resident #1 was a little confused and she heard the resident say someone was coming to get her. CNA F stated she did not see Resident #1 wandering or exit-seeking prior to her exit from the nursing facility. She stated after the facility was notified that Resident #1 had eloped, she went with LVN B to pick the resident up. She stated Resident #1 was observed outside sitting in a chair talking to another lady. She stated the resident did not have visible injuries or appear to be in distress. CNA F stated LVN B assessed Resident #1 upon return to the facility and one-to-one supervision was implemented for the remainder of the shift. CNA F stated the resident sat at the nurse's station and eventually went to bed and slept through the night. She stated she had been trained on elopement by her charge nurse. She stated since the incident, she had been in-serviced by the DON on ANE, wandering, door alarms and to alert a nurse if a door alarm sounds, so the nurse could account for all residents. During an interview on 09/02/25 at 4:25 PM, CNA E stated she worked 6 PM - 6AM on the evening Resident #1 eloped. She stated she had observed Resident #1 the previous night (07/19/25) ambulating in the hallway with LVN B. She stated Resident #1 pushed on the door on Hall 500 and set off the alarm and LVN B redirected her. She stated she observed Resident #1 sitting at the nurse's station with LVN B. CNA E stated during her shift on 07/20/25 she observed Resident #1 talking to other residents at the nurse's station. CNA E stated she took the smoking residents outside, which sounded the door alarm. CNA E stated she did not hear another door alarm sound during her shift. She stated when she re-entered the building, she was told Resident #1 had left the facility. She stated she was trained on wandering and elopement prior to the incident and was in-serviced on ANE, wandering, elopement and door alarms immediately after the elopement incident. CNA E stated she participated in the one-to-one supervision of Resident #1 on 07/20/25, following the elopement and stated the resident was in bed asleep most of the remainder of the night. During an interview on 09/03/25 at 9:42 AM, LVN C stated she was on duty on 07/19/25 and admitted Resident #1 around 5:00 PM. She stated she completed most of the admission paperwork and the resident's family was present for admission. She stated Resident #1 answered admission questions and did not appear to be confused at the time of admission. She stated the initial Elopement Risk Assessment was negative and Resident #1 did not exhibit wandering or exit seeking behavior. LVN C stated she passed care on to LVN B about an hour after the resident's admission, due to shift change. LVN C stated she returned to duty on 07/20/25 and observed Resident #1 to be more active but still did not exhibit exit-seeking behavior on her shift. She stated she did not update the Elopement Risk Assessment for Resident #1 and would not have implemented interventions based on lack of observation of exit-seeking behavior by the resident. LVN C stated she had been trained on elopement and door alarms prior to Resident #1 exiting the facility and received in-services for ANE, wandering and elopement and door alarms upon return to duty on 07/21/25. During a follow up interview on 09/03/25 at 3:41 PM, the DON stated the Elopement Risk Assessment was a tool used to help determine whether a resident was at-risk for elopement and was included in the facility admission packet. She stated an assessment alone did not automatically determine whether a resident would require interventions and that a resident's behavior should always be considered when determining a plan of care. The DON stated her expectation of staff if a resident was determined to be at-risk for elopement would be to increase supervision of the resident, implement interventions for wandering behavior, and notify administration, family, and the physician. She stated she and the weekend RN were responsible to assure residents were assessed and interventions were made for any resident deemed at-risk for elopement. The DON stated a potential negative outcome for failure to provide adequate supervision for residents at-risk of elopement would be the resident exiting the facility and potentially being harmed. The facility implemented the following interventions from 07/20/25 - 07/21/25: Record review of the Assessment for Risk of Elopement, created by LVN B and dated 07/20/25 at 10:08 PM, revealed Resident #1 was at risk for elopement and required frequent monitoring. Record review of Resident #1's Comprehensive Care Plan, dated 07/20/25, revealed: Problem: I wander due to my diagnosis of dementia. I am an elopement risk. Goal: I will not elope from the center in the next 90 days. Approach: Assure that I have proper fitting and appropriate foot attire. If I begin to wander, please provide me assistance to where I need to be going. Staff will monitor me and report changes in exit seeking behaviors to the facility Administrator, Director of Nursing, Physician, and guardian/responsible party. Record review of documentation of one-to-one monitoring for Resident #1 from 07/20/25 - 07/21/25 revealed staff signed for the whereabouts of Resident #1 every 15 minutes beginning on 07/20/25 at 8:15 PM through 07/21/25 at approximately 4:00 PM, when Resident #1 was discharged from the facility. Record review of the 07/20/25 facility in-service training, which was conducted by the DON and signed by fifty-eight staff members, for Checking Door Alarms revealed: Always respond immediately to door alarms. Never assume someone else checked - personally verify and ensure no resident is outside Record review of the 07/20/25 facility in-service training, which was conducted by the DON and signed by sixty-two staff members, for Elopement revealed: Elopement is when a resident who is cognitively impaired leaves the facility without staff knowledge or permission, putting them at serious risk of harm. See attached for policy. The policies attached to the in-service were titled Wandering and Elopement and Emergency Procedure - Missing Resident. Record review of the 07/21/25 facility in-service training, which was conducted by the DON and signed by fifty-six staff members, for Alarm door ring revealed: If a door alarm sounds and no one is visibly at the door, staff must immediately go outside to ensure no resident has exited. If no one is found outside, a full head count of all residents must be conducted without delay by a nurse. If someone is present at the door, staff should ask whether the alarm was already ringing when they arrived or if it began after they reached the door. Record review of the 07/21/25 facility in-service training, which was conducted by the ADM and signed by fifty-nine staff members, for Abuse and Neglect Policy & Resident to Resident Policy revealed: You must notify the abuse prevention coordinator immediately if there is any type of abuse suspected or alleged. The ADM was listed as the abuse prevention coordinator and contact information was provided. The policy attached to the in-service was titled Abuse, Neglect, and Exploitation. Record review of the facility's documents titled, Door Alarm Check Q Shift, revealed daily checks of door alarms on each shift for the months of July 2025 and August 2025. Record review of the facility's documented record for proper functioning of facility exit doors revealed doors were checked on random dates between 07/07/25 - 08/25/25 and all doors were noted to pass. During an observation on 09/02/25 between 1:01 PM - 1:04 PM, the DON tested staff response to the front door alarm and Hall 200 door alarm sounding. Surveyor observed several staff members respond to both doors within 30 seconds of alarm sounding and check to see if any residents were in the area near the door. During an interview on 09/02/25 at 1:02 PM, the Housekeeping Director- day shift, stated she had been in-serviced on 07/21/25 regarding ANE, elopement and wandering behavior, responding immediately to door alarms, checking the exterior perimeter for a residents' exit and notifying a charge nurse immediately so the nurse could conduct a head count to assure all residents were safe. During an interview on 09/02/25 at 1:06 PM, the SW stated she had been in-serviced on 07/21/25 regarding ANE, elopement and wandering behavior, responding immediately to door alarms, checking the exterior perimeter for a residents' exit and notifying a charge nurse immediately so the nurse could conduct a head count to assure all residents were safe. During an interview on 09/02/25 at 2:22 PM, LVN B - night shift, stated he had been in-serviced on 07/20/25 regarding ANE, elopement and wandering behavior, responding immediately to door alarms, checking the exterior perimeter for a residents' exit and conducting a head count to ensure all residents were accounted for if a door alarm sounded. During an interview on 09/02/25 at 3:13 PM, RN A - day shift, stated she had been in-serviced on 07/20/25 regarding ANE, elopement and wandering behavior, responding immediately to door alarms, checking the exterior perimeter for a residents' exit and conducting a head count to ensure all residents were accounted for if a door alarm sounded. During an interview on 09/02/25 at 3:35 PM, CNA F- night shift, stated she had been in-serviced on 07/20/25 regarding ANE, elopement and wandering behavior, responding immediately to door alarms, checking the exterior perimeter for a residents' exit and notifying a charge nurse immediately so the nurse could conduct a head count to assure all residents were safe. During an interview on 09/02/25 at 4:25 PM, CNA E- night shift, stated she had been in-serviced on 07/20/25 regarding ANE, elopement and wandering behavior, responding immediately to door alarms, checking the exterior perimeter for a residents' exit and notifying a charge nurse immediately so the nurse could conduct a head count to assure all residents were safe. During an interview on 09/03/25 at 9:42 AM, LVN C - day shift, stated she had been in-serviced on 07/21/25 regarding ANE, elopement and wandering behavior, responding immediately to door alarms, checking the exterior perimeter for a residents' exit and conducting a head count to ensure all residents were accounted for if a door alarm sounded. During interviews conducted on 09/03/25 between 11:45 AM - 3:00 PM, the following staff members - (PTA I, PTA J, PT, MA H, ADON, and CNA G) reported they had been in-serviced on 07/20/25 and 07/21/25 regarding ANE, elopement and wandering behavior, responding immediately to door alarms, checking the exterior perimeter for a residents' exit and notifying a charge nurse immediately so the nurse could conduct a head count to assure all residents were safe. Record review of the facility's policy titled Wandering and Elopements, Revised April 2025 revealed: Policy StatementThe facility will ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care.Policy Interpretation and Implementation1. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wanderinga. Residents will be assessed by the IDT for risk of elopement and unsafe wandering on admission, readmission, quarterly, and/or with a change of condition (e.g., increased agitation, changes in mobility, wandering).c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, and minimize risk associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements- . The noncompliance was identified as PNC. The IJ began on 07/20/25 and ended on 07/21/25. The facility had corrected the noncompliance before the survey began.

Based on observations, interviews, and record review, the facility failed to treat residents 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 for 2 of 8 residents (Resident #2 and #3) reviewed for respect. CNA D failed to treat residents with respect and dignity when she told Resident #2 and Resident #3, she did not have to take them out to smoke, on an unknown date in July 2025. These failures could place the residents at risk of feeling disrespected.Findings included: Record review of Resident #2's undated face sheet revealed a [AGE] year-old male admitted on [DATE]. Resident #2 had a medical history of COPD (a group of lung diseases that cause airflow obstruction and breathing difficulties), alcohol induce dementia (a type of alcohol-related brain damage), and muscle weakness. Record review of Resident #2's quarterly MDS dated [DATE], Section C-Cognitive Patterns revealed a BIMS score of 06, which indicated Resident #2 had severe cognitive deficit. Record review of Resident #3's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #3 had a medical history of schizophrenia (a serious mental health condition that affects how people think, feel and behave), HIV (a virus that attacks the body's immune system), insomnia (persistent problems falling and staying asleep), and alcoholic cirrhosis of liver (a chronic liver disease caused by excessive alcohol consumption over many years). Record review of Resident #3's admission MDS dated [DATE], Section C-Cognitive Patterns revealed a BIMS score of 09, which indicated Resident #3 had moderate cognitive deficit. Record review of facility document titled Grievance Decision Report, dated 7/30/2025 revealed: .Detail of Complaint/Grievance: Resident showed [ADM] + [and] DON video of employee having an interaction with another resident and threatened to take away his smoking privilege. Date complaint/grievance occurred: unknown.Summary statement of grievance: Resident [Resident #3] reported concerns of how an employee spoke to him and another resident. Steps taken to investigate the grievance: other resident [Resident #2] interviewed that had the interaction with the employee, resident [Resident #2] didn't report concerns. Summary of pertinent findings of conclusions: prior to employee [CNA D] working another shift, employee will have one on one conversation on expectations. During an interview on 9/2/2025 at 12:23pm with Resident #3, he stated CNA D had been telling another resident that she was not going to take him to smoke. He stated he did not remember what resident it was but that she did not have the right to refuse to take anyone out to smoke. He stated he did record her because he felt that she was violating their rights to smoke. Resident #3 stated CNA D did take them to smoke a few moments later but that he felt she did not treat them with respect and was rude. Resident #3 was unable to recall the date of the incident but stated he did do a grievance report a few days later.During an interview on 9/2/2025 at 2:23pm with LVN B, he stated he does not remember there being any incidents between CNA D, Resident #3 or Resident #2. He stated there was only one night when CNA D told him Resident #2 was cussing and yelling at her because they were running behind on their smoke break and CNA D had told Resident #2 to give her a minute and she would take them out. LVN B stated CNA D did not mention denying the residents their smoke break. He stated there were no reports made to him by any residents. LVN B stated if he had to guess which resident was cussing at CNA D, he would guess [Resident #2] because he can be aggressive if staff are late with smoke breaks. During an interview on 9/2/2025 at 5:02pm with CNA D, she stated she did not recall the date but that she remembers the night shift being busy and running behind. She stated they were running a little behind on going to smoke and had told the smoking residents they would be late taking them to smoke. She stated Resident #2 was mumbling something, and she told him she would not take him to smoke and that they are not always going to be able to take them at the same time. CNA D stated she did ask Resident #3 if he was recording her, and he stated yes. She stated she did take the residents out to smoke within a few seconds of saying she would not. CNA D stated her behavior was inappropriate and she had just been irritated from being behind on schedule. She stated she understood how she spoke to the residents was not how they were trained and that she had been in serviced on resident rights and customer service. She stated she does have a strong voice, and it is often mistaken for yelling, even when she is not. She stated all residents had a right to be treated with respect and she felt she did not treat the residents with respect when she spoke to them in that manner. She stated she will not do that again and will treat all residents with respect. During an interview on 9/3/2025 at 9:30AM with Resident #2, he stated he did not remember the time or date of that incident. He stated he does not remember what started it or why she was telling him he couldn't go smoke. He stated he did not remember how it made him feel but he guessed not good. He stated he felt like he was not treated with respect. He stated he had been a fire fighter and an officer for many years and knew he had rights. He stated he felt safe at the facility and did not have any ongoing concerns with staff members or with his care. He stated that incident had passed, and it was over with. During an observation and review of a 36 second video provided by the ADM on 9/3/2025 at 10:32AM, the undated video revealed CNA D being recorded by Resident #3. The video revealed CNA D standing in front of Resident #3 but looking in a different direction. CNA D stated No you're not to a resident not shown in the video. CNA D turned to look at Resident #3 when he spoke to her. Resident #3 stated You can't take his privilege ma'am. CNA D replied, Yes I can, are you recording me? Resident #3 replied Mhm [yes]. CNA D replied, Let me see. CNA D did not reach for the phone and did not yell at Resident #3. CNA D's tone of voice was stern and argumentative. Resident #3 replied I don't have to let you see; this is my phone. CNA D stated, And I don't have to let y'all [you all] go smoke [LVN B]!. CNA D did not yell at residents but did yell out for LVN B. CNA D walked away from Resident #3 and leaned against the hallway wall after calling for LVN B. Resident #3 stated Do what you want to do ma'am. CNA D was seen leaning against the wall with bag on her shoulder. After a few seconds CNA D walked back down the hall shaking her head and stated, that's alright, I'll talk to administration about it.y'all should be glad someone is taking y'all. CNA D walked towards smoking door exit, and door is heard opening. Resident #3 followed a few seconds later, video ended. During an interview on 9/3/2025 at 2:39pm with the DON, she stated she was not sure what date the interaction had occurred, but they had received a grievance from Resident #3 on 7/30/2025. She stated from her understanding, smoke break had run a little behind on schedule one night. She stated Resident #2 got defensive and was cussing at the staff member. She stated the staff member told him she didn't have to take him out to smoke and that's when the other resident started recording. The DON stated Resident #3 told CNA D that she could not take away his [Resident #2's] smoke break away and she [CNA D] said yea I can. The DON stated she did feel CNA D violated the residents right for respect and she did not have the authority to refuse to take any resident out to smoke. She stated CNA D did take the residents out to smoke. She stated CNA D was in-serviced on customer service training and educated on not speaking to residents rudely. She stated CNA D was educated that she can not deny or revoke residents right to smoke and that if smoke break is going to run late, to let the ADON, or DON know, and they can notify the residents in a timely manner. She stated the potential negative outcome of residents not being treated with respect could be the residents having emotional distress and fearful of not being able to do things freely in the facility. Record review of facility document titled Employee Corrective Action form dated 8/7/2025 revealed; Type of action taken: Final WarningState subject of code of conduct rule violated: Conduct, attitude and behavior.Incident: A resident presented to both the DON and ADM that [CNA D] engaged in an unprofessional verbal exchange with a resident. In the exchange [CNA D] is speaking inappropriately to the resident and implying that smoking privileges could be taken away.Follow up review date: 9/7/2025.Consequences: Could lead to further disciplinary action up to or include termination. Signed by CNA D, DON and ADM on 8/7/2025.Record review of facility policy titled Conduct, attitude and behavior last revised December 2019, revealed; .Employees must maintain good attitude toward his/her job positions, co-workers, residents and visitors. All employees will treat residents, visitors and co-workers with respect kindness and dignity.6. Examples of conduct and behavior that are considered inappropriate and are therefore prohibited by this policy include, but are not limited to the following: a. Failure to treat all residents, visitors and fellow employees with kindness respect and dignity.Record review of facility policy titled Resident Rights implemented 7/2025 revealed; .Respect and Dignity: The resident has the right to be treated with respect and dignity.

