Every finding on record at Madisonville Care Center

Based on interviews and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Resident #46) reviewed for resident rights.The facility failed to ensure Resident#46's preference for showers were adhered to as he received a bed bath instead of a shower.This failure could place residents at risk of psychosocial harm.Findings included:Review of Resident #46's admission Record dated 03/03/26, showed he was admitted to the facility on [DATE], and was his own responsible party. Resident#46 also had diagnoses that included cerebral infarction (stroke), morbid (severe) obesity due to excess calories, other impulse disorders, depression, mood disorders, hemiplegia (total paralysis, and hemiparesis(weakness), generalized muscle weakness, and need for assistance with personal care. Review of Resident #46's Quarterly MDS assessment, dated 02/25/26, showed he had a 15 BIMS score which indicated his cognition was intact.Review of Resident #46's Care Plan showed staff initiated a note on 11/26/2024 that reflected Resident #46 required two staff for bathing assistance. There were no notes initiated or revised that reflected Resident #46 choice of wanting showers instead of bed baths.Review of Resident #46's Plan of Care Task from 02/20/26 through 03/18/26 showed 1-2 staff gave him bed baths. No staff documented giving showers to Resident#46.During an interview with Resident#46 on 03/19/26 at 12:45 p.m., he said he had been getting a bed bath, and they had not been giving him a shower. Resident #46 stated he would feel cleaner if he got a shower.During an interview with Student Nurse Aide E on 03/19/26, at 1:00 p.m., she said Resident#46 told her he did not mind getting a bed bath. She said when the bed bath is complete, she asked him if he feels clean and he has told her he feels like a new man.During an interview with LVN B on 03/19/26 at 1:15 p.m, she stated Resident#46 never expressed that he would prefer a shower over a bed bath.During an interview with DON on 03/19/26 at 1:20 p.m., DON stated she expected CNAs to shower according to their shower schedule and preferences. She told me they had offered the shower bed, and he refused so he got a bed bath. She told me they had recently implemented a new form to monitor resident preferences for shower or bed bath for staff to fill out daily and turn into DON.During an interview with the RNC on 03/19/26 at 1:45 p.m., she said if Resident#46 was not going to the shower, they should be offering the shower bed. I asked her if this should be in Resident#46 care plan. She said yes.Review of the facility's Resident Rights policy, undated reflected, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement or his or her quality of life recognizing each resident's individuality The facility must protect and promote the rights of the resident. Respect and dignity - The resident has a right to be treated with respect and dignity, including:3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.Self-determination -The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice.

Based on observation, interview, and record review, the facility failed to ensure care was provided in accordance with professional standards of practice that will meet each resident's physical needs for two of two residents reviewed for insulin administration. (Resident #27 and Resident #46) A) The facility failed to ensure LVN A primed the insulin pen during insulin administration for Resident #27 on 03/18/2026. B) The facility failed to ensure LVN B primed the insulin pen during insulin administration for Resident #46 on 03/18/2026. This failure could place residents at risk of not receiving the physician ordered medication at therapeutic levels which could cause blood sugar complications.Findings included: A) Review of Resident #27's face sheet dated 03/19/2025 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses diabetes mellitus (A condition results from insufficient production of insulin, causing high blood sugar.) Review of Resident #27's quarterly MDS assessment dated [DATE] reflected that she was assessed to have a BIMS score of 0 indicating severe cognitive impairment. Resident #27 was assessed to receive insulin injections daily. Review of Resident #27's comprehensive care plan reflected a focus area dated 03/20/2025 The resident has dx of Diabetes Mellitus interventions included .Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of Resident #27's consolidated physician orders reflected an order dated 01/31/2026 Insulin Aspart subcutaneous solution pen-injector 100 units/ml per sliding scale. Observation on 03/18/2026 at 11:12 AM revealed LVN A performing a finger stick blood sugar on Resident #27. LVN A prepared Resident #27's insulin for administration by putting on a new needle and dialing the pen to 1 unit. LVN A administered the insulin without priming the insulin pen. In an interview on 03/18/2026 at 12:25 PM, LVN A stated she did not prime the Insulin Aspart pens prior to insulin administration. In a follow up interview on 03/19/2026 at 12:50 PM, LVN A stated priming the insulin pens prevents air from being injected into the resident, and the resident would not get enough insulin. She denied being trained on priming insulin pens since she started working there about 4 months ago. She reported she was in-serviced on priming insulin pens yesterday afternoon. B) Review of Resident #46's face sheet dated 03/19/2026 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the follow diagnoses morbid (severe) obesity (a chronic medical condition characterized by a body mass index (BMI) of 40 or higher, or a BMI of 35 or higher when serious obesity-related health conditions are present, significantly increasing the risk of life-threatening diseases.) and diabetes mellitus type 2 (A condition results from insufficient production of insulin, causing high blood sugar.) Review of Resident #46's quarterly MDS dated [DATE] reflected he was assessed to have a BIMS score of 15 indicating his cognition was intact. Resident #46 was assessed to receive insulin injections daily. Review of Resident #46's comprehensive care plan reflected a focus area dated 11/26/2024 The resident has diabetes mellitus. Interventions included .Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of Resident #46's consolidated physician orders reflected an order dated 01/06/2026 Humalog subcutaneous solution pen-injector 100 units/ml before meals. Observation and interview on 03/18/2026 at 12:01 PM revealed LVN B performing a finger stick blood sugar on Resident #46. LVN B prepared Resident #27's insulin for administration by putting on a new needle and dialing the pen to 10 units. LVN B administered the insulin without priming the insulin pen. LVN B stated she did not primed the insulin pen stating she did not know she needed to. In an interview on 03/19/2026 at 12:27 PM, the RNC stated that staff were supposed to prime the insulin pens to ensure the entire dose of insulin was administered. She stated she was performing an in-service with staff to ensure all nurses are aware of the facility policy. Review of the facility's undated policy using an insulin pen reflected .Attach the needle Remove the cap of the insulin pen. Clean the rubber seal with an alcohol swab. Attach a new pen needle by screwing it on tightly. Remove the outer and inner needle caps, keeping the outer cap for later disposal. 3. Prime the pen; Dial 2 units of insulin. Hold the pen upright (needle pointing up) and tap it gently to remove air bubbles. Press the injection button to release insulin until a drop appears at the needle tip. Repeat if necessary. 4. Set your dose; Turn the dose selector to the number of units prescribed by your healthcare provider. Confirm the dose on the pen's display. 5. Inject the insulin.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of five residents (Resident #5) reviewed for infection control practices. The facility failed to ensure CNA C and CNA D used enhanced barrier precautions during incontinent care for Resident #5 on 03/18/2026. These failure could place residents at risk for developing wounds, upper respiratory infections, and risk for healthcare associated cross-contamination and infections. Finding included: Review of Resident #5's face sheet dated 03/19/2026 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease.) and cirrhosis of the liver (is a complication of long-term inflammation of the liver.) Review of Resident #5's admission MDS assessment dated [DATE] reflected Resident #5 was assessed to have a BIMS score of 13 indicating his cognition was intact. Resident #5 was further assessed to have pressure ulcers. Review of Resident #5's comprehensive care plan reflected a focus area dated 01/16/2026 Resident is on enhanced barrier precautions related to foley catheter and wounds. Interventions included Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. Review of Resident #5's consolidated physician orders reflected an order dated 02/21/2026 Enhanced barrier precautions (EBP) related to PICC line, Foley Cath and wounds. Observation on 03/18/2026 at 1:48 PM revealed CNA C and CNA D entering Resident #5's room to perform peri care. CNA C and CNA D entered Resident #5's room without properly donning PPE. Gloves were donned during peri care; no gowns were used. In an interview on 03/18/2026 at 2:00 PM, CNA C stated PPE was available outside of Resident #5's room. CNA C stated her and CNA D were called in quickly and everyone was outside, so they didn't have time, but they were supposed to wear PPE to prevent the spread of infection. In an interview on 03/18/2026 at 2:05 PM, CNA D stated PPE was available outside of Resident #5's room. CNA D stated her and CNA C were called in quickly and everyone was outside, so they didn't have time, but they were supposed to wear PPE to prevent the spread of infection. In an interview on 03/19/2026 at 12:27 PM, the RNC stated she expected staff to use their PPE if a resident was on EBP, no matter what was going on, to prevent cross contamination. Review of the facility's policy infection control plan: overview dated March 2024 reflected .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. A single set of PPE cannot be used for more than 1 patient. EBP are indicated for residents with any of the following: or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Indwelling medical device examples include central lines, urinary catheters.

Based on observations, interviews and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (R#1). 1. The facility failed to ensure R#1's preferences for showers were adhered to as he was receiving a bed bath, which made him feel dirty, down, depressed, and like a prisoner. 2. The facility failed to ensure R#1 was assessed timely for safety awareness in his electric wheelchair after his last reassessment on 12/27/25. These failures could place residents at risk of psychosocial harm. Findings include:R#1Review of R#1's admission Record, dated 03/03/26, showed he was admitted to the facility on [DATE] and was his own RP. R#1 also had diagnoses that included cerebral infarction (stroke), morbid (severe) obesity due to excess calories, other impulse disorders, depression, mood disorders, hemiplegia (total paralysis) and hemiparesis (weakness), generalized muscle weakness, and need for assistance with personal care. Review of R#1's Annual MDS, dated [DATE] , showed he had a 11/15 BIMS, which indicated he had moderate cognitive impairment. R#1 also did not exhibit any behavioral symptoms, used a manual wheelchair to turn and wheel, and was dependent on two or more staff to shower and transfer him. Review of R#1's Care Plan showed staff initiated a note on 11/26/24 that reflected R#1 required two staff for bathing assistance. There were no notes initiated or revised that reflected R#1 choice of wanting showers instead of bed baths. Staff also initiated a note on 12/03/24 that reflected R#1 required two staff participation with transfers using the mechanical lift. Staff also initiated a note on 09/14/25 that reflected R#1 was operating a motorized wheelchair that potentially poses a risk of injury to himself and others due to decreased awareness of surroundings/speed control and interventions that included therapy was required to perform a safety test on R#1 for operating his motorized chair, review and reinforce facility safety policies for use of motorized devices, reassess need for continued independent use of motorized wheelchair if unsafe behaviors persist and provide education/reinforcement on safe driving practices: speed control, awareness of pedestrians and stopping when others are nearby. This note was revised on 10/19/25 and reflected R#1 was operating a motorized wheelchair that potentially poses a risk of injury to himself and others due to decreased/impaired vision. This note was revised on 01/20/26 and reflected R#1's wheelchair was unplugged from the battery, he was dependent on staff for locomotion in the facility, and he was upset he was no longer able to use his electric wheelchair. This note was revised on 01/27/26 and reflected R#1 was now in a Geri-Chair due to comfort and safety measures. Review of R#1's BIMS Assessment, dated 02/23/26, showed he had a 15/15 BIMS, which indicated he was cognitively intact. Review of R#1's PHQ-9 Assessment (Depression Severity Assessment), dated 02/23/26, showed he exhibited depression symptoms and reported feeling bad about himself nearly every day (12-14 days). Review of R#1's Electric Wheelchair Safety Assessments showed he could return demonstration of understanding wheelchair operation safety precautions, effectively control speed, safely maneuver chain in and out of obstacles and around corners, stop the chair on command, aware of surroundings that may intercept wheelchair, stop at intersections before proceeding, been informed of privilege to operate his electric chair/cart can be revoked if he demonstrated unsafe operation or disregard to staff and resident safety and maintenance performed a safety check of the wheelchair on 09/13/25. R#1 was unable to stop at hallway intersections and benefitted from safety training on 09/15/25. R#1 could not return demonstration of understanding wheelchair operation safety precautions, effectively control speed, could not safely maneuver chain in and out of obstacles and around corners, stop the chair on command, was not aware of surroundings that may intercept wheelchair, does not check for clearance before backing wheelchair up or turning the wheelchair around, stop at intersections before proceeding, been informed of privilege to operate his electric chair/cart can be revoked if he demonstrated unsafe operation or disregard to staff and resident safety and maintenance performed a safety check of the wheelchair, eyesight diminished, discussed with family that he is not safe to operate electric wheelchair, will provide alternative mobility options and discuss with wheelchair company on obtaining a specialized manual wheelchair to accommodate his size and positioning needs on 10/07/25. R#1 was lacking in the areas indicated due to medical/physical restrictions and would be referred to evaluation and treatment if appropriate and the maintenance supervisor did not perform a safety check of the wheelchair on 12/27/25. There were no subsequent evaluations. Review of R#1's Weekly Nursing Summaries showed he did not exhibit any wandering, verbal, physical, or other behavioral symptoms on 01/03/26, 01/10/26, 01/17/26, 01/24/26, 02/01/26, 02/08/26, 02/15/26, 02/22/26 and 03/01/26. Review of R#1's care plan conferences showed his most recent one was his quarterly on 12/18/25. Review of R#1's POC, from 02/03/26 through 03/03/26, showed 1-2 staff gave him bed baths. No staff documented giving showers to R#1. Staff documented they did not observe R#1 have any types of behaviors from 02/02/26 through 03/03/26. Review of R#1's Psychological Services Progress Notes showed he reported his mood was down, appeared irritated during the discussion, required redirection due to frustration regarding current circumstances. R#1 refused the services on 2/6/26 and was ill on 1/30/26. R#1 reported his mood was alright, felt he slept too much, and discussed thought about potentially moving to live with family member and exploring home health options on 01/16/26. Review of R#1's Diabetic Exam on 01/28/26 showed he had blurred vision, did not have glasses and contacts. Review of R#1's Progress Notes showed: -The SW created a note on 01/28/26 at 1:41 p.m. that said, I also discussed with R#1 the opportunity of him transferring to one of our sister facilities in another city. At these facilities there are longer hallways for him to maneuver his chair. R#1 stated he is not interested in moving outside the current city. -LVN A created a note on 02/05/26 at 8:36 a.m. that said, During morning med pass, this nurse asked resident if he would like to get up into the Geri chair today to try it out and he agreed. When the CNA arrived to get him up, he stated, 'fuck that chair, i aren't getting up.' DON notified.-LVN B created a note on 02/07/26 at 1:35 p.m. that said, Resident asked if staff could assist him into chair and out of bed today. Resident refused. This nurse encouraged resident but resident continued to refused. Resident stated, 'Not today, I will get up on Monday.'-RN C created a note on 02/09/26 at 1:58 a.m. that said, Resident has not been up to chair in over a month at this time. He stated, 'I will get up tomorrow,' Informed him I will let the dayshift Nurse know. -LVN D created a note on 02/09/26 at 3:51 p.m. that said, resident has refused to get out of bed multiple times today when staff offered, resident stated, 'I'll get up in the morning.'During an observation and interview of R#1 on 03/03/26 at 11:32 a.m., R#1 was lying in his Geri-Chair in the living room area. He appeared clean, dressed and comfortable. During an interview of R#1 on 03/03/26 at 12:04 p.m., he said he had not received a shower in over a month. He said he often notified staff of his shower over bed bath choices and they still did not ask or shower him. He said he felt like a prisoner, dirty, down, and depressed. He said he often notified his family that staff would not shower him. R#1 said staff took and stored his electric wheelchair away approximately a month and a half ago because they told him that he was running over other residents. He said therapy told him approximately a month ago that they would reevaluate him for safety awareness and never did. He said his Geri chair that he sat in during the interview was not his usual wheelchair. He said he had to beg staff to move him from room to room, they still would not whenever he requested to be moved, and he could not independently move himself in the Geri chair. He said he been to jail twice, felt like he was still being treated like a prisoner, was upset, felt restrained because he could not independently go anywhere and had to ask staff to move him, staff would not move him, and depressed. During an interview with R#1's FAM on 03/03/26 at 12:28 p.m., they said R#1 often called and told them that staff did not shower him in over two weeks and they did not understand why he was not being showered. They said R#1 was a paraplegic, needed help with showering himself, and was supposed to receive two showers every week. They said R#1 told them that he felt like a dog, racially discriminated against because he observed other residents receive showers, down and depressed. They also said, It's not right. He wants to be showered. Everyone deserves to feel clean. FAM said the ADM, DON and ADON took away R#1's electric wheelchair approximately a month ago and told them because his eyes were bad. They said R#1 was receiving vision treatment. They said R#1 told them that he did not like the regular Geri chair because he was a large man, he expressed he was angry and upset and cursed profanities whenever he called them because he felt like staff were messing and picking on him, R#1 was in his right mind, and they felt R#1 was being racially discriminated against because staff did not mention anything to them about reevaluating R#1 for safety awareness. They also said, The Geri chair is a restraint. They are restraining him from going anywhere without them having to push him because he can't push that chair on his own and they don't push him when he asks. He has a right to independently go where he wants. During an interview with the DOR on 03/03/26 at 1:38 p.m., she said she did not observe or interact with R#1. She said OT and PT evaluated residents for electric wheelchair safety awareness and anyone could request for the evaluation. She also said she did not know how often residents were evaluated for electric wheelchair safety awareness and started her employment with the facility last month. She said she knew the importance of reevaluating residents for electric wheelchair safety awareness and said, Because there is a big safety component. Residents could become aware and not aware. Residents want to be independent. Resident could have risk of decline in function, depression, and being able to go out and be independent. She said she oversaw and ensured OT and PT evaluated residents for electric wheelchair safety awareness. She did not receive any inquiries from R#1 or other staff about him wanting to reevaluate for electric wheelchair use. She said she must set up the evaluation for safety awareness and documented evaluations in residents' EHR.During an interview with the MDS Nurse on 03/03/26 at 2:03 p.m., she said CNAs and nurses showered residents at the facility according to their choices and schedule. She said staff try to offer residents the option of bed baths or showers and accommodated based on their preference. She said R#1 did not express and staff did not notify her that R#1 was wanting showers over bed baths. She said she knew it was important to respect residents' rights and said, Because it's their right, especially if they were able to tell us what they want. She said R#1 was unable to transfer himself, get in a car and go out on pass and currently used a Geri chair, which staff pushed to move him from room to room. She said therapy evaluated electric wheelchair safety awareness and she used that assessment to determine if the electric wheelchair was unsafe for residents to use. She was unsure how often residents could be reevaluated for safety awareness. She said she knew it was important to respect residents' rights to not be restrained and said, Makes them feel like they are still a person and they have the right. We are not a prison. They are allowed to go in and out as they please. Family is more than welcome to take them out. Residents could be at risk of feeling sad, depressed and not respected. She said R#1 never expressed wanting his electric wheelchair over the Geri chair to her. She said R#1 started to exhibit lack of safety awareness in November and December 2025 and started to show signs of vision impairment. She did not know if R#1 had been reevaluated since last year and the time frame for reevaluating. She said she knew it was important to assess residents and ensure safety awareness and said, For their safety and want to ensure they and other residents are safe. Residents could be at risk of feeling like they were not being respected as an individual. During an interview with the SW on 03/03/26 at 2:52 p.m., she said the CNAs and nurses showered residents at the facility according to their choices and schedule. She said staff offer residents the choice of bed baths or showers and accommodated based on their choice. She said R#1 and his FAM did not report any concerns to her about not receiving any showers. She said R#1 had the capacity to consent and make informed decisions. She said R#1 expressed concern of not being able to use his electric wheelchair. She said R#1's electric wheelchair was taken away from him approximately some months back due to it being unsafe and his vision worsening. She said she did not know how often residents could be reevaluated for electric wheelchair safety awareness and therapy or nursing staff evaluated residents. She said she did not know why R#1 was not reevaluated after December 2025. She said R#1 should be able to independently go out on pass and did not know that he was denied to go out on pass. She said R#1 was referred to counseling and psychological services for depression and she was not aware he was depressed. She said she knew it was important to respect residents' right to go out on pass and said, It's important to respect all residents' rights, especially if it's within their rights. Residents could be upset if they were unable to go out on pass independently.During an interview with the ADON on 03/03/26 at 3:17 p.m., she said CNAs showered residents according to their choices and shower schedule. She said R#1 did not express to her that he wanted showers over bed baths. She also said R#1 did not want to get up and out of bed. She said R#1 could not see and ran into things last year, went to the optometrist, learned he had poor vision, she told staff to turn off his electric wheelchair and push him and she did not know if he was reevaluated for safety awareness after December 2025. She said R#1 had poor vision even with eye injections he received in mid-December 2025. She said she did not know how often residents were reevaluated for safety awareness, knew R#1 did not want to get out of bed because he did not have his electric wheelchair, and she did not know R#1 was exhibiting signs and symptoms of depression and was not notified. She said she knew it was important to respect residents' right and said, It promotes independence and helps with mood. If you prevent them from going out on pass, that's like imprisonment. During an interview with the DON on 03/03/26 at 3:46 p.m., she said she expected CNAs to shower residents according to their shower schedule and preferences. She said R#1 did not express to her wanting showers over bed baths. She said R#1 could not transfer, could no roll his wheelchair, was responsible for himself, voiced his needs, could not be reevaluated for electric wheelchair safety awareness until his eyesight improved, and she did not know when R#1's optometrist, who visited him bimonthly, communicated about his vision status. She said R#1 was seen by two different specialists regarding his vision and received eye injections to help with his vision. She said she knew it was important to respect residents rights and said, Because you don't want them to feel like they are in prison. Residents could become upset or frustrated. You don't want them to have any emotional distress. During an interview with the MD on 03/03/26 at 4:11 p.m., he said R#1 had the capacity to make informed decisions for himself. He said he had not discussed electric wheelchair safety awareness issues regarding R#1 and did not know why a reevaluation was not conducted. He said he believed a reevaluation was not completed due to the DOR being new and likely caused a lapse in reevaluation.During an interview with the ADM on 03/03/26 at 6:22 p.m., he said staff were required to adhere to residents' rights. He said he knew it was important to respect residents' choices and said, If we don't, then other staff cant access it and provide accurate care. Must provide accurate care possible. He said he heard in the past that R#1 preferred not to get in the shower and most of the time got a bed bath. He said he could not recall discussing R#1's shower choices with the IDT team. He said he could not remember if there was an incident that resulted in R#1 not being able to use his electric wheelchair, R#1's ADL status must change for him to be able to be reevaluated for safety awareness, R#1's vision must improve, December 2025 was his last evaluation because he failed it, he was unable to allow R#1 to use his electric wheelchair because he failed the assessment, and staff were expected to reevaluate quarterly and if there was a significant change. He said staff were expected to accommodate if a resident expressed wanting to use their electric wheelchair again. Review of the facility's Resident Rights policy, undated, reflected, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.5. The facility shall not extend the resident representative the right to make decisions on behalf of the resident beyond the extent required by the court or delegated by the resident, in accordance with applicable law.7b. The resident's wishes and preferences must be considered in the exercise of rights by the representative.Respect and dignity - The resident has a right to be treated with respect and dignity, including:1. The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms.3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.Self-determination -The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice.1. The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or herinterests, assessments, plan of care and other applicable provisions of this part.2. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.Review of the facility's Electric or Motorized Wheelchair policy, undated, reflected, It is our policy to ensure, to the best of our ability, the safety of residents who own and use an electric wheelchair, as well as the safety of all other resident's, staff and visitors in the facility. Therefore, resident's owning/using an electric wheelchair will be assessed on admission, quarterly, and upon a significant change of condition for their ability to drive/guide the wheelchair.

