Every finding on record at Madison Medical Resort

Based on observation, interview and record review the facility failed to ensure a resident who was fed by eternal means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of eternal feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for 3 of 5 residents (Residents #3, #9 and #10) reviewed for PEG tube feeding. 1. The facility failed to ensure Resident #3's enteral feedings bag was correctly dated when it was changed on 07/21/2026 at 9:07 a.m. 2. The facility failed to ensure Resident #3 was in a proper position while on continuous enteral formula to mitigate the potential for aspiration on 07/21/2026 at 9:21 a.m. and 07/22/2026 at 1:35 a.m. 3. The facility failed to ensure Resident #9 enteral feeding bag was labeled and dated with order information on 07/21/2026 at 11:58 a.m. 4. The facility failed to ensure Resident #10 enteral feeding bag was labeled and dated with order information on 07/21/2026 at 12:23 p.m. These deficient practices could place residents at risk of potential aspiration or administration errors by not labeling the enteral feeding bag. Findings include: 1. Record review of Resident #3's admission sheet, dated 07/22/2026, revealed a [AGE] year-old-female with an initial admission date of 06/24/2026. Record review of Resident #3's unspecified MDS dated [DATE], revealed the resident had a BIMS score of 99, with the significance being the resident was unable to complete the interview. Under section GG - Mobility revealed the resident was coded for being dependent for rolling left to right, sit to lying, lying to sitting on side of bed, and chair/bed-to-chair transfer. Under section K - Swallowing/nutritional status revealed the resident had a feeding tube on admission and while a resident. Record review of Resident #3's care plan, dated 06/25/2026, revealed the resident had a focus for the resident's tube feeding and aspiration pneumonia (a lung infection caused by breathing food, liquid, vomit, or saliva into the airways) with an intervention in the form of the resident needs head of bed elevated to 45 degrees during and 35 minutes after tube feed. An additional focus area for the risk for pressure ulcer development with the intervention of assist, with turning and repositioning frequently. Record review of Resident #3's history and physical, dated 07/06/2026, revealed the resident was diagnosed with chronic obstructive pulmonary disorder (a long-term lung condition that makes it hard to breathe, mainly caused by emphysema and chronic bronchitis), cerebellar stroke (blood flow to the cerebellum is blocked or a blood vessel bursts), elevated troponin likely type II demand ischemia (heart muscle experienced stress from an oxygen supply and demand mismatch), and aspiration pneumonia. In an observation on 07/21/2026 at 8:58 a.m., Resident #3 was unable to engage in an interview due to cognitive deficits. It was observed the resident was on PEG tube feedings with a pump in place for delivery. The eternal feeding bag and hydration bag were dated 07/20/2026 at 3:30 a.m. by RN N. Resident #3 was resting at a 30-degree angle but was leaning towards the right side of her bed hugging her legs and sinking her head below chest level, until 9:33 a.m. when she was transferred to the shower by staff. In a follow-up observation Resident #3 was in a compromised position, sinking in the bed to a flat position and knees to chest, on 07/22/2026 at 1:35 a.m. until it was brought to attention of RN J at 2 a.m. and corrected. 2. Record review of Resident #9's admission sheet, dated 07/23/2026, revealed a [AGE] year-old female with an original admission date of 06/03/2026. Record review of Resident #9's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 15, with the significance being the resident was cognitively intact. Under section K - Swallowing/nutritional status revealed the resident had a feeding tube while a resident. Record review of Resident #9's care plan, dated 06/04/2026, with an intervention in the form of requiring tube feeding and goal to remain free of side effects or complications related to tube feeding through review date (06/22/2026). Record review of Resident #9's history and physical, dated 06/05/2026, revealed the resident was diagnosed with myopathy (a disease of the muscle fibers that causes muscle weakness, cramps, and stiffness), malnutrition (getting too few, too many, or the wrong balance of nutrients), parotoid gland tumor (an abnormal growth of cells in the parotid glands, which are the largest salivary glands located just in front of the ears.), thyroid cancer (a growth of cells in the butterfly-shaped gland at the base of the neck), and chronic dysphagia (trouble swallowing). In an observation on 07/21/2026 at 11:57 a.m., Resident #9 stated she had not been at the facility long and she had difficulty communicating due to throat cancer. She was observed coughing and expressed difficulty breathing due to build-up of phlegm and saliva in her mouth and was on NPO orders. She stated she did not want to notify staff to provide suctioning because they were completing meal delivery at the time. She stated she had been on her PEG tube feeding for 5 years. It was observed her eternal feeding bag and hydration bag was unlabeled. She stated she could not recall when the facility had changed her feeding bag. 3. Record review of Resident #10's admission, dated 07/23/2026, revealed a [AGE] year-old male with and original admission date of 04/17/2026 and a readmission date of 07/16/2026. Record review of Resident #10's Significant change MDS, dated [DATE], revealed the resident had a BIMS score of 1, with the significance being the resident had severe cognitive impairment. Under section GG - Mobility revealed the resident was coded for needing substantial to maximal assistance for rolling left to right, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, and sit to stand. Under section K - Swallowing/nutritional status revealed the resident had a feeding tube while a resident. Record review of Resident #10's care plan, dated 05/20/2026, revealed the resident had a focus area for the risk for pressure ulcer development with the intervention of assist with turning and repositioning frequently. An additional focus area for PEG tube with interventions of keeping the head of bed at a 45-degree angle at all times while receiving continuous feed. Record review of Resident #10's history and physical, dated 06/11/2026, revealed the resident was diagnosed with cerebral infarction (the death of brain tissue caused by a blocked blood vessel) and Alzheimer's disease with late onset (a progressive brain disorder that destroys memory, thinking skills, and the ability to carry out simple tasks but with an onset later than [AGE] years of age) In an observation on 07/21/2026 at 11:53 a.m., Resident #10 was observed in his geriatric chair resting at a 30-degree angle for PEG tube feeding. His eternal feeding bag and hydration bag were both undated and unlabeled. Resident #10 was only able to acknowledge conversation but not able to participate or complete yes/no questions. In an interview on 07/21/2026 at 10:10 a.m., LVN F stated Resident #3 was leaning toward the right side of the bed since 6:45 a.m. She stated the resident was meeting the 30-degree angle required for PEG tube feeding and the resident had a wedge to her right side since she often self-adjusted. She stated Resident #3 often attempted to get into a fetal position. She stated Resident #3 could not be in fetal position due to her PEG tube feeding in place and added Resident #3's head needed to be near the top of the head rest. She stated this was done to ensure Resident #3 did not aspirate and limit the use of her abdominal muscles. She stated she did not know if Resident #3 was in a fetal position before her transfer to the shower or for how long Resident #3 was in that position since she rounded on her earlier. She stated Resident #3 was on continuous feeding. She stated Resident #3 was not in the proper position when she went in to assist in transferring the resident to the shower chair. She stated there was frequent repositioning training and added the last in service was July 2026. She stated Resident #3 was non-responsive and was having respiratory distress sent to the hospital on [DATE]. She stated Resident #3 was admitted into the hospital with an admitting diagnosis of aspiration pneumonia. She stated Resident #3 was on the eternal feeding tube since admission. She stated the eternal feeding bag was usually changed at night by the overnight nurse. She stated once the bag was empty the resident would receive a new bag. She stated the eternal feeding bag and hydration bag were changed daily. She stated the nurse was responsible for changing the eternal feeding bag and hydration bag and it needed to be labeled with flow rate, formula, name of nurse and resident, date and time. She stated the nurses received annual competency check on hire and their anniversary. She stated the last one she completed was in September 2025 and provided by one of the ADONs. She stated the machine would notify staff if it was malfunctioning. She stated if the eternal feeding bag was unlabeled it could spoil and cure and needed to be checked daily. She stated if the eternal feeding bag was older than 24 hours, she would discard it and start a new bag and proceeded to do so for Resident #3. In an interview on 07/21/2026 at 2:49 p.m., CNA G stated Resident #3 needed to be rotated every 2 hours. She stated a resident who was on a feeding tube needed to have their feeding paused during the staff repositioning. She stated the process was to lay the bed down and adjust their head near the headboard, then return the bed to an angle of 80 degrees (minimum) and then resume the feeding. She stated she could not recall the last in service she received for repositioning residents on feeding tubes. She stated this needed to be done so residents did not aspirate during feeding or care. She stated that if a resident aspirated, they could choke and die. She stated the nurses and CNAs were responsible for ensuring Resident #3 was not in a compromised position or lying near flat. She stated Resident #3 had a habit of curling into a fetal position and added they did in frequent checks in passing in addition to rounding every 2 hours. She stated she just checked eternal feeding bags to see if they were empty but did not make any adjustments or changes. She stated the nurse was responsible for ensuring the eternal feeding bag was dated, labeled, and not spoiled. In an interview on 07/22/2026 at 1:09 AM, CNA H stated she was not aware about the incident regarding Resident #3 being sent to the hospital and there had not been any complications with the Resident #3 and #11utilizing a feeding tube in her hallway. She stated the resident needed to be at a 45-degree angle and could not lie flat. She stated a resident with a feeding tube who was laying flat could develop pneumonia, vomiting, or get food in their lungs. She stated during incontinent care she had to stop the feeding tube, and waited sometimes 5-10 minutes before laying residents flat for incontinent care. She stated Resident #3 could not be flat at all because she had a lot of mucus and it could cause her to choke or aspirate. She stated she monitored Resident #3's position every 30 minutes specifically for residents with frequent falls and feeding tubes. She stated a resident with feeding tube complications would have their machine beep, monitor facial queues, moaning and hurting. She stated she did not participate in feeding tube care and did not know when the eternal feeding bag needed to be changed. She stated a resident with a feeding tube could have an NPO and could not provide water or food. She stated the nurses checked on the residents every 2 hours. She stated she had not checked the in-service binder and had not received in service for repositioning residents on eternal feeding tubes. In an interview on 07/22/2026 at 1:39 a.m., RN I stated a resident on eternal feeding could experience complications in the form of aspirations, dehydration, or infection. She stated she had 2 residents in her hall with eternal feedings. She stated the residents needed to be high in Fowler's position (standard patient posture with the head of the bed elevated to 15 to 30 degrees), head of the bed needed to be raised to the 45 degree and needed to be upright almost seated. She stated if they began hunching, fetal position, or side lying they needed to be repositioned by nurses and CNAs. She stated she ensured residents were not experiencing complications with their eternal feeding by the osculating, push the fluid into the stomach and listen for gurgles, and monitored residual overflow. She stated she checked residuals at the beginning of her shift and every 4 hours after and documented under the MAR. She stated Resident #3 had complications relating to their feeding tubes. She stated sometimes Resident #3 tended to bring her legs up to her chest and this was not permitted due to aspiration. She stated she made sure the resident was not in a compromised position by raising the headboard and ensuring the resident was upright, and the tube feeding was not kinked or being laid on. She stated the special instruction provided to CNAs was to call for any complications and pause the feeding during incontinent care. She stated some signs and symptoms would be pain, alarm on the pump or the pump stopped. She stated she needed to change the tube when it was clogged and nothing could be pushed through it. She stated she ensured the care plan was implemented correctly by ensuring the feeding was being administered daily, checking complications, keeping it continuous if ordered. She stated the eternal feeding bags needed to be labeled always to ensure the right formula and additives were specific to the order. She stated the bag needed to be changed once a shift by the nurse coming on. She stated not changing/labeling the eternal feeding bag affected the residents by causing an infection. She stated the only system in place to monitor when it was old was the labeling on the eternal feeding bag. She stated writing on the bag directly with a pen was not acceptable because it could pierce the bag and add contaminants. She stated she had not received reports of the resident going to the hospital due to feeding tube complications and added Resident #3 was transferred based on respiratory complications. She denied receiving in service for feeding tube or monitoring for aspiration within the past month. She stated she checked on Resident #3's position approximately 20 minute prior and she had to reposition her. She went to check on Resident #3 and stated the resident was in a compromised position by having her legs to her chest and slouching in the bed and was at risk for aspiration at 1:58 a.m. In an interview on 07/22/2026 at 2:04 a.m., RN J stated residents on eternal feeding tubes were at risk for aspiration so the head of the bed needed to be elevated, PEG tube flushed and push fluid to see that it was flushing, cover the insertion cite and ensure it was not clogging. She stated the resident should be angled at 75 degree and 90 degree was the best angle for the resident. She stated she assessed complications in the form of crackling in the lungs, checked for aspiration on feed, redness and signs or symptoms of the insertion cite. She stated she monitored to ensure the residents position was correct, checking residuals every shift at least twice and if there was no residue she did not document anything. RN J stated a gurgling sound or coughing could be a sign of complications. She stated the tubing needed to be replaced when it came out of the insertion cite, when it was clogged, no residual was coming out, or if she suspected and infection was going on. She stated nutrition and hydration needs were determined by the labs ordered by the physician. She stated she checked the order to see how many units and rate the resident was ordered to receive and the time for the flushing from the provider. She stated she monitored the rate and flow on the machine settings. She stated she would notify the provider for any complications with the feeding tube to the provider. She stated she followed the procedures in the care plan to adhere to for continuous care. She stated no one had ever aspirated from a feeding tube. She stated no residents went to the hospital for aspirations. She stated the eternal feeding bags needed to be labeled always to ensure the right formula was given to the resident. She stated the bag needed to be changed once a shift by the charge nurse. She stated not changing/labeling the eternal feeding bag affected the residents by not informing the nurse of when it was changed and what their order being received was. She stated the last in service for feeding tube had not occurred since March 2026. She stated she could not recall the last in service for repositioning residents. In an interview on 07/22/2026 at 2:32 a.m., CNA K stated residents with feeding tubes required frequent rounding and listen for the alarm to prevent complications. She stated sometimes she cleaned the residents face area and would review if there was residual coming out their mouth from the feeding tube. She stated residents with feeding tubes needed to be seated upright. She stated the resident could not be at an incline, they had to always be at an upright position. She stated the DON told her the resident needed to be seated up higher. She stated she felt confident providing care to a resident with a feeding tube. She stated the resident needed to be readjusted to hold the position. She stated a resident out of the proper position could be choking. She stated she would be able to tell if a resident was in distress based on their facial expressions. She stated she would report to the head nurse for any complications or concerns with feeding tubes. She stated the nurses round several times a night but did not know the specifics or frequency for residents with feeding tubes. She stated when she provided incontinent care, she paid attention to the feeding tube to ensure it did not get in the way. She stated she did not do anything to the residents feeding tube or machine before providing incontinent care or repositioning. She stated she was not allowed to touch the machine. In an over-the-phone interview on 07/22/2026 at 10:08 a.m., CNA L stated Resident #3 had flat lined and stopped breathing on 07/05/2026. She stated she did not know the reason why she stopped breathing. She stated in the early morning RN M was screaming that Resident #3 was cold to touch. She stated she was at the end of the hall completing rounds and care for other residents. She stated the event had occurred around 12:00 a.m. to 2:00 a.m. on 07/05/2026. She stated she rounded on Resident #3 a little before 11:30 and not again because Resident #3 was sent to the hospital. She stated the resident had stiffness, liked to fold herself like a pretzel or fetal position. She stated they repositioned Resident #3 from left to right and tried to do so every 2 hours she stated when they provided the repositioning Resident #3 usually appeared uncomfortable by the grimaces and moans. She stated Resident #3 liked to be bundled up with knees to chest. She stated she thought the resident had a feeding tube in place. She stated she checked the cords were straight and not tangled with her. She stated the resident was mostly supposed to be on her back because she was on a feeding tube and placed at a 30-to-45-degree angle. She stated the head of the bed was always up but the resident curled back up within minutes after receiving repositioning from staff. She denied receiving in services for repositioning for residents with tube feeding and caring for residents with tube feeding. She stated she would monitor for the machine malfunctioning, leaking from the tube, and notify the nurse of any concerns. In an over-the-phone interview on 07/22/2026 at 3:42 p.m., RN M stated Resident #3 did not stay in one position or raised in bed. He stated Resident #3 usually readjusted before staff left the room she was already moved around. She stated Resident #3 had a lot of congestion and mucous and could not expel. He stated Resident #3 needed to be suctioned and from the nose she became combative. He stated he was not comfortable with the way Resident #3 presented on 07/05/2026. He stated he ensured the head of the bed was lifted up and stated he was getting orders from the physician. He stated he found Resident #3 cold and he disconnected the PEG tube. He stated there was no pulse, called for help. He stated he was on the phone with 911. He stated the pulse was restored before the ambulance arrived. He stated they had to lay the resident flat to perform CPR. He stated before the event they found the resident sliding down in bed and trying to get into a fetal position. He stated from the beginning of the shift he conducted a round and it seemed like she was discharging a lot of mucous. He stated he did not receive report from the previous shift nurse about any change in Resident #3's condition. He stated there was waste in the suction pump to show that it had been done before hand. He stated the resident was never lying flat during his rounds or checks. He stated the only thing being used to prop up Resident #3 was pillows. He stated residents on feeding tubes were at risk for aspirating if their bed was not propped up and seated at an angle of 45 degrees, if tolerable. He stated there was need for review placement, residue, and ensure the machine was continuous, stop the machine during incontinent care and the head was raised up. He stated he reviewed the placement of the feeding tube by listening for hair spray noise in the gastrointestinal (stomach) tract he stated the conditions to change the feeding tube was if it was clogged, after a day, not taking residue levels or every 24 hours and flushed. He stated the eternal feeding tube needed to be labeled with time date, rate, type by the nurse who changed the eternal feeding bag. He stated he entered the settings in the machine as prescribed by the dietician. He stated he notified the dr, DON, family and incoming nurse about the complications with the tube feeding. He stated Resident #3 was not aspirating on 07/05/2026 as this was determined by the resident not being in distress and stayed within her baseline. He stated there was no in-service on repositioning or tube feeding that he knew of following the residents transfer. In an over the phone interview on 07/23/2026 at 11:31 a.m., the Nurse Practitioner stated aspiration was always a risk for residents with tube feedings. He stated there were no new orders and ensuring the resident was always up in a 45 angle was the only order to prevent complications for Resident #3 and pausing tube feeding during incontinent care. He stated Resident #3 was always trying to get in the fetal position and ensuring the bed stayed up and had side rails and continued monitoring was his only recommendation. He stated his expectation was to adhere to protocol, check residual (200ml below for less aspiration risk), hold tube feeding as needed and monitor the gut motility. He stated the eternal feeding bag should always be labeled to inform staff what the contents were, rate, unit measurements, monitor calories, protect the feed from going over 24 hours and needed to be changed. He stated the nurse was responsible for monitoring, reporting, changing, feeding and labeling the bags. In an interview on 07/23/2026 at 12:40 p.m., the DON stated a resident on a PEG tube feeding needed to be placed at a 35 degree angle or higher to prevent aspiration. She stated the CNA and nurse needed to readjust the residents' position as needed. She stated she was aware Resident #3 was always trying to get into the fetal position and the facility used apparatuses to keep her open such as wedges, pillows, bolster mattress, and quarter rails with physician orders. She stated the enteral feeding bag needed to be labeled. She stated the resident's name, date, time, formula, rate, additives needed to be labeled on the feeding bag. She stated the nurse was responsible for ensuring the enteral feeding bags were labeled. She stated it did not affect the residents if it was not labeled but it was necessary to do. She stated she completed tube feeding during the week and could not recall the last in service for repositioning and tube feeding prior to 07/21/2026. She stated the expectations for repositioning Resident #3 was every 2 hours and as needed to ensure she was not at risk for aspiration. In an interview on 07/23/2026 at 3:05 p.m., the Administrator stated he expected staff to adhere to the policy and procedures on safe patient handling for residents with tube feeding in place. He stated Resident #3 needed to be seated upright at a 35-degree angle. He stated nurses and CNAs were responsible for ensuring Resident #3 was at that angel. He stated staff were rounding every 2 hours to reposition residents or as needed. He stated he was made aware of Resident #3 preference for fetal seeking position recently. He stated if a resident was not repositioned in a timely manner then they could aspirate. He stated he did not know why Resident #3 was sent to the hospital. He stated the eternal feeding bags needed to be labeled so staff could be aware of the contents and date it was changed. He stated if the label was not there, residents could get sick. He stated nurses were responsible for ensuring the label was on at all times. Record review of the facility's, undated, policy titled, Enteral Feeding Pump read in part: (purpose) to provide continuous or slow infusion feedings of residents with feeding tubes. (Procedure). (14) Label bag with time and amount of formula. (15) follow feeding with amount of water ordered. (17) Feeding bags and tubing must be labeled with date, name of resident, and amount of prescribed formula. (18) Resident should remain in comfortable position with bed at 45 degree angle. Record review of the facility's, undated, policy titled, Positioning and Moving Residents read in part: . (procedure, Fowlers position) (1) position resident in supported Fowlers position . (b) elevate head of bed to 45 to 60 degrees. (c) Rest head against mattress or on a small pillow. (d) Use pillows to support arms and hand if resident does not have voluntary control of use of hands and arms (e) position pillow at lower back (f) Place small pillow or roll under thighs (g) Place small pillow or roll under ankles (h) Place footboard at bottom if (confirmed typo, verbatim) resident's feet.(2) Position resident who is hemiplegic in supported Fowler's position. (c) Sit resident as straight as possible. (d)Position head with chin slightly forward. (e) Provide support for involved arm and hand on over bed table in front of resident; place arm away from the resident's side and support elbow with pillow. (f) Position flaccid hand in normal resting position with wrist slightly extended arches of hand maintained, and fingers partially flexed, may use section of rubber ball or hand roll to keep hand open. (g) Position spastic hand with wrist in neutral position or slightly extended, fingers should be extended with palm down or may be left in relaxed position with palm up. (h) Flex knees and hips by using pillow or folded blanket under knees. (i) Support feet in dorsiflexion with soft pillow or footboard.