Based on interviews and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promoted the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 1 of 7 (Resident #1) residents reviewed for resident rights. CNA B failed to allow Resident #1 to call her Family Member when Resident #1 requested to make that call at approximately 2:30 AM on 01/24/25. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth. Findings included: Record review of Resident #1's undated face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE]. Resident #1 had a medical history of type 2 Diabetes Mellitus (inability of the body to use insulin properly), altered mental status (change in a person's awareness and alertness), major depressive disorder (feelings of sadness), urinary tract infection (bacteria in the urinary tract), anxiety disorder (intense, excessive, persistent worry and fear), restlessness and agitation (feeling uneasy, anxious), insomnia (problems falling or staying asleep), cognitive communication deficit (communication difficultly caused by cognitive impairment) Record review of Resident #1's MDS dated [DATE] revealed Section C- Cognitive patterns a BIMS score of 13 which indicated Resident #1 was cognitively intact. Section D - Mood: B. Feeling down, depressed, or hopeless - yes, 7-11 days. D. Feeling tired or little energy - yes, 7-11 days. Section F - daily preferences - F. how important is it to you to have your family or a close friend involved in discussions about your care? 1-Very important Record review of Resident #1's comprehensive care plan dated 12/05/25 revised on 01/24/25, revealed the resident has history of verbal outbursts and physical aggression when getting care done. Goal: Resident #1 will demonstrate a reduction in aggressive behaviors during care. Approach: Staff will maintain a calm, non-threatening presence. Talk the resident through the whole care process. Psychosocial well-being, Goal: Resident #1 will express/exhibit satisfaction. Approach: Allow to express feelings, keep topics of conversation light and cheerful, listen carefully and be non-judgmental. Mood state: Resident #1 has history of depression and anxiety. Goal: Resident #1 will express/exhibit satisfaction. Approach: Be reassuring and listen to concerns. Record review of Resident #1's psychological evaluation visit note dated 01/03/25, revealed Resident #1 was seen for adjustment difficulty, anxiety, depression/sadness, long-term memory problems, short-term memory problems and sleep disturbance. Resident #1 reported she was very nervous and anxious all the time, and nothing helped to calm her nervous. Resident #1 reported she felt on edge, and highly irritable, she only slept about three hours a night. Resident #1 contributed her uncontrolled anxiety with separation from her son and home. Record review of written statement dated 01/24/25 from CNA B, revealed Resident #1 was screaming and asking for her Family Member. I stated that it was 2:30 AM and that Family Member was sleeping. I reassured Resident #1 that Family Member would be back as soon as Family Member woke up. During an interview on 2/4/2025 at 3:15 PM with Resident #1, she was unable to answer any questions regarding the events from the night of 01/24/25. During an interview on 02/05/25 at 12:26 PM with the ADM, she stated Resident #1 had the right to call Family Member at 2:00 AM and CNA B should have let Resident #1 call her Family Member. During an interview on 02/05/25 at 2:50 PM with Family Member, he stated if Resident #1 wanted to call him at 2:00 AM, 3:00 AM, 4:00 AM, he would be fine with that, he wanted the facility to let her call him at any time. He stated Resident #1 could not recall the incident however thought if she could, it would have bothered her that CNA B did not let her call him. He stated that Resident #1 usually wanted to call him because she was afraid when away from him and needed reassurance from him. During an interview on 02/05/25 at 3:50 PM with CNA B, she stated on 01/24/25 around 2:00 AM she was doing her rounds and heard Resident # 1 yelling out. She stated she entered Resident #1 room and Resident #1 yelled she wanted to call (Family Member) . She stated she told Resident #1 no because (Family Member) is at home and asleep. CNA B stated Family Member had never told her not to call in the night, and in the past, they had called Family Member when Resident #1 was upset or refusing care. During an interview on 02/05/25 at 5:24 PM with NP, she stated Resident #1 should have been allowed to call Family Member. Family Member was awake and there for Resident #1. She stated the situation could have been handled differently, and not allowing Resident #1 to call her Family Member could have increased her anxiety. During an interview on 02/05/25 at 6:21 PM with LVN E, she stated she was in the room, providing care for Resident #1 with CNA D . She stated Resident #1 yells out during care because she is afraid, she will fall. She stated CNA B entered the room and started to talk to Resident #1. She stated Resident #1 wanted to call her Family Member, and CNA B stated not at this hour it's 2:00 in the morning. Record review of a progress notes dated 01/24/25 revealed LSBW observed Resident #1 in her room. She was resting peacefully with no signs of distress. Family Member was also in room. Family Member advised that Resident #1 reported that she had no recollection of any problems or concerns during the previous night. Family Member reported that Resident #1 had been refusing medication and that she resists care and at times becomes combative during care, especially in the mornings. Family Member stated Resident #1 is hard of hearing and tonal adjustment is required in order for Resident #1 to hear. Record review of the facility's policy titled; Resident Rights dated 2001 revised date February 2021 Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to 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. aa. visit and be visited by others from outside the facility. cc. access to a telephone, mail, email.

Based on interview and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 7 residents (Resident #1) reviewed for hygiene, in that. 1. The facility failed to provide incontinence care on three separate opportunities for Resident #1 on 1/26/2025. These failures could place residents at risk for skin breakdown and infections. Findings include: Record Review of Resident #1's undated face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE]. Resident #1 had a medical history of nondisplaced fracture of third cervical vertebra (fracture of bones in the neck), anxiety disorder, major depressive disorder, restlessness and agitation, type 2 diabetes, hypertension (high blood pressure) and chronic pain. Record Review of Resident #1's MDS dated [DATE] revealed Section C- Cognitive patterns a BIMS score of 13 which indicated Resident #1 was cognitively intact. Section GG- Functional Abilities revealed resident was Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity, for personal hygiene, toileting hygiene and toilet transfer. Section GG- Functional Abilities revealed Resident #1 required Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort for rolling left to right, sit to lying and lying to sitting on side of bed. Record Review of Resident #1's care plan revealed a problem of Functional urinary incontinence R/T Dementia created on 1/28/2025. Resident #1's care plan revealed an approach of apply moisture barrier to skin and Provide incontinence care after each incontinent episode. Record Review of Resident #1's grievance form dated 01/27/2025 revealed: Person making complaint and relationship to resident: Resident #1's family member. Detail of Complaint/Grievance: Stated Resident #1 sat in poop for about two hours. Date Complaint/Grievance occurred: 01/26/2025. What shift did the complaint/grievance occur? 3-11pm . .Summary statement of grievance: Resident #1's family member was disappointed in call light response time and stated Resident #1 needed to go to the restroom and had BM (bowel movement) on her for about 2 hours . Summary of pertinent findings or conclusions: Resident #1 pushed the call light three times before Resident #1's needs were met . .Decision: Grievance was confirmed: In service conducted with staff by ADM and DON over call light response time, not turning off call light until service is completed. During an interview with Resident #1's family member on 2/4/2025 at 11:21 AM, he stated the other day, he had called to have Resident# 1 go to the bathroom and the CNA stated she would be right back and turned off the call light. He stated about 15 minutes later he called again, and the CNA stated they were pretty busy, but she would try to find somebody to help her. He stated she did eventually come back but he was not sure how long it had been. He stated the first time he called Resident #1 was not wet and did not have a bowel movement. He stated after that, she was wet and did have a bowel movement and at that point she needed to be changed. During a second interview with Resident #1's family member on 2/5/2025 at 2:50pm he stated he remembers calling the first time around 7pm, it may have been 6:45pm, and the CNA did not come back. He stated she came into the room said, I'll be right back and turned off the call light. He stated he hit the call light again, and she came back and said, I'm going to turn off the call light and be back in a minute. He stated it took her longer to come back after the second time he pushed the call light button. He stated he rang it a third time and she was already on her way back with a second person and the CNA had stated they were pretty busy. He stated they changed her around 8:45pm- 8:50pm. He stated that day Resident #1 was telling him she needed to use the bathroom. Resident #1's family member stated Resident #1 does not remember how she felt but he believes she would have been upset because she does not like to sit in a dirty brief. He stated he felt that this was neglect. He stated he did not remember the CNA's name and did not recall the exact date. During an interview with Resident #1 on 2/4/2025 at 3:15pm, Resident #1 was unable to answer any questions regarding the events from night 1/26/2025. During an interview with the ADM on 2/5/2025 at 12:28pm, she stated Resident #1's call light was pushed by the son. The ADM stated, CNA A had stated she was getting her rounds together and she would try to find a second person. The ADM stated she was told that he called again and at that time, the CNA's were under the impression that she had not gone yet, and CNA A was trying to find someone. CNA A was then pulled by the smoking residents to be taken outside to smoke. She stated, then CNA C told CNA A that Resident #1 had a bowel movement and when CNA A came back from smoking, they went to change her. The ADM stated staff were not trained to prioritize resident smoke breaks over providing resident care. She stated she expected the CNA's to find assistance in a timely manner. She stated when she spoke to CNA A, she said she was doing the best she could, and CNA A apologized several times and stated every resident was just as important. The ADM stated there had been three opportunities for Resident #1's needs to be met. The ADM stated they did in-services on call lights and abuse and neglect on 1/27/2025. During an interview with FNP on 2/5/2025 at 5:24pm, she stated she expected the staff at the facility to provide resident care immediately. She stated she was aware it was not always possible to attend to residents immediately but being left in a dirty brief was unacceptable. She stated residents being left in a dirty brief could increase the risk of infection or skin breakdown. During an interview with CNA C on 2/5/2025 at 7:49 pm, she stated she was working on 1/26/2025. She stated she was working with three other CNA's including CNA A. CNA C stated she had been working 100 hall that night and saw the call light going off in 200 hall. She stated CNA A asked if CNA C could assist her in changing Resident #1. CNA C stated she was unable to at that moment because she had another resident, she was providing care for. She stated she did see the call light go off again for hall 200 and about 30 minutes later she saw it go off again. She stated she went to answer the call light and Resident #1's family member stated, she needs to be changed. CNA C stated she told him they would come change Resident #1, but they were very busy. She stated CNA A was assigned to do the 8:30pm smoke break, and CNA A did take the residents out to smoke. She stated around the time of the smoke break, she became available to assist CNA A with her residents. CNA C stated her, and CNA A went into the room to change Resident #1 and Resident #1 was happy and Resident #1's family member was okay. CNA C stated they did apologize and Resident #1's brief was barely dirty and wet. CNA C stated CNA A's Hall is very heavy, and the other CNAs don't always offer to help. CNA C stated everyone was busy that night with call lights and resident care. CNA C stated she does not believe Resident #1 can tell when she has to go to the bathroom. She sated stated there have been times when Resident #1's family member will state Resident #1 needs to go to the bathroom and when they go in, Resident #1 will ask What are you doing? I don't need to go to the bathroom. CNA C stated Resident #1 does not use the bedpan or the bedside commode because she does not always know when she has to go. CNA C stated resident was incontinent and wears briefs. CNA C stated she has been trained on abuse and neglect and did not feel that CNA A's actions were neglectful. Record Review of document titled Provider Investigation Report dated 1/31/2025 revealed the following statement by CNA A, CNA C and LVN F: Interviewee's Name: CNA A . .2. Please explain fully what you know of the incident: Resident #1's family member stated that Resident #1 needed to go to the restroom. I informed him I had to wait for a 2nd person. Call light went off again and Resident #1 was saying she needed to go to restroom. CNA A stated the smokers then wanted to be taken out. When CNA A came inside, CNA C stated Resident #1 had a BM. We then changed her. 3.About what time did it happen? Around 7ish .5. Do you have any knowledge about possible causes of the incident? It was a cluster of events. Interviewee's Name: CNA C . .2. Please explain fully what you know of the incident: I was working my hall when I answered Resident #1's call light since CNA A was with the smokers. Resident #1's family member stated Resident #1 had a BM. When CNA A came back inside and I saw her, I asked her if she needed help with Resident #1. We then change her. The BM was fresh. 3.About what time did it happen? during 1st rounds. .5. Do you have any knowledge about possible causes of the incident? We are all busy during shift changes and getting residents ready for bed and changed. We did the best we could. Interviewee's Name: LVN F . .2. Please explain fully what you know of the incident: When I was doing my PM med pass, I went into Resident #1's room and did my assessment with her. She didn't voice any concerns. Call light was not on .Resident #1's family member stated Resident #1 had BM and needed to be changed .LVN F stated the aid is in the next room and if Resident #1's family member would like the door left open or closed he stated closed, and I told CNA A. 3.About what time did it happen? Around 8 pm Record review of facility document titled Topic: Call Light response time/Grievances/Abuse Instructor: ADM/DON, Date Inservice initiated: 1/27/2025 revealed: Call light response time. Anyone is able to answer a call light, no one should walk past a call light going off. If you go into a room and are unable to provide the service, you need to make sure the leave the call light on. Do not turn off the call light if the resident still needs help. Record review of facility policy titled Answering the Call Light last revised on March 2021, revealed: Purpose The purpose of this procedure is to ensure timely responses to the resident's requests and needs. .Steps in the Procedure . 2. a. If the resident needs assistance, indicate the approximate time it will take for you to respond. b. If the resident's request requires another staff member, notify the individual. c. If the resident's request is something you can fulfill, complete the task within five minutes if possible. d. If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance.