Based on interviews and record reviews, the facility failed to allow residents to make choices about aspects of his or her life in the facility that are significant to the resident for 1 of 4 (R#2) residents. The facility failed to revise R#2's care plan to reflect redirecting her whenever she was near or entering a male resident's room. These failures could place residents at risk of not receiving care and services according to their preferences. Findings include:Review of R#2's admission Record, dated 03/03/26, showed she was admitted to the facility on [DATE], she was her own RP and had two other RPs. R#2 also had diagnoses that included cerebral infarction, weakness, cognitive communication deficit, need for assistance with personal care, lack of coordination, dementia, generalized muscle weakness, difficulty walking, unsteadiness on feet, lack of coordination, and major depressive disorder. Review of R#2's Quarterly MDS, dated [DATE], showed she had a 4/15 BIMS, which indicated she was severely cognitively impaired. R#2 did not exhibit any wandering, inattention, disorganized thinking, altered level of consciousness, physical, verbal or other behaviors. Review of R#2's Care Plan, showed staff initiated a note on 11/25/24 that she had a communication problem, had impaired cognitive function/dementia or impaired thought processes, at risk for wandering, and staff were required to communicate with her/FAM/caregivers regarding her needs and capabilities. There were no notes initiated or revised that reflected redirecting her from male residents' rooms. Review of R#2's Psychosocial Evaluation, dated 01/16/26, showed her cognition was functionally intact, she was fully oriented, memory was intact, her judgement was adequate, and her thought process was circumstantial/confusing. Review of R#2's Psychological Progress Note, dated 01/23/26, reflected, [R#2] was seen this week in her room at the facility. She was awake, alert, and oriented times three. Grooming, hygiene, and eyecontact were within normal limits. Speech was clear, with tone and volume within normal limits. Thought processes were logical andcoherent. Reported mood was 'good,' and affect was congruent with stated mood. No acute concerns were noted regarding memory or cognition during the session. During an interview with R#2 on 03/03/26 at 12:05 p.m., she said the staff would not allow her and R#1 to be alone in each other's rooms. She said staff also told her that she was not allowed to enter and be alone in R#1's room, R#1 would get her pregnant if she did, and because her FAM had an issue with her being alone in R#1's room. She said she was alert, oriented, knew who to consent and refuse, and her and her FAM did not have any issues or concerns with her and R#1 being alone and having privacy time together. She said she felt rotten and down because staff did not allow her and R#1 to have privacy time alone together and she felt update because she had no privacy from staff at all. During an interview with the MDS Nurse on 03/03/26 at 2:03 p.m., she said R#2's FAM expressed on an unknown date that they did not want R#1 alone in the room with R#2 because she fluctuated cognitively throughout the day. She said she was not present when the conversation with R#2's FAM took place and was informed by the SW and DON on unknown date. She said she revised the care plans after the IDT team, which comprised of nursing, therapy, dietary, and social services department heads, met, discussed and decided on revisions to residents' plan of care. She did not revise R#2's care plan to reflect her FAM not wanting R#1 alone in the room with R#2. She said she knew it was important to revise residents' care plans to reflect their choices and said, Because it's their right, especially if they were able to tell us what they want. During an interview with the SW on 03/03/26 at 2:52 p.m., she said the DON told her that R#2's FAM expressed on unknown date that they did not want R#1 alone in the room with R#2 because she did not have the capacity to consent and make informed decisions for herself. She said R#2's FAM was listed as her RP, she did not know if R#2 had an MPOA, and she did not know who made informed decisions on R#2's behalf. She said the MDS Nurse revised care plans after the IDT team met, discussed and decided on changes to residents' care and services and said, All staff were responsible for ensuring residents' rights were accommodated.During an interview with the ADON on 03/03/26 at 3:17 p.m., she said the DON told her sometime in 2025 that R#2's FAM did not want R#2 in R#1's room alone because they did not want her in the room alone with R#1 and they did not want R#2 going into any male residents' rooms. She said the MDS Nurse revised care plans after the IDT team met and discussed changes. During an interview with the DON on 03/03/26 at 3:46 p.m., she said R#2 voiced she wanted to go into R#1's room on unknown date and her FAM was contacted and wanted staff to redirect her whenever she entered male residents' rooms. The surveyor attempted to call R#2's FAM twice on 03/03/26 and left a voicemail and call back number. R#2's FAM did not return the surveyor's calls before exit. During a follow-up interview with the DON on 03/03/26 at 5:27 p.m., she said her and the MDS nurse revised residents' care plans. She said she did not know R#2's care plans was not revised to reflect preferences and choices. She said she knew it was important to revise residents' care plans to reflect their choices and said, Because it's reflection of care and everyone knows how to provide adequate care for them. Residents could be at risk of staff not adhering to their or their family's wishes.During an interview with the ADM on 03/03/26 at 6:22 p.m., he said the IDT team met before revising residents' care plans. He said the MDS nurse revised residents' care plans. He said he knew it was important to revise residents' care plans to reflect their choices and said, If we don't, then other staff cant access it and provide accurate care. Must provide accurate care possible. He said he expected whoever spoke with R#2's FAM should have revised her care plan and implemented interventions. He said this was the first time he heard that R#2's interventions were not implemented in her care plan. Review of the facility's Comprehensive Care Planning policy, undated, reflected, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with residents' rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals.Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices and goals during their stay at the facility.Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan.

Based on observation, interview, and record review the facility failed to provide the care and supervision to prevent accidents for 1 of 7 (Resident #1) residents reviewed for accidents and hazards. The facility failed to ensure that Resident #1, who had a history of wandering and was high risk for elopement on admission, was prevented from exiting the facility without staff supervision on 10/22/2025 and found wandering outside the facility alone approximately 20 minutes later by staff. The facility was not aware that she was not in the building when she was found. The noncompliance was identified as Past Noncompliance (PNC). The IJ template was provided to the facility on [DATE] at 5:05PM. The IJ began on 10/22/2025 and ended 10/23/2025. The facility corrected the noncompliance before the survey began on 11/06/2025. This failure placed residents at risk for elopement with the potential for serious injury or death. Findings Include: Record review of Resident #1's Face sheet dated 11/06/2025 reflected a [AGE] year old female admitted to the facility on [DATE] for respite care. Resident #1's diagnoses included: Alzheimer's disease (dementia that damages the brain), hypertension (high blood pressure), age-related cataract (cloudy appearance to the lens of the eye causing difficulty seeing), auditory hallucinations (hearing things that are not there), and generalized anxiety disorder (intense and excessive worry and fear). Record review of Resident #1 admission Elopement assessment dated [DATE] revealed Resident #1 was noted to have a score of 10, indicating she was high risk for elopement. Record Review of Resident #1's Orders on 11/06/2025 reflected a physician's order (start date not listed) with a revision date of 10/23/2025 that reflected, Admit to secure unit d/t (due to) hx (history) of elopement with active exit seeking behavior r/t (related to) Alzheimer's (dementia that damages the brain). Record review of Resident #1's admission MDS (Minimum Data Set) dated 10/28/2025 reflected a BIMS score of 3 (severe cognitive impairment). Review of Resident #1 care plan dated 11/06/2025 revealed Resident #1 was noted to have a Focus area that reflected, The resident is at risk for wandering Date Initiated: 10/17/2025 with a goal, The resident will not leave facility unattended through the review date. Date Initiated: 10/17/2025. Interventions/Tasks related to this Focus Area included: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date Initiated: 10/17/2025 CNA, Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 10/17/2025, and If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. Date Initiated: 10/17/2025. Resident #1's care plan had a Focus Area that reflected, The resident is at risk for falls r/t (related to) Date Initiated: 10/17/2025. The related Intervention/Tasks included an intervention dated 10/17/2025 stating, The resident needs a safe environment. Record review of Resident #1's Care plan dated 11/06/2025 reflected a Focus Area that reflected, Resident resides in the Secure Care Unit, related to diagnosis of Alzheimer's with exit seeking and risk for elopement. Disoriented to place Date Initiated: 10/23/2025 Revision on: 10/23/2025. Record review of Resident #1's Physician Assessment Notes dated 6/25/2025 and signed by MD C reflected, Alzheimer's disease, agitation - between 4-6pm gets agitated more easily, seeing cats and dogs, someone is always stealing something, used her walker to lock [family member] out of the room, tries to hit people- on sertraline- eating okay, no Issues with chewing or swallowing- Uses walker but gets up In the night and rummages through things without the walker and takes and hides things- Had an episode of wandering a few weeks ago- apathetic, only wants to watch tv, won't participate in anything else See above, we are going to work back her seroquel since taking at 4 PM now and then wakes up later thinking is daytime againSundowners (a state of confusion or agitation that occurs in the late afternoon or evening, especially in people with dementia), better, not yelling out at TV or agitated at talkshow or blocking [family member] w (with) walker. The agitation has gone down. Record Review of Resident #1's Physician Assessment signed by MD D dated 10/16/2025 at 12:30PM, reflected, [AGE] years old female with a complex medical history who presented for evaluation of memory problems and behavioral disturbances associated with late-onset Alzheimer's disease. She experiences visual and auditory hallucinations, frequent falls, and episodes of agitation, particularly in the late afternoon. Her caregiver, [family member], reports wandering behavior, apathy, and nighttime coughing. Record review of Resident #1's Event Note dated 10/22/2025 at 5:00 PM reflected Resident #1 exited the front door and was missing for 20 minutes. The note reflected, notified by staff that resident was found outside on the sidewalk to the left of the building. Resident followed a visitor outside and then was questioned by therapy staff. Therapy didnt realize resident needed to be back inside the building. Staff redirected pt inside and pt was placed on 1:1 (one on one staff observation) until moved into secure unit. For the resident statement portion of the note, it reflected resident stated that she was pregnant and that she had to go outside to help with the kids. The RP and MD D were notified at that time. Record review of Accuweather website's weather history on 11/10/2025 for the area the facility was located on 10/22/2025 showed a high temperature of 83 degrees Fahrenheit and a low temperature of 53 degrees Fahrenheit for the day. Record review of Google maps on 11/10/2025 reflected the walking distance from the facility to the business at a nearby intersection as approximately 476 ft. or a 2 minute walk. In an interview with HA E on 11/06/2025 at 9:50AM, she stated that she was assigned to assist with the secure unit. She stated that Resident #1 was primarily Spanish speaking. She stated that the resident was not known to wander the unit. She stated that she would follow prompts from staff and was easily redirectable. In a Spanish Interpreter (Interpreter #2363) assisted interview with Resident #1 on 11/06/2025 at 10:00AM, she stated that she did recall going outside alone a few weeks prior. She stated that she went outside because one of her children was crying. She talked intermittently about the doll in her lap and described it as her child. She stated that she felt safe in the facility. In an interview with the ADMIN on 11/06/2025 at 10:40AM, he stated that the video footage for the facility was maintained on a two week loop and was no longer available for review. He stated that in his review of the video footage on 10/22/2025 at 4:00PM, the camera could see a visitor was going in and Resident #1 went out. The investigation revealed that staff followed her out to try to see if she was okay. He stated that Resident #1 was Spanish speaking. He stated that another staff member saw her outside unsupervised and walked her back in. He stated that he did a one-on-one training with the PTA after the incident. He stated it was the staff person's first position in a long term care facility. He stated that he should have stayed with her or called someone. He stated that they were able to estimate she was out of the facility for 19 minutes. He stated that Resident #1 was assessed and found to have no injuries. He stated that she was seen leaving and found with her walker, and was just standing on the sidewalk when the staff found her. He stated that the cameras could only see her walking out the door on the front. The stated she was brought in a side door. He stated that Resident #1 was seen by the laundry on the side of the building. He stated that after the staff brought her back into the facility, she came to the ADMIN's office right away and told the ADMIN. He stated there was no indication that Resident #1 was attempting to leave prior to the episode. He stated that Resident #1 was able to safely ambulate alone. He stated that when he interviewed the resident she said she was trying to take her babies to school. He stated that Resident #1 had two baby dolls that she brought from home. He stated that she had been at the facility less than a month before the incident. In an interview with the RNC on 11/06/2025 at 10:50AM, she stated that she was in the facility when the Resident #1 eloped and did not realize it initially. She stated that she realized when she reviewed the camera footage after the resident was found. She stated that in the facility investigation the PTA, who was new to the facility, spoke some Spanish and attempted to speak with Resident #1. She stated she seemed relatively normal and he left her. Then, she stated a nurse aide in training saw her and brought her back in the facility. Interview with Student CNA A on 11/06/2025 at 11:10AM, she stated that in the afternoon of 10/22/2025, she found Resident #1 outside at the left side of the building. She stated she was walking toward the laundry room and Resident #1 was walking from the back of the facility, by the end of the paved walkway, towards her. She stated the resident was well dressed, no tears or debris on her clothing, and had no visible injuries or signs of distress. She stated that she did not recall a lot of traffic outside at that time, but stated she thought the road in front of the facility was busy. She stated that there could be traffic on the road around 5:00PM. She stated she could not recall exactly what time it was when she found Resident #1 outside. She stated that she could not understand what Resident #1 was saying as she walked in because she was speaking Spanish. She stated that she walked her back to her room and went immediately to the DON and the ADMIN to report that she had found Resident #1 wandering alone outside. She stated she last saw the resident with her family member less than an hour prior to finding the resident outside. She stated that she did every two hour monitoring. She stated she was not aware Resident #1 had a risk for wandering and elopement in her history or on her care plan. She stated that she had never seen Resident #1 wandering in the facility. Observation of the outside of the facility at 11:08AM on 11/06/2025 revealed a concrete walkway around the left side of the building that connected to a paved driveway that terminated directly to the street. There was a drainage ditch at the end of the driveway before the driveway to the adjacent business. It was approximately 500ft to the intersection with a state highway road. There was no sidewalk on the right side of the building. The left side of the facility had a business directly adjacent to the building. There was a fence behind the facility blocking access to a mostly dry creek bed that met a culvert on the corner of the right side of the building. There was less than three inches of water in the drainage ditch on the right side of the building. In an interview with Resident #1's RP on 11/06/2025 at 12:40AM, she stated that she was happy with the care for Resident #1. She stated that she was notified of the elopement after it happened. She stated the was out of the country on 10/22/2025. She stated that her husband had been in the facility that day to visit Resident #1. She said he told her that Resident #1 was in a good mood. She stated that prior to coming to the facility for respite, Resident #1 had a few episodes of wandering inside the house at night in the kitchen. She stated that her doctor started her on a medication to help her sleep at night and she had no other episodes. She stated she had a history of auditory and visual hallucinations at home. She stated Resident #1 was a very timid and polite. She stated that Resident #1 had been known to follow people aimlessly and she could see how if she might have followed someone or politely exited the door if it was held open for her. She stated that she planned to bring Resident #1 home from respite on 11/15/2025. In an interview with RNC on 11/06/2025 at 1:05PM, she stated that a high-risk score for the elopement risk assessment was 10 or above. In an interview with the PTA on 11/06/2025 at 1:30PM, he stated that he had started at the facility a few months ago. He stated that on 10/22/2025 he walked out the entrance door and saw Visitor B, who was outside the facility and looked like he was trying to get in the front door. He stated that it was normal to use the code for visitors to get in the front door. He stated that as Visitor B went into the facility, Resident #1 walked out the door. He stated that he did not know Resident #1 and had not seen her in the facility. He stated that she was well dressed and walking steady with a walker. He stated that he asked her how she was doing in Spanish, because she appeared to possibly be Hispanic, and she said she was good. He stated that she seemed with it and he did not think much of it at the time. He stated that he should have checked with others to try to identify Resident #1. He stated that he and other staff had been watching the front door for any other residents who might attempt to leave. He stated that he did not recall a specific training on elopement at the facility, but stated that he knew to watch for anyone leaving the door who might be a resident. He stated that he did not let her out the door himself. He stated that on the video footage of the entrance door, it looked like Resident #1 came to the door right at the moment he pushed the code. He stated that she just went through the door right at the same time that Visitor B was coming into the facility. He stated that the risk to the residents of allowing them to leave the facility unsupervised is that they could get lost, hurt, or worse. In an interview with RN on 11/06/2025 at 1:48PM, she stated that she was assigned to Resident #1 as her nurse on 10/22/2025. She stated that Resident #1 liked to stay in her room, including eating her meals in her room, at that time. She stated that she had not seen her engage in any wandering behavior prior to her elopement that day. She stated that staff were to check on the resident every two hours for her monitoring requirements at the time, but stated that they were not watching her for wandering at the time because she did not seem like a risk. She stated that Resident #1 seemed content in the facility and was adjusting well from her observations. She stated that she primarily saw Resident #1 in the halls with family members, but could not say that she had not seen Resident #1 ambulate outside of her room alone. She stated that her family came to visit her often at the facility. She stated she last saw Resident #1 in the dining room with her family member. She stated it was after lunch, but she could not recall the time. She stated that she did not see Resident #1's family member leave the building. She stated that an elopement score of 10 or higher would indicate a resident was high risk. She stated that the elopement risk score should be done on admission and with any changes. She stated Resident #1 had no episodes of crying, restlessness, or behaviors. She stated that staff could look at the last elopement risk score or the care plan to know if a resident was at risk for wandering and elopement. She stated she did not check the care plan to know that Resident #1 was a risk for wandering and elopement. She stated that she should have checked the care plan for Resident #1. She stated that she did not know that Resident #1 was screened as a high-risk for elopement on her admission screening. She stated that if a resident was allowed to leave the facility unsupervised they could be hit by a car, kidnapped, or anything could happen. In an interview with Student CNA A on 11/06/2025 at 2:09PM, she stated that she was assigned to care for Resident #1 on 10/22/2025. She stated that she her with her family member and he was walking her around the building. She stated that she did not see him walk her by the entrance. She stated that she thought when she last saw the resident, she was with him by the dining area. She stated that she thought he was showing her around the facility. She stated that he never took her outside. She stated it was probably less than an hour before she eloped was the last time she saw her. She had just admitted but Student CNA A did not know about any special monitoring prior to her elopement. She stated that her responsibilities for Resident #1's care included rounding on her every two hours and helping change her briefs when she was soiled. She stated that rounding on a resident meant to check them and their environment. She stated that she asked if residents were okay, tried to address any needs they might have. She stated she was expected to make sure there was not trash or fall hazards in the area, ensure that residents had water or other drinks available, and that they had their call light with them. She stated she did not think the facility had a sign-in sheet for visitors. In an interview with the DON on 11/06/2025 at 1:12PM, she stated that when a resident was admitted to the facility, a nurse did an initial assessment for elopement. She stated that Resident #1 was not a risk for elopement when she was first admitted to the facility. She stated that Resident #1 would not come out of her room after her admission. She stated that Resident #1's family member came to visit while her another family member was on vacation, and he was seen walking her around the building. She stated that on 10/22/2025 the family member walked her further than she had seen her walk in the building up to that point. She stated that a high risk for elopement score was over 10. She stated the risk assessment scoring was based on the ability of a resident to ambulate, and stated they would monitor them to see if they were walking near doors. She stated that if she had seen any exit seeking behavior the staff should increase monitoring and watch the resident's routine. She stated that Resident #1 was eating her meals in her room prior to 10/22/2025. She stated that it was her expectation that nursing staff watched Resident #1 for elopement during all her activities in the facility and keep communication between staff about her location. She stated that all residents were monitored on an every two hour schedule by the nursing staff, including Resident #1. She stated that if a resident had not attempted to elope or shown exit seeking behaviors, they stayed on an every two hour monitoring schedule. She stated that a resident had to have a high enough elopement risk score and show exit seeking behaviors for the facility to then do the secure care consult to assess a resident for the need for the secure unit. She stated that the facility did a teams meeting to do the secure unit assessment. It would be a combination of factors that would prompt the secure assessment. She stated that it was case by case as to what elopement score would necessitate further intervention for the elopement score. Interview with RNC on 11/06/2025 at 2:23PM, she stated that for a resident with a high risk score of 10 for elopement she would expect staff to monitor for exit seeking behavior and assess their capability to get out of the facility. She stated they would need more than a high risk score to know if they were a candidate for secure unit. They could keep them with every two hour monitoring without a reason to increase the monitoring schedule. She stated that when a resident screened for high risk for elopement, a care plan intervention was added automatically. She stated that staff should check the care plan to know if a resident was a risk for wandering or elopement. She stated that home wandering did not necessarily equate to a risk for elopement in the facility. She stated that when she viewed the video footage of Resident #1 exiting the front entrance on 10/22/2025, she looked like a visitor in the clothes she was wearing. She stated that after the incident the facility took the codes to the door away from everyone except staff. They changed door signage to make it more noticeable for visitors who might be complacent. It was changed from a sign with text only to a sign with a large red stop sign in the middle and the wording and formatting were adjusted. She stated that she did not recall seeing when Resident #1's family left the building on camera prior to the incident. She stated that the risk of allowing a resident to leave the facility was that they could get hurt. She stated that the road in front of the building could be busy around 5PM. She stated that Resident #1 was gone over ten minutes to the best of her recollection. She stated the staff were not found to be neglectful in the investigation of the events. She stated there was not a sign in sheet that visitors were required to sign. She stated that she did not recall seeing when Resident #1's last visitor exited the front door. In a phone interview with Visitor B on 11/06/2025 at 2:51PM, he stated that he was visiting a resident at the facility on 10/22/2025. He stated that he had never seen Resident #1 in the facility prior to that day. He stated that he walked up to the door and put the code in. He stated that Resident #1 was at the door and looked like she was on her way out, so he opened the door. He stated that he thought they were just passing each other at the door. He stated that Resident #1 was well dressed. He stated that she smiled at him and asked how he was. He stated that she appeared to be steady on her feet with her walker. He denied observing any signs of distress or agitation in her demeanor. Observation on 11/07/2025 at 9:28AM revealed that in a seventeen minute time frame the road in front of the facility had regular car traffic with several semi-trucks traveling the street. In an interview with the DON on 11/07/2025 at 11:00 AM, she stated she was not aware of the actual findings from the facility's investigation related to the elopement incident. She stated that, from the clinical perspective, all required assessments were completed and the resident was relocated to a secure unit following the incident. The DON stated her expectations of staff regarding elopement prevention and response were for staff to continuously monitor residents for changes in behavior, remain alert to any variations that may indicate risk of elopement, and intervene timely. She stated staff were expected to notify her, the Director of Nursing, the physician, or the nurse practitioner so that medical related issues related to exit seeking behavior or elopement could be ruled out. The DON stated that the process typically began with obtaining labs for the resident. She stated there were pictures of residents on all face sheets to help assist staff to know a resident from a visitor. The DON stated her expectation was that staff would ask appropriate questions to establish whether an individual resided in the facility or not. The DON stated that if a resident was allowed to leave the facility unsupervised it could result in physical injury, becoming lost, or, in the worst-case scenario, death. In an interview with the ADMIN on 11/07/2025 at 11:37AM, he stated that through his investigation he determined the resident had followed a visitor to the front door and a visitor allowed the resident to exit the facility. The Administrator stated he obtained a signed statement from the visitor, who apologized and explained that he was simply being polite in letting the resident out. He stated that he became aware of the incident when staff coming from the side door observed the resident on the sidewalk and immediately escorted her back into the facility. He stated his expectations of staff regarding elopement prevention and response, were that if staff did not recognize an individual, they are expected to verify with the charge nurse, the Director of Nursing, or himself before allowing anyone to exit the building. He stated that the risk to the resident when allowing them to leave the building unsupervised was they could sustain a possible injury, such as a fall, or other adverse outcomes. Record Review of the facility Elopement Policy (no date) reflected: Policy Statement Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission. The assessment should be completed by reviewing the resident's medical history and social history. Information may be obtained by reviewing current medical records, if available, interview with resident/family, or conference with the interdisciplinary team member. The assessment tool should be completed, and interventions implemented as indicated. The Elopement Risk Assessment is to be completed at least quarterly and upon change of condition.2. All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team.3. The resident's current chart and assessments will be reviewed to determine what changes have occurred that would trigger elopement episodes.4. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes.5. Interventions into elopement episodes will be entered onto the resident's care plan and medical record.6. Should an elopement episode occur, the contributing factors, as well as the interventions tried, will be documented on the nurses' notes. Director of Risk Management and\or Director of Nursing Services should be notified of elopement.7. If a resident is discovered to be missing, a search shall begin immediately. (See policy entitled Elopement Response.)Intervention Strategies1. Reduce physical discomfort (e.g., analgesia to reduce pain, more comfortable seating, and scheduled toileting).2. Use personal items, family photos, or familiar objects to label resident's room clearly.3. Maintain familiar routines as much as possible.4. Schedule regular ambulation program or opportunity for exercise.5. Reduce excess sensory stimulation (sensory overload), decrease noise level and confusion.6. Use simple, clear language. Tell the resident what you want him/her to do, not what you don't want them to do. (e.g., come with me instead of don't go outside).7. Approach the resident in non-threatening manner.8. Do not confront or argue with the resident. Acknowledge the resident's concerns and gentlyredirect the resident.9. Follow the resident to see where he/she goes. If the destination is safe, consider use of volunteer companion or family member as a suitable escort.10. Give resident something to do that makes him/her feel useful (e.g., winding yam or foldingtowels).11. Allow verbalization of feelings .12. Obtain information from family on pattern of physical activity, daily home routine, style ofcoping with stress, etc.Staff Training Staff will receive training during their orientation process and then annually regarding: Elopement prevention Operation of all exit devices Actions to take if elopement occurs Record Review of facility policy for Elopement Response (no date): Policy Statement Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented. Policy Interpretation and Implementation1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical.2. Determination of missing resident either by routine nursing rounds or door alarms:A. Note: A resident is determined missing when he/she leaves the facility without the staff's knowledge.B. A resident having a wander guard warning system that sets off an alarm by stepping outside a door and is found immediately does not constitute an elopement.C. A resident must demonstrate a free and willful intent to leave the facility without prior notification of staff or is a wandering, confused resident who leaves the facility unattended.3. Should an employee observe a resident leaving the premises, he/she should:A. Attempt to prevent the departure:B. Obtain assistance from other staff members in the immediate vicinity, if necessary:C. Instruct another staff member to inform the charge nurse or Director of Nursing that a resident has left the premises; andD. Be courteous in preventing the departure and in returning the resident to the facility.4. Should an employee discover the resident is missing from the facility, he/she should:A. Report to the charge nurseB. Determine if the resident is out on an authorized leave or pass. If not;C. Make a thorough search of the building(s) and premises. If not located;D. Notify the Administrator and the Director of Nursing;E. Notify the resident's responsible party.F. Notify the attending physician;G. Notify VP of Risk Management, ADO, COO, and VP of Clinical Services.H. If necessary, notify volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.);I. Provide search teams with resident identification information: andJ. Make an extensive search of the surrounding area.7. Post return resident evaluation and care:A. Upon any resident elopement resulting in injury or death, the facility will immediately notify Risk Management, ADO, COO, and VP of Clinical Services.B. Any inquiries (e.g., press) should be referred to the Administrator. The Administrator will notify the VP of Risk Management.C. The facility will evaluate its elopement prevention program and all residents will be reassessed for elopement risk. 8. Documentation:An event note is to be made out on all residents who, without knowledge of the staff, leave the facility.Including the following: Date Time resident was first determined missing Responsible party notified and time Attending physician notified and time Emergency Personnel [NAME] ion of resident when located Where located and time locatedIf resident is located within the facility or immediately outside the nearest entryway, chart the following in the Nurses' notes: Date and time resident was first determined missing Location within or immediately outside the facility where found Condition of resident when found If injury or fall resulted, complete event note as above.Upon return of the resident to the facility, the Director of Nursing or charge nurse should: Examine the resident for injuries Contact the attending physician and report findings and condition of the resident. Follow orders Notify the resident's legal representative (sponsor) Notify search teams that the resident has been located Complete and file an incident report and Make appropriate entries into the resident's medical record . After an elopement the care plan coordinator will reevaluate the resident's care plan . The following actions were taken by the facility prior to surveyor entering on 11/06/2025 to abate the IJ: In an interview with ADMIN on 11/06/2025 at 2:40PM, he stated that after the elopement of Resident #1 all the residents in the facility had their elopement risk assessments redone and those with moderate to high risk for elopement had interventions in place to prevent elopement. Record review of the Elopement Risk Assessment History dated 10/24/2025 at 4:34PM reflected a list of 56 residents with a date of 10/22/2025 and a status listed as, Complete. Record review of Resident #1's 1:1 Monitoring Chart document dated 10/22[TRUNCA

