Every finding on record at Marion Health and Rehab, LLC

Based on record review, interviews, and facility policy review, the facility failed to apply a shoulder restraint during transportation in the facility van for one (1) of three (3) sampled residents (Resident #1).Findings include: A review of the facility's policy Procedure Accidents/Incident Reporting, undated, revealed, .Accident/Incident is defined as an unexpected happening, which may or may not have caused loss or injury to a visitor, resident and/or staff person. A review of the facility's policy Providing Resident Transport out of Facility, dated 7/2008, revealed, .It is the policy of this facility to arrange transportation for our residents to, out of the facility, consultation visits. A record review of the manufacture's guidelines Wheelchair Tie-Downs revealed, .Wheelchair restraints ensure the passenger remains in a safe, forward-facing position when the vehicle is in use.The wheelchair user should also use a shoulder and lap seat belt. A record review of the Resident Council Meeting Minutes dated 5/21/2026, revealed, Resident #1 was in attendance and discussed van safety with the Person Responsible listed as the Administrator.On 6/16/26 at 9:50 AM, an interview with the facility's State Ombudsman revealed that during the 5/21/26 Resident Council meeting, Resident #1 voiced a concern that during transportation to a physician appointment, the driver secured the wheelchair with the four-point securement system and lap belt but failed to apply the shoulder restraint. On 6/16/26 at 11:00 AM, during an interview, Resident #1 stated that when transported to a physician appointment, the transport team secured the resident's wheelchair using a four-point wheelchair securement system and applied a lap belt; however, a shoulder restraint was not applied. Resident #1 confirmed feeling unsafe during the transport and requested that the shoulder restraint be applied. Resident #1 revealed that despite the request, the transport driver did not apply the shoulder restraint. Resident #1 further revealed that the matter was later discussed with the Administrator, who informed the resident that the facility was not required to utilize both a lap belt and shoulder restraint during resident transportation.On 6/16/26 at 11:50 AM, during an interview, the Activities Director, who was responsible for transportation at the time of Resident #1's transport, revealed that during the Resident Council meeting held on 5/21/26, Resident #1 voiced concerns regarding transportation safety and reported that only a lap belt was applied during van transportation. Resident #1 expressed feeling unsafe being transported without a shoulder restraint. The Activities Director revealed that both the Ombudsman and Administrator were present during the meeting. According to the Activities Director, the Administrator explained that shoulder restraints were available and could be provided upon request; however, the facility believed it was operating in compliance with transportation requirements. The Activities Director confirmed being unaware of any other residents who had voiced concerns regarding transportation safety. The Activities Director further confirmed transporting Resident #1 to a physician appointment on 3/26/26 and securing the resident's wheelchair using the four-point securement system and lap belt; however, the shoulder restraint was not applied due to a lapse in judgment.On 6/16/26 at 1:15 PM, during an interview, the Administrator confirmed that Resident #1 was transported to a scheduled medical appointment on 3/26/2026. The Administrator revealed that the transportation driver secured the resident's wheelchair using the four-point floor securement system and applied the lap restraint; however, a shoulder restraint was not applied during the transport. The Administrator stated that transportation staff are expected to follow the manufacturer's safety guidelines when transporting residents and securing wheelchairs within the transport van. The Administrator further revealed that the manufacturer's guidelines require the use of both a lap restraint and shoulder restraint for wheelchair occupants during transport. The Administrator confirmed that transportation staff had received training on the proper use of the wheelchair securement system and occupant restraints. The Administrator acknowledged that the shoulder restraint should have been applied during Resident #1's transport and indicated that the failure to do so was an isolated occurrence and not consistent with the facility's usual transportation practices. The Administrator confirmed that he was not aware of the incident until the Resident Council meeting on 5/21/2026. A record review of the admission Record revealed Resident #1 was admitted by the facility on 9/22/2023 and had current diagnoses including Urinary Tract Infection and Anemia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/2/2026 revealed Resident#1 had a Brief Interview for Mental Status (BIMS) summary score of 14, which indicated Resident #1's cognition was intact.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure appropriate pain management when nursing staff continued performing wound care to a resident's Stage 4 pressure ulcer after the resident verbalized pain and requested pain medication, resulting in the resident experiencing pain during the treatment for one (1) of three (3) residents reviewed for pain management. (Resident #7).Findings include:A review of the facility's policy, Pain Assessment/Management, revised 6/2005, revealed, .It is the policy of the facility to provide guidelines for the identification and treatment of residents at risk for acute and chronic pain.If possible the nurse will discuss with the resident the severity and quality of pain using the pain reference scale.On 3/11/26 at 8:42 AM, during an observation of wound care for Resident #7, Registered Nurse (RN) #3 and Certified Nursing Assistant (CNA) #2 washed their hands and applied personal protective equipment prior to beginning the wound care treatment. During the treatment, RN #3 removed the dressing from the resident's pressure ulcer to the sacrum/coccyx area. The resident began moaning and stated he was hurting. When asked if he was hurting, the resident responded, yes. When asked if he needed something for pain, the resident responded, yes. RN #3 turned on the call light and continued performing the wound care treatment. During the remainder of the procedure, the resident continued to moan and groan and used explicit words stating he was in pain while RN #3 completed the wound care treatment.On 03/11/26 at 8:57 AM, during an interview, RN #3 confirmed the resident complained of pain during the wound care treatment. RN #3 stated she turned on the call light to notify the medication nurse. RN #3 stated the resident normally says the wound care tickles, but acknowledged she should have stopped the procedure and waited until the resident received pain medication before continuing the treatment.On 03/11/26 at 8:58 AM, during an interview, CNA #2 confirmed the resident moaned and groaned while the wound care treatment was being provided and confirmed the nurse continued performing the treatment.On 03/11/26 at 9:19 AM, during an interview, the Director of Nursing (DON) stated when a resident expresses pain during wound care the nurse should stop the procedure, administer pain medication, and allow time for the medication to take effect (approximately 30 minutes) before resuming treatment.On 03/11/26 at 9:31 AM, during an interview, the Administrator stated he expects nursing staff to follow the facility's pain management policy when providing wound care to residents.A record review of the admission Record revealed the facility initially admitted Resident #7 on 11/9/22 with diagnoses including Pressure Ulcer of the Sacral Region.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/19/26 revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 99, indicating the interview could not be completed and a staff assessment for cognition was required. The staff assessment revealed the resident had short-term and long-term memory problems and his cognitive skills for daily decision making were moderately impaired, with decisions described as poor and cues or supervision required.A record review of the Care Plan Report revealed Resident #7 had a Focus of Update stage 4 coccyx. with an intervention revised on 2/3/26 for wound care treatment to Stage 4 Pressure Ulcer to coccyx.A record review of the Order Summary Report with active orders as of 3/12/26 revealed Resident #7 had a physician order, dated 12/9/25, for Hydrocodone-Acetaminophen Tablet 7.5-325 milligrams (mg), Give one (1) tablet every four (4) hours as needed for pain. A record review of the Medication Administration Record (MAR) for March 2026 revealed Resident #7 received Hydrocodone-Acetaminophen for pain on 3/11/26 at 9:06 AM, after the wound care treatment was observed at 8:42 AM, documenting the pain intensity level as a six (6) out of ten (10) pain scale.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure residents' rights to personal privacy and confidentiality of their medical records when resident charts containing identifying information were stored in hallways near the nurses' stations for two (2) of (2) nurses stations observed. Findings include:A review of the facility's policy, Resident Rights updated 04/04/25, revealed, .Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.d. Privacy and confidentiality.A record review of the facility's Confidentiality and Non-Disclosure Agreement, dated revised 05/16/22, revealed staff are not to leave workstations unattended without securing hard copy information so that it may not be disclosed to unauthorized persons and that staff must abide by Health Insurance Portability and Accountability Act (HIPAA) policy and procedures and current regulations governing privacy issues.On 03/09/26 at 3:00 PM, during an observation of the hallway areas near the nurses'' stations, multiple resident medical charts were stored in the hallway with resident names and room numbers visible on the chart labels. The medical charts contained information such as resident Face Sheets, Physician's Orders, Care Plans, Labs, Advance Directives, History and Physicals, and hospital records. On 03/10/26 at 2:00 PM, during the Resident Council meeting, Resident #74 expressed concern that resident medical record charts were stored in the hallway where anyone could access them. Resident #74 reported obtaining a medical record chart from the hallway shelf and keeping the chart in the resident's possession for a period of time without staff noticing or addressing the removal.On 03/10/26 at 3:40 PM, during an interview with Licensed Practical Nurse (LPN) #2, she reported that resident medical charts were moved to the hallway approximately (2) weeks ago after a new company assumed management of the facility. She explained that the charts were temporarily placed in the hallway and that a designated storage location for resident medical records was expected to be built later.On 03/11/26 at 11:35 AM, during an observation of the hallway areas near the nurses' stations on Dogwood Hall and Magnolia Hall, resident medical charts were observed stored in gray plastic folders in the hallway. The charts were easily accessible from the hallway, and chart labels were turned toward the wall.On 03/11/26 at 11:42 AM, during an interview with the Director of Nursing (DON), she confirmed resident medical charts were previously kept in the medical records office and explained the medical charts were moved to the hallway so nursing staff and the medical director could access the records more quickly. She acknowledged staff had been able to access and document in the charts while they were kept in the medical records office and reported that a chart cubby was planned to be constructed at a later time.On 03/11/26 at 11:50 AM, during an interview with Unit Manager Registered Nurse (RN) #1, she reported that resident medical records had previously been stored in the medical records room behind a locked door. She explained that the charts had been moved to the hallway approximately one and one-half to (2) weeks earlier and reported she was unsure why the records were relocated from the secured medical records room to the hallway.On 03/11/26 at 12:01 PM, during an interview with LPN #1 in Medical Records, she explained that prior to the facility buyout the facility did not maintain paper charts. She reported that after the buyout, resident medical charts were created and assembled and were initially stored in the medical records office. She explained the medical charts were later moved to the hallway so that nurses could access them during care. She reported staff were instructed to monitor the charts to prevent resident access and stated staff had discussed confidentiality and HIPAA requirements. After being informed that a resident reported retrieving a chart from the hallway shelf and keeping it without staff noticing, she acknowledged the charts had previously been secured in the medical records room and that a permanent chart storage location was expected to be constructed later.On 03/12/26 at 2:53 PM, during an interview with the Administrator, he explained the resident medical charts were temporarily placed in the hallway to allow quicker access for nursing staff and the physician to review information such as code status. He reported the medical charts had been moved from the medical records room approximately (2) weeks earlier and stated staff were expected to monitor the medical charts and safeguard resident information. He explained the current cart location was intended as a temporary solution until a permanent medical chart storage cubby could be constructed and reported he expects staff to comply with HIPAA requirements and ensure resident health information remains protected and confidential.

Based on interview, record review, and facility policy review, the facility failed to provide residents with account statements upon request for two (2) of three (3) residents reviewed for resident funds (Resident #65 and Resident #74), with the potential to affect all (43) residents with facility-managed trust funds.Findings include:A review of the facility's Resident Personal Funds policy, dated 6/2022, revealed, .Policy: The resident has a right to manage his or her financial affairs to include the right to know, in advance, what charges a facility may impose against a resident's personal funds . Accounting and Records .3. The individual financial record must be available to the resident .upon request .A record review of the facility's list Residents with Trust Funds revealed (43) residents had facility-managed trust funds.Resident #65A record review of the admission Record revealed the facility admitted Resident #65 on 03/13/24 with diagnoses including Diabetes Mellitus.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/03/26 revealed Resident #65 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact.On 03/09/26 at 12:56 PM, during an interview with Resident #65, the resident stated that since the change of ownership in January, he was unable to access personal funds. He also reported that he had requested a statement from his account, but he never received it.Resident #74A record review of the admission Record revealed the facility admitted Resident #74 on 09/22/23 with diagnoses including Chronic Atrial Fibrillation.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/05/26 revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact.On 03/09/26 at 1:36 PM, during an interview with Resident #74, the resident reported being unable to access personal funds since the facility changed ownership on 1/1/26 and had asked for a statement but was given the balance of his account on a piece of paper.On 03/10/26 at 1:32 PM, during an interview, the Administrator stated residents received a quarterly trust fund statement for the fourth quarter from the previous ownership and the next quarterly statement would be issued by 4/10/26. The Administrator stated the facility provides statements quarterly and upon request; however, when residents requested their account balances, he did not provide a printed statement and instead wrote the balance amount on a sticky note. The Administrator stated several residents requested their account balances and he provided the amounts on sticky notes rather than providing printed statements.

Based on interview, record review, and facility policy review, the facility failed to safeguard and ensure residents had access to their personal funds entrusted to the facility when the facility failed to deposit resident trust funds into an interest-bearing account and failed to ensure residents could access their funds following the change of ownership on 1/1/26 for three (3) of three (3) residents reviewed for resident funds (Resident #62, Resident #65, and Resident #74) and had the potential to affect all forty-three (43) residents with facility-managed trust funds.Findings include:A review of the facility's Resident Personal Funds policy, dated 6/2022, revealed, .Policy: The resident has a right to manage his or her financial affairs to include the right to know, in advance, what charges a facility may impose against a resident's personal funds. Policy Explanation and Compliance Guidelines .2. If the resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility. Deposit of Funds 1. The facility will deposit any resident's personal funds in excess of $100 in an interest-bearing account .and will credit all interest earned on resident funds to that account .Accounting of Records 1. The facility will establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf .3. The individual financial record must be available to the resident .upon request .A record review of the facility's list Residents with Trust Funds revealed forty-three (43) residents had facility-managed trust funds.A record review of two undeposited checks issued by the previous owner during the change of ownership revealed one check in the amount of $55,638.16, dated 12/31/25, and another check in the amount of $506.94 dated 12/31/25, representing resident trust funds.Resident #62A record review of the admission Record revealed the facility admitted Resident #62 on 04/25/18 with diagnoses including Peripheral Vascular Disease.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/12/26 revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident's cognition was moderately impaired.A record review of the Resident Statement Landscape for October, November, and December 2025 revealed Resident #62 had a balance of $3,921.48 and withdrew funds for personal use four (4) times during the quarter.On 03/09/26 at 2:00 PM, during an interview with Resident #62, the resident reported being informed by the facility that personal funds were not available following the change of ownership on 01/01/26. Resident #62 explained he had wanted to withdraw funds to avoid exceeding Medicaid asset limits but reported not being given a timeframe for when the funds would be available.Resident #65A record review of the admission Record revealed the facility admitted Resident #65 on 03/13/24 with diagnoses including Diabetes Mellitus.A record review of the Quarterly MDS with an ARD of 02/03/26 revealed Resident #65 had a BIMS score of fifteen (15), which indicated the resident was cognitively intact.A record review of the Resident Statement Landscape for October, November, and December 2025 revealed Resident #65 had a balance of $88.00 and had not withdrawn funds for personal use during the quarter.On 03/09/26 at 12:56 PM, during an interview Resident #65, reported living at the facility for approximately two years and stated that since the change of ownership in January the resident had been unable to access personal funds. Resident #65 reported staff explained the facility was waiting to receive funds from the previous ownership.Resident #74A record review of the admission Record revealed the facility admitted Resident #74 on 09/22/23 with diagnoses including Chronic Atrial Fibrillation.A record review of the Quarterly MDS with an ARD of 01/05/26 revealed Resident #74 had a BIMS score of fifteen (15), which indicated the resident was cognitively intact.A record review of the Resident Statement Landscape for October, November, and December 2025 revealed Resident #74 had a balance of $2,227.81 and withdrew funds for personal use one (1) time during the quarter.On 03/09/26 at 1:36 PM, during an interview with Resident #74, the resident reported being unable to access personal funds since the facility changed ownership. Resident #74 explained the previous owner reported the funds would transfer within approximately one week; however, the resident reported the funds had not been available for approximately three (3) months.On 03/10/26 at 1:00 PM, during an interview with the Local Ombudsman, she reported that Resident #74 informed her the facility was not allowing residents to access personal trust funds. The Ombudsman explained contacting the Administrator and being informed the facility was working to establish an account and that resident funds were not currently available.On 03/10/26 at 1:32 PM, during an interview with the Administrator, he reported serving as Administrator since the change of ownership on 01/01/26. The Administrator explained the previous owner issued a check representing resident trust funds; however, the facility did not establish a new interest-bearing resident trust account until 03/06/26. He confirmed the check had not yet been deposited and acknowledged the funds were not available to residents during that time. The Administrator explained the facility maintained $500 in petty cash and reported residents were informed during a January Resident Council meeting they could request funds from petty cash if needed. The Administrator confirmed the funds had not been placed in an interest-bearing account and residents had not accrued interest during that time.On 03/10/26 at 2:00 PM, during a Resident Council meeting with twelve (12) residents present, Residents #62, #65 and #74 reported being unable to access their personal funds since the change of ownership.On 03/10/26 at 2:50 PM, during an interview with the Social Worker, she reported attending the January 2026 Resident Council meeting and explained the Administrator informed residents it could take approximately two (2) to three (3) months to resolve issues related to resident trust funds following the change of ownership. She reported residents were informed the facility did not currently have funds available for resident trust accounts during that time. The Social Worker stated she had received multiple complaints from residents regarding access to personal funds and had directed those residents to the Business Office. She stated she was unaware residents could obtain money through petty cash and confirmed the January Resident Council meeting minutes did not document the discussion regarding resident trust funds.

Based on interview, record review, and facility policy review, the facility failed to provide an ongoing activities program designed to meet the interests and preferences of residents when scheduled weekend activities were not conducted and residents reported limited opportunities for activities on weekends, for one (1) of (20) residents reviewed for activities (Resident #74), which affected all residents who participate in activities.Findings include:A record review of the facility's policy, Activity Program, dated 01/21/2022, revealed, .An ongoing program of activities is designed to meet the needs of each resident. Policy Interpretation and Implementation.2. Activities are scheduled daily and residents are given the opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the program. 3. Our activity program consists of individual, and small and large group activities which are designed to meet the needs and interests of each resident and includes.b. Indoor and outdoor activities.6. Individualized and group activities are provided that a. Reflect the schedules, choices and rights of the residents; b. Are offered at hours convenient to the residents, including evenings, holidays and weekends.A record review of the Activities Calendar for January 2026 listed Activity Cart each Saturday and Devotion and Bingo for each Sunday of the month.A record review of the Activities Calendar for February 2026 listed Activity Cart each Saturday and Devotion and Bingo for each Sunday of the month.A record review of the Activities Calendar for March 2026 listed 2:00 Outdoor Day for 3/7/26.A record review of the admission Record revealed Resident #74 was admitted by the facility on 9/22/2023 with diagnoses including Atrial Fibrillation. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/05/2026 revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment.A record review of the Annual Comprehensive MDS with an ARD of 07/17/2025 Section F Preferences for Routine and Activities for Resident #74 revealed that it was Very Important to do things with groups of people, do favorite activities, and go outside to get fresh air when the weather is good. On 03/09/26 at 1:41 PM, during an interview with Resident #74, the resident reported the facility does not allow residents to go outside as much as when the previous owners operated the facility because there are not enough staff members available to monitor residents. Resident #74 reported not liking being inside the facility all day and wanting to enjoy the sunshine.On 03/09/26 at 3:45 PM, during an interview with Activities Director (AD) #1, she reported that prior to the company buyout activity staff rotated weekend hours to ensure activities were provided on Saturdays and Sundays. AD #1 reported that since the buyout there has not been an AD or assistant scheduled on weekends. She explained residents are provided access to an activities cart located in the dining room and may use items from the cart when activity staff are not present Monday through Friday. AD #1 reported a Certified Nursing Aide (CNA) is expected to accompany residents for outdoor activities on weekends. AD #1 explained that prior to 03/01/26 there was no documentation system to verify whether scheduled weekend activities were completed. AD #1 reported the scheduled weekend activity for February 2026 involved the use of the activities cart but she could not confirm whether those activities were completed. AD #1 further reported an outdoor activity scheduled for 03/07/26 did not occur despite no weather conditions preventing the activity and that during a visit to the facility on [DATE] residents were observed in the dining room watching a movie with a CNA present. AD #1 said that prior to the company takeover residents were allowed to go outside both the front and back of the building with supervision. AD #1 reported that since the takeover residents are only permitted to go outside in the back of the building with supervision.On 03/10/26 at 2:00 PM, during the Resident Council meeting conducted in the facility dining hall, there were (12) residents in attendance (Resident #14, #8, #38, #42, #48, #61, #63, #64, #65, #9, #68, and #74). The residents expressed concerns regarding the lack of weekend activities. Resident #74 stated that during February, Activity Cart was scheduled every Saturday and the residents reported staff assistance was required to access the activity cart; however, staff were not available on Saturdays to assist residents in accessing the activities. Residents explained weekends were boring and that they usually remained in their rooms watching television. Residents further reported that since the facility was taken over by new management they are no longer allowed to go outside independently and may only access the back porch when staff supervision is available. Residents reported that on 03/07/26 the activity calendar listed an outdoor activity; however, residents instead watched a movie in the dining room despite favorable weather conditions.On 03/11/26 at 3:30 PM, during an interview with the Administrator, he reported he was aware that weekend activity staff were not scheduled and acknowledged residents did not have organized weekend activities. The Administrator explained residents are not supposed to participate in activities without staff present and reported that staff were in-serviced after learning weekend activities were not being conducted.On 03/11/26 at 3:51 PM, during a follow up interview with AD #1, she confirmed the activity calendar used in January appeared similar to the February calendar, indicating that weekend activities primarily consisted of the activities cart.On 03/12/26 at 11:42 AM, during an interview with the Director of Nursing (DON), she stated her expectation for the Activity Department was to ensure nursing and CNA staff were available on weekends to assist residents with activities. On 03/12/26 at 2:35 PM, during a follow up interview with the Administrator, he reported his expectation for the Activity Department is to ensure activities are conducted with residents and that staff are available to facilitate those activities. The Administrator explained the Activities Director is expected to follow up to ensure scheduled activities are completed.

Based on observation, interview, record review, and facility policy review, the facility failed to follow the posted menu as written and failed to ensure alternate menu items were available as listed on the menu for two (2) of (20) residents reviewed for food services. Residents #65 and #74.Findings include:A review of the facility's policy, Alternative Foods For Food Preferences or Menu Changes, dated 10/23, revealed, .Procedure: 1. The food and nutrition services departments prepares an alternate food choice that is available for residents who refuse food or beverages at meals. 2. Alternate foods and beverages are prepared or are available at each meal.7.Menu changes will be posted.On 03/09/26 at 11:15 AM, during an observation and record review of the posted menu, the menu for Monday Lunch revealed Red Beans and Rice, Mustards, Cornbread or Country Fried Steak, French Fries, and Seasoned Cabbages. The dessert was Banana Pudding with Whip Cream.On 03/09/26 at 11:20 AM, during an observation of the lunch meal preparation, country fried steak was not prepared or available on the steam table as an alternate entree for the lunch meal as listed on the posted menu.A record review of the posted menu for Tuesday Dinner revealed Barbeque Pork Chop, Mashed Sweet Potatoes, Seasoned Cabbage, Buttered Cornbread or Beef Tips, Buttered Rice, and Spinach, with dessert listed as [NAME] or Peach Slices.Resident #65On 03/09/26 at 12:28 PM, during an observation and interview with Resident #65, the resident reported the menu is frequently not followed and residents do not always receive the items listed on the menu. Resident #65 reported staff sometimes state the kitchen has run out of food and explained there is not always an alternate meal available even when residents request another option.On 03/11/26 at 10:00 AM, during an interview with Resident #65, the resident reported the dinner menu for 03/10/26 included an alternate meal of beef tips, rice, and spinach and a main entree of baked pork chop with mashed sweet potatoes. Resident #65 reported requesting the alternate meal but instead received (2) turkey sandwiches which were not requested.A record review of the admission Record revealed the facility admitted Resident #65 on 03/13/2024 with diagnoses including Type 2 Diabetes Mellitus.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/03/26 revealed Resident #65 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact.Resident #74On 03/09/26 at 1:00 PM, during an interview with Resident #74, the resident reported that since the new company assumed management of the facility in January the food has changed and the menus are often not followed. Resident #74 explained that previously menus were provided daily and residents could select the items they wanted. Resident #74 reported the menus are now only posted in the dining room and residents must write down their meal selections and provide them to the kitchen staff, but residents do not always receive the items requested and alternate meals are not consistently available.On 03/11/26 at 10:13 AM, during an observation and interview with Resident #74, the resident reported requesting the alternate meal of beef tips, buttered rice, and spinach listed on the menu for dinner on 03/10/26. Resident #74 reported receiving the regular meal of pork chop, cabbage, and a sweet potato patty instead of the requested alternate meal.A record review of the admission Record revealed the facility admitted Resident #74 on 09/22/2023 with diagnoses including Chronic Atrial Fibrillation.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/05/26 revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact.On 03/12/26 at 10:25 AM, during an interview with the Dietary Manager, she confirmed the facility did not have the alternate entree of country fried steak available for lunch on 03/09/26 and did not have the alternate entree of beef tips, buttered rice, and spinach available for dinner on 03/10/26. She reported she had been instructed by supervisors not to serve the alternate meals. She acknowledged it was her responsibility to ensure foods listed on the menu were available and to notify residents when menu items were not available.On 03/12/26 at 3:30 PM, during an interview with the Administrator, he confirmed that menu alternates are expected to be available at each meal. He explained the Dietary Manager is responsible for ensuring foods listed on the menu are available and that residents are informed of menu changes when items are unavailable.

