Every finding on record at Maison de Lafayette

Based on interviews and record reviews, the facility failed to follow physician orders to obtain daily weights for residents with diagnoses that included congestive heart failure and fluid overload for 2 (Resident #2, Resident #3) of 2 residents in the facility ordered daily weights in a sample of 3 residents. This deficient practice was evidenced by 33 undocumented daily weights for Resident #2 and no documented daily weights on two consecutive weekends for Resident #3.Findings: Review of the facility's policy titled, Weighing and Measuring the Resident, with a revision date of March 2011, read in part: Purpose: The purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident.Reporting: 1. Report significant weight loss/weight gain to the nurse supervisor.4. Report other information in accordance with facility policy and professional standards of practice. Resident #2 Review of Resident #2's EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, essential hypertension, acute on chronic combined systolic and diastolic heart failure, and fluid overload. Review of Resident #2's plan of care initiated on 12/01/2023 revealed the following in part: I am at risk for impaired cardiac output and impaired cardiovascular circulation r/t (related to) CAD (coronary artery disease), CHF (congestive heart failure ), HTN (hypertension), HLD (hyperlipidemia), FVO (fluid volume overload), anemia, VHD (vascular heart disease), CAS, A-FIB (atrial fibrillation), A-flutter, first degree heart block.Interventions included in part, weights as ordered. Review of Resident #2's progress notes revealed the following in part: -08/14/2025 13:30 (1:30 p.m.) - S6LPN (Licensed Practical Nurse wrote: NON (New Orders Noted) per S4Cardiologist. Daily weights. Call with weight gain of 2-3#in one day and/or 5# in one week. Call with any HF (heart failure) symptoms. Ok for additional Lasix 20 mg (milligrams) PRN (as needed) qday (every day) for weight gain.-11/17/2025 16:13 (4:13 p.m.)- S2ADON wrote: New order S4Cardiologist. Daily weight dx (diagnosis): CHF. Review of Resident #2's physician's orders revealed the following: -order by S4Cardiologist dated 08/14/2025: Daily weights. Call with weight gain of 2-3# (pounds) in one day and/or 5# in one week. Call S4Cardiologist with any HF (Heart Failure) symptoms.discontinued by S5NP (Nurse Practitioner) on 11/11/2025. -order dated 11/21/2025: Weigh Res (Resident) daily and record weight in (name of facility's electronic health record system) daily one time a day for CHF related to acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure. Review of Resident #2's progress notes and weight log from August 2025 to December 2025 revealed 33 dates where no weight was recorded:August 202508/16-17/2025 (Saturday - Sunday)08/24/2025 (Sunday)September 202509/06-07/2025 (Saturday - Sunday)9/9-11/2025 (Tuesday - Thursday)9/13-15/2025 (Saturday - Monday)9/20-22/2025 (Saturday - Monday)9/28/2025 (Sunday)October 202510/04/2025 (Saturday)10/08/2025 (Wednesday); Progress note dated 10/08/2025 07:42 (7:42 a.m.) -S3CNAWT (Certified Nursing Assistant/Weight Tech) wrote: weight never got taken.10/11-12/2025 (Saturday - Sunday)10/16/2025 (Thursday); Progress note dated 10/16/2025- 13:41 (1:41 p.m.) - S3CNAWT wrote: couldn't get weight for today.10/18-19/2025 (Saturday- Sunday)10/22/2025 (Wednesday)10/26/2025 (Sunday)November 202511/01-02/2025 (Saturday - Sunday) 11/08-09/2025 (Saturday - Sunday)11/23/2025 (Sunday)11/27/2025 (Thursday)11/29/2025 (Saturday)December 202512/5/2025 (Friday)12/7/2025 (Sunday)Review of the weight log and progress notes also revealed no documentation that the resident refused to be weighed on the dates where no weight was obtained.On 12/15/2025 at 11:11 a.m., a phone interview was conducted with Resident #2's RP (responsible party) who stated Resident #2 went into the hospital in August 2025 due to chronic heart failure and the facility was supposed to weigh her daily, but they did not. The facility gave excuses as to why the resident wasn't being weighed such as, the scale malfunctioning or not being able to find the scale. He also stated that Resident #2's cardiologist had ordered this [daily weights] for her a long time ago. The facility did not implement the orders from her physician at the time it was originally ordered, so in November 2025, he brought an order for daily weights from her cardiologist and gave it to the facility. On 12/15/2025 at 2:55 p.m., an interview was conducted with S3CNAWT. She stated that she was responsible for obtaining and recording resident weights Monday through Friday. If she could not obtain the weight, she would either notify the resident's nurse or the supervisor. S3CNAWT was then asked why she documented the resident's weight was not taken on 10/8/2025, 10/16/2025, and 10/23/2025. She stated that if the resident was already up in the chair, the weight would not be taken because she had to be weighed in a Hoyer lift and could not obtain the weight if the resident was in the chair. S3CNAWT further stated that if she was not working or if it was the weekend, the CNA (Certified Nursing Assistant) working the floor was responsible for obtaining resident weights.On 12/15/2025 at 3:12 p.m., an interview was conducted with S1DON (Director of Nursing). S1DON stated that Resident #2 had a cardiologist and was ordered daily weights due to CHF and fluid overload. On 12/15/2025 at 3:40 p.m., a joint interview was conducted with S1DON and S2ADON. S2ADON stated that she was responsible for running the weight report for the previous week on Mondays and providing these reports to the interdisciplinary (IDT) team. S2ADON stated that she only reviewed the report, and did not go into each resident's chart and look at each day a weight should have been obtained to ensure it was done. S2ADON was then asked if she knew that Resident #2's weights had not been recorded on 33 days as the resident was ordered daily weights. She stated that she was not aware because she did not go into the resident's chart to ensure that it was done each day. S2ADON agreed that the interdisciplinary team utilized the weight report to help determine that the resident's weights were stable and utilized it in planning care for the resident. S2ADON also agreed that the daily weights should have been obtained as ordered to determine if the physician needed to be notified of a weight gain. S2ADON was then asked if the resident could not be weighed if she was in the chair. She stated that the resident could be weighed and should have been weighed even if she was in the chair because the Hoyer lift pad could be placed under the resident while in the chair and can be lifted from the chair to obtain the weight. S2ADON was asked who was responsible for ensuring weights were obtained when S3CNAWT was not working, such as on the weekends. She stated that the floor CNAs should obtain the weights, but the nurses were responsible for ensuring the weight was obtained. S2ADON stated that their staff should have identified that the weights were not being obtained on the weekends. S1DON also confirmed that the nurses should have ensured the daily weights were obtained. On 12/16/2025 at 4:18 p.m., a phone interview was conducted with S6CardioNP (Cardiology Nurse Practitioner) who was a clinician involved and familiar with Resident #2's cardiac condition. She stated Resident #2 had a diagnosis of systolic heart failure and obtaining daily weights was part of the management for systolic heart failure. S8CardioNP stated that the weights helped to monitor the resident's fluid status and identify if the resident was in fluid volume overload. Resident #3Review of Resident #3's EHR revealed she was admitted to the facility on [DATE] and had diagnoses which included, but were not limited to, chronic obstructive pulmonary disease, fluid overload, and localized edema. Review of Resident #3's care plan initiated on 12/01/2025 revealed the following focus and intervention in part: I have diagnoses of hypo/hyperkaliemia, vitamin D def (deficiency), fluid overload, fluid depletion.Intervention: .weights per NH (nursing home) protocol, MD (Medical Director) order and prn (as needed).Review of Resident #3's December 2025 physician's orders revealed an order dated 12/06/2025 that read: Daily weight and record in (name of facility's electronic health record system).Review of Resident #3's weight log for December 2025 revealed no weights were recorded on the following dates which were on weekends: 12/6, 12/7, 12/13, and 12/14. On 12/16/2025 at 11:30 a.m., an interview was conducted with S2ADON. S2ADON confirmed Resident #3 was ordered daily weights. A review of Resident #3's weights for December 2025 was conducted with S2ADON who confirmed the resident did not have weights recorded on 12/6, 12/7, 12/13, and 12/14. S2ADON confirmed that either the CNAs or nurses were responsible for obtaining the daily weight, but the nurses should have ensured that those weights were obtained. She confirmed that she was responsible for generating the weekly weight report, but stated she did not go into each chart to ensure that the weights were obtained daily. S2ADON confirmed their staff had not identified that the resident's weights were not being obtained daily.

Based on observations, interview, and record review, the facility failed to ensure menus were followed for 7 (#1, #3, #71, #89, #121 #145, #148) residents who required mechanical soft diets out of a final sample of 56 residents. Findings: Review of the facility's policy titled, Menus, with a last revision date of October 2017, read in part: 1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board. Review of the diet spread sheet for residents prescribed mechanical soft diets revealed the following meal was to be served on 08/11/2025: Beans [NAME] Northern f (featured)/Dry Ham buffet, [NAME] Steamed, Carrot Sliced Parslied, Cornbread, Crisp Pear. On 08/11/2025 at 11:30 a.m., an observation was made during lunch in Dining Hall B. Residents #1, #3, #71, #89, #121 #145, and #148 were all prescribed Mechanical Soft diets and had whole Brussel sprouts on their plates. Residents #1 and #145 had eaten all of the Brussel sprouts that were served on their plates. Resident #89 attempted to eat the Brussel sprouts but stated that she could not chew them. On 08/11/2025 at 11:55 a.m., dietary staff was observed bringing a covered pan to the serving kitchen for Dining Hall B. An interview was conducted with S25Dietary who confirmed the pan contained sliced carrots. S25Dietary stated that the dietary staff from the main kitchen was responsible for bringing the carrots to the Dining Hall B serving kitchen. She stated that she saw that the meal tickets read that the residents who received mechanical soft diets were to have sliced carrots with their meals and not Brussel sprouts. She stated that she still served them Brussel sprouts because she did not want them to start their meal without a vegetable. On 08/11/2025 at 12:09 p.m., an interview was conducted with S7DD (Dietary Director) who confirmed residents on mechanical soft diets were to have sliced carrots with their meals. She stated that the dietary staff responsible for serving the lunch meal from Dining Hall B's kitchen should have followed the menu and meal tickets, which included sliced carrots. S7DD further stated the dietary staff should not have served residents, who were prescribed mechanical soft diets, Brussel sprouts instead of carrots. She explained that the dietary staff member should have notified the main kitchen that they did not receive carrots for the mechanical soft diets prior to serving any resident meals.

Based on observations, interviews and record reviews, the facility failed to implement the plan of care and follow physician orders for 6 (#13, #52, #65, #69, and #120) of 56 sampled residents. This was evidenced by failing to:1. provide Resident #13 with Nepro (dialysis supplement) as ordered;2. apply a carrot stretcher (used for hand contractures) to Resident #52's right hand as ordered; 3. supervise Resident #65 for all meals4. administer medication for Resident #69; and5. provide Resident #120 with two person assistance for toileting.Findings:Resident #13 Review of Resident #13’s EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] and had diagnoses including end stage renal disease and diabetes type 2. Review of Resident #13’s quarterly MDS (Minimum Data Set Assessment) dated 07/11/2025 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 12, indicating her cognition was intact. Review of Resident #13’s August 2025 physician’s orders revealed an order dated 07/18/2025 that read: Nepro , two times a day related to end stage renal disease, give 1 carton twice daily. Review of Resident #13’s plan of care initiated on 03/14/2025 revealed in part: I have altered diet needs r/t (related to) diverticulosis, HTN (hypertension), HLD (hyperlipidemia), GERD (gastro-esophageal reflux disease), DM2 (diabetes mellitus type 2), ESRD (end stage renal disease). I am at risk for malnutrition, dehydration and weight fluctuations r/t vitamin deficiency, obesity vertigo, depression, hemodialysis… Interventions in part: Serve my diet and supplements as ordered. On 08/12/2025 at 9:35 a.m., an interview was conducted with Resident #13. Resident #13 was asked if she drank her Nepro twice daily. She stated that she drank her Nepro when the facility provided it to her, but she had not received it in a while. She stated she has not had it this week at all (08/11/2025, 08/12/2025) and did not think she got it at the end of last week either. She stated the nurse told her that it was on back order. On 08/12/2025 at 9:42 a.m., an interview was conducted with S23LPN (Licensed Practical Nurse) who stated the resident did not receive her Nepro because it is was on back order and could not say the last time she received the Nepro. S23LPN then stated that Nepro was stored in the nutrition room, and there was none in the nutrition room. An observation of the nutrition room was made with S23LPN. There was no Nepro in the nutrition room. On 08/12/2025 at 10:05 a.m., an interview was conducted with S6QA (Quality Assurance Nurse) who stated that she was responsible for ensuring nutritional supplements were ordered and available for residents who required them. She stated that she, along with her central supply assistant, ensured that supplements were in stock, and ordered when the supply got low. S6QA was asked when the last time an order was placed for Nepro. S6QA could not provide evidence of when Nepro was last ordered. S6QA stated that if a supplement was on back order, they would contact the ordering physician and get a backup supplement to give until the other one came in. S6QA stated that because there was a physician’s order for Nepro, the facility was responsible for ensuring that the resident received Nepro and should have had it available. Resident #52 Resident #52 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to, cerebral infarction, syncope and collapse, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of Resident #52’s quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 14, indicating the resident’s cognition was intact. Review of August 2025 physician’s orders, revealed an order written on 05/05/2025 which read, “Carrot stretcher for R (right) hand contracture. Apply daily & (and) remove once per day to clean hand.” Review of the resident’s July 2025 and August 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no evidence the carrot stretcher was placed in Resident # 52’s hand daily as ordered. On 08/11/2025 at 1:00 p.m., an observation and interview was conducted of Resident #52. The resident’s right hand was contracted with her fingers turned into her palm. The resident was unable to open her right hand. Resident #52 did not have a carrot stretcher or hand roll in her hand. The resident was unable to remember the last time she had a hand roll placed in her hand and stated it had been “a while.” On 08/13/2025 at 10:35 a.m., an interview and review of Resident #52’s electronic health record was conducted with S2DON (Director of Nursing), S6QA (Quality Assurance Nurse), and S5ADON (Assistant Director of Nursing). They all confirmed the physician’s order for the carrot stretcher to be applied to the resident’s right hand daily. They also confirmed there was no evidence on the MAR or TAR to prove the carrot stretcher was placed in the resident’s right hand daily, and stated that it should have been documented to prove it was done. On 08/13/2025 at 1:19 p.m., an interview was conducted with S20CNA (Certified nursing Assistant). S20CNA stated she had been working with Resident #52 since June 2025 and had never seen a carrot stretcher in her right hand, and didn’t know she needed one. Resident #69 Review of Resident #69’s electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, osteomyelitis of vertebra, lumbar region. Review of Resident #69’s July 2025 physician’s orders revealed an order dated 07/03/2025 Cefazolin Sodium Injection Solution reconstituted 2 gm (gram). Use 2 gram intravenously every 8 hours related to infection and inflammatory reaction due to internal fixation device of spine. Review of Resident #69’s July 2025 MAR (medication administration record) revealed no evidence Cefazolin Sodium 2gm Injection Solution was administered intravenously for the resident on the dates of 07/05/2024 at 0400 and 07/26/2025 at 0400. On 08/13/2025 at 11:54 a.m., an interview and record review was conducted with S2DON (Director of Nursing). She reviewed Resident #30’s MAR and confirmed the resident’s medication was not administered as ordered on 07/05/2025 at 0400 and 07/26/2025 at 0400. Resident #120 Review of the Resident’s electronic medical record revealed Resident #120 was admitted to the facility on [DATE] with diagnoses including, but not limited to: hemiplegia and hemiparesis following cerebrovascular disease affecting left dominant side, difficulty in walking, generalized muscle weakness, peripheral vascular disease, major depressive disorder, generalized anxiety disorder, stiffness of left knee, lack of coordination and degenerative disease of nervous system. Review of Resident #120’s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was assessed as having a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. Resident #120’s bowel and bladder status was assessed as the resident always having bowel and bladder incontinence. Review of Resident #120’s care plan revealed the resident required ADL (Activities of Daily Living) assistance r/t (related to) lack of coordination, difficulty walking, muscle weakness, left hemiplegia with an intervention to assist with ADL's as needed including mobility and toileting hygiene; may require more assistance as condition warrants. Review of Resident #120’s POC (Plan of Care) revealed a task for toileting/urinary continence require two (2) person assistance provided by CNAs (Certified Nursing Assistants) every shift. On 08/13/2025 at 10:45 a.m., an observation was made of Resident #120 lying in bed, awake and alert. S13CNA knocked on the resident’s room door and stated she was coming to change the resident’s soiled adult brief. S13CNA verified S14CNA was the other CNA working with her. S13CNA stated she was able to change the resident’s soiled brief herself. S13CNA proceeded to turn and clean the resident by herself. S13CNA never attempted to call for assistance to help with changing and cleaning the resident. On 08/13/2025 at 2:01 p.m., an interview was conducted with S24LPN. S24LPN reported Resident #120 was bedbound and dependent on staff. S24LPN would neither confirm nor deny that Resident #120 required two person assistance for brief change. Resident #65 Review of Resident #65’s electronic medical record (EMR) revealed she admitted on [DATE] with diagnoses including but limited to cognitive communication deficit, gastrostomy, type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction, dysphagia oropharyngeal, and adult failure to thrive. Review of Resident #65’s admission MDS (Minimum Data Set Assessment) dated 05/29/2025 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 11, indicating severely impaired cognition. Review of Resident #65’s August 2025 physician’s orders revealed an order dated 07/30/2025 that read: Speech therapy recommends Resident #65 return to oral intake, mechanical soft with thin liquids by straw, resident to be placed in dining room/supervised for all meals. Review of Resident #65’s care plan initiated on 05/24/2025 read in part: “I have altered diet needs related to diabetes, hypertension, dysphagia, and chronic kidney disease.” Interventions – serve my diet and supplements as ordered, provide verbal encouragement, cues, reinforcement if need, refer to therapy services s ordered. On 08/11/2025 at 12:01 p.m., observation of Resident #65 in the dining room was conducted. The resident was observed sitting at a table with two other residents. The resident was not being monitored by staff, or being cued by staff. The resident was observed trying to get the attention of the staff, because she did not want the carrots, rice, white beans, and corn bread. On 08/13/2025 at 8:05 a.m., another dining room observation was conducted. Resident #65 was observed during breakfast meal. The resident was not being supervised. She sat at a table with two other residents. The resident’s nurse was observed outside of the dining room, preparing medications at her medication cart. On 08/13/2025 at 8:10 a.m., an observation and subsequent interview was conducted with S16LPN (Licensed Practical Nurse). S16LPN confirmed that she was the nurse for Resident #65. She stated she was not aware the resident had an order to be monitored for all meals. S16LPN reviewed Resident #65’s physician orders and confirmed that the resident was supposed to be supervised for all meals. S16LPN also confirmed that she had not been monitoring the resident during her meals as per the physician’s orders.