Based on interviews and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 10 (4/13, 4/14, 4/28, 5/18, 5/19, 5/26, 6/15, 6/16, 6/23, and 6/29/2024) of 91 days reviewed for RN coverage. The facility failed to maintain RN coverage of eight hours a day for 10 days 4/13, 4/14, 4/28, 5/18, 5/19, 5/26, 6/15, 6/16, 6/23, and 6/29/2024). This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care. Findings included: Record review of the CMS report PBJ Staffing Data Report dated 10/23/24 reflected no RN hours for 4/13, 4/14, 4/28, 5/18, 5/19, 5/26, 6/15, 6/16, 6/23, and 6/29/2024. Record review of the facility''s employee survey roster undated reflected there were seven RNs employed at the facility. Record review of Schedule Sheet dated April 2024 reflected RN A was scheduled to work on (4/13, 4/14, and 4/28/2024). Record review of Schedule Sheet dated May 2024 reflected RN A was scheduled to work on (5/18, 5/19, and 5/26/2024). Record review of Schedule Sheet dated June 2024 reflected RN A was scheduled to work on (6/15, 6/16, 6/23, and 6/29/2024). During an interview on 10/29/24 at 01:00 PM with HR, she stated the previous DON did not clock in or out because she was salary. She stated she was not sure how her time was reported. She stated corporate submits time to CMS for the PBJ but she was not sure how it was done or submits it. During an interview on 10/29/24 at 02:00 PM, the DON stated the previous DON was scheduled to work 4/13, 4/14, 4/28, 5/18, 5/19, 5/26, 6/15, 6/16, 6/23, and 6/29/2024. She stated she was not sure why her hours were not reported. She stated there had been several turnovers in staff at the corporate level and someone just dropped the ball. She stated the ADON and DON were responsible for scheduling the RN coverage. She stated the potential negative outcome for not having an RN eight hours a day could be not having someone to lead and direct the LVN staff related to resident assessment who might need to be sent out to the ER. During an interview on 10/29/24 at 02:00 PM, the corporate resource nurse stated he was not aware there was no RN coverage for 4/13, 4/14, 4/28, 5/18, 5/19, 5/26, 6/15, 6/16, 6/23, and 6/29/2024. He stated the previous ADM did tell him she was worried about RN coverage because there were several days, they did not have coverage. He stated he did not know what days she was referring to. During an interview on 10/29/24 at 02:15 PM, the ADM stated it was the policy to have an RN 8 hours a day 7 days a week. She stated she was not aware of not having RN coverage as she was not in the building at that time. She stated they currently have RN coverage. She stated she was currently working on a new system to track RN hours when the coverage was done by a salaried RN that does not clock in. She stated the potential negative our come of not having an RN in the building 8 hours a day 7 days a week could be missing assessments and not having leadership for the LVN staff. Record review of the policy provided by the facility titled, Staffing, revised 9/28/23 revealed in part the following: Policy Statement - Our center provides sufficient nursing staff with the appropriate skills and competencies necessary to provide care and related services to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with resident care plans and the facility assessment. Policy and Implementation . 4. The facility utilizes the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week . 7. Direct care staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice for 2 (Residents #40 and #114) of 2 residents reviewed for respiratory care. 1. The facility failed to ensure that Resident #40 and Resident #114's oxygen tubing was replaced every week on Sunday, according to physician's orders. These failures could place residents at risk for respiratory compromise and infection. Findings included: Resident #40 Record review of Resident #40's clinical record reflected a face sheet, dated 10/28/24, which indicated the resident was an [AGE] year-old female admitted to the facility on [DATE]. Resident #40's diagnoses included chronic obstructive pulmonary disease (lung disease) and dementia (memory loss). Record review of Resident #40's annual MDS dated [DATE] revealed a BIMS score of 04, indicating the resident had severe cognitive impairment. Section O - Special Treatments, Procedures and Programs revealed Resident #40 used oxygen therapy while a resident. Record review of Resident #40's comprehensive care plan, dated 09/26/24, revealed Resident #40 required oxygen therapy related to COPD. Record review of Resident #40's current Physician Orders dated 10/28/24 revealed an order to change oxygen tubing, cannula/mask once a week on Sunday. During an observation on 10/28/27 at 11:10 AM, Resident #40 had oxygen being administered at 3 liters/minute via nasal cannula. Oxygen tubing was not dated. Ziplock bag on oxygen concentrator was dated 10/20/24. Resident #114 Record review of Resident #114's clinical record reflected a face sheet, dated 10/28/24, which indicated the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #114's diagnoses included congestive heart failure (decrease pumping power of the heart muscle), chronic respiratory failure, diabetes (high blood sugar), and lung cancer. Record review of Resident #114's annual MDS dated [DATE] revealed a BIMS score of 14, indicating the resident had no cognitive impairment. Section O - Special Treatments, Procedures and Programs revealed Resident #40 used oxygen therapy while a resident. Record review of Resident #114's comprehensive care plan, dated 10/15/24, revealed Resident #114 required oxygen therapy related to decreased cardiac output. Record review of Resident #40's current Physician Orders dated 10/28/24 revealed an order to change oxygen tubing, cannula/mask once a week on Sunday. During an observation on 10/28/27 at 10:32 AM, Resident #114 had oxygen being administered at 4 liters/minute via nasal cannula. Oxygen tubing was not dated. During an interview on 10/29/24 at 10:15 AM with the DON, she stated oxygen tubing should be changed and dated weekly on Sunday. She stated she had agency nurses working on Sunday. She stated all staff have been trained. She stated the ADON and DON were responsible for monitoring compliance. She stated the potential negative outcome was infection control. During an interview on 10/29/24 at 10:35 AM with the ADM, she stated oxygen tubing should be changed according to the physician orders. She stated the tubing should be changed. She stated the nurses, ADON and DON were responsible for monitoring compliance with changing tubing and dating the tubing. She stated the potential negative outcome could be increase negative consequences to the resident related to infection. Record review facility policy titled Departmental (Respiratory Therapy) - Prevention of Infection, revised November 2011 reflected the following: Purpose - The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff . Infection Control Considerations Related to Oxygen Administration . 7. Change the oxygen cannulae and tubing every seven (7) days, or as needed .

Based on observation, interview, and record review the facility failed to ensure that its medication error rates are not 5 percent (%) or greater. The facility had a medication error rate of 20% based on 6 out of 30 opportunities, which involved 2 of 4 residents (Residents #58 and #55) reviewed for medication administration, in that: 1. The facility failed to ensure Resident #55 had Xifaxa n (helps prevent a brain condition that can occur with severe liver disease )550mg, available for administration, resulting in a missed dose. 2. Med Aide C failed to verify the dosage and amount on Resident #55's Lactulos e (treats constipation) resulting in Resident #55 being underdosed. 3. Med Aide C failed to verify the dosage for Resident #58's Magnesium 200mg (treats low magnesium levels), and thiamin B1 (treats low thiamine) 50mg resulting in an incorrect dose given. 4. Med Aid C failed to verify physician order for Resident #58's Multivitamin resulting in the incorrect multivitamin given. 5. Med Aid C administered Ferrous Sulfate (treats low iron) 325mg, without a physician order to Resident #58. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: Resident #55 During a medication administration observation for Resident #55 on 10/28/2024 at 7:30 AM, Med Ai d C poured 15mL of Lactulose into a measuring cup and administered, she did not give Xifaxan 550 mg tablet, it was unavailable. Record review of Resident #55's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #55 had a medical history of toxic encephalopathy (a neurologic disorder caused by exposure to neurotoxic organic solvents), hypertension (high blood pressure), and alcoholic cirrhosis of liver with ascites (a condition where the liver is scarred due to chronic alcohol use, and fluid builds up in the abdomen). Record review of Resident #55's physician orders revealed an order for lactulose solution 10 gram/15 mL (15 mL); amt: 30 mL BID; oral with a start date of 9/11/2024 to be given between 7AM-10AM and 7PM-10PM. Physician orders also revealed an order for Xifaxan (rifaximin) tablet; 550 mg; amt: 1 tab PO BID; oral with a start date of 9/12/2024 to be given 7AM-10AM and 7PM-10PM. Resident #58 During a medication administration observation on 10/28/2024 at 7:41 AM , Med Aid C administered the following medications to Resident #58: - One-Daily multi-vitamin, 1 tablet -ferrous sulfate 325mg, 1 tablet; -Magnesium 400mg, 1 tablet; and -thiamine 100mg, 1 tablet. Record review of Resident #58's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #58 had a medical history of disorders of phosphorus metabolism (abnormal levels of phosphorus which can result in various other conditions), schizophreniform disorder (short-term mental health condition that causes psychosis), and hypomagnesemia (low magnesium levels). Record review of Resident #58's physician orders revealed the following active orders: thiamine HCl (vitamin B1) 50 mg, 1 tab PO, QD with a start date of 12/09/2023. magnesium 200mg, 1 tablet, twice a day with a start date of 1/1/2024. Adults Multivitamin (multivitamin-min-iron-fa-vit k) 18 mg iron-400 mcg-25 mcg with a start date of 12/09/2023. Record review of Resident #58's physician orders did not reveal an order for Ferrous Sulfate 325mg. During an interview on 10/28/2024 at 12:03 PM, the Med Aid C stated she gave 15mL of Lactulose to Resident #55 and verified the order stated 30mL. The Med Aid C stated she gave Resident #58 Magnesium 400mg and verified the order was for 200mg of Magnesium. The Med Aid C stated she gave Resident #58 Thiamin 100mg and verified the order was for 50mg. The Med Aid C stated she gave Resident #58 the One Daily multivitamin and added the iron pill because the facility did not have the ordered Adults Multivitamin (multivitamin-min-iron-fa-vit k) 18 mg iron-400 mcg-25 mcg. The Med Aid C stated she had been trained to verify orders and on medication administration rights. She stated her last training was in March 2024 when she was hired. She stated the DON is responsible for her training, but she had been trained by the last med aid who no longer worked at the facility. She stated the previous med aid told her she could supplement the ferrous sulfate 325mg to Resident #58's multi-vitamin since they did not have the right one. The Med Aid C stated she could have cut the Magnesium and Thiamin pills in half to give him the correct dose, but she was nervous and forgot. She stated she had been trained to cut the pills in half if needed. The Med Aid C stated did not know what the potential negative outcome of giving a medication without an order could be. The Med Aid C was unable to verbalize the potential negative outcomes for medication errors. She stated she knew her five rights of medication administration which were the name, time, pill, dose, and documentation. The Med Aid C stated she had been trained to report medication errors to the DON. The Med Aid C reported the medication errors to the ADON. During an interview on 10/29/2024 at 10:26 AM, the ADM stated the ADON and DON were responsible for training the nurses and med aides on medication administration. She stated the potential negative outcome of medication errors and residents not receiving their medication regimen could be any adverse effect and a negative consequence on the resident's health. The ADM stated she was not aware of the Med Aid C giving an iron tablet without an order. She stated staff is not trained to give any medication without an order. The ADM stated the nurses and med aids should follow their five rights of medication administration. During an interview on 10/29/2024 at 10:54 AM with the Clinical Resource Nurse and the ADON, the ADON stated the DON and ADON were responsible for training the nurses and med aids on medication administration. The ADON stated she was not sure when the last training was as she had just been hired at this facility, but she would be providing in-services on medication administration. The Clinical Resource Nurse stated that nursing staff and med aids were trained on the five rights of medication administration and the Med Aid C would be doing a training on medication administration. The Clinical Resource Nurse and ADON stated that a potential negative outcome of residents not receiving their ordered medication could be any adverse effect such as, depending on the type of medication, could be low blood pressure if it's a blood pressure mediation. The ADON stated she was not aware that the Med Aid C had been adding any supplemental medication to Resident #58's multi-vitamin. The ADON stated the nursing staff is not trained to do that without a physician order. The ADON stated the nursing staff and med aids were trained to verify the order and medication and if they do not match, they were to let the charge nurses, ADON and DON know in order to notify the physician for verification or to obtain the correct medication. Record review of facility policy titled MEDICATION ADMINISTRATION-GENERAL GUIDELINES dated 6/1/2022 revealed: A .4) FIVE RIGHTS - Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away . 6) Tablet Splitting: Splitting of tablets should be avoided and every attempt should be made to obtain an alternative dosage form, medication, or dosing schedule to avoid splitting. If breaking tablets is ultimately necessary to administer the proper dose, hands are washed with soap and water or alcohol gel (and examination gloves worn) prior to handling tablets and examination gloves must be worn to prevent touching of tablets during the process. The following guidelines are followed: a. Assure the tablet is appropriate and able to be split . b. A tablet-splitter is used to ensure accuracy and to minimize contact with the tablet. The splitter blade and surface contacting tablet are cleaned before and after each use. If the tablet is scored, every attempt is made to break along score lines . B .2.) Medications are administered in accordance with written orders of the prescriber.

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 dietary services, in that: 1. The facility failed to store and date foods stored in the refrigerator. 2. The facility failed to store pans upside down on shelfs. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on 10/27/24 at 09:45 AM, during initial observation of the kitchen: Observed the following: Inside the Refrigerator: Three trays with individual deserts in bowl uncovered and no date. -A bowl of puree food covered with plastic wrap with no date. -Two half sandwiches in plastic wrap with no date. Shelf: -One large pot laying on side on bottom shelf in pantry. -Three small pans stored right side up on shelf in kitchen. During an interview on 10/29/24 at 10:35 AM with the ADM, she stated all food should be stored covered and dated. She stated pots/pans should be stored upside down. She stated all kitchen staff have been trained. She stated the DM was responsible for monitoring the kitchen. She stated the potential negative outcome could be harm to the resident. During an interview on 10/29/24 at 10:45 AM with the DM, she stated all food items in the refrigerator needs to be dated and in a sealed container. She stated all pots and pans should be stored upside down on the shelf. She stated all staff have been trained. She stated the DM was responsible for monitoring storage of food and pots and pans. She stated the potential negative outcome of not properly storing food was you do not know how long it has been in refrigerator and could be given to a resident causing them to get sick. She stated the potential negative outcome for not properly storing pots/pans could be the pots/pans could get debris in them and mix with the food. Record review of the facility policy, titled Food Storage, undated reflected the following: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: . 2. d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approve for food storage.