Based on interview, record review and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment when the facility coded an antipsychotic medication on the MDS despite no physician orders or Medication Administration Record (MAR) documentation for an antipsychotic medication for one (1) of (20) residents reviewed for MDS accuracy. (Resident #12).Findings include:A review of the facility's policy, MDS Assessment, dated 5/2006, revealed, .The facility will follow direction per federal and state guidelines for resident assessment protocol and will refer to the MDS RAI (Resident Assessment Instrument) manual.A record review of the admission Record revealed the facility admitted Resident #12 on 2/18/2022 with diagnoses including Alzheimer's Disease.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/28/26 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident's cognition was severely impaired. A review of Section N revealed Resident #12 was coded as receiving an antipsychotic medication during the last seven (7) day lookback period.A record review of the Order Summary Report revealed there were no active physician orders for an antipsychotic medication for Resident #12.A record review of the Medication Administration Record (MAR) for January 2026 revealed there were no antipsychotic medications administered to Resident #12.On 03/12/26 at 12:16 PM, during an interview and record review with Registered Nurse (RN) #2, she reviewed the MDS for Resident #12 and confirmed the assessment was coded to indicate the resident received an antipsychotic medication. After reviewing the physician orders and Medication Administration Record (MAR), she acknowledged there were no physician orders for an antipsychotic medication, and none had been administered to Resident #12 during the lookback period. She explained the MDS nurse is responsible for ensuring the MDS is coded accurately using the physician orders and medication administration records as the source documents.On 03/12/26 at 12:28 PM, during an interview and record review with the Director of Nursing (DON), she compared the MDS for Resident #12 to the resident's physician orders and confirmed the assessment was coded incorrectly to reflect the resident as receiving an antipsychotic medication. She reported that both she and RN #2 were responsible for monitoring MDS assessments quarterly to ensure the information was accurate. She explained that the facility would correct Resident #12's MDS and implement more frequent monitoring to ensure the accuracy of future MDS assessments.

Based on observation, interview, and record review, and facility policy review the facility failed to ensure residents were allowed to make choices regarding food preferences when dietary staff continued to serve pureed bread to Resident #68 after the resident had requested not to receive it and when the facility failed to accommodate Resident #49's preference for fried eggs after the facility stopped ordering eggs, affecting two (2) of (20) residents reviewed for resident choices.Findings include:A review of the facility's policy, Resident Rights, dated 4/4/25, revealed, .Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation.2. Residents are entitled to exercise their rights and privileges to the fullest extent possible.Resident #68On 3/9/26 at 2:02 PM, during an observation and interview, Resident #68 reported she had complained to staff that she did not want pureed bread served on her meal trays. Resident #68 stated the pureed bread was too thick and she believed she could choke on it. Resident #68 reported she had informed both nursing staff and dietary staff that she did not want bread served on her tray.On 3/10/26 at 2:45 PM, during an interview, Licensed Practical Nurse (LPN) #3 stated Resident #68 usually ate meals in the dining room and confirmed she had observed the resident's tray containing pureed bread. LPN #3 stated the resident had complained the bread was too thick to eat. LPN #3 reported she had not notified dietary staff that the resident disliked the bread.On 3/11/26 at 7:55 AM, during an observation and interview, Resident #68 was served oatmeal and grits on the same plate with both food items touching. A record review of the meal tray ticket revealed the resident's breakfast likes were oatmeal and grits and the only documented dislike was cheese. Resident #68 reported she had informed staff she did not want cheese or bread served on her tray.On 3/12/26 at 3:40 PM, during an interview, Dietary Department Staff #1 stated Resident #68 had been assessed for likes and dislikes on admission. Dietary Department Staff #1 reviewed the resident's Dietary New Admit Questionnaire and tray cards and confirmed bread was not listed as a dislike. Dietary Department Staff #1 stated the resident had recently informed her she did not want bread served and acknowledged the information should have been updated on the resident's preference list.A record review of the admission Record revealed the facility admitted Resident #68 on 1/13/26 with diagnoses including Hemiplegia.A record review of the Order Summary Report revealed Resident #68 had Physician's Orders, dated 1/13/26 for a pureed diet.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/19/26 revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of (13), which indicated the resident was cognitively intact. Section K revealed she received a mechanically altered diet.A record review of Resident #68's tray card for breakfast, lunch, and dinner revealed .Dislikes cheese. listed for all meals. Bread was not listed under the Dislikes portion of the meal tray card.A record review Resident #68's Dietary New Admit Questionnaire dated 01/15/26 revealed . puree . breakfast likes: oatmeal and grits . food dislikes: cheese . Resident #49On 3/9/26 at 12:40 PM, during an observation and interview, Resident #49 reported dissatisfaction with the breakfast meals and stated she disliked the powdered eggs served at breakfast. Resident #49 reported she had requested fried eggs on several occasions but had been told they were not available.On 3/10/26 at 8:30 AM, during an interview, Resident #49 stated she continued to receive powdered eggs for breakfast despite requesting fried eggs. Resident #49 reported she had voiced this concern multiple times and stated she did not recall whether dietary staff had spoken with her since the new dietary company began providing services.On 3/10/26 at 1:10 PM, during an interview, Certified Nursing Aide (CNA) #1 stated Resident #49 had complained about the breakfast meals and confirmed the resident had requested fried eggs but had been told the kitchen only had powdered eggs available.On 3/10/26 at 2:45 PM, during an interview, LPN #2 stated Resident #49 had complained about the food since the new dietary company began providing services.On 3/11/26 at 12:23 PM, during an interview, Dietary Department Staff #1 confirmed the facility had been instructed by the new owners of the facility to discontinue ordering eggs used for frying. Dietary Department Staff #1 stated approximately (15) residents previously received fried eggs and confirmed the facility currently only had powdered eggs available for breakfast. Dietary Department Staff #1 stated the facility still had pre-boiled eggs available for residents who requested boiled eggs.On 3/12/26 at 2:34 PM, during an interview, the Administrator stated he expected staff to honor residents' choices and preferences whenever possible and stated staff should notify the appropriate department if a resident's preference could not be accommodated.A record review of the admission Record revealed the facility admitted Resident #49 on 11/25/25 with diagnoses including Type 2 Diabetes Mellitus.A record review of the Comprehensive MDS with an ARD of 12/2/25 revealed Resident #49 had a BIMS score of fifteen (15), which indicated the resident was cognitively intact. Section K revealed the resident had no swallowing problems and was on a therapeutic diet.A record review of the Order Summary Report revealed Resident #49 had a Physician's Order, dated 12/1/25, for a Low Concentrated Sweets (LCS)/No salt packet (No Salt Packet) diet, regular texture.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to reasonable accommodation of individual needs when the facility failed to ensure soap was available in the resident's bathroom to allow the resident to maintain personal hygiene after the installation of a wall-mounted soap dispenser for one (1) of (20) residents reviewed for resident rights. Resident #50.Findings include:A review of the facility's policy, Resident Rights, dated 4/4/25, revealed, .Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation.2. Residents are entitled to exercise their rights and privileges to the fullest extent possible.A record review of the admission Record revealed the facility admitted Resident #50 on 7/18/23 with diagnoses including Bipolar Disorder.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/16/26 revealed Resident #50 had a Brief Interview for Mental Status (BIMS) score of (15), which indicated the resident was cognitively intact. Section GG he required supervision or touching assistance for toileting and personal hygiene.On 3/9/26 at 11:35 AM, during an observation and interview, Resident #50 reported he did not have any hand soap available in his bathroom. Resident #50 stated a wall-mounted soap dispenser had been installed approximately one month earlier but no soap had been placed in the dispenser. Resident #50 reported staff had told him the facility did not order enough soap for the new dispensers and stated his wife had purchased a bottle of soap for him to use. During the observation, the wall-mounted soap dispenser in the resident's bathroom was empty. A small bottle of soap was observed on the sink, which the resident reported his wife had brought to the facility because he did not have soap available in the dispenser.On 3/10/26 at 2:06 PM, during an observation and interview, Resident #50 reported the soap dispenser in his bathroom still did not contain soap. The wall-mounted dispenser was observed to remain empty.On 3/10/26 at 2:13 PM, during an interview, Certified Nursing Aide (CNA) #1 stated the new soap dispensers had been installed approximately one month earlier. CNA #1 confirmed Resident #50 had not had soap available in the dispenser since the dispenser was installed.On 3/10/26 at 2:25 PM, during an interview, Licensed Practical Nurse (LPN) #1 stated Resident #50 spent most of his time in his room and preferred privacy. LPN #1 confirmed the soap dispenser in the resident's room had not contained soap since it was installed approximately one month earlier.On 3/10/26 at 2:46 PM, during an interview, Housekeeping/Maintenance Staff #1 stated housekeeping services were provided through a contracted company, and the facility had recently replaced the previous soap and towel dispensers with new wall-mounted dispensers. The staff member confirmed the facility currently did not have soap available for the dispensers and was unsure how long the dispensers had been empty.On 3/11/26 at 9:15 AM, during an observation and interview, Resident #50 again reported that the soap dispenser in his bathroom did not contain soap. The wall-mounted dispenser was observed to remain empty.On 3/11/26 at 3:10 PM, during an interview, Housekeeping/Maintenance Staff #2 stated the facility replaced all soap and towel dispensers with a single type of dispenser used by the contracted company. The staff member confirmed the new dispensers had been installed in February, but the facility did not have enough soap available for the dispensers. The staff member stated the soap had been on back order and the facility had only recently received additional soap.On 3/11/26 at 4:00 PM, during an interview, Housekeeping/Maintenance Staff #3 stated maintenance staff were instructed to remove the previous dispensers and install the new dispensers throughout the facility approximately two (2) to three (3) weeks earlier. The staff member confirmed the facility did not have enough soap available for the newly installed dispensers.On 3/12/26 at 2:25 PM, during an interview, the Administrator stated the facility replaced several different types of soap dispensers with one standardized dispenser throughout the facility. The Administrator stated Resident #50's dispenser may have been overlooked when soap was distributed to the dispensers and stated his expectation was that residents have access to soap at all times.

Based on observation, staff interview, record review, facility investigation review, and facility policy review, the facility failed to implement comprehensive care plan interventions related to resident transfers when a Certified Nurse Aide (CNA) transferred a resident without assistance, using the incorrect sling size, which resulted in the resident falling during the transfer, receiving a fracture and head laceration for one (1) of four (4) care plans reviewed. Resident #1 Findings include: A record review of the facility's policy Using the are Plan with revised date of 8/2/22 revealed, Policy Statement The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident . Policy Interpretation and Implementation . 2. uses the care plan to direct care provided by the CNAs and nurses daily . A record review of Resident #1's Comprehensive Care Plan revealed a care plan Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit .Interventions/Task .Transferring [NAME] total lift x 2, large sling, NON weight bearing. Care plan was initiated on 10/20/22 and revised on 10/25/24 to include non-weight bearing. A record review of Resident #1's Investigative Summary-Final Report, dated 10/21/2024, revealed (Proper name of CNA #1) operated lift alone without verifying resident sling size. She used a small sling which contributed to (Proper name of Resident #1) incident . A record review of written statement from Licensed Practical Nurse (LPN)#1 on 10/20/24, revealed, . CNA was standing in the doorway of room, called out for a nurse, when I entered the room, I saw (proper name) lift with lift pad on it up in the air, resident was lying on her right side face down with blood coming from the right side of her head . CNA stated, I put her on the (proper name) lift by myself, I had no one to help me! . A record review of CNA #1's written statement, dated 10/25/2024, revealed that CNA #1 admitted to transferring Resident #1 without assistance. She stated she used the sling already attached to the lift and did not check the Kardex for the required sling size. She also acknowledged asking another staff member for help, but no one came to help. The witness statement further revealed I (CNA #1) operated the lift and (Proper name of Resident #1) fell -hit her head. A record review of the Admission Record revealed the facility admitted Resident #1 on 10/20/2022 with diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Left Non-Dominant Side. During an observation on 11/25/2024 at 8:15 AM, Resident #1, she recalled only one person was present during the transfer. She stated she kept telling CNA #1, Something's not right. She became emotional while recalling the incident, describing severe pain and a subsequent hospital stay. Resident #1 stated she wanted to stay up in her wheelchair until after lunch and would be assisted back to bed at that time. There was a mechanical lift sling underneath her that had a red trim. On 11/25/24 at 10:30 AM, during an interview with the Licensed Practical Nurse (LPN) #2, she verified Resident #1 required a full body lift prior to after the fall. It is the policy and procedures for the facility, that when a lift is used two staff members must be present at all times. She explained Resident #1's care plan for needing assistance with transfers did not change after the fall. The purpose of the care plan is a guide to go by for residents' care to provide quality care for each resident. She stated she expects all staff to follow the residents' care plans at all times to have the knowledge of how to care for the individual residents. At 12:55 PM on 11/25/24, during an interview with the Administrator, he confirmed Resident #1 was care planned for two-person assistance with transferring with lift. He stated he expects all staff to follow the facility's policies and procedures and residents individual care plans to provide quality care for all the residents at all times. During an observation on 11/25/2024 at 1:25 PM, Resident #1 was transferred by the facility staff via mechanical lift from her wheelchair to the bed. Three (3) CNAs entered the room to assist with the transfer. It was noted that the resident was sitting in a wheelchair with a red lift pad under her, indicating a medium sling, which was not the correct size. CNA #2 confirmed the sling needed to be replaced with a blue (large) sling. The CNAs were able to remove the medium sling and place the large sling while the resident was in the wheelchair and then transferred her using the correct large sling size. During an interview on 11/25/2024 at 1:45 PM, CNA #2 confirmed the wrong size of lift pad was under the resident, indicating that the incorrect lift pad was used earlier that morning during a transfer from bed to wheelchair. He stated he did not assist with the resident's transfer that morning because the transfer occurred on the previous shift. On 11/25/2024 at 3:00 PM, during an interview with the Administrator, he stated he was unaware that Resident #1 had been transferred this morning with the wrong size lift pad. He explained that all staff had been educated on proper lift pad identification and the need to check the Kardex before using the lift. He reiterated that sufficient lift pads were available and expected staff to follow policies. He stated that CNA #4 had been assigned to Resident #1 this morning. During an interview, on 11/25/2024 at 3:40 PM, CNA #4 admitted she was assigned to care for Resident #1 during the night shift last night. She reported transferring Resident #1 using a mechanical lift and a red-trimmed/medium size sling pad. She stated she did not check the Kardex that morning, assuming the resident required a large sling. She also noted that only medium sling pads were available at the time. During a post survey interview on 11/26/2024 at 9:30 AM, CNA #1 stated that on the morning of 10/21/24, she had asked the nurse for assistance with the mechanical lift transfer of Resident #1, but no one came to help. She admitted not checking the Kardex for the correct sling size and using the sling already attached to the lift.

Based on observation, interviews, record review, facility investigation review, and facility policy reviews the facility failed to ensure a resident was transferred safely while using a mechanical lift when a Certified Nurse Aide (CNA) performed the transfer without assistance and used the incorrect sling size, which caused the resident to fall, resulting in a fracture and head laceration for one (1) of four (4) sampled residents. (Resident #1) Findings include: A review of the facility's policy, Safe Transfer and Lifting of Residents, revised 08/02/2022, revealed, .In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents . General Guidelines .6. Enough slings in sizes required by residents should be available at all times . VI. Procedure for transferring resident with full body lift .c. Ensures proper transfer is followed per care plan .e. Ensures resident is within weight requirements of lift f. Ensures a 2nd person is assisting . A record review of Resident #1's Progress Notes, dated 10/21/2024 at 7:10 AM, revealed the resident was found crying loudly on the floor with a large laceration on the right side of her forehead and a hematoma on her right forearm. CNA #1 stated the resident slid out of the sling during a transfer using a mechanical lift. A record review of Resident #1's Kardex revealed the resident required a total lift with two (2) staff and a large sling. The record indicated the resident was non-weight-bearing. A record review of Resident #1's Investigative Summary-Final Report, dated 10/21/2024, revealed (Proper name of the CNA) operated lift alone without verifying resident sling size. She used a small sling which contributed to (Proper name of Resident #1) incident . A record review of CNA #1's written statement, dated 10/25/2024, revealed that CNA #1 admitted to transferring Resident #1 without assistance. She stated she used the sling already attached to the lift and did not check the Kardex for the required sling size. She also acknowledged asking another staff member for help, but no one came to help. The witness statement further revealed I (CNA #1) operated the lift and (Proper name of Resident #1) fell -hit her head. A record review of the Fall During Assist report, dated 10/21/2024, revealed that CNA #1 attempted to transfer Resident #1 using a mechanical lift without the assistance of a second staff member. The report noted that CNA #1 used a medium sling instead of the required large sling, which resulted in the resident sliding out of the sling and falling to the floor. The report documented that the resident sustained a laceration to the right side of the forehead and a hematoma on the right arm and was sent to the emergency room for further evaluation. A record review of Resident #1's Emergency Department History and Physical, dated 10/21/2024, revealed the resident sustained a displaced femur fracture and a laceration requiring sutures. She also complained of left hip and knee pain. A record review of the X-ray Femur, dated 10/21/2024, revealed Resident #1 had an acute displaced, obliquely oriented fracture through the distal femoral shaft. A record review of the Discharge Summary, dated 10/25/2024, revealed Resident #1 underwent Open Reduction and Internal Fixation (ORIF) surgery for the femur fracture and was discharged back to the facility with a non-weight-bearing status. A record review of the Admission Record revealed the facility admitted Resident #1 on 10/20/2022 with diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Left Non-Dominant Side. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/01/2024 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated the resident's cognition was moderately impaired. On 11/25/2024 at 8:15 AM, during an observation and interview with Resident #1, she recalled only one person was present during the transfer. She stated she kept telling CNA #1, Something's not right. She became emotional while recalling the incident, describing she had some pain and a subsequent hospital stay. Resident #1 stated she wanted to stay up in her wheelchair until after lunch and would be assisted back to bed at that time. There was a mechanical lift sling underneath her that had a red trim. On 11/25/2024 at 10:55 AM, during an interview, the Administrator confirmed CNA #1 admitted to transferring the resident alone using the sling already attached to the lift without verifying its size. The fall occurred at the end of the shift as the staff were assisting residents up for the day. On 11/25/2024 at 11:20 AM, during an interview with Resident #1's family member, she explained that the nurse informed her that her sister fell out of the lift and sustained a gash on her forehead, which would not stop bleeding, necessitating emergency medical care. She stated that Resident #1 required four (4) stitches to her forehead and added that hospital tests revealed her sister had a fractured femur requiring surgery, and a plate was subsequently inserted. On 11/25/2024 at 1:20 PM, during an observation and interview with CNA #2, he confirmed the resident required a large sling for transfers and stated two staff members are always required when using a lift. He reviewed the resident's Kardex and identified the correct sling size for the resident was a large. On 11/25/2024 at 1:25 PM, during an observation of Resident #1 being transferred by facility staff via the mechanical lift from her wheelchair to the bed, three (3) CNAs entered the room to assist with the transfer. It was noted that the resident was sitting in a wheelchair with a red lift pad under her, indicating a medium sling, which was not the correct size. CNA #2 confirmed the sling needed to be replaced with a blue (large) sling. The CNAs were able to remove the medium sling and place the large sling while the resident was in the wheelchair and then transferred her using the correct large sling size. On 11/25/2024 at 1:45 PM, during an interview with CNA #2, he confirmed the wrong size of lift pad was under the resident, indicating that the incorrect lift pad was used earlier that morning during a transfer from bed to wheelchair. He stated he did not assist with the resident's transfer that morning because the transfer occurred on the previous shift. On 11/25/24 at 2:00 PM, during an interview, CNA #3 confirmed Resident #1 had a medium lift pad underneath her while in the wheelchair and stated Resident #1 was already up in her chair when she arrived to work. CNA #3 confirmed a medium sling was incorrect according to the residents Kardex. During an interview on 11/25/2024 at 3:00 PM, the Administrator stated he was unaware that Resident #1 had been transferred this morning with the wrong size lift pad. He explained that all staff had been educated on proper lift pad identification and the need to check the Kardex before using the lift. He reiterated that sufficient lift pads were available and expected staff to follow policies. He stated that CNA #4 had been assigned to Resident #1 this morning. On 11/25/2024 at 3:40 PM, during an interview with CNA #4, she admitted she was assigned to care for Resident #1 during the night shift last night. She reported transferring Resident #1 using a mechanical lift and a red-trimmed/medium size sling pad. She stated she did not check the Kardex that morning, assuming the resident required a large sling. She also noted that only medium sling pads were available at the time. On 11/26/2024 at 9:30 AM, during a post survey interview, CNA #1 stated that on the morning of 10/21/24, she had asked the nurse for assistance with the mechanical lift transfer of Resident #1, but no one came to help. She admitted not checking the Kardex for the correct sling size and using the sling already attached to the lift.

Based on observation, interviews, record review, and facility's policy review the facility failed to ensure resident's food was served at an appetizing temperature for one (1) of 15 sampled residents. This had the potential to affect 74 residents receiving food from the kitchen. (Resident # 38) Findings include: A review of the facility's policy Food Preparation Guidelines dated 10/5/22 revealed, . The facility will prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status . Definitions .Proper (safe and appetizing) temperature means both appetizing to the resident and minimizing the risk for scalding and burns . Policy Interpretation and Implementation .3. Food and drinks will be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: . c. Serving hot foods/drinks hot and cold foods/drinks cold . This tag is cross referenced to the tag F565: 1. Based on observation, interviews, record review, and facility policy review the facility failed to ensure resident council members' complaints regarding food that was served cold were recorded and resolved in a timely manner for nine (9) of 11 Resident council members. (Resident #4, #18, #20, #27, #42, #49, #52, #62, and #68) On 7/8/24 at 12:30 PM, during an observation of two (2) lunch meal trays, the meal consisted of fried pork chop, pinto beans, turnip greens, corn bread, fruited gelatin, tea and water. The Administrator brought the two trays directly from the kitchen and the food was cold to taste and touch. On 7/8/24 at 2:18 PM, during an interview with Resident#38, she complained she is currently upset at the facility because she had issues with staff not wanting to reheat her food. She complained her breakfast was always cold and she was tired of it because it had been going on for a while. At 11:15 AM on 7/9/24, during an interview with Resident #38, she explained her breakfast was cold again this morning and she had to get someone to reheat the food. On 7/9/24 at 11:28 AM, during an observation and interview with Dietary #2/Cook, he prepared the meal trays to be served to residents in the dining room. He stated he cannot prepare meal trays for the residents on the hall until all residents in the dining room were served. At 11:42 AM, the cook began preparing the meal trays for the halls. At 11:57 AM, one of the dietary aides began placing meal trays onto the cart but stopped because she had to prepare more silverware for the trays. At 12:00 PM, Dietary #2 had to stop preparing hall trays to make more mechanical soft meat loaf for the residents, and Dietary #1 continued preparing the trays for the residents on the hall. On 7/9/24 at 12:11 PM, during an observation, the last tray cart was sent to the last hall with two (2) test trays on the cart. The tray cart was an open metal tray cart that was not insulated. There were three (3) insulated carts pushed to the side and one (1) insulated tray cart that did not have a door. The open tray cart was pushed to the hall by a Dietary Aide and Dietary #1 and explained the Certified Nurse Aides (CNAs) on the hall would pass out the trays to the residents. After four (4) minutes a CNA started to pull trays and pass them out to the residents. At 12:23 PM on 7/9/24, during an interview and observation, Dietary #1 tested the temperature of the last tray on the last cart. The temperatures were the following: country meatloaf 80 degrees Fahrenheit (F); garlic mashed potatoes 100 F; buttered green peas 84 F; pork cutlet 80 F; stewed tomatoes 90 F and steamed rice 84 F. The temperatures of the individual food items had dropped from country meatloaf 170 F; garlic mashed potatoes 170 F; buttered green peas 164 F; pork cutlet 160 F, stewed tomatoes 135 F; and steamed rice 170 F. The food on the two test trays were tasted by the State Agency (SA) and Dietary #1 and was cold and not at an appetizing temperature. Dietary #1 explained the food was at room temperature, but confirmed it was cold. She explained if she was served the food at a restaurant, she would send it back because the food was not hot enough for her to eat. At 1:10 PM on 7/9/24, during an interview with CNA #1, she explained Resident #38 had complained that her food was cold, and it had been reported to the kitchen staff several times. During an interview on 7/11/24 at 11:18 AM, with the Administrator, he confirmed the residents had complained the food was cold. He had dietary to started serving the dining room first and then serve the residents on the hall that were complaining first. He thought the complaints were resolved, and he did not know the resident's council continued to complain in June. He expected all residents to be served food at an appetizing temperature. Resident #38 A record review of the Admission Record revealed the facility admitted Resident #38 on 11/19/18 with diagnoses including Bipolar Disorder and Anxiety Disorder. A record review of the Order Summary Report with active orders as of 7/9/24, revealed Resident #38 had a Physician's Order, dated 5/3/24, for a Regular diet, Regular texture, and Regular consistency with chopped ham and turkey. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/9/24, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated she was cognitively intact.