Based on interview and record reviews, the facility failed to ensure the resident's right to make choices about aspects of her life that were significant to the resident for 1 (#49) resident out of a final sample of 56 residents. Findings: Review of the facility's policy titled Resident Rights, with a last revised date of February 2021, read in part: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: e. self-determination.v. have the facility respond to his or her grievance. Review of Resident #49's EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] and had diagnoses including spastic diplegic cerebral palsy, major depressive disorder, and anxiety disorder.Review of Resident #49's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating that her cognition was intact.On 08/11/2025 at 10:01 a.m., an interview was conducted with Resident #49. She stated that she had an issue with S15CNA (Certified Nursing Assistant) that began last year. She stated there were instances where she asked for assistance and S15CNA would not help her. She further stated S15CNA did not respect her wishes as far as assisting her with ADLs (Activities of Daily Living) in the way that she liked or in a way that would not increase her pain due to her diagnoses (spastic diplegic cerebral palsy) of which she experiences pain all of the time. Resident #49 went on to say that S15CNA was fired, but recently got rehired. She had spoken with the previous administrator, S5ADON (Assistant Director of Nursing), and S2DON (Director of Nursing) about her issue with S15CNA, and stated she did not want her as her CNA because the CNA made her uncomfortable, and she did not like the way the CNA cared for her. Resident #49 stated S2DON told her that she just had to get used to S15CNA. The former administrator, S5ADON and S2DON also told her that they didn't move resident rooms or CNA assignments. The resident stated she felt she should not have to be cared for by someone who made her uncomfortable. On 08/12/2025 at 1:43 p.m., an interview was conducted with S2DON and S5ADON. Both confirmed that approximately three to four weeks ago, a conversation was had with Resident #49 regarding S15CNA. S2DON stated that Resident #49 reported to both of them that she did not want S15CNA to be her CNA, but when asked if S15CNA had done something, Resident # 49 could not give an answer, only that she just did not like the CNA. S2DON further stated that she told Resident #49 during that meeting that she could not simply move CNAs around because she did not like someone. There had to have a legitimate reason to move the CNA or not allow the CNA to work with her. She stated that if she removed the resident from the CNA's assignment, it would not be fair to the CNA. As a solution, to protect S15CNA, she told S15CNA to have another CNA go in the room with her so that the resident could not say anything occurred that did not occur. S2DON did not remove S15CNA from Resident #49's room assignment as the resident requested.

Based on interviews and record reviews, the facility failed to address and act upon grievances for 1 (#49) resident out of 56 sampled residents. Findings:Review of the facility's policy titled, Grievances/Complaints, Filing, with a last revised date of April 2017, read in part: 3. All grievances, complaints, or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including rationale for the response.7. Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and report the findings to the administrator.13. The results of all grievances files, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision.Review of Resident #49's EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] and had diagnoses including spastic diplegic cerebral palsy, major depressive disorder, and anxiety disorder.Review of Resident #49's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating that her cognition was intact.On 08/11/2025 at 10:01 a.m., an interview was conducted with Resident #49. She stated that she had an issue with S15CNA (Certified Nursing Assistant) that began last year. She stated there were instances where she asked for assistance and S15CNA would not help her. She further stated S15CNA did not respect her wishes as far as assisting her with ADLs (Activities of Daily Living) in the way that she liked or in a way that would not increase her pain due to her diagnoses (spastic diplegic cerebral palsy) of which she experiences pain all of the time. Resident #49 went on to say that S15CNA was fired, but recently got rehired. She had spoken with the previous administrator, S5ADON (Assistant Director of Nursing), and S2DON (Director of Nursing) about her issue with S15CNA, and stated she did not want her as her CNA because the CNA made her uncomfortable, and she did not like the way the CNA cared for her. Resident #49 stated S2DON told her that she just had to get used to S15CNA. The former administrator, S5ADON and S2DON also told her that they didn't move resident rooms or CNA assignments. The resident stated she felt she should not have to be cared for by someone who made her uncomfortable.Review of the facility's grievance log from April 2025 to August 2025 did not reveal a grievance was filed for Resident #49.On 08/12/2025 at 1:43 p.m., an interview was conducted with S2DON and S5ADON. Both confirmed that approximately three to four weeks ago, they had a conversation with Resident #49 regarding S15CNA. S2DON stated that Resident #49 reported to both of them that she did not want S15CNA to be her CNA, but when asked if S15CNA had done something, the resident did not give an answer. When asked why there was no grievance form or investigation for the resident regarding her complaint, S2DON stated that she did not complete a grievance form or investigation because the resident could not explain what she actually complained about.

Based on record review and interview, the facility failed to ensure a discharge Minimum Data Set (MDS) assessment was completed timely for 1 (#111) out of 56 total sampled residents. Findings:Review of the CMS (Center for Medicare and/or Medicaid Services) RAI (Resident Assessment Instrument) Manual Version 3.0 provided by the facility as their policy titled, Chapter 5: Submission and Correction of MDS Assessments read in part .5.2 Timeliness Criteria: In accordance with the requirements at 42 CR 483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: Completion Time: For all non-admission OBRA (Omnibus Budget Reconciliation Act) and PPS (Prospective Payment System) assessments, the MDS completion date (Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD)(A2300). Review of Resident #111's electronic health record (EHR) revealed an initial admission date of 03/24/2025 and a discharge date of 06/13/2025. Further review of Resident #111's EHR failed to reveal that a Discharge MDS assessment was completed and transmitted within 14 days after the resident was discharged from the facility. On 08/12/2025 at 3:37 p.m., an interview and record review of Resident #111's EHR was conducted with S4MDS. After review of the resident's EHR, she confirmed that Resident #111 did not have a discharge MDS assessment. She confirmed Resident #111's discharge MDS should have been completed and transmitted within 14 days after the resident discharged from the facility.

Based on record review and interview, the facility failed to ensure that the minimum data set (MDS) assessment accurately reflected the status of 2 (Resident #69 and #179) of 56 sampled residents. The facility failed to: 1.Accurately code medication on the MDS for Resident #69; and 2.Accurately code the discharge type on the MDS for Resident #179.Findings: Resident #69 Review of Resident #69’s (EHR) electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included but were not limited to paroxysmal atrial fibrillation. Review of Resident #69’s physician’s orders revealed an order dated 07/04/2025 that read in part, Aspirin 81mg (milligrams) 1 tablet by mouth daily related to paroxysmal atrial fibrillation. Review of Resident #69’s MAR (Medication Administration Record) for July 2025 revealed she had been administered Aspirin daily from 07/04/2025 to 07/31/2025. Review of Resident #69’s Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/09/2025 revealed in Section N (Medications) she was coded for taking anticoagulant and blank for antiplatelet use. On 08/12/2025 at 3:45 p.m., an interview and record review was conducted with S4MDS. She confirmed Resident #69 was coded as taking anticoagulants and blank for use of an antiplatelet. She then confirmed the resident was not prescribed an anticoagulant and was prescribed Aspirin which was an antiplatelet. She confirmed the MDS was coded incorrectly. Resident #179 Review of the resident’s care plan revealed in part: date initiated 06/23/2025 “I wish to return to the community after completion of skilled therapy services.” Goal: I will be able to return to the community with the assistance of community resources of my choice after completion of skilled therapy services…Interventions: assist me with discharge planning. Review of Resident #179’s admission /Medicare - 5 Day /DRNA (Discharge Return Not Anticipated) /End of PPS (Prospective Payment System) Part A Stay MDS assessment dated [DATE] by S3MDS revealed the resident was admitted to the facility on [DATE] and discharged on 06/28/2025. Section Q of the MDS assessment revealed the resident’s overall goal was to discharge to the community…discharge plan “yes”… the source of this information was from the resident’s family…a referral been made to the Local Contact Agency. Review of the following information in Section A of the assessment revealed: Discharge status “Home/Community” F. entry/discharge reporting “Discharge return not anticipated” G. type of discharge “unplanned” Further review of the resident’s record did not reveal any evidence indicating the resident had an unplanned or emergent discharge. On 08/12/2025 at 3:32 p.m., a review of Resident #179’s electronic health record, care plan and the resident’s admission /Medicare - 5 Day /DRNA /End of PPS Part A Stay dated 06/28/2025 was conducted with S3MDS who confirmed she was responsible for Resident #179’s MDS and care plan assessments. She explained the resident was admitted to the facility on [DATE] for skilled services and discharged to home on [DATE] after her skilled service days ended on 06/27/2025. S3MDS confirmed the resident’s MDS assessment was coded as an unplanned discharge, but recalled the resident’s spouse discussed upon admission that the resident’s discharge would be a planned discharge. She then stated she would review the record further to see if there was evidence indicating an unplanned discharge. Upon further review of the resident’s and facility records, S3MDS confirmed there was no evidence the resident’s discharge was unplanned therefore the resident’s MDS assessment was inaccurate. On 08/13/2025 at 11:15 a.m., a phone interview was conducted with Resident #179’s spouse who stated the resident’s discharge had been planned with the facility upon her admission. The resident’s spouse stated the resident was discharged after her therapy days ended, confirming the resident was an anticipated planned discharge.

Based on observation, interview, and record review, the facility failed to ensure oxygen equipment was stored appropriately when not in use for 3 (Resident #30, Resident #89, Resident #116) out of 5 (Resident #30, Resident #84, Resident #89, Resident #94, Resident #116) sampled residents reviewed for respiratory care. Findings: On 08/13/2025, a review of the facility’s policy titled, “Oxygen Administration”, with a last revision date of October 2010, failed to address the procedure for oxygen equipment storage. On 08/13/2025, a review of the facility’s policy titled, “Administering Medications through a Small Volume (Handheld) Nebulizer”, with a last revision date of October 2010, failed to address the procedure for oxygen equipment storage. On 08/13/2025, a review of the facility’s policy titled, “CPAP(Continuous Positive Airway Pressure)/BiPap (Bilevel Positive Airway Pressure) Support” with a last revision date of March 2015, indicated “Masks, nasal pillows and tubing…Once dry place in zip lock bag until used by resident…” Resident #116 Review of Resident #116’s “admission Record” revealed resident was admitted to the facility on [DATE] with diagnoses which included in part, obstructive sleep apnea, pulmonary hypertension, and pleural effusion. Review of Resident #116’s Physician’s orders revealed an order dated 09/25/2024, which stated, “CPAP—wear at night during hours of sleep. Remove in morning. Directions: at bedtime related to morbid (severe) obesity due to excess calories.” On 08/11/2025 at 11:01 a.m., an observation was made of Resident #116’s CPAP mask stored in the top drawer of her bedside dresser. Resident #116’s CPAP mask was not stored in a plastic bag. On 08/11/2025 at 11:23 a.m., a concurrent interview and observation was conducted with S10LPN (Licensed Practical Nurse) in Resident #116’s room. S10LPN confirmed that Resident #116’s CPAP mask was not stored in a plastic bag and it should have been. On 08/13/2025 at 1:41 p.m., an interview was conducted with S11IP (Infection Preventionist). S11IP confirmed that CPAP masks should be stored in a plastic bag when not in use. Resident #89 Review of Resident #89’s electronic health record revealed she was admitted to the facility on [DATE] with diagnoses, which included, but were not limited to, dysphagia following cerebral infarction, type 2 diabetes mellitus, emphysema, and asthma. Review of Resident #89’s August 2025 physician’s orders revealed an order dated 07/30/2025, which read in part: check oxygen saturation every shift. Apply oxygen at 2L (Liters) per nasal cannula as needed for oxygen saturation less than 92%. Review of Resident #89’s care plan read in part… I have diagnoses of emphysema and persistent asthma. Interventions included: Oxygen as ordered and as needed. On 08/11/2025 at 9:00 a.m., an observation was made of Resident #89’s room. An oxygen concentrator was observed running and oxygen tubing was observed on the side of the garbage can on the floor. On 08/11/2025 9:06 a.m., an observation and interview was conducted with S18LPN (Licensed Practical Nurse) who confirmed the oxygen tubing should not have been on the floor, and the tubing had to be thrown discarded. Resident #30 Review of Resident #30’s electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, pneumonia, abscess of lung with pneumonia, acute respiratory failure with hypoxia, and chronic respiratory failure with hypoxia. Review of Resident #30’s August 2025 physician’s orders revealed an order dated 07/31/2025 Oxygen at 2 liters per nasal cannula continuous, Monitor every shift every for shortness of breath/dyspnea. Further review revealed an order dated 08/04/2025 Albuterol Sulfate Nebulization Solution 2.5 mg (milligrams) inhale orally via nebulizer two times a day for sob (shortness of breath) for 10 days. Review of Resident #30’s care plan read in part…I have diagnosis of acute hypoxic respiratory failure, chronic hypercapnic respiratory failure, right upper lobe PNA (pneumonia) with lung abscess, cough. Interventions included: Change nebulizer mask and tubing every Sunday 6-2 shift prn (as needed) usage. Change O2 (oxygen) tubing every Sunday 6-2 shift while in use. Review of Resident #30’s MAR (medication administration record) and TAR (treatment administration record) for August 2025 revealed no evidence that Resident #30’s nebulizer mask and tubing, and O2 tubing were changed. On 08/11/2025 at 10:26 a.m., an observation was made of Resident #30 with Oxygen at 2 liters per nasal cannula in progress. There was no date on the oxygen tubing. Further observation revealed a nebulizer mask and tubing on the counter top. There was no date on the nebulizer mask and tubing. On 08/11/2025 at 10:30 a.m., S12LPN (Licensed Practical Nurse) was asked to enter Resident #30’s room. S12LPN observed the oxygen tubing and confirmed the tubing was not labeled with the date it was changed. S12LPN also observed the nebulizer mask and tubing and confirmed the mask and tubing were not labeled with the date it was changed. On 08/13/2025 at 12:04 p.m., an interview and record review was conducted with S2DON (Director of Nursing) who confirmed Resident #30’s nebulizer mask and oxygen tubing should have been labeled with the date it was changed, but was not. S2DON reviewed Resident #30’s MAR and TAR for August 2025 and confirmed there was no evidence that Resident #30’s nebulizer mask and tubing, and O2 tubing were changed, but should have been.