Based on interviews and records review, the facility failed to ensure that medical records were accurately documented for three (3) of eight (8) residents (Resident #1, Resident #2, Resident #3) reviewed for accurate clinical records, in that: The facility failed to ensure Resident #1, Resident #2, and Resident #3's EMRs contained orders upon admission with corresponding clinical criteria to admit them to the secure unit. This deficient practice could result in errors in care and treatment and violate resident rights. Findings included: Resident #1 Review of Resident #1's face sheet dated 2/17/2025, reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease (a progressive disease that destroys memory), Dementia (a group of conditions characterized by impairment of at least two brain functions), Hypertension (high blood pressure), Benign Prostatic Hyperplasia (enlargement of the prostate gland) and history of Colorectal cancer (cancer of the colon and rectum.) Review of Resident #1's admission MDS dated [DATE], reflected a BIMS of 0 (zero) suggesting severe cognitive impairment. Review of MDS Section E on behaviors reflected resident had rejected care and had wandering behaviors in the last 1 to 3 days. Further, behaviors reflected Resident #1's wandering placed him at risk of potential harm and intruded on the privacy of others, *Review of Resident #'1s undated care plan reflected the problem: Resident resides in the Secure Care Unit, related to diagnosis of dementia and Alzheimer's Disease and risk for elopement. Intervention included Admit to SecureCare unit per MD orders. Review of Resident #1's orders dated 2/16/2025 reflected the following order: May admit to the secure unit. Review of Resident #1's EMR orders from 1/31/2025 to 2/15/2025 revealed there were no clinical criteria/problems referenced for the resident's admission to the secured unit. Resident #2 Review of Resident #2's face sheet dated 2/17/2025, reflected a [AGE] year-old male admitted [DATE] with diagnoses that included: Major Depressive Disorder, Anemia (low iron in the blood), Vascular Dementia (Cognitive decline related to decreased blood flow in the brain), Hypertension (high blood pressure), Atrial Fibrillation (irregular heart rhythm) and personal history of Cerebral Infarction (stroke.) Review of Resident #2's admission MDS dated [DATE] reflected a BIMS of 3 suggesting severe cognitive impairment. Review of MDS Section E on behaviors reflected resident had daily wandering behaviors. *Review of Resident #2's undated care plan reflected the problem: Resident resides in the Secure Care Unit, related to diagnosis of dementia and risk for elopement. Intervention included Admit to SecureCare unit per MD orders. Review of Resident #2's orders dated 2/16/2025 reflected the following order: May admit to the secure unit. Review of Resident #2's EMR orders from 1/24/2025 to 2/16/2025 revealed There were no clinical criteria/problems referenced for the resident's admission to the secured unit. Resident #3 Review of Resident #3's face sheet dated 2/17/2025, reflected an [AGE] year-old female admitted on [DATE] with diagnoses that included: Alzheimer's Disease (a progressive disease that destroys memory), Major Depressive Disorder, Bipolar Disorder, (disorder associated with episodes of mood swings), generalized anxiety disorder and insomnia due to other mental disorder (inability to fall asleep.) Review of Resident #3's admission MDS dated [DATE] reflected a BIMs of 9 suggesting moderate cognitive impairment. Review of MDS Section E on behaviors, reflected resident had wandering behaviors in the last 1 to 3 days. **Review of Resident #3's undated care plan reflected the problem: Resident resides in the Secure Care Unit, related to diagnosis of dementia delirium. Intervention included Admit to SecureCare unit per MD orders. Review of Resident #3's orders dated 2/16/2025 reflected the following order: May admit to the secure unit. Review of Resident #3's EMR orders from 1/9/2025 to 2/15/2025 revealed there were no clinical criteria/problems referenced for this the resident admission to the secured unit. During an interview on 2/17/2025 with LVN A, she stated she had done the admission for Resident #2 but did not remember putting in orders for him to be admitted to the secure unit. She stated she had just started at the facility and had not been familiar with the EMR and had not known how to do batch orders for admissions. She stated she was not sure who was responsible for putting in orders for a resident to be admitted to the secure unit, but she thought it was the corporate nurse or ADON. She stated not having orders in the system for admission to the secure unit could be a concern because we could be holding them against their will. During an interview on 2/24/2025 with LVN B, she stated she had done the admission for Resident #3 but did not recall if she had put in an order in for her because someone from admissions had come up and told her Resident #3 was being admitted to the secure unit. She stated she had only been responsible for the admission assessment and the skin assessment on Resident #3 and was not sure who was supposed to complete the orders. She stated she thought the orders were being completed by one of the corporate nurses. LVN B stated it could be against a resident's right to be confined to a secure unit without an order saying why they needed to be there. She stated orders were important because all staff needed to know what they were dealing with for residents. During an interview on interview on 2/17/2025 at 1:15 pm the ADO stated the charge nurse that does the admission was responsible for putting in the orders. She stated orders should have been put in the EMR timely and accurately. She further stated the DON should have reviewed documentation including orders upon admission. She stated her concerns with orders not being put in were that there could have been inaccurate documentation including inaccurate orders on a resident's chart. During an interview on 2/17/2025 at 3:32 pm, the IDON stated she had put the admission orders for the secure unit for Resident #'s 1, 2 and 3 on 2/16/2025. She stated she had been auditing the system [EMR] and noticed the orders were missing, so she put them in. She stated she had been aware that the orders to admit Residents #1, 2 and 3 were put in well after the residents had been admitted . She stated the admitting nurse was supposed to put in the orders and the nurses had the ability to do batch orders for admissions. She stated a problem with not having orders in for residents to be on the secure unit could be considered involuntary seclusion for those residents. She stated she had been covering as the interim DON and when she went to a facility, she would start auditing charts and if she found things missing, she would correct them and that was what happened with Resident #'s 1, 2 and 3 for their orders to be admitted to the secure unit. During an interview on 2/17/2025 at 3:39 pm, the Medical Director stated his expectations upon admission to the secure unit was that orders would be put in for those residents. He further stated he had been aware that Resident #'s 1, 2 and 3 were admitted to the secure unit and he had seen them/assessed them on the unit. He stated he expected orders to be completed timely and should be reviewed by either a physician or a midlevel provider [NP or PA]. He stated he will have to go through this process with the nursing facility to be sure the policies are being followed. Review of facility policy SecureCare Environment Admission Criteria and Process dated Revised February1, 2007 revealed: 1. Residents eligible for admission to the SecureCare Environment will have a diagnosis of a dementia related illness. 2. The need for admission to the SecureCare Environment must have a physician[s] order.

Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 3 residents (Resident #172) reviewed for privacy The facility failed to ensure RN B provided privacy by drawing the privacy curtain during wound care for Resident #172. This failure could place residents at risk of a lack of privacy and not having residents rights acknowledged. The findings include: Record review of Resident #1's face sheet dated 12/19/24 revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were, Acute hematogenous osteomyelitis (Bone Infection) , Dementia, Type 2 diabetes, Elevated white blood cell count, Hypertension, Cellulitis (Bacterial infection of the skin) of left lower limb, Local infection of the skin and subcutaneous tissue and Puncture wound with foreign body, left foot. Record review of Resident #172's face sheet dated 12/19/24 revealed he was admitted 2 days ago and his MDS assessment was not completed. Record review on 12/19/24 of Resident #172's care plan dated 12/17/24 reflected resident had Cellulitis of left foot and relevant intervention was treating wound as per facility protocol. During an observation and interview on 12/19/24 at 9:30 am RN B and RN C had provided wound care to Resident #172 in his room. Neither RN B nor RN C drew the privacy curtain during the wound care. The wound care would have been fully visible to anyone who entered the room or anyone in the hallway, if the door was opened during the wound care. When the wound care was progressing, a friend of Resident #172 (as stated by the visitor) and about 5 minutes later one FM of Resident #172 entered the room. Both visitors observed the wound care and remained in the room until the wound care was completed. Initially it was not known if Resident #172 was OK them seeing the wound and the wound care however during an interview at 10:10 am ,Resident #172 stated their presence had not distorted his privacy and/or dignity as they were very close to him in relationships. During an interview on 12/19/24 at 11:10 am RN B stated she was the ADON at the facility and was also the in charge for wound care. She stated it was a mistake that the privacy curtain was not closed. RN B said she was thinking that it was OK to keep it open as Resident #172 was not sharing the room with anyone else. She stated the wound care was observed by the visitors and as a matter of fact it would have been visible to anyone who was entering the room. RN B said the privacy of the resident would be less compromised by closing the privacy curtain as there would be sufficient time to redirect if anyone entered the room unexpectedly . During an interview on 12/19/24 at 11:15 am RN C stated she started working at the facility recently however was an experienced RN. She stated she should have closed the privacy curtain of Resident #172 while providing the wound care. RN C said, by not closing the curtain, the privacy and dignity of Resident #172 were compromised as anyone opened the door to the room could see the wound on his body and the wound care. During an interview on 12/19/24 at 11:30 am the CCN stated it was mandatory to respect and maintain privacy and dignity of residents during nursing care that includes wound care, by closing the door and windows and drawing privacy curtains. She stated the privacy curtain of Resident #172 should have been closed completely by the nurses before commencing the wound care. She said the trainings were ongoing process and resident rights was one of them. The CCN stated the facility ensured all the new hires had gone through skill checks. She said, as per plan every nursing staff also had to complete an annual evaluation to ensure their nursing skills and knowledge including competency in respecting resident's rights. Record review of undated facility policy Resident Rights reflected: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality The resident has a right to personal privacy and confidentiality of his or her personal and medical records. Personal privacy includes medical treatment , personal care.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 4 residents (Residents #17 and Resident #3) reviewed for infection control, as indicated by: MA A did not clean and disinfect the blood pressure monitor while using it on residents. This failure could place the residents at risk of transmission of disease and infection. Findings included: Record review of Resident #17's face sheet on 12/19/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were, Cerebral infarction (stroke), Deficiency of other vitamins, Chronic kidney disease ( kidney failure with slow progression) , Type 2 diabetes, and Hypertension. Record review on 12/19/24 of Resident #17's initial MDS assessment, dated 11/26/24 revealed it was in the process of completion and the BIMS was yet to be conducted. Record review on 12/19/24 of Resident #17's care plan dated 12/13/24 indicated resident had hypertension and relevant intervention was obtaining blood pressure readings at least weekly unless ordered by the physician to be obtained more frequently. Record review of the MAR for December 2024 revealed: Carvedilol Oral Tablet 25 MG (Carvedilol): Give 1 tablet by mouth two times a day related to Essential Hypertension. Hold if SBP < 110 or HR < 60. Record review of Resident #3's face sheet on 12/19/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were, ,Type 2 diabetes, Hypertension, Muscle weakness, Acute kidney failure ( Kidney failed to work) , Unsteadiness on feet, and Dizziness and giddiness Record review on 12/19/24 of Resident #3's initial MDS assessment dated [DATE] revealed it was in the process of completion and the BIMS was yet to be conducted. Record review on 12/19/24 of Resident #3's care plan dated 11/26/24 indicated resident had hypertension and relevant intervention was obtaining blood pressure readings at least weekly unless ordered by the physician to be obtained more frequently. Record review of the MAR for December 2024 revealed: Metoprolol Tartrate Tablet 50 MG: Give 1 tablet by mouth two times a day related to essential (primary) hypertension. Hold SBP less than 90, DBP less than 50, Pulse less than 50 and notify charge nurse/MD. An observation on 12/18/24 at 9:19 am revealed, MA A failed to sanitize the blood pressure monitor before using it on Resident #17, in between Resident #3 and Resident #17 and after Resident #3. MA A took the blood pressure monitor from the top of the med cart and without sanitizing it she took the blood pressure of Resident #17. MA A then moved on to Resident #3 and took his blood pressure with the same blood pressure monitor without sanitizing it. After completing the measurement on Resident #3, without cleaning the blood pressure monitor ,she kept it on the top of the med cart and moved to next resident for taking blood pressure and medication administration. During an interview on 12/18/24 at 10:50 am, MA A stated she had been working at the facility for about two weeks, however she had experience as a MA for many years. She said it was essential to minimize the risk of spreading contagious diseases by sanitizing the blood pressure cuff in between the residents. MA A stated she did not receive any training since started working at the facility. During an interview on 12/19/24 at 11:35 am the CCN stated MA A should have sanitized the blood pressure cuff immediately after she used it on residents. She said this was necessary to stop spreading contagious disease . The CCN stated MA A was working at a sister facility before joining this facility . The CCN said MA A reported to her that MA A did not need any refreshing training on any subjects related to nursing care as she was up to date with them from the previous facility. She added, for that reason the facility had not provided any training on disinfecting medical equipment. The CCN stated the facility did not have a policy available specifically for disinfecting durable medical equipment like stethoscope and blood pressure monitors, in between residents. The CNN stated MA A's noncompliance to infection control practice had the risk of spreading contagious diseases. Record review of undated facility policy Fundamentals of Infection Control Precautions reflected : A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections

Based on observation, interview and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one (Resident #3) of three residents reviewed for pressure ulcers. The facility failed to ensure Resident # 3 who had no pressure ulcers and was at risk for the development of pressure ulcers did not develop a Stage II pressure ulcer that progressed to an unstageable pressure ulcer in 14 days. These failures placed the residents at risk for developing worsening pressure ulcers, [CONDITION(S)] (skin infection), [CONDITION(S)] (infection of the bone), [CONDITION(S)] (infection of the blood) or severe pain. Findings included: Review of Resident #3's face sheet dated 01/30/2022 revealed Resident #3 was an [AGE] year-old female admitted to the facility 08/30/2021 with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's care plan dated 12/21/2021 revealed Resident #3 did not have care plan focus or interventions for prevention of pressure ulcer development and treatment. Review of Resident #3's quarterly MDS assessment dated [DATE] revealed Resident #3 had a BIMS score of nine indicating moderate cognitive impairment, required one-person assist for bed mobility and transfer from bed to wheelchair, has an indwelling catheter and was at risk for pressure ulcer development. The assessment revealed the following for skin and ulcer/injury treatments including a pressure reducing device for her bed, nutrition/hydration to address skin issues and applications of ointments/medications other than to her feet. Record review of Resident #3 skin assessment dated [DATE] revealed Resident #3 had no moisture associated skin damage, pressure ulcers or other skin issues. Record review of nursing progress note dated 01/20/2022 revealed the following documentation by LVN C CNA called this nurse to shower room due to an open area to buttocks. This nurse observes a stage 2 pressure ulcer to R inner buttock that measures 2.0 x 3.0 x 0.1. Area cleaned with wound cleanser, skin prep and collagen powder applied, covered wound with a silicone bordered dressing. Record review of weekly ulcer assessment dated [DATE] revealed Resident #3 to have a stage II pressure ulcer on her right buttock. Record review of nursing progress note dated 01/24/2022 revealed the following documentation by LVN C Stage 2 pressure ulcer to R buttocks is now unstageable. Physician notified and new orders received to clean with wound cleanser, apply skin prep to peri wound, apply medi honey and calcium alginate to wound bed and cover with a bordered foam dressing daily. In an interview on 01/25/2022 at 11:08 AM with LVN C , the wound care nurse, stated she was out for 10 days because she tested positive for COVID-19 and returned to the facility to find residents with increased skin issues. She stated the facility had been short staffed due to multiple staff members testing positive for COVID-19. She stated Resident #3 had a stage 2 pressure ulcer when she returned on 01/20/2022 and it has since progressed to an unstageable pressure ulcer on her buttock. She stated when she documented Resident #3's last skin assessment on 01/10/2022, Resident #3 did not have any skin damage. She stated there was not a skin assessment completed while she was out. She stated she referred Resident #3 to the wound doctor who would see her tomorrow 01/26/2022. She stated Resident #3 has a history of a stage IV pressure ulcer in a different spot and it has healed. She stated Resident #3 was in COVID-19 isolation due to testing positive on 01/19/2022. She stated there were other residents who had increased moisture associated skin damage, but no new pressure ulcers. She stated she believed the facility working short staffed did not allow for residents to be turned and changed as much as they needed which resulted in the pressure ulcer development in Resident #3. She said charge nurses were in charge of skin assessments while she was out on leave. In an interview on 01/25/2022 at 11:40 AM CNA D stated the facility was short staffed recently due to the COVID-19 outbreak and it was difficult when there were only three CNAs to assist 66 residents. She stated residents who could not turn and reposition themselves could not be turned every two hours to prevent skin breakdown. She stated there were normally at least four aides during the day and six aides was best for providing resident care. She stated residents were not changed as quickly when their brief was wet or had feces. She stated agency aides were not using peri-cream and the result was increased moisture associated skin damage. She could not identify any residents with ongoing skin damage today or a resident with a new pressure ulcer. An observation on 01/26/2022 at 1:50 PM revealed Wound Physician providing skin care for Resident #3 with no concerns. The wound was measured at 3.5 x 5.5 cm and was unstageable related to a cap of white skin and necrotic tissue at the center. Wound Physician performed the debridement at bedside after applying a numbing agent to the skin. He then applied wound cleanser, anticept gel and a silver alginate dressing to prevent infection and promote healing. The skin surrounding the wound was pink and healthy with no signs of infection. In an interview on 01/26/2022 at 1:53 PM Wound Physician stated this was the first visit with Resident #3. Wound Physician stated he would attempt to debride the area with a scalpel and completed the debridement. He stated he did not see any signs of infection. In an interview on 01/26/2022 at 1:50 PM ADMIN stated the facility had a plan to cover the skin assessments for the residents for the time period that LVN C was out for COVID-19. She stated there was a set schedule by room number for each nurse to complete skin assessments based on the resident assigned to the room. She stated with residents testing positive for COVID-19 and having to be moved a skin assessment may have been missed. She said each charge nurse was in charge of the weekly skin assessment for a set of room numbers. She stated Resident #3 tested positive for COVID-19 and had to be moved to the hot hallway for isolation. She stated in the process of moving residents around, Resident #3's skin assessment likely was missed. Review of the facility's policy Skin Integrity Management dated 10/05/16 reflected .4. Reposition residents at risk for pressure sores or with pressure sores at least every two (2) hours, if unable to turn themselves. 5. Use pillows or foam wedges to keep bony prominences from direct contact .8. Any person at risk for developing a pressure ulcer should avoid uninterrupted sitting in any chair or wheelchair. The individual should be repositioned, shifting the points under pressure at least every 2 hours .12. The presence of a pressure reducing device/ specialty bed does not negate the need to turn/ reposition the resident at least every two (2) hours .15. Skin should be cleansed at the time of soiling and at routine intervals .19. Use aseptic techniques for all topical treatments . Review of the facility's policy Pressure Injury: Prevention, Assessment, and Treatment dated 08/12/16 reflected .2. Early prevention and/or treatment is essential upon initial nursing assessments of the condition of skin .9. Assess for early signs of skin breakdown and report any findings. Early signs of skin breakdown and report any abnormal findings .

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 and to help prevent the development and transmission of communicable diseases and infections for two (Resident #1 and #2) of four residents who tested positive for COVID-19 and were observed for infection control practices. -The facility failed to post required isolation precautions for Resident #1 and Resident #2 after they tested positive for COVID-19 and were isolated in their rooms on the locked unit which also housed COVID-19 negative residents. -The facility failed to ensure staff wore required PPE based on the type of isolation required for the COVID-19 positive residents. These failures could place residents at risk of cross-contamination and transmitting the COVID-19 infection. Findings included: 1. Record review of Resident #1 face sheet dated 01/30/2022 revealed Resident #1 to be an [AGE] year-old female admitted to the facility 10/20/2020 with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1 Care Plan dated 03/12/2020 revealed Resident #1 to be risk for signs and symptoms of COVID-19 with the goal Resident #1 will not experience signs and symptoms of COVID-19 through the next review period ending 11/08/2021. The following interventions were identified: -Educate staff, resident, family and visitors of COVID-19 signs and symptoms and precautions. - Following Facility Protocol for COVID-19 Screening/Precautions. -Observe for psychosocial and mental status changes-document and report as indicated. -Observe for signs and symptoms of COVID-19-document and promptly report s/sx: fever, coughing, sneezing, sore throat, respiratory issues. - Provide alternative methods of communications with family/visitors. -Provide in room activities of choice, as able. -Provide support and allow resident to express feelings, fears and concerns. Record review of Resident #1 Annual MDS assessment dated [DATE] revealed Resident #1 to have a BIMS (Baseline Interview for Mental Status) score of five to indicate a severe cognitive impairment. The assessment revealed Resident #1 required supervision and limited assistance with activities of daily living. An observation on 01/30/2022 at 11:35 AM revealed Resident #1 in her room sitting on her bed with the door open. Record review of nursing progress note dated 01/27/2022 revealed Resident #1 tested positive for COVID-19 during routine facility testing on 01/27/2022. Resident #1 noted to be fully vaccinated and have received the COVID-19 booster immunization on 09/29/2021. Resident #1 was noted to not have symptoms of COVID-19. In an observation on 01/30/2022 at 11:50 AM CNA A delivered a meal tray into Resident #1's room wearing an N-95 and no other PPE. CNA A observed to set the tray on Resident #1's tray table and leave the room, then sanitize her hands. CNA A observed to enter the next resident's room with a meal tray. 2. Record review of Resident #2 face sheet dated 01/30/2022 revealed Resident #2 to be an [AGE] year old female admitted to the facility 02/27/2020 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2 care plan dated 11/24/2021 revealed Resident #2 to be risk for signs and symptoms of COVID-19 with the goal Resident #2 will not experience signs and symptoms of COVID-19 through the next review period ending 11/28/2021. The following interventions were identified: -Educate staff, resident, family and visitors of COVID-19 signs and symptoms and precautions. - Following Facility Protocol for COVID-19 Screening/Precautions. -Observe for psychosocial and mental status changes-document and report as indicated. -Observe for signs and symptoms of COVID-19-document and promptly report s/sx: fever, coughing, sneezing, sore throat, respiratory issues. -Provide alternative methods of communications with family/visitors. -Provide in room activities of choice, as able. -Provide support and allow resident to express feelings, fears and concerns. Record review of Resident #2 Quarterly MDS assessment dated [DATE] revealed Resident #2 to have a BIMS score of seven to indicate severe cognitive impairment. The assessment of Resident #2 revealed Resident #2 required supervision and limited assistance with activities of daily living. An observation on 01/30/2022 at 11:38 AM revealed contact isolation sign on the door of Resident #2 and the door was closed. Record review of the contact isolation sign (undated) posted on Resident #2's door revealed personnel should wear a mask, gloves and gown when entering the room. In an interview on 01/30/2022 at 11:40 AM CNA A stated Resident #1 and Resident #2 were both confirmed to have tested positive for COVID-19 and were in isolation. She stated she was not sure of the exact date they tested positive, but they were not supposed to leave their rooms. She stated neither resident had more than mild symptoms of COVID-19. She stated she knew Resident #1 was positive for COVID-19 because she was told at shift report by the CNA who worked last night. She stated there should have been sign on the door to show that Resident #1 required isolation. She stated Resident #1 does not like her door closed and requested the door remain open. She stated Resident #2 was also positive for COVID-19 and was in isolation. She stated she wore a gown, gloves and N-95 mask when entering their room and then would take off the gloves and gown prior to leaving their room. She stated she did not wear goggles or a face shield when in their room and there were none on the PPE cart beside Resident #2's room. She confirmed there was not a PPE cart placed by Resident #1's room and she got the PPE to enter her room from down the hall. She stated she received training on COVID-19 and infection control procedures. Record review of nursing progress note dated 01/27/2022 revealed Resident #2 tested positive for COVID-19 during routine facility testing on 01/27/2022. Resident #2 noted to have received the COVID-19 booster vaccination on 09/29/2021. Resident #2 was noted to have a runny nose and no additional symptoms of COVID-19. In an observation on 01/30/2022 at 11:55 AM, LVN B observed to tape a sign on Resident #1's door to indicate Resident #1 was in isolation with airborne isolation precautions. LVN B observed to change the sign on Resident #2's door to airborne isolation precautions. In an interview on 01/30/2022 at 12:00 PM, LVN B stated the signs for Resident #1 should have been put up on Resident #1 and Resident #2's doors when they tested positive on 01/27/2022. She stated Resident #1 had no sign to indicate she was in isolation, but staff knew she was positive because the information was relayed on shift report. She stated all residents on the locked unit were fully vaccinated with the booster shot as well for COVID-19. She said there have not been other residents that have tested positive for COVID-19 since 01/27/2022 or had signs and symptoms of COVID-19. She did not know why Resident #2 did not have the isolation signs posted. She said Resident #2 had the wrong sign for isolation. She said it should have been airborne isolation precautions and not contact isolation precautions. In an interview on 01/30/2022 at 12:30 PM, ADMIN stated the aerosol isolation signs should have been posted on Resident #1 and Resident #2 doors on the day they tested positive. She stated both residents were on the locked unit due to being an elopement risk and therefore they were isolated on the locked unit. She stated she did not know why Resident #1 did not have any isolation notification sign or why Resident #2 did not have the correct isolation sign. She stated staff have been trained on what PPE they should wear when entering the room of a COVID-19 positive resident. She said staff should wear full PPE when entering the room including an N-95 mask, face shield or goggles, gown and gloves. She stated they should remove all PPE prior to exiting the room except for their N95 mask. She stated they should then disinfect their hands after exiting the room. She stated Resident #1 had the preference of having her door open and the facility honors her preference but did not allow any residents to enter the room or Resident #1 to exit the room. She stated all residents on the locked unit were fully vaccinated with a booster vaccination. Record review of COVID-19 Response Plan dated 06/08/2021 revealed for residents with a known COVID-19 positive test, they should be isolated in a private room. The policy further revealed staff caring for resident's positive for COVID-19 should wear gloves, isolation gown, eye protection and an N95 mask. Record review of PPE Use and CDC Guidance for Restrictions Inservice Training dated 01/19/2022 revealed staff caring for COVID-19 positive residents should don PPE in the following sequence prior to entering the resident's room: gown, N95 mask, goggles or face shield and then gloves.