41480 Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 2 residents (Residents #4 and #38) and 2 of 2 (LVN A and LVN B) staff reviewed for infection control. LVN A failed to wash hands between glove changes during wound care for Resident #38. LVN B failed to wash or sanitize hands after reaching in his pocket and prior to starting wound care. These failures could place residents at risk for spread of infection and cross contamination. Findings include: Resident #4 Record review of Resident #4's clinical record reflected a face sheet, dated 10/29/24, which indicated the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #4's diagnoses included dementia (loss of cognitive functioning, thinking, remembering, and reasoning) unspecified open wound right foot (break in the skin exposing underlying tissue), and cellulitis of lower limbs (bacterial infection that affects the deep layers of the skin and underlying tissue). Review of Resident #4s Comprehensive MDS Assessment, dated 09/20/24, reflected the resident was cognitively intact with a BIMS score of 12 . Resident #4 functional abilities and goals reflected resident #4 required substantial/maximum assistance with toileting, upper body dressing and personal hygiene. Resident #4 skin conditions reflected number of stage 4 pressure ulcers as 1, and number of pressure ulcers present at time of admission/entry or reentry as 1. Record review of Resident #4's care plan dated 09/23/24 reflected resident had a pressure ulcer infection on right heel. Approach - use aseptic techniques (disease-free, sterile, uninfected) when preforming dressing changes. Dress and cover wound before dressing other wounds, washing hands and observe aseptic technique. Record review of Resident #4's physician orders dated 10/28/24 reflected Wound Treatment Order: Location: Right heel - clean with wound cleanser, apply calcium alginate, cover with Silicone Foam Dressing once a day on Mon., Wed., Fri., dated 10/24/24. During an observation on 10/28/24 at 3:35 PM, reflected LVN B provided wound care for Resident #4. LVN B reached in his pocket with the gloves on and removed alcohol packets from his pocket and tossed them on the over bed table on the clean alginate. He opened an alcohol pad cleaned around the wound where the previous bandage was. He reached over and moved the alcohol prep packets off the alginate and placed the alginate on the adhesive bandage and placed it over the wound. During an interview on 10/28/2024 at 4:05PM, LVN B stated he performed wound care when the wound care nurse was not at the facility or if he noticed wound care needs to be completed. He stated that he should have changed gloves and sanitized his hands after he reached in his pocket and removed the alcohol wipe packages. He stated that when he tossed the alcohol wipe packages on the over bed table on the parchment paper and alginate, then placed the alginate over the wound it could have caused an infection. He stated he should have stopped the wound care procedure after he reached in his pocket and grabbed the alcohol wipe packets , then washed his hands and started the wound care over. He stated he was an agency nurse and had not received training on wound care form the facility. Resident #38 Record review of Resident #38's clinical record reflected a face sheet, dated 10/28/24, which indicated the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #38's diagnoses included osteomyelitis of vertebra (bone infection), spinal stenosis (narrowing of the spinal canal), hypertension (high blood pressure), and congested heart failure (decrease pumping power of the heart muscle). Review of Resident #38s Comprehensive MDS Assessment, dated 09/26/24, reflected the resident was cognitively intact with a BIMS score of 14 . Resident #38 functional abilities and goals reflected resident had impairment on one side upper and lower. Resident #38 used a wheelchair. Resident #38 requires substantial/maximal assistance with toileting, showering, dressing and personal hygiene. MDS skin conditions reflected Resident #38 had a risk for developing pressure ulcers and had one diabetic ulcer and 1 surgical wound. Record review of Resident #38's care plan dated 09/23/24 reflected no care plan for wounds. Record review of Resident #38's physician orders dated 10/28/24 reflected Wound Treatment Order: Location: Right buttocks clean with normal saline/wound cleanser, pat dry, apply calcium alginate, cover with Opti foam once a day on Tue., Thu., Sat., dated 10/22/24. During an observation on 10/28/24 at 03:45 PM, revealed LVN A cleaned Resident #38's right buttock wound with wound cleanser and gauze and patted dry with gauze. LVN A removed gloves and donned new gloves. LVN A did not wash hands or use ABHR when changing gloves between dirty and clean. LVN A applied calcium alginate to wound bed and covered with Opti foam. During an interview on 10/28/24 at 03:52 PM with LVN A, she stated she should have washed her hands with soap and water or ABHR between gloves changes. She stated there was no reason why she did not wash her hands or use ABHR. She stated she had been trained on infection control and hand washing. She stated the potential negative outcome could be spread of infection to the resident or herself. During an interview on 10/29/24 at 10:40 AM with the Interim DON, she stated hands should be washed with soap and water or ABHR between glove changes. She stated the staff have been trained on handwashing and infection control. She stated the ADON was the infection preventionist. She stated the DON and ADON was responsible for monitoring staff for infection control. She stated the potential negative outcome could be spreading infection . Record review Hand Hygiene Competency Validation, dated 09/11/24 for LVN A, reflected competency goals met. Record review facility policy titled Handwashing/Hand Hygiene, undated reflected the following: Policy statement - This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 5. Hand hygiene must be performed prior to donning and after doffing gloves. 49279

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 7 of 15 confidential residents. The facility failed to ensure 7 confidential residents were provided, through postings in prominent locations, the Grievance Procedure, was provided access to the Grievance form, was provided information who the facility grievance official was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews and record review during Resident Council on, 10/28/2024 at 10:00 a.m., 7 confidential residents, stated they did not know the grievance process, they did not know where to obtain or submit a grievance form, they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending the group meeting did not know how to file a grievance. Residents did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. The residents did not know they had the right to receive a written decision once their grievance was resolved. Seven residents in attendance had all been residents of the facility for 6 plus months. Record review of the facility Grievance policy on 10/29/2024 at 11:05 a.m., revealed a copy of the Grievance/complaint procedure should be posted on the prominently in the facility. Observation of prominent postings on 10/29/2024 at 11:30 a.m., indicated the facility did not include instructions regarding the Grievance procedure with any of the prominent postings. Grievance forms were not available to residents and there was no access to submit a Grievance anonymously. Interview with the ADM on 10/29/2024 at 12:05 p.m., the ADM stated she was the Grievance Officer for the facility. The ADM stated the Grievance form was kept in her office and the office of the Social Worker. The ADM stated she had been employed at the facility for 6 days; therefore, she has not addressed any Grievances to date. The ADM stated from reviewing the Grievance notebook it was apparent to her the Social Worker and the ADM address the Grievances. The Grievances were completed when a Resident comes to her or another staff member with a complaint, and/or if complaints were voiced in Resident Council. The ADM stated the Grievance Procedure was not posted for residents. The ADM stated the residents cannot file a Grievance anonymously due to the residents not having access to the Grievance form and having no means of submitting a Grievance form anonymously. The ADM stated she was responsible for assigning a Grievance to a staff member to address, she stated her expectation was Grievances be resolved as soon as possible. The ADM stated residents who voice a complaint were interviewed by the staff member assigned to resolve the Grievance; she stated this was the first step in resolving the Grievance. These interviews were documented on the Grievance form. The ADM stated the resolution to the Grievances were documented on the Grievance form. The ADM stated the resolution to Grievances was discussed with residents face to face. The ADM stated would monitor the Grievance process for success by following up with the staff member assigned to resolve the Grievance, the ADM stated she would also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated she was responsible for ensuring staff were trained on the Grievance process. The ADM stated she was not aware the Grievance procedure was not being discussed in Resident Council. Interview with the Social Worker on 10/29/2024 at 1:25 p.m., the SW stated process for completing a Grievance included talking to the resident with a complaint, the SW completing the Grievance form, assigning the Grievance to the appropriate Department head, that Department head investigating and solving the Grievance, and emailing the ADM a copy of the Grievance with the interviews documented as well as the resolution. The SW stated the Grievance form was available at the nurses' station, the SW's office, and the ADM's office if the residents ask for the form. The SW stated the forms were not available for the residents to complete without asking the staff for a form. The SW stated there was no confidential manner for a Grievance to be submitted anonymously. The SW stated the timeframe for addressing a Grievance was as soon as possible, she stated Grievances were discussed at every morning meeting. The SW stated the resident who filed a Grievance should be interviewed by the Department hired to complete the Grievance and this interview would be documented on the Grievance form. The SW stated the resolution to the Grievance should be documented on the Grievance form by the Department head who addressed the Grievance. The SW stated the ADM was responsible for ensuring the Grievance was addressed. The SW stated the ADM was responsible for the education of staff on. the Grievance procedure. The SW stated there was no potential harm to residents if the Grievance procedure was not discussed in Resident Council, there was no potential harm to residents if Grievances were ignored, there was no potential harm to residents if they were not offered an avenue to file a Grievance anonymously, and there was no potential harm to residents if the Grievance procedure was not displayed for residents. The SW stated there was an open-door policy throughout the facility; therefore, residents can discuss any issues they have with staff informally, a formal Grievance does not need to be filed. Record review of the Grievance Policy revised 1/12/2023 indicated: Policy Statement: All grievances filed with the facility will be investigated and corrective action will be taken to resolve the grievances. Policy Interpretation and Implementation: The facility will make the information for filing a grievance available to residents and their representatives. The ADM will assign the responsibility of investigating the grievance. Each Resident Grievance form will include the date, time, and details of the grievance. The Grievance forms will be maintained all Grievances and evidence related to the Grievance for three years. The Grievance will be resolved within three working days. The Resident or their Representative will be informed of the finding of the Grievance and any corrective action taken within three working days of the filing of the Grievance.

Based on observations, interviews, and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biologicals were stored properly in the treatment cart for 1 of 1 treatment carts observed for drug storage. The facility failed to ensure 2 bottles of wound cleaners was not left on top of the treatment cart unattended. This failure could place residents at risk of access and ingestion of non-narcotic medications. The findings were: During an observation on 10/28/24 at 03:45 PM, LVN A prepared wound care supplies on the treatment cart outside of resident's room. LVN A gathered supplies leaving 2 bottles of wound cleaners on top of treatment cart and entered resident's room. LVN A closed the door to resident's room. During an observation on 10/28/24 at 03:50 PM, the wound cleanser bottle on top of treatment care reflected the following warnings: Keep out of reach of children. If swallowed seek medical attention or call a Poison Control Center. During an interview on 10/28/24 at 03:52 PM, LVN A stated she should not have left the wound cleaners on top of the treatment cart. She stated the wound cleaner's bottle did state Keep out of reach of children. She stated she did not have a reason for leaving the 2 bottles of wound cleaners on top of treatment cart except she just forgot to put it back in the treatment cart. She stated she had been trained on proper medication and supply storage. She stated the potential negative outcome could be a resident opening the bottle and drinking the solution. She stated some could also tamper with the solution adding to it or pouring the solution out. During an interview on 10/29/24 at 10:15 AM, the DON stated the wound cleaner was considered a medication. She stated the nurse was responsible for making sure they store medication and supplies in a locked cart. She stated they all have been trained. She stated the potential negative outcome could be someone drinking the solution, contaminating the solution, or spraying the solution on someone. During an interview on 10/29/24 at 10:35 AM, the ADM stated the wound cleaner should not be stored on top of the treatment cart. She stated all staff have been trained. She stated the DON and ADON were responsible for monitoring storage of medications and wound care supplies. She stated the potential negative outcome could be a resident ingest the solution and could cause harm. Record review of facility policy titled Storage of Medications revised November 2020 reflected the following: Policy: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications .

Based on observation, interviews 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 2 of 6 residents (Resident #1 and Resident #2) reviewed for care plans. The facility failed to have a care plan in place to accurately address Resident #1's wound care. The facility failed to have a care plan in place to accurately address Resident #2's oxygen use. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Resident #1 Record review of Resident #1's Face Sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included Stroke (damage to brain from interruption of blood supply), Traumatic Brain Dysfunction (a disruption in the normal function of the brain), Amputation (surgical removal of a limb), Diabetes Mellitus (a metabolic disease involving inappropriately elevated blood glucose levels), Hypertension (persistently elevated blood pressure), Non-Alzheimer's Dementia (impaired cognition not related to Alzheimer's Disease). Record review of Resident #1's Admission MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #1 was cognitively intact. Section M-Skin Conditions indicated she had surgical wounds and open lesions and requiring wound care, dressings and application of ointments and medications. Record review of Resident #1's Care Plan dated 06/20/24 indicated wound care was not included on this plan. Record review of Resident #1's Physician's Orders dated 06/20/24 revealed order to cleanse bilateral labial (skin folds on each side of vagina) wounds with wound cleanser and apply silver alginate and cover with abdominal pad daily. During an interview on 08/15/24 at 2:30 p.m., the hospital's Registered Nurse, indicated Resident #1 was diagnosed with vaginal cancer upon her admission to the hospital on 08/13/24, and was scheduled for wound debride on 08/15/24. Observation on 08/15/24 at 3:01 pm of Resident #1, who was awake, revealed she was lying in her bed. Resident #1's wounds were not observed because she was waiting to go to surgery for wound debride. During an interview on 08/15/24 at 3:01 p.m., Resident #1 indicated she responded to the questions asked of her by nodding her head but did not seem to understand the questions . During an interview on 08/16/24 at 12:55 p.m., LVN A indicated Resident #1 upon admission (06/18/24) completed a skin assessment, which included an unstageable wound to her labial that was covered with slough. Resident #1 was seen at the wound care clinic on 06/25/24, 07/03/24, 07/09/24, 08/05/24, and 08/06/24. This clinic referred Resident #1 to the oncologist on 08/12/24 who sent her to the hospital. LVN A said Resident 1's wounds were addressed through the wound care clinic, wound care at the facility, and an air mattress was offered to this resident; however, her family refused. During an interview on 08/16/24 at 2:36 p.m., LVN B indicated she assessed and measured Resident #1's wound and provided wound care per physician's orders; however, the wounds did not improve. During a phone interview on 08/16/24 at 3:48 PM, the DON indicated she did not know why the care plan did not address wound care and that she or the MDS Coordinator was responsible for initiating and updating care plans. She stated a potential negative outcome for failure to ensure accuracy of care plans was missing the goal for informed care of residents. During an interview on 08/16/24 at 5:03 PM, the Clinical Resource RN indicated any resident condition or change of condition should have been included in Resident #1's care plan. The RN said the order for wound care, should have been added to the care plan. Resident #2 Record review of Resident #2's Face Sheet she was [AGE] year-old female admitted to the facility 11/28/22. Resident #2's diagnoses included Dementia (thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (lung diseases that blocks airflow and makes it difficult to breathe), pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), shortness of breath, altered mental status (changes in awareness, and movement) systolic heart failure (left ventricle is weak and can't contract normally when the heart beats). Record review of Resident #2's Physician Order Report dated 07/22/24 - 08/22/24 indicated the order was changed on 06/18/24 to nasal cannula (continuous) with oxygen at 2 liters a minute on every shift day and night. Record review of Resident #2's Quarterly MDS dated [DATE] revealed she scored a 12 on her BIMS. Section E-Behavior of this MDS indicated she had not displayed behaviors of rejecting her care. Record review of Resident #2's Care Plan dated 06/27/24 and reviewed/revised by the DON on 07/22/24 revealed oxygen therapy via nasal cannula was not included on this plan. Observation and attempted interview on 08/15/24 at 10:34 a.m., indicated Resident #2 was sitting in her wheelchair in her room, she was not wearing her nasal cannula, because she was sitting on the tubing. Resident #2 could not respond to questions asked her about her nasal cannula. During an interview on 08/15/24 at 11:21 a.m., CNA D indicated she assisted Resident #2 from her bed where she was wearing her nasal cannula from the oxygen concentrator. After, she transferred Resident #2 to her wheelchair she switched her to the nasal cannula from her e-tank (aluminum tank that stores supplemental oxygen) that was on her wheelchair. CNA D said Resident #2 had a history of removing her nasal cannula. During an interview on 08/15/24 at 11:51 a.m., CNA E indicated Resident #2 had a history of removing her nasal cannula. During an interview on 08/15/24 at 12:07 p.m., CNA G indicated Resident #2 had a history of removing her nasal cannula. During an interview on 08/16/24 at 3:45 p.m., the DON indicated upon admission of a resident using oxygen, this would be care planned, but if the oxygen was ordered after admission, she would add it to the plan. The DON said she was not sure why it had not been added to the plan. During an interview on 08/16/24 at 3:51 p.m., the Clinical Resource RN, indicated Resident #2's order for using oxygen, should have been added to the care plan. Review of the facility's policy and procedure for Comprehensive Care Plans dated 01/26/24 indicated it was the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment. Qualified staff responsible for carrying out the interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. The services provided or arranged by the facility, as outlined in the comprehensive care plan, will meet professional standards of quality, and will be provided by qualified persons in accordance with each resident's written plan of care. Review of the facility's policy and procedure for Care Plans, Comprehensive Person-Centered dated 2001 indicated The care planning process will: describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; incorporate risk factors associated with identified problems; incorporate identified problem areas and incorporate risk factors associated with identified problems. The Interdisciplinary Team must review and updated the care plan: when there has been a significant change in the resident's condition and when the desired outcome is not met.