Based on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations were thoroughly investigated for the incident and if the alleged violation was verified appropriate corrective action was taken for 2 of 3 residents (Residents #1 and #2) reviewed for abuse and neglect. 1. The facility failed to thoroughly investigate a self-reported incident with an allegation of resident abuse for Resident #1 who alleged CNA A hit his foot during incontinent care on 04/23/2026. 2. The facility failed to thoroughly investigate a self-reported incident with an allegation of resident neglect for Resident #2 who notified RN B that CNA A allegedly had left him soiled on the toilet, on 05/26/2026. These deficient practices could place residents at risk by failing to prevent further neglect, abuse, and taking appropriate corrective action based on investigation findings. Findings include:1. Record review of Resident #1's admission sheet, dated 07/23/2026, revealed a [AGE] year-old male with an original admission date of 03/15/2023 and a readmission dated of 11/20/2023. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 12, with the significance being that the resident had moderate cognitive impairment. Under section GG - functional abilities revealed the resident required partial to moderated assistance for toileting hygiene, lower body dressing, and personal hygiene. Under section H - Bladder and Bowel revealed the resident was frequently incontinent of bowel and bladder. Record review of Resident #1's care plan, dated 07/02/2026, revealed the resident had a focus area for required assistance with ADLs by 1 person related to Parkinson (a slow brain disorder marked by tremors, muscle stiffness, and slow movement) with interventions of provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs. An additional focus area to address residents' resistance to care with interventions of allowing the resident to make decisions about treatment regime, to provide a sense of control. Record review of Resident #1's physical and history, dated 06/11/2026, revealed the resident was diagnosed with parkinsonism (a clinical syndrome defined by core movement signs including slow movement, muscle stiffness, resting tremor, and balance problems), brief psychotic disorder (a short-term mental condition defined by the sudden start of psychotic behaviors-like hallucinations, delusions, or disorganized speech and resolve completely within one month), major depressive disorder (a serious mental health condition characterized by a persistent low mood, loss of interest in activities, and fatigue lasting at least two weeks), acute insomnia (short-term sleep problem lasting from a few days up to a few weeks, usually triggered by stress, life changes, or illness), and paranoid personality disorder (a mental health condition defined by a lifelong pattern of deep distrust, extreme suspicion of others, and a belief that people's motives are mean or harmful) 2. Record review of Resident #2's admission sheet, dated 07/23/2026, revealed an [AGE] year-old male with an original admission date of 05/06/2026 and a discharge date of 06/14/2026. Record review of Resident #2's admission MDS, dated [DATE], revealed the resident had a BIMS score of 6, with the significance being the resident had severe cognitive impairment. Under section GG - functional abilities the resident was coded for requiring partial to moderate assistance for toileting hygiene, upper/lower body dressing, and personal hygiene; under mobility the resident was coded for needing substantial to maximal assistance for lying to sitting on side of bed, sit to stand, toilet transfer, and chair/bed to chair transfer. Record review of Resident #2's care plan, dated 05/06/2026, revealed the resident had an ADL self-care performance deficit with an intervention in the form of requiring 1 person assistance for transfers. The resident had an additional focus area for short term memory problems and required assistance with decision making with an intervention in the form of break down task daily, reorient as needed, and speak clearly and slowly. Record review of Resident #2's physical and health, dated 05/07/2026, revealed the resident was diagnosed with myopathy (muscle disease characterized by muscle fiber dysfunction), rhabdomyolysis (medical condition where damaged muscle tissue breaks down rapidly, releasing proteins and electrolytes like myoglobin [iron and oxygen binding protein found in muscle tissue] into the bloodstream), and a recent history of falls at home that resulted in hospitalization. Record review of the Provider Investigation Report for incident intakes did not include detailed information such as interviews conducted with key personnel, what documentation was reviewed, and what interventions the facility took to correct or prevent further incidents. This included the following separate intakes which involved Residents #1 and #2. Record review of the provider investigation report for Resident #1 revealed the Administrator collected 1 written statement from the alleged perpetrator CNA A and 9 safety surveys from residents in the 200 hallway. CNA A was suspended for 1 day pending investigation; the facility self-report was created on 04/16/2026 at 1:53 p.m., CNA A was suspended on 04/17/2026 and returned to work on 04/18/2026 at 10:02 p.m. The provider investigation report was signed and submitted to the state survey agency on 04/23/2026. The section titled investigation summary read in part, Patient ended up saying nothing happened after investigation. Patient is paranoid and has major depressive disorder. No interviews or attempts to interview Resident #1 were documented. A police report was submitted with case number (26-003955). Record review of the provider investigation report for Resident #2 revealed the Administrator collected 1 written statement from the alleged perpetrator CNA A, received 3 written statements from the reporter RN B and collected 7 safety surveys from residents in the 200 hallway. RN B had alleged Residents #1, # 2, #6 and #7 vocalized confrontation and mistreatment from CNA A but no interviews or safety surveys were collected by the Administrator for the potentially alleged victims. RN B detailed in writing CNA A was treating residents in a demeaning manor, was racist towards Hispanic residents, sleeping/watching movies while on duty (graveyard), and had left Resident #2 on the toilet with urine on the floor and his pajamas. RN B documented a collected statement from Resident #2 that read in part, that lady [CNA A] hates me, I just need help, she [CNA A] just hates me and leaves me. The section titled investigation summary read in part, Upon investigatio [sic], it seems like these two employees were not getting along with each other. After interviewing the residents, [NAME] [sic] had any issues with [CNA A]. Record review did not reveal any documented interviews with residents or resident representatives. Record review of the safety surveys revealed 3 questions for residents to respond to (1) Have you been physically abused by staff? (2) Do you feel comfortable letting staff know if you have any issues or concerns? (3) Do you feel you are being treated with dignity and respect? and a portion for the interviewer to determine if the resident needed to be referred for follow-up. Record review of text messages received on 07/23/2026 at 7:05 a.m. between RN B and the Administrator read in part, [05/18/2026 at 4:17 a.m.] (from RN B) I left a few statements under you [sic]door regarding hall 200 [CNA A]. If possible maybe moving aide to another hall permanently due to frequent issues with multiple residents, or if not can we move [Resident #2] to hall 100 with [Resident #8] (delivered; no response) . [05/28/2026 at 3:18 p.m.] (from Administrator) Can you sign in service at nurse station (no response). In an interview with the administrator additional records in the form of statements and interviews were requested from the on 07/22/2026 at approximately 4:00 p.m. for the investigations for Resident #1 and #2. The DON provided 3 documents on 07/23/2026 at 9:00 a.m. Record review of the 3 documents provided by the DON revealed they were statements from the Administrator that stated he interviewed Resident #1 (dated 04/16/2026) Resident #2 (dated 05/18/2026), and CNA D (dated 05/18/2026). An interview was attempted with Resident #1 on 07/21/2026 at 11:04 a.m. and 3:22 p.m., the resident refused. A follow-up was attempted on 07/22/2026 at 9:50 a.m. and was refused. An over the phone interview was attempted with Resident #2's family member on 07/21/2026 at 3:14 p.m. and with Resident #2 on 07/23/2026 at 10:19 a.m.; no answer on either attempt, a voicemail was left both times. In an interview on 07/22/2026 at 1:04 p.m., LVN C stated she completed a skin assessment on Resident #2 at the request of the Administrator. She stated the assessment was completed due to the allegation of neglect reported but there were no findings during the head-to-toe assessment. She stated the abuse coordinator was the Administrator and needed to be notified immediately because it needed to be reported to the state survey agency within 2 hours. She stated this was completed to prevent further harm tasks needed to be completed during the investigation. In an over-the-phone interview on 07/23/2026 at 6:51 a.m. RN B stated she was transferred to a sister facility at the end of May 2026 because she felt the administrator was not submitting staff reports to the State Survey Agency. She stated she felt things would get reported and swept under the rug. She stated she was never interviewed by the Administrator or the DON regarding the typed reports she had printed and slipped underneath the Administrators door on 05/18/2026. She stated CNA A was not placed on suspension regarding her reports of abuse and neglect; record review of CNA A's timesheet revealed CNA A was suspended on 05/19/2062 and returned to work on 05/22/2026. She stated there was a resident who refused to let CNA A enter their room but could not recall which resident it was. She stated during her employment at the facility she was the nurse who oversaw hall 100 and half of hall 200. She stated she notified the on call management about the allegation of Resident #2 being left soiled but could not recall the name of the ADON who answered nor did have the information in her call log. She stated she texted the Administrator about her concerns regarding CNA A and the statements she left in his office. She stated all allegations of suspected abuse or neglect needed to be reported to the Administrator immediately to prevent harm to the resident. She stated if these investigations were not thoroughly investigated then it was her responsibility to report it to the State Survey Agency. She stated she did not report it to the State Survey Agency because she had heard it had already been reported to the State Survey Agency and there was going to be an investigation. She stated she directly heard CNA A say comments quoted in her written statement about the residents. She stated Residents #2 and #7 did not allow CNA A to provide care. She stated Residents #1, #2, #6, and #7 told her CNA A was rude and hateful towards them and added this was a repetitive theme during her shift and detailed in her typed statement that she provided to the Administrator. She stated she had never submitted grievances on the residents behalf to the facility but suspected they did; record review of facility grievances revealed none of the residents referenced had submitted grievances. She stated she located Resident #2 on the toilet and he was soaked in his own urine. She stated she did not know for sure if CNA A put Resident #2 on the toilet and added she would be shocked if Resident #2 was able to complete this task on his own based on his condition. In an interview on 07/23/2026 at 9:18 a.m. with the Social Worker, she stated the Administrator instructed her to complete the resident safety surveys as needed for investigations. She stated he usually instructed her to conduct a certain number of resident safety surveys and sometimes provided more specific details to complete the safety surveys. She stated this was important to the investigation because it included more people in the process to help provide the information, it was her role as a social worker and allowed the facility to review with residents the care they received. She stated she used the safety survey handout and did not ask questions beyond those listed. She stated safety surveys were completed to review immediate concerns and resident safety. She stated the DON, HR, and Administrator conducted the remainder of the investigation regarding record reviews and interviews with key personnel. She stated it was important for an investigation to be thorough to ensure the residents were seen and heard. She stated the investigation would help determine if there was and wasn't abuse. She stated she would document all interactions, written statements, attempts to interview key individuals, and document residents who refused to participate in the investigations. She stated it was required to interview as many employees as possible during the shift and document what they knew or observed. She stated it was the DON, ADONs, and Administrator's responsibility to collect all information required for a facility investigation. She was provided with the provider investigation reports, form 3613-a that had the summary and all statements/interviews collected and stated it did not appear to be a thorough investigation because of the lack of documentation. She stated the abuse coordinator was the Administrator who needed to be notified as soon as possible of allegations of abuse and neglect. In an interview on 07/23/2026 at 11:50 a.m., the DON stated Resident #1 had complained about CNA A to his family member and alleged CNA A threw his legs off the side of the bed and hit his foot during incontinent care. She stated she participated in the investigation by assessing Resident #1's foot (no findings on the sock) and meeting with law enforcement. She stated she was not asked to interview staff for the investigation regarding Resident #1. She stated Resident #1 could be resistant to care, medication, showers, and weights. She stated CNA A was suspended but did not know for how long. She stated suspensions depended on how the investigation progressed. She stated the facility spoke with the CNA A about calming residents, stepping away, asked for assistance from colleagues and a facility wide in-service for abuse and neglect was conducted. She stated she had completed 3 facility reported investigations in the past. She stated if she was completing the investigation she would interview the alleged victim resident, staff on the shift, conduct safety rounds, roommates, complete observations at night, conduct audit on rounding on residents, monitor call light responses, bed checks, and skin assessments. She stated the interviews would need to be documented or employees needed to provide statements. She stated it was important to collect and verify all information and allegations to ensure the investigation was thorough. She stated a thoroughly documented investigation would assist in deciding if the investigation had findings or not. She stated she did not want to comment on if the investigation for Resident #1 was thorough or not. She stated she did not participate in the investigation for Resident #2, but was aware the investigation yielded unfounded results. She stated the summary for Resident #2's investigation was not enough to reveal the findings. She stated she did not believe there was an incident with CNA A and Resident #2. She stated this was employee to employee conflict and no residents were affected. She stated safety rounds were completed, and no reports came from residents regarding concerns about CNA A. She stated CNA A was interviewed along with other staff, however there was no documentation provided supporting this. She stated the Administrator attempted to interview RN B, but she was unreachable. She stated the facility could have done better as a facility regarding Resident #2's provider investigation report. In an interview on 07/23/2026 at 2:25 p.m,. the Administrator stated Resident #1's family member called the facility and said the resident reported CNA A punched his leg. He stated the facility initiated their abuse and neglect protocol, police were contacted, and a skin assessment was conducted (no findings). He stated he attempted to use family member to conduct the interview, but Resident #1 was still reluctant. He stated Resident #1's family member reported Resident #1 had said it was the black CNA who worked at night. He stated CNA A was suspended for 1 day. He stated the facility continued care and close monitoring and added Resident #1 had not made further allegations since the incident. He stated he could have been more thorough in his investigation with Resident #1 by documenting attempts of interviews, roommate interviews, and interviewing more staff members. He stated it would ensure the investigation was thorough and help in his decision making for the findings. He stated sometimes he provided tasks to department heads to complete as needed. He stated it was important to collect documentation for interview attempts and observations to ensure nothing had happened and added credit to the investigation. He stated he was responsible for completing a thorough investigation. He stated the provider investigation report would go to state office for further review. He stated Resident #2's investigation was a he said/she said issue between employees. He stated he talked to the Resident #2 but he denied anything happening. He stated there were issues between RN B and CNA A which resulted in RN B creating false allegations. He stated he tried to interview RN B, but she would not return his phone calls. He stated he did not have the phone call log or documentation of his attempts when he tried to contact RN B. He stated it was essential to collect RN B's interview. He stated he interviewed the CNA A who alleged it was drama amongst the shift. He stated the graveyard shift developed some form of clique but the friendship was dissolved and RN B began targeting CNA A. He stated he interviewed CNA D who collaborated the two did not get along based on his observations during his shift. He stated he interviewed LVN E but could not recall the details and clarified he did not document what was reported to him from LVN E. He stated everyone associated with the incident needed to be interviewed. He stated he talked to Residents #1, #2, #6 and #7 who were identified on RN B's statement but did not document what they reported to him. He stated he did not include them in his safety survey he tasked the Social Worker to complete. He stated it was determined unfounded based on interviews completed but not documented. Record review of the facility's, undated, policy titled, Policy to prohibit the mistreatment, neglect, and abuse of residents read in part: . (Investigation) All staff in the nursing facility and all residents, responsible parties, and legal representatives has been properly notified through facility policy that any abuse will not be tolerated at all. All allegations, no matter what types of incidents reported, will be investigated fully. All employees who suspect abuse at any time it is identified are to report it to their immediate supervisor . An immediate investigation will be instigated and evidence that all alleged violations were thoroughly investigated will be documented. The person responsible for this coordination of the investigations will be the director of nursing. (Protection). When abuse identified a perpetrator that is identified by an eyewitness, the facility will immediately remove the perpetrator from the facility pending the outcome of the investigations.If a staff member is mentioned, but the abuse cannot be proved, then the staff member would be reassigned to other duties and/or areas and be closely monitored for the next 30 days by the charge nurse or other appropriate supervisor.Record review of the facility's, undated, policy titled Abuse/Neglect Coordinator read in part: Administrator is designated as the person responsible for coordination and implementation of the facility's policy and procedures for the prohibition of abuse and neglect. and was signed by the Administrator.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services.The facility failed to ensure floors were not soiled with food, grease, dust, and other dried substances.The facility failed to ensure floors in the walk-in refrigerator/freezer were not soiled with pieces of brown and clear plastic wrappers as well as dust buildup.The facility failed to ensure food items in the refrigerator were not opened to air.The facility failed to ensure food items were stored properly per the manufacturer.These failures could place residents at risk for foodborne illness and a decline in health status.The findings include:Observation of the kitchen on 03/30/2026 at 5:50am with the DM revealed the floors were dirty with food particles, a white dried substance, and a greasy film. The wall and floor behind the warmer oven was covered in grease and dust built up along with a white dried substance.Observation on 03/30/2026 at 5:58am of dry storage with the DM revealed food particles on the floor and under shelves. There was dust buildup in the corners, a cardboard box lined with a plastic bag contained approximately 15 large white tea bags open-to-air, 1 plastic bottle of caramel sauce with an open date of 3/5/2026, 1 plastic bottle of caramel sauce with an open date of 3/24/26, and 1 bottle of chocolate sauce with an open date of 3/24/26. All sauce bottles had manufacturer's instructions to refrigerate after opening.Observation on 03/30/2026 at 6:10am of the large walk-in refrigerator freezer with the DM revealed a large clear plastic zip lock bag in the refrigerator that was open with a large bag of shredded cheese that was open to air, and dust buildup under the storage shelves. In the freezer section there were several brown and clear pieces of wrappers under the storage shelf along with dust buildup and little white pieces of an unknown substance.Observation on 03/30/2026 at 6:15am of the dishwasher room with the DM revealed the floor had dust build up in the corner beside the dishwasher along with pieces of white and pink sugar packets.In an interview on 03/30/2026 at 6:29am with [NAME] A, she stated she has worked here for 1 year. She stated when she opens items, she labels the item with the date open and covers it as required. She stated it was all kitchen staff responsibility for checking items in the refrigerator and freezer for expired dates and to make sure everything was cleaned as needed and at the end of shift. She stated they try to clean the floors after every meal if time allows. She stated they have a schedule and sign off sheet for when a task was done. She stated a negative outcome for residents if all of that was not done correctly, was they may get sick. She stated she was not aware the chocolate and caramel syrups needed to be refrigerated but that she would pay closer attention.In an interview on 03/30/2026 at 7:24am with DON, she stated all residents ate out of the kitchen. She stated there was 1 resident with a gastric tube but that she did eat by mouth and that the gastric tube was only used to supplement tube feeding if the resident does not eat a certain percentage of her meals. She stated her expectation for the kitchen was for the staff to follow policies and procedures and was aware the staff had schedules for what needs to be cleaned or deep cleaned and when. She stated food items were to be dated, labeled, and stored properly. She further stated a negative outcome could be food borne illness. The DON also stated there had not been any outbreaks of foodborne illness.In an interview on 03/31/2026 at 9:39am with [NAME] B, she stated she had worked here for four (4) years. She stated cleaning the kitchen was a team effort but that they have assigned tasks to do daily and weekly. She stated all opened items were to be dated, labeled and sealed or stored properly. She stated a negative outcome could be the residents becoming ill. She stated they try to clean the floors as best they can daily but the area behind the warmer was just missed she guessed.In an interview on 03/31/2026 at 9:41 AM DA C stated she had worked here almost 6 months. She stated she assists with all aspects of the kitchen with cleaning, stocking, and helping any way she can. She stated she did not know why the floors were as dirty as they were. She stated they do have schedules and a log of when to clean appliances and floors as well as a deep clean schedule. She stated if they did not clean appropriately the residents could get sick. In a follow-up observation on 04/01/2026 at 9:30 AM with the DM, dust build up and food particles remained on the floor in the dry storage. Plastic wrappers and dirt build up remained under the storage shelves in the walk-in freezer. And dust built up with pieces of pink and white sugar packets also remained on the floor of the dishwashing room.In an interview on 04/01/2026 at 9:35 AM with DM, she stated the floors are mopped every shift and in between meals as needed. She stated deep cleanings happen once a week, the dry storage was gone through once a month to check for expired foods and thorough cleaning, refrigerators and freezers were gone through to remove expired items or leftovers once a week. She stated with the freezer that she was waiting on her dry-freeze chemical to clean it and it should arrive soon. She also stated the floor in the dishwasher room was swept and mopped twice a day, and that they did not do a good job but she was not sure why. She stated the monthly cleaning schedules for March were not signed and had no answer why it was not filled out, nor why the second shift did not initial the daily schedule for the week, stating just a lack of oversight. She stated with the cardboard box of tea bags in the dry storage, that the plastic bag that lines the box of tea bags should be wrapped up after an employee retrieves a bag to make tea and not leave it open to air. The DM further stated she has not done any in-services, trainings, or competencies for employees regarding storage, labeling, or cleaning. She stated when she had a new employee they were trained by a cook and watched to make sure they complete tasks appropriately but that she did not have a competency sheet or any kind of new hire training to provide. She stated the staff were supposed to follow the cleaning schedules posted and sign off when the task was completed. She also stated she was ultimately responsible for making sure the staff were completing tasks as assigned, according to policies, and that was her expectation. She stated a negative outcome for residents could be a food borne illness. In an interview on 04/01/2026 at 10:00 AM with the ADMN, he stated that all items in the kitchen from cleaning, labeling, and storage of foods were to be labeled and stored appropriately , and that the floors and other items were cleaned per schedule and policy. He stated a negative outcome could be the residents getting sick. He stated there has not been any outbreaks of foodborne illnesses.Record review of Cleaning schedules reviewed for 03/2026:March Monthly Deep Cleaning - Aides that included the item or area that was to be cleaned, the week it was to be done, and title of responsible party. This review revealed that there were no signature/initials on this page to show that any task had been completed for the month of March.March Monthly Deep Cleaning - Cooks that included the item or area that was to be cleaned, the week it was to be done, and title of responsible party. This review revealed that there were no signature/initials on this page to show that any task had been completed for the month of March.Daily/After Each use Cleaning Schedule that included the name of the item that was cleaned, day of the week, and title of responsible party. It revealed that only the employees on the 1st shift signed that the task was completed.Record review of the guidelines titled Dry Food Storage, not dated, revealed:All items will be dated with a receive date on the package. It is appropriate for individual/piece items to have one date on the case instead of each individual piece.Any items in dry storage without a manufacturer's used by date will be used within six months of received dates with the exception of spices and extracts. Spices and extracts will be used within a year of received dates. Items that have a manufacturer's used by date, we will honor that date.Any open items will be covered/sealed. They will be relabeled if the original label was obscured in any way.Record review of the policy titled Food Safety in Receiving and Storage, dated revised 1/1/10, revealed [in part]:Policy: Food will be received and stored by methods to minimize contamination and bacterial growth.Procedure: Dry Storage Guidelines8. Storeroom floors will be swept and mopped dailyRecord review of the policy titled Cleaning the Floor, dated revised 1/1/10, revealed [in part]:Policy: The floor will be kept in a clean and sanitary condition. Floors are to be mopped at the end of each meal.Procedure:After each meal:Sweep the floor and dispose of dirt particles. Sweep under the equipment. Move the equipment, if mobile, in order to sweep under it.Mop vigorously to remove food spills and stains. Be sure to mop under equipment. Floor ledges and baseboards should also be cleaned to prevent soil build up.Review of Food Code 2022 Recommendations of the United States Public Health Service Food and Drug Administration revision date 01/18/2023 revealed, in part:3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation.(A) FOOD shall be protected from cross contamination by:(4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages.

