Every finding on record at Maple Springs of Palmer

.Based on observation, interview, and record review, the facility failed to ensure: 1) drugs and biologicals used in the facility were properly labeled; and 2) removed medications and supplies when expired in 3 medication carts, out of 5 total carts, and 1 medication room, out of 2 storage rooms inspected. Specifically, the facility failed to: 1) label opened glucometer test-strip containers used in four units (Willow, Susitna, Denali, and [NAME]); and 2) remove expired medications and supplies from three medication carts ([NAME], Denali, and Susitna) and one medication room ([NAME] Pass). These failed practices: 1) placed 13 residents (#'s 4, 7, 10, 11, 15, 18, 23, 24, 25, 31, 36, 44, and 46) at risk of inaccurate blood glucose results that could contribute to delayed or inappropriate treatment decisions; and placed all residents (based on a census of 43) at risk for receiving expired and ineffective medications or supplies, placing residents at risk of adverse drug reactions. Findings:Undated Opened Glucometer Test-Strip Containers Random observations with concurrent interviews on 8/12/26, revealed opened glucometer test-strip containers without opened dates labeled were found on multiple nursing unit medication carts: At 3:15 PM on the [NAME] unit, one opened glucometer test-strip container without a labeled open date. Certified Nursing Assistant (CNA) #1 stated the containers were normally labeled with the date opened and he/she would expect the date to be documented on the packaging; At 3:24 PM on the Susitna unit, one opened glucometer test-strip container without a labeled open date. CNA #2 stated he/she thought the container should have been labeled and confirmed he/she could not verify the date the strips were opened; At 3:25 PM on the Denali unit, two opened glucometer test-strip containers without labeled open dates. Licensed Nurse (LN) #3 stated the containers should have been labeled when opened and confirmed he/she did not see a label; and At 3:46 PM on the [NAME] unit, one opened glucometer test-strip container without a labeled open date. CNA #3 stated he/she could not identify the date the container was opened and stated he/she believed it should have been labeled. During an interview on 8/13/26 at 1:18 PM, the Director of Nursing (DON) stated the facility expected glucometer quality-control checks to be completed daily, including when a new container of test strips or quality-control solution was opened. When asked whether staff were expected to label glucometer test-strip containers when opened, the DON stated, Yes, the container should be labeled with the date, time, initials, and the date it was opened. The DON stated whoever opened the container was responsible for labeling it. The DON further stated the nightshift charge nurse was responsible for auditing medication carts, look for expiration dates, and glucometer strips. Review of the facility-provided manufacturer's guide EvenCare G2 Blood Glucose Monitoring System Healthcare Professional Operator's Manual, undated, revealed: . In Service Training. 2. Be familiar with the EvenCare G2 test strip bottle and location of the lot number, expiration date, and control solution ranges. and staff were instructed EvenCare G2 Control Solution Testing, to check the expiration date printed on the test-strip bottle, not use expired test strips, and record the date opened on the bottle label. The manufacturer's guide further instructed that the bottle and remaining test strips be discarded six months after the date of opening. Review of the facility's policy Obtaining a Fingerstick Glucose Level, last revised 12/2025, revealed staff were to: .4. Ensure that the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer or facility. The procedure further directed staff to use test strips before their expiration date and not use test strips that were wet, bent, or otherwise damaged. Expired Medications and/or Supplies An observation on 8/11/26 at 11:52 AM, revealed the [NAME] Pass nurses' station medication room contained the following expired items: 1) 34 packets- Curad (brand) triple antibiotic ointment, expired on 4/2026;2) five- 92-inch IV (intravenous) administration sets, expired on 8/6/2026;3) one- EnteraFlo (brand) gastrostomy feeding tube (tube that provides direct access to the stomach for nutrition, fluids, and medications), 22FR (French), expired on 8/9/26; and4) one- EnteraFlo gastrostomy feeding tube, 16FR, expired on 6/27/26. During an interview on 8/11/26 at 12:43 PM, LN #1 verified the identified items were expired. An observation on 8/11/26 at 1:47 PM, revealed the [NAME] medication cart contained the following expired items: 1) one- Medihoney (medical grade honey product that supports wound healing) Gel, 1.5 fluid ounces, expired on 9/1/25;2) five packets- We Care (brand) Hydrocortisone Cream 1%, 0.9 grams, expired on 7/2026; and3) three- 5-mL (milliliter) saline bullets (single-use vials), expired on 6/2026. During an interview on 8/11/26 at 1:51 PM, LN #2 verified the identified items were expired. An observation on 8/11/26 at 2:10 PM, revealed the Denali medication cart contained the following expired items: 1) two- packages of lubricating jelly, 0.9 ounces, expired on 10/31/25; and2) one packet- of antibacterial ointment expired on 4/2026. During an interview on 8/11/26 at 2:10 PM, LN #3 verified the identified items were expired. An observation on 8/11/26 at 2:27 PM, revealed the Susitna medication cart contained the following expired item: 1) one- BD (brand) 1-mL syringe, expired on 2/28/23. During an interview on 8/14/26 at 2:28 PM, LN #4 verified the identified item was expired. During an interview on 8/12/26 at 9:17 AM, the DON was asked how the facility identified and removed expired medical supplies from medication rooms and carts. The DON stated charge nurses on night shift completed monthly audits of medications and supplies. The DON stated staff may have focused more on medications and forgotten other supplies, including products such as bacitracin. The DON further stated the person responsible for ordering tracked lot numbers and upcoming expiration dates was also responsible for sending internal messages to staff regarding items approaching expiration so they could be identified and removed. The DON stated, obviously that did not happen this time. When asked whether expired items should ever be present in medication rooms or carts, the DON stated, No. Review of the facility policy Medication and Medical Supply Storage and Labeling, last revised 6/2026, revealed the facility required medications and supplies to be clearly and accurately labeled, rotated to remain within their expiration dates, and removed from use when discontinued, outdated, deteriorated, or compromised. The policy further required medications and medical supplies to be rotated on a first-in, first-out basis and storage areas to be checked on a scheduled basis for expired, deteriorated, or damaged items. The policy required expired or compromised medical supplies to be removed and discarded according to facility procedure. The policy also required point-of-care testing supplies, including test strips, to be stored clean and dry, maintained within their expiration dates, and stored according to manufacturer instructions

.Based on record review and interview, the facility failed to maintain complete and accurately documented medical records for 2 of 2 sampled residents (#s 32 and 40), and 2 of 2 unsampled residents (#'s 6 and 30), reviewed for Advance Directive (AD - A written instruction, such as a living will or durable power of attorney for health care, recognized under State law, that relates to the provision of health care when the individual is incapacitated) and Physician Orders for Life-Sustaining Treatment (POLST - a medical order that communicated a patient's wishes for emergency and end-of-life care) documentation. Specifically, the facility failed to ensure material differences between residents' documented treatment preferences in their ADs and POLSTs were identified and clarified in the medical record and failed to ensure staff accurately documented whether an AD had been reviewed when completing a POLST. This failed practice resulted in residents' medical records containing inaccurate and/or unreconciled treatment-preference information and placed the residents at risk for staff relying on inaccurate or incomplete information when making healthcare decisions. Findings:Resident #6 Review of Resident #6's AD, dated [DATE], revealed the resident selected an option directing that artificial nutrition and hydration be provided indefinitely unless it clearly increased the resident's suffering and was no longer in the resident's best interest. Review of Resident #6's POLST, dated [DATE], revealed the section for medically assisted nutrition documented: No decision made (standard of care provided). Further review of the POLST revealed the physician signed the document; however, the physician did not date the signature as required by the POLST form. Review of Resident #6's medical record revealed there were no revised POLST forms after [DATE] when the resident's AD was completed. During an interview on [DATE] at 11:30 AM, Licensed Nurse (LN) #1 reviewed Resident #6's POLST and confirmed his/her signature on the document. When discussing the section indicating the resident's AD had been reviewed to confirm there was no conflict with the POLST orders, LN #1 stated he/she did not believe Resident #6 had an AD at the time of admission and stated, I probably did that wrong. Resident #30 Review of Resident #30's AD, dated [DATE], revealed individualized instructions: It is my intent that artificial nutrition and hydration be part of comfort care. and not as a means of artificially extending life. Review of Resident #30's POLST, dated [DATE], revealed: No decision made (standard of care provided) was selected for medically assisted nutrition. Resident #32 Review of Resident #32's AD, dated [DATE], revealed: . END-OF-LIFE DECISIONS. Except to the extent prohibited by law, I direct my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below. Choice Not To Prolong Life. I want comfort care only and I do not want my life to be prolonged with medical treatment if, in the judgement of my physician. Further review of the AD revealed the resident selected an option indicating he/she did not wish to receive artificial nutrition and hydration. Review of Resident #32's POLST, dated [DATE], revealed: YES CPR: Attempt Resuscitation including mechanical ventilation, defibrillation and cardioversion. Full Treatments. Goal: Attempt to sustain life by all medically effective means. Provide appropriate medical and surgical treatments as indicated to attempt to prolong life, including intensive care . was selected under Section A. Further review of the POLST revealed No decision made was selected for medically assisted nutrition. Resident #40 Review of Resident #40's AD, dated [DATE], revealed the resident selected an option indicating he/she wished to receive artificial nutrition and hydration indefinitely. Review of Resident #40's POLST, dated [DATE], revealed No decision made (standard of care provided) was selected for medically assisted nutrition. Further review of Resident #40's POLST revealed Advance directive not available was selected. Facility Process During an interview on [DATE] at 11:30 AM, LN #1 stated he/she completed POLST forms with residents during the admission process. LN #1 stated the POLST contained a section indicating whether the resident's AD had been reviewed to confirm there was no conflict with the POLST orders. LN #1 stated, I used to always check 'yes,' and now I'm not doing that because I don't have access to the Advance Directive . I shouldn't have been checking that. During an interview on [DATE] at 12:45 PM, the Resident Advocate (RA) stated she assisted residents with ADs but did not complete POLST forms. When asked whether she reviewed the POLST and AD to ensure the documents accurately reflected the resident's treatment wishes, the RA stated, I haven't been. I haven't been looking at the POLST. The RA stated she relied on information documented in PointClickCare (PCC - the facility's electronic charting system), which she believed reflected the POLST. When asked who was responsible for ensuring residents' POLSTs and ADs accurately reflected the residents' wishes, the RA stated she performed that review occasionally but did not know whether there was someone specifically responsible for reviewing all residents' documents. During an interview on [DATE] at 1:00 PM, the Director of Nursing (DON) stated responsibility for ensuring residents' ADs, POLSTs, physician orders, care plans, and other treatment-preference documentation were accurate and consistent was shared among staff who cared for the residents. The DON stated that, regarding quarterly AD and POLST reviews, she relied primarily on the RA. When asked about the facility's process for identifying and correcting conflicting or inconsistent AD and POLST information, the DON stated the IDT meeting should be the primary location where differences were identified and corrected. After reviewing an example in which an AD contained a specific artificial nutrition and hydration decision while the POLST documented that no decision had been made, the DON acknowledged there was a discrepancy between the documents. Review of the facility's policy Advance Directives, revised 11/2025, revealed: . 1. If the resident or resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff.2. The director of nursing services (DNS) or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the resident's medical record and plan of care.3. The resident's wishes are communicated to the resident's direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the resident's wishes in care planning meetings.4. The plan of care for each resident is consistent with their documented treatment preferences and/or advance directive. 10. The interdisciplinary team will review annually with the resident their advance directives to ensure such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded in the medical record. The interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident's medical record and care plan. The policy defined a POLST as: . a form designed to improve patient care by creating a portable medical order form that records the resident's treatment wishes so emergency personnel know what treatments the resident wants in the event of a medical emergency, taking the resident's current medical condition into consideration. A POLST paradigm form is not an advance directive. Review of the facility's policy Do Not Resuscitate Order, revised 11/2025, revealed: . The interdisciplinary care planning team will review advance directives with the resident during annual care planning sessions to determine if the resident wishes to make changes in such directives.

.Based on record review and interview, the facility failed to ensure a resident was provided the right to be informed in advance, by the physician or other professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for 1 resident (#7), out 13 residents reviewed for informed consent and psychotropic medication use. Specifically, the facility failed to obtain and document informed consent before Duloxetine (an antidepressant used to treat depression, anxiety, nerve pain, and certain chronic pain conditions) was initiated. This failed practice denied the resident and/or resident representative the opportunity to be informed of the medication's intended benefit, potential risks and side effects, available alternatives, and the option to accept or refuse the treatment. Findings:Record review on 8/10-14/26 revealed Resident #7 was admitted to the facility with diagnoses that included unspecified anxiety disorder, unspecified depression, and chronic pain. Review of Resident #7's physician orders revealed an order for Duloxetine HCl (Hydrochloride) 30 milligrams (mg). The medication record showed Duloxetine was initiated on 4/15/26, subsequently discontinued and then reordered, and remained active as of 7/8/26. During an interview on 8/13/26 at 3:00 PM, the Director of Nursing (DON) stated there was no informed consent for Resident #7's Duloxetine, and further stated, We are working on it now. Review of the facility-provided policy Informed Consent, last revised 6/2026, revealed: .It is the policy of Maple Springs that no treatment, procedure, or service requiring informed consent is initiated without the informed consent of the resident, or of the resident's representative. Each resident has the right to be informed, in language he or she can understand.in advance, by the physician or other practitioner or professional, of the risk and benefits of proposed care, of treatment and treatment alternative options, and to choose the option he or she prefers. Further review of the policy revealed psychotropic medications as care, required documented informed consent before initiation. The policy further directed that, before initiating a psychotropic medication, the prescriber or designee must discuss the target symptom or condition, intended benefit, potential risks and side effects, and available alternatives with the resident or representative, and must obtain and document informed consent

.Based on record review and interview, the facility failed to ensure the resident and/or resident representative (RR) were able to exercise their right to participate in the development and revision of the person-centered plan of care for 1 resident (#40), out of 13 sampled residents. Specifically, the facility failed to provide Resident #40 and/or the resident representative the opportunity to participate in the development and revision of the person-centered care plan, including establishing expected goals, outcomes, preferences, and choices, when the facility reviewed and revised the resident's care plan between January and August 2026. This failed practice placed Resident #40 at risk of having the comprehensive care plan revised without the resident's or RR's input regarding the Resident's goals, preferences, choices, and desired outcomes of care. Findings:Record review from 8/10-14/26 revealed Resident #40 was admitted to the facility with diagnoses that included anoxic brain damage (injury to the brain caused by a significant or prolonged lack of oxygen), pulmonary hypertension (abnormally high blood pressure in the blood vessels of the lungs), and paraplegia (paralysis or severe loss of motor function affecting both lower extremities). Comprehensive Assessment Review Review of Resident #40's electronic medical record (EMR) revealed there were multiple Minimum Data Set (MDS - a federally required nursing assessment) assessments that were completed during 2026: 1) one MDS Significant Change Assessment, dated 2/2/26;2) one MDS Quarterly Assessment, dated 3/9/26; and3) one MDS Quarterly Assessment, dated 6/7/26. Care Plan Review Review of Resident #40's Care Plan initiated on 4/30/25, revealed: . The resident is at risk for a psychosocial well-being problem r/t [related to] Anxiety, depression, little interest/pleasure in doing things. History of trauma related experiences. Goal. The resident will have no indications of psychosocial well being problem by/through review date. Interventions. Encourage participation from resident who depends on others to make own decisions. Increase communication between resident/family/caregivers about care and living environment. Provide opportunities for the resident and family to participate in care. Further review revealed Resident #40's Care Plan was revised on 2/12/26. Review of Resident #40's EMR revealed documented Interdisciplinary Team (IDT) care conferences occurred on 1/15/26 and 8/13/26 and the documentation supported that the resident and RR were involved during these conferences. There were no other documented care conferences between 1/15/26 and 8/13/26. Further review of the EMR revealed no documentation that Resident #40 and/or the RR were notified of, invited to, or participated in any care conferences from 1/15/26 to 8/13/26. There was no documentation that the resident or RR participated in the development or revision of the care plan from 1/15/26 to 8/13/26. During an interview on 8/13/26 at 3:20 PM, the Resident Advocate (RA) stated she generally scheduled Resident #40's IDT care conferences and attempted to schedule the conferences around the RR's availability. The RA stated the RR generally attended Resident #40's IDT meetings and did attend the IDT meeting held on 8/13/26. When asked about the period between the 1/15/26 and 8/13/26 IDT meetings, the RA stated she reviewed the record and did not find notes documenting why the meetings had been pushed off or rescheduled. The RA stated she would normally enter a note in PointClickCare (PCC - the facility's electronic charting system) but did not find such documentation for Resident #40. During an interview on 8/14/26 at 10:30 AM, the Corporate Quality Assurance Nurse (CQAN) stated the facility's normal quarterly care-planning process included an IDT meeting and that the RA scheduled the meeting with the resident and/or RR. The CQAN stated meeting notes were completed and subsequently reviewed by the MDS Coordinator when the resident's care plan was updated. During the same interview, the CQAN stated the facility used a Care Plan Summary Signature Page where the care plan was reviewed with the resident and the resident could acknowledge the review, ask questions, or request changes. The CQAN stated the Care Plan Summary Signature Page was supposed to be getting signed quarterly to prove the involvement with the resident or the resident representative. After reviewing Resident #40's medical record, the CQAN was unable to locate a Care Plan Summary Signature Page documenting that the care plan had been reviewed with Resident #40 and/or the RR. When asked whether documentation demonstrated Resident #40 and/or the RR participated in the development or revision of the care plan after January 2026, the CQAN stated, I also cannot find any evidence at the moment . During an interview on 8/14/26 at 11:00 AM, the MDS Coordinator stated she was responsible for completing quarterly care plan reviews. The MDS Coordinator stated she reviewed information obtained during the MDS chart review, the resident's order summary, nursing documentation, previous care plan information, and IDT notes when available. When asked how the resident's or RR's wishes were incorporated into quarterly care plan revisions, the MDS Coordinator stated if there was something specific the resident desired, the team would usually notify her so the information could be care planned. When asked how she completed a quarterly care plan review when an IDT meeting had not occurred, the MDS Coordinator stated, If an IDT hasn't been held, then I would assume there's nothing specifically that's changed significantly on their care plan. So I go by what's in the nurse's notes and what's on their orders. When asked about Resident #40's quarterly care plan revisions during the period when IDT conferences had not occurred, the MDS Coordinator stated, I do them quarterly regardless of whether an IDT's been held or not. Review of the facility-provided policy Resident Rights, dated February 2022, revealed: . Each Resident has the right to be fully informed in a language they can understand of their total health status, including but not limited to, their medical condition . Each Resident has a right to be fully informed in advance, about changes in care, treatment, medications, or any changes that may affect the resident's well-being. Each Resident has a right to participate in planning and choosing their care and treatment or changes in care and treatment unless incompetent or otherwise found to be incapacitated under the State of Alaska laws. Residents may grant permission for family members to help with care planning and the resident has the right to give permission for family members to make important decision on their behalf. Each resident has a right to choose activities, schedules and health care consistent with their interests, and plans of care including what time to rise in the morning, eat their meals and retire to bed at night. Each Resident has the right to reasonable accommodations of individual needs and preferences except where the health and safety of the resident or other residents would be endangered . Each Resident has a right to freedom of choice. Review of the facility-provided policy Care Planning - Interdisciplinary Team, revised June 2026, revealed: . The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan . The policy further revealed: . Care plan meetings are scheduled at the best time of the day for the resident and family when possible. If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record .