Based on interview, observation and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 7 residents (Resident #1) reviewed for MDS assessment accuracy. Resident #1's quarterly MDS assessment dated [DATE] was coded incorrectly for wandering reflecting that she did not wander when she had a consistent presence of the behavior (wandering). Resident #1's quarterly Significant Change assessment dated [DATE] was coded incorrectly for wandering reflecting that she did not wander when she had a consistent presence of the behavior (wandering). Resident #1's quarterly and comprehensive assessment did not reflect the behavior for wandering even though staff (ADM, DON, LVN A, LVN B, The Activity Director, CNA C, CNA D, the MDS Coordinator and CNA E) had witnessed her wandering since her admission (10/29/21) into other resident room and specifically Resident #2's room. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Review of Resident #1's face sheet (undated) indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had a diagnosis of dementia with agitation (loss of cognitive functioning), generalized anxiety disorder (feelings of worry, tension and fear), and intermittent explosive disorder (repeated, sudden bouts of impulsive of physical or verbal outburst). Resident #1 resided on Hall 100. Review of Resident #1's quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 99 which indicated Resident #1 was unable to complete the interview. The MDS Assessment for Resident #1 revealed in section E0900 that the Resident #1 had not exhibited the behavior of wandering. Review of Resident #1's Significant Change MDS dated [DATE] revealed Resident #1 had a BIMS score of 03 which indicated Resident #1's cognition was severely impaired. The MDS Assessment for Resident #1 revealed in section E0900 that the Resident #1 had not exhibited the behavior of wandering. Section E100 did not contain any data regarding the impact of Resident #1 wandering on others. Section E1100 did not capture if Resident #1's wandering had remained the same, worsened or improved. Review of Resident #1's care plan dated 2/15/24 did not reveal a care plan for the behavior of wandering. Review of Resident #1's progress notes did not reveal any ongoing prevention or intervention about Resident #1 wandering. Review of Resident #2's face sheet (undated) indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had a diagnosis of hemiplegia and hemiparesis following cerebral infarction (paralysis of partial or total body function and aphasia (language disorder making it difficult to communicate). Resident #2 resided on Hall 500. Review of Resident #2's MDS dated [DATE] revealed Resident #2 had a BIMS score of 06 which indicated Resident #2 cognition was severely impaired. An interview on 03/06/24 at 10:32 AM with the ADM revealed an incident between Resident #1 and Resident #2 in the hall of 400. She said she was unsure what provoked Resident #2 but that it resulted in Resident #2 hitting Resident #1. She said that Resident #1 would reach out and try to hug and or stick out her hands to others. She said she was curious to know if Resident #1 did either of these things to provoke Resident #2. She said she could not interview Resident #2 because he was upset the day the incident happened. She stated the physical incident between Resident #1 and Resident #2 had not happened before. An Interview on 03/06/24 at 10:33 AM with the DON revealed that there was a physical incident that occurred between Resident #1 and Resident #2 but this had not happened before. An interview on 03/06/24 at 11:18 AM with LVN A revealed that she did not have much information about the physical altercation between Resident #1 and Resident #2, but that Resident #1 wanders the halls. She said Resident #1 would sometimes bump into other people and enter their rooms. An interview on 03/06/24 at 11:31 AM with LVN B revealed that an incident occurred in the hallway between Resident #1 and Resident #2. She was unsure of the date and time. She said they must have been crossing paths, she observed Resident #2 with Resident #1 wrist in his hand, and Resident #2 was screaming. She said she broke them apart and could not get what happened from Resident #1 because he was upset. She said Resident #1 was confused all the time and wanders over the facility. An interview on 03/06/24 at 11:48 AM with the Activity Director revealed that she had not been present for the physical incident with Resident #1 and #2. She said she does know there have been at least two incidents. She said one occurred by his room door, and he kicked her. The second incident she witnessed was when they were near the nurse's station, and she observed Resident #2 hand go up in the air and Resident #1 was near him. She said she yelled for LVN B to look and ran to get Resident #1 away from Resident #2. She said she could not remember the exact date of the incident, but it was about two months ago. An interview on 03/06/24 at 12:01 PM with CNA C revealed that she was not present when the physical altercation occurred between Resident #1 and Resident #2, but that report was given to her that Resident #1 was attempting to wander into Resident #2 room and Resident #1 kicked her. She said Resident #1 had a history of wandering all over the facility. An interview on 03/06/24 at 12:06 PM with the CNA D revealed that Resident #1 does try to go in other resident's room. She said she tried to go in Resident #2 room Resident #2 did not like it. An interview on 03/06/24 at 12:28 PM with CNA E revealed that she did not have any information regarding the physical altercation between Resident #1 and Resident #2 but that she had worked with both residents. She said Resident #1 has a history of wandering around the facility. She said she repeatedly tried to keep Resident #1 off 500 Hall. An interview on 03/06/24 at 1:26 PM with Resident #2 revealed that Resident #1 tried to come into his room multiple times. He said she had tried to come into his room at least five times. He said that he did not know the exact date and time. He said he had not reported these attempts to staff but that there was always staff around when Resident #1 tried to come into his room. He said that he does not like it when residents come into his room. He said Resident #1 entered his room because she wanted to steal from him. An observation was made on 03/06/24 at 1:55 of Resident #1 self-propelled slowly near the nurse's station. An observation was made on 03/06/24 at 2:03 PM, Resident #1 self-propelled slowly down the hall. She entered room [ROOM NUMBER]. Another resident (unknown) propelled behind her, telling her not to go into the room. Resident #1 enter room [ROOM NUMBER] in her wheelchair. She went to the nightstand in the room and began to rummage. The Investigator notified the DON, and she and another staff (unknown) intervened. They redirected her physically out of the resident's room. An interview on 03/06/24 at 2:38 PM with the MDS Coordinator revealed that Resident #1 likes to wander around the facility. She said sometimes Resident #1 would go into the wrong room. She said Resident #1 had wandered since being admitted to the facility. She said usually, staff intervene. She said when Resident #1 gets into the room across from hers, the resident in that room will yell at her, and then staff will get her. She said that she was responsible for completing the MDS assessments for all the residents in the facility. She said the DON was responsible for the resident care plans. She said she believed that Resident #1 behavior for wandering was in the care plan but was not sure. She said the behavior should be captured in the care plan. She said she did not believe there was a potential negative outcome for Resident #1's wandering behavior not being reflected in the care plan. She said the only potential negative outcome that she could think of for the wandering not being reflected in the MDS assessment was there could be a monetary penalty. She said the staff that provide direct care do not look at the MDS assessment to provide care, but they do look at the care plan. She said Resident #1's wandering was not reflected in the MDS assessments because she did not consider her wandering up and down the halls without a purpose significant enough to put in the MDS. She said Resident #1 was not trying to leave the facility or bother other residents. She said she does obtain information from staff for her assessments. She said she knew that a male resident became upset about Resident #1 going into his room, but she did not know when. She said she had been trained on how to complete MDS assessments. She said she taught herself. She said another reason the wandering may not have been in the MDS assessments was that there was a time when Resident #1 did not wander. An interview on 03/06/24 at 2:54 PM with the DON revealed the potential negative outcome for the inaccurate MDS that could affect the care plan. She said it could cause the care plan to not be appropriate for the resident. Regarding Resident #1, all the staff knew her very well. She said she was unaware that the quarterly or the latest comprehensive MDS assessment did not capture Resident #1's wandering behavior. She said she had been trained regarding the accuracy of MDS assessments. She said her training was 3-4 years ago. She said Resident #1 does wander and had exhibited the behavior since she had been employed at the facility. She said Resident #1 was intentional when she wanders. She said Resident #1 would go to the same people daily to see staff she knew. She said she expected that the MDS be completed accurately and reflect current information. She said the MDS Coordinator was responsible for completing the MDS assessments. An interview on 03/06/24 at 3:24 PM with CNA E revealed Resident #1 had always had a history of wandering around the facility and into other residents' rooms since she had been employed at the facility. She said she had been employed at the facility for six months. She said that when she stated in her earlier interview that she tried to keep Resident #1 from Hall 500, it was because of Resident #2. She said she had observed him kick Resident #1 out of his room. She said she did not know what a care plan was and had not looked to see if wandering was on it. She said she had not been specifically trained on what to do about Resident #1's wandering behavior. She said she knew about Resident #1 behavior from working with her. An interview on 03/06/24 at 3:32 PM with the LVN A revealed Resident #1 had always exhibited wandering behavior. She said the only time Resident #1 does not wander was if she does not feel well or was in bed. An interview on 03/06/24 at 3:37 PM with the ADM revealed the potential negative outcome for the MDS not being accurate was billing could be off or skewed. She said she was unaware that Resident #1's wandering behavior was not reflected in her most recent quarterly and Significant Change MDS assessment. She said there was no specific system in place to monitor MDS assessments. She said they do not look at the assessment's individual sections but look at if there was an overall decline. She said she had not been trained in completing accurate MDS Assessments. She said she expected MDS assessments to be accurate and reflect current information regarding residents. She said she had observed Resident #1 wandering around the facility. She said the MDS Coordinator was responsible for accurately completing the MDS assessments. She said she had no reason the MDS was not completed accurately. She said the potential negative outcome of not reflecting Resident #1's behavior of wandering or current behaviors in the care plan was that she or other residents may not receive the care they need. She said Resident #1 had exhibited wandering behavior the entire time she had known her. She said she was unaware that Resident #1 had been in Resident #2's room multiple times. An interview on 03/06/24 at 03:51 PM with CNA D revealed that Resident #1 had always wandered around the facility and in other residents' rooms. She stated she had seen Resident #1 enter Resident #2 room more than once. An interview on 03/06/24 at 03:52 PM with CNA C revealed that Resident #1 had always wandered around the facility and in other residents' rooms. She stated she had seen Resident #1 enter Resident #2 room more than once. She said she observed Resident #2 blocking Resident #1 and attempting to wave her out of his room because he could not speak. An interview on 03/06/24 at 04:20 PM with the ADM revealed that there was no specific policy for the MDS assessments but that they use the Long-Term Care RAI manual. An interview on 03/06/24 at 04:19 PM with the DON revealed she stated she was unaware if Resident #1's wandering was tracked. An interview on 03/11/24 at 05:08 PM with the social worker revealed that on 01/29/24, there was a physical altercation between Resident #1 and Resident #2. She said she could not interview Resident #1 because of her cognitive status. She said she was able to interview Resident #2 through the use of his communication board. She said Resident #2 told her he grabbed Resident #1's arm because she grabbed his leg as she rolled by. She said he motioned that the incident happened in the hallway. She said she did not, and he did not clarify if the incident specifically happened in Hall 500 or where it happened. She assumed it was outside his room because of how he motioned. She said Resident #1 goes up and down the hallways and wanders throughout the facility. She said sometimes she would go into other residents' rooms, but some residents were familiar with her. She said she could not answer the potential negative outcome if Resident #1 went into a room where she was unwanted. She said she could not say what risks Resident #1 would be at if she went into a resident's room that she was unwanted in because it would all depend on the other resident. She said she hoped they would tell Resident #1 to leave, and she would listen and leave. Review of the Intake Investigation Worksheet 480251, dated 01/29, revealed the following: The incident occurred on 01/29/24 at 10:00 AM. LVN B witnessed Resident #2 grabbing Resident #1's arm and twisting it. The Social Worker was told by Resident #2 that Resident #1 touched his leg when she rolled by. Review of the Intake Investigation Worksheet 480251, dated 01/29, revealed the following: The incident occurred on 01/29/24 at 10:00 AM. LVN B witnessed Resident #2 grabbing Resident #1's arm and twisting it. The Social Worker was told by Resident #2 that Resident #1 touched his leg when she rolled by. Review of the facility policy, Behavioral, Intervention and Monitoring, Revised December 2021, revealed the following: Policy Statement: The center will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral symptoms will be identified using center-approved behavioral screening tools and the comprehensive assessment. The center will comply with regulatory requirements related to the use of medications to manage behavioral changes. Policy Interpretation and Implementation General Guidelines 1. Behavior is the response of an individual to a wide variety of factors. These factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes. a. Behavior is regulated by the brain and is influenced by past experiences, personality traits, environment, and interactions with other people. b. Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that cannot be articulated. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations: a. The resident's usual patterns of cognition, mood and behavior; 4. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. Cause Identification 1. The interdisciplinary team will evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition, including: Management 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. a. Atypical behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress. b. If the behavior is atypical but not problematic or dangerous and the resident does not appear to be in distress, then the IDT will monitor for changes but not necessarily intervene to normalize the behavior. 2. The care plan will incorporate findings from the comprehensive assessment and PASRR Level II determinations (as appropriate), and be consistent with current standards of practice. 3. The resident and family or representative will be involved in the development and implementation of the care plan. Resident and family involvement, or attempts to include the resident and family in care planning and treatment, will be documented. 4. The resident and family/representatives will be informed of the resident's condition as well as the potential risks and benefits or proposed interventions. 5. The resident and/or resident surrogate will have the right to refuse treatment. 6. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. 7. Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include, as a minimum: a. A description of the behavioral symptoms, including: (1) Frequency; (2) Intensity; (3) Duration; (4) Outcomes; (5) Location; (6) Environment; and (7) Precipitating factors or situations. b. Targeted and individualized interventions for the behavioral and/or psychosocial symptoms; c. The rationale for the interventions and approaches; d. Specific and measurable goals for targeted behaviors; and e. How the staff will monitor for effectiveness of the interventions. Monitoring 1. If the resident is being treated for altered behavior or mood, the IDT will seek and document any improvements or worsening in the individual's behavior, mood, and function. 2. The IDT will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. 3. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, October 2023, revealed the following: an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.