Based on interview and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 10 of 10 (Resident #5, Resident #6, Resident #12, Resident #44, and Resident #58, Resident #61, Resident #65, Resident #100, Resident #113, Resident #133) residents reviewed for comprehensive person-centered care plans. 1. The facility failed to develop a comprehensive person-centered care plan based on assessed needs with measurable objectives in the focus areas of risk for infections, at risk for injury/immobility due to the need for quarter for half side rails, discharge plans are long term care, required assist with ADLs, limited range of motion, little or no activity involvement, ADL self-care performance deficit r/t right femoral neck arthroplasty (surgical procedure to replace or repair a joint with an artificial prosthesis), diagnosis of Hyperlipidemia (condition characterized by high levels of lipid in the blood), Hypertension, short-term memory problems, use of antidepressants, and pain management for Resident #5. 2. The facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives in the focus areas of at risk for psychosocial well-being r/t medically imposed restrictions r/t to COVID-19 restrictions, at risk for injury/immobility due to the need for quarter or half side rails, discharge plans are long term care, risk for infections, required assistance with ADLs r/t blindness, lack of coordination, and mobility, and dialysis, limited range of motion, behavior problems, Hypertension, and diagnosis of Hyperlipidemia (condition characterized by high levels of lipid in the blood) for Resident #6. 3. The facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives in the focus areas of discharge plans are long term care, at risk for injury/immobility due to the need for quarter or half side rails to assist with turning and repositioning, at risk for psychosocial well-being concern r/t medically imposed restrictions r/t to COVID-19 precautions, at risk for COVID-19, requires assistance with ADLs, ADL self-care r/t right femur fracture, behavior problems, short-term memory loss, hypertension, Edema, difficulty hearing, dehydration, Hypothyroidism, anticoagulant therapy, antidepressant therapy, antianxiety therapy, and use of opioid medication for Resident #12. 4. The facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives in the areas of at risk for injury/immobility due to the need for quarter or half side rails to assist with turning and repositioning, at risk for COVID-19, discharge plans are long term care, requires assistance with ADLs, the resident will participate in activities of choice, limited range of motion, Multiple sclerosis, Hypertension, short-term memory loss, difficulty making self-understood and understanding others, Edema, Dehydration, GERD, Anti-anxiety therapy, antidepressants, and pain management for Resident #44. 5. The facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives in the areas of medically imposed restrictions r/t COVID-19 restrictions, at risk for injury/immobility due to the need for quarter or half side rails to assist with turning and repositioning, risk for infections, discharge plans are long term care, requires assistance with ADLs, ADL self-care performance deficit, Hypertension, impaired cognitive function/dementia, dehydration, Diabetes Mellitus, Hypothyroidism, GERD, antidepressant therapy, and use of antianxiety medication for Resident #58. 6. The facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives in the areas of at risk for injury/immobility due to the need for quarter or half side rails to assist with turning and repositioning, at risk for COVID-19, discharge plans are long term care, ADL self-care deficit r/t Myopathy 2nd to UTI, behavior problems, short-term memory loss, Edema, difficulty making self be understood, at risk for dehydration, Hypothyroidism, will be compliant with diet through the review date, GERD, anti-anxiety therapy, antidepressant therapy, opioid medication, and pain management for Resident #61. 7. The facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives in the areas of at risk for injury/immobility due to the need for quarter or half side rails to assist with turning and repositioning, medically imposed restrictions r/t to COVID-19 restrictions, risk for infections, discharge plans are long term care, requires assistance with ADLs, limited range of motion, ADL self-care performance deficit r/t Asymptomatic Bradycardia (resting heart rate below 60 beats per minute), Hypertension, Edema, impaired cognitive function/impaired thought processes, communication problem r/t English/Spanish speaking, dehydration, Hypothyroidism , Hyperglycemia, Alteration in gastro intestinal status GERD, antidepressants, antianxiety medication, opioid medication, and pain management for Resident #65. 8. The facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives in the areas of at risk for injury/immobility due to the need for quarter or half side rails to assist with turning and repositioning, risk for infections, medically imposed restrictions r/t to COVID-19 restrictions, discharge plans are long term care, requires assistance with ADLs, behavior problem, short-term memory, long-term memory impairment, Hypertension, dehydration, GERD, antidepressants, diuretic therapy, and pain management for Resident #100. 9. The facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives in the areas of discharge plans are long term care, at risk for injury/immobility due to the need for quarter or half side rails to assist with turning and repositioning, medically imposed restrictions r/t COVID-19 restrictions, risk for infections, ADL self-care performance deficit r/t right femur fracture, behavior problem-incidents, short-term memory problems, Edema, dehydration, Hypothyroidism, antianxiety medication, opioid medication use, and pain management for Resident #113. 10. The facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives in the areas of allergies, at risk for injury/immobility due to the need for quarter or half side rails to assist with turning and repositioning, requires supplements, discharge plans are long term care, requires assistance with ADLs, limited range of motion, ADL self-care performance deficit, behavior problems, Hypertension, altered cardiovascular status, Edema, anticoagulant therapy, Dehydration, short-term memory problems, Diabetes Mellitus, GERD, gastral intestinal alterations, diuretic therapy, antianxiety medication and pain/pain management for Resident #133. These failures could place residents at risk for not receiving care and services to meet their needs and deficits. The findings include:1. Record review of Resident #5's Face Sheet, dated 04/02/2026, revealed a [AGE] year-old male, with an admission date into the facility of 10/17/2025. Resident #5 had diagnoses which included Encounter for other orthopedic aftercare, Unspecified fracture of left femur (longest bone extending from the hip to the knee) , Unspecified Dementia (diagnosis used when symptoms of cognitive decline, such as memory loss, confusion, and impaired thinking, are present, but the underlying cause cannot be determined or does not fit a specific pattern), unspecified severity, without behavioral disturbance, Depression, Hyperlipidemia (condition characterized by high levels of lipid in the blood), and Dysarthria (motor speech disorder) following cerebral infarction (stroke).Record review of Resident #5's Quarterly MDS assessment, dated 02/19/2026, revealed Resident #5 had a BIMS score of 08, which indicated moderate cognitive impairment. Section I - Active Diagnoses revealed Resident #5's primary medical condition was Other Orthopedic Conditions, as I0020 was coded 11. Section N0415 - High-Risk Drug Classes: Uses and Indication revealed Resident #5 took medication by pharmacological classification for antidepressant and opioid.Record review of Resident #5's Care Plan, with a recent review date of 03/04/2026, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: Resident will not exhibit s/sx of COVID-19, through next review date (risk for infections), will not experience any injuries due to the need for quarter or half side rails x 90 days (at risk for injury/immobility due to the need for quarter or half side rails to assist with turning and repositioning), anticipate and meet residents needs through the next review date (discharge plans are long term care), resident is able to perform self-care to optimal level and maintains strength and endurance x 90 days (resident required assist with ADLs), no contractures to become worse next 180 days (limited range of motion), the resident will participate in activities of choice by review date (the resident has little or no activity involvement), the resident will maintain current level of function through the review date (resident has an ADL self-care performance deficit r/t right femoral neck arthroplasty (surgical procedure to replace or repair a joint with an artificial prosthesis), the resident will exhibit reduction of cardiac symptoms through the review date (diagnosis of Hyperlipidemia (condition characterized by high levels of lipids and fats in the blood that often cause no symptoms but increase the risk of heart attacks or strokes), the resident will remain free of complications related to hypertension through review date (Hypertension), resident will effectively communicate simple needs to staff x 90-days (short-term memory problems); the resident will be free from discomfort or adverse reactions related to antidepressant therapy through review date (use of antidepressant), and resident will be at a tolerable level of pain x 90-days (pain management). 2. Record review of Resident #6's Facesheet, dated 04/02/2026, revealed a [AGE] year-old male, with an admission date into the facility of 10/19/2022. Resident #6 had diagnoses which included Legal blindness, Type II diabetes mellitus, Heart failure, Unspecified dementia (diagnosis used when symptoms of cognitive decline, such as memory loss, confusion, and impaired thinking, are present, but the underlying cause cannot be determined or does not fit a specific pattern), unspecified severity, without behavioral disturbance, Major Depressive Disorder, Hyperlipidemia (condition characterized by high levels of lipid in the blood), Essential (primary) hypertension (chronic high blood pressure without a known single organic cause), Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness or reduced muscle control on one side of the body) following cerebral infarction (stroke), and End stage renal disease.Record review of Resident #6's Change in Status MDS assessment, dated 12/21/2025, revealed Resident #6 had a BIMS score of 09, which indicated moderate cognitive impairment. Section I - Active Diagnoses revealed Resident #6's primary medical condition was Medically Complex Conditions, as I0020 was coded 13.Record review of Resident #6's Care Plan, with a recent review of date of 02/03/2026, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: The resident will not show a decline in psycho social well-being or experience adverse effects through next care review (medically imposed restrictions r/t to COVID-19 restrictions), will not experience any injuries due to the need for quarter or half side rails x 90-days (at risk for injury/immobility due to the need for quarter or half side rails to assist with turning and repositioning), anticipate and meet residents needs through the next review date (discharge plans are long term care), resident will not exhibit s/sx of COVID-19, through next review date (risk for infections), resident is able to perform self-care to optimal level and maintains strength and endurance x 90 days (requires assistance with ADLs r/t blindness, lack of coordination, and mobility, and dialysis day Tuesday, Thursday, and Saturday end stage renal disease, legal blindness), no contractures to become worse next 180 days (limited range of motion), the resident will have no evidence of behavior problems by review date (behavior problems), the resident will remain free of s/sx of hypertension through review date (Hypertension), the resident will exhibit reduction of cardiac problems through the review date (diagnosis of Hyperlipidemia). 3. Record review of Resident #12's Face Sheet, dated 04/02/2026, revealed an [AGE] year-old female, with an admission date into the facility of 12/01/2020. Resident #12 had diagnoses which included Hyperlipidemia (condition characterized by high levels of lipid in the blood), unspecified, Other specified depressive episodes, Dehydration, Hypothyroidism, Essential (primary) hypertension, and Edema.Record review of Resident #12's Quarterly MDS assessment, dated 02/10/2026, revealed Resident #12 had a BIMS score of 04, which indicated severe cognitive impairment. Section I - Active Diagnoses revealed Resident #12's primary medical condition was Medically Complex Conditions, as I0020 was coded 13. Section N0415 - High-Risk Drug Classes: Uses and Indication revealed Resident #12 took medication by pharmacological classification for anticoagulant and antiplatelet.Record review of Resident #12's Care Plan, with recent review of date of 02/23/2026, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: Anticipate and meet residents needs through next review date (discharge plans are long term care), will not experience any injuries due to the need for quarter or half side rails x 90-days (at risk for injury/immobility due to the need for quarter or half side rails to assist with turning and repositioning), the resident will not show a decline in psycho social well-being or experience adverse effects through next care review (at risk for psychosocial well-being concern r/t medically imposed restrictions r/t to COVID-19 precautions), resident will not exhibit s/sx of COVID-19 (at risk for COVID-19), resident is able to perform self-care to optimal level and maintains strength and endurance (requires assistance with ADLs), resident will maintain current level of function through next review date (ADL self-care deficit r/t right femur fracture), the resident will have fewer episodes [of by review date] (behavior problems), the resident will effectively communicate simple needs to staff (short-term memory loss), the resident will remain free from s/sx of hypertension (hypertension), the resident will decrease fluid retention within x 90 days (Edema), the resident will be able to participate in social conversations (difficulty hearing), the resident will remain hydrated (at risk for dehydration), the resident will be compliant with thyroid replacement therapy through review date (hypothyroidism), the resident will be free from discomfort or adverse reactions related to anticoagulant use (anticoagulant therapy), the resident will be free from discomfort or adverse reactions related to antidepressant therapy (antidepressant therapy), the resident will be free from discomfort or adverse reactions related to anti-anxiety therapy (anti-anxiety therapy), and resident has desired benefit of current therapy and perceived risks are outweighed (use of opioid medication). 4. Record review of Resident #44's Face Sheet, dated 03/31/2026, revealed a [AGE] year-old female, with an admission date into the facility of 12/30/2024. Resident #44 had diagnoses which included Multiple Sclerosis (chronic, immune-mediated disease where the immune system attacks the protective myelin sheath covering nerves in the brain and spinal cord), Anxiety Disorder, GERD, Pain in right knee, and Other specified depressive episodes.Record review of Resident #44's Quarterly MDS assessment, dated 03/16/2026, revealed Resident #44's had a BIMS score of 10, which indicated moderate cognitive impairment. Section I - Active Diagnoses revealed Resident #44's primary medical condition was Medically Complex Conditions, as I0020 was coded 13. Section N0415 - High-Risk Drug Classes: Uses and Indication revealed Resident #44 took medication by pharmacological classification for antianxiety and antidepressants.Record review of Resident #44's Care Plan, with recent review of date of 03/27/2026, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: Will not experience any injuries due to the need for quarter or half side rails x 90-days (at risk for injury/immobility due to the need for quarter or half side rails to assist with turning and repositioning), resident will not exhibit s/sx of COVID-19 (at risk for COVID-19), Anticipate and meet residents needs through next review date (discharge plans are long term care), resident is able to perform self-care to optimal level and maintains strength and endurance (requires assistance with ADLs), prevent further contractures next 90 days (limited range of motion), the resident will participate in activities of choice (little or no activity involvement), resident will maintain current level of function through next review date (multiple sclerosis, history CVA), the resident will remain free from s/sx of hypertension (hypertension), the resident will effectively communicate simple needs to staff (short-term memory loss), [resident] will be able to make myself understood within the next 90 days (difficulty making self-understood and understanding others, will decrease fluid retention within 90 days (Edema), will not experience any symptoms of dehydration (dehydration), the resident will remain free from discomfort, complications, or s/sx related to GERD (GERD), the resident will be free from discomfort or adverse reactions related to anti-anxiety therapy (anti-anxiety therapy), resident will show decreased episodes of s/sx of depression through review date (use of antidepressants), and resident will be at a tolerable level of pain for 90 days (pain management). 5. Record review of Resident #58's Face Sheet, dated 03/31/2026, revealed a [AGE] year-old female, with an admission date into the facility of 03/28/2024. Resident #58's diagnoses included Heart failure, Anxiety Disorder, Altered mental status, Type II Diabetes, Essential (primary) hypertension (chronic high blood pressure without a known single organic cause), and Hyperlipidemia (condition characterized by high levels of lipid in the blood).Record review of Resident #58's Quarterly MDS assessment, dated 03/05/2026, revealed Resident #58 had a BIMS score of 07, which indicated severe cognitive impact. Section I - Active Diagnoses revealed Resident #58's primary medical condition was Medically Complex Conditions, as I0020 was coded 13. Section N0415 - High-Risk Drug Classes: Uses and Indication revealed Resident #58 took medication by pharmacological classification for antianxiety and antidepressants.Record review of Resident #58's Care Plan, with recent review of date of 03/18/2026, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: The resident will not show a decline in psycho social well-being or experience adverse effects through next care review (medically imposed restrictions r/t COVID-19 restrictions), will not experience any injuries due to the need for quarter or half side rails x 90-days (at risk for injury/immobility due to the need for quarter or half side rails to assist with turning and repositioning), resident will not exhibit s/sx of COVID-19, through next review date (risk for infections), anticipate and meet residents needs through the next review date (discharge plans are long term care), resident is able to perform self-care to optimal level and maintains strength and endurance x 90 days (requires assistance with ADLs), resident will maintain current level of function through next review date (ADL self-care performance deficit), the resident will remain free of s/sx of hypertension through review date (Hypertension), the Resident will improve current level of cognitive function through review date (impaired cognitive function/dementia), resident will remain free of s/sx or complications related to deep vein thrombosis through review date, the resident will remain free of symptoms of dehydration (dehydration), the resident will remain s/sx of hyperglycemia (Diabetes Mellitus), the resident will remain free from s/sx of Hypothyroidism (Hypothyroidism), the resident will remain free from discomfort, complications, and s/sx related to GERD (GERD), the resident will remain free from discomfort or adverse reactions related to antidepressant therapy (antidepressants), and the resident will remain free from discomfort or adverse reactions related to antianxiety therapy (antianxiety medication). 6. Record review of Resident #61's Face Sheet, dated 03/31/2026, revealed a [AGE] year-old female, with an admission date into the facility of 02/11/2025. Resident #61 diagnoses included Myopathy (disease of the skeletal muscles causing weakness, cramps, stiffness, and fatigues, usually affecting shoulders and hips), Other specified depressive episodes, Acute pain due to trauma, Hypothyroidism, Anxiety disorder, and Hypotension.Record review of Resident #61's Annual MDS assessment, dated 01/27/2026, revealed Resident #61's had a BIMS score of 09, which indicated moderate cognitive impairment. Section I - Active Diagnoses revealed Resident #61's primary medical condition was Medically Complex Conditions, as I0020 was coded 13.Record review of Resident #61's Care Plan, with recent review of date of 02/23/2026, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: Will not experience any injuries due to the need for quarter or half side rails x 90-days (at risk for injury/immobility due to the need for quarter or half side rails to assist with turning and repositioning), resident will not exhibit s/sx of COVID-19 (at risk for COVID-19), anticipate and meet residents needs through next review date (discharge plans are long term care), resident will maintain current level of function through next review date (ADL self-care deficit r/t Myopathy 2nd to UTI), the resident will have no evidence of behavior problems by review date (behavior problems), Resident will effectively communicate simple needs to staff (short-term memory problems), the resident will decrease fluid retention within x 90 days (Edema), will be able to make self understood within next 90 days (difficulty make self be understood), the resident will remain hydrated (at risk for dehydration), the resident will be compliant with thyroid replacement therapy through review date (hypothyroidism), will be compliant with diet through the review date (endocrine status), the resident will remain free from discomfort, complications, and s/sx related to GERD (GERD), the resident will be free from discomfort or adverse reactions related to anti-anxiety therapy (anti-anxiety therapy), the resident will be free from discomfort or adverse reactions related to antidepressant therapy (antidepressant therapy), resident has desired benefit of current therapy and perceived risks are outweighed x 90 days (opioid medication), and the resident will be at a tolerable level of pain (pain management). 7. Record review of Resident #65's Face Sheet, dated 03/31/2026, revealed a [AGE] year-old female, with an admission date into the facility of 01/03/2025. Resident #65's diagnoses included Major Depressive Disorder, Generalized Anxiety Disorder, Bradycardia, Diverticulosis of intestine (asymptotic condition where small, bulging pouches form on the colon wall), Type II Diabetes, Dehydration, and Heart failure.Record review of Resident #65's Quarterly MDS assessment, dated 02/20/2026, revealed Resident #65 had a BIMS score of 06, which indicated severe cognitive impairment. Section I - Active Diagnoses revealed Resident #65's primary medical condition was Medically Complex Conditions, as I0020 was coded 13.Record review of Resident #65's Care Plan, with recent review of date of 02/23/2026, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: Will not experience any injuries due to the need for quarter or half side rails x 90-days (at risk for injury/immobility due to the need for quarter or half side rails to assist with turning and repositioning), the resident will not show a decline in psycho social well-being or experience adverse effects through next care review (medically imposed restrictions r/t to COVID-19 restrictions), resident will not exhibit s/sx of COVID-19, through next review date (risk for infections), anticipate and meet residents needs through the next review date (discharge plans are long term care), resident is able to perform self-care to optimal level and maintains strength and endurance x 90 days (requires assistance with ADLs), no contractures to become worse next 90 days (limited range of motion), resident will maintain current level of function through next review date (ADL self-care performance deficit r/t Asymptomatic Bradycardia), the resident will remain free of s/sx of hypertension through review date (Hypertension), will decrease fluid retention x 90 days (Edema), the Resident will maintain improve current level of cognitive function through review date (impaired cognitive function/impaired thought processes), resident will maintain current level of communication function through review date (communication problem r/t English/Spanish speaking), the resident will remain free of symptoms of dehydration (dehydration), the resident will remain free from s/sx of Hypothyroidism (Hypothyroidism), the resident will remain free from s/sx of Hyperglycemia (high blood sugar, caused by insufficient insulin or high insulin resistance)(Hyperglycemia), the resident will remain free from any s/sx of alteration in gastro intestinal status (alteration in gastro intestinal status), the resident will remain free from discomfort, complications, and s/sx related to GERD (GERD), the resident will remain free from discomfort or adverse reactions related to antidepressant therapy (antidepressants), the resident will remain free from discomfort or adverse reactions related to antianxiety therapy (antianxiety medication), resident has desired benefit of current therapy and perceived risks are outweighed x 90 days (opioid medication), and the resident will be at a tolerable level of pain (pain management). 8. Record review of Resident #100's Face Sheet, dated 03/30/2026, revealed a [AGE] year-old female, with an admission date into the facility of 04/03/2024. Resident #100's diagnoses included Acute pain due to trauma, Type II Diabetes, Hyperlipidemia (condition characterized by high levels of lipid in the blood), Depression, unspecified, Essential (Primary) Hypertension (chronic high blood pressure without a known single organic cause), and Unspecified Dementia (diagnosis used when symptoms of cognitive decline, such as memory loss, confusion, and impaired thinking, are present, but the underlying cause cannot be determined or does not fit a specific pattern), unspecified severity, without behavioral disturbance.Record review of Resident #100's Quarterly MDS assessment, dated 02/10/2026, revealed Resident #100 had a BIMS score of 06, which indicated severe cognitive impairment. Section I - Active Diagnoses revealed Resident #100's primary medical condition was Other Orthopedic Conditions, as I0020 was coded 11. Section N0415 - High-Risk Drug Classes: Uses and Indication revealed Resident #100 took medication by pharmacological classification for antidepressants and diuretics.Record review of Resident #100's Care Plan, with recent review of date of 02/03/2026, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: Will not experience any injuries due to the need for quarter or half side rails x 90-days (at risk for injury/immobility due to the need for quarter or half side rails to assist with turning and repositioning), resident will not exhibit s/sx of COVID-19, through next review date (risk for infections), the resident will not show a decline in psycho social well-being or experience adverse effects through next care review (medically imposed restrictions r/t to COVID-19 restrictions), anticipate and meet residents needs through the next review date (discharge plans are long term care), resident is able to perform self-care to optimal level and maintains strength and endurance x 90 days (requires assistance with ADLs), resident will maintain current level of function through next review date (ADL self-care performance deficit r/t to dementia, difficulty walking, and history of falls), the resident will have no evidence of behavior problem by review date (behavior problem), resident will effectively communicate simple needs to staff x 90 days (short-term memory), resident will maintain level of functioning and be aware of environment and orientations preserved x 90 days (long-term memory impairment), the resident will remain free of s/sx of hypertension through review date (Hypertension), will decrease fluid retention x 90 days (Edema), the resident will remain well hydrated x 90 days (dehydration), the resident will remain free from discomfort, complications, and s/sx related to GERD (GERD), the resident will remain free from discomfort or adverse reactions related to antidepressant therapy (antidepressants), the resident will be free from discomfort or adverse side effects of diuretic therapy (diuretic therapy), and the resident will be at a tolerable level of pain x 90 days (pain management). 9. Record review of Resident #113's Face Sheet, dated 04/02/2020, revealed an [AGE] year-old female, with an admission date into the facility of 12/01/2020. Resident #113's diagnoses included Hyperlipemia, Other specified depressive episodes, Dehydration, Hypothyroidism, and GERD. Record review of Resident #113's Quarterly MDS assessment, dated 01/21/2026, revealed Resident #113 had a BIMS score of 05, which indicated severe cognitive impairment. Section I - Active Diagnoses revealed Resident #113's primary medical condition was Medically Complex Conditions, as I0020 was coded 13.Record review of Resident #113's Care Plan, with recent review of date of 02/23/2026, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: Anticipate and meet residents needs through the next review date (discharge plans are long term care), will not experience any injuries due to the need for quarter or half side rails x 90-days (at risk for injury/immobility due to the need for quarter or half side rails to assist with turning and repositioning), the resident will not show a decline in psycho social well-being or experience adverse effects through next care review (medically imposed restrictions r/t COVID-19 restrictions), resident will not exhibit s/sx of COVID-19, through next review date (risk for infections), resident will maintain current level of function through next review date (ADL self-care performance deficit r/t right femur fracture), the resident will have fewer episodes of by review date (behavior problem-incidents), the resident will effectively communicate simple needs to staff x 90 days (short-term memory problems), will decrease fluid retention x 90 days (Edema), the resident will remain well hydrated x 90 days (dehydration), the resident will be compliant with thyroid replacement therapy through review date (hypothyroidism), the resident will remain free from discomfort or adverse reactions related t