Based on interviews, record review, and facility policy review the facility failed to ensure resident council members' complaints regarding food that was served cold were recorded and resolved in a timely manner for nine (9) of 11 Resident council members. (Resident #4, #18, #20, #27, #42, #49, #52, #62, and #68) Findings include: Review of the facility's policy, Resident and Family Grievances revised 6/1/23 revealed, . It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal .Policy Explanation and Compliance Guidelines .8. Grievances may be voiced in the following forums .d. Verbal complaint during resident or family council meetings .10. Procedure .d. The Grievance Official will take steps to resolve the grievance .e. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances .12. The facility will make prompt efforts to resolve grievances . Review of the Resident Council Minutes dated 6/27/24 revealed the resident council members complained the nurses take too long to come to the dining room during lunch and dinner and the residents complained the food was cold because of the wait. The Recommendations/Solutions dated 7/1/24 revealed an in-service was conducted on dining room times with staff and the dining room schedule was posted on each unit and with the receptionist. Review of January through June 2024 of resident council meeting minutes revealed the June 2024 minutes was the only month in which complaints regarding food being served cold were recorded. During the Resident Council Meeting on 7/8/24 at 2:00 PM, the members revealed they had complained for several months, not just June 2024, that the food was served cold for all meals. They explained they originally thought the problem was with the nurses coming to the dining room timely and therefore causing the food to be served cold, however, the problem had not been resolved since the nurses had been coming to the dining room timely. The members said they expected the Social Services Assistant (SSA) to record all their complaints every month and share them with the Dietary Manager (DM) and the Administrator. During an interview on 7/11/24 at 10:21 AM, the SSA explained she was responsible for writing the resident council meeting minutes and confirmed the residents had complained for several months that the meals were served cold. She said she was unsure why the residents' complaints were not included in the April 2024 and May 2024 minutes and determined she may have forgotten to record them. The SSA reported that she had placed the residents' complaints in the DM's box and did not provide a copy for the Administrator. The SSA explained the residents' complaints regarding cold food had been discussed several times during daily stand-up meetings with the interdisciplinary team. During an interview on 7/11/24 at 10:45 AM, with the Director of Nursing (DON), she confirmed she was aware the residents had complained food was served to them cold and was told it was because the nurses were late coming to the dining room. She explained she then began posting nursing assignments indicating which nurses were to serve in the dining room and she had been observing to ensure the nurses were not late getting to the dining room. She confirmed the resident's complaints regarding cold food had been discussed during stand-up meetings. In an interview on 7/11/24 at 11:13 AM, with the Assistant Dietary Manager, she stated she was unaware the residents were complaining the food served was cold and she had not received any complaints from the resident council for the month of June. She explained the Dietary Manager was not at the facility this week and had not advised her there were complaints regarding cold meals served to the residents. She stated she had recently been attending stand up meetings and was not aware there was any discussion during those meetings that the residents were complaining the food was served to them cold. During an interview on 7/11/24 at 11:18 AM, the Administrator confirmed the residents had previously complained the food was cold and he had instructed Dietary services to serve the dining room first and then serve the residents who complained of cold food on the halls. He had thought the complaints were resolved and was unaware the residents in resident council continued to complain the food was served cold. He stated he had not been given a copy of the resident council meetings for June 2024. Resident #4 A record review of the Admission Record revealed the facility admitted Resident #4 on 8/18/23. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/29/24 revealed Resident #4 had a Brief Interview for Mental Status (BIMS score of 15, which indicated she was cognitively intact. Resident #18 A record review of the Admission Record revealed the facility admitted Resident #18 on 4/17/23. A record review of the Quarterly MDS with an ARD of 6/13/24 revealed Resident #18 had a BIMS score of 14, which indicated she was cognitively intact. Resident #20 A record review of the Admission Record revealed the facility admitted Resident #20 on 11/9/22. A record review of the Quarterly MDS with an ARD of 6/27/24 revealed Resident #20 had a BIMS score of 10, which indicated his cognition was moderately impaired. Resident #27 A record review of the Admission Record revealed the facility admitted Resident #27 on 3/9/22. A record review of the Quarterly MDS with an ARD of 6/19/24 revealed Resident #27 had a BIMS score of 15, which indicated he was cognitively intact. Resident #42 A record review of the Admission Record revealed the facility admitted Resident #42 on 3/7/18. A record review of the Quarterly MDS with an ARD of 5/9/24 revealed Resident #42 had a BIMS score of 15, which indicated she was cognitively intact. Resident #49 A record review of the Admission Record revealed the facility admitted Resident #49 on 1/8/24. A record review of the Quarterly MDS with an ARD of 5/2/24 revealed Resident #49 had a BIMS score of 15, which indicated she was cognitively intact. Resident #52 A record review of the Admission Record revealed the facility admitted Resident #52 on 7/5/23. A record review of the Annual MDS with an ARD of 6/12/24 revealed Resident #52 had a BIMS score of 15, which indicated he was cognitively intact. Resident #62 A record review of the Admission Record revealed the facility admitted Resident #62 on 12/28/22. A record review of the Quarterly MDS with an ARD of 5/23/24 revealed Resident #62 had a BIMS score of 11, which indicated her cognition was moderately impaired. Resident #68 A record review of the Admission Record revealed the facility admitted Resident #68 on 1/19/24. A record review of the Quarterly MDS with an ARD of 4/18/24 revealed Resident #68 had a BIMS score of 15, which indicated she was cognitively intact.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure vision services were provided for a resident who was visually impaired for one (1) of 15 sampled residents. Resident #4 Findings include: A review of the facility's policy, Social Services Policy revised 6/1/23 revealed, Policy: The facility .will provide medically-related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Policy Explanation and Compliance Guidelines .4. The social worker .will pursue the provision of any identified need for medically-related social services of the resident .Services to meet the resident's needs may include .d. Making arrangement for obtaining items, such as adaptive equipment, clothing, and personal items .g. Making referrals and obtaining needed services from outside entities . On 7/8/24 at 2:47 PM, during an interview and observation, Resident #4 reported she had lost her prescription glasses and the facility had provided her with a pair of reading glasses from a local retail store. She was unsure when she had lost the glasses and was unsure if she had reported it to the facility. She explained she enjoyed reading but was unable to use the glasses provided by the facility because she could not see through them, and it was difficult to read. The resident was not wearing glasses. On 07/10/24 at 9:18 AM, an interview with Social Services Director (SSD) revealed Resident #4 had reported to her that she could not afford the prescription glasses that had been prescribed to her in April. The resident advised the SSD that she could not see well, so the SSD went to a local retail store and purchased a pair of over the counter reading glasses for the resident. The SSD reported she did not seek assistance for the resident in attaining new prescription glasses through any alternative community support agencies and she did not consult with the Administrator regarding the resident's inability to pay for the new prescription glasses. On 7/10/24 at 10:00 AM, in an interview with the Director of Nursing (DON), she acknowledged Resident #4 had a new prescription in her medical record for glasses that she received when she had an eye exam on 4/8/24. The DON reported the prescription was not filled because the resident did not have the money in her account to pay for them. The DON confirmed the facility did not secure other means to assist the resident in having her new prescription filled and the Administrator was not informed that the resident was unable to afford the new glasses. On 07/10/24 at 10:15 AM, an interview with the Administrator revealed he had not been informed Resident #4 was unable to pay for new prescription glasses. The Administrator reported that the facility had occasion to purchase glasses and dentures for residents who were not able to afford them. The Administrator stated, although it was not the policy of the facility to broadly purchase glasses for all residents, if there was a need, the facility would assess the resident's ability to pay for services and would assist accordingly. The Administrator reported his expectation going forward was to get the residents what they needed to provide a better quality of life for them. A record review of the Transfer/Discharge Report revealed the facility admitted Resident #4 on 8/18/2023 with diagnoses including Hypothyroidism. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/29/24 revealed in Section B that Resident #4 had corrective lenses and in Section C the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. A record review of the Admission MDS with an ARD of 8/24/23 revealed it was very important for Resident #4 to have books, newspapers, and magazines to read. Record review of an eyeglass prescription, dated 4/8/24, revealed Resident #4 had visual impairment in both eyes that required corrective lenses.

Based on record review, staff interview, and facility policy review, the facility failed to provide evidence that residents refused the COVID-19 vaccine for two (2) of five (5) residents reviewed for immunizations. Resident #22 and Resident #37 Findings include: A review of the facility's policy, Vaccination of Residents, dated 8/2/22, revealed, .All residents will be offered vaccines .Policy Interpretation and Implementation 1. Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations .2. Provision of such education shall be documented in the resident's medical record .5. If vaccines are refused, the refusal shall be documented in the resident's medical record . Resident #22 A record review of the facility's Transfer/Discharge Report revealed the facility admitted Resident #22 on 11/22/23 with diagnoses including Hemiplegia and Hemiparesis. A review of the medical record revealed there was no documentation that indicated Resident #22 had received or refused a COVID-19 vaccination. Resident # 37 A record review of the facility's Transfer/Discharge Report revealed the facility admitted Resident #37 on 09/22/23 with diagnoses including Chronic Atrial Fibrillation. A review of the medical record revealed there was no documentation that indicated Resident #22 had received or refused a COVID-19 vaccination. During an interview on 7/10/24 at 10:15 AM, the Director of Nursing (DON), she stated Resident #22 and Resident #37 had refused COVID-19 vaccines. She confirmed the facility did not have a signed copy of the declination or refusal forms for Resident #22 and Resident #37 in their medical records. The DON explained the Resident Care Coordinator (RCC) was responsible for ensuring immunization records were available in the resident's medical record. During an interview on 7/11/24 at 11:00 AM, with the Administrator, he stated he was aware the facility was unable to provide evidence Resident #22 and Resident #37 had refused COVID-19 vaccines. The Administrator stated the RCC was responsible for maintaining immunization documents in the medical records and expected the RCC to have documentation available as required. In an interview on 07/11/24 at 11:37 AM, with the RCC, she confirmed she was unable to provide declination forms or documentation of refusal for Resident #22 and Resident #37 regarding COVID-19 vaccines. The RCC confirmed she was responsible for maintaining the immunization records and she planned to begin scanning the documents herself to ensure they were properly added to the medical record.

Based on staff interview, record review, and facility policy review, the facility failed to accurately complete the Minimum Data Set (MDS) assessments for residents who were discharged from the facility for two (2) of 18 residents reviewed. (Resident #77 and Resident #79) Findings include: A review of the facility's policy Conducting an Accurate Resident Assessment, dated 11/6/23 revealed, . The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas . Definition: Accuracy of assessment means that the appropriate, qualified health professionals correctly document .using the appropriate Resident Assessment Instrument (RAI) . Resident #77 A record review of the Admission Record revealed the facility admitted Resident #77 on 3/13/24 with current diagnoses including Hemiplegia and Hemiparesis. A record review of the Discharge MDS with an Assessment Reference Date (ARD) of 4/10/24 revealed Resident #77 was discharged from the facility to a nursing home (long-term care facility). A record review of a Progress Note, dated 4/10/24, revealed Resident #77 was transferred to an acute care hospital and not a long-term care facility. Resident #79 A record review of the Admission Record revealed the facility admitted Resident #79 on 3/20/24 with current diagnoses including Type 2 Diabetes Mellitus. A record review of the Discharge MDS with an ARD of 4/22/24 revealed Resident #79 was discharged from the facility to a short-term general hospital. A record review of the Discharge Summary and Instructions, dated 4/22/24, revealed Resident #79 was discharging to a nursing home (long-term care) facility per the family's request. A record review of the Progress Notes, dated 4/22/24 at 11:20 AM, revealed Resident #79 was discharged to a long-term care facility and not a short-term general hospital. At 3:40 PM on 7/9/24, during an interview with Licensed Practical Nurse (LPN) #2/MDS Nurse, she explained Resident #79 went to a long-term care facility when he was discharged . She also explained Resident #77 was discharged to an acute hospital when he left the facility. LPN #2 reviewed Resident #77's and #79's Discharge MDS and confirmed the MDS assessments were not accurate and explained she was unsure how the error had occurred. At 11:50 AM on 7/11/24, during an interview with the Director of Nursing (DON), she explained she was made aware of the inaccuracy of the MDS assessments, and the facility was working on making corrections regarding Resident #77 and Resident #79. She stated she expected all residents to have accurate MDS assessments.

Based on record review, staff interview, and facility policy review, the facility failed to provide evidence that residents refused the Influenza and/or Pneumococcal vaccine for two (2) of five (5) residents reviewed for immunizations. Resident #22 and Resident #37 Findings include: A review of the facility's policy, Vaccination of Residents, dated 8/2/22, revealed, .All residents will be offered vaccines .Policy Interpretation and Implementation 1. Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations .2. Provision of such education shall be documented in the resident's medical record .5. If vaccines are refused, the refusal shall be documented in the resident's medical record . Resident #22 A record review of the facility's Transfer/Discharge Report revealed the facility admitted Resident #22 on 11/22/23 with diagnoses including Hemiplegia and Hemiparesis. A review of the medical record revealed there was no documentation that indicated Resident #22 had received or refused an influenza and pneumococcal vaccination. Resident # 37 A record review of the facility's Transfer/Discharge Report revealed the facility admitted Resident #37 on 09/22/23 with diagnoses including Chronic Atrial Fibrillation. A review of the medical record revealed there was no documentation that indicated Resident #22 had received or refused an influenza and pneumococcal vaccination. On 7/10/24 at 10:15 AM, in an interview with the Director of Nursing (DON), she stated Resident #22 and Resident #37 had refused the influenza and pneumococcal vaccines. She confirmed the facility did not have a signed copy of the declination or refusal forms for Resident #22 and Resident #37 in their medical records. The DON explained the Resident Care Coordinator (RCC) was responsible for ensuring immunization records were available in the resident's medical record. On 7/11/24 at 11:00 AM, in an interview with the Administrator, he acknowledged he was aware the facility was unable to provide evidence Resident #22 and Resident #37 had refused influenza and pneumococcal immunizations. The Administrator stated the RCC was responsible for maintaining immunization documents in the medical records and expected the RCC to have documentation available as required. On 07/11/24 at 11:37 AM, in an interview with the RCC, she confirmed she was unable to provide declination forms or documentation of refusal for Resident #22 and Resident #37 regarding the influenza and pneumococcal immunizations. The RCC confirmed she was responsible for maintaining the immunization records and she planned to begin scanning the documents herself to ensure they are properly added to the medical record.

Based on observation, staff interview, and facility policy review, the facility failed to ensure the chemical sanitizer for a low-temperature dishwasher had a concentration of at least 50 parts per million (ppm) for one (1) of two (2) dishwasher observations. Findings Include: Review of the facility's policy, Sanitization with a revision date 10/04/22, revealed, The food service area will be maintained in a clean and sanitary manner. Policy Interpretation and Implementation .3. All equipment, food contact surfaces and utensils will be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and or chemical sanitizing solutions .6. Dishwashing machines must be operated using the following specifications .Low-Temperature Dishwasher (Chemical Sanitization) .b. Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) for at least 10 seconds . On 7/9/24 at 11:08 AM, during an observation and interview of the tray line, Dietary #2/Cook was preparing trays for the residents in the dining room. Dietary #2 frequently stopped the line and placed dishes to the side. He stated that upon inspection, the dishes were not clean. There were 12 small bowls, five (5) plates, three (3) large serving bowls, and one (1) platter set aside. Some of the dishes had large amounts of dried food on them and some of them had small specks of food residue on them. On 7/9/24 at 1:48 PM, in a follow-up interview with Dietary #2, he stated he thought the dishwasher was not cleaning the dishes properly and explained that he never used soiled dishes when preparing meal trays for the residents. On 7/9/24 at 1:59 PM, in an interview with Dietary #1/Assistant Dietary Manager, she confirmed the facility had problems with the dishwasher and it had been rebuilt approximately two (2) months ago. She explained they had minor problems with the dishwasher which required a repairman to come to the facility to repair it. She reported it was the responsibility of the dietary aides to check the dishes before the dishes were stored to make sure they were clean. On 7/9/24 at 2:10 PM, in an observation with Dietary #1 and Dietary #3, there were four (4) dirty plates. Dietary #3 sprayed the dishes and placed them in the low temperature dishwasher. After the dishwasher cycle ended, she removed the plates, and they had specks of food residue on them. The dishwasher temperature reached 130 degrees Fahrenheit (F), which was within the required temperature range and the chlorine measured 10 ppm on the dish surface, which was less than 50 ppm. Dietary #1 confirmed the plates were not clean and the sanitation was less than the required amount. On 7/9/24 at 2:25 PM, in an interview with the Corporate Dietary Consultant, she stated the sanitation had been changed earlier today and was not coming through the tubing properly because the tubing had not been primed. She stated that after priming the tubing, the sanitation reading was 50 ppm. On 7/11/24 at 1:00 PM, in an interview with the Administrator, he stated he was made aware the dietary staff had not primed the sanitation tubing after installing a new container of sanitation in the dishwasher and explained that education and training had begun immediately for the dietary staff as soon as the issue was observed.

Based on the interview, record review, and facility policy review, the facility failed to notify the Resident Representative (RR) when a resident required a change in the level of care and required one-on-one (1:1) supervision due to confusion for one (1) of four (4) residents reviewed. Resident #1. Findings Include: A review of the facility's policy, Notification of Change in a Resident's Condition or Status, revised 8/2/22, revealed .Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care) .Policy Interpretation and Implementation .5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . A record review of the facility's document (Proper Name of Resident #1) Investigation, dated 1/20/24, revealed that on 1/18/24, Resident #1 had gotten out of the building for approximately 36 seconds. She was assisted back into the building by a therapy staff member. Resident #1 was assessed, interviewed, and placed on 1:1 supervision and offered activities due to her confusion. Review of the medical record revealed there was no documentation that the RR was notified that Resident #1 required 1:1 supervision due to her confusion and that she had walked out of the facility. On 1/29/24 at 12:00 PM, during an interview with the RR, he confirmed that the facility did not notify him that Resident #1 had walked out of the facility and that she required 1:1 supervision. On 1/30/24 at 12:10 PM, an interview with the Interim Director of Nursing (I-DON), she confirmed there was no documentation that Resident #1's RR had been notified of the event on 1/18/24. She stated the facility phoned the RR but did not leave a message. The I-DON confirmed she did not call the RR back later in the shift to inform him of the incident and stated that the RR should have been notified and it should have been documented. She explained it was the facility's policy to notify the RR of any changes with the residents and she expected the nursing staff to follow the facility's policy. On 1/30/24 at 12:51 PM, in an interview with the Administrator, he explained that Resident #1 did not have any injuries and her vital signs were normal, so he felt the facility did not have to notify the RR. He stated that when he was made aware of the incident, he returned to the facility to investigate and review the video footage. He contended that it was not necessary for the facility to notify the RR of the investigation, the outcome of the investigation, or that Resident #1 required 1:1 supervision due to confusion. Record review of the Admission Record revealed the facility admitted Resident #1 on 7/21/22 with current medical diagnoses including Alzheimer's Disease and Dementia. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/7/23, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated her cognition was severely impaired.