Based on observation, record review, and interviews the facility failed to make an appointment with a dentist in a timely manner for 1 (#3) of 1 (#3) residents investigated for dental care. Findings:Record review revealed Resident #3 was admitted to the facility on [DATE] with accumulative diagnoses including cerebral infarction, diabetes mellitus, speech and language deficits following cerebral infarction, dysarthria following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and depressive disorders.Record review of Resident #3's physician orders dated 08/06/2025 read in part: Consult dentist related to dental pain right upper gums has broken teeth with redness/tenderness.Record review of Resident #3's care plan read in part, I require dental care. I am experiencing dental pain and a potentially abscessed tooth. Interventions included refer resident and follow up with dentist as needed. Assess oral cavity and dentition. Monitor for any irritation, sores, loose or missing teeth and complaints discomfort or pain.Review of Resident #3's Minimum Data Set (MDS) admission dated 06/30/2025 revealed a Brief Interview for Mental Status (BIMS) score of 07, which indicated severely impaired cognition. On 08/11/2025 at 10:24 a.m., an observation revealed Resident #3's oral cavity had missing teeth. Further observation revealed resident's bottom left tooth was dark in color.On 08/11/2025 at 11:51 a.m., an observation revealed Resident #3's during the lunch meal. The resident was served white beans, rice, carrots, and corn bread. The consumed 25% of meal, and was observed having difficulty chewing his food. The resident would not close his mouth fully to bite down and chew the food. Resident was observed with facial grimaces while eating.On 08/12/2025 at 2:15 p.m., an interview was conducted with S8SSD (Social Services Director) who stated she was responsible for arranging dental consults for the residents. She stated the process when she receive an order for a resident to have a dental consultation, was to complete a referral form for the resident. Then, the resident is added to the list to be seen when the dentist comes to the facility. She confirmed that the dental team was in the facility on 08/11/2025 and on 08/12/2025 and Resident #3 was not seen. S8SSD stated she was not aware that Resident #3 had an order written on 08/06/2025 for him to be seen by the dentist due to dental pain and possible abscess. On 08/13/2025 at 7:56 a.m., an interview was conducted with S18LPN (Licensed Practical Nurse). S18LPN confirmed she entered a dental consult order into the computer for Resident #3. She stated that the order should have gone to S8SSD and the ward clerk. She stated she was not aware if S8SSD or the ward clerk had received the order and completed the referral. She confirmed she did not follow up on the order, but assumed the order had been completed.

Based on observations, interviews, 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 of communicable diseases and infection. This was evidenced by staff failing to perform appropriate hand hygiene during the provision of care and services, and failing to appropriately dispose of medical waste.Findings:A. Review of the facility’s Handwashing/Hand Hygiene Policy and Procedure, with a review date of October 2023, read in part: “…Indication for Hand Hygiene: 1. hand hygiene is indicated: e. after touching the resident's environment…” Review of a document titled “Medical Waste, Handling of”, with a revision date of 09/2010, which read in part: “Purpose – is to provide a definition of and guidelines for the safe and appropriate handling of medical waste…General Guidelines – 1. Medical waste includes human blood and blood soiled articles contaminated items (i.e., soiled dressings)… 4. Disposable items, which are contaminated with excretions or secretions from residents believed to be infectious, must be placed in red plastic bags and sealed…” Observations of the dining room on 08/12/2025 at 11:58 a.m. revealed S17CNA (Certified Nursing Assistant) feeding two residents. S17CNA repeatedly touched the utensils and cups of the two residents without performing hand hygiene. An interview with S17CNA was conducted on 08/12/2025 at 12:05 p.m. S17CNA confirmed that she had not used hand sanitizer between feeding the two residents. She stated she did not have the sanitizer in her pocket at the time she assisted the two residents, and she should have had hand sanitizer and utilized it while assisting the residents. On 08/12/2025 at 11:45 a.m., an observation on Hall A revealed a treatment cart positioned against the wall. The treatment cart had a trash can attached with the lid of the trash can opened. A red biohazard trash bag was observed lining the trash can. A yellow soiled discarded personal protective gown was observed hanging half way outside of the red trash bag, along with other discarded materials, and a smaller bio hazard trash bags. On 08/12/2025 at 12:30 p.m., another observation was made of the same treatment cart on Hall A. The cart’s trash can lid was open and inside the trash can was more red biohazard bags and a yellow soiled personal protective gown hanging out of the trash can. On 08/12/2025 at 2:41 p.m., an observation and subsequent interview was conducted with S11IP (Infection Preventionist). After making an observation of the treatment cart on Hall A, S11IP confirmed that the treatment cart’s trash was overflowing with soiled personal protective gowns and biohazard bags. She confirmed the soiled personal protective gowns and the read biohazard bags were not contained and discarded appropriately. B. On 08/13/2025, a review of the facility’s policy titled “Handwashing/Hand Hygiene” with a revision date of October 2023, read in part: This facility considers hand hygiene the primary means to prevent the spread of health-care associated infections. Policy Interpretation and Implementation: Administrative Practices to Promote Hand Hygiene 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare- associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors. Indications for Hand hygiene 1. Hand hygiene is indicated: a. after contact with blood, body fluids, or contaminated surfaces… On 08/12/2025 at 9:07 a.m., S21CNA (Certified Nursing Assistant) was observed walking down Hall W with a plastic bag containing laundry items in her bare hands. S21CNA opened the hopper room and discarded the bag. She did not perform hand hygiene. S21CNA immediately walked across the hall and removed linen from the clean linen cart. During an interview with S21CNA, she stated that she brought dirty linen from a resident’s room and disposed of it in the hopper room. S21CNA confirmed she did not wash or sanitize her hands before picking up the clean linen, and should have. On 08/12/2025 at 9:16 a.m., S22CNA was observed walking towards the hopper room on Hall W with a bag containing linen. She opened the hopper room, disposed of the linen, and did not perform hand hygiene. S22CNA walked back down the hall and uncovered a clean linen cart parked in the hallway. During an interview with S22CNA, she stated the bag she took to the hopper room contained dirty linen from a resident’s bed. She confirmed she did not perform hand hygiene before handling the covered clean linen cart and stated she should have. On 08/12/2025 at 2:20 p.m., an interview was conducted with S11IP (Infection Preventionist). She stated that all staff were aware of proper hand hygiene practices and the CNAs should have sanitized their hands between contact with the contaminated and clean surfaces.

Based on observations, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure expired foods were removed from the kitchen.This had the potential to affect the 166 residents that consumed food from the kitchen.Findings:On 08/12/2025, a review of the facility's policy titled, Food Receiving and Storage, with a last revision date of 11/2022, revealed in part. Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Dry Food Storage.4. Dry foods that are stored in bins are removed from original packaging, label and dated ( used by date). Such foods are rotated using a first in-first out system. On 08/11/2025 at 8:30 a.m., an initial tour of the kitchen was conducted with S7DD (Dietary Director). During the tour, S7DD confirmed: 15 cups of prune juice on the shelf in the dry storage room, had an expiration date of 07/03/2025; 4 loafs of bread had a best use by date of 07/24/2025; 22 loafs of bread had a best by date of 08/06/2025; and 10 loafs of bread with a best by date of 08/08/2025. She stated the expired and past the best by date items should have discarded by the date printed on the food items.

Based on record review and interviews, the facility failed to ensure individual financial records were provided to the resident through quarterly statements for 1 (Resident #35) out of 56 residents included in the sample.Findings:On 08/11/2025 at 3:54 p.m., an interview was conducted with Resident #35. Resident #35 stated she had not received quarterly statements for her personal funds account.On 08/12/2025, a review of Resident #35's Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition.On 08/12/2025, a review of Resident #35's admission Record revealed resident was admitted to the facility on [DATE] with diagnoses which included in part, unspecified dementia, Parkinson's disease, and Alzheimer's disease. Further review under the Contacts section revealed Resident #35's Responsible Party (RP) was a family member.On 08/13/2025 at 10:39 a.m., an interview was conducted with S9OD (Office Director). She stated if a resident was his or her own RP, then the quarterly statements were given to the resident, if not, the statements were mailed to the resident's RP.On 08/13/2025 at 10:50 a.m., a telephone interview was conducted with Resident #35's RP. Resident #35's RP confirmed the resident did have a personal funds account at the facility. Resident #35's RP stated she had not received quarterly statements from the facility.On 08/13/2025 at 11:00 a.m., an interview was conducted with S9OD. She confirmed that a resident with an admission date in April of 2025 should have received a quarterly statement in June of 2025.On 08/13/2025 at 1:43 p.m., an interview was conducted with S9OD. S9OD confirmed that Resident #35 had a trust account at the facility. S9OD could not provide evidence that Resident #35 received a quarterly statement or that a quarterly statement was mailed to Resident #35's RP.On 08/13/2025, a review of the facility's policy titled, Resident Trust Fund Policy, indicated the following: Accounting and Recordkeeping.The individual financial record shall be available through quarterly statements.

Based on interviews and record review, the facility failed to provide the resident or RP (Responsible Party) with written notice which specifies the duration of the bed-hold policy at the time of transfer to the hospital for 1 resident (#2) out of 3 (#1, #2, #3) sampled residents. Findings: Review of the facility's policy titled Transfer or Discharge, Preparing a resident for , with a last revised date of December 2016, read in part: The business office is responsible for .b. Informing the resident, or his or her representative (sponsor) of our facility's readmission appeal rights, bed- holding policies , etc; . Review of the facility's Emergency Transfer Log for March 2025 revealed Resident #2 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Further review of the Emergency Transfer Log revealed the written notification to resident portion of the log was blank. On 05/14/2025 at 9:04 a.m., a review of the Emergency Transfer Log was conducted with S12SSD (Social Services Director). She stated that she was unaware that she had to send written notification at the time of Resident #2's transfer to the hospital about the duration of the bed hold or the payment policy to the resident or RP. On 05/14/2025 at 11:15 a.m., an interview was conducted with S2ADMAsst (Administrative Assistant). She stated that she provided written notification to the RP or resident of the bed hold policy and provided the notification that she sends to the RP upon transfer to the hospital. A review of the document titled Bed Hold Agreement was conducted with S2ADMAsst and revealed the notice did not provide information to the resident or RP that explained the duration of the bed-hold. S2ADMAsst confirmed that the agreement did not have information that explained the duration of the bed-hold.

Based on record review and interview, the facility failed to ensure that the minimum data set (MDS) assessment accurately reflected the status of 1 (Resident #3) of 3 (Residents #1 - #3) sampled residents. Findings: Resident #3 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to metabolic encephalopathy, cerebral infarction, memory deficit following cerebral infarction, and hemiplegia and hemiparesis following infarction affecting right dominant side. During an interview with Resident #3 on 05/13/2025 at 9:09 a.m., she stated that she experienced pain from her pressure ulcer but had been receiving pain medication which helps with the pain. Review of Resident #3 Physician Orders, revealed an order written on 06/20/2024 for Tylenol 8 hour oral tablet extended release 650 milligram (mg) (Acetaminophen) Give 1 tablet by mouth two times a day. Review of Resident #3's quarterly MDS with an assessment reference date (ARD) of 03/19/2025, revealed in Section J0100 that the resident did not receive any scheduled pain medications. On 05/13/2025 at 10:17 a.m., an interview and review of Resident 3#'s quarterly MDS assessment with ARD of 03/19/2025 was conducted with S3MDS and S4MDS. S4MDS stated she completed the assessment and confirmed that she did not code the resident for receiving pain medication. S3MDS confirmed that Resident #3 received pain medication during the look back period of her quarterly MDS assessment and it should have been coded yes for receiving pain medication.

Based on record review and interview, the facility failed to provide ADL (Activities of Daily Living) care for dependent residents by failing to ensure rounding was conducted every two hours for 1 (#2) resident out of 3 (#1,#2,#3) sampled residents. Findings: Review of Resident #2's medical record revealed she was admitted to the facility on [DATE] and had diagnoses including unspecified dementia and urinary tract infection. Review of section GG- Functional Abilities of Resident #2's MDS (Minimum Data Set) assessment dated [DATE] revealed the resident could not walk ten feet and required substantial or maximal assistance for toileting. Review of section H- Bowel and Blader revealed the resident was always incontinent of bowel and bladder. On 05/12/2025 at 8:05 a.m., a phone interview was conducted with Resident #2's family member. She stated that the CNAs were not rounding on the resident every two hours, and her mom was left soiled for several hours before being changed. On 05/12/2025 at 3:50 p.m., a follow up interview was conducted with Resident #2's family member who provided video footage from the resident's electronic monitoring device in her room. The device was positioned facing the resident's bed, with visualization of the resident in bed. The surveyor observed the following: On 05/11/2025, staff was observed entering the resident's room at 3:50 p.m., and performed peri-care. Staff did not perform peri-care again until 8:30 p.m. Further review of the video evidence revealed staff did not round or return to perform peri-care for Resident #2 until 05/12/2025 at 12:00 a.m. On 05/13/2025 at 10:28 a.m., an interview was conducted with S7CNA(Certified Nursing Assistant) who stated that the CNAs were to round every two hours on the residents. She further stated that during two hour rounds, she ensured residents were clean, briefs were not soiled, provided peri- care, ensure residents had hydration, and that the residents' needs were met. On 05/13/2025 at 1:27 p.m., an interview was conducted with S1ADM (Administrator) who stated that the facility's staff was instructed to round every two hours. S1ADM could not provide video evidence from the facility's camera footage of CNAs conducting two hour rounds on Resident #2.

Based on interview and record reviews, the facility failed to develop a plan of care after a fall for 1 (Resident #3) of 7 (#1, #2, #3, #R1, #R2, #R3, #R4) sampled residents. Findings: Review of Resident #3's Discharge Minimum Data Set with an Assessment Reference Date of 03/02/2025 revealed, in part, section J had yes to falls. Review of Resident #3's Nursing Progress note dated 02/13/2025 8:11p.m., read in part .Summoned to resident's room by CNA (Certified Nursing Assistant), who was doing rounds. Upon entering resident's room he was noted lying in supine position on floor next to bed. When assisted to bed facial grimace noted, although he denied pain. Review of Resident #3's Nursing Progress note dated 02/18/2025 8:19 p.m., read in part . I the writer was in the middle of going to give resident his HS (Hours sleep) medications, when I noticed Resident #3 on floor laying down in supine position , head beneath bed. I called another Agency Nurse to assisted resident back into bed. Resident was cover in feces and he stated he was going to use bathroom Review of Resident #3's Plan of Care revealed, in part, Resident #55 was at risk for falls r/t (related to) rhabdomyolysis, falls, muscle weakness, abnormal gait/mobility, unsteadiness on feet, muscle wasting/atrophy, cognitive deficit, Dementia, femur fracture. I have fall with femur fracture prior to admission, 02/13/2025- I had a fall OOB (out of bed), and 02/18/2025 I had a fall in my room. Interventions read in part . call bell within reach when in bed/room, reinforce and re-educate me on the importance of safety, please keep my assistive devices within reach as needed/ordered, I need to be toileted before bed. On 04/02/2025 at 9:34 am, a joint interview was conducted with S2RN (Registered Nurse), and S1RN. S1RN stated she S2RN was their quality nurse and she was the one who would update care plans for residents after falls. S2RN reviewed Resident #3's medical records and confirmed the resident had two falls on 02/13/2025 and 02/18/2025. She then reviewed the fall from 02/18/2025 and stated the updated intervention stated bed in lowest position, call light within reach. S2RN agreed that this intervention was already in place and was a standard nursing of care, she stated the intervention was not resident specific this was already applied to the resident.

Based on record review and interview, the facility failed to ensure a comprehensive Minimum Data Set (MDS) assessment was completed timely for 1 (#1) out of 7 (#1, #2, #3, #R1, #R2, #R3, #R4) total sampled residents. Findings: A request was made on 04/03/2025 to S3RA (Regional Administrator) for a policy regarding MDS completion and submission time frames. A policy was not provided by the time of survey exit. Review of CMS's (Centers for Medicare and Medicaid Services) RAI Version 3.0 Manual- RAI OBRA (Omnibus Budget Reconciliation Act)-required Assessment Summary revealed that Assessment Reference Date for an Admission Comprehensive Assessment should be completed no later than the 14th calendar day of the resident's admission. Findings: Review of Resident #1's progress notes revealed he was hospitalized on [DATE] and readmitted on [DATE]. Further review of Resident #1's progress notes revealed he was hospitalized again on 02/27/2025 and readmitted on [DATE]. Review of Resident #1's electronic clinical record failed to reveal that a comprehensive MDS assessment was completed and transmitted within 14 days after the resident was readmitted to the facility after each hospitalization . On 04/03/2025 at 11:00 a.m., a request was made to S3RA for an interview with the MDS nurse. S3RA stated that an interview could not be conducted unless questions were submitted in writing as a formal request.