Based on observation, interview and record review the facility failed to provide ongoing activity program designed to meet the interest of and support the physical, mental and psychosocial well-being for three (Resident #1, Resident #2 and Resident #3) of six residents reviewed for activities of the facility. The facility failed to provide ongoing activities for Resident's #1, Resident #2, and Resident #3. This failure could place residents at risk for a decline in social, mental, psychosocial well-being and decreased quality of life. Findings included: Resident #1 Face Sheet dated 01/06/2021 reflected an [AGE] year-old female resident with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set, dated dated dated [DATE] reflected she had unclear speech and sometimes understood others. Resident #1 was not capable of completing cognitive assessment. Resident #1 had short- and long-term memory recall. Her decision-making ability was severely impaired per staff assessment. Resident #1 was further assessed to require two-person extensive assistance with bed mobility, transfers, dressing and toileting. She required one-person total assistance with locomotion on and off unit and personal hygiene. Review of Resident #1's Comprehensive Care Plan initiated 1/25/2021 and updated 11/2/2021 reflected she was dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits and physical limitations. Assure that the activities the resident was attending are compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed such as large print, holders if resident lacks hand strength and task segmentation, compatible with individual needs and abilities. Provide in room activities of choice, as able. Review of Resident #1's Activity Progress Note dated 01/25/2021 reflected resident enjoyed dominos, going outside, she liked to read, play uno and visit with her grandchildren. She will be visited by activity staff for sensory type activities such as music, hand massages, nail painting, etc. Review of Resident #1's Activity Assessment effective date 04/08/2021 and signed by Activity Director on 04/13/2021 reflected resident unable to participate in group activities. Resident participated in one-to one activity. She required assistance to attend activities. She was a passive participant. Resident #1's activity preference was to be around people, she had difficulty making friends, she enjoyed small groups and she preferred to stay in her room. Her psychosocial needs were one to one interaction and sensory stimulation. Review of Resident #1's Activity Progress Note dated 04/13/2021 reflected resident does not participate in activities on a regular basis. Resident liked for staff to talk with her and hold her hand. Review of Resident #1's Activity Quarterly assessment dated [DATE] reflected resident unable to participate in group activities (large or small). Resident participates in one-to one- visits in her room. Resident required assistance to attend group activities and is a passive participant. She preferred to be with people and had difficulty making friends. She preferred to stay in her room and enjoys small groups. Activity Assessment further indicated resident psychosocial needs were one to one interaction and sensory stimulation. Review of Resident #1's Activity Quarterly assessment dated [DATE] reflected she participated in one-to-one visit. She was unable to participate in group activities. Activity quarterly assessment further indicated resident required assistance to attend activities and was passive participant, prefers to be with people, had difficulty making friends, preferred to stay in room, enjoyed small groups and was able to make needs known to others. Resident#1's psychosocial needs were one-to-one interaction and sensory stimulation. Review of Resident #1's Activity Progress Notes dated 9/27/2021 reflected there had not been any changes in resident's activity level since last quarter . (date of last activity progress notes 07/02/2021 Review of Resident #1's Activity Participation records from July 2021 through November 2021 reflected resident did not have a participation record for July 2021. Resident #1 attended one activity in August 2021- chit chat with friends on 08/9/2021. Resident #1 did not attend any activities or receive one - one visits for the months of September, October and for November 1st through November 25th according to Resident #1's participation records. Observation on 11/25/2021 at 8:35 AM Resident #1 was in sleeping in her room. Resident's bed was in low position, the lights were on and the room was quiet. Observation on 11/25/2021 at 9:30 AM Resident #1 was in bed eyes and mouth were opened wide. The lights were turned off and the room did not have any type of stimulation such as music or TV. Resident was staring toward the wall in front of her. Observation on 11/25/2021 at 11:00 AM Resident #1 was in bed with her eyes and mouth opened wide. The lights were off and the door to her room was closed. There was not any type of stimulation such as music or TV. Resident #1 was staring toward the ceiling. Observation on 11/25/2021 at 1:20 PM Resident #1 was in bed eyes and mouth were opened wide. The lights were off, and the door was closed to her room. The room was quiet and there was not any type of stimulation in her room. Resident was starring toward wall in front of her. In an interview on 11/25/2021 at 8:45 AM CNA A stated Resident #1 did not get out of her bed very often. CNA A stated she had not heard any music or any type of stimulation in resident's room. She also stated she had not seen activity staff in the resident's room. She stated she was not aware of anyone doing activities with any of the residents except for the activity staff. She also stated Resident #1 usually napped after breakfast. In an interview on 11/25/2021 at 10:20 AM Activity Assistant stated Resident #1's calendar was blank and did not receive in room visits. The activity assistant also stated Resident #1 could not respond to activities. She stated if a resident was unable to respond they do need to have some type of activity. She stated she had not attempted to do activity with Resident #1. She stated she did not know why she thought Resident #1 was not able to do activity. Review of Resident #2's Face Sheet dated 03/06/2018 reflected a [AGE] year-old female resident with a Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 2's full Minimum Data Set assessment dated [DATE] reflected resident had a Brief Interview for Mental Status of 1 indicating cognition was severely impaired. It was very important to resident to be around animals and go outside when had nice weather. It was important for the resident to have books, newspapers, and magazines but she had no choice or unable to do this activity. Resident required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, eating, toileting, and personal hygiene. Review of Resident #2's Quarterly Minimum Data Set assessment dated [DATE] reflected resident had unclear speech and vision was moderately impaired (limited vision; not able to see newspaper headlines but can identify objects). Resident was rarely/ never understood. Resident unable to completed section of Brief Interview for Mental Status (BIMS). Staff assessed resident had poor short- and long-term memory recall. Resident was assessed to have severely impaired daily decision-making ability. She rarely/ never made decisions. She was total dependent on staff for personal hygiene and locomotion off unit. Locomotion on unit did not occur during assessment look back period. She was further assessed to require extensive assistance with bed mobility, transfers, dressing, eating and toileting. Review of Resident #2's Comprehensive Care Plan date initiated on 3/6/2018 and last revised on 10/21/2021. Activities notify nursing if incontinent during activities. Resident was dependent on staff for activities, cognitive stimulation, and social interaction. Assure that the activities the resident was attending were compatible with physical and mental capabilities; compatible with known interests and preferences; adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), compatible with individual needs and abilities. Invite the resident to schedule activities. Resident was at risk for signs/ symptoms of COVID -19. Provide in room activities of choice, as able. Review of Resident #2's Activity Quarterly assessment dated [DATE] reflected resident chose not to participate in group activities. Participates in one - to -one visits. Residents preferred activity setting was own room and activity room. She did require assistance to attend activities and she was an active participant. She preferred to be with people. She had difficulty making friends. Preferred to stay in her room. Enjoyed small groups. Her vision and hearing were poor. Her psychosocial needs were one-to-one interaction, spiritual growth, and sensory stimulation. Review of Resident #2's Activity Progress Note dated 06/10/2021 reflected most of the time resident chose not to participate in activities. She was hard of hearing and had poor vision. She liked to visit at times and go outside. She enjoyed listening to gospel singing and eat snacks. Review of Resident #2's Activity Quarterly assessment dated [DATE] reflected resident participated in: one-to-one visits. She preferred visits in the morning. Her preferred activity setting was her own room and in activities room. Resident required assistance to attend activities. She was an active participant. Resident preferred to be with people. She had difficulty making friends, preferred to stay in room, enjoyed small groups. Her vision and hearing were poor. Her psychosocial needs were one to one interaction and sensory stimulation. Review of Resident #2's Activity Progress Note dated 9/10/2021 reflected Resident was not out of bed on a regular basis. When she preferred to be alone, she wanted to sleep. She enjoyed snacks. Review of Resident #2's Activity Participation records dated July 2021 reflected resident attended one activity appetizers in B dining room and she did not receive one-one activities. Participation record also indicated resident did not refuse any activities. Review of Resident # 2's Activity Participation record dated August 2021 reflected resident did not refuse any activities or receive one-one activities. Review of Resident #2's Activity Participation record dated September 2021 reflected resident did not attend group activities or receive one-one activities. Resident did not refuse any activities Review of Resident # 2's Activity Participation record dated October 2021 reflected resident attended appetizers two times in B dining room. She did not receive one-one activities. Resident did not refuse to attend group activities or receive one-one activities. Review of Resident # 2's Activity Participation record dated November 2021 reflected resident did not attend group activities or receive one-one activities. She did not refuse any type of activity programs including group and one-one activities. Observation on 11/25/2021 at 8:58 AM revealed Resident #2 was in bed. She did not respond verbally to any questions or conversation. (asked yes/ no type questions). Resident made eye contact and moved her eyes. She did not speak. Observation on 11/25/2021 at 9:45 AM revealed Resident #2 was in bed. Her eyes were opened, and she did not speak during visit. She did make eye contact. Observation on 11/25/2021 at 11:15 AM revealed Resident #2 was in bed. Her eyes were opened, and she mumbled during conversation. Resident made eye contact. Observation on 11/25/2021 at 1:40 PM revealed Resident #2 was in bed. She mumbled very little during conversation. Resident did make eye contact. In an interview on 11/25/2021 9:10 AM CNA A stated Resident #2 enjoyed being in her room. She stated resident did not sleep all the time. She also stated would take a nap sometimes after lunch. She further stated over the past 2 months resident had become more confused and required more assistance. She stated she had seen activity staff place a paper on resident bedside table and leave the room. She had not seen anyone do activities with resident in her room or offer to assist her to group activities. In an interview with Activity Assistant on 11/25/2021 at 10:20 AM the Activity Assistant stated she could not recall Resident #2's activity preference or level. She stated the documentation on the participation records was the activities Resident #2 attended. Resident # 3 Review of Resident # 3's face sheet dated 11/25/2021 reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 3's Quarterly Minimum Data Set assessment dated [DATE] reflected resident had Brief Interview for Mental Status (BIMS) of 14 indicating cognition was intact. Resident can understand others and make self-understood. Resident did not walk or transfer during assessment period. She required supervision with bed mobility, locomotion on and off unit, eating, toileting and personal hygiene. She ambulated with walker or wheelchair. Review of Resident #3's full Minimum Data Set assessment dated [DATE] reflected resident had a Brief Interview for Mental Status (BIMS) of 15 indicating cognition was intact. It was somewhat important for resident to do her favorite activities and to keep up with the news. It wasn't very important for resident to have magazines, newspapers, or books to read. Resident required supervision with bed mobility, locomotion on and off unit, eating, toileting and personal hygiene. Review of Resident #3's Comprehensive Care Plan initiated on 11/09/2020 and reviewed on 11/22/2021 without making any changes to activity care plans and interventions reflected the activity director will encourage and remind the resident of current activities. The activity director will provide the resident with reading material for mental stimulation. Activity staff would praise the resident for attending activities of their choice. The resident required the following: visual aids such as large print books, books on tape related to having impaired visual function. Activity staff would provide in room activities of choice. Review of Resident #3's last Activity Progress Note documented in the electronic records dated 07/27/2021 reflected resident is not interested in participating in activity. She liked to watch TV, eat snacks. She preferred to be in her room. Review of Resident #3's Activity Quarterly assessment dated [DATE] reflected resident chooses not to participate in group activities. Resident participated in one-to-one visit. Resident's preferred activity setting was own room. Resident required assistance to attend activities. She was also assessed to be a passive participant in activity programs. Resident preferred to stay in her room, has difficulty making friends and did not prefer any size group. Resident's psychosocial needs was one to one interaction and sensory stimulation. It did not indicate she required any adaptive equipment such as large print or talking books. Review of Resident #3's Activity Quarterly assessment dated [DATE] reflected resident chose not to participate in group activities. She participated in one-to-one visits. Resident preferred activity setting was her room. Resident required assistance to attend activities. She was a passive participant. Resident was assessed to have difficulty making friends. Resident psychosocial needs were one-to- one interaction and sensory stimulation. There had not been any significant changes in resident's activity level since last quarter. Resident assessment indicated she did not require any adaptive equipment such as talking books or large print. Review of Activity Participation Records from July 2021 through November 2021 reflected Resident #3 had participation records for July 2021, August 2021, and September 2021. Resident did not receive one-one visits from activity department or attend any activities for these months. She was not offered activity items or refused any activities. Observation on 11/25/2021 at 11:30 AM revealed resident was in bed watching TV. In an interview on 11/25/2021 at 11:33 AM Resident #3 stated she would enjoy someone coming in her room and talking to her. She stated the activity staff did bring her a sheet of paper with different information of what happened in the past on that particular day most mornings, but she was unable to read it, the print was not as large as she preferred. Resident stated the activity staff did not read to her and she did ask them one time and the activity staff walked out of room and she never asked again for the staff to read to her. Resident stated she was not given an option to attend group activities. She stated she did prefer to stay in her room most of the time. She stated she had not been offered one-one visits from the activity department. She stated it would be nice to have books on tape and she could listen to them. Resident also stated she had not been offered books on tape. She stated she can see very large print with her glasses. In an interview on 11/25/2021 at 12:00 PM CNA B stated Resident #3 preferred to stay in her room. She stated Resident #3 had expressed she would enjoy having someone to come in her room and visit with her or do some type of activity with her. She stated she reported this to a nurse (did not remember which nurse) around the end of October 2021 or first of November 2021. She stated she had not seen activity staff in the residents' room except to enter the room and place a sheet of paper on resident's bedside table and exit the room. In an interview on 11/25/2021 at 10:20 AM Activity Assistant stated when a resident attends an activity or if a resident received one-one visits it was documented on an activity calendar. She stated each resident had a monthly activity calendar in a binder. She stated the residents name is on a calendar and it was highlighted when a resident attended an activity or received one - one visits. The calendars was the only records where activity participation is recorded. She also stated if a resident received one-one visits we highlight the activity we did with the resident. The activities we do during one-one visits is reading daily chronicles sheet we print from an activity website or we play country or gospel music from her phone this was the standard music of what everyone enjoys. She stated she did not review assessments to determine what type of music a resident preferred. She stated if a resident was unable to talk this was when they would play country or gospel music She also stated if a resident refused to attend group activity or refused to have one-one activity visits , activity staff documented refused on the calendar for that resident. She stated if a calendar is blank, she could not answer why it would be blank except if they did not attend group activities or have one-one visits. She stated Resident #1, Resident #2 and Resident #3 was not on the one-one activity program. In an interview with the Administrator on 11/25/2021 at 4:00 PM stated every resident activity need was to be specific to that resident. She stated if there were residents unable to speak, she expected the activity staff to interview the family and ask what type of activities that resident enjoyed. She stated residents unable to be out of bed required to have some type of stimulation based on their interests. She also stated all activities were to be documented such as group, independent and in room activities. She stated if a resident refused to attend group activities or did not want in room activities, it was required to be documented on the records the activity documents every resident's participation in activities if the resident refused. She stated she would need to discuss further with the activity director about their process of documentation. She stated she had been at the facility approximately a month and had not met with every department to discuss any issues in that department. Review of Facility Policy on Activity Participation Records dated 2011 reflected The Activity Department will maintain accurate records of group and individual program participation for each resident. Practice Guidelines: 1. Resident attendance in programs is recorded on a daily basis to reflect resident attendance and will be used as a source of information for recording resident's progress or lack of progress in the progress note. 2. Each resident has separate participation records of group activities and/ or individual attendance and participation. 3. Active, passive, and refused is noted on participation records. 4. Individual programs (one on ones) note the response to intervention by either a checklist or narration for each program or visit. Review of Facility Policy Activity Programming dated 2011 reflected The Activity Director and staff will provide for ongoing Activity programs. Recreation programs are based on the interest and needs of the residents expressed through the Activity assessment. Activity programs are designed based on resident's leisure interests implemented to meet the needs (physical, cognitive, creative, social, spiritual, independent, and sensory) of the residents. Review of Facility Policy Activity Progress Notes dated 2011 reflected The Activity Director or designee will complete a progress note for each resident that is timely and comprehensive at a minimum of quarterly (every 3 months). Practice Guidelines: 1. Each progress note addresses the resident's general participation level and should address: A. The resident's response to programming B. An evaluation of goal achievement C. Any changes needed in the plan of care. 2. Subsequent or intervention notes are documented in the medical record at any time, discussing any pertinent observations or interventions used during a specific time period. 3. All progress notes are written prior to interdisciplinary care conference meetings and are considered part of the assessment process.

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 and to help prevent the development and transmission of communicable diseases and infections for 3 of 20 staff (Dietary Staff A, TNA B and Housekeeper C) reviewed for infection control. The facility failed to ensure Dietary Staff A, TNA B and Housekeeper C wore their N-95 masks properly (covering their mouth and noses) while in the presence of residents and other facility staff. These failures place residents at an increased risk of exposure to infections to include COVID-19, decreased quality of life, hospitalization s, and/or death. Findings include: During an observation and interview on 11/18/2021 at 11:37 AM, Dietary Staff A was sitting at a table in the dining room with his mask down under his chin. He stated, I just took the test (regarding Covid-19 precautions.) I learned to keep my mask on and stay safe. The entire interview he had his mask down. Three female residents not wearing mask were observed sitting at a table next to Dietary Staff A, less than six feet distance. He stated he was not vaccinated for Covid -19 and the virus is spread Through the air. In an interview on 11/18/21 at 11:44 AM, the Director of Food and Nutrition stated she is Dietary Staff A's supervisor. There is no reason he has his mask down. He's been counseled on it before. We've all been through the training to keep our mask on. The staff is tested twice a week (for Covid -19.) He could potentially be spreading Covid by having his mask down. That's an ongoing thing with him. Observation on 11/18/21 at 11:50 AM, TNA B was sitting at the nurses' station next to the dining room with her mask below her chin. She stated I don't know why (my mask is down.) I know I can pass germs or catch germs. She stated, Covid-19 is Airborne. They always talk about it (Covid-19). Residents could catch it from staff coming in with it In an Interview on 11/18/2021 at 11:58 AM, the DON stated Staff should have masks up over their mouth and nose at all times while in the building. The staff had Covid-19/PPE instructions. I gave them a pre-test, a lecture and then re-tested them. We're so short staffed there are no consequences. They will just stay home and won't come into work. Observation on 11/18/2021 at 10:30 AM of a basket of N-95 masks at the front entrance on a table next to the electronic screening tool used for admittance and Covid -19 symptoms. A note was on the wall indicating N-95 masks should be worn while in the facility. Observation on 11/18/21 at 1:11 PM, Housekeeper C was not wearing her mask while talking to another staff on the hallway where the one confirmed COVID-19 positive resident resides in the facility. Housekeeper C said I forgot to pull it back up when I came out of the bathroom. I was coming back from lunch. I have been trained on PPE, gowns, gloves, mask and shields. I know that if someone comes up positive and you're coughed on, you can get it (Covid) When asked if there was a COVID-19 positive resident in the facility she stated Yes I know the residents can get COVID-19 from employees. They don't have to have symptoms to spread it. In an interview on 11/18/2021 at 2:51, PM the RNC stated We're in an outbreak. Staff has to wear a KN-95 or N-95 mask to cover their mouth and nose at all times while in the facility. In an interview on 11/18/2021 at 2:56 PM, the Housekeeping Supervisor stated Staff know they're supposed to wear masks at all times over their nose and mouth. They have all been trained. In an interview on 11/18/2021 at 3:15 PM, the Administrator stated I expect the staff to wear masks properly and to wear the right mask. They are to wear them at all times while in the facility. Review of a facility Infection Control Policy and Procedure Manual 2019 states A mask that covers both the nose and mouth are worn by personnel to provide protection of the mucous membranes of the nose and mouth from contact transmission of pathogens. Review of an undated facility policy PPE use when positive Covid Residents are in the facility Area without Covid. All staff must wear N95 if available, if not surgical mask.