Based on observation, interview, and record review the facility failed to ensure follow their policy and procedures to prevent neglect for 1 of 13 residents (#1) reviewed for neglect. Nurse Aide #12 transferred resident #1 alone, and resident #1 required a 2-person transfer. This resulted in a fracture to resident #1's left knee. Failure of the facility to provide the necessary services to avoid physical harm could put at risk the health, safety and well-being of the other 15 residents requiring 2 person transfer assistance. Findings include: Record review of Resident #1's Resident Admission Record printed by the facility on 10/12/15 documented the resident was a [AGE] year old Hispanic male with a legal representative admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. of left tibia, late effects. In an interview conducted with ADON #2 on 10/12/15 at 10:20am, she stated Resident #1 was admitted to the facility two months prior and was dependent upon staff for mobility in a wheeled chair. He required two person transfer assistance. Resident #1 had [MEDICAL CONDITION] (the wearing down of the cartilage that cushions the ends of the bones that usually occurs with aging or after injury) and a healed right knee injury received at his previous placement. Resident #1 currently had a fracture to the left leg received during a one person transfer performed by NA#12. Resident #1's leg was not surgically repaired because it was non-displaced. Observation of Resident #1 conducted in his bedroom on 10/12/15 at 11:10am revealed he was seated in a Geri-chair with his legs elevated, visiting with a family member. Observation revealed the outline of the left knee brace under his sweat pants. In an interview conducted with Resident #1 on 10/12/15 at 11:10am, when asked how his left knee was injured, he stated in Spanish that he fell . When asked where he fell he stated at school. His visitor stated Resident #1 was confused. Confidential Interview L stated Resident #1 was injured when a nurse aide transferred the resident by herself. Resident #1 had lived at the facility for approximately two months. The resident was transferred with a lift at his former placement because his legs were weak and he had a non-surgically repaired knee fracture obtained during a fall earlier in the year. Record review of Resident #1's admission comprehensive MDS dated [DATE] documented the resident was admitted from another nursing home. The MDS documented the resident's preferred language was Spanish. He could usually understand others and others could usually understand him. He had no temporal orientation and his BIMS was 3 of 15 indicating severely impaired cognition. Resident #1 was totally dependent (full staff performance) upon 2 staff for transfers and totally dependent upon 1 staff for locomotion, requiring a wheelchair for mobility. He had impairment in ROM to both lower extremities. The resident received prn pain medication for occasional pain but could not rate the pain. The resident had not fallen since admission on 8/6/15. The resident's family did not participate in the assessment or goal setting. The resident's history, [DIAGNOSES REDACTED]. Record review of Resident #1's chart kept at the facility's nurse's station on 10/15/15 showed a handwritten note taped to the inside of the left leaf of the chart. The note was undated, time 1:27pm, and included information regarding medications, diagnoses, incontinence, and Geri-chair with lift. Record review of Resident #1's Admission Care Plan, admitted [DATE], admission [DIAGNOSES REDACTED]. The plan recommended the resident receive assistance from 2 staff for ambulation/transferring. Both lower extremities had limited ROM. The plan called for orthostatic precautions to reduce falls and injuries risk. (Orthostatic [MEDICAL CONDITION], also called postural [MEDICAL CONDITION], is a sudden fall in blood pressure that occurs when a person assumes a standing position, resulting in reduced blood flow to the brain and dizziness or [MEDICAL CONDITION].) Record review of Resident #1's Nursing Assistant Care Plan, dated 8/6/15, signed by LVN #3, reflected the resident was to receive 2 staff transfer assistance. The plan was located in a 3 ring binder labeled ADLs located at the nurse's station. Record review of Resident #1's Care Plan, problem start date 9/24/15, signed and dated by the DON, documented the resident had a left knee immobilizer related to a fractured left tibia. Record review of Resident #1's significant change in status comprehensive MDS assessment, observation reference date 9/25/15, documented his BIMS was 2, dropping 1 point since the previous comprehensive performed the month prior. Review fall history documented the resident experienced 1 fall since admission resulting in major injury. Major injury was defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. The assessment reflected impairment in ROM to both lower extremities. He received scheduled and prn pain medication for frequent pain. The resident was unable to describe pain intensity. In an interview with LVN #1 on 10/13/15 at 9:56am, she stated Resident #1 had a fractured left tibia obtained when he fell during a staff assisted transfer. In an interview with the DON on 10/13/15 at 2:23pm, when asked about Resident #1's history, she stated the resident had osteopenia -fragile bones- and had suffered a right knee fracture at his prior placement, approximately 6 months prior to admission. He required two staff transfer assist since admission. When asked to describe her knowledge of Resident #1's incident/injury, she stated on 9/21/15 NA #12 answered Resident #1's call light. NA #12 had asked LVN #3 to assist her transfer the resident, which LVN #3 denied hearing. NA #12 attempted the transfer from Geri-chair to bed without assistance, and ended up having to guide Resident #1 to the floor. NA #12 exited the bedroom to seek assistance from LVN #3 with Resident #1 and was described as being upset. The DON stated she was notified and observed the resident seated on the floor when she went to do the assessment. The physician was contacted to obtain an order to x-ray the resident's knee related to complaints of pain, swelling and bruising. X-ray results obtained at 9:30pm showed no fracture. The physician assessed Resident #1 on 9/24/15 and ordered an MRI. The MRI, scheduled for 9/26/15, could not be completed because Resident #1 had a pacemaker. The physician was notified and ordered a CT scan. The CT scan was performed on 9/30/15 confirming presence of fractured left tibia. When asked to describe the facility's procedure to ensure staffing ratios to meet the needs of the residents during the day shift, she stated the facility had 2 charge nurses responsible for supervising the nurse aids and residents for the halls to which they were assigned. Halls 100, 200 and the memory unit comprised one assignment, and Halls 300, 400 and 500 the other assignment. The DON stated the charge nurses and administrative nurses provided assistance to residents when necessary. When asked to describe the facility's procedure of training newly hired nurse aides, she stated the new nurse aide shadowed a tenured nurse aide for 3 days per halls assignment. NA #12 was a new hire and assigned to Halls 300, 400 and 500. Resident #1 lived in the 100 hall when the incident occurred. When asked why NA #12 answered Resident #1's call light, she stated all staff was expected to assist in any hall when needed. Record review of Form 3613-A Provider Investigation Report for Resident #1's injury reflected it was dated 9/30/15 on the FAX Cover Sheet, and signed and dated by the Administrator on 10/2/15. The report reflected the incident occurred on 9/21/15 at 3:25pm and was categorized as neglect. It described the resident as requiring extensive assistance with functional ability, did not ambulate independently and had weakness of the lower extremities. The document identified the resident as having the capacity to make informed decisions. Nurse Aide #12 was identified as the alleged perpetrator and written in the column for license/certificate number was nurse aide. There was no witness to the incident other than Nurse Aide #12 and Resident #1. Description of the allegation was nurse aide was attempting to transfer a resident from chair to bed and resident's legs gave way and staff member stated she lowered him to the floor. The resident's left leg was painful and began to swell. He was assessed by a nurse at 3:30pm and had small amount of swelling, no bruising, and voiced some pain. The Provider's Response reflected the CT scan completed on 9/30/15 showed a fracture to the left tibia. Additional investigation documents included: · Resident #1's Admission/Readmission Data Summary dated 8/6/15 that reflected he required 2 person transfer assistance. · Resident #1's Radiology Interpretation, report completion date 8/7/15 (prior to incident), that reflected the resident's right knee was x-rayed, 2 views, due to history of pain. The report documented the resident had a previous fracture in January 2015. The resident had moderate osteopenia (loss of bone mass not as severe as [MEDICAL CONDITION]). Alignment was normal and no fracture, dislocation or acute bony abnormality was seen. · NA #12's signed Witness Statement dated 9/21/15 that reflected the resident's legs gave out during transfer and she sat him down. · Incident/Accident report written by LVN #3, signed by the DON on 9/22/15 and by the Admin. on 9/23/15 reflected the incident occurred in Resident #1's bedroom on 9/21/15 at 3:25pm. Documentation showed LVN #3 asked CNA #7 to assist NA #12 transfer Resident #1, and CNA #7 reported to LVN #3 that she entered Resident #1's bedroom to assist NA #12 and saw the resident sitting on the floor with NA #12 stating she did not drop the resident. The DON was notified and assisted with transferring the resident from the floor to the bed. The DON assessed the resident. The resident complained of left knee pain, which was swollen and reported that he twisted his left knee. He received [MEDICATION NAME] for pain and the physician was notified. · Notice of Disciplinary Action, notice date 9/22/15, that reflected the DON gave NA #12 a verbal notice on 9/22/15 for violating policy when she transferred Resident #1 from the Geri-chair to the bed without getting assistance from other staff on 9/21/15. The employee comments section was blank and on the employee signature line was refused to sign. The DON signature was dated 9/22/15 and the Admin. signature was dated 9/23/15. The space for the Witness Signature and date was blank. At the bottom of the document was (Witness Signature is only needed if employee refuses to sign the form). · Accident/Incident Final Disposition Report, signed by the DON 9/22/15 and by the Admin. on 9/23/15, documented NA #12 assisted Resident #1 to the floor when his legs became weak and gave out when transfer to bed from Geri-chair was attempted. X-ray results received the same day showed no fracture. The following day the facility began in-services on transfers, abuse, neglect. In an interview with CNA #7 on 10/14/15 at 10:58am, she stated LVN #3 requested her assistance with helping NA #12 transfer Resident #1. Resident #1 was seated on the floor when she entered his bedroom. The DON entered the bedroom soon after CNA #7. She stated staff was aware the resident could not bear weight since admission and that he required two person transfer assistance. In an interview with CNA #13 on 10/14/15 at 11:30am she stated Resident #1 could not bear weight prior to the incident and at admission his family had requested the resident be transferred using a lift. The facility implemented 2 staff transfer assistance at admission. She was aware the resident had a history of [REDACTED]. In an interview with LVN #3 on 10/14/15 at 12:04pm she stated she was Resident #1's charge nurse the day of the incident. She stated NA #12 was new to the facility at the time of the incident. LVN #3 was at the nurse's station when NA #12 asked her to help transfer Resident #1. She told NA #12 she would get another aide to help. NA #12 went back to his bedroom and attempted the transfer without assistance. She went back to the nurse's station and reported to LVN #3 she needed help. LVN #3 went to assist and observed the resident sitting on the floor with his legs in front of him. The DON was notified, performed the assessment, and assisted 2 staff with transferring the resident to his bed from the floor. No injuries were noted. He did not complain of pain at that time and was taken to the dining room for supper later that day. Resident #1's left knee was x-rayed and showed no fracture. Staff was aware the resident required 2 staff transfer assistance. LVN #3 stated she could not remember if the family had requested transfer with a lift. She stated NA #12 needed more assistance and training; she was not performing as well as expected. She stated LVN #4 had to coach NA #12 and provide more supervision. In an interview with LVN # 4 on 10/14/15 at 3:26pm she stated she provided direct supervision to NA #12, and that NA #12 was a new employee. NA #12 had never been assigned to Resident #1's hall but each aide was expected to assist in other halls when needed. NA #12 was not catching on as quickly as the other aides and needed more assistance and coaching than other staff. NA #12 reported that she was not able to perform the lifts. NA #12 completed her shift after the incident but called in to the next day. NA #12 worked one more day that week after being approved for prn status and shorter work hours. NA #12 text the on call ADON to self-terminate employment. When asked if she had made administration aware of NA #12's performance issues she stated she had spoken with the ADONs, following the chain of command. Record review of NA #12's Employee Information Sheet reflected the hire date was 8/10/15. Record review of the facility's August 2015 CNA Staffing Schedule for the 6a-6p shift, documented NA #12 began training on 8/31/15. In an interview with NA #12 on 10/15/15 at 7:48am, she stated she was hired on 8/10/15 but then had a family emergency and did not return to work until 8/30/15 on the night shift. She worked day shifts the rest of her employment. She was not certified but within her 4 month window to take the test for certification. She had never been assigned Resident #1's hall. The day of the incident, she answered Resident #1's call light because the other aides were on break. Resident #1 asked to be transferred to his bed from the Geri-chair. She knew she would need assistance and went to the nurse's station to ask LVN #3 for assistance with his transfer. LVN #3 told her that she would get a CNA to assist her. She returned to the room and attempted the transfer to complete the task and move on to the next task. She was not tall enough or strong enough to guide him onto the bed and his legs slipped from under him. He fell on to his left knee and sat on the floor with his left leg underneath him. She got his leg from underneath him and went to inform LVN #3 who notified the DON. She stated she worked the rest of the shift but called in the next day. The next scheduled work day was Friday. She called the DON on Thursday to request working only 9-6 and on a prn basis, which was approved. She worked Friday then and quit Saturday because she was overwhelmed and felt she could not fulfill her duties. She stated her supervisors were aware she was overwhelmed with her duties. Record review of the facility's Incident/Accident Tracking and Trending Log for September 2015 showed the incident was documented as a non-preventable fall, dated 9/21/15. Record review of the facility's Lifting and Movement of Resident-Safe policy and procedure effective 2/2015 reflected it was policy to protect resident safety and well-being by using appropriate techniques and devices to lift and move residents. Resident safety and medical condition would be incorporated into goals and decisions regarding lifts and transfers. Manual lifting should be eliminated when feasible and ongoing assessment for transfer assistance needs. Assessments should include resident preference, degree of mobility, size, weight-bearing ability, cognitive status, etc. Mechanical lifts should be made available and accessible 24 hours a day. Record review of the All Direct Care Staff Inservice Training Report dated 9/23/15, subject transferring resident, reflected staff was in-serviced by nursing administration for 5-10 minutes on using gait belts to assist residents transfer and ensuring residents requiring 2 staff transfers received assistance from 2 staff. Record review of the facility's undated and non-enumerated multiple paged document entitled Transfer Training provided by the Admin. on 10/15/15 reflected one page titled TRANSFER SAFETY recommended to consider using a lift transfer device if the patient was particularly heavy or had difficulty supporting own weight, and when in doubt, request additional assistance. Record review of Resident #1's Care Plan, page 22 of 25, category ADL Functional/Rehabilitation Potential, problem start date 8/27/15, reflected the resident required extensive assistance by 2 staff for transfers. The page was signed by the DON but not dated. Review of the Falls category, page 7 of 22, problem start date 8/27/15, reflected the resident had a history of [REDACTED]. The DON signed the page and dated 8/27/15. Record review of Resident #1's Physician's Telephone Orders, copied from the chart by the surveyor on 10/13/15 showed the following: a) An original copy of an order signed by the physician on 9/24/15, received by LVN #1 (no time noted), for the knee immobilizer, MRI left knee, and [MEDICATION NAME] 800mg three times daily for 2 weeks for the [DIAGNOSES REDACTED]. b) An unsigned chart control copy dated 10/1/15 received by LVN #3 for a long leg posterior splint with orthopedic referral due to comminuted tibia fracture. The noted time was 3:55pm. c) A chart control copy received by LVN #1 and signed by the occupational therapist on 10/7/15 to remain on strict non-weight bearing on the lower left extremity, left knee brace convert to hinged please and to work on ROM/ADLs. Record review of the facility's Abuse-Reportable Events policy and procedure revised 5/2014 showed it was policy to prohibit resident abuse or neglect in any form and to report in accordance with the law. Neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. In an interview with the Admin. on 10/15/15 at 1:40pm, when asked if the circumstances of Resident #1's injury resulting from improper transfer met the facility's definition of neglect, and after reviewing the facility's Abuse-Reportable Events policy and procedure revised 5/2014, he stated it was neglect. Record review of the document Statement of Resident Rights provided to resident/responsible party, revised 7/2006 reflected that each resident had the right to receive all care necessary to have the highest possible level of health and the right to be free from abuse/neglect. Record review of the Resident Roster printed and provided by the facility on 10/13/15 documented Resident #1 required 2 person transfer assistance. The document reflected 15 other residents required two person transfer assistance, 32 required one person, and 30 were independent.