Based on observations and interviews, the facility failed to treat each resident with respect, dignity and care by: 1. the facility failed to ensure residents were assisted with meals in a dignified manner as evidenced by staff standing over Residents #122, #138, and #563 while assisting them to eat, 2. the facility failed to ensure that a resident with a urinary catheter had a privacy bag or covering over their urine collection bag for dignity for Resident #128. Findings: On 06/12/2024, a review of the facility's policy titled Assistance with meals with a revision date of 01/17/2024, read in part, Policy Statement: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. not standing over residents while assisting them with meals. Resident # 122 Review of the Resident #122's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Alzheimer's Disease, Dementia, Contracture Right Hand, and Contracture of Muscle Left Hand. Resident # 138 Review of the Resident #138's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, Senile Degeneration of Brain, Dementia, Other Lack of Coordination, and Major Depressive Disorder. Resident # 563 Review of the Resident #563's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Other Frontotemporal Neurocognitive Disorder, Major Depressive Disorder Recurrent Severe with Psychotic Symptoms, and Unspecified Dementia. On 06/10/2024 from 8:05 a.m. until 8:15 a.m., observations were conducted of S15CNA (Certified Nursing Assistant) in the dining room. She was observed at the feeding table standing up and feeding Resident #122, Resident #138, and Resident #563 during the that time frame. An interview was conducted with S15CNA, and she stated she was standing up feeding the residents because it was easier for her to feed them. When asked if she should be standing up while feeding the resident she stated oh, no I need to be sitting. On 06/12/2024 at 11:44 a.m., an interview was conducted with S2DON (Director of Nursing). She stated that staff should not stand over residents while feeding and assisting them with meals. 49176 Resident #128 Review of Resident #128's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to .Cerebral Infarction, Obstructive and Reflux Uropathy, and Retention of Urine. Review of Resident #'s 128's June 2024 physician's orders revealed an order dated 05/24/2024 that read: Indwelling foley catheter 16F (French)/30CC (cubic centimeters). Review of Resident #128's current care plan revealed in part .The resident had a urinary catheter that had been re-inserted on 05/24/2024. On 06/10/2024 at 6:20 a.m., an observation was made of Resident #128 in his room. The resident was lying in his bed with his urinary catheter drainage bag hanging underneath the bed. The drainage bag was half filled with urine. There was no privacy bag or covering on the catheter drainage bag. On 06/10/2024 at 8:08 a.m., a second observation was made of Resident #128 in his room. The resident was sitting in his wheelchair with his urinary catheter drainage bag hanging off the left of the wheelchair. There was urine in the drainage bag and visible to others in the hall. There was no privacy bag or covering on the catheter drainage bag. On 06/10/2024 at 8:34 a.m., an interview and observation was made of Resident #128's drainage bag with S20LPN (Licensed Practical Nurse). She confirmed the resident's catheter drainage bag should have had privacy bag or covering over it and it did not.

Based on observations, record reviews, and interviews, the facility failed to ensure recipes for pureed, and chopped diets were followed. This failure had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs, and weight loss for the 7 residents who received pureed or chopped meals. Findings: On 06/11/2024 at 11:09 a.m., an observation was made of S23DS (Dietary Supervisor) preparing the lunch meal pureed dessert of a chocolate peanut butter bar. S23DS was observed taking an unmeasured amount of chocolate peanut butter bars and placing them in the food processor and blended the bars. She then stopped blending the mixture and added an unmeasured amount of milk from 1- half pint of milk, then blended the mixture and shortly after stopped blending. S23DS was observed manually breaking the large pieces of bars that had not processed into smaller pieces and then blended the mixture. She then added an unmeasured amount of milk from a half pint of milk, blended mixture, stirred mixture and added unmeasured amount of milk from a second half pint of milk and blended mixture. S23DS never used a recipe to prepare the pureed desserts. On 06/11/2024 at 11:22 a.m., an observation was made of S12Cook preparing the lunch meal's purred black eyed peas. S12Cook was observed placing an unmeasured amount of cooked black eyed peas into the food processor, added an unmeasured amount of milk from 1- half pint of milk and then blended the mixture. S12Cook stated that total number of residents who consumed pureed diets were between 10 or 11. She denied knowledge of a pureed recipe being available to ensure an adequate amount was being served to those residents. S12Cook was then observed adding 1 single serving packet of thickener to the mixture, then blended the mixture, stopped and added a second single serving packet of thickener to the blended mixture. After blending the mixture, S12Cook was then observed separating the mixture into 3 different sized metal serving bins using a disposable plastic spoon. S12Cook failed to measure how much of the mixture was divided up to ensure an adequate amount among the 3 serving steam tables. On 06/11/2024 at 11:33 a.m., S12Cook was observed removing a total of 7 scoops of rice from the main steam table to the food processor to prepare the pureed rice. She added an unmeasured amount of milk from 1- half pint container, blended the mixture, stopped blending, then added more of an unmeasured amount of milk, and continued to blend the mixture without use of a recipe. On 06/11/2024 at 11:39 a.m., an observation was made of S23DS approach S12Cook and informed her that she would need more chopped meat and black eyed peas because there was not enough on the main kitchen's serving steam table. On 06/11/2024 at 12:02 p.m., an observation was made of S12Cook removing an unmeasured amount of black eyed peas from the main kitchen's serving steam table to blend more for chopped diets because S23DS informed her there was not enough. S12Cook failed to use a recipe. On 06/11/2024 at 3:53 p.m., an interview was conducted with S11DM (Dietary Manager). She stated recipes were located in the main kitchen in designated binders and should be used. She stated S12Cook was filling in and confirmed she should have used the recipes when preparing the lunch meal on yesterday 06/10/2024.

Based on observation, and interview the Facility failed to promote and facilitate residents' self- determination through support of the residents' choice about aspects of his or her life in the facility that were significant to the resident for 2 (#25, #35) out 5 (#2, #25, #35, #63, and #106) residents investigated for choices as evidence by: 1. failure to remove completed food trays from resident's room for Resident #25; 2. failure to support food choices for Resident #35 Findings: Resident #25 Review of Resident #25's medical record revealed an admitted [DATE] with diagnoses which included in part, Type 2 Diabetes Mellitus, Major Depressive Disorder, recurrent severe without psychotic features. Review of Resident #25's annual Minimum Data Sets (MDS) assessment dated [DATE] revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. On 06/10/2024 at 7:35 a.m., an observation was conducted in Resident #25's room, which revealed two food trays. Further review of the food trays revealed that the food trays were from breakfast and lunch dated 06/09.2024. On 06/10/2024 at 7:36 a.m., an interview was conducted with Resident #25 who stated that he did not like when staff left the food trays in his room, because it attracted roaches. The resident stated that this was not the first time, and it happened often. On 06/11/2024 at 2:23 p.m., an interview was conducted with S4CNA (Certified Nursing Assistant) who confirmed that she was assigned to the resident on Sunday 06/09/2024. She stated that food trays were picked up as soon as the residents completed their meal. She stated that she was aware that Resident #25 did not like his food trays to be left in his room, because of roaches. She confirmed that she should have picked up the breakfast and lunch trays on, 06/09/2024, and had not. 49176 Resident #35 Review of Resident #35's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to .Heart Failure, Atrial Fibrillation, Hypertension, Edema and Gastro-Esophageal Reflux Disease. Review of Quarterly MDS (Minimum Data Set) dated 03/20/2024 revealed the resident has a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident is cognitively intact. Review of Resident #35's June 2024 physician's orders revealed an order dated 02/02/2023 that read: Regular diet, Regular texture, Thin consistency, NAS (no added salt). Review of Resident's #35's Meal ticket dated 06/11/2024 revealed in part .Dislikes: Oats/Oatmeal; Bacon .Special Notes: No oatmeal .bacon .at breakfast. Review of Resident #35's current care plan revealed in part .I have altered diet needs r/t HTN (hypertension), HLD (hyperlipidemia), CAS (carotid artery stenting), heart failure, GERD (gastro-esophageal reflux disease), heartburn, indigestion .Maintain a current list of my food likes and dislikes. On 06/10/2024 at 8:21 a.m., an interview was conducted with Resident #35 who stated that even if a food is listed as a dislike on the meal ticket, the food will still be served on her meal tray. The resident stated that this happens often. On 06/10/2024 at 8:54 a.m., an observation was conducted in Resident #35's room, which revealed her breakfast tray and meal ticket. Resident's breakfast tray consisted of one fried egg, one biscuit and four slices of bacon. Further review of the resident's meal ticket revealed in part .dislikes: bacon .special notes: no oatmeal, grits, bacon or ham at breakfast. On 06/11/2024 at 8:09 a.m., an observation was conducted in Resident #35's room, which revealed her breakfast tray and meal ticket. Resident's breakfast tray consisted of scrambled eggs, one biscuit, two slices of bacon and a container of oatmeal. Further review of the resident's meal ticket revealed in part . dislikes: oats/oatmeal; bacon .special notes: no oatmeal, grits, bacon or ham at breakfast. On 06/11/2024 at 8:24 a.m., an interview and meal ticket review was conducted with S16ADON (Assistant Director of Nursing) who confirmed that Resident #35's meal ticket listed oatmeal and bacon as dislikes and should not be served on resident's breakfast tray. An observation of Resident #35's breakfast tray was conducted in resident's room with S16ADON who confirmed oatmeal and bacon were served for breakfast and should not have been.

Based on record review, and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by failing to initiate orders to conduct blood sugar levels on a newly admitted resident with a significant history of Type 1 Diabetes Mellitus and was receiving insulin, for 1 (#4) of 5 (#1-5) sampled residents, and 7 (R1-R7) randomly selected residents. This deficient practice resulted in an actual harm for Resident #4 on 08/18/2023 when became sluggish, lethargic, and short of breath and the levels obtained with the glucometer were too high to be read. On 08/16/2023, the resident was admitted with a significant history of Type 1 Diabetes Mellitus, including a Right Below the Knee Amputation, a recent diagnosis of Diabetic Ketoacidosis, Diabetic foot ulcers, and Gangrene. Resident #4 was hospitalized on [DATE] with a blood glucose level of 814. He was admitted to the ICU (Intensive Care Unit) with diagnosis the included Diabetic Ketoacidosis without coma associated with Type 1 Diabetes Mellitus, and AKI (Acute Kidney Injury) Acute. Resident #4 was hospitalized from 08/18/2023 through 08/24/2023. The facility implemented corrective actions and was in substantial compliance on 08/21/2023, prior to the State Agency's survey, thus it was determined to be a Past Noncompliance citation. Findings: A review of the nursing facility's policy titled Nursing Care of the Older Adult with Diabetes Mellitus was conducted. The policy included, in part: Purpose: To provide an overview of diabetes in the older adult, its symptoms and complications, and the principals of glucose monitoring. 1. Hyperglycemia uncontrolled diabetes from lack of insulin or inadequate insulin results in hyperglycemia. 2. Diabetic Ketoacidosis (DKA) (diabetic coma). Ketoacidosis occurs when hyperglycemia is untreated and the cells begin to metabolize fat for energy. DKA is a life threatening emergency that needs immediate medical attention. The policy included: Blood Glucose Monitoring: 3. for the resident receiving insulin who is well controlled. Monitor blood glucose levels twice a day if on insulin. The policy did not include a protocol for blood glucose monitoring of a resident receiving insulin who was not well controlled. A review of a document titled New Admit/Readmit Checklist revealed: CBG (Capillary Blood Glucose) check daily x 7 days on new admits. A review of hospital documentation in Resident #4's nursing home chart revealed that on 08/16/2023, Resident #4 was discharged from the hospital to the nursing home. Diagnoses included Resolved- Diabetic Ketoacidosis without coma associated with Diabetes Mellitus Type 1, Right left Below the Knee Amputation, (BKA), Gangrene of toe Right foot, Lower Limb Ischemia, Peripheral Artery Disease, Anxiety, Chronic Systolic Heart Failure, Coronary Artery Disease, Diabetes Mellitus Type 1, and Diabetic Ulcer of Left Great Toe. Resident #4's medications included an order for Insulin -Lantus 100 u/ml (units per milliliter). 25 units in the morning. Further review revealed Resident #4's Blood glucose levels while in the hospital ranged as follows: 08/07/23- elevated at 523 mg/dL (milligrams per deciliter), 08/08/23 elevated at 340, 357, and 401 mg/dl. 08/15/23 low at 43 mg/dl. No ranges were noted on the hospital lab results. The Mayo Clinic states that a normal blood sugar level for a Type 1 diabetic ranges between 80 and 130 mg/dL before meals and no higher than 180 mg/dL after eating. Source: Mayo Clinic: Diabetes Conditions and Treatment, May 3, 2023. Review of Resident #4's nursing home record confirmed an admitted [DATE] with diagnoses including Disorder of Circulatory System, Malnutrition, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, and Acute Metabolic Acidosis. A review of Resident #4's Care Plan revealed the following: 08/16/2023: I suffer from DM II (Diabetes Mellitus Type 2); I suffer from diabetic neuropathy and diabetic ulcers; I have history of hyperglycemia (high blood sugar) and DKA (Diabetic Ketoacidosis). Interventions included: CBGs (Capillary Blood Glucose) (accuchecks) as ordered and PRN (as needed); Monitor me for s/s (signs and symptoms) of hyper polyuria, thirst, restlessness, agitation, confusion; Monitor me for complications such as decreased healing, decreased circulation. A review of handwritten admission orders dated 08/16/2023, signed by S1MD and S4LPN was conducted. An order for Lantus insulin 25 units administered Q AM (every morning) was noted. Further review of the orders revealed no order for CBG's to be conducted on Resident #4. A review of the August 2023 printed orders and telephone orders revealed the following: 08/16/2023-Lantus (insulin glargine) inject 25 u (units) sq (subcutaneously) one time a day. There was no order for CBG testing. 08/18/2023-Lantus 27 u sq one time a day. 08/18/2023 CBG's AC/HS (before meals and before sleep) with Humalog sliding scale related to type 2 diabetes mellitus with diabetic polyneuropathy. S4LPN's signature was noted; 08/18/2023 Give 12 u Lispro now recheck CBG. S5LPN's signature was noted; 08/18/2023 give 5 u Lispro now recheck CBG in 30 minutes. S5LPN's signature was noted; 08/18/2023- Send to ER for DX (Diagnosis) hyperglycemia. CBG unable to read. S5LPN's signature was noted. A review of Resident #4's MAR (Medication Administration Record) revealed the Humalog insulin order dated 08/18/2023. Lantus 25 u was administered on 08/18/2023 at 8:00 a.m. The documentation for BS (Blood Sugar) was 400 at 5:00 p.m., and 8:00 p.m., by S5LPN. Lispro 5 u and 12 u were administered by S5LPN on 08/18/2023 as ordered. The BS readings were recorded as 400 for both Lispro administrations. A review of Resident #4's Progress Notes revealed the following: 08/18/2023 at 3:11 p.m. New order per S1MD. CBG AC/HS with sliding scale. Signed by S4LPN; 08/18/2023 at 3:39 p.m. CBG was HI on reading by S5LPN; 08/18/2023 at 4:42 p.m. Res (resident) appears sluggish, CBG checked reads hi. New order noted give 12 u per s/s (sliding scale) by S5LPN; 08/18/2023 at 4:43 p.m. CBG checked reading show hi. New order give 5 units of s/s and recheck in 30 minutes by S5LPN; 08/18/2023 at 5:36 p.m. Greater than 400 by S5LPN; 08/18/2023 at 5:37 p.m. Not given send to ER for hypoglycemia [Sic.] by S5LPN. A review of a document titled Transfer To Other Facility Or Hospital, dated 08/18/2023 was conducted. The document included: Situation 1. Hyperglycemia. CBG unable to read to high. A review of the Emergency Department notes dated 08/18/2023 at 6:30 p.m., was conducted. The History included that the patient presented with Hyperglycemia- was given 12 units Lispro at nursing home, reports CBG still elevated .persistent glucose elevation greater than 600 was given 12 units of Lispro at the nursing home but no change to his glucose levels. Blood sugar level PTA (prior to arrival) 600, Diabetic status: controlled with insulin. Risk factors: History of DKA. Critical Care: Comments included: elevated glucose levels, labs consistent with acute DKA given depressed bicarb levels elevated glucose greater than 800. Started on DKA protocol and admitted to the ICU. Comprehensive metabolic panel: glucose level 814. Diagnosis: 1. Diabetic Ketoacidosis without coma associated with Type 1 Diabetes Mellitus; 2. AKI (Acute Kidney Injury) Acute. A review of a Grievance/Complaint Form dated 08/21/2023 for Resident #4 revealed a complaint that the resident was not getting insulin/CBG checks. The Investigation Findings revealed orders written for CBG/Accuchecks. CBG taken and meds administered per orders. Follow Up Action Taken included: Admissions nurse counseled on obtaining correct orders. The documentation included a Physician's Telephone Order dated 08/18/2023 that included: CBG AC & HS Humalog SS; Lantus 27 units SQ daily. The order was signed by S5LPN. A Notice of Disciplinary Action dated 08/21/2023 with employee name S4LPN noted. The form included: Rule violation-upon admit accuchecks was not initiated. Upon admit any res with DX of DM (Diabetes Mellitus) will have orders for accuchecks with sliding scale to create a baseline for MD (Medical Doctor) to review. The form was dated 08/21/2023 and signed by both S4LPN and S3RN/QA (Quality Assurance). An Inservice Record dated 08/21/2023 signed by S4LPN was noted. The inservice included: Upon admission, if a resident has a diagnosis of Diabetes Mellitus please refer to providers standing orders for accuchecks and sliding scales. All residents are required to have accuchecks with sliding scale to develop a baseline for MD review. An assessment dated [DATE] conducted by S1MD of Resident #4 was reviewed. The assessment included a review of problems, which included Type 1 diabetes mellitus uncontrolled, and Metabolic Acidosis. Further review of S1MD's assessment revealed the following: He has a medical history significant of type 1 diabetes. He was initially admitted and required transfer back to the hospital within about 24-48 hours. During his readmission he was treated for hyperglycemia, diabetic ketoacidosis. On 08/29/2023 at 11:55 a.m., an observation and interview were conducted with Resident #4. He was aphasic and a family member spoke on his behalf. The family member stated that he was admitted to the nursing home from the hospital on 08/16/2023. He stated that on the afternoon of 08/18/2023 he reported to the nurse that the resident was sluggish, lethargic and was having a hard time breathing, and that he was a brittle diabetic and asked what the resident's accuchecks had been reading. They stated that nursing home staff had not checked his sugar until that time. He stated that the staff were administering insulin to him from 08/16/2023 through 08/18/2023 but were not checking his blood sugars. On 08/18/2023 he spoke to S5LPN regarding the resident's blood sugar and the nurse reported that they did not have an order to conduct blood sugars on the resident so they had not been checking it since his admit on 08/16/2023. The family member stated that S5LPN took his blood sugar but it was so high that it did not register a number on the glucometer. They stated that Resident #4 was sent to the ER and then admitted to the ICU (Intensive Care Unit) and that his sugar was over 800. He was in the hospital from 08/18/2023 to 08/24/2023. Resident #4 nodded his head in agreement with his family's account. On 08/29/2023 at 2:45 p.m., an interview was conducted with S5LPN. She stated that Resident #4 was admitted on [DATE], and confirmed that he had a diagnosis of Diabetes Mellitus. She stated that no order for a CBG had been initiated upon his admission and that staff had not conducted blood glucose checks on the resident from 08/16/2023 to 08/18/2023 because there was no order. S5LPN stated that on 08/18/2023, the resident was sluggish and an order for CBG/Accuchecks was received. She stated that the reading on the glucometer on 08/18/2023 was too high to be read. She confirmed that documentation of 400: on the MAR, and clarified that this indicated it was too high to read. S5LPN confirmed that she documented on the transfer form that CBG was too high to be read and they sent Resident #4 to the ER related to hyperglycemia. On 08/29/2023 at 4:30 p.m., an interview was conducted with S2DON. She stated that a plan was put into place to correct lack of CBGs being conducted on Resident #4. She stated that as a result of the CBG's not being conducted, the admissions nurse will follow a new admit/readmit checklist that included that CBGs will be checked daily for 7 days on the new residents. S2DON stated that new or readmitted residents who have a Diabetes diagnosis and are receiving insulin will have CBG's ordered AC/HS for 7 days. On 08/30/2023 at 10:30 a.m., an interview was conducted with S4LPN, who stated that she was the admissions nurse for the nursing home. S4LPN reviewed her handwritten admission orders profile dated 08/16/2023 for Resident #4 and the hospital documentation she transcribed her orders from. She stated that she reviewed all Resident #4's diagnoses, orders, and medications with S1MD. S4LPN confirmed that she had discussed the diagnoses listed on the hospital admission packet including Diabetic ketoacidosis without coma associated with Type 1 Diabetes Mellitus, Right Below Knee Amputation, Diabetes Mellitus, Diabetic Ulcer of Left Great Toe, Gangrene of toe of Right Foot, Lower Limb Ischemia, Peripheral Arterial Disease, Anxiety, Chronic Systolic Heart Failure, and Coronary Artery Disease. She made him aware of the order for the insulin Lantus 25 units q day. She further stated that if S1MD had made any additional orders for Resident #4, including conducting CBG checks on him, she would have written them down. She stated he had not given her an order to conduct CBG checks on the resident. S4LPN stated that S1MD was aware that no CBG's had been ordered on 08/16/2023 when the resident was admitted . She stated that since this situation with Resident #4, S2DON had initiated a procedure to conduct CBGs on all new residents and on readmitted residents. She stated that staff will conduct CBGs AC & HS for 7 days on residents who are have diabetes and are receiving insulin if they don't have orders on admission. S4LPN stated that on 08/18/2023, she overheard Resident #4's family speaking to the nurse at the nurse's station about the CBGs. The family member stated that the nursing home staff needed to be doing the CBG's as the resident was a severe diabetic and when she heard that, it was a red flag to her. She stated that she texted S1MD and got an order from him for CBG's AC and HS to be conducted on Resident #4. On 08/30/2023 at 2:00 p.m., a telephone interview was conducted with S1MD. He stated that when Resident #4 was admitted to the nursing home, the admission nurse called him and they reviewed all the orders, medications, and diagnosis. He confirmed that the only assessment he had conducted on Resident #4 was on 08/29/2023 as the resident was sent out to the hospital shortly after he was initially admitted , and before he (S1MD) was able to see him. This surveyor read the diagnoses from the admission paperwork dated 08/16/2023, from the admitting hospital, and that Resident #4 was receiving the insulin Lantus. S1MD stated that he was aware of all the Resident's diagnoses and that he had been receiving insulin. He further stated that he was aware that no accuchecks had been ordered for the resident from the discharging hospital. S1MD stated that the hospital had discharged the resident to the nursing home with no accuchecks ordered and he saw no reason to add accuchecks to the orders for this resident. He stated that nothing that the admission nurse from the nursing home informed him about the resident, including the diagnoses, made him consider changing any of the orders from the hospital including adding accuchecks for the resident. S1MD stated that If the hospital felt he was stable for discharge to the nursing home, and wrote those orders, why would I add to them? S1MD confirmed that he had been made aware that on 08/18/2023 the resident's Blood Glucose/Accucheck readings were too high for the glucometer to read, and that upon admission to the hospital on 08/18/2023 his blood glucose was over 800. S1MD further stated that he did not think the nursing home staff should have been conducting Accuchecks on the resident when he was admitted on [DATE]. On 08/30/2023 at 4:07 p.m., an interview was conducted with S2DON. She was asked if the nursing home should have been conducting CBG's on Resident #4 between 08/16/2023 and 08/18/2023, when he was admitted and before he became symptomatic and had to be sent out to the hospital due to hyperglycemia on 08/18/2023. S2DON stated they were following the discharge orders from the hospital and the orders did not include CBGs. S2DON further stated that S1MD had not ordered CBGs on the resident, and that S4LPN followed the hospital orders. Review of in-services during the survey revealed the following Corrective Action Plan was implemented. A review of residents admitted from 08/21/2023 revealed that CBG's had been ordered and conducted appropriately. Interviews with multiple nursing staff verified that they were in-serviced and were conducting CBGs per the corrective action plan. The facility had implemented the following actions to correct the deficient practice and was in the process of in servicing all nursing staff with substantial compliance accomplished on 08/21/2023. 08/21/2023- Continuous Quality Assessment and Improvement Corrective Action Plan was initiated: 08/21/2023- In-service conducted for the admission nurse to ensure CBG's/Accuchecks were conducted on any resident with a diagnosis of Diabetes Mellitus; 08/21/2023- A New Admit/Readmit Checklist including CBG checks daily x 7 days on all new admits; 08/29/2023- In-service conducted with nursing staff on signs and symptoms of Hyperglycemia, new admits with a Diabetes diagnosis and/or order of insulin, clarify need of order for accuchecks as needed with NP or MD. 08/29/2023- In-service conducted with nursing staff on signs and symptoms of Hypoglycemia; and Monitoring of CBG orders for new/readmitted residents ongoing from 08/21/2023 for 12 weeks by QA nurse.