Based on staff and Resident Representative interviews, record review, and facility policy review, the facility failed to protect the resident's right to be free from neglect when staff provided inaccurate body audits and services for one (1) of four (4) sampled residents. Resident #1 The facility's failure to ensure that body audits were completed accurately resulted in Resident #1 sustaining an amputation of the fifth digit of her right foot and placed other residents in a situation that was likely to cause serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 10/18/23 when facility staff completed an inaccurate weekly body audit. The facility Administrator was notified of the IJ and SQC on 11/15/23 at 12:12 PM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 11/15/23, in which they alleged all corrective actions to remove the IJ were completed on 11/15/23, and the IJ removed on 11/16/23. The State Agency (SA) validated the Removal Plan on 11/16/23 and determined that the IJ was removed on 11/16/23, prior to exit. Therefore, the scope and severity for CFR 483.12 Freedom from Abuse, Neglect, and Exploitation- F600 was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy, Abuse Prevention Program, undated, revealed, .Our residents have the right to be free from .neglect . Review of the facility's policy, Skin Assessment, revised 11/1/22, revealed, .It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/ re-admission and weekly thereafter . Record review of the facility's Resident Incident, Complaint or Information Report, dated 11/13/2023, revealed, .On 11/7/23, Resident was noted to have a discolored right fifth toe. The nurse assessed resident's foot, noting discoloration and a small bandage on the toe. Resident sent out to hospital for evaluation. Course of treatment in hospital was amputation related to infection of the toe . A record review of the hospital Discharge Summary, dated 11/9/23, revealed .ADM (admission) Date: 11/07/23 .Discharge Diagnoses: Infection right fifth toe .Underwent amputation right fifth toe on 11/08/2023 **ADDENDUM** .On exam, the toe appears ischemic .Unfortunately, she seems to be developing some infection within the ischemic toe. I have recommended amputation today .Assessment and Plan .(1) Gangrene of toe Status: Acute Right fifth toe malodorus .Exam: .Extremities right fifth toe malodorus and necrotic at the distal end with erythema progressing more proximally . During an interview with the Administrator on 11/13/23 at 12:10 PM, he stated that Resident #1 was treated by the Podiatrist Nurse Practitioner (NP) on 10/18/23. He stated the Podiatrist NP performed nail care and wrapped the resident's fifth right toe (small toe) with a pink cohesive bandage. The Administrator agreed the facility staff did not perform skin or body audit correctly for Resident #1 on 10/18/23, 10/25/23, and 11/1/23 and this caused Resident #1 to undergo an amputation of her toe. On 11/13/23 at 12:54 PM, an interview with the facility's Nurse Practitioner (NP), confirmed that on 11/7/23, she was requested to go to Resident #1's room by Registered Nurse (RN) #1 and the Resident Care Coordinator (RCC) to evaluate the resident's right fifth toe. She stated that upon her evaluation, the resident's toenail area was approximately 50 % necrotic (dead tissue) and had black discoloration. Also, towards the resident's foot, the toenail area had a red and purple discoloration. The NP notified the Medical Director, Administrator, the Director of Nurses (DON), the Resident Representative (RR), and emergency services after her evaluation. The NP stated that the Occupational Therapist (OT) reported that Resident #1 had complained of pain in her right foot/toe area and the OT observed the pink bandage around the resident's toe. The OT then notified RN #1 who had removed the bandage, which was reportedly very tight. On 11/13/23 at 1:15 PM, during an phone interview with the Podiatry NP, she revealed that on 10/18/23, she treated Resident #1 for dystrophic (deformed, thickened, or discolored) nails. The podiatry NP stated she remembered that the resident had some bleeding on her fifth right digit area, but it subsided with pressure. She denied putting a bandage on the resident's toe but confirmed that she used pink Coban bandages when treating residents. She reported that her visit on 10/18/23 was her first time to be in the facility and verified that she did not report to facility staff following her treatment of the residents. She stated that she thought the facility nurses, or the facility NP, would read her documentation and follow up as needed. She confirmed she did not write or recommend any treatment for Resident #1. She also stated that her documentation was for her left fifth digit, but she was unable to remember if it was for the left or right. A record review of Health Services Progress Note, with an encounter date of 10/18/23, completed by the Podiatry NP, revealed .Performed debridement of nine nails (all except left fifth nail) for reduction of thickness and length. Left fifth toenail came off spontaneously as I cleaned it gently with adult skin wipe before debridement began. Nail bed oozed a small amount of blood. Bleeding stopped after I applied pressure with clean gauze . In a phone interview on 11/13/23 at 1:40 PM, with the Resident Representative (RR), she stated that on 11/7/23, she received a phone call from the facility NP, who reported that her mother (Resident #1) was noted to have a pink dressing on her toe and was being transferred to the local emergency department for an evaluation. On 11/13/23 at 2:34 PM, during an interview with Certified Nurse Assistant (CNA) #1, she confirmed that during Resident #1's baths, she had observed a bright pink bandage around the resident small right toe. CNA #1 stated that the resident did not complain of any pain during any of her baths. During the interview with CNA #1 confirmed that she normally was assigned to Resident #1. On 11/13/23 at 3:00 PM, during an interview with RN #1 confirmed the OT requested she come to Resident #1 room to evaluate her foot. RN #1 stated upon seeing the pink dressing on the toe, she immediately attempted to remove it with her surgical scissors but it was so tight around her toe. She used a pair of suture scissors to remove the bandage and the toe bed area was black with purple and redness discoloration proceeding down the toe area. Record review of the .Skin Only Evaluation, dated 10/25/23, revealed License Practical Nurse (LPN) #1 documented that Resident #1 did not have current skin issues. During a phone interview on 11/14/23 at 2:00 PM, LPN #1 stated that she performed the skin/body audit on Resident #1 on 10/25/23. LPN #1 confirmed she failed to remove the resident's socks to assess her feet and toes. She explained she was unaware that Resident #1 had a bandage on her right toe. Record review of the .Skin Only Evaluation, dated 10/18/23 and 11/1/23, revealed LPN #2 documented that Resident #1 did not have current skin issues. On 11/14/23 at 2:30 PM, a phone interview with LPN #2 confirmed that she documented the skin/body audits on Resident #1 on 10/18/23 and 11/1/23. LPN #2 stated that she did not actually perform the body audits but had asked a CNA on 10/18/23 and 11/1/23 to ascertain if the resident had any marks or sores on her body and was told the resident had none. LPN #2 confirmed that she failed to perform the body audits herself. She explained she did not know there was a bandage on Resident #1's right foot. On 11/14/24 at 2:42 PM, during an interview with the OT, she confirmed that on 11/7/23, she was assisting Resident #1. The resident requested her socks to be changed to match her outfit and when she removed her socks, she observed a pink bandage on her right foot, fifth digit. The resident jumped while removing the sock on her right foot and complained of pain in her foot area. The OT notified RN #1, who came to her room and removed the dressing. During the removal of the pink dressing the OT confirmed that the dressing was tight and difficult for the nurse to remove. Following the removal of the dressing, the residents toe looked black in color. During an interview with the Administrator on 11/14/23 at 3:00 PM, he stated that he expected the nursing staff to do a complete head-to-toe skin assessment to prevent further damage to a compromised resident. During an interview on 11/14/23 at 3:56 PM, with the DON, she confirmed the staff failed to perform accurate head-to-toe body audits on Resident #1, and she was unaware that was not being performed correctly. The DON also confirmed that she was unaware the resident had a Coban dressing on her right fifth toe for 20 days, which was not assessed by staff which caused the resident to have an amputation. The DON stated the facility had been performing and continuing to perform in-services to nursing staff on head-to-toe body audits. Record review of the Admission Record revealed the facility admitted Resident #1 on 9/9/22 with diagnoses including Psychotic Disturbance, Mood Disturbance, Anxiety, Hypertension, and Autonomic Neuropathy. Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/17/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated she was severely impaired. The facility submitted the following acceptable Removal Plan on 11/15/23: On 11/15/23 at 12:12pm, the State Survey Agency notified the Administrator that the facility 1. ) neglected to provide accurate body audits and services to Resident #1 from 10/18/23 until 11/7/23, as evidenced by staff admission of incomplete body audits, resulted in Resident #1 sustaining an amputation of the fifth digit of her right foot. 2.) failed to implement care plan interventions for Resident #1 when the facility failed to provide complete and accurate weekly body audits from 10/18/23 through 11/7/23. The Immediate Jeopardy Templates for F600 and F656 were provided to the Administrator on 11/15/23, at 12:12pm. At Approximately 12:00pm on 11/7/23, Occupational Therapist (OT) notified Registered Nurse #1 that Resident was experiencing discomfort of a toe on her right foot. RN #1 and Resident Care Coordinator/Infection Preventionist (RCC/Infection Preventionist) removed a pink bandage from the toe and requested that Nurse Practitioner evaluate Resident. Nurse Practitioner noted the right fifth toe to be necrotic at the nail bed, with plantar surface to have red and purple discoloration proceeding down the toe. Nurse Practitioner sent the Resident to the hospital for further evaluation and treatment. Resident was admitted to hospital 11/7/23, underwent surgery for toe amputation related to infection on 11/8/23, and discharged from the facility per family request on 11/9/23. On 11/7/23, the facility initiated an investigation. The type of pink dressing found on Resident's foot is not a type purchased or used by the facility. Podiatry Nurse Practitioner saw Resident on 10/18/23. Interview revealed Podiatry Nurse Practitioner did use this type of pink dressing and stated to facility staff that she did use this type dressing on Resident. Her visit documentation did not indicate a dressing was applied. Body audits conducted on 10/18/23 and 11/1/23 by LPN #1 did not indicate dressing present. Body audits conducted on 10/25/23 by LPN #2 (Agency) did not indicate dressing present. Due to inaccurate assessments, employment of LPN #1 was ended on 11/7/23 and the agency notified on 11/7/23 that LPN#2 (Agency) would not be allowed to work in the facility again. On 11/7/23, Staff Development Nurse initiated training of nursing staff to include reporting skin issues, reporting undated dressings, correct process to conduct a body audit, and accurate documentation. No nursing staff members were allowed to work until trained. On 11/7/23, Director of Nursing (DON) and RCC/Infection Preventionist conducted 15 verification audits of documented body audits to ensure accuracy. No errors in accuracy of documentation were found. On 11/10/23, potential for skin problem care plans were reviewed on 76 residents with no changes made. Reviews conducted by MDS Nurse #1 and MDS Nurse #2. On 11/7/23 DON and RCC/Infection Preventionist conducted a visual evaluation of the feet of all residents who received podiatry services on 10/18/23 with no skin problems noted. These were conducted due to interview with Podiatry Nurse Practitioner in which she stated she was uncertain of which residents she may have left bandages on. Quality Assurance Committee (QAC) recommendation of 11/7/23 implemented that all future Podiatry in-facility visits will be accompanied by a nurse for a minimum of two (2) months. Additional requirement made that Podiatry staff exit with DON, RCC/Infection Preventionist or RN Supervisor prior to leaving the facility at the end of each visit. QAC meetings conducted on 11/7, 11/9 and 11/10/23 to review investigative steps and corrective actions taken. On 11/11/23 and 11/12/23, body audits were conducted by the DON accompanied by the Administrator on seventy-five (75) residents. Body audits on all residents were completed by 11/14/23. On 11/13/23 LPN #1 and LPN #2 were reported to the Mississippi (MS) Board of Nursing. On 11/15/23 training conducted at 2:30pm on reporting skin issues, reporting undated dressings, correct process to conduct a body audit, and accurate documentation presented by an Outside Facility Director of Nursing. No nursing staff will be allowed to work until they have been trained. Emergency Quality Assurance committee meeting was conducted 11/15/23 at 1:45pm. Attending the meeting were Administrator, DON, RCC/Infection Preventionist, Medical Director (via phone), Social Services, OT, MDS Nurse #1 and MDS Nurse #2. Discussed in the meeting were: Recap of incident and investigation involving Resident #1, which had been reviewed in QAC meetings on 11/7, 11/9, and 11/10, Corrective actions taken, and Review of policies related to neglect, skin audits and care plans. The facility implemented all corrective measure on 11/15/23 and alleges the immediate jeopardy was removed 11/16/23. The SA validated the removal plan on 11/16/23 and immediacy removed on 11/16/23 prior to exit. The State Agency (SA) validated the facility's removal plan on 11/16/23. The SA validated through interview and record review that at approximately 12:00pm on 11/7/23, Occupational Therapist (OT) notified Registered Nurse #1 that Resident was experiencing discomfort of a toe on her right foot. RN #1 and Resident Care Coordinator/Infection Preventionist (RCC/Infection Preventionist) removed a pink bandage from the toe and requested that Nurse Practitioner evaluate Resident. Nurse Practitioner noted the right fifth toe to be necrotic at the nail bed, with plantar surface to have red and purple discoloration proceeding down the toe. Nurse Practitioner sent the Resident to the hospital for further evaluation and treatment. Resident was admitted to hospital 11/7/23, underwent surgery for toe amputation related to infection on 11/8/23, and discharged from the facility per family request on 11/9/23. The SA validated through interview and record review that on 11/7/23, the facility initiated an investigation. The type of pink dressing found on Resident's foot is not a type purchased or used by the facility. Podiatry Nurse Practitioner saw Resident on 10/18/23. Interview revealed Podiatry Nurse Practitioner did use this type of pink dressing and stated to facility staff that she did use this type dressing on Resident. Her visit documentation did not indicate a dressing was applied. The SA validated through interview and record review that body audits were conducted on 10/18/23 and 11/1/23 by LPN #1 did not indicate dressing present. Body audits conducted on 10/25/23 by LPN #2 (Agency) did not indicate dressing present. Due to inaccurate assessments, employment of LPN #1 was ended on 11/7/23 and the agency notified on 11/7/23 that LPN#2 (Agency) would not be allowed to work in the facility again. The SA validated through interview and record review on 11/7/23, Staff Development Nurse initiated training of nursing staff to included reporting skin issues, reporting undated dressings, correct process to conduct a body audit, and accurate documentation. No nursing staff members were allowed to work until trained. The SA validated through interview and record review on 11/7/23, Director of Nursing (DON) and RCC/Infection Preventionist conducted 15 verification audits of documented body audits to ensure accuracy. No errors in accuracy of documentation were found. The SA validated through interview and record review on 11/10/23 potential for skin problem care plans were reviewed on 76 residents with no changes made. Reviews conducted by MDS Nurse #1 and MDS Nurse #2. The SA validated through interview and record review on 11/7/23 DON and RCC/Infection Preventionist conducted a visual evaluation of the feet of all residents who received podiatry services on 10/18/23 with no skin problems noted. The SA validated through interview and record review the Quality Assurance Committee (QAC) recommendation of 11/7/23 implemented that all future Podiatry in-facility visits will be accompanied by a nurse for a minimum of two (2) months. Additional requirement made that Podiatry staff exit with DON, RCC/Infection Preventionist or RN Supervisor prior to leaving the facility at the end of each visit. The SA validated through interview and record review QAC meetings conducted on 11/7, 11/9 and 11/10/23 to review investigative steps and corrective actions taken. The SA validated through interview and record review on 11/11/23 and 11/12/23, body audits were conducted by the DON accompanied by the Administrator on seventy-five (75) residents. Body audits on all residents were completed by 11/14/23. The SA validated through interview and record review on 11/13/23 LPN #1 and LPN #2 were reported to the MS Board of Nursing. The SA validated through interview and record review on 11/15/23 training conducted at 2:30pm on reporting skin issues, reporting undated dressings, correct process to conduct a body audit, and accurate documentation presented by an Outside Facility Director of Nursing. No nursing staff will be allowed to work until they have been trained. The SA validated through interview and record review that an Emergency Quality Assurance committee meeting was conducted on 11/15/23 at 1:45 pm. Attending the meeting were the Administrator, DON, RCC/Infection Preventionist, Medical Director (via phone), Social Services, OT, MDS Nurse #1, and MDS Nurse #2.

Based on interviews, record reviews, and facility policy reviews, the facility failed to implement comprehensive care plan interventions related to skin assessments for one (1) of four (4) sampled residents. Resident #1 The facility's failure to implement a care plan for weekly body audits and ensure the body audits were completed accurately resulted in Resident #1 sustaining an amputation of the fifth digit of her right foot and placed other residents in a situation that was likely to cause serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 10/18/23 when facility staff completed an inaccurate weekly body audit. The facility Administrator was notified of the IJ on 11/15/23 at 12:12 PM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 11/15/23, in which they alleged all corrective actions to remove the IJ were completed on 11/15/23, and the IJ removed on 11/16/23. The State Agency (SA) validated the Removal Plan on 11/16/23 and determined that the IJ was removed on 11/16/23, prior to exit. Therefore, the scope and severity for F656- Care Plans- was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility's policy, Comprehensive Care Plans, revised 8/24/22, revealed, .It is the policy of this facility to .implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, and mental and psychosocial needs .Policy explanation and Compliance Guidelines .8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions . Record review of the Comprehensive Care Plan with an initiation date of 9/13/22, revealed Focus: The resident has potential impairment to skin integrity r/t (related to) chronic illness, dementia, and edema .Interventions : Weekly skin evaluation and nursing summary every Wednesday, Revision on 9/15/2022 . Record review of the Admission Record revealed the facility admitted Resident #1 on 9/9/22 with diagnoses including Psychotic Disturbance, Mood Disturbance, Anxiety, Hypertension, and Autonomic Neuropathy. Record review of the .Skin Only Evaluation, dated 10/25/23, revealed License Practical Nurse (LPN) #1 documented that Resident #1 did not have current skin issues. In a phone interview on 11/14/23 at 2:00 PM, LPN #1 stated she incorrectly performed the skin/body audit on Resident #1 on 10/25/23. LPN #1 also confirmed she failed to follow the care plan for Resident #1, performing her body audit incorrectly. Record review of the .Skin Only Evaluation, dated 10/18/23 and 11/1/23, revealed LPN #2 documented that Resident #1 did not have current skin issues. During a phone interview on 11/14/23 at 2:30 PM, LPN #2 confirmed that she performed the skin/body audits on Resident #1 on 10/18/23 and 11/1/23 incorrectly by not performing them herself. LPN #2 also stated that she did not implement the care plan correctly on Resident #1 by not performing the skin audits correctly. On 11/14/23 at 3:56 PM with the Director of Nurses (DON), she confirmed the facility staff failed to follow the care plan by not assessing or accurately performing head-to-toe body audits on Resident #1. On 11/15/23 at 10:16 AM, an interview with Minimum Data Set (MDS) Nurse #2 confirmed that staff should follow the care plans for residents' dignity, integrity, and safety. She reported that care plans were developed individualized to ensure consistency in the nursing care of the resident, which helps improve services. She added that she expects all nursing staff in the facility to follow care plans for the residents. The facility submitted the following acceptable Removal Plan on 11/15/23: On 11/15/23 at 12:12pm, the State Survey Agency notified the Administrator that the facility 1.) neglected to provide accurate body audits and services to Resident #1 from 10/18/23 until 11/7/23, as evidenced by staff admission of incomplete body audits, resulted in Resident #1 sustaining an amputation of the fifth digit of her right foot. 2.) failed to implement care plan interventions for Resident #1 when the facility failed to provide complete and accurate weekly body audits from 10/18/23 through 11/7/23. The Immediate Jeopardy Templates for F600 and F656 were provided to the Administrator on 11/15/23, at 12:12pm. At approximately 12:00pm on 11/7/23, Occupational Therapist (OT) notified Registered Nurse #1 that Resident was experiencing discomfort of a toe on her right foot. RN #1 and Resident Care Coordinator/Infection Preventionist (RCC/Infection Preventionist) removed a pink bandage from the toe and requested that Nurse Practitioner evaluate Resident. Nurse Practitioner noted the right fifth toe to be necrotic at the nail bed, with plantar surface to have red and purple discoloration proceeding down the toe. Nurse Practitioner sent the Resident to the hospital for further evaluation and treatment. Resident was admitted to hospital 11/7/23, underwent surgery for toe amputation related to infection on 11/8/23, and discharged from the facility per family request on 11/9/23. On 11/7/23, the facility initiated an investigation. The type of pink dressing found on Resident's foot is not a type purchased or used by the facility. Podiatry Nurse Practitioner saw Resident on 10/18/23. Interview revealed Podiatry Nurse Practitioner did use this type of pink dressing and stated to facility staff that she did use this type dressing on Resident. Her visit documentation did not indicate a dressing was applied. Body audits conducted on 10/18/23 and 11/1/23 by LPN #1 did not indicate dressing present. Body audits conducted on 10/25/23 by LPN #2 (Agency) did not indicate dressing present. Due to inaccurate assessments, employment of LPN #1 was ended on 11/7/23 and the agency notified on 11/7/23 that LPN#2 (Agency) would not be allowed to work in the facility again. On 11/7/23, Staff Development Nurse initiated training of nursing staff to include reporting skin issues, reporting undated dressings, correct process to conduct a body audit, and accurate documentation. No nursing staff members were allowed to work until trained. On 11/7/23, Director of Nursing (DON) and RCC/Infection Preventionist conducted 15 verification audits of documented body audits to ensure accuracy. No errors in accuracy of documentation were found. On 11/10/23, potential for skin problem care plans were reviewed on 76 residents with no changes made. Reviews conducted by MDS Nurse #1 and MDS Nurse #2. On 11/7/23 DON and RCC/Infection Preventionist conducted a visual evaluation of the feet of all residents who received podiatry services on 10/18/23 with no skin problems noted. These were conducted due to interview with Podiatry Nurse Practitioner in which she stated she was uncertain of which residents she may have left bandages on. Quality Assurance Committee (QAC) recommendation of 11/7/23 implemented that all future Podiatry in-facility visits will be accompanied by a nurse for a minimum of two (2) months. Additional requirement made that Podiatry staff exit with DON, RCC/Infection Preventionist or RN Supervisor prior to leaving the facility at the end of each visit. QAC meetings conducted on 11/7, 11/9 and 11/10/23 to review investigative steps and corrective actions taken. On 11/11/23 and 11/12/23, body audits were conducted by the DON accompanied by the Administrator on seventy-five (75) residents. Body audits on all residents were completed by 11/14/23. On 11/13/23 LPN #1 and LPN #2 were reported to the Mississippi (MS) Board of Nursing. On 11/15/23 training conducted at 2:30pm on reporting skin issues, reporting undated dressings, correct process to conduct a body audit, and accurate documentation presented by an Outside Facility Director of Nursing. No nursing staff will be allowed to work until they have been trained. Emergency Quality Assurance committee meeting was conducted 11/15/23 at 1:45pm. Attending the meeting were Administrator, DON, RCC/Infection Preventionist, Medical Director (via phone), Social Services, OT, MDS Nurse #1 and MDS Nurse #2. Discussed in the meeting were: Recap of incident and investigation involving Resident #1, which had been reviewed in QAC meetings on 11/7, 11/9, and 11/10, Corrective actions taken, and Review of policies related to neglect, skin audits and care plans. The facility implemented all corrective measure on 11/15/23 and alleges the immediate jeopardy was removed 11/16/23. The SA validated the removal plan on 11/16/23 and immediacy removed on 11/16/23 prior to exit. The State Agency (SA) validated the facility's removal plan on 11/16/23. The SA validated through interview and record review that at approximately 12:00pm on 11/7/23, Occupational Therapist (OT) notified Registered Nurse #1 that Resident was experiencing discomfort of a toe on her right foot. RN #1 and Resident Care Coordinator/Infection Preventionist (RCC/Infection Preventionist) removed a pink bandage from the toe and requested that Nurse Practitioner evaluate Resident. Nurse Practitioner noted the right fifth toe to be necrotic at the nail bed, with plantar surface to have red and purple discoloration proceeding down the toe. Nurse Practitioner sent the Resident to the hospital for further evaluation and treatment. Resident was admitted to hospital 11/7/23, underwent surgery for toe amputation related to infection on 11/8/23, and discharged from the facility per family request on 11/9/23. The SA validated through interview and record review that on 11/7/23, the facility initiated an investigation. The type of pink dressing found on Resident's foot is not a type purchased or used by the facility. Podiatry Nurse Practitioner saw Resident on 10/18/23. Interview revealed Podiatry Nurse Practitioner did use this type of pink dressing and stated to facility staff that she did use this type dressing on Resident. Her visit documentation did not indicate a dressing was applied. The SA validated through interview and record review that body audits were conducted on 10/18/23 and 11/1/23 by LPN #1 did not indicate dressing present. Body audits conducted on 10/25/23 by LPN #2 (Agency) did not indicate dressing present. Due to inaccurate assessments, employment of LPN #1 was ended on 11/7/23 and the agency notified on 11/7/23 that LPN#2 (Agency) would not be allowed to work in the facility again. The SA validated through interview and record review on 11/7/23, Staff Development Nurse initiated training of nursing staff to included reporting skin issues, reporting undated dressings, correct process to conduct a body audit, and accurate documentation. No nursing staff members were allowed to work until trained. The SA validated through interview and record review on 11/7/23, Director of Nursing (DON) and RCC/Infection Preventionist conducted 15 verification audits of documented body audits to ensure accuracy. No errors in accuracy of documentation were found. The SA validated through interview and record review on 11/10/23 potential for skin problem care plans were reviewed on 76 residents with no changes made. Reviews conducted by MDS Nurse #1 and MDS Nurse #2. The SA validated through interview and record review on 11/7/23 DON and RCC/Infection Preventionist conducted a visual evaluation of the feet of all residents who received podiatry services on 10/18/23 with no skin problems noted. The SA validated through interview and record review the Quality Assurance Committee (QAC) recommendation of 11/7/23 implemented that all future Podiatry in-facility visits will be accompanied by a nurse for a minimum of two (2) months. Additional requirement made that Podiatry staff exit with DON, RCC/Infection Preventionist or RN Supervisor prior to leaving the facility at the end of each visit. The SA validated through interview and record review QAC meetings conducted on 11/7, 11/9 and 11/10/23 to review investigative steps and corrective actions taken. The SA validated through interview and record review on 11/11/23 and 11/12/23, body audits were conducted by the DON accompanied by the Administrator on seventy-five (75) residents. Body audits on all residents were completed by 11/14/23. The SA validated through interview and record review on 11/13/23 LPN #1 and LPN #2 were reported to the Mississippi (MS) Board of Nursing. The SA validated through interview and record review on 11/15/23 training conducted at 2:30pm on reporting skin issues, reporting undated dressings, correct process to conduct a body audit, and accurate documentation presented by an Outside Facility Director of Nursing. No nursing staff will be allowed to work until they have been trained. The SA validated through interview and record review that an Emergency Quality Assurance committee meeting was conducted on 11/15/23 at 1:45 pm. Attending the meeting were the Administrator, DON, RCC/Infection Preventionist, Medical Director (via phone), Social Services, OT, MDS Nurse #1, and MDS Nurse #2.

Based on interviews, record review, and facility policy review, the facility failed to identify and provide treatment to an open scalp wound for one (1) of four (4) sampled residents. Resident #1 Findings Include: Review of the facility's policy, Abuse Prevention Program, undated, revealed, .Our residents have the right to be free from .neglect . Review of the facility's policy, Skin Assessment revised 11/1/2022, revealed .It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment .Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/ re-admission and weekly thereafter . In a phone interview on 10/5/23 at 10:15 AM, with the Resident Representative (RR) and his wife, they stated they visited Resident #1 at the facility on 9/18/23 and the resident was wearing a bonnet. The wife stated that when she removed the bonnet, there was a bandage on her head that was discolored a brown color, and had no date written on the bandage to indicate when the bandage was applied. She said the area had drainage and was crusted around the edges, so she notified the nurse. The Nurse Practitioner (NP) assessed the resident and ordered the resident to be transferred to the hospital. The family revealed that when the resident arrived at the hospital, the hospital staff noted the bandages were unchanged. The family said the facility neglected to provide treatments to her scalp and failed to provide care to prevent a wound infection. Record review of the Progress Note, dated 9/18/23, created by the facility's NP, revealed the Chief Complaint/Nature of Presenting Problem was Wound infection of Scalp. The History of Present Illness was Patient seen today per facility request for evaluation of wound infection for scalp .Patient's family member is at bedside and reports concern for recurrent wound infection to her scalp. Patient currently has recurrent squamous cell carcinoma (a type of skin cancer) of her scalp and is currently receiving chemotherapy .Patient previously treated .in May. Scalp does have increased drainage and crusting with no foul odor noted .Family request patient be sent to (Proper Name of Local Hospital) for further evaluation and treatment. Record review of a Discontinue Order, dated 6/12/23, for Resident #1, revealed a Physician's Order for .Cleanse scalp with wound cleanser pat dry Apply Mupirocin Ointment every day shift was discontinued on 6/12/23 and the reason for discontinue was Wound healed per (Proper Name of Physician). This was the last Physician's Order related to treatments for Resident #1's scalp in the medical record. Record review of the of the Discharge Summary Note, dated 9/25/23, from a local acute hospital revealed Resident #1 was admitted through the Emergency Department on 9/18/23 and was discharged from the hospital on 9/25/23, which was seven (7) days later. The Hospital Course of the summary note revealed, .At presentation, she had unchanged dressings on her wounds. Family was concerned of adult neglect at the facility .Squamous cell carcinoma of scalp .Known to dermatology .and oncology . Record review of the .Skin Only Evaluation, dated 8/6/23, revealed Licensed Practical Nurse (LPN) #2 documented that Resident #1 did not have current skin issues. During a phone interview on 10/5/23 at 12:45 PM, with LPN #2, she confirmed she completed a skin evaluation, or body audit, for Resident #1 on 8/6/23. LPN #2 explained that she failed to remove the resident's bonnet to assess her scalp during the skin evaluation. She stated she was not aware the resident had a bandage on her scalp and that she did not apply the bandage. Record review of the .Skin Only Evaluation, dated 8/13/23, revealed Licensed Practical Nurse (LPN) #3 documented that Resident #1 did not have current skin issues. During a phone interview on 10/5/23 at 1:00 PM, with LPN #3, she confirmed she completed a skin evaluation/body audit for Resident #1 on 8/13/23. LPN #3 also confirmed she failed to remove the residents bonnet to assess her scalp. She explained she did not know there was a bandage on her scalp because she did not apply any bandages to the resident's head. Review of the medical record revealed there were no skin evaluations for 8/20/23 or 8/27/23. Record review of the .Skin Only Evaluation, dated 9/6/23, revealed Licensed Practical Nurse (LPN) #1 documented that Resident #1 did not have current skin issues. During a phone interview on 10/5/23 at 12:30 PM, with LPN #1, she confirmed she completed a body audit for Resident #1 on 9/6/23. LPN #1 also confirmed she failed to remove the residents bonnet to assess her scalp area. She stated she did not apply any bandages to the resident's scalp and was not aware she had a bandage on her head. Record review of the .Skin Only Evaluation, dated 9/10/23, revealed Registered Nurse (RN) #1 documented that Resident #1 did not have current skin issues. During a phone interview on 10/5/23 at 12:15 PM, RN #1 confirmed she failed to do a complete head-to-toe skin assessment on 9/10/23 for Resident #1. RN #1 explained she assessed the resident's skin, but she did not remove the bonnet to assess her head. RN #1 said she was not aware that Resident #1 had a bandage to her scalp, and she did not apply a bandage to that area. During an interview on 10/5/23 at 1:12 PM, with Certified Nursing Aide (CNA) #1, she stated that she provides care to the Resident #1. She explained that she removed the bonnet and saw a bandage on the resident's head and only cleaned around he bandage when she gave the resident a shower. During an interview on 10/5/23 at 1:20 PM, with CNA #2, she explained she provided care for Resident #1 prior to her hospitalization . CNA #2 stated Resident #1 had a bandage on her head, and she washed around the bandage. She stated that she thought the nurses knew about the drainage on the wound and was taking care of it. During an interview on 10/5/23 at 1:30 PM, with the facility's NP, she confirmed she assessed Resident #1 because the family had concerns with her scalp. The NP said the resident had been wearing a bonnet, and upon assessment she noted an area on the scalp that had increased drainage, that was dry and crusted around the wound edges. The NP said she agreed with the family and sent the resident to the Emergency Department (ED) for evaluation because the resident had signs of infection to the scalp. The NP said she did not culture the wound because the resident is immunocompromised, due to chemotherapy. The NP explained that residents who receive chemotherapy should be assessed frequently and closely monitored for infections. The NP said that the nurses should have completed head-to-toe skin assessments on the resident for early detection and to prevent infection. During an interview on 10/5/23 at 1:45 PM, with the Director of Nursing (DON), she confirmed the staff failed to do a head-to-toe skin assessment on Resident #1 and she did not realize this was not being done. The DON said she expected the staff to assess the resident head-to-toe when completing body audits. The DON revealed she did not know the residents wound had re-opened until the family came to visit and had concerns. The DON said she started in-services with the staff on appropriate body audits and the importance of reporting changes on the resident's body. During an interview on 10/5/23 at 2:00 PM, with the Administrator, stated he expected staff to do a complete head-to-toe skin assessment to prevent further damage to a compromised resident. Record review of the Admission Record revealed the facility admitted Resident #1 on 1/04/23 with diagnoses including Diabetes Mellitus and Carcinoma of the skin of scalp. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/18/23 revealed Resident #1 required a staff interview to assess cognition and her cognition was moderately impaired. Further review revealed she was totally dependent upon staff for Activities of Daily Living (ADL's).