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #55, Resident #207) of 6 residents reviewed for incontinent care and transfers in that 1. CNA D and CNA E failed to comply with enhanced barrier precaution regulations during incontinent care for Resident #55. 2. CNA B and CNA C failed to comply with enhanced barrier precaution regulations during a transfer for Resident #207. These failures could place resident's risk for cross contamination and the spread of infection. Finding included: Record review of Resident #55's admission record revealed resident was a [AGE] year-old female admitted to the facility 11/14/2024. Resident #55 had diagnosis that included muscle weakness, hypertension (high blood pressure), and pneumonia (infection of the lungs). Record review of Resident #55's Significant change minimum data set assessment indicated the resident had an indwelling catheter and was always incontinent of stool. Resident was considered to need substantial/maximal assistance for transferring and positioning. Record review of Resident #55's care plan revealed special instructions of assist x2 transfer *full weight bearing left leg* Enhanced Barrier Precaution . Record review of Resident #207's admission record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis that include acute kidney failure, urinary tract infection, weakness, and dementia. Record review of Resident #207's Significant change minimum data set indicated the resident had an indwelling catheter and is always incontinent of stool. Resident is considered to need substantial/maximal assistance for transferring and positioning. Record review of Resident #207's care plan revealed focus of The resident has UNSTAGABLE TO COCCYX. With interventions of STAFF TO MAINTAIN ENHANCED BARRIER PRECAUTIONS D/T PRESSURE WOUND. The focus of Resident utilizing indwelling F/C (foley catheter) placing resident at risk for UTI (urinary tract infection). And Interventions of STAFF TO MAINTAIN ENHANCED BARRIER PRECAUTIONS D/T (due to) F/C. Observation of incontinent care on 01/29/25 at 10:30 AM for Resident #55 with CNA E and CNA D. Neither CNA's donned Enhanced Barrier Precaution (EBP) prior to performing incontinent care. In an interview on 01/29/25 at 11:34 AM, CNA D stated that for incontinent care they should introduce themselves, wash hands, put on their EBP , that included gown and gloves, and set up supplies. CNA D stated EBP was in place when residents have catheters or open wounds. CNA D stated he was in a rush and was nervous and forgot to use EBP. CNA D stated if they do not use EBP it could be a concern for cross contamination. In an interview on 01/29/25 at 11:37 AM, CNA E stated residents who has wounds, or catheters staff need EBP on when caring for those residents. CNA E stated they just forgot to put it on. CNA E stated, if we don't wear them, we could get stuff on our clothes and contaminate others. Observation of a mechanical lift transfer from bed to chair on 01/30/25 at 10:10 AM for Resident #207 with CNA B and CNA C. Neither staff member donned Enhanced Barrier Precaution (EBP) prior to performing Hoyer transfer. In an interview with CNA B and CNA C on 01/30/25 at 10:28 AM , they both stated they were informed they did not need to wear EBP for transfers. [NAME] interview with the DON on 01/30/25 at 01:51 PM revealed that EPB should be used on anyone who has a line, catheter, wounds and should be worn when providing patient care, incontinent care, but not transfers because they are not in contact with the reason the residents are on precautions. The DON stated she understood now how not wearing EBP during transfers could be a concern of cross contamination. Record review of facility policy titled ENHANCED BARRIER PREECAUTIONS (EBP) with a signed date of 1/23/25 stated in part EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provides opportunities for transfer of MDRO's (Multi-drug resistant organisms) to staff hands and clothing.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 2 (Residents #61 and #253) of 4 residents observed for oxygen management. The facility failed to ensure Oxygen (O2) in use signage was on the doorways of Resident #61 and Resident #253. This failure could place residents at risk of not receiving appropriate respiratory care . The findings were: 1. Record review of Resident #61's admission record dated 01/31/2025 revealed Resident #61 was a [AGE] year-old male with an admitted to the facility of 11/21/2024. Admission record revealed Resident #61 had diagnoses that included diabetes mellitus, dementia, peripheral vascular disease (condition that reduces blood flow to the limbs), muscle weakness, and pleural effusion (buildup of flood between the linings of the lungs and chest). Record review of Resident #61's MDS assessment revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. Record review of Resident #61's Care plan dated 12/05/2024 revealed a focus of Use of oxygen therapy, has shortness of breath, and has respiratory symptoms. Record review of Resident #61's order summary dated 01/31/2025 revealed an order of Oxygen at 2-4 L/PM via nasal canula OR 5-8 L/PM via mask as needed for SOB (SHORTNESS OF BREATH). 2. Record review of Resident #253's admission record dated 01/31/2025 revealed Resident #253 was a [AGE] year-old female with an admitted to the facility of 01/27/2025. Admission record revealed Resident #253 had diagnoses that included diabetes mellitus, pulmonary edema (condition caused by excess fluid in the lungs), respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), and end stage renal disease (loss of kidney function that requires ongoing medical treatment to maintain life). Record review of Resident #253's MDS dated [DATE] revealed the MDS had not been completed due to her recent admission. Record review of Resident #253's Care plan dated 01/28/2025 revealed a focus of Use of oxygen therapy and has altered respiratory status/difficulty breathing. Record review of Resident #253's order summary dated 01/31/2025 revealed the following orders: OXYGEN - CONTINUOUSLY = Oxygen at _2-4_L/PM via nasal cannula continuously. OXYGEN as needed = Oxygen at 2-4 L/PM via nasal canula OR 5-8 L/PM via mask as needed for SOB Observation on 01/28/2025 at 7:58 AM revealed that there was no oxygen in use sign on Resident #61's door. Observation on 01/29/2025 at 10:38 AM revealed that there was no oxygen in use sign on Resident #61's door. Observation on 01/28/2025 at 7:32 AM revealed that there was no oxygen in use sign on Resident #253's door. Observation on 01/29/2025 at 10:56 AM revealed that there was no oxygen in use sign on Resident #253's door. Observation on 01/30/2025 at 10:00 AM revealed that there was no oxygen in use sign on Resident #253's door. In an interview on 01/30/2025 at 3:10 PM, the DON stated that the ADONs and all staff members (including management) were responsible for ensuring that oxygen in use signs were posted on the doors of residents receiving oxygen therapy. For monitoring the oxygen in use signs, the CNAs made rounds every 2 hours and the ADONs made rounds daily. The DON stated she did not think any adverse outcomes or harm could occur to the residents in relation to the signs not being posted. Regarding training/in-services provided to staff, the DON stated the facility had not conducted any. Record review of the undated facility policy titled Regular Oxygen Storage and Handling indicated in part .Oxygen in Use-No Smoking signs will be posted at doors leading to rooms where oxygen is in use.

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 3 resident (Resident #11) reviewed for privacy, in that: CNA A did not close Resident #11's window blinds while providing incontinent care for the resident. This deficient practice could place residents who received perineal care at risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #11's admission record dated 01/30/25 indicated she was admitted to the facility on [DATE] with diagnoses of overactive bladder and muscle weakness. She was [AGE] years of age. Record review of Resident #11's significant change MDS assessment dated [DATE] indicated her BIMS score was 06 indicating the resident's mental status was severely impaired. The resident's bladder and bowel status was coded as frequently incontinent. Record review of Resident #11's care plan dated 12/13/2024 indicated in part: Focus: Resident is incontinent of bladder related to physical/mental decline. Goal: Will have decline in incontinent episodes and be free of UTI next 90 days. Interventions: Provide care in a nonjudgmental manner, maintaining the resident's privacy and dignity. During an observation on 01/30/25 at 09:30 AM, CNA A was seen performing incontinent care to Resident #11. The observation was made from the outside of the facility. The state surveyor drove up to the front parking lot, and when he had parked, he saw the CNA performing care through the open blinds of the resident's room. This area of the parking lot was a high trafficked area, and several people walked through that sidewalk. The state surveyor then got out of the vehicle and continued to observe the CNA take some wet wipes and wipe the resident's private areas, apply some skin cream to her buttocks, and then fasten the new brief on the resident. Resident #11 was seen standing up and holding onto to her walker while CNA A performed the incontinent care. CNA A then assisted the resident to sit back down on her recliner and was done with the care, but never closed the blinds. During an interview on 01/30/25 at 09:48 AM, Resident #11 said the staff were good about providing privacy during personal care. The resident said she was not aware that the staff had left the blinds open during incontinent care on 01/30/25. Resident #11 said if the blinds were left open, then that would make her feel very embarrassed as she did not want to be exposed to the people passing by. Resident #11 said CNA A had indeed just changed her brief and had her stand up so that she could remove her brief, wipe her with some wet wipes and then fasten the new brief. During an interview on 01/30/25 at 10:08 AM, CNA A said that whenever she performed incontinent care on a resident she would close the door, pull the privacy curtain, and close the window blinds. CNA A was made aware of the observation this surveyor had of her performing incontinent care for Resident #11 and having the blinds open. CNA A said that she usually closed the blinds, but that obviously she had made an error and forgotten to close them that morning. CNA A said she felt bad that she had done that and understood her leaving the blinds open could expose the resident to the outside especially since she had performed personal care on the resident. CNA A said she had not done that on purpose and from now on would make sure that she would close the blinds during incontinent care. During an interview on 01/30/25 at 04:47 PM, the DON and the Administrator were asked what their expectations when nursing staff provided incontinent care as far as privacy. The DON said that the staff were expected to close the door, pull the privacy curtain, and close the window blinds, if on bed B which is close to the window. The Administrator said the CNA should have closed the blind before she performed the incontinent care. The Administrator said if the blinds were left opened then that could lead to the resident being exposed. Record review of the facility's undated policy titled Perineal care indicated in part: .Procedure: Knock at door, enter room, explain what you are going to do. Provide for privacy (Close door, pull curtain, close blinds) .

Based on observation, record review, and interview the facility failed to ensure residents were provided supervision and assistive devices to prevent accidents for 6 of 6 (Residents #1, 11, 6, 8, 10, and 7) residents reviewed for accidents. The facility allowed CNAs to determine the amount of assistance to provide to each resident and determine if they could transfer residents alone or ask for assistance. Resident #1 had a fall on 12/7/23 during transfer and was injured with acute fracture of the surgical neck of the left humerus. Resident #11 had slipped and landed on floor on 12/12/23 during a transfer with no injuries. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/31/24. The IJ template was provided to the Administrator. The IJ was removed on 02/01/24, but the facility remained out of compliance. These deficient practices have the potential to affect residents who require extensive assistance with transfers, which could result in residents having pain, falls or injuries including fractures. Findings include: Resident #1 Record review of Resident #1's face sheet dated 12/30/12 revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of vascular dementia, unsteadiness to feet, other abnormalities of gait and mobility, difficulty in walking, hemiplegia (paralysis of one side of the body), hemiparesis (one-sided muscle weakness), muscle weakness, age-related osteoporosis, and other lack of coordination. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score 08, which indicated she was moderately cognitive impaired and 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 chair/bed to chair transfer. Record review of Resident #1's care plan dated 12/13/2023 revealed a focus area for resident requires assist with ADLs but did not have interventions for level of assistance needed for transfers. Review of Resident #1's facility note dated 12/26/23 at 10:11 p.m. Change of Condition -Describe Change - Pain in Left Elbow. Nursing Interventions: notified Nurse Practitioner, got orders to give pain medication. Response: Elbow x-ray new order acetaminophen #3 by mouth every 6 hours as needed. Family aware, DON aware. Review of Resident #1's facility note dated 12/27/23 at 6:28 p.m. Change of Condition -Describe Change- resident has pain to left arm, purplish bruising to arm. Nursing Interventions- attempted in-house x-ray. Physician Notified. Physician Response: send to emergency room for evaluation due to unable to complete in-house x-ray. Family and DON notified. Review of Resident #1's facility note dated 12/27/23 at 7:23 p.m. Transfer Out - Clinical Condition/Reason for Transfer Complain of pain to her left elbow. Interventions attempted prior to discharge? If linked to Change of Condition? X-ray unable to be done in facility. Time left facility 7:18 p.m. Family, physician, and DON notified. Record review of Resident #1's local hospital diagnostic radiology report dated 12/27/2023 revealed reason for exam was pain and impression was acute fracture of the surgical neck of the left humerus (a bony constriction at the proximal end of shaft of humerus). Record review of Resident #1's local hospital discharge instructions dated 12/27/2023 revealed diagnoses of left humeral fracture and left elbow pain. Review of the Incident/Accident Report dated 12/28/23 documented: Incident- Resident stated that upon transferring in shower, she was lifted up under both arms and it hurt her left arm. Actions taken - was put back to bed, administered as needed pain medication, was checked on in approximately one hour and was resting comfortably and stated she was ok. During an interview on 01/29/2024 at 6:47 pm, CNA B stated she was assigned to Resident #1 on the day of the incident (12/27/2023). CNA B stated Resident #1 required a one person assist transfer and Resident #1 was able to assist with her good side. CNA B stated she had assisted Resident #6 to the shower, during the transfer from the wheelchair to the shower chair, she had attempted to assist Resident #1 to a standing position in which Resident #1 told her she needed to ask for help because she felt weak. CNA B stated she assisted Resident #1 to sit down on her wheelchair and called CNA A for help. CNA B stated her and CNA A assisted Resident #1 to a standing position and she left CNA A holding Resident #1 alone while she just turned to grab the shower chair that was not placed at a 90-degree angle as required. CNA B stated she let go of Resident #1, she slid down and landed on CNA A's feet. CNA B stated CNA C heard Resident #1 scream and went in the shower room to ask if they needed help and then assisted with lifting Resident #1 by herself off CNA A's feet to place her on the shower chair. CNA B stated she did not check Resident #1's care plan to check for the level of assistance she required for transfers. CNA B stated they (CNAs) would ask other CNAs and charge nurses about the type of transfers a resident may need. CNA B stated if comfortable they would decide to do a one person transfer and would only ask for help if they felt they needed it. CNA B stated there were no risk due to them receiving training on transfer technique. During an interview on 01/30/2024 at 9:30 am, Resident #1 was alert and oriented to person, place, and event. Resident #1 stated she did not remember the date of the fall but stated it had occurred in the shower room. Resident #1 stated she did not remember if she slipped but had ended up on the floor. Resident #1 stated there were 3 CNAs in the shower room and only one had assisted her off the floor. Resident #1 could not remember their names and further details. Resident #1 stated she had a lot of pain to her left arm and was sent out to the hospital the following day. Resident #1 stated staff usually transfer her either 1 or 2 people at a time. During an interview on 01/30/2024 at 9:39 am, RN H stated Resident #1 required a 2-person assist with a gait belt for transfers. RN H stated normally the CNAs had access to the residents' care on their electronic records under POC (plan of care). RN H stated CNAs also received verbal report from the charge nurse. RN H stated she was not aware of CNAs conducting one person assist for transfers. RN H stated she was not aware if therapy had given specific instructions on the level of care Resident #1 required for transfers. Resident #11 Record review of Resident #11's face sheet dated 1/30/14 revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of legal blindness, anxiety, muscle weakness, hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), osteoarthritis of knee (causes the cartilage in your knee joint to thin and the surfaces of the joint to become rougher, which means that the knee doesn't move as smoothly as it should, and it might feel painful and stiff), and low back pain. Record review of Resident #11's annual MDS assessment dated [DATE] revealed a BIMS score of 08, which indicated he was moderate cognitive impaired and required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half). Record review of Resident #11's care plan last revised on 01/15/2024 revealed a focus area for resident requires assist with ADLs with interventions of Hoyer lift (mobility tool used to help seniors with mobility challenges get out of bed) for all transfers. Record review of Resident #11's fall investigation sheet dated 12/12/23 revealed section B.1 CNA was transferring resident from shower chair to bed. [Resident #11] slipped down to floor. No changes were identified. Correct level of assist provided during transfers was extensive: lifted manually or mechanically. Analysis facts section revealed [Resident #11] slipped on floor post shower, was not wearing any shoes or non-slip socks. Educated staff to ensure proper footwear, and transfers per directions and educated [Resident #11] to voice if lower extremities feel weak. No injuries identified and pain level of 0/10 was noted. During an interview on 01/31/2024 at 11:07 am, CNA B stated she was Resident #11's assigned CNA the day of the incident. CNA B stated Resident #11 had slid to the floor when she was assisting him with a transfer from the shower chair to the bed. CNA B stated she assisted Resident #11 alone, used a gait belt to do a one-person assistance transfer. CNA B stated Resident #11 had voiced he felt weak and slipped to the floor. CNA B stated she did not look at Resident #11's care plan, did have access to care plan and forgot to look. CNA B stated she was new to the hall and had asked an unidentified CNA about the type of transfer Resident #11 was and was told he was able to assist with a one-person assistance. During an interview in 1/31/2024 at 11:50 am, Resident #11 was alert and oriented to person and event. Resident #11 sated a CNA whose name he can't remember had assisted him to transfer from the chair to the bed and during the transfer he fell . Resident #11 stated staff had always transferred him alone but recently they had started using the lift and had felt safe since then. Resident #11 stated staff had been assisted with transfers alone (one-person transfer) prior to the incident. Resident #6 Record review of Resident #6's face sheet dated 01/31/2024 revealed an [AGE] year-old male who was admitted on [DATE] with diagnoses of abnormalities of gait and mobility, muscle wasting atrophy, lack of coordination, arthritis to right knee, Alzheimer's, muscle weakness, unsteadiness to feet. Record review of Resident #6's other payment MDS assessment dated [DATE] revealed a BIMS score of 11, which indicated he was cognitively intact and required extensive assistance with 2-person physical assist for transfers. Record review of Resident #6's care plan last reviewed on 12/28/2023 revealed no interventions addressing 2-person physical assist for transfers. During an observation and interview on 01/29/2024 at 3:39 pm, revealed Resident #6 was alert and oriented to person, place, and event. Resident #6 was in his room, bed at the lowest position (ankle high) with the call light within reach. Resident #6 denied needing any assistance from staff to do anything including transfers and stated he was very independent. Resident #8 Record review of Resident #8's face sheet dated 01/31/2024 revealed a [AGE] year old male who was admitted on [DATE] with diagnoses of dementia, muscle weakness, muscle spasm, lack of coordination, multiple fractures of ribs, right side, and subsequent encounter for fracture with routine healing, displaced bicondylar fracture of left tibia(significant soft tissue swelling precluding arthroscopic or open repair of soft tissues), unspecified fracture of shaft of right tibia (tibia is the big bone between your knee and ankle, shaft is the middle of that bone), unspecified fracture of unspecified talus (large bone in the ankle that articulates with the tibia of the leg and the calcaneum and navicular bone of the foot), pain due to internal orthopedic prosthetic devices, implants and grafts, pedestrian on foot injured in collision with car in traffic accident. Record review of Resident #8's other payment assessment dated [DATE] revealed a BIMS score of 09, which indicated he was moderately cognitively impaired and required extensive assistance with 2-person physical assist with transfers. Record review of Resident #8's care plan last reviewed on 11/01/2023 revealed a focus area for resident requires assist with ADLs with interventions of two-person assist in room at all times per request. The care plan did not address level of care needed for transfer. During an observation and interview on 01/29/2024 at 3:50 pm, revealed Resident #8 was alert and oriented to person and event. Resident #8 had a brace to his left foot. Resident #8 stated he was involved in a car accident and broke his foot but did not remember how long ago it happened. Resident #8 stated he did not need assist with getting in and out of bed. Resident #8 stated he was able to get out of bed alone and attempted to demonstrate. During an interview on 01/30/2024 at 10:49 am, CNA I stated Resident #8 could put some weight on his left foot with the brace and was normally good about assisting with the transfers. CNA I stated they do not have a care plan to reference for level of care residents may need with transfers. CNA I stated they would ask other CNAs who had worked with a resident and were familiar with their care, charge nurse and therapy were good about teaching them on the transfer they needed. CNA I stated the residents electronic record under POC only reflected the services they provided for the day, it did not give guidance on the level of assistance a resident needed for transfers. CNA I stated depending on a resident they would decide on the type of transfer they would do, for example Resident #8 required one person assist and if he felt weak they would go ask for another CNA's help to complete the transfer. CNA I stated the level of assistance was done by their judgement not per special instructions because they did not have anything to refer to. During an interview on 01/30/2024 at 11:14 am, CNA J stated she was not familiar with Resident #8 as much. CNA J stated she had asked other CNAs who were more familiar with him about n his transfer status. CNA J stated she would also ask the residents if they were able to talk, and what they needed assistance with. CNA J stated electronic records only gave them a little bit of information but no special instructions on transfers. CNA J stated the POC was to document what was done for them that day but did not give instructions on transfers. CNA J stated the level of assistance was done by their judgement, based on verbal report gathered and not per special instructions because they did not have any to refer to. Resident #10 Record review of Resident #10's face sheet dated 01/31/2024 revealed a [AGE] year-old female who was readmitted on [DATE] with diagnoses of localized edema (swelling), hearing loss, unspecified osteoarthritis, muscle weakness, age related osteoporosis, difficulty in walking, other lack of coordination, pain due to internal orthopedic prosthetic devices, and unspecified fall. Record review of Resident #10's admission MDS assessment dated [DATE] revealed a BIMS score of 04, she was severely cognitive impaired and was dependent on chair/bed to chair transfer. Record review of Resident #10's care plan last reviewed 01/19/2024 revealed a focus area for resident requires assist with ADLs with no interventions on level of care needed for transfers. Resident #7 Record review of Resident #7's face sheet dated 01/31/2024 revealed a [AGE] year-old female who was admitted on [DATE] with diagnoses of lack of coordination, unsteadiness to feet, abnormalities of gait and mobility, age related physical debility, muscle weakness, difficulty in walking, restless leg syndrome. Record review of Resident #7's other payment MDS assessment dated [DATE] revealed a BIMS score of 01, which indicated she was severely cognitively impaired and required extensive assistance with two-person physical assist for transfers. Record review of Resident #7's care plan last reviewed on 1/17/24 revealed a focus area for resident requires assist with ADLs with no interventions on level of care needed for transfers. During an interview on 01/30/2024 at 11:32 am, MDS Nurse L stated anything that was mentioned on a resident's physician's orders would be included in their care plans. MDS Nurse L stated after she completed a MDS assessment the DON was the person responsible to review it. MDS Nurse L stated transfers with special instructions would typically be included on a resident's electronic record profile bar. MDS Nurse L stated if there were no special instructions on their electronic record profile it was assumed that they did not require special instruction, or a specified level of care needed for transfers. MDS Nurse L stated if no special instructions were documented for reference on the resident's electronic record profile, the transfer used for the resident was left to the CNAs discretion to decide. MDS L Nurse stated the reason for transfers not being included was due to the residents' care frequently changing and they would have to be changing and updating all the time. CNAs did have access to care plans but level of care for transfers were not implemented for guidance. During an interview on 01/30/2024 at 1:53 pm, CNA K stated she worked the night shift. CNA K stated for transfers she would ask other CNAs, charge nurses, and even the resident about what type of transfer they required. CNA K stated the level of assistance was done by their judgement not per special instructions because they did not have anything to refer to. During an interview on 01/30/2024 at 4:28 pm, the DON stated transfers were not included in the residents' care plans due to the residents' level of care changing from day to day. The DON explained that a resident one day might be a 2 person transfer and the following day they might be OK and only require a one-person transfer. The DON stated CNAs made the judgement on what level of assistance to provide during a transfer based on asking and seeing how much a resident could assist with the transfer. The DON explained and gave an example: if a resident's MDS assessment reflected they were a 2 person transfer and she felt she could do a one person transfer because she felt she had the strength to do so, she would do a one person transfer and not follow the MDS assessment. The DON stated the example was what the facility system was when determining the level of assistance a resident needed. Transfer policy was not obtained. Record review of Comprehensive Person-Centered Resident Care Planning policy undated reflected in part VI. 5- The facility will develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. VI.7- Each resident's plan of care shall be periodically reviewed and revised by and interdisciplinary team after each MDS assessment, including both the comprehensive and quarterly review assessments to reflect the resident's current care needs. The services provided or arranged by the facility, as outlined in the comprehensive care plan, must meet professional standards of quality; be provided by qualified persons in accordance with each residents written plan of care. VII.2- Based on the comprehensive assessment of a resident and consistent with the resident's needs and choice, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individuals clinical condition demonstrate that such diminution was unavoidable. The facility will provide care and services for the following activities: hygiene, mobility (transfer and ambulation, including walking), elimination, dining, and communication. The Administrator and DON were informed on 01/31/24 at 6:00 PM that Immediate jeopardy (IJ) had been identified and copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested. The Plan of Removal was accepted on 01/01/2024 at 1:14 pm. The Plan of Removal revealed the facility took the following actions: 1- Every resident (108 Census) was assessed for transfer status with a transfer proficiency assessment by nurse management to include the DON and ADONs and it was documented under resident care profile in PCC. Completed on 1/31/24. 2- All assessments were reviewed by the DOR of resident transfer status to include Resident #1 and Resident #11; agreed to all resident assessments (108 Census) but one. This resident was changed from 2 person to one person on 1/31/24. 3- The comprehensive care plans were updated to reflect the appropriate transfer status i.e. One person, two-person, Hoyer lift for all residents (108 census) on 1/31/24. The MDS Nurse will monitor transfer status and update as needed completed on 1/31/24. 4- The CNA Care Profile was updated to reflect transfer status to allow the CNAs to review transfer requirement for all residents on 1/31/24 on the facility room roster. The Care profile updates will occur during daily stand-up meetings and updates to be reflected on their care profile. The ADONs will be responsible for updating the care profile and any changes in transfer status. This was completed on 1/31/24. The CNAs will have to acknowledge any changes in transfer status in the task tab. Completed on 1/31/24. 5-All direct care staff were in-serviced by the Staffing Coordinator on where to look for transfer status. Return demonstration required by the CNAs. This will be included in the orientation process for newly hired staff and all current staff cannot return to the floor until complete. The Staffing Coordinator will be responsible for all continuing education upon annual competencies in regard to this moving forward. Inservice started on 1/30/24 all direct care staff 1/31/2024-ongoing. 6- The Director of Clinical Services in serviced DON regarding the proper transfer techniques using the proper amount of assistance and the MDS/Care plan updating process. Completed 2/1/24 and monitor ongoing. Action plan to be incorporated to ensure systems are in place to monitor corrections. -The Administrator/designee to monitor of these processes during the morning meeting daily 1/31/24 ongoing -The DON/designee to monitor during SOC weekly. 1/31/24 ongoing -The DON and or designee to monitor 10 random staff members for 8 weeks on how to demonstrate how to find the transfer status on the C.N.A. Care Profile. 1/31/24 -The DON/designee to monitor 10 random staff members for 8 weeks to ensure they can demonstrate proper transfer techniques utilizing the recommended amount of assistance 1/31/24 -The facility Medical Director and attending physicians of the SQC/IJ have received a copy of this plan 1/31/24 -The QAAC committee will review and evaluate this system for effectiveness to prevent any reoccurrence of this deficient practice. 1/31/24 ongoing. - The Director of Clinical Services to monitor the facility DON's understanding/compliance with the following 2/1/24 ongoing a. Transfer proficiencies b. Resident transfer status c. Transfer status updates d. CNA care profile updates e. Annual Competencies Interviews, observations, and record review to confirm implementation of the Plan of Removal were conducted as follows: Observations on 02/01/2024: 1:32 pm, CNA M logged into Resident #12's electronic profile and located special instructions and the POC transfer task and stated Resident #12 required a one person assist. CNA M proceeded to complete a one person assist transfer. No concerns were identified. 1:37 pm, CNA N and CNA O logged into Resident #13's electronic profile and located special instructions and the POC transfer task and stated Resident #13 required a 2-person physical assist with a Hoyer lift transfer. CNA N and CNA O proceeded to complete a 2-person physical assist transfer with a Hoyer lift. No concerns were identified. 1:48 pm, CNA A and CNA P logged into Resident #14's electronic profile and located special instructions and the POC transfer task and stated Resident # required a 2-person physical assist with a Hoyer lift transfer. CNA A and CNA P proceeded to complete a 2-person physical assist transfer with a Hoyer lift. No concerns were identified. 1:55 pm, CNA Q and CNA R logged into Resident #15's electronic profile and located special instructions and the POC transfer task and stated Resident #15 required a 2-person physical assist transfer. CNA Q and CNA R proceeded to complete a 2-person physical assist transfer. No concerns were identified. Interviews: 1:32 pm - 1:55 pm (interviews were conducted with observations), CNA A, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S confirmed in-services provided regarding residents' transfer status and weight bearing status located in the special needs instructions in PCC; task in PCC to complete every shift regarding each residents' transfer status; if not sure of any resident's transfer status they will ask the assigned nurse or check with therapy; pay attention to each resident's transfer status; if there was a change in transfers, ADLs, mobility, or residents complain of pain/discomfort notify the nurse immediately. 1:45 pm, the MD confirmed receiving copies of the IJ templates. 2:47 pm, MDS Nurse T and MDS Nurse U both stated they had already updated all care plans to reflect the residents' current level of assistance required. Both stated they will continue to update as needed on admission, quarterly, significant change and annually. 2:55 pm, the DON confirmed in-services provided regarding care plans needed to be updated to reflect transfer status, transfer technique to be decided by nurses, MDS and a therapy evaluation if needed, transfer status should reflect on the POC to be available for CNAs. The DON stated she or ADON X will review the standard of care in daily morning meetings. The DON stated she will monitor at random different staff to ensure they can properly demonstrate transfer and locate level of care needed for transfers and will document on the monitoring tool for 8 weeks. The DON stated she had already started the monitoring as of 1/31/24. 3:05 pm, the Administrator stated he will be overseeing the QAAC meeting and ensure all topics are being discussed any address any new concerns. 3:15 pm, The DOR stated she in-serviced the DON on updating and including transfers on the care plan. The DOR stated she in-serviced DON on resident assessment for level of care needed to be completed by nurses, a therapy evaluation if needed and to ensure level of care for transfers were available in PCC for CNAs to have access to. The DOR stated she reviewed all 108 residents with the nurses and DON to ensure the residents' care plans reflected their current level of care needed for transfers and signed the forms after each review. The DOR stated they will be discussing in morning meetings for new admission transfers and refer to the DON to ensure the PCC and care plans matched. Record review: Record review of the in-service training report dated 1/30/24 revealed it addressed the following: residents' transfer status and weight bearing is located in the special needs instructions on PCC; there is also a task in PCC to complete every shift regarding each residents transfer status; if staff was not sure of any resident's transfer status to please ask the nurse or check with therapy; pay attention to each resident's transfer status; if staff noticed a change in transfers, ADLs, mobility, or residents complained of pain/discomfort the staff was to notify their nurse immediately; it is the nurse's responsibility to notify the physician, therapy and document changes. Record review of Residents #1, 6, 7, 8, 10, 11, 12, 13, 14, and 15's electronic medical records reflected: a special instructions bar included level of assistance each resident required; POC tasks for transfers had the level of assistance needed for transfers and care plans were updated on 1/30/24. Record review of the transfer assessments for 108 residents (census) revealed they were completed with the DOR signature of review. The IJ was removed on 02/1/24, but the facility remained out of compliance at a scope of actual harm and severity level of isolated because the facility failed to have documented plans of care in place to provide guidance to the CNAs when performing resident transfers.