Based on observation, interview, and record reviews, the facility failed to protect the resident's right to be free from abuse for 2 (#1, #2) residents out of 5 (#1, #2, #3, #4, #5) sampled residents. The facility failed to protect: 1. Resident #2 from verbal and psychosocial abuse by S2LPN (Licensed Practical Nurse). 2. Resident #1 from verbal abuse made by S4HSK. This deficient practice resulted in psychosocial harm for Resident #2 on 06/08/2023 at 1:15 p.m. when S2LPN yelled expletives at her. Resident #2 was observed crying by staff after the incident. Resident #2 stated during an interview that she was deathly scared of S2LPN and hoped she didn't return to the facility. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: A review of the facility's Abuse/Neglect Policy statement read in part: Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Types of Abuse .4. Emotional abuse- emotional abuse (also known a verbal or psychological abuse) occurs when someone insults a resident or uses threats to control them. It is the most commonly occurring of all the nursing home types of abuse. 1. Resident # 2 A record review of Resident #2's EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] with diagnoses in part: Chronic Kidney Disease Stage 4, Insomnia, Major Depressive Disorder, and Generalized Anxiety Disorder. A record review of Resident # 2's quarterly MDS (Minimum Data Set) dated 06/21/2023 revealed that the resident had a Brief Interview for Mental Status (BIMS) of 13 which indicated she had intact cognition. A review of Resident #2 care plan, with a start date of 02/04/2019, revealed she was care planned for suffering from anxiety and depression, my target behaviors include: feeling down, depressed, hopeless. Care planned interventions included to allow resident to verbalize feelings and listen in a non-judgmental manner. Review of the facility's incident report, dated 06/08/2023 at 5:22 p.m. Read in part .Resident #2 allegation of verbal abuse by staff that occurred with Resident #2 and S2LPN. Further review of the facility's incident report: Staff reported alleged verbal abuse towards Resident #2 (victim). Staff member (S2LPN) was sent home pending investigation. Resident #2 was interviewed to determine if resident feared staff member; denied fear or concern at the time. Review of Resident #2 handwritten statement by S9CNA on behalf of Resident #2 read in part . Date 6/8/2023. Statement: Resident #2 reported that the S2LPN screamed at me. Resident said she tells me where to go, even when I want to go to my room. She leans in and whispers things sometimes. I don't like to ask her for help. Resident then stated I don't know why she doesn't like me and is mean to me. She makes me wait on my meds (medications) and when I go too far she yells at me to wait until she comes, but she is always smoking. Resident noted with tears in her eyes. Resident stated She was just screaming at me but I don't what she said. I felt like she was yelling at me. Review of S6CNA (Certified Nursing Assistant) handwritten statement dated 6/8/2023 read in part Resident #2 approached S2LPN to let her know she needed a bandage on her hand. S2LPN replied You're not my only resident. I have 30 f***ing other residents. Review of S9CNA handwritten statement dated 6/8/23 read in part I was sitting at nurse's station and noticed Resident #2 being pushed to nurse S2LPN cart. I then heard S2LPN loudly and sternly scream at Resident #2 You are not my only f***ing patient, I have 30 more to care about. The resident tried to speak and S2LPN told her to just shut up you understand me then aggressively turned her chair around aggressively and rolled off. About 20 minutes later she returned and put the resident in the dining room. Resident #2 dropped her head and was shaking it. Resident #2 looked up at me (S9CNA) and said I'm terrified. She is so mean to me and no one listens or believe me. She tortures me. On 08/07/2023 at 1:07 p.m., an interview was conducted with Resident #2. She was questioned about the incident from 06/08/2023. She stated S2LPN, that nurse is mean. She was mean to me and I was deathly scared of her. She is a nurse so she can give me any medications that could hurt me. I am deathly scared of her and I hope she never comes back. Resident #2 stated she needed a bandage for her thumb so she went up to S2LPN and S2LPN started yelling and fussing at her. She stated I do not know exactly what she said to me but she was yelling and fussing. Resident #2 mentioned that after she was given her bandage, S2LPN wheeled her fast down the hall to her room. She stated S2LPN never hurt me physically, but she was just mean and I did not report it to anyone. Phone calls made to S2LPN on 08/07/2023 at 8:56 a.m., 08/07/2023 at 3:15 p.m., and 08/08/2023 at 8:00 a.m. were not returned and therefore she was unable to be interviewed. On 08/08/2023 at 11:06 a.m., a phone interview was conducted with S6CNA. S6CNA was tearful while describing the events that occurred on 6/8/2023. She stated she was by the nurse's station when Resident #2 approached S2LPN to let her know she needed a bandage on her hand. S2LPN replied You're not my only resident. I have 30 f***ing other residents. S2LPN then took wheeled Resident #2 down to her room. S6CNA stated when S2LPN responded to the Resident she was yelling at her. S6CNA said after S2LPN assisted the Resident, she went to check on Resident #2. That is when Resident #2 told her was scared of S2LPN. However now, she stated that Resident #2 seems happier and comes out of her room more now that S2LPN is no longer in the facility. On 08/08/2023 at 11:45 a.m., an interview was conducted with S1ADM and S5LPNAA. S1ADM confirmed verbal abuse did occur. He was aware that Resident #2 was scared of the nurse after this incident. The facility has implemented the following actions to correct the deficient practice: 06/08/2023- Plan of correction Quality Assurance and Performance Improvement: 1. Staff member was sent home pending investigation. Resident was interviewed to determine if resident feared staff member alleged or if resident had concern for their safety. 2. Social Services conducted targeted core rounds in the area where staff member alleged of verbal abuse was assigned continued core rounds were conducted for residents to determine if other residents were affected by alleged abusive practice. 3. Facility staff were in serviced on verbal abuse, examples of verbal abuse, how verbal abuse affects residents, signs of verbal abuse and preventing verbal abuse. Continued care rounds will be conducted at least 3 times a week for 4 weeks to ensure compliance 4. The facility continues care round ambassador will report allegations of verbal abuse to administrator immediately. Administrator and or designee will monitor continued care rounds through report in standup meeting. This monitoring will be 5 times weekly for 4 weeks. The results of this monitoring will be taken to the monthly QAA meeting. 5. Date of compliance: 6/9/2023 06/08/2023- All staff have received in service on verbal abuse; monitoring conducted and documented with ongoing trainings continued. 2. Resident #1 What were our findings from the evidence? Did this rise to the level of verbal abuse? Review of Resident #1's medical record revealed she was admitted on [DATE]. Resident #1's diagnoses included Unspecified Dementia, Anxiety Disorder, Major Depressive Disorder, Chronic Kidney Disease, Hypokalemia, Hypertension, and Hyperlipidemia. Review of the resident's most recent quarterly MDS dated [DATE] revealed the resident had a BIMS score of 7, indicating the resident had severely impaired cognition. Review of the facility's incident report dated 06/20/2023 read in part, Accused: (S4HSK). Victim: (Resident #1). Staff member was alleged as having committed verbal abuse toward a resident requesting assistance from the staff. Staff member sent home. Resident safety ensured. Investigation underway. Review of handwritten witness statement 06/20/2023 at 10:40 a.m., by S3LAN read in part .Resident #1 was in her room and S4HSK was out in the hall when Resident #1 had asked S4HSK to come see. S4HSK walked into Resident #1's room and S4HSK stated I had already told you I was going to bring you some toilet paper with a bit of an attitude. Resident #1 then stated I just wanted to show you something. At that point S4HSK just continued to repeat herself but got a little uglier about it. I (writer) had went bring clothes next door and when I got out I heard S4HSK and Resident #1 arguing in a very heated way so I had stepped into the room to try to defuse the situation which I barely could get a word out except okay, okay guys, because of how heated they were then. They threatened to report each other and stormed into the hall way and as Resident #1 and S4HSK started walking away from each other, S4HSK told Resident #1 you better find something safe to do. On 08/07/2023 at 12:52 p.m., an interview and observation was conducted with Resident #2. When asked about her incident with S4HSK, she stated she did not remember who S4HSK was or having any arguments with them. On 08/07/2023 at 11:37 a.m., an interview was conducted with S3LAN. She was questioned about the incident from 06/20/2023. She stated S4HSK was out in the hall when Resident #1 had asked S4HSK to come see. S4HSK walked into Resident #1's room and S4HSK stated I had already told you I was going to bring you some toilet paper with an attitude. Resident #1 then stated I just wanted to show you something. At that point, S4HSK just continued to repeat I had already told you I was going to bring you some toilet paper. S3LAN went to bring clothes next door and when she walked out of the room she heard S4HSK and Resident #. They were in a heavy heated argument and Resident #1 and S4HSK were yelling at each other while they were arguing. S3LAN said when she walked into the room they were very close to each other, but no physical abuse had occurred. Resident #1 and S4HSK started walking away from each other and S4HSK told Resident #1 you better find something safe to do. S3LAN immediately notified her supervisor. S3LAN stated that when S4HSK said Resident #1 you better find something safe to do, she found it threatening to the resident and felt the need to report it right away to her supervisor. On 08/08/2023 at 11:56 a.m., an interview was conducted with S1ADM. S1ADM confirmed verbal abuse was allegation was substantiated. He stated he was not employed during this incident, but S4HSK was terminated immediately. S1ADM explained he was recently hired as the administrator of the facility and did not have access to the State Agency incident reporting system and therefore had emailed the state agency directly to report the findings and allegations of this incident. He stated they did an in-service after the incident and the staff completed rounds on the residents. The facility implemented the following corrective action: 1. 06/29/2023- All staff had received re-education on different types of abuse, how to protect the elderly on abuse, and reporting policies. 2. Care rounds were conducted with residents 3 times a week for 4 weeks, and monitoring was completed 5 times weekly for 4 weeks. Completion date was 07/18/2023.