Based on interview, record review and facility policy review, the facility failed to implement comprehensive care plan interventions related to skin assessments for one (1) of four (4) sampled residents. Resident #1 Findings Include: Review of the facility's policy, Comprehensive Care Plans, revised 8/24/22, revealed, .It is the policy of this facility to .implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, and mental and psychosocial needs .Policy Explanation and Compliance Guidelines .8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions . Record review of the Comprehensive Care Plan revealed a Focus of Resident has a dx (diagnosis) of carcinoma .of skin of scalp ., with a revision date of 7/11/2023. A review of the Interventions revealed, Assess for s/s (signs and symptoms) of infection. Report to NP (Nurse Practitioner). Record review of the Admission Record revealed the facility admitted Resident #1 on 1/04/23 with diagnoses including Diabetes Mellitus and Carcinoma of the skin of scalp. Record review of the .Skin Only Evaluation, dated 8/6/23, revealed Licensed Practical Nurse (LPN) #2 documented that Resident #1 did not have current skin issues. On 10/5/23 at 12:45 PM, in an interview with LPN #2, she confirmed she did not remove the resident's bonnet to assess her scalp during the skin evaluation she conducted on 8/6/23. Record review of the .Skin Only Evaluation, dated 8/13/23, revealed Licensed Practical Nurse (LPN) #3 documented that Resident #1 did not have current skin issues. On 10/5/23 at 1:00 PM, during a phone interview with LPN #3, she confirmed she failed to remove the residents bonnet to assess her scalp when she completed the body audit on 8/13/23. Review of the medical record revealed there were no skin evaluations for 8/20/23 or 8/27/23. Record review of the .Skin Only Evaluation, dated 9/6/23, revealed Licensed Practical Nurse (LPN) #1 documented that Resident #1 did not have current skin issues. On 10/5/23 at 12:30 PM, in an phone interview with LPN #1, she confirmed she failed to remove the residents bonnet to assess her scalp area on 9/6/23. Record review of the .Skin Only Evaluation, dated 9/10/23, revealed Registered Nurse (RN) #1 documented that Resident #1 did not have current skin issues. On 10/5/23 at 12:15 PM, in an interview with RN #1, she confirmed she failed to do a complete head-to-toe skin assessment on 9/10/23 for Resident #1. In an interview on 10/5/23 at 1:45 PM, with the Director of Nursing (DON), she confirmed the facility staff failed to follow the care plan by not assessing the resident's scalp for signs and symptoms of infection. In an interview at 2:10 PM on 10/5/23, with RN #2, she confirmed the facility failed to follow the care plan by not assessing the resident for signs and symptoms of infection. RN # 2 said she expected the staff to follow the care plan when taking care of the residents.

Based on interviews, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions related to the use of a mechanical lift for one (1) of three (3) resident care plans reviewed. (Resident #1) The facility did not implement the care plan intervention for a sit-to-stand mechanical lift transfer for Resident #1. The facility's failure to implement care plan interventions placed this resident and other residents at risk in a situation that caused and was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 2/27/23 when facility staff transferred Resident #1 using a pivot transfer and did not use the sit-to-stand mechanical lift as required. The facility Administrator was notified of the IJ on 3/28/23 at 4:25 PM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 3/30/23, in which they alleged all corrective actions to remove the IJ were completed, and the IJ removed on 3/30/23. The SA validated the Removal Plan on 3/31/23 and determined that the IJ was removed on 3/30/23, prior to exit. Therefore, the scope and severity for CFR 483.21 (b)(1) Comprehensive Care Plans was lowered fro a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's policy, Comprehensive Care Plans, revised 08/24/22, revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment.8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially, and when changes are made . Record review of the Admission Record revealed the facility admitted Resident #1 on 05/24/2018 with a diagnosis of Unspecified Dementia. A record review of the Comprehensive Care Plan for Resident #1 revealed a Focus . (Proper name of Resident #1) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) limited mobility secondary to Parkinson's Disease, decreased cognitive status .Revision on: 07/21/2020 and had Interventions including Transfer: Mech (Mechanical) stand lift x 2 (two) extensive assistance using medium belt to move between surfaces daily and as necessary. Date initiated 11/01/2019 . On 3/14/23 at 9:44 AM, in an interview with Certified Nurse Assistant (CNAs) #1, she confirmed that she was able to review resident care plans on the kiosk to see the type of transfer residents required. She verified that she did not follow the care plan when she transferred Resident #1 on 2/27/23 around 5:00 PM because she and another CNAs did a pivot transfer rather than transfer Resident #1 with the sit-to-stand lift. On 3/14/23 at 2:22 PM, an interview with Minimum Data Set (MDS) #2, she stated that Resident #1 had a care plan for staff to use a sit-to-stand mechanical lift for transfers. She explained that her expectation is for staff to follow the care plan and that the care plan addressed the needs and safety of residents. On 3/14/23 at 2:30 PM, in an interview with the Director of Nurses (DON), she revealed that Resident #1 had a care plan for a sit-to-stand lift for transfers. She stated that the CNAs admitted that they did not follow the care plan because they transferred the resident by pivoting instead of using the lift. She said that she expected all staff to follow the residents' care plans, and the purpose of the care plan was to provide each resident with care that was based on their individual needs. On 3/28/23 at 11:05 AM, an interview with CNAs #4, she confirmed that on 3/1/23, after lunch, she transferred Resident #1 back to her bed via a pivot transfer by herself and did not use the sit-to-stand lift. CNAs #4 stated that she was aware Resident #1 required a sit-to-stand lift with transfers. CNAs #4 revealed she did not follow the care plan of using the sit-to-stand lift on Resident #1 because it was easier that day to perform the pivot transfer alone. On 3/28/23 at 1:22 PM, in an interview with CNAs #3, she stated that she conducted a pivot transfer on 2/28/23 without assistance on Resident #1 and did not use the sit to stand lift. CNAs #3 revealed she was aware that Resident #1 required a lift for transfers, and she did not follow the care plan. She confirmed that she was aware she should follow the care plans on resident transfers but had no excuse that day. On 3/28/23 at 3:30 PM, in an interview with the Interim Administrator, she stated that she expected the staff to follow the comprehensive care plans for residents and that if a resident is to be transferred with a sit-to-stand lift, then she expected staff to perform the transfer with the lift. The facility submitted the following acceptable Removal Plan on 3/30/23: On 3/28/23 at 4:25 PM the State Survey Agency notified the Interim Administrator that the facility failed to ensure 1. ) Resident #1 was transferred with the sit-to-stand mechanical lift as determined necessary by the comprehensive care plan 2.) Evaluate and provide pain management for Resident #1. 3.) To implement care plan interventions for Resident #1 when the facility did not transfer her using the sit-to-stand mechanical lift and did not provide pain management for her when she experienced pain. On 3/28/23 at 4:25 PM the Immediate Jeopardy Templates for F656, F689 and F697 were provided to the Interim Administrator. At approximately 11:10 AM on Friday, March 3, 2023 the Nurse Practitioner reported that Resident #1 was experiencing bilateral leg pain. X-ray reports revealed bilateral fractures of the Tibia/Fibula. Resident #1 was sent to a local hospital emergency room for orthopedic evaluation. These findings were reported 3/3/23 to the State Survey Agency at 1:03 PM and the State Attorney General at 1:21 PM. On March 3, 2023, at approximately 11:30 the facility initiated an investigation including staff interviews, obtaining statements and reviewing video. Because the facility could not determine the date, time or cause of the injury the facility requested that the Attorney General's office assign an investigator to assist in this investigation. The investigator arrived on site on 3/13/23 to initiate their investigation. As of 3/29/23 a specific incident that caused the injury to Resident #1 has not been identified. Training for ALL nursing staff, prior to working their next scheduled shift: Beginning on 3/3/23, no nursing staff was allowed to work until completion of training, provided by the Director of Nursing (DON), on the following topics, Falls and Accidents Care Plans Mandatory Lift training video located in the [NAME] Care Centers Education Library Additional training started on 3/28/23, for ALL staff and no staff was allowed to work until trained on the following topics, Pain Assessment and Management Accidents Care Plan Implementation All training was provided by DON and Staff Development Nurse. Lift assessments have been completed/updated on all residents due to the fact that all residents who require the use of mechanical lifts have the potential to be affected by use of incorrect lifts. Lift Assessments were completed by Registered Nurse (RN) #1 starting on 3/3/23 and completed on 3/4/23. Care plans have been reviewed for all residents who require the use of mechanical lifts. Review was completed by Minimum Data Set (MDS) Nurse #1, started on 3/4/23 and completed on 3/6/23. Review indicated all residents were care planned for the correct lift. Monitoring for use of appropriate lift, sling/belt is being carried out by the DON. The Lift/Transfer Monitoring Tool is being used to document monitoring and was initiated on 3/28/23. All residents have been assessed for pain using the Pain Evaluation which includes the pain scale. Assessments were completed on 3/29/23 by the DON and RN #2. The Pain Alert Monitoring log is being used to monitor and audit for pain management and was initiated on 3/28/23. The DON and RCC/IP are responsible for conducting pain management audits. Care Plans for all residents have been reviewed regarding pain management. The review was completed by MDS Nurse #1 and MDS Nurse #2 on 3/29/23. No resident's care plans required updating. Audit has been performed for all Resident Kardex. The audit was completed by the assisting Interim Administrator, on 3/3/23. No discrepancies were noted. Facility lifts have been inspected for proper use and function. Environmentalist/Maintenance Director completed the inspections on 3/10/23. Five (5) sit to stand lifts were inspected. One was removed from service to replace a part related to the switch. Four (4) total/full body lifts were inspected with no maintenance required. Emergency Quality Assurance meetings were conducted on 3/7/23 and 3/29/23. Attending the meetings were Interim Administrator, assisting Interim Administrator, Corporate Nurse, Medical Director, Director of Nursing, Resident Care Coordinator/Infection Preventionist, MDS Nurses, and Social Services. Discussed in the meeting were: Review of Resident #1 injury identified on 3/3/23 Results/status of investigation Actions taken including training, monitoring and audits of care plans and assessments of pain and transfer status/lift utilization Review of policies related to care plans, accidents and injuries, lift utilization and transfer. No changes to policies were recommended or made. The facility alleges that the Immediate Jeopardy has been removed as of March 30, 2023. The SA validated the facility's removal plan on 3/31/23: On 3/31/23, the SA validated through a record review of the meeting sign in sheet and through staff interviews that the facility held a Quality Assurance Performance Improvement (QAPI) Committee meeting on 3/7/23 and 3/29/23. On 3/31/23, the SA validated through a record review of the meeting sign-in sheet and through staff interviews that the facility held a QAPI meeting on 3/7/23 and 3/29/23 regarding care plans, assessments of pain and transfer status/lift utilization. Review policies related to care plans, accidents, injuries, lift utilization, and transfer. On 3/31/23, the SA validated through staff interview and record review that the facility provided education beginning on 3/3/23 for falls, accidents, care plans, and mandatory lift training. The staff attended additional training beginning on 3/28/23 for pain assessment and management, accidents, and care plan implementation. On 3/31/23, the SA validated through staff interviews and record reviews that the facility performed lift assessments and updated all residents who require the use of mechanical lifts. On 3/31/23, the SA validated through staff interviews and record reviews that the facility reviewed care plans for all residents who require the use of mechanical lifts. On 3/31/23, the SA validated through staff interviews and record reviews that the facility monitored the use of the appropriate lift, sling/belt for all residents. On 3/31/23, the SA validated through staff interviews and record reviews that the facility assess all residents for pain using the Pain Evaluation, which includes the pain scale. On 3/31/23, the SA validated through staff interviews and record reviews that the facility all resident care plans have been reviewed regarding pain management. On 3/31/23, the SA validated through staff interviews and record reviews that the facility audited all resident Kardex. On 3/31/23, the SA validated through staff interviews and record reviews that the facility lifts have been inspected for proper use and function. On 3/31/23, the SA validated through a record review of the meeting sign-in sheet and through staff interviews that the facility held a Quality Assurance Performance Improvement (QAPI) Committee meeting on 3/7/23 and 3/29/23. On 3/31/23, the SA validated through a record review of the meeting sign-in sheet and through staff interviews that the facility held a QAPI meeting on 3/7/23 and 3/29/23 regarding care plans, assessments of pain and transfer status/lift utilization. Review policies related to care plans, accidents, injuries, lift utilization, and transfer. On 3/31/23, the SA validated through staff interview and record review that the facility provided education beginning on 3/3/23 for falls, accidents, care plans, and mandatory lift training. The staff attended additional training beginning on 3/28/23 for pain assessment and management, accidents, and care plan implementation. On 3/31/23, the SA validated through staff interviews and record reviews that the facility performed lift assessments and updated all residents who require the use of mechanical lifts. On 3/31/23, the SA validated through staff interviews and record reviews that the facility reviewed care plans for all residents who require the use of mechanical lifts. On 3/31/23, the SA validated through staff interviews and record reviews that the facility monitored the use of the appropriate lift, sling/belt for all residents. On 3/31/23, the SA validated through staff interviews and record reviews that the facility assess all residents for pain using the Pain Evaluation, which includes the pain scale. On 3/31/23, the SA validated through staff interviews and record reviews that the facility all resident care plans have been reviewed regarding pain management. On 3/31/23, the SA validated through staff interviews and record reviews that the facility audited all resident Kardex. On 3/31/23, the SA validated through staff interviews and record reviews that the facility lifts have been inspected for proper use and function.

Based on interviews, record review, and facility policy review, the facility failed to evaluate and provide pain management for a resident who sustained bilateral lower leg fractures for one (1) of three (3) sampled residents. (Resident #1) The failure to evaluate and provide pain management caused Resident #1 to experience avoidable pain and is likely to prevent other residents who require pain management the ability to attain or maintain their highest practicable level of well-being and is likely to cause serious injury, serious harm, or serious impairment. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 3/1/23 when facility staff reported that Resident #1 was yelling out in pain, hollering, screaming, and crying. The facility Administrator was notified of the IJ on 3/28/23 at 4:25 PM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 3/30/23, in which they alleged all corrective actions to remove the IJ were completed on 3/29/23, and the IJ removed on 3/30/23. The State Agency (SA) validated the Removal Plan on 3/31/23 and determined that the IJ was removed on 3/30/23, prior to exit. Therefore, the scope and severity for CFR 483.25(d)(1) Pain Management (F697) was lowered to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy, Pain Assessment and Management Revised 8/2/22, revealed, Purpose: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain .3. Pain management is a multidisciplinary care process that includes .a. Assessing the potential for pain; b. Effectively recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of pain .g. Monitoring for the effectiveness of interventions .5. Conduct a comprehensive pain assessment .when there is onset of new pain or worsening of existing pain. 6. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain . On 3/27/23 at 11:45 AM, an interview with the Director of Nurses (DON) revealed that on 3/3/23, Resident #1 had bruising and complained of pain in her legs. She received x-rays that showed bilateral fractures of the tibia and fibula. She explained the facility was unsure of how or exactly when the fractures occurred. She stated that she expected her staff to assess residents for pain every shift, record details related to pain in the progress notes, and administer pain medication as prescribed. The DON said that the nurse should follow up with the resident within one (1) hour of administration of pain medication to determine if the medication was effective and if pain medication is not prescribed or is not effective for a resident, she expected the nurse to notify the physician. The DON explained that Resident #1 used a wheelchair (wc) to move about the facility. The wc had bilateral footrests for her feet, but she used her arms to propel herself. She added that normally when Resident #1 was in pain, she used her call light and asked for her pain pill, which meant Tylenol. She usually complained of pain in her right hip and knee. The DON revealed that she was not sure if Resident #1's cognition affected her ability to accurately describe her pain, such as location and intensity using a numeric scale. 3/1/23 On 3/28/23 at 8:50 AM, in an interview with LPN #3, she stated that on 3/1/23, she worked from 7:00 AM to 7:00 PM. When she arrived at work that morning, Resident #1 was up and moving around in her wheelchair. Around 5:00 PM, Resident #1 was in bed and complained of hip pain, which was not unusual. She explained that she gave Resident #1 Tylenol for the pain but forgot to document the administration on the MAR or in the nurse's notes. On 3/28/23 at 9:16 AM, an interview with CNA #1, she stated that on 3/1/23 during the 11:00 PM to 7:00 AM shift, she heard Resident #1 hollering and crying in pain throughout the night, and she reported it to the nurse. 3/2/23 During an interview with CNA #2 on 3/28/23 at 9:35 AM, she stated that she remembered Resident #1 yelling out in pain during the early morning hours on 3/2/24. She explained that Resident #1 often complained of pain, but this was a different type of complaint. She said she told the nurse and the nurse stated she would give the resident pain medication. On 3/28/23 at 9:25 AM, in an interview with CNA #8, she stated that on her early morning rounds on 3/2/23, Resident #1 was complaining of pain in her legs, so she and another CNA got her up with the sit-to-stand lift. During the transfer, Resident #1 still complained of pain. CNA #8 explained that it was not unusual for Resident #1 to get up early and she took the resident to the nurses' station to report her pain. The nurse said she would give her pain medication. CNA #8 commented that Resident #1 was squirming around and agitated. On 3/27/23 at 4:29 PM, an interview with Licensed Practical Nurse (LPN) #2, she stated that on 3/2/23 at 6:45 AM, she was informed by a CNA that Resident #1 was up and dressed, in her wheelchair, and had complained of pain in her legs. LPN #2 gave the resident Ultram 50 mg by mouth on 3/2/23 at 6:45 AM. LPN #2 said that the resident was up and dressed, so she did not notice if she had any bruising on her lower extremities. LPN #2 explained that when a pain pill is given to a resident, the process at the facility is to evaluate and document the pain and to follow up with the resident at least one (1) hour following the administration of the medication to determine if the pain medication was effective. LPN #2 confirmed that Resident #1 was able to tell the staff a number related to her pain intensity, even though she had low cognition. On 3/27/23 at 4:21 PM, an interview with CNA #5 revealed that on 3/2/23 at 3:00 PM, she assisted with transferring Resident #1 from her wheelchair to her bed and explained that during the transfer, Resident #1 began hollering in pain. CNA #5 confirmed they notified Licensed Practical Nurse (LPN) #1 and she came and looked at her legs. CNA #5 said that Resident #1 was in tears around 10:15 PM that night and complained of pain in her legs. CNA #5 stated, This was different for her and they reported it to the nurse. On 3/28/23 at 8:29 AM, in an interview with CNA #6, she stated that on 3/2/23 at 3:00 PM, Resident #1 complained of pain in both legs, was upset, and crying while she was being transferred with the lift. CNA #6 also commented that the resident was up in her chair all day, which was unusual because she did not ask for her peri-pad to be changed and she refused her bath. On 3/28/23 at 8:36 AM, an interview with CNA #7, she confirmed that on 3/2/23 in the afternoon about 3:00 PM, Resident #1 complained that her legs were hurting, and was hollering out loud when she was transferred with the sit-to-stand lift from her wheelchair to the bed, which was not normal for her. CNA #7 revealed she reported the resident's complaints of pain to LPN #1. On 3/29/23 at 9:00 AM, during an interview with LPN #1, she stated that on 3/2/23 at 3:00 PM, a CNA reported that Resident #1 had pain while being transferred to the bed. She said that she assessed the resident, and when she removed the resident's sock, she let out with a loud burst, not a scream, like my fingernails may have tickled her or something. LPN #1 explained that she is an agency nurse, and this was her first day to work with Resident #1. She said that the CNA told her that something was wrong with Resident #1, but after her assessment, the resident did not complain of pain and did not have facial expressions of pain. She stated that she was in the process of administering routine medications and she thought the resident had Gabapentin (medication used for neuropathy) pain medication ordered with her routine medications. LPN #1 commented that she probably gave her Tylenol also, just forgot to chart it. On 3/28/23 at 3:30 PM, in an interview with the Interim Administrator, she stated that she expected the staff to give pain medications as prescribed by the physician and to follow up with the physician if the pain was not relieved. A record review of the Admission Record revealed the facility admitted Resident #1 on 05/24/2018 with a diagnosis of Unspecified Dementia. A record review of the Order Summary Report with orders as of 3/1/23, for Resident #1, revealed a Physician's Order, dated 3/19/20, for Acetaminophen Table 325 MG (Milligrams) Give 2 tablet by mouth every 4 hours as needed for fever, headache, mild pain. Resident #1 also had a Physician's Order, dated 3/19/20 for, Gabapentin Capsule 100 MG Give 1 capsule by mouth at bedtime for pain and a Physician's Order, dated 1/19/21, for Ultram Tablet 50 MG .Give 50 mg by mouth every 8 hours as needed for moderate pain. A record review of the Medication Administration Record, for 3/1/23 through 3/31/23, revealed Ultram Table 50 MG was administered to Resident #1 on 3/2/23 at 6:39 AM with a Pain Level of 3, and on 3/3/23 at 6:45 AM with a Pain Level of 10. There was no documentation that Tylenol was administered on 3/1/23 or 3/2/23 for pain. A record review of the facility's Progress Notes for Resident #1 revealed an Administration Note, at 6:39 AM on 3/2/23 for Ultram Table 50 MG). There was no documentation which evaluated the description or location of the pain. Further review revealed an Administration Note, at 4:09 PM on 3/2/23 for PRN (As needed) Administration was: Effective which indicated the pain medication that was administered at 6:39 AM was not evaluated for effectiveness until 4:09 PM. Review of the progress notes revealed there was no other documentation regarding the resident's pain until 3/3/23. Record review of the facility's investigation, Interviews Conducted on 3/7/23 . revealed CNA #1, .Wed 3/1- Heard resident hollering all night (3/1 into 3/2). Resident requested pain meds. Thurs 3/2 - Resident was still complaining with pain Thursday morning - leg looked a little swollen. CNA #2, .Wed 3/1 - Remembers resident yelling out in pain during the early morning hours. Resident frequently complains of pain but this was different. Told (Proper Name of LPN #2); nurse stated resident had already received pain meds. Thurs 3/2 - Resident was in w/c complaining that her hip was hurting. CNA #8, .Thurs 3/2 - Resident complained of legs hurting - had already received pain meds; started screaming 3:30 - 4 AM; put her in w/c and rolled to nurses station . CNA #6, .Resident began to complain that her legs were hurting. While changing brief, took off pants and saw that legs were blue and swollen . CNA #5, . Thurs 3/2 - went to resident's room .(Proper Name of Resident #1) stated her leg hurt and that she wanted to go to bed .noticed resident's legs looked bruised .notified (Proper Name of LPN #1). This was (Proper Name of LPN #1) first day to work in the facility and she was not familiar with this resident (or any residents) ., CNA #7, .resident stated leg was hurting. (Proper name of CNA #7) told resident nurse would give her pain meds .she noticed bruising on legs .went to get a nurse to check resident's legs ., LPN #1, .Thurs 3/2; approx. 3 PM - (Proper Name of CNA #3) reported resident's legs were hurting and something didn't look right .resident did not verbalize any pain nor show facial expressions. Lower extremities only revealed visible veins. No redness, bleeding or bruising noted. Nothing else was reported to me about the patient ., CNA #4, .says resident requested to go to bed shortly after lunch and that this was not an extra ordinary request .says resident did not complain about legs, says she did use the lift, and another C.N.A. assisted her but she cannot recall who that would have been. Surveillance video shows that (Proper Name of CNA #4) pushed resident into room [ROOM NUMBER] at 12:39 PM and then came out alone, returning moments later with an underpad. At 12:45 (Proper Name of CNA #4) came out alone, with dirty linen bag . Record review of the handwritten statement from CNA #2, dated 3/6/23, revealed, .hear someone yelling it was coming from the 200 hall. We all got up to see who it was. It was (Proper Name of Resident #1) yelling that her hip and her legs were hurting. We all told the nurse (Proper Name of LPN #2) and the nurse stated that she already give (Proper Name of Resident #1) something for pain . Record review of the handwritten statement from CNA #5, dated 3/3/23, revealed .I came in about 2:55/3:00 PM on 3-2-23 .stated her leg hurt .So they put her back on bed took her pants down and noticed her legs was bruised looking. I went and got nurse .I checked her after diner around 6:45/6:50 (PM) she didn't show any signs of pain but my last rounds around 10:15/10:20 (PM) she (Resident #1) was almost in tears screaming I knew then something wasn't right . she always complain of her right leg and hip but this was different. Legs both right and left was a blueish looking color almost like her vein or something was popped out. Wasn't freshly looking color like its been there some days or something to me. Record review of the handwritten statement from CNA #6, dated 3/3/23, revealed, I came in at 3-2-23 7:22 in the morning .So she started to complain that her legs were hurted, so we changed her brief and I took off her pant after we layed her down that when I say her legs were looking blue and swollen . Record review of the handwritten statement from CNA #7, dated 3/3/23, revealed, .Resident #1 said her leg was hurting CNA #6 saw noticed her legs were bruised we put her in the bed, CNA #5 went and got the nurse checked her legs over . Record review of the handwritten statement from CNA #8, dated 3/3/23, revealed, I came in at 11 p.m (Proper Name of Resident #1) was complaining about leg pain and that the pain was down her right side .I told the nurse that she asked for medication and the nurse stated I already gave her meds and it will be six hours before she will get anymore. Throughout the night she complained and relayed the message to the nurse. She stated, I already gave her meds. This was 3/1/23 .3/2/23 approx (approximately) 0445 (4:45 AM) I decided to get her up early on my rounds, because she was still complaining I used the sit to stand. I brought her to nurse station. After she was squirming around and agitated (Proper Name of CNA #1) and I took her to her room to check her brief while sitting in the chair . The facility submitted the following acceptable Removal Plan on 3/30/23: On 3/28/23 at 4:25 PM the State Survey Agency notified the Interim Administrator that the facility failed to ensure 1. ) Resident #1 was transferred with the sit-to-stand mechanical lift as determined necessary by the comprehensive care plan 2.) Evaluate and provide pain management for Resident #1. 3.) To implement care plan interventions for Resident #1 when the facility did not transfer her using the sit-to-stand mechanical lift and did not provide pain management for her when she experienced pain. On 3/28/23 at 4:25 PM the Immediate Jeopardy Templates for F656, F689 and F697 were provided to the Interim Administrator. At approximately 11:10 AM on Friday, March 3, 2023 the Nurse Practitioner reported that Resident #1 was experiencing bilateral leg pain. X-ray reports revealed bilateral fractures of the Tibia/Fibula. Resident #1 was sent to a local hospital emergency room for orthopedic evaluation. These findings were reported 3/3/23 to the State Survey Agency at 1:03 PM and the State Attorney General at 1:21 PM. On March 3, 2023, at approximately 11:30 the facility initiated an investigation including staff interviews, obtaining statements and reviewing video. Because the facility could not determine the date, time or cause of the injury the facility requested that the Attorney General's office assign an investigator to assist in this investigation. The investigator arrived on site on 3/13/23 to initiate their investigation. As of 3/29/23 a specific incident that caused the injury to Resident #1 has not been identified. Training for ALL nursing staff, prior to working their next scheduled shift: Beginning on 3/3/23, no nursing staff was allowed to work until completion of training, provided by the Director of Nursing (DON), on the following topics, Falls and Accidents Care Plans Mandatory Lift training video located in the [NAME] Care Centers Education Library Additional training started on 3/28/23, for ALL staff and no staff was allowed to work until trained on the following topics, Pain Assessment and Management Accidents Care Plan Implementation All training was provided by DON and Staff Development Nurse. Lift assessments have been completed/updated on all residents due to the fact that all residents who require the use of mechanical lifts have the potential to be affected by use of incorrect lifts. Lift Assessments were completed by Registered Nurse (RN) #1 starting on 3/3/23 and completed on 3/4/23. Care plans have been reviewed for all residents who require the use of mechanical lifts. Review was completed by Minimum Data Set (MDS) Nurse #1, started on 3/4/23 and completed on 3/6/23. Review indicated all residents were care planned for the correct lift. Monitoring for use of appropriate lift, sling/belt is being carried out by the DON. The Lift/Transfer Monitoring Tool is being used to document monitoring and was initiated on 3/28/23. All residents have been assessed for pain using the Pain Evaluation which includes the pain scale. Assessments were completed on 3/29/23 by the DON and RN #2. The Pain Alert Monitoring log is being used to monitor and audit for pain management and was initiated on 3/28/23. The DON and RCC/IP are responsible for conducting pain management audits. Care Plans for all residents have been reviewed regarding pain management. The review was completed by MDS Nurse #1 and MDS Nurse #2 on 3/29/23. No resident's care plans required updating. Audit has been performed for all Resident Kardex. The audit was completed by the assisting Interim Administrator, on 3/3/23. No discrepancies were noted. Facility lifts have been inspected for proper use and function. Environmentalist/Maintenance Director completed the inspections on 3/10/23. Five (5) sit to stand lifts were inspected. One was removed from service to replace a part related to the switch. Four (4) total/full body lifts were inspected with no maintenance required. Emergency Quality Assurance meetings were conducted on 3/7/23 and 3/29/23. Attending the meetings were Interim Administrator, assisting Interim Administrator, Corporate Nurse, Medical Director, Director of Nursing, Resident Care Coordinator/Infection Preventionist, MDS Nurses, and Social Services. Discussed in the meeting were: Review of Resident #1 injury identified on 3/3/23 Results/status of investigation Actions taken including training, monitoring and audits of care plans and assessments of pain and transfer status/lift utilization Review of policies related to care plans, accidents and injuries, lift utilization and transfer. No changes to policies were recommended or made. The facility alleges that the Immediate Jeopardy has been removed as of March 30, 2023. The SA validated the facility's removal plan on 3/31/23: On 3/31/23, the SA validated through record review of the meeting sign in sheet and through staff interviews that the facility held a Quality Assurance Performance Improvement (QAPI) Committee meeting on 3/7/23 and 3/29/23. On 3/31/23, the SA validated through record review of the meeting sign-in sheet and through staff interviews that the facility held a QAPI meeting on 3/7/23 and 3/29/23 regarding care plans, assessments of pain, and transfer status/lift utilization. Review policies related to care plans, accidents, injuries, lift utilization, and transfer. On 3/31/23, the SA validated through staff interview and record review that the facility provided education beginning on 3/3/23 for falls, accidents, care plans, and mandatory lift training. The staff attended additional training beginning on 3/28/23 pain assessment and management, accidents and care plan implementation. On 3/31/23, the SA validated through staff interviews and record reviews that the facility performed lift assessments and updated all residents who require the use of mechanical lifts. On 3/31/23, the SA validated through staff interviews and record reviews that the facility reviewed care plans for all residents who require the use of mechanical lifts. On 3/31/23, the SA validated through staff interviews and record reviews that the facility monitored the use of the appropriate lift, sling/belt for all residents. On 3/31/23, the SA validated through staff interviews and record reviews that the facility assess all residents for pain using the Pain Evaluation, which includes the pain scale. On 3/31/23, the SA validated through staff interviews and record reviews that the facility all resident care plans have been reviewed regarding pain management. On 3/31/23, the SA validated through staff interviews and record reviews that the facility audited all resident Kardex. On 3/31/23, the SA validated through staff interviews and record reviews that the facility lifts have been inspected for proper use and function.