Based on observation, interview and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 6 (Residents #1, 11, 6, 8, 10, and 7) of 6 residents reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan that included transfer goals and interventions for Residents #1, 11, 6, 8, 10, and 7. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/31/24. The IJ template was provided to the Administrator. The IJ was removed on 02/01/24, but the facility remained out of compliance. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings include: Resident #1 Record review of Resident #1's face sheet dated 12/30/12 revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of vascular dementia, unsteadiness to feet, other abnormalities of gait and mobility, difficulty in walking, hemiplegia (paralysis of one side of the body), hemiparesis (one-sided muscle weakness), muscle weakness, age-related osteoporosis, and other lack of coordination. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score 08, which indicated she was moderately cognitive impaired and 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 chair/bed to chair transfer. Record review of Resident #1's care plan dated 12/13/2023 revealed a focus area for resident requires assist with ADLs but did not have interventions for level of assistance needed for transfers. Review of Resident #1's facility note dated 12/26/23 at 10:11 p.m. Change of Condition -Describe Change - Pain in Left Elbow. Nursing Interventions: notified Nurse Practitioner, got orders to give pain medication. Response: Elbow x-ray new order acetaminophen #3 by mouth every 6 hours as needed. Family aware, DON aware. Review of Resident #1's facility note dated 12/27/23 at 6:28 p.m. Change of Condition -Describe Change- resident has pain to left arm, purplish bruising to arm. Nursing Interventions- attempted in-house x-ray. Physician Notified. Physician Response: send to emergency room for evaluation due to unable to complete in-house x-ray. Family and DON notified. Review of Resident #1's facility note dated 12/27/23 at 7:23 p.m. Transfer Out - Clinical Condition/Reason for Transfer Complain of pain to her left elbow. Interventions attempted prior to discharge? If linked to Change of Condition? X-ray unable to be done in facility. Time left facility 7:18 p.m. Family, physician, and DON notified. Record review of Resident #1's local hospital diagnostic radiology report dated 12/27/2023 revealed reason for exam was pain and impression was acute fracture of the surgical neck of the left humerus (a bony constriction at the proximal end of shaft of humerus). Record review of Resident #1's local hospital discharge instructions dated 12/27/2023 revealed diagnoses of left humeral fracture and left elbow pain. Review of the Incident/Accident Report dated 12/28/23 documented: Incident- Resident stated that upon transferring in shower, she was lifted up under both arms and it hurt her left arm. Actions taken - was put back to bed, administered as needed pain medication, was checked on in approximately one hour and was resting comfortably and stated she was ok. During an interview on 01/29/2024 at 6:47 pm, CNA B stated she was assigned to Resident #1 on the day of the incident (12/27/2023). CNA B stated Resident #1 required a one person assist transfer and Resident #1 was able to assist with her good side. CNA B stated she had assisted Resident #6 to the shower, during the transfer from the wheelchair to the shower chair, she had attempted to assist Resident #1 to a standing position in which Resident #1 told her she needed to ask for help because she felt weak. CNA B stated she assisted Resident #1 to sit down on her wheelchair and called CNA A for help. CNA B stated her and CNA A assisted Resident #1 to a standing position and she left CNA A holding Resident #1 alone while she just turned to grab the shower chair that was not placed at a 90-degree angle as required. CNA B stated she let go of Resident #1, she slid down and landed on CNA A's feet. CNA B stated CNA C heard Resident #1 scream and went in the shower room to ask if they needed help and then assisted with lifting Resident #1 by herself off CNA A's feet to place her on the shower chair. CNA B stated she did not check Resident #1's care plan to check for the level of assistance she required for transfers. CNA B stated they (CNAs) would ask other CNAs and charge nurses about the type of transfers a resident may need. CNA B stated if comfortable they would decide to do a one person transfer and would only ask for help if they felt they needed it. CNA B stated there were no risk due to them receiving training on transfer technique. During an interview on 01/30/2024 at 9:30 am, Resident #1 was alert and oriented to person, place, and event. Resident #1 stated she did not remember the date of the fall but stated it had occurred in the shower room. Resident #1 stated she did not remember if she slipped but had ended up on the floor. Resident #1 stated there were 3 CNAs in the shower room and only one had assisted her off the floor. Resident #1 could not remember their names and further details. Resident #1 stated she had a lot of pain to her left arm and was sent out to the hospital the following day. Resident #1 stated staff usually transfer her either 1 or 2 people at a time. During an interview on 01/30/2024 at 9:39 am, RN H stated Resident #1 required a 2-person assist with a gait belt for transfers. RN H stated normally the CNAs had access to the residents' care on their electronic records under POC (plan of care). RN H stated CNAs also received verbal report from the charge nurse. RN H stated she was not aware of CNAs conducting one person assist for transfers. RN H stated she was not aware if therapy had given specific instructions on the level of care Resident #1 required for transfers. Resident #11 Record review of Resident #11's face sheet dated 1/30/14 revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of legal blindness, anxiety, muscle weakness, hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), osteoarthritis of knee (causes the cartilage in your knee joint to thin and the surfaces of the joint to become rougher, which means that the knee doesn't move as smoothly as it should, and it might feel painful and stiff), and low back pain. Record review of Resident #11's annual MDS assessment dated [DATE] revealed a BIMS score of 08, which indicated he was moderate cognitive impaired and required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half). Record review of Resident #11's care plan last revised on 01/15/2024 revealed a focus area for resident requires assist with ADLs with interventions of Hoyer lift (mobility tool used to help seniors with mobility challenges get out of bed) for all transfers. Record review of Resident #11's fall investigation sheet dated 12/12/23 revealed section B.1 CNA was transferring resident from shower chair to bed. [Resident #11] slipped down to floor. No changes were identified. Correct level of assist provided during transfers was extensive: lifted manually or mechanically. Analysis facts section revealed [Resident #11] slipped on floor post shower, was not wearing any shoes or non-slip socks. Educated staff to ensure proper footwear, and transfers per directions and educated [Resident #11] to voice if lower extremities feel weak. No injuries identified and pain level of 0/10 was noted. During an interview on 01/31/2024 at 11:07 am, CNA B stated she was Resident #11's assigned CNA the day of the incident. CNA B stated Resident #11 had slid to the floor when she was assisting him with a transfer from the shower chair to the bed. CNA B stated she assisted Resident #11 alone, used a gait belt to do a one-person assistance transfer. CNA B stated Resident #11 had voiced he felt weak and slipped to the floor. CNA B stated she did not look at Resident #11's care plan, did have access to care plan and forgot to look. CNA B stated she was new to the hall and had asked an unidentified CNA about the type of transfer Resident #11 was and was told he was able to assist with a one-person assistance. During an interview in 1/31/2024 at 11:50 am, Resident #11 was alert and oriented to person and event. Resident #11 sated a CNA whose name he can't remember had assisted him to transfer from the chair to the bed and during the transfer he fell . Resident #11 stated staff had always transferred him alone but recently they had started using the lift and had felt safe since then. Resident #11 stated staff had been assisted with transfers alone (one-person transfer) prior to the incident. Resident #6 Record review of Resident #6's face sheet dated 01/31/2024 revealed an [AGE] year-old male who was admitted on [DATE] with diagnoses of abnormalities of gait and mobility, muscle wasting atrophy, lack of coordination, arthritis to right knee, Alzheimer's, muscle weakness, unsteadiness to feet. Record review of Resident #6's other payment MDS assessment dated [DATE] revealed a BIMS score of 11, which indicated he was cognitively intact and required extensive assistance with 2-person physical assist for transfers. Record review of Resident #6's care plan last reviewed on 12/28/2023 revealed no interventions addressing 2-person physical assist for transfers. During an observation and interview on 01/29/2024 at 3:39 pm, revealed Resident #6 was alert and oriented to person, place, and event. Resident #6 was in his room, bed at the lowest position (ankle high) with the call light within reach. Resident #6 denied needing any assistance from staff to do anything including transfers and stated he was very independent. Resident #8 Record review of Resident #8's face sheet dated 01/31/2024 revealed a [AGE] year old male who was admitted on [DATE] with diagnoses of dementia, muscle weakness, muscle spasm, lack of coordination, multiple fractures of ribs, right side, and subsequent encounter for fracture with routine healing, displaced bicondylar fracture of left tibia(significant soft tissue swelling precluding arthroscopic or open repair of soft tissues), unspecified fracture of shaft of right tibia (tibia is the big bone between your knee and ankle, shaft is the middle of that bone), unspecified fracture of unspecified talus (large bone in the ankle that articulates with the tibia of the leg and the calcaneum and navicular bone of the foot), pain due to internal orthopedic prosthetic devices, implants and grafts, pedestrian on foot injured in collision with car in traffic accident. Record review of Resident #8's other payment assessment dated [DATE] revealed a BIMS score of 09, which indicated he was moderately cognitively impaired and required extensive assistance with 2-person physical assist with transfers. Record review of Resident #8's care plan last reviewed on 11/01/2023 revealed a focus area for resident requires assist with ADLs with interventions of two-person assist in room at all times per request. The care plan did not address level of care needed for transfer. During an observation and interview on 01/29/2024 at 3:50 pm, revealed Resident #8 was alert and oriented to person and event. Resident #8 had a brace to his left foot. Resident #8 stated he was involved in a car accident and broke his foot but did not remember how long ago it happened. Resident #8 stated he did not need assist with getting in and out of bed. Resident #8 stated he was able to get out of bed alone and attempted to demonstrate. During an interview on 01/30/2024 at 10:49 am, CNA I stated Resident #8 could put some weight on his left foot with the brace and was normally good about assisting with the transfers. CNA I stated they do not have a care plan to reference for level of care residents may need with transfers. CNA I stated they would ask other CNAs who had worked with a resident and were familiar with their care, charge nurse and therapy were good about teaching them on the transfer they needed. CNA I stated the residents electronic record under POC only reflected the services they provided for the day, it did not give guidance on the level of assistance a resident needed for transfers. CNA I stated depending on a resident they would decide on the type of transfer they would do, for example Resident #8 required one person assist and if he felt weak they would go ask for another CNA's help to complete the transfer. CNA I stated the level of assistance was done by their judgement not per special instructions because they did not have anything to refer to. During an interview on 01/30/2024 at 11:14 am, CNA J stated she was not familiar with Resident #8 as much. CNA J stated she had asked other CNAs who were more familiar with him about n his transfer status. CNA J stated she would also ask the residents if they were able to talk, and what they needed assistance with. CNA J stated electronic records only gave them a little bit of information but no special instructions on transfers. CNA J stated the POC was to document what was done for them that day but did not give instructions on transfers. CNA J stated the level of assistance was done by their judgement, based on verbal report gathered and not per special instructions because they did not have any to refer to. Resident #10 Record review of Resident #10's face sheet dated 01/31/2024 revealed a [AGE] year-old female who was readmitted on [DATE] with diagnoses of localized edema (swelling), hearing loss, unspecified osteoarthritis, muscle weakness, age related osteoporosis, difficulty in walking, other lack of coordination, pain due to internal orthopedic prosthetic devices, and unspecified fall. Record review of Resident #10's admission MDS assessment dated [DATE] revealed a BIMS score of 04, she was severely cognitive impaired and was dependent on chair/bed to chair transfer. Record review of Resident #10's care plan last reviewed 01/19/2024 revealed a focus area for resident requires assist with ADLs with no interventions on level of care needed for transfers. Resident #7 Record review of Resident #7's face sheet dated 01/31/2024 revealed a [AGE] year-old female who was admitted on [DATE] with diagnoses of lack of coordination, unsteadiness to feet, abnormalities of gait and mobility, age related physical debility, muscle weakness, difficulty in walking, restless leg syndrome. Record review of Resident #7's other payment MDS assessment dated [DATE] revealed a BIMS score of 01, which indicated she was severely cognitively impaired and required extensive assistance with two-person physical assist for transfers. Record review of Resident #7's care plan last reviewed on 1/17/24 revealed a focus area for resident requires assist with ADLs with no interventions on level of care needed for transfers. During an interview on 01/30/2024 at 11:32 am, MDS Nurse L stated anything that was mentioned on a resident's physician's orders would be included in their care plans. MDS Nurse L stated after she completed a MDS assessment the DON was the person responsible to review it. MDS Nurse L stated transfers with special instructions would typically be included on a resident's electronic record profile bar. MDS Nurse L stated if there were no special instructions on their electronic record profile it was assumed that they did not require special instruction, or a specified level of care needed for transfers. MDS Nurse L stated if no special instructions were documented for reference on the resident's electronic record profile, the transfer used for the resident was left to the CNAs discretion to decide. MDS L Nurse stated the reason for transfers not being included was due to the residents' care frequently changing and they would have to be changing and updating all the time. CNAs did have access to care plans but level of care for transfers were not implemented for guidance. During an interview on 01/30/2024 at 1:53 pm, CNA K stated she worked the night shift. CNA K stated for transfers she would ask other CNAs, charge nurses, and even the resident about what type of transfer they required. CNA K stated the level of assistance was done by their judgement not per special instructions because they did not have anything to refer to. During an interview on 01/30/2024 at 4:28 pm, the DON stated transfers were not included in the residents' care plans due to the residents' level of care changing from day to day. The DON explained that a resident one day might be a 2 person transfer and the following day they might be OK and only require a one-person transfer. The DON stated CNAs made the judgement on what level of assistance to provide during a transfer based on asking and seeing how much a resident could assist with the transfer. The DON explained and gave an example: if a resident's MDS assessment reflected they were a 2 person transfer and she felt she could do a one person transfer because she felt she had the strength to do so, she would do a one person transfer and not follow the MDS assessment. The DON stated the example was what the facility system was when determining the level of assistance a resident needed. Record review of Comprehensive Person-Centered Resident Care Planning policy undated reflected in part VI. 5- The facility will develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. VI.7- Each resident's plan of care shall be periodically reviewed and revised by and interdisciplinary team after each MDS assessment, including both the comprehensive and quarterly review assessments to reflect the resident's current care needs. The services provided or arranged by the facility, as outlined in the comprehensive care plan, must meet professional standards of quality; be provided by qualified persons in accordance with each residents written plan of care. VII.2- Based on the comprehensive assessment of a resident and consistent with the resident's needs and choice, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individuals clinical condition demonstrate that such diminution was unavoidable. The facility will provide care and services for the following activities: hygiene, mobility (transfer and ambulation, including walking), elimination, dining, and communication. The Administrator and DON were informed on 01/31/24 at 6:00 PM that Immediate jeopardy (IJ) had been identified and copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested. The Plan of Removal was accepted on 01/01/2024 at 1:14 pm. The Plan of Removal revealed the facility took the following actions: 1- Every resident (108 Census) was assessed for transfer status with a transfer proficiency assessment by nurse management to include the DON and ADONs and it was documented under resident care profile in PCC. Completed on 1/31/24. 2- All assessments were reviewed by the DOR of resident transfer status to include Resident #1 and Resident #11; agreed to all resident assessments (108 Census) but one. This resident was changed from 2 person to one person on 1/31/24. 3- The comprehensive care plans were updated to reflect the appropriate transfer status i.e. One person, two-person, Hoyer lift for all residents (108 census) on 1/31/24. The MDS Nurse will monitor transfer status and update as needed completed on 1/31/24. 4- The CNA Care Profile was updated to reflect transfer status to allow the CNAs to review transfer requirement for all residents on 1/31/24 on the facility room roster. The Care profile updates will occur during daily stand-up meetings and updates to be reflected on their care profile. The ADONs will be responsible for updating the care profile and any changes in transfer status. This was completed on 1/31/24. The CNAs will have to acknowledge any changes in transfer status in the task tab. Completed on 1/31/24. 5-All direct care staff were in-serviced by the Staffing Coordinator on where to look for transfer status. Return demonstration required by the CNAs. This will be included in the orientation process for newly hired staff and all current staff cannot return to the floor until complete. The Staffing Coordinator will be responsible for all continuing education upon annual competencies in regard to this moving forward. Inservice started on 1/30/24 all direct care staff 1/31/2024-ongoing. 6- The Director of Clinical Services in serviced DON regarding the proper transfer techniques using the proper amount of assistance and the MDS/Care plan updating process. Completed 2/1/24 and monitor ongoing. Action plan to be incorporated to ensure systems are in place to monitor corrections. -The Administrator/designee to monitor of these processes during the morning meeting daily 1/31/24 ongoing -The DON/designee to monitor during SOC weekly. 1/31/24 ongoing -The DON and or designee to monitor 10 random staff members for 8 weeks on how to demonstrate how to find the transfer status on the C.N.A. Care Profile. 1/31/24 -The DON/designee to monitor 10 random staff members for 8 weeks to ensure they can demonstrate proper transfer techniques utilizing the recommended amount of assistance 1/31/24 -The facility Medical Director and attending physicians of the SQC/IJ have received a copy of this plan 1/31/24 -The QAAC committee will review and evaluate this system for effectiveness to prevent any reoccurrence of this deficient practice. 1/31/24 ongoing. - The Director of Clinical Services to monitor the facility DON's understanding/compliance with the following 2/1/24 ongoing a. Transfer proficiencies b. Resident transfer status c. Transfer status updates d. CNA care profile updates e. Annual Competencies Interviews, observations, and record review to confirm implementation of the Plan of Removal were conducted as follows: Observations on 02/01/2024: 1:32 pm, CNA M logged into Resident #12's electronic profile and located special instructions and the POC transfer task and stated Resident #12 required a one person assist. CNA M proceeded to complete a one person assist transfer. No concerns were identified. 1:37 pm, CNA N and CNA O logged into Resident #13's electronic profile and located special instructions and the POC transfer task and stated Resident #13 required a 2-person physical assist with a Hoyer lift transfer. CNA N and CNA O proceeded to complete a 2-person physical assist transfer with a Hoyer lift. No concerns were identified. 1:48 pm, CNA A and CNA P logged into Resident #14's electronic profile and located special instructions and the POC transfer task and stated Resident # required a 2-person physical assist with a Hoyer lift transfer. CNA A and CNA P proceeded to complete a 2-person physical assist transfer with a Hoyer lift. No concerns were identified. 1:55 pm, CNA Q and CNA R logged into Resident #15's electronic profile and located special instructions and the POC transfer task and stated Resident #15 required a 2-person physical assist transfer. CNA Q and CNA R proceeded to complete a 2-person physical assist transfer. No concerns were identified. Interviews: 1:32 pm - 1:55 pm (interviews were conducted with observations), CNA A, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S confirmed in-services provided regarding residents' transfer status and weight bearing status located in the special needs instructions in PCC; task in PCC to complete every shift regarding each residents' transfer status; if not sure of any resident's transfer status they will ask the assigned nurse or check with therapy; pay attention to each resident's transfer status; if there was a change in transfers, ADLs, mobility, or residents complain of pain/discomfort notify the nurse immediately. 1:45 pm, the MD confirmed receiving copies of the IJ templates. 2:47 pm, MDS Nurse T and MDS Nurse U both stated they had already updated all care plans to reflect the residents' current level of assistance required. Both stated they will continue to update as needed on admission, quarterly, significant change and annually. 2:55 pm, the DON confirmed in-services provided regarding care plans needed to be updated to reflect transfer status, transfer technique to be decided by nurses, MDS and a therapy evaluation if needed, transfer status should reflect on the POC to be available for CNAs. The DON stated she or ADON X will review the standard of care in daily morning meetings. The DON stated she will monitor at random different staff to ensure they can properly demonstrate transfer and locate level of care needed for transfers and will document on the monitoring tool for 8 weeks. The DON stated she had already started the monitoring as of 1/31/24. 3:05 pm, the Administrator stated he will be overseeing the QAAC meeting and ensure all topics are being discussed any address any new concerns. 3:15 pm, The DOR stated she in-serviced the DON on updating and including transfers on the care plan. The DOR stated she in-serviced DON on resident assessment for level of care needed to be completed by nurses, a therapy evaluation if needed and to ensure level of care for transfers were available in PCC for CNAs to have access to. The DOR stated she reviewed all 108 residents with the nurses and DON to ensure the residents' care plans reflected their current level of care needed for transfers and signed the forms after each review. The DOR stated they will be discussing in morning meetings for new admission transfers and refer to the DON to ensure the PCC and care plans matched. Record review: Record review of the in-service training report dated 1/30/24 revealed it addressed the following: residents' transfer status and weight bearing is located in the special needs instructions on PCC; there is also a task in PCC to complete every shift regarding each residents transfer status; if staff was not sure of any resident's transfer status to please ask the nurse or check with therapy; pay attention to each resident's transfer status; if staff noticed a change in transfers, ADLs, mobility, or residents complained of pain/discomfort the staff was to notify their nurse immediately; it is the nurse's responsibility to notify the physician, therapy and document changes. Record review of Residents #1, 6, 7, 8, 10, 11, 12, 13, 14, and 15's electronic medical records reflected: a special instructions bar included level of assistance each resident required; POC tasks for transfers had the level of assistance needed for transfers and care plans were updated on 1/30/24. Record review of the transfer assessments for 108 residents (census) revealed they were completed with the DOR signature of review. The IJ was removed on 02/1/24, but the facility remained out of compliance at a scope of actual harm and severity level of isolated because the facility failed to have documented plans of care in place to provide guidance to the CNAs when performing resident transfers.