.Based on record review and interview, the facility failed to ensure appropriate information was provided to a receiving health care institution or provider during a transfer for 1 resident (#40), out of 1 resident transfer reviewed. Specifically, the facility failed to provide Resident #40's Advance Directive (AD - A written instruction, such as a living will or durable power of attorney for health care, recognized under State law, that relates to the provision of health care when the individual is incapacitated) information to the receiving hospital, but instead provided an inaccurate Physician Orders for Life-Sustaining Treatment (POLST - a medical order that communicated a patient's wishes for emergency and end-of-life care) during the hospital transfer which failed to document the resident's choice to receive artificial nutrition and hydration treatment information if needed, which was documented within the resident's AD. This failed practice placed Resident #40 at risk for not receiving life-saving treatment that was consistent with his/her documented healthcare wishes. Findings:Record review on 8/10-14/26 revealed Resident #40 was admitted to the facility with diagnoses that included anoxic brain damage (injury to the brain caused by a significant or prolonged lack of oxygen), pulmonary hypertension (abnormally high blood pressure in the blood vessels of the lungs), and paraplegia (paralysis or severe loss of motor function affecting both lower extremities). Further review revealed Resident #40 was transferred to a hospital on 7/25/26 due to a medical emergency. Review of the Nurse Progress Note, dated 7/25/26 at 6:33 PM, revealed: . resident with seizure type activity in w/c [wheelchair], eyes closed and generalized twitching that lasted approx [approximately] 4 mins 20 sec. Immediately after, res [resident] tearful and disoriented for approx 10-15 mins [minutes]. Further review revealed the Nurse Practitioner (NP) was notified and directed staff to continue to monitor Resident #40 and send the resident to the hospital for worsening symptoms. Review of the Nurse Progress Note, dated 7/25/26 at 10:47 PM, revealed: . At approximately 2020 [8:20 PM], this nurse was alerted by CNAs [certified nursing assistants] that the resident was having a seizure. This nurse immediately went to the resident's room and found the CNA and resident in the room, where the resident was having a seizure. The resident was lying on [his/her] side to prevent aspiration. This nurse immediately began timing the seizure and asked the CNA how long the seizure had been occurring, to which the CNA said 'about 30. seconds'. this nurse continued to time the seizure. The seizure lasted about 2 minutes and 30 seconds before ceasing, however the resident was not responsive to verbal or tactile stimuli for 3 more minutes. Further review of the Nurse Progress Note revealed the on-call NP was notified and ordered Resident #40 sent to the emergency room for further evaluation. The charge nurse called 911, notified the resident representative, and Resident #40 was transferred by ambulance to Mat-Su Regional Medical Center. During the course of this survey, the medical record paperwork that was sent with Resident #40 on 7/25/26 to the receiving hospital was reviewed. The resident's POLST was sent along with additional paperwork. The AD was not sent to the receiving hospital. Review of Resident #40's AD, dated 11/24/24, revealed Resident #40 selected: . I wish to receive artificial nutrition and hydration indefinitely. Review of Resident #40's POLST, dated 12/30/25, revealed the section for medically assisted nutrition documented: . No decision made (standard of care provided) . Further review of the POLST revealed Advance directive not available was selected despite Resident #40 having an executed AD maintained in the facility's medical record. During an interview on 8/12/26 at 2:40 PM, the Director of Nursing (DON) reviewed the documentation associated with Resident #40's facility transfer. The DON stated the facility generally sent the POLST during hospital transfers and not every resident had an AD. After reviewing Resident #40's transfer documentation and confirming Resident #40 had an AD in the facility record, the DON acknowledged the documentation showed the POLST was sent and stated, . the advanced directive did not [get sent to the receiving facility]. Review of the facility's policy Advance Directives, revised November 2025, revealed: . The nurse supervisor is required to inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of the advance directive or POLST when transferring from the facility via ambulance or other means . Review of the facility's policy Transfer or Discharge, revised June 2026, revealed: . When the facility transfers or discharges a resident. appropriate information is communicated to the receiving health care institution or provider.

.Based on record review and interview, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program. Specifically, the facility failed to follow the directives of the PASRR Level I determination to notify the State of Alaska Division of Senior and Disability Services (SDS) for 1 resident (#4), out of 13 residents reviewed, when the resident stayed beyond their approved convalescent care period. This failed practice resulted in Resident #4 remaining in the facility without the required PASRR Level II evaluation to determine whether the resident required specialized services, which had the potential to adversely affect the resident's ability to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. Findings:Record review on 8/10-14/26 revealed Resident #4 was admitted to the facility with diagnoses that included vascular dementia(dementia resulting from impaired blood flow to the brain), post-traumatic stress disorder (PTSD), and unspecified depression. Review of Resident #4's Level 1 PASRR, dated 4/10/25, revealed: .Convalescent care for a period of 90 days or less, as certified by the physician. If the individual stays beyond the 90 days, an individualized PASRR Level II evaluation must be completed. The facility shall notify SDS on day 85 that it anticipates the resident will need services more than 90 days. Day 85 is: 7/4/25. During an interview on 8/12/26 at 10:08 AM, the Director of Nursing (DON) stated the facility was unable to locate any record that indicated Resident #4 received a PASRR Level II evaluation and that SDS has been contacted to continue the process for the assessment. Review of email correspondence between the surveyor and SDS, dated 8/11/26 at 3:49 PM, revealed: SDS was not notified of ongoing LTC [Long Term Care] [stay] by 07/04/2025 - as indicated on the admission PASRR (page 4). Unfortunately, this case [is] non-compliant with PASRR process and no, [he/she] never got a PASRR level II evaluation. The facility notified us today of this case. SDS requested a new PASRR form and recent records. Once, submitted, we'll do a resident review and update the client's PASRR determination vs. refer for a level II evaluation. The facility failed to notify SDS by 7/4/25 and did not initiate corrective contact until 8/11/26, more than one year later. Review of the facility's policy Preadmission Screening And Resident Review (PASRR), last revised 6/2026, revealed: .The facility coordinates its assessment and care-planning activities with the PASRR program to the maximum extent practicable. incorporates all Level II recommendations into the resident's comprehensive assessment and person-centered care plan, and promptly refers any resident. to the appropriate State-designated authority for resident review.The facility ensure the individual is referred to the appropriate State-designated authority for a Level II evaluation.the facility follows the specific screening, referral, and notification procedures, forms, and contacts of the State in which it operates. Staff are familiar with their State's PASRR program requirements and know how to locate current PASRR contact information for the State-designated authorities and the State Medicaid Agency.

.Based on record review and interview, the facility failed to ensure the comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team (IDT) after quarterly assessments for 1 resident (#40), out of 1 resident reviewed for care plan revision. Specifically, the facility's IDT failed to review Resident #40's quarterly care plan reviews and revisions, following the resident's quarterly assessments. This failed practice placed Resident #40 at risk for changes in his/her comprehensive care plan without the involvement of individuals who have knowledge of the resident's needs, placing the resident at risk for inappropriate or subtherapeutic care interventions that could adversely affect his/her health and well-being. Findings:Record review on 8/10-14/26 revealed Resident #40 was admitted to the facility with diagnoses that included anoxic brain damage (injury to the brain caused by a significant or prolonged lack of oxygen), pulmonary hypertension (abnormally high blood pressure in the blood vessels of the lungs), and paraplegia (paralysis or severe loss of motor function affecting both lower extremities). Review of Resident #40's care planning documentation revealed an IDT care conference was completed in January 2026. Review of Resident #40's MDS assessments revealed a Significant Change Assessment was completed on 2/2/26 and Quarterly Assessments were completed on 3/9/26 and 6/7/26; however, no other IDT care conferences were documented until 8/13/26. Review of Resident #40's most recent Care Plan revealed revisions were completed on the following dates after January 2026 but before 8/13/26: - 2/12/26; 2/17/26; 2/22/26; 2/23/26; 2/25/26; 3/25/26; 4/6/26; 4/15/26; 4/21/26; 5/4/26; 5/13/26; 6/9/26; 7/30/26; 8/7/26; and 8/10/26. During an interview on 8/14/26 at 10:30 AM, the Corporate Quality Assurance Nurse (CQAN) stated when a resident's quarterly Minimum Data Set (MDS - a federally required nursing assessment) assessment was due, the MDS Coordinator opened the care plan for review. The CQAN stated the facility's quarterly care planning process also included an IDT meeting, and the MDS Coordinator reviewed the quarterly meeting notes, MDS look-back period, current physician orders, treatments, and information provided by other IDT members to determine whether information should be added or discontinued from the care plan. During the same interview, the CQAN stated the IDT generally included therapy or restorative nursing, a Certified Nursing Assistant (CNA) who cared for the resident, a nurse who cared for the resident, a Licensed Clinical Social Worker (LCSW), Resident Advocate (RA), dietary staff, and the resident's healthcare provider. The CQAN stated the IDT meeting notes were subsequently reviewed by the MDS Coordinator when updating the resident's care plan. When asked whether the IDT significantly influenced the information incorporated into the quarterly care plan, the CQAN stated, Correct. The CQAN reviewed Resident #40's record during the interview and confirmed the resident's quarterly care plan reviews had continued to be completed. When asked about the absence of an IDT care conference between January 2026 and the IDT care conference conducted during the survey in August 2026, the CQAN stated the facility's assessment information supported that finding. The CQAN stated that when a formal quarterly care conference did not occur, the MDS Coordinator could obtain information from other sources, including weekly Connections meetings, therapy meetings, resident assessments, provider documentation, and psychotropic medication meetings. The CQAN stated these sources provided some interdisciplinary information used by the MDS Coordinator when updating a resident's care plan. During an interview on 8/14/26 at 11:00 AM, the MDS Coordinator stated she was responsible for completing quarterly care plan reviews and revisions. The MDS Coordinator stated she reviewed the resident's MDS information, physician orders, nursing documentation, previous care plan information, and available IDT documentation when completing the quarterly care plan review. When asked how the quarterly care plan was reviewed when an IDT meeting had not occurred, the MDS Coordinator stated, If an IDT hasn't been held, then I would assume there's nothing specifically that's changed significantly on their care plan. I go by what's in the nurse's notes and what's on their orders . When asked about completing Resident #40's quarterly care plan reviews during the period in which IDT care conferences had not occurred, the MDS Coordinator stated, I do them quarterly regardless of whether an IDT's been held or not. Review of the facility's policy Care Planning - Interdisciplinary Team, revised June 2026, revealed: . The interdisciplinary team is responsible for the development of resident care plans. Resident care plans are developed according to the timeframes and criteria established by S483.21. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). The IDT includes but is not limited to: . the resident's attending physician. a registered nurse with responsibility for the resident. a nursing assistant with responsibility for the resident. a member of the food and nutrition services staff. [and] other staff as appropriate or necessary to meet the needs of the resident.

.Based on observation, interview, and record review, the facility failed to ensure food was served at a safe temperature for 2 residents (#15 and #24), out of 2 residents reviewed for reheated food. Specifically, the facility failed to ensure that food temperatures were checked after reheating food in the microwave. The facility served microwave-reheated chicken noodle soup to Resident #15 at 190.4 F (degrees Fahrenheit) and almond milk to Resident #24 at 182 F without ensuring the food and beverage had cooled to a safe temperature before being served. This failed practice placed Residents #15 and #24 at risk for scalding and burn injuries from consuming excessively hot food and beverages. Findings:During a meal service observation on 8/12/26, the following were revealed: At 11:52 AM, [NAME] #1 reheated a cup of almond milk in the microwave for Resident #24. After reheating, [NAME] #1 placed the milk on the counter without measuring the temperature. Dietary Aide (DA) #2 then served the milk to Resident #24. Upon the surveyor's request, DA #2 checked the temperature and stated it measured 182 F. During an interview on 8/12/26 at 11:53 AM, when asked if 182 F was a safe temperature, DA #2 stated the safe temperature should not exceed 165 F. At 12:13 PM, [NAME] #1 reheated a bowl of chicken noodle soup for Resident #15. The soup was microwaved for two minutes, stirred, reheated for an additional minute, and stirred again. [NAME] #1 placed the soup on the counter without checking the temperature. DA #1 transported the food cart that contained Resident #15's lunch tray to the [NAME] Unit, where Certified Nursing Assistant (CNA) #4 served the reheated soup to Resident #15. When asked if the temperature had been checked before serving, CNA #4 stated, . the kitchen does that. At 12:23 PM, the surveyor requested CNA #4 to measure the temperature; CNA #4 stated it was 190.4 F. During an interview on 8/12/26 at 12:23 PM, CNA #4 stated the safe reheating temperature was 165 F, but that there is no maximum temperature listed in the log. When asked if 190 F was a safe temperature, CNA #4 stated, Yes. CNA #4 then served the soup to Resident #15. During an interview on 8/12/26 at 12:48 PM, [NAME] #1 stated that his/her microwave reheating process involved heating food for two minutes and continued to reheat until it's hot. When asked if he/she checked temperatures after reheating, [NAME] #1 stated, no. [NAME] #1 stated the milk and soup had been reheated until steaming and bubbly, acknowledging the temperatures were very hot. [NAME] #1 stated he/she assessed temperature by stirring and reheating, and also by dipping a gloved finger into the food to check hotness. [NAME] #1 stated he/she would tell staff to leave hot food at the counter to cool before serving. During an interview on 8/13/26 at 8:33 AM, the Kitchen Manager (KM) confirmed that food reheated in the microwave must reach at least 165 F. He stated this was the standard temperature for items such as milk and soup. When asked about the risk of scalding or burns, the KM stated that food cools rapidly once served to the resident. Review of the facility's policy Summary of Chart for Minimum Food Temperatures and Holding Times for Reheating Foods for Hot Holding, dated 2019, revealed that microwave-reheated foods must reach 165 F. The policy did not instruct staff to check temperatures after reheating to ensure food was not excessively hot before serving, nor did it address prevention of resident burns or scalding. Review of the Food and Drug Administration (FDA) Food Code 2022, 3-403.11 Reheating for Hot Holding, accessed on 8/14/26 at this link: https://www.fda.gov/media/164194/download?attachment, revealed Time/Temperature Control for Safety (TCS) foods reheated in a microwave for hot holding must reach at least 74 C (165 F), be stirred or rotated, covered, and allowed to stand covered for 2 minutes after reheating. Commercially processed ready-to-eat TCS foods must be reheated to at least 57 C (135 F) for hot holding. Review of the American Burn Association's Scald Injury Prevention Educator's Guide, undated, accessed on 8/19/26 at this link: https://dds.dc.gov/sites/default/files/dc/sites/dds/publication/attachments/ABA%20Scald%20Injury%20Prevention%20Educator%27s%20Guide.pdf, revealed: . The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. When the temperature of a hot liquid is increased to 140 F/60 C it takes only five seconds or less for a serious burn to occur. High risk Groups. Older Adults. have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications. Microwave Scald Prevention. Microwaved foods and liquids may reach temperatures greater than boiling without the appearance of bubbling. Stir and test food thoroughly before serving or eating.