Based on record review and interviews, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to prevent and control the spread of COVID-19 to 5 (#6, #7, #9, #10, and #12) sampled residents, and had the potential to affect all 161 residents residing in the facility. This failed practice resulted in an Immediate Jeopardy (IJ) on 1/20/22 when the facility's administration failed to have a system in place to 1. Ensure staff who have signs and symptoms of COVID-19 and/or test positive for COVID-19 are immediately removed from the workplace; 2. Ensure that staff, who tested positive for COVID-19, do not return to work if they have not met Return to Work Criteria; 3. Ensure that the facility's Infection Preventionist was responsible for the facility's Infection Prevention and Control Program. This failed practice resulted in 5 residents testing Positive for COVID-19 after exposure to COVID-19 positive staff. One (1) of the 5 resident was admitted to the hospital with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Cross reference F880 and F882. Review of the facility's policy titled Infection Prevention and Control Program, read in part . Staff Notification of COVID-19 and removal from the Workplace: This facility requires staff to immediately notify their supervisor when they are having signs or symptoms of COVID-19, have tested positive for COVID-19, or have been diagnosed with COVID-19 by a licensed healthcare provider . Medical removal from the workplace: The facility will immediately remove staff from the workplace if they have signs and symptoms of COVID-19, have received a positive COVID-19 test, or have been diagnosed with COVID-19 by a licensed healthcare provider (i.e., immediately send them home or to seek medical care, as appropriate). Review of the facility's policy titled Return to Work Criteria, read in part . Symptomatic staff may return to work after all the following are true: Without fever at least 10 days have passed since symptoms first appeared and at least 24 hours have passed with no fever-reducing medication, and other symptoms of COVID-19 are improving (loss of taste and smell may persist for weeks or months and need not delay the end of isolation). On 02/08/2022 at 1:15 p.m., an interview was conducted with S2MDS (Minimum Data Set) who was the certified Infection Preventionist (IP). S2MDS stated that she assisted in training S10ADONIC (Assistant Director of Nursing/Infection Control) but her current duties were in the MDS office. S2MDS stated that she is not involved with the day to day duties of the infection control position. S2MDS stated that she is not made aware of any employees who test positive, she only has access to resident's information. On 02/09/2022 at 1:47 p.m., an interview was conducted with S10ADONIC who stated that she was informed by S1DON (Director of Nursing) when an employee tested positive, but was not involved in the decision of whether to allow the employee to work or send them home. On 02/09/2022 at 4:14 p.m., an interview was conducted with S1DON who stated that she was aware that the employees (S13LPN, S14LPN and S5LPN) were having symptoms of COVID-19 and still allowed them to work because of the crisis mandate by the CDC. S1DON added that she was well aware of the situation because S18NP (Nurse Practitioner) lets her know who tested positive and of any symptoms they were experiencing. S1DON stated that administration makes the decision whether to allow the employee to continue working or not. On 02/10/2022 at 10:33 a.m., another interview was conducted with S1DON (Director of Nursing) who stated that S22IC (Infection Control) was on staff as the infection preventionist, but did not play an active role within the facility's infection control program. The infection preventionist position was not filled and had been vacant for 3 weeks. S1DON stated that she and S10ADONIC (Assistant Director of Nursing/Infection Control) were not certified in infection control and that S2MDS was the only certified full time infection control employee, but her main duties were in the MDS office. S1DON further stated that the staff should have been sent home after testing positive for COVID-19. She verified that when those staff came to work and tested positive for COVID-19, she did not make an attempt to replace the nurses but allowed them to continue to work. S1DON stated that when staff had symptoms and/or test positive for COVID-19, they should be sent home immediately and isolate for 5 days. On 02/10/2022 at 11:00 a.m., an interview was conducted with S17Owner who stated that if the staff has mild or no symptoms, if they are feeling well enough, then they can work with residents. On 02/11/2022 at 10:54 a.m., a phone interview was conducted with the S23MD (Medical Director) who stated that in December 2021, the S17Owner, and S19Adm (Administrator) had discussed with him that the facility may get to the point of crisis staffing. S23MD stated that he relied on the Administrative staff, S17Owner, S19Adm and S1DON to make the day to day decisions about how they would provide nursing coverage in the facility if staff were COVID-19 positive. He was not aware that the facility began allowing COVID positive staff who had signs and symptoms to work with COVID negative residents. On 02/11/2022 at 1:25 p.m., a follow up interview was conducted with S1DON who confirmed that she should have reviewed the COVID-19 rapid test results and been more aware of the signs and symptoms the employees were experiencing.

Based on record review and interview, the facility failed to take actions to prevent the transmission of COVID-19 to 5 (#6, #7, #9, #10, and #12) sampled residents. This deficient practice had the likelihood to affect all 161 COVID negative residents residing in the facility. The facility failed to 1. Ensure staff who had signs and symptoms of COVID-19 and/or test positive for COVID-19 were immediately removed from the workplace, and not allowed to work with COVID-19 negative residents; and 2. Ensure that staff, who tested positive for COVID-19, did not return to work if they did not meet Return to Work Criteria. This failed practice resulted in an Immediate Jeopardy (IJ) on 1/20/2022 when the provider allowed symptomatic and or COVID-19 positive staff to provide care to COVID-19 negative residents. On 01/20/22, S12LPN, tested COVID-19 positive with symptoms and worked with COVID-19 negative residents on Halls B and C. On 01/22/22, S13LPN worked 8 hours after testing positive for COVID-19 with shortness of breath (SOB) and coughing. On 01/24/22, S14LPN, who tested positive for COVID-19 with watery eyes and congestion worked 6 hours with COVID-19 negative residents on Hall A and B. On 01/24/22, S11LPN returned to work 3 days after testing positive for COVID-19 on Halls A and B. On 01/24/22, S5LPN returned to work 3 days after testing positive for COVID-19 on Halls A and B. On 01/24/22, Resident #9 on Hall B tested positive for COVID-19. On 01/25/22, Residents #10 and #12 on Hall B tested positive for COVID-19. On 01/27/22, Resident #6 on Hall A and Resident #7 on Hall B tested positive for COVID-19. On 02/02/22, Resident #6 was admitted to a local hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . S17Owner stated that, in staffing crisis they can use COVID-19 Positive staff with signs and symptoms to work with COVID-19 Negative residents as long as the nurse feels well enough to work. The administrator was notified of the Immediate Jeopardy on 2/10/2022 at 5:05 p.m. The IJ was removed on 2/11/2022 at 4:10 p.m., when the facility presented an acceptable POR (plan of removal), which by record review and interview, the survey team verified was in progress. This deficient practice continues at a potential for more than a minimal level of harm for the COVID-19 negative residents who reside in the home. The POR read as follows: IJ Plan of Removal: A plan to maintain proper staffing levels and monitor for COVID symptoms must be implemented. 1. The residents identified by numbers 5, 6, 7, 9, 10, and 12 are no longer on isolation or quarantine precautions. Following CDC and CMS recommendations, these residents who have tested positive will not receive subsequent testing until 90 days. Resident identified by number 6 returned to our facility on the 5th of February from the hospital. 2. All other residents in the facility were tested on [DATE] and no residents were identified as being positive for COVID. 3. Screening was initiated on 2/10/2022 at 5:11 p.m. The Nursing Administration Team screen facility wide for the signs and symptoms of COVID-19 including those symptoms specific for the Omicron variant. Screening for staff and visitors will continue at the entrance to the facility. Staff or visitors who have a positive screen will be directed towards the nursing supervisor on the floor in order to determine next action. Next action to be a point of care or rapid antigen test for COVID-19 or the Omicron variant. Visitors will be asked to not enter the facility. Routine testing based on outbreak status or parish transmission rate is to be completed by the Nursing Supervisor on staff. The Nursing Supervisor on staff will be required to communicate positive results to the Director of Nursing Services. Positive staff members will be asked to leave the facility. Staff testing that was initiated by staff displaying sign or symptoms of COVID-19 or the Omicron variant, is to be completed by the Nursing Supervisor on staff. The Nursing Supervisor on staff will be required to communicate positive results to the Director of Nursing Services. Positive staff members will be asked to leave the facility. The Director Nursing or designee will be responsible for the implementation of the policy regarding staff screen, sending home after testing positive, and return to work policy. In response to routine testing due to the community positivity rate, staff will be required to take the point of care testing/rapid antigen prior to the start of t heir shift, regardless of the presence or lack of symptoms. The nurse supervisor on shift will be responsible for administering this test and continuing to report any positive tests to DON as listed above. If a staff member is suspected of developing signs and symptoms of COVID during their shift, staff will be in serviced by the director of nursing or designee instructing them to report the suspected symptoms to the nursing supervisor on shift right away. The nursing supervisor on shift will initiate a point of caré/rapid antigen test. Positive rapid antigen test and the form with symptoms will be reviewed by the nursing supervisor on shift and will result in the employee being sent home. Nursing supervisor on duty will then inform the director of nursing of the positive rapid test and employee leaving the facility post positive test. 4. The screening logs will be monitored 5 times a week by the administrator or designee. DON or designee will monitor the community transmission rate, weekly testing, as well as symptomatic testing 5 days per week. During these checks, the administrator, director of nursing, or designee will check for competency of screener, ward clerk, and nurse supervisors on shift to ensure that their understanding or proper procedure in place. Staff found to not be competent or other issues wil be addressed in real time leading to termination. Staff will be monitored by administrator or designee 5 times a week on reporting signs and symptoms of COVID-19 or Omicron variant to nursing supervisor on shift. Any staff found not to be competent will be re in-serviced leading to termination. Monitors will be kept on a QA (Quality Assurance) tool for the next 6 weeks. Procedures will remain in place after monitoring stops. Training: 1. As of 2/10/2022 all residents were tested and no residents were identified as being positive for COVID. 2. The Director of Nursing in-serviced the designated screener and ward clerks on 2/10/2022. The in-service covered asking questions about the symptoms listed on the AHC/NCAL (American Health Care Association/National Center for Assisted Living) COVID-19 screening checklist for visitors and staff. 3. Regional Operations will in-service DON, Administrator and Administrative Staff on the screening signs and symptoms process, return to work criteria, routine rapid testing to be conducted at the start of the staff member's shift, and sending positive staff home. This in-service took place at approximately 6:30 p.m., on 2/10/2022. Findings: Review of the facility's policy titled Infection Prevention and Control Program, read in part . Staff Notification of COVID-19 and removal from the Workplace: This facility requires staff to immediately notify their supervisor when they are having signs or symptoms of COVID-19, have tested positive for COVID-19, or have been diagnosed with COVID-19 by a licensed healthcare provider . Medical removal from the workplace: The facility will immediately remove staff from the workplace if they have signs and symptoms of COVID-19, have received a positive COVID-19 test or have been diagnosed with COVID-19 by a licensed healthcare provider (i.e., immediately send them home or to seek medical care, as appropriate). Review of the facility's policy titled Return to Work Criteria, read in part . Symptomatic staff may return to work after all the following are true: Without fever at least 10 days have passed since symptoms first appeared and at least 24 hours have passed with no fever-reducing medication, and other symptoms of COVID-19 are improving (loss of taste and smell may persist for weeks or months and need not delay the end of isolation). S11LPN reported to S18NP during her shift of 01/19/22, symptoms of sinus issues and feeling tired. Review of the facility's 24-hr Staffing Schedule, dated 01/19/22, revealed S11LPN worked Halls A, D and E. On 01/20/22, S11LPN's rapid [CONDITION(S)] COV-2 (COVID 19 antigen test) revealed a positive result at 6:06 a.m. and she went home. Review of the PrintTimeCardDialog revealed that S11LPN returned to work on 01/24, and 01/25/22, prior to meeting Return To Work Criteria and was assigned to Hall A and B. Review S12LPN's rapid [CONDITION(S)] COV-2, dated 01/20/22, revealed a positive test upon arriving for her shift, via onsite rapid test. She worked giving medications to COVID-19 negative residents. According to the facility's document, titled PrintTimecardDialog revealed S12LPN worked on 01/20, 01/21 and 01/24/22 on Hall B and C. Review of S5LPN's rapid SARSCOV-2 revealed she tested positive on 01/21/22 and she went home. According to the facility's document, titled PrintTimecardDialog, S5LPN returned to work on Monday, 01/24/22, prior to meeting Return To Work Criteria and was assigned to Hall A and B. Review of S13LPN's rapid SARSCOV-2 test revealed she tested positive on 01/22/22 and reported signs and symptoms of dyspnea (shortness of breath) and cough. According to the facility's document, titled PrintTimecardDialog, S13LPN worked on 01/22/22 from 6:41 a.m., to 2:52 p.m. S13LPN was a nursing supervisor on duty. S14LPN reported S/S to S18NP of feeling tired and body aches on 01/21/22. Review of the facility's document titled PrintTimecardDialog revealed she proceeded to work on 01/21/22 from 11:58 a.m. to 10:09 p.m. Further review of S18NP's notes on Saturday, 01/22/22, revealed S14LPN reported body aches and congestion and on Sunday, 01/23/22, she reported yellow productive [MEDICATION(S)] and body aches. On 01/24/22, S14LPN's rapid SARSCOV-2 test was positive. Review of the facility's document titled PrintTimecardDialog, dated 01/24/22 S14LPN worked from 1:34 p.m. to 7:18 p.m. giving medications on Halls A and B. Resident #6. Resident #6, who resided on Hall A, was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's MAR (Medication Administration Record), dated January 2022, revealed that on 1/24, 1/25, and 1/26, S5LPN and S14LPN were assigned to the resident and administered his medication as well as other patient care. S5LPN tested positive for COVID-19 on 01/21/22 and did not self-isolate, but continued working with the residents. S14LPN tested positive for COVID-19 on 01/24/22, prior to the beginning of her shift, and continued to work her shift until 7:00 p.m. S14LPN also administered the resident his medications and provided other patient care Review of Resident #6's COVID antigen test, dated 1/27/2022, revealed positive COVID-19 results Review of Resident #6's nurses' notes revealed the following: 02/01/22 at 2:19 p.m., the resident had new orders for O2 (Oxygen) at 2 liters per nasal cannula to keep oxygen Sat (saturation) above 94%; [MEDICATION(S)] (inhaler) 2 puffs 4 times a day (for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 02/02/22 at 9:12 a.m., [MEDICATION(S)] (inhaler) 2 puffs administered for wheezing. O2 Sat was 85%. 