Based on observation, interview and record review, the facility failed to ensure each resident environment remains as free of accident hazards as is possible for 2 of 5 residents (Residents #2, and #68 ) reviewed for accidents and hazards in that: CNA B, CNA C, and CNA D failed to lock Resident #2 and Resident #68's wheelchair during transfers. This deficient practice could place residents at risk for avoidable injuries during transfers. The findings included: Review of Resident #2's Admission Record, dated [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including heart failure, history of falls, and difficulty walking. Review of Resident #2's Annual MDS Assessment, dated [DATE] revealed: She scored a 9 of 15 on her mental status exam indicating moderate cognitive impairment. She needed extensive assistance of two or more staff for transfers. She had no falls in the previous look back timeframe. Review of Resident #2's Care Plan revealed: Focus updated [DATE]: Resident requires assist with ADLs. Goal: Resident is able to perform self-care to optimal level and maintain strength, and endurance. Interventions included: mechanical lift for all transfers; provide level of support to complete transferring needs every shift. Focus updated [DATE] Focus: Resident has limited physical mobility related to non-weight bearing to Right lower extremity. Goal: the resident will remain free of complication relate to immobility, including contractures, skin breakdown, fall-related injury through the next review date. Interventions included: non-weight bearing to right lower extremity until further notice. Focus updated [DATE]: Resident has a history of falling, history of falls. Goal: Resident will not experience any injury from falls for 90 days. Interventions included: mechanical lift for all transfers (dated [DATE]) Review of Resident #2's Order Summary Report, dated [DATE] revealed orders dated [DATE] for Mechanical lift for all transfers. Observation on [DATE] at 2:53 p.m. Resident #2 up in her wheelchair. CNA B and CNA C hooked Resident #2 to the mechanical lift. CNA B prompted Resident #2 to cross her arms as CNA C operated the lift. As the lift was rising, Resident #2's hip bumped against the side of the wheelchair causing the wheelchair to move. Resident #2 became visibly upset (facial expression changed and she appeared tense) when the wheelchair moved and began gripping CNA B's hand and murmuring in Spanish. It was noted that only one side of the wheelchair was locked. Once in the air, CNA B folded the wheelchair and moved the wheelchair to the side. CNA B steadied Resident #2 as CNA C maneuvered the mechanical lift. CNA B steadied Resident #2 as CNA C lowered Resident #2 to the bed. Interview on [DATE] at 3:37 p.m. CNA B said the lift transfer went ok. She said the room was small and she had to fold the wheelchair just so the mechanical lift could move Resident #2 to the bed. CNA B said Resident #2 was afraid of the lift. CNA B said the facility trained staff to do a mechanical lift with two people, open the legs of the lift, put the sling on the hooks, have the resident cross their arms and lift the resident. CNA B said the wheelchair wheels needed to be locked. She stated she did not lock Resident #2's wheelchair. Review of Resident #68's Admission Record, dated [DATE], revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including abnormal gait, dementia, stroke with paralysis to the right side, generalized muscle weakness, and reduced mobility. Review of Resident #68's Quarterly MDS Assessment, dated [DATE], revealed: He scored a 5 of 15 on his mental status exam, indicating severe cognitive impairment. He needed extensive assistance of two or more staff for transfers. He had one fall with no injury in the previous look back timeframe. Review of Resident #68's Care Plan revealed: Focus updated [DATE]: Resident is at risk for falls due to new environment and/or age. No other indicator that would suggest high fall risk. Goal: the resident will be free of falls through the review date. Interventions included: Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs and ensure that resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. Focus updated [DATE]: Resident has history of falling, fall [DATE] and [DATE]. Goal: Resident will not experience any injuries from falls for 90 days. Interventions included: anticipate and meet resident's needs, bathroom before and after meals, ensure that resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, and may have anti-roll backs on wheelchair every shift. Observation on [DATE] at 3:20 p.m. revealed Resident #68 slouched down in his wheelchair in a way that his shoulders were on the seat of the wheelchair his head was propped on the back of the wheelchair, his bottom hung off the wheelchair and his feet rested on the bed. Resident #68's responsible party gave permission for the transfer to be observed. Because of Resident #68's position, three CNAs were needed to lift him safely. As CNA B lifted Resident #68's shoulders up to place the gait belt, the wheelchair moved, and the responsible party told the aides they needed to lock the wheelchair or Resident #68 would fall. All CNAs stopped what they were doing, and CNA D locked the wheelchair. CNA B was then able to safely place the gait belt on Resident #68 and she and CNA C attempted to lift him back into a sitting position in the wheelchair but due to how far down he had sunk in the wheelchair they were unable to lift him. CNA D then held onto Resident #68 in a hug-like grip while CNA B and CNA C lifted the resident from under his arms using the gait belt and pulled him up into a sitting position in the wheelchair. In an interview on [DATE] at 3:35 p.m. the DON stated that her expectation was that during transfers, wheelchairs were to be locked by staff to prevent accidents or injuries to the residents and staff. She stated that during a routine stand pivot transfer, the wheelchair should always be close by, and the wheels should absolutely be locked. The DON stated that sometimes, because of the lack of space in the resident rooms, it was easier for staff to not lock the wheelchair when performing a mechanical lift transfer because the wheelchair was smaller and easier to maneuver than the lift. She explained that once the resident was placed in the sling and lifted from the bed, the wheelchair could be moved around easier and tilted to better position the resident comfortably into the wheelchair. The DON stated that when moving a resident out of a wheelchair with a mechanical lift the wheelchair should be locked. She stated that Resident #2 was fearful of being transferred with the mechanical lift due to her history of falls and that staff was aware to be cautious when transferring her. When the transfer involving Resident #68 was described to her, she had no comments. Review of facility in-service dated [DATE] topic New Admission and Resident Transfers revealed in part: All admissions need assistance; 2 person transfer at all times, wheelchair use ONLY prior to therapy evaluation. Review of facility in-service dated [DATE] topic Hoyer Lift revealed in part: All Hoyer lift transfers require 2 people at all times during the use of this machine, no exceptions. Review of undated facility policy titled One Person Pivot Transfer revealed, in part: Procedure: 1. Explain procedure to resident. 2. Clear obstacles. Lock wheels/brakes; remove leg rests and/or wheelchair arms if able. Position wheelchair next to bed. Review of undated facility policy titled Two Person Pivot Transfer revealed, in part: Procedure: 1. Explain procedure to resident. 2. Clear obstacles. Lock wheels/brakes; remove leg rests and/or wheelchair arms if able. Position wheelchair next to bed. Review of undated facility policy titled Two Person Hoyer (Mechanical) Lift revealed, in part: Procedure: 1. Gather equipment and bring to bedside. 2. Position wheelchair so that you can maneuver the lift safely from the bed to over the chair. Lock the wheels/brakes.

Based on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 1 treatment cart reviewed for medication storage and security. The facility staff failed to ensure the treatment cart was secured when it was left unattended and unsupervised. These failures could place clients at risk for drug diversion or accidental ingestion. Findings included: During an observation on 12/03/23 at 09:44 AM the facility treatment cart was observed unlocked and unattended by facility staff. Inside the cart were bottles of normal saline, medication ointments, antifungal powder, fungal creams, fingernail clippers, containers of zinc oxide and scissors. During an interview on 12/06/23 at 10:38 AM treatment nurse A said the treatment cart was supposed to be locked when unattended. Treatment nurse A said the cart was supposed to be locked to prevent others such as residents getting into the treatment medications, scissors and such. The treatment nurse said she was not the treatment nurse that was working the floor on 12/03/2023. During an interview on 12/06/23 at 03:08 PM the Administrator said it was his expectation for staff to lock the treatment cart and take the keys with them when they were not using the cart. The Administrator said if the cart was left unlocked and unattended residents or other staff could get into the cart. During an interview on 12/06/23 at 03:15 PM the DON said her expectation was for the treatment cart to be locked if it was left unattended. The DON said the cart was supposed to be locked to keep the items secured. The DON said it was a shared cart and any one with the keys could have left it unlocked. The DON said it was not okay for it to be left unlocked. Record review of the facility's undated document titled Medication cart, administration of drugs indicated in part: Purpose: To administer medication more quickly and efficiently. If the cart is left at any time during medication pass due to an emergency, it must be locked.

Based on observation, interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices were complete, accurately documented, readily accessible and systematically organized for 1 of 4 residents (Resident #1) reviewed for accuracy of medical records, in that: Resident #1's Weekly Skin and Wound Evaluation was not completed for Resident #1 from 5/4/23 to 6/2/23. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #1's face sheet, dated 5/25/23, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes mellitus, kidney disease, sepsis, and defibrinating syndrome (Condition affecting the blood's ability to clot and stop bleeding). Record review of Weekly Skin and Wound Evaluation dated 5/3/23 indicated: Resident #1 had 3 wounds that were POA from Hospital. Wound #1 Surgical wound, Right Below Knee Amputation BKA wound measuring 13x15x0.3. Wound #2 Surgical wound, Right arm measuring 30x30x0.2. Wound #3 Surgical Wound, left pinky measuring 4x0.2x0. Record review of Resident #1's MAR dated 5/26/23 indicated that wound care was not missed from 5/3/23 to 5/26/23. MAR indicated DON, charge nurse, or night nurse performed wound care. During an interview on 5/26/23 at 11:15 AM WCN-A stated she was out of the facility from 5/5/23 to 5/27/23. She stated that when she first saw the resident and did the initial assessment on 5/3/23 the right arm from elbow down was black. She stated there was a wound down between the index and middle finger, on the right hand. She stated the other wound was up on the forearm 2 inches below the elbow. She stated when she assessed the arm on 5/28/23 the entire arm from elbow down was still black. She stated that two wounds looked to be improving but had drainage. She stated near the wrist it looked as if the necrotic tissue had fallen off and red skin was underneath. She stated she cleaned it and it looked to be healthy skin. She stated it did have some drainage that she cleaned up. She stated overall there was not a huge difference from initial to the last day she saw him in the improvement of his skin. She stated I don't know why the Weekly Skin and Wound assessment was not complete for pretty much the entire month of May. She stated that when she is not at the facility, wound care is to be done by the DON, ADON, or charge nurse and the Weekly Skin and Wound assessment should be done by DON, ADON, or charge nurse. During an interview on 6/2/23 at 1:15 PM DON stated that the RN's on shift should have done the weekly skin and wound assessment of the resident. She stated it was a rough month and multiple people were out and the skin and wound weekly assessment got missed. She stated each time she saw the resident the wound did not look to be improving or getting worse. She stated for wound care, all the employees must do is, go into the MAR and stated wound care is done. She stated they are to go into progress notes to notate if any changes to the wounds was seen. During an interview on 5/26/23 at 12:40 PM LVN-B stated that she did the wound care for Resident #1 but only on his leg. She stated she never did any wound care on his arm. She stated that wound care was split, she did wound care on the leg and RN-D did wound care on the arm. She stated that she understood that the weekly skin and wound assessment should be done by the ADON or DON if the wound care nurse was not present. She stated all she must do was click in the MAR that wound care is complete, she does not do any of the measuring or describing of the wounds. During an interview on 5/26/23 at 12:45 PM RRN-C stated that all the employees must do is fill out the MAR. She stated that no progress notes, skin notes, basically no notes were done for wound care. She stated the only reason anyone should make any notes on wound care, and they would be in progress notes, is if they see something new. She stated she is not sure why the Weekly Skin and Wound assessment was not done for Resident #1. She stated this should not have happened because this is the best way to track if a wound is improving or getting worse. She stated in the absence of the WCN-A the DON, ADON, or charge nurse should have completed this at least once weekly for each resident. She stated this is important to do because it is tracking a wound for each resident to identify if the wound is healing or not healing. During a phone interview on 5/26/23 at 1:25 PM RN-D stated that he did the wound care on the leg and on the right arm for Resident #1. He stated from the first time he saw Resident #1 to his most recent wound care; the resident's arm was just black. He stated no shearing or sluff coming off the skin was just black. He stated the wound did not really look bad to him. He stated the wound never changed, he stated the entire time the resident was under his care the wound never really improved or got worse. He stated he never did any notes of the wounds or anything in progress notes, he only initialed the MAR that wound care was complete. He stated he is not sure why the Weekly Skin and Wound assessment was not complete. He stated that the Weekly Skin and Wound assessment should be done by the wound care nurse, ADON or DON. Record review of Facilities Skin Assessment Policy and Procedure dated June 2018 revealed: Purpose: To ensure that all residents skin integrity remains intact and that all adverse skin problems are identified quickly, documented correctly, treated accordingly, and monitored for complications. Procedure: 3. All adverse skin problems must have a Skin & Wound Evaluation V5.0 (one for each site) completed and/or updated weekly to determine progress or lack thereof. The individual skin sheets are to be kept in the Treatment book until they are resolved.

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 2 residents (Resident #1) reviewed for transfers in that: The facility failed to prevent Resident #1 from getting his toes scraped and injured when being pushed by staff on his wheelchair due to him not having foot rests to hold his feet up. This failure could put residents at risk of accidents and serious injuries which could result in a reduced quality of life. Findings included: Record review of Resident #1's admission record, dated [DATE], indicated he was admitted to the facility on [DATE] with diagnoses of dislocation of T9/T10 thoracic vertebra subsequent encounter (spinal column injury), fusion of the spine, and lack of coordination. He was [AGE] years of age. Record review of Resident #1's admission MDS assessment, dated [DATE], indicated in part: BIMS = 14 indicating resident was cognitively intact. Functional status = Locomotion on unit, If in wheelchair, self-sufficiency once in chair = Extensive assistance and one-person physical assist. Record review of Resident #1's care plan, dated [DATE], indicated in part: Focus: Resident requires assist with ADLs. Goal: Resident is able to perform self-care to optimal level and maintains strength andendurance x 90 days. Interventions: [DATE] requires foot pedals while out of facility to wheelchair. Record review of Resident #1's nurses notes, completed by LVN A and dated [DATE], indicated in part: Resident returned to facility and toes noted with blood on them. Treatment nurse and DON notified. NP in facility and assessed resident. Right foot great toe 1x1 skin tear. 2nd toe skin tear X2, 3rd toe 0.5x 0.5, 4th toe 0.8x0.5. Left foot great toe 1x2. 2nd toe 0.5x0.5. Area cleaned dry dressing in place. Sister called and notified of incident, voiced appreciation for calling and letting her know. Stated she will call resident and see how he's doing. Resident stated I didn't know they were dragging; my feet weren't that low. Vitals 97.1, ,d+[DATE], 91, 18, 97% 2L via n/c. Resident denies any pain or discomfort, no bleeding noted at this time. (Note: interview with LVN A - she verified measurements were in centimeters). During an observation and interview on [DATE] at 12:14 PM, Resident #1 was resting in his bed awake and alert. The resident said he recalled the day the staff got him out of bed and his feet were dragged on the floor which caused the toes on his feet to bleed. Resident #1 said he was not even aware his toes had been scrapped since he was paralyzed from the waist down. The resident said CNAs B and C got him out of bed that day and transferred him to his wheelchair with the use of a mechanical lift. Resident #1 said the wheelchair he used that day [DATE] did not have footrests and that was the reason his feet had dragged. The resident said the staff pushed him to the dining room and then to the therapy room. Resident #1 said the van driver then wheeled him into the van to take him to a doctor's appointment. The resident said that when the Van Driver pushed him into the doctor's office the Van Driver noticed his toes were bleeding. Resident #1 said he did not feel his toes dragging because he was paralyzed or else, he would have said something. Resident #1 said the Van Driver called the facility nurse and they had to come back to the facility so the nurse could assess him. The resident said he felt that it was the CNAs fault for not placing the footrests on his wheelchair after they got him out of bed. Resident #1 said when they got back to the facility, the nurse had to bandage up several of his toes because they were scrapped pretty bad. During an interview on [DATE] at 1:30 PM, the Van Driver said she recalled taking Resident #1 to the doctor's appointment on [DATE]. The Van Driver said the resident was sitting up in his wheelchair in the therapy room doing exercises and that was where she picked him up. She said the resident had 2 blankets on him and one covered his feet. The Van Driver said she pushed Resident #1 on his wheelchair to the facility van which was parked out in the back by the therapy room. She said when she pushed the resident outside to the van, she did not notice any resistance or that his feet were dragging. The Van Driver said she pushed the resident up the ramp of the van and secured the wheelchair in the van with the straps and did not notice the resident's feet or toes were bleeding. She said there were no footrests on the wheelchair. She said when they arrived at the doctor's appointment, she unloaded Resident #1 and while she was pushing the resident into the building that's when she noticed the residents toes were bleeding. The Van Driver said the resident's feet probably got dragged on the sidewalk as she pushed him but was not sure how it occurred. The Van Driver said she called the facility nurse, LVN A, and reported to her what happened and the nurse told her to bring the resident back to the facility. The Van Driver said she picked up the resident's feet by grabbing his socks and pulling the wheelchair by the armrest and took him back to the van. She said after she loaded the resident back into the van, she brought him back to the facility. The Van Driver said when she got back CNA B assisted her with bringing the resident into the facility. She said she held his feet up while CNA B pushed the wheelchair. The Van Driver said Resident #1 had not told her that he could not raise his feet and she was not aware the resident could not raise his feet. The Van Driver said that was the first time she had taken Resident #1 and was not aware if he used footrests. The Van Driver said she had taken Resident #1 to an appointment since [DATE] and he now wore footrests when attending them. The Van Driver said she had been trained by the transportation director. During an interview on [DATE] at 2:32 PM the occupational therapist said from what he could recall, Resident#1 wore footrests when he attended therapy before [DATE]. He said the resident was paralyzed from the waist down so he had to wear them to prevent his feet from dragging. During an interview on [DATE] at 2:44 PM, the occupational therapy assistant said from the time that Resident #1 started attending therapy, he recalled the resident using the footrests, since the resident was unable to move his legs. He said the resident had to wear footrests to prevent his feet from dragging. During an interview on [DATE] at 11:14 AM, CNA C said they used a mechanical lift to transfer Resident #1 as he was paralyzed from the waist down. CNA C said CNA B and he transferred Resident #1 from his bed to the wheelchair on [DATE]. CNA C said after they transferred the resident to his wheelchair, he did not notice any footrests for the wheelchair in the room and that Resident #1's feet were not dragging on the floor. CNA C said if he had noticed the resident's feet dragging, he would have found some footrests for his wheelchair. CNA C said he heard that after Resident #1 returned from the doctor's visit, that his feet were bloodied but he did not recall the resident's feet being injured when the resident was still at the facility. During an interview on [DATE] at 11:25 AM, CNA B said CNA C and her got Resident #1 out of bed on [DATE] with the lift and placed him on his wheelchair. CNA B said Resident #1's feet were dangling from the wheelchair and he did not have any footrests. CNA B said she had pushed the resident to the dining room and his feet were not dragging and not even touching the floor. CNA B said then from the dining room, the therapy people got him and took him to the therapy room. CNA B said then, later, the van driver got him from therapy and took him to the doctor's appointment. CNA B said later after Resident #1 and the van driver had left, the van driver called LVN A and said his toes were bleeding. sSo the van driver brought the resident back to the facility. CNA B said she went and helped the van driver bring Resident #1 into the facility and then LVN A assessed him. During an interview on [DATE] at 12:24PM LVN A said she did not notice if Resident #1 used footrests prior to [DATE] when he had gone to the doctor's appointment. LVN A said Resident #1 had been up on his wheelchair before and had not worn footrest and his feet were not touching the floor. LVN A said it was everyone's job to make sure residents that required footrests were using them. LVN A said after the Van Driver left to the doctor's office with Resident #1, she later called to inform her that Resident #1's toes were bleeding because she thought his feet got dragged under the wheelchair. LVN A said she advised the Van Driver to bring the resident back to the facility and that she would assess him when they got back. LVN A said the Van Driver and the resident arrived at the facility and came in through the back door of hall 3, she said she was waiting for them and they took the resident to his room and that's where she assessed him. LVN A said she also got the DON, treatment nurse, and the NP to come see Resident #1's toes. LVN A said the NP told her to clean the wounds and cover them with a dressing. LVN A said Resident #1 might have slid down the wheelchair which caused his feet to drag on the floor or sidewalk. LVN A said the measurements that were on Resident #1's nurses notes were measurements in centimeters. LVN A said the resident wore footrests now when he was up in his wheelchair. During an interview on [DATE] at 12:54PM the Transportation Director said she had trained the van driver on how to transport residents on the facility van. The Director said she was not working that day [DATE] and the Van Driver had called and reported to her that the Resident #1's toes were bleeding and that she had called the facility nurse. The Director said the Van Driver said the resident was not wearing footrests on that day. The Director said she took Resident #1 on another appointment and he was wearing footrests at that time. The Director said the resident got his toes scraped because the resident feet and toes touched the floor. The Director said they communicated with the nursing staff to have the resident's ready 30 minutes before they had to leave to give themselves plenty of time to make it to the appointment on time and got anything the resident's needed with them such as coats. The Director said they also had extra footrests in the van just in case they need them. During an interview on [DATE] at 1:38PM, the DON said it was the staff's responsibility to make sure the resident's that needed footrests had them or get them from the maintenance department. The DON said the times she saw Resident #1, he was in his bed, so she did not notice if he used footrests. The DON said Resident #1 might have slid down some when he was in his wheelchair and his feet were dragged on scraped sometime during his doctor's appointment. The DON said when she asked the Van Driver if she felt any resistance when pushing the resident, that she said she had not. The DON said they did not a specific policy for accidents. Review of the facility's undated policy titled Standards of care policy and procedures for transporting residents indicated in part: Before loading residents, the facility driver is expected to know the residents medical problems and needs. In some emergencies the driver or staff member may need to know if the resident is a no code or full code and/or if an emergency does occur, they may be better informed to convey important information to emergency personnel during an emergency. Once it is determined the needs of residents to be transported, it should be determined if one or more personnel are needed to accompany residents transported by van.