.Based on record review, observation, and interview, the facility failed to establish and maintain an effective infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections for 1 resident (#43), out of 13 sampled residents reviewed for transmission-based precautions. Specifically, the facility failed to ensure appropriate infection control practices were consistently implemented for Resident #43 while the resident was being evaluated for Clostridioides difficile (C. difficile - a bacterial infection that can cause diarrhea and inflammation of the colon), including appropriate transmission-based precaution signage, appropriate hand hygiene, availability and use of an appropriate disinfectant, and staff knowledge of the precautions required. This failed practice placed residents, staff, and visitors at risk for the transmission of infectious organisms through contaminated hands, resident-care equipment, and environmental surfaces. Findings:Record review on 8/10-14/26 revealed Resident #43 was admitted to the facility with diagnoses that included anoxic brain damage (injury that occurs when the brain is completely deprived of oxygen, leading to rapid and often irreversible injury to brain cells), neuromuscular dysfunction of bladder (condition where nerve or muscle problems impair bladder control), and disorder of the autonomic nervous system. Review of Resident #43's medical record, on 8/11/26 at 9:39 AM, revealed a laboratory test for C. difficile had been ordered for Resident #43. Further review revealed the specimen had not yet been collected because the resident had not produced stool. An observation on 8/11/26 at 9:40 AM, revealed Dental Hygienist (DH) #1 provided dental care to Resident #43 while wearing a gown and gloves. A sign posted outside Resident #43's room identified the transmission-based precautions as Contact Precautions. Review of the Contact Precautions transmission-based precautions sign on Resident #43's door, undated, revealed: Contact Precautions Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. During an interview on 8/11/26 at 10:05 AM, DH #1 stated he/she had been informed that he/she could enter the resident's room and needed to wear gown and gloves; however, no one informed him/her of the suspected C. Difficile infectious organism. The dental hygienist further stated no one had instructed him/her regarding the use of bleach for disinfection or the need to wash his/her hands with soap and water. During an interview on 8/11/26 at 9:54 AM, the Infection Preventionist (IP) stated the sign outside Resident #43's room should have identified the precautions as contact enteric. The IP stated that when C. difficile was suspected, the resident should have been placed on the appropriate precautions when the order to obtain the specimen was initiated. An observation on 8/11/26 at 10:02 AM, revealed a Contact Precautions. Special Enteric sign, bleach wipes, gowns, and gloves were observed outside the resident's room. Review of the Contact Precautions. Special Enteric sign on Resident #43's door, dated 12/26/24, revealed: Contact Precautions. Visitors must report to nursing station before entering. Special Enteric Perform hand hygiene before entering room AND wash hands with soap and water before leaving room. Wear gloves when entering room or cubicle, and whenever touching the patient's intact skin, surfaces, or articles of close proximity. Wear gown when ever entering room or cubicle and whenever anticipating that clothing will touch patient items or potentially contaminated environment surfaces. Use patient-dedicated or single-use disposable shared equipment or clean and disinfect shared equipment (BP cuff, thermometers) between patients. Further review revealed the contact-enteric precaution sign did not identify the disinfectant required for equipment or environmental disinfection. An observation on 8/13/26 at 8:40 AM, revealed bleach wipes were not available outside Resident #43's room. During an interview on 8/13/26 at 8:52 AM, Certified Nursing Assistant (CNA) #5 stated he/she had never heard of contact enteric and did not know what contact-enteric precautions required. CNA #4 stated he/she believed enteric precautions required a gown, goggles, and gloves. CNA #4 stated he/she had heard that handwashing and bleach wipes were required. An observation on 8/13/26 at 3:00 PM, revealed CNA #6 and CNA #7 entered Resident #43's room without performing hand hygiene before donning Personal Protective Equipment (PPE). During cares, CNA #7 removed his/her gloves and handled and used a hand-held radio that was under his/her PPE gown without performing hand hygiene. After donning new gloves, CNA #7 returned the radio to his/her clothing under the PPE gown. CNA #6 was noted to have used the alcohol-based hand sanitizer during glove changes when he/she provided care to Resident #43, who was being evaluated for C. difficile. During an interview on 8/14/26 at 9:03 AM, CNA #8 stated that Resident #43 was on precautions due to an airborne pathogen and to wash hands with soap and water. When asked which disinfectant should be used on equipment when removed from the resident's room, CNA #8 stated either the purple disinfectant wipes (Ecolab Disinfectant 1 Wipe - active ingredient dodecylbenzenesulfonic Acid 0.29%, other ingredients 99.71%) or bleach wipes could be used. The CNA stated he/she would personally use bleach because he/she believed bleach killed more. Review of the Ecolab Disinfectant 1 Wipe container revealed there was no documentation on the container to state it killed the C. Difficile bacteria: . Kills SARS-Related Coronavirus 2, SARS-CoV-2 [a COVID-related illness: a severe acute respiratory syndrome coronavirus 2], in 30 seconds. Kills HIV-1, HBV [Hepatitis B Virus], HCV [Hepatitis C Virus] on pre-cleaned environmental surfaces/objects previously soiled with blood/body fluids. During an interview on 8/14/26 at 9:26 AM, Licensed Nurse (LN) #5 stated soap and water and bleach wipes should be used when caring for a resident with C. difficile. When asked the required contact time for the bleach wipes, LN #5 stated he/she did not know and stated the information should have been available on the resident's door sign. An observation on 8/14/26 at 9:28 AM, revealed the required disinfectant contact time was not identified on Resident #43's precaution sign. After staff reviewed the disinfectant container, the required contact time was identified as four minutes. During an interview on 8/13/26 at 11:35 AM, the IP stated Resident #43's suspected C. difficile infection arose at approximately 3:00 AM and the IP sent staff a message the following morning informing them the resident was on C. difficile precautions and reminding staff of the required infection control practices. The IP stated LNs should already know the required procedures through their standard training and were responsible for notifying and reminding CNAs of the required precautions. The IP stated staff received annual C. difficile training and confirmed LNs were expected to ensure staff implemented the appropriate precautions until the IP was available to provide additional education or reminders. Review of the facility's policy Isolation - Initiating Transmission-Based Precautions, dated 6/2019, revealed: .Transmission-Based Precautions were to be initiated when a resident developed signs and symptoms of a transmissible infection; arrives with symptoms of an infection; or has a laboratory-confirmed infection; and is at risk of transmitting the infection to other residents. Further review revealed the IP was responsible for identifying the type of precautions, necessary PPE, and appropriate notification so staff and visitors were aware of the required precautions. Review of the facility's policy Clostridium difficile, dated 6/2019, revealed: .Measures are taken to prevent the occurrence of Clostridium difficile infections (CDI) among residents. Precautions are taken while caring for residents with C. difficile to prevent transmission to other[s] residents. The primary reservoirs for C. difficile are infected people and surfaces. Spores can persist on resident-care items and surfaces for several months and are resistant to some common cleaning and disinfection methods. Further review revealed: . Steps toward prevention and early intervention include. Increasing awareness of symptoms and risk factors among staff, residents and visitors. Frequent hand washing with soap and water by staff and residents. Disinfection of items with potential fecal soiling. using a disinfecting agent recommended for C. difficile (e.g., household bleach and water solution or an EPA registered germicidal agent against C. difficile spores). Resident with diarrhea and suspected with C. difficile are placed on Contact Precautions while awaiting laboratory results. When caring for residents with CDI, staff is to maintain vigilant hand hygiene. Hand washing with soap and water is superior to ABHR [alcohol-based hand rub] for the mechanical removal of C. difficile spores from hands. Review of the facility's policy Isolation - Categories of Transmission-Based Precautions, dated 6/2026, revealed: .Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection. Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions. When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee): Clearly identifies the type of precautions, the anticipated duration, and the personal protective equipment (PPE) that must be used; Explains to the resident (or representative) the reason(s) for the precautions; Provides and/or oversees the education of the resident, representative and/or visitors regarding the precautions and use of PPE; Determines the appropriate notification on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions; The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. Ensure that protective equipment and supplies needed to maintain precautions during care are in the resident's room. Review of the facility's policy Hand Hygiene and Equipment Cleaning, undated, revealed: . Hand hygiene should be performed. before and after direct contact with residents. Before and after entering isolation precaution settings. Before and after adjusting any worn PPE including mask, face shield, and gown.

.Based on record review and interview, the facility failed to immediately report an allegation of verbal abuse to the State Survey Agency in accordance with CFR (Code of Federal Regulations) S483.12 (b)(5) for 1 resident (#2), out of 4 sampled residents reviewed. Specifically, the facility failed to notify the State Survey Agency of alleged violations involving abuse no later than two hours after allegation was made. This failed practice had the potential for continued abuse and placed vulnerable residents at risk of harm .Record review on 8/4-5/25 revealed Resident #2 was admitted to the facility with diagnoses that included Parkinson's disease (a brain disorder that affects movement and causes tremors, stiffness and slowness), anxiety disorder (a mental disorder characterized by uncontrollable feeling of anxiety and fear), post-traumatic stress disorder (a mental health condition that is caused by extremely stressful or terrifying event) and depression.Review of the IDT [Interdisciplinary Team] Care Conference 1.0 note, dated 7/17/25 at 2:01 PM, revealed: [Resident #2] has also verbalized concerns about the use of profanities and inappropriate names during interactions.During an interview on 8/4/25 at 2:45 PM, the Resident Advocate (RA) stated the Administrator, Director of Nursing (DON), and RA attended the IDT Conference on 7/17/25. RA further stated, regarding Resident #2's expressed concerns of profanity, when IDT members inquired further about the profanity Resident #2 mumbled it was one nurse, Resident #2 was not so sure who it was, and that he/she would prefer not to work with him/her if he/she had to. RA stated Resident #2 later stated the staff member was LN#1. The RA further stated there was no formal investigation conducted in relation to the allegation. During an interview on 8/5/25 at 1:20 PM, the Administrator stated he was aware of the allegations made during the IDT meeting. He further stated the alleged verbal abuse was not reported to the State Survey Agency.Review of the facility's Abuse Policies, dated 6/2025, revealed: .Maple Springs strives to achieve and maintain an abuse free-environment. There is zero tolerance for the abuse.of a resident.promptly investigating all reported incidents of resident abuse and allegations of abuse . Allegations of abuse. can be reported to any employee at any time by resident's [sic], family and or legal representative[s].All allegations of abuse.will be reported immediately to the Administrator and/or designee.the Administrator or designee will ensure that all violations involving abuse.are reported immediately, but not later than 2 hours after the allegation is made.

.Based on record review and interview, the facility failed to respond to an allegation of verbal abuse for 1 resident (2), out of 4 sampled residents reviewed, in accordance with CFR (Code of Federal Regulations) S483.12(c). Specifically, the facility failed to:1) thoroughly investigate allegations of verbal abuse;2) prevent further potential abuse while the investigation was in progress; and3) report results of an investigation to the State Survey Agency within 5 working days of the incident to include verification of allegations and corrective actions taken.This failed practice resulted in Resident #2's unhappiness in the facility and fear of retaliation. This failed practice also placed Resident #2 at risk of continued abuse and receiving care in a less-than-optimal setting .Record review on 8/4-5/25 revealed Resident #2 was admitted to the facility with diagnoses that included Parkinson's disease (a brain disorder that affects movement and causes tremors, stiffness and slowness), anxiety disorder (a mental disorder characterized by uncontrollable feeling of anxiety and fear), post-traumatic stress disorder (a mental health condition that is caused by extremely stressful or terrifying event) and depression.Verbal Abuse AllegationsDuring a joint interview on 8/5/25 at 12:30 PM with Resident #2 and Resident #2's Representative (RR), RR stated Licensed Nurse (LN) #1 called Resident #2 a FAH [Fucking Ass Hole] on 5/20/25 and an idiot on 6/12/25. Resident #2 stated he/she was unhappy in the facility and was afraid of speaking up for himself/herself due to the fear of retaliation. Resident #2 further stated every time LN#1 entered the room for cares he/she doesn't say anything, and that he/she would rather put himself/herself to bed at night.Review of the IDT [Interdisciplinary Team] Care Conference 1.0 note, dated 7/17/25 at 2:01 PM revealed: [Resident #2] has also verbalized concerns about the use of profanities and inappropriate names during interactions.Lack of InvestigationReview on 8/4-5/25 of the facility's incident report log for 2025, revealed no investigation was conducted about the allegations of verbal abuse after the IDT meeting.During an interview on 8/4/25 at 2:45 PM, the Resident Advocate (RA) stated the Administrator, Director of Nursing (DON), and RA attended the IDT Conference on 7/17/25. RA further stated, regarding Resident #2's expressed concerns of profanity, when IDT members inquired further about the profanity Resident #2 mumbled it was one nurse, Resident #2 was not so sure who it was, and that he/she would prefer not to work with him/her if he/she had to. RA stated Resident #2 later stated the staff member was LN#1. The RA further stated there was no formal investigation conducted in relation to the allegation. During an interview on 8/4/25 at 3:46 PM, the DON stated there was an investigation inquiry about LN#1 regarding the profanity but not a formal one. There was no documentation provided at the end of the survey.During an interview on 8/5/25 at 1:20 PM, the Administrator stated he was aware of the allegations made during the IDT meeting on 7/17/25. He further stated the alleged verbal abuse was not reported to the state agency nor was a thorough investigation conducted. The Administrator further stated LN #1 was not taken off the work schedule after the IDT meeting.LN #1's Work ScheduleReview of LN #1's schedule on 8/5/25 at 1:20 PM, revealed LN#1 worked as a charge nurse on 7/20-22/25, 7/26-29/25, 8/3-4/25 and was scheduled to work on 8/5/25. During an interview on 8/5/25 at 2:07 PM, the DON stated when LN#1 was assigned to work as the charge nurse, he/she could be working in the unit where Resident #2 resided, depending on the needs of the facility.Abuse PolicyDuring an interview on 8/5/25 at 1:20 PM, the Administrator stated if there was an allegation of verbal abuse, the facility would follow the normal process based on the facility's Abuse Policy. The Administrator further stated an allegation of abuse should be reported to the State Agency within two hours, and a final report of the investigation should be submitted 5 calendar days after the incident took place.Review of the facility's Abuse Policies, dated 6/2025, revealed: .Maple Springs strives to achieve and maintain an abuse free-environment. There is zero tolerance for the abuse.of a resident.promptly investigating all reported incidents of resident abuse and allegations of abuse . Allegations of abuse .can be reported to any employee at any time by resident's [sic], family and or legal representative[s].All allegations of abuse.will be reported immediately to the Administrator and/or designee.the Administrator or designee will ensure that all violations involving abuse.are reported immediately, but not later than 2 hours after the allegation is made. As appropriate, the state agencies.will be contacted. All pertinent information will be reviewed during the investigation. Maple Springs will notify the resident, designated family members and/or legal representative [s] of the investigation. A list of witnesses and other persons knowledgeable about the event will be compiled.interviews will be conducted. The alleged perpetrator will be placed on administrative leave and/ or denied access until the investigation is resolved. Results from the report will be sent to the State Agency within 5 working days of the incident. resident's designated family member [s] and/or legal representative [s] will be notified.