02/02/22 at 12:09 p.m., the resident was noted sleeping and falling asleep mid conversation . O2 Sat 90%. resident stated he was very tired. Gave inhaler and O2 went up to 95%. 02/02/22 at 3:20 p.m., resident resting, refused care due to not feeling well. 02/02/22 at 4:08 p.m., resident was taken to a local hospital for treatment via ambulance. He was admitted for COVID-19, Shortness of Breath, and [CONDITION(S)] (low oxygen levels). Resident #7. Resident #7, who resided on Hall B, was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's MAR, dated January 2022, revealed that S12LPN administered medication to the resident on 1/20, 1/21, and 1/24. S12LPN tested positive for COVID-19 on 1/20/22 and continued to work on 1/20, 1/21, and 1/24/22. Review of Resident #7's COVID antigen test dated 1/27/22 revealed positive COVID-19 results. Resident #9. Resident # 9, who resided on Hall B, was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's MAR, dated January 2022, revealed that on 1/24, the resident's medication was administered by S14LPN. Further review revealed that on 1/24/22, S14LPN tested positive for COVID-19 and complained of having signs and symptoms of COVID-19. Review of Resident #9's COVID antigen test dated 1/24/2022 revealed positive COVID-19 test results. Resident #10. Resident #10, who resided on Hall B, was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's MAR, dated January 2022, revealed that on 1/20 and 1/24, S5LPN and S14LPN administered Resident #10's medications. Review of Resident #10's COVID antigen test result, dated 1/25/22, revealed a positive result for COVID-19. Resident #12. Resident #12, who resided on Hall B, was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's MAR, dated January 2022, revealed that on 1/24/22 and 1/25/22, S5LPN and S14LPN administered medications to the resident. Review of Resident #12's COVID antigen test result, dated 1/25/22, revealed a positive COVID-19 test result. On 02/08/22 at 3:48 p.m., an interview was conducted with S14LPN who stated that she worked 2 p.m. to 10 p.m. and always worked on Halls A and B. S14LPN stated that when she clocked in on 01/24/22 she had watery eyes and congestion. A rapid test was then completed onsite, and about 15 minutes after being on the hall, S1DON notified her that the rapid test she had just completed was positive for COVID-19. S14LPN stated that her eyes were watery and her voice was deep like a man from the congestion but stated to S1DON that she could work. S14LPN stated that no one told her after testing positive for COVID-19 she was supposed to go home immediately. S14LPN added that S1DON asked her if she felt well enough to continue working and she said yes but later began to experience increased symptoms. S14LPN stated that is when she verbalized to the supervisor on duty that she needed to go home. She confirmed that she passed her medications on Halls A and B. On 02/09/22 at 4:00 p.m., an interview was conducted with S5LPN who stated that she had been feeling bad for about four days but continued to work before she tested positive for Covid-19. S5LPN stated that she had a runny nose and she thought it was sinus but she just was not feeling well. She added that she was rapid tested on site 4 days consecutively because she did not feel well. S5LPN stated that on Friday, 01/21/22, she felt tired, had body aches and headache, and she tested positive and went home. On 02/10/22 at 8:45 a.m., an interview was conducted with S13LPN who stated that she had a little tickle in her throat not a real cough. S13LPN stated that she performed an onsite rapid test on herself and tested positive on 01/22/22. S13LPN stated she remained at work but stayed in the ADON's office because of her cough. She stated that she did not work her usual 12 hour shift because when her cough became worse at 3:00 p.m., she went home. S13LPN confirmed that on Monday, 01/24/22, she returned to work, 2 days after her positive test. On 02/10/22 at 10:30 a.m., an interview was conducted with S1DON. She stated they were in a staff crisis at the end of December 2021. She stated that the facility hired new staff at the beginning of January so staffing leveled out by January 15th - 17th, and they were no longer in a staffing crisis by that time. She confirmed that she did not attempt to call other staff to come in to work, or rearrange work duties although she knew they tested positive for COVID-19. She verified again that they were not in a staffing crisis on 01/20/22 and onward because they had hired new staff. During the interview, DON provided the January 2022 staffing schedule for permanent facility staff, not including agency staff. She reviewed the schedule to show that 7 new nurses started in the beginning of January, were all out of orientation, and were working before 01/20/22. On 2/10/22 at 11:00 a.m., an interview was conducted with S17Owner who stated that, in a staffing crisis they can use COVID-19 Positive staff with signs and symptoms to work with COVID-19 Negative residents as long as the nurse feels well enough to work. On 2/10/22 at 12:15 p.m., an interview was conducted with S20LPN who stated that she conducted the Rapid Testing for staff on Monday's and Thursday's or if someone had symptoms. S20LPN stated that when she received the results, she communicated the positive results to S1DON. She added that S18NP was also made aware of the positive results and would follow up with the staff to find out how they were doing and if they had received treatment from an outside facility. During an interview on 02/10/22 at 12:16 p.m., S18NP stated that the facility did not want her to do employee health, but she did write notes on the symptoms that S5LPN, S11LPN, S12LPN, and S14LPN had reported to her. S18NP stated that she forwarded her notes to S19ADM. On 02/10/22 at 5:00 p.m., an interview was conducted with S1DON who confirmed that she was aware that S5LPN, S11LPN, S12LPN, S13LPN and S14LPN had tested positive for COVID-19 and continued to work with residents. S1DON confirmed that S14LPN informed her that she was feeling tired, aching and not eating. S1DON confirmed that she observed S13LPN coughing and had commented to her to try to cough whatever it was up. S1DON also confirmed that S12LPN reported to her that she felt achy and was not feeling well. She also confirmed that she was aware that S5LPN was experiencing sinus issues and congestion as well as S11LPN who was experiencing fatigue and headaches. S1DON stated that the employees should have been sent home immediately after testing positive for COVID-19. On 02/11/22 at 10:30 a.m., an interview was conducted with S19ADM who stated that in January 2022, when the facility had the outbreak of COVID-19, he and S17Owner had discussed with S23MD the option of Crisis Staffing. S19ADM stated that S23MD was notified of all resident's and staff who tested positive for COVID-19 and that S23MD was aware that staff who tested positive and had symptoms were working with residents who were not positive for COVID-19. S19ADM stated that S23MD agreed with the plan to implement Crisis Staffing, as long as the facility was operating within the guidelines of the CDC Crisis Staffing protocol. On 02/11/22 at 10:54 a.m., a phone interview was conducted with the S23MD (Medical Director) who stated that in December 2021, the S17Owner, and S19Adm (Administrator) had discussed with him that the facility may get to the point of crisis staffing. S23MD stated that he relied on the Administrative staff, S17Owner, S19Adm and S1DON to make the day to day decisions about how they would provide nursing coverage in the facility if staff were COVID-19 positive. He was not aware that the facility began allowing COVID positive staff who had signs and symptoms to work with COVID negative residents. On 02/11/22 at 1:25 p.m., another interview was conducted with S1DON who confirmed that she did not review the screening sheets for S13LPN, S14LPN, S12LPN or S5LPN when they tested positive for COVID-19. She confirmed that she should have reviewed the Rapid test results and been aware of the signs and symptoms the employees were experiencing. S1DON also confirmed that the employees who tested positive should have been sent home and not allowed to work until they met the return to work criteria. Based on observation, record review, and interview the facility's failed to ensure appropriate infection control practice was implemented during wound care treatments for 3 of 3 (#2, #3, #4) residents investigated for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings: 1. Review of the facility's policy titled, Wound Care read in part, 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 .2. 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. 13. Dress wound .Be certain all clean items are on clean field. 16. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container .19. Use clean field saturated with alcohol to wipe overbed table .21. Wipe reusable supplies with alcohol as indicated (i.e., outsides of containers that were touched by unclean hands, scissor blades, etc.). Return reusable supplies to resident's drawer in treatment cart. 22. Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart. Resident #2 Review of Resident #2's clinical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply silver alginate and cover with dry clean dressing QOD (every other day) and PRN (as needed) soiled/dislodged. On 2/7/22 at 2:29 p.m., S3TxNurse was observed preparing clean supplies for Resident #2's wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . She entered the resident's room with supplies in hand then placed them on the resident's rolling bedside table. S3TxNurse did not disinfect the bedside table or place a cloth on the table before setting down the supplies. Resident #2 was observed sitting in her wheel chair wearing socks and slippers with feet touching the floor. S3TxNurse knelt on both knees on the floor then proceeded to remove the resident's slipper and sock off her right foot. The resident's bare foot was observed flat on the floor. After removing the old wound dressing, S3TxNurse removed the cup of gauze soaked in wound cleanser from the bedside table and placed it on the floor next to the resident's left foot. She proceeded to clean the wound observed between the resident's right 4th and 5th toe with the resident's bare foot on the floor. She removed the Band-Aid and medicine cup of silver alginate off the bedside table then placed it on the floor. S3TxNurse proceeded with the treatment with the resident's foot on the floor. She placed the silver alginate between the resident's right 4th and 5th toe then placed the resident's right bare foot on the wheel chair footrest, and placed the Band-Aid dressing. S3TxNurse discarded used supplies then exited the room without disinfecting the resident's bedside table. An interview with S3TxNurse was conducted immediately after wound care observation. When asked if wound treatment protocol allowed supplies and the treatment to be done on the floor, she stated that she sometimes does the resident's wound care on the floor. S3TxNurse stated that she probably shouldn't have placed the clean supplies on the floor during Resident #2's wound treatment. Resident #4 Review of Resident #4's clinical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] order dated 2/7/22 arterial ulcer to left dorsal foot cleanse with wound cleanser, pat dry. Apply [MEDICATION(S)] (antibacterial gel) and foam boarder dressing daily and prn soiled/dislodged one time a day every other day and every 8 hours as needed; and an order dated 12/23/21 rt (right) 2nd toe arterial ulcer clean with wound cleanser, pat dry. Apply collagen Ag (alginate) and cover with DCD (dry clean dressing) QOD (every other day) & PRN soiled/dislodged one time a day every other day and every 4 hours as needed. On 2/7/22 at 2:32 pm, Resident #4 was observed sitting in a chair in her room with a wheelchair parked nearby. S3TxNurse entered Resident #4's room and removed 2 cups of water off a small table attached to the resident's wheelchair. She reentered the room with a Band-Aid, plastic cup with gauze moist with wound cleanser, medi honey inside medicine cup with a wooden spatula, and a packet of collagen Ag. She placed the supplies on the small table. She did not set the supplies on a cloth or paper towel. S3TxNurse did not disinfect the table prior to placing items on table. After the wound treatment, S3TxNurse did not disinfect the table. She placed the 2 cups of water back on the resident's table then exited the room. Resident #3 Review of Resident #3's clinical record revealed he was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply unna boots and cover with coban (starting from the foot and working up the leg) every M,W,F (Monday, Wednesday, Friday) and PRN soiled/dislodged. On 2/8/22 at 3:17 p.m., a tray lined with a paper towel of clean supplies containing 2 bottles of hand sanitizer, a package of gauze, a spray bottle of wound cleaning solution, a marker and a pair of scissors was observed on top of the wound care cart. S3TxNurse placed a box of gloves on the tray then entered Resident #3's room with the wound care Nurse Practitioner (NP). S3TxNurse placed tray of supplies on the resident's beside table. The resident was observed sitting in his wheelchair with feet placed on a towel on the floor. S3TxNurse and the NP knelt on the floor, removed the old dressing with scissors, and continued the treatment using the supplies on the tray. Serous drainage and bleeding from the resident's legs was observed during treatment with blood noted on the floor. After the treatment, S3TxNurse exited the room to get supplies to clean the blood off the floor. The resident placed the bottle of wound cleanser onto the clean tray to move around the room in his wheelchair. The NP placed the used scissors on the tray containing the pack of gauze, bottle of hand sanitizer, box of gloves, and spray bottle of wound cleanser. On 2/8/22 at 3:55 pm, S3TxNurse exited room with tray of used supplies. She placed the packet of gauze, box of gloves, and a spray bottle of wound cleaner in a storage shelf on the left side of treatment cart. S3TxNurse was not observed disinfecting the spray bottle before placing it into storage. S3TxNurse confirmed the pack of gauze and box of gloves was used during Resident #3's wound treatment and that she had stored the supplies in the cart. She confirmed that supplies used during wound treatment should be discarded or disinfected after use. On 2/9/22 at 12:15 pm, an interview was conducted with S1DON who stated that the nurse should disinfect the bedside tables before treatment, create a clean field, then disinfect the table after treatments. S1DON stated that nurses should not put clean supplies on the floor. She stated that on 2/8/22 she observed blood on the floor from Resident #3's wound treatment and S3TxNurse exit Resident #3's room with used supplies. S1DON stated that S3TxNurse should have disinfected the reusable supplies and/or discarded the supplies, or left the supplies in the resident's room. She confirmed that S3TxNurse did not follow infection control practices or facility policy for wound treatment.