Based on interviews, record review, and facility policy review, the facility failed to ensure a resident was free from accident hazards when a resident who was determined to require a sit to stand mechanical lift for transfers was transferred without a lift, for one (1) of three (3) sampled residents. Resident #1 The facility's failure to ensure that the resident was transferred with a sit-to-stand mechanical lift resulted in Resident #1 sustaining right and left (bilateral) tibia/fibula (two bones in the lower leg) fractures and placed other residents who required a mechanical lift transfer at risk for sustaining serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 2/27/23 when facility staff transferred Resident #1 using a pivot transfer and did not use the sit-to-stand mechanical lift as required. The facility Administrator was notified of the IJ on 3/28/23 at 4:25 PM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 3/30/23, in which they alleged all corrective actions to remove the IJ were completed on 3/29/23, and the IJ removed on 3/30/23. The State Agency (SA) validated the Removal Plan on 3/31/23 and determined that the IJ was removed on 3/30/23, prior to exit. Therefore, the scope and severity for CFR 483.25(d)(2) Accidents F689 was lowered from a J to an D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy, Safe Transfer and Lifting of Residents, Revised 8/2/22, revealed, Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation I. General Guidelines .3. Staff is responsible for knowing/following the transfer assessment before transferring any resident. Any deviation from the transfer assessment must be approved by the nurse and documented by the approving nurse .II Assessment Guidelines: . 9. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe transfer and lifting of residents. 10. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance . A record review of the Admission Record revealed the facility admitted Resident #1 on 05/24/2018 with a diagnosis of Unspecified Dementia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/2/2023 revealed Resident #1 required extensive two (2) person assistance with transfers. Record review of the facility's Change of Transfer Status form, dated 2/26/20, revealed Resident #1 had a Current Transfer Status of sit to stand lift. Assist of 2. Med (Medium) belt. The form was signed by the Physical Therapist (PT) and a nurse. Record review and interview on 3/27/23 at 1:01 PM, with Registered Nurse (RN) #2 of the facility's Lift/Transfer Evaluation, dated 2/2/23, revealed that Resident #1 could not bear weight, was not cooperative with transfers, and did not have upper extremity strength. The evaluation was signed by Registered Nurse (RN) #2. She confirmed that she completed the Lift/Transfer Evaluation on 2/2/23 for Resident #1. She stated the evaluation is a tool used to determine appropriate transfers for residents. She commented that she completed the evaluation incorrectly because Resident #1 was able to bear weight, cooperative with transfers, and had upper body strength. A record review of the Facility Investigation (undated) revealed, .At approximately 11:10 AM on Friday, March 3, 2023 (Proper Name of Nurse Practitioner) came into the conference room to report . (Proper Name of Resident #1) .Legs were warm and tender to touch with bruising .ordered x-rays and an ultrasound. X-rays were obtained and revealed fractures of the right and left tibia/fibula . A record review of the facility's investigation timeline revealed, that on 2/27/23 at 5:13 AM, CNA #1 Brought resident out of room in wheelchair .admitted she did not use a lift when getting resident up ., on 2/28/23 at 5:53 PM, CNA #3, Entered room .with resident in w/c (wheelchair), no lift, and then left at 18:10 (6:10 PM) with dirty linens ., and on 3/1/23 at 12:30 PM, CNA #4, .pushed resident into room .(without a lift) and then came out alone . Record review of the Nurse Practitioner (NP) Progress Note, dated 3/3/23 revealed, .Pt (patient) seen today per facility request for c/o (complain) pain in bilateral legs .Pt noted to be in pain at time of evaluation .Pt noted to have swelling, erythema (redness), and bruising to bilateral tibia .X-rays were obtained and revealed fractures of left and right tibia and fibula . Record review of the Radiology Interpretation dated 3/3/23 revealed, .Left Tibia/Fibula X-ray .Findings: There is a fracture of the proximal tibia and fibula. There is moderate impaction and angulation. Impression: Fractures of the tibia and fibula with angulation, of uncertain age .Right Tibia/Fibula X-ray .Impression: Fractures of the tibia and fibula of uncertain age . On 3/13/23 at 11:00 AM, in an interview with the Interim Administrator, she stated that on 3/3/23, the NP informed the staff at the facility that Resident #1 had a bilateral fracture of the tibia and fibula. The facility transferred Resident #1 to the local Emergency Department (ED) and immediately began their investigation. During their investigation that began on 3/3/23, the facility interviewed staff and watched surveillance videos, and reviewed all staff that were assigned to Resident #1. The Interim Administrator confirmed the facility is unclear on how the resident received the fractures but discovered that several employees did not use the sit-stand-lift while transferring the resident. On 3/13/23 at 11:20 AM, an interview with the Director of Nurses (DON) revealed that on 3/3/23, Resident #1 sustained bilateral fractures of the tibia and fibula. During the investigation, the facility discovered that several Certified Nurse Assistants (CNAs) transferred the resident without using the sit-to-stand mechanical lift and conducted pivot transfers instead. The DON expressed it was strange that Resident #1 had fractures on both legs in the same area, and she thought it could have been caused by the sit-to-stand lift, but she was not sure. On 3/13/23 at 12:00 PM, during an interview with the Nurse Practitioner (NP), she said that a nurse notified her on 3/3/23 that Resident #1 had bruising and pain in both legs. She assessed Resident #1 and confirmed that both her lower extremities had swelling, erythema, and bruising and the injuries were in the same area on both legs. She stated that she ordered bilateral x-rays, which showed Resident #1 had left and right tibia/fibula fractures. She then requested that the resident be sent to the local ER. The NP confirmed there were no injuries or falls reported to her regarding Resident #1 and she was unclear how the accident occurred. On 3/14/23 at 9:44 AM, in an interview with Certified Nurse Assistant (CNA) #1, she stated that on 2/27/23 around 5:00 AM, she did not use the sit-to-stand lift when transferring the Resident #1, but instead got another CNA to help pivot transfer her from the bed to her wheelchair. CNA #1 said that she normally used the lift, but she did it the easy way. On 3/14/23 at 10:00 AM, in an interview with CNA #2, she confirmed that she assisted CNA #1 with a pivot transfer on Resident #1 on 2/27/23 and they did not use the sit-to-stand lift. On 3/28/23 at 11:05 AM, an interview with CNA #4 revealed that on 3/1/23, after lunch, she transferred Resident #1 back to her bed. She stated she did a pivot transfer by herself and did not use the sit-to-stand lift. She explained that Resident #1 was weight-bearing and was able to help with the transfer. CNA #4 expressed she was aware Resident #1 required a sit-to-stand lift with transfers, but Resident #1 was an easy pivot transfer and the resident assist with the transfer. CNA #4 stated she conducted a pivot transfer by herself. On 3/28/23 at 1:22 PM, in an interview with CNA #3, she stated that she broke protocol and did not use the sit to stand lift during the transfer of Resident #1 on 2/28/23. She said that she used a pivot transfer to transfer Resident #1 from her wheelchair to her bed and did not have assistance with the transfer. CNA #3 revealed she was aware that Resident #1 required a lift for transfers, but she performed the transfer alone because Resident #1 was not a big person and was easy to transfer. On 3/27/23 at 4:21 PM, an interview with CNA #5 revealed that on 3/2/23 at 3:00 PM, she assisted with transferring Resident #1 from her wheelchair to her bed using the sit-to-stand mechanical lift. She explained that during the transfer, Resident #1 began hollering in pain. Another CNA assisted with the transfer and they both noticed that Resident #1's legs were bruised. They notified Licensed Practical Nurse (LPN) #1 and she came and looked at her legs. CNA #5 said that Resident #1 was in tears around 10:15 PM that night and complained of pain in her legs. CNA #5 stated, This was different for her and they reported it to the nurse. On 3/28/23 at 8:29 AM, in an interview with CNA #6, she stated that Resident #1 was up, dressed, and in her wheelchair on 3/2/23 during the day shift. She said Resident #1 often requested pain medication for pain to her legs and hip, and often requested to have her peri-pad changed throughout the day. However, on 3/2/23, Resident #1 complained of pain but did not request her peri-pad to be changed, which was unusual for her. On 3/2/23 at 3:00 PM, CNA #6 confirmed that she assisted other CNAs with transferring Resident #1 back to bed with the lift and Resident #1 complained of pain during the transfer. CNA #6 said that they noticed the resident's legs were blue and swollen and went to get the nurse. On 3/28/23 at 8:36 AM, an interview with CNA #7, she confirmed that on 3/2/23 in the afternoon about 3:00 PM before getting off that day, Resident #1 complained that her legs were hurting, and was hollering out loud when she was transferred with the sit-to-stand lift from her wheelchair to the bed, which was not normal for her. CNA #7 confirmed that the resident's legs had bruising and that it was reported to LPN #1. On 3/28/23 at 3:30 PM, an interview Interim Administrator revealed she expected the staff to follow the recommended transfer evaluation and if the evaluation indicated resident should be transferred with a sit-to-stand lift, then the staff should perform the transfer using the lift. The facility submitted the following acceptable Removal Plan on 3/30/23: On 3/28/23 at 4:25 PM the State Survey Agency notified the Interim Administrator that the facility failed to ensure 1.) Resident #1 was transferred with the sit-to-stand mechanical lift as determined necessary by the comprehensive care plan 2.) Evaluate and provide pain management for Resident #1. 3.) To implement care plan interventions for Resident #1 when the facility did not transfer her using the sit-to-stand mechanical lift and did not provide pain management for her when she experienced pain. On 3/28/23 at 4:25 PM the Immediate Jeopardy Templates for F656, F689 and F697 were provided to the Interim Administrator. At approximately 11:10 AM on Friday, March 3, 2023, the Nurse Practitioner reported that Resident #1 was experiencing bilateral leg pain. X-ray reports revealed bilateral fractures of the Tibia/Fibula. Resident #1 was sent to a local hospital emergency room for orthopedic evaluation. These findings were reported 3/3/23 to the State Survey Agency at 1:03 PM and the State Attorney General at 1:21 PM. On March 3, 2023, at approximately 11:30 the facility initiated an investigation including staff interviews, obtaining statements and reviewing video. Because the facility could not determine the date, time or cause of the injury the facility requested that the Attorney General's office assign an investigator to assist in this investigation. The investigator arrived on site on 3/13/23 to initiate their investigation. As of 3/29/23 a specific incident that caused the injury to Resident #1 has not been identified. Training for ALL nursing staff, prior to working their next scheduled shift: Beginning on 3/3/23, no nursing staff was allowed to work until completion of training, provided by the Director of Nursing (DON), on the following topics, Falls and Accidents Care Plans Mandatory Lift training video located in the [NAME] Care Centers Education Library Additional training started on 3/28/23, for ALL staff and no staff was allowed to work until trained on the following topics, Pain Assessment and Management Accidents Care Plan Implementation All training was provided by DON and Staff Development Nurse. Lift assessments have been completed/updated on all residents due to the fact that all residents who require the use of mechanical lifts have the potential to be affected by use of incorrect lifts. Lift Assessments were completed by Registered Nurse (RN) #1 starting on 3/3/23 and completed on 3/4/23. Care plans have been reviewed for all residents who require the use of mechanical lifts. Review was completed by Minimum Data Set (MDS) Nurse #1, started on 3/4/23 and completed on 3/6/23. Review indicated all residents were care planned for the correct lift. Monitoring for use of appropriate lift, sling/belt is being carried out by the DON. The Lift/Transfer Monitoring Tool is being used to document monitoring and was initiated on 3/28/23. All residents have been assessed for pain using the Pain Evaluation which includes the pain scale. Assessments were completed on 3/29/23 by the DON and RN #2. The Pain Alert Monitoring log is being used to monitor and audit for pain management and was initiated on 3/28/23. The DON and RCC/IP are responsible for conducting pain management audits. Care Plans for all residents have been reviewed regarding pain management. The review was completed by MDS Nurse #1 and MDS Nurse #2 on 3/29/23. No resident's care plans required updating. Audit has been performed for all Resident Kardex. The audit was completed by the assisting Interim Administrator, on 3/3/23. No discrepancies were noted. Facility lifts have been inspected for proper use and function. Environmentalist/Maintenance Director completed the inspections on 3/10/23. Five (5) sit to stand lifts were inspected. One was removed from service to replace a part related to the switch. Four (4) total/full body lifts were inspected with no maintenance required. Emergency Quality Assurance meetings were conducted on 3/7/23 and 3/29/23. Attending the meetings were Interim Administrator, assisting Interim Administrator, Corporate Nurse, Medical Director, Director of Nursing, Resident Care Coordinator/Infection Preventionist, MDS Nurses, and Social Services. Discussed in the meeting were: Review of Resident #1 injury identified on 3/3/23 Results/status of investigation Actions taken including training, monitoring and audits of care plans and assessments of pain and transfer status/lift utilization Review of policies related to care plans, accidents and injuries, lift utilization and transfer. No changes to policies were recommended or made. The facility alleges that the Immediate Jeopardy has been removed as of March 30, 2023. The SA validated the facility's removal plan on 3/31/23: On 3/31/23, the SA validated through record review of the meeting sign in sheet and through staff interviews that the facility held a Quality Assurance Performance Improvement (QAPI) Committee meeting on 3/7/23 and 3/29/23. On 3/31/23, the SA validated through record review of the meeting sign-in sheet and through staff interviews that the facility held a QAPI meeting on 3/7/23 and 3/29/23 regarding care plans, assessments of pain, and transfer status/lift utilization. Review policies related to care plans, accidents, injuries, lift utilization, and transfer. On 3/31/23, the SA validated through staff interview and record review that the facility provided education beginning on 3/3/23 for falls, accidents, care plans, and mandatory lift training. The staff attended additional training beginning on 3/28/23 pain assessment and management, accidents and care plan implementation. On 3/31/23, the SA validated through staff interviews and record reviews that the facility performed lift assessments and updated all residents who require the use of mechanical lifts. On 3/31/23, the SA validated through staff interviews and record reviews that the facility reviewed care plans for all residents who require the use of mechanical lifts. On 3/31/23, the SA validated through staff interviews and record reviews that the facility monitored the use of the appropriate lift, sling/belt for all residents. On 3/31/23, the SA validated through staff interviews and record reviews that the facility assesses all residents for pain using the Pain Evaluation, which includes the pain scale. On 3/31/23, the SA validated through staff interviews and record reviews that the facility all resident care plans have been reviewed regarding pain management. On 3/31/23, the SA validated through staff interviews and record reviews that the facility audited all resident Kardex. On 3/31/23, the SA validated through staff interviews and record reviews that the facility lifts have been inspected for proper use and function.