Based on observation, interview, record review, facility policy review, and review of the manufacturer's manual, the facility failed to conduct monthly inspections of seven of seven facility owned Hoyer (mechanical) lifts and of lifts owned by two of two (Resident (R) 2 and R6) residents with personal mechanical lifts. This failure increased the risks of accidents due to mechanical failure. Findings include: Review of the facility's policy titled, Specialized Medical Equipment, dated 04/04/24, revealed, . Maple Springs will ensure that all specialized medical equipment is identified and assessed for safety and necessity . Review of the undated MedLine Battery Operated Patient Lift manual, provided by the Maintenance Director (MD), revealed, . At least once a month, the patient lift should be thoroughly inspected to recognize any signs of wear, and/or looseness of bolts or parts. Replace any worn parts immediately . Always follow the maintenance and cleaning schedule closely and fully while including any specific state regulations should they apply. Keep a logbook of maintenance times and work performed or parts replaced . 1. During an interview on 06/03/25 at 3:46 PM, the Maintenance Director (MD) stated he did not conduct inspections on the facility's Hoyer lifts. He stated, I check on them and tighten them, clean hair out of the wheels. He stated, If they break, and they don't, we have a company come in. The MD was asked if he kept logs of his checks. He stated, No. The MD was asked if there were manufacturers' manuals for the lifts. He stated yes, left the room, and retrieved a manual. Continuing with the interview on 06/03/25 at 4:03 PM, the MD provided a manufacturer's manual for the Hoyer lifts. Review of the manual revealed the lifts were to be inspected monthly and a logbook recording maintenance services should be kept. The MD was asked how often he completed his checks of the lifts. He stated, Not as frequently as it says in there (pointing to the manual). During an interview on 06/05/25 at 1:47 PM, the Administrator was asked what the expectation was related to inspections of the mechanical lifts. He stated, Per the manual, monthly. The Administrator confirmed there were no logbooks for any maintenance or inspection of the lifts. On 06/05/25 at 12:30 PM, the Corporate Quality Nurse (CQN) confirmed the facility had seven Hoyer lifts. 2. Review of R2's Profile tab of the electronic medical record (EMR) revealed R2 was readmitted to the facility on [DATE] with diagnoses that included hypertensive heart and chronic kidney disease with heart failure. Review of R2's Care Plan, dated 12/08/23, revealed staff was to use a Hoyer lift for transfers. There was no documentation R2 had her own personal lift. Review of R2's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/30/25 and located under the MDS tab of the EMR, revealed R2 was dependent on staff for chair-to-bed and bed-to-chair transfers. It was recorded that R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R2's Physician Orders, dated 10/22/23 through 06/04/25 and located under the Orders tab of the EMR, revealed no physician's order for the use of a personal mechanical lift. Review of R2's Misc (Miscellaneous) tab of the EMR revealed no documentation of monthly inspections of a personal mechanical lift. Review of R2's Progress Note, dated 05/11/25 at 6:52 PM, revealed, . CNA [Certified Nurse Aide] was transferring from bed to wheelchair using Hoyer lift. While resident was in the air the Hoyer lift suddenly fell onto its side with resident still in it . It was recorded that the resident did not have any injuries and refused to go to the emergency room for assessment. Review of the investigative file of the incident, provided by the Resident Advocate (RA), revealed documentation of an interview with R2 on 05/13/25, where R2 agreed to no longer use her personal mechanical lift. During an interview on 06/03/25 at 3:45 PM, R2 stated the lift being used at the time of the incident was her personal lift. R2 denied any knowledge of the facility completing inspections on the lift. She stated her family member had taken the lift for repairs, but the facility did not do anything with the lift as far as she knew. During an interview on 06/03/25 at 4:03 PM, the Maintenance Director (MD) was asked if he completed any inspections on R2's lift while she had it. He stated, No. 2. Review of R6's Profile tab of the EMR revealed R6 was admitted to the facility on [DATE] with diagnoses that included quadriplegia. Review of R6's Care Plan, dated 09/26/23 and located under the Care Plan tab of the EMR, revealed staff was to use a Hoyer lift for transfers to the shower chair and commode. Review of R2's Physician Orders, dated 09/26/23 through 06/04/25 and located under the Orders tab of the EMR, revealed no physician's order for the use of a person mechanical lift. Review of R2's Misc (Miscellaneous) tab of the EMR revealed no documentation of monthly inspections of the personal mechanical lift. Review of R6's quarterly MDS, with an ARD of 04/10/25 and located under the MDS tab of the EMR, revealed R6 was dependent on staff for chair-to-bed and bed-to-chair transfers. It was recorded R6 had a BIMS score of seven out of 15, which indicated the resident was severely cognitively impaired. On 06/03/25 at 4:00 PM, a personal mechanical lift was noted in R6's room. R6 stated he thought his family member had brought the lift to the facility. During an interview on 06/03/25 at 4:03 PM, the MD confirmed R6 had a personal lift. He was asked if he had completed inspections on the lift. He stated, No. During an interview on 06/05/25 at 1:47 PM, the Administrator stated there was no documented evidence that either R2 or R6's mechanical lifts had been assessed for safety. He stated that neither resident had a physician's order for the use of a personal mechanical lift. The Administrator confirmed there was no documentation that either lift had been inspected monthly by the facility. The Administrator stated staff did not use the personal lift with R6, but he did not know how long it had been in the resident's room. The Administrator stated his expectation was for staff to try and discourage the use of personal lifts, but if the resident insisted, he should be notified so that the policy could be implemented. The Administrator stated the mechanical lifts should be inspected monthly.

Based on interview, record review, and review of facility policy, the facility failed to report injuries of unknown origin and allegations of abuse and neglect immediately to the Resident Advocate (RA) and within two hours to the State Survey Agency (SSA) for three of three residents (Resident (R) 3, R1, and R5) reviewed for abuse and neglect out of a total sample of six. Failure to report injuries of unknown origin and allegations of abuse and neglect places residents at risk for continued potential abuse. Findings include: Review of the facility's policy titled, Abuse Policies, dated 12/2023, revealed, . All allegations of abuse and/or neglect will be reported to the Administrator and/or designee, including incidents involving injured resident's where the origin of the injury in [sic] unknown . Facility will report immediately, but not later than two hours after forming the suspicion or allegation, if the events that cause the suspicion or allegation result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury . 1. Review of R3's Profile tab of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance. Review of R3's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/11/25 and located under the MDS tab of the EMR, revealed R3 had a Brief Interview for Mental Status (BIMS) score of two out of 15, which indicated the resident was severely cognitively impaired. It was recorded R3 was dependent on staff for toileting hygiene, required substantial to maximum assistance with most activities of daily living (ADLs), and was always incontinent of bladder and bowel. Review of the facility's investigative file, provided by the RA, for an incident of alleged abuse involving R3 revealed that on 05/05/25 at approximately 11:04 PM, Certified Nurse Aide (CNA) 2 was assisting CNA1 in changing R3's brief. CNA2 reported that R3 became combative and CNA1 grabbed R3's wrist and forcefully shoved the incontinent brief under the resident. The investigative file contained: a. An Initial Report, with a submission date and time of 05/06/25 at 5:44 PM. Review of the Initial Report revealed the report was blank and did not contain any information regarding the allegation. This blank form was submitted to the SSA approximately 18.75 hours after the incident was alleged to occur. b. A Follow-up Investigation Report, with a submission date and time of 05/13/25 at 5:48 PM, that revealed, . [CNA2] reports that she was assisting [CNA1] with changing [R3]'s brief when [R3] became combative. [CNA2] states that [CNA1] grabbed [R3] wrist and forcibly placed the chuck pad and brief underneath [R3] . During an interview on 06/04/25 at 11:16 AM, CNA2 stated that on 05/05/25, she was assisting CNA1 with providing incontinent care for R3. CNA2 stated CNA1 had her hand balled in a fist and was forcefully shoving an incontinent brief under the resident. CNA2 reported that the resident often screamed out and yelled during care, but during this care, the resident yelled ouch in a different manner that indicated to her that the action had caused the resident pain. CNA2 reported during the care, R3 had reached out to grab her arm, and CNA1 grabbed R3's wrist and pretty aggressively pushed it back down. CNA2 confirmed the incident occurred around 11:00 PM. CNA2 stated she did not report the incident to the nurse until close to the end of her shift, which ended at 6:00 AM. CNA2 stated the nurse instructed her to notify the nurse educator, which she did at 5:57 AM. CNA2 stated the nurse educator instructed her to notify the Human Resources Director (HR), which she did at 6:17 AM. CNA2 stated allegations of abuse were supposed to be reported as soon as possible, not to exceed two hours. CNA2 first reported the allegation of abuse approximately seven hours after the alleged incident occurred. During an interview on 06/04/25 at 11:36 AM, the HR Director confirmed that she was notified of the alleged incident on 05/06/25 at 6:17 AM. HR confirmed she reported the alleged incident to the Resident Advocate (RA) during the afternoon of 05/06/25. HR confirmed allegations of abuse were to be reported immediately, as soon as possible. HR reported the alleged incident to the RA at least six hours after learning of the incident. During an interview with the RA, Administrator, and Corporate Quality Nurse (CQN) on 06/05/25 at 1:19 PM, the RA, who was the facility's abuse coordinator, confirmed she was responsible for submitting incident reports to the SSA. She confirmed the incident was reported to the state survey agency on 05/06/25 at 5:44 PM. RA stated she did not receive the information from HR until the afternoon of 05/06/25 and then she reported it within the first couple of hours after she received knowledge of the allegation. The Administrator confirmed allegations of abuse should be reported immediately and to the SSA within two hours. 2. Review of R1's Profile tab of the EMR revealed R1 was admitted to the facility on [DATE] with diagnoses that included dementia, nondisplaced fracture of the sacrum, hallucinations, and unspecified fracture of the thoracic vertebrae. Review of R1's quarterly MDS, with an ARD of 03/20/25 and located under the MDS tab of the EMR, revealed R1 had a BIMS score of three out of 15, which indicated the resident as severely cognitively impaired. It was recorded that R1 was dependent on staff for toileting hygiene and showers/baths and required substantial to maximum assistance with transfers. It was recorded R1 was always incontinent of bladder and bowel. Review of R1's Progress Note, dated 04/13/25 at 2:48 AM and located under the Progress Notes tab of the EMR, revealed, . This writer was called to resident's room by CNA to see resident's right leg. On the resident's right outer leg there were several areas of bluish-purple bruising observed. When questioned, resident stated she didn't know it was there. Denies pain . Provider and acting DON [Director of Nursing] notified via Tiger connect [facility's text communication system] at 04:42 [AM] . Review of the investigative file for R1 related to the bruising of unknown origin, provided by the RA, revealed an Initial Report of the bruising was submitted to the SSA on 04/13/25 at 9:36 AM. This was approximately five hours after the bruising was first identified. During an interview on 06/04/25 at 5:18 PM, the CQN confirmed staff should have reported R1's bruising as soon as it was noted. The CQN stated she did not know why staff had not identified and reported R1's bruising prior to 04/13/25, as the colors of the bruises showed they were not new. During an interview on 06/05/25 at 1:00 PM with the RA, Administrator, and CQN, the RA confirmed the initial incident report was not submitted to the SSA until 04/13/25 at 9:36 AM. The Administrator confirmed the initial report should have been sent to the SSA within two hours after the bruises were identified. 3. Review of R5's Profile tab of the EMR revealed R5 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction and vascular dementia. Review of R5's quarterly MDS, with an ARD of 04/12/25 and located under the MDS tab of the EMR revealed R5 had a BIMS score of eight out of 15, with indicated the resident was moderately cognitively impaired, was dependent on staff for toileting hygiene, and was frequently incontinent of bladder, and always incontinent of bowel. Review of an Initial Report, provided by the SSA and with a received fax date stamp of 05/29/25 at 5:13 PM, revealed, . Allegation Type Neglect . Information about when the Facility became aware of the incident 5/28/25 8:25 pm [CNA5] notified [Nurse Educator] . Date/Time administrator was notified of the incident and by whom 5/28/25 8:52 pm [Nurse Educator] notified [Administrator] of the allegations . Alleged Victim(s) . [R5] . [CNA5] reported that [R5]'s brief and bedding were saturated with urine when she came on to shift yesterday. [CNA5] believes that the resident's brief wasn't changed for several hours . Name/title of person submitting report [RA] . Date/time (am/pm) report was submitted 5/29/25 3:00 PM . This was 18.5 hours after the allegation of neglect was first made by CNA5. During an interview with the RA, Administrator, and CQN on 06/05/25 at 1:26 PM, the RA reviewed the Initial Report and confirmed the allegation was an allegation of neglect and stated that it was reported to the SSA on 05/29/25 at 3:00 PM. The RA stated she reported it as soon as she received knowledge of the allegation. The RA stated she was notified of the allegation on the morning of 05/29/25. The RA was asked to provide the time she was notified. RA left the room and returned and stated the Nurse Educator had notified her at 2:00 PM on 05/29/25 (it was documented on the Initial Report that the Nurse Educator had notified the Administrator on 05/28/25 at 8:52 PM). The RA was asked why Initial Reports involving allegations of abuse, neglect, and injuries of unknown origin were not reported within two hours to the SSA. The RA did not comment. The Administrator confirmed he was responsible for monitoring to ensure the timely submission of Initial Reports related to abuse, neglect, and injuries of unknown origin. He stated the facility had not identified a problem with submissions before today.

Based on interview, record review, and review of facility policy, the facility failed to thoroughly investigate an allegation of abuse and bruising of unknown origin for two of five residents (Resident (R) 3 and R1) reviewed for abuse and neglect out of a total sample of six. Failure to thoroughly investigate allegations of neglect and injuries of unknown origin places residents at risk for potential continued abuse. Findings include: Review of the facility's policy titled, Abuse Policies, dated 12/2023, revealed, . All allegations of abuse and/or neglect will be reported to the Administrator and/or designee, including incidents involving injured resident's where the origin of the injury in [sic] unknown . All pertinent information will be reviewed during the investigation . A list of witnesses and other persons knowledgeable about the event will be compiled . Interviews will be conducted with the following individuals: a. The individual(s) making the report. B. The individual(s) alleged to be involved with the incident. C. If they are capable of and/or willing to be interviewed, the resident . 1. Review of R3's Profile tab of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance. Review of R3's Care Plan, revised 04/03/25 and located under the Care Plan tab of the EMR, revealed R3 had behavior problems of grabbing, yelling, and rejection of care. It was recorded that the resident had the potential to be physically aggressive towards staff. Interventions included explaining all procedures before starting, to maintain an appropriate distance as possible, and assess and anticipate resident's needs. Review of R3's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/11/25 and located under the MDS tab of the EMR, revealed R3 had a Brief Interview for Mental Status (BIMS) score of two out of 15, which indicated the resident was severely cognitively impaired. It was recorded R3 was dependent on staff for toileting hygiene, required substantial to maximum assistance with most activities of daily living (ADLs), and was always incontinent of bladder and bowel. Review of the facility's Initial Incident Report, dated 05/06/25 and provided by the Resident Advocate (RA), revealed, . [CNA2] reports helping [CNA1] change [E3]'s brief last night. During this brief change [CNA2] reports that the resident became combative. [CNA2] states that [CNA1] was rough with the resident grabbing her wrist and forcefully shoving the brief underneath her . Review of the investigative file of the alleged incident revealed no documented evidence that R3 was assessed for signs of physical abuse. There was no documented evidence that non-interviewable residents cared for by CNA1 were assessed for signs of physical abuse. There was documentation that four residents were interviewed regarding abuse. It was recorded that Licensed Practical Nurse (LPN) 1, the nurse on duty at the time of the alleged incident, CNA1, and CNA2 were interviewed; however, no other staff members were interviewed. The final report indicated the facility had been unable to verify the allegation. During an interview on 06/04/25 at 10:36 AM, the Resident Advocate (RA), who was the facility's abuse coordinator, stated CNA1, CNA2, and LPN1 were interviewed regarding the incident but there were no written statements. RA stated CNA1 and CNA2 were called to get their statements. RA confirmed that four residents were interviewed but that the non-interviewable residents were not assessed for signs of physical abuse. RA confirmed CNA1 was suspended pending the investigation and that abuse education was assigned to CNA1. During an interview on 06/04/25 at 11:16 AM, CNA2 stated that on 05/05/25, she assisted CNA1 in providing incontinent care to R3. CNA2 stated that CNA1 had her hand balled in a fist and was forcefully shoving an incontinent brief under the resident. CNA2 reported that the resident often screamed out and yelled during care, but during this care, the resident yelled ouch in a different manner that indicated to her that the action had caused the resident pain. CNA2 reported during the care, R3 had reached out to grab her arm, and CNA1 grabbed R3's wrist and pretty aggressively pushed it back down. CNA2 stated that she did not remember anyone asking her to provide a statement of the alleged incident after she first reported it. During an interview on 06/04/25 at 11:36 AM, the Human Resources Director (HR) confirmed CNA1 was suspended during the investigation and was cleared to return to work on 05/12/25. HR confirmed CNA1 was assigned abuse training on 05/12/25 but stated CNA1 had not completed the training yet. HR stated CNA1 was sent daily electronic reminders to complete the training and that staff checked daily to see if it was done. HR stated CNA1 had 90 days to complete the training before she would be pulled from the schedule. Review of timecards and staff schedules revealed from 05/19/25 through 06/04/25, CNA1 worked nine shifts without having completed the assigned abuse education. CNA1 was on duty on 06/04/25. During an interview on 06/04/25 at 12:04 PM, CNA1 denied the allegation and stated she had completed the assigned abuse training. During an interview on 06/04/25 at 12:25 PM, the HR stated CNA1 did complete the training on this day, but she could not provide a time at which it was completed. During an interview on 06/05/25 at 1:19 PM with the RA, Administrator, and Corporate Quality Nurse (CQN), the RA, who was the facility's abuse coordinator, confirmed that R3 and the other non-interviewable residents on R3's hall had not been assessed for bruising or signs of abuse. The Administrator and CQN confirmed all non-interviewable residents on R3's hall should have been assessed for bruising and signs of abuse and neglect. They confirmed that all interviewable residents should have been interviewed related to abuse. 2. Review of R1's Profile tab of the EMR revealed R1 was admitted to the facility on [DATE] with diagnoses that included dementia, nondisplaced fracture of the sacrum, hallucinations, and unspecified fracture of the thoracic vertebrae. Review of R1's Care Plan, revised 03/15/25 and located under the Care Plan tab of the EMR, revealed R1 had a potential behavior problem related to anxiety, hallucinations, and behaviors such as repetitive movements, grabbing, and rejection of care. Interventions included anticipating and meeting the resident's needs. Review of R1's quarterly MDS, with an ARD of 03/20/25 and located under the MDS tab of the EMR, revealed R1 had a BIMS score of three out of 15, which indicated the resident was severely cognitively impaired. It was recorded that R1 was dependent on staff for toileting hygiene and showers/baths and required substantial to maximum assistance with transfers. It was recorded R1 was always incontinent of bladder and bowel. Review of R1's Progress Note, dated 04/13/25 at 2:48 AM and located under the Progress Notes tab of the EMR, revealed, . This writer was called to resident's room by CNA to see resident's right leg. On the resident's right outer leg there were several areas of bluish-purple bruising observed. When questioned, resident stated she didn't know it was there. Denies pain . Provider and acting DON [Director of Nursing] notified via Tiger connect [facility's text communication system] at 04:42 [AM] . Review of R1's Skilled Charting, dated 04/13/25 at 7:18 AM and located under the Assessments tab of the EMR, revealed, . 6 [six] bruises to rt [right] lateral thigh, different colors ranging from yellow to darker purple in central areas of the bruise; bruise lateral and proximal distal lt [left] elbow, light purple; 2 smaller bruises distal to previous noted bruise with one small scab in bruising path; lt lower back redness discoloration over bony prominence; yellow bruising medial lt lower leg proximal to ankle; small scab rt shin . Review of the facility's investigative file related to R1's bruising of unknown origin revealed LPN2, CNA4, who was assigned to the resident on the shift the bruising was identified, and CNA4, who was also working on the floor on that shift, were interviewed regarding the resident's bruising. It was also documented Registered Nurse (RN) 1 performed the skin assessment on 04/13/25. There was evidence that three alert and oriented residents on R1's floor were interviewed regarding abuse and neglect. There was no documented evidence that any staff members who had taken care of R1 in the preceding days had been interviewed in an effort to determine their knowledge of the origin of R1's bruising or why the bruising had not been reported earlier. There was no documented evidence that other non-interviewable residents on R1's floor had been assessed for bruising and signs of abuse and neglect. During an interview on 06/05/25 at 1:00 PM with the RA, Administrator, and the CQN, the RA confirmed that no other staff members had been interviewed regarding R1's bruising of unknown origin. The RA confirmed that the other non-interviewable residents located on R1's floor had not been assessed for bruising or signs of abuse and neglect. The Administrator and CQN confirmed their expectation that all staff who had been caring for the resident would have been interviewed. The Administrator and CQN confirmed all non-interviewable residents on R1's hall should have been assessed for bruising and signs of abuse and neglect.