Based on observation, interview, and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing and prevent new ulcers from developing for three of six residents reviewed for pressure ulcers. (Resident #52, #46, and #2) A) The facility failed to ensure Resident #52 who was admitted to the facility without pressure ulcers and was low risk for the development of pressure ulcers did not developed a Stage II pressure ulcer that progressed to a Stage IV pressure ulcer in 26 days. Once developed the facility failed to provide wound care within professional standards regarding infection control and wound cleaning techniques. B) The facility failed to do weekly Skin assessments or develop a plan of care for Resident #46 who was found with a Stage III pressure on 08/16/2021 which progressed to a Stage IV pressure ulcer. Once developed the facility failed to provide wound care within professional standards regarding infection control. Non-Immediate Jeopardy C) The facility failed to ensure RN A followed standard precautions during wound care for Resident #2's Stage IV sacral pressure ulcer and Stage IV right and left ischial pressure ulcers when he failed to perform hand hygiene throughout the procedure, sterilize his scissors or use a cleaning technique on the wounds that did not contaminate the pressure ulcers. These failures resulted in an Immediate Jeopardy (IJ) situation on 10/06/2021. While the IJ was removed on 10/08/2021, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. These failures placed the residents at risk for developing worsening pressure ulcers, [CONDITION(S)] (skin infection), [CONDITION(S)] (infection of the bone), [CONDITION(S)] (infection of the blood), severe pain or death. Finding Include: A) Review of Resident #52's face sheet dated 10/04/2021 revealed Resident #52 was an [AGE] year old female admitted to the facility 08/30/2021 with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #52's care plan dated 09/20/2021 revealed Resident #52 to require an indwelling catheter, history of surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #52's Admission MDS assessment dated [DATE] revealed Resident #52 had a BIMS score of 15 which indicated resident was cognitively intact, required two-person assist for bed mobility and transfer from bed to wheelchair, has an indwelling catheter and had a stage II pressure ulcer. Review of hospital history and physical dated 08/30/2021 revealed Resident #52 had surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no indication on the discharge paperwork to indicate Resident #52 had a pressure ulcer upon leaving the hospital. Review SNF rehabilitation discharge summary indicated Resident #52 was at the facility from 08/16/21 to 08/30/21. There was no indication on the discharge summary Resident #52 had a pressure ulcer or other skin issue. Review of Resident #52's initial skin assessment dated [DATE] revealed no issues noted except blanchable redness on coccyx. Review of Resident #52's care plan dated 09/05/2021 revealed Resident #52 to be a risk for development of a pressure ulcer with the following interventions Follow facility policies/ protocols for the prevention/ treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .the resident needs assist to turn/ reposition at least every 2 hours . Review of Resident #52's nursing progress note dated 09/08/21 revealed Resident #52 to have a stage II pressure ulcer to left and right buttocks. Review of Resident #52's weekly skin assessment dated [DATE] revealed stage 2 ulcer noted to left and right buttocks (no measurements or pressure ulcer description was documented). Review of Resident #52's weekly skin assessment dated [DATE] revealed stage 2 ulcer noted to left and right buttocks. Review of Resident #52's weekly ulcer assessment dated [DATE] revealed a stage 3 pressure ulcer on coccyx with measurements of 1.8 cm in length, 0.8 cm in width and the depth was unable to be determined. The ulcer assessment revealed the pressure ulcer had slough, yellow or white tissue adhered to the wound, approximately 50% of necrotic tissue, no exudate present, and the edges had maceration with the surrounding skin color noted to be bright red. The pressure ulcer was not noted to have an odor or signs/symptoms of infection. The ulcer assessment revealed Resident #52 to have nutritional interventions including Vitamin C, Zinc and Prostat Advanced Wound care liquid supplement. Review of Resident #52's nursing progress note dated 09/16/21 revealed Resident #52 to have a stage III pressure ulcer on coccyx. Review of Resident #52's weekly skin assessment dated [DATE] revealed stage 2 ulcer noted to left and right buttocks. Review of Resident #52's weekly ulcer assessment dated [DATE] revealed a stage IV pressure on coccyx with measurements of 2.4 cm in length, 1.2 cm in width and 0.2 cm in depth. The ulcer was ntoed to have slough (yellow or white tissue adhered to the wound) with granulation. The slough was or necrotic tissue was approximately 75% of the wound and granulation was 25% of wound. The exudate was noted to light, bloody and clear with no undermining or tunneling present. There was no bone, tendon, or hardware visible or directly palpable in the wound. The wound deges were noted to have had maceration with the surrounding skin color noted to be pink. There were not signs/symptoms of infection noted. The ulcer assessment revealed Resident #52 to have nutritional interventions including Vitamin C, Zinc and Prostat Advanced Wound care liquid supplement. Review of Resident #52's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #52's weekly skin assessment dated [DATE] revealed stage 4 ulcer noted to coccyx. Review of Resident #52's weekly ulcer assessment dated [DATE] revealed a stage 4 pressure ulcer on coccyx with measurements of 1.5 cm in length, 0.5 cm in width and 0.75 cm in depth. The ulcer was noted to have slough (yellow or white tissue adhered to the wound) with granulation. The slough was or necrotic tissue was approximately 25% of the wound and granulation was 75% of wound. The was no exudate present and no undermining or tunneling. The wound deges were noted to not have any issues and the surrounding skin color noted to be pink. There were not signs/symptoms of infection noted. The ulcer assessment revealed Resident #52 to have nutritional interventions including Vitamin C, Zinc and Prostat Advanced Wound care liquid supplement. Review of Resident #52's Braden scaled for assessment of pressure ulcer risk revealed assessments completed weekly between 08/30/21 - 09/23/21 noted Resident #52 to be at low risk of pressure ulcer development. In an interview on 10/03/21 at 11:20 AM CNA E stated it was difficult to respond to call lights when there are only 2-3 aides working the whole facility. She said they have been short staffed for several months, but it is improving. She said they try to get to everyone as fast as they can but when you were showering a resident, you could not leave and if there is not someone else available on your hallway, residents had to wait. In an interview on 10/04/21 at 3:30 PM DON stated Resident #52's pressure ulcer was facility acquired. DON stated she spoke with Wound Care Physician and did not believe the pressure ulcer had declined to a stage IV pressure ulcer. DON stated the Treatment Nurse does the initial skin assessment upon admission and if the Treatment Nurse was not available, the charge nurse would complete it. DON said weekly skin assessments were completed by the charge nurse on the day the assessment was due. DON said she did not know of any issues Resident #52 had with being able to turn and reposition herself in bed. She said Resident #52 was weak upon admission and may have needed some help but could assist in turning herself. She said the Treatment Nurse was involved with pressure ulcers usually at stage II and floor staff complete treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated wounds are referred to Treatment Nurse the same day or next day for treatment. She confirmed the wound confirmed in progress notes as stage II for Resident #52 on 09/08/21 should have been referred to the Treatment Nurse that day or the next day. She said the Treatment Nurse was out with COVID in September and that is probably why the first weekly ulcer assessment and treatment was not completed until 09/16/21. DON did not know how Resident #52 had a stage II ulcer on 09/08/21, a stage 3 ulcer on 09/16/21 and a stage IV ulcer on 09/24/21. DON said incontinence might be an issue, but Resident #52 was confirmed to have a catheter for urinary incontinence. She said the incontinence with the Braden scale of pressure ulcer risk and resident having a current pressure ulcer should not be there. If a resident has a stage III-IV pressure and it was facility acquired, it would make them more than a low risk for pressure ulcers. She said a low air mattress is ordered for a stage III or greater pressure ulcer. All residents have a pressure relieving mattress upon admission. Observation on 10/05/2021 at 8:41 AM of wound care for Resident # 52's coccyx pressure ulcer revealed the Treatment Nurse used her clean gloved hand to move the resident's adult brief out of the way, then cleaned the ulcer with gauze using the same gloved hand. She then pushed calcium alginate into the wound with the same gloved hand that touched the brief. In an interview on 10/05/2021 at 2:55 PM with the Treatment Nurse stated I was trained to clean wounds from inside to out. She stated I don't remember touching the brief on (Resident # 52.) In an interview on 10/05/21 at 12:05 PM the Wound Care Physician stated he had only seen Resident #52 once on 09/24/2021 and debrided her pressure ulcer. He confirmed Resident #52 had no prior history of a stage III or IV pressure ulcer that he knew of or had treated. He was not sure why it was documented that she had a previous pressure ulcer. He said the pressure ulcer was a stage IV after debridement and with the resident being so new to the facility, he assumed she was admitted with the pressure ulcer. When informed she was admitted with no pressure ulcer, he confirmed the pressure ulcer did form quickly and declined quickly. When asked if he thought this was avoidable for the resident, he could not say without reviewing her record. He confirmed the resident did not have any condition that would make her more likely to form a pressure ulcer. In an interview on 10/06/21 at 12:11 PM, Resident #52's Primary Care Physician stated Resident #52 was essentially bed bound upon admission and therefore spent a lot of time sitting or lying in bed which resulted in the pressure ulcer. When asked if the pressure ulcer could have been avoided if Resident #52 was turned frequently as ordered every two hours, she said yes. She said turning and repositioning would have likely reduced the likelihood of a pressure ulcer. She said now Resident #52 was stronger and able to reposition herself but at admission to the facility she would have required staff assistance. In an interview on 10/05/21 at 2:10 PM Resident #52 stated she required assistance from staff to reposition and move in bed or to transfer from the bed to a chair. She said she was better at turning herself now, but when she was first admitted she was weak and needed help. She said she does not remember them turning and repositioning her frequently or even once per day when she was first admitted . She said she did not know she was supposed to turn or reposition in bed or in her wheelchair to prevent the pressure ulcer from forming or declining. She stated her daughter bought her a wedge pillow so she could shift her weight while she was lying in bed. She said sometimes the call light response was slow if the staff were busy. In an interview on 10/05/21 at 2:35 PM the Treatment Nurse stated she returned from leave on 09/16/21 and assessed Resident #52. She said it was the first time she saw the pressure ulcer and identified it as a stage III pressure ulcer. She stated Resident #52 did not have an underlying reason for the fast development and decline of the pressure ulcer. When asked what could have caused the fast development and decline of Resident #52's pressure ulcer, she stated it was likely caused from lack of repositioning or turning Resident #52 in bed as ordered every two hours. She confirmed the facility was short staffed and aides did not always have the time to reposition residents every two hours. Review of Resident #52's point of contact documentation of repositioning/turning dated September 2021 revealed Resident #52 to not have reposition/turning documentation for 24 out of 30 days on at least one shift per day. In an interview on 10/05/2021 at 3:00 PM the DON stated the facility was short staffed over the last month. She stated normally five aides were scheduled during the daytime shift and they frequently worked with only two to three aides. She confirmed it would have been difficult for the aides to turn and reposition residents as required every two hours. B) Review of Resident #46's Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #46's Quarterly MDS dated [DATE] reflected she was rarely or never understood and was totally dependent on two-person physical assist for bed mobility (moving to and from a lying position, turning side to side and positioning body) and transfers. Review of Resident #46's Care plan dated 04/14/21 reflected The resident has potential for pressure ulcer development. Interventions: The resident needs assistance to turn/reposition at least every two hours. Review of a weekly skin assessment for Resident #46 completed on 07/16/21 reflected she did not have any pressure, venous, arterial or diabetic ulcers. Review of a weekly skin assessment for Resident #46 completed by the facility's Treatment nurse on 08/16/21 reflected she had a pressure ulcer. Review for weekly skin assessments for Resident #46 reflected no skin assessment were completed between 07/16/21 and 08/16/21. Review of a Weekly Ulcer Assessment for Resident #46 completed on 8/16/21 by the facility Treatment Nurse reflected discovery of a new Stage III pressure ulcer to her coccyx with slough (yellow or white tissue adhered to the wound) and 25% necrotic (dead) tissue. Stage III pressure ulcer involves the full thickness of the skin and may extend into the fatty tissue layer. The pressure injury was not present on admission. The Stage III pressure ulcer to her coccyx measured 2.5 cm length, 0.5 cm width and <0.1 cm deapth. Review of a Weekly Ulcer Assessment for Resident #46 completed on 09/30/21 reflected her coccyx ulcer had progressed to a Stage IV pressure ulcer. According to the National Institutes of Health website (nih.gov) in an article dated January 2015, a stage IV pressure ulcer is the is the most severe type of pressure ulcer. The skin is severely damaged, and the surrounding tissue begins to die. The characteristics are: full thickness skin loss with extensive destruction, tissue necrosis (death) or damage to muscle, bone or supporting structures. Observation on 10/05/2021 at 8:14 AM for wound care on Resident # 46's coccyx revealed the Treatment Nurse touched the resident's unclean bedding with her clean gloved hand and did not sanitize her hands or change gloves before she cleaned the wound. She used gauze to clean across the wound and dried all over, working from potentially contaminated areas of skin outside of the open wound. In an interview on 10/05/2021 at 2:55 PM with the Treatment Nurse stated I was trained to clean wounds from inside to out. I didn't realize I touched bedding before touching the wound on (Resident # 46.) In an interview on 10/05/2021 at 11:45 AM the DON stated the skin assessment shower sheets which had areas for staff to note alterations in skin integrity, was a new assessment she just initiated and did not have any for Resident #46 for 07/16/21 through 08/16/21. In an interview on 10/05/21 at 12:05 PM the Wound Care Physician stated the first time he examined Resident #46 was on 09/24/2021. The Wound Care Physician stated he did not know why the resident was not referred to him sooner. He stated the facility should be assessing the resident's skin frequently. In an interview on 10/05/21 at 1:13 PM Resident #46's PCP was asked his expectations for repositioning residents to prevent skin breakdown stated, he stated With folks who are confined to bed, they need to be more vigilant in moving and turning them. They need to check their vulnerable areas and keep them clean. In an interview on 10/05/2021 at 1:54 PM with the Treatment Nurse who stated When I returned from leave, someone told me Resident #46 had not been assessed in a while. The CNAs are supposed to come to me or the charge nurse with any skin issues. I found (Resident # 46's) pressure ulcer. In an interview on 10/05/21 at 3:35 PM with a CNA who chose to remain anonymous and was asked about having enough staff to turn and change residents stated, We were definitely understaffed in July, August and September. It makes everything harder and the wait times longer for residents. In an interview on 10/05/21 at 4:00 PM the ADON stated she and LVN B were Charge Nurses on Resident #46's hall during July and August 2021 when her weekly skin assessments were not completed from 07/16/2021 until 08/16/2021. On 08/16/2021 a stage three pressure ulcer was discovered on her coccyx. The facility ADON stated the charge nurses were responsible for doing the weekly skin assessments and there should always be a weekly skin assessment. In an interview on 10/06/21 at 8:40 AM LVN M, who worked at the facility and quit in September 2021, stated she did not remember if she was scheduled to do Resident #46's weekly skin assessments. She stated if it popped up on her schedule, she would do it. She stated if she did not do it the ADON (who is the current DON) would let her know the next morning. LVN M stated she did not recall any skin problems with Resident #46. In an interview on 10/06/21 at 11:39 AM the DON who stated she had been the DON for three weeks stated she was the ADON previously. When asked if it was her responsibility to ensure weekly skin assessments were completed, she stated, Yes, If I saw that it (skin assessment) was flagged on my computer and I had time to look at the computer, I would. I was working 12-hour shifts on the floor and always doing patient care. There was no opportunity to do the ADON job or ensure staff were completing the skin assessments. The DON further stated regarding issues on staffing We hire them, and they never show up or they show up and then stay for two days and quit. The pay is not competitive. We've lost four aides to (another facility in town.) In an interview on 10/06/21 at 4:00 PM CNA F stated We try to get to the residents as soon as we can. We saw redness on some of their skin, (Resident's #46). She stated Resident #46 could not turn herself. The residents need more attention which means we need more staff. Last night was the first time I've seen six staff. I've never seen that before. In an interview on 10/07/21 at 10:49 AM CNA N stated when she saw Resident # 46's coccyx area on a Thursday (08/12/2021) it was red with a white dot in the middle and she applied barrier cream. I told a nurse but I'm not sure who. She stated she was gone for a three-day weekend and when she returned on Monday, 08/16/2021, there was a hole in Resident # 46's coccyx. She stated, We were short staffed. In an interview on 10/07/21 at 10:52 AM with LVN B who stated, We were understaffed when Resident #46 got her pressure ulcer, so I don't know if she was turned or kept clean. She stated RN A mainly did the wounds during that time on the weekends and sometimes during the week. During the nighttime we don't have enough staff. There's only 2 or 3 for the whole place. C) Review of Resident #2's face sheet dated 10/04/2021 revealed resident #2 was a [AGE] year-old male admitted to the facility 04/27/20 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's comprehensive care plan dated 08/09/21 revealed resident #2 to require care for an ostomy, treatment with an anticoagulant, wound care for stage 4 pressure ulcer to sacrum, require pain medication, an indwelling catheter and history of major infection. Review of resident #2's Quarterly MDS assessment dated [DATE] revealed resident #2 to have a BIMS score of 14, required two-person assist with bed mobility and transfer from bed to chair, had an indwelling catheter and [CONDITION(S)], Stage IV pressure ulcer and required a prevention plan for reducing risk of pressure ulcers. Observation and interview on 10/04/21 at 11:00 AM revealed RN A in Resident #2's room to preform wound care. RN A already had the treatment field set up in room when surveyor arrived. RN A donned gloves outside at the treatment cart and entered the room. RN A did not perform hand hygiene prior to donning his gloves. RN A then removed the dressing from residents left inside knee. RN A stated the wound was from hardware from his knee replacement penetrating the skin and causing it to open. After removing the dressing RN A pushed around on the wound with his gloved hands and reached for the gauze from the table. With the same gloves' RN A cleaned around the area, cleaning across the wound. RN A then reached for a spray bottle (skin prep spray) on his field and sprayed it on the gloves and applied it to the wound with his gloves. RN A then retrieved a dressing from the field and applied it to the wound. RN A with same gloves felt up and down Resident #2's leg then repositioned Resident #2 and removed his brief and turned him over (still wearing the same gloves) and removed the coccyx dressings to reveal a large Stage IV pressure ulcer to the coccyx and Stage IV pressure ulcers to his right and left ischial tuberosity. In an interview with Resident #2 he stated he was admitted with the pressure ulcers. RN A without hand hygiene or a glove change cleaned the coccyx wound cleaning across the wound which was approximately 12 cm x 12 cm with .3 depth. RN A touched the wound all over with his gloves and cleaning with the gauze only certain areas of the wound. RN A then with same gloves began cleaning Resident #2's left and right ischial Stage IV pressure ulcers cleaning across the wounds and touching the wounds with is gloves (he did get a new gauze for each wound) he then applied hydrogel to the wounds with his gloves going from one wound to another. RN A then applied the collagen powder with his gloves patting it into the pressure ulcers going from one pressure ulcer to another. RN A without changing gloves or performing hand hygiene applied clean dressings to coccyx wound with the dressing reaching only to middle of pressure ulcer and with the tape being applied directly on the open pressure ulcer. RN A then applied a foam dressing to right ischial with the tape being on the coccyx pressure ulcer. RN A did the same with the left ischial pressure ulcer. RN A then stated he needed to get another brief, so he took off his gloves and without hand hygiene left room he came back in room with gloves on applied the brief to the resident. RN A then with the same gloves he took the spray bottle he used during treatment and put it in his left chest pocket of his scrubs, and he put the scissors that were on the overbed table with the treatment supplies in the side pants pocket of his scrubs without cleaning them. RN A then gathered the left-over treatment supplies and took them back to the treatment cart. In an interview on 10/04/21 at 3:21 PM RN A sated he was not trained in wound care and stated his training at the facility consisted of making rounds with treatment nurse. RN A stated he did not change his gloves or wash his hands throughout the procedure and did not clean his scissors before or after the procedure. RN A stated I should know better than that he stated he was not aware of the no touch technique for applying medication to wounds (the use of a sterile applicator). RN A stated he was not aware you could not remove treatment supplies from the room or that they were considered contaminated. RN A agreed he had touched the supplies with the gloves that he did not change during the entire wound care procedure. In an interview on 10/07/21 at 1:23 PM the RNC stated he expected staff to clean hands before donning gloves and before they start a treatment and when going from clean to dirty. When he was asked about going from wound to wound, he stated they should not do that. He stated no supplies should be removed from the room that cannot be sanitized and they should be sanitized. The RNC stated the remaining dressing supplies should have been disposed of. He stated there was no corporate policy regarding training staff for wound care other than the policy that was provided to surveyors. Review of the facility's policy Skin and wound management dated 2021 reflected The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Steps in the Procedure Steps in the Procedure. 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. 7. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. 8. Pour liquid solutions directly on gauze sponges on their papers. 9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. 10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. 11. Place one (1) gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water .16. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. Review of the facility's policy Skin Integrity Management dated 10/05/16 reflected .4. Reposition residents at risk for pressure sores or with pressure sores at least every two (2) hours, if unable to turn themselves. 5. Use pillows or foam wedges to keep bony prominences from direct contact .8. Any person at risk for developing a pressure ulcer should avoid uninterrupted sitting in any chair or wheelchair. The individual should be repositioned, shifting the points under pressure at least every 2 hours .12. The presence of a pressure reducing device/ specialty bed does not negate the need to turn/ reposition the resident at least every two (2) hours .15. Skin should be cleansed at the time of soiling and at routine intervals .19. Use aseptic techniques for all topical treatments . Review of the facility's policy Pressure Injury: Prevention, Assessment, and Treatment dated 08/12/16 reflected .2. Early prevention and/or treatment is essential upon initial nursing assessments of the condition of skin .9. Assess for early signs of skin breakdown and report any findings. Early signs of skin breakdown and report any abnormal findings . The Interim Administrator was notified of the Immediate Jeopardy on 10/06/21 at 5:00 PM and the IJ template was provided. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on 10/08/21 at 1:04 PM and included the following: Problem: Treatment/Services to Prevent/Heal Pressure Ulcers. Interventions: o 100% skin rounds to be completed (10/7/2021) by DON, Patient Care Coordinator, and Treatment Nurse, with Regional Compliance Nurse [RCN] oversight. o Skin assessment for resident #46 and resident #52 current. Update on current wound condition provided to resident #46's primary care physician on 10/6/21 with review of current treatment order to ensure appropriate treatment in place. Weekly ulcer assessment in place with current measurements for resident # 46 and resident #52. Care plans for resident #46 and resident #52 were reviewed and revised on 10/6/21. o The following in-services were initiated by the Director of Nursing on 10/6/2021: Pressure Ulcer Prevention and Treatment (Licensed Staff), including notification and documentation of pressure ulcers (Certified Nurse Aid/Non-certified Nurse Aid) Notification of Physician with change of condition (Licensed staff) Completing Weekly Skin Assessments and Weekly Ulcer Assessments in the absence of the Treatment Nurse (Licensed staff) Ongoing in-services will be completed by DON/ADON/TREATMENT NURSE, until all nursing staff have completed the in-services. The Director of Nursing/Designee will in-service licensed staff on the proper process for wound care beginning 10/7/21. Ongoing in-services will be completed by DON/Treatment Nurse/Designee until all licensed staff has completed the in-service. o Residents requiring assistance with ADL's have the potential to be affected by alleged deficient practice. o The medical director was notified of the immediate jeopardy situation on 10/6/2021 at approximately 5:40pm Monitoring o The DON/designee will review all pressure ulcers to ensure Weekly Skin Assessments have been completed, Weekly Ulcer Assessments have been completed, Care plans are in place and notification of the physician and responsible party is documented x6 weeks using available monitoring tools beginning week ending 10/8/21 and continue through week ending 11/19/21. o The DON/designee will audit all skin assessments weekly to ensure all assessment match the resident's current condition for 6 weeks using current monitoring tool beginning week ending 10/8/21 and co [TRUNCATED]