Based on observation, interviews, record review, and facility policy review, the facility failed to follow COVID-19 infection control guidelines to prevent the spread of the COVID-19 virus which likely led to the death of one (1) resident (Resident #49) who had not been outside the facility and failed to prevent the possible spread of the COVID-19 virus between positive and negative COVID-19 residents for Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 and #13, as evidenced by the facility's failure to change Person Protective Equipment (PPE) between positive and negative COVID-19 residents rooms. The facility also failed to provide a biohazard barrel to dispose of doffed PPE at the exit door. The facility census at the time of survey was 90 residents. On [DATE], the State Agency (SA) surveyor observed facility staff failing to change PPE when between entering positive and negative resident rooms wearing the same PPE. Record review revealed the facility had one resident death due to (1) COVID-19. The facility's failure to follow appropriate COVID-19 infection control guidelines for not changing PPE between positive and negative residents and not providing a biohazard barrel for doffed PPE has caused, or likely to cause serious injury, harm, impairment or death to residents who tested positive for the COVID-19 virus while residing solely in the facility. The Immediate Jeopardy (IJ) was determined to exist at a scope and severity of a K on [DATE], at the time of Resident #49's death and affected 32 COVID-19 positive residents. The SA notified the facility of the IJ on [DATE] related to the death of the COVID-19 positive resident and provided the facility the IJ template for Infection Control F880 at 42 CFR(s): 483.80(a)(1)(2)(4)(e)(f). The facility provided a Removal Plan stating the facility completed all actions for removal as of [DATE] and the IJ was removed on [DATE]. The SA validated on [DATE] prior to exit that the facility actions were completed and the IJ was removed as of [DATE] and the scope was lowered to an E for F880. Findings include: Review of the facility's policy titled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, revised [DATE], revealed, Policy Statement: This facility follows recommended standard and transmission-based precautions, environmental cleaning and social distancing practices to prevent the transmission of COVID-19 .7. Standard precautions are utilized when caring for all residents .12. For a resident with known or suspected COVID-19: a. Staff wear gloves, isolation gown, eye protection and an N 95 or higher-level respirator if available .and b. Resident is placed in a private room with a dedicated bathroom (if available) and close the door . Contact and droplet precautions are implemented for any residents with symptoms of respiratory infection. Current CDC guidelines will be followed for infection prevention and control of residents diagnosed with [REDACTED]. Review of the facility's policy titled, Infection Prevention and Control Program, revised ,[DATE], revealed, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the facility 700 Hall resident list revealed the residents were last tested on [DATE]. The resident's results were negative. Review electronically of the National Healthcare Safety Network (NHSN) facility report revealed 32 positive residents were housed on 500, 600 and 800 halls. Review of the facility's employee spread sheet revealed 25 positive staff members. Five (5) staff recovered and returned to work. During an interview on [DATE], at 10:00 AM, with the Administrator (ADM) confirmed the facility had 32 COVID-19 positive resident cases in the building. The facility also has 25 positive staff cases. The ADM confirmed Dogwood is the designated unit which houses the positive residents. An observation of COVID-19 Unit on [DATE], at 10:45 AM, revealed the unit is closed and is referred to as Dogwood Unit. The unit consisted of four halls; 500, 600 and 800 halls for positive residents and the 700 hall for negative residents. The staff on the Dogwood Unit were dressed in full PPE and were screened upon entrance. The staff donned PPE at the door while entering the unit. Dogwood Unit did not have a red barrel close to the door to doff PPE. Observation revealed staff wearing the same PPE when caring for both positive and negative residents. Record review the electronic NHSN facility report and Admission Record revealed Resident #22 residing in room [ROOM NUMBER]-A tested positive for COVID-19 on [DATE]. An observation on [DATE] at 10:30 AM, revealed the Physical Therapist Assistant (PTA) removing PPE in the soiled utility room. The PTA did not put on clean PPE. The PTA then went to an open area of the COVID-19 positive unit documenting on his personal laptop computer without wearing any PPE. There were residents roaming up and down the COVID-19 halls. Resident #22 who tested positive was confused and sitting in the open area rolling around in her wheelchair. During an interview on [DATE], at 1:35 PM, with the PTA confirmed he removed his PPE in the soiled utility room. The PTA confirmed he failed to put on new PPE while he was charting on the computer. The PTA said he did not know he needed to continue to wear his PPE in the open area and confirmed he walk down a hall with positive residents before leaving the building without PPE. The PTA stated he was not in-serviced on when to wear PPE. Observation on [DATE], at 10:45 AM, revealed Resident #22 continued to be confused and rolled in and out of resident's rooms on the 700 hall which housed negative residents. Registered Nurse (RN) #3 observed the resident and removed the resident from room [ROOM NUMBER] then assisted Resident #22 to the center of the hall to watch television. An observation on [DATE], at 11:00 AM, revealed RN #2 answered call light in room [ROOM NUMBER] (negative room) after passing medications on the 600 halls with positive residents. RN #2 did not change her PPE between rooms. An observation on [DATE], at 11:00 AM, revealed Resident #22 continued to roam around the 700 Hall containing negative residents. Resident entered rooms #701, #703, #706 and #710. The resident was re-directed by Certified Nurse Assistant (CNA) #1. Resident #22 was again rolled to the open area of the unit to watch the television. An observation on [DATE] at 12:00 PM revealed CNA #3 and CNA #4 passed out and picked up trays to the residents on the 700 hall which housed negative residents and 800 hall which house positive residents without changing their PPE. Observation also revealed CNA #1 passing out trays on the 600 Hall, 700 Hall, and 800 Hall. The SA observed CNA #1 passing out and picking up trays on the negative hall after passing out trays on the positive halls. CNA #1 did not change his PPE. During an interview on [DATE], at 1:30 PM, CNA #1 revealed he's responsible for providing care to all the men on Dogwood Unit. CNA #1 said he works on all the halls of the unit. CNA #1 said he did not know the residents were negative on the 700 halls. CNA #1 confirmed he wore the same PPE to provide care for the positive and negative residents. CNA #1 confirmed he removed his PPE at the end of his shift in the soil utility room. CNA #1 confirmed he walked down the positive hall without PPE to go out the back door. An observation on [DATE], at 12:15 PM, revealed CNA #3 feeding resident in room [ROOM NUMBER]-A. CNA #3 did not change her PPE prior to entering the residents' room. CNA #3 had just finish providing care for residents on the positive halls. During an interview on [DATE] at 2:15 PM with CNA #3 confirmed she did not know the residents on the 700 Hall is negative. She was told all the residents on the Dogwood unit were positive. CNA #3 also confirmed she wore her same PPE for the whole day except if she got it soiled or when she left the building. CNA #3 confirmed she assisted a resident in room [ROOM NUMBER]A with her lunch and did not change her PPE. CNA #3 acknowledged that due to her not changing her PPE, a resident could become COVID-19 positive. On [DATE], at 1:00 PM, upon the State Agency (SA) asking RN #1 where the staff normally removed and placed soiled PPE, RN #1 tied a red biohazard bag on the handrail in the hall. The facility did not have a red barrel for dirty PPE. On [DATE], at 12:00 PM, observation revealed CNA #6 passing out trays to positive and negative residents without changing her PPE. CNA #6 also picked up trays from positive and negative rooms without changing PPE. During an interview on [DATE], at 2:30 PM, with CNA #6, the CNA confirmed she did not know the residents on the 700 halls were negative residents. CNA #6 said she was told all the residents on Dogwood Unit were positive. CNA #6 also confirmed she wore the same PPE the whole day except when it got soiled or when she left the building. CNA #6 confirmed she doffed her PPE in the soiled utility room and walked down the positive hall with positive residents to go out the back door of the facility. CNA #6 said she don't' know what happened to the red barrel. Observation on [DATE], at 12:00 PM, revealed CNA #5 passing out trays to the positive and negative residents without changing her PPE. CNA #5 also picked up trays from positive and negative rooms without changing PPE. During an interview on [DATE], at 2:45 PM, with CNA #5 confirmed she did not know the resident on the 700 halls were negative residents. CNA #5 said she was confused. She thought all the residents on Dogwood Unit were positive. CNA #5 confirmed she wore the same PPE to take care of positive and negative residents. CNA #5 said she took off PPE and placed it in a garbage can that was available. She doesn't know what happen to the red barrels. Observation on [DATE], at 12:20 PM, of RN #3's medication cart garbage can revealed several soiled gowns and shoe covers. During an interview on [DATE], at 12:30 PM, with RN #3 confirmed she takes her PPE off and puts it in her garbage can on her cart. She doesn't know what happened to the red barrels that the facility had at one time. During an interview on [DATE], at 2:00 PM with RN #2, the Infection Preventionist, revealed the nurse had done the Infection Preventionist training. RN #2 confirmed 32 positive residents and 25 positive staff for the facility. RN #2 said because a lot of staff has tested positive for COVID-19, she has had to work the floor passing medication. RN #2 confirmed the staff was not in-serviced on the negative and positive residents. RN #2 said she thought the staff knew which residents were positive and negative. RN #2 also confirmed she failed to change her PPE after giving medication to residents on the 600 halls (positive residents) and before answering a call light for room # 706 (a negative resident). RN #2 said she did not know what she was thinking. RN #2 said at one time the 700 hall doors were closed to separate the negative residents from the positive residents. RN #2 said she did not know why the doors were opened. RN #2 also confirmed the facility failed to have red barrels at the back door to doff their PPE. RN #2 said she don't know what happened to the barrels. RN #2 confirmed it is not the facility's policy to tie the red biohazard bags on the handrails in the hallway. RN #2 said she did not know where the barrels were, so she tied the biohazard bag on the handrail. During an interview, on [DATE], at 3:00 PM, the Medical Director (MD) confirmed the facility had an outbreak of COVID-19 positive residents in [DATE]. The MD said he did not know how the outbreak started. The MD said he believed it started with an employee. The MD said he did not know the facility staff were not observing standard precautions and were wearing the same PPE to take care of positive and negative residents. The MD confirmed that practice could cause the negative residents to test positive. The MD said he believed that because so many staff members had tested positive, this required the staff to work extra days which caused them to make poor decisions. During an interview on [DATE], at 3:10 PM, the Director of Nurses (DON) confirmed as of [DATE], the facility had 32 positive COVID-19 residents in the building. The DON said the facility also had 25 COVID-19 positive staff. On [DATE] when the facility tested the staff, three staff members tested positive. The residents were tested on [DATE], one resident tested positive. The DON said all the staff has been in-serviced on donning and doffing PPE. The DON confirmed the staff failed to follow the facility policy by not doffing PPE in a red biohazard barrel. The DON also said the double doors to the 700 Hall that housed negative residents should have been closed. The DON confirmed the staff failed to follow the facility policy by wearing the same PPE in positive and negative residents' rooms. The DON said the negative residents could become positive because the staff failed to change their PPE from positive to negative residents. During an interview on [DATE], at 4:00 PM, the Administrator (ADM) confirmed as of [DATE], the facility has 32 positive COVID-19 residents and 25 positive staff. The ADM said the residents and staff are tested every 3 to 7 days. The ADM said she documents the positive residents and staff members on her calendar. The ADM confirmed the facility did not have red barrels in the building. The ADM revealed the maintenance personnel was out with COVID-19. The ADM said she did not know the red biohazard barrels were not in the building because she had not been on the COVID-19 unit. The ADM also said she did not know that staff were wearing the same PPE for negative and positive residents. The ADM confirmed one (1) resident died at the hospital related to COVID-19. The Administrator also confirmed on [DATE] two (2) of 13 residents converted from negative to positive status Resident #12 and Resident #13. Record review of the facility's Admission Record for Resident #49, revealed he was admitted to the facility on [DATE], with the included [DIAGNOSES REDACTED]. Resident #49 resided on the 800 halls. Resident #49 tested positive for COVID-19 on [DATE]. Resident #49 transferred to the hospital on [DATE], where he expired on [DATE]. Record review of the facility's Admission Record for Resident # 12, revealed Resident #12 was admitted [DATE] with the included [DIAGNOSES REDACTED]. Resident #12 resides on the 700 halls. Resident #12 converted to positive status on [DATE]. Resident was removed to the positive hall. Record review of the facility's Admission Record for Resident # 13, revealed Resident #13 was admitted [DATE] with the included [DIAGNOSES REDACTED]. Resident #13 resides on the 700 halls. Resident #13 converted to positive status on [DATE]. Resident was removed to the positive hall. The facility submitted an acceptable Immediate Jeopardy (IJ) Removal Plan on [DATE]. Review of the Removal Plan revealed the facility took the following actions to remove the immediate Jeopardy: 1. The facility was informed by the State Agency of the Immediate Jeopardy (IJ) at 3:15 PM on [DATE], related to the facility's failure to follow infection control practices per the Centers for Disease Control and Prevention (CDC) guidelines. The facility failed to provide a biohazard barrel to dispose of doffed Personal Protective Equipment (PPE), and failed to change PPE from a positive COVID-19 Resident to a COVID-19 negative Resident, (going from room to room). The facility is licensed for 120 beds and had a census of 91 on [DATE]. Census breakdown is: Dogwood Unit: Hall 700 - total Residents 13 /13 COVID-19 negative Residents Hall 600 - total Residents ,[DATE] COVID-19 positive Residents and 2 COVID-19 negative Residents Hall 800 - total Residents ,[DATE] COVID-19 positive Residents Hall 500 - total Residents ,[DATE] COVID-19 negative Resident, 2 COVID-19 recovered Residents, 1 COVID-19 positive Resident Magnolia Unit - total Residents ,[DATE] COVID-19 negative Residents 2. A Quality Assurance (QA) meeting was conducted on [DATE], at approximately 4:40 PM. Attendees included the Medical Director, Administrator, Director of Nursing, Nurse Practitioner, Resident Care Coordinator/Registered Nurse/Infection Preventionist, Activities Director, Social Service Director, Corporate Registered Nurse, Director of Long Term Care Operations, Corporate Training and Development Coordinator to discuss the following findings: a.) The failure of employees to change Personal Protective Equipment (PPE) when going from a positive COVID-19 resident care area to a negative COVID-19 resident care area and b.) The failure of the facility to maintain the appropriate placement of biohazard waste bins at the exits of the COVID-19 units. The committee recommended training for all staff related to CDC Guidelines for COVID-19 regarding Donning and Doffing of PPE to include disposal in designated biohazard waste bins, appropriate sequencing of PPE, and proper changing of PPE between positive COVID-19 Residents and COVID-19 negative Residents. Recommendations were made to follow the policies and procedures of Donning/Doffing PPE. 3. As of [DATE], Care Plans of 33 COVID-19 positive Residents were reviewed and updated by Licensed Practical Nurse/MDS Nurse #1 related to COVID-19 problems and interventions. 4. On [DATE], at approximately 4:00 PM, biohazard barrels were placed on halls 600, 800 and 500. At approximately 7:30 PM, signage was placed identifying the location of COVID-19 positive residents. On [DATE], training was initiated by the Staff Development Registered Nurse (RN) employed by another facility entitled Donning/Doffing of PPE to include appropriate disposal in biohazard waste bins, appropriate sequencing of PPE, and proper changing of PPE between positive COVID-19 Residents and COVID-19 negative Residents. The following employees received this in-service: one (1) of one (1) Administrator one (1) of one (1) Central Supply nineteen (19) of forty-three (43) Certified Nursing Assistants eight (8) of twelve (12) Dietary five (5) of thirty-five (35) Licensed Practical Nurses five (5) of fifteen (15) Registered Nurse one (1) of one (1) Resident Care Coordinator/Registered Nurse/Infection Preventionist two (2) of three (3) Social Service one (1) of one (1) Director of Nursing one (1) of one (1) Medical Records two (2) of three (3) Activity two (2) of four (4) Clerical one (1) of three (3) Laundry two (2) of eight (8) Housekeeping No staff members will be allowed to work until they have been trained on Donning/Doffing of PPE to include appropriate disposal in biohazard waste bins, appropriate sequencing of PPE, and proper changing of PPE between positive COVID-19 Residents and COVID-19 negative Residents. 5. Fifty-five (55) asymptomatic Residents were screened, assessed, and tested for COVID-19 on [DATE]. Fifty-two (52) Residents were negative. Resident #23, Resident #40, and Resident #24 were positive and moved to the COVID-19 Unit. Sixty-four (64) asymptomatic staff were screened, assessed, and tested for COVID-19 on [DATE]. Fifty-eight (58) staff were negative. Six (6) staff were positive and sent home to quarantine. Thirteen (13) asymptomatic Residents residing on 700 Hall were screened, assessed, and tested for COVID-19 on [DATE]. Results were ten (10) out of twelve (12) Residents were negative for COVID-19. One (1) 700 Hall Resident, Resident #10, was at the hospital at the time of testing and tested negative at the hospital. Resident #13 and Resident #12 were moved to the COVID-19 Unit. 6. The facility alleges that the Immediate Jeopardy was removed on [DATE]. The State Agency (SA) validated the facility's Immediate Jeopardy Removal Plan through observation, interview, record review and review of sign-in-sheets [DATE]. 1. The SA validated through observations that no further issues were observed regarding staff not changing PPE when exiting COVID-19 positive residents' rooms on the 700 Hall. 2. The SA validated through interviews and review of the facility's in-service sign-in sheets that in-service education was provided by the facility to all the staff in the form of lectures and films. 3. The SA validated through Observation and interviews the facility placed red biohazard barrels at the exit doors to doff PPE. 4. The SA validated through record review that all residents in the facility were assessed for signs and symptoms of COVID-19. 5. The SA validated a Quality Assessment and Assurance Committee meeting was held on Tuesday, [DATE] by interview of persons who attended and review of sign in sheets. 6. The SA validated facility wide testing for staff and residents was done on [DATE], [DATE], [DATE] and [DATE]. 7. The SA validated that all the facility's IJ Removal Plan's corrective actions were completed and the IJ was removed as of [DATE], and validated by the SA's exit on [DATE].

Based on observation, staff interview, record review, and facility policy review, the facility failed to develop and implement the care plan for weekly skin assessments related to risk of pressure ulcers; and, the resident removing devices for prevention, for one (1) of three (3) wound care care plans reviewed, Resident #87. The resident was identified with an acquired unstageable pressure ulcer on 3/24/19. Findings include: A review of a facility policy titled Care Plans-Comprehensive, revised (MONTH) (YEAR), revealed an individualized person centered care plan that includes measurable objectives and timetables to meet the resident's needs is developed for each resident. The care plan team develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The care plan aides in preventing or reducing declines in the resident's functional status and/or functional levels. A review of a facility policy titled Prevention of Pressure Ulcers, revised (MONTH) 2010, revealed to assess the resident's skin, according to facility protocol and review the care plan to assess for any special needs of the resident. During an interview on 6/20/19 at 10:20 AM, The DON said the care plan should address the Care Area Assessment's and Braden score to determine the resident's risk for pressure ulcers. The DON said the facility policy was to complete weekly skin checks. Review of a care plan, dated 3/6/19, revealed Resident #87 had a risk for skin breakdown related to the increased need for mobility. The care plan was revised on 3/6/19 for positioning and cleaning related to a recent [MEDICAL CONDITION]. There were no interventions for weekly skin audits. A review of Resident #87's Event Tracking Report dated 3/6/19, revealed a care plan problem At risk for skin breakdown related to increased need for mobility positioning and right [MEDICAL CONDITION]. A review of the Resident #87's care plan, dated 3/25/19, revealed an unstageable pressure injury to right heel-progression of wound to Stage 3 pressure injury 4/30/19. The care plan had interventions with wound care and off loading boot to right lower extremities every shift to keep heel floated at all times. Resident #87's care plan did not list any concerns of the resident removing her off loading boot and staff having to replace it often during the day. The care plan also did not include weekly skin evaluations. A review of the Resident #87's Braden scale dated 2/26/19, completed by RN #2, with a score of 16, indicated a moderate risk for skin breakdowns. Review of skin audits revealed no documentation related to the right heel on the skin audit that was completed on 2/26/19, upon hospital return. There was no further documentation of a skin assessment until 3/19/19, and the audit revealed no skin problems. A review of Resident #87's Care Area Assessments (CAA's) section, on the MDS, dated [DATE], indicated the care area Pressure ulcer was triggered and the decision to care plan was marked to proceed related to Resident #87's declined mobility and continent status . Review of nurses notes dated 3/21/19, revealed Resident #87 became agitated and aggressive when staff attempted to perform daily care. Review of nurses notes dated 3/24/19 at 5:07 PM, revealed Licensed Practical Nurse (LPN) #5 was called to Resident #87's room and noted a pressure ulcer to the resident's right heel with some blackness noted around the area and the charge nurse then assessed Resident #87. A review of the weekly wound assessment, dated 3/25/19, revealed a new pressure ulcer, unstageable with slough/eschar, that measured 2.8 centimeters (cm) in length, by 5.3 cm width, by 0 cm depth, identified on 3/24/19, and signed by RN #3. A review of Resident # 87's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/26/19, revealed Section M0210, was documented 1 and Section M0300, F, was documented 1 indicating one (1) unstageable wound with slough and or eschar. A review of Resident #87's physician's orders [REDACTED]. An interview on 06/19/19 at 10:21 AM with Registered Nurse (RN) #3, Treatment Nurse, confirmed Resident #87 had a pressure ulcer on her right heel and said the ulcer was facility acquired in (MONTH) 2019. An interview on 06/19/19 at 11:16 AM, with RN #2, confirmed Resident #87's weekly skin audit was completed on 3/19/19, and the documentation revealed no skin problems. RN #2 stated the documentation indicated eschar on the wound care assessment completed on 3/25/19, by RN #3. She also confirmed the previous skin assessment was completed on 2/26/19, on the form Nursing Admission History and Physical Assessment on hospital return and said skin conditions would only be documented if there was a problem. RN #2 confirmed there was no documentation related to the right heel. An observation of Resident #87's wound care, provided by RN #3, on 06/19/19 at 1:32 PM, revealed the resident had a right heel ulcer. An interview on 06/19/19 at 1:36 PM, with RN #3, revealed Resident #87 did remove her boot, and she had to put the boot back on very often during the day. An interview on 06/20/19 at 10:21 AM with RN #3, Treatment Nurse, revealed the prevention measures would include a weekly body audit that was done by the licensed practical nurses (LPN's). RN #3 considered Resident #87 would be at risk for skin breakdown related to the recent right [MEDICAL CONDITION]. RN #3 confirmed the wound was eschar with a blister when she evaluated the wound on Monday 3/25/19, which was first identified on the previous day, 3/24/19. An interview on 6/20/19 at 10:20 AM, with Director of Nursing (DON), revealed she would expect Resident #87 to be at risk for pressure ulcers after the right hip surgery related to her limited range of motion. The DON said the care plan should address the CAA's and Braden score to determine the resident's at risk. The DON said the facility policy was to complete weekly skin checks by the LPN's, but the nurses had only completed a weekly skin check on 3/19/19, since Resident #87's 2/26/19 hospital return. An interview on 06/20/19 at 11:03 AM, with Resident #87's Medical Doctor (MD) revealed the facility had policies for preventive measures for wounds but would have to review Resident #87's chart and call back. The MD never returned the call. An interview on 06/20/19 at 11:09 AM, with LPN #4, MDS Nurse, revealed residents were evaluated for at risk of skin breakdowns by the Braden scale and the Care Area Assessments (CAA's) would trigger the care plan to be completed. An interview on 06/20/19 at 1:09 PM, with the DON revealed the 16 on the Braden scale indicated Resident #87 was at risk for skin breakdowns. An interview on 06/20/19 at 1:41 PM, with DON, revealed the care plans for prevention of pressure ulcers were completed for Resident #87 that focused on immobility and incontinence. The DON said once the care plan was completed, the expectation was the staff to follow the interventions. She said the care plan for Resident #87 was updated on 5/29/19, and the computer system removed the at risk for breakdown when the care plan was updated to an actual pressure ulcer.

Based on observation, staff interview, record review, and facility policy review, the facility failed to prevent a resident from developing a heel pressure ulcer, as evidenced by failure to perform weekly assessments, and failure to ensure interventions were provided to prevent the pressure ulcer, for Resident #87, a resident who was at risk of a pressure ulcer, related to immobility and recent surgery. This affected one (1) of three (3) residents observed with pressure sores, resulting in actual harm for Resident #87. Findings include: A review of a facility policy titled, Prevention of Pressure Ulcers, revised (MONTH) 2010, revealed to assess the resident's skin, according to facility protocol. Interview with the Director of Nursing (DON) on 6/20/19 at 10:20 AM, revealed the policy was to perform skin assessments weekly. An observation on 6/17/19 at 4:57 PM, revealed Resident #87 was up in wheelchair with a padded boot on the right foot. Review of an assessment, upon return from the hospital on [DATE], on the form Nursing Admission History and Physical Assessment, revealed skin conditions would only be documented if there was a problem. There was no documentation of skin issues to Resident #87's right heel. The assessment revealed documentation of dry skin/island dressing intact to right hip and bruise to left foot, right hand and wrist, bilateral arms. The lower extremities were documented not applicable.There were no weekly skin assessments documented from 2/26/19 until 3/19/19, and again no issues were identified on the assessment. A review of the Resident #87's Braden scale dated 2/26/19, completed by RN #2, revealed a score of 16, which indicated a moderate risk for skin breakdowns. A review of Resident #87's Care Area Assessments (CAA's) section on the Minimum Data Set (MDS), dated [DATE], indicated the care area Pressure Ulcer was triggered, and the decision to care plan was marked to proceed, related to Resident #87's declined mobility and continent status . A review of Resident #87's Even Tracking Report dated 3/6/19 revealed a care plan problem at risk for skin breakdown related to increased need for mobility positioning and right [MEDICAL CONDITION]. There were no interventions for skin assessments and/or interventions for prevention of heel breakdown. Review of Nurse's Notes, dated 3/21/19, revealed Resident #87 became agitated and aggressive when staff attempted to perform daily care. Review of Nurse's Notes, dated 3/24/19 at 5:07 PM, revealed Licensed Practical Nurse (LPN) #5 was called to Resident #87's room and noted a pressure ulcer to the resident's right heel with some blackness noted around the area and the Charge Nurse then assessed Resident #87. A review of Resident #87's Incident Case Report, dated 3/24/19 at 4:47 PM, revealed a noted pressure ulcer to the right heel with some blackness noted. The documentation on the incident report revealed the Nurse Practitioner was notified, footwear was on; the resident used a wheelchair and required assistance. A review of the Resident #87's care plan with a problem, dated 3/25/19, revealed an unstageable pressure injury to right heel-progression of wound to stage 3 pressure injury 4/30/19. The care plan had interventions with wound care, and off loading boot to right lower extremities every shift to keep heel floated at all times. A review of Resident #87's Initial Wound Assessment, dated 3/24/29, revealed the wound was new and located on the right heel. The wound assessment also listed the etiology was other, unstageable with slough/eschar that measured 3 centimeters (cm) length by 4.6 cm width. A review of the Resident #87's Weekly Wound assessment dated [DATE], revealed a new pressure ulcer with unstageable with slough/eschar that measured 2.8 cm length by 5.3 cm width by 0 cm depth, identified on 3/24/19, and signed by RN #3. Review of the Treatment Administration Record (TAR) for (MONTH) 2019, revealed Off Loading Boot to right lower extremity every shift to keep heel floated at all times, initiated 3/25/19. An interview on 06/19/19 at 1:36 PM, with RN #3, revealed Resident #87 did remove her boot, and she had to put the boot back on very often during the day. A review of Resident #87's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/26/19, revealed Section M0210 was documented 1 and Section M0300, F, was documented 1 indicating one (1) unstageable wound with slough and/or eschar. A review of Resident #87's physician's orders [REDACTED]. Review of a Procedure Note, dated 5/9/19, by the Wound Doctor, revealed the pre-operation [DIAGNOSES REDACTED]. A review of a facility statement dated 6/19/19, signed by the DON, revealed the facility believed that Resident #87's right heel wound was clinically unavoidable related to impaired mobility due to fracture, lab levels, weight loss, and refusal of care, however there were no documented interventions for the refusal of care by Resident #87. An interview on 06/19/19 at 10:21 AM, with Registered Nurse (RN) #3/Treatment Nurse, confirmed Resident #87 had a pressure ulcer on her right heel and said the ulcer was facility acquired in (MONTH) 2019. She said it was found on a weekly skin check over a weekend. RN #3 said Resident #87's ulcer started as a blister and quickly developed into a Stage 3. She stated the resident was able to move extremities freely but not able to walk. RN #3 said Resident #87 used her feet to scoot herself in the wheelchair. RN #3 also said the resident had not been going to the wound clinic, but the Wound Doctor had seen and debrided the wound. An interview on 06/19/19 at 11:16 AM, with RN #2, confirmed Resident #87's weekly skin audit was completed on 3/19/19, and the documentation revealed no skin problems. RN #2 stated the documentation indicated it was eschar on the wound care assessment completed on 3/25/19, by RN #3. She also confirmed the last prior skin assessment was completed on 2/26/19, on the form Nursing Admission History and Physical Assessment upon hospital return, which documented skin conditions would only be documented if there was a problem. RN #2 confirmed there was no documentation related to the right heel on the assessment. RN #2 confirmed there were no documented weekly assessments from 2/26/19 until 3/19/19. During an interview on 06/19/19 at 1:26 PM, Certified Nursing Assistant (CNA) #2 said she did not remember seeing a skin problem with Resident #87 before they found the ulcer on her heel. She said the resident wore tennis shoes and sandals before she went out to the hospital. She said when Resident #87 would walk, it was on the side of her foot. CNA #2 said the resident's sandals did not cover her heel. CNA #2 also said Resident #87 moved her own legs and positioned them independently. An observation of Resident #87's wound care on 06/19/19 at 1:32 PM, provided by Registered Nurse (RN) #3, revealed the resident had a right heel ulcer, which measured 1.2 cm length by 1.3 cm width by 1.4 cm depth. The wound was located above the back of the heel about 0.5 inch from the bottom of the foot. The wound was round with distinct edges, pink and no discharge. An interview on 06/20/19 at 9:50 AM, with CNA #3, Bath Aide, revealed Resident #87 had always had a covering on her heel since she started bathing her. CNA #3 stated Resident #87 would complain of pain, but it was related to the right [MEDICAL CONDITION]. CNA #3 said the policy was to do a complete body check during the bath and to notify her nurse if any problems were noted. On 06/20/19 at 10:21 AM, an interview and observation with the DON and RN #3/Treatment Nurse, revealed one (1) pair of Resident #87's tennis shoes was a pink, size 7.5 with a stiff back that was indented halfway down the heel and had shoe laces. The DON placed the tennis shoe on Resident #87 and confirmed it would hit the area of the breakdown if she was wearing the shoes prior to the breakdown. RN #3, said the prevention measures should included a weekly body audit that was done by the LPN's, and Resident #87 would be at risk for breakdown from the recent [MEDICAL CONDITION]. RN #3 said once the wound was found, the boot was applied, weekly checks were performed by the RN Wound Care Nurse, and an air mattress was applied to the bed. RN #3 said the resident did not wear any shoes on the right foot since the wound was found. RN #3 confirmed it was eschar with a blister when she evaluated Resident #87's heel wound on Monday 3/25/19, which was originally found on 3/24/19. The DON said she would expect Resident #87 to be at risk for pressure ulcers after the surgery, related to her limited range of motion (ROM), and the care plan should address the CAA's and Braden score to determine if the resident's at risk. The DON said the facility policy was to complete weekly skin checks by the LPN's, but the nurses had only completed a weekly skin check on 3/19/19, since Resident #87's 2/26/19 hospital return. The DON then stated an investigation was completed by her on 6/19/19, with the review of the Resident #87's medical record. The DON did not have a reason as to why the investigation was done at this time, and did not provide a policy for the investigation. An interview on 06/20/19 at 11:03 AM, with Resident #87's Medical Doctor (MD) revealed the facility had policies for preventive measures for wounds, but would have to review Resident #87's chart and call back. MD never returned the call. An interview on 06/20/19 at 11:09 AM, with Licensed Practical Nurse (LPN) #4/MDS Nurse, revealed residents were evaluated for risk of skin breakdowns by the Braden scale, and the Care Area Assessments (CAA's) would trigger the care plan to be completed, with interventions to prevent breakdown. On 06/20/19 at 11:31 AM, an interview with LPN #5 confirmed she was working the day the pressure ulcer was found on Resident #87's right heel. LPN #5 said she had been here about five (5) months and was one (1) of the nurses that took care of Resident #87. LPN #5 said CNA #4 called her to the resident's room, during the 3-11 shift, because Resident #87's sock was soiled. LPN #5 said the drainage was brown tinted. She said Resident #87 would previously walk on the outside of her heels because her sandals were too small and had to get new shoes prior to the wound being found. LPN #5 said Resident #87 never complained of pain with right ankle/foot. LPN #5 said she notified the Charge Nurse and completed the incident report. An interview on 06/20/19 at 2:30 PM, with CNA #4, revealed she had been working in the facility since (MONTH) of 2019. CNA #4 stated she was working the day the ulcer was found on Resident #87's right heel. CNA #4 said the resident had on the gray tennis shoes when she put her to bed that afternoon on 3/24/19. CNA #4 stated she took off Resident #87's shoes and the inside of the right shoe was wet and the sock was wet around the heel with a brown discharge stain. CNA #4 said she then notified LPN #5. CNA #4 said the facility policy was to check the skin every time you assist a resident and report to the supervisor any abnormal findings. An interview on 06/20/19 at 1:09 PM, with the DON, revealed the 16 on the Braden scale indicated the resident was at risk for skin breakdowns. The DON also said with the CAA's and the Braden scale, Resident #87 should have a care plan related to the risk of skin breakdown, with interventions in place. On 06/20/19 at 1:16 PM, an attempt was made to interview the Wound Doctor, but he was out of town and not available at his office.