Based on interview, record review, and facility policy review, the facility failed to complete skin assessments for one of six sampled residents (Resident (R) 1) whose records were reviewed. Failure to complete routine skin assessments placed residents at increased risk of alterations in skin integrity. Findings include: Review of the facility's policy titled, Resident Assessment, revised 02/2024, revealed, . Head-to-toe assessments will be performed by nursing staff at least weekly on all residents . Physical Exam: . Skin: a. intactness; b. moisture; c. color; d. texture; e. presence of bruises . The following information should be recorded in the resident's medical record . All assessment data obtained during the procedure . Review of R1's Profile tab of the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses that included dementia, nondisplaced fracture of the sacrum, hallucinations, and unspecified fracture of the thoracic vertebrae. Review of R1's Care Plan, revised 01/28/25 and located under the Care Plan tab of the EMR, revealed R1 had impaired skin integrity and the potential for pressure ulcer development related to fissure to the heels, episodes of incontinence, and impaired mobility. The goal was the resident would have intact skin, free of redness, blisters, or discoloration through the review date. Interventions included following facility policies/protocols for the prevention/treatment of skin breakdown. Review of R1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/25 and located under the MDS tab of the EMR, revealed R1 had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. It was recorded that R1 was dependent on staff for toileting hygiene and showers/baths and required substantial to maximum assistance with transfers. It was recorded R1 was always incontinent of bladder and bowel. Review of R1's Assessment tab of the EMR revealed a Skilled Charting document, dated 04/01/25. The Skill Charting revealed no documented evidence that R1 had any bruising on her body. There was no documented evidence of skin assessments from 04/02/25 through 04/13/25. Review of R1's Progress Note, dated 04/13/25 at 2:48 AM and located under the Progress Notes tab of the EMR, revealed, . This writer was called to resident's room by CNA [Certified Nurse Aide] to see resident's right leg. On the resident's right outer leg there were several areas of bluish-purple bruising observed. When questioned, resident stated she didn't know it was there. Denies pain . Provider and acting DON [Director of Nursing] notified via Tiger connect [facility's text communication system] at 04:42 [AM]. Will pass on to day shift nurse . Review of R1's Skilled Charting, dated 04/13/25 at 7:18 AM and located under the Assessments tab of the EMR, revealed, . 6 [six] bruises to rt [right] lateral thigh, different colors ranging from yellow to darker purple in central areas of the bruise; bruise lateral and proximal distal lt [left] elbow, light purple; 2 smaller bruises distal to previous noted bruise with one small scab in bruising path; lt lower back redness discoloration over bony prominence; yellow bruising medial lt lower leg proximal to ankle; small scab rt shin . During an interview on 06/03/25 at 2:40 PM, CNA6, who was assigned to R1, confirmed any changes in skin integrity, including bruising, were to be reported to the nurse immediately. CNA6 stated R1 did not have any bruising at this time. CNA6 denied knowledge of the bruising that was found on R1 on 04/13/25. During an interview on 06/04/25 at 9:50 AM, Licensed Practical Nurse (LPN) 3 confirmed skin assessments were to be completed weekly and that the information was documented on the Skill Charting form. LPN3 confirmed that any changes should be reported immediately. LPN3 denied any knowledge that R1's skin assessments were not completed as per policy. LPN3 stated all staff should report any changes in skin integrity, including bruising, immediately. During an interview on 06/04/25 at 5:18 PM, the Corporate Quality Nurse (CQN) confirmed there was no documented evidence that R1's skin had been assessed after 04/01/25 until 04/13/25 when the resident was noted with bruising. The CQN confirmed weekly skin assessments should have been completed. The CQN confirmed that if the weekly assessment between 04/01/25 and 04/13/25 had been completed, the bruising might have been noted quicker. The CQN confirmed she expected skin assessments to be completed weekly and for any abnormality to be reported immediately. The CQN stated she did not know why the assessment had not been completed or why the bruising was not reported sooner.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure one of three residents (Resident (R) 2) reviewed for the use of mechanical lifts out of a total sample of six was transferred in a safe manner, using two people as per facility policy. Failure to transfer residents in a safe manner placed R2 at risk for injury. Following the incident, the facility identified and implemented a Performance Improvement Plan (PIP) to ensure staff followed the facility's policy requiring two staff members when using a mechanical lift. Findings include: Review of the facility's policy titled, Lifting Machine, Using a Mechanical, dated 07/2017, revealed, . At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift . Review of R2's Profile tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses that included hypertensive heart and chronic kidney disease with heart failure. Review of R2's Care Plan, dated 12/08/23, revealed staff was to use a Hoyer lift to transfer R2. Review of R2's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/30/25 and located under the MDS tab of the EMR, revealed R2 was dependent on staff for chair-to-bed and bed-to-chair transfers. It was recorded that R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R2's Progress Note, dated 05/11/25 at 6:52 PM, revealed, . CNA [Certified Nurse Aide 7] was transferring from bed to wheelchair using Hoyer lift. While resident was in the air the Hoyer lift suddenly fell onto its side with resident still in it. Resident fell straight on the ground. Nurse was at nursing station when CNA called for urgent help. Writer went to the Residents room immediately, to find Resident on the floor with CNA next to them. Brief neuro check completed with resident request to get into bed before completing assessment. Extra staff collected to ensure safe transfer process from floor to bed. Once transfer was completed Vitals and neuros re-collected, along with complete head to toe assessment. Noted findings are tenderness of crown of head along with palpable tenderness to mid/lower back following spinal column. Resident offered ER visit for further evaluation but refused. Education provided to notify staff for any changes or symptoms, reported willingness and understanding. Provider and DON notified . Review of R2's Plan of Care Note, dated 05/14/25 at 9:43 AM, revealed, . The IDT [Interdisciplinary Team] met to review fall prevention measures for the resident. The resident has had no falls since last review. Staff continue to use Hoyer x 2 for transfers. Therapy working with resident on strengthening and ROM. No new concerns or changes in resident condition noted. Will continue current interventions as planned . Review of the facility's investigative file of the incident revealed: a. A statement from CNA 7, dated 05/11/25, that recorded, . Resident stated she needed a brief change. I then grab resident [sic] Hoyer and hook her up [sic]. I then asked resident if they are [sic] ready to transfer. Resident stated yes. As I am conversing with Resident I press the up button to lift her up. We were doing her normal transfer (she only allows 1 [one] CNA for transfer) All CNAs do it. As we are conversing about the day I rotate the lift to the left towards her bed as her normal routine is. As I push [sci] lift to bed it tipped over. I then as a reflex try to catch resident from falling. She then landed on ground and on my right leg. I immediately call [sic][Licensed Practical Nurse (LPN) 3] the nurse [and] told him help now! [LPN3] came in and then grabbed [CNA10] and [Nurse Educator]. [CNA10] and I got the okay to get her into bed. No pain has been stated by resident. As we got her in bed, [LPN3] then does a skin assessment. No marks were visual. Lower back to the touch was tender per resident. I asked resident if they wanted to stay in bed or get back up. [CNA6] then came in and helped me transfer because I refuse to due [sic] x1 transfer per resident. Resident complained of back hurt and head hurting. CNA7 recorded on the statement that she was the only CNA assigned to the resident's hall. b. A statement from LPN3, dated 05/12/25, that recorded he received a call on his personal cell phone from CNA7 who reported that she was transferring R2 and they both fell. LPN found R2 and CNA7 on the floor with the Hoyer tipped over on top of them. LPN completed a head-to-toe assessment on the resident and recommended that she be seen at the hospital. c. A statement from CNA8, dated 05/12/25, that recorded she only transferred residents using mechanical lifts with two staff. CNA8 reported she would call over the radio for additional assistance if needed. CNA8 reported she was not working with R2 on the day of the incident but does work with her regularly. d. A statement from CNA9, dated 05/12/25, that recorded she knew two staff were to be present for all Hoyer lifts. CNA9 reported she would call for assistance with all transfers. e. A statement from CNA11, dated 05/12/25, that confirmed all lifts should be operated by two people. f. A statement from R2, dated 05/13/25, that recorded CNA7 was helping her transfer with the Hoyer lift when the feet of the lift got stuck, causing the lift to fall over. R2 reported no one was available to help CNA7 but that she did call for assistance prior to moving her. g. A copy of CNA7's agreement, dated 01/08/25, to follow the facility's lift safety policy. CNA7 agreed that she had been trained and understood her responsibility for her safety and the resident's safety. h. A copy of CNA7's Hoyer Lift Training Skills Checkoff, dated 01/08/25, which recorded CNA7 had demonstrated competent skills in performing Hoyer lift transfers, including the use of two staff members. i. A copy of an employee file audit results which showed all nursing staff members had been assessed to be competent in the use of mechanical lifts. j. A copy of morning meeting notes, dated 05/12/25 through 05/16/25, that recorded staff were reminded that all residents who use Hoyer lifts MUST be completed by 2 staff. k. May Staff Meeting notes, dated 05/22/25, that recorded, . Any mechanical lift must be operated by two [in bold] licensed staff every single time . l. Audit results from the weeks of 05/19/25, 05/26/25, and 06/02/25, showing staff had been observed to ensure two people were present for mechanical lift transfers and that the resident remained safe during the transfers. During an observation on 06/03/25 at 12:15 PM, CNA8 and CNA10 were observed transferring R3 from her bed to her chair with a mechanical lift, using proper lifting techniques. On 06/03/25 at 12:37, the Corporate Quality Nurse (CQN) provided staffing records for 05/11/25. Review of the staff records showed for the 6:00 AM to 6:00 PM shift, there were 10 aides and four nurses to care for 64 residents. The staff records showed for the 6:00 PM to 6:00 AM (05/12/25) shift, there were six nurses and four aides to care for 64 residents. During an interview on 06/03/25, CNA9 confirmed two people were required for transfers using a mechanical lift. CNA9 confirmed she had received training on proper lift techniques and had been observed using the lift. CNA9 confirmed there had recently been an incident when R2 was transferred by one person using a mechanical lift, and the lift tipped over. CNA9 stated following the incident, all staff received education and reminders of the facility's policy that required the use of two staff members with a mechanical lift. During an interview on 06/03/25 at 2:34 PM, CNA12 confirmed two people were required for transfers using a mechanical lift. CNA12 confirmed she had received training on proper lift techniques recently and stated she had been observed using the lift. During an interview on 06/03/25 at 2:40 PM, CNA6 confirmed two people were required for transfers using a mechanical lift. CNA6 confirmed she had received training on proper lift techniques following the incident with R2 and had been observed using the lift. During an interview on 06/03/25 at 3:45 PM, R2 confirmed there had been an incident on 05/11/25 when she was being transferred by CNA7 where the lift tipped over. R2 stated she had been asking the staff to transfer her using only one person, but after the incident, the staff had talked to her, and she no longer asked for just one person to transfer her. R2 stated the aides were using two people to complete the transfers. During an observation on 06/04/25 at 9:50 AM, R1 was observed being transferred from the shower chair to her bed. CNA13 and CNA14 were observed transferring R1, using proper lifting techniques. During an interview on 05/03/25 at 5:05 PM, the CQN confirmed the incident with R2 did occur. The CQN stated the resident was assessed to need a Hoyer lift for transfers, and facility policy required two staff members when using mechanical lifts. The CQN reported CNA7 had been assessed to be competent in lifting techniques and had signed that she was aware of the facility's policy requiring two staff members for mechanical lifts. The CQN stated CNA7's employment had been terminated following the incident due to the failure of not following facility policy. The CQN stated following the incident, a PIP had been implemented that included providing re-education to all nursing staff and reminders of the facility's policy requiring the use of two staff members when using a mechanical lift. The CQN stated the care plans for all residents were reviewed to ensure the proper mode of transfers/lifting had been identified for each resident. The CQN stated audits had been conducted for three weeks, with the last week of audits being 06/02/25, to ensure staff were using two people for transfers and were using proper lifting techniques. The CQN reported there had been no further incidents related to the mechanical lifts.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards. Specifically, the facility failed to: 1) Establish safety measures for proper cigarette disposal and the use of required adaptive devices, identified during smoking safety assessments, for residents who smoke tobacco on the facility's campus for 5 residents (#'s 9, 10, 21, 32, and 47), out of 7 total residents who smoked; 2) Complete annual smoking safety screening assessments for 4 residents (#'s 9, 21, 32, and 47), out of 7 total residents who smoked; 3) Complete smoking safety screening assessments for 3 residents (#'s 12, 25, and 54), out of 3 total residents who used electronic cigarettes (known as vapes); and 4) Secure lighters within the facility for 6 residents (#'s 9, 10, 21, 32, 47, and 53), out of 7 total residents who smoked. These failed practices placed all 9 residents at immediate risk of injury and/or death and placed all residents (based on a census of 60) at immediate risk for exposure to a smoke/fire environment which could have resulted in injury and/or death, which constituted an immediate jeopardy at CFR 483.25(d) Accidents. This situation was brought to the attention of the facility's administration on 3/26/25 at 1:30 PM, at which time the facility was notified of the identified immediate jeopardy. The facility submitted an acceptable removal plan on 3/26/25 at 6:17 PM. The State Agency verified onsite that the immediacy was removed on 3/26/25 at 8:30 PM. Following the removal of the immediacy, noncompliance remained at isolated actual harm that was not immediate. Findings: Campus Layout Observations on 3/23-27/25 revealed the facility campus was situated on a property with maintained grass around the front of the building within 6 feet of the entrances and within 1 foot of the building walls. Further observation revealed a rock border, with planted foliage, was positioned flush against the building's walls, which extended approximately one foot to the grass border and around the grass to the sidewalks that led to the entrances. The facility had two entrances, most often used, at the front of the building: the main entrance (which entered the main lobby of the building) and a secondary entrance (which entered a resident common space and dining room area for the facility). There was a third entrance as well, which lead directly into the hospice wing of the building. Surrounding the property, directly off the paved driveway, parking lot, and sidewalks of the building was tall, dry grass-like foliage and trees that were not maintained. It was observed that, due to the time of the year, this grass-like foliage was last year's growth and was yellow, dry and brittle in appearance. Further observation revealed no designated smoking area with a fire-proof receptable for cigarette butts on campus, nor was there any directly off the campus property. During an interview on 3/24/25 at 10:26 AM, the Director of Nursing (DON) stated the facility was a smoke-free facility and residents were to smoke off property. Facility Smoking Policy Review of the facility-provided smoking policy, received on 3/24/25, revealed: Smoking/Vaping Policy. Maple Springs is a smoke-free and vape-free campus. Smoking and vaping are not permitted on Maple Springs property. Employees and residents who wish to smoke or vape must do so off the property. There are no designated smoking times or locations. During an interview on 3/27/25 at 12:32 PM, the DON stated this smoking policy was signed by all residents upon admission. Tobacco Use During an interview on 3/26/25 at 1:52 PM, the DON stated when a resident was identified as a smoker, a smoking safety screening assessment was completed, and smoking interventions were placed in care plans. The DON further stated smoking safety screening assessments were to be completed annually. Resident #9 Record review on 3/23-27/25 revealed Resident #9 was admitted in the facility with diagnoses that included hemiplegia (paralysis on one side of the body), hemiparesis (weakness on one side of the body), unspecified epilepsy (unprovoked seizures caused by abnormal electrical activity in the brain), GERD (gastric esophagial reflux disease) and major depressive disorder. Review of Resident #9's Smoking - Safety Screen (a screening assessment to determine if a resident was safe to smoke), revealed the resident was last assessed on 12/8/23. Further review revealed the resident had visual and dexterity problems and Resident #9 needed to use adaptive equipment of a smoking apron to smoke safely. An observation on 3/25/25 at 5:33 PM, revealed Resident #9 was smoking by the secondary entrance and was positioned by a handicapped parking space. Further observation revealed the resident was not wearing a smoking apron. Resident #9 was observed extinguishing his/her cigarette on the wheelchair's right wheel [NAME]. He/she discarded the cigarette by throwing it into the parking space. An observation on 3/25/25 at 4:30 PM, outside, near the secondary entrance, revealed more than 200 cigarette butts, lying 6 feet from the right side of the entrance and 9 feet from the left side of the entrance, scattered on the grass and rock borders of the sidewalk to the entrance. Most of these butts were not flattened, or crushed, to indicate they were not extinguished prior to being discarded on the grass or rocks. Further observation revealed there was no fireproof receptacle in the vicinity to which cigarette butts could be deposited. Further observation revealed there was one non-fireproof trash can, with a lid that had a circular, uncovered hole at its center, with a non-fire proof black, plastic garbage bag in the trash can near the entrance. There was ignitable paper products within this trash can. Further observation revealed a sign on the entrance door Smoking on premises prohibited by law including vapes. Fine $50. Smokefree.alaska.gov AS [Alaska Statute] 18.35.301. During an interview on 3/26/25 at 10:10 AM, Resident #9 stated that he/she smoked nearly every day and that he/she kept his/her supplies (cigarettes and lighters) in the side pouch of his/her wheelchair or in his/her room. He/she stated that he/she usually smoked by the front of the main entrance or in front of the secondary entrance. Resident #9 stated that he/she put out his/her cigarette butts by extinguishing them on the wheelchair's control panel or on the wheelchair's [NAME]. He/she further stated he/she discarded the cigarettes by throwing them into the parking lot or the trash can by the entrances of the facility. Resident #9 stated that he/she had gotten burned before and proceeded to show two burn holes on the left side of the shirt he/she was wearing. He/she further stated that most of his/her clothing had these types of burn holes. Resident #9 further stated that he/she didn't like the apron because it flaps everywhere in the wind outside. Review of Resident #9's Behavior Note, dated 3/26/25 (the day the immediate jeopardy was issued), revealed: .Resident was smoking outside facility and somehow [his/her] fire fell off to [his/her] lap burning a hole in [his/her] jeans through to [his/her] brief and through the brief to [his/her] L [left] side scrotum. Small blister noted to skin, provider made aware as well . as nursing administration. Area dry without noted weeping, cleansed with soap and water LOA [left open to air]. Will evaluate area shift by shift to determine possible tx [treatment] options. Review of Resident #9's care plan, last revised 2/29/24, revealed: .Goal: The resident will not suffer injury from unsafe smoking practices through the review date . Interventions: Observe clothing and skin for signs of cigarette burns . resident safe to smoke without supervision as long as smoking apron is used when smoking. Resident #10 Record review on 3/23-27/25 revealed Resident #10 was admitted to the facility with diagnoses that included left leg below the knee amputation, type 2 diabetes, dementia, COPD (chronic obstructive pulmonary disease - a lung disease that blocks airflow making it difficult to breathe), and kidney disease. Review of Resident #10 Smoking - Safety Screen, dated 10/29/24, revealed the resident needed to use adaptive equipment of a smoking apron to smoke safely. Resident is able to get [himself/herself] outside to smoke on [his/her] own and can light [his/her] own cigarette to smoke. During an interview and concurrent observation on 3/26/25 at 9:25 AM, when asked about smoking, Resident #10 stated, I'm a smoker, and I've smoked here for longer than most people have worked here. I smoke outside and don't go with anyone. I put my cigarette butts in the trash can outside, there are several trash cans for that out there. I've never been told I can't smoke outside, but the staff have asked me to move away from the premises. I've also had problems getting back in the building because nobody would help me. I keep a full pack of cigarettes in my night drawer, but there's no lighter there. The doctor tells me I shouldn't smoke, but that's what I do. A full pack of [NAME] cigarettes was observed in the first drawer of the resident's nightstand. Review of Resident #10's care plan, last revised on 3/23/25, revealed: the resident is a cigarette smoker .will not suffer injury from unsafe smoking practices through the review date .interventions: instruct resident about smoking risks and hazards and about smoking cessation aids that are available; instruct resident about the facility policy on smoking: locations, times, safety concerns; notify charge nurse immediately if it is suspected resident has violated facility smoking policy; observe clothing and skin for cigarette burns; offer/encourage/assist resident with the use of smoking apron while smoking as resident allows; resident can smoke unsupervised; the resident is able to light own cigarette safely. Resident #21 Record review on 3/23-27/25 revealed Resident #21 was admitted to the facility with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction (stroke that is caused by lack of blood flow to the brain) that affected the left non-dominant side, left above the knee amputation, and mild cognitive impairment. Review of Resident #21's Smoking - Safety Screen, revealed the resident was last assessed on 1/2/24. Further review revealed the resident had cognitive loss and Resident #21 needed to use adaptive equipment of a smoking apron to smoke safely. During an interview on 3/27/25 at 11:57 AM, the DON stated that all smokers in the facility should have a Smoking-Safety Screen completed annually. When asked if Resident #21's 2025 annual Smoking-Safety Screen was completed, the DON stated it was not. Resident #32 Record review on 3/23-27/25 revealed Resident #32 was admitted to the facility with diagnoses that included nontraumatic chronic subdural hemorrhage (a slow-developing collection of blood beneath the dura mater, the outermost layer of the brain's covering), dysphagia (difficulty swallowing), acute kidney failure, and repeated falls. Review of Resident #32's Smoking - Safety Screen, revealed the resident was last assessed on 1/2/24. Further review revealed the assessment indicated the resident was able to smoke safely independently. During an interview on 3/26/25 at 8:53 AM, Resident #32 stated he/she had been at the facility for about 5 years. He/she stated he/she smoked daily for the last 2 years here at the facility. Resident #32 stated he/she smoked outside by the handicap parking on the sidewalk in front of the building. Resident #32 stated staff have never told him/her he/she couldn't smoke on the facility's property. When asked how he/she deposited his/her cigarette butts, Resident #32 stated he/she crushed the butt and threw it into the trash can by the entrances to the building. Resident #32 further stated that other residents throw their butts all over the ground and residents have complained repeatedly to leadership about this and asked for a cigarette butt canister with sand in it. When asked how leadership had responded, Resident #32 stated leadership would not do it. An observation on 3/25/25 at 4:40 PM, outside near the main entrance, revealed more than 150 cigarette butts, lying 6 feet 8 inches from the right side of the entrance and 5 feet from the left side of the entrance, scattered on the grass and rock borders of the sidewalk to the entrance. Most of these butts were not flattened, or crushed, to indicate they were not extinguished prior to being discarded on the grass or rocks. Further observation revealed there was no fireproof receptacle in the vicinity to which cigarette butts could be deposited. Further observation revealed there was one non-fireproof trash bin, with a lid that had a circular, uncovered hole at its center, with a non-fire proof, black plastic garbage bag in the trash can. There was ignitable paper products within this trash can. Further observation revealed a sign on the entrance door Smoking on premises prohibited by law including vapes. Fine $50. Smokefree.alaska.gov AS 18.35.301. Resident #47 Record review on 3/23-27/25 revealed Resident #47 was admitted to the facility with diagnoses that included quadriplegia (paralysis of all four limbs), orthopedic aftercare following surgical amputation, stage 4 (deep wound that may impact muscle, tendons, ligaments and bone) pressure ulcer of the sacral region, unspecified neuromuscular dysfunction of the bladder, and GERD. Review of Resident #47's Smoking - Safety Screen, revealed the resident was last assessed on 1/19/24. Further review revealed the assessment indicated the resident had dexterity problems and Resident #47 needed to use adaptive equipment of a smoking apron and cigarette holder to smoke safely. Resident wears smoking apron and able to light up [his/her] cigarette independently and hold [his/her] cigarette his own as well . Resident is able to use electric wheelchair to ambulate outside and able to use holder to hold cigarette and light up cigarette [himself/herself]. An observation on 3/23/25 at 8:26 AM, as the survey team was entering the facility to initiate the survey, revealed Resident #47 sitting in his/her wheelchair approximately 15 feet from the main entrance of the building smoking a cigarette. Further observation revealed the resident had the cigarette between the tines of a plastic fork taped to the resident's hand brace. Further observation revealed no smoking apron was used. An observation on 3/25/25 at 4:40 PM, as surveyors were exiting the main entrance, revealed Resident #47 smoking approximately 20 feet directly in front of the entrance. Cigarette smoke entered the building on an incoming current of air from the outside as the sliding doors opened. Further observation revealed Resident #47 had the cigarette between the tines of a plastic fork taped to the resident's hand brace. Further observation revealed no smoking apron was used. An observation on 3/25/25 at 8:05 AM revealed Resident #47 was smoking by the facility's emergency generator located off to the side of the secondary entrance. Further observation revealed the resident's cigarette was skewered on one of the tines of the plastic fork. He/she stated that he/she utilized the fork to keep the cigarette stable which was taped onto a small grey Velcro hand brace. Further observation revealed no smoking apron was used. Resident #47 further stated he/she declined using the smoking apron because the apron flaps in the wind. Resident #47 further stated it was very windy all the time. An observation on 3/26/25 at 8:20 AM, revealed Resident #47 was smoking by the facility's emergency generator located off to the side of the secondary entrance. Resident #47 was not wearing an apron, and the cigarette was lodged in the space between the tines of the plastic fork. During an interview on 3/25/25 at 3:15 PM, Resident #47 stated that he/she smoked daily. During a follow-up interview on 3/26/25 at 8:22 AM, Resident #47 stated that he/she kept his/her supplies in his/her own room by his/her nightstand. He/she stated he/she usually smoked by the front of the main entrance or by the secondary entrance where the generators were located. He/she extinguished and disposed of the cigarettes in his/her own ashtray that was located on the left side of his/her wheelchair. Resident #47 denied any injuries from smoking but further added due to his/her diagnoses, he/she waited on the wind to blow the cigarette ash away when it fell on his/her clothing. Review of Resident #47's care plan, last revised on 3/23/25, revealed: .Goal: The resident will not suffer injury from unsafe smoking practices through the review date . Interventions: .resident safe to smoke without supervision as long as smoking apron and cigarette holder is used when smoking . Smoking Aprons During an interview with a concurrent observation, on 3/26/25 at 2:52 PM, when asked how a resident could obtain a smoking apron, the MDS Nurse pulled a smoking apron from her desk drawer and stated residents would need to come to her office and ask for one. The MDS Nurse's office was in the main dining plaza area (by the secondary entrance). During an interview with a concurrent observation, on 3/26/25 at 2:57 PM, the receptionist stated she would be able to provide a smoking apron if a resident asked for one. The receptionist stated they were kept behind the receptionist's desk. She also stated if a resident from the second floor wanted to grab one on the way down, they could grab one from a drawer in the main plaza area by the elevator. Vapes Resident #12 Record review on 3/23-27/25 revealed Resident #12 was admitted to the facility with diagnoses that included type 2 diabetes, depression, chronic pain, atrial fibrillation (irregular heart rhythm), hepatic encephalopathy (brain dysfunction from liver failure) and alcoholic cirrhosis of the liver with ascites (liver scarring from alcohol with fluid buildup). During an interview on 3/26/25 at 9:08 AM, when asked about smoking, Resident #12 stated, I'd vape, but they (the facility) put me on a patch and weaned me off. I'd rather smoke indoors, but they won't let you. He/she said, Currently, I don't go out to smoke, but I have used the ashtrays by the front desk and another by the side door (referring to the trash cans outside). They just told me I had to stay away from the door. Resident #12 also stated that when he/she needed help getting back inside, he/she had to wait by the door (it locks if you go out). Otherwise, you just sit there and freeze in the winter. This happened to me about three or four months ago. Resident #12 also stated he/she does not currently have a vape in his/her room. Resident #12 stated that he/she vaped but no longer kept the vape in his/her room. He/she mentioned the doctor recently prescribed patches to help with smoking cessation, then discontinued the patch altogether. The resident further stated he/she, does not remember signing any waivers for smoking in the facility. Review of Resident #12's medical record revealed no smoking safety screening assessment. Review of Resident #12's care plan, last revised on 3/23/25, revealed: the resident is at risk for nicotine dependence r/t [related to] nicotine vape use. The resident will not suffer injury from unsafe vaping practices through the review date . interventions: instruct resident about smoking/vaping and hazards and about nicotine cessation aids that are available; instruct resident about the facility policy on smoking/vaping: locations, times, safety concerns; monitor oral hygiene; notify charge nurse immediately if it is suspected resident has violated facility smoking/vaping policy. Resident #25 Record review on 3/23-27/25 revealed Resident #25 was admitted to the facility with diagnoses that included paraplegia (paralysis of the lower half of the body), cellulitis of the lower limb (potentially serious bacterial skin infection), orthopedic aftercare following surgical amputation, and neuromuscular dysfunction of bladder (a condition where the bladder's ability to store and empty urine is impaired due to nerve damage or dysfunction). During an interview on 3/26/25 at 8:50 AM, Resident #25 stated that he/she quit smoking when he/she was admitted and switched to vape products. The resident stated that he/she usually went with his/her sister to the smoke shop to smoke. The resident further stated that he/she did not smoke while in the facility. The resident further added that his/her vaping products were kept near his/her nightstand. Review of Resident #25's medical record revealed no smoking safety screen assessment. Review of Resident #25's care plan, last reviewed 3/23/25, revealed: .Goal: The resident will not suffer injury from unsafe vaping practices through the review date .Interventions . Instruct resident about smoking/vaping risks and hazards and about smoking/nicotine cessations aids that are available . Instruct resident about the facility policy on smoking/vaping: locations, times, safety concerns . Notify charge nurse immediately if it is suspected resident has violated facility smoking/vaping policy. Review of the Food and Drug Administration article, Tips to Help Avoid Vape Battery Fires or Explosions, dated 4/12/23, at https://www.fda.gov/tobacco-products/products-ingredients-components/tips-help-avoid-vape-battery-fires-or-explosions, revealed: You may have heard that e-cigarettes, or vapes, can catch on fire or explode and seriously hurt people. Although these incidents are uncommon, vape fires and explosions are dangerous to the person using the vape product and others around them . The exact causes of fires or explosions are not yet clear, but some evidence suggests that battery-related issues may be a cause . Until all vapes and vape batteries conform to strong and consistent safety standards, your best protection against vape battery fires or explosions may be knowing as much as possible about your device and how to properly handle and charge its batteries . Charge your vape on a clean, flat surface, away from anything that can easily catch fire and someplace you can clearly see it - not on a couch or pillow where it may more easily overheat or get turned on accidentally . Protect your vape from extreme temperatures by not leaving it in direct sunlight . Don't vape around flammable gasses or liquids, such as oxygen . Make sure you know how to safely dispose of e-cigarettes . Resident #54 Record review on 3/23-27/25 revealed Resident #54 was admitted to the facility with diagnoses that included anoxic brain damage (damage to the brain caused by a complete lack of oxygen, which may lead to serious and permanent neurological problems), unspecified convulsions (sudden, involuntary muscle contractions or movements of unknown cause or type), alcoholic cirrhosis of the liver without ascites (chronic liver disease caused by excessive alcohol use where the liver becomes scarred and impairs liver function), and pulmonary hypertension (high blood pressure in the artery of the lungs that makes the heart work harder to pump blood and can lead to heart failure). Review of Resident's #54's care plan, last revised on 3/23/25, revealed: Focus .The resident is at risk for nicotine dependence r/t [related to] nicotine vape use .Goal .The resident will not suffer injury from unsafe vaping practices through the review date .Interventions . Instruct resident about smoking/vaping risks and hazards and about smoking/nicotine cessations aids that are available . Instruct resident about the facility policy on smoking/vaping: locations, times, safety concerns . Notify charge nurse immediately if it is suspected resident has violated facility smoking/vaping policy. Review of Resident #54's medical record revealed no smoking safety screening assessment. Review of Resident #54's Plan of Care Note, a late entry note effective 12/20/24 at 3:20 PM, but was created on 3/26/25 at 3:25 PM, revealed: CNA [Certified Nursing Assistant] brought to this writer's attention that Resident frequently goes outside with significant other to use [his/her] nicotine vape. This writer had discussion with resident and provided to education to resident about the risks of nicotine dependence and the option for nicotine cessation if [he/she] would like. Resident declines nicotine cessation at this time. During an interview on 3/26/25 at 1:26 PM, the DON stated that residents who vape should have smoking safety assessments performed. During an interview on 3/26/25 at 4:05 PM, the DON stated Resident #54 did not smoke or vape on admission. Resident #54 was observed on 12/20/24 to have family putting a cigarette to his/her lips during visits outside. During an interview on 3/27/25 at 11:36 AM, the DON stated Resident #54 should have had a smoking safety assessment performed earlier. Lighters in the Building During an interview on 3/26/25 at 1:52 PM, the DON stated that resident lighters were allowed to stay with the residents who smoked cigarettes. The DON stated the facility did not maintain accountability of these lighters because the facility was a smoke-free campus. Resident #9 Review of Resident #9's Smoking - Safety Screen, dated 12/8/23, revealed: . Does resident need facility to store lighter and cigarettes? Answer: No. During an interview on 3/26/25 at 10:11 AM, Resident #9 stated that his/her cigarettes and lighters were all self-purchased. He/she further stated that these were typically stored in the side pouch of his/her wheelchair and proceeded to show the pouch containing his/her cigarettes and 4 pocket style BiC (brand name) lighters. He/she also stated that there were extra lighters stored in his/her room. Resident #10 Review of Resident #10 Smoking - Safety Screen, dated 10/29/24, revealed: . Does resident need facility to store lighter and cigarettes? Answer: No. Resident #21 Review of Resident #21's Smoking - Safety Screen, dated 1/2/24, revealed: . Does resident need facility to store lighter and cigarettes? Answer: No. Resident #32 Review of Resident #32's Smoking - Safety Screen, dated 1/19/24, revealed: . Does resident need facility to store lighter and cigarettes? Answer: No. During an interview on 3/26/25 at 8:53 AM, Resident #32 stated he/she purchased his/her own cigarettes and lighters and has them hidden in his/her bedroom. Resident #47 Review of Resident #47's Smoking - Safety Screen, dated 1/19/24, revealed: . Does resident need facility to store lighter and cigarettes? Answer: No. An observation on 3/25/25 at 3:15 PM, revealed Resident #47's electric arc lighter and cigarettes were unsecured on his/her nightstand. During an interview on 3/25/25 at 3:16 PM, Resident #47 stated his/her cigarettes and lighters were all self-purchased. He/she further added these were usually stored by his/her nightstand or by the wheelchair for ease of access as he/she smoked daily. Resident #53 Review of Resident #53's Smoking - Safety Screen, dated 2/19/25, revealed: . Does resident need facility to store lighter and cigarettes? Answer: No. During an interview and concurrent observation on 3/26/25 at 9:27 AM, revealed Resident #53 indicated he/she kept his/her cigarette and lighters in his/her coat pocket. Resident #53 also indicated to the surveyor that he/she kept his/her coat in his/her wardrobe. While talking with Resident #53 an empty [NAME] cigarette pack was lying on the floor of Resident #53's room. Observations on 3/23-27/25 revealed the facility had 69 resident rooms. These rooms were unsecure an often the bedroom doors were left open and accessible to all current 60 residents of the facility. Resident room doors were left open when the residents who resided in them were elsewhere in the facility. Review of the MDS Resident Matrix (a form used to identify pertinent care categories during a survey), completed by the facility on 3/23/25, revealed 17 residents in the facility had some form of Alzheimer's or dementia (increasing the risk of exposure to unsecure lighters and introducing a smoke/fire environment within the facility). .