Based on observation, interview and record review, the facility failed to implement its written policy and procedure that prohibits neglect for 1 of 13 residents (#1). The facility failed to: 1.) Nurse Aide #12 transferred resident #1 alone, and resident #1 required a 2-person transfer. This resulted in a fracture to resident #1's left knee. 2.) Thoroughly investigate Resident #1's fall with serious injury as a neglect allegation. 3.) Report Resident #1's incident to the appropriate authority within established procedures and timeframe. Failure of the facility to thoroughly investigate and report all suspected allegations of abuse and neglect within mandatory timeframe and to protect residents from further potential abuse or neglect affected 1 resident and could affect the protection from harm for the other 77 residents of the facility. Findings include: Record review of Resident #1's Resident Admission Record printed by the facility on 10/12/15 documented the resident was a [AGE] year old Hispanic male with a legal representative admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. of left tibia, late effects. In the entrance conference interview conducted with the Admin. on 10/12/15 at 9:35am, he stated the facility self-reported Resident #1's serious injury late because the facility was not aware the resident had a fracture until the week after the incident. The x-ray taken the day of the incident was negative for fracture. In an interview conducted with ADON #2 on 10/12/15 at 10:20am, she stated Resident #1 was admitted to the facility two months prior and was dependent upon staff for mobility in a wheeled chair. He required two person transfer assistance. Resident #1 currently had a fracture to the left leg received during a transfer performed by NA#12. Resident #1 had [MEDICAL CONDITION] (the wearing down of the cartilage that cushions the ends of the bones that usually occurs with aging or after injury) and a healed right knee injury received at his previous placement. Observation of Resident #1 conducted in his bedroom on 10/12/15 at 11:10am revealed he was seated in a Geri-chair with his legs elevated and had a visitor. Observation revealed the outline of the left knee brace under his sweat pants. In an interview conducted with Resident #1 on 10/12/15 at 11:10am, when asked how his left knee was injured, he stated in Spanish that he fell . When asked where he fell he stated, in Spanish, at school. His visitor stated he was confused. Confidential Interview C stated Resident #1 was injured when a nurse aide transferred him by herself. Record review of Resident #1's admission comprehensive MDS dated [DATE] documented the resident was admitted from another nursing home. The MDS documented the resident's preferred language was Spanish. He could usually understand others and others could usually understand him. He had no temporal orientation and his BIMS was 3 of 15 indicating severely impaired cognition. Resident #1 was totally dependent (full staff performance) upon 2 staff for transfers and totally dependent upon 1 staff for locomotion, requiring a wheelchair for mobility. He had impairment in ROM on both lower extremities. The resident received prn pain medication for occasional pain but could not rate the pain. He had not fallen since admission on 8/6/15. The resident's family did not participate in the assessment or goal setting. The resident's history, [DIAGNOSES REDACTED]. Record review of Resident #1's Admission Care Plan, admitted [DATE], admission [DIAGNOSES REDACTED]. The plan recommended the resident receive assistance from 2 staff for ambulation/transferring. Both lower extremities had limited ROM. The plan called for orthostatic precautions to reduce falls and injuries risk. (Orthostatic [MEDICAL CONDITION], also called postural [MEDICAL CONDITION], is a sudden fall in blood pressure that occurs when a person assumes a standing position, resulting in reduced blood flow to the brain and dizziness or [MEDICAL CONDITION].) Record review of Resident #1's Nursing Assistant Care Plan, dated 8/6/15, signed by LVN #3, reflected the resident was to receive 2 staff transfer assistance. Record review of Resident #1's Care Plan, problem start date 9/24/15, signed and dated by the DON, documented the resident had a left knee immobilizer related to a fractured left tibia. Record review of Resident #1's significant change in status comprehensive MDS assessment, observation reference date 9/25/15, documented his BIMS was 2, dropping 1 point since the previous comprehensive performed the month prior. Review fall history documented the resident experienced 1 fall since admission resulting in major injury. Major injury was defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. The assessment reflected impairment in ROM to both lower extremities. He received scheduled and prn pain medication for frequent pain. The resident was unable to describe pain intensity. In an interview with LVN #1 on 10/13/15 at 9:56am, she stated Resident #1 had a fractured left tibia obtained when he fell during a staff assisted transfer. In an interview with the DON on 10/13/15 at 2:23pm, when asked about Resident #1's history, she stated the resident had osteopenia -fragile bones- and had suffered a right knee fracture at his prior placement, approximately 6 months prior to admission. He required two staff transfer assist since admission. When asked to describe her knowledge of Resident #1's incident, she stated she was made aware during investigation that NA #12 answered Resident #1's call light. The date was 9/21/15. NA #12 had asked LVN #3 to assist her transfer the resident, which LVN #3 denied hearing. NA #12 attempted the transfer from geri-chair to bed without assistance, and ended up having to guide Resident #1 to the floor. NA #12 exit the bedroom to seek assistance from LVN #3 with Resident #1 and was described as being upset. The DON stated she was notified and observed the resident seated on the floor when she went to do the assessment. She stated she did not observe any evidence of injury or swelling and he did not complain of pain when assessed. Resident #1 tolerated PROM. She was notified by LVN #3 later that the resident was complaining of pain and observed swelling to his knee. The physician was notified and gave the order for an x-ray performed that day. X-ray results obtained at 9:30pm showed no fracture. The facility based its decision to not report the incident on the x-ray results obtained 9/21/15. The facility investigated the incident as an abuse allegation and determined the incident did not constitute abuse. The physician assessed Resident #1 on 9/24/15 and recommended left knee immobilizer and ordered an MRI. The MRI, scheduled for 9/26/15, could not be completed because Resident #1 had a pacemaker. The physician was notified and ordered a CT scan. The CT scan was performed on 9/30/15 confirming presence of fractured left tibia. Record review of Form 3613-A Provider Investigation Report for Resident #1's injury reflected it was dated 9/30/15 on the FAX Cover Sheet, and signed and dated by the Administrator on 10/2/15. The report reflected the incident occurred on 9/21/15 at 3:25pm and was categorized as neglect. It described the resident as requiring extensive assistance with functional ability, did not ambulate independently and had weakness of the lower extremities. The document identified the resident as having the capacity to make informed decisions. Nurse Aide #12 was identified as the alleged perpetrator and written in the column for license/certificate number was nurse aide. There was no witness to the incident other than Nurse Aide #12 and Resident #1. Description of the allegation was nurse aide was attempting to transfer a resident from chair to bed and resident's legs gave way and staff member stated she lowered him to the floor. The resident's left leg was painful and began to swell. He was assessed by a nurse at 3:30pm and had small amount of swelling, no bruising, and voiced some pain. The Provider's Response reflected the resident was assessed and there was no signs or symptoms of injury, and requested an x-ray. The x-ray was done 9/21/15 and showed no evidence of a fracture. Abuse was ruled out. The incident was not called in at that time. Review of the Investigation Summary on page 3 of Form 3613-A noted the resident's leg continued to swell over days and the resident was taken to see the physician. The physician ordered an MRI which could not be performed because Resident #1 had a pacemaker. A CT scan was ordered and completed on 9/30/15 which showed a fracture to the left tibia, which initiated the neglect investigation. Form 3613-A had additional documents attached as part of the investigation including: · Resident #1's Admission/Readmission Data Summary dated 8/6/15 that reflected he required 2 person transfer assistance. · Resident #1's Radiology Interpretation, report completion date 8/7/15 (prior to incident), that reflected the resident's right knee was x-rayed, 2 views, due to history of pain. The report documented the resident had a previous fracture in January 2015. The resident had moderate ostopenia (loss of bone mass not as severe as [MEDICAL CONDITION]). Alignment was normal and no fracture, dislocation or acute bony abnormality was seen. · NA #12's signed Witness Statement dated 9/21/15 that reflected the resident's legs gave out during transfer and she sat him down. · Incident/Accident report written by LVN #3, signed by the DON on 9/22/15 and by the Admin. on 9/23/15 reflected the incident occurred in Resident #1's bedroom on 9/21/15 at 3:25pm. Documentation showed CNA #7 reported to LVN #3 that she entered Resident #1's bedroom to assist NA #12 transfer the resident but the resident was sitting on the floor with NA #12 stating she did not drop the resident. The DON was notified and assisted with transferring the resident from the floor to the bed. The resident complained of left knee pain, which was swollen and reported that he twisted his left knee. He received [MEDICATION NAME] for pain and the physician was notified. · Notice of Disciplinary Action, notice date 9/22/15, that reflected the DON gave NA #12 a verbal notice on 9/22/15 for violating policy when she transferred Resident #1 from the Geri-chair to the bed without getting assistance from other staff on 9/21/15. · Accident/Incident Final Disposition Report, signed by the DON 9/22/15 and by the Admin. on 9/23/15, documented NA #12 assisted Resident #1 to the floor when his legs became weak and gave out when transfer to bed from Geri-chair was attempted. X-ray results received the same day showed no fracture. Record review of Resident #1's Radiology Interpretation, exam date 9/21/15, report completion date/time of 9/23/15 at 2:09pm, indicated the resident's left knee was x-rayed due to pain. The document indicated: PHYSICIAN: Fall, HISTORY: Swelling, and Comparison: None. Findings: There are arthritic and [DIAGNOSES REDACTED]lacia changes of the knee (damage to the cartilage lining the knee and under the kneecap) with [DIAGNOSES REDACTED] (bony overgrowth) changes to the patella (kneecap), femur (thighbone), and tibia (highest part of the shinbone) with interspace narrowing (joint space narrowing), but there is no acute trauma. The document had a Faxed stamp mark with LVN #1's initials, dated 9/23/15 and timed 3pm. In an interview with CNA #7 on 10/14/15 at 10:58am, she stated LVN #3 requested her assistance with helping NA #12 transfer Resident #1. Resident #1 was seated on the floor when she entered his bedroom. The DON entered the bedroom soon after CNA #7. She stated staff was aware the resident could not bear weight since admission and that he required two person transfer assistance. In an interview with CNA #13 on 10/14/15 at 11:30am she stated Resident #1 could not bear weight and the facility implemented 2 staff transfer assistance at admission. She was aware the resident had a history of [REDACTED]. In an interview with LVN #3 on 10/14/15 at 12:04pm she stated she was Resident #1's charge nurse the day of the incident. She stated NA #12 was new to the facility at the time of the incident. LVN #3 was at the nurse's station when NA #12 asked her to help transfer Resident #1. She told NA #12 she would get another aide to help. NA #12 went back to his bedroom and attempted the transfer without assistance. She went back to the nurse's station and reported to LVN #3 she needed help. LVN #3 went to assist and observed the resident sitting on the floor with his legs in front of him. The DON was notified, performed the assessment, and assisted 2 staff with transferring the resident to his bed from the floor. Resident #1's left knee was x-rayed and showed no fracture. Staff was aware the resident required 2 staff transfer assistance. In an interview with LVN # 4 on 10/14/15 at 3:26pm she stated she provided direct supervision to NA #12, and that NA #12 was a new employee. NA #12 had never been assigned to Resident #1's hall but each aide was expected to assist in other halls when needed. NA #12 was not catching on as quickly as the other aides and needed more assistance and coaching than other staff. NA #12 reported that she was not able to perform the lifts. She stated she had made her supervisors aware that NA #12 was not meeting duty expectations. Record review of NA #12's personnel record reflected the Application for Employment was dated 7/29/15. The application documented she had completed her CNA coursework but was not certified. The facility performed checks of the EMR and NAR. No results were found for NA #12 on either registry. Record review of NA #12's iSeries History report printed by the facility on 10/15/15 at 12:17pm documented a complete report of the dates worked including time punched in, time punched out, and number of hours worked since 8/10/15. The document reflected on 9/21/15 NA #12 worked from 6:34am to 6:52pm. In an interview with NA #12 on 10/15/15 at 7:48am, she stated she was hired on 8/10/15 but then had a family emergency and did not return to work until 8/30/15. She was not certified but within her 4 month window to take the test for certification. She had not provided care to Resident #1 prior to the incident. The day of the incident, Monday, she answered Resident #1's call light because the other aides were on break. Resident #1 asked to be transferred to his bed from the Geri-chair. She knew she would need assistance and went to the nurse's station to ask LVN #3 for assistance with his transfer. LVN #3 told her that she would get a CNA to assist her. She returned to the room and attempted the transfer to complete the task and move on to the next task. She was not tall enough or strong enough to guide him onto the bed and his legs slipped from under him. He fell on to his left knee and sat on the floor with his left leg underneath him. She got his leg from underneath him and went to inform LVN #3 who notified the DON. She stated she worked the rest of the shift but called in the next day. The next scheduled work day was Friday. She called the DON on Thursday to request working only 9-6 and on a prn basis, which was approved. She worked Friday then and quit Saturday because she was overwhelmed and felt she could not fulfill her duties. She stated her supervisors were aware she was overwhelmed with her duties. She stated she was not aware the facility self-reported the incident the following week naming her as the alleged perpetrator of neglect. Record review of the facility's Incident/Accident Tracking and Trending Log for September 2015 showed the incident was documented as a non-preventable fall, dated 9/21/15. The injury was documented as swelling to the leg. Record review of the facility's Lifting and Movement of Resident-Safe policy and procedure effective 2/2015 reflected it was policy to protect resident safety and well-being by using appropriate techniques and devices to lift and move residents. Resident safety and medical condition would be incorporated into goals and decisions regarding lifts and transfers. Record review of the All Direct Care Staff Inservice Training Report dated 9/23/15, subject transferring resident, reflected staff was in-serviced by nursing administration for 5-10 minutes on using gait belts to assist residents transfer and ensuring residents requiring 2 staff transfers received assistance from 2 staff. Record review of the facility's undated and non-enumerated multiple paged training tool entitled Transfer Training provided by the Admin. on 10/15/15 reflected one page titled TRANSFER SAFETY recommended to consider using a lift transfer device if the patient was particularly heavy or had difficulty supporting own weight, and when in doubt, request additional assistance. Record review of Resident #1's Care Plan, page 22 of 25, category ADL Functional/Rehabilitation Potential, problem start date 8/27/15, reflected the resident required extensive assistance by 2 staff for transfers. The page was signed by the DON but not dated. Review of the Falls category, page 7 of 22, problem start date 8/27/15, reflected the resident had a history of [REDACTED]. The DON signed the page and dated 8/27/15. Record review of Resident #1's Physician order [REDACTED]. Review of the General flow sheet section documented the orders dated 9/24/15 for bed rest and the knee immobilizer both carried the [DIAGNOSES REDACTED]. Record review of Resident #1's Physician's Telephone Orders, copied from the chart by the surveyor on 10/13/15 showed the following: · original copy of an order signed by the physician on 9/24/15, received by LVN #1 (no time noted), for the knee immobilizer, MRI left knee, and [MEDICATION NAME] 800mg three times daily for 2 weeks for the [DIAGNOSES REDACTED]. · unsigned chart control copy of an order dated 9/24/15 received by LVN #1 to place on bed rest until further orders for the [DIAGNOSES REDACTED]. · unsigned chart control copy of the order dated 9/26/15 received by LVN #3 for a CT scan of the left knee. · unsigned chart control copy dated 10/1/15 received by LVN #3 for a long leg posterior splint with orthopedic referral due to comminuted tibia fracture. Record review of Resident #1's All Disciplines to Use Progress Notes showed the following: Monday 9/21/15 · 3:25pm: LVN #3 documented a nurse aide reported to her that she found Resident #1 sitting on the floor when she entered his room to assist a different nurse aide with transferring the resident to bed. The DON was called to assist with transferring the resident to bed. · 3:45pm: LVN #3 documented she called the physician and spoke with his nurse due to Resident #1 complaining of left knee pain. His left knee was swollen and painful when touched. LVN #3 documented the quote attributed to the resident my knee got twisted. Do you have a shot for my knee? It was documented that she reassured the resident he would be medicated with [MEDICATION NAME]. · 3:45pm: LVN #3 documented another call to the physician, spoke with his nurse about the resident's left knee, and obtained an order for [REDACTED].>· 4:30pm: LVN #3 contacted the x-ray provider to request an x-ray. · 8:05pm: LVN #5 documented the mobile x-ray provider was in building to obtain xray of L knee. X 1 staff assisted. Resident tolerated procedure well. · 9:30pm: LVN #5 received results of x-ray via fax and documented findings of moderate joint effusion, no evidence of acute fracture or dislocation. Findings state multiple views of R knee, which is an error the L knee was examined and xrayed this nurse and family were @ bedside during procedure. LVN #5 faxed the results to the physician and documented she would notify the next shift. Wednesday 9/23/15 · 3:30pm: LVN #1 called the physician and scheduled an appointment for Resident #1 for 10:30am on 9/24/15 due to the continued swelling and bruising of the left knee. Thursday 9/24/15 · 6:45am: LVN #1 documented Resident #1 was at 72 hours status [REDACTED]. A knot had developed above the left knee. · 12:35pm: LVN #1 documented Resident #1 returned from his appointment with orders for a knee immobilizer, MRI to left knee and [MEDICATION NAME] 800mg three times daily for 2 weeks. · 12:35pm (second entry): LVN #1 was told by CNA/Transport #9 the doctor recommended bed rest until the MRI was completed. LVN #1 contacted the hospital and scheduled the MRI for Saturday 9/26/15. Saturday 9/26/15 · 4:50pm: The MRI was canceled due to Resident #1 having a pacemaker. · 6:20pm: Resident #1's physician called LVN #3 with an order to obtain a CT scan of the left knee. Wednesday 9/30/15 · 3:04pm: LVN #3 was contacted by the physician's nurse and notified LVN #3 that Resident #1 had a left tibia fracture. Record review of Resident #1's Physical Therapy Daily Note, service date 9/23/15, electronically signed by the physical therapist on 9/27/15 documented observation of pt. L knee. Extensive bruising, entire knee TTP, increased [MEDICAL CONDITION] compared to R knee, warm to touch, and decreased knee extension ROM secondary to pain. Pt. stated that he landed on his knee. This was discussed with nursing who stated he was lowered to the ground. Nursing was asked to speak with the physician regarding ordering an MRI for pt. L knee. The document reflected the resident received physical therapy for difficulty walking, lack of coordination and general muscle weakness. His discharge date was 9/30/15. The resident described his pain as 9 of 10. Record review of Resident #1's Department of Radiology CT exam results performed 9/30/15 and electronically signed by the reading radiologist on 9/30/15 at 3:32pm indicated the resident's distal femur (thighbone just above the knee) and patella were intact. There was comminuted fracture (shattering) of the proximal tibia (the top part of the shinbone) with a [MEDICATION NAME] component through the metaphysis (horizontal break of the flared part of the shinbone underneath the knee) and a vertical (up and down) component into the articular surface near the intercondylar notch (the area of the knee where the tibia and femur are joined making the fracture triangular shaped). Also noted was the non-displaced [MEDICAL CONDITION] head (stable [MEDICAL CONDITION] of the smaller bone of the leg), and small associated joint effusion (fluid buildup in the knee joint causing swelling, caused by arthritis or by injury or trauma). Record review of both pages of Resident #1's Pain Management Flow Sheet, containing entries for September 2015, reflected prn administration of medication used for pain. On 9/21/15, the resident received Tylenol at 2am for general pain and [MEDICATION NAME] ([MEDICATION NAME]), a narcotic-like pain reliever at 11:45am for general pain. On 9/21/15 the resident received [MEDICATION NAME] (Schedule II narcotic) at 3:30pm for leg pain and at 8:05pm for left knee pain. On 9/22/15 he received [MEDICATION NAME] at 12:35am and 8:3pm for left knee pain. Page 2 reflected the resident received [MEDICATION NAME] for left knee pain on 9/23/15, twice on 9/24/15, on 9/27/15, and twice on 9/30/15. Review reflected from 9/21/15 to 9/20/15 the resident received the narcotic pain reliever [MEDICATION NAME] only once. In an interview with the DON on 10/15/15 at 12:21pm, she stated the decision to not implement the facility's abuse/neglect policy and procedure when Resident #1 fell during an improper transfer was based on the first x-ray taken of the left knee that was negative for fracture. In an interview with the Admin. on 10/15/15 at 1:40pm, he stated he delegated the investigation to the DON and was unaware Resident #1's signs and symptoms of injury appeared immediately and he was told the x-ray results showed he was negative for a fracture and abuse was ruled out the same day of the incident. The Admin. was asked if the circumstances surrounding the incident-immediate signs and symptoms of injury severe enough to warrant immediate and frequent doses of narcotic pain medication, obtained from staff failure to follow the care plan, and with the Resident #1 reporting he twisted his leg and fell on his knee- met the facility's definition of neglect. After reviewing the facility's Abuse-Reportable Events policy and procedure revised 5/2014 he stated he should have called the incident when it happened rather than waiting to receive confirmation of the fractures. Record review of the facility's Abuse-Reportable Events policy and procedure revised 5/2014 showed it was policy to prohibit resident abuse or neglect in any form and to report in accordance with the law. Neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Incidents resulting in serious bodily injury, definition including extreme physical pain, impairment of the function of a bodily member, had a 2 hour reporting timeline if abuse/neglect was suspected and a 24 hour reporting timeframe for all other allegations not involving serious injury. Record review of the Resident Roster printed and provided by the facility on 10/13/15 documented census of 78.