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 for 1 of 1 kitchen reviewed for dietary services in that: 1. The facility failed to label, date, and properly seal food items. 2. The facility failed to discard expired food items. 3. The facility failed to store dishes/utensils inverted. These deficient practices could affect residents who received meals prepared meals from the kitchen at risk for food borne illness and cross-contamination. Findings included: Observation on [DATE] at 11:10 AM during a walk-through inspection of the kitchen revealed the following: - plates in the dish rack were stored not inverted and not covered - plate holders stored were not inverted and not covered - Spice containers stored on the shelf above sink/prep table: 7 containers with lids left open while not in use - 1 1-gallon pitcher with label which read tomato soup, prep date [DATE] and expiration date [DATE] in the walk-in refrigerator - 1 1-gallon pitcher with label which read chicken noodle soup, prep date [DATE] and expiration date [DATE] in the walk-in refirgerator - 1 1-gallon pitcher with label which read super cereal, prep date [DATE] and expiration date [DATE] in the walk-in refrigerator - 1 metal bowl with label which read Joyce's pasta, prep date [DATE] and expiration date [DATE] - 7 2-gallon resealable plastic bags of various frozen foods with dates but no labels that indicated contents in the walk-in freezer - 1 2-gallon resealable plastic bag of cereal with dates but no label that indicated contents in the dry storage room Observation on [DATE] at 9:50 AM during a walk-through inspection of the kitchen revealed the following: - Plates in rack continued to be stored not inverted or covered. - Plate holders not inverted or covered. - Large plastic tub of clean bowls drying outside of dishwashing area not stacked and inverted, placed into tub to dry. - Serving spoons and ladles hanging from rack not inverted. In an interview on [DATE] at 10:00 AM with Director of Food Services, she stated that during the last visit from the corporate dietary manager, she was told to store plates serving side up. She stated that she was not aware that serving utensil, scoop, ladles had to be stored inverted or in drawers. She stated that expired foods should not be in the refrigerator and that she was unsure why it had not been removed. She stated that the kitchen staff has been trained to label everything and she had no explanation for why there were bags of food in the freezer and dry storage that were not labeled. In an interview on [DATE] at 1:05 PM with the Administrator, he stated that his expectation for the kitchen was that everything should be in good working order. He stated that utensils and dishes should be stored in a sanitary/clean environment. He stated that expired foods should be discarded properly and never left in the kitchen. Review of facility policy titled Food Safety in Receiving and Storage dated [DATE], revealed, in part: - Food that is repackaged is placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. The container/lid is labeled with the name of contents and dated with the date it was transferred to the container. Review of FDA Food Code 2017 revealed the following: https://www.fda.gov/food/retail-food-protection/fda-food-code Food storage/labelling ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO -EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Packaged food (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: Packaged food (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Packaged food and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Packaged food (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest-prepared or first prepared ingredient. Packaged food 92 (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method APPROVED by the REGULATORY AUTHORITY for refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for 3 of 4 medication carts reviewed for medication storage and security in that: The facility failed to ensure the medication carts on Hall 100, Hall 200 and Hall 300 were locked when unattended. This failure could place residents at risk of having access to unauthorized medications, risk for drug diversion or accidental ingestion. Findings included: Review of Resident #51's admission record dated 08/21/19 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of type 2 diabetes mellitus, Dementia with behavioral disturbance. Record review of Resident #51's MDS assessment, dated 08/29/22, indicated in part: BIMS = 09 indicating the resident had moderate cognitive impairment. Record review of Resident #51's care plan, dated 09/12/22, indicated in part: FOCUS: Short term memory problems. Decision poor and requires supervision and cueing. Impaired decision making. GOAL: Resident will effectively communicate simple needs to staff. INTERVENTIONS: Break down tasks of daily life into smaller steps, encourage verbalization, follow same routine daily, reorient as needed, speak, clearly slowly and face to face. Review of Resident #21's admission record, dated 01/21/22, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia, psychotic disturbance, mood disturbance, and anxiety. Record review of Resident #21's MDS assessment dated [DATE] indicated in part: BIMS = 08 indicating the resident had moderate cognitive impairment. Record review of Resident #21's care plan dated 09/01/22 indicated in part: FOCUS: The resident has a behavior problem of stating suicidal thoughts. GOAL: The resident will have fewer episodes of behavior by review date. INTERVENTIONS: Intervene as necessary to protect the rights and safety of others, divert attention, minimize potential for the resident's disruptive behaviors by offering tasks which divert attention. An observation on 10/09/22 at 11:10 AM revealed an unattended unlocked medication cart on Hall 200. The cart contained multiple medicine bottles, over the counter medications and prescription blister packs that contained pills. Resident # 51 was observed wheeling herself passed the unlocked medication cart to her room. No staff was in the vicinity of the unlocked medication cart. At 11:14 AM LVN A came by and locked the cart with surveyor's intervention. LVN A stated that she does not know where LVN B was at that time but the medication cart should be locked while unattended. An observation on 10/09/22 at 11:20 AM revealed an unattended unlocked medication cart on Hall 100. The cart contained multiple medicine bottles, over the counter medications and prescription blister packs that contained pills. Resident #21 was observed sitting in his wheelchair hall, 5 feet away. No staff was observed in the vicinity of the unlocked medication cart. At 11:22 AM LVN C came by and locked the cart with surveyor's intervention. An observation on 10/09/22 at 11:25 PM revealed an unattended unlocked medication cart on Hall 300. The cart contained multiple medicine bottles, over the counter medications and prescription blister packs that contained pills. No staff or residents were seen in the vicinity. LVN D walked by and locked the cart with surveyor intervention. LVN D stated that LVN A was passing medications from the medication cart, but she did not know where LVN A was at the time. An observation on 10/09/22 at 2:53 PM revealed an unattended unlocked medication cart on Hall 100. The cart contained multiple medicine bottles, over the counter medications and prescription blister packs that contained pills. No staff was observed in the vicinity of the unlocked medication cart. During an interview on 10/09/22 at 11:14 AM with LVN A stated that no the medication cart should not be unlocked while unattended. During an interview on 10/09/22 at 11:30 AM, LVN B stated that she was distracted to another hall where she had to go to another residents room and forgot to lock it. We keep meds in the medication carts and it could be dangerous to other residents. I have been here 5 years and I know it should be locked. During an interview on 10/09/22 at 11:30 AM, LVN C stated that she was in a resident's room administering medications and left the medication cart unlocked and unattended which can be dangerous because anyone could get into the medication cart and get medications that they should not have. During an interview on 10/11/22 at 12:00 PM, the DON stated that she was aware of the unlocked and unattended medication carts. She stated that she put out an in-service on 10/10/22 that read in part make sure that medication cart is locked and privacy screen is on every time you are not within arms reach of your medication cart. Review of the facility's policy, titled Medication Cart, Administration of Drugs, reflected (in part): I the cart is left at any time during medication pass due to an emergency, it must be locked.

Based on observation, interview, and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for 1 of 8 residents (Resident # 72) reviewed for resident call systems, in that: The facility failed to ensure Resident #72's call button was functioning. This failure could have placed residents at risk of being unable to obtain assistance when needed. The findings were: Review of Resident #72's Admission Record, dated 10/11/22, revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] . He had diagnoses which included end stage renal disease with dependence on dialysis, need for assistance with personal care, diabetes, and history of strokes. Review of Resident #72's Quarterly MDS Assessment, dated 9/26/22, revealed: -He scored a 7 of 15 on his mental status exam (indicating severe cognitive impairment). -He needed extensive assistance of one or two staff for ADLs. -He had no range of motion impairments but needed a wheelchair. -He was on dialysis. Review of Resident #72's Care Plan, initiated 9/19/19, revealed a focus that resident required assistance with ADLs. The identified goal was Resident is able to perform self-care to optimal level and maintain strength and endurance. Interventions included: encourage independence in performance of self-care and mobility within limitations and provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs each shift. Review of Resident #72's Care Plan, revised 10/4/22, revealed a focus that: Resident has a history of falling. Identified interventions included: 10/24/19 Fall found on floor in room, no apparent injuries noted. Intervention: education on call light Observation and interview on 10/09/22 at 2:26 PM showed Resident #72 was in bed. He had no call light, and the call light cord was missing from the base of the call light plug. The part of the plug that would have the call light cord coming out of it faced Resident #72's roommate (opposite of Resident #72's bed). Resident #72 said when he needed help, he needed to wait until staff came and that could take a long time. Resident #72 stated he had not fallen but did have to wait for pain medications. Resident #72 was asked how he could call for help and replied, I don't, I wait. During an observation and interview on 10/09/22 at 02:31 PM, ADON F was shown Resident #72's call light. ADON F said, Oh my God, his call light broke completely. She pulled the call light plug out of the socket and the call light sounded. So ADON F plugged it back in and stated, that needs to be fixed. She stated the staff did rounds to prevent this from happening. She said the aides were the first round of defense, but Managers did checks during the work week to check things. ADON F did not know who the nurse manager over Resident #72's hall was. The resident was present and was unable to say how long the call light had been not working. During an interview on 10/10/22 at 4:50 PM, the DON said the nurses did care and companion rounds Monday through Friday before the morning meeting. She said during those rounds, the nurse was supposed to see if the resident had any complaints and if the room was clean, including the call light being within reach. She stated Resident #72 had a lot of behaviors and she did not know if he ripped the call light out of the plug or what. She said ADON F sent her a picture of it, and she did not know how it got broken. During an interview and observation on 10/11/22 at 1:33 PM, the Administrator stated his expectation for call lights were that they were working, answered in a timely manner and within reach of the residents. He stated there was no time it was acceptable for resident not to have a call light. He stated he was informed by the staff of the call light. The Administrator said he was under the impression that the resident ripped the call light out of the wall because he could be extremely combative. He said he did not know how it got ripped out, but it needed to be replaced . He was informed there was no cord observed in the room and said he did know how that happened. He did bring up the picture of what ADON F sent him. Surveyor explained that where the cord was facing away from the resident, if the resident pulled it out of the wall himself, it would face the resident. The Administrator pulled the Corporate Maintenance Director and showed him the picture. The Corporate Maintenance Director stated he had never seen a call light cord be pulled out of the plug like that because they were designed to come out of the wall and sound. After more discussion the Administrator stated if the resident pulled the cord out himself it would be straight down, and his bed was too far away from the plate for that. Review of the facility's undated Policy and Procedure on Call Lights revealed: Purpose: to respond to a resident's call light for their needs. Equipment: functioning call light. Procedure: if the call light does not work, it is important to report it to the charge nurse who in turn will notify the maintenance supervisor. The call light must always be within resident's reach before you leave the room. Review of the facility's undated Policy and Procedure on Resident Call Systems documented: The nurses' station is equipped to receive resident calls through a communication system from resident at each resident's bedside and at toilet, shower and bathing facilities. The call system shall be accessible to a resident lying on the floor. The call system in resident room will be accessible to alert, confined residents and confused residents and the residents will be instructed to it's' availability and location.

Based on observation, interview and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 1 of 3 (Resident #1) reviewed for infection control. The facility failed to ensure: CNA A failed to change her gloves after they became contaminated during incontinent care while assisting Resident #1. These failures could place resident's risk for cross contamination and the spread of infection. Findings included: Record review of Resident #1's admission record dated 01/19/2022 indicated he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was [AGE] years of age. Record review of Resident #1's MDS dated [DATE] indicated in part: BIMS = 06 indicating resident had severe impairment. Bladder and bowel: Urinary continence = Always incontinent (no episodes of continent voiding). Bowel continence = Always incontinent (no episodes of continent bowel movements). Record review of Resident #1's care plan dated 01/05/2022 indicated in part: Focus: Resident is incontinent of bladder r/t physical/mental decline. Resident has bowel incontinence Interventions: Monitor routinely for bladder incontinence. Provide [MEDICATION(S)] care with moisture barrier and change soiled protective garments, clothing and or linen. Perineal care after each incontinent episode. During an observation on 01/18/2022 at 11:18 AM CNAs A and B provided incontinent care for Resident #1. CNA A donned gloves and undid the resident's brief and wiped the resident's front peri area with wet wipes. The resident's brief was noted to be wet with urine. Both CNAs turned the resident on his side and CNA A wiped the resident's rectal area as the resident had some bowel movement. CNA A then proceeded to apply the clean brief, change the resident's shirt, look in the resident's closet for his shoe and assist the resident from the bed to his wheelchair while wearing the same gloves. During an interview on 01/18/2022 at 12:56 PM CNA A said she had gotten nervous and had forgotten to change her gloves after they had become contaminated during the incontinent care. The CNA said she understood how that could cause cross contamination by her touching other areas with the gloves that had come in contact with urine and bowel movement. During an interview on 01/18/2022 at 3:38 PM the DON was made aware of the incontinent care observation. The DON said the CNA should have changed her gloves once they became contaminated. The DON said if the aide did not change her gloves then she could cause contamination of the other areas she touched with her gloves. The DON believed the failure occurred because staff would get in a rush or forget to change their gloves when indicated. The DON said the staffing nurse would conduct CNA proficiencies and conduct observations of staff conducting incontinent care. During an interview on 01/18/2022 at 3:48 PM the staffing nurse was made aware of the incontinent care observation. The staffing nurse said the CNA should have changed her gloves once they became contaminated. The staffing nurse said she conducted observations of staff performing incontinent care and would tell them to make sure to change their gloves when applying the clean items. The staffing nurse said she would continue to retrain and retrain the staff. Record review of the facility's policy titled infection prevention program or review dated 2012 indicated in part: The goals of the infection prevention program are to decrease the risk of infection to residents and personnel. Record review of the facility's undated document titled Incontinent care procedure and proficiency evaluation indicated in part: Use towel to pat dry the front area and cover area with open towel for privacy. Turn resident on side. Fold soiled pad under resident. Clean rectal area with a new washcloth wipe using upward gentle strokes and then a different part of the washcloth wipe for each stroke continue cleaning until the washcloth wipe is free of discoloration. Pat rectal area dry with a clean towel remove soiled pad and clothing and place in plastic bag. Wash hands and change Gloves. Place clean pad under resident. Replace gown or clothing if wet or soiled.

Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for was provided 1 of 4 residents (Resident #177) reviewed for transfers. The facility failed to ensure CNA A and CNA B transferred Resident #177 in a manner to prevent injuries on 8/18/21. As a result, Resident #177 sustained a spiral fracture to her right arm. This failure could place residents who required assistance during transfers at risk for pain and significant injury. Findings included: Review of Resident #177's Admission Record dated 8/26/21 documented she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included arthritis to the right shoulder, [CONDITION(S)] nodules to the right hip, and age-related [CONDITION(S)] without current pathological fracture. Diagnoses of displaced spiral fracture of shaft or humerus right arm was added 8/18/21. Review of Resident #177's initial MDS assessment dated [DATE] revealed the following: She had a mental status exam score of 10 of 15 indicating moderate cognitive impairment; She showed signs of [CONDITION(S)] included inattention and disorganized thinking; She needed extensive assistance of two people for transfers and bed mobility; She had range of motion impairments of upper and lower extremities on both sides. Review of Resident #177's Initial assessment dated [DATE] revealed the following: She was able to communicate her needs and wants Her short- and long-term memory was ok; Transfers: The resident is unable to bear weight or CNA does not pivot or has a feeding tube, assist of two or mechanical lift. Areas of Risk Identified During Assessment- At risk for falls at risk for pain. Nursing Entry: Assist of two staff with all ADL s, transfers, and showers. Able to voice needs. Contractures to upper bilateral extremities. Review of Resident #177's Care Plan for Half Side Rails initiated 8/16/21 revealed the following: Resident #177 was at risk for injury/immobility due to need for quarter or half side rails to assist with turning and repositioning. The identified goal was: Will not experience any injuries due to the need for quarter or half side rails. Review of Resident #177's Care Plan for ADL care initiated 8/16/21 revealed the following: Goal: Resident is able to perform self-care to optimal level and maintains strength and Endurance (Initiated: 08/16/2021) Identified interventions in place at the time of the incident included: Provide level of support to complete transferring needs every shift. (Initiated: 08/16/2021); Reinforce use of aids to mobility as indicated (Initiated: 08/16/2021) Review of Resident #177's Range of Motion Care plan initiated 8/17/21 revealed the following: Goal: Prevent contractures next 90 days Interventions included: Monitor for increased stiffness (Initiated: 08/17/2021); And monitor for pain with ADL's and or movement (Initiated: 08/17/2021) Review of Resident #177's Care Plan on Falls initiated 8/16/21 revealed the following: Goal: The resident will be free of falls through the review date. Identified interventions included: Anticipate and meet the resident's needs. (Initiated: 8/16/2021); Staff to assist with all mobility and transfers (initiated 8/17/2021) Review of Resident #177's Incident Note dated 8/18/21 at 1:07 p.m. revealed the following: around 8 a.m. the nurse was called to resident's room due to when assisting with transfer, CNA staff noted right shoulder pop. Resident was in pain with facial grimacing and crying. The nurse noted the resident's right upper extremity was non-movable. The Resident voiced when being transferred her arm popped and started hurting upon movement. The nurse placed Resident #177's right arm in a sling, notified the doctor, and received an order for x-rays. Resident continued with increased pain and orders were received for acetaminophen with [MEDICATION(S)] #4 every 6 hours as needed. The initial dose was given around 9 a.m. The resident requested to go to the emergency room and was sent. Resident #177 told staff she was able to transfer herself without assistance with a sliding board. Resident was educated that therapy would evaluate her for the sliding board. Resident was sitting at the side of the bed and sliding off the bed and refusing staff to touch or assist her. Therapy staff came into the room and assisted Resident #177 back to bed. Review of the Diagnostic Radiology Report for Resident #177 completed 8/18/21 revealed: reason for x-ray: pain right humerus. Clinical information: there is an acute spiral fracture of the proximal humeral shaft with at least mild displacement. There is osteopenia. Probable [CONDITION(S)] changes of the shoulder joint. Review of CNA A and CNA B's statement (written jointly) dated 8/18/21 revealed the following: went to resident's room to transfer her to wheelchair for breakfast, when moving resident to upright sitting position on side of bed resident started yelling, she was falling. I reassured her because she was not. CNA B was passing room, CNA A yelled to her to assist her in the transfer. Resident #177 said she could not use her arms and the aides could not touch her due to arthritis. One of them replied OK just relax and she was going to have to let go of the bed. Resident #177 released the bed and the aides proceeded to do the transfer. CNA B was behind Resident #177 and CNA A was standing in front of her with her hands on her waist and CNA B's hands were under her butt, placing her in chair we heard a pop. CNA B went to get a nurse. Review of Resident #177's Health Status note dated 8/18/2021 at 2:28 p.m. revealed the following: Resident returned from emergency room around 1:45 p.m. via non-emergency ambulance service. Resident alert and oriented and able to voice needs to staff. Splint noted to RUE post humerus fracture, came with new orders for acetaminophen with [MEDICATION(S)] 5/325 one tab every six hours as needed. Interview on 8/27/21 at 10:06 a.m. with Resident #177 revealed the fracture was facility acquired. She stated one aide was lifting her from the bed to the chair. Resident #177 stated she told them she could not lift her arm and one of the aides grabbed under her arm and put it on her shoulder. Resident #177 stated then the aide put her down hard and my bone snapped. She said another lady offered to help her and the aide said she could. Resident #177 stated the aide was wearing a belt but did not put it on the resident and when the resident communicated the aide needed an additional person the aide would not listen. Resident #177 stated she did not know the aide's names because it was only her second day in the facility. The resident stated she for sure felt it was preventable because the staff did not listen to her, I know my body, but they didn't listen. Resident #177 stated I don't think it was intentional, but she should have listened; she just wanted it over with, but her coworker was right there; it was like she was in a hurry or a rush. Resident #177 stated she did not know which staff members (nurses or aides) she told only one aide transferred her, but she told everyone that it was one staff member. Interview on 8/27/21 at 10:22 a.m. the DON stated CNA A and CNA B were involved with Resident #177's incident. She stated CNA A was in the room first and was trying to get Resident #177 set up on the side of the bed and Resident #177 felt like she was falling off the bed. The DON stated that evaluation for use of transfer board had not not been completed prior to Resident #177s incident. The DON stated the x-ray did not document if it was an old or new fracture. The DON stated after the incident, they changed Resident #177 from a two-person assist to a mechanical lift. The DON stated the only thing the facility was sure of was it happened at the facility. She stated the x-ray report documented it was a spiral fracture which would require someone to twist and no one twisted her arm, no one said they touched her arm and she can't even lift her arm to get a drink. The DON stated every newly admission resident was considered a two-person transfer when they come in until therapy evaluates them. Interview on 8/27/21 at 10:47 AM CNA A confirmed she was one of the aides involved in the 8/18/21 incident with Resident #177. She stated the incident occurred at breakfast time and Resident #177 wanted to get up. CNA A stated it was the first time she worked with Resident #177, Resident #177 stated that she used a sliding board to transfer herself at home. CNA A reported she told Resident #177 she could not use the sliding board at the facility because it was not approved by therapy yet . CNA A stated she got Resident #177 dressed and was going to transfer her. CNA A stated she assisted Resident #177 in sitting up and pivoting on the bed. CNA A stated Resident #177 told her (CNA A) that she (Resident #177) did not want to use a gait belt because it hurt her all over when used. CNA A stated she sat Resident #177 up and Resident #177 started screaming for help because she was falling. CNA A reported at that time she saw CNA B walking by. CNA A stated CNA B came in and they had Resident #177 sitting up in the bed. CNA A stated she (CNA A) had Resident #177 at the waist and CNA B had Resident #177 at the bottom. CNA A stated Resident #177 told her (CNA A) that she could use her hands and CNA A told her to relax because she was holding on the ½ side rail. CNA A stated she instructed Resident #177 to let go of the side rail. CNA A stated herself and CNA B transferred Resident #177 into the chair. CNA A stated when Resident #177 sat in the chair they heard a loud crack. CNA A stated CNA B went to get the nurse. CNA A stated she did not know how it happened because she was holding Resident #177 by the hips. CNA A said they did not go get the nurse prior to the crack because they did not think of it. Interview on 8/27/21 at 11:05am, CNA B stated they were super busy, but she did assist with the transfer. She stated Resident #177 was up and felt like she was falling and grabbed the ½ side rail. CNA B stated Resident #177 was not falling, but described Resident #177 as being contracted and all she could think of was that while Resident #177 reached up to grab the bar was when the fracture happened. CNA B stated the left arm of the wheelchair was down. CNA B stated no one touched Resident #177's arm so she did not know how the fracture happened. CNA B stated Resident #177 told them she transferred herself at home all the time but she didn't really assist with the transfer. Interview on 8/27/21 at 11:32 AM LVN D revealed 8/18/21 was her first day working with Resident #177 and during morning report she (LVN D) was told Resident #177 was a one-person transfer. LVN D stated CNA B went and called LVN D to the room. She said she was told CNA A and CNA B were trying to transfer Resident #177, Resident #177 did not want to use a gait belt, and Resident #177 was hurting. LVN D revealed she got a therapy staff and went into the room. LVN D stated when she went into the room Resident #177 was in her wheelchair but her and the therapist got her back into the bed. LVN D stated Resident #177 did not specify if it was one aide, which aide, or if both had hurt her. LVN D stated the aides reported to her that one aide was holding the wheelchair while the other aide slid the resident over. LVN D stated no one said anything about grabbing Resident #177's arm. LVN D stated Resident #177 felt the mobile x-ray was not moving fast enough so requested to go to the emergency room . LVN D stated all Resident #177 told her was the aides insisted she get up and at home she used a sliding board. Interview on 8/27/21 at 11:48 a.m. PT D confirmed he was the PT involved with the 8/18/21 incident with Resident #177. He stated he remembered he came into work and LVN D peeked in and asked if he could help with a transfer. He stated LVN D and he completed a maximum assist, two-person transfer on Resident #177. He said he felt Resident #177's shoulder and knew it was dislocated because there were three fingers of space between the shoulder and the joint when there should only be one or two fingers of space. PT D stated Resident #177 reported to him that only one aide transferred her even after Resident #177 told the aide she needed two people. He stated he reported it to the Administrator. PT D stated he did not know if the aides used a gait belt or if they just put their hands on her sides but Resident #177 stated it was a hug transfer. He stated Resident #177 told him that the aide put her arms on the aide's shoulder, and they heard a pop and knew something was wrong. He repeated Resident #177 told him it was one aide doing the transfer and this was communicated with the Administrator. He stated he did not recommend the hug transfer. He stated Resident #177 had a sliding board and that was going to be their way of transferring her. He stated he had trained the staff in how to do a gait belt transfer and a mechanical lift but had not instructed them in how to use a sliding board. PT D revealed due to her diagnosis of [CONDITION(S)] Arthritis her joints were very fragile. He stated he learned a spiral fracture occurred when there was a twist. He stated he could see how the dislocation occurred from an incorrect transfer but not the spiral fracture because it would take a twist. He said it was probably easily preventable if the staff would have asked someone from therapy about the sliding board. He was shown how the aides pantomimed the transfer. PT D stated bent over the wheelchair was never a safe transfer and if someone held Resident #177's arm from across her body it would make a twist when returning to the original side, so a spiral fracture was possible. Observation and interview on 8/27/21 at 1:18 p.m. revealed CNA A and CNA B demonstrated to the surveyor how they transferred Resident #177. CNA A stood in front of the resident held her by the waist. CNA B stepped behind the wheelchair and placed her foot immediately behind the left side of the wheelchair. CNA B explained it was Resident #177's personal wheelchair and they did not see the brake on the left side so she (CNA B) stayed behind it to keep it steady. CNA B leaned over the wheelchair and slid her hands under Resident #177's lower buttock/upper thigh while CNA A slid Resident #177 over into the chair by the waist. They indicated Resident #177 reached across herself with her right arm and grabbed the 1/2 side rail. CNA B stated she assisted Resident #177 pull her arm away from the ½ side rail by the wrist when Resident #177 slid into the chair was when they heard the pop as soon as Resident #177 hit the back of the wheelchair. They both acknowledged it was not a safe transfer. They both said they did not think of getting the nurse or the therapy department know Resident #177 refused wearing the gait belt. Interview on 08/27/21 at 4:14 PM the DON and Administrator acknowledged they did not have CNA A and CNA B do a demonstration on the transfer with Resident #177. They were shown the transfer CNA A and CNA B pantomimed. They both acknowledged the transfer would not be appropriate. Neither could think of any additional information. There were no inservices on transfer of residents provided in the six months prior to the incident. Review of the facility's policy and procedure of Transfer of Patient, undated, documented: Purpose to safely move resident from one place to another. Procedure: help resident to sit on edge of bed with legs and feet hanging over edge so; stand in front of the resident with a firm grasp on gait belt that has been secured around the residence waist; help resident to stand; pivot your body helping resident to pivot towards chair; bend your knees to keep back straight to help resident sit. Review of the facility's policy and procedure on Two-Person Pivot Transfer, undated, documented: Purpose: get resident from one surface to another by allowing resident to participate by weight-bearing during transfer. Procedure: Staff will use gait belt to assist in getting resident to stand and guiding resident to pivot. Clear obstacles. Lock wheelchair brakes; remove leg rest and/or wheelchair arms if able. Position resident next to bed. Assist resident to sit at bedside with feet on the floor. The resident's knees should be separated to provide a wide base of support. Apply gait belt snugly around waist. Stand in front of the resident. Each resident member place is one hand under the front of the belt and one hand under the back of the belt, using an underhand grip. The staff member closest to the chair stands in a position so that he or she CNA pivot or move away, allowing the resident unobstructed access to the chair. On the count of three both nursing assistance will move resident at the same time. Coordination of movement is important. Instruct the resident on the count of three to lean forward and push up from the bed with his or her hands while you assist bringing the residents weight forward with the belt. Support the resident's knees and feet by placing your knees and feet firmly against them. On the count of three, the resident is assisted to a standing position. The staff members pivot slowly and smoothly by moving their feet, legs and hips until the resident CNA feel the back of the wheelchair with his or her legs. Review of the facility's policy and procedure on Two Person Total Lift, undated, documented: Purpose: to safely get resident from one surface to another one resident is unable/unwilling to bear weight on his or her lower extremities. Procedure: clear obstacles. Lock wheelchair/breaks; remove leg rest and or wheelchair arms if able. Position resident next to bed. One staff member (the tallest one) stand behind the patient in places his/her arms under the resident's arms and grabs the residence opposite cross arms in front. Second staff members squats and supports the resident's legs and thighs and calves. On the count of three, both staff members simultaneously lift the resident off the wheelchair and onto the bed. Reverse the