Based on interview and record review, the facility failed to ensure a registered nurse served as the Director of Nursing on a full-time basis for one of one facility reviewed for registered nurse coverage in that: The facility failed to ensure the Director of Nursing did not serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents preventing her from providing supervision and oversight of the staff for 6 of 30 days in September 2021. These failures placed residents at risk for not having their nursing and medical needs met. Finding include: Review of the average daily census of the facility from 07/14/21 to 10/03/21 reflected the average census of the facility was 65. Review of the facility's staff schedule dated September 2021 revealed the DON worked as a charge nurse for six out of 30 days. The average daily census for the facility during September was 65. In an interview on 10/06/21 at 9:30 AM the RNC stated he had been in his position for 3 years. The RNC stated the old DON would cover shifts on the floor if they were short. The RNC stated they started a recruiting and retention plan on 08/20/2021 that included HR posting positions on hiring sites and face book. The plan included the administrative nurses (ADON and DON) filling in and working the floor. The RNC stated that PCC would give the alerts to the administrative nurses when assessments were not being done. In an interview on 10/06/21 at 9:33 AM the DON stated she had been in her position for 3 weeks. She stated the facility has reached out to agencies and the facility has two contracts with staffing agencies, but they are never able to get anyone. She stated they were able to get a staff member once but then they called in. The DON stated she is aware of the staff storages but was not aware the skin assessments were not being done. She stated the ADON assist her with oversight on this, but she is working the floor most days. She stated PCC will give her clinical alerts when things are not being done but she has worked on the floor almost every day except for this week even working night shift and has not had time to do audits or check that assessments are being done. She stated she was absolutely not able to give 40 hours a week to the DON position or DON responsibilities. Review of the facility's Job Description for the Director of Nursing dated 2014 reflected .Accountable for nursing compliance, excellence, and delivery of resident care services in adherence with the Company, local, state and federal regulations .Mange nursing staff through appropriate hiring, training, evaluation, assignment and delegation of duties .Augment floor staffing if needed . Review and ensure proper resident charting and procedure documentation .Train and develop nursing staff to achieve positive resident outcome . The facility did not provide a policy regarding the DON working the floor when the census was over 60 residents prior to exit.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for three of six Residents (Resident #2, #52 and #46) reviewed for pressure ulcers wound care. A) The facility failed to ensure RN A followed standard precautions during wound care for Resident #2's Stage IV coccyx pressure ulcer and Stage IV's right and left ischial pressure ulcers when he failed to perform hand hygiene, gloves changes or proper wound cleansing. B) The facility failed to ensure the Treatment Nurse followed standard precautions during wound care for Resident #52 when she failed to perform proper wound cleansing and failed to perform hand hygiene after contamination of her gloves. C) The facility failed to ensure the Treatment Nurse followed standard precautions during wound care for Resident #46 when she failed to perform proper wound cleansing. These failures could place residents at risk for developing wound infections. Findings included: A) Review of Resident #2's face sheet dated 10/04/2021 revealed resident #2 was a [AGE] year-old male admitted to the facility 04/27/20 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's comprehensive care plan dated 08/09/21 revealed resident #2 to required care for an ostomy, treatment with an anticoagulant, wound care for stage 4 pressure ulcer to sacrum, require pain medication, an indwelling catheter and history of major infection. Review of resident #2's Quarterly MDS assessment dated [DATE] revealed resident #2 to have a BIMS score of 14, required two-person assist with bed mobility and transfer from bed to chair, had an indwelling catheter and [CONDITION(S)], stage IV pressure ulcer and required a prevention plan for reducing risk of pressure ulcers. Observationand interview on 10/04/21 at 11:00 AM revealed RN A in Resident #2's room to preform wound care. RN A already had the treatment field set up in room when surveyor arrived. RN A donned gloves outside at the treatment cart and entered the room. RN A did not perform hand hygiene prior to donning his gloves. RN A then removed the dressing from residents left inside knee Resident #2 stated the wound was from hardware from his knee replacement penetrating the skin and causing it to open. After removing the dressing RN A pushed around on the wound with his gloved hands and reached for the gauze from the table. With the same gloves RN A cleaned around the area, cleaning across the wound. RN A then reached for a spray bottle (skin prep spray) on his field and sprayed it on the gloves and applied it to the wound with his gloves. RN A then retrieved a dressing from the field and applied it to the wound. RN A with same gloves felt up and down Resident #2's leg then repositioned Resident #2 and removed his brief and turned him over (still wearing the same gloves) and removed the coccyx dressings to reveal a large Stage IV pressure ulcer to the coccyx and Stage IV pressure ulcers to his right and left ischial tuberosity. RN A without hand hygiene or a glove change cleaned the coccyx wound cleaning across the wound which was approximately 12 cm x 12 cm with .3 depth. RN A touched the wound all over with his gloves and cleaning with the gauze only certain areas of the wound. RN A then with same gloves began cleaning Resident #2's left and right ischial Stage IV pressure ulcers cleaning across the wounds and touching the wounds with is gloves (he did get a new gauze for each wound) he then applied hydrogel to the wounds with his gloves going from one wound to another. RN A then applied the collagen powder with his gloves patting it into the pressure ulcers going from one pressure ulcer to another. RN A with changing gloves or performing hand hygiene applied clean dressings to coccyx wound with the dressing reaching only to middle of pressure ulcer and with the tape being applied directly on the open pressure ulcer. RN A then applied a foam dressing to right ischial with the tape being on the coccyx pressure ulcer. RN A did the same with the left ischial pressure ulcer. RN A then stated he needed to get another brief, so he took off his gloves and without hand hygiene left room he came back in room with gloves on applied the brief to the resident. RN A then with the same gloves he took the spray bottle he used during treatment and put it in his left chest pocket of his scrubs, and he put the scissors that were on the overbed table with the treatment supplies in the side pants pocket of his scrubs without cleaning them. RN A then gathered the left-over treatment supplies and took them back to the treatment cart. In an interview on 10/04/21 at 3:21 PM RN A sated he was not trained in wound care and stated his training at the facility consisted of making rounds with treatment nurse. RN A stated he did not change his gloves or wash his hands throughout the procedure and did not clean his scissors before or after the procedure. RN A stated I should know better than that he stated he was not aware of the no touch technique for applying medication to wounds (the use of a sterile applicator). RN A stated he was not aware you could not remove treatment supplies from the room or that they were considered contaminated. RN A agreed he had touched the supplies with the gloves that he did not change during the entire wound care procedure. B) Review of Resident #52's face sheet dated 10/04/2021 revealed resident #52 was an [AGE] year-old female admitted to the facility 08/30/2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #52's care plan dated 09/20/2021 revealed resident #52 to require an indwelling catheter, history of surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #52's MDS assessment dated [DATE] revealed resident #52 had a BIMS score of 15, required two-person assist for bed mobility and transfer from bed to wheelchair, has an indwelling catheter and had a stage II pressure ulcer. Observation on 10/05/2021 at 8:41 AM of wound care for Resident # 52's coccyx pressure ulcer revealed the Treatment Nurse used her clean gloved hand to move the resident's adult brief out of the way, then cleaned the ulcer with gauze using the same gloved hand. She then pushed calcium alginate into the wound with the same gloved hand that touched the brief. Interview on 10/05/2021 at 2:55 PM with the Treatment Nurse stated I was trained to clean wounds from inside to out. She stated I don't remember touching the brief on (Resident # 52.) C) Review of Resident #46's Face Sheet reflected she is an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #46's Quarterly MDS dated [DATE] reflected she is rarely or never understood and was totally dependent on two-person physical assist for bed mobility (moving to and from a lying position, turning side to side and positioning body) and transfers. Review of Resident #46's Care plan dated 04/14/21 reflected The resident has potential for pressure ulcer development. Interventions: The resident needs assistance to turn/reposition at least every two hours. Observation on 10/05/2021 at 8:14 AM for wound care on Resident # 46's coccyx revealed the Treatment Nurse touched the resident's unclean bedding with her clean gloved hand and did not sanitize her hands or change gloves before she cleaned the wound. She used gauze to clean across the wound and dried all over, working from potentially contaminated areas of skin to the open wound. Interview on 10/05/2021 at 2:55 PM with the Treatment Nurse stated I was trained to clean wounds from inside to out. I didn't realize I touched bedding before touching the wound on (Resident # 46.) In an interview on 10/07/21 at 1:23 PM the RNC stated he expected staff to clean hands before donning gloves and before they start a treatment and when going from clean to dirty. When he was asked about going from wound to wound, he stated they should not do that. He stated no supplies should be removed from the room that cannot be sanitized and they should be sanitized. The RNC stated the remaining dressing supplies should have been disposed of. He stated there was no corporate policy regarding training staff for wound care other than the policy that was provided to surveyors. Review of the facility's policy Infection control Plan: Overview dated 2019 reflected The facility will establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Review of the facility's policy Skin and wound management dated 2021 reflected The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Steps in the Procedure Steps in the Procedure. 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. 7. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. 8. Pour liquid solutions directly on gauze sponges on their papers. 9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. 10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. 11. Place one (1) gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water .16. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly.

Based on observation, interview and record review the facility failed to ensure all drugs and biological medications were not past their expiration dates for two of three medication carts reviewed and one of one wound care carts reviewed and failed to ensure potential contaminants were kept off of the medication carts for 2 of 3 medication carts reviewed. The facility failed to ensure expired medications were removed from the carts and failed to ensure potential contaminants including loose pills, debris, and personal items were not on the carts. This failure could place residents at risk of not receiving the intended therapeutic benefits of their medications A) Observation on 10/03/2021 at 2:33 PM of the Nurses' med cart located on Hall A revealed Pro-Stat Sugar-free liquid supplement with no date on the bottle to indicate when it was opened. The bottle instructions state Discard 3 months after opening, Record date opened on bottom of container. Interview on 10/03/2021 at 2:42 PM with LVN Q who stated (Pro Stat Sugar-free) is supposed to be dated when it's opened. Potentially it could lose potency and effectiveness. It could spoil and be contaminated. Observation on 10/03/2021 at 2:48 PM of the Nurses wound care cart on Hall B revealed [MEDICATION(S)] with an expiration date of 9/2021 and [MEDICATION(S)] Cream 1% for a resident no longer in the facility. Interview on 10/03/2021 at 2:50 PM with LVN R who stated the [MEDICATION(S)] should be off the cart. That resident had her funeral last week. Observation on 10/03/2021 at 2:59 PM of the med cart for Hall B revealed four packets of Vitamin A and D ointment with expiration dates of 6/2021 and [MEDICATION(S)] [MEDICATION(S)] 10% with an expiration date of 01/03/2021. Interview on 10/03/2021 at 3:05 PM with LVN R who was asked if the Vitamin A and D ointment and [MEDICATION(S)] [MEDICATION(S)] with the expired dates should be discarded, she stated Oh yes. Interview on 10/04/2021 at 10:00 AM with the RNC who when asked if outdated meds should be on the cart stated, No, there shouldn't be any. Those should be pulled off. The Pro Stat is supposed to be dated. We should be following manufacturer's instructions. Interview on 10/04/2021 at 4:13 PM with the DON who stated I expect anything outdated not to be on the carts. The ADON goes through the med carts and does med audits. In an interview on 10/06/21 at 9:33 AM the DON stated she had been in her position for 3 weeks. She stated the ADON assists her with oversight on this. She has worked on the floor almost every day except for this week even working night shift and has not had time to do audits. She stated she was not able to give 40 hours a week to the DON position or DON responsibilities. Interview on 10/04/2021 at 10:12 AM with the ADON who stated The expired meds could lose potency and not be effective. There could be an adverse reaction from expired medications. B) Observation and interview on 10/03/2021 at 2:36 PM of the Nurses' med cart for A Hall revealed four white pills and other debris in the bottom left drawer. LVN Q could not identify the pills and stated, they shouldn't be there. Observation on 10/03/2021 at 3:19 PM of the Med Cart for Hall C revealed a cup of ice in a Styrofoam cup, four pieces of candy and a hairbrush inside the cart. Interview on 10/03/2021 at 3:22 PM with LVN S who when asked if the cup of ice, candies and hairbrush should be in the med cart, stated Not with the meds. Interview on 10/04/2021 at 10:12 AM with the ADON who when asked about the four white pills and debris found in the bottom of the med cart on Hall A, stated The nurses sometimes pop pills and lose them. They drop into the bottom of the cart. They're supposed to clean the carts. There should be no loose medications. Interview on 10/04/2021 at 4:13 PM with the DON indicated there should be no food on the carts, no personal drinks and nothing hygiene related should be on there either. Interview on 10/04/2021 at 4:20 PM with the RNC who was asked for any policies regarding protocol for keeping the medication carts free of contaminants but none was provided. Review of the facility Recommended Medication Storage policy from the Pharmacy Policy and Procedure Manual revised 7/2021 and provided by the facility ADON reflected Medications that require an open date as directed by the manufacturer should be dated when opened, in a manner that is clear when the medication was opened. The document included a list of medications that require a date when opened and stated, the list is not all inclusive and the manufacturers recommendations will supersede this list.

Based on observation, record review and interviews, it was determined the facility failed to ensure the facility remained free of accidents as possible for one of eight residents (Resident #1) and have proper operation of one of four exit doors with alarms. A. The facility failed to ensure Resident #1's care plan was followed during a transfer from her bed to her wheelchair. Resident #1's care plan reflected she was a two person assist with transfers and CNA C transferred her without assistance. The resident sustained a spiral fracture to her left femur (thigh bone) during the transfer. B. A door leading to the outside from the dining room was left unmonitored and the alarm deactivated. These failures placed residents at risk for decline in health status, injuries, and hospitalization , and exiting the building without alerting the facility which could result in an injury, heat exhaustion, elopement and/ or significant change in condition. Findings included: A. Review of Resident #1's electronic Face Sheet, reviewed on 6/4/2021 at 10:00 AM reflected she was a [AGE] year old female initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Unsteadiness on feet, Muscle Weakness, Muscle Wasting and Atrophy, not elsewhere classified, multiple sites, Contracture of muscle, left shoulder and left hand, [CONDITION(S)] and [CONDITION(S)] following other [CONDITION(S)] Disease Affecting left Dominant Side. Review of Resident #1's Quarterly MDS assessment, dated 09/07/2020, reflected Resident #1 had a BIMS score of 3 which indicated her cognition was severely impaired. The MDS reflected Resident #1 was assessed to require extensive assistance with two plus person physical assist with transfers and bed mobility. Review of Resident #1's Comprehensive Care Plan, dated 7/23/2020, reflected Resident #1 had Diagnoses of [CONDITION(S)] (Stroke) r/t left side weakness/ hemi left hand contracture. PT/ OT to evaluate and treat as necessary. Resident was at risk for falls. PT evaluate and treat as ordered or PRN. Staff times two to assist with transfers. Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove of any potential causes if possible. Educate resident/ family / caregivers/ IDT as to causes. Resident had an ADL Self Care Performance Deficit r/t CVA. Transfer: The resident had required (2) staff participation with transfers. Review of Resident #1's Nurses Notes, dated 9/30/2020 at 2:27 PM, reflected Resident #1 complained of left knee pain during therapy. Resident #1 was assessed for swelling, bruising and redness. Resident #1 stated she was dropped during a transfer and her knee hurt. The MD was notified of the incident and an x-ray was ordered. The x-ray results reflected the resident had a distal fracture. Resident #1 to be transferred to hospital via Emergency Medical Services. Review of Resident #1's Facility Investigation Report, dated 9/30/2020 reflected Resident #1 reported pain to her left knee. An x-ray was ordered, and the results reflected a left femoral spiral (caused by a twisting force) fracture. Resident #1 reported that during a transfer from her bed to her wheelchair CNA C dropped her. She reported CNA C had her hands on her the entire time during the transfer and that she did assist her to the floor. The Kardex reflected Resident #1 was a two person assist with transfers. CNA C was suspended pending an investigation. CNA C reported to the Administrator that Resident #1 was a one person assist. She stated PT had informed CNA C Resident #1 was safely a one-person transfer. Review of Resident # 1's Nurses Notes, dated 10/01/2020, reflected Resident #1 was admitted to the hospital. Resident #1 had diagnosis of a left femur spiral fracture and surgery scheduled for 10/01/2020. In an interview on 6/4/2021 at 9:12 AM Resident #1 stated, I did fall before Thanksgiving [2020]. A girl who works here was trying to help me to my chair and I fell . It felt like I was dropped. I was in bed when she tried to help me to my wheelchair. In an interview on 6/4/2021 at 10:50 AM CNA D stated residents care including ADLs was in the Kardex. CNA D stated she had been inserviced regarding using the Kardex. In an interview 6/4/2021 at 11:02 AM CNA C stated at the time of the incident in September or October of last year (2020) Resident #1 was a one person assist as stated by a therapist who was no longer an employee at this facility. She stated she did not remember who told her. CNA C stated that transfer information was not on the Kardex the day of the incident. She stated she did not speak with the nurse about how many staff were required to assist Resident #1 of any other residents. She stated Resident #1 was later changed to a two person assist sometime last year after the incident. She stated she did not remember who told her Resident #1 was changed to a two person assist. She stated she knew the residents and the care they needed. She stated she did not always look at the Kardex or talk to nurses about resident's care. When asked how she knew the Kardex reflected Resident #1 was a one person transfer on the day of the incident, she did not respond. CNA C stated on the day of the incident she used the gait belt under Resident #1 breasts, and she grabbed both sides of the gait belt. She stated the resident told her she was falling when she was assisting her from bed to wheelchair. CNA C stated she assisted her to the floor and left the room to get help. She stated she did not do anything else when assisting the resident to the wheelchair. She reported to the nurse Resident #1 was assisted to the floor during transfer and the nurse came to the room and assessed resident. When asked which nurse the incident was reported to she stated she did not know. In an interview on 6/4/2021 at 11:15 AM LVN E stated the CNAs looked at the Kardex in the computer system and followed the guidance on the Kardex system for each residents' care. LVN E stated she was not aware of any therapy staff informing any staff what type of assistance a resident required. She stated the residents' care was documented on the care plan and that was transferred to the Kardex and that is what the nursing staff were to follow. She stated if therapy staff wanted to change anything with a residents' care, they would need to change it on the care plan for it to reflect on the Kardex. LVN E stated Resident #1's documentation (care plan) indicated she was a two person assist when the incident occurred in September (2020) when CNA C was transferring her. In an interview on 6/4/2021 at 12:10 PM the PT Assistant stated Resident #1 was assessed to be one person assist by the therapy department in September 2020. She stated she was not aware of the information on the nursing home care plans completed by the MDS staff or how each CNA received information on what type of care each resident required. She stated she did not recall sharing information about Resident #1's transfer needs with the MDS nurses. She stated if this had of occurred, the MDS nurses probably would have made changes on the care plan. In an interview on 6/4/2021 at 1:05 PM CNA F stated the nursing staff had been trained to look at the Kardex in the computer before giving care to a resident. CNA F stated the Kardex had everything on it about all ADL's including transfers. CNA F stated no one from the therapy department had ever came to her personally to share what type of care a resident needed but if they did, she would go to her supervisor for guidance. CNA F stated she had been trained to follow what the nurse told her about residents' care and what was on the Kardex. She stated she could not recall if she gave care to Resident #1 in September of 2020. In an interview on 6/4/2021 at 1:30 PM RN G stated all CNAs were to follow the Kardex on the computer system. She stated if they have any questions about what is documented on the Kardex, they are to report to the nursing supervisor. RN G stated the Kardex informed the CNAs of all the assistance and care each resident needed and required. RN G stated that was the most accurate information available to the CNAs. She also stated the information on the Kardex was from each residents care plan. She stated she could not recall if she gave care to Resident #1 on the day of Resident #1's fall in September 2020. In an interview on 6/4/2021 at 2:05 PM the MDS Nurse H stated Resident #1's care plan that was in place on 9/30/2020 would have been the care plan reviewed on 7/23/2020. There were no revisions to the care plan prior to the incident. MDS Nurse H stated the care plan indicated Resident #1 was a two person assist with transfers. MDS Nurse H stated no one from therapy department had consulted with her about Resident #1's therapy assessment being a one person assist. She stated the Kardex for the CNAs to follow was populated from the care plan. She stated Resident #1's care plan indicated transfers were two person assist. She stated, facility protocol was to discuss any resident changes in the morning meeting or in the care plan meeting and revisions would be made to a resident's care plan if needed. Therapy staff did attend care plans at times and were in the morning meetings. In an interview on 6/4/2021 at 2:30 PM the Administrator stated any staff assistance related to transfers should have been care planned and revised as changes occurred. Administrator stated usually the therapist assigned to the resident or the Director of Therapy Department should have informed the IDT in stand-up meetings of any changes for it to be care planned. She stated the CNAs were to follow the Kardex in the computer system and it was in the investigation report that the Kardex reviewed the date of the incident on 9/30/2020 was a two person assist. She stated she was not able to print the Kardex. She stated she had called corporate and they unable to print Kardex for that date. The Administrator stated she did review the care plan and it was on the care plan Resident #1 was a two person assist at time of the incident. She stated during the investigation, CNA C reported a therapist told her Resident #1 was a one person assist on the day of the incident. The ADM stated if this information was shared during care plan meeting or during the morning meeting with all the disciplines including therapy and MDS, she would have expected Resident #1's care plan to be revised. She stated therapy staff were expected to attend care plan meetings for the residents receiving any type of therapy. An interview was attempted on 6/4/2021 at 4:15 PM Resident #1's PCP. A message was left but the PCP did not return the call. Record Review of Facility Policy on Comprehensive Care Planning (Undated) reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical , nursing , and mental and psychosocial needs that are identified in the comprehensive assessment. Interventions are the specific care and services that will be implemented. Interdisciplinary means that professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/ or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident in response to current interventions. B. Observation on 6/03/2021 at 10:55 AM revealed the alarm on one of the two exit doors near C hall nurses' desk and near the food supply storage room off of the dining room was not activated. When door was opened, the alarm wasn't activated as there was no sound due to opening. The door led to a side walk, a ramp and an additional sidewalk. There is an area with uneven rocks then the employee parking lot. In an interview on 6/03/2021 at 11:02 AM The Administrator stated the dietary staff had turned the alarm off to bring in boxes of food from outside. She stated the dietary staff would be outside and could see if any residents exited from the door. She stated there were a few Residents who would seek exit at this door. Observation on 6/03/2021 at 11:05 AM revealed there weren't any boxes of food or any dietary staff outside C hall door near the food storage supply room. Observation on 6/3/2021 at 11:10 AM revealed Dietary Staff A was in the locked food supply storage unit unable to observe the door or hear the alarm sounding. He was unable to see the exit door from the locked food supply storage room. Observation on 6/3/2021 at 1:30 PM revealed residents around the area of the door near the locked food supply storage room and nurses desk. In an interview on 6/3/2021 at 11:15 AM the Administrator stated Dietary Staff A was not in view of the exit door and the alarm was not activated. The Administrator stated Dietary Staff A was required to turn the alarm on with his key after all the food had been carried into the food supply room. In an interview on 6/3/2021 at 12:50 PM Dietary staff A stated he always turned the alarm off when he would go out that door (beside the food supply storage room). He stated he didn't report to any staff the door alarm would not be on and he probably needed to report to someone when the alarm isn't on. He stated he wouldn't be near the door to monitor. He stated someone else would need to watch the door. In an interview on 6/3/2021 at 2:40 PM The Administrator stated the Door Alarm Check policy wasn't being followed by any staff. She stated she did not know that their policy required daily alarm checks. She stated no one was testing door alarms daily and there was not any documentation of alarms being tested . She stated there was a possibility an alarm could malfunction. Administrator reviewed the Door Alarm policy and did not know the meaning of AON@ position only written in the policy. The Administrator stated she talked to Maintenance Supervisor and he stated there wasn't any records of daily alarm checks. Facility Policy of Door Alarm Checks dated 2003 reflected: 1. All door alarms will be tested daily for proper operation. Written documentation will be maintained for all checks. The Maintenance Supervisor will be responsible for ensuring that the daily checks have been completed. 2. All door alarms will be left in the AON @ position only. 3. Any problems and corrections will be noted on the daily log. All logs will have the name of the person completing the test, the date of the test, the time of the test, the location of the alarm tested , and the signature of the person completing the testing. If there are problems with the operation of the door alarm system that cannot be repaired immediately, notify the Administrator and make provisions for repairs as soon as possible.