Based on observation, interview and record review, the facility failed to ensure that 1 of 13 residents (#1) received the adequate supervision and assistance devices to prevent accidents. Nurse Aide #12 transferred resident #1 alone, and resident #1 required a 2-person transfer. This resulted in a fracture to resident #1's left knee. Failure of the facility to protect against avoidable accidents resulted in injury for 1 resident and could affect the health, safety and well-being of the other 15 residents requiring 2 person transfer assistance. Findings include: Record review of Resident #1's Resident Admission Record printed by the facility on 10/12/15 documented the resident was a [AGE] year old Hispanic male with a legal representative admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. of left tibia, late effects. Record review of Resident #1's Admission Care Plan, admitted [DATE], admission [DIAGNOSES REDACTED]. The plan recommended the resident receive assistance from 2 staff for ambulation/transferring. Both lower extremities had limited ROM. The plan called for orthostatic precautions to reduce falls and injuries risk. (Orthostatic hypotension, also called postural hypotension, is a sudden fall in blood pressure that occurs when a person assumes a standing position, resulting in reduced blood flow to the brain and dizziness or fainting.) Record review of Resident #1's admission comprehensive MDS dated [DATE] documented the resident was admitted from another nursing home. The MDS documented the resident's preferred language was Spanish. He could usually understand others and others could usually understand him. He had no temporal orientation and his BIMS was 3 of 15 indicating severely impaired cognition. Resident #1 was totally dependent (full staff performance) upon 2 staff for transfers and totally dependent upon 1 staff for locomotion, requiring a wheelchair for mobility. He had impairment in ROM to both lower extremities. The resident received prn pain medication for occasional pain but could not rate the pain. The resident had not fallen since admission on 8/6/15. The resident's family did not participate in the assessment or goal setting. The resident's history, [DIAGNOSES REDACTED]. Record review of Resident #1's Care Plan, page 22 of 25, category ADL Functional/Rehabilitation Potential, problem start date 8/27/15, reflected the resident required extensive assistance by 2 staff for transfers. The page was signed by the DON but not dated. Review of the Falls category, page 7 of 22, problem start date 8/27/15, reflected the resident had a history of [REDACTED]. The DON signed the page and dated 8/27/15. Record review of Resident #1's Nursing Assistant Care Plan, dated 8/6/15, signed by LVN #3, reflected the resident was to receive 2 staff transfer assistance. The plan was located in a 3 ring binder labeled ADLs located at the nurse's station. In an interview conducted with ADON #2 on 10/12/15 at 10:20am, she stated Resident #1 was admitted to the facility two months prior and was dependent upon staff for mobility in a wheeled chair. He required two person transfer assistance. Resident #1 had osteoarthritis (the wearing down of the cartilage that cushions the ends of the bones that usually occurs with aging or after injury) and a healed right knee injury received at his previous placement. Resident #1 currently had a fracture to the left leg received during a one person transfer performed by NA#12. Resident #1's leg was not surgically repaired because the fracture was non-displaced (stable). Observation of Resident #1 conducted in his bedroom on 10/12/15 at 11:10am revealed he was seated in a Geri-chair with his legs elevated, visiting with a family member. Observation revealed the outline of the left knee brace under his sweat pants. In an interview conducted with Resident #1 on 10/12/15 at 11:10am, when asked how his left knee was injured, he stated in Spanish that he fell . When asked where he fell he stated at school. His visitor stated Resident #1 was confused. Confidential Interview C stated Resident #1 was injured when a nurse aide transferred the resident by herself. Resident #1 had lived at the facility for approximately two months. The resident was transferred with a lift at his former placement because his legs were weak and he had a non-surgically repaired knee fracture obtained during a fall earlier in the year. In an interview with LVN #1 on 10/13/15 at 9:56am, she stated Resident #1 had a fractured left tibia obtained when he fell during a staff assisted transfer. In an interview with the DON on 10/13/15 at 2:23pm, when asked about Resident #1's history, she stated the resident had osteopenia -fragile bones- and had suffered a right knee fracture at his prior placement, approximately 6 months prior to admission. He required two staff transfer assist since admission. When asked to describe her knowledge of Resident #1's incident/injury, she stated on 9/21/15 NA #12 answered Resident #1's call light. NA #12 had asked LVN #3 to assist her transfer the resident. NA #12 attempted the transfer from Geri-chair to bed without assistance, was unable to complete the transfer and guided Resident #1 to the floor. In an interview with CNA #7 on 10/14/15 at 10:58am, she stated LVN #3 requested her assistance with helping NA #12 transfer Resident #1. Resident #1 was seated on the floor when she entered his bedroom. The DON entered the bedroom soon after CNA #7. She stated staff was aware the resident could not bear weight since admission and that he required two person transfer assistance. In an interview with CNA #13 on 10/14/15 at 11:30am she stated Resident #1 could not bear weight prior to the incident and at admission his family had requested the resident be transferred using a lift. The facility implemented 2 staff transfer assistance at admission. She was aware the resident had a history of [REDACTED]. In an interview with LVN #3 on 10/14/15 at 12:04pm she stated she was Resident #1's charge nurse the day of the incident. She stated NA #12 was new to the facility at the time of the incident. LVN #3 was at the nurse's station when NA #12 asked her to help transfer Resident #1. She told NA #12 she would get another aide to help. NA #12 went back to his bedroom and attempted the transfer without assistance. She went back to the nurse's station and reported to LVN #3 she needed help. LVN #3 went to assist and observed the resident sitting on the floor with his legs in front of him. LVN #3 stated she was aware that NA #12 had difficulty performing her tasks. Record review of the facility's Incident/Accident Tracking and Trending Log for September 2015 showed Resident #1's fall was documented as non-preventable, dated 9/21/15. Record review of Form 3613-A Provider Investigation Report for Resident #1's injury reflected it was dated 9/30/15 on the FAX Cover Sheet, and signed and dated by the Administrator on 10/2/15. The report reflected the incident occurred on 9/21/15 at 3:25pm and was categorized as neglect. It described the resident as requiring extensive assistance with functional ability, did not ambulate independently and had weakness of the lower extremities. NA #12 was identified as the alleged perpetrator and written in the column for license/certificate number was nurse aide. Description of the allegation was nurse aide was attempting to transfer a resident from chair to bed and resident's legs gave way and staff member stated she lowered him to the floor. The resident's left leg was painful and began to swell. He was assessed by a nurse at 3:30pm and had small amount of swelling, no bruising, and voiced some pain. The Provider's Response reflected the CT scan completed on 9/30/15 showed a fracture to the left tibia. Additional investigation documents included: · Resident #1's Admission/Readmission Data Summary dated 8/6/15 that reflected he required 2 person transfer assistance. · Resident #1's Radiology Interpretation, report completion date 8/7/15 (prior to incident), that reflected the resident's right knee was x-rayed, 2 views, due to history of pain. The report documented the resident had a previous fracture in January 2015. The resident had moderate osteopenia (loss of bone mass not as severe as osteoporosis). Alignment was normal and no fracture, dislocation or acute bony abnormality was seen. · NA #12's signed Witness Statement dated 9/21/15 that reflected the resident's legs gave out during transfer and she sat him down. · Incident/Accident report written by LVN #3, signed by the DON on 9/22/15 and by the Admin. on 9/23/15 reflected the incident occurred in Resident #1's bedroom on 9/21/15 at 3:25pm. Documentation showed LVN #3 asked CNA #7 to assist NA #12 transfer Resident #1, and CNA #7 reported to LVN #3 that she entered Resident #1's bedroom to assist NA #12 and saw the resident sitting on the floor with NA #12 stating she did not drop the resident. The resident complained of left knee pain, which was swollen and reported that he twisted his left knee. · Accident/Incident Final Disposition Report, signed by the DON 9/22/15 and by the Admin. on 9/23/15, documented NA #12 assisted Resident #1 to the floor when his legs became weak and gave out when transfer to bed from Geri-chair was attempted. Record review of Resident #1's Radiology Interpretation, exam date 9/21/15, report completion date/time of 9/23/15 at 2:09pm, indicated the resident's left knee was x-rayed due to pain. The document indicated: PHYSICIAN: Fall, HISTORY: Swelling, and Comparison: None. Findings: There are arthritic and [DIAGNOSES REDACTED]lacia changes of the knee (damage to the cartilage lining the knee and under the kneecap) with [DIAGNOSES REDACTED] (bony overgrowth) changes to the patella (kneecap), femur (thighbone), and tibia (highest part of the shinbone) with interspace narrowing (joint space narrowing), but there is no acute trauma. Record review of Resident #1's Physical Therapy Daily Note, service date 9/23/15, electronically signed by the physical therapist on 9/27/15 documented observation of pt. L knee. Extensive bruising, entire knee TTP, increased edema compared to R knee, warm to touch, and decreased knee extension ROM secondary to pain. Pt. stated that he landed on his knee. The document reflected the resident received physical therapy for difficulty walking, lack of coordination and general muscle weakness. His discharge date was 9/30/15. The resident described his pain as 9 of 10. Record review of the All Direct Care Staff Inservice Training Report dated 9/23/15, subject transferring resident, reflected staff was in-serviced by nursing administration for 5-10 minutes on using gait belts to assist residents transfer and ensuring residents requiring 2 staff transfers received assistance from 2 staff. Record review of Resident #1's significant change in status comprehensive MDS assessment, observation reference date 9/25/15, documented his BIMS was 2, dropping 1 point since the previous comprehensive performed the month prior. Review fall history documented the resident experienced 1 fall since admission resulting in major injury. Major injury was defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. The assessment reflected impairment in ROM to both lower extremities. He received scheduled and prn pain medication for frequent pain. The resident was unable to describe pain intensity. Record review of Resident #1's Care Plan, problem start date 9/24/15, signed and dated by the DON, documented the resident had a left knee immobilizer related to a fractured left tibia. Record review of Resident #1's Department of Radiology CT exam results performed 9/30/15 and electronically signed by the reading radiologist on 9/30/15 at 3:32pm indicated the resident's distal femur (thighbone just above the knee) and patella were intact. There was comminuted fracture (shattering) of the proximal tibia (the top part of the shinbone) with a transverse component through the metaphysis (horizontal break of the flared part of the shinbone underneath the knee) and a vertical (up and down) component into the articular surface near the intercondylar notch (the area of the knee where the tibia and femur are joined making the fracture triangular shaped). Also noted was the non-displaced fracture of the fibular head (stable fracture of the top of the smaller bone of the leg), and small associated joint effusion (fluid buildup in the knee joint causing swelling, caused by arthritis or by injury or trauma). In an interview with LVN # 4 on 10/14/15 at 3:26pm she stated she provided direct supervision to NA #12. She stated she was aware that NA #12 had difficulty with performing transfers and had made her supervisors aware. In an interview with NA #12 on 10/15/15 at 7:48am, she stated she had never been assigned Resident #1's hall. The day of the incident, she answered Resident #1's call light because the other aides were on break. Resident #1 asked to be transferred to his bed from the Geri-chair. She knew she would need assistance and went to the nurse's station to ask LVN #3 for assistance with his transfer. LVN #3 told her that she would get a CNA to assist her. She returned to the room and attempted the transfer by herself to complete the task and move on to the next task. She was not tall enough or strong enough to guide him onto the bed and his legs slipped from under him. He fell on to his left knee and sat on the floor with his left leg underneath him. She got his leg from underneath him and went to inform LVN #3 who notified the DON. She finished her shift the day of the incident and worked one more day before self-terminating her employment. She was overwhelmed and felt she could not fulfill her duties. She stated her supervisors were aware she was overwhelmed with her duties. In an interview with ADON #1 on 10/15/15 at 9:57am, she stated she was aware that NA #12 was not performing as expected and did not think she was going to make it. Record review of the facility's Lifting and Movement of Resident-Safe policy and procedure effective 2/2015 reflected it was policy to protect resident safety and well-being by using appropriate techniques and devices to lift and move residents. Resident safety and medical condition would be incorporated into goals and decisions regarding lifts and transfers. Manual lifting should be eliminated when feasible and ongoing assessment for transfer assistance needs. Assessments should include resident preference, degree of mobility, size, weight-bearing ability, cognitive status, etc. Mechanical lifts should be made available and accessible 24 hours a day. Record review of Resident #1's Physician's Telephone Orders, copied from the chart by the surveyor on 10/13/15 showed the following: · original copy of an order signed by the physician on 9/24/15, received by LVN #1 (no time noted), for the knee immobilizer, MRI left knee, and Ibuprofen 800mg three times daily for 2 weeks for the [DIAGNOSES REDACTED]. · unsigned chart control copy dated 10/1/15 received by LVN #3 for a long leg posterior splint with orthopedic referral due to comminuted tibia fracture. The noted time was 3:55pm. · chart control copy received by LVN #1 and signed by the occupational therapist on 10/7/15 to remain on strict non-weight bearing on the lower left extremity, left knee brace convert to hinged please and to work on ROM/ADLs. Record review of the facility's undated and non-enumerated document entitled Transfer Training provided by the Admin. on 10/15/15 reflected one page titled TRANSFER SAFETY recommended to consider using a lift transfer device if the patient was particularly heavy or had difficulty supporting own weight, and when in doubt, request additional assistance. Record review of the Resident Roster printed and provided by the facility on 10/13/15 documented Resident #1 required 2 person transfer assistance. The document reflected 15 other residents required two person transfer assistance, 32 required one person, and 30 were independent.