Based on observation and interview, the facility failed to ensure nursing staff had the appropriate skill sets to administer medications accurately for 1 resident (#8), out of 9 residents observed for medication administration. Specifically, the Licensed Nurse (LN) removed and administered a medication from a blister pack (a 30-day supply of medications in a card with bubbled packaging for individual doses of the medication) that was not labeled for the intended recipient. This failed practice placed the resident at risk for potential adverse outcomes of medication errors, or the possibility of running out of medications that were borrowed. Findings: Resident #8 Record review on 3/23-27/25 revealed Resident #8 was admitted to the facility with diagnoses that included unspecified injury at C1 level of cervical spinal cord, sequela (past injury at the top of the spinal cord in the neck that has resulted in long term or residual effects, such as weakness, paralysis, or other neurological impairments) and quadriplegia, unspecified (partial or complete paralysis of all four limbs, often caused by spinal cord injuries or diseases, without specifying the level of injury or the completeness of the paralysis) and GERD (Gastric Esophagial Reflux Disease). During a concurrent observation of medication administration and interview, on 3/26/25 at 7:41 AM, LN #3 stated Resident #8's scheduled pantoprazole (a proton pump inhibitor used to treat GERD) was not available so he/she would borrow the medication from someone else's blister pack. LN #3 then removed a pantoprazole tablet from a blister pack that was labeled for Resident #28. LN #3 then proceeded to administer it to Resident #8. LN #3 stated when a resident was out of a medication, he/she would see if he/she could borrow the medication from another resident that was also prescribed the same medication. When asked how the LNs would keep track of medications that were taken from another resident's blister pack, LN #3 stated he/she would tell the oncoming nurse so they could replace it once the medication was restocked, or he/she would give it back the next day if he/she were scheduled to work the next day. Review of Resident #8's physician's orders revealed: Pantoprazole Sodium Oral Tablet Delayed Release (Pantoprazole Sodium) Give 20 mg [milligrams] by mouth one time a day for GERD .Start Date .12/22/2023 09:00 [9:00 AM]. Review of Resident #28's physician's orders revealed: Pantoprazole Sodium Oral Tablet Delayed Release 20 MG (Pantoprazole Sodium) Give 1 tablet by mouth one time a day for GERD . Start Date . 3/30/2024 09:00. During an interview, on 3/26/25 at 2:41 PM, LN #4 stated he/she often worked as a charge nurse in the facility. When asked if it was appropriate to take medication from another resident's blister pack to administer it to another resident that was out of that same medication, LN #4 stated, Absolutely not. During an interview on 3/27/25 at 11:36 AM, the Director of Nursing (DON) stated nurses should not take medications from a resident's blister pack and administer it to another resident. Review of the facility's policy Administering Medications, revised 4/2019, revealed: 26. Medications ordered for a particular resident may not be administered to another resident . .