Based on interview, observation and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection during lunch service on three (3) of four (4) halls and two (2) of three (3) dining rooms and three (3) staff observed not wearing masks. A. LVN A, Restorative Aide B, CNA C, CNA D, CNA E failed to sanitize residents' hands (4 Residents on hall C, 1 Resident in the A Hall dining room, 4 Residents in the Secured Unit dining room, 3 Residents on Hall A, 5 Residents on Hall B) prior to eating lunch. B. Cook F, LVN A and CNA C failed to wear masks near Residents and other staff according to CDC guidelines. This failure could place all residents at risk for transmission of infectious diseases. Findings included: A. An observation on 04/13/2020 from 12:00 PM through 12:45 PM revealed four (4) Residents on C Hall (Resident #1, Resident # 2, Resident #3, and Resident # 4), one (1) resident in A hall dining room (Resident #5), four (4) residents in dining room on secured unit (Resident #6, Resident #7, Resident #8 and Resident #9), three (3) residents on A Hall (Resident #10, Resident #11, and Resident #12) and five (5) residents on B Hall (Resident #13, Resident #14, Resident #15, Resident #16 and Resident #17) were served their lunch without staff sanitizing residents' hands. In an interview on 04/13/2020 at 12:15 PM Resident #1 and Resident #2 stated, staff didn't wash their hands or ask if their hands had been washed before they gave them their tray. In an interview on 04/13/2020 at 12:32 PM Resident #5 stated I haven't washed my hands since this morning before breakfast. No one has asked me about washing hands. In an interview on 04/13/2020 at 12:45 PM Resident #10 stated, I need to wash my hands. The workers didn't ask if I needed to wash my hands before I ate. They brought my tray and I began to eat in a hurry. I was hungry. In an interview on 04/13/2020 at 1:00 PM CNA E stated, We are to wash Residents' hands before meals and I forgot. I didn't see anyone wash Residents' hands during lunch or before trays were on the hall. In an interview on 04/13/2020 at 1:15 PM Restorative Aide B stated, I didn't wash Residents' hands in the dining room (on A Hall). We are to wash Residents' hands when needed and before meals. In an interview on 04/13/2020 at 1:25 PM CNA C stated, Residents' hands were not washed before lunch. I forgot to wash their hands. In an interview on 04/13/2020 at 1:40 PM LVN A stated I don't know if Residents' hands had been washed prior to lunch. I didn't wash Residents' hands today. In an interview on 04/13/2020 at 3:30 PM the Administrator stated Residents hands are to be washed prior to all meals. In an interview on 04/13/2020 at 3:45 PM The Director of Nurses stated Staff are required to wash Residents hands before meals. B. An observation on 04/13/2020 at 9:50 AM revealed CNA C was not wearing a mask in the dining room on secured unit. There were six (6) residents in dining room. An observation on 04/13/2020 at 10:10 AM revealed Cook F standing beside a nurse near the C Hall nurses desk without wearing a mask. An observation on 04/13/2020 at 11:20 AM revealed LVN A not wearing a mask according to CDC guidelines. LVN A was standing at the medication cart near C Hall nurses desk with a mask around her neck. In an interview on 04/13/2020 at 9:52 AM CNA C stated, I am to wear a mask in the facility and I did take my mask off in the dining room. We have been inserviced on everything about the mask. In an interview on 04/13/2020 at 10:15 AM the Patient Care Coordinator G stated Staff is to wear mask when in facility. All departments have been inserviced on the proper way to wear the mask by CDC guidelines and to wear it at all times when in the facility. In an interview on 04/13/2020 at 11:22 AM LVN A stated, I did pull my mask down off my face. I have been inserviced on how to wear mask and have it on when in the facility. In an interview on 04/13/2020 at 3:30 PM The Administrator stated, All staff has been inserviced to wear mask in the facility. In an interview on 04/13/2020 at 3:45 PM The Director of Nurses stated, Staff are required to wear a mask. Review of CDC guidelines dated 4/13/20 and titled Key Strategies to Prepare for COVID-19 in Long Term Care Facilties (LTCFs): reflected the following: Ensure all HCP wear a facemask or cloth face covering for source control while in the facility. Cloth face coverings are not considered personal protective equipment (PPE) because their capability to protect healthcare personnel (HCP) is unknown. Cloth face coverings should NOT be worn instead of a respirator or facemask if more than source control is required. Review of facility policy Infection Control Guidelines reflected handwashing before and after eating. Review of the facility policy letter regarding mask use sent from Corporate Office on 04/02/2020 reflected Effective immediately until further notice we are asking all staff to wear a mask that covers their mouth and nose while at work.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled with cautionary instructions or the expiration date for two vials of opened Purified Protein [MEDICATION NAME] derivative. The B hall refrigerator had an opened multi-use vial of Purified Protein [MEDICATION NAME] derivative that was not labeled with an expiration date. The A hall refrigerator had an opened multi-use vial of Purified Protein [MEDICATION NAME] derivative with an opened date of (MONTH) 2019 and no expiration date. This failure to label medications with the expiration date led to the opened medications remaining available for use which could have led to a failure of the derivative to identify a staff or resident that may have had a positive [MEDICAL CONDITION] reaction. Findings included; Observation on 08/28/2019 at 2:15 PM revealed the Hall B medication refrigerator had an opened multiuse vial of Purified Protein [MEDICATION NAME] derivative that was not dated when it was opened. In an interview on 08/28/19 at 2:15 PM LVN S stated the [MEDICATION NAME] derivative should have been dated when it was opened. Observation on 08/28/19 at 02:37 PM revealed LVN T stated the [MEDICATION NAME] derivative should have been dated when it was opened. In an interview on 08/28/19 at 3:000 PM the DON stated the [MEDICATION NAME] derivative should have been dated when it was opened and it should have been disposed of 30 days after it was opened. Review of the website: https://www.fda.gov/media/ /download on 08/30/2019 reflected: STORAGE A vial of [MEDICATION NAME] (purified protein derivative) which has been entered and in use for 30 days should be discarded. Do not use after expiration date.

Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (1) of five (5) residents reviewed for accidents and hazards. (Resident #1). Certified Nurse Assistant (CNA) A failed to utilize a gait belt (belt placed around the waist to enable transfers) to conduct a transfer of Resident #1. As a result of the unsafe transfer, Resident #1 sustained a broken left humerus. This failure led to the injury to one resident and had the potential to harm 22 residents that relied on assistance for transfers. Findings Include: Review of Resident #1's Face Sheet reflected a birthdate of 10/10/1950 with the following diagnoses' Unspecified Fracture of First Lumbar Vertebra, Sequela (admitting [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Minimum Data Set (MDS) assessment dated [DATE] reflected a BIMS (Brief Interview for Mental Status) score of three (3) indicating severe cognitive impairment. The assessment also reflected a functional status for transfers at a three (3) indicating assistance with two (2) or more individuals required. Review of Resident #1's Care Plan dated 02/10/2015 reflected The Resident has an ADL Self Care Performance Deficit. The intervention/tasks for transfers reflected the resident required extensive assist of one (1) to two (2) persons with transfers. Review of Resident #1's Medication Administration Record [REDACTED]. Review of a facility generated incident report dated 11/26/17 reflected a statement from the Administrator: On Monday, (MONTH) 27, (YEAR) (Resident #1) stated that on Sunday (MONTH) 26, (YEAR), during a transfer, a CNA grabbed him from behind his arms and he felt a pop. He also stated the CNA wasn't using a gait belt at that time. Review of the facility's (S-BAR) Situation, Background, Assessment, and Recommendation report dated 11/26/17 reflected Resident having pain to the left shoulder at this time. Will request order for XRAY. Review of Resident #1's X-ray report dated 11/26/2017 reflected: Findings: There is acute displaced fracture involving the proximal humorous probably at the region of the surgical neck. In an interview on 12/12/2017 at 11:33AM CNA A stated The Sunday after Thanksgiving I was laying him (Resident #1) down and he complained about his arm. The CNA further stated he always complains about his arm. The CNA stated she was making her last round when she asked Resident #1 if he wanted to lay down and the resident responded yes. She took the resident to his room and laid him down. She stated she had chicken winged (a high risk transfer method in which the caregiver assists the resident by placing his/her arms underneath the resident's armpits and lifting.) the resident during the transfer and did not use a gait belt. She stated I take fault for the incident because I was supposed to use the gait belt. She then stated LVN A assessed the resident who stated he wasn't in pain. Then the facility told her to go home because her shift was over. The following day CNA A was informed of Resident #1's injury and suspended pending an internal investigation. When CNA A returned from her suspension she was educated by the physical therapy department on transferring correctly. In an interview on 12/12/2017 at 1:48 PM Resident #1 stated the facility staff used a gait belt sometimes and they hurt him a lot during the transfer with no gait belt. The resident further stated his left arm was in a lot of pain from the injury and there was also pain on his left side. In an interview on 12/12/2017 at 2:31 PM the Director of Nursing (DON) stated he did morning rounds three times per day to monitor the use of gait belts. He further stated he didn't know how staff were not using the gait belt. The DON further stated the therapy department had reevaluated Resident #1 and he was still a one person transfer so the care plan wasn't updated. He stated he was not aware she (the CNA that transferred the resident) was not using the gait belt at the time of the incident. Review of policy Moving a Resident, Bed to Chair/ Chair to Bed dated 2003 reflected: Purpose: The purposes of this procedure are to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident. If moving resident from bed to chair: h. Position a gait belt around the resident's waist and clasp it. If moving a resident from chair to bed: h. Support the resident by placing a gait belt around the resident's waist for you to hold and steady the resident. The facility's Administrator provided a CMS Form 672 reflecting 22 residents that required physical and or equipment assistance for transfers.

Based on interview and record review the facility failed to implement their written abuse/neglect policies and procedures that prohibit neglect for one (1) of six (6) residents (Resident #1) reviewed for neglect. CNA I failed to request assistance from another staff member when Resident #1 became resistant to perineal care. CNA I forced Resident #1 ' s legs open in an attempt to access the residents perineal area thus causing an acute angulated mid femoral shaft [MEDICAL CONDITION] leg. This deficient practice caused injury to one (1) resident and placed 60 residents requiring perineal care at risk for injury. Findings included: Review of the facility Abuse and Neglect Policy and Procedures dated 01/08/03 reflected: " Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently. The facility will provide the residents, families and staff an environment free from abuse and neglect. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and or Task 5G coordinator within 24 hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator and per policy. " Review of Resident #1 ' s Face Sheet reflected an [AGE] year old female admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Plan of Care dated 04/03/14 reflected: " Resident is incontinent of bowel and bladder due [MEDICAL CONDITION]. Interventions included: Provide incontinent care every two (2) hours and as needed. Provide briefs as needed. Review of Resident #1's Plan of Care dated 10/22/13 reflected: "Resident is resistive to care r/t (related to) Dementia. Resident refuses to let staff remove dentures to clean them." Interventions listed included: "If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again." In an interview on 04/16/14 at 11:28 PM the Director of Nursing (DON) stated she had received a call on 04/11/14 that CNA I had been attempting to provide perineal care for Resident #1. During the care, the resident was combative and would not freely allow the CNA to part her legs to provide the care. At some point during the process the CNA heard a " pop " . The charge nurse was notified. The charge nurse assessed the resident ' s physical status and noticed swelling of the femoral area of the right leg. The charge nurse then notified the resident ' s physician and the physician ordered an x-ray. The DON initiated an investigation and suspended CNA I pending results of the investigation. The DON also called CNA I requesting an interview but the CNA refused to come in for the interview. The DON also stated that a staff member should obtain assistance from another staff member when attempting to treat a combative resident. Review of Resident #1 ' s Nurse ' s Notes dated 04/11/14 reflected : " Reported to this nurse by (CNA I) while CNA was adm (sic) incontinence care Resident was hitting at CNA, acting resistant towards care while CNA was opening resident ' s legs for incontinence care CNA heard a " pop " sound and resident started complaining of pain to right leg. Upon assessment, right mid-femur noted with swelling. Zero discoloration or warm to touch. Resident complained of severe pain during movement. MD (Medical Doctor) notified. Received new orders of x-ray of right hip, right femur and right knee. Administer [MEDICATION NAME] 5/325 milligrams 1 tab PO Q6 hours PRN Pain (1 tab every 6 hours as needed for pain). Attempted to notify responsible party. No answer. Voicemail left. Mobile imaging notified of new orders for x-rays. Pharmacy faxed new order. MAR (Medication Administration Record) updated. (Resident #1's) son also notified. Review of an incident report dated 04/11/14 reflected: " On Friday 4/11/14 at 5:20 AM (CNA I) was in the room with (Resident #1) providing routine peri care. Resident became combative and was hitting and slapping CNA (CNA I). CNA continued with peri care until she heard a pop while attempting to open the patient ' s legs. CNA reported to charge nurse and charge nurse assessed resident. Resident complained of pain to right leg. Right mid femur swelling was noted and no skin discoloration or warmth to touch was noted. MD (Medical Doctor) notified and new orders were received for X-rays and pain medication. Final X-ray was read at 1:01 PM revealing Acute Angulated Mid Femoral Shaft Fracture. Patient transferred to ER for further evaluation and treatment. " Review of a written statement signed by CNA I on 04/11/14 reflected: " I was change (Resident #1) at 5:20 AM. She was fight and hit, slap at me so I was change her try to tell her to stop so I try to change her and open her legs and hear some pop. Then left the room to get the charge nurse. After get the nurse she was still fight and hit. (Sic). " Review of Resident #1 ' s x-ray results dated 04/11/14 reflected: " An acute angulated [MEDICAL CONDITION] aspect of the femoral prosthesis. " Review of Resident #1 ' s Physician order [REDACTED]. " Review of Resident #1 ' s Hospital History and Physical Report assessment dated [DATE] reflected: " The right lower extremity is shortened and externally rotated. There is swelling in the mid-thigh region. X-rays reveal a spiral [MEDICAL CONDITION]-shaft of the right femur at the distal portion of the stem of the [MEDICAL CONDITION] prosthesis. " Further review of Resident #1 ' s Hospital History and Physical Care Plan reflected: She will require open reduction internal fixation of the right femur. The patient is very osteoporotic. We will plan on using plates for the femoral shaft fracture both anteriorly and laterally. Potential risks with the condition of surgery include but are not limited to infection, bleeding, pain, damage to blood vessels or nerves, nonunion, malunion. The patient may require additional surgery [MEDICAL CONDITION] and PE formation. " Review of the facility's " In-Service on Prevention of Injuries " dated 04/07/14 reflected: " When you handle a resident, do so in a gentle fashion. Make sure you do not pull or push on a resident. Use proper help/equipment when caring for a resident. " CNA I failed to respond to three separate attempts for interview via telephone calls made to her home telephone number on 04/16/14 at 9:10 AM and 04/17/14 at 12:08 PM and 1:09 PN. Messages were left on the CNA's answering machine on all three occasions with no response received as of 5:00 PM 04/17/14. The DON provided a list of 60 residents identified as requiring assistance with perineal care.

Based on observation, interview, and record review the facility failed to implement policies and procedures that prohibit neglect for one (1) of six (6) residents reviewed for perineal care. (Resident #1). Certified Nursing Assistant (CNA) I failed to request assistance from another staff member when Resident #1 became resistant to perineal care. CNA I forced Resident #1 ' s legs open in an attempt to access the residents perineal area for care, thus causing an acute angulated mid femoral shaft [MEDICAL CONDITION] leg. The resident will require an Open Reduction Internal Fixation of the right leg. This deficient practice caused injury to one (1) resident and placed 60 residents requiring perineal care at risk for injury. Findings included: Review of Resident #1 ' s Face Sheet reflected an [AGE] year old female admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Plan of Care dated 04/03/14 reflected: " Resident is incontinent of bowel and bladder due [MEDICAL CONDITION]. Interventions included: Provide incontinent care every two (2) hours and as needed. Provide briefs as needed. Review of Resident #1's Plan of Care dated 10/22/13 reflected: "Resident is resistive to care r/t (related to) Dementia. Resident refuses to let staff remove dentures to clean them." Interventions listed included: "If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again." In an interview on 04/16/14 at 11:28 PM the Director of Nursing (DON) stated she had received a call on 04/11/14 that CNA I had been attempting to provide perineal care for Resident #1. During the care, the resident was combative and would not freely allow the CNA to part her legs to provide the care. At some point during the process the CNA heard a " pop " . The charge nurse was notified. The charge nurse assessed the resident ' s physical status and noticed swelling of the femoral area of the right leg. The charge nurse then notified the resident ' s physician and the physician ordered an x-ray. The DON initiated an investigation and suspended CNA I pending results of the investigation. The DON also called CNA I requesting an interview but the CNA refused to come in for the interview. The DON also stated that a staff member should obtain assistance from another staff member when attempting to treat a combative resident. Review of Resident #1 ' s Nurse ' s Notes dated 04/11/14 reflected : " Reported to this nurse by (CNA I) while CNA was adm (sic) incontinence care Resident was hitting at CNA, acting resistant towards care while CNA was opening resident ' s legs for incontinence care CNA heard a " pop " sound and resident started complaining of pain to right leg. Upon assessment, right mid-femur noted with swelling. Zero discoloration or warm to touch. Resident complained of severe pain during movement. MD (Medical Doctor) notified. Received new orders of x-ray of right hip, right femur and right knee. Administer [MEDICATION NAME] 5/325 milligrams 1 tab PO Q6 hours PRN Pain (1 tab every 6 hours as needed for pain). Attempted to notify responsible party. No answer. Voicemail left. Mobile imaging notified of new orders for x-rays. Pharmacy faxed new order. MAR (Medication Administration Record) updated. (Resident #1's) son also notified. Review of an incident report dated 04/11/14 reflected: " On Friday 4/11/14 at 5:20 AM (CNA I) was in the room with (Resident #1) providing routine peri care. Resident became combative and was hitting and slapping CNA (CNA I). CNA continued with peri care until she heard a pop while attempting to open the patient ' s legs. CNA reported to charge nurse and charge nurse assessed resident. Resident complained of pain to right leg. Right mid femur swelling was noted and no skin discoloration or warmth to touch was noted. MD (Medical Doctor) notified and new orders were received for X-rays and pain medication. Final X-ray was read at 1:01 PM revealing Acute Angulated Mid Femoral Shaft Fracture. Patient transferred to ER for further evaluation and treatment. " Review of a written statement signed by CNA I on 04/11/14 reflected: " I was change (Resident #1) at 5:20 AM. She was fight and hit, slap at me so I was change her try to tell her to stop so I try to change her and open her legs and hear some pop. Then left the room to get the charge nurse. After get the nurse she was still fight and hit. (Sic). " Review of Resident #1 ' s x-ray results dated 04/11/14 reflected: " An acute angulated [MEDICAL CONDITION] aspect of the femoral prosthesis. " Review of Resident #1 ' s Physician order [REDACTED]. " Review of Resident #1 ' s Hospital History and Physical Report assessment dated [DATE] reflected: " The right lower extremity is shortened and externally rotated. There is swelling in the mid-thigh region. X-rays reveal a spiral [MEDICAL CONDITION]-shaft of the right femur at the distal portion of the stem of the [MEDICAL CONDITION] prosthesis. " Further review of Resident #1 ' s Hospital History and Physical Care Plan reflected: She will require open reduction internal fixation of the right femur. The patient is very osteoporotic. We will plan on using plates for the femoral shaft fracture both anteriorly and laterally. Potential risks with the condition of surgery include but are not limited to infection, bleeding, pain, damage to blood vessels or nerves, nonunion, malunion. The patient may require additional surgery [MEDICAL CONDITION] and PE formation. " Review of the facility's " In-Service on Prevention of Injuries " dated 04/07/14 reflected: " When you handle a resident, do so in a gentle fashion. Make sure you do not pull or push on a resident. Use proper help/equipment when caring for a resident. " CNA I failed to respond to three separate attempts for interview via telephone calls made to her home telephone number on 04/16/14 at 9:10 AM and 04/17/14 at 12:08 PM and 1:09 PN. Messages were left on the CNA's answering machine on all three occasions with no response received as of 5:00 PM 04/17/14. Review of the facility Abuse and Neglect Policy and Procedures dated 01/08/03 reflected: " Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently. The facility will provide the residents, families and staff an environment free from abuse and neglect. The DON provided a list of 60 residents identified as requiring assistance with perineal care.