Based on interview, the facility failed to ensure the individual designated as the infection preventionist with specialized training in infection prevention and control was responsible for and involved in the facility's infection prevention and control program. This deficient practice resulted in an Immediate Jeopardy (IJ) on 1/20/22 when the facility failed to ensure a designated Infection Control Preventionist was performing ongoing involvement, oversight, monitoring and supervision of the facility's infection control program on a day-to-day basis. Findings: Cross Reference F880 and F835 On 2/8/2022 at 1:15 p.m., an interview with S2MDS (Minimum Data Set) who was the facility's certified Infection Preventionist (IP). S2MDS stated that her current duties were in the MDS office and that she was not involved with the day to day duties as the IP. On 2/10/2022 at 10:33 a.m.,an interview was conducted with S1DON (Director of Nursing) who stated that S22IC (Infection Control) was on staff as the infection preventionist, but did not play an active role within the facility's infection control program. The infection preventionist position was not filled and had been vacant for 3 weeks. S1DON stated that she and S10ADONIC (Assistant Director of Nursing/Infection Control) were not certified in infection control and that S2MDS was the only certified full time infection control employee, but her main duties were in the MDS office.

Based on observation, interview and record review the facility failed to ensure adequate supervision to residents to ensure the plan of care for those needing assistance with transfers from staff were being followed for 3 (#4, #6, #7) of 10 (1-#10) sampled residents. This failed practice resulted in an Immediate Jeopardy situation on 12/15/2019 at 1:10 p.m., when Resident #4, who required 2-person assistance for transfers, was dropped to the floor when one CNA (Certified Nursing Assistant) attempted to transfer the resident from a wheelchair to a recliner. After the fall, the resident complained of left arm pain and was transferred to a local hospital where she was diagnosed with [REDACTED]. The facility did not conduct ongoing monitoring and supervision to ensure safe transfer of residents which resulted in continued improper transfers. On 04/22/2020, Resident #4 was assisted again by one CNA during a transfer, became weak and was lowered to the bathroom floor. The Administrator was notified of the Immediate Jeopardy on 07/01/2020 at 2:00 pm. The Immediate Jeopardy was removed on 07/01/2020 at 6:00 p.m. when the facility presented an acceptable plan of removal which included the following: IJ Plan of Removal Goal/Expected Outcome To assure all 54 identified residents are free of harm from improper 2 person transfers. The facility has initiated the following to assure at risk residents are transferred appropriately and appropriate monitoring systems are in place. 1. As of 07/01/2020 any resident who has been assessed and deemed a two person assist will be identified. Staff members are being in serviced on two person assist transfers. This includes meaning of door identifier, instructions in task bar, and care plans. 2. Competency levels will be documented. A monitoring log will include the date, shift, staff member's name/signature, and trainer's name/signature. 3. The monitoring will be ongoing weekly x 4 weeks or until compliance is met. 4. To ensure continued compliance, the DON/designee will perform random two person assist transfer audits once a week. A monitoring log will be kept for long term compliance. 5. Upon return, staff that are PRN or on leave will be trained upon return to work date. 6. If you perform a two person assist without adequate assistance, the disciplinary action will be as following: 1st Offense - Suspension 2nd Offense - Termination This deficient practice has the likelihood to affect the 54 residents identified by the facility as requiring 2 person assistance for transfers. Findings: Resident #4: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Sheet) dated 12/20/2019 revealed: Functional Status: Bed mobility 3/3 (extensive assistance; 2 person physical assistance); Transfer 3/3 (extensive assistance; 2 person physical assistance); Toilet use 3/3 (extensive assistance; 2 person physical assistance); Mobility Devices - wheelchair Review of the Quarterly MDS (Minimum Data Sheet) dated 03/21/2020 revealed: Functional Status: Bed mobility 3/3 (extensive assistance, 2 person physical assist); Transfer 3/3 (extensive assistance, 2 person physical assist); Toilet use 3/3 (extensive assistance, 2 person physical assist) Mobility- wheelchair. A review of the resident's current Care Plan (no date) revealed ADL (Activities of Daily Living) Required assistance. Intervention in place was that the resident was a two person assist for transfers with a gait belt. On 12/16/2019 a BSC (Bed Side Commode) was added as a new intervention. Review of a Post Fall Assessment Report dated 12/15/2019 at 1:10 PM, revealed that Resident #4 called for assistance on the call bell. A CNA responded and did not seek for or wait for assistance. The CNA attempted to transfer Resident #4 from her wheelchair to the recliner by herself. Resident #4's recliner slipped backwards and the CNA dropped the resident on the floor. Resident #4 complained of left arm and right hip pain and was transported to the emergency room for evaluation and treatment. Further review of the report revealed that the facility's intervention was to reeducate staff on transfer x 2 people, dycem (Non slip material) under recliner legs, and suspension of CNA until further investigation. A review of the emergency room assessment dated [DATE] at 2:51 PM, revealed that a x-ray of the resident's left arm was obtained. The results of that x-ray on 12/15/2019 at 3:51 PM, revealed a closed [MEDICAL CONDITION] end of the left humerus. Review of the Witness Statement dated 12/15/2019 by the CNA revealed that she was transferring Resident #4 from the wheelchair to the recliner. When she picked her up, the recliner slid backwards and Resident #4 slid to the floor. On 6/23/2020 at 11:15 AM, an interview was conducted with Resident #4 who was awake, alert and able to answer questions appropriately. Resident #4 stated that on the day her arm was hurt she had called for help. The aide came and wanted to transfer her by herself. Resident #4 stated that she told the aide that she needed 2 people. Resident #4 stated that the aide said no I can do it, I can do it. Resident #4 stated that she was in the bathroom in her wheelchair and she wanted to get to the recliner. The aide insisted that she could do it but she dropped me and I hurt my left arm. Resident #4 added that the aide called for the nurse and they helped pick me up. Resident #4 stated that when she first came into the nursing home she was evaluated and the nurse who evaluated her saw that she needed 2 people for transfers. Review of another Post Fall Assessment Report dated 04/22/2020 at 12:38 PM, revealed that Resident #4 called for assistance via call bell. S3CNA responded to the call and she (S3CNA) attempted to transfer the resident by herself. Resident #4 became weak and was lowered to the bathroom floor. Resident #4 did not sustain any injuries during this incident. The facility's intervention was for the staff to please read all identifiers related to resident on the door and in chart. A review of the Witness Statement dated 04/22/2020, signed by S3CNA, revealed that the resident told her she could stand with assistance in the bathroom and that the resident stated she could hold on to the rail. S3CNA documented that the resident was going down so she put her on the floor. A review of the Care Plan revealed that no new interventions were added after the 04/22/2020 incident. On 06/25/2020 at 12:30 PM, an interview was conducted with S7ADM who stated that when the CNA's were hired the certification they had qualified them to perform all the tasks that were incumbent for a CNA to perform. S7ADM stated that the CNAs had to perform these tasks in order to get their certification, therefore when they were hired they were already competent to perform the work. On 06/29/2020 at 7:40 AM, an interview was conducted with S32LPN who stated that on 04/22/2020 she assessed the resident and found no abnormalities. The resident was able to move all her extremities except for her left arm which was her paralyzed arm. 06/30/2020 at 11:00 AM, an interview was conducted with S8LPN who worked on Hall B/C. S8LPN confirmed that the nurses are responsible for supervising the CNA's. 07/01/2020 at 8:45 AM, an interview was conducted with S3CNA. S3CNA stated that when the incident occurred on 04/22/2020, she thought that Resident #4 could stand and assist her during transfer. S3CNA confirmed that she did not feel like she needed to call for assistance. S3CNA stated that Resident #4 was previously on Hall C and stated that when she cared for Resident #4 on the Hall C, she always transferred the resident by herself. S3CNA stated the resident moved to Hall D and had been on that hall for a few days when she cared for her on 04/22/2020. S3CNA stated that she was not aware the resident was a two person assist. When S3CNA was asked about the door indicators and resident information from the kiosk, S3CNA stated that the door indicators were not on the outside of the door at the time. S3CNA added that the kiosk charting was the last thing she did before her shift ended, so she would not have been aware that the resident was a 2 person assist. S3CNA stated that after the incident there was a memo that was put out for staff to read and sign. S3CNA stated that she never attended an in service about 2 person assist transfers. On 07/01/2020 at 10:40 AM, an interview was conducted with S9LPN on Hall C. S9LPN was asked how she supervised CNAs. S9LPN stated that if she was in the area giving medications and walked into the resident's room while the CNA was giving care, then she will observe the CNA. S9LPN stated that for her to get up and go check on the CNA to ensure the CNA was doing things correctly, no I don't have time for that. On 07/01/2020 at 11:10 AM, an interview was conducted with S17DON who stated that the nurses on the hall were supposed to supervise the CNA's and she did not know why some nurses said they didn't have time to properly monitor the CNA's. Resident #6: A review of the face sheet revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS revealed on 06/09/2020 an annual review was conducted which revealed that resident's cognitive skills for daily decision making - severely impaired. ADL's reveal bed mobility 3/3; Transfer 3/3; Dressing 4/2; Eating 3/2 and toilet use 3/3. Ability to hear -moderate difficulty; Speech Clarity - no speech; Makes self-understood - rarely/never understood; Ability to understand others - rarely/never understands; Vision - moderately impaired. Bowel and Bladder revealed the resident - always incontinent. BIMS score was left blank. On 06/24/2020 at 8:35 AM, an observation was made of Resident # 6 during a 2 person assist transfer by S1CNA and S2CNA. S1CNA sat Resident #6 up in bed and S2CNA assisted by supporting the resident's head and shoulders. The resident was leaning to her right side, her legs were not straightened, and her feet were not touching the floor. After S1CNA and S2CNA sat up straight in the bed, S1CNA grabbed the resident under the left arm. S2CNA asked S1CNA if she was not going to use a lift. S1CNA stated no, the resident could be transferred with them holding her under her arms. S2CNA then grabbed the resident under her right arm and S1CNA told S2CNA to grab the resident's pants. S1CNA and S2CNA lifted the resident off of the bed by picking her up from under her arms and S2CNA grabbed the back of her pants. The CNA's then pivoted with the resident and placed her in the geri chair. On 06/25/2020 at 11:10 AM, an interview was conducted with S21PT (Physical Therapist) who stated that grabbing a resident under the arm and transferring them was not recommended because of possible injury to the axillary and arm area. Resident #7: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Sheet), ARD (Assessment Reference Date), 04/08/2020 Section G: for Functional Status revealed the resident was coded 3- Extensive Assistance - resident involved in activity, staff provide weight bearing support; 3 - Two plus person assistance for transfers. Section C: Cognition was coded 2 indicating severe impairment. Review of the Tasks sheet for CNAs (Certified Nursing Assistants) regarding routine daily care of Resident #7 revealed the resident required 2 persons for transferring. Review of the resident's current Care Plan (no date) - ADL (Activities of Daily Living) assistance required. Interventions/Tasks - Assist x 2 with ADL's and transfers. The Witness Statement dated 04/17/2020 at 8:00 (p.m.) by S6CNA read Transferring (Resident #7) into her bed her leg brush again her wheel chair . (Sic) During an observation and interview with Resident #7 on 06/29/2020 at 11:50 a.m., the sign outside of the room on the wall name plate had 2 stick figures, indicating the resident was a 2 person assist for transfers. The resident was observed to be small, thin and had thin skin with bruises noted on the back of her hands. She was lying in bed and was oriented to place, time of day and person. When asked how many people came to help her move from the bed to the chair or the chair to the bed, she stated that usually one person helped but sometimes 2 people came. She stated that she had scrapes on her arms and legs from bumping on the bed and wheelchair but they were better. She was unable to recall the details of the incidents. On 06/30/2020 at 12:00 p.m., an interview was conducted with S6CNA. She stated that she transferred Resident #7 on 04/17/2020 with S15CNA and the resident bumped her leg on the bed frame. On 06/30/2020 at 12:10 p.m., an interview was conducted with S15CNA. She stated that she did not assist S6CNA with the transfer of Resident #7 on 4/17/20 when she was transferred and had a skin tear. During an interview with S13LPN on 6/30/2020 at 2:00 p.m., he stated that he was working when the resident was transferred into her bed by S6CNA on 04/17/2020 and he filled out the incident report. He stated that S6CNA transferred the resident alone but should have had a second person because she was a 2 person assist. He stated that he did an in-service with the 4 staff who were working on the unit at that time to reinforce 2 person assistance for the resident. On 06/29/200 at 3:35 p.m., an interview was conducted with S13LPN. He stated he was working on 06/04/2020 when a CNA, who he could not remember her name, transferred the resident and scraped her leg. He stated the resident should have been a 2 person transfer. On 06/30/2020 at 3:00 p.m., an interview was conducted with S14LPN, Treatment Nurse. She stated that she was called to Resident #7's room on 06/04/2020 by a CNA (unknown) to inspect the resident's leg. She stated she could not recall the CNA's name as she was new. She stated the CNA was alone in the room and had just transferred the resident into the chair. The resident had a new LLL (Left Lower Leg) skin tear measuring 3.5 x 6.5 x 0.0 cm. She stated the nurse was then called to the room.

Based on record review and interview, the facility failed to provide the necessary care and services to attain or maintain the resident at the highest practicable physical well-being by failing to consult the physician and accurately assess the resident after a fall for a resident who continued to have complaints of pain to her left arm for 1 (#4) out of 5 sampled residents. As a result of this deficient practice, the receiving facility noted bruises and excruciating pain upon touch to the resident's left arm and subsequently identified that the resident's arm was fractured which resulted in the resident being sent to the emergency room for treatment. (#4) Findings: Resident #4. Review of resident #4 ' s clinical records revealed that the resident was originally admitted to the facility on [DATE]. The resident ' s [DIAGNOSES REDACTED]. Review of resident #4 ' s MDS dated [DATE] revealed that the resident was coded for modified independence for cognition. Further review of the resident ' s MDS dated [DATE] revealed that the resident was independent with no set-up or physical help from staff for ambulating in her room and limited assistance with one person physical assist for ambulating in the corridor. Review of resident #4 ' s nurses note dated 3/11/15 at 0600 revealed, " Fall or injury nurses note: Complete with risk mgmt. report Date and time this occurred: 3/11/15 at 0545 Assessment to include vital signs and range of motion: head to toe assessment done, c/o lt arm pain, range of motion wnl, vs 186/72, 92, 20, 98.0 O2 sat 95% Where did fall or injury occur?: resident ' s room between bed and dresser If injury, describe type of injury, such as skin tear, bruise, laceration, fracture, etc: none............. neuro checks started, NP book for c/o lt arm pain, attempted x1 for RP no answer........". Further review of the note revealed no documenation that the resident's physician was consulted concerning the resident's fall and complaints of left arm pain. Review of resident #4 ' s nurses ' note dated 3/11/15 at 10:26 revealed, " Resident is speaking to all staff and family members that pass by her stating that there is a man that wants to have sex with her. She is saying she has a broken arm and she cannot move it. Insisting that we call her son and all doctors to tell them..........." There was no documentation that the resident's medical/general physician was consulted concerning the resident's statements that she had a broken arm and that she could not move it. Further review of the note revealed documentation that the nurse consulted with staff at the psychiatric physician's office and received orders for inpatient treatment. Review of the Nurse Practitioner Note dated 3/11/15 at 11:58 revealed, " [AGE] year old white female, resident continuing to exhibit unstable behavior-see nurses ' progress notes. Behavior has increased since last week, ua done recently was unremarkable, neg for uti, recent blood work from 3/9/15 cbc, and tsh unremarkable-wnl. Resident telling nurses her arm is broken and can ' t move it. Upon assessment resident is moving arm, no obvious boney deformities or abnormalities noted. +2 radial pulses bilat and cap refill < 2 secs bilat. Followed by psych. " Review of the resident ' s nurses ' notes dated 3/11/15 at 16:23 revealed, " Resident left with (transportation driver) to be transported to (psychiatric hospital). Review of the resident ' s nurses ' notes dated 3/11/15 at 18:30 revealed, " SN received a call from _______RN from (psychiatric hospital) regarding the patient. (RN) stated that the patient stated that she had fell down last night at the nursing home and hurt her left arm. (RN) also stated that the patient has a bruise to her left arm. " Review of resident #4 ' s psychiatric hospital nursing notes dated 3/11/15 at 1645 revealed, " Upon entering unit pt. was complaining of ' excruciating pain ' in lt arm & shoulder. Lt shoulder appeared lower than rt side. Pt states she fell at the nursing home last night. Contacted nsg home staff (S3LPN) who states that there was no entry regarding a fall last night but pt did complain of arm pain when she was being placed in wheelchair to come here..........Pt. screamed whenever area was touched. Dr. ____ notified. X-ray of lt shoulder ordered...........States that she has [MEDICAL CONDITION] ' s Disease which leads to her bad ' posture ' & that she may not be in as much pain as she says. Noted on lt upper arm bruises to mid upper outer surface of arm & discolored area near wrist-painful to touch ... ... ... " Review of the resident ' s psychiatric hospital nursing notes dated 3/11/15 at 2315 revealed, " Rec ' d verbal report from _____ that pt has a ' broken humerous ' . " Review of the resident ' s psychiatric hospital nursing notes dated 3/11/15 at 11:30 pm revealed, " Spoke c (S6LPN) from nsg. Home to discuss the incident-at first she stated that the pt had not fallen-(S6LPN) was on duty the night pt says she fell ) after examining her records (S6LPN) says the pt was on the floor in the bathroom-states pt told her that she was not hurt........" Review of the resident ' s psychiatric hospital comments note dated 3/11/15 at 2300 revealed, " ... ....Upon arrival on unit pt complained of ' excruciating pain ' in lt arm. States she had fallen at the nursing home the night before. Upon examination the left upper arm had a large bruise & the lt shoulder appeared lower than his right. Nursing home staff report pt. has been having (increased) agitation-flight of ideas & talking to dead people. Oriented to person & place.........." Review of the resident ' s psychiatric hospital nursing notes dated 3/12/15 at 0220 revealed that the resident was transferrred to the hospital emergency room . Review of resident #4 ' s hospital emergency room notes dated 3/12/15 at 3:35 revealed, " Triage Chief Complaint/Mechanism of Injury: Pt transferred from (psychiatric hospital) re: fractured left humerus. Pt reports ' getting out of bed to look at clock, lost balance and fell on left arm ' . Denies.....hitting head. Noted bruising to left anterior upper arm. Splint and ace wrap, arm sling .... " Review of the resident ' s ED physician note dated 3/12/15 at 0344 revealed, " ... ....The patient presents with left arm injury. The onset was 1 day ago. Type of injury: fall. The location where the incident occurred was at a nursing home. Location: Left arm. The character of symptoms is pain. The degree of pain is moderate. The degree of swelling is moderate. Risk factors consist of none. Prior episodes: none. Associated symptoms: none. Recently transferred from nursing home to behavioral unit, apparently fell at nursing home prior to transfer. Discovered on x-ray yesterday to have a displaced [MEDICAL CONDITION] left humerus.............. she is here for further evaluation of the left arm injury. No loss of consciousness or head injury. Splint, ace wrap and sling in place. " Review of the resident ' s x-ray report dated 3/12/15 at 03:57 revealed, " Left humerus: Clinical indication: Trauma. AP and oblique views demonstrate a [MEDICATION NAME] fracture the distal third of the humerus, with the nondisplaced linear component extending inferiorly to the metaphyseal region. There is angulation of the proximal fracture.......... Impression: Compound angulated fracture distal humerus. " On 3/17/15 at 11:10 am, S8CNA stated that the resident was cognitive and required limited assistance. S8CNA stated that she was not aware or informed that the resident had a fall on the morning of 3/11/15. S8CNA stated that the only thing the resident was complaining to her about was that she wanted to take some clothes back to the store. S8CNA stated that she did not witness the resident exhibiting any unusual behaviors that day. On 3/17/15 at 12:30 pm, a telephone interview was conducted with S7LPN. S7LPN stated that the resident was not cognitive and was talking gibberish. S7LPN stated that she was not aware if the resident had any recent falls. S7LPN stated that on last Wednesday on 3/11/15 that the resident was rambling and complaining of pain and that her arm was broken. Also, S7LPN stated that the resident stated that she could not move her arm. S7LPN stated that while the resident was complaining about her arm hurting, she was rambling that there was a man who was in the facility and that he wanted to have sex with her. S7LPN stated that she felt that all the resident ' s rambling was from her psych behaviors. S7LPN stated that her shift began at 6:00 am that morning and that the night nurse going off did not report anything to her about the resident having a fall. S7LPN stated that she text the doctor concerning the resident ' s ramblings and that she was seeing a man in her room and that she was complaining of pain in her arm. S7LPN stated that she was not aware of any fall the resident had. S7LPN stated that the nurse at the psychiatric doctor ' s office responded to the text message and gave an order to send the resident to the psych hospital. S7LPN stated that she did not verbally communicate with a physician. On 3/17/15 at 1:10 pm, a telephone interview was conducted with S6LPN. S6LPN stated that she worked with the resident on 3/11/15 on the morning she fell . S6LPN stated that the resident was cognitive and coherent when she worked with her. S6LPN stated that the resident was found on the floor by the bed. S6LPN stated that she documented in the nurse practitioner book that the resident had a fall and that she was complaining of pain in her left arm. S6LPN confirmed that she did not consult with the resident ' s physician concerning the fall and that the resident was complaining of pain in her left arm. Also, S6LPN stated that she did not report to the oncoming shift of nurses that the resident fell and was complaining of left arm pain. On 3/17/15 at 1:50 pm, S3LPN stated that she came on her shift and was informed by the nurse at shift change that the resident was exhibiting some delusional behaviors and that she was being transferred to psychiatric hospital. S3LPN stated that no one reported to her that the resident had a fall. Also, S3LPN stated that she did not assess the resident ' s left arm prior to being transferred to the psychiatric hospital. 3/17/15 at 2:35 pm, S2NP stated that that the resident was having ongoing behaviors about talking about a man and that he wanted to have sex with her for a while. S2NP stated that the nurse that was on duty on the day shift told her about the resident ' s comments about the man and that he wanted to have sex with her, but did not tell her that the resident had a fall and that she was having any pain. S2NP stated that she assessed the resident ' s left arm when she seen her and that the resident was not complaining about pain and that she was not exhibiting any signs of pain. S2NP stated that the nurse had called the resident ' s psychiatric physician and received orders to transfer the resident to the behavioral hospital. S2NP stated that she did not see the note about the resident ' s fall with the complaint of pain to her left arm in the NP book until after the resident was transferred out of the facility. On 3/17/15 at 3:15 pm, S1ADON confirmed that the physician should have been called when the resident was complaining of pain after the fall. Also, S1ADON confirmed that when the nurse did not report that the resident had a fall with complaints of pain that it delayed the resident receiving treatment for [REDACTED].