Based on observation, record review, and interview, the facility failed to ensure: 1) concentrations of kitchen sanitizing solutions were maintained within acceptable parameters to ensure it adequately cleaned kitchen surfaces; and 2) concentrations of fruit and vegetable cleaning solution was maintained within acceptable parameters to ensure produce was appropriately cleaned prior to being served to residents. These failed practices created a potential for food borne illness and/or cross contamination for 57 residents who received food from the kitchen. Findings: Sink & Surface Cleaner Sanitizer An observation on 3/25/25 at 11:15 AM, revealed three red buckets that were labeled on the front that stated, Ecolab Sanitizing Solution Only. One bucket was located on the bottom shelf of the food preparation line table used by the cooks while plating meals, one was located by the dishwashing station, and one bucket was located by the food preparation sinks. During an interview on 3/25/25 at 11:25 AM, [NAME] #1 stated the red buckets contained a solution that was located by the dishwasher. He/she stated this solution was called, Ecolab SMARTPOWER Sink & Surface Cleaner Sanitizer. He/she further stated this solution was used to clean surfaces in the kitchen. [NAME] #1 stated the solution in the red buckets were to be changed .every hour . and when the solution was tested with the test strips, there was no log that documented when those tests were completed and/or the results of the tests. Review of Ecolab Sink & Surface Cleaner Sanitizer FAQ [Frequently Asked Questions], accessed at https://www.ecolab.com/offerings/sink-surface-cleaner-sanitizer, revealed the active ingredients in the solution were Dodecylbenzenesulfonic Acid (DDBSA) and Lactic Acid. When the mixed solution was tested, the recommended color on the test strip would be a dark to bright green color which indicated the target concentration of 272-700 ppm (parts per million) of DDBSA and [PHONE NUMBER] ppm of Lactic Acid. Further review revealed: .Are the ingredients approved for food-contact surface sanitizing? .all ingredients in Sink & Surface Cleaner Sanitizer have been reviewed .for use in food-contact surface sanitizing solutions and are approved for use on food-contact surfaces . Review on 3/25/25 of the Ecolab Sink & Surface Cleaner Sanitizer Test Strip used by the facility, with an expiration date of November 2026, revealed the following instructions: .Immerse the test strip in sample for 5 seconds. Excess sample should be shaken off of strip .Evaluate the color 10 seconds after removing the test strip from the sample .Match the center of the test strip pad to the color chart to determine concentration . During an interview on 3/25/25 at 11:49 AM, [NAME] #2 stated that the buckets were to be changed .every two hours . He/she further added that it was tested intermittently but there was no log that could be reviewed for times when tested or the results of the tests. During an interview on 3/26/25 at 7:40 AM, Dietary Aide (DA) #2 stated that the buckets were to be changed .every two hours . and further added that the test strips were used to check the concentration level. He/she stated that it was checked when the buckets were made. DA #2 stated that the results were not logged. Sanitation Bucket by Food Preparation Line An observation on 3/25/25 at 11:49 AM, revealed [NAME] #2 used the red sanitizing bucket's solution to clean a kitchen knife that was being utilized to chop food on the line for the lunch service. Review of the test strip results, on 3/25/25 at 11:51 AM, of the red sanitizing bucket used by [NAME] #2, revealed a bright blue color. According to the Sink & Surface Cleaner Sanitizer Test Strip color chart located on the test strip kit, a bright to dark blue color would be indicative of 0-170 ppm DDBSA and 0-452 ppm Lactic Acid (below the required target concentration level). During an interview 3/25/25 at 11:52 AM, [NAME] #1 stated that the red sanitizing bucket was last replaced an hour ago. Sanitation Bucket by the Dishwashing Station An observation on 3/25/25 at 12:07 PM, revealed DA #3 used the red sanitizing bucket's solution to clean a black, wheeled cart from the kitchen. DA #3 washed down the handles and surfaces of the cart. Review of the test strip results, on 3/25/25 at 12:08 PM, of the red sanitizing bucket used by DA #3, revealed a bright blue color (which was below the required target concentration level). Sanitation Bucket by the Food Preparation Sinks An observation on 3/25/25 at 4:32 PM, revealed [NAME] #3 stated the red sanitizing buckets on the line and by the preparation sink, was just changed, and [NAME] #1 stated, about 30 or so minutes ago. Review of the test strip results on 3/25/25 at 4:33 PM, revealed a bright blue color, which was again below required target concentration level. During a follow up interview on 3/26/25 at 1:05 PM, the Kitchen Manager (KM) attempted to try to test the solution that was labeled, Ecolab SMARTPOWER Sink & Surface Cleaner Sanitizer and found that the container of the solution was empty. He then replaced the solution, instructed staff in the vicinity to monitor, and change accordingly. An observation on 3/26/25 at 1:07 PM, DA #1 came back to the kitchen with a red sanitizing bucket which he/she stated was just made 30 minutes ago. When asked what the red sanitizing bucket was used for, DA #1 stated it was used to wipe the table surfaces in the main dining room. The solution in the bucket was tested with the Sink & Surface Cleaner Sanitizer Test Strips and the result was a bright blue color which indicated it was below the target concentration level. The KM then instructed DA #1 to throw away the solution in the bucket. During an interview on 3/27/25 at 9:33 AM, the KM stated the sanitation solution .should be changed every two hours or when visibly soiled . Review of a wall poster next to the ECOLAB dispensing device in the kitchen, on 3/25/25 at 10:30 AM, revealed the device was identified as an Ecolab SMARTPOWER Sink & Surface Sanitizer. The poster indicated to use Ecolab SMARTPOWER Sink & Surface Cleaner test strips to test the concentration levels of sanitation solution. The poster indicated the sanitation solution should be tested at or above room temperature of 65 degrees F [Fahrenheit], and the test paper strip should be placed in solution for 5 seconds, and the acceptable range for sanitation solution concentration is .between 272-700 ppm DDBSA and [PHONE NUMBER] ppm Lactic Acid . Review of facility's Sanitation Bucket Policy, undated, revealed: .Purpose .the policy establishes procedures for maintaining and using sanitation buckets to prevent cross-contamination and effectiveness to ensure a safe and sanitary environment . The sanitizer solution must be changed every two (2) hours or sooner if it becomes visibly soiled . A test strip should be used to verify that the sanitizer concentration is within the appropriate range as per manufacturer guidelines .Supervisors or designated personnel will perform routine checks to ensure compliance with this policy .Any non-compliance must be reported and corrected immediately . Antimicrobial Fruit & Vegetable Treatment An observation on 3/25/25 at 11:18 AM, revealed a produce wash solution dispenser labeled, Ecolab Antimicrobial Fruit & Vegetable Treatment to the right side of the food preparation sinks. It was also observed that there were test strips on top of the dispenser, and it was noted that a blue water pipe was on the right side of the dispenser with a water line connecting to the dispenser. During an interview on 3/25/25 at 11:25 AM, [NAME] #1 stated this solution was used to wash produce prior to being prepared and served to the residents. Review on 3/26/25 of the Ecolab Antimicrobial Fruit & Vegetable Treatment Test Strip, used by the facility, with an expiration date of February 2026 and November 2026, revealed the following instructions: .Immerse the strip in sample .Evaluate the color .Match the center of the test strip pad to the color chart to determine Antimicrobial Fruit & Vegetable Treatment concentration . Further review of the Antimicrobial Fruit & Vegetable Treatment Test Strip, revealed the manufacturer's target result for recommended concentrations was a green color, and the manufacturer indicated on the bottom of the green color that this result had a dilution ratio (a proportion of the solution's concentration to water) of 1:170. During an observation and concurrent interview, on 3/26/25 at 12:55 PM, the KM tested the running solution of the Ecolab Antimicrobial Fruit & Vegetable Treatment, straight from the dispenser with a test strip. The test strip's color result was bright blue with a dilution ratio of 0, according to the test strip kit. The KM stated a bright blue color result meant that the Antimicrobial Fruit & Vegetable Treatment solution was not at the recommended concentration per the manufacturer. The KM tested the dispensed solution three more times and received the same color result. Afterwards, the KM looked underneath the sink and realized that the produce wash solution was empty. He then replaced the empty container with a new container of Antimicrobial Fruit & Vegetable Treatment solution. The KM tested the solution again, which resulted in bright blue. This result was identical to all the previous results. Next, the KM opened the dispenser to troubleshoot and upon inspection, he stated that he believed there was air in the line which was preventing the solution from dispensing. The KM further stated that there were no logs kept for testing the solution to ensure the proper concentration of the produce wash solution was completed. He stated that he would periodically come in during each dining service to test the solution for compliance. He further added that an Ecolab technician came in every one to one and a half months to conduct maintenance on the Ecolab products to include the produce wash solution dispenser. During an interview on 3/26/25 at 3:35 PM, the KM stated the vegetable wash dispenser is working properly and was serviced by an Ecolab technician. He stated the technician found the motor was not properly functioning, which caused the solution to not cycle through the dispenser. During an interview on 3/27/25 at 3:29 PM, the KM was asked if the facility had a policy or process to monitor the solution. He deferred to the Maintenance Director, who stated that staff should be following the manufacturer's wall poster located on the kitchen wall to the left of the preparation sink. Review of a facility poster Ecolab Antimicrobial Fruit & Vegetable Treatment, undated, revealed: . Periodically check wash solution for proper concentration . use test strip or test kit supplied . .