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 single kitchen. 1) The juice dispenser was not cleaned. 2) The vent hood over the oven was greasy. 3) The fryer for food had an excess of food particles in the oil. 4) Food was not discarded when it was past it's use by date. These failures could place residents at risk for food borne illness and cross contamination. Findings include: Observation on 8/24/21 at 9:12 AM revealed the walk-in refrigerator had: There was a bag of cheese with a use by date of 8/22/21; There was a bag of bacon with a use by date of 8/14/21. The FSS saw the outdated bags and threw them out. Observation and interview on 8/24/21 at 11:10 a.m. revealed staff using the juice dispenser. Surveyor request the spigot be taken off. The juice dispenser had dried, black accumulation in the threads of the spigot and a black slime build-up on the mechanism. The FSS looked at it and screeched EW! That needs to be cleaned right now! The FSS stated it did not take long for an accumulation of juice to build up but acknowledged it looked like a few days since it had been cleaned. She stated it was supposed to be cleaned every day. Observation on 8/24/21 at 11:10am of the vent hood over the range and oven revealed a heavy accumulation of grease and grime on it. The grease was beginning to drip down and the food fryer had an accumulation of food particles floating in the oil. Record review of the cleaning schedule posted on walk in fridge of weekly deep clean and daily regular cleaning showed the juice spigot was on neither. The vent hood was on the weekly deep clean. The cleaning schedules were all blank. Interview on 8/27/21 at 1:37 PM the FSS stated the kitchen review did not go as well as she hoped. She acknowledged staff did not catch the outdated food and she was mad the staff did not throw it away prior. She acknowledged the juice spigot was awful and the staff knew better than to let it get to that point. She stated the staff would follow the cleaning schedule but not document they did it. She acknowledged the vent hood needed to be cleaned and after 8/24/21 she told the staff to take it down and clean it. She acknowledged the accumulation of food particles in the fryer and said, a lot of deep cleaning needs to be done. Review of the facility's posted daily schedule, undated, documented: no reminder for the juice dispenser to be cleaned. Review of the facility's posted monthly schedule, undated documented: The Hood/Vent needed to be cleaned by Cook 1 once a month; the Deep Fryer needed to be cleaned every month by Cook 2. Review of the facility's policy and procedure on Nutrition Services on Cleaning the Juice Dispenser, revised 1/1/10, documented: The juice dispenser will be maintained in a clean and sanitary condition. Procedure: At the end of everyday: Remove the black nozzle and clean with soapy water, rinse, sanitize; Wipe down the head of the handle with soapy water and rinse; re-attach the nozzle and let entire handle assembly soak in sanitizer overnight. Review of the facility's policy and procedure on Cleaning Vent Hoods and Filters documented: Venting equipment will be maintained clean and free of grease. Monthly: clean entire vent hood to prevent accumulation of dirt and grease. Review of the Food and Drug Administration 2017 Food Code documented: Food prepared and held in a Food Establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days.

Based on observation, 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 2 of 12 residents (#3 and #24) reviewed for drug administration in that: MA E failed to administer Resident #24's medications as ordered by the physician. MA E administered 10 MG of [MEDICATION(S)] instead of 5 MG and administered 20 MG of [MEDICATION(S)] instead of 40 MG. MA F failed to administer Resident #3's medications as ordered by the physician. MA F administered one multivitamin with minerals instead of a multivitamin without minerals as indicated on the physician orders. Resident #3 had an additional order for a vitamin that contained minerals. These failures could place residents at risk for receiving less than therapeutic benefits from prescribed medications. The findings were: Record review of Resident #24's admission record dated 08/26/2021 indicated she was admitted to the facility on [DATE] with diagnoses of allergic rhinitis and high blood pressure. She was [AGE] years of age. Record review of Resident #24's order summary report dated 08/27/2021 indicated in part: [MEDICATION(S)] tablet 5 MG Give 1 tablet by mouth one time a day for allergies order date 02/10/2021. [MEDICATION(S)] Tablet 40 MG Give 1 tablet by mouth one time a day for hypertension order date 06/10/2021. During an observation on 08/25/21 at 09:14 AM, MA E administered Resident #24's medications to include one 10mg tablet of [MEDICATION(S)] and one 20mg tablet of [MEDICATION(S)]. During an interview on 08/26/21 at 10:56 AM, MA E said she should have given 5mg of [MEDICATION(S)] and 40mg of [MEDICATION(S)]. MA E acknowledged she did not administer the correct dosage as indicated on the physician orders. MA E said she was under the impression that the facility did not carry the 5mg [MEDICATION(S)] and should have told the nurse about it. MA E said the blister pack of [MEDICATION(S)] indicated to administer 1 tablet of 20mg but the actual physician order indicated to administer 40mg so she should have administered 40mg. Record review of Resident #3's admission record dated 08/27/2021 indicated she was admitted to the facility on [DATE] with diagnoses of muscle weakness and high blood pressure. She was [AGE] years of age. Record review of Resident #3's order summary report dated 08/27/2021 indicated in part: Multivitamin Tablet (Multiple Vitamin) Give 1 tablet by mouth one time a day for supplement. [MEDICATION(S)] [MEDICATION(S)] Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth two times a day for SUPPLEMENT. During an observation on 08/27/21 at 08:44 AM, MA F administered Resident #3's medications to include one multivitamin with minerals. During an interview on 08/27/21 at 09:52 AM, MA F said she had not noticed Resident #3's order indicated just the multivitamin and not minerals. MA F said she did not believe they carried the multivitamin without minerals. During an interview on 08/27/21 at 11:14 AM, the DON said MA E should have notified the nurse that they only had the 10mg [MEDICATION(S)] and to get it clarified with the doctor. The DON said MA E should have given Resident #24's 40mg of [MEDICATION(S)] instead of 20mg. The DON said MA F should have told nurse to get Resident #3's multivitamin order clarified as the resident was already receiving another vitamin that contained minerals. The DON said they would get the medications clarified with the doctor. During an interview on 08/27/21 at 03:44 PM the Administrator was made aware of the medication errors. The Administrator said the medication aides should have followed the physician orders. Record review of Resident #3's and #24's clinical records did not reveal the residents suffered any adverse effects due to receiving incorrect dosage or incorrect medications. Record review of the facility's undated policy titled Physicians orders indicated in part: All residents must have current, dated, and signed doctor's orders. As all care given to the resident must have the direct order of the attending physician it is important to follow a set format so all areas are covered.

Based on interview and record review, the facility failed to ensure care was provided based on a comprehensive assessment and treatment orders in accordance with professional standards of practice to promote healing for 1 of 11 residents reviewed for pressure injury. (Resident #1) Wound care for Resident #1's pressure injury on her sacral area and right heel was not documented it was done daily as ordered by the physician, on 9/08/18, 09/09/18, and 09/10/18. Resident #1's pressure injury to the right heel declined in conditon during the time. This failure affected Resident #1 and could place 14 residents who had pressure injuries at risk for worsening and the development of pressure injuries. Findings included: Record review of Resident #1's Face Sheet dated 09/14/18, indicated she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] indicated: - BIMs (Brief Interview for Mental Status) score was 13 (13-15 cognitively intact). - Required extensive assistance of two staff for bed mobility, transfers and toileting. Required extensive assistance of one staff for dressing, eating, personnel hygiene and bathing. Not ambulatory. - Had urinary and bowel incontinence. - Range of motion: Upper and lower was impaired on one side. - Had two unstaged pressure ulcers on admit. Had stage 3 or 4 pressure ulcer: length 2.0 (cm-centimeters), width (same ulcer) 3.0 cm. Tissue type for ulcer at most advanced stage - 4. Eschar - black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges. (MONTH) be softer or harder than surrounding skin. Record review of Resident #1's Care Plans indicated the following, in part: Right Heel - Problem onset 06/21/18: Unstageable pressure ulcer to Right Heel. - Goal: Area will remain free of infection x90 days. - Approaches: Needs wound care as ordered by physician. Needs a daily observation of skin with routine care. 09/06/18 cleanse open area to right heel with normal saline, pat dry, apply santyl and calcium alginate with silver, cover with abdominal pad, wrap with kerlix and secure with tape everyday. Sacrum - Problem onset 06/21/18: Unstageable pressure ulcer, DTI (deep tissue injury) to sacrum. Changed to unstageable/slough/eschar 6/24/18. 07/09/18 wound is now a stage 3. - Goal: Area will remain free of infection x90 days. - Approaches: Needs wound care as ordered by physician. Needs a daily observation of skin with routine care. 07/10/18 cleanse open area to sacrum with normal saline, pat dry, apply collagen and cover with dry dressing, everyday. Record review of Resident #1's 60-day MDS assessment dated [DATE] indicated: - BIMs 99-Resident unable to complete. Short term memory problem. Long term memory-ok. Skills for daily decision making - moderately impaired. - Required extensive assistance of two staff for bed mobility, transfers and toileting. Required extensive assistance of one staff for dressing, eating, personnel hygiene and bathing. Not ambulatory. - Indwelling urinary catheter. Bowel incontinence. - Had one Stage 3 and one unstageable pressure ulcers. Both identified upon admit. Stage 3 or 4 pressure ulcer: length 1.8 cm, width (same ulcer) 1.3 cm, depth 0.3 cm. Tissue type for ulcer at most advanced stage - 4. Eschar - black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges. (MONTH) be softer or harder than surrounding skin. Record review of Resident #1's physician progress notes [REDACTED]. - 09/04/18: Patient (Resident #1) was seen and examined. Patient having nausea/vomiting, no clear etiology. IV (intravenous) fluids will be given. CBC (complete blood count), CMP (comprehensive metabolic panel), UA (urinalysis), Lipase level and Amylase level. - 09/06/18: Patient (Resident #1) was seen and examined. Patient is having nausea/vomiting, no clear etiology. Symptoms have improved. Still with upper abdominal pain. No fever. Repeat IV fluids. Repeat lab work. Leukocytosis - elevated white blood cell count. Repeat CBC. Right upper quadrant ultrasound has been ordered. - 09/11/18: Patient (Resident #1) was seen and examined. Patient is having nausea/vomiting, no clear etiology. Symptoms have improved. Still with upper abdominal pain. No fever. Recommend-send to ER (emergency room ). Case discussed with ER Doctor. Record review of Resident #1's Wound Assessment Reports dated 09/06/18 documented the following, in part: - Right Heel: unstageable due to slough/eschar, length 2.0 cm, width 2.5 cm, depth 0.0 cm, drainage serous/small, infection-no, pain-no, [MEDICAL CONDITION]-none, wound bed: slough-75% & eschar-25%, surrounding skin: pink/slight [MEDICAL CONDITION]. - Sacrum: (original unstageable/slough), Stage 3, length 1.0 cm, width 0.8 cm, depth 0.3, drainage serous/scant, infection-no, pain-no, wound bed: granulation tissue 80% & [MEDICATION NAME] tissue 20%, surrounding skin: pink, slight [MEDICAL CONDITION]. Record review of Resident #1's consolidated Physician orders [REDACTED]. 07/10/18 - Cleanse open area to sacrum with ns (normal saline), pat dry, apply collagen and cover with dry dressing qd (everyday). Dx (diagnosis) stage 3. 09/06/18 - Cleanse open area to right heel with ns, pat dry, apply santyl and calcium alginate with silver, cover with abd (abdominal) pad, wrap with kerlix and secure with tape, qd (everyday). Dx unstageable/slough. Record review of Resident #1's Treatment Administration Record (TAR) for (MONTH) (YEAR) indicated there was no documentation wound care for the sacral area or the right heel was done on 09/08/18, 09/09/18 and 09/10/18. The boxes on the TAR for 09/08/18, 09/09/18 and 09/10/18 were blank where the nurses enter their initials to show the treatment was done (Resident #1 was sent to theER on [DATE]). Record review of Resident #1's hospital records dated 09/11/18 documented the following, in part: - History and Physical Report dated 09/11/18 documented: - Review of Systems: Integumentary - Right lateral heel dressing revealed wound approximately 4-5 cm in diameter, dark black necrotic in the center, stage 2 with draining purulent green drainage; stage 2 skin breakdown on bilateral buttocks was reddened area. - Assessment/Plan: 1. Acute UTI (urinary tract infection). 2.[MEDICAL CONDITION]. 3. Wound care to assess and treat wounds. During an interview on 09/14/18 at 3:52 p.m. the DON (Director of Nurses) was informed there was no documentation on the treatment sheets wound care was done for Resident #1 on (MONTH) 8th, 9th or 10th and she was sent to the hospital on the 11th. The DON said the Treatment Nurse is off on the weekends. The Nurses are to do the treatments. During an interview on 09/14/18 at 3:56 p.m. LVN (Licensed Vocational Nurse - treatment nurse) A said the floor nurses do the treatments on the weekends. LVN A said she only does treatments Monday through Friday from 8am to 5pm. LVN A said she was on call last weekend and worked, but not doing treatments. During an interview on 09/14/18 at 4:10 p.m. the DON said their computer system shows red when a treatment is past due. She said whoever didn't do the treatments was the only one the computer will let cancel it. The DON said the computer was supposed to show red. The DON said LVN A was off on 9/10/18 because she was on call for the weekend. The DON said LVN A was on call for the floor nurse, not treatments. During an interview on 09/14/18 at 4:35 p.m. LVN B said she worked the morning of 09/08/18 on hall 4. She said she did not remember doing Resident #1's treatments. She said she worked a double shift and at 2:00 p.m. she switched to hall 2. She said she did treatments on hall 2. LVN B said in the computer treatments are scheduled from 8am to 5p.m. so they would be highlighted yellow to show they were due and would not be red to show they were late until after 5pm. LVN B said usually the shifts divide the treatments. During an interview on 09/14/18 at 4:40 p.m. the DON said LVN B worked 6am to 2p.m., hall 4, on Saturday (09/08/18) and Sunday (09/09/18). The DON said LVN C worked 2p.m. to 10p.m., hall 4, on Saturday and Sunday. The DON said on Monday (09/10/18) LVN D work 6a to 2p on hall 4 and LVN E worked 2p to 10p on hall 4. The DON said I am going to write all of the nurses up, there is no excuse not to get all the treatments done. The DON said the Staff Coordinator was going to be assigned to come in over the weekend to check and monitor, to make sure all treatments are done. During an interview on 09/14/18 at 5:25 p.m. with the DON, Administrator, and Corporate Nurse (by speaker phone), the DON acknowledged there was no documentation Resident #1's treatments were done for (MONTH) 8,9 and 10. The DON said she was going to get statements from the nurses and write them up. The Corporate Nurse said with the computer system the nurse must click on the Treatment Administration Record (TAR) tab to review any treatments. The Corporate Nurse said so, unless the nurse clicks on the TAR it won't show yellow (due) or red (late). During an interview on 10/02/18 at 1:20 p.m. LVN A said on Monday 9/10/18 she came to the facility that morning and was going over to the Midland facility to a training. She said the DON helped her post notes at each nurse's desk for the floor nurses to do their own treatments. LVN A said, now on weekends the time frame for the treatments was changed. She said for each hall, 6a-2p shift does the treatments on the odd side room numbers and 2p-10p shift does the treatments on the even side numbers. LVN A said all the nurses had been instructed to check every Medication Administration Record [REDACTED]. During an interview on 10/03/18 at 9:30 a.m. LVN D said she had worked at the facility as needed, Monday-Friday, morning or evening shift for 3 years. LVN D said Monday-Friday there was a wound care nurse. She said if the wound care nurse wasn't there, a list of residents with wound care would be at the desk. LVN D said 6a-2p shift would do some treatments and then 2p-10p would do the others. She said the shifts would split the hall. LVN D acknowledged she signed a disciplinary form for Resident #1's treatments not getting done on 09/10/18. LVN D said if a resident refused treatment she would have documented, it. During an interview on 10/03/18 at 3:07 p.m. LVN C said she only worked hall 4. LVN C said on weekends the treatment nurse would leave a print out of residents that had treatments. LVN C said the list would be at the desk in the book or sometimes the treatment nurse would tape it on the desk. LVN C said if the morning shift was not as busy, they would do more treatments and at shift change let her know who hadn't been done. When asked how Resident #1's treatments were not done over the weekend, LVN C said, only thing that comes to my mind, is that I thought they had already been done. LVN C said, now we check every resident's treatment orders in the computer and if there's not a current date, do the treatment. LVN C said each treatment is now assigned. She said 2p-10p does the right side of the hall and 6a-2p does the left side of the hall. She said she did not want any resident to have a treatment missed. During an interview on 10/03/18 at 4:35 p.m. LVN E said she had worked at the facility for three years. She said she had changed to as needed four months ago. She said she worked 6a to 2p shift, mostly on hall 4. LVN E said she worked on Monday 9/10/18, 2p-10p shift. She said when there wasn't a treatment nurse, the schedule would say to do your own treatments. LVN E said she didn't check the schedule that day and should have. LVN E said now all treatments are assigned and nurses are to check every residents TAR's in the computer to see if the resident has a treatment or if the treatment had been done. Record review of the facility's undated policy/procedure Pressure Ulcer, Care and Prevention of indicated the following, in part: Purpose: To prevent and treat further breakdown of pressure sores. Treatment: treatment of [REDACTED]. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers. Record review of the facility's Wound and Skin Status Report dated 09/14/18 indicated there were 14 residents with pressure injuries.