Based on interview, facility policy review, and facility record review, the facility failed to ensure adequate assistance to prevent falls, resulting in a fall with fracture for one (1) of five (5) residents reviewed, Resident #1. Findings include: A review of the facility's policy titled Safety and Supervision of Residents, with a revision date of (MONTH) (YEAR), revealed our facility strives to make the environment as free from accidents and hazards as possible. Resident safety, supervision and assistance to prevent accidents are facility wide priorities. Further review of the policy revealed the care team analyzes information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce risks related to the environment, adequate supervision and assuasive devices. Implementation of interventions to reduce accidents and hazards shall include: communication of specific all relevant staff, assignment of responsibility for carrying out interventions and ensuring interventions are implemented. A review of the facility Document, titled Fall Risk Assessment, and dated 11/3/18, revealed Resident #1 had balance problems while standing. Further review revealed the resident had [DIAGNOSES REDACTED]. Review of the facility documentation of point of care training, revealed CNA #1 was in-serviced on 9/4/18, and demonstrated competence in accessing the Kiosk for information regarding resident care. Review of the facility's CNA information sheet in the Kiosk revealed Resident #1 required extensive assistance of two (2) for cleaning and changes/toileting needs. A review of Resident #1's chart revealed a nurse's note from 12/09/18 at 2:30 PM, which stated, Upon entering room saw the resident upright on bottom with left leg bent under right leg and CNA's holding resident up. A review of the facility document, titled, Alleged Abuse Incident Report, dated 12/12/18, revealed the resident was standing while peri-care was being performed by CNA #1 the resident lost her balance and was eased to the floor. The resident's physician was notified and orders were obtained for an x-ray of the resident's left hip. The x-ray revealed an acute [MEDICAL CONDITION] femoral joint. Resident #1 was sent to the emergency room for further evaluation where it was determined she had an acute Comminuted [MEDICAL CONDITION] Left Femur. Resident #1 was admitted to the hospital and underwent surgery on 12/10/18, for Left Femur Intramedullary Nailing. The conclusions documented in the report revealed: Investigation revealed CNA did not follow the careplan for the resident and the CNA was immediately suspended and terminated as a result. Review of the hospital history and physical, dated 12/9/18, for Resident #1, revealed the resident is a [AGE] year old, wheel chair bound female, with very limited mobility. She presents with history of fall at a nursing facility with severe pain, deformity, and shortening of her left leg. Review of the hospital operative note for Resident #1, dated 12/10/18, revealed a [DIAGNOSES REDACTED]. The procedure to repair the fracture was a Left Femur Intramedullary Nailing and was carried out under general anesthesia. A review of the written statement made by CNA #1, dated 12/10/18, revealed, It took several minutes to clean her, and when I was putting the new brief between her legs she started to lose her balance. I noticed she was wobbling and put my knee up so she could rest on it. I tried to assist her back to the chair but was unable to do so safely. Further review revealed when CNA #2 came to assist the two (2) CNA's tried to assist the resident to her chair but were unable to do so. The resident was lowered to the floor. Once on the floor her left leg was bent underneath her right leg. An interview with Registered Nurse (RN) #1, Staff Development Nurse, on 1/4/19, at 3:27 PM, revealed CNA's are taught to check to Kiosk every shift under the information tab. Under that tab there is information concerning specific requirements for the care of each resident. They are taught that they must follow these guidelines when giving care. An interview with Resident #1 on 1/4/19 at 1:30 PM, revealed only one (1) CNA was assisting her when the accident occurred. She further stated, That girl dropped me and broke my leg, I told her to let me hold on to the chair but she said she could do it, she let go and I fell . Resident #1 also stated that she continued to have pain and continued to require therapy. She further stated that she had been able to get around much better before the incident. Interviews with CNA's #3, #4, #5, #6, #7, and #8 on 1/4/19 between 2:00 PM and 2:45 PM, revealed they had all been trained to check the Kiosk daily to determine the level of assistance each resident required. CNA #3 confirmed that failure to use the care plan to provide care was equal to neglect. In a telephone interview with CNA #1 on 01/07/19 at 4:00 PM, she confirmed that she had attempted to change Resident #1 without assistance of another person and the resident got weak and lost her balance. She stated that she got down on one (1) knee and let the resident slide down and rest on the other knee. She stated Resident #1's roommate pushed the call light and went out into the hallway to get help. She stated that when CNA #2 came into the room, We tried to get her up to her wheelchair, but she was too weak so we let her slide down onto the floor. She stated, That's when I noticed her leg was bent under her. CNA #1 confirmed that she had been taught to use the Kiosk to find out what kind of assistance a resident needed. She further stated, I knew this resident was a one (1) person assist and one (1) person stand by. The only thing I didn't do was have someone on stand-by. A post survey telephone interview with CNA #2, on 01/21/19 at 3:15 PM, revealed when she got to the room, CNA #1 was in the room alone and there was no stand-up lift in the room. She further stated that she was aware that the resident required two (2) person assist for cleaning and changing/toileting. She further stated that CNA's at the facility were taught to use the Kiosk to determine the level of assistance a resident required. A review of the facility's time sheets and schedule, for CNA #1, confirmed that CNA #1 was scheduled to work the 7 am-3 pm shift on 12/09/18, and clocked in at 7:14 AM, and clocked out at 4:38 PM, on 12/09/18, the date of the incident. The CNA did not clock in to work thereafter. Review of Resident #1's face sheet revealed the facility admitted the resident on 1/11/18. Resident #1's [DIAGNOSES REDACTED]. Review of Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/18, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact.

Based on interview, facility policy review, and record review, the facility failed to follow the Comprehensive Care Plan for toileting/changing assistance for one (1) of five (5) residents reviewed, Resident #1. Findings include: Review of the facility document entitled Using the Care Plan, with a review date of (MONTH) (YEAR), revealed the care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have the responsibility for providing care and services to the resident. The Nurse Supervisor uses the care plan to direct care provided by Certified Nurse Assistants (CNA's) and nurses daily. Review of Resident #1's current Comprehensive Care Plan revealed a stated problem, with an original date of 12/31/15, and an effective date of 10/16/18, that the resident required extensive assistance from staff for toilet use due to frequent incontinent episodes. An intervention, with an effective date of 11/8/17, noted to provide extensive assistance of two (2) for changing/toileting needs. Further review of the resident's care plan revealed a problem, with an original date of 1/4/16, and an effective date of 10/5/18, that indicated the resident was at risk for falls related to difficulty with balance, and a past history of falls on 1/28/17, 7/12/18, and 10/2/18. Stated goal for this problem was to be free from injury related to falls. Interventions included ensure transfer with one (1) person assist and one (1) person stand by (which equals to two staff available) and with extensive assistance of two (2) when having fatigue and weakness. Review of the facility's CNA information sheet in the Kiosk revealed Resident #1 required extensive assistance of two (2) for cleaning and changes/toileting needs. A review of the facility document, titled Alleged Abuse Incident Report, dated 12/12/18, revealed Resident #1 was standing while peri-care was being performed by CNA #1 the resident lost her balance and was eased to the floor. The resident's physician was notified and orders were obtained for an X-ray of the resident's left hip. The conclusions documented in the report revealed: Investigation revealed CNA did not follow the careplan for the resident and the CNA was immediately suspended and terminated as a result. Review of the X-ray report, dated 12/9/18, revealed an acute [MEDICAL CONDITION] femoral joint. Resident #1 was sent to the emergency room for further evaluation where it was determined she had an acute Comminuted [MEDICAL CONDITION] Left Femur. Resident #1 was admitted to the hospital and underwent surgery on 12/10/18, for Left Femur Intramedullary Nailing. A review of the written statement made by CNA #1 on 12/10/18, revealed: It took several minutes to clean her. The statement noted, I was putting the new brief between her legs she started to lose her balance. Further review revealed when CNA #2 came to assist the two (2) CNA's tried to assist the resident to her chair but were unable to do so. The resident was lowered to the floor. The statement documented, Once on the floor, her left leg was bent underneath her right leg. Review of a written statement from CNA #1, dated 12/9/18, revealed her answer to the question, did anything unusual happening during the care interaction, was she (the resident) was weaker than usual. An interview with the Director of Nursing (DON) on 1/4/18 at 1:30 PM revealed the facility expects staff to follow the care plans. The DON stated that care plans were located in the Kiosk on the hall and staff used them to know how to care for residents. She stated the CNA's are taught to use the care plan. She confirmed that if a care plan stated two (2) people are needed and only one (1) is present, the care plan was not followed. Interview with Registered Nurse #1, the Staff Development Nurse, on 1/4/19 at 3:27 PM, revealed staff are taught to use a resident's care plan and are expected to follow each resident's care plan. Review of the facility documentation revealed CNA #1 was in-serviced and demonstrated competence in accessing the Kiosk for information regarding resident care. In a telephone interview with CNA #1 on 01/07/19 at 4:00 PM, she confirmed that she had attempted to change Resident #1 without assistance of another person. CNA #1 also confirmed that she had been taught to use the Kiosk to find out what kind of assistance a resident needed. She further stated, I knew this resident was a one (1) person assist and one (1) person stand by. The only thing I didn't do was have someone on stand-by. A post survey telephone interview with CNA #2, on 01/21/19 at 3:15 PM, revealed CNA #1 was in the room alone with the resident at the time of the incident. She further stated that CNA's at the facility were taught to use the Kiosk to determine the level of assistance a resident required. Review of Resident #1's face sheet revealed the facility admitted the resident on 1/11/18. Resident #1's [DIAGNOSES REDACTED]. Review of Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/18, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement appropriate measures to aid in the prevention of a fall and injury for one (1) of four (4) residents reviewed (Resident #8). On 1/5/11 at 11:30 a.m., Resident #8 was found lying on the side of the bed with a large hematoma to the right side of the head. Resident #8 had a bed alarm in place that was not sounding when she was found on the floor. The bed alarm did not have a battery in place. There was no documentation as to when the alarm was last checked for functioning. Resident #8 was transferred to the emergency room for evaluation and treatment. Findings include: Record review revealed that Resident #8 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of Resident #8's Significant Change Minimum Data Set ((MDS) dated [DATE], revealed her Cognitive Status was coded as being severely impaired in cognitive skills for daily decision-making with cueing and supervision required. Further review of the MDS revealed transfer needs require extensive assistance; resident involved in activity; staff provides weight-bearing support with two (2) person physical assistance. Resident #8's Fall Risk assessment dated [DATE], was scored a "16", which indicated a "HIGH RISK". Review of the Nurse's Notes (NNs) dated 1/5/11 at 11:30 a.m., revealed the following: "Notified per (name) Licensed Practical Nurse (LPN) #1 that resident was on floor in room. Stated she found resident lying on ? (right) side. Resident noted sitting (up) up in floor beside bed alert & (and) responsive. Noted with large hematoma to ? (right) forehead. No other injury noted. No c/o (complain of) voiced. Resident stated she was trying to get in w/c (wheelchair) from bed unassisted. Bed alarm intact but noted without battery & (and) was not alarming @ (at) time of fall. Neuro (check mark) checks initiated." On 1/5/11 at 11:40 a.m. "Dr. (name) notified of fall & (and) n.o. (new order) to send to (name of hospital) ER (emergency room ) for eval (evaluation) r/t hitting head." On 1/5/11 at 11:45 a.m. "(Ambulance Name) notified of transport. R.P. (Representative Person) (Name) notified of incident & stated "On no, thank you for calling." On 1/5/11 at 12:00 "(Ambulance Name) here to transport to ER for eval and N.O. for monitor bruising X 5 (five) days r/t fall." Review of the January 2011 physician's orders [REDACTED]. Neuro checks R/T fall. The CT Head Without Intravenous Contrast completed on 1/5/11 at 12:57 p.m. at (Name of Hospital) revealed a Right Frontal Hematoma Within The Frontal Scalp. No Underlying Skull Fracture was demonstrated. Review of the NNs dated 1/5/11 at 1500 (3:00 p.m.), revealed that Resident #8 returned back to the facility. The Neuro Check Sheet, dated 1/5/11, revealed that Neuro Checks were performed at 1515 (3:15 p.m.); 1915 (7:15 p.m.); 2315 (11:15 p.m.); and then on 1/6/11 at 0715 (7:15 a.m.). The NNs revealed an assessment at 0215 (2:15 a.m.) on 1/6/11. Review of Resident #8's Medication Administration Record (MAR) and Treatment Record for January 2011, revealed that there was no documentation for monitoring the bed and chair alarms for proper functioning/battery placement. Review of Resident #8's monthly physician's orders [REDACTED]. Observation on 6/2/11 at 1:45 p.m., revealed that Resident #8 was in her wheelchair at the bedside. An interview at that time with Certified Nursing Assistant (CNA) #1, revealed that Resident #8 has the chair and bed alarms in place to alert staff if she attempts to get out of bed/wheelchair without assist. CNA #1 reported that Resident #8 also has the bar on the back of her wheelchair so the wheelchair will not roll out from under her if she attempts to stand up. CNA #1 reported that the bed pad alarm is in place on Resident #8's bed and when she presses down on the pad it alarmed. CNA #1 reported that Resident #8 requires two (2) person assistance with transfers. CNA #1 reported that they check the bed and chair alarms every shift and notify the nurses if they need a new battery if it is or not working right. CNA #1 reported that they do not document the checks, they just tell the nurses of any problems. Interview on 6/2/11 at 2:15 p.m., with Registered Nurse (RN) #1 revealed that she has been employed as RN Supervisor since March 2011. RN #1 reported that when the battery weakens on the bed alarms, they will beep constantly to notify us to change them out. RN #1 stated that they don't document the battery change or that we check them daily. LPN #1 reported the same. They check the bed and chair alarms daily, but do not document the checks. An interview on 6/2/11 at 2:20 p.m., with LPN #2 (Restorative Nursing Program), revealed that all staff are trained on how to use and check the bed and chair alarms. LPN #2 also reported that the alarms are locked so the residents cannot turn them off. The staff carries the keys to the locks. LPN #2 stated that they do check the bed and chair alarms daily and they don't document any checks or battery checks. An interview on 6/2/11 at 2:30 p.m., with LPN #1, revealed that she was at work on 1/5/11, when Resident #8 was found on the floor at the bedside with the Hematoma to her right forehead. LPN #1 reported that they noticed the alarm was not on after they had assessed Resident #8. After Resident #8 was taken care of and sent out, they began checking the bed alarm to see why it did not alarm. LPN #1 stated that was when they discovered the battery was missing. LPN #1 reported that when the resident is in the bed, the green light on the alarm blinks, or when you first put the resident in the bed it will alarm and then stop. The nine (9) volt battery was not in the bed alarm battery box. LPN #1 reported that she worked on 1/4/11 and remembered the green light blinking on Resident #8's bed alarm. LPN #1 revealed that they do not document the bed and chair alarm checks, but they do check them daily. Interview on 6/2/11 at 2:30 p.m., with the Director of Nursing (DON), revealed that the facility does have a system to check the bed and chair alarms. The Central Supply Person checks them, but she was not sure about the documentation for the checks. She will follow up with the Central Supply Person. Interview on 6/2/11 at 3:30 p.m., with Resident #8's Attending Physician and the facility Medical Director, revealed that he remembered Resident #8 having the fall on 1/5/11 and sent to the ER for evaluation related to the Hematoma. (Name of Physician) reported the facility does notify him of falls routinely, and they are very good about following through with Quality Assurance (QA) with concerns and problems. (Name of Physician) reported that he really could not recall that the bed alarm did not sound due to the battery not being in place at the time of Resident #8's fall on 1/5/11. Interview on 6/2/11 at 3:35 p.m., with the Central Supply/Nursing Secretary, revealed that she is responsible for stocking the floor supplies daily, and at that time she checked all the bed and chair alarms in the facility. Central Supply/Nursing Secretary) reported that she does not have a list of residents with bed and chair alarms each day; she just knows who all has one because she is the one who issues them out. The Central Supply/Nursing Secretary reported that she checks to see if the green light is blinking on the box. This means it is functioning. Central Supply/Nursing Secretary reported that the bed alarms will have a yellow light that blinks indicating the battery or pad needs to be changed. The Central Supply Person/Nursing Secretary reported that she was trained on how to monitor the bed and chair alarms for appropriate functioning/battery replacement. The Central Supply Person/Nursing Secretary reported that the batteries are changed every month now for the past couple of months. She stated, "We were leaving batteries at the Nurse's Stations for staff to change them out when needed. Now we change them out on a schedule. Certain rooms are done each week starting on the first week of the month." She confirmed that there was no documented information to verify that the bed and chair alarms were checked and the batteries were changed. Review of the following statements provided by (Name) Central Supply revealed the following: (1) 6/2/11 "(Name - former Resident Care Coordinator RCC) and I completed an audit of 100% (one hundred percent) of our residents after this incident occurred on 1/5/11. No other residents were found at that time to have any problems with their safety monitoring devices.). (2) 6/2/11 "I (Name) work in central supply. Prior to the incident occurring on 1/5/11, when I put out stock for the residents who have alarms, I would check both bed and chair alarms on a daily basis. After the incident on 1/5/11, we divided the halls and created a more structured schedule on when to check each hall and change the batteries. Every week, I check the batteries to make sure that they are working and I then change out the batteries on a monthly basis. (signed (Name of Central Supply)." Review of the schedule provided by (Name) Central Supply revealed the following: "Batteries will be changed in bed and chair alarms at least monthly and more often if identified as necessary. The schedule for changing the batteries in the alarms will be as follows: "200 Hall and 600 Hall the first full week of each month. 300 Hall and 700 Hall the second week of each month. 400 Hall, 100 Hall, and 200 Hall the third week of each month." "All batteries will be replaced, regardless of how recent they were placed in the alarms or when the alarms were ordered. The Central Supply person is designated as the person who will be responsible for making sure the alarms are replaced. (Name of Facility - QA document January 2011). A review of Resident #8's February to April 2011, and June 2011 MARs and Treatment Records revealed that there was no documentation for the monitoring or appropriate functioning and battery replacements for her bed and chair alarms. Review of Resident #8's nursing notes 1/5/11 through 5/26/11 revealed the bed/chair alarms were documented in place on the following dates: 0745 (7:45 a.m.) 1/6/11, 0030 (12:30 a.m.) 1/15/11, 1020 (10:20 a.m.) 1/20/11, 1455 (2:55 p.m.) 2/2/11, 2405 (12:05 a.m.) 3/24/11, 0850 (8:50 a.m.) 3/13/11, 0600 (6:00 a.m.) 3/2/11, 2330 (11:30 p.m.) 4/6/11, 0915 (9:15 a.m.) 4/4/11, 0935 (9:35 a.m.) 4/8/11, 0928 (9:28 a.m.) 4/9/11, 0845 (8:45 a.m.) 4/13/11, 0740 (7:40 a.m.) 4/12/11, 0735 (7:35 a.m.) 4/19/11, 0115 (1:15 a.m.) 4/17/11, 0130 (1:30 a.m.) 4/22/11, 2100 (9:00 p.m.) 4/21/11, 0140 (1:40 a.m.) 5/6/11, 0100 (1:00 a.m.) 5/10/11, 0120 (1:20 a.m.) 5/14/11, and 2445 (12:45 a.m.) 5/11/11. The documentation does not address the functional status of the devices. Review of Resident #8's Monthly physician's orders [REDACTED]. Interview on 6/2/11 at 4:15 p.m., with the DON and Administrator, revealed that the former DON and RCC left in February 2011 and they cannot locate the in-service that was completed after Resident #8's fall on 1/5/11. The Administrator stated that when she could not locate an in-service, they did another one on 2/16/11 for Wheelchair and Bed Alarms in Place. The DON reported that the staff member was counseled and given a Corrective Action Report on 1/5/11. The DON reported that CNA #2, assigned to Resident #8 on 1/5/11, was currently working the 11:00 p.m. to 7:00 a.m. shift. Review of the staffing schedule for 1/3/11 - 1/6/11, revealed that CNA #2 was scheduled to work 6:00 a.m. to 1:00 p.m. on 1/5/11. Review of the in-service conducted on 2/16/11, revealed CNA #2's signature was not documented. The DON reported that the new schedule for designated weeks to change out the chair and bed alarms is the policy/procedure for monitoring the devices. Resident #8's fall on 1/5/11 was presented in the QA Meeting on 1/12/11 with the agenda for staff discipline regarding the incident. The Administrator also presented the facility's daily staff meeting on 1/6/11, which documented "Putting alarm batteries on schedule". Review of the facility's policy with the DON and Administrator revealed the following: Falls and Fall Risk, Managing (revised 9/10): Policy Interpretation and Implementation: Minimizing Serious Consequences of Falls. (6) In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g. hip padding, bed alarms or treatment of [REDACTED]. See Strategies for Reducing Risk of Falls. Strategies for Reducing the Risk of Falls: Staff Communication: Check bed/wheelchair alarms daily and change batteries as needed at minimum of monthly. The DON reported they do not document bed/chair alarms nor the battery replacements, their policy does not state to document, and they did not have any further problems. The Administrator and DON further reported that it would probably be a good idea to include the checks and battery replacements on the MARs or Treatment Records to ensure verification for checking the devices and replacing the batteries. Interview on 6/2/11 at 5:00 p.m., with CNA #2, revealed that she was assigned to Resident #8 on 1/5/11. CNA #2 reported that she was walking down the hall and heard Resident #8 yelling. She found Resident #8 on the floor at the bedside with the knot on her forehead. She called for the nurse to come and check Resident #8. After the nurse got there and they checked Resident #8, the nurse asked why the bed alarm was not sounding. CNA #2 stated, "We checked the bed alarm and found the battery was missing. CNA #2 reported that the nurse was the RN Supervisor at the time and was no longer working at facility. CNA #2 did remember that LPN #1 was also there that day. CNA #2 reported that the nurses and CNAs check the bed and chair alarms daily to be sure they are working alright. CNA #2 reported that when you first put the resident on the bed it will alarm, then the green light will start blinking to let you know the battery is working. CNA #2 reported that she was in-serviced on the bed and chair alarms when she was hired two (2) years ago, and then again after the incident on 1/5/11. CNA #2 reported that they do not document the checks or the battery replacements. CNA #2 stated, " we just check them." CNA #2 was not aware of anyone designated to check the devices, and that extra batteries were kept at the Nurse's Stations. Review of Resident #8's Care Plan dated November 2010 (reviewed 2/17/11 and 5/11/11) revealed the Problem/Strengths: "Risk injury or fall r/t [DIAGNOSES REDACTED]. Continued review of the Care Plan revealed the following included Interventions: " Bed and Chair Alarm to alert staff if attempting to arise. Transfer with sit to stand lift x 2 assist. When fall occurs examine resident for any injury. Contact MD as needed. Try to determine the causative factors regarding fall and ways to prevent. Lock wheelchair prior to transfer. Zoloft 50 mg. (milligram) per peg daily r/t Depression. Observe for side effects of Zoloft q (every) shift such as insomnia, agitation, dizziness, headaches, or seizures. Keep call light within easy reach and answer promptly. Psych Consult as needed (prn). Observe for signs and symptoms (s/s) of Depression q shift, such as sad facial expression, crying, withdrawal from activities of interest, decreased appetite. 1/5/11 Actual Fall - Send to (Name of hospital), q hr. checks, Staff education, therapy evaluation, and monitor bruise x 5 days."