Based on observation, record review, and interview, the facility failed to ensure a produce wash solution dispenser was in operating condition. This failed practice placed 57 residents that received food from the kitchen at risk for foodborne illnesses and communicable diseases from subquality cleaning of fresh produce. Findings: An observation on 3/25/25 at 11:18 AM, revealed a produce wash solution dispenser labeled, Ecolab Antimicrobial Fruit & Vegetable Treatment to the right side of the food preparation sinks. It was also observed that there were test strips on top of the dispenser, and it was noted that a blue water pipe was on the right side of the dispenser with a water line connecting to the dispenser. During an interview on 3/25/25 at 11:25 AM, [NAME] #1 stated this solution was used to wash produce prior to being prepared and served to the residents. Review on 3/26/25 of the Ecolab Antimicrobial Fruit & Vegetable Treatment Test Strip, used by the facility, with an expiration date of February 2026 and November 2026, revealed the following instructions: .Immerse the strip in sample .Evaluate the color .Match the center of the test strip pad to the color chart to determine Antimicrobial Fruit & Vegetable Treatment concentration . Further review of the Antimicrobial Fruit & Vegetable Treatment Test Strip, revealed the manufacturer's target result for recommended concentrations was a green color, and the manufacturer indicated on the bottom of the green color that this result had a dilution ratio (a proportion of the solution's concentration to water) of 1:170. During an observation and concurrent interview, on 3/26/25 at 12:55 PM, the KM tested the running solution of the Ecolab Antimicrobial Fruit & Vegetable Treatment, straight from the dispenser with a test strip. The test strip's color result was bright blue with a dilution ratio of 0, according to the test strip kit. The KM stated a bright blue color result meant that the Antimicrobial Fruit & Vegetable Treatment solution was not at the recommended concentration per the manufacturer. The KM tested the dispensed solution three more times and received the same color result. Afterwards, the KM looked underneath the sink and realized that the produce wash solution was empty. He then replaced the empty container with a new container of Antimicrobial Fruit & Vegetable Treatment solution. The KM tested the solution again, which resulted in bright blue. This result was identical to all the previous results. Next, the KM opened the dispenser to troubleshoot and upon inspection, he stated that he believed there was air in the line which was preventing the solution from dispensing. The KM further stated that there were no logs kept for testing the solution to ensure the proper concentration of the produce wash solution was completed. He stated that he would periodically come in during each dining service to test the solution for compliance. He further added that an Ecolab technician came in every one to one and a half months to conduct maintenance on the Ecolab products to include the produce wash solution dispenser. During an interview on 3/26/25 at 3:35 PM, the KM stated the vegetable wash dispenser is working properly and was serviced by an Ecolab technician. He stated the technician found the motor was not properly functioning, which caused the solution to not cycle through the dispenser. During an interview on 3/27/25 at 3:29 PM, the KM was asked if the facility had a policy or process to monitor the solution. He deferred to the Maintenance Director, who stated that staff should be following the manufacturer's wall poster located on the kitchen wall to the left of the preparation sink. Review of a facility poster Ecolab Antimicrobial Fruit & Vegetable Treatment, undated, revealed: . Periodically check wash solution for proper concentration . use test strip or test kit supplied . .

Based on record review, interview and observation, the facility failed to ensure the resident's environment for 1 resident (#1), out of 5 sampled residents, was free of accident hazards. Specifically, a pair of scissors was found in the resident's room, who had a history of cutting his/her medical devices. This failed practice of not monitoring the resident environment caused harm as the resident used scissors to cut his/her foley catheter (a sterile tube inserted into the bladder to drain urine), causing a segment of the catheter tubing to be left in the bladder and requiring further interventions to remove the tubing. Findings: Record review on 6/20/23 revealed Resident #1 was admitted to the facility with diagnoses that included dementia and anxiety disorder. Review of a Nurse's Note, dated 6/15/23 at 6:00 AM, revealed Resident #1 was found in [his/her] room with [his/her] Foley [catheter] cut off. The bag and base of the foley were found in the trash next to [his/her] bed. The remainder of the Foley was not located and is assumed to be still inside the resident. Resident was sent to MATSU ED [Mat-Su Regional Medical Center Emergency Department] via ambulance . During an interview on 6/20/23 at 9:39 AM, Resident #1 was confused and disoriented to time and place, and the events leading up to his/her Emergency Department visit. During an interview on 6/20/23 at 12:08 PM, Certified Nursing Assistants (CNAs) #1 and #2 stated they went into the Resident's room and had initially thought the Resident had pulled out his/her Foley catheter, but then realized the Foley catheter had been cut . The CNA's stated they did not find any scissors in the resident's room. When asked what interventions were put in place after the incident, the CNAs stated no new interventions were put in place, but the Resident had increased supervision and liked to follow staff around the facility. The CNAs stated the Resident liked to sit with them and wanted a job (the Resident enjoyed having a purpose). During an interview on 6/20/23 at 12:13 PM, Licensed Nurse (LN) #3 stated Resident #1 had dementia and forgot why he/she had a Foley catheter, he/she just knew the catheter had bothered him/her. When asked about the incident of the Resident cutting the Foley catheter, LN #3 stated the Resident had cut his/her Foley catheter in the past and a pair of scissors was found in the Resident's room. When asked what interventions were put in place to prevent further accidents, the LN stated the facility had gone through the resident's room after the incident and removed any sharp objects. The LN further stated staff kept a close eye on the resident because he/she was mobile, and staff provided the resident with activities, such as stapling fliers. The LN further stated the resident attended activities where he/she could have picked up a pair of scissors. The interview continued while performing an observation of Resident #1's room. A pair of bandage scissors was found in the resident's unlocked bathroom closet, located in a basin with nursing supplies. LN #3 removed the scissors from the resident's room. The LN stated the Resident was not closely monitored while in his/her room because he/she would go to his/her room to lay down, but the Resident would wander about in his/her room instead of lying in bed. When asked if the facility checked the resident's room for sharp objects outside of the incidents, the LN stated he/she had not checked the Resident's room for sharp objects. Review of Resident #1's Nurse's Note from the previous incident of cutting his/her catheter, dated 3/13/23 at 6:30 PM, revealed: Resident foley catheter was cut approximate 1 1/2 [inches] above urethral opening [the tube that carries urine out of the bladder], making deflation and removal of catheter difficult, provider [physician name] MD notified and approved transfer of resident to ED. Suspected resident cut [his/her] own catheter due to proximity of open nail cutters on residents side table and previous reported [history] of resident cutting catheter in past . Review of Resident #1's current Care Plan revealed no documentation for care of the Resident's Foley catheter, nor any documentation regarding the Resident's history of cutting his/her catheter or interventions to address or prevent future accidents. During an interview on 6/20/23 at 12:40 PM, the Director of Nursing (DON) stated the facility was aware Resident #1 had a history of cutting his/her equipment and the resident had used fingernail clippers in the past to cut his/her foley catheter. When asked what interventions were put in place to prevent future accidents, the DON replied the facility increased safety checks, which included room checks, every 2 hours. When asked if these interventions should have been included in the Resident's care plan, the DON replied yes, interventions should have been documented in the Resident's care plan. During a follow up interview on 6/20/23 at 2:00 PM, LN #3 stated the scissors found in the resident's room were bandage scissors used by the nursing staff to cut pieces of medical equipment for use by the resident. Review of ED Physician Documentation, dated 6/15/23 at 6:37 AM, revealed There is a visible Foley catheter balloon in the middle of the bladder . for which the resident will likely require a cystoscopy (a hollow tube (cystoscope) equipped with a lens is inserted into the urethra and slowly advanced into the bladder) for the removal of the retained Foley catheter segment. Review of the facility's policy Safety and Supervision of Residents, dated 12/2022, revealed: 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 2. The interdisciplinary care team shall analyze information obtained from assessment and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, included adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring that interventions are implemented; and e. Documenting interventions.

Based on record review, interview, and observation the facility failed to identify and implement safe application, as well as, education and training for staff on appropriate utilization of a seatbelt securement system used for securing wheelchair bound residents during transport in the facility van and/or bus. This failed practice led to 1 resident (#1) obtaining a significant injury, specifically, a compound fracture of the lower leg after sliding out of his/her wheelchair. This failure placed 3 resident's (#'s 2;3;4) who were observed using the facility transportation on 2/14/23 and 9 resident's (#s' 5; 6; 7; 8; 9; 10; 11; 12; 13) scheduled to use the van and/or bus transportation during the week of 2/14/23, including wheelchair-bound residents using the facility transportation for activities, at immediate risk for serious harm and or injury from possible ejection, dislodgment, or injury during a sudden stop and/or accident while riding in the facility vehicle. Findings: Record review on 2/14/23 revealed Resident #1 had diagnoses that included osteoarthritis, depression, and anxiety. Review of Nurses Notes, dated 1/25/23 at 1:55 PM, revealed Facility transportation staff called the facility to let them know the res [Resident #1] slid forward when [he/she] stopped and [his/her] ankle is injured. [He/she] had already pulled over and called 911. This RN [Registered Nurse] notified [Resident Representative] via phone at 1328 [1:28 PM]. Notified [him/her] that the res has an injury to [his/her] ankle and an ambulance was on their way to pick [his/her] up and would be taking [him/her] to [hospital emergency room ]. During an interview on 2/14/23 at 10:19 AM, the Administrator stated the facility provided a shuttle bus and a [NAME] van to transport residents to appointments. The Administrator stated Resident #1 was riding in the [NAME] van and was injured when the driver came to an abrupt stop at a red light. Further stating Resident #1 had slid out of the seatbelt and ended up sitting on the pedals of the wheelchair. He stated the Resident was admitted to the hospital for an open fracture of the right leg and other injuries. The Administrator stated Resident #1 had not returned to the facility after admission to the hospital. Observations of the [NAME] van, with the Administrator, revealed the backseats of the van were removed and there was enough space to accommodate 2 wheelchairs. The Administrator demonstrated how the wheelchairs were secured using the Q'Straint Securement System and further explained the process that a resident in a wheelchair is brought into the van, and the brakes on the wheelchair are locked. The wheelchair is then secured to the floor using 4 tie-downs with the Q'Straint system. The 2 tie-downs for the rear of the wheelchair had a lap belt that is to be placed through the armrests and over the resident and connected in front of the resident. When asked about the seatbelts observed hanging on the left side of the van wall, the Administrator stated the one pre-installed by the manufacturer was not used and the other seatbelt, a Q'Straint shoulder belt was not used. During an observation on 2/14/23 at 11:00 AM, Driver #2 pushed Resident #2 out to the [NAME] van in his/her wheelchair. The Driver pushed the wheelchair up the ramp and secured the wheelchair in the van using the Q'Straint tie-downs. Driver #2 then pulled the lap belt over the top of the wheelchair armrests and snapped the buckle in front of the Resident. A gap between the resident and the lap belt was observed. A shoulder strap was not used. During a second interview on 2/14/23 at 12:35 PM, the Administrator was asked for the manufacturer's instructions or education on the use of the Q'Straint Securement System. The Administrator stated he would have to check, when asked if he knew of any Q'Straint training videos, he stated that he had never seen them. No information on the manufacturer's instructions or education was provided by the facility prior to the survey exit on 2/14/23 at 5:00 PM. During an interview on 2/14/23 at 12:35 PM, Driver #1 stated he/she drove Resident #1 to an appointment when the incident occurred. He/she stated he/she used both the [NAME] van and the facility bus when transporting residents. When asked what training the facility had provided, he/she stated Driver #3 trained him/her by demonstrating how to secure the residents in the vehicles. Driver #1 stated he had also shadowed Driver #3 and did ride-alongs for a couple of days. Driver #1 further stated that on 1/25/23 he/she loaded Resident #1 in the van as usual. The Resident was seated in a wheelchair and positioned on a blue sling and the resident was leaning to one side. Driver #1 stated he/she locked the wheels of the chair, attached the tie-downs to the front and back wheels and positioned the lap belt over Resident #1. The Driver stated because of the Resident's larger size, there was no room to run the lap belt between the arm rest and the back of the wheelchair. While driving he/she looked back and asked the Resident if he/she was okay, to which the Resident replied, Yeah. Driver #1 further stated he/she had come to an abrupt stop at a red light, he/she looked back and saw that Resident #1 had slid out of the wheelchair and was sitting on the foot pedals of the wheelchair and the lap belt was up around the Resident's chin. He/she pulled over and removed the strap from around the Resident's neck. The Resident was unable to get up or move, at which point the Driver noticed the Resident's right leg was bleeding. Driver #1 stated he/she called 911, then the Administrator of the facility. During an observation on 2/14/23 at 12:52 PM, Driver #1 demonstrated, using the wheelchair, used by Resident #1, how he/she had locked the wheels, tied down the wheelchair and had placed the lapbelt between the back of the wheelchair and the armrests and in front of the resident. The wheelchair was large and had a blue nylon cushion in the seat. During an interview on 2/14/23 at 1:22 PM, Driver #3 stated he/she had been training facility staff on how to secure and transport the residents in the facility van. When asked what training had been provided and utilized, the Driver stated his/her training consisted of verbal instruction and shadowing another driver. Driver #3 stated the facility started conducting audits after the incident with Resident #1. When asked about specific training on the Q'Straint system, the Driver stated he/she had not reviewed any Q'Straint videos, and his/her training had been verbal. Observation on 2/14/23 at 1:39 PM revealed Resident #3 arrived in the van with Driver #2 driving. When the door opened, the Resident was observed seated in a wheelchair in the van. The wheelchair was anchored to the floor with the Q'Straint anchor straps, and the lap belt came up from the two back anchors, between the seat and the wheels and around the outside of the armrest panel. The seat belt was buckled in the front and was not touching the Resident, leaving a large gap between the resident's abdomen and the lapbelt. The shoulder strap was not attached to the seatbelt system. During an interview on 2/14/23 at 2:00 PM, Occupational Therapist and the Physical Therapist (PT) stated the facility had not asked their department to review the seatbelt securement system since the incident with Resident #1. Further stating they had not been involved in the facility investigation nor trainings with securement systems. During an interview on 2/14/23 at 3:35 PM, when asked about his/her van ride, Resident #3 stated the drivers have straps everywhere with one over his/her lap. The Resident stated they did not use a shoulder strap. Resident #3 stated he/she feels like he/she is going to fall out of the wheelchair at times. An observation on 2/14/23 at 4:10 PM, revealed Driver #2 returned to the facility with Resident #4. During an interview at 4:20 PM, when asked about the use of the lap belt and the shoulder harness, Driver #2 stated he/she was unsure how it attached and stated he/she had never used the shoulder harness. Review of the transport schedule on 2/14/23 revealed 9 residents were scheduled to use the facility transportation from 2/15-17/23, for activities. Review on 2/14/23 of a facility Follow-up Investigation report, dated 1/30/23, revealed secured resident in the van and departed to [his/her] doctor's visit. While the van was breaking routinely for a traffic light, the Resident slid from [his/her] seat twisting [his/her] right ankle and becoming stuck on the seatbelt. Driver then pulled over, removed seatbelt, and called 911 for assistance. if Systemic actions . While our investigation did not find abuse or neglect, increased training and oversight will be implemented to ensure the safe transport of our residents. Non-emergency braking procedures will be reviewed with all transport drivers. Proper securing of residents being transported will also be reviewed with all transport drivers. Spot audits will be conducted within the next 60 days to ensure that residents or property secured when being transported in a Maple vehicle. Review of employee training records on 2/14 /23 revealed that Drivers #'s 1; 2; 3; 4 and the Administrator had no documented training on how to utilize the Q'Straint Securement Systems for securing wheelchair bound residents in the facility provided van and/or bus. Review of the Transportation Safety Competency Checklist for Driver #3, dated 1/27/23, signed off by the Director of Nursing (DON), revealed Pre-Transport Checklist .6. Resident's seatbelt is appropriately fastened, positioned and tight prior to departure. Review of the Transportation Safety Competency Checklist for Driver #1, dated 1/27/23, signed off by Driver #3 and the DON revealed Pre-Transport Checklist .6. Resident's seatbelt is appropriately fastened, positioned and tight prior to departure. Review of the Transportation Safety Competency Checklist for Driver #2, dated 1/27/23, signed off by Driver #3 and the DON revealed Pre-Transport Checklist .6. Resident's seatbelt is appropriately fastened, positioned and tight prior to departure. Review of the Transportation Safety Competency Checklist for Driver #4, dated 1/27/23, signed off by Driver #3 and the DON revealed Pre-Transport Checklist .6. Resident's seatbelt is appropriately fastened, positioned and tight prior to departure. Review of the Administrator's training record revealed there was not a Transportation Safety Competency Checklist or information about the use of the Q'Straint Securement System. The review of the checklist's revealed there was no information specific to the Q'straint securement system for the wheelchairs. Review of the facility Driver Safety Policy -General Industry policy, effective 4/26/2019, revealed Basic Vehicle Operation Guidelines: Employees are required to adhere to the following basic vehicle operation principles: Always use seat belts. There was no manufacturer information about the use of the Q'Straint Securement